procedural sedation - timelinecms-library.vpng.org.au · anzca procedural sedation • definition:...

Procedural Sedation

Procedural Sedation

Procedural Sedation

• Lecture content:– Review:

• Australian and New Zealand College of Anaesthetist (ANZCA) Guidelines on Sedation and/or Analgesia for Diagnostic and Interventional Medical, Dental or Surgical Procedures

– Review: • Emergency Department – Paediatric Procedural Sedation

Policy and Procedure

– Discuss: a practical approach to procedural sedation

– Discuss: case scenarios

ANZCA Procedural Sedation Guidelines

• Applied to diagnostic and interventional procedures

• Not relevant to situations where sedation is used for longer term management of patients such as intensive care units or for acute psychiatrically disturbed patients

ANZCA Procedural Sedation

• Definition: Procedural sedation implies the patient is in a state of drug-induced tolerance of painful diagnostic or interventional procedures

– Conscious sedation• Patient responds purposefully to verbal commands or light tactile stimulation.

Unconsciousness unlikely.

– Deeper sedation• Loss of consciousness with response to only painful stimuli. Similar risks to general

anaesthesia.

– Analgesia• Reduction of pain perception. Drugs may act locally or centrally (depression of pain in

central nervous system).

• (General anaesthesia)– Absence of purposeful response to any stimulus, loss of protective airways

reflexes, depression of respiration and disturbance of circulatory reflexes

ANZCA Procedural Sedation

• Aim– Enhance patient comfort whilst facilitating completion of the planned

procedure

• Risks– Transition from complete consciousness through the various depths of

sedation to general anaesthesia is a continuum– Margin for safety of the drugs used varies greatly between patients– Must be prepared to manage

• Loss of airway protective reflexes and patency• Respiratory depression• Cardiovascular depression• Drug reactions (including anaphylaxis)• Possibility that a deeper sedation or anaesthesia may be required to complete

the procedure

ANZCA Procedural Sedation

• Patient preparation– Consent (benefits and risks of the procedure and of the procedural sedation)

• Patient assessment– History

• Past history of General Anaesthesia (GA)• Family history of complications of GA• Teeth (loose teeth, caps, crowns, dentures)• Exercise tolerance• Fasting status

– Examination• Vital signs: blood pressure, pulse rate, oxygen saturation, respiratory rate• Airway (Mallampati score, mouth opening, thyromental distance, neck mobility)• Cardiorespiratory (breath sounds and heart sounds)

– Investigations• Dependent on the procedure and patient factors

ANZCA Procedural Sedation

• Staffing– Minimum 3 trained staff

– (except when conscious sedation with low dose oral sedation or inhaled sedation such as Nitrous Oxide or Methoxyflurane

• 1. Credentialed medical practitioner administering sedation• 2. The proceduralist• 3./4. Additional staff member to provide assistance to either

the practitioner administering the sedation and/or the proceduralist– To have 4 persons present for procedural sedation (that is, an

assistant to each medical practitioner) is recommended if assistance is likely to be required for the majority of the case (for example, an emergency case or a complex case)

– (More information about staffing is in the course booklet)

ANZCA Procedural Sedation

• Facilities and Equipment

– Adequate room to perform resuscitation– Adequate lighting– Suction– Oxygen– Self-inflating bag– Advanced airway equipment

• Guedel, laryngeal mask, laryngoscope, endotracheal tube

– Resuscitation drugs and fluids• Adrenaline, amioderone, normal saline, (atropine)

– Pulse oximetry– Blood pressure monitor– Defibrillator– Emergency call procedure– Capnography

ANZCA Procedural Sedation

• Technique and Monitoring

– Venous access• This may not be practical in some patients receiving non-

intravenous sedation (eg. children, intellectually disabled patients)

– Start low and go slow with drug dosing

– Continuous oximetry

– Regular blood pressure and pulse rate

– Consider need for capnography depending on the depth of sedation or patient factors

