Procedural SedationKate Donaghy

26th March 2015

-American College of Emergency Physicians

“Procedural sedation and analgesia refers to the

technique of administering sedatives or dissociative

agents with or without analgesics to induce an

altered state of consciousness that allows the

patient to tolerate painful or unpleasant procedures

while preserving cardiorespiratory function.”

When Use it?

Fracture reduction

Joint Relocation

Wound management

Abscess I+D

DC cardioversion

Why Use it?

Avoid theatre

Cost saving: £614 (

$1164) for P.S. vs OT

Pain saving, anxiety-

relieving

Alternatives

Local anaesthetic direct

infiltration

Nerve blocks

Bier’s Block

GA

Text

PolicyGuidelines from collaboration of Australian and New Zealand

College of Anaesthetists (ANZCA), ACEM, etc

Levels of Sedation (ASA)

Minimal Sedation

Moderate Sedation (‘Conscious sedation’)

Deep Sedation

General Anaesthesia

Dissociative Sedation

The Ideal agent

Predictable induction and maintenance of sedation

prompt recovery

minimal recall

no complications

Often an opioid analgesic with a sedative and

amnesic agent

Options

Nitrous Oxide

Propofol

Ketamine

Midazolam

Etomidate

Opioids in combination

Combination eg Ketamine-

Propofol

Propofol

Benefits: rapid onset and recovery

Onset: 30-60sec; Peak 60-120sec, Duration 3-10min

Contraindication: allergy to egg and soy

Caution:haemodynamically unstable, elderly

SEs: hypotension, bradycardia, resp depression, pain on

infusion

No analgesic properties: give with an opioid

Dose: 0.5-2mg/kg

Midazolam

Anxiolytic, sedative, amnesic. No analgesia

Reversible

onset 1-5min, peak 10-15min, duration 1-2.5hrs

SEs: hypotension, resp depression, paradoxical reaction

Dose: 0.025-0.05mg/kg titrated to 0.4mg/kg max

caution: avoid alcohol and mental-alert activities for

24hrs

Nitrous Oxide

Inhalational: amnesia, sedation, analgesia

Fast induction

Contraindication: pneumothorax, bowel obstruction

Caution: diffusion hypoxia: O2 for 20min after

SEs: vomiting

Dose: mask inhalation: 30-70%, safety valve, if pt overly

sedated, mouth piece falls

Ketamine

Dissociative Anaesthetic

IV: Onset 1-2min, peak 2-3min, duration 5-15min

Benefits: Increase HR and BP, maintain airway reflexes, bronchodilator

SEs: laryngospasm, emergence reactions, oral secretions, reduce seizure

threshold, vomiting, resp depression, ???raised ICP

Good for children more than adults

Contraindications: schizophrenia, raised IOP, (URTIs)

Warn parents re stare; pleasant dreams!, room quiet

Dose: 0.5-1.5mg/kg IV, 2-4mg/kg IM

Etomidate

Acts on GABA receptor

onset 20-60sec, peak 1min, duration 3-8min

limited effects on cardiovascular function

good for altered myocardial contractility and raised ICP

SEs: n+v, pain at injection site, myoclonus, adrenocortical

suppression?

Dose: 0.1-0.15mg/kg

Opioids

Morphine 0.05-0.1mg/kg every 5-15min

onset 1-2.5min, peak 10-20min, duration 1-4hrs

SEs: n+v, dizziness, injection site pain, agitation, flushing,

paraesthesia

Fentanyl 1-2mcg/kg

onset immediate, peak 1-3min, duration 30-60min

SEs: resp depression, rigidity (rapid IV), brady and

hypotension, dizzy, n+v, diaphoresis

Ketofol

Ketamine - emergence reactions in adults, emesis

Propofol - hypotension and respiratory depression

combination to give sedation that is closer to ideal,

avoid opioid use with propofol

RCTs suggest ketofol no better than propofol

Australia

EMA - Procedural Sedation Practices - 2011

Propofol used in 2/3 cases (adults 94%)

