Procedural Sedation

Procedural SedationJan 27, 2011

Jason MitchellDr. Gil Curry

Dr. Marc Francis

AcknowledgmentsDr. James Huffman

Dr. Dave Choi

OUTLINE

INTRODUCTION PRE-SEDATION PREPARATION AGENTS MONITORING OTHER CONTROVERSIES FUTURE DIRECTIONS

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

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):179-1963. Gross JB, Farmington CT, Bailey PL, et al. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology 2002;96(4)1004

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.

INTRODUCTION

SEDATION CONTINUUM

INTRODUCTION

SEDATION CONTINUUM

INTRODUCTION

SEDATION CONTINUUM

INTRODUCTION

SEDATION CONTINUUM

INTRODUCTION

SEDATION CONTINUUM

DISSOCIATIVE SEDATION

INTRODUCTION

The deeper the sedation, the greater the risk of: Loss of airway protection

Apnea

Cardiovascular compromise

Hemodynamic collapse

PRE-SEDATION PREPARATION

CASE 26 yo M Tennis Injury R Shoulder Dislocation No # NV stable

History??

PRE-SEDATION ASSESSMENT

PATIENT ASSESSMENT Focused history:

PMHX Assess degree of cardiopulmonary reserve

I II III IV VHealthy Mild

Systemic

Disease

SevereSystemi

c Disease

DiseaseConstantThreat

to Life

Moribund

Not expecte

d to survive beyond

24 hours




I II III IV VHealthy Mild

Systemic

Disease

SevereSystemi

c Disease

DiseaseConstantThreat

to Life

Moribund

Not expecte

d to survive beyond

24 hours

✗✓✓ ✗?




Medications Allergies Anesthetic history Pre-procedural fasting


CASE Focused history:

PMHX Medications Allergies Anesthetic history Pre-procedural fasting



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


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!


PATIENT ASSESSMENT – FASTING ASA recommends the following:

INGESTED MATERIAL MINIMUM FASTING TIME

Clear Liquids 2 hBreast Milk 4 h

Infant Formula 6 hCows Milk 6 hLight Meal 6 h

Heavy Meal >6 h


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 literature6. 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.


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.


Guidelines: ACEP and CAEP

Insufficient evidence

Recent food intake is not an absolute contraindication But must be considered in timing of procedure


ED Specific Practice Advisory 2007 Risk Assessment

1. Baseline risk2. Timing/nature of intake3. Urgency of procedure

Emergent: Cardioversion Urgent: Abscess I&D Semi-urgent: Shoulder reduction Non-urgent: Ingrown toenail

4. 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 PREPEARAT


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


BACK TO THE CASE 26 yo M R Shoulder Dislocation PMHx Healthy No Meds, No Allergies Fasted

Physical Exam??


PATIENT ASSESSMENT Focused physical:

Vitals

Mental status

Airway

Cardiopulmonary exam


CASE CONTINUED 26 yo M R Shoulder Dislocation PMHx: Healthy No Meds, No Allergies Fasted AVSS P/E: Normal


EQUIPMENT

IN THE ROOM READILY AVAILABLEECG monitor Defibrillator

Pulse oximeter Resuscitation drugsAirway equipment Sedation/Analgesic

agentsSuction

Blood pressure monitorReversal agentsAdequate staff

Supplemental oxygen*Capnography*


CASE CONTINUED 26 yo M R Shoulder Dislocation PMHx: Healthy Egg allergy Fasted AVSS P/E: Normal


CASE CONTINUED 26 yo M R Shoulder Dislocation PMHx: Psychosis Egg allergy Fasted AVSS P/E: Normal

AGENTS

Sedatives Propofol Midazolam Etomidate

Analgesics Opioids Nitrous oxide

Dissociative agents Ketamine

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 minStrengths Weaknesses Contraindications

Rapid onset/offset Resp. depression Egg allergyTitratable Hypotension Soy allergyAntiemetic Injection pain Hypotensive/Unstable

Cerebral protective No analgesia?Anti-epileptic

AmnesticBronchodilator

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

Strengths Weaknesses ContraindicationsRapid onset/offset Emergence < 3 mo ageHemodynamically

stableEmesis Elevated ICP

Airway reflexes maintained

Laryngospasm Significant CVD/CAD

Analgesic ?Increased IOP/ICP Prior psychosisHypersalivation

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 minStrengths Weaknesses Contraindications

Rapid onset Respiratory depression

Pregnancy (Class D)

