procedural sedation

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Procedural SedationHesham YoussefPGY1, Anesthesia

+Procedural Sedation/Analgesia.

A technique of administering sedatives or dissociative agents with or without analgesics to induce a state that allows the patient to tolerate unpleasant procedures while maintaining cardiorespiratory function.

Godwin SA, Caro DA, Wolf SJ, et al. Clinical policy: procedural sedation and analgesia in the emergency department. Ann Emerg Med. 2005; 45(2):177-196.

+Goals of Sedation and Analgesia

Maintain patient safety and welfare.

Minimize physical discomfort and pain.

Control anxiety, minimize psychological trauma, maximize amnesia.

Control behaviour and/or movement to allow safe performance of procedures.

Return the patient to a state in which safe discharge from medical supervision is possible.

+Indications

Diagnostic Imaging (requiring sedation only)

a. CT

b. MRI

+Indications

Painful Diagnostic (requiring both sedation and analgesia), including:

a. Lumbar puncture

b. Sexual assault examination with forensic evidence collection

+Indications

Painful Therapeutic (requiring both sedation and analgesia), including:

a. Fracture/ dislocation reduction

b. Complex laceration repair

c. Foreign body removal

d. Abscess incision and drainage

+Patient Assessment

History:a. Concurrent medical illnesses.

b. Medications.

c. Allergies .

d. History of sleep disordered breathing or snoring .

e. Major medical illnesses

f. Previous adverse reactions to anesthetic/ sedative agents

g. Family history of an adverse reaction to sedation, analgesia, or GA

h. Last oral intake

+Patient Assessment

Fasting:

ER literature: No correlation found between fasting status and incidence

of aspiration in procedural sedation outside the OR

Analgesia, anesthesia, and procedural sedation. In: Tintinalli JE, Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD, eds. Tintinalli's emergency medicine. Seventh ed. The McGraw-Hill Companies, Inc.; 2011.

+Patient Assessment

Fasting:

ACEP: procedural sedation may be safely administered to pediatric patients

in the ED who have had recent oral intake.

However, theoretical risk of aspiration should still be considered ASA Fasting Guidelines

Green SM, Roback MG, Miner JR, Burton JH, Krauss B. Fasting and emergency department procedural sedation and analgesia: a consensus-based clinical practice advisory. Ann Emerg Med. 2007; 49(4):454-461.

+Patient Assessment

Physical Exam:

a. Cardio-respiratory status & Neurological Status.

b. Airway Assessment. Features of difficult BMV/intubation Previous history of difficult airway

+Exclusion criteria

Difficult airway – abnormal face, mouth, dentition or neck

Sleep apnea, stridor, airway obstruction, severe asthma

Tracheal abnormalities

Severe cardiorespiratory disease

Severe GERD

Severe obesity

Raised intracranial pressure

Severe neurological impairment and/ or bulbar dysfunction

+ASA

Coté CJ, Wilson S. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update. Pediatrics. 2006; 118(6):2587-2602.

+Personnel

Physicians should be competent in:

a. Pediatric airway management and resuscitation

b. Patient assessment & preparation

c. Patient monitoring

d. Pharmacology of PSA

e. Recognition and treatment of the complications of PSA

+Personnel

Nurses & ancillary personnel (i.e. RT) should be :

a. Comfortable with basic airway management and resuscitation

b. Knowledgeable of patient preparation and monitoring procedures

c. Familiar with proper documentation of PSA technique

d. Able to prepare a time-based record of the treatment procedure

+Consent

Written consent.

proposed benefits (performing procedure effectively while minimizing pain/anxiety/psychological trauma).

possible risks (Air Way compromise, hypoxia, vomiting),

Drug: options - potential routes - Alternatives

+Equipment and Monitoring (SOAPME).

S (suction)

O (oxygen)

A (airway)

P (pharmacy)

M (monitors)

E (extra equipment) - (e.g., defibrillator)

Coté CJ, Wilson S. Guidelines for monitoring and management of pediatric patients during and after sedation for diagnostic and therapeutic procedures: an update. Pediatrics. 2006; 118(6):2587-2602.

