Procedural Sedation Perils and pearls to avoid them - Dr. Rackers

States of sedation

1. Minimal - mild anxiolysis and pain control
2. Moderate - sleepy patient arousable by voice/ light touch (conscious)
3. Deep - Painful stimuli for purposeful response
4. General - no purposeful response
   

• Sedation is a dynamic process

• Politics - FDA considers etomidate, propofol, ketamine to be general anesthetics
  
• CMS says EM docs are qualified to use these medications.
  

• Pearl #1 - Match duration of action of medication with length of procedural stimulation

• Pearl #2 - Preparation is key

        -- Don't get complacement - known what you’re supposed to have and be prepared to set it up yourself
        -- Aspiration risk - sedation depth and length don’t correlate with poor outcomes;
                                   - solids vs liquids - can impact aspiration risk;
                                   - GERD & age can increase risk;
                                   - no evidence based literature that has a definite time that patient needs to be NPO for
        -- Monitoring - pulse ox, response to commands, ventilation, CO2 monitoring, continuous cardiac monitoring
                             - ETCO2 - goal 35-45 mmHg 

•   Some Specific Rxs
  

Ketamine - dissociative agent, relaxation, pain relief

• Pitfall - Emergence reaction - try to avoid this by talking about pleasant things before ketamine; occurs in 10-20% in patients; vomiting in 5-15%
• Don’t use in elderly, hypertensive, pysch patient
  

Etomidate - complications of myoclonus

Propofol - benefits - gives deep sedation, doesn’t give analgesia (need pain relief too); patients can have apnea and laryngospasm

Combining sedatives - like ketofol?  - may improve HD stability

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