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Procedural Sedation: Technique for Safe and Effective Sedation in Medical Procedures

Learn about the technique of procedural sedation, which induces a state allowing patients to tolerate unpleasant procedures while maintaining cardiorespiratory function. Discover the benefits, alternative treatments, and preprocedure evaluation.

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Procedural Sedation: Technique for Safe and Effective Sedation in Medical Procedures

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  1. Procedural Sedation M Anto ED prov fellow Mona Vale Hospital 29 Sep 2016

  2. What is proc sed • ACEP: • Technique of administering sedatives or dissociative agents • With or without analgesics • Induce a state that allows the patient to tolerate unpleasant procedures while maintaining cardiorespiratory function • Procedural sedation and analgesia is intended to result in a depressed level of consciousness that allows the patient to maintain oxygenation and airway control independently • ANZCA/ACEM: • State of drug induced tolerance of uncomfortable/painful medical/dental/surgical procedure

  3. Indications • Reduction of dislocation or fracture • Laceration repair • DCCV • Abcess incision and drainage • LP

  4. Benefits • Provides analgesia • Avoid OT • Cost • Reduces LOS • Safe in ED

  5. Alternative treatments • LA – topical, local infiltrate • Nerve blocks • Biers block • GA (in OT) • Nothing

  6. Definitions • Minimal sedation: • Normal response to verbal stimuli • Cognition + coordination may be affected • CVS/resp normal • Moderate sedation: • Depression of consciousness • Response to verbal stimuli • Airway patent, resp good, CVS usually normal

  7. Definitions • Deep sedation: • Depression of consciousness • Not easily aroused • May have impaired ventilatory function • May need assistance to maintain patent airway • CVS usually maintained • GA: • Loss of consciousness • Ventilatory function requires assistance • Assistance for patent airway • CVS may be affected

  8. History Examination Investigations Preprocedure evaluation

  9. Preprocedure eval: hx • Details of the current problem • Co-existing and past medical and surgical history • History of previous sedation and anaesthesia • Current medications (including non-prescribed medications) • Allergies • Fasting status • Dentition - false, damaged or loose teeth • Other evidence of potential airway problems • Patient’s exercise tolerance or functional status

  10. Preprocedure eval: exam • Airway • Respiratory • CVS • Other systems as indicated by the history, including that relevant to the current problem

  11. Preprocedure eval: Ix • ?Baseline ECG • BSL

  12. High risk patients • All children less than 2 years of age • Elderly • Pregnancy • Severe comorbidities • CVS, CNS, resp, liver, renal disease • Morbid obesity • Severe OSA • Acute gastrointestinal bleeding +/- shock • Severe anaemia • Potential for aspiration of stomach contents (which may necessitate endotracheal intubation) • Patients in ASA Grades P4-5 • Previous adverse events due to sedation, analgesia or anaesthesia • Known or suspected difficult ETT

  13. Patient counselling • Informed consent • Indications • Complications • Alternative treatments • Discharge advice

  14. Preprocedure fasting • Regurgitation, aspiration syndrome – 0.5% all PSA • ANZCA: • Prolonged fasting from fluids for more than 6 hours fails to achieve an optimally empty stomach • Clear fluids up to 2hrs • Limited solid food 6hrs • ACEP: Fasting not required – Level B • ?Antacids

  15. Personnel • Single trained person to monitor patient during mod and deep sedation • ED consultant or most senior doctor needs to be aware of the patient receiving sedation – does not necessarily need to be in room • Proceduralist (1-2) • Nursing staff to document and assist

  16. Training • Supervised training • CRM • BSL/ALS • CPD • Audit

  17. Preparation • Room/location • Lighting • OT table/trolley/chair preferred • Suction • O2 • Emergency equipment • Monitoring • Meds • Equipment for procedure • Means of summoning assistance • Clinical response plan

  18. Monitoring • The following data should be recorded at appropriate intervals before, during, and after the procedure, with alarms set: • Pulse oximetry • Response to verbal commands (when practical) • Pulmonary ventilation (observation, auscultation) • EtCO2 • BP/HR q5min • ECG for patients with significant cardiovascular disease

  19. Emergency equipment • Airway trolley (+ difficult airway trolley) • BVM • Defib • ECG • IV trolley

  20. Supplemental O2 • Considered and available for all patients for as much of the procedure as possible • Prior to sedation may not benefit all patients, and may not need be practical e.g. small children, IH • Pulse oximetry

  21. IV access • Required in most cases for medication and analgesia • Not requiring with low doses inhaled/oral meds

  22. Analgesia NO2 Fentanyl Morphine Ketamine Medications • Sedation • Propofol • Ketamine • Midazolam

  23. Propofol • Onset 30sec, peak 120sec, duration 3-10min • CI: allergy to egg, soy • SE: hypotension, bradycardia, resp depression, pain on infusion • No analgesia • Dose: 0.5-2mg/kg

  24. Ketamine • Disassociative • Onset 2min, peak 3min, duration 15min IV or 30min IM • Benefits: maintains airway reflexes + spont resp, CVS stable, bronchodilator • SE: laryngospasm, emergence, secretions, reduces seizure threshhold, vomiting • Technique • Dose: IV 0.5-2mg/kg, IM 2-4mg/kg

  25. Midazolam • Anxiolysis, sedation, amnesia, no analgesia • Onset 1-5min, peak 10-15min, duration 60min • SE: hypotension, resp depression, paraxodical rxn • Dose: 0.025-0.05mg/kg max 0.4mg/kg • Avoid EtOH

  26. NO2 • Inhalation, sedative, amnesiac, analgesia • Fast induction • Requires scavenging system • CI: bowel obstruction, Ptx • Monitor for diffusion hypoxia – O2 post procedure • SE: vomiting • Dose: 30-70%

  27. Opiates • Morphine • Fentanyl

  28. Reversal agents • Naloxone • Flumazenil

  29. Recovery • Sedation Dr present until: • Spont resps • Obs stable • Protecting airway • Monitor in ED until: • Fully awake • Tolerating oral intake • Analgesia adequate • Mobilising

  30. Documentation • Name of staff involved • Hx, exam, Ix • Doses/time of meds • Monitor readings inc during recovery

  31. Discharge advice • Written instructions • Supervision at home • E+D • Analgesia • Resumption of normal activities • Legally binding decisions • EtOH • Driving • Heavy machinery

  32. Take home message • Assess the patient adequately • Prepare • Understand your meds • Situational awareness

  33. References • ANZCA Guidelines on Sedation and/or Analgesia for Diagnostic and Interventional Medical, Dental or Surgical Procedures • Emcrit • HETI clinical update 349 (27/2/04) • Medscape • Uptodate • PEMSoft • LITFL • SCGH ED CME

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