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Procedural Sedation. Jan 27, 2011 Jason Mitchell Dr. Gil Curry Dr. Marc Francis. Acknowledgments. Dr. James Huffman Dr. Dave Choi. OUTLINE. INTRODUCTION PRE-SEDATION PREPARATION AGENTS MONITORING OTHER CONTROVERSIES FUTURE DIRECTIONS. INTRODUCTION. Procedural Sedation

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procedural sedation
Procedural Sedation

Jan 27, 2011

Jason Mitchell

Dr. Gil Curry

Dr. Marc Francis

acknowledgments
Acknowledgments

Dr. James Huffman

Dr. Dave Choi

outline
OUTLINE
  • INTRODUCTION
  • PRE-SEDATION PREPARATION
  • AGENTS
  • MONITORING
  • OTHER CONTROVERSIES
  • FUTURE DIRECTIONS
introduction
INTRODUCTION
  • Procedural Sedation
    • Technique to induce a state of lowered awareness and pain sensation
    • Preserves independent cardiac and respiratory functions
    • Employs sedative, dissociative, and analgesic agents
    • CORE COMPETENCY for ED Practice
introdution
INTRODUTION
  • CAEP, ACEP, and ASA Guidelines assert sedation provider must:
    • understand agent characteristics and relevant antagonists
    • be able to maintain desired sedation level
    • be able to manage potential complications
      • agent specific
      • airway management
      • hemodynamic instability

1 Innes G, Murphy M, Nijssen-Jordan C, et al. Procedural Sedation and Analgesia in the Emergency Department. Canadian Consensus Guidelines. J Emerg Med 1999:17(1);145-156.

2. Godwin SA, Caro DA, Wolf SJ, et al. Clinical policy: procedural sedation and analgesia in the emergency department. Ann Emerg Med 2005 ;45(2):179-196

3. Gross JB, Farmington CT, Bailey PL, et al. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology 2002;96(4)1004

introduction1
INTRODUCTION
  • SEDATION CONTINUUM

4. American Society of Anesthesiologists. Continuum of depth of sedation definition of general anesthesia and levels of sedation/analgesia. October 27, 2004. Available at http://www.asahq.org/publicationsAndServices/sgstoc.htm

5. Green SM, Mason KP. Reformulation of the Sedation Continuum. JAMA 303(9);876-877.

introduction2
INTRODUCTION
  • SEDATION CONTINUUM
introduction3
INTRODUCTION
  • SEDATION CONTINUUM
introduction4
INTRODUCTION
  • SEDATION CONTINUUM
introduction5
INTRODUCTION
  • SEDATION CONTINUUM
introduction6
INTRODUCTION
  • SEDATION CONTINUUM

DISSOCIATIVE SEDATION

introduction7
INTRODUCTION
  • The deeper the sedation, the greater the risk of:
    • Loss of airway protection
    • Apnea
    • Cardiovascular compromise
    • Hemodynamic collapse
pre sedation preparation
PRE-SEDATION PREPARATION
  • CASE
    • 26 yo M Tennis Injury
    • R Shoulder Dislocation
    • No #
    • NV stable
    • History??
pre sedation assessment
PRE-SEDATION ASSESSMENT
  • PATIENT ASSESSMENT
    • Focused history:
      • PMHX
        • Assess degree of cardiopulmonary reserve
pre sedation preparation1
PRE-SEDATION PREPARATION
  • PATIENT ASSESSMENT
    • Focused history:
      • PMHX
        • Assess degree of cardiopulmonary reserve

?

