Procedural sedation: Difference between revisions

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*Position the patient in a position you would intubate if neeeded (ear at level of sternal notch)
*Position the patient in a position you would intubate if neeeded (ear at level of sternal notch)
*Consider nasal airway in patients with likely OSA
*Consider nasal airway in patients with likely OSA
Although the routine use of capnography appears to decrease the incidence of hypoxia and respiratory events as defined in these studies (Level B recommendation), currently there is a
lack of evidence that capnography reduces the incidence of serious adverse events during procedural sedation and analgesia such as neurologic injury caused by hypoxia, aspiration, or death.


{{Sedative agents}}
{{Sedative agents}}

Revision as of 23:48, 15 August 2016

Background

Definition

ACEP Definition: Procedural sdeation is 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. [1]

Sedation Levels

Sedation levels

Level Definition Comments
Minimal Sedation Standard pain medications
Moderate Sedation Awake and able to respond to questions use in: LP, I+D
Dissociative Sedation Trance-like state, airway reflexes preserved
Deep Sedation React purposefully to painful stimuli use in: Reduction
General Anesthesia Unarousable, requires intubation/advanced airway

Procedural Checklist[2]

  • Consent in chart
  • PIV with fluids attached
  • ETCO2 and NC
  • Airway preparation
    • Suction with yankaeur attached
    • BVM attached to wall oxygen
    • Oral/nasal airway
    • Mac/miller blade
    • ETT with stylet placed and 10 cc syringe
  • Meds at bedside
    • Sedation Meds
    • Narcan 0.4mg if opioid being used, not drawn up
    • Epinephrine, cardiac syringe (1:10,000) unopened and 10 cc NS Flush with needle
    • Glycopyrollate, 1 vial; not drawn up

Fasting

  • ACEP Level B Reccomendation: Do not delay procedural sedation in adults or pediatrics in the ED based on fasting time. Preprocedural fasting for any duration has not demonstrated a reduction in the risk of emesis or aspiration when administering procedural sedation and analgesia. [1]
  • Outside EM, other socities rec
    • 2-hour fasting time for clear liquids
    • 4-hour fasting time for breast milk
    • 6-hour fasting time for solids

Airway Monitoring

  • ACEP Level B Reccomendation: Capnography may be used as an adjunct to pulse oximetry and clinical assessment to detect hypoventilation and apnea earlier than pulse oximetry and/or clinical assessment alone. However, there is a lack of evidence that capnography reduces the incidence of serious adverse events (neurologic injury caused by hypoxia, aspiration, death). [1]
  • Placing the patient on ETCO2 + SpO2 is ideal[3]
  • Position the patient in a position you would intubate if neeeded (ear at level of sternal notch)
  • Consider nasal airway in patients with likely OSA

Sedative agents

  • The ideal agent is short-acting with minimal respiratory or hemodynamic depression
  • Ketamine offers the greatest safety profile overall but caution in the elderly or patients with known cardiovascular disease due to sympathetic surge
  • Propofol is often used for orthopedic procedures due to muscle relaxation, but can cause respiratory depression and hypotension
  • Etomidate used less frequently than other agents; causes myoclonus that is undesirable for orthopedic reduction

Fentanyl/Midazolam

  • Dose fentanyl first: 0.5-1mcg/kg
  • Follow with 1-2 mg of midazolam
  • Designed for moderate sedation
  • Duration 30min

Fentanyl/Etomidate

  • Similar to fentnayl/midazolam, but better because shorter duration of action
  • An alternative to propofol for brief sedation
    • E.g. shoulder/hip reduction, cardioversion
  • Can cause myoclonus[4] and occaisonly adrenal supression.
  • Dose fentanyl first: 0.5-1mcg/kg
  • Etomidate 0.15mg/kg (8-10mg avg)
  • Duration: 6min

Brevital (Methohexital)/Fentanyl

  • Suppresses the reticular activating center in the brainstem and cerebral cortex, thereby causing sedation
  • Sedation and amnesia, no analgesia
  • Dose fentanyl first: 0.5-1mcg/kg
  • Initial dose 0.75 to 1mg/kg IV
  • Repeat doses of 0.5mg/kg IV can be given every two minutes.
  • Immediate onset, duration <10 minutes

