Transcript Procedural Sedation - Calgary Emergency Medicine

Procedural Sedation
Jan 27, 2011
Jason Mitchell
Dr. Gil Curry
Dr. Marc Francis
Acknowledgments
Dr. James Huffman
Dr. Dave Choi
OUTLINE
 INTRODUCTION
 PRE-SEDATION PREPARATION
 AGENTS
 MONITORING
 OTHER CONTROVERSIES
 FUTURE DIRECTIONS
INTRODUCTION
 Procedural Sedation
 Technique to induce a state of lowered awareness and pain
sensation
 Preserves independent cardiac and respiratory functions
 Employs sedative, dissociative, and analgesic agents
 CORE COMPETENCY for ED Practice
INTRODUTION
 CAEP, ACEP, and ASA Guidelines assert sedation provider
must:
 understand agent characteristics and relevant antagonists
 be able to maintain desired sedation level
 be able to manage potential complications
 agent specific
 airway management
 hemodynamic instability
1 Innes G, Murphy M, Nijssen-Jordan C, et al. Procedural Sedation and Analgesia in the Emergency Department. Canadian
Consensus Guidelines. J Emerg Med 1999:17(1);145-156.
2. Godwin SA, Caro DA, Wolf SJ, et al. Clinical policy: procedural sedation and analgesia in the emergency department. Ann
Emerg Med 2005 ;45(2):179-196
3. Gross JB, Farmington CT, Bailey PL, et al. Practice guidelines for sedation and analgesia by non-anesthesiologists.
Anesthesiology 2002;96(4)1004
INTRODUCTION
 SEDATION CONTINUUM
4. American Society of Anesthesiologists. Continuum of depth of sedation definition of general anesthesia and levels of
sedation/analgesia. October 27, 2004. Available at http://www.asahq.org/publicationsAndServices/sgstoc.htm
5. Green SM, Mason KP. Reformulation of the Sedation Continuum. JAMA 303(9);876-877.
INTRODUCTION
 SEDATION CONTINUUM
INTRODUCTION
 SEDATION CONTINUUM
INTRODUCTION
 SEDATION CONTINUUM
INTRODUCTION
 SEDATION CONTINUUM
INTRODUCTION
 SEDATION CONTINUUM
DISSOCIATIVE SEDATION
INTRODUCTION
 The deeper the sedation, the greater the risk of:
 Loss of airway protection
 Apnea
 Cardiovascular compromise
 Hemodynamic collapse
PRE-SEDATION PREPARATION
 CASE
 26 yo M Tennis Injury
 R Shoulder Dislocation
 No #
 NV stable
 History??
PRE-SEDATION ASSESSMENT
 PATIENT ASSESSMENT
 Focused history:
 PMHX
 Assess degree of cardiopulmonary reserve
I
II
III
IV
V
Healthy
Mild
Systemic
Disease
Severe
Systemic
Disease
Disease
Constant
Threat to
Life
Moribund
Not
expected
to survive
beyond 24
hours
PRE-SEDATION PREPARATION
 PATIENT ASSESSMENT
 Focused history:
 PMHX
 Assess degree of cardiopulmonary reserve
I
II
Healthy
Mild
Systemic
Disease
?✗ ✗
III
IV
V
Severe
Systemic
Disease
Disease
Constant
Threat to
Life
Moribund
Not
expected
to survive
beyond 24
hours
PRE-SEDATION PREPARATION
 PATIENT ASSESSMENT
 Focused history:
 PMHX
 Assess degree of cardiopulmonary reserve
 Medications
 Allergies
 Anesthetic history
 Pre-procedural fasting
PRE-SEDATION PREPARATION
 CASE
 Focused history:
 PMHX
 Medications
 Allergies
 Anesthetic history
 Pre-procedural fasting
PRE-SEDATION PREPARATION
PRE-SEDATION PREPARATION
 PATIENT ASSESSMENT – FASTING
 Controversial
 Loss of airway reflexes and vomiting exceptionally rare
 No evidence-based ED guidelines for optimal fasting
 Limited data for improved ED outcomes with prolonged
fasting duration
PRE-SEDATION PREPARATION
 PATIENT ASSESSMENT – FASTING
 Most data derived from GA literature
 Aspiration 1:3,420 elective Sx; 1:895 emergent Sx
 Mortality 1:125,109
 Not our patients!