65% ketamine use was in children

Half of pts did not have pre-procedural analgesia:

oligoanalgesia is an issue

Morphine:Fentanyl 4:1

Methods

Assessment

Preparation

Procedure

Aftercare

Assessment

Patient: HPC, PMHx, DHx, Allergies, prev anaesthetics, loose teeth,

exercise tolerance, LMP

Fasting status

Airway grade: Mallampati score

CVS/Resp exam

Review results

Department Status

Consent

Cautions

elderly, children <2yr

heart, lung, Cerebrovascular, renal, liver disease

morbid obesity, OSA, difficult AW

cardiovascular compromise, severe anaemia

potential for aspiration e.g. Pregnant

anaesthetic adverse events previously

ASA grades P4-5

Preparation

At least 3 appropriately trained staff (1 for drugs and AW, 1 proceduralist,

assistant) (AW, ALS competent)

Procedure Room appropriate, lighting

oxygen (FM, NC)

BMV apparatus, airways, intubation equip, suction

crash cart, defibrillator

medications, emergency drugs

monitoring (cardiac, pulse oximeter, capnography, BP)

Emergency Plan

Procedure

IVC, positioning

Pre-oxygenation

Baseline observations

Medications

Monitoring, depth of

sedation

Aftercare

Documentation: drugs, IVF, monitoring, rescue

interventions, complications

Recovery: Doc present until spont respiration, stable vitals,

protective reflexes, sedation level 2

Further recovery: fully awake, obs, pain, dressing,

mobilising, E+D, voided

discharge to responsible adult

advice: E+D, analgesia, driving/machinery/decisions

Complications

Sedation related events common: 1 in 5

Vomiting, aspiration, hypo/hypertension,

brady/tachycardia, hypoventilation, desaturation,

obstructed airway

Adverse outcomes rare

Higher risk (resp): age, level of sedation, premed,

sedation drug (person in charge)

Managing Complications

Resp Depression: stimulation, airway manoeuvres, BMV, Airways

Hypotension: IVF, elevate legs, metaraminol

Laryngospasm: 100% O2 with mask, tight seal, closed expiratory valve ->

positive pressure

manually ventilate

Break laryngospasm - Larson’s point

Deepening sedation - propofol

suxamethonium IV or IM

Intubate

Controversies

Fasting status? 2+6 or no evidence of decreased aspiration?

Capnography? prevent hypoxia but no difference in outcome

How many doctors? 1 or 2?

Supplemental Opioids? Respiratory depression vs catecholamine

surge

Nasal NIV?? - AJEM 2015

Conclusion

Essential skill for ED

trainees

Know of policies and

departmental

credentialing

Choose your patient

Anticipate complications

ReferencesAustralian and New Zealand College of Anaesthetists (ANZCA) (2014) Guidelines on Sedation and/or Analgesia for Diagnostic and

Interventional Medical, Dental or Surgical Procedures. [Online]. Available at: http://www.anzca.edu.au/resources/professional-

documents/pdfs/ps09-2014-guidelines-on-sedation-and-or-analgesia-for-diagnostic-and-interventional-medical-dental-or-surgical-

procedures.pdf (Accessed: 24/3/15).

Bell A, Taylor DM et al. (2011) 'Procedural sedation practices in Australian Emergency Departments', Emergency Medicine

Australasia, 23, pp. 458-465.

Godwin SA, Burton JH et al. (2014) 'Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department', Annals of

Emergency Medicine, 63, pp. 247-258.

Boyle A, Dixon V et al. (2010) 'Sedation of children in the emergency department for short painful procedures compared with

theatre, how much does it save? Economic evaluation', Emergency Medicine Journal, 28, pp. 383-386.

Andolfatto G, Abu-Laban RB et al (2012) 'Ketamine-Propofol Combination (Ketofol) Versus Propofol Alone for Emergency

Department Procedural Sedation and Analgesia: A Randomized Double-Blind Trial', Annals of Emergency Medicine, 59(6), pp. 504-

512.

Miner JR, Moore JC et al (2013) 'Randomized Clinical Trial of the Effect of Supplemental Opioids in Procedural Sedation with

Propofol on Serum Catecholamines', Academic Emergency Medicine, 20(4), pp. 330-337.

Strayer RJ, Caputo ND (2015) 'Noninvasive ventilation during procedural sedation in the ED: a case series', American Journal of

Emergency Medicine, 33, pp. 116-120.

Taylor DM, Bell A et al. (2011) 'Risk factors for sedation-related events during procedural sedation in the emergency department',

Emergency Medicine Australasia , 23(), pp. 466-473.