Transcript 2008_09_04-Choi-Analgesia__sedation

Analgesia and
Procedural Sedation
Dave Choi
PGY-4 ER Edmonton
Dr. A. Storck
Objectives
• Very basic pain pathophysiology
• Pain assessment
• Management of pain
• Will not cover nerve blocks, local
anesthetics, or chronic pain
management
QuickTime™ and a
H.264 decompressor
are needed to see this picture.
Pain
• Most common complaint in ED
• Essential goal of healthcare is to
prevent and relieve pain
• Patients judge us by how we treat pain
• We cause pain
• Physiologic / psychologic outcomes
Case 1
• 45 yo male
• Left flank pain x 8 hrs
• 8/10 pain, can’t get comfortable
• PmHx: HTN, renal colic
• Please help doc!
Case 2
• 70yo female
• Slipped on stairs 2 hrs ago
• Obvious deformity to left ankle
• PmHx: HTN, NIDDM, MI last year
• Grimacing in pain
Case 3
• 21 yo male
• RLQ pain x 2/7
• Anorexia, mild nausea, fever
• PmHx: healthy
• Please don’t touch my stomach doc!
Pain Physiology
• Nociceptor (pain receptor)
- Superficial somatic
- Deep somatic
- Visceral
• Neuropathic
- Peripheral
- Central
• Psychogenic
Pain Definition
•An unpleasant sensory and emotional
experience associated with actual or
potential tissue damage, or described in
terms of such damage.
• International Association for the Study of Pain (IASP) 2007
Judging pain
• Patient complaint
• Physician impression, HR, BP, facial
expression poor indicators
• Age, Sex, Race, cognitive functioning
• Numeric scale
• All very subjective
We any good?
Study
• Convenience cohort of 71 patients
>18yo
• Pt rated pain with VAS and NRS
• ER docs and nurses rated patients pain
Conclusion
• Docs and nurses consistently rated pain
less than the patient
• Only 30% of patients were satisfied with
their pain control
• Mild/moderate pain unlikely to receive
any analgesia
• 2/3 of severe pain received analgesia
Pain Control
• We suck at estimating
pain
• We undertreat pain
• Patients not happy
• Should give patients
benefit of the doubt
Are we getting
better?
•Use of analgesics increased by 18%
from 1997 to 2001
• McCaig. National Hospital Ambulatory Medical Care Survey: 2001 ED
Summary. National Center for Health Statistics, 2003
Pain control options
• Local / Regional
• Systemic
- Anti-inflammatories
- Opioids
- Others: TCAs, anti-convulsants,
relaxants, cannabis, distractions, music
Pain control
• We can make pain better
• No reliable objective measures
• Avoid the “squeaky wheel gets the oil”
• Individualized pain control
• Anticipate pain and treat it
• Let patient control pain if possible
NSAIDS
• Inhibit enzyme cyclooxygenase (COX)
• Enzyme responsible for formation of
prostaglandin and thromboxane
• Messenger molecules for inflammation,
pain, and fever
• Also gastric lining and platelet function
Ibuprofen
• Contraindications
- GI ulcer
- Pregnancy (esp 3rd trimester)
- Acute bleeds
- Renal dysfunction
- Recent CABG
Ibuprofen
• Cautions
- ASA sensitive asthma
- ASA for cardioprotection
- ACE inhibitors / ARB
Ibuprofen
• Dosing?
• Evidence?