pre sedation preparation2
PRE-SEDATION PREPARATION
  • PATIENT ASSESSMENT
    • Focused history:
      • PMHX
        • Assess degree of cardiopulmonary reserve
      • Medications
      • Allergies
      • Anesthetic history
      • Pre-procedural fasting
pre sedation preparation3
PRE-SEDATION PREPARATION
  • CASE
    • Focused history:
      • PMHX
      • Medications
      • Allergies
      • Anesthetic history
      • Pre-procedural fasting
pre sedation preparation5
PRE-SEDATION PREPARATION
  • PATIENT ASSESSMENT – FASTING
    • Controversial
    • Loss of airway reflexes and vomiting exceptionally rare
    • No evidence-based ED guidelines for optimal fasting
    • Limited data for improved ED outcomes with prolonged fasting duration
pre sedation preparation6
PRE-SEDATION PREPARATION
  • PATIENT ASSESSMENT – FASTING
    • Most data derived from GA literature
      • Aspiration 1:3,420 elective Sx; 1:895 emergent Sx
      • Mortality 1:125,109
    • Not our patients!
pre sedation preparation7
PRE-SEDATION PREPARATION
  • PATIENT ASSESSMENT – FASTING
    • ASA recommends the following:
pre sedation preparation8
PRE-SEDATION PREPARATION
  • PATIENT ASSESSMENT – FASTING
    • Pediatric prospective observational study
    • n = 905, 56% noncompliant with ASA guidelines
    • Emesis in 15 (1.5%) of patients, 1 during procedure
      • No evidence of pulmonary aspiration
      • No significant difference in fasting duration and emesis or airway complications
    • No reports of pediatric aspiration pneumonitis in the literature

6. Agrawal D, Manzi SF, Gupta R, et al. Preprocedural fasting state and adverse events in children undergoing procedural sedation and analgesia in a pediatric emergency department. Ann Emerg Med 2003:42(5);636-646.

pre sedation preparation9
PRE-SEDATION PREPARATION
  • PATIENT ASSESSMENT – FASTING
    • A review of 25 papers addressing adult emesis with ED PSA:
      • 4657 cases non-compliant with ASA fasting
      • 17 cases of emesis (0.3%)
      • 1 case intubation, 1 case ICH
      • 0 cases evidence of aspiration
    • One reported case of adult aspiration after PSA

7. Thorpe RJ, Binger J. Pre-procedural fasting in emergency sedation. Emerg Med J 2010:27;254-261.

8. Cheung KW, Watson ML, Field S, et al. Aspiration pneumonitis requiring intubation after procedural sedation and analgesia: a case report. Ann Emerg Med 2007:49(4)462-464.

pre sedation preparation10
PRE-SEDATION PREPARATION
  • Guidelines:
    • ACEP and CAEP
      • Insufficient evidence
      • Recent food intake is not an absolute contraindication
        • But must be considered in timing of procedure
pre sedation preparation11
PRE-SEDATION PREPARATION
  • ED Specific Practice Advisory 2007
    • Risk Assessment
      • Baseline risk
      • Timing/nature of intake
      • Urgency of procedure
        • Emergent: Cardioversion
        • Urgent: Abscess I&D
        • Semi-urgent: Shoulder reduction
        • Non-urgent: Ingrown toenail
      • Required depth of sedation

9. Green SM, Roback MG, Miner JR, et al. Fasting and emergency department procedural sedation and analgesia: a concensus-based clinical practice advisory. Ann Emerg Med 2007;49(4):454-461

pre sedation preparation13
PRE-SEDATION PREPARATION
  • PATIENT ASSESSMENT – FASTING
    • Bottom line:
      • Risk of aspiration event is rare
      • Very limited data
      • Recent food intake is not an absolute contraindication
      • Weigh the risks of possible aspiration vs. urgency of procedure
pre sedation preparation14
PRE-SEDATION PREPARATION
  • BACK TO THE CASE
    • 26 yo M R Shoulder Dislocation
    • PMHx Healthy
    • No Meds, No Allergies
    • Fasted
    • Physical Exam??
pre sedation preparation15
PRE-SEDATION PREPARATION
  • PATIENT ASSESSMENT
    • Focused physical:
      • Vitals
      • Mental status
      • Airway
      • Cardiopulmonary exam
pre sedation assessment1
PRE-SEDATION ASSESSMENT
  • CASE CONTINUED
    • 26 yo M R Shoulder Dislocation
    • PMHx: Healthy
    • No Meds, No Allergies
    • Fasted
    • AVSS
    • P/E: Normal
pre sedation assessment2
PRE-SEDATION ASSESSMENT
  • CASE CONTINUED
    • 26 yo M R Shoulder Dislocation
    • PMHx: Healthy
    • Egg allergy
    • Fasted
    • AVSS
    • P/E: Normal
pre sedation assessment3
PRE-SEDATION ASSESSMENT
  • CASE CONTINUED
    • 26 yo M R Shoulder Dislocation
    • PMHx: Psychosis
    • Egg allergy
    • Fasted
    • AVSS
    • P/E: Normal
agents
AGENTS
  • Sedatives
    • Propofol
    • Midazolam
    • Etomidate
  • Analgesics
    • Opioids
    • Nitrous oxide
  • Dissociative agents
    • Ketamine
agents sedatives
AGENTS - SEDATIVES
  • PROPOFOL
    • PSA Starting Dose: 0.5-1.0 mg/kg, titrate 0.25-0.5 q45-60 sec
    • Onset: <1 min
    • Duration: 5-10 min
agents sedatives1
AGENTS - SEDATIVES
  • KETAMINE
    • PSA Starting Dose: IV 1-2 mg/kg, repeat 0.25-0.5 mg/kg prn