PRE-SEDATION PREPARATION
 PATIENT ASSESSMENT – FASTING
 ASA recommends the following:
INGESTED MATERIAL
MINIMUM FASTING TIME
Clear Liquids
2h
Breast Milk
4h
Infant Formula
6h
Cows Milk
6h
Light Meal
6h
Heavy Meal
>6 h
PRE-SEDATION PREPARATION
 PATIENT ASSESSMENT – FASTING
 Pediatric prospective observational study
 n = 905, 56% noncompliant with ASA guidelines
 Emesis in 15 (1.5%) of patients, 1 during procedure
 No evidence of pulmonary aspiration
 No significant difference in fasting duration and emesis or
airway complications
 No reports of pediatric aspiration pneumonitis in the
literature
6. Agrawal D, Manzi SF, Gupta R, et al. Preprocedural fasting state and adverse events in children undergoing procedural
sedation and analgesia in a pediatric emergency department. Ann Emerg Med 2003:42(5);636-646.
PRE-SEDATION PREPARATION
 PATIENT ASSESSMENT – FASTING
 A review of 25 papers addressing adult emesis with ED PSA:
 4657 cases non-compliant with ASA fasting
 17 cases of emesis (0.3%)
 1 case intubation, 1 case ICH
 0 cases evidence of aspiration
 One reported case of adult aspiration after PSA
7. Thorpe RJ, Binger J. Pre-procedural fasting in emergency sedation. Emerg Med J 2010:27;254-261.
8. Cheung KW, Watson ML, Field S, et al. Aspiration pneumonitis requiring intubation after procedural sedation and analgesia: a
case report. Ann Emerg Med 2007:49(4)462-464.
PRE-SEDATION PREPARATION
 Guidelines:
 ACEP and CAEP
 Insufficient evidence
 Recent food intake is not an absolute contraindication
 But must be considered in timing of procedure
PRE-SEDATION PREPARATION
 ED Specific Practice Advisory 2007
 Risk Assessment
1.
2.
3.
4.
Baseline risk
Timing/nature of intake
Urgency of procedure

Emergent: Cardioversion

Urgent: Abscess I&D

Semi-urgent: Shoulder reduction

Non-urgent: Ingrown toenail
Required depth of sedation
9. Green SM, Roback MG, Miner JR, et al. Fasting and emergency department procedural sedation and analgesia: a concensusbased clinical practice advisory. Ann Emerg Med 2007;49(4):454-461
PRE-SEDATION PREPARATION
PRE-SEDATION PREPEARAT
PRE-SEDATION PREPARATION
 PATIENT ASSESSMENT – FASTING
 Bottom line:
 Risk of aspiration event is rare
 Very limited data
 Recent food intake is not an absolute contraindication
 Weigh the risks of possible aspiration vs. urgency of procedure
PRE-SEDATION PREPARATION
 BACK TO THE CASE
 26 yo M R Shoulder Dislocation
 PMHx Healthy
 No Meds, No Allergies
 Fasted
 Physical Exam??
