PowerPoint Presentation

Hazards of Procedural Sedation and Analgesia in theEmergency Department

Intro.Practitioners inadequately treat pain for many reasons, including:Fear of over-sedationFear of adverse effectsInadequate inquiryInadequate knowledgeInadequate dose/routeUnderestimation of patients needPain relief not seen as high priorityInsufficient time and resources

Purpose/IndicationsProcedure producing anxiety or requiring immobilization /cooperation: Treat with sedative only (eg, head CT of an uncooperative, confused, anxious, or intoxicated patient)Procedure producing anxiety and pain: Treat with sedative and analgesic (eg, fracture/dislocation reduction, abscess I&D, cardioversion, chest tube placement, burn debridement, PEDScomplex facial laceration repair)

Emergent indications for PSA Cardioversion for life-threatening arrhythmiasNeuroimaging for head traumaReduction of fractures or dislocations with soft tissue or vascular compromiseCare of contaminated woundsIntractable pain

Urgent PSAStable fracturesAbscess incision and drainageCare of clean woundsForeign body removalSexual assault examinations require lessNon-urgent indications for sedation Removal of a soft tissue foreign bodyPlacing splints on fractures that require minimal manipulationChanging splints on fractures that have already been reduced

Standards

Written informed consent specific for conscious sedationPre-anesthesia patient assessmentAnesthesia plan: drugs selected, dosages, routesFlow sheet to document procedure/recoveryAppropriate monitoringAppropriate disposition

Preprocedural FastingWhile preprocedural fasting is still preferred and should be considered according to expert opinion, the weight of this recommendation has shifted and is now considered Level C evidenceMultiple studies in emergency department patients failed to demonstrate that gastric emptying had any impact on the incidence of complications or outcomes in procedural sedation and analgesia.

ContraindicationsAbsolute:Unstable patient requiring immediate interventionRefusal by competent patientInexperienced or inadequate number of staffInadequate monitoring equipmentRelative:Hemodynamic or respiratory compromiseSignificant past medical history (eg, atherosclerotic heart disease, COPD, procedures lasting > 1 hour or better performed in the operating room).Recent meal (< 2 hours) in patient at risk for aspirationsigns of a difficult airway

Risk ReductionInformed, written consent for elective conscious sedationPre-sedation evaluation to identify high-risk patientAspiration risk factors: recent oral intake, obese, pregnant, alcohol/prescription/elicit drug usePrepare for difficult airway or bag-valve-mask ventilation: Assess for short stocky neck, large tongue (Mallampati score), dental prosthesis, airway disease, previous neck surgery, bearded patient, neck immobility (eg, cervical collar, cervical spine fusion)Past medical history, past psychiatric history (eg, psychosis)Responsible adult to accept/monitor discharged patient

Question the patient or caregiver regarding the following:Abnormalities of major organ systemsHistory of adverse events with sedation or analgesia, or regional or general anesthesiaDrug allergiesCurrent medications or herbal productsDescription and time of last oral intake (for elective procedures, should be fasting)Tobacco, alcohol, or substance abuseVital signsHeart and lung assessmentAirway evaluation

Equipment and supplies:OxygenSuctionAirway management equipmentReversal agents for opioids or benzodiazepines (eg, naloxone, flumazenil)Resuscitation medications and equipmentIntravenous access

Equipment and supplies:Monitor vital signs before, during, and after the procedure.ECG monitoring should be continuous for high-risk patients, during prolonged procedures, or during deep sedation.Continuous pulse oximetry for patients with comorbidities (eg, chronic obstructive pulmonary disease [COPD], asthma, congestive heart failure) or when high doses of sedatives or multiple drugs that may depress respirations are used.Observe the patient's appearanceMonitor airway patency.Monitor response to physical stimuli and verbal commandConsider capnography for high-risk patients. resulted in a decrease in hypoxia and identified all hypoxic events before onset.

Commonly Used Drugs for Procedural Sedation and Analgesia in Adults

Commonly Used Drugs for Procedural Sedation and Analgesia in Pediatric Patients

Elderly and patients with major comorbid diseaseGiving a lower starting doseUsing slower rates of administrationRepeated dosing of medications at less frequent intervals

Aspiration riskClinically significant aspiration during emergency department PSA appears to be rare, though much feared complicationThe ASA guidelines recommend that patients undergoing PSA for "elective procedures" fast according to the standards used for general anesthesia. This requires that patients not eat or drink for two hours after drinking clear liquids and six hours after ingesting solid foods or cow's milk If these standards cannot be met, the guidelines recommend that the clinician consider delaying the procedure, reducing the level of sedation, or protecting the airway with endotracheal intubation.

