Procedural Sedation in ED

Procedural Sedation/Analgesia in
ED
Procedural Sedation/Analgesia in ED
Goals
• To provide safe sedation/analgesia
• To decrease adverse psychological responses
• To facilitate procedure through:
- Minimize pain of procedure
- Minimize fear and anxiety
- Control behavior
- Provide amnesia
Indications of procedural sedation/analgesia

• Fracture, dislocation reduction
• Foreign body removal
• Laceration repair
• Endoscopy
• CT, MRI imaging
• Pediatric gynecology examination
• Invasive procedures
- Lumbar puncture
- Abscess incision
- Others
Procedural sedation/analgesia provider should be competent in:

• Techniques of various modes of sedation
• Appropriate monitoring
• Response to complications
• Use of reversal agents
• At least basic life support
Responsibilities of procedural sedation/analgesia provider

• Obtain consent
• Evaluate the patient prior to procedure
• Document the assessment
• Refer to Anesthesia Department if needed
• Administer medications
• Ensure monitoring of patient progress
• Present in procedure area throughout the entire procedure and remain in recovery
area during recovery
• Ensure appropriate discharge of the patient
Documentation
• ASA Classification
• Airway Classification
• Physical examination
• Lab results
Copyrights apply
Mallampati Airway Classification

Minimal Sedation (Anxiolysis)

• A drug-induced state during which patient responds normally to verbal commands.
Although cognitive function and coordination may be impaired, ventilatory and
cardiovascular functions are unaffected
Moderate Sedation
• A drug-induced depression of consciousness during which patient cannot be easily
aroused, but respond purposefully following repeated or painful stimulations. No
interventions are required to maintain a patent airway and spontaneous
ventilation is adequate. Cardiovascular function is usually maintained
Deep Sedation
• A drug-induced depression of consciousness during which patient cannot be easily
aroused, but respond purposefully following repeated or painful stimulations. The
ability to independently maintain ventilatory function may be impaired. Patient
may require assistance in maintaining a patent airway and spontaneous
ventilation may be inadequate. Cardiovascular function is usually maintained
Common medications for Sedation/Analgesia

• Benzodiazepines
• Opioids
• Sedative-Hypnotics
• Neuroleptics
• Anesthetic agents
Desired actions of drugs used for sedation/analgesia

• Short duration of action
• Lack of cumulative effects
• Promote rapid recovery
• Minimal side effects
• Residual analgesia
Unfortunately no single pharmacological agent satisfies all requirements. Medications

have to be generally combined
Benzodiazepines
• Potentiate the effects of neuroinhibitor GABA. This creates anticonvulsant,
amnesic and sedative effects
• Mimic inhibitory actions of Glycine, causing muscle relaxation and anxiolysis
• Affect the limbic system, thalamus and hypothalamus
Benzodiazepines indicated for:

• Anxiety
• Insomnia
• Seizures
• Muscle relaxation
• Induction of general anesthesia
• Preoperative sedation
• Conscious sedation
• Alcohol withdrawal
Most commonly used Benzodiazepines:

• Diazepam
• Lorazepam
• Midazolam
Benzodiazepines
• Have no analgesic properties
• Combining sedatives and Opioids creates a synergistic action
• Recommended to reduce dose of Benzodiazepine and Opioid by 1/3 when used
concurrently
Benzodiazepines contraindicated in:

• Acute narrow angle glaucoma
• Untreated open angle glaucoma
• Shock
• Coma
• Acute alcohol intoxication
• Children < 6 month old
Adverse effects of Benzodiazepines

• Respiratory
- Respiratory depression, apnea, respiratory arrest (especially Midazolam)
• Cardiovascular
- Diazepam: Decreased SVR and CO
- Midazolam: Hypotension and bradycardia
• CNS
- Diazepam: drowsiness, confusion, slurred speech, syncope
- Midazolam: agitation, hyperactivity, involuntary movement, combativeness
Midazolam (Versed)
• Rapid onset
• Short duration 20-30 minutes
• Dose
- IV: 0.1 mg/kg; max. 5 mg; onset 2-3 minutes
- Oral: 0.5 mg/kg; onset 20-25 minutes
- Intranasal: 0.4 mg/kg; onset 15-20 minutes
- Rectal: 0.5 mg/kg; onset 5-10 minutes
Opioids
• Provide analgesia and some sedation
• Alterations in mood and perception of surroundings
• May depress cough reflexes
Most commonly used Opioids

• Morphine
• Hydromorphone
• Meperidine
• Fentanyl
Meperidine (Pethidine)
• Synthetic Opioid
• Used cautiously in patients with renal/hepatic disease and those at high risk for
seizure due to accumulation of active metabolite Normeperidine
• Dose: 0.5-2 mg/kg IV bolus, may repeat as necessary
• Not used in pediatric patients
Fentanyl
• Synthetic Opioid
• May cause chest wall and glottic rigidity, particularly when administered rapidly.
This may make manual ventilation difficult
• Route of administration: IV
• Onset: 1-3 minutes
• Duration 30-60 minutes
• Dose:
- Adult: 25-50 mcg/dose
- Pediatric: 2-5 mcg/kg/dose
Propofol (Diprivan)
• Widely distributed in the body and is eliminated via hepatic and pulmonary
systems
• No dosage adjustments is necessary in patients with hepatic/renal diseases
• To prevent hypotension consider reduced doses in elderly, hypovolemic or
patients receiving other narcotics/sedatives
• Supports rapid bacterial growth, should be discarded 6 hours after opening
Propofol (Diprivan)
• Short acting non-opioid sedative hypnotic
• Dose: 1-2 mg/kg IV over 1-2 minutes, followed by infusion of 6 mg/kg/hour
• Duration of action: 8-10 minutes
• Side effects
- Deeper sedation
- Cardiorespiratory depression (hypotension 3-10%)
- Pain at injection site
- Contraindicated in patients with hypersensitivity
Ketamine
• Sedative
• Amnesia
• Powerful analgesic
• General anesthesia
Adverse effects of Ketamine

