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REVIEW ARTICLE
Year : 2020  |  Volume : 18  |  Issue : 1  |  Page : 40-44

Procedural sedation and analgesia in the emergency department


1 Department of Emergency Medicine, Christian Medical College, Vellore, Tamil Nadu, India
2 Department of Emergency Medicine, Christian Medical College and Hospital, Vellore, Tamil Nadu, India

Date of Submission25-Nov-2019
Date of Decision05-Dec-2019
Date of Acceptance21-Dec-2019
Date of Web Publication03-Feb-2020

Correspondence Address:
Dr. Sandeep Nathanael David
Department of Emergency Medicine, Christian Medical College, Vellore - 632 004, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmi.cmi_63_19

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  Abstract 


Emergency medicine as a medical specialty has come a long way since its evolution from the now obsolete “Casualty Department.” A prevalent challenge in the emergency department (ED) is safe and effective administration of anesthetic agents to a patient in pain or altered mentation without compromising their airway control and hemodynamics. Fear and unfamiliarity with the use of various anesthetic agents is the major stumbling block in this regard. Procedural sedation and analgesia (PSA) in the ED improve patient satisfaction, reduces physiological stress and allows for rapid return of consciousness after traumatic procedures while providing sedation, analgesia, and amnesia. PSA is a planned service which should be provided under strict monitoring with proper preanesthetic workup and emergency measures easily available. PSA strengthens the armament of the emergency physician, allowing a better understanding of pain control and sedation without resorting to general anesthesia.

Keywords: Analgesia, ketamine, procedural sedation, propofol


How to cite this article:
David SN, Ganesan P. Procedural sedation and analgesia in the emergency department. Curr Med Issues 2020;18:40-4

How to cite this URL:
David SN, Ganesan P. Procedural sedation and analgesia in the emergency department. Curr Med Issues [serial online] 2020 [cited 2020 Feb 24];18:40-4. Available from: http://www.cmijournal.org/text.asp?2020/18/1/40/277532




  Introduction Top


Procedural sedation is described by the American College of Emergency Physicians as “a technique of administering sedatives or dissociative agents with or without analgesics to induce a state that allows the patient to tolerate unpleasant procedures while maintaining cardiorespiratory function.” Procedural sedation and analgesia (PSA) involve reducing a patient's degree of awareness while maintaining stable hemodynamics and airway control.[1]

Peri-procedural apprehension or pain can lead to untoward sympathetic responses or posttraumatic stress disorder in patients undergoing invasive or painful procedures. A fine balance between sedation and analgesia while maintaining stable cardiorespiratory responses will obviate the need for general anesthesia (GA) and airway control for minor procedures.

As the administration of anesthetic agents outside the operation theater becomes more prevalent, it is necessary for emergency physicians to be aware of various pharmacological options for PSA, as well as the assessment of patients requiring PSA.


  Procedures Requiring Procedural Sedation and Analgesia Top


  • Pediatric suturing
  • Joint reduction
  • Fracture fixation
  • Imaging in noncooperative or pediatric patients
  • Burn victims
  • Elective cardioversion
  • Transcutaneous pacing.



  Grades of Sedation Top


Sedation is graded according to the classification set by the American Society of Anesthesiologists (ASA)[1] [Table 1]. The goal of PSA is to establish minimal or moderate sedation, without the need for cardiorespiratory supports.
Table 1: Grades of sedation

Click here to view



  Assessment Before Procedural Sedation and Analgesia Top


History

PSA should be a planned procedure which involves a history and the evaluation of the patient's airway. History can be quickly taken with the “SAMPLE” pneumonic tool.[2],[3]

  1. Signs and symptoms
  2. Allergies
  3. Medications
  4. Past medical, anesthetic, and surgical history
  5. Last meal
  6. Events leading to the patient's condition.


Patients with traumatic brain injury or history of seizures must be noted, as ketamine would preferably be avoided in such patients. Medications such as beta-blockers and calcium channel blockers should be noted in the event of symptomatic bradycardia or anaphylaxis which would require glucagon for treatment. The presence of existing cardiac disease and concomitant use of B-blockers would also alert to the possibility of hypotension when administering propofol or dexmedetomidine. Beta-agonist inhalers or inhaled steroids should alert the health-care professional to possible reactive airway disease, which could be a risk factor for anaphylaxis.