Aspiration riskAmerican College of Emergency Physicians policy statement on PSA states: "Recent food intake is not a contraindication for administering procedural sedation and analgesia, but should be considered in choosing the timing and target of sedationSuggest the following approach to reducing aspiration risk:Carefully consider the risks and benefits of performing the procedure emergently. Wait if the patient's stomach is full and the procedure is not a true emergencyAvoid deep sedation. lighter sedation may permit the patient to maintain protective airway reflexes, which reduces risk.

Various sedation depths

Monitoring and preoxygenationWe suggest that high flow oxygen by face mask be given to patients undergoing PSA because it may reduce the likelihood of hypoxic episodes, particularly with prolonged proceduresAmong patients not provided with supplemental oxygen, respiratory difficulty during PSA can manifest earlier as hypoxia, as detected by pulse oximetry, rather than as hypoventilation, as determined by EtCO2 monitorsEtCO2 measurements correlate closely with arterial CO2 and provide an early sign of hypoventilation or apnea, especially if supplemental oxygen is used

Considerations in pregnancy

Preprocedural administration of medication to improve :gastroesophageal sphincter tone and reduce gastric volume (eg, metoclopramide) decrease stomach acidity (eg, H2 antagonists, sodium citrate) may reduce the risk of vomiting and aspirationPreprocedural hydration and left lateral displacement of the uterus (in the late second and the third trimester)Fetal monitoring is not required, but should be considered for women in the third trimesterOxygen by face-mask is administered because of the risk of sedation-related maternal desaturation (primarily due to decreased FRC).

COMPLICATIONS Adverse outcomes may include: respiratory depression with hypoxia or hypercarbia (develops in less than 1% of cases )cardiovascular instabilityvomiting and aspiration (5% , higher when opioids are used )emergence reactionsHypoventilation and apnea may occur but are usually short-lived due to the brief duration of the drugs used for PSA. These complications nearly always resolve with patient stimulation, supplemental oxygen, positioning of the airway, or brief ventilatory support using a bag-valve mask

Propofol highly lipophilic and therefore crosses the BBBtakes effect within approximately 40 secondsduration of action is approximately six minutesacts as a sedative and amnestic, but provides no analgesiacan cause pain during injection through an intravenous catheter (using larger catheters placed in larger veins)For PSA in adults, initial loading dose of 0.5 to 1 mg/kg IVcontains egg lecithin and soybean oil, and therefore is contraindicated in patients with a sensitivity to either of these substances Potential side effects include hypotension (due to myocardial depression) and respiratory depression.

Etomidate etomidate is given IV over 30 to 60 seconds in doses of 0.1 to 0.15 mg/kgmaintains cardiovascular stabilityhas no analgesic propertiesEtomidate causes pain during injection into peripheral veinsPotential side effects of etomidate include myoclonus (most frequently), respiratory depression, adrenal suppression, and nausea and vomitingWhen given by continuous infusion,causes adrenal insufficiency.reductions in plasma cortisol concentrations have been reported in patients receiving a single induction dose of etomidate

Etomidate The degree of myoclonus may be dose dependentSevere myoclonus associated with PSA are rare. we suggest:immediate airway support treatment with midazolam 1 to 2 mg IV approximately q60 seconds until myoclonus abatesStrategies to prevent myoclonus :Pretreatment dose of 0.03 to 0.05 mg/kg of etomidate given 50 seconds before the PSA Small dose of midazolam (0.015 mg/kg) given at the same time as etomidate Magnesium sulfate administered 90 seconds prior to etomidate

Benzodiazepines (midazolam) are commonly used for minimal sedation (anxiolysis), but less often for deeper sedation due to the superior effectiveness of the ultrashort-acting agents propofol and etomidate no analgesic propertiesmidazolam penetrates the BBB quicklytime of onset is 2-5 minutes, and its duration of action is 30 to 60 minutes 0.02 to 0.03 mg/kgNo single dose should exceed 2.5 mgCompared with ultrashort-acting agents, midazolam has a longer duration of action that makes it better suited for anxiolysis than for PSA

Short-acting opioidsfentanyl ,alfentanil , and remifentanil , are usedFentanyl is:Synthetic opioid that has 75 to 125 times the potency of morphinerapid onset of action (two to three minutes)short duration of effect (30 to 60 minutesno amnestic propertiesslow IV push in doses of 0.5 to 1 mcg/kg every two minutes rarely causes hypotension and does not stimulate histamine releaseRemifentanil and alfentanil are opioids similar in structure to fentanyl with a rapid onset and duration of action of approximately five minutesalfentanil is one-fifth to one-tenth as potent