Ibuprofen vs Toradol
CJEM Jan 2007
Ibuprofen vs Toradol
• Numerous studies show no benefit of
parenteral ketorolac over oral ibuprofen
• Belief that IM/IV medication are
perceived as being stronger has been
shown to be false
• Ketorolac has higher cost, risk of
extravasation, risk of needle stick
injuries
Other NSAIDS
• Diclofenac 50mg TID
• Naproxen 250-500mg BID
• Indomethacin 25-50mg TID
Opioids
• Opioid receptors
- Mu: analgesia, respiratory depression,
euphoria
- Kappa: analgesia, sedation, respiratory
depression, miosis
- Sigma: dysphoria, hallucinations,
tachypnea, tachycardia
Opioids
• Metabolized by liver, excreted by kidney
• Should be given IV
• Fixed intervals with PRNs
Morphine
• Onset: 5-10min
• Peak: 15-30min
• Duration: 2-4hrs
• Routes: IV/IM/PO
• Dose: IV 0.05-0.2mg/kg, PO 0.20.5mg/kg
Morphine: the GOOD
• Reliable
• Lots of experience with it
• Reversal agent
Morphine: the BAD
• Histamine release
• Decreased GI motility
• Nausea
• CVS/Resp depression
Demerol
• Generic: meperidine
• Onset: 5-10min
• Peak: IV 5-15min, IM 30-60min
• Duration: 3-4hrs
• Route: PO/IV/SC/IM
• Dose: 1-2mg/kg (for all routes)
Demerol: the GOOD
• Theoretical benefit of Sphincter of Oddi
relaxation
• Helps some chronic migraine patients
➡ NOT MUCH ELSE
Demerol: the BAD
• Cerebral irritant (anxiety, disorientation,
tremors, seizures, hallucination,
psychosis)
• Not very good analgesic compared to
other opioids
• Nausea
• Dependence
• Serotonin syndrome
Demerol = Ugly
Fentanyl
• Onset: 1-2min
• Peak: 3-10min
• Duration: 30-75min
• Routes: IV/IM/TM
• Dose: IV 0.5-3ug/kg
Fentanyl: the GOOD
• Fast acting
• Potent (100x morphine)
• No histamine release
Fentanyl: the BAD
• Doesn’t last very long
• Cardiorespiratory depression
• Nausea, itchy nose
• Chest wall, glottis, diaphragm rigidity
• Potential AV prolongation and
bradycardia in pediatrics with rapid
dosing
Percocet
• Acetaminophen 325mg, oxycodone
5mg
• Onset: 30min
• Peak: 1hr
• Duration: 2-4hrs
• Route: PO
• Dose: 1-2tabs (max 12/day)
Tylenol #3
• Acetaminophen 300mg, codeine 30mg,
caffeine 15mg
• Onset: 30min
• Peak: 1hr
• Duration: 2-4hrs
• Route: PO
• Dose: 1-2tabs (max 12/day)
Codeine
• Metabolized (cytochrome P450) by liver
to morphine
• 10% caucasians lack enzyme
• Good cough suppressant
Tylenol vs
Tylenol+Codeine
• Systematic Review by Craen et al. BMJ
1996
• 5% increase in analgesia with added
codeine for single dose (stat significant)
• Multiple doses increased side effects
• NNT = 9 for 50% pain reduction
➡Use if patient says it works for them
Dilaudid
• Generic: hydromorphone
• Onset: IV 5-10min
• Peak: IV 15-30min
• Duration: 2-4hrs
• Route: IV/SC/IM/PO
• Dose: IV 0.01-0.05mg/kg, PO x2-3 dose
Anti-emetic
• Opioid induced nausea multifactorial:
histamine, direct gastroparesis, central
chemoreceptor
• ~20% emesis
• No need to pre-treat unless history of
significant emesis/nausea previously
Competence
• Some say use of opioids affects
competence and ability to give consent
• 2 studies which show otherwise
• Maybe patients even pressured to sign
consent if they’re in pain?
Smithline HA, Mader TJ, Crenshaw BJ. Do patients with acute medical conditions have the capacity to give informed
consent for emergency medicine research? Acad Emerg Med. 1999;6:776-80 Vessey W, Siriwardena A. Informed
consent in patients with acute abdominal pain. Br J Surg. 1998;85:1278-80
Masking pathology
• Lee study
• how much is too
much opioids?
Pediatrics
• Yes, they feel pain too
• We are especially bad at treating kids
with pain
• Choices?