Fasting

The ASA recommends a 2-h period of fasting for clear fluids and 6–8 h for solid feeds to minimize the chance for emesis and aspiration.[4] However, there are no confirmed reports of adverse events secondary to aspiration during PSA in the emergency department (ED) following inadequate fasting.[5],[6] PSA by definition preserves airway responses, thus fasting may not be necessary or practical for all patients.[7],[8] There are no outcome studies showing benefits from fasting before PSA. If needed, a prophylactic anti-emetic may be given before the procedure; however, there are no studies confirming the added benefit of this. In particular, children may not tolerate prolonged periods of fasting, and the stress response to fasting may be physiologically detrimental to them.

American Society of Anesthesiologists grading

The patient must be classified based on the ASA physical classification system [Table 2]. The risk of a complication from ED PSA in ASA Class I and II patients is low, usually <5%. Informed consent for PSA must be obtained for all patients as the risk of an adverse PSA event is correspondingly higher in patients with an ASA Class of III or IV.[9],[10]
Table 2: American Society of Anesthesiologists Grading

Click here to view


Airway assessment

A thorough examination of the patient's airway must be performed before any procedure requiring PSA in case airway reflexes are lost during the procedure and manual or mechanical ventilatory support is needed. The presence of facial hair, short neck, and dentures must be documented. The Mallampati score, while a staple component of airway assessment for difficult intubation,[11] has poor correlation with difficult bag-mask ventilation and does not relate to clinical outcome.[12],[13] Rather than a single screening method, a composite approach such as the familiar LEMON mnemonic can be used to predict a potentially difficult airway.


  Personnel Top


The American College of Emergency Physicians recommends at least 2 ED personnel, at least one of whom is skilled in vascular access and advanced airway control.[14] In the event that a doctor is unable to be present, an appropriately trained nurse or physician assistant can monitor the patient, provided they have adequate experience with anesthetics.[15] The treating health-care professional must have knowledge of the various pharmacological options and their respective pharmacokinetics and pharmacodynamics. They must also be aware of the various routes of administration and side effects. The overseeing doctor is responsible for the entire PSA procedure, including the identification and management of adverse events.[14],[15]


  Equipment Top


  1. Oxygen
  2. BMV device
  3. Suction
  4. Oral/nasal airway(s)
  5. Intubation equipment
  6. Pulse oximeter
  7. Monitor for electrocardiography (ECG), blood pressure (BP), capnography
  8. Defibrillator, transcutaneous pacemaker
  9. Vascular access equipment
  10. Reversal agents– Naloxone, flumazenil.


It would be prudent to have a difficult airway trolley in the area designated for PSA, containing equipment required for airway management, including rescue devices such as supraglottic airway devices and equipment for the emergency front of neck access.


  Monitoring Top


Interactive monitoring

The treating doctor should have an unobstructed view of the patient's face and chest during the procedure, paying special attention for the signs of airway obstruction and hypopnea. The presence of stridor, paradoxical breathing, reduced respiratory effort, and reduced respiratory rate should be rapidly addressed. Other possible complications are laryngospasm and vomiting.

Mechanical monitoring

  • Pulse rate
  • SaO2
  • BP
  • ECG
  • ET-CO2 if available.


Although end-tidal CO2 monitoring is a relatively new and effective monitoring tool in the ED,[16] it is expensive and its use during PSA has no shown any improvement in patient outcomes.[17],[18],[19] Furthermore, there is evidence from a recent randomized controlled trial that the use of capnography may be associated with an increased incidence of positive pressure ventilation during transient periods of hyperpnea leading to hypotension and increased usage of airway maneuvers.[20] Thus, despite its many advantages during GA and mechanical ventilation, it is currently not considered a vital monitor for PSA in the ED.


