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![Fasting
Fasting times : 2hrs (clear fluids),4hrs(breast milk,6hrs(solid foods incl. milk)
NICE guidelines [on sedation of children] recommends fasting before sedation
unless sedation is limited to:
Minimal sedation, Sedation with nitrous oxide (in oxygen)
Moderate sedation during which the child or young person will maintain
verbal contact
ED patients often require emergency procedures that’s often not possible to
delay the procedure.
Undertake a risk assessment for aspiration like alcohol ingestion, obsesity,
pregnancy, proposed sedation agent(ketamine/propofol)](https://image.slidesharecdn.com/proceduralsedation-230405201614-836f959b/85/procedural-sedation-pptx-12-320.jpg)
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Similar to procedural sedation .pptx
procedural sedation .pptx
- 1. Procedural sedation & Analgesia (PSA) DR.ARUNKUMAR A&EREGISTRAR FAIRFIELD GENERAL HOSPITAL CESR TRAINEE IN ANAESTHESIA
- 2. Purpose of mytalk …. Concept of Procedural sedation & analgesia(PSA) Sedation grading Clinical decision making & Procedural consent Pre-procedural assessment Preparation Considerations in Pregnant, Younger & elderly patients Choice of drugs for Procedural sedation Common complications Discharge criteria
- 3. Procedural sedation –what ? Administration of one or more pharmacological agents to facilitate a diagnostic or therapeutic procedure while targeting a state during which airway patency, spontaneous respiration, protective airway reflexes, and hemodynamic stability are preserved, while alleviating anxiety and pain’ Goals – patient comfort, safety, improve efficiency & adequate recovery Practise of procedural sedation differs from the practise of general anaesthesia Why do we use it – avoiding theatre, cutting costs, pain saving, anxiety- relieving.
- 4. Monitored anaesthesia careliability Oversedation leading to respiratory depression was an important mechanism of patient injuries during MAC. Appropriate use of monitoring, vigilance, and early resuscitation could have prevented many of these injuries.
- 5. Procedural sedation innon-theatre environments • Sedation frequently provided outside the theatre environment. • Mainly aimed for mild and moderate sedation. • Theatre standards of care must be provided for those receiving sedation.
- 6. Non theatre environmentsfor PSA Gastroenterological procedures – upper GI procedures Cardiology – cardioversion, trans-esophageal echo, angiography, pacemaker insertion Dental care – conscious sedation adjunct to local anaesthesia Radiological procedures – phobia for CT/MRI & Interventional radiological procedure Emergency room Pediatric sedation Respiratory procedures Maxillofacial surgery
- 7. Sedation scoring –ASA grading
- 8.
- 9. Clinical decision making Factorsinto consideration before decision making for PS 1. The urgency of the procedure 2. Availability of appropriately trained staff for the procedure 3. Availability of appropriate space and equipment 4. Patient Assessment - high risk factors 5. Patient consent Alternatives to PS should be considered eg:regional anaesthesia Multimodal strategies to be considered in regards to PS in children (distraction, topical analgesia, intranasal analgesia)
- 10. Procedural sedation consent Risksand benefits must be clearly explained If clinically appropriate, alternatives to sedation should be explained (typically general anaesthesia or local anaesthesia) Patient should be aware that they require a competent adult to escort them home after receiving sedation
- 11. Pre procedural assessment 1. Anyissues with previous sedation procedures/general anaesthesia 2. ASA classification – risk assessment tool 3. AMPLE assessment (Allergies,Medications,Past illness,Last meal,Events leading to it)
- 12. Fasting Fasting times: 2hrs (clear fluids),4hrs(breast milk,6hrs(solid foods incl. milk) NICE guidelines [on sedation of children] recommends fasting before sedation unless sedation is limited to: Minimal sedation, Sedation with nitrous oxide (in oxygen) Moderate sedation during which the child or young person will maintain verbal contact ED patients often require emergency procedures that’s often not possible to delay the procedure. Undertake a risk assessment for aspiration like alcohol ingestion, obsesity, pregnancy, proposed sedation agent(ketamine/propofol)
- 13. Fasting controversies Noclear evidence that non compliance with elective fasting increase aspiration risk or other adverse events during PS. Clinically significant aspiration during emerg. dept PSA appears to be rare. Aspiration can occur despite presence of endotracheal tube Airway manipulation involved in performing intubation appears to increase risk of aspiration.