IM 2-5 mg/kg, repeat 1 mg/kg prn

PO 6-10 mg/kg

    • Onset: IV: 1 min IM: 5 min
    • Duration: 15-30 min Complete Recovery: 1-2 hours
agents sedatives2
AGENTS - SEDATIVES
  • MIDAZOLAM
    • PSA Starting Dose: IV 0.05-0.2 mg/kg IM 0.1-0.2 mg/kg

IN 0.2-0.6 mg/kg PO 0.5-0.75 mg/kg

    • Onset: 1-30 min
    • Duration: 30-12o min
agents sedatives3
AGENTS - SEDATIVES
  • BENZODIAZEPINE REVERSAL
  • FLUMAZENIL
    • Dose: Adults: 0.1-0.2 mg IV q 1-2 minutes to max 2 mg

Peds: 0.02 mg/kg titrated to a max of 0.2 mg

    • Onset: 1-2 min
    • Duration: 5-10 min peak
    • Half-life: 45-90 min
  • CAUTION: May precipitate status epilepticus in those with benzo dependence or seizure history
agents sedatives4
AGENTS - SEDATIVES
  • ETOMIDATE
    • PSA Starting Dose: IV 0.1-0.2 mg/kg
    • Onset: <1 min
    • Duration 5-10 min
agents analgesics
AGENTS - ANALGESICS
  • FENTANYL
    • PSA Starting Dose: IV 1.0-3.o mcg/kg TM 10-20 mcg/kg
    • Onset: IV 1-2min TM 10-30 min
    • Duration: IV 30-40 min TM 60-120 min
agents analgesics1
AGENTS - ANALGESICS
  • OPIATE REVERSAL
  • NALOXONE
    • Dose: 0.1-0.2 mg q 1-2 min
    • Onset: < 1 min
    • Duration 15-30 minutes
  • CAUTION: Complete reversal in pts who are dependent on opioids may precipitate acute opioid withdrawal
agents analgesics2
AGENTS - ANALGESICS
  • NITROUS OXIDE
    • PSA Starting Dose: 30%-70% inhaled N2O
    • Onset: 1-2 min
    • Offset: 3-5 min
agents1
AGENTS
  • CASE CONTINUED
    • 26 yo M R Shoulder Dislocation
    • Sedated with propofol
    • Currently undergoing reduction
    • What should you be monitoring?
monitoring
MONITORING
  • GUIDELINES
    • Recommend monitoring:
      • Sedation level
      • Heart rate
      • Blood pressure
      • Pulse oximetry with supplemental oxygen
        • Controversial
monitoring1
MONITORING
  • SUPPLEMENTAL OXYGEN
    • Helpful or harmful?
    • Controversial
    • Supplemental O2 impairs ability to detect respiratory depression

10. Green SM, Krauss B. Supplemental oxygen during propofol sedation: yes or no? Ann Emerg Med. 2008 Jul;52(1):9-10.

monitoring2
MONITORING
  • SUPPLEMENTAL OXYGEN
    • Does it prevent respiratory depression?
    • n=80, sedation: propofol

11. Deitch K, Chudnofsky CR, Dominici P. The utility of supplemental oxygen during emergency department procedural sedation and analgesia with propofol: a randomized, controlled trial. Ann Emerg Med. 2008;52(1)1-8.

