Safe Procedural Sedation - PowerPoint Presentation

1. Safe Procedural SedationGeraldine Boyle, 3rd Year Medical StudentSSC: Emergency Medicine Practical ProceduresAntrim Area Hospital: 14/01/2019 - 01/02/2019

2. Procedural SedationSedation: spectrum of pharmacologically induced levels of depressed consciousness PSA: Induce state where patient can tolerate unpleasant or painful procedures + maintain Cardio-respiratory functionFractures, dislocationsED: Minimal (Anxiolysis), Moderate Sedation/Analgesia, Deep Sedation*, Dissociative Sedation* Spontaneous ventilation may be inadequate and intervention requiredSedation Risks: cardio-respiratory complications, hypoxia(1-7)PSA: Procedural Sedation & Analgesia

3. StagesPre-ProcedureAssess patient suitabilityDevise a safe discharge planEnsure safety of the procedureObtain consentProcedurePost-operative care(3, 8) (Fig 1.)

4. Pre Sedation Assessment & ConsentPM History Cardiorespiratory, co-morbidities, aspiration risk, drug and food allergiesECGAsk about FastingNo clear evidence for fasting reducing aspiration Written Consent: < age 16 cannot give consent, <13 cannot receive IV sedation in ED ASA Grade:  ≤ 2 Examination: Cardiovascular and Respiratory Difficult Airway Examination: LEMON (3-5, 8,11) (Fig 1a.)

5. Ensure Safety of Procedure Staffing: IV Sedation: 1 sedation doctor + 1 sedation nurse + another doctor present in EDOnly proceed if competent in intubation/ALSEnvironment: Resus Check Equipment: Procedure, Monitoring, POC, Airways, Supplemental OxygenDocumentation:See Pro-forma Vital signs throughout procedurePrescribed drugs(3, 8)

6. EquipmentCardiac Monitor, Pulse Oximeter, BP CuffTilting TrolleyFull oxygen cylinder under patient’s trolley with 100% oxygen mask attachedBag Valve MaskNasopharyngeal & Oropharyngeal AirwaysEndotracheal tubesLaryngoscopes & laryngeal masksAnaesthetic machine with oxygen on at 10 litres/minSuction + suction catheterNaloxone & Flumazenil(3, 8)Nasopharyngeal A.Oropharyngeal A.Supraglottic A.Endotracheal TubesLaryngoscope

7. SedationPre-oxygenate patient: Reduce procedural hypoxemia. Administer drug +/- additional analgesia, according to guidelinesSedation Continuum: ED aim level 3 - 4 for most proceduresMonitor: Frequent intervals: HR, RR, BP (BP cuff) Constant: SpO2, Cardiac monitoring (chest leads), EtCO2 (capnography) Sats <92%, stop procedure, attend to airwayPulse OximeterCapnographyBP CuffChest Leads (ECG)Vital Signs MonitorAirway Equipment(1-3,8,9)

8. RoleSedation/ AmnesiaSedation/ AmnesiaSedation/ Analgesia Sedation (dissociative), amnesia, analgesia, PropertiesFast acting water soluble benzodiazepineLipophilic agent: GABA inhibitory effectSynthetic Opioid Phencyclidine derivative Onset Duration1-2.5 mins10-40 mins0.5 mins5 mins2-3 mins30-60 mins0.5 mins20 minsSide EffectsHypotension, respiratory depressionProlonged sedation in elderly, obese, hepatic, renal Profound Hypotension & respiratory depression (esp. with opioids). Pain at injection site. Respiratory depression (esp. with sedatives).Prolonged effects in elderly, obese, hepatic, renal.Emergence delirium, tachycardia, hypertension. OtherNot licensed for use in children <6mths (oral/ buccal route)Reversal Agent: Flumazenil (only in emergency)Not licensed for children though NICE recommends. Contains soya and egg lecithin (allergies)Reversal agent: NaloxoneAirways and respiration maintained.Contraindicated in <3 months old, schizophrenia (10,2,11)Drug selection is based on range of factors e.g. patient (CV risk), pain, post-procedure agitation, recovery time, fasting status