- 14. Preparation Analgesia Anxiolysis Amnesia Preprocedure safety briefing (Nurse & clinician performing the procedure) Roles Intended plan, including intended depth and length of sedation as well as determining when the procedure can commence. Confirmation of correct side of patient (where applicable) Confirmation of equipment checks have taken place (eg. suction working) Confirmation of location of rescue devices and drugs - Anticipated problems
- 15. Staff preparation Workingin the relative isolation of non theatre or non hospital setting where skilled assistance of operating department practitioner & familiar equipment may be lacking . Dedicated trained anaesthetist in addition to ODP ED : ER nurse, emergency practitioner Endoscopy nurse More team members are required as complexity increases Medical staff for DC cardioversion ECT trained staff
- 16. Requirement for EDsedation (RCOA & RCEM College guidelines)
- 17. TRAINING REQUIREMENTS FORADULT PROCEDURAL SEDATION
- 18.
- 19. Considerations in Youngerpatients Children < 1yr are not normally sedated in the ED & Procedural sedation in 1-5yr age group in ED needs to involve senior clinical decision makers. Paediatric PS ↓ admission rates, ↓ length of hospital stay and avoid the need for procedures to be performed in theatre. Common indication of PS in children - suturing of lacerations, manipulation of dislocation and fractures, foreign body removal and imaging (CT) . For many paediatric procedures that require sedation involvement of partner specialities such as plastics, max fax, orthopaedics is warranted.
- 20. Considerations in Younger patients Age-appropriate distraction techniques is strongly recommended,. Parent & carers accompanying the child is strongly recommended, except where the parent is unable to provide calm support. Play specialists if available. Use of analgesia prior to and during the procedure should always be considered. Commonly used sedation agent in UK for paediatric patients is IV ketamine followed by variable concentration nitrous oxide. Sedation given should be the minimum necessary to facilitate the procedure.
- 21. Considerations in Pregnant Procedural sedation in pregnant patients especially in 2ND & 3RD trimester should be considered to be high risk & requires early involvement of a senior clinical decision maker. Considerations include positioning, oxygenation, foetal monitoring, and pre-procedural medication. In 2ND & 3RD trimester, placing the patient on their left side or placing bolster under right flank will reduce the risk of hypotension and foetal hypoxaemia Pre-procedural administration of antacid and anti-emetic such as metoclopramide should be considered.
- 22. Consideration in olderpatients Co-morbidities which impact their respiratory and cardiovascular functional reserves & patient’s regular medications, need to be considered during PS decision making. Detailed airway assessment prior to undertaking procedural sedation. In elderly patient - drug choice, dosage and interactions are to be noted. There is often delayed onset time for sedation agents in this group. Slower rates of administration and repeated doses at less frequent intervals are recommended Prolonged recovery time in a suitable area should also be anticipated. Decision making regarding procedural sedation in this older age group should carefully balance the risk of sedation (or other options) versus the impact on the patient’s quality of life.
- 23. Choice of drugsfor Procedural sedation The appropriate choice of pharmacological agents for PS depends on: The nature of the procedure The planned level of sedation Training and familiarity of the sedating practitioner with potential pharmacological agents Patient factors ex: cardiovascular stability, fasting status, age. The local environment
- 26. Pharmacological agents usedas infusions Agent Role Dose Propofol (TCI) Sedation ~2.0 mcg/ml (plasma concentration) Remifentanil (TCI) Sedation/ Analgesia ~2.0 ng/ml (plasma site concentration) Clonidine Sedation/ Anxiolysis/ Analgesia 0.5-2mcg/kg/hour Dexmedetomidine Sedation/ Anxiolysis 0.7mcg/kg/hr (0.2-1.4 mcg/kg/hr)
- 27. Other choices ofsedation/analgesia Remimazolam – benzodiazepine Oliceridine – opioid analgesic Methoxyflurane Sevoflurane Remifentanil Dexmedetomidine
- 28. Penthrox(methoxy flurane) Non-opioid,non-controlled drug, emergency analgesic. Indications : dislocations,lacerations/wounds,fractures,burns/ scalds,chest/abdominal injuries, neck of femur fracture Suitable for moderate to severe pain associated with a wide-range of trauma injuries Not be used in children and adolescents under 18 years One bottle of 3 ml PENTHROX as a single dose, administered using the device provided. Max dose in a single day - 6 ml, and the max total dose in a week should not exceed 15 ml. Onset of pain relief is rapid and occurs after 6-10 inhalations Caution in the elderly or other patients with known risk factors for renal disease, and in patients diagnosed with clinical conditions which may pre-dispose to renal injury
- 29. Reversal agents Flumazenil: Properties:Competitive antagonist at central benzodiazrpeine receptors Use: Reversal of respiratory depression following benzodiazepine use. Administration: 100-200mcg over 15 seconds, every minute. Maximum dose 1mg (adults), Acts in 30-60 seconds. Side Effects: Use with caution in those on long term benzo diazepines. Hypertension, dysrhythmias and vomiting. Naloxone: Properties: Competitive antagonist at opiate receptors Use: Reversal respiratory depression secondary to opioid administration Administration: Adults:100-200mcg every 1-2 minutes; Children 11month-11yrs 1- 10mcg/kg (max 200mcg per dose, total max dose 2mg); children 12-17yrs 100-200mcg every 1-2 minutes (max dos 2mg). Acts within 2 minutes and lasts approximately 20 minutes. Titrate to reverse respiratory depression without reversing analgesia. Side Effects: Precipitation of withdrawal in chronic opiate use. Arrhythmias, nausea vomitng.
