Procedural Sedation

A/Prof Vasilios Nimorakiotakis (Bill Nimo)MBBS, FACEM, FACRRM, Dip MgtDeputy DirectorEmergency Department Epworth RichmondClinical Associate ProfessorThe University of Melbourne

Disclosure

• I talk a lot

Overview

• Why is it important?

• What is the definition?

• Summary of the ANZCA 2014 guidelines (which had been endorsed by a lot of other colleges)

• We will look at some evidence to a few clinical questions such as:

Fasting status

Capnography

Minimum number of people required

Drugs used

• The future

Why is it important?

• There are many situations when “sedation” has to be given quickly

• Procedural sedation improves the quality and safety of patient care

1. decreasing the length of time necessary to perform a procedure

2. increasing the likelihood of success, and reducing risk of injury to the patient or health care worker due to uncontrolled movements

• Historically anaesthetist would be the only ones administering “anaesthetic” drugs. Who is the expert now?

• Boundaries into who preforms “procedural Sedation”. It is a GROWING area of medicine:• ED physician

• General Physicians

• Intensivists

• Rural Doctors

• Dentist

• Paramedics

• Drugs we are using has expanded

Common Drugs used

• Combo with local measures

• Inhaled/IN

• N2O

• Methoxyflurane (Penthrane)

• Fentanyl

• Oral

• NSAI

• Paracetamol/Codeine

• Endone

• IV

• Morphine

• Fentanyl

• Ketamine

• Propofol

• Midazolam

Why do I have an interest in this topic:

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Soft tissue injuries

Semi elective procedures

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Paediatrics

Trauma

Definitions

Procedural sedation was formally and inaccurately known as “conscious sedation” :• Procedural sedation should be viewed as a

treatment strategy for the administration of sedative or analgesic medications to intentionally suppress a patient’s level of consciousness.

• The intended sedation depth should vary in accordance with the specific needs of the patient and procedure.

• Sedation depths of “mild,” “moderate,” and “deep” levels of altered consciousness are frequently cited in the medical literature.

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Brief Summary of 15 page document

• Definition:

Procedural sedation and/or analgesia imply that the patient is in a state of drug-induced tolerance of uncomfortable or painful diagnostic or interventional medical, dental or surgical procedures. Lack of memory of distressing events and/or analgesia may be desired outcomes, but lack of response to painful stimulation is not assured

Conscious sedation

defined as a drug-induced depression of consciousness during which patients are able to respond purposefully to verbal commands or light tactile stimulation.

Deeper sedation

is characterised by depression of consciousness that can readily progress to the point where consciousness is lost and patients respond only to painful stimulation

Analgesia

is reduction or elimination of pain perception, usually induced by drugs that act locally (by interfering with nerve conduction) or generally (by depressing pain perception in the central nervous system)

General Anaesthesia

a drug-induced state characterised by absence of purposeful response to any stimulus, loss of protective airway reflexes

PATIENT PREPARATION

RECOMMENDATION

• Informed consent for sedation and/or analgesia and for the procedure should be obtained from the patient, or a person entitled to give consent on behalf of the patient, according to applicable legislation (see ANZCA professional document PS26 Guidelines on Consent for Anaesthesia or Sedation).

REALITY

• Not often performed for multiple reasons

• Time

• Patient barriers

STAFFING

RECOMMENDATION

• Except for techniques such as inhaled nitrous oxide, inhaled methoxyflurane or low dose oral sedation (see scenario 0, appendix 3), there must be a minimum of three appropriately trained staff present

REALITY

• Can be achieved in most tertiary hospitals

• NOT achievable in a lot of places where procedural sedation is often performed

Rural and remote

Prehospital

FACILITIES AND EQUIPMENT

RECOMMENDATION

• In essence to be done in a resuscitation equipped cubicle

REALITY

• Most times can be achieved BUT not always

TECHNIQUE AND MONITORING

RECOMMENDATIONS

• Monitoring of the depth of sedation, typically by assessing the patient’s response to verbal commands or stimulation must be routine

• All patients undergoing procedural sedation and/or analgesia must be monitored continuously with pulse oximetry and this equipment must alarm when appropriate limits are transgressed

REALITY

• Achievable

• Most placed also monitor ETCO2… not recommended in this document

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DOCUMENTATION

RECOMMENDATIONS

• The clinical record should include the names of staff performing sedation and/or analgesia, with documentation of the history, examination and investigation findings. A written record of the dosages of drugs and the timing of their administration must be kept as a part of the patient's records.

REALITY

• Reality this is poorly done

AUDIT

RECOMMENDATIONS

• Practitioners carrying out sedation and/or analgesia should be subject to regular and effective audit of sedation administration complying with local jurisdictional requirements

REALITY

• Not done

• Need a better documentation system to measure sedation level that has clinical relevance

• Need a standardised auditing process

• What are trying to achieve

• Improve evidence

How do we measure and document the levels of sedation?

