Avoiding Procedural Sedation Errors

Transcription

1 Avoiding Procedural Sedation Errors Sanjay Arora MD Associate Professor of Clinical Emergency Medicine Keck School of Medicine USC+Los Angeles County Hospital Pitfall #1 Forgetting the Goals of PS&A 1

2 Sedation Goals Minimize pain Alleviate anxiety Maximize amnesia Control behavior Maintain cardiovascular and respiratory status Reach the perfect place in the spectrum Pitfall #2 Not Respecting the Spectrum of Sedation Sedation Spectrum Awake Moderate Deep General 2

3 Sedation Spectrum Awake Moderate Deep General Moderate Sedation Depressed level of consciousness Responds purposefully to verbal commands Maintains airway Spontaneous ventilation CV function not affected Sedation Spectrum Awake Moderate Deep General 3

4 Deep Sedation Depressed level of consciousness Not easily aroused Responds purposefully to repeated or painful stimuli Potential loss of ventilation or airway CV usually stable Sedation Spectrum Awake Moderate Deep General General Anesthesia Loss of consciousness Not responsive to any stimuli Loss of airway Possible loss of CV function 4

5 Respect the Spectrum Set a goal but be prepared to rescue from the next level Pitfall #3 Using PS&A for the Wrong Procedure or the Wrong Patient The Right Procedures Endoscopy Cardioversion Joint/ fracture reduction Diagnostic radiology Laceration repair 5

6 Other Good Procedures Abscess I&D Chest tube Foreign body Lumbar puncture Dressing changes 6

7 Picking the Right Patient Previous sedation experiences PMH Pregnancy Status Physical exam Airway assessment ASA risk classification Airway Assessment Habitus Head and neck Mouth Jaw Mallampati Mallampati I 7

8 Mallampati II Mallampati III Mallampati IV 8

9 ASA Risk Classification I! Normal healthy patient! II! III! IV! V! Patient with mild, controlled systemic disease! Patient with severe, uncontrolled systemic disease! Severe systemic disease that is a constant threat to life! Moribund patient not expected to survive more than 24 hours! Pitfall #4 Not Knowing the Laws of Fasting Fasting JCAHO: should not drink fluids or eat solids for a sufficient period of time to allow for gastric emptying ASA: 2 hours for clear liquids and 6 hours for solids Recs based studies in general anesthesia All rules out the window in an emergency 9

10 Know the Local Laws! Age! Solids, non-clear liquids! Clear liquids! Adult! 6-8 hours! 2-3 hours! Kids >36mos! 6-8 hours! 2-3 hours! 6-36 mos! 6 hours! 2-3 hours! 0-5 mos! 4-6 hours! 2 hours! Non- General Anesthesia Fasting Literature Prospective pediatric case series N = 905: 396 F and 509 NF AE: hypoxia, stridor, aspiration... AE: 6.9% F and 8.1% NF No clinically evident pulmonary aspiration Agrawal et al, Preproced fasting state and AE in children undergoing PS&A in a Pediatric ED Annals of Emergency Medicine 2003; 42 No5! Fasting Literature Fasting and Emergency Department PS&A: A Consensus-Based Clinical Practice Advisory Annals of Emergency Medicine 2007; 49(4)! 10

11 Pitfall #5 Not Preparing Adequately Equipment Oxygen Suction IV access Basic airway equipment Advanced airway equipment Crash cart/ defibrillator Monitoring equipment Qualified Monitor Monitoring Oxygenation Ventilation Breathing CO2 Hemodynamic BP at regular intervals ECG 11

12 Pre-Procedure?s PS&A is not for everyone! Time for procedure too long/ too short Unsafe prior experience Upper airway obstruction Lack of personnel Unstable patients ASA class V Pitfall #6 Discharging a Patient Before They Are Ready 12

13 Discharge Criteria CV function and airway satisfactory and stable Baseline level of consciousness Patient can talk Can walk/ sit up (age-appropriate) Tolerating oral fluids Has a responsible adult to go home with Pitfall #7 The Drugs: Not Knowing Who, What When, Where, Why and How 13

