Procedural Sedation in the ER LMH Er Rounds Prepared by Shane Barclay

Procedural Sedation The biggest obstacles for emergency physicians to effectively and safely treat patients with analgesia and sedation are: Hospital Bureaucracy and Anesthesiologists

Procedural Sedation ACEP October 2013 – “Procedural Sedation and Analgesia in the Emergency Department” Does preprocedural fasting reduce risk of emesis or aspiration? NO – preprocedural fasting has not shown to reduce the risk of emesis or aspiration. (level B) 2. Does capnography reduce the incidence of adverse respiratory events? - capnography may detect hypoventilation and apnea earlier than oximetry and/or clinical assessment. (level B)

Procedural Sedation ACEP October 2013 – “Procedural Sedation and Analgesia in the Emergency Department” 3. What is the minimum number of personnel necessary to manage sedation complications? Besides the attending physician, one other nurse or qualified individual should be present for sedation. (level C) 4. Can Propofol and Ketamine be safely administered in the ER for sedation? Ketamine can be safely administered to children. Propofol can safely be administered to children and adults. (level A)

Procedural Sedation Pre-oxygenate with non re-breather for 5 minutes. Will delay/blunt the O2 saturation measurements. Use EtCO2 – more sensitive for apnea/hypoxia

Procedural Sedation First – consider the degree of sedation you want and the implications. Can be from simple IM/PO analgesia, which is sedating, to full general anesthesia.

Procedural Sedation Minimal sedation Analgesia Moderate sedation   Minimal sedation Analgesia Moderate sedation “conscious sedation” Deep sedation General Anesthesia Responsiveness Airway Spontaneous ventilation

Procedural Sedation Moderate sedation “conscious sedation”   Moderate sedation “conscious sedation” Deep sedation Responsiveness Purposeful response to verbal or tactile stimulation Purposeful response following repeated or painful stimuli Airway No intervention required Intervention may be required Spontaneous ventilation Adequate May be inadequate

Procedural Sedation In recent years, the most common PSA medications have been Midazolam and Fentanyl. These were used for ‘deep sedation’ procedures ie fracture reduction etc. However, as per the previous slide, responsiveness is often only to painful or repeated stimuli. Once the procedure is complete, you can still have 30 +/- minutes of deep sedation on board. This is traditionally when interventions for airway and ventilation could/did occur.

b1 b1 b1 Drug a1 Inotr Chron Dromo b2 V/C V/D Ketamine   _ +   + Fentanyl Morphine ++ Propofol Midazolam

Midazolam and Fentanyl ER literature is suggesting using this combination in lower doses for ‘moderate sedation’ that traditionally only local anesthesia or nothing was given. i.e. I&D of abscess, LP, complex lacerations, road rash debridement, burn dressings …

Propofol Dr. James Miner Chief of Emergency Medicine Hennepin County Medical Center, Hennepin, Minnesota.

Dr. James Miner Miner, James R, Mark Danahy, Abby Moch, and Michelle Biros. 2006. Randomized clinical trial of etomidate versus propofol for procedural sedation in the emergency department. Annals of emergency medicine, no. 1 (September 25). http://www.ncbi.nlm.nih.gov/pubmed/16997421. Miner, James R, Richard O Gray, Jennifer Bahr, Roma Patel, and John W McGill. 2010. Randomized clinical trial of propofol versus ketamine for procedural sedation in the emergency department. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, no. 6. doi:10.1111/j.1553-2712.2010.00776.x. http://www.ncbi.nlm.nih.gov/pubmed/20624140. Miner, James R, Richard O Gray, Dana Stephens, and Michelle H Biros. 2009. Randomized clinical trial of propofol with and without alfentanil for deep procedural sedation in the emergency department. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, no. 9. doi:10.1111/j.1553-2712.2009.00487.x. http://www.ncbi.nlm.nih.gov/pubmed/19845550. Miner, James R, Marc L Martel, Madeline Meyer, Robert Reardon, and Michelle H Biros. 2005. Procedural sedation of critically ill patients in the emergency department. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, no. 2. http://www.ncbi.nlm.nih.gov/pubmed/15692132. Miner, James R, Johanna C Moore, Erin J Austad, David Plummer, Laura Hubbard, and Richard O Gray. 2014. Randomized, double-blinded, clinical trial of propofol, 1:1 propofol/ketamine, and 4:1 propofol/ketamine for deep procedural sedation in the emergency department. Annals of emergency medicine, no. 5 (October 16). doi:10.1016/j.annemergmed.2014.08.046. http://www.ncbi.nlm.nih.gov/pubmed/25441247. Miner, James R, Johanna C Moore, David Plummer, Richard O Gray, Sagar Patel, and Jeffrey D Ho. 2013. Randomized clinical trial of the effect of supplemental opioids in procedural sedation with propofol on serum catecholamines. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine, no. 4. doi:10.1111/acem.12110. http://www.ncbi.nlm.nih.gov/pubmed/23701339.

Propofol – key points Propofol for short procedures (2-3 minutes) in a stable patient is safer than any other sedation medication. 2. Use Pre- procedural analgesia rather than peri-procedural. 3. Use 1 – 2 mg/kg Propofol. 4. Use less in the elderly, especially if they have opioids on board. 5. Use more in thin and obese patients. 6. Use less in volume depleted patients. 7. Need to wait 60 seconds (by the clock!) before giving a second dose

Propofol 8. Patient will have 30 – 60 seconds retrograde amnesia. 9. Amnesia is while Propofol is starting to work, NOT when it is wearing off. 10. After the first dose of 1.5 mg/kg the patient may still be talking etc, but as long you have the given the patient adequate pre-analgesia, they will have amnesia for the event.

Ketamine Can be used to start and maintaining anesthesia, sedation, analgesia, amnesia and treatment of bronchospasm. Acts on many receptors, one of which are the opioid receptors. Can be used is sub dissociative doses for pain. Downside is the psychological reactions as it wears off – agitation, confusion, psychosis. ‘Recovery agitation’ is associated with dosage, younger age and co-morbid conditions, thus ranging from 15-35%.

Ketamine Historically recommended for intubation of asthmatics and head injury patients as it causes bronchodilation and does not increase ICP. Now is recommended for procedural sedation in children and adults. Can be used for the above as well as RSI in hypotensive trauma patients. In combination?

“Ketofol” This is a ketamine/propofol combination that has been advocated for use in both pediatric and adult sedation. Mixing instructions: take a 20 cc syringe and draw up 10 cc of Propofol 10 mg/ml. Then draw up 2 ml of Ketamine 50mg/ml. Then draw up 8 cc of normal saline. You know have 20 ml of “ketofol” mixture of 10 mg/ml concentration.

“Ketofol” Dosage: 0.5 mg/kg Wait 30-45 seconds, if not sedated give a second dose 0.5 mg/kg. May continue boluses of 0.25 - 0.5 mg/kg q 1 -1.5 minute intervals.

A Procedural Sedation Protocol? Have a PSA check list Pre-oxygenate with non rebreather for 5 minutes Use SpO2 and EtCO2 monitor Have at least one other person – nurse Plan your procedure before you give the drugs Use pre- procedure analgesia – fentanyl, morphine, hydromorph … Bolus Propofol 1 -1.5 mg/kg. Do the procedure

One example in your handouts. PSA Checklist One example in your handouts.

Questions ?