Procedural sedation

Background

  • ACEP Definition: Procedural sdeation is a technique of administering sedatives or dissociative agents with or without analgesics to induce a state that allows the patient to tolerate unpleasant procedures while maintaining cardiorespiratory function. [1]

Sedation Levels

Sedation levels

Level Definition Comments
Minimal Sedation Standard pain medications
Moderate Sedation Awake and able to respond to questions use in: LP, I+D
Dissociative Sedation Trance-like state, airway reflexes preserved
Deep Sedation React purposefully to painful stimuli use in: Reduction
General Anesthesia Unarousable, requires intubation/advanced airway

Procedural Checklist[2]

  • Consent in chart
  • PIV with fluids running
  • ETCO2 and NC connected to patient
  • Airway preparation
    • Suction with Yankauer attached
    • BVM attached to wall oxygen
    • Oral/nasal airways
    • Mac/Miller blades
    • ET tubes with stylets
  • Meds at bedside
    • Sedation Meds
    • Narcan 0.4mg if opioid being used, not drawn up
    • Epinephrine, cardiac syringe (1:10,000) unopened and 10 cc NS Flush with needle
    • Glycopyrrolate, 1 vial; not drawn up

Fasting

  • No need to delay procedure based on fasting time. Preprocedural fasting for any duration has not demonstrated a reduction in the risk of emesis or aspiration when administering procedural sedation and analgesia (ACEP Level B) [1]
  • Some specialty societies recommend:
    • 2-hour fasting time for clear liquids
    • 4-hour fasting time for breast milk
    • 6-hour fasting time for solids

Airway Monitoring

  • Capnography may be used as an adjunct to pulse oximetry and clinical assessment to detect hypoventilation and apnea earlier than pulse oximetry and/or clinical assessment alone. However, there is a lack of evidence that capnography reduces the incidence of serious adverse events (neurologic injury caused by hypoxia, aspiration, death) (ACEP Level B). [1]
  • Placing the patient on ETCO2 + SpO2 is ideal[3]
  • Position the patient in a position you would intubate if needed (ear at level of sternal notch)
  • Consider nasal airway in patients with likely OSA

Sedative agents

  • The ideal agent is short-acting with minimal respiratory or hemodynamic depression
  • Ketamine offers the greatest safety profile overall but caution in the elderly or patients with known cardiovascular disease due to sympathetic surge
  • Propofol is often used for orthopedic procedures due to muscle relaxation, but can cause respiratory depression and hypotension
  • Etomidate used less frequently than other agents; causes myoclonus that is undesirable for orthopedic reduction

Fentanyl/Midazolam

  • Dose fentanyl first: 0.5-1mcg/kg
  • Follow with 1-2 mg of midazolam
  • Designed for moderate sedation
  • Duration 30min

Fentanyl/Etomidate

  • Similar to fentnayl/midazolam, but better because shorter duration of action
  • An alternative to propofol for brief sedation
    • E.g. shoulder/hip reduction, cardioversion
  • Can cause myoclonus[4] and occaisonly adrenal supression.
  • Dose fentanyl first: 0.5-1mcg/kg
  • Etomidate 0.15mg/kg (8-10mg avg)
  • Duration: 6min

Brevital (Methohexital)/Fentanyl

  • Suppresses the reticular activating center in the brainstem and cerebral cortex, thereby causing sedation
  • Sedation and amnesia, no analgesia
  • Dose fentanyl first: 0.5-1mcg/kg
  • Initial dose 0.75 to 1mg/kg IV
  • Repeat doses of 0.5mg/kg IV can be given every two minutes.
  • Immediate onset, duration <10 minutes

Ketamine

  • Noncompetitive NMDA receptor antagonist that produced dissociative state
  • Sedation, analgesia, and amnesia
  • Safe to use in children undergoing procedural sedation and analgesia (Level A recommendation)[1]
  • Maintains upper airway tone, protective reflexes, and spontaneous breathing
  • Little evidence to advocate for prevention of emergence phenomenon, may pretreat with midazolam 0.05 mg/kg (2-4 mg for most adults)[5]
    • Versed can be used subsequently if emergence reaction occurs
  • 1-2 mg/kg IV, followed by 0.5-1 mg/kg IV PRN
  • 4-5 mg/kg IM → repeat 2-4 mg/kg IM after 10 min if first dose unsuccessful
  • Duration 10 to 20 minutes