• Tylenol, Ibuprofen, Opioids
• Topical / Sucrose / Sprays
• Double blind RCT
• Term newborns within 2 days
• 24% sucrose PO
• Venipuncture, IM Vit K injection, heel
poke for c/s
Conclusion
• Overall decrease in pain scores
(Premature Infant Pain Profile)
• Reduction for venipuncture
• No reduction for IM injections
• Double blind RCT
• Children 6-12yo venipuncture
• Vapocoolant spray vs placebo
• All distracted
• Visual analogue scale
Results
• Modest reduction in pain
- 56.1 vs 36.9 (out of 100)
• Higher success rate first attemt (NNT 5)
- ?why
Case 1
• 45 yo male
• Left flank pain x 8 hrs
• 8/10 pain, can’t get comfortable
• PmHx: HTN, renal colic
• Please help doc!
Case 2
• 70yo female
• Slipped on stairs 2 hrs ago
• Obvious deformity to left ankle
• PmHx: HTN, NIDDM, MI last year
• Grimacing in pain
Case 3
• 21 yo male
• RLQ pain x 2/7
• Anorexia, mild nausea, fever
• PmHx: healthy
• Please don’t touch my stomach doc!
Procedural
Sedation
Objectives
• Definitions
• Indications
• Contraindications
• Approach
• Drugs (no gases)
• Few interesting topics
Scope of Practice
• Emergency physicians are trained to:
- Monitor patients
- Recognize potential problems early
- Intervene when necessary
• American Society of Anesthesiologists
“suggestion” for granting privileges to
administer moderate sedation
• Suggestions on personnel, equipment,
monitoring, etc
• ?evidence based?
CAEP Guidelines
1999
ACEP Guidelines
2005
Case 1
• 18 yo male
• Fell snowboarding and hurt right
shoulder
• Obvious dislocation
• First time
Case 2
• 73yo female
• FOOSH left
• Colle’s fracture
• PmHx: HTN, hypothyroid
Case 3
• 3yo female
• Fell and hit forehead on coffee table
• Laceration forehead too deep/wide for
glue
• No previous procedures
• ++++crying, thrashing
Case 4
• 61yo male
• Sudden onset palpitation during
breakfast 2 hours ago
• Rapid A.fib on ECG
• PmHx: HTN, NSTEMI, ↑CHOL, smoker
Case 5
• 56 yo male
• Slipped 2 steps
• Obviously deformed R ankle
• Neurovasc intact
• PmHx: morbid obesity, HTN, IDDM, MI
last year, COPD, sleep apnea, smoker
Goals of PS
• Patient wellness #1
• Sedation, analgesia, anxiolysis and
amnesia during painful procedure
• Minimize associated adverse
psychological response
• Facilitation of procedure
• Return patient to baseline state
Innes et al. Procedural Sedation and Analgesia in the Emergency
Department. Canadian Consensus Guidelines. Journal of Emergency
Medicine. 1999: 17:1. 145-156
Procedural Sedation
•
•
•
•
Reduce the patient’s anxiety and
nervousness as much as possible prior to
the procedure. (Anxiolysis)
Reduce the patient’s awareness of the
external environment. (Sedation)
Reduce/eliminate any pain the patient feels
during the procedure (Analgesia)
Ensure that the patient does not remember
the procedure (Amnesia)
Definition
• Technique of administering sedatives or
dissociative agents and analgesia to
induce a state that allows the patient to
tolerate unpleasant procedures while
maintaining cardio-respiratory fuction /
reflexes
Terminology
• Minimal sedation (anxiolysis): a drug
induced state where patients respond
normally to verbal commands, cognitive
function and coordination may be
impared
Green et al. Procedural Sedation Terminology: Moving Beyond “Conscious
Sedation” Annals of Emergency Medicine, 2002: 39:4. 433-435.
Terminology
•Moderate sedation (formerly “conscious
sedation”): a drug induced depression of
consciousness where patients respond
purposely to verbal command,
cardiorespiratory function not impared
Green et al. Procedural Sedation Terminology: Moving Beyond “Conscious
Sedation” Annals of Emergency Medicine, 2002: 39:4. 433-435.
Terminology
•Dissociative sedation: trance like
cataleptic state characterized by
profound analgesia and amnesia with
retention of cardiorespiratory function
Green et al. Procedural Sedation Terminology: Moving Beyond “Conscious
Sedation” Annals of Emergency Medicine, 2002: 39:4. 433-435.