PRE-SEDATION PREPARATION
 PATIENT ASSESSMENT
 Focused physical:
 Vitals
 Mental status
 Airway
 Cardiopulmonary exam
PRE-SEDATION ASSESSMENT
 CASE CONTINUED
 26 yo M R Shoulder Dislocation
 PMHx: Healthy
 No Meds, No Allergies
 Fasted
 AVSS
 P/E: Normal
PRE-SEDATION PREPARATION
 EQUIPMENT
IN THE ROOM
READILY AVAILABLE
ECG monitor
Defibrillator
Pulse oximeter
Resuscitation drugs
Airway equipment
Sedation/Analgesic agents
Suction
Blood pressure monitor
Reversal agents
Adequate staff
Supplemental oxygen*
Capnography*
PRE-SEDATION ASSESSMENT
 CASE CONTINUED
 26 yo M R Shoulder Dislocation
 PMHx: Healthy
 Egg allergy
 Fasted
 AVSS
 P/E: Normal
PRE-SEDATION ASSESSMENT
 CASE CONTINUED
 26 yo M R Shoulder Dislocation
 PMHx: Psychosis
 Egg allergy
 Fasted
 AVSS
 P/E: Normal
AGENTS
 Sedatives
 Propofol
 Midazolam
 Etomidate
 Analgesics
 Opioids
 Nitrous oxide
 Dissociative agents
 Ketamine
AGENTS - SEDATIVES
 PROPOFOL
 PSA Starting Dose: 0.5-1.0 mg/kg, titrate 0.25-0.5 q45-60 sec
 Onset: <1 min
 Duration: 5-10 min
Strengths
Weaknesses
Contraindications
Rapid onset/offset
Resp. depression
Egg allergy
Titratable
Hypotension
Soy allergy
Antiemetic
Injection pain
Hypotensive/Unstable
Cerebral protective
No analgesia
?Anti-epileptic
Amnestic
Bronchodilator
AGENTS - SEDATIVES
 KETAMINE
 PSA Starting Dose: IV 1-2 mg/kg, repeat 0.25-0.5 mg/kg prn
IM 2-5 mg/kg, repeat 1 mg/kg prn
PO 6-10 mg/kg
 Onset: IV: 1 min
IM: 5 min
 Duration: 15-30 min Complete Recovery: 1-2 hours
Strengths
Weaknesses
Contraindications
Rapid onset/offset
Emergence
< 3 mo age
Hemodynamically stable
Emesis
Elevated ICP
Airway reflexes
maintained
Laryngospasm
Significant CVD/CAD
Analgesic
?Increased IOP/ICP
Prior psychosis
AGENTS - SEDATIVES
 MIDAZOLAM
 PSA Starting Dose: IV 0.05-0.2 mg/kg
IN 0.2-0.6 mg/kg
IM 0.1-0.2 mg/kg
PO 0.5-0.75 mg/kg
 Onset: 1-30 min
 Duration: 30-12o min
Strengths
Weaknesses
Contraindications
Rapid onset
Respiratory depression
Pregnancy (Class D)
Titratable
Hypotension with opioids
Many routes available
No analgesia
Anxiolysis
Paradoxical reactions
Retrograde amnesia
AGENTS - SEDATIVES
 BENZODIAZEPINE REVERSAL
 FLUMAZENIL
 Dose: Adults: 0.1-0.2 mg IV q 1-2 minutes to max 2 mg
Peds: 0.02 mg/kg titrated to a max of 0.2 mg
 Onset: 1-2 min
 Duration: 5-10 min peak
 Half-life: 45-90 min
 CAUTION: May precipitate status epilepticus in those with
benzo dependence or seizure history
AGENTS - SEDATIVES
 ETOMIDATE
 PSA Starting Dose: IV 0.1-0.2 mg/kg
 Onset: <1 min
 Duration 5-10 min
Strengths
Weaknesses
Contraindications
Rapid onset/offset
Respiratory depression
Poor adrenal function
Minimal CV effects
Myoclonus
Prior seizures
Cerebral protective
?Adrenal suppression
No analgesia
Emesis
AGENTS - ANALGESICS
 FENTANYL
 PSA Starting Dose: IV 1.0-3.o mcg/kg TM 10-20 mcg/kg
 Onset:
IV 1-2min
 Duration: IV 30-40 min
TM 10-30 min
TM 60-120 min
Strengths
Weaknesses
Contraindications
Rapid onset
Respiratory depression
Hypersensitivity rxn
Minimal CV effects
Rigid chest syndrome
Decreased histamine
release
Short duration
AGENTS - ANALGESICS
 OPIATE REVERSAL
 NALOXONE
 Dose: 0.1-0.2 mg q 1-2 min
 Onset: < 1 min
 Duration 15-30 minutes
 CAUTION: Complete reversal in pts who are dependent on
opioids may precipitate acute opioid withdrawal
AGENTS - ANALGESICS
 NITROUS OXIDE
 PSA Starting Dose: 30%-70% inhaled N2O
 Onset: 1-2 min
 Offset: 3-5 min
Strengths
Weaknesses
Contraindications
Rapid onset/offset
Nausea/emesis
PTX
Minimal CV effects
Cannot be used in moddeep sedation
Bowel obstruction
Respiratory depression
COPD
Decompression Sickness
AGENTS
 CASE CONTINUED
 26 yo M R Shoulder Dislocation
 Sedated with propofol
 Currently undergoing reduction
 What should you be monitoring?