ANZCA Procedural Sedation

• Oxygenation

– Pre-oxygenate all patients where possible

– Continuous oxygen supply throughout the procedure

– If hypoxaemia is detected (patient appearance or pulse oximetry), staff should devote their whole attention to correcting the situation, which may include ceasing the procedure

ANZCA Procedural Sedation

• Medications– Routes of administration:

• Oral, intra-nasal, rectal, subcutaneous, intravenous or inhaled

– Common intravenous drugs• Benzodiazepines (amnesia)

– midazolam

• Opioids (analgesia)– Fentanyl

» Synergism between these drugs may result in loss of consciousness in some patient

• Anaesthetic agents– Propofol

» Higher risk of unintentional loss of consciousness

ANZCA Procedural Sedation

• Recovery

– Appropriately trained staff in an properly equipped area

– Ability to safely transfer a patient who has received procedural sedation to another area if recovery is not to take place in the area in which the procedure took place

– Discharge from recovery is reliant on an authorised practitioner

– Discharge to the care of an adult with clear post discharge advice (eg no driving for 24 hours, analgesia, legal implications etc)

ANZCA Procedural Sedation

• Other considerations

– Clear documentation

– Audit of outcomes

Paediatric Procedural Sedation in the Emergency Department

• Indications: relief of pain and suffering for procedures on the paediatric population who are deemed suitable to have sedation in the emergency department

– Examples• Suturing• Intravenous cannula insertion• Removal of foreign bodies• Minor fracture manipulation/moulding of plaster• Burns dressing• Wound debridement• Other painful procedures

Paediatric Procedural Sedation in the Emergency Department

• Drugs of choice– Nitrous Oxide or– Ketamine

This talk will focus on the use of ketamine

Ketamine primarily antagonises N-methyl-D-aspartate receptors resulting in:- dissociative trance-like cataleptic state- profound analgesia and amnesia- retain protective reflexes, spontaneous respiration and cardiopulmonary

stability

Paediatric Procedural Sedation in the Emergency Department

• Ketamine

– Side Effects• Increase pulse rate and blood pressure• Hyper salivation• Increased muscle tone• Emergence reactions (including hallucinations and vivid dreams)

– Contraindications:• Age < 1• Previous adverse reaction• Head injury in LOC, altered conscious state or vomiting• Active respiratory tract infection• Pyschosis, ADHD• Unstable epilepsy• Fasting < 4 hours solids, < 2 hours clear fluids• Systemic disease limiting daily activity

Paediatric Procedural Sedation in the Emergency Department

• Staffing

– As per ANZCA Procedural Sedation guidelines

• 3 personnel– The proceduralist

– The credentialed medical practitioner providing sedation

– The assistant (to both)

• Equipment

– As per ANZCA Procedural Sedation guidelines

– Have atropine available for hypersecretions

Paediatric Procedural Sedation in the Emergency Department

• Procedure– Ensure adequate facilities and equipment

– Parental informed consent

– Assess fasting status

– Continuous oximetry and ECG

– Pre-oxygenate

– Drug dosing

– Recovery

– Discharge: Parental Information Sheet

Paediatric Procedural Sedation in the Emergency Department

• Ketamine Dose

– IV injection

• 1mg/kg initially – effect in 30 seconds, lasting 5-10 minutes

• 0.5mg/kg subsequent dose if required at 10 minutes

– IM injection

• 4mg/kg – effect in 3-4 min, lasting 12-25 min

Practical Approach to Procedural Sedation

Key questions:

• What is the patient fasting status?

• Is the procedure time critical?

Practical Approach to Procedural Sedation

• Is the case elective or an emergency?– If the case is elective, the risk of aspiration is low if

the patient is fasted. If the patient is not fasted, delay the procedure until the patient satisfies fasting guidelines.

– If the case is an emergency, balance the risk of aspiration vs the timing of the procedure• Don’t forget the options of regional anaesthesia, nerve

blocks or local anaesthetic infiltration!