  Drugs Top


The ideal agent for PSA in the ED provides rapid and predictable anxiolysis, analgesia, and amnesia with little to no side effects, and with rapid return of consciousness.[21] There is no ideal single agent for PSA in the ED and drugs are usually given in combination with one another. Common pharmacological agents used for PSA in the ED are given below [Table 3].
Table 3: Common agents for Emergency Department procedural sedation and analgesia

Click here to view


Although concomitant use of midazolam and ketamine has been successfully used in the past for ED PSA,[22],[23] the combination of ketamine and propofol (“Ketofol”) has been shown to be particularly effective due to the synergistic pharmacodynamics between its two components. Ketamine has analgesic and sympathomimetic properties but has the undesirable side effects of tachycardia hypertension, emesis, increased laryngeal secretions, increase in intracranial pressures, and the chance of seizures.[24] Propofol is a rapidly acting sedative and hypnotic agent which blunts sympathetic activity, is a natural bronchodilator and has anti-emetic properties,[25] but can be disastrous if given to hypotensive and hypovolemic patients, as well as those with decompensated cardiac disease. Either given individually or coadministered in the same syringe, ketofol (0.5 mg/kg of both agents) maintains stable hemodynamics and the preservation of airway reflexes while inducing moderate sedation and analgesia with rapid recovery.[24],[25],[26],[27],[28]

There are concerns about propofol being administered for patients with egg or soy allergy;[29] however, these were found to be inconsequential. Propofol contains lecithin derived from egg yolk which is nonantigenic compared to albumin which is present in egg white and responsible for allergic reactions to egg.[30] With regard to soy allergy, propofol is manufactured with refined soy oil, which contains little to no protein capable of inducing a response.[31] Care must be taken in known cases of atopy;[32] however, a recent study by Asserhøj et al. showed that allergy to egg or soy is not a contraindication to the administration of propofol.[33]

Dexmedetomidine is a relatively new anesthetic agent, an evolution of clonidine. It is derived from medetomidine, a veterinary anesthetic,[34] and is an alpha-2 adrenergic agonist. It produces excellent sedation, analgesia, and anxiolysis while maintaining airway reflexes. However, it can cause dangerous bradycardia, hypotension, and hypertension.[35],[36] A recent meta-analysis comparing dexmedetomidine and midazolam for procedural sedation was found to be promising;[37] however, cost and unfamiliarity may limit its use in the ED as an agent for procedural sedation.


  Adverse Effects Top


Most adverse events occur during PSA, generally within a few minutes of sedative administration. The occurrence of adverse events >5 min after the completion of the procedure is rare.[38],[39] Apnea is the most commonly reported major adverse reaction,[15],[40] with others being hemodynamic compromise and anaphylaxis. In the event of oversedation and airway compromise, airway adjuncts should be used in patients prone to obstruction such as obese and pregnant patients with gentle positive pressure ventilation to prevent gastric insufflation. In the pediatric population, delayed awakening may occur,[41],[42] and hence, children must be monitored closely till fully awake and tolerating oral feeds.


  Management of Specific Complications during Procedural Sedation and Analgesia Top


  1. Benzodiazepene overdose-Flumazenil 0.01 mg/kg slow intravenous (IV) push
  2. Opioid overdose-Naloxone 0.01 mg/kg IV/intramuscular
  3. Laryngospasm from ketamine– Employ Larson's maneuver to break the laryngospasm. Additional boluses of Propofol or even minimal boluses of Succinylcholine with Positive Pressure ventilation may be needed to break the Laryngospasm, in which cases advanced airway management would be required.



  Patient Disposition Top


Patients should be monitored until a return to baseline mental status with stable vitals and minimal pain and nausea. Children and the elderly in particular should be closely observed for delayed reactions. Nausea is common after PSA, especially following the administration of opioids and ketamine.[14]


  Conclusion Top


PSA has become a standard practice in the ED and must be considered a vital component of emergency care and competency. It must be approached as a planned procedure with backup measures in the event of an adverse drug reaction or cardiorespiratory instability. There is no single ideal agent for PSA; however, the combination of pharmacological agents such as ketofol can ensure good sedoanalgesia while maintaining airway reflexes and stable hemodynamics. The entire procedure must be documented and the patient must be monitored till the return of baseline vital signs and consciousness.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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Deitch K, Miner J, Chudnofsky CR, Dominici P, Latta D. 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;55:258-64.  Back to cited text no. 17
    
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24.
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41.
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  In this article
Abstract
Introduction
Procedures Requi...
Grades of Sedation
Assessment Befor...
Personnel
Equipment
Monitoring
Drugs
Adverse Effects
Management of Sp...
Patient Disposition
Conclusion
References
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