MONITORING
 GUIDELINES
 Recommend monitoring:
 Sedation level
 Heart rate
 Blood pressure
 Pulse oximetry with supplemental oxygen
 Controversial
MONITORING
 SUPPLEMENTAL OXYGEN
 Helpful or harmful?
 Controversial
 Supplemental O2 impairs ability to detect respiratory depression
10. Green SM, Krauss B. Supplemental oxygen during propofol sedation: yes or no? Ann Emerg Med. 2008 Jul;52(1):9-10.
MONITORING
 SUPPLEMENTAL OXYGEN
 Does it prevent respiratory depression?
 n=80, sedation: propofol
11. Deitch K, Chudnofsky CR, Dominici P. The utility of supplemental oxygen during emergency department procedural sedation
and analgesia with propofol: a randomized, controlled trial. Ann Emerg Med. 2008;52(1)1-8.
MONITORING
 CAPNOGRAPHY
 Controversial
 Adjunct to evaluate pre-hypoxic respiratory depression
 Superior to clinical exam and oximetry
MONITORING
 CAPNOGRAPHY
MONITORING
 CAPNOGRAPHY - EVIDENCE
 Pediatrics
 Comparison of oximetry, capnography, clinical observation in
patients receiving midaz/fent
 Capnography provided an earlier indication of respiratory
depression than pulse ox and clinical exam alone
 RCT: blinded staff reported hypoventilation in 3% of cases, did
not identify apnea
 Capnography disclosed 56% hypoventilation, 24% apnea
 Also identified all cases of hypoxia before it occured
12. Hart LS, Berns SD, Houck CS, et al. The value of end-tidal CO2 monitoring when comparing three emthods of conscious
sedation for children undergoing painful procedures in the emegency department. Pediatr Emerg Care 1997:13(3);189-193.
13 Lightdale JR, Goldmann DA, Feldman HA, et al. Microstream capnography improves patient monitoring during moderate
sedation: a randomized, controlled trial. Pediatrics 2006:117(6);e1170-1178.
MONITORING
 CAPNOGRAPHY – EVIDENCE
 Adults
 Prospective observation study, n=60
 70% of patients with an ‘acute respiratory event’ had capnographic
changes occurring up to 4 min prior to oximetry or clinical
assessment
 RCT: Study of hypoxia w/ and w/o capnography
 Significantly increased hypoxia w/o capnography
 ?Clinical importance
14. Burton JH, Harrah JD, Germann CA, et al. Does end-tidal carbon dioxide monitoring detect respiratory events prior to current
sedation monitoring practices? Acad Emerg Med 2006;13(5):500-5004.
15. Deitch K, Miner J, Chudnofsky C. Does end tidal CO2 monitoring during emergency department procedural sedation and
analgesia with propofol decrease the incidence of hypoxic events? A randomized, controlled trial. Ann Emerg Med 2010
;55(3):258-264.
MONITORING
 CAPNOGRAPHY – EVIDENCE
 What these studies show:
 Capnography predicts respiratory depression
 Earlier than oximetry or clinical assessment
 What these studies don’t show:
 Capnography improves pt outcomes
 Transient hypoxia/hypercarbia is harmful
 So why care about detecting transient respiratory depression?
MONITORING
 CAPNOGRAPHY
MONITORING
 CAPNOGRAPHY
 Limitations
 Clinical effect has not been proven
 False positives
 Cost benefit ratio unclear
 Low – Moderate specifity
 Mod – High sensitivity
 More research required
POST-SEDATION MONITORING
 MORE CASE
 26 yo M R Shoulder Dislocation
 Successful reduction
 No complications with sedation
 Is sitting upright
 A&O x 3
 Is he safe for discharge?
POST-SEDATION MONITORING
 Highest risk of adverse events
 Clinical recovery:
 Normal LOC, vitals, respiratory status
 Normal motor function
 Follow commands
 Speaks clearly
 Tolerating oral fluids
DISCHARGE
 Guidelines recommend:
 Baseline vitals
 Baseline cognition
 Pt can sit unassisted
 Pt can take oral fluids without vomiting
 Pt can understand discharge instructions
DISCHARGE
 DISCHARGE INSTRUCTIONS:
 ADULT
1.
Avoid dangerous activities (bicycling, swimming, driving,
?tennis) until effects have passed
2.