Terminology
•Deep sedation: drug induced depression
of consciousness where patients cannot
be easily roused, but respond purposely
after repeated or painful stimulation,
respiratory function may be impared
Green et al. Procedural Sedation Terminology: Moving Beyond “Conscious
Sedation” Annals of Emergency Medicine, 2002: 39:4. 433-435.
Terminology
•General anesthesia: drug induced loss of
consciousness where patients are not
rousable, usually need help with
ventilation, cardiovascular function may
be impared
Green et al. Procedural Sedation Terminology: Moving Beyond “Conscious
Sedation” Annals of Emergency Medicine, 2002: 39:4. 433-435.
Ideal Medication
• Anxiolytic, analgesia, amnesia
• Rapid onset, short duration
• No neurologic or cardiorespiratory
depression
• Safe, effective, easy to administer, and
reversible
➡DOESN’T EXIST
Indications
• Painful procedures
• Imaging
• Violent /
uncooperative /
anxious patient
Contraindications
• Absolute
- Inadequate experience with airway
management and ALS or medications
- Inadequate monitoring or resuscitative
equipment
- Allergy / sensitivity to medications
Innes et al. Procedural Sedation and Analgesia in the Emergency
Department. Canadian Consensus Guidelines. Journal of Emergency
Medicine. 1999: 17:1. 145-156
Contraindications
• Relative
- Minor airway issues
- High aspiration risk
- Hemodynamically or neurologically
unstable
- ASA III/IV
Innes et al. Procedural Sedation and Analgesia in the Emergency
Department. Canadian Consensus Guidelines. Journal of Emergency
Medicine. 1999: 17:1. 145-156
General Approach
• Pre-sedation:
indication/contraindication, Hx/PE,
consent, preparation
• Sedation: O , monitoring, drugs
• Post sedation: monitor, d/c criteria /
2
instructions
Procedural Urgency
•
•
•
Emergent (eg, cardioversion for life-threatening dysrhythmia,
reduction of markedly angulated fracture or dislocation with
soft tissue or vascular compromise, intractable pain)
Urgent (eg, care of dirty wounds and lacerations, animal and
human bites, abscess incision and drainage, fracture
reduction, hip reduction, lumbar puncture for suspected
meningitis, arthrocentesis, neuroimaging for trauma)
Semi-urgent (eg, care of clean wounds and lacerations,
shoulder reduction, neuroimaging for new-onset seizure,
foreign body removal, sexual assault examination)
•
Non-urgent or elective (eg, non-vegetable foreign body in
external auditory canal, chronic embedded soft tissue foreign
body,
toenail)
Green
et al.
Fasting and Emergency Department Procedural Sedation and
Analgesia: A Consensus-Based Clinical Practice Advisory. Annals of
Emergency Medicine. March 2006
ASA
Class
1. Healthy
2. Mild systemic disease w/o functional
limitation
3. Severe systemic disease w/ functional
limitation
4. Severe systemic disease w/ constant
threat to life
5. Moribund patient who will die without
operation
6. Probably will die during operation
Some Pearls
• Extremes of age
• TITRATE
• Minimum required medication
• Know how the procedure will be done
History
• Recent illness
• PmHx
• Medications
• Allergies
• Prior sedations / general anesthetic
• NPO?
Physical Exam
• Vitals
• LOC
• CVS/resp
exam
• Airway
QuickTime™ and a
H.264 decompressor
are needed to see this picture.
Airway
• Look for external characteristics known
to causes problems with BVM or
intubation.
