Procedural Sedation M Anto ED prov fellow Mona Vale Hospital 29 Sep 2016

What is proc sed ACEP: Technique of administering sedatives or dissociative agents With or without analgesics Induce a state that allows the patient to tolerate unpleasant procedures while maintaining cardiorespiratory function Procedural sedation and analgesia is intended to result in a depressed level of consciousness that allows the patient to maintain oxygenation and airway control independently ANZCA/ACEM: State of drug induced tolerance of uncomfortable/painful medical/dental/surgical procedure

Indications Reduction of dislocation or fracture Laceration repair DCCV Abcess incision and drainage LP

Benefits Provides analgesia Avoid OT Cost Reduces LOS Safe in ED

Alternative treatments LA – topical, local infiltrate Nerve blocks Biers block GA (in OT) Nothing

Definitions Minimal sedation: Moderate sedation: Normal response to verbal stimuli Cognition + coordination may be affected CVS/resp normal Moderate sedation: Depression of consciousness Response to verbal stimuli Airway patent, resp good, CVS usually normal

Definitions Deep sedation: Depression of consciousness Not easily aroused May have impaired ventilatory function May need assistance to maintain patent airway CVS usually maintained GA: Loss of consciousness Ventilatory function requires assistance Assistance for patent airway CVS may be affected

Preprocedure evaluation History Examination Investigations

Preprocedure eval: hx Details of the current problem Co-existing and past medical and surgical history History of previous sedation and anaesthesia Current medications (including non-prescribed medications) Allergies Fasting status Dentition - false, damaged or loose teeth Other evidence of potential airway problems Patient’s exercise tolerance or functional status

Preprocedure eval: exam Airway Respiratory CVS Other systems as indicated by the history, including that relevant to the current problem

Preprocedure eval: Ix ?Baseline ECG BSL

High risk patients All children less than 2 years of age Elderly Pregnancy Severe comorbidities CVS, CNS, resp, liver, renal disease Morbid obesity Severe OSA Acute gastrointestinal bleeding +/- shock Severe anaemia Potential for aspiration of stomach contents (which may necessitate endotracheal intubation) Patients in ASA Grades P4-5 Previous adverse events due to sedation, analgesia or anaesthesia Known or suspected difficult ETT

Patient counselling Informed consent Indications Complications Alternative treatments Discharge advice

Preprocedure fasting Regurgitation, aspiration syndrome – 0.5% all PSA ANZCA: Prolonged fasting from fluids for more than 6 hours fails to achieve an optimally empty stomach Clear fluids up to 2hrs Limited solid food 6hrs ACEP: Fasting not required – Level B ?Antacids

Personnel Single trained person to monitor patient during mod and deep sedation ED consultant or most senior doctor needs to be aware of the patient receiving sedation – does not necessarily need to be in room Proceduralist (1-2) Nursing staff to document and assist

Training Supervised training CRM BSL/ALS CPD Audit

Preparation Room/location Lighting OT table/trolley/chair preferred Suction O2 Emergency equipment Monitoring Meds Equipment for procedure Means of summoning assistance Clinical response plan

Monitoring The following data should be recorded at appropriate intervals before, during, and after the procedure, with alarms set: Pulse oximetry Response to verbal commands (when practical) Pulmonary ventilation (observation, auscultation) EtCO2 BP/HR q5min ECG for patients with significant cardiovascular disease

Emergency equipment Airway trolley (+ difficult airway trolley) BVM Defib ECG IV trolley

Supplemental O2 Considered and available for all patients for as much of the procedure as possible Prior to sedation may not benefit all patients, and may not need be practical e.g. small children, IH Pulse oximetry

IV access Required in most cases for medication and analgesia Not requiring with low doses inhaled/oral meds

Medications Sedation Analgesia Propofol Ketamine Midazolam NO2 Fentanyl Morphine Ketamine

Propofol Onset 30sec, peak 120sec, duration 3-10min CI: allergy to egg, soy SE: hypotension, bradycardia, resp depression, pain on infusion No analgesia Dose: 0.5-2mg/kg

Ketamine Disassociative Onset 2min, peak 3min, duration 15min IV or 30min IM Benefits: maintains airway reflexes + spont resp, CVS stable, bronchodilator SE: laryngospasm, emergence, secretions, reduces seizure threshhold, vomiting Technique Dose: IV 0.5-2mg/kg, IM 2-4mg/kg

Midazolam Anxiolysis, sedation, amnesia, no analgesia Onset 1-5min, peak 10-15min, duration 60min SE: hypotension, resp depression, paraxodical rxn Dose: 0.025-0.05mg/kg max 0.4mg/kg Avoid EtOH

NO2 Inhalation, sedative, amnesiac, analgesia Fast induction Requires scavenging system CI: bowel obstruction, Ptx Monitor for diffusion hypoxia – O2 post procedure SE: vomiting Dose: 30-70%

Opiates Morphine Fentanyl

Reversal agents Naloxone Flumazenil

Recovery Sedation Dr present until: Monitor in ED until: Spont resps Obs stable Protecting airway Monitor in ED until: Fully awake Tolerating oral intake Analgesia adequate Mobilising

Documentation Name of staff involved Hx, exam, Ix Doses/time of meds Monitor readings inc during recovery

Discharge advice Written instructions Supervision at home E+D Analgesia Resumption of normal activities Legally binding decisions EtOH Driving Heavy machinery

Take home message Assess the patient adequately Prepare Understand your meds Situational awareness

References ANZCA Guidelines on Sedation and/or Analgesia for Diagnostic and Interventional Medical, Dental or Surgical Procedures Emcrit HETI clinical update 349 (27/2/04) Medscape Uptodate PEMSoft LITFL SCGH ED CME