Progressive diet
3.
No alcohol, sleeping pills, or other medications causing
drowsiness for 24 hours.
DISCHARGE
 DISCHARGE INSTRUCTIONS
 PEDS
1.
No food or drink for two hours. If under 1 age, give half of normal
feed 1 hour after discharge
2.
No play requiring balance, strength, and coordination for 12 hours
3.
Closely supervise your child for next 8 hours
1.
The child should not bathe, shower, cook, or use electrical devices
for next 8 hours
CONTROVERSIES
 Propofol for children – Is it safe?
 2 year, prospective case series n=393
16. Bassett KE, Anderson JL, Pribble CG, et al. Propofol for procedural sedation in children in the emergency department. Ann
Emerg Med 2003;42:773.
 Propofol for children – Is it safe?
CONTROVERSIES
 Propofol for children – is it safe?
 RCT n=113, propofol vs. ketamine in orthopedic reductions
17. Godambe SA, Elliot V, Matheny D, Pershad J. Comparison of propofol/fentanyl versus ketamine/midazolam for brief
orthopedic procedural sedation in a pediatric emergency department. Pediatrics 2003;112:116xc
CONTROVERSIES
 Propofol for children – is it safe?
CONTROVERSIES
 Propofol for children – is it safe?
 No difference in orthopod and nurse satisfaction.
 Parental VAS for pain not significantly different.
 No pts recalled procedure
 Delayed adverse events (<72hrs) noted only in ketamine
 Dysphoric reactions (nightmares, behaviour change)
 Nausea/emesis
CONTROVERSIES
 Propofol for children – is it safe?
 Studies suggest propofol is safe but has a higher associated
risk of transient respiratory depression.
 Few studies in ED PSA setting
 Use with caution
CONTROVERSIES
 Ketamine in adults – is it effective?
 2010 RCT Propofol vs. Ketamine in adults
 n=97
 Found:
 Significant increase of subclinical respiratory depression for
ketamine
 Prolonged recovery time for ketamine
 Increased emergence with ketamine
18. Miner JR, Gray RO, Bahr J, et al. Randomized clinical trial of propofol versus ketamine for procedural sedation in the
emergency department. Acad Emerg Med 2010;(17)6:604-611
CONTROVERSIES
 Ketamine for adults – is it effective?
 2008 ’narrative’ review, 87 studies, 70 000 pts
 Found that significant adverse reactions rarely occur
 1:70 000 CP; 0 cases aspiration
 Reported effects:
 Tachycardia
 Hypertension
 Hypersalivation
 Laryngospasm
 N/V (5-15%)
 Emergence Rxns (10-20%)
19. Strayer RJ, Nelson LS. Adverse events associated with ketamine for procedural sedation in adults. Am J Emerg Med
2008;26(9):985-1028.
CONTROVERSIES
 KETAMINE – Emergence Reactions
 Most common side effect
 Rare <5 years, greatest >15 years
 Large rapid doses
 Pretreatment agitation/anxiety/excessive stimulation
 Female sex
 Personality disorder
 Prior psychosis
CONTROVERSIES
 KETAMINE – Emergence Reactions
 Effect may be blunted by 0.03-0.05 mg/kg midazolam
 2 ED RCTs show no measurable benefit in children
20. Sherwin TS, Green SM, Khan A, et al. Does adjunctive midazolam reduce recovery agitation after ketamine sedation for
pediatric procedures? a randomized, double-blinded, placebo-controlled trial. Ann Emerg Med 2000;35:229-244.
21. Wathen JE, Roback MG, Mackenzie T, et al. Does midazolam alter the clinical effects of intravenous ketamine sedation in
children? A double-blind, randomized, controlled emergency department trial. Ann Emerg Med. 2000;36:579-588.
CONTROVERSIES
 KETAMINE – Emergence Reactions
 What about adults?
 Prior case series show questionable effects of midazolam
 2011 ED RCT: n=182 ketamine w/ or w/o 0.03 mg/kg midaz
22. Sener S, Eken C, Schultz C, et al. Ketamine with and without midazolam for emergency department sedation in adults: a
randomized controlled trial. Ann Emerg Med 2011:57(2);109-114.
CONTROVERSIES
 KETAMINE – Emergence Reactions
 Should we give midazolam to all adult patients?