monitoring3
MONITORING
  • CAPNOGRAPHY
    • Controversial
    • Adjunct to evaluate pre-hypoxic respiratory depression
    • Superior to clinical exam and oximetry
monitoring4
MONITORING
  • CAPNOGRAPHY
monitoring5
MONITORING
  • CAPNOGRAPHY - EVIDENCE
    • Pediatrics
      • Comparison of oximetry, capnography, clinical observation in patients receiving midaz/fent
      • Capnography provided an earlier indication of respiratory depression than pulse ox and clinical exam alone
      • RCT: blinded staff reported hypoventilation in 3% of cases, did not identify apnea
      • Capnography disclosed 56% hypoventilation, 24% apnea
      • Also identified all cases of hypoxia before it occured

12. Hart LS, Berns SD, Houck CS, et al. The value of end-tidal CO2 monitoring when comparing three emthods of conscious sedation for children undergoing painful procedures in the emegency department. Pediatr Emerg Care 1997:13(3);189-193.

13 Lightdale JR, Goldmann DA, Feldman HA, et al. Microstream capnography improves patient monitoring during moderate sedation: a randomized, controlled trial. Pediatrics 2006:117(6);e1170-1178.

monitoring6
MONITORING
  • CAPNOGRAPHY – EVIDENCE
    • Adults
      • Prospective observation study, n=60
      • 70% of patients with an ‘acute respiratory event’ had capnographic changes occurring up to 4 min prior to oximetry or clinical assessment
      • RCT: Study of hypoxia w/ and w/o capnography
      • Significantly increased hypoxia w/o capnography
      • ?Clinical importance

14. Burton JH, Harrah JD, Germann CA, et al. Does end-tidal carbon dioxide monitoring detect respiratory events prior to current sedation monitoring practices? Acad Emerg Med 2006;13(5):500-5004.

15. Deitch K, Miner J, Chudnofsky C. 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 ;55(3):258-264.

monitoring7
MONITORING
  • CAPNOGRAPHY – EVIDENCE
    • What these studies show:
      • Capnography predicts respiratory depression
      • Earlier than oximetry or clinical assessment
    • What these studies don’t show:
      • Capnography improves pt outcomes
      • Transient hypoxia/hypercarbia is harmful
    • So why care about detecting transient respiratory depression?
monitoring8
MONITORING
  • CAPNOGRAPHY
monitoring9
MONITORING
  • CAPNOGRAPHY
    • Limitations
      • Clinical effect has not been proven
      • False positives
      • Cost benefit ratio unclear
      • Low – Moderate specifity
      • Mod – High sensitivity
    • More research required
post sedation monitoring
POST-SEDATION MONITORING
  • MORE CASE
    • 26 yo M R Shoulder Dislocation
    • Successful reduction
    • No complications with sedation
    • Is sitting upright
    • A&O x 3
    • Is he safe for discharge?
post sedation monitoring1
POST-SEDATION MONITORING
  • Highest risk of adverse events
  • Clinical recovery:
    • Normal LOC, vitals, respiratory status
    • Normal motor function
    • Follow commands
    • Speaks clearly
    • Tolerating oral fluids
discharge
DISCHARGE
  • Guidelines recommend:
    • Baseline vitals
    • Baseline cognition
    • Pt can sit unassisted
    • Pt can take oral fluids without vomiting
    • Pt can understand discharge instructions
discharge1
DISCHARGE
  • DISCHARGE INSTRUCTIONS:
    • ADULT
      • Avoid dangerous activities (bicycling, swimming, driving,

?tennis) until effects have passed

      • Progressive diet
      • No alcohol, sleeping pills, or other medications causing drowsiness for 24 hours.
discharge2
DISCHARGE
  • DISCHARGE INSTRUCTIONS
    • PEDS
      • No food or drink for two hours. If under 1 age, give half of normal feed 1 hour after discharge
      • No play requiring balance, strength, and coordination for 12 hours
      • Closely supervise your child for next 8 hours
      • The child should not bathe, shower, cook, or use electrical devices for next 8 hours
controversies
CONTROVERSIES
  • Propofol for children – Is it safe?
    • 2 year, prospective case series n=393

16. Bassett KE, Anderson JL, Pribble CG, et al. Propofol for procedural sedation in children in the emergency department. Ann Emerg Med 2003;42:773.

controversies1
CONTROVERSIES
  • Propofol for children – is it safe?
    • RCT n=113, propofol vs. ketamine in orthopedic reductions

