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Procedural Sedation

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Procedural Sedation

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Procedural Sedation

  1. 1. Procedural Sedation James Winton Feb 2018
  2. 2. Procedural Sedation • What we’ll focus on – Concept – Safety – You • What we won’t – Drug specifics – Procedure itself
  3. 3. What is procedural sedation? “The patient is in a state of drug induced tolerance of uncomfortable or painful diagnostic or interventional medical, dental or surgical procedures” – ANZCA guideline endorsed by colleges including ACEM • American (ACEP) definition includes the idea that cardiorespiratory function is maintained • Australian (ANZCA) definition recognises the fact that although this is intended, there may be a degree of compromise that needs to be managed by someone trained in the skills to do so
  4. 4. Aims of procedural sedation • Focus on patient – Comfort – Awareness – Ability to complete procedure • Focus on safety – Depth of sedation – Variability of effect – Risks
  5. 5. Procedural sedation terminology • Conscious sedation 1985 – Describing lightly sedated dental patients – Used then in paediatric sedation guidelines • Deep sedation – Patients difficult to rouse • General anaesthesia – Unable to rouse patient – Needs an anaesthetist • Procedural sedation and analgesia (PSA) – Describes a continuum which also includes dissociative sedation
  6. 6. Sedation Continuum 6 Inadequate 5 Minimal 4 Moderate 3 Moderate/Deep 2 Deep 1 Deep 0 Anaesthesia Taken from Rosen’s emergency medicine Anxious, agitated or in pain Spontaneously awake without stimulus Drowsy, eyes open or closed, easily roused verbally Rouses with moderate tactile, loud verbal stimulus Rouses slowly to consciousness with painful stimulus Rouses, but not to consciousness with painful stimulus Unresponsive to painful stimulus
  7. 7. Risks of procedural sedation • Depression of protective airway reflexes • Loss of patency of airway • Depression of respiration • Depression of cardiovascular system • Neurological and behavioural events • Vomiting and aspiration • Individual variation in response • Possibility of deeper sedation being required • Drug interactions, anaphylaxis • Risk inherent in procedure
  8. 8. Quebec Criteria
  9. 9. Clinical governance for Procedural sedation in ED • Training – Procedures – Drugs – Equipment – Monitoring • Risk – Identification – Management • Audit – Safety – Future advancements
  10. 10. ANZCA Guidelines on Sedation and/or Analgesia for Diagnostic and Interventional Medical, Dental or Surgical Procedures • https://acem.org.au/getattachment/9ef3110d-9863-44e8-89e5-aaa894b18236/P09-Guidelines-on- Sedation-and-or-Analgesia-for-Di.aspx
  11. 11. Outline the steps in performing and episode of procedural sedation in the ED • Patient/Procedure selection • Consent • Assessment • Staff • Equipment/Monitoring • Drugs • Perform procedure • Documentation • Recovery and discharge
  12. 12. Risk Assessment • Airway • Cardiorespiratory • Sedation • Patient factors
  13. 13. Staff • Minimum staffing requirements • Adequate training
  14. 14. Equipment/Monitoring What do you need? • Location • Lighting • Oxygen • Suction • Self inflating bag and mask • Airway trolley/advanced airway devices • IV access/iv fluid • Emergency drugs • Pulse oximeter • Blood pressure • CO2 monitoring • ECG monitoring • Defibrillator • Means of summoning assistance • Plan for clinical deterioration
  15. 15. Drugs – which should you choose? Sedation • Propofol • Ketamine • Benzodiazepines, e.g. midazolam • Barbituates e.g. thiopentone • Tranquilisers, e.g. haloperidol Considerations • Effect profile • Side effects • Duration of action • Contraindications Analgesia Anxiolysis • Fentanyl • Morphine • Nitrous Oxide • Ketamine Other drugs • Ketofol • Alpha 2 agonists, e.g. dexmedetomidine, clonidine
  16. 16. • Ketofol does not reduce adverse events • Propfol does not cause significant* hypotension • Ketofol recovery is longer • Patient satisfaction is no different
  17. 17. Drugs – what dose do I give? • Depends on many factors – Age – Clinical status – Comorbidities – Prior meds – Tolerance – Procedure
  18. 18. Evidence Based Practice – ACEP policy guideline • Literature concludes PSA is safe in ED • Propofol and ketamine most widely studied and safe – level A • Fasting not required – level B • Capnography should be used – level B • Minimum personnel – level C – At least 2 – continuous monitoring and ability to identify and manage complications
  19. 19. Adequate sedation – how do you know when to start ?
  20. 20. Responsibility during procedure • Patient safety – sedationist • Procedure – proceduralist
  21. 21. Situational Awareness • The skill of maintaining an overall view of the situation at hand, not becoming preoccupied with minor details missing the most critical aspect of the moment
  22. 22. Human Factors – sources of error • Lack of communication • Complacency • Lack of knowledge • Distraction • Lack of teamwork • Fatigue • Lack of resources • Pressure • Lack of assertiveness • Stress • Lack of awareness • Norms
  23. 23. Post procedure • Recovery • Documentation – SCGH ED procedural sedation checklist • Discharge advice
  24. 24. Procedural Sedation THM • It is performed safely in the ED if you – Assess the patient adequately – Prepare for worst case scenario – Know your poison – Develop skills in situational awareness
  25. 25. References • ANZCA guideline on sedation/analgesia – https://acem.org.au/getattachment/9ef3110d-9863-44e8-89e5-aaa894b18236/P09-Guidelines-on-Sedation-and-or-Analgesia- for-Di.aspx • Ketofol for procedural sedation revisited: pro and con. Ann Emerg Med. 2015 – Ann Emerg Med. 2015 May;65(5):489-91. doi: 10.1016/j.annemergmed.2014.12.002. Epub 2014 Dec 24. • ACEP Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department – Annals of Emergency Medicine Volume 63, Issue 2, February 2014 • https://lifeinthefastlane.com/procedural-sedation/ • Rosen’s Emergency Medicine 8th edition 2014 • @hughcards

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