Morning Report: 10/7/2014 - The Original Kings of County

Dr. Gomes presents today’s Morning Report!

PROCEDURAL SEDATION

Definition:

-technique of administering a sedative or dissociative agent along with analgesia to induce a state that allows patient to tolerate unpleasant procedures while maintaining adequate spontaneous cardiorespiratory function

Complications:

-oversedation, respiratory depression/arrest, hypoxia, hypotension, prolonged awakening, agitation, nausea/vomiting, tachycardia, bradycardia

Common errors:

-delayed recognition of respiratory depression and respiratory arrest

-inadequate monitoring

-inadequate resuscitation

3 Stages to procedural sedation:

Initial pre-sedation evaluation
Sedation during the procedure
Post-procedural recovery

Pre-Sedation evaluation:

-History: allergies, adverse reactions to prior anesthesia/sedative agents, h/o intubation/difficult intubation, pulmonary disease, cardiac disease, hepatic/renal failure, etc.

-ABCs: Mallampati

-GI: last meal (aspiration risk…something to note but usually have no control of this in ER setting)

Sedation during procedure:

-Monitoring

2 persons (at least)- someone to watch the patient throughout entire sedation/procedure process- chest rise, apnea, respiratory depression, emesis, hypersalivation, monitors. Someone to push medications and perform procedure
Pulse oximetry
- Note- there is a lag between hypoventilation and a drop in O2 sats
Capnography
- offers breath by breath measure of RR and CO2 exchange
- Earliest indicator of airway or respiratory compromise
EKG monitor
Vital signs- at least q5 min
IV fluids

-Equipment

Airway/Intubation/resuscitation
- Suction, BVM, ET tubes, ETCO2 detector, Miller/Mac, O2, back-up
- Fluids
- Drug reversal agents
IV
Supplemental O2? (some use some don’t)
- Interferes with ability to use low pulse ox readings as an early warning device for hypoventilation as hyperoxygenated patients will desat only after prolonged apnea

Post procedure recovery:

-alert and oriented at patient’s baseline

-return to age appropriate baseline

-stable vitals

Medications:

-Ideal properties

Easily titratable
Fast onset
Short duration OR
Readily reversible

Drug	Clinical Effects	Adult Dose	Time to onset	Duration	Comments
Midazolam	Anxiolytic, motion control, sedative No Analgesia	Start with 1mg and titrate up to max 5mg	2-3 min	45-60 min	-flumazenil for reversal
Etomidate	Sedation, motion control, anxiolytic No Analgesia	0.1mg/kg. Can repeat for optimal sedation	<1 min	5-15 min	-no reversal agent
Propofol	Sedation, motion control, anxiolysis No Analgesia	1mg/kg (start low and go slow)	<1 min	5-15 min	-no reversal agent -half dose when combined with ketamine
Fentanyl	Analgesia	50 ug (repeat q3min for optimal pain control)	2-3 min	30-60 min	-naloxone for reversal Reduce dose if used in combination with midazolam
Ketamine	Analgesia, dissociation, amnesia, motion control	1mg/kg	1 min	15-60 min	-no reversal -push slowly -half dose when combined with propofol

Source: Roberts and Hedges, Clinical Procedure in Emergency Medicine, 5^th ed, 2010

The views expressed on this blog are the author's own and do not reflect the views of their employer. Please read our full disclaimer here. Any references to clinical cases refer to patients treated at a virtual hospital, Janus General Hospital.

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Jay Khadpe MD

Editor in Chief of "The Original Kings of County" Assistant Professor of Emergency Medicine Assistant Residency Director SUNY Downstate / Kings County Hospital