17. Godambe SA, Elliot V, Matheny D, Pershad J. Comparison of propofol/fentanyl versus ketamine/midazolam for brief orthopedic procedural sedation in a pediatric emergency department. Pediatrics 2003;112:116xc

controversies2
CONTROVERSIES
  • Propofol for children – is it safe?
controversies3
CONTROVERSIES
  • Propofol for children – is it safe?
    • No difference in orthopod and nurse satisfaction.
    • Parental VAS for pain not significantly different.
    • No pts recalled procedure
    • Delayed adverse events (<72hrs) noted only in ketamine
      • Dysphoric reactions (nightmares, behaviour change)
      • Nausea/emesis
controversies4
CONTROVERSIES
  • Propofol for children – is it safe?
    • Studies suggest propofol is safe but has a higher associated risk of transient respiratory depression.
    • Few studies in ED PSA setting
    • Use with caution
controversies5
CONTROVERSIES
  • Ketamine in adults – is it effective?
    • 2010 RCT Propofol vs. Ketamine in adults
    • n=97
    • Found:
      • Significant increase of subclinical respiratory depression for ketamine
      • Prolonged recovery time for ketamine
      • Increased emergence with ketamine

18. Miner JR, Gray RO, Bahr J, et al. Randomized clinical trial of propofol versus ketamine for procedural sedation in the emergency department. Acad Emerg Med 2010;(17)6:604-611

controversies6
CONTROVERSIES
  • Ketamine for adults – is it effective?
    • 2008 ’narrative’ review, 87 studies, 70 000 pts
    • Found that significant adverse reactions rarely occur
      • 1:70 000 CP; 0 cases aspiration
    • Reported effects:
      • Tachycardia
      • Hypertension
      • Hypersalivation
      • Laryngospasm
      • N/V (5-15%)
      • Emergence Rxns (10-20%)

19. Strayer RJ, Nelson LS. Adverse events associated with ketamine for procedural sedation in adults. Am J Emerg Med 2008;26(9):985-1028.

controversies7
CONTROVERSIES
  • KETAMINE – Emergence Reactions
      • Most common side effect
      • Rare <5 years, greatest >15 years
      • Large rapid doses
      • Pretreatment agitation/anxiety/excessive stimulation
      • Female sex
      • Personality disorder
      • Prior psychosis
controversies8
CONTROVERSIES
  • KETAMINE – Emergence Reactions
    • Effect may be blunted by 0.03-0.05 mg/kg midazolam
    • 2 ED RCTs show no measurable benefit in children

20. Sherwin TS, Green SM, Khan A, et al. Does adjunctive midazolam reduce recovery agitation after ketamine sedation for pediatric procedures? a randomized, double-blinded, placebo-controlled trial. Ann Emerg Med 2000;35:229-244.

21. Wathen JE, Roback MG, Mackenzie T, et al. Does midazolam alter the clinical effects of intravenous ketamine sedation in children? A double-blind, randomized, controlled emergency department trial. Ann Emerg Med. 2000;36:579-588.

controversies9
CONTROVERSIES
  • KETAMINE – Emergence Reactions
    • What about adults?
      • Prior case series show questionable effects of midazolam
      • 2011 ED RCT: n=182 ketamine w/ or w/o 0.03 mg/kg midaz

22. Sener S, Eken C, Schultz C, et al. Ketamine with and without midazolam for emergency department sedation in adults: a randomized controlled trial. Ann Emerg Med 2011:57(2);109-114.

controversies10
CONTROVERSIES
  • KETAMINE – Emergence Reactions
    • Should we give midazolam to all adult patients?
controversies11
CONTROVERSIES
  • KETAMINE – Emergence Reactions
    • Argued that:
      • Emergence reactions have a wide spectrum of severity
      • NNT of 6 may represent maximally effective treatment
      • Emergence reaction affected by baseline risk
        • Should all patients receive midazolam or just high risk patients?
        • Pretreat or only treat when there’s a reaction?