• Evaluate the 3-3-1 Rule:
-
Mouth, hyoid, ant jaw subluxation
• Mallampati Score
• Obstruction – any pathology within or
surrounding the upper airway
• Neck Mobility - full flexion & extension
Fasting
Green et al. Fasting and Emergency Department Procedural Sedation and
Analgesia: A Consensus-Based Clinical Practice Advisory. Annals of
Emergency Medicine. March 2006
Fasting Guideline
• Expert panel of emergency physicians
• MEDLINE search relevant articles
• Reviewed by emergency and nonemergency physician experts
Fasting Guideline
• Aspiration risk in procedural sedation
extremely low
• Aspiration of clear liquids little risk of
mobidity
• Sedation length not enough evidence
• Avoid PPV
• Rx pretreatment doesn’t help
Aspiration Risk
Factors
• Airway difficulties
• Age >70
• ASA 3 or greater
• GERD predisposition: esophageal dzs,
hiatus hernia, PUD, gastritis, bowel
obstruction, ileus, elevated ICP
• NOT: pregnancy, DM, opioid, obesity
Fasting Guidelines
Fasting Guidelines
Consent
• Verbal / Written
• Discussion
- Objective of sedation
- Risk/benefit
- Limitations/alternatives
- Post sedation monitoring/activities
Sedation levels
Sedation
Response
Airway
Ventilation
CVS
Light/Mo
d
Purposeful
Respond to
verbal
Normal
Normal
Normal
Deep
GA
Pain
Possibly Possibly Usually
intervene abnormal normal
None
Frequentl
Maybe
Intervene
y
abnormal
abnormal
Well...
• Sedation is more of a continuum rather
than set categories
Innes et al. Procedural Sedation and Analgesia in the Emergency
Department. Canadian Consensus Guidelines. Journal of Emergency
Medicine. 1999: 17:1. 145-156
Smooth Sedation
• Pland ahead
• Risk assessment
• TITRATE
Oxygen Controversy
• Should pre-oxygenate?
• YES: increase reserve, lower risk
desaturation
• NO: decrease detection hypoventilation
➡Probably should give some oxygen
• Nasal cannula CO
detector for
pediatric orthopedic procedures
2
• Prospective convenience sample
observational study
Annals of Emergency Medicine, January 2007
Result
• ETCO >50 or increase by 10
• O sat <90
• Apnea >30sec
• ETCO detected apnea before clinical
2
2
2
exam or pulse oximetry in all cases
5/125
• ETCO detected airway obstruction first
2
in 6/10 occurrences
• Prospective observatinal study
• Adults undergoing PS
• Observer ’s Assessment of
Alertness/Sedation scale (OAA/S),
pulse ox, nasal ETCO2
Results
• Pulse oximetry alone detected 11/33
• ETCO detected all episodes of
2
respiratory depression (same cut off
values)
• ETCO had no correlation with OAA/S
2
Capnography
• Clinical significance of increased
ETCO2 without hypoxemia,
obstruction?
• Subclinical respiratory depression
important?
• ETCO
• ETCO
2
threshold?
monitoring going to decrease
incidence of hypoxemia or
interventions needed?
2
Checklist
• Who do you want?
• What do you want?
• Where do you want it?
Personnel
•
•
•
•
1 or 2 docs
Nurse
RT
Evidence?
Equipment
• Bedside
- Drugs
- Pulse oxymeter, BP cuff, IV
- Oxygen, suction
- BVM, oral airway
Equipment
• Readily available
- Reversal agents
- Cardiac monitoring
- Intubation stuff
- Crash cart with drugs
Drugs
• Propofol
• Midazolam
• Fentanyl
• Etomidate
• Ketamine
• Ketafol
Propofol
• Alkyl phenol (non-opioid, nonbarbituate)
• Sedative hypnotic
• Highly lipid soluble (BBB)
• Rapidly cleared by liver
Propofol
• Onset: 1min
• Duration: 8-10min
• IV, 10mg/ml vials
• Dosing: start low, go slow, titrate to
effect
• Egg / Soy allergies
Propofol: the GOOD
• Quick on / off
• Anti-emetic
• No hangover
• Increase seizure threshold
• Amnesia
• Decreased ICP / IOP
Propofol: the BAD
• Respiratory depression
• Myocardial depressant
• No analgesia
• Pain at injection site
• Goes bad
Propofol: the
Evidence
Miner and Burton. Clinical Practice Advisory: Emergency Department Procedural
Sedation with Propofol. Annals of Emergency Medicine. 2007.