CONTROVERSIES
 KETAMINE – Emergence Reactions
 Argued that:
 Emergence reactions have a wide spectrum of severity
 NNT of 6 may represent maximally effective treatment
 Emergence reaction affected by baseline risk
 Should all patients receive midazolam or just high risk patients?
 Pretreat or only treat when there’s a reaction?
23. Green SM, Krauss B. The Taming of Ketamine - 40 years later. Ann Emerg Med 2011;57(2):115-116.
CONTROVERSIES
 Ketamine in adults
 Safe and effective
 Higher emergence in adults
 Midazolam effective in treating
CONTROVERSIES
 KETAMINE
 Cons: Emesis
Emergence
CONTROVERSIES
 PROPOFOL
 Pros: Antiemetic
Smooth recovery
 KETAMINE
 Cons: Emesis
Emergence
CONTROVERSIES
 PROPOFOL
 Pros: Antiemetic
Smooth recovery
 Cons: Hemodynamically unstable
No analgesia
 KETAMINE
 Cons: Emesis
Emergence
CONTROVERSIES
 PROPOFOL
 Pros: Antiemetic
Smooth recovery
 Cons: Hemodynamically unstable
No analgesia
 KETAMINE
 Pros: Hemodynamically stable
Analgesic
 Cons: Emesis
Emergence
CONTROVERSIES
 KETOFOL
 4 ED case series
24. Green SM, Andolfatto G, Krauss B. Ketofol for procedural sedation? pro and con. Ann Emerg Med 2011 In Press.
CONTROVERSIES
 KETOFOL
 2 Meta-analyses
 Pharmacology 2007
 Ketofol not superior to propofol monotherapy
 Variable mixed dosing regimens ?optimal ratio
 Conflicting data re: hypotension and respiratory depression
 Conclusion:
 Available evidence does not support the use of ketofol for PSA
25. Slavik VC, Zed PJ. Combination ketamine and propofol for procedural sedation and analgesia in the emergency department.
Pharmacotherapy 2007;27:1588-1598
CONTROVERSIES
 KETOFOL
 2 Meta-analyses
 Annals of Pharmacotherapy 2007
 No significant difference in time to discharge
 Fewer cases of hypotension/resp depression in ketofol

No difference in interventions required
 Emesis and emergence occurred with higher doses of ketamine
 Conclusion
 Insufficient evidence to support ketofol for routine use
26. Loh G, Dalen D. Low-dose ketamine in addition to propofol for procedural sedation and analgesia in the emergency
department. Ann Pharmacother 2007;41:485-492
CONTROVERSIES
 KETOFOL
 3 ED RCTs
27. Messenger DW, Murray HE, Dungey PE, et al. Subdissociative-dose ketamine versus fentanyl for analgesia during propofol
procedural sedation: a randomixed controlled trial. Acad Emerg Med 2008;15:877-886
28. Shah A, Mosdossy G, McLeod S, et al. A blinded, randomized controlled trial to evaluate ketmine-propofol versus ketamine
alone for procedural sedation in children. Ann Emerg Med. In Press
29. David H, Shipp J. Combined ketamine/propofol for emergency department procedural sedation. Ann Emerg Med. In Press.
CONTROVERSIES
 KETOFOL
 Pro-Arguments
 Ketofol is safe and effective
 Ketamine likely synergistic with propofol
 Promotes less required propofol
 Less erratic sedation and ?improved hemodynamic stability
 Precludes need for opioid analgesia
 Recovery time
 Less emesis and ?emergence
CONTROVERSIES
 KETOFOL
 Con-Arguments
 Contentious evidence with respect to:
 Respiratory depression
 Superior sedation
 ?Clinical importance of promoting hemodynamic stability
 Recovery time
 Adds complexity
CONTROVERSIES
 KETOFOL
 Conclusion
 More data required.
