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Procedural sedation in the emergency department
 

Procedural sedation in the emergency department

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Presentation by Dr.Hussein Sabri at Emergency Medicine Update Course held at Cairo, Egypt.Emergency Medicine Update Course is the leading emergency medicine event in Egypt. www.emegypt.org

Presentation by Dr.Hussein Sabri at Emergency Medicine Update Course held at Cairo, Egypt.Emergency Medicine Update Course is the leading emergency medicine event in Egypt. www.emegypt.org

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    Procedural sedation in the emergency department Procedural sedation in the emergency department Presentation Transcript

    • Sedation & Analgesiain theEmergencyDepartment
    • Workshop : Objectives: Learn the levels of sedation Identify key features of each level Learn how to select the suitable level foryour patient / procedure
    • DefinitionSedation is produced bythe administration of pharmacologicagents, that result in a depressed levelof consciousness but - still allows thepatient to independently maintain apatent airway and respond appropriatelyto verbal commands or physical stimuli.
    • Levels of SedationMinimalSedation)Anxiolysis(ModerateSedation/Analgesia)Conscious Sedation(DeepSedation/AnalgesiaGeneralAnesthesiaResponsivness Normal toverbalPurposeful to verbal& tactile++Purposeful afterrepeated /painful++unarousableAirway unaffected NointerventionMay needinterventionNeedinterventionSpontaneousventilation/CardiovascularSystemUnaffectedAdequate/maintainedInadequate/maintainedInadequate/impaired
    • Goals: You should learn how to: Provide a safe analgesia - sedation, andamnesia during stressful procedures. Do adequate Monitoring & documentation . Minimize & treat the adverse effects Follow the discharge guidelines
    • Indications: To relieve apprehension. Mostly combined with analgesia Excellent combination with Regional Analgesia In non invasive procedures is quite safe
    • Sedation Scoring Systems( Modified Ramsy’s Score ) Sedation Score 1 = Anxious Sedation Score 2 = Awake , Tranquil Sedation Score 3 = Drowsy, responds easily toverbal commands. Sedation Score 4 = Asleep, Brisk response totactile or loud auditory + Sedation Score 5 = Asleep, Minimal response totactile or loud auditory + Sedation Score 6 = Asleep, No Response
    • Sedation Scoring Systems( Modified Ramsy’s Score ) For Moderate sedation: do not exceed level 4 For Deep sedation: reached at level 5
    • MCQ ?What is the best description of :“MODERATE SEDATION” ?a- A risk-free treatmentb- A point on the continuum of sedationc- A lesser form of sedation than “minimal sedation”d- A treatment entirely different from generalanesthesia.
    • Remember: Moderate sedation is a point on acontinuum. It falls between minimalsedation and deep sedation.------------------xxxxxxxx--------------Annn Because sedation is a continuum, theresponse of any patient is individual andvariable ( may be unpredictable ).
    • General Considerations :Key points age: very old / very young(children may fear never waking up) duration of ( procedure ) sedation Inter-individual variability of response to drugs potential for sedation failure alternatives to sedation potential for adverse events plan for monitoring by a nurse / assistantduring the procedure and recovery period
    • Patient Assessment Prior to Sedation Perform a History and physical exam Apply American Society of Anesthesiologist s(ASA) health class Sedation plan Informed consent
    • ASAASA 1ASA 2ASA 3ASA 4ASA 5No known systemic diseaseMild or well-controlled systemicdisease.Multiple or moderate controlledsystem disease.Poorly controlled systemicdiseaseMoribund patientMay have conscious sedationwithout other consultationSame as aboveConsider medical consultation.Mandatory involvement ofAnesthesiology DepartmentSame as above
