Procedural & Emergency Sedation for EMET Townsville Based on a talk by Jane Dutson FACEM Townsville Hospital Emergency Department

Emergency Procedural Sedation What is it? Why are we doing it? Should we be doing it? What do we need? What next? Not just the standard procedural sedation should be the aim of this talk but also emergency sedation to help the management of the acutely agitated – there will be some objection to doing any sedations at all – so mention acute limb threat and also ketamine assisted intubation

Procedural Sedation ?‘Conscious Sedation’. A state of drug induced tolerance of uncomfortable or painful diagnostic or interventional medical, dental or surgical procedures. Previously the remit of anaesthetists ‘& Analgesia’

Aims Minimise Pain & Discomfort Enable procedure Minimise Recall Minimise Risk Lack of response to painful stimulation is not a requirement.

If we are going to do this….. We need to understand the characteristics of medication being administered We must be able to monitor patients and maintain the desired level of sedation & We must be able to manage complications Cardiovascular instability Respiratory depression / airway compromise

Is Procedural Sedation Really Necessary? What are we trying to achieve? When practical ask the patient what they want. Consider alternative techniques Regional anaesthesia? Adequate pain relief? Is an RSI indicated? Regional & cultural differences / expectations Avoid ‘Out of Hours’ unless procedure is time critical

Factors to Consider History Examination ASA Score Mallampati Score Obstructive Sleep Apnoea Elderly / Co-morbidities Airway / Previous Anaesthetic Problems Fasting Examination ASA Score Mallampati Score 3 or 4 Risks Airway Compromise Urgency of Intervention Obstructive Sleep Apneoa

ASA Score American Society of Anaesthesiologists ASA I Normal Healthy Patient ASA II Mild Systemic Disease ASA III Severe Systemic Disease ASA IV Severe Disease / Constant Life Threat ASA V Moribund / Not Expected to Survive ASA I & II & possibly III ASA IV & V likely to need GA

Mallampati Score

Should they be Fasted? Debated Beyond 2 hours of fasting there is no increase in risk or change in gastric pH. Present ACEM / ASA Guidelines 2 hours post clear liquids 6 hours post ingestion of solids Most aspiration events occur during airway manipulation.

Fasting versus Intervention Recent ingestion of food / fluids should be weighed against the urgency of the procedure The goal is to maintain airway reflexes Examples….. Limb threatening injury for reduction v Incision and drainage procedure. Inhalational agents are more emetogenic.

Levels of Procedural Sedation ANXIOLYSIS MODERATE SEDATION DEEP SEDATION GENERAL ANAESTHESIA Responsiveness NORMAL Purposeful to Light Stimulation Purposeful to Repeated Stimulation NO Response to Painful Stimulation Airway PATENT +/- Intervention Needs Intervention Ventilation Adequate +/- Assistance Needs Assistance CVS Function Usually Adequate Impairment Risk This is important !!! The usual just give the patient (including children) a dissociative dose of Ketamine is – yes right – a GA!!!!

Dissociative Anaesthesia ‘A trance like cataleptic state characterised by profound analgesia and amnesia, with retention of protective airway reflexes, spontaneous respirations, and cardiovascular stability’ And as mentioned a type of GA – not actually a procedural sedation

Minimal Sedation /Anxiolysis Still normally responsive to verbal stimulation Entonox = Nitrous Oxide + Oxygen Useful for making short, uncomfortable procedures tolerable. Mix may be titrated up to 70%N2O:30%O2 Laughing Gas

Moderate Sedation (‘Conscious Sedation’) BENZODIAZEPINES Purposeful movements to light stimulation (midazolam) & Making interventions tolerable OPIATES Always allow peak drug effect before titrating additional doses (fentanyl / morphine)

Moderate Sedation Opiates & Benzodiazepine FENTANYL MORPHINE Rapid Onset Longer Onset Short Duration Longer Acting No Histamine Release Useful if long procedure Histamine Release No Amnesic Effect Emetogenic 0.5-1mcg/kg May cause Hypotension Halve in elderly 0.1mg/kg

Moderate Sedation Opiates & Benzodiazepines MIDAZOLAM Amnesic and Anxiolytic 0.03 – 0.1mg/kg SLOW onset of 2-5 minutes More rapid than diazepam 30-60 minute duration Increase risk of respiratory depression when combined with opiate Watch for compounding effects of opioids and benzos but also other substances and drugs !! Mention the reversibility of both opiods and benzos!! Should always be available !!!!

