Transcript Procedural Sedation

Procedural Sedation
- alternatives to Brutane
Dr Garry Clearwater
MBChB FACEM
Overview
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What is procedural sedation?
Alternatives: Analgesia
Preparation
Drugs
Discharge
More alternatives…
Overview
DISCLAIMER….
This is a very simplified overview of a complex topic.
It is not a substitute for in-depth research, background knowledge and
training.
What is Procedural Sedation?
To reduce patient anxiety and awareness
To facilitate a medical procedure
Patient maintains their airway & breathing
- a.k.a “conscious sedation” “deep sedation”
Uses
Reduction of dislocations:
 shoulder, elbow, hip, patella, ankle
Reduction of fractures:
 wrist, ankle
 washout compound fracture
Paediatric injuries:
 wound inspection, closure, suturing
Abscess I&D
Advantages
Compared to Brutane:
 Less stress and anxiety… for nearly everyone
 Better chance of success (relaxation, time)
Compared to GA:
 PS is quicker – for the patient
 PS is generally safer
Still some uses for Brutane…?
Simple, very quick, curative procedures:
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Reduction of “pulled elbow”:
- Pronate/supinate flexed elbow
- with pressure over the radial head
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Reduction of simple patella dislocation:
- Extend the knee
- with sideways pressure on the patella towards the midline.
Supplementary analgesia may be warranted before and during.
ANALGESIA
Procedural sedation is:
Pain relief
+
Relaxation
• Pain relief by itself often reduces anxiety
ANALGESIA
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Reassurance and explanation
Simple analgesia: paracetamol
ANALGESIA
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Reassurance and explanation
Simple analgesia: paracetamol
Entonox
ANALGESIA
Entonox: Nitrous Oxide
Weak analgesic
 Onset 1 min (12-15 breaths)
 Peak 5 min
Need co-operative patient
Avoid in:
 retained gas: SABO, pneumothorax etc
 Cardiac disease, shock
st
 Pregnancy 1 trimester
S/Es: Dysphoria, nausea
ANALGESIA
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Reassurance and explanation
Simple analgesia: paracetamol
Entonox
Methoxyflurane
ANALGESIA
Penthrox: Methoxyflurane
Moderate analgesic
Fluorinated Hydrocarbon
- Metabolised to Fluoride
 Onset 1-2 minutes
 Peak 5 min
Avoid in:
 Renal impairment, diabetes
S/Es:
- Nephrotoxic; nausea, dizziness.
- bradycardia, low BP
ANALGESIA
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Reassurance and explanation
Simple analgesia: paracetamol
Entonox
Methoxyflurane
Intranasal Fentanyl
ANALGESIA
Fentanyl Intranasal
Narcotic analgesic
Children >2 yo, up to max 70 kg
Via atomiser on end of syringe
 Rapid onset: 2 minutes
 Duration 30 mins
Avoid in:
 Nasal congestion
S/Es:
- nausea, dizziness.
- low BP
ANALGESIA
Fentanyl Intranasal
(Starship CED guideline):
100 mcg / 2 ml with 1 ml tuberculin syringe
- 1.5 mcg/kg (0.03 ml/kg)
Repeat if necessary:
- 0.5 mcg/kg
Patient sits at 45 degrees
Syringe held horizontal:
- one quick spray
Observe for 20 min after dose
ANALGESIA
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Reassurance and explanation
Simple analgesia: paracetamol
Entonox
Methoxyflurane
Intranasal Fentanyl
Intravenous Morphine
ANALGESIA
Morphine IV
- Titrate
- Reversible
0.1 mg / kg
- 2 mg increments in adults
S/Es:
- nausea, dysphoria.
- low BP
- Transient anaphylactoid rash (often mislabelled as
allergy)
ANALGESIA
Morphine IV
Tricks of the trade:
 EMLA or Ametop skin anaesthesia for at least 30 mins
- or insulin syringe local injection
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Have the morphine ready to inject as soon as IV
established
Alternatives to Procedural Sedation…not
In general, stay away from:
 SC and IM injections: variable and prolonged effects
Fallen out of favour …
 Intranasal Midazolam: not an analgesic, works by
ingestion
In the future …
 Fentanyl lollipop?
 Fentanyl nebulised?
ANALGESIA
Horses for Courses:
Renal colic:
 NSAIDs
Biliary colic:
 NSAIDs
 Antacids
ANALGESIA
Caution….