CONTROVERSIES
 ETOMIDATE
 2004 Meta-analysis
 Etomidate effective for PSA
 Onset/duration comparable to propofol
 Hemodynamically stable
 Respiratory depression (~10%)
 No major complications, hypotension
 Side effects include:
 Myoclonus (20-45%)
 Emesis
 Adrenal suppression
30. Falk J, Zed PJ. Etomidate for procedural sedation in the emergency department. Ann Pharmacother 2004;38:1272
CONTROVERSIES
 ETOMIDATE - Adults
 ED RCT, n=214, etomidate vs propofol for PSA
 No difference in:
 Respiratory depression or airway interventions
 Depth of sedation
 Pt satisfaction
 Differences in:
 Myoclonus (20% vs 2%)
 Procedural success (89% vs 97%)
31. Miner JR, Danahy M, Moch A, et al. Randomized clinical trial of etomidate versus propofol for procedural sedation in the
emergency department. Ann Emerg Med 2007;49:15
CONTROVERSIES
 ETOMIDATE – Peds
 ED RCT, n=23, Etomidate/fent vs ketamine/midaz
32. Lee-Jayaram J, Green A, Siembieda J, et al. Ketamine/midazolam versus etomidate/fentanyl procedural sedation for pediatric
orthopedic reductions. Ped Emerg Care 2010;26(6):408-412.
CONTROVERSIES
 ETOMIDATE – Peds
 ED RCT, n=100, etomidate/fent vs. midaz/fent
 No differences in:
 Respiratory depression
 Emesis
 Procedural success
 Differences in:
 Depth of sedation
 Induction and recovery time
 Myoclonus
 Pain on injection
33. Di Liddo L, D'Angelo A, Nguyen B, et al. Etomidate versus midazolam for procedural sedation in pediatric outpatients: a
randomized controlled trial. Ann Emerg Med 2006;48:433-440
CONTROVERSIES
 ETOMIDATE
 Studies show:
 Safe and effective in PSA
 Limited evidence
 Higher rates of myoclonus, may lead to less procedural success
 FDA does not recommend etomidate in children < 10 years
FUTURE DIRECTIONS
 DEXMEDETOMIDINE
 a2-agonist with sedative, analgesic, anxiolytic properties
 Produces a sedated state comparable to natural sleep
 Advantages
 Many available routes – particularly IN (~90% IV Absorption)
 Tolerated better than oral or IN midaz
 May be useful is sedating autistic patients
 Potential reversibility with atipamezole
 No respiratory depression
34. Kost S, Roy A. Procedural sedation and analgesia in the pediatric emergency department: a review of sedative
pharmacology. Clin Ped Emerg Med 2010;11(4):233-243
FUTURE DIRECTIONS
 DEXMEDETOMIDINE
 Disadvantages
 Slower onset
 Longer recovery times (Halflife 2-3 hours)
 Hypertension/Reflex bradycardia
 Cost
 Potential ED Applications
 Mild sedation for imaging
 Sedation w/o IV/IM requirements
 Behavioural/Autism
35. Lubisch N, Roskos R Berkenbosch JW. Dexmedetomidine for procedural sedation in children with autism and other
behavioural disorders. Pediatr Neurol 2009;41:88-94
FUTURE DIRECTIONS
 FOSPROPOFOL
 Water soluble prodrug converted to propofol w/i minutes
 Undergoing Phase III Trials
 Side effects:
 Paresthesias (62%)
 Pruritis (27.6%)
 Hypotension (3%)
 Emesis (3%)
36. Garnock-Jones KP, Scott LR. Fospropofol. Drugs 2010;70(4):469-477
37. Sneyd JR, Rigby-Jones AE. New drugs and technologies, intravenous anesthesiology is on the move (again). Br J Anaesth
2010;105(3):246-254
FUTURE DIRECTIONS
 PATIENT CONTROLLED SEDATION
 Increasing focus in literature
 PCS vs. PMS
 Complicated psychobiological effects
38. Atkins JH, Mandel JE. Recent advances in patient-controlled sedation. Curr Opin Anes 2008;21:759-765
FUTURE DIRECTIONS
 PATIENT CONTROLLED SEDATION
FUTURE DIRECTIONS
 PATIENT CONTROLLED SEDATION
 ED Evidence?
 Limited
 ED RCT 2010, n=166, PCS vs EPCS using propofol
39. Bell A, Lipp T, Greenslad J, et al. A Randomized controlled trial comparing patient-controlled and physician-controlled
sedation in the emergency department. 2010;56(5):502-508.
FUTURE DIRECTIONS
 PATIENT CONTROLLED SEDATION
 Shows promise in the literature
 Requires more ED specific evidence