No advice given by this document to guide us which is the best way to document the level of sedation

So what do we use……

AVPU:

• A is alert, or

• V responds to voice, or

• P responds to pain by localizing appropriately, flexing limbs or extending limbs to pain, or

• U is unresponsive.

GCS

One of the better ones:Practice guidelines for sedation and analgesia by anaesthetist:

• Adopted from the Ramsey Sedation Scale which was published in 1974

Another sedation scoring system currently being used

BB score

BB score

• An alternative to the GSC and AVPU

• Similar to the Ramsey score

• 4 levels

• Allow for accurate documentation

• Easily taught and understood by both medical and non medical people

• More relevance for procedural sedation than we are currently using

4 levels of BB score “Bill’s Beer”

Minimal SedationBB1 (1-4 beers)

TIPSY STATE

• Just starting off

• Dutch courage is increased to a point where you will have enough courage to speak to someone you normally wouldn't

• Still intact cognition, only slurring words a little

MEDICAL CORRELATION

• relief of pain without intentionally producing a sedated state.

• Altered mental status may occur as a secondary effect of medications administered for analgesia

Moderate sedation BB2 (4-6 Beers)

DRUNK STATE

• Now officially disinhibited

• Common features of this state are:

• People who never dance start dancing

• Slurred speech

• Hypersalivation and spitting when talking are a common feature

MEDICAL CORRELATION

• the patient responds purposefully to verbal commands alone or when accompanied by light touch.

• Protective airway reflexes and adequate ventilation are maintained without intervention

• Cardiovascular function remains stable.

General anaesthesiaBB3 (>10 Beers)

VERY DRUNK STATE

• Now officially “unconscious”

• Common features of this state are:

• Lying in inappropriate places

• When recovered from this sate has little recollection of events

MEDICAL CORRELATION• the patient cannot be roused and often requires assistance to protect the airway and maintain ventilation.

• At risk of aspiration

• Cardiovascular function may be impaired

BK

The K state

• Patients look “wired” and behave in an unusual manner

• Acting erratically with a “high” pain threshold

MEDICAL CORRELATION

• a trance-like cataleptic state in which the patient experiences profound analgesia and amnesia, but retains airway protective reflexes, spontaneous respirations, and cardiopulmonary stability.

• Ketamine is the pharmacologic agent used for procedural sedation that produces this sate

WHAT IS THE EVIDENCE:

• Good review of literature on specific questions we commonly ask

• Translation of Class of Evidence to Recommendation levels

Clinical Questions ?

FASTING:

• Q: In patients undergoing procedural sedation and analgesia in the emergency department, does pre-procedural fasting demonstrate a reduction in the risk of emesis or aspiration?

EVIDENCE/ RECOMMENDATION:

• Most guidelines for fasting are based on patients having general anaesthesia

• Four class two trials looking at fasting status in adults and paediatric patients of fasting time (0 to >8hrs) did NOT demonstrate a significant difference in rate of emesis and aspiration

Clinical Question?

End tidal CO2

• Q: In patients undergoing procedural sedation and analgesia in the emergency department, does the routine use of capnography reduce the incidence of adverse respiratory events?

EVIDENCE/ RECOMMENDATION

• Monitoring ETCO2 detects hypoventilation earlier than other methods such as pule oximetry and HR alone particular when supplemental oxygen is given

• Level B studies show routine capnography decreases the incident of hypoxia BUT there is little evidence to say that it correlates to serious adverse events during procedural sedation (neurologic injury secondary to hypoxia, aspiration or death)

Clinical Question?

Number of People?

• Q: In patients undergoing procedural sedation and analgesia in the emergency department, what is the minimum number of personnel necessary to manage complications?

EVIDENCE/RECOMMENDATION

• No clear data on the number and personal required.

• If patients are potentially more complex it was postulated a minimum of two physicians should be involved however no evidence for this model.

• It is important for institutions to:

• Ensure that all individuals who perform moderate or deep sedation are able to choose an appropriate pharmacologic agents that they are familiar with

• Monitor patients to detect complications such as hypotension, hypoventilation, hypoxia, and dysrhythmias; and

• Know how to manage any potential complications.

Clinical Question?What drugs are safe?

• Q: In patients undergoing procedural sedation and analgesia in the emergency department, can ketamine, propofol, etomidate, dexmedetomidine, alfentanil, and remifentanil be safely administered?

EVIDENCE/RECOMMENDATION

• More and more evidence to show the safety of drugs used for procedural sedation such as Propofol, Ketamine, fentanyl etc.

Summary

• Lack of good evidence

• Documentation of “level of sedation” for future audit has not been agreed on

• Growing area of Medicine

• We need to educate to ensure safety

• We require more formalisation of credentialing to ensure those that are performing it are qualified• Drugs they are credentialed to use

• Tailor to the environment they work in (BB restrictions )

• Requirement of re-credentialing

• Minimum history required to document (also help with Audit)

• Consent (verbal/written)

• Discharge

• Audit

Good Resource

https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0006/218580/Minimum_Standards_for_Safe_Procedural_Sedation_Project_-_Final_-_updated_June_2015.PDF

Questions