Paradex / Capadex / Dextropropoxyphene
Pethidine
 (Fentanyl is an alternative to morphine)
Tramadol: Potential serotonergic interactions with…
 SSRIs
 Dextropropoxyphene
 Pethidine
A Little Bit of Sedation…
Oral sedation: anxiolysis for children
Use the IV preparation, mix with Paracetamol or Sprite
Variable onset and effect
Low-level prolonged sedation.
Starship Hospital CED “Sedation – Paediatric” guideline:
www.starship.org.nz/index.php/pi_pageid/1065.
ANXIOLYSIS
Midazolam PO
Onset:
10-30 min
Duration:
30-90 min
Analgesia: No
Dose:
0.5 mg/kg, max 15 mg
Variable effect
May cause Paradoxical Agitation
ANXIOLYSIS
Ketamine PO (3 mo – 12 yrs)
Onset:
15-30 min
Duration:
15-60 min
Analgesia: Some
Dose:
5-7 mg/kg
mix with 15-25 ml cold Sprite
Maintains airway
Multiple contra-indications
ANXIOLYSIS
Ketamine PO (3 mo – 12 yrs)
Contra-indications:
 URTI
 Head injury
 Psychiatric or personality disorder
Risks:
 Nausea, vomiting
 Transient respiratory events
 Requires low-stimulation recovery
PREPARATION
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Prepare for the worst
2 clinical staff
Choose your patient carefully
Choose your poison carefully
PREPARATION
Prepare for the worst …
What can go worng?
 Unexpected drug reaction or anaphylaxis
 Vomit and aspirate
 Obstructed airway (e.g. laryngospasm, tongue)
 Apnoea, respiratory arrest
 Profound hypotension
PREPARATION
Not quite the worst …
What can go worng?
 Disinhibition / agitation
 Terrors, nightmares
 Unexpected drug reactions: dystonias
 Inadequate sedation
 Unsuccessful procedure… still needs GA
PREPARATION
ACEM POLICY DOCUMENT USE OF INTRAVENOUS SEDATION FOR
PROCEDURES IN THE EMERGENCY
DEPARTMENT
© ACEM. 5 December 2001
PREPARATION
2. ENVIRONMENT
The procedure must be performed in a suitable clinical
area with facilities for:
 Monitoring,
 Oxygen
 Suction
 immediate access to emergency
resuscitation equipment, drugs
and other skilled staff.
PREPARATION
2. ENVIRONMENT
Readily available equipment must include:
 resuscitation trolley
 defibrillator
PREPARATION
2. ENVIRONMENT
Readily available equipment must include:
 resuscitation trolley
 Defibrillator
 Bag-Valve-Mask device for ventilation
PREPARATION
3. MONITORING
Cardiac rhythm, non-invasive blood pressure and pulse
oximetry must be monitored throughout the procedure
and recovery period
PREPARATION
1. PERSONNEL
The involvement of at least two clinical staff is required:
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PERSON PERFORMING PROCEDURE
must understand the procedure and its potential
complications.
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PERSON GIVING DRUGS AND MONITORING PATIENT must have training and experience of resuscitation,
emergency drugs and …. (details of) the drugs used.
This person is not involved in the performance of the
procedure but is dedicated to care and monitoring of the
patient.
PREPARATION
1. PERSONNEL
The involvement of at least two clinical staff is required:
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PERSON PERFORMING PROCEDURE
must understand the procedure and its potential
complications.
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PERSON GIVING DRUGS AND MONITORING PATIENT must have training and experience of resuscitation,
emergency drugs and …. (details of) the drugs used.
This person is not involved in the performance of the
procedure but is dedicated to care and monitoring of the
patient.
PREPARATION
1. PERSONNEL
The involvement of at least two clinical staff is required:
SUPERVISING PERSON –
a specialist or advanced trainee in emergency medicine who
has specific experience in airway control and resuscitation
must be either directly involved in the procedure (taking one
of the above roles) or must be aware of the procedure and
provide overall supervision and back-up assistance.
PREPARATION
5. PATIENT PREPARATION
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Explanation
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Consent
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Secure IV access is mandatory.
PREPARATION
Other requirements
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Separate space to perform the procedure
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A recovery space: ideally quiet, available for 1-2 hours,
easily observed.