Ketamine

  • Noncompetitive NMDA receptor antagonist that produced dissociative state
  • Sedation, analgesia, and amnesia
  • Safe to use in children undergoing procedural sedation and analgesia (Level A recommendation)[1]
  • Maintains upper airway tone, protective reflexes, and spontaneous breathing
  • Little evidence to advocate for prevention of emergence phenomenon, may pretreat with midazolam 0.05 mg/kg (2-4 mg for most adults)[5]
    • Versed can be used subsequently if emergence reaction occurs
  • 1-2 mg/kg IV, followed by 0.5-1 mg/kg IV PRN
  • 4-5 mg/kg IM → repeat 2-4 mg/kg IM after 10 min if first dose unsuccessful
  • Duration 10 to 20 minutes

Propofol

  • Potentiates GABA receptors, sedative hypnotic agent without analgesic properties
  • Rapid onset <1 min, short duration <10 min, predictable dose dependent potency
  • 0.5-1mg/kg IV over 3-5 mins, repeat 0.5 mg/kg q3-5 min PRN
  • Can cause dose-related respiratory depression, hypotension, and decreased cardiac output, however, rarely leads to unplanned intubation, prolonged observation, or complications requiring admission [6]
  • Can cause sympathomimetic effects, such as tachycardia, hypertension, and increased cardiac output, and caution should be used in patients with known or suspected coronary artery disease

Propofol/Ketamine (Ketofol)

  • 1:1 mixture of ketamine and propofol[7]
  • Safe in children and adults undergoing procedural sedation and anesthesia (Level B Reccomendation)[1]
  • Theorized that side-effect profiles counter one another
    • Propofol-associated hypotension and respiratory depression can theoretically be reduced with increases in circulatory norepinephrine induced by ketamine
    • Ketamine associated nausea and emergence reactions are theoretically reduced by the antiemetic and anxiolytic properties of propofol
  • A study of pediatric patients found the total patient sedation times to be shorter (3 minutes) with the combined ketamine and propofol regimen compared with ketamine alone[8]
  • Dose: 0.5mg/kg propofol with 0.5mg/kg ketamine (may be mixed in same syringe or given separately)

Dexmedetomidine

  • 1 mcg/kg loading dose followed by 0.2-1 mcg/kg/hr maintenance dose
  • Side effects include bradycardia and hypotension.
  • Avoid in patients with heart blocks
  • May need to supplement with 1-2 mg of midazolam

Etomidate

  • 0.1mg/kg one time dosing
  • Max: 10mg
  • Minimal respiratory depression but decrease blood pressure and heart rate (alpha2 agonism)

Side Effects

  • Desaturation
    • Stimulate
      • Try pressure behind ear
    • Jaw thrust
    • Nasal airway
    • BVM (just 10 breaths/min) count to 5 between breaths
    • NIV
    • LMA
    • Intubation

See Also

References

  1. 1.0 1.1 1.2 1.3 1.4 ACEP Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department full text
  2. http://emcrit.org/wp-content/uploads/Sedation_Checklist-8-1-10.pdf
  3. Deitch K, Miner J, Chudnofsky CR, Dominici P, Latta D. Does end tidal CO2 monitoring during emergency department procedural sedation and analgesia with propofol decrease the incidence of hypoxic events? A randomized, controlled trial. Ann Emerg Med. 2010 Mar;55(3):258-64.
  4. Van Keulen SG, Burton JH. Myoclonus associated with etomidate for ED procedural sedation and analgesia. Am J Emerg Med. 2003;21:556-558.
  5. Sener S, Eken C, Schultz CH, Serinken M, Ozsarac M. Ketamine with and without midazolam for emergency department sedation in adults: a randomized controlled trial. Ann Emerg Med. 2011 Feb;57(2):109-114.e2
  6. Blackburn 2000, Burnton JH, Miner JR, et al. Propofol for emergency department procedural sedation and analgesia: a tale of three centers. Acad Emerg Med. 2006;13(1):24-30
  7. Andolfatto G, Abu-Laban RB, Zed PJ, et al. Ketamine-propofol combination (ketofol) versus propofol alone for emergency department procedural sedation and analgesia: a randomized double-blind trial. Ann Emerg Med. 2012; 59(6): 504-12.e1-2. PMID: 22401952
  8. Shah A, Mosdossy G, McLeod S, et al. A blinded, randomized controlled trial to evaluate ketamine/propofol versus ketamine alone for procedural sedation in children. Ann Emerg Med. 2011;57:425-433.