KetamineProvides sedation, analgesia(partial agonism at opiate mu-receptors), and amnesiapreserving upper airway muscle tone, airway protective reflexes, and spontaneous breathingrespiratory depression may occur if administered too rapidly or in high dosesit is often used for brief, painful procedures, such as fracture reduction or laceration repair duration of effect is 10 to 20 minutes1 to 2 mg/kg is given IV over one to two minutesThe reported side effects of ketamine include tachycardia, hypertension, laryngospasm, emergence reactions(most commonly reported), nausea and vomiting, increased intracranial and intraocular pressure, and hypersalivation exacerbate schizophrenia Emergence reactions vary in their intensity and have been described as disorientation, dream-like experiences, or hallucinations that may be frighteningFor prevention, midazolam, approximately 0.05 mg/kg IV prior to administering ketamine

Barbiturates Methohexital is the most commonly used barbiturate for PSAimmediate onset, a duration of action less than 10 minutes, and provides sedation and amnesia but no analgesiaThe initial dose of methohexital is 0.75 to 1 mg/kgcauses myocardial depression, hypotension and tachycardiaUnlike other barbiturates, methohexital can precipitate or exacerbate seizures and should be avoided in patients with a seizure disorder Thiopental is a barbiturate used for induction of general anesthesia, and rarely used in the performance of PSA. It is similar in efficacy and side effects to methohexital , but suppresses seizures

Dexmedetomidinefor procedural sedation in pediatric and adult patientsan alpha2-adrenergic agonist that provides sedation, anxiolysis, hypnosis, analgesia, and sympatholysisFDA has only approved its use for short-term mechanically ventilated adults in the ICU, but it is currently being used off-label in many settings outside the ICUprovides little to no respiratory depressionpatients are able to follow commands and respond to verbal and tactile stimulus but fall quickly asleep when not stimulatedprovide some pain relief, like ketamine, but not to the same degree (use of other analgesics necessary for the more painful procedures)Minimal cardiovascular effects are seen and include mild bradycardia and a decrease in systemic vascular resistance

Ketamine and propofol (ketofol)The concept of ketofol is that the benefits of the two medications are synergistic and allow lower doses of each to be usedStudies of ketofol to date have not shown this combination therapy to be more efficacious or safer than propofol or ketamine alone when performing PSA in adults The median dose of ketamine and propofol was 0.7 mg/kg

Propofol versus etomidateboth possess similar times to onset and recovery Propofol may result in a higher procedural success rateFactors to consider when choosing between them:Etomidate provides greater hemodynamic stability, as propofol can cause hypotension. Etomidate can cause myoclonus, which appears to reduce the rate of procedural success Etomidate causes dose-dependent adrenal suppression, which may be harmful in patients with severe disease (eg, sepsis, multiple trauma)

Patients at increased riskRisk of hypotension: etomidate or ketamine Risk for airway or respiratory complications: ketamine Elderly patients: lower starting dose with slower rates of administration Procedures in elderly patients with major comorbidities are probably best performed in the operating room.

Discharge CriteriaReturn toNormal vital signs relative to age and injuriesBaseline mental status and verbal skillsBaseline motor function:infant: sits unattendedchild/adult: ambulates unassistedTolerating oral fluidsPain controlled with oral analgesiaDischarged to responsible adult who understands and can comply with discharge instructions

Sample Discharge Instructions (Adult)During the next 8 hours you may experience drowsiness, nausea, dizziness or mild changes in the ability to think clearly.During the next 24 hours:Do not drive; operate heavy machinery, dangerous equipment, or tools; or engage in physically dangerous activities requiring clear thought and physical coordination.Do not make any important decisions or sign important documents.Eat a light diet (clear liquids if nauseous or vomiting).Remain in the presence of a responsible adult.Do not drink alcoholReturn to the ED or call 911 if you develop shortness of breath or persistent nausea and vomiting.

Sample Discharge Instructions (Infants/Children)medications may cause him or her to be sleepy and less aware of his or her surroundings, making it easier for accidents to occur as your child walks or crawls.Nausea and vomiting is also common after sedating and/or pain medications. This is generally self limiting, but if persistent they should be reevaluated. Because of these side effects, watch your child closely for the next 8 hours. If you notice anything unusual about your child, or he or she cannot take oral fluids within the next 4 to 6 hours, please call the Emergency Department.We also recommend:No oral food/fluids for the next 2 hoursOver the next 8 hours, adult supervision is required for activities such as baths, showers, cooking, use of dangerous appliances/tools/toys, playing, etc.Over the next 24 hours, no activity requiring normal physical coordination (eg, biking, climbing, swinging, etc.)