Titratable Hypotension with opioids

Many routes available No analgesiaAnxiolysis Paradoxical reactions

Retrograde amnesia

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 - SEDATIVES

ETOMIDATE PSA Starting Dose: IV 0.1-0.2 mg/kg Onset: <1 min Duration 5-10 min

Strengths Weaknesses ContraindicationsRapid onset/offset Respiratory

depressionPoor adrenal function

Minimal CV effects Myoclonus Prior seizuresCerebral protective ?Adrenal suppression

No analgesiaEmesis

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

Strengths Weaknesses ContraindicationsRapid onset Respiratory

depressionHypersensitivity rxn

Minimal CV effects Rigid chest syndromeDecreased histamine

releaseShort duration

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 - ANALGESICS

NITROUS OXIDE PSA Starting Dose: 30%-70% inhaled N2O Onset: 1-2 min Offset: 3-5 min

Strengths Weaknesses ContraindicationsRapid onset/offset Nausea/emesis PTXMinimal CV effects Cannot be used in

mod-deep sedationBowel obstruction

Respiratory depression

COPD

Decompression Sickness

AGENTS

CASE CONTINUED 26 yo M R Shoulder Dislocation Sedated with propofol Currently undergoing reduction

What should you be monitoring?

MONITORING

GUIDELINES Recommend monitoring:

Sedation level

Heart rate

Blood pressure

Pulse oximetry with supplemental oxygen Controversial

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.

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.

MONITORING

CAPNOGRAPHY Controversial Adjunct to evaluate pre-hypoxic respiratory

depression Superior to clinical exam and oximetry

MONITORING

CAPNOGRAPHY

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 occured12. 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.

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.

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?

MONITORING

CAPNOGRAPHY

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

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 MONITORING

Highest risk of adverse events Clinical recovery:

Normal LOC, vitals, respiratory status Normal motor function Follow commands Speaks clearly Tolerating oral fluids

DISCHARGE

Guidelines recommend: Baseline vitals

Baseline cognition

Pt can sit unassisted

Pt can take oral fluids without vomiting

Pt can understand discharge instructions

DISCHARGE

DISCHARGE INSTRUCTIONS: ADULT

1. Avoid dangerous activities (bicycling, swimming, driving, ?tennis) until effects have passed

2. Progressive diet

3. No alcohol, sleeping pills, or other medications causing drowsiness for 24 hours.

DISCHARGE

DISCHARGE INSTRUCTIONS PEDS

1. No food or drink for two hours. If under 1 age, give half of normal feed 1 hour after discharge

2. No play requiring balance, strength, and coordination for 12 hours

3. Closely supervise your child for next 8 hours

4. The child should not bathe, shower, cook, or use electrical devices for next 8 hours

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.

Propofol for children – Is it safe?

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

CONTROVERSIES

Propofol for children – is it safe?

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

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

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

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.

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

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.

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.

CONTROVERSIES

KETAMINE – Emergence Reactions Should we give midazolam to all adult

patients?

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.

CONTROVERSIES

Ketamine in adults Safe and effective

Higher emergence in adults Midazolam effective in treating

CONTROVERSIES

KETAMINE

Cons: Emesis Emergence

CONTROVERSIES

PROPOFOL Pros: Antiemetic Smooth recovery

KETAMINE


CONTROVERSIES


Cons: Hemodynamically unstable

No analgesia

KETAMINE


CONTROVERSIES


Cons: Hemodynamically unstable

No analgesia

KETAMINE Pros:

Hemodynamically stable

Analgesic


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.

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

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

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;15:877-88628. 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 Press29. David H, Shipp J. Combined ketamine/propofol for emergency department procedural sedation. Ann Emerg Med. In Press.

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

CONTROVERSIES

KETOFOL Con-Arguments

Contentious evidence with respect to: Respiratory depression Superior sedation

?Clinical importance of promoting hemodynamic stability

Recovery time Adds complexity

CONTROVERSIES

KETOFOL Conclusion

More data required.

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

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

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.

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

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

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 depression34. 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 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 DIRECTIONS

FOSPROPOFOL Water soluble prodrug converted to propofol

w/i minutes 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):469-47737. 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 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 DIRECTIONS

PATIENT CONTROLLED SEDATION

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 DIRECTIONS

PATIENT CONTROLLED SEDATION

Shows promise in the literature

Requires more ED specific evidence

Procedural Sedation

Documents

sedation stages

sedation provider

degree of sedation

typical sedation grade

desired sedation levelbe

continuum of depth

stimuliairway intervention

deep sedationno