23. Green SM, Krauss B. The Taming of Ketamine - 40 years later. Ann Emerg Med 2011;57(2):115-116.

controversies12
CONTROVERSIES
  • Ketamine in adults
    • Safe and effective
    • Higher emergence in adults
      • Midazolam effective in treating
controversies13
CONTROVERSIES

KETAMINE

Cons: Emesis

Emergence

controversies14
CONTROVERSIES

KETAMINE

Cons: Emesis

Emergence

  • PROPOFOL
    • Pros: Antiemetic

Smooth recovery

controversies15
CONTROVERSIES

KETAMINE

Cons: Emesis

Emergence

  • PROPOFOL
    • Pros: Antiemetic

Smooth recovery

    • Cons: Hemodynamically unstable

No analgesia

controversies16
CONTROVERSIES

KETAMINE

Pros: Hemodynamically stable

Analgesic

Cons: Emesis

Emergence

  • PROPOFOL
    • Pros: Antiemetic

Smooth recovery

    • Cons: Hemodynamically unstable

No analgesia

controversies17
CONTROVERSIES
  • KETOFOL
    • 4 ED case series

24. Green SM, Andolfatto G, Krauss B. Ketofol for procedural sedation? pro and con. Ann Emerg Med 2011 In Press.

controversies18
CONTROVERSIES
  • KETOFOL
  • 2 Meta-analyses
    • Pharmacology 2007
      • Ketofol not superior to propofol monotherapy
      • Variable mixed dosing regimens ?optimal ratio
      • Conflicting data re: hypotension and respiratory depression
    • Conclusion:
      • Available evidence does not support the use of ketofol for PSA

25. Slavik VC, Zed PJ. Combination ketamine and propofol for procedural sedation and analgesia in the emergency department. Pharmacotherapy 2007;27:1588-1598

controversies19
CONTROVERSIES
  • KETOFOL
  • 2 Meta-analyses
    • Annals of Pharmacotherapy 2007
      • No significant difference in time to discharge
      • Fewer cases of hypotension/resp depression in ketofol
        • No difference in interventions required
      • Emesis and emergence occurred with higher doses of ketamine
    • Conclusion
      • Insufficient evidence to support ketofol for routine use

26. Loh G, Dalen D. Low-dose ketamine in addition to propofol for procedural sedation and analgesia in the emergency department. Ann Pharmacother 2007;41:485-492

controversies20
CONTROVERSIES
  • KETOFOL
    • 3 ED RCTs

27. Messenger DW, Murray HE, Dungey PE, et al. Subdissociative-dose ketamine versus fentanyl for analgesia during propofol procedural sedation: a randomixed controlled trial. Acad Emerg Med 2008;15:877-886

28. Shah A, Mosdossy G, McLeod S, et al. A blinded, randomized controlled trial to evaluate ketmine-propofol versus ketamine alone for procedural sedation in children. Ann Emerg Med. In Press

29. David H, Shipp J. Combined ketamine/propofol for emergency department procedural sedation. Ann Emerg Med. In Press.

controversies21
CONTROVERSIES
  • KETOFOL
    • Pro-Arguments
      • Ketofol is safe and effective
      • Ketamine likely synergistic with propofol
        • Promotes less required propofol
          • Less erratic sedation and ?improved hemodynamic stability
      • Precludes need for opioid analgesia
      • Recovery time
      • Less emesis and ?emergence
controversies22
CONTROVERSIES
  • KETOFOL
    • Con-Arguments
      • Contentious evidence with respect to:
        • Respiratory depression
        • Superior sedation
      • ?Clinical importance of promoting hemodynamic stability
      • Recovery time
      • Adds complexity
controversies23
CONTROVERSIES
  • KETOFOL
  • Conclusion
    • More data required.
controversies24
CONTROVERSIES
  • ETOMIDATE
    • 2004 Meta-analysis
      • Etomidate effective for PSA
      • Onset/duration comparable to propofol
      • Hemodynamically stable
        • Respiratory depression (~10%)
      • No major complications, hypotension
      • Side effects include:
        • Myoclonus (20-45%)
        • Emesis
        • Adrenal suppression

30. Falk J, Zed PJ. Etomidate for procedural sedation in the emergency department. Ann Pharmacother 2004;38:1272

controversies25
CONTROVERSIES
  • ETOMIDATE - Adults
    • ED RCT, n=214, etomidate vs propofol for PSA
      • No difference in:
        • Respiratory depression or airway interventions
        • Depth of sedation
        • Pt satisfaction
      • Differences in:
        • Myoclonus (20% vs 2%)
        • Procedural success (89% vs 97%)

