2. Purpose of my talk ….
Concept of Procedural sedation & analgesia(PSA)
Sedation grading
Clinical decision making & Procedural consent
Pre-procedural assessment
Preparation
Considerations in Pregnant, Younger & elderly patients
Choice of drugs for Procedural sedation
Common complications
Discharge criteria
3. Procedural sedation – what ?
Administration of one or more pharmacological agents to facilitate a diagnostic
or therapeutic procedure while targeting a state during which airway patency,
spontaneous respiration, protective airway reflexes, and hemodynamic stability
are preserved, while alleviating anxiety and pain’
Goals – patient comfort, safety, improve efficiency & adequate recovery
Practise of procedural sedation differs from the practise of general anaesthesia
Why do we use it – avoiding theatre, cutting costs, pain saving, anxiety-
relieving.
4. Monitored anaesthesia care liability
Oversedation leading to respiratory
depression was an important
mechanism of patient injuries during
MAC.
Appropriate use of monitoring,
vigilance, and early resuscitation could
have prevented many of these injuries.
5. Procedural sedation in non-theatre environments
• Sedation frequently provided outside the theatre
environment.
• Mainly aimed for mild and moderate sedation.
• Theatre standards of care must be provided for those
receiving sedation.
6. Non theatre environments for PSA
Gastroenterological procedures – upper GI procedures
Cardiology – cardioversion, trans-esophageal echo, angiography,
pacemaker insertion
Dental care – conscious sedation adjunct to local anaesthesia
Radiological procedures – phobia for CT/MRI & Interventional
radiological procedure
Emergency room
Pediatric sedation
Respiratory procedures
Maxillofacial surgery
9. Clinical decision making
Factors into consideration before decision making for PS
1. The urgency of the procedure
2. Availability of appropriately trained staff for the procedure
3. Availability of appropriate space and equipment
4. Patient Assessment - high risk factors
5. Patient consent
Alternatives to PS should be considered eg:regional anaesthesia
Multimodal strategies to be considered in regards to PS in children (distraction,
topical analgesia, intranasal analgesia)
10. Procedural
sedation consent
Risks and benefits must be clearly
explained
If clinically appropriate,
alternatives to sedation should be
explained (typically general
anaesthesia or local anaesthesia)
Patient should be aware that they
require a competent adult to
escort them home after receiving
sedation
11. Pre procedural
assessment
1. Any issues with previous sedation
procedures/general anaesthesia
2. ASA classification – risk assessment
tool
3. AMPLE assessment
(Allergies,Medications,Past illness,Last
meal,Events leading to it)
12. Fasting
Fasting times : 2hrs (clear fluids),4hrs(breast milk,6hrs(solid foods incl. milk)
NICE guidelines [on sedation of children] recommends fasting before sedation
unless sedation is limited to:
Minimal sedation, Sedation with nitrous oxide (in oxygen)
Moderate sedation during which the child or young person will maintain
verbal contact
ED patients often require emergency procedures that’s often not possible to
delay the procedure.
Undertake a risk assessment for aspiration like alcohol ingestion, obsesity,
pregnancy, proposed sedation agent(ketamine/propofol)
13. Fasting controversies
No clear evidence that non compliance with
elective fasting increase aspiration risk or other
adverse events during PS.
Clinically significant aspiration during emerg.
dept PSA appears to be rare.
Aspiration can occur despite presence of
endotracheal tube
Airway manipulation involved in performing
intubation appears to increase risk of
aspiration.
14. Preparation
Analgesia
Anxiolysis
Amnesia
Preprocedure safety briefing (Nurse & clinician performing the procedure)
Roles
Intended plan, including intended depth and length of sedation as well
as determining when the procedure can commence.
Confirmation of correct side of patient (where applicable)
Confirmation of equipment checks have taken place (eg. suction
working)
Confirmation of location of rescue devices and drugs - Anticipated
problems
15. Staff preparation
Working in the relative isolation of non theatre or non hospital setting where skilled assistance
of operating department practitioner & familiar equipment may be lacking .
Dedicated trained anaesthetist in addition to
ODP
ED : ER nurse, emergency practitioner
Endoscopy nurse
More team members are required as complexity increases
Medical staff for DC cardioversion
ECT trained staff
19. Considerations in Younger patients
Children < 1yr are not normally sedated in the ED & Procedural sedation in 1-5yr age
group in ED needs to involve senior clinical decision makers.
