procedural analgesia and sedation adverse event
DESCRIPTION
Procedual analgesia and sedation: complications and adverse eventsTRANSCRIPT
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PROCEDURAL ANALGESIAS AND SEDATION:
COMPLICATIONS AND ADVERSE EVENTS
Winchana Srivilaithon, MD.Emergency Physician
Thammasat University
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Procedural analgesia and sedation: complication and adverse event
• Overview of adverse events
• Factor predisposing to adverse event
• Evidences review of adverse events
• Adverse event terminology
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Overview of adverse event
• Procedural sedation and analgesia is: – The use of anxiolytic, sedative, analgesic, or
dissociative drugs to induce an alter state of consciousness–Help to facilitate the performance of a
necessary diagnostic or therapeutic procedure–Preserving cardio-respiratory function
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Overview of adverse event
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Overview of adverse event
• Pre-sedation phase: Anxiolytic or Analgesia
• Sedation phase: Sedative agents
• Mainly focus on Airway-Breathing-Circulation
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Factor predisposing to adverse event
• Patient clinical status
• Fasting time before procedure
• Depth of sedation
• Type and used of analgesic agents
• Type and used of sedative agents
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Potential adverse effects • Lack of adequate sedation• Oversedation• Hypoxemia• Respiratory depression• Airway obstruction• Pulmonary aspiration• Hemodynamic instability• Arrhythmia• Nausea, emesis• Pain with injection
• Myoclonus• Muscle rigidity• Seizure • Unplanned admission
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EVIDENCES REVIEW OF ADVERSE EVENTS
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Evidences review of adverse events
• How safe for Emergency medicine physicians to do PSA?
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• From 131,751 cases of pediatric sedation • Examine for major complications: aspiration,
death, cardiac arrest, unplanned hospital admission, level-of-care increase and emergency anesthesia consultation
• No difference among providers’ complication rate
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From 1,180 patients
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From 1,244 proceduresComplication rate = 17.8%No major complication observed
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• Compared patients at least 65 yr. with aged 18 to 49 and 50 to 64 yr.
• Number of patients in each group: 50, 665 and 149, respectively
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Propofol: potential adverse effects
• Respiratory depression
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Propofol: potential adverse effects
• Hypotension –Risk in hypovolemic patient–Only 3.5% of patients experienced BP
decreases of > 20% before procedure• Pain with injection –Uncommon–Reported 2-20%
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Ketamine: potential adverse effects
• Laryngospasm – Reported 0.3% – Risk factor: URI, active pulmonary disease, asthma
• Respiratory depression– Uncommon– Associated with rapid IV injection
• Emesis
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Ketamine: potential adverse effects
• Recovery reaction– Emergence reaction (0-30%)– Hallucination– Nightmare – Delirium– Physical combativeness
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Etomidate Versus Propofol
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ADVERSE EVENT TERMINOLOGY
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Adverse event terminology
• Airway–Partial upper airway obstruction–Complete upper airway obstruction– Laryngospasm
• Breathing –Oxygen desaturation–Central apnea–Clinical apparent pulmonary aspiration
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Adverse event terminology
• Circulation–Bradycardia– Tachycardia–Hemodynamic instability
• Excitatory movements–Myoclonus–Muscle rigidity–Generalized motor seizure
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Airway
• Partial upper airway obstruction– Incomplete obstruction to air exchange –Manifestation• Stridor• Snoring• Chest wall and suprasternal retraction (child)
–Rapid resolution by• Airway repositioning• Suctioning• Oral or nasal airway placement
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Airway
• Complete upper airway obstruction– Ventilatory effort with no air exchange – Require one or more following interventions• Airway repositioning• Suctioning• Oral or nasal airway placement• Positive pressure with bag mask +/- assisted
ventilation• Tracheal intubation• Administration of neuromuscular blockade agents