Propofol Highlights
• Age >55 or ASA 3 or greater have
higher chance hypotension
• Should have 2 docs when available
• Give oxygen
• Monitor with pulse oxymetry +/capnography
• Consider lidocaine 0.5mg/kg in syringe
Propofol Highlights
• Age >55 or ASA 3 or greater have
higher chance hypotension
• Should have 2 docs when available
• Give oxygen
• Monitor with pulse oxymetry +/capnography
• Consider lidocaine 0.5mg/kg in syringe
Propofol in Pediatrics
• Havel et al. A Clinical Trial of Propofol
vs Midazolam for Procedural Sedation
in a Pediatric Emergency Department.
Acad Emerg Med. 1999;6:989-997.
• Skokan et al. Use of Propofol Sedation
in a Pediatric Emergency Department:
A Prospective Study. Clin Pediatr.
2001;40:663-671
Propofol in Pediatrics
• Propofol as effective as midazolam with
shorter recovery time
• Complication rates for propofol and
midazolam comparable
• Propofol safe and effective
Midazolam
• Short acting benzodiazepine
• Anxiolysis, amnesia, sedation
• Facilitates GABA action by inhibiting
glycine
• Water soluble and lipophilic so quickly
crosses BBB
• Metabolized by cytochrome P450,
excreted by kidneys
Midazolam
• IV/IM/PO/PR/TM
• Onset: IV 1-5min, IM 5-15min,
PO>30min
• Peak: IV 1-2min, IM 15-60 min
• Duration: up to 2 hrs
• Dose: IV 0.02-0.1mg/kg, titrate to effect
Midazolam: the
GOOD
• Short half life
• Good sedation, amnesia, anxiolysis
• Muscle relaxant, anticonvulsant
• Reversible
• Multiple routes
Midazolam: the BAD
• Potent respiratory depression
• Hypotension, bradycardia
• Above worse with opioid (but need it)
• Agitation, involuntary movements,
nystagmus, paradoxical hyperactivity
• Class D in pregnancy
Etomidate
• Non barbituate sedative hypnotic
• GABA receptor
• Sedation
• No analgesia
Etomidate
• Dose: 0.1-0.2mg/kg
• Onset: 1min
• Duration: 10-15min
Etomidate 3Ps
• CONTRAINDICATIONS
1. Pregnant
2. Poor adrenal function
3. Prior seizures
Etomidate: the
GOOD
• Cardiovascular stability
• Reduction in ICP
• Less respiratory depression
Etomidate: the BAD
• Respiratory depression
• Vomitting
• Myoclonus
• Adrenal suppression
Annals of Emergency Medicine, Jan 2007
• Propofol and Etomidate had similar
efficacy and side effect profile
• Etomidate caused more myoclonus and
hence slightly lower procedural success
rate
Etomidate: the
Evidence
•
•
•
•
Vinson DR, Bradbury DR. Etomidate for procedural sedation in
emergency medicine. Ann Emerg Med 2002;39(6):592–8.
Ruth WJ, Burton JH, Bock AJ. Intravenous etomidate for procedural
sedation in emergency department patients. Acad Emerg Med
2001;8(1):13–8.
Keim SM, Erstad BL, Sakles JC, et al. Etomidate for procedural
sedation in the emergency department. Pharmacotherapy
2002;22(5):586–91.
Burton JH, Bock AJ, Strout TD, et al. Etomidate and midazolam for
reduction of anterior shoulder dislocation: a randomized, controlled
trial. Ann Emerg Med 2002;40(5):496–504.