    • ASA Patient Classification ASA 1 = Healthy patient ASA 2 = Patient smokes and has well-controlled hypertension. ASA 3 = Diabetes, stable angina, takesmedications. ASA 4 = Diabetes, angina, CHF, dyspnea,chest pain. ASA 5 = Patient is unstable, but notexpected to survive withoutprocedure.
    • Focused History and Exam History should focus on: patient age / allergies to sedatives/analgesics Medications & current illness DM / Hypertension / ……. Cardio-pulmonary problems Airway & Dental Assessment Ensure iv line
    • Focused History and Exam Cardiopulmonary disease may accentuatehemodynamic/respiratory depression caused by sedativesand analgesics. May require decreased drug dosages;ECG monitoring warranted. Hepatic or renal abnormalities may impair drugmetabolism, causing altered sensitivity and duration ofaction when sedatives/analgesics are administered. Medication interactions between a patient’s routinemedications & sedatives/analgesics may alter normal drugresponses.
    • Focused Airway Assessment Airway classification ( Malampati ) Mouth opening Thyromental distance (distance from chin to thyroid) Range of motion of the neck
    • Focused History and Exam Patient allergies must be known anddocumented. Alcohol / illicit substance abuse may increasetolerance to sedatives / analgesics while acute useprior to conscious sedation will be additive orsynergistic with medication effects. Tobacco use increases airway irritability and riskof bronchospasm during sedation. Prior adverse reaction to anesthesia/sedationmay increase risk during subsequent procedures.
    • Airway Assessment Procedures for SedationHistoryStridor, snoring, or sleep apneaAdvanced rheumatoid arthritisChromosomal abnormality (e.g., trisomy 21)Physical ExaminationSignificant obesity (especially involving the neck and facial structures)Head and NeckShort neck, limited neck extension, decreased hyoid–mentaldistance ( 3 cm in an adult), neck mass, cervical spine disease or trauma,tracheal deviation, dysmorphic facial features (e.g., Pierre-Robin syndrome)MouthSmall opening ( 3 cm in an adult); edentulous; protruding incisors; loose orcapped teeth; dental appliances; high, arched palate; macroglossia; tonsillarhypertrophy,Micrognathia, retrognathia, trismus, significant malocclusion
    • Focused Airway Assessment
    • Mallampati classification is used to predict the ease of Intubation
    • Mallampati classification Modified Mallampati Scoring is as follows:Class 1: Full visibility of tonsils, uvula and softpalateClass 2: Visibility of hard and soft palate, upperportion of tonsils and uvulaClass 3: Soft and hard palate and base of theuvula are visibleClass 4: Only Hard Palate visible
    • Focused Airway Assessment Mallampati class 1This individual should be easy to mask ventilate orto intubate with a laryngoscope andendotracheal tube.
    • Focused Airway Assessment Mallampati class 3None of the uvula or tonsillar pillars are seen.Difficult to mask ventilate or to intubate with alaryngoscope and endotracheal tube.
    • Thyro mental distance
    • Thyro mental distance extremely short thyromentaldistance, indicating tremendousdifficulty in tracheal intubation,and possible difficulty ofventilation
    • Pre-procedural Fasting Guidelines tominimize Aspiration RiskSubstance Ingested Minimal fasting periodClear Liquids 2Breast Milk 4Infant Formula 6Non-human Milk 6Light Meal 6
    • Informed Consent The provider should review the sedation plan with thepatient / guardian as early as possible ( Auditing ).Discussion and documentation should include: potential risks and benefits potential problems after the procedure potential for sedation failure consequences of not providing sedation/analgesia alternatives to receiving sedation/analgesia Post procedure instructions
    • Monitoring guidelinesBoth conscious and deep sedation, patients’ level of consciousness,ventilatory and oxygenation status, and hemodynamic variables should beassessed and recorded at a frequency that depends on the type andamount of medication administered, the length of the procedure, and thegeneral condition of the patient.At a minimum, this should be:(1) before the beginning of the procedure;(2) after administration of sedative–analgesic agents;(3) at regular intervals during the procedure,(4) during initial recovery;(5) Just before discharge.If recording is performed automatically, Device alarms should be set toalert the care team to critical changes in patient status.