14 The Perfect Drug The Perfect Drug Analgesia Anxiolysis Amnesia Behavioral modification Maintains CV and respiratory status Easy to dose Quick on/ quick off Chloral Hydrate Nitrous Oxide Benzodiazepines Barbiturates Ketamine Etomidate Propofol The Drugs 14

15 Attending: Wisdom Chloral Hydrate Lots of experience Pure sedative No analgesia Dose: mg/kg PO, PR Onset: approx 40 min Duration: 60 min (up to 24 hrs) AE: vomiting & disinhibition Chloral Hydrate J Formos Med Assoc 2006 Yu-Cheng Lin! 15

16 Nitrous Oxide Discovered in 1772 First used for anesthesia in 1790s Nitrous Oxide The Good Amnesia Anxiolysis Analgesia Dose: 50-66% N2O / O2 Onset: 3-5 min Duration: 3-5 min Nitrous Oxide The Bad Vomiting Accumulates in enclosed body cavities Increases cerebral blood flow Unpredictable Potential for abuse 16

17 Benzodiazepines Decent amnesia No analgesia Respiratory depression Hypotension with high doses Disinhibition And the Winner Is... Lorazepam (Ativan) Diazepam (Valium) Midazolam (Versed) Midazolam (Versed) 3-4 times more potent than Ativan Meta-analysis showed increased satisfaction and amnesia Onset: 3-5 minutes Duration: minutes Dose: mg/kg McQuaid et al, A Systematic review and MA of RCT of MS for routine endoscopic procedures GI Endoscopy 2008; 67(6)! 17

18 Midazolam (Versed) 3-4 times more potent than Ativan Meta-analysis showed increased satisfaction and amnesia Onset: 3-5 minutes Duration: minutes Dose: mg/kg McQuaid et al, A Systematic review and MA of RCT of MS for routine endoscopic procedures GI Endoscopy 2008; 67(6)! Before... After... 18

19 It s Like Drinking a 6- pack of Beer Barbiturates Act at GABA receptor complex Amnesia Anxiolysis No analgesia Hypotension Laryngospasm All effects dose dependent Methohexital (Brevital) Onset < 1 minute Duration <10 minutes Dose mg/kg 3 syringe method 19

20 Ketamine PCP derivative Vitamin K Special K Dissociative anesthetic Trance-like cataleptic state Dissociates thalamoneocortical and limbic areas Ketamine The Good Analgesia Amnesia Airway reflexes maintained No perception of pain Dosing: IM, IV, PO, PR 1-2 mg/kg IV 4-5 mg/kg IM Ketamine The Bad Sympathomimetic action: ICP, IOP, BP Transient laryngospasm Emesis Emergence reaction Increases muscle tone Patient will still move Hyper-salivation Nystagmus 20

21 Ketamine Contraindications Infants < 3mo Severe CAD Significant hypertension Increased ICP or IOP Psychosis Tracheal surgery Too much of a good thing? Reports of overdoses collected Dosages ranged from 5x to 100x the intended dose of Ketamine Brief respiratory depression Brief assisted ventilation Prolonged sedation No adverse outcomes Green S, Acad Emerg Med 1999! 21

22 Minimizing Emergence Recovery What goes in must come out Minimize stimulation quiet room lights dimmed parent at bedside Annals Emerg Med 2000 Sherwin No difference Who s you favorite superhero? Etomidate New induction agent in Europe 1972 First used in the US in 1982 Nonbarbiturate hypnotic Works via GABA receptors Highly lipophilic 22

23 Pros Rapidly distributed, metabolized and excreted No histamine release Minimal cardio-respiratory effects? Amnesia Cons Myoclonus Nausea/ vomiting No analgesic properties? Decreased cortisol/ aldosterone production 23

24 Administration mg/kg bolus Repeat 0.1mg/kg bolus prn Etomidate: The Science Retrospective observational over 2 years n=134 (age 6-93) in 150 procedures Mean cumulative dose 0.2mg/kg All patients ASA class I or II Vinzon et al, Etomidate for procedural sedation in emergency medicine Annals of Emergency Medicine 2002; 39 No 6! Etomidate: The Science Sedation depth Moderate 34% Deep 68% No significant CV effects Hypoxia 5/134 Older, inc dose, NC pre-oxygenation 95% extremely satisfied on phone f/u No way to quantify myoclonus 24