Paediatric PS ↓ admission rates, ↓ length of hospital stay and avoid the need for
procedures to be performed in theatre.
Common indication of PS in children - suturing of lacerations, manipulation of
dislocation and fractures, foreign body removal and imaging (CT) .
For many paediatric procedures that require sedation involvement of partner
specialities such as plastics, max fax, orthopaedics is warranted.
20. Considerations in Younger
patients
Age-appropriate distraction techniques is strongly
recommended,.
Parent & carers accompanying the child is strongly
recommended, except where the parent is unable to
provide calm support. Play specialists if available.
Use of analgesia prior to and during the procedure
should always be considered.
Commonly used sedation agent in UK for paediatric
patients is IV ketamine followed by variable
concentration nitrous oxide.
Sedation given should be the minimum necessary to
facilitate the procedure.
21. Considerations in Pregnant
Procedural sedation in pregnant patients especially in 2ND &
3RD trimester should be considered to be high risk &
requires early involvement of a senior clinical decision
maker.
Considerations include positioning, oxygenation, foetal
monitoring, and pre-procedural medication.
In 2ND & 3RD trimester, placing the patient on their left side
or placing bolster under right flank will reduce the risk of
hypotension and foetal hypoxaemia
Pre-procedural administration of antacid and anti-emetic
such as metoclopramide should be considered.
22. Consideration in older patients
Co-morbidities which impact their respiratory and
cardiovascular functional reserves & patient’s regular
medications, need to be considered during PS decision making.
Detailed airway assessment prior to undertaking procedural
sedation.
In elderly patient - drug choice, dosage and interactions are to
be noted.
There is often delayed onset time for sedation agents in this
group.
Slower rates of administration and repeated doses at less
frequent intervals are recommended
Prolonged recovery time in a suitable area should also be
anticipated.
Decision making regarding procedural sedation in this older age
group should carefully balance the risk of sedation (or other
options) versus the impact on the patient’s quality of life.
23. Choice of drugs for Procedural sedation
The appropriate choice of pharmacological agents for PS depends
on:
The nature of the procedure
The planned level of sedation
Training and familiarity of the sedating practitioner with potential
pharmacological agents
Patient factors ex: cardiovascular stability, fasting status, age.
The local environment
24.
25.
26. Pharmacological agents used as infusions
Agent Role Dose
Propofol (TCI) Sedation
~2.0 mcg/ml
(plasma concentration)
Remifentanil (TCI) Sedation/ Analgesia
~2.0 ng/ml
(plasma site
concentration)
Clonidine
Sedation/ Anxiolysis/
Analgesia
0.5-2mcg/kg/hour
Dexmedetomidine Sedation/ Anxiolysis
0.7mcg/kg/hr
(0.2-1.4 mcg/kg/hr)
28. Penthrox(methoxy flurane)
Non-opioid, non-controlled drug, emergency analgesic.
Indications : dislocations,lacerations/wounds,fractures,burns/
scalds,chest/abdominal injuries, neck of femur fracture
Suitable for moderate to severe pain associated with a wide-range
of trauma injuries
Not be used in children and adolescents under 18 years
One bottle of 3 ml PENTHROX as a single dose, administered using
the device provided. Max dose in a single day - 6 ml, and the max
total dose in a week should not exceed 15 ml. Onset of pain relief
is rapid and occurs after 6-10 inhalations
Caution in the elderly or other patients with known risk factors for
renal disease, and in patients diagnosed with clinical conditions
which may pre-dispose to renal injury
29. Reversal agents
Flumazenil:
Properties: Competitive antagonist at central
benzodiazrpeine receptors
Use: Reversal of respiratory depression following
benzodiazepine use.
Administration: 100-200mcg over 15 seconds,
every minute. Maximum dose 1mg (adults),
Acts in 30-60 seconds.
Side Effects: Use with caution in those on long
term benzo diazepines. Hypertension,
dysrhythmias and vomiting.
Naloxone:
Properties: Competitive antagonist at opiate receptors
Use: Reversal respiratory depression secondary to
opioid administration
Administration: Adults:100-200mcg every 1-2 minutes;
Children 11month-11yrs 1- 10mcg/kg (max 200mcg
per dose, total max dose 2mg); children 12-17yrs
100-200mcg every 1-2 minutes (max dos 2mg).
Acts within 2 minutes and lasts approximately 20
minutes. Titrate to reverse respiratory depression
without reversing analgesia.