• CNS: hallucinations, delirium, tremors, increased intracranial pressure
• Cardiovascular: Increase in blood pressure, tachycardia, decreased blood pressure
in hypovolemic patients
• Respiratory: copious secretions my be pre-treated with Atropine
Contraindications of Ketamine
• Hypertension, heart failure, recent myocardial infarction, history of cardiovascular
disease
• Increased intracranial pressure
• Increased intraocular pressure
• Acute psychiatric illness
• Thyrotoxicosis
Barbiturates
• Provide sedation but no analgesia
Reversal agents – Naloxone

• Reverses effects of Opioids
• Dose for reversal: IV, IM, SC
- Titrate 0.01-0.1 mg/kg to desired effect (1-2 mcg/kg over less than 30 seconds to
reverse sedation)
- May need multiple doses. Repeat every 2-3 minutes
• Onset of action: 1-2 minutes
Reversal agents – Flumazenil

• Reverses effects of Benzodiazepines
• Dose for reversal: IV, IM
- Pediatric: 0.01-0.2 mg/kg, max: 0.2 mg. May be repeated ½ dose every 1 minute
- Adult: 0.2 mg bolus to total 1 mg. May be repeated every 10 minutes
• Onset of action: 1-5 minutes
Complications of procedural sedation/analgesia

High risk patients
• Elderly
• Hepatic disorders
• Renal disorders
• Respiratory disorders
• Cardiac disorders
• Drug abusers
• Obese patients
Monitoring/Equipment - SOAPME
• S – Suction machine and different size suction catheters
• O – Oxygen supply
• A – Airway management supplies
• P – Pharmacy – All resuscitation medications, sedatives and antagonists if available
• M - Monitors (Vital signs, End-tidal CO2 monitor, ECG, non-invasive blood pressure)
• E – Extra equipment (defibrillator and etc)
- Vigilant monitoring is the key to prevention of overdose and other potential

complications
- If the patient and medication selection is appropriate and the patient is monitored
adequately, incidence of complications due to sedation/analgesia will be very low
Sedation
• Inadequate sedation
- Insuitability of the patient
- Medication errors
• Excessive sedation can be avoided by:
- Monitoring level of consciousness
- Titration of medications
Respiratory depression and hypoventilation

• Detected by:
- Decrease in oxygen saturation
- Decrease in rate and depth of respirations
• Treatment
- Stimulate the patient
- Open the airway
- Give oxygen
- If no improvement, ventilate with bag and mask. If no response, or the patient
develops apnea, intubate
Cardiac complications and hypotension

• Cardiac arrythmias
- Must be recognized and treated quickly for positive patient outcome
• Hemodynamic instability caused by variety of factors
- Hypovolemia
- Myocardial ischemia
- Medications
- Acidosis
- Parasympathetic stimulation
Treatment of cardiac complications and hypotension

• IV fluids
• Oxygen
• Vasopressors or specific agonists
Anesthesia consultation
• Adult patient ASA III or above
• Pediatric patient ASA IV or above
• Patient with complex airway problems
• Previous failure of sedation/analgesia
• Patient ASA I or above undergoing a diagnostic and/or therapeutic procedure (s)
performed by a physician who is not privileged to perform sedation/analgesia
Discharge criteria
• The procedure should be of sufficiently low risk that additional monitoring for
complications is unnecessary
• Symptoms, such as pain, lightheadedness, and nausea should be well-controlled
• Vital signs and respiratory and cardiac function should be stable
• Mental status and physical function should have returned to a point where the
patient can care for himself or herself with minimal to no assistance
• A reliable person who can provide support and supervision should be present at
the patient's home for at least a few hours
Thank you for your attention

Procedural Sedation in ED

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Procedural Sedation in ED

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Procedural Sedation/Analgesia in

Indications of procedural sedation/analgesia

Procedural sedation/analgesia provider should be competent in:

Responsibilities of procedural sedation/analgesia provider

Mallampati Airway Classification

Minimal Sedation (Anxiolysis)

Common medications for Sedation/Analgesia

Desired actions of drugs used for sedation/analgesia

Unfortunately no single pharmacological agent satisfies all requirements. Medications

Benzodiazepines indicated for:

Most commonly used Benzodiazepines:

Benzodiazepines contraindicated in:

Adverse effects of Benzodiazepines

Most commonly used Opioids

Adverse effects of Ketamine

Reversal agents – Naloxone

Reversal agents – Flumazenil

Complications of procedural sedation/analgesia

- Vigilant monitoring is the key to prevention of overdose and other potential

Respiratory depression and hypoventilation

Cardiac complications and hypotension

Treatment of cardiac complications and hypotension

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