- 30. Administering sedation Acombination of short acting analgesics & sedatives are may be required Ketamine has the potential to provide analgesia, sedation, anxiolysis and amnesia Dexmedetomidine provides sedation, anxiolysis and analgesia with limited respiratory depression. No one sedation technique is suitable for all patients or procedures Ideally sedationist should aim for: Minimum intervention; Simplest and safest effective technique; Based on patient assessment and clinical need Delivery of sedation - Bolus or continuous propofol delivery, Patient-controlled sedation , Computer-assisted personalized sedation (CAPS), Target-controlled infusion
- 31. Procedure steps Positioningof patient Preoxygenation Baseline observations Medications Monitoring depth of sedation
- 32. Monitoring during &after procedure 3 lead ECG, Oxygen saturations, Continuous capnography, Non-invasive blood pressure Nurse & Clinician performing the PS should remain with the patient until the patient has ‘woken up’. Clinical scales, Processed EEG, Anaesthesia responsiveness monitoring, Assessment of ventilation –pulse oximetry, capnograpghy, transcutaneous CO2 monitoring , Impedance monitoring , Acoustic monitoring
- 34. Common problems Inadequatemonitoring Over sedation: Excessive doses in children, elderly or frail patient Failure to titrate drugs to effect Availability of high strength midazolam presentations (never event) Lack of appreciation of the risks of drug combinations, e.g. synergism Agitation – paradoxical agitations especially in children, adolescents, and elderly Laryngospasm – BMV, Larsons point pressure,deepening sedation with propofol or sux. and intubate. Hypotension – can by due to sedation or analgesia (but consider other causes too)- IVF, leg elevation,metaraminol. Nausea and vomiting – suction for any vomitus. Antiemetics to help relieve nausea Respiratory depression – supplemental oxygen,airway manoeveurs,BMV. Minimal training for administering sedation and lack of supervision of inexperienced trainees
- 35. Discharge criteria Vitalsigns returned to baseline (no additional oxygen requirement) Alert & Orientated Able to tolerate oral fluids Adequate analgesia No / minimal nausea 2 hours elapsed since use of reversal agent** Appropriate care available at home Sedation advice leaflet
- 36.
Editor's Notes
- #2 Good mor , my talk is about proced seda. It’s a vast topic, I will try to about the approach in non theatre environment
- #3 Drug choices tend to differ based on each person expertise.
- #4 Conscious sedation was replaced by PSA
- #5 More than 40% of claims associated with MAC involved death or permanent brain damage, similar to general anesthesia claims.
- #11 Whilst the urgency of the clinical situation or patient status may sometimes necessitate treatment in the absence of consent, and in the patient’s best interests, every effort should be made to obtain prior written consent for both the proposed procedure and sedation technique. This includes the risks and benefits, with average risk and personalised risk, alternatives to sedation, and the requirements for discharge.
- #12 I use the approach of LEMON assessment
- #15 – WHO pain ladder principle - Non pharmacological measure,environment particularly in children & dementic patients
- #20 1. delivered by clinicians with the additional competencies and experience as determined by local governance arrangements
- #21 ex: using a large computer screen / tablet or a parent’s mobile phone to play videos
- #23 Decision making regarding undertaking procedural sedation in this older age group should carefully balance the risk of sedation (or other options) versus the impact on the patient’s quality of life and the prevention of significant rapid functional decline if procedure not carried out.
- #26 Dosage they have formulated after discussion between the 2 colleges RCOA & RCEM
- #28 sedated state produced by remimazolam appears broadly similar to that caused by midazolam with faster onset. Unlike midazolam, remimazolam metabolites have negligible sedative effects. Dex - sole agent, bradycardia and hypotension were problematic and recovery was slow. 2. reduced tendency to cause sedation and respiratory depression
- #29 Simple, fast setup – no need for signatories, canisters or cannulas. May avoid the need for procedural sedation >x3 faster than Entonox (10.54 minutes vs not achieved by 30 minutes) >x3 faster than IV Paracetamol (9.66 minutes vs 37.53 minutes) x2 faster than IV Morphine (10.47 minutes vs 20.09 minutes)
- #33 A computerized voice asks the patient to push the button and the handset vibrates up to four times over a 10 s period. The system quan- tifies how quickly the patient responds, and a lack of response signals a sedation level deeper than moderate sedation.