Side Effects: Precipitation of withdrawal in chronic
opiate use. Arrhythmias, nausea vomitng.
30. Administering sedation
A combination of short acting analgesics & sedatives are may be required
Ketamine has the potential to provide analgesia, sedation, anxiolysis
and amnesia
Dexmedetomidine provides sedation, anxiolysis and analgesia with
limited respiratory depression.
No one sedation technique is suitable for all patients or procedures
Ideally sedationist should aim for:
Minimum intervention; Simplest and safest effective technique;
Based on patient assessment and clinical need
Delivery of sedation - Bolus or continuous propofol delivery,
Patient-controlled sedation , Computer-assisted
personalized sedation (CAPS), Target-controlled infusion
31. Procedure steps
Positioning of patient
Preoxygenation
Baseline observations
Medications
Monitoring depth of sedation
32. Monitoring during & after procedure
3 lead ECG,
Oxygen saturations,
Continuous capnography,
Non-invasive blood pressure
Nurse & Clinician performing the PS should
remain with the patient until the patient has
‘woken up’.
Clinical scales, Processed EEG, Anaesthesia
responsiveness monitoring, Assessment of
ventilation –pulse oximetry, capnograpghy,
transcutaneous CO2 monitoring , Impedance
monitoring , Acoustic monitoring
33.
34. Common problems
Inadequate monitoring
Over sedation:
Excessive doses in children, elderly or frail patient
Failure to titrate drugs to effect
Availability of high strength midazolam presentations (never event)
Lack of appreciation of the risks of drug combinations, e.g. synergism
Agitation – paradoxical agitations especially in children, adolescents, and elderly
Laryngospasm – BMV, Larsons point pressure,deepening sedation with propofol or sux. and intubate.
Hypotension – can by due to sedation or analgesia (but consider other causes too)- IVF, leg elevation,metaraminol.
Nausea and vomiting – suction for any vomitus. Antiemetics to help relieve nausea
Respiratory depression – supplemental oxygen,airway manoeveurs,BMV.
Minimal training for administering sedation and lack of supervision of inexperienced trainees
35. Discharge criteria
Vital signs returned to baseline (no additional oxygen requirement)
Alert & Orientated
Able to tolerate oral fluids
Adequate analgesia
No / minimal nausea
2 hours elapsed since use of reversal agent**
Appropriate care available at home
Sedation advice leaflet
Good mor , my talk is about proced seda.
It’s a vast topic, I will try to about the approach in non theatre environment
Drug choices tend to differ based on each person expertise.
Conscious sedation was replaced by PSA
More than 40% of claims associated with MAC involved death or permanent brain damage, similar to general anesthesia claims.
Whilst the urgency of the clinical situation or patient status may sometimes necessitate treatment in the absence of consent, and in the patient’s best interests, every effort should be made to obtain prior written consent for both the proposed procedure and sedation technique. This includes the risks and benefits, with average risk and personalised risk, alternatives to sedation, and the requirements for discharge.
I use the approach of LEMON assessment
– WHO pain ladder principle
- Non pharmacological measure,environment particularly in children & dementic patients
1. delivered by clinicians with the additional competencies and experience as determined by local governance arrangements
ex: using a large computer screen / tablet or a parent’s mobile phone to play videos
Decision making regarding undertaking procedural sedation in this older age group should carefully balance the risk of sedation (or other options) versus the impact on the patient’s quality of life and the prevention of significant rapid functional decline if procedure not carried out.
Dosage they have formulated after discussion between the 2 colleges RCOA & RCEM
sedated state produced by remimazolam appears broadly similar to that caused by midazolam with faster onset. Unlike midazolam, remimazolam metabolites have negligible sedative effects.
Dex - sole agent, bradycardia and hypotension were problematic and recovery was slow.
2. reduced tendency to cause sedation and respiratory depression
Simple, fast setup – no need for signatories, canisters or cannulas.
May avoid the need for procedural sedation
>x3 faster than Entonox (10.54 minutes vs not achieved by 30 minutes)
>x3 faster than IV Paracetamol (9.66 minutes vs 37.53 minutes)
x2 faster than IV Morphine (10.47 minutes vs 20.09 minutes)
A computerized voice asks the patient to push the button and the handset vibrates up to four times over a 10 s period. The system quan- tifies how quickly the patient responds, and a lack of response signals a sedation level deeper than moderate sedation.
