Procedural Sedation
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This document discusses procedural sedation in the emergency department. It covers the concept of procedural sedation, focusing on safety and ensuring adequate monitoring and management of risks. Key aspects that are outlined include determining the appropriate level of sedation needed, assessing patient risk, having adequately trained staff and necessary equipment, selecting appropriate sedative medications and doses, monitoring the patient during and after the procedure, and properly documenting the process. Procedural sedation can be performed safely in the emergency department if patients are well assessed, the team is prepared to manage complications, appropriate drugs and doses are selected, and situational awareness is maintained throughout.
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Procedural Sedation
- 2. Procedural Sedation • What we’ll focus on – Concept – Safety – You • What we won’t – Drug specifics – Procedure itself
- 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. Aims of procedural sedation • Focus on patient – Comfort – Awareness – Ability to complete procedure • Focus on safety – Depth of sedation – Variability of effect – Risks
- 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. 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
- 10. 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
- 11. Quebec Criteria
- 12. Clinical governance for Procedural sedation in ED • Training – Procedures – Drugs – Equipment – Monitoring • Risk – Identification – Management • Audit – Safety – Future advancements
- 13. 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
- 14. 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
- 15. Risk Assessment • Airway • Cardiorespiratory • Sedation • Patient factors
- 16. Staff • Minimum staffing requirements • Adequate training
- 17. 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
- 18. 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
- 19. • Ketofol does not reduce adverse events • Propfol does not cause significant* hypotension • Ketofol recovery is longer • Patient satisfaction is no different
- 20. Drugs – what dose do I give? • Depends on many factors – Age – Clinical status – Comorbidities – Prior meds – Tolerance – Procedure
- 21. 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
- 22. Adequate sedation – how do you know when to start ?
- 23. Responsibility during procedure • Patient safety – sedationist • Procedure – proceduralist
- 24. 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
- 25. 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
- 26. Post procedure • Recovery • Documentation – SCGH ED procedural sedation checklist • Discharge advice
- 27. 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
- 28. 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
Editor's Notes
- A core skill in emergency medicine and something you will all be familiar with but it doesn't hurt to go over the topic and review why do things the way we do
- Specifics of doses and choice of drug not really going to go into – pros and cons of side effects There are reasons you may choose one drug over another and there are many factors you need to consider. As with anything you need to have a number of weapons in your arsenal and know when and how to modify things depending on the situation
- Recent definitions include 5 stages you can read them in the guidelines and policy documents
- Transition from one to another can be difficult to predict and can occur without giving further sedation and will be different for each individual patient. So be careful and use judicious doses
- This is the ideal picture of the level of sedation for a painful procedure – this is really what we are aiming for. Calm, relaxed, maintaining own airway, breathing spontaneously rousable to painful stimulus but nicely sedated with adequate pain relief anxiolysis and amnesia for the event
- This is an image of a patient in deep sedation or perhaps even general anaesthesia
- Perfect level of sedation something we often see after the administration of propofol for example – disinhibited, not responsive to verbal stimuli, even the doorbell probably wouldn't elicit a reponse.
- It is unanticipated risks that we need to prepare for most because they are unanticipated and occur without warning. Predictable risks may be life threatening but more manageable because they are predictable. Procedure risks are important sometimes like in a respiratory procedure
- Quebec criteria developed for use in kids and includes Respiratory CVS, vomiting, excitatory movements and behavioural disturbances – in an attempt to standardise terminology for adverse events for paeds undergoing sedation – it is transferrable to adult population
- Clinical governance is where the Managing bodies – clinical and administrative – oversee and implement a plan for the continuous improvement, risk minimisation, and fostering and environment of excellence in care for patients, carers DSI with NIV or proc sed with NIV safely in groups of people – great work ruben strayer
- Now patient/procedure selection AND consent Assessment ASA 1-3
- Anaesthetic assessment not the scope of this talk but….
- From ACEM policy regarding staffing and level of training required
- Emergency drugs and supplies should include at least the following: adrenaline atropine dextrose 50 per cent lignocaine naloxone flumazenil portable emergency O2supply
- Before 2 – what do you need to consider/know about all these drugs? I would encourage you to go away and read up about these drugs - but really you need to get experience with them by using them obviously in a supervised environment until you are happy and comfortable with the effect they have on patients
- It will be different for everybody and difficult to predict. Considerations – duration of procedure, painfulness of procedure, requirement for lack of movement,
- When is the patient ready for the procedure to commence? How do you know? What do you look for? Three different levels of sedation judging can be tricky.
- Where having the right staffing mix comes in. You need to really have both aspects covered.
- Jason Bourne – has it in spades Important in environments where there is a high turn over of information and poor decisions can lead to serious consequences. (think – military, aviation and critical care medicine) Lacking or inadequate situational awareness is a major contributor to human error Innate in some Can be learned/taught Emergency medicine/critical care probably not your field if this happens to you
- Interesting area - whole talk in itself Human factors engineering and ergonomics Much in medicine recently. Vortex airway approach heavily linked to limiting error via attention to human factors
- Recovery – depends on drug used and dose specifics may be different Documentation – procedural sedation record