Etomidate
• Adequate sedation
• Short duration of action
• Stable hemodynamic profile
• Few minor complications:
apnea/desats, vomitting, myoclonus
Bahn and Holt. Procedural Sedation and Analgesia: A Review and New
Concepts. Emerg Med Clin N Am 23 (2005) 503-517
Ketamine
• Dissociative agent
• Disconnects thalamus from limbic
sysem
• Depresses cortical function while
stimulating limbic system
• Trancelike state: analgesia, sedation,
amnesia
Ketamine
• Routes: IV/IM/PO/PR/IN
• Dose: IV 1-2mg/kg, IM 2-4mg/kg
• Onset: IV 1min, IM 5min
• Duration: IV 15min, IM 15-30min
• Highly lipid soluble
• Metabolized by liver, excreted by kidney
Ketamine
• Direct myocardial depressant
• Increased sympathetic outflow
• Tachycardia and vasoconstriction
• NOTE: profound hypovolemia or
minimal sympathetic reserve may
cause severe hypotension
• Ketamine Eyes
Ketamine: the GOOD
• Rapid onset / offset
• Minimal cardiovascular effects
• Minimal respiratory depression
• Analgesia
• Bronchodilation
Ketamine: the BAD
• Laryngospasm
• Increased secretions
• Muscular tone / movements
• Vomitting
• ICP? IOP
• Emergence phenomena
Emergence
Reactions
• Risk Factors
- Age>15
- Women
- Large, rapid doses, after Atropine
- Already aggitated
- Personality disorder
- Excessive physical stimulation
Emergence
Reactions
• Floating sensations
• Dizziness
• Blurred vision
• Out of body experiences
• Vivid dreams / nightmares
Contraindications
• Ischemic heart disease
• Prolonged stress response
• Poorly controlled hypertension
• Recent URTI
• History of psychotic illness
Ketafol: the new kid
on the block
Annals of Emergency Medicine. Vol 48 No1. Jan 2007. pp 23-30.
Study
• Prospective case series in community
teaching hospital July 2005 to Feb 2006
• 114 procedural sedations
• Mostly orthopedic procedures
• All age groups
• Ketafol (Ketamine and Propofol at 1:1 in
same syringe)
• Some pretreated with opioids
Results
• Median dose 0.75mg/kg of each
• High procedure success rate
• Low complication rate
• Hemodynamically very stable (mild
tachycardia and hypertension)
• Fast recovery time (median 15min)
• High patient satisfaction
Questions
• Study under powered to do subgroup
analysis for different procedures
• Optimal ratio?
• How much additional analgesia?
Pediatrics
• Higher mg/kg dosing
• Narrow safety margin
• <6mth: slower drug clearance,
increased BBB permeability
Age Limit?
• Propofol >3yo
• Ketamine >3mth
• Etomidate >12yo
Reversal Agents
Narcan
• Opioid receptor antagonist
• Onset: 1-2min
• Peak: 5-10min
• Duration: 1-4hrs
• Dose: 2mg or 0.1-0.2mg (10100mcg/kg) titrate to response up to
10mg
Narcan
• Contraindications
- Allergy
- Caution in opioid dependent patients
and agitated patients
• Need to monitor for 2hrs post
Flumazenil
• Benzodiazepine receptor antagonist
• Onset: 1-2min
• Peak: 5-10min
• Duration: 45-90min
• Dose: 0.1mg (0.01mg/kg) tirate to max
2mg
Flumazenil
• Contraindications
- Allergy
- Seizure disorder
- Chronic benzo use
• Need to monitor for 2hrs post
Discharge Criteria
• Baseline physical status / mental status
• Sit, walk, and talk appropriately
• Tolerating oral fluids
• Caregiver presence
• Min 2hr observation if reversal given
• Verbal / written instructions
Discharge
Instructions
• Avoid dangerous activities until 100%
• May feel dizzy, nauseated
• Avoid EtOH or other sedatives x 24h
Case 1
• 18 yo male
• Fell snowboarding and hurt right
shoulder
• Obvious dislocation
• First time
Case 2
• 73yo female
• FOOSH left
• Colle’s fracture
• PmHx: HTN, hypothyroid
Case 3
• 3yo female
• Fell and hit forehead on coffee table
• Laceration forehead too deep/wide for
glue
• No previous procedures
• ++++crying, thrashing
Case 4
• 61yo male
• Sudden onset palpitation during
breakfast 2 hours ago
• Rapid A.fib on ECG
• PmHx: HTN, NSTEMI, ↑CHOL, smoker
Case 5
• 56 yo male
• Slipped 2 steps
• Obviously deformed R ankle
• Neurovasc intact
• PmHx: morbid obesity, HTN, IDDM, MI
last year, COPD, sleep apnea, smoker
QUESTIONS?