31. Miner JR, Danahy M, Moch A, et al. Randomized clinical trial of etomidate versus propofol for procedural sedation in the emergency department. Ann Emerg Med 2007;49:15

controversies26
CONTROVERSIES
  • ETOMIDATE – Peds
    • ED RCT, n=23, Etomidate/fent vs ketamine/midaz

32. Lee-Jayaram J, Green A, Siembieda J, et al. Ketamine/midazolam versus etomidate/fentanyl procedural sedation for pediatric orthopedic reductions. Ped Emerg Care 2010;26(6):408-412.

controversies27
CONTROVERSIES
  • ETOMIDATE – Peds
    • ED RCT, n=100, etomidate/fent vs. midaz/fent
      • No differences in:
        • Respiratory depression
        • Emesis
        • Procedural success
      • Differences in:
        • Depth of sedation
        • Induction and recovery time
        • Myoclonus
        • Pain on injection

33. Di Liddo L, D'Angelo A, Nguyen B, et al. Etomidate versus midazolam for procedural sedation in pediatric outpatients: a randomized controlled trial. Ann Emerg Med 2006;48:433-440

controversies28
CONTROVERSIES
  • ETOMIDATE
    • Studies show:
      • Safe and effective in PSA
        • Limited evidence
      • Higher rates of myoclonus, may lead to less procedural success
    • FDA does not recommend etomidate in children < 10 years
future directions
FUTURE DIRECTIONS
  • DEXMEDETOMIDINE
    • a2-agonist with sedative, analgesic, anxiolytic properties
    • Produces a sedated state comparable to natural sleep
    • Advantages
      • Many available routes – particularly IN (~90% IV Absorption)
        • Tolerated better than oral or IN midaz
      • May be useful is sedating autistic patients
      • Potential reversibility with atipamezole
      • No respiratory depression

34. Kost S, Roy A. Procedural sedation and analgesia in the pediatric emergency department: a review of sedative pharmacology. Clin Ped Emerg Med 2010;11(4):233-243

future directions1
FUTURE DIRECTIONS
  • DEXMEDETOMIDINE
    • Disadvantages
      • Slower onset
      • Longer recovery times (Halflife 2-3 hours)
      • Hypertension/Reflex bradycardia
      • Cost
    • Potential ED Applications
      • Mild sedation for imaging
      • Sedation w/o IV/IM requirements
        • Behavioural/Autism

35. Lubisch N, Roskos R Berkenbosch JW. Dexmedetomidine for procedural sedation in children with autism and other behavioural disorders. Pediatr Neurol 2009;41:88-94

future directions2
FUTURE DIRECTIONS
  • FOSPROPOFOL
    • Water soluble prodrug converted to propofol w/iminutes
    • Undergoing Phase III Trials
    • Side effects:
      • Paresthesias (62%)
      • Pruritis (27.6%)
      • Hypotension (3%)
      • Emesis (3%)

36. Garnock-Jones KP, Scott LR. Fospropofol. Drugs 2010;70(4):469-477

37. Sneyd JR, Rigby-Jones AE. New drugs and technologies, intravenous anesthesiology is on the move (again). Br J Anaesth 2010;105(3):246-254

future directions3
FUTURE DIRECTIONS
  • PATIENT CONTROLLED SEDATION
    • Increasing focus in literature
    • PCS vs. PMS
    • Complicated psychobiological effects

38. Atkins JH, Mandel JE. Recent advances in patient-controlled sedation. Curr Opin Anes 2008;21:759-765

future directions4
FUTURE DIRECTIONS
  • PATIENT CONTROLLED SEDATION
future directions5
FUTURE DIRECTIONS
  • PATIENT CONTROLLED SEDATION
    • ED Evidence?
      • Limited
      • ED RCT 2010, n=166, PCS vs EPCS using propofol

39. Bell A, Lipp T, Greenslad J, et al. A Randomized controlled trial comparing patient-controlled and physician-controlled sedation in the emergency department. 2010;56(5):502-508.

future directions6
FUTURE DIRECTIONS
  • PATIENT CONTROLLED SEDATION
    • Shows promise in the literature
    • Requires more ED specific evidence