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Airway
• Laryngospasm–Partial or complete upper airway
obstruction with oxygen desaturation –Caused by involuntary and sustained
closure of vocal cord–Not relieved by routine airway repositioning
maneuvers, suctioning, or nasal or oral airway
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Airway
• Laryngospasm–Clinical diagnosis–Associated with common sedation drug– Interventions• BMV ventilation• Administration of neuromuscular blockade
agents
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Breathing• Oxygen desaturation– Combination of threshold and duration– Intervention to improve oxygen saturation• Vigorous tactile stimulation• Airway repositioning• Suctioning• Supplemental or increased oxygen delivery• Oral or nasal airway placement• Application of positive pressure or ventilation with
bag mask• Tracheal intubation
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Breathing
• Central apnea–Cessation or pause of ventilatory effort–One or more interventions are performed • Vigorous tactile stimulation• Application of bag mask with assisted ventilation• Tracheal intubation• Administration of reversal agents (opioid or
benzodiazepine antagonists)
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Breathing
• Clinical apparent pulmonary aspiration– Suspicion or confirmation† of oropharyngeal
or gastric contents in the trachea during the sedation
And – The appearance of respiratory signs and
symptoms that were not present before the sedation
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Breathing
• Clinical apparent pulmonary aspiration–Physical signs• Cough• Crackles/rales• Decreased breath sounds• Tachypnea• Wheeze or Rhonchi• Respiratory distress
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Breathing
• Clinical apparent pulmonary aspiration–Oxygen requirement: decrease in oxygen
saturation from baseline, requiring supplemental oxygen–Chest radiograph findings: focal infiltrate,
consolidation or atelectasis
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Circulation
• Arrhythmia–Bradycardia– Tachycardia
• Hemodynamic instability–Hypotension–Hypertension
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Agent BP Cardiac contractility
CBF ICP
Etomidate _ _
Propofol
Midazolam _ _
Ketamine
Fentanyle _ _
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Excitatory movements
• Myoclonus– Involuntary, brief contraction of some
muscle fibers, of a whole muscle, or of different muscles of one group– Interferes with the procedure, requiring an
intervention or administration of medications –Hiccupping is a form of myoclonus
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Excitatory movements
• Muscle rigidity– Involuntary muscle stiffening in extension
that can be associated with shaking – Interferes with the procedure–Requiring an intervention or administration
of medications
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Excitatory movements
• Generalized Motor Seizure–Contractions can be sustained (tonic) or
repeated (tonic-clonic)–Confirming a true seizure may require the
use of electroencephalography– Interrupt the procedure and require
additional medications
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References• Maala B, Robert M, Martin H, et al. Consensus-Based Recommendations for Standardizing
Terminology and Reporting Adverse Events for Emergency Department Procedural Sedation and Analgesia in Children. Ann Emerg Med. 2009;53:426-435.
• Robert E, Andrew S, John H, et al. Procedural Sedation and Analgesia in the Emergency Department: Recommendations for Physician Credentialing, Privileging, and Practice. Ann Emerg Med. 2011;58;365-370.
• Couloures KG, Beach M, Cravero JP, et al. Impact of provider specialty on pediatric procedural sedation complication rate. Pediatrics. 2011;127:e1154-e1160.
• Barbara M,Barucb K. Adverse Events of Procedural Sedation and Analgesia in a Pediatric Emergency Department. ANNALS OF EMERGENCY MEDICINE OCTOBER 1999, 34:4.
• Christopher S, Kevin M, Robert B, et al. ED procedural sedation of elderly patients: is it safe? American Journal of Emergency Medicine (2011) 29, 541–544.
• James R. Miner,John H. Burton. Clinical Practice Advisory: Emergency Department Procedural Sedation With Propofol. Annals of Emergency Medicine Volume August 2007.
• Steven M. Green, MD, Mark G. Roback, MD, Robert. Clinical Practice Guideline for Emergency Department Ketamine Dissociative Sedation: 2011 Update. Ann Emerg Med. 2011;57:449-461.
• James R. Miner, Mark Danahy, Abby Moch. Randomized Clinical Trial of Etomidate Versus Propofol for Procedural Sedation in the Emergency Department. Ann Emerg Med. 2007;49:15-22.
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