Deep Sedation Benzodiazepine & Opiate Propofol Purposeful movements to repeated stimulation Benzodiazepine & Opiate Propofol At risk of becoming….. General Anaesthesia

Milk Of Amnesia

Propofol Deep Sedation Pre-oxygenation required End Tidal CO2 Monitoring No analgesic effect 1-1.5mcg/kg fentanyl pre-sedation Propofol Dose 0.5 - 1mg/kg 0.25 - 0.5mg/kg increments thereon usually 200mg/20ml vial Apnoea up to 60seconds (less if stimulus applied) This is not reversible !!!!! As always the apnoea – drop in responsiveness always follows reduction of pain (ie post successfully reduction)

Dissociative Anaesthesia

‘How they go down is how they come up’ Ketamine Patient maintains own airway and respiratory drive Pain free relaxation Suitable for prolonged procedures 20 second apneoic episode common Emergence Phenomena ‘How they go down is how they come up’

Ketamine Sympathomimetic Raised BP Raised HR Relatively !!! contraindicated in hypertensive, elderly or patients with a history of psychosis Emergency phenomena may be effectively treated with benzodiazepines Avoidable if quiet, calm environment Encourage pleasant thoughts at induction Especially the relative contraindication of psychosis is probably rubbish – good experience has been gained from psych aeromedical transfers

Triple Check Doses

Procedural Drugs And remember for rural locations – advantages of being able to reverse some of these drugs over others

Who Do We Need? Staff Clinician to administer the ‘sedation’ Another clinician to perform the procedure (unless only using anxiolysis) Separate operator for monitoring, recording drug doses, times and observations This will be hard in a one doctor town – nice how “big city” talks sometimes are incompatible with life 

What Do We Need? Equipment Intubation Kit Oxygen / Nasal Prongs Intravenous Access Plus ETCO2 sensor Reversal Agents Suction Optimal Patient Positioning Bag Valve Mask (BVM) Airway Adjuncts

What Do We Need? Monitoring Clinical & Objective End Tidal CO2 (ETCO2) monitoring Better predictor of respiratory depression than SpO2 Pulse Oximetry ECG monitoring Blood Pressure monitoring Consider Sp02 monitoring on RA or ETCO2 on 15LFiO2. Raised CO2 – acidosis – bradyarrythmias…..

What Do We Need? Documentation Names of medical staff and their allocated roles Pre-sedation Assessment Drugs used, doses and times administered Document vitals pre / mid / post sedation Used for audit of practice in the ED very helpful if patient reattends

What Do We Need? Supervised Recovery Phase Duration determined by practitioner responsible for procedural sedation If discharged home then provide post sedation advice Patient should be back to baseline level of consciousness Patient should have normal vital signs Pain and discomfort issues must be addressed

What Next? Ketamine + Profopol = ‘Ketofol’ Deep Sedation with Propofol Amnesia, Decrease BP, Decrease HR Analgesia with Ketamine Pain Control, Increase BP, Increase HR Mix 100mg Propofol with 100mg Ketamine and dose as per Propofol (0.5mg/kg). Not the holy grail it was promised to be – some issues of onset vs offset – pharmacologically the good idea may just suffer a couple of hicups

Summary Procedural Sedation has an important role in expediting and preventing suffering during painful but necessary procedures Assess the suitability of each patient and work within your level of experience Use drugs which are familiar to you but tailored to the needs of the patient Always aim to have separate clinicians performing sedation and intervention Check your drugs and be patient!

Levels of Procedural Sedation ANXIOLYSIS MODERATE SEDATION DEEP SEDATION GENERAL ANAESTHESIA Responsiveness NORMAL Purposeful to Light Stimulation Purposeful to Repeated Stimulation NO Response to Painful Stimulation Airway PATENT +/- Intervention Needs Intervention Ventilation Adequate +/- Assistance Needs Assistance CVS Function Usually Adequate Impairment Risk

Discussion of local experience Would you ever use procedural sedation? Why if not… Would you consider the same principle to prepare the resuscitation of agitated patients… Ketamine assisted or Delayed sequence induction? What are the cases you have struggled with?

Any Questions about Procedural Sedation in the ED? No cats were harmed in the making of this presentation.