2. Procedural Sedation
• What we’ll focus on
– Concept
– Safety
– You
• What we won’t
– Drug specifics
– Procedure itself
3. What is procedural sedation?
“The patient is in a state of drug induced tolerance of
uncomfortable or painful diagnostic or interventional
medical, dental or surgical procedures”
– ANZCA guideline endorsed by colleges including ACEM
• American (ACEP) definition includes the idea that
cardiorespiratory function is maintained
• Australian (ANZCA) definition recognises the fact that
although this is intended, there may be a degree of
compromise that needs to be managed by someone
trained in the skills to do so
4. Aims of procedural sedation
• Focus on patient
– Comfort
– Awareness
– Ability to complete procedure
• Focus on safety
– Depth of sedation
– Variability of effect
– Risks
5. Procedural sedation terminology
• Conscious sedation 1985
– Describing lightly sedated dental patients
– Used then in paediatric sedation guidelines
• Deep sedation
– Patients difficult to rouse
• General anaesthesia
– Unable to rouse patient
– Needs an anaesthetist
• Procedural sedation and analgesia (PSA)
– Describes a continuum which also includes dissociative
sedation
6. Sedation Continuum
6 Inadequate
5 Minimal
4 Moderate
3 Moderate/Deep
2 Deep
1 Deep
0 Anaesthesia
Taken from Rosen’s emergency medicine
Anxious, agitated or in pain
Spontaneously awake without stimulus
Drowsy, eyes open or closed, easily roused verbally
Rouses with moderate tactile, loud verbal stimulus
Rouses slowly to consciousness with painful stimulus
Rouses, but not to consciousness with painful stimulus
Unresponsive to painful stimulus
7.
8.
9.
10. Risks of procedural sedation
• Depression of protective
airway reflexes
• Loss of patency of airway
• Depression of respiration
• Depression of
cardiovascular system
• Neurological and
behavioural events
• Vomiting and aspiration
• Individual variation in
response
• Possibility of deeper
sedation being required
• Drug interactions,
anaphylaxis
• Risk inherent in
procedure
12. Clinical governance for Procedural
sedation in ED
• Training
– Procedures
– Drugs
– Equipment
– Monitoring
• Risk
– Identification
– Management
• Audit
– Safety
– Future advancements
13. ANZCA Guidelines on Sedation and/or
Analgesia for Diagnostic and Interventional
Medical, Dental or Surgical Procedures
• https://acem.org.au/getattachment/9ef3110d-9863-44e8-89e5-aaa894b18236/P09-Guidelines-on-
Sedation-and-or-Analgesia-for-Di.aspx
14. Outline the steps in performing and
episode of procedural sedation in the ED
• Patient/Procedure selection
• Consent
• Assessment
• Staff
• Equipment/Monitoring
• Drugs
• Perform procedure
• Documentation
• Recovery and discharge
17. Equipment/Monitoring
What do you need?
• Location
• Lighting
• Oxygen
• Suction
• Self inflating bag and
mask
• Airway trolley/advanced
airway devices
• IV access/iv fluid
• Emergency drugs
• Pulse oximeter
• Blood pressure
• CO2 monitoring
• ECG monitoring
• Defibrillator
• Means of summoning
assistance
• Plan for clinical
deterioration
18. Drugs – which should you choose?
Sedation
• Propofol
• Ketamine
• Benzodiazepines, e.g. midazolam
• Barbituates e.g. thiopentone
• Tranquilisers, e.g. haloperidol
Considerations
• Effect profile
• Side effects
• Duration of action
• Contraindications
Analgesia Anxiolysis
• Fentanyl
• Morphine
• Nitrous Oxide
• Ketamine
Other drugs
• Ketofol
• Alpha 2 agonists, e.g.