9. Post-Operative Care Supervised recovery time no less than 4 hoursDischarge when:Regain pre-procedure baseline vital signs and level of consciousnessWalk unaidedDrink fluids, pass urinePain has been addressedVerbal and written instructionsSupervision by responsible adult(2,3,8) (Fig.2)

10. ConclusionProcedural Sedation is a useful tool in EDSerious complications are rare and safe practice reduces risk of complicationsProblems arise due to:inappropriate patient selection Lack of organisation or resourcesEquipment not available or not workinglack of skills and drug knowledgeE.g. rapid titration, not adjusting doses for elderly patients, chronically ill, or childrenUndue pain and discomfort: Not allowing analgesia or sedative to take maximal effect or not providing analgesiaPremature discontinuation of monitoring Discharge without supervision or written advice(2,3)

11. ReferencesED Antrim Area Hospital. Emergency Department Antrim Area Hospital Doctor’s Handbook, August 2018. Antrim; 2018. Available from http://gcs3.co.uk/ed/wp-content/uploads/2018/08/HANDBOOK-2018.pdf [Accessed on 27/01/19]Frank RL. Procedural Sedation in Adults Outside the Operating Room. 2018. Available from: https://www-uptodate-com.queens.ezp1.qub.ac.uk/contents/procedural-sedation-in-adults-outside-the-operating-room?search=procedural%20sedation&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1 [Accessed on 26/01/19]Russell D, Thakore SB. Adult Procedural Sedation. 2017. Available from: https://www.rcemlearning.co.uk/references/adult-procedural-sedation/ [Accessed on 26/01/19]AoMRC. Safe Sedation Practice for Healthcare Procedures: Standards and Guidance. 2013. Available from: https://www.rcoa.ac.uk/system/files/PUB-SafeSedPrac2013.pdf [Accessed on 29/01/19]RCoA and RCEM. Safe Sedation of adults in the Emergency Department. 2012. https://www.rcem.ac.uk/docs/College%20Guidelines/5z7.%20Safe%20Sedation%20in%20the%20Emergency%20Department%20-%20Report%20and%20Recommendations.pdf [Accessed on 26/01/19]Atkinson Paul, French James, Nice C Andrew. Procedural Sedation and Analgesia for Adults in the Emergency Department. BMJ: British Medical Journal [Internet]. 2014;348. Available from: http://queens.ezp1.qub.ac.uk/login?url=http://search.ebscohost.com.queens.ezp1.qub.ac.uk/login.aspx?direct=true&db=edsjsr&AN=edsjsr.26514748&site=eds-live&scope=site [Accessed on 29/01/19]Knape JT, Adriaensen H, van Aken H, Blunnie WP, Carlsson C, Dupont M, Pasch T. Guidelines for Sedation and/or Analgesia by Non-Anaesthesiology Doctors. European Journal of Anaesthesiology. 2007;24(7):563-7.Conway A, Douglas C, Sutherland J. Capnography Monitoring During Procedural Sedation and Analgesia: A Systematic Review Protocol. Systematic Reviews. 2015; 4:92. Baldwin A, Hjelde N, Goumalatsou C, Myers G. Oxford Handbook of Clinical Specialties. Tenth [Mini ed. Oxford; 4: Oxford University Press; 2016RCEM. Pharmacological Agents for Procedural Sedation and Analgesia in the Emergency Department: Best Practice Guideline. 2016 Available from: https://www.rcem.ac.uk/docs/College%20Guidelines/Pharmacological%20Agents%20for%20Procedural%20Sedation%20and%20Analgesia%20(Oct%202016).pdf [Accessed on 25/01/19]BC Emergency Medicine Network. Procedural Sedation and Analgesia (PSA).2018. Available from: https://www.bcemergencynetwork.ca/clinical_resource/procedural-sedation-analgesia/ [Accessed on 30/01/19]Figure 1 & 1a: Adult Sedation Pro Forma from Antrim Area Hospital ED. 2019.Figure 2: Post Sedation Advice Sheet from Antrim Area Hospital ED. 2019.All images taken by author in Antrim Area ED, 2019