Propofol

  • Potentiates GABA receptors, sedative hypnotic agent without analgesic properties
  • Rapid onset <1 min, short duration <10 min, predictable dose dependent potency
  • 0.5-1mg/kg IV over 3-5 mins, repeat 0.5 mg/kg q3-5 min PRN
  • Can cause dose-related respiratory depression, hypotension, and decreased cardiac output, however, rarely leads to unplanned intubation, prolonged observation, or complications requiring admission [6]
  • Can cause sympathomimetic effects, such as tachycardia, hypertension, and increased cardiac output, and caution should be used in patients with known or suspected coronary artery disease

Propofol/Ketamine (Ketofol)

  • 1:1 mixture of ketamine and propofol[7]
  • Safe in children and adults undergoing procedural sedation and anesthesia (Level B Reccomendation)[1]
  • Theorized that side-effect profiles counter one another
    • Propofol-associated hypotension and respiratory depression can theoretically be reduced with increases in circulatory norepinephrine induced by ketamine
    • Ketamine associated nausea and emergence reactions are theoretically reduced by the antiemetic and anxiolytic properties of propofol
  • A study of pediatric patients found the total patient sedation times to be shorter (3 minutes) with the combined ketamine and propofol regimen compared with ketamine alone[8]
  • Dose: 0.5mg/kg propofol with 0.5mg/kg ketamine (may be mixed in same syringe or given separately)

Dexmedetomidine

  • 1 mcg/kg loading dose followed by 0.2-1 mcg/kg/hr maintenance dose
  • Side effects include bradycardia and hypotension.
  • Avoid in patients with heart blocks
  • May need to supplement with 1-2 mg of midazolam

Etomidate

  • 0.1mg/kg one time dosing
  • Max: 10mg
  • Minimal respiratory depression but decrease blood pressure and heart rate (alpha2 agonism)

Side Effects

  • Desaturation
    • Stimulate
      • Try pressure behind ear
    • Jaw thrust
    • Nasal airway
    • BVM (just 10 breaths/min) count to 5 between breaths
    • NIV
    • LMA
    • Intubation

Disposition

  • Monitor until patient alert, at baseline level of consciousness, have purposeful neuromuscular activity, and have baseline vital signs [9]
  • Not necessary to tolerate oral challenge [10]

See Also

References

  1. 1.0 1.1 1.2 1.3 1.4 ACEP Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department full text
  2. http://emcrit.org/wp-content/uploads/Sedation_Checklist-8-1-10.pdf
  3. Deitch K, Miner J, Chudnofsky CR, Dominici P, Latta D. 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 Mar;55(3):258-64.
  4. Van Keulen SG, Burton JH. Myoclonus associated with etomidate for ED procedural sedation and analgesia. Am J Emerg Med. 2003;21:556-558.
  5. Sener S, Eken C, Schultz CH, Serinken M, Ozsarac M. Ketamine with and without midazolam for emergency department sedation in adults: a randomized controlled trial. Ann Emerg Med. 2011 Feb;57(2):109-114.e2
  6. Blackburn 2000, Burnton JH, Miner JR, et al. Propofol for emergency department procedural sedation and analgesia: a tale of three centers. Acad Emerg Med. 2006;13(1):24-30
  7. Andolfatto G, Abu-Laban RB, Zed PJ, et al. Ketamine-propofol combination (ketofol) versus propofol alone for emergency department procedural sedation and analgesia: a randomized double-blind trial. Ann Emerg Med. 2012; 59(6): 504-12.e1-2. PMID: 22401952
  8. Shah A, Mosdossy G, McLeod S, et al. A blinded, randomized controlled trial to evaluate ketamine/propofol versus ketamine alone for procedural sedation in children. Ann Emerg Med. 2011;57:425-433.
  9. Joint Commission on Accreditation of Healthcare Organizations. Care of patients: examples of compliance. in: Joint Commission on Accreditation of Healthcare Organizations, Oakbrook Terrace, IL; 1999:87-91
  10. Newman DH, Azer MM, Pitetti RD, et al. When is a patient safe for discharge after procedural sedation? The timing of adverse effect events in 1367 pediatric procedural sedations. Ann Emerg Med. 2003;42(5):627