25 Adrenocortical Dysfunction? Prospective, randomized trial of 31 consecutive patients undergoing RSI 0.3mg/kg average etomidate dose vs 0.1mg/kg versed AC function measured at 4, 12, 24 hours Schenarts et al, Academic Emergency Medicine 2001; 8 No 1! AC Dysfunction: Results Significant difference seen only in 4 hour cosyntropin stimulation test Conclusion: adrenocortical dysfunction resolves within 12 hours after single bolus of etomidate What about in patients with sepsis? Propofol: History England 1973 Sedative hypnotic First clinical trial 1977 High incidence of anaphylaxis Lipid-based emulsion 1983 US launch

26 Formulation 1% propofol 2.25% glycerol 10% soybean oil 1.2% egg phospholipid EDTA Formulation 1% propofol 2.25% glycerol 10% soybean oil 1.2% egg phospholipid EDTA Administration Mix with 1% lidocaine Pre-oxygenate Minimum 2 people Slow push Give only what is necessary 1mg/kg bolus then 0.5mg/kg q1-2min 26

27 Pros Quick on, quick off Antiemetic Amnestic Anticonvulsant Decreases ICP/ IOP Burns during injection No analgesic effect Hypotension Decreased respiratory drive Apnea Cons Propofol: The Science Consecutive cases over 2 years (n=397) 1 mg/kg propofol and 0.5 mg/kg BP 84% of patients 92% resolved <2min 100% resolved <7min O2 saturation 5% of patients Only 0.8% required BVM 0 intubations Bassett et al, Propofol for procedural sedation in children in the emergency department Annals of Emergency Medicine 2003; 42! 27

28 Literature Review: Head to Head Trials Propofol vs Methohexital Randomized prospective ortho 51 Propofol and 52 Methohexital Success rate 98% P and 94% M RD 49% P and 48% M Sedation depth equal Pain, recall, satisfaction similar Miner et al, RCT of Propofol versus methohexital for PS during fracture and dislocation reduction in the ED Acad Emerg Med 2003; 10(9)! Propofol vs Etomidate Randomized prospective NB 109 Propofol and 105 Etomidate Success rate 97.2% P and 88.6% E RD 42.2% P and 34.3% E Myoclonus 20% with Etomidate Miner et al, RCT of Etomidate versus Propofol PS in the ED Ann Emerg Med 2007; 49(1)! 28

29 Pitfall #8 Not Keeping Up With Whatʼs New Dexmedetomidine Currently FDA approved for sedation in the ICU <24 hours Highly selective α2 adrenoreceptor agonist Sympatholytic effect in locus ceruleus of brain stem Possible bradycardia/ hypotension No respiratory depression Dexmed: The Science Prospective, randomized, single blind All patients ASA class I or II Colonoscopy patients in three groups Dexmed 1μg/kg over 15 minutes followed by an infusion of 0.2 μg/kg/hr Meperidine 1mg/kg+midazolam 0.05mg/kg Fentanyl mg on demand Berkenbosch et al, Sole Use of dexmedetomidine has limited utility for conscious sedation during outpatient colonoscopy Anesthesiology 2005; 103 No 2! 29

30 Dexmed: The Science D! M+M! F! Number of patients! 19! 21! 24! MAP decrease! 26%! 14%! 3%! Heart rate decrease! 17%! 9%! 7%! Time till ok for dispo! 85! 39! 32! Inspiration From Above Compare and Contrast Prop! Ket! Blood pressure! Dec! Inc! Emetic! Anti! Pro! Analgesia! No! Yes! Emergence reactions! Blunts! Frequent! 30

31 Hmm... Ketamine Propofol Hmm... Ketamine Propofol Ketofol Prospective case series (n=114) 1:1 Ratio median dose 0.75mg/kg Success rate 96.5% Hypoxia 2.6% Emergence reaction 2.6% No hypotension or vomiting Patient, nurse, & physician satisfaction 10 Willman et al, A Prospective eval of ketofol for PS&A in the ED Ann Emerg Med 2007; 49 (1)! 31

32 I saw everything... Lessons Learned Procedural sedation is not for everyone Set a goal and be prepared for deeper Indications and patient selection Know the properties of your drug Be aware of contraindications Know what s new 32

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