    • Monitoring and Equipment Oxygen Suction Airway management facilities Monitoring Pulse Oximeter ECG Automated blood pressure device Resuscitation Equipments
    • Resuscitative equipments / medications Bag-valve-mask device ( Ambu bag ) Defibrillator with ECG recorder Emergency drugs ( Atropine, ephedrine, Adrenaline, ….. ) Anti dote for sedative ( if available ) Emergency drug card and ALS guidelines
    • Emergency Equipment for Sedation and AnalgesiaIntravenous equipmentGloves, Tourniquets, Alcohol wipesSterile gauze padsIntravenous catheters [24-22-gauge]Intravenous fluidAssorted needles for drug aspiration, IM injectionTapePharmacologic AntagonistsNaloxoneFlumazenilEmergency medicationsEpinephrine,Ephedrine,Vasopressin,AtropineNitroglycerin (tablets or spray)Amiodarone,LidocaineGlucose, 50% [10 or 25%]Hydrocortisone, methylprednisolone, ordexamethasoneBasic airway management equipmentSource of oxygen (tank with regulator or pipelinesupply with flowmeter)Source of suctionSuction cathetersFace masks [infant/child]Self-inflating breathing bag-valve set [pediatric]Oral and nasal airways [infant/child-sized]LubricantAdvanced airway management equipment(for practitioners with intubation skills)Laryngeal mask airways [pediatric]Laryngoscope handlesEndotracheal tubesStylet (appropriately sized for endotracheal tubes)
    • Seek help when : : : +/- 30 mmHg of BP from baseline. Tachycardia or Bradycardia Rise or fall in respiratory rate(RR) Oxygen saturation less than 90% or significantly belowpre-sedation level. Marked decrease in patient responsiveness to verbal orpainful stimulation Symptoms & signs of medication intolerance orallergies Patient does not meet discharge criteria.
    • Post-Sedation Assessment & DischargeAfter Moderate Sedation, patients must be: Assessed in the post-sedation recovery area Discharged by a qualified physician accordingto established criteria & guidelines Discharged home with a responsible adultNB: Meeting discharge criteria should bedocumented in the medical record.
    • Discharge Criteria Vital signs to pre-procedural baseline Gag reflex / able to swallow To pre-procedural level of awareness Modified Alderet Score
    • MODIFIED ALDRETE SCORE SCOREACTIVITY Moves all extremitiesMoves 2 extremitiesNo control210RESPIRATION Deep breath& coughDyspnea or splintingAbsent effort210CIRCULATION Bp +/- 20% of pre-anesth levelBp +/- 21%- 49% of pre-anesth levelBp +/- 50% of pre-anesth level210CONSCIOUSNESS AlertRespondsAbsent responses210COLOUR NormalAlterationcyanosis210O2 SAT Maintain o2 sat> 92% room airNeeds 02 to Maintain o2 sat> 92%o2 sat< 90 % with o2 supplement210TOTAL SCORE A score 10/12 points required before discharge 12
    • Discharge Instructions Instructions should cover: Home medications administration Dietary requirements Limitations on activity Post-procedural care Signs and symptoms of complications Emergency numbers / physician numbers Follow-up appointment
    • ReviewA provider qualified to give moderate sedationshould be trained in:a. How to evaluate patients before sedationb. How to rescue patients from deep sedationc. How to give drugs to achieve ModerateSedationd. How to monitor patients to keep themmoderately sedatede. All the above
    • SummaryR e m e m b e r: Patients must be assessed before moderate sedation.ASA class should be determined Sedation options and risks must be discussed with eachpatient. A sedation care plan must be developed for each patient. Moderate sedation must be given by a qualified provider. Patients must be monitored during sedation. Patients must be assessed after sedation. They may bedischarged from the post-sedation recovery area only by aqualified HCP according to established criteria.