PATIENT SELECTION
Can you hold the fort if something goes wrong?
AIRWAY:
 Thyromental distance
 Open mouth > 3 FB
 Stable teeth
 View hypopharynx
 Mobile neck
PATIENT SELECTION
Can you hold the fort if something goes wrong?
BREATHING & CIRCULATION:
 Lung disease?
 Stable cardiac status?
 BP stable?
Medications
Allergies (e.g. watch out for soy, eggs: Propofol)
PATIENT SELECTION
Starved for how long…?
Controversial.
Probably not as rigid as anaesthetic guidelines for GA...
Depends on degree and duration of sedation
Starship CED paediatric guideline:
 Clear fluids:
at least 2 hours
 Non-clear fluids and solids:
at least 4 hours
READY TO GO…
Explain
Pre-oxygenate
IV Access and IV fluid running
Splints or plaster or equipment all ready to go
Hand over your phone or pager…
DRUGS
Choose your poison carefully…
Wide variation in individual responses
Clearwater’s Textbook Rule:
Doctors read textbooks…
but patients don’t.
Titrated is best.
DRUGS
FENTANYL: IV adjunct
Onset:
2-5 min
Duration:
30 min
Analgesia: Yes
Advantage: Reversible (Naloxone)
Alternative to Morphine
But…
BP drop
Chest wall rigidity
Nausea
DRUGS
MIDAZOLAM
Onset:
1-2 min
Duration:
10-30 min
Analgesia: No
Advantage: Reversible
But…
Propofol
BP drop
Slower, not as deep as
DRUGS
ETOMIDATE
Onset:
<1 min
Duration:
5-8 min
Analgesia: No
Advantage: BP maintained
But…
Twitching / myoclonus
Nausea
Not fully registered (s.29)
DRUGS
PROPOFOL
Onset:
<1 min
Duration:
5-10 min
Analgesia: No
Advantage: Not cumulative
But…
BP drop
Allergy soy or eggs
DRUGS
KETAMINE
Onset:
1-3 min
Duration:
5-20 min
Analgesia: Yes!
Advantage: Preserves ABC
But…
Emergence phenomena
Eyes open, random
movements
Salivation,
Laryngospasm
DRUGS
KETAMINE
Atypical reactions more common in:
 older children >10 yrs
 girls
 agitated children
 URTI / rhinitis
Need low-stimulus recovery room.
May need IV Midazolam
OFF WE GO….
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Prepare for the worst
2 clinical staff
Choose your patient carefully
Choose your poison carefully
Keep watching the patient … during
Keep watching the patient … after
Discharge with a well-advised capable observer
PATIENT DISCHARGE
Allow at least 1 hour after last dose given
Various criteria for discharge:
 Normal vital signs
 Alert / orientated / back to baseline
 Able to sit / mobilise unaided
 Able to drink
 Sensible capable observer
 Good advice
More alternatives to Procedural Sedation
Infant analgesia: 0 – 3 mo.
25-33% sucrose
0.25 – 2 ml PO (give with dummy)
Mild analgesia
Releases endogenous opiods:
- Reversible with Naloxone
Onset
Duration
2-5 mins
5-8 mins
More alternatives to Procedural Sedation
Wound Care:
Topical anaesthesia:
“Topicaine”:
0.1 ml/kg
Apply to open wound
on a small gauze swab;
Cover with Opsite
… and wait
More alternatives to Procedural Sedation
Wound Care:
Topical anaesthesia:
“Topicaine”:
0.1 ml/kg
Apply to open wound
on a small gauze swab;
Cover with Opsite
… and wait
… 30 mins
More alternatives to Procedural Sedation
Dislocated shoulder
Intra-articular anaesthesia:
More alternatives to Procedural Sedation
Dislocated shoulder
Intra-articular anaesthesia:
Lignocaine 1% 20 ml
20G 3.5 cm needle.
Insert just lateral to acromion.
Aim to glenoid.
Aspirate sero-sanguinous fluid
Inject over 30 sec.
Takes 15-20 min to work
Acknowledgements & resources
ACEM (Info Centre > Policies Guidelines):
 www.acem.org.au
Starship Hospital CED (Health professionals > Clinical
guidelines:
 www.starship.org.nz
Kidz First / Middlemore Hospital ED clinical guidelines
RCH Melbourne guidelines
 www.rch.org.au/rchcpg