Practical Approach to Procedural Sedation

• Emergency Procedures

– If the patient is fasted…• Consider proceeding after history, examination and review of

investigations

– If the patient is not fasted…• Is there a threat to life or limb if the procedure is delayed?

– If yes, you need to balance the risk of the sedation vs the risk aspiration» Consider rapid sequence induction and endotracheal tube

placement to protect airway from aspiration– If no, you can consider delaying the procedure until adequately fasted

» Consider delayed gastric emptying secondary to pain or medication (analgesia)

Procedural Sedation - Cases

• Case Scenarios

– 1. The adult female presenting for elective gastroscopy to assess for chronic epigastric pain

– 2. The adult male presenting after dislocation of his shoulder while wrestling

– 3. The distressed and crying child who has broken their arm and requires a plaster

Procedural Sedation – Case 1

• Gastroscopy

Procedural Sedation – Case 1

• The adult female presenting for elective gastroscopy to assess for chronic epigastric pain

- Minimally invasive procedure appropriately done under sedation

- Must be fasted

- History, Examination, Investigations

- Considerations:- Awake with local anaesthetic mouth spray

- Conscious sedation with opioids and midazolam

- Deeper sedation with the use of propofol

Procedural Sedation – Case 2

Shoulder dislocation (Australian Rules Football)

Procedural Sedation – Case 2

• The adult male presenting after dislocation of his shoulder while playing a contact sport

• Reduction of a dislocated shoulder can appropriately be trialled under sedation

• Emergency case – assess threat to neurovascular supply of the arm– assess risk of delay of reduction (the longer it is dislocated the harder it can be to reduce)– assess fasting status

• History, examination, investigations (consider X-ray to assess for fracture)

• Considerations:– Reduce without sedation early (soon after dislocation)– Conscious sedation– Deeper sedation with propofol if patient adequately fasted

» Jaw thrust to prevent upper airway obstruction– Consider rapid sequence induction with endotracheal intubation if risk of aspiration is too

great and delay in procedure not preferable– Delay procedure until patient adequately fasted, then trial deeper sedation with propofol

Procedural Sedation – Case 3

• Paediatric plaster application

Procedural Sedation – Case 3

• The distressed and crying 5yo child who has broken their arm and requires a plaster• Plastering a fracture is generally well tolerated, but a distressed child may

require sedation to facilitate a good plaster without distressing a child

• Emergency case– Assess fasting status– Assess neurovascular compromise– History, examination, investigations

• Considerations:– Ketamine if adequately fasted (assess for contraindications)– If no intravenous access, consider intramuscular injection and obtain intravenous

access when child is sedated and before the procedure takes place– If intravenous access, consider intravenous ketamine– (Angel cream or EMLA cream is a topical preparation that numbs the skin and can

relieve distress when gaining intravenous access – it takes 45 minutes to work)

Procedural Sedation

• Suggested medications and doses….

– Paediatric sedation• Refer to Ketamine Policy and Procedure

– Remember:

» If concerns about fasting – consider definitive airway management with an endotracheal tube

• Many cases that could be undertaken in the adult population under procedural sedation may require general anaesthesia in paediatric population

• If the child < 4yo and if the case doesn’t present a threat to life or limb, consider referral to an anaesthetist, or credentialed medical practitioner with specialist skills in managing paediatric patients

Procedural Sedation

• Suggested medications and doses….

– Adult sedation• Conscious sedation

– Midazolam 2mg (1mg in older patients or sick patients)

– Fentanyl 100mcg (25-50mcg in older patients or sick patients)

(both drugs can be used in combination)

• Deeper sedation– Propofol 1mg/kg (0.5mg/kg in older patients or sick patients)

» Titrate with boluses of 30-50mg (10-20mg in older or sick patients)

» Can be used in combination with midazolam and fentanyl

Procedural Sedation

• Further Questions?

Procedural Sedation

• Summary

– Guidelines are available for procedural sedation

– When delivering procedural sedation, we need to consider:

• Equipment and Facility

• Practitioner credentialing

• Patient factors

• Procedural (surgical) factors

• Drug pharmacology