dexmedetomidine, clonidine
19. • Ketofol does not reduce adverse events
• Propfol does not cause significant* hypotension
• Ketofol recovery is longer
• Patient satisfaction is no different
20. Drugs – what dose do I give?
• Depends on many factors
– Age
– Clinical status
– Comorbidities
– Prior meds
– Tolerance
– Procedure
21. Evidence Based Practice
– ACEP policy guideline
• Literature concludes PSA is safe in ED
• Propofol and ketamine most widely studied and
safe – level A
• Fasting not required – level B
• Capnography should be used – level B
• Minimum personnel – level C
– At least 2 – continuous monitoring and ability to
identify and manage complications
24. Situational Awareness
• The skill of maintaining an overall view of the
situation at hand, not becoming preoccupied
with minor details missing the most critical
aspect of the moment
25. Human Factors – sources of error
• Lack of communication
• Complacency
• Lack of knowledge
• Distraction
• Lack of teamwork
• Fatigue
• Lack of resources
• Pressure
• Lack of assertiveness
• Stress
• Lack of awareness
• Norms
27. Procedural Sedation THM
• It is performed safely in the ED if you
– Assess the patient adequately
– Prepare for worst case scenario
– Know your poison
– Develop skills in situational awareness
28. References
• ANZCA guideline on sedation/analgesia
– https://acem.org.au/getattachment/9ef3110d-9863-44e8-89e5-aaa894b18236/P09-Guidelines-on-Sedation-and-or-Analgesia-
for-Di.aspx
• Ketofol for procedural sedation revisited: pro and con. Ann Emerg Med.
2015
– Ann Emerg Med. 2015 May;65(5):489-91. doi: 10.1016/j.annemergmed.2014.12.002. Epub 2014 Dec 24.
• ACEP Clinical Policy: Procedural Sedation and Analgesia in the Emergency
Department
– Annals of Emergency Medicine Volume 63, Issue 2, February 2014
• https://lifeinthefastlane.com/procedural-sedation/
• Rosen’s Emergency Medicine 8th edition 2014
• @hughcards
Notes de l'éditeur
A core skill in emergency medicine and something you will all be familiar with but it doesn't hurt to go over the topic and review why do things the way we do
Specifics of doses and choice of drug not really going to go into
– pros and cons of side effects
There are reasons you may choose one drug over another and there are many factors you need to consider. As with anything you need to have a number of weapons in your arsenal and know when and how to modify things depending on the situation
Recent definitions include 5 stages you can read them in the guidelines and policy documents
Transition from one to another can be difficult to predict and can occur without giving further sedation and will be different for each individual patient. So be careful and use judicious doses
This is the ideal picture of the level of sedation for a painful procedure – this is really what we are aiming for. Calm, relaxed, maintaining own airway, breathing spontaneously rousable to painful stimulus but nicely sedated with adequate pain relief anxiolysis and amnesia for the event
This is an image of a patient in deep sedation or perhaps even general anaesthesia
Perfect level of sedation something we often see after the administration of propofol for example – disinhibited, not responsive to verbal stimuli, even the doorbell probably wouldn't elicit a reponse.
It is unanticipated risks that we need to prepare for most because they are unanticipated and occur without warning. Predictable risks may be life threatening but more manageable because they are predictable.
Procedure risks are important sometimes like in a respiratory procedure
Quebec criteria developed for use in kids and includes Respiratory CVS, vomiting, excitatory movements and behavioural disturbances – in an attempt to standardise terminology for adverse events for paeds undergoing sedation – it is transferrable to adult population
Clinical governance is where the Managing bodies – clinical and administrative – oversee and implement a plan for the continuous improvement, risk minimisation, and fostering and environment of excellence in care for patients, carers
DSI with NIV or proc sed with NIV safely in groups of people – great work ruben strayer
Now patient/procedure selection AND consent
Assessment
ASA 1-3
Anaesthetic assessment not the scope of this talk but….
From ACEM policy regarding staffing and level of training required
Emergency drugs and supplies should include at least the following:
adrenalineatropinedextrose 50 per cent
lignocainenaloxoneflumazenilportable emergency O2supply
Before 2 – what do you need to consider/know about all these drugs?
I would encourage you to go away and read up about these drugs - but really you need to get experience with them by using them obviously in a supervised environment until you are happy and comfortable with the effect they have on patients
It will be different for everybody and difficult to predict.
Considerations – duration of procedure, painfulness of procedure, requirement for lack of movement,
When is the patient ready for the procedure to commence?
How do you know? What do you look for?
Three different levels of sedation judging can be tricky.
Where having the right staffing mix comes in.
You need to really have both aspects covered.
Jason Bourne – has it in spades
Important in environments where there is a high turn over of information and poor decisions can lead to serious consequences. (think – military, aviation and critical care medicine)
Lacking or inadequate situational awareness is a major contributor to human error
Innate in some
Can be learned/taught Emergency medicine/critical care probably not your field if this happens to you
Interesting area - whole talk in itself
Human factors engineering and ergonomics
Much in medicine recently.
Vortex airway approach heavily linked to limiting error via attention to human factors
Recovery – depends on drug used and dose specifics may be different
Documentation – procedural sedation record