+Pharmacology

+Ketamine

Ketamine is a dissociative anasthetic with sedative, analgesic and amnestic properties

Administration IV 1 mg/kg, repeat 0.5-1 mg/kg q10min prn Onset: 1-2 min Duration: 10-15 min Recovery: 60 min.

+Ketamine


Advantages Anesthetic and Analgesic Short-acting Maintain airway protective reflexes, spontaneous

respirations, and cardiopulmonary stability

+Ketamine


Disadvantages Emesis Laryngospasm Agitation/Emergence reaction Increases salivation Increase ICO & IOP

+Ketamine


Contraindications: Age < 3 months Psychosis Intraocular trauma or glaucoma Systemic hypertension Thyrotoxicosis

+Propofol

Propofol is a short acting sedative hypnotic which, due to its potency, has been used for both painful and painless procedures

Administration IV 1-2 mg/kg, repeat 0.5 mg/kg q3-5 min IV Infusion: start at 25-50 mcg/kg/min Onset seconds Duration minutes

+Propofol


Advantages Rapid onset, short recovery time, easy titratability. reliable potency to induce deep sedation Mild anti-emetic properties Decreases CMRO2 and CBF, as well as ICP

+Propofol


Disadvantages Anesthetic, with NO analgesia Pain on IV Administration Respiratory and cardiovascular depressant

+Ketofol

Advantage:

a. Shorter recovery time

b. Decreases dose for both agents - minimize side

effects (resp + cardiac depression, emesis,

emergence reaction)

+Ketofol

Administration:

In 2010, Andolfatto and Willman published a series of 219 pediatric patients who received a 1:1 mixture of 10 mg/ml ketamine and 10 mg/ml propofol in a single syringe .

Another 2007 study by Sharieff et al described a different method of “ketofol” administration, ketamine 0.5 mg/kg followed 1 minute later by propofol 1 mg/kg. Additional doses of ketamine 0.25 mg/kg and/ or propofol 0.5 mg/kg were given as deemed necessary by the ED physician.

+Midazolam

Midazolam is a short-acting benzodiazepine that provides sedation, amnesia and anxiolysis.

Administration IV/IM 0.05-0.1 mg/kg (max single dose 2 mg), repeats q2-5

min Routes: PO, PR, IV, IM, IN Onset: IV 1-2min, IM 5-10 min Duration: IV 45-60min, IM 60-120min

+Midazolam


Advantages Rapid onset Anxiolytic, amnestic, sedative Many routes of administration Rare resp depression when used as sole agent Effective reversal agent (Flumazenil)

+Midazolam


Disadvantages No analgesia Respiratory depression/Apnea (Specially when combined

with opioids) Paradoxical reactions (hyperactivity, aggressive behaviour)

+Fentanyl

Fentanyl is a potent synthetic opioid.

Administration: IV: 1.0 mcg/kg, repeat dose every 3 minutes as needed Onset: IV: 3-5 minutes Duration: IV: 30-60 minutes

Advantage: Rapid onset, short duration, less N/V

Disadvantage: resp depression, chest wall rigidity, facial pruritus

Reversal: Naloxone

+Other Medications

Nitrous Oxide. 50-70 %.

Etomidate. 0.1-0.3 mg/kg.

Pentobarbital. (IV, IM, PO).

a. <4 years: 3-6 mg/kg PO

b. >4 years: 1.5-3 mg/kg PO.

Chloral Hydrate. 50-75 mg/kg/dose 30 to 60 minutes prior to procedure; may repeat 30 minutes after initial dose if needed.

+Emergency States During Sedation

Airway Obstruction (Pharyngeal)

Laryngospasm

Hypoventilation/Apnea

Aspiration

Cardiovascular instability

+Recovery & Discharge

Airway patency, Resp, cardiovascular function, and hydration are satisfactory.

The patient’s level of consciousness has returned to baseline .

The patient can sit unassisted.

The patient can take oral fluids without vomiting;

The patient, or a responsible person who will be with the patient, can understand the discharge instructions.

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Thank You

procedural sedation

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