Balanced Sedation in the ED. St.Emlyn’s

So I said………..

…., because I was trying to be a bit cheeky.

There is a serious point here though. I don’t know the exact motivation for asking the question but there is still a fair bit of scepticism out there about whether ED docs can do procedural sedation, but as it would be spectacularly dull to go over that ‘again’ and this is hardly the place to discuss it (anaesthetic common room seems to be the best place), it is fair to ask about whether we can do it better. Have you ever heard any of your colleagues (or maybe it’s you) say the following?

“I only ever use propofol for procedural sedation in the ED”

“Ketofol is fantastic, for everything”

“I never use Midazolam”

“Alfentanyl is loads better than Morphine’

Really? I have and when I do I secretly smile to myself and think that  1. You’re a bit of an idiot. 2. You are wrong at least some of the time 3. You are about to ‘get some learning‘……, and it may not be entirely cosy learning. I’m only joking of course as it really is a conversation that can get ED docs thinking about their practice in a way that can benefit patients.

So, what’s my problem here? Basically I have two issues. Firstly there is the one size fits all issue, and secondly (and perhaps more importantly) there is the issue of balance (which conveniently will help us deal with the first problem). Why don’t we start with a couple of examples and if you are in the ‘one size fits all camp’ give me your thoughts on the following cases.

A 72 year old man is brought to the ED following a fall. He has had 10mg Morphine prehospital, but still has some moderate pain. His ankle is clearly broken and the skin is tented and dusky over a nasty looking dislocation. He has significant COPD and can only usually manage to walk ab0ut 15-20 metres without getting out of breath. He is starved at the moment. His ECG is unremarkable and he is cardiovascularly stable with an SaO2 of 92% on 2L by nasal cannula. It’s clear that his ankle needs repositioning but even when examining the ankle it’s clear that he is in a fair bit of pain. Theatre is full and there is no chance of getting a slot for at least a couple of hours.

A 22 year old chap is brought to the ED following a nasty tackle on the football pitch (that’s rugby not soccer by the way). He has a deformed, swollen, tented fracture dislocation of the ankle. He is in agony and is crying and generally whimpering in the way that normally brave young men sometimes do in the ED. It’s pretty clear that you need to crack on and relocate the ankle but he is scared, anxious and in pain. You’re not going to be doing this with entonox!

So, if you were in the one size fits all camp…., are you still there? I hope not as although these patients have very similar injuries and very similar requirements for the ‘procedure’ the approach to how we facilitate this must surely be different. For starters let’s just break down what we are trying to achieve when we give procedural sedation. I think it is essentially four fold, and ‘sedation’ is just one part of what we require.

  1. Sedation - OK, let’s start with the obvious one. Sedation involves a reduction in the conscious level for the patient. This is beneficial in many ways as it allows a procedure to take place in a controlled manner with the patient’s passive or active cooperation.
  2. Analgesia - Most (if not all) the procedural sedation procedures we do in the ED involve pain so analgesia is clearly important.
  3. Amnesia - If you are going to do something unpleasant then perhaps there are benefits to not remembering it.
  4. Anxiolysis - If your patient is terrified, scared and anxious they will not be having a great time and may well be more sensitive to pain and distress. Surely it’s a good thing to do something about this?
  5. Muscle relaxation? - Did I say 4?? I think I did but I’m just going to put this 5th one in here as you might be thinking about it, and therefore you might be wrong……Some procedures (such as relocating shoulders) might well benefit from a degree of relaxation, but this is not the sort of muscle relaxation anaesthetists talk about when discussing balance. I would argue that in the ED ‘muscle relaxation’ is really just about sedation and analgesia rather than ‘true’ muscle relaxation, so although some people talk about muscle relaxation I don’t really buy it as a primary concern. Let’s not advocate microdosing muscle relaxants & if you suggest buscopan I will refer you to the regulator………(only joking, actually on second thoughts….).

In essence what I’m trying to say here is that the aim of procedural sedation is at least 4-fold (‘cos I still think muscle relaxation is actually about pain!). For patients the requirements for each of these elements will differ. In the earlier example we had two patients. One with extreme pain and anxiety, the other with moderately managed pain but pre-existing medical conditions.

Now it is entirely possible for us to use the same method in both patients. Let’s take an example of Propofol which seems to be very popular at the moment. We could give Propofol to the second chap, but we would have to give a TON of drug to achieve all the elements as although Propofol is a great sedative it ‘pants’ as an analgesic! Sure if we give enough of the magic milk to our patient their pain will be controlled (in that they won’t move to pain), but once that ankle is reduced and the pain is also relieved then they will quite possibly not breathe to pain either! As a learning opportunity that’s great as you get to practice your ventilation skills, and if you are really enthusiastic you might be able to run through a few ALS protocols as well, but as a clinical episode – pants. In the second patient we could use Midazolam, but really? Sedation requirements are minimal and do you really want to give a fairly long acting respiratory depressant to this man? I don’t and I don’t want you to do it in my resus room.

Arguably we could do either procedure (any procedure) with enough Fentanyl or morphine or midazolam or pretty much whatever you like really. The problem is that if you intend to use single agents then you may well end up giving a large dose of drug in order to get an adequate effect in all 4 of the areas that your patient needs.

The most important thing to remember is that sedation does not equal analgesia.

balanced sedation

Getting a balance.

Balanced anaesthesia has been around for ages. Once we moved away from Ether as a sole agent (give enough and your patient will be asleep, relaxed and analgesed – oh and nearly dead) our anaesthetic chums have been mixing exquisite cocktails of drugs tailored to ever nuance and subtlety of the patients in front of them. A drop of this, a dash of that, sometimes it’s like watching Tom Cruise in Cocktail, and although such subtly is beyond our requirements we should be able to manage a pretty good G&T rather than serving warm beer all the time.

Balanced sedation is exactly the same principle. Evaluate your patient’s relative requirements for sedation, analgesia, anxiolysis & amnesia. How much of each do you need and which drugs shall we choose? Another example you ask? Why of course, let’s revisit our earlier patients and devise a strategy for each of them…

A 72 year old man is brought to the ED following a fall. He has had 10mg Morphine prehospital, but still has some moderate pain. His ankle is clearly broken and the skin is tented and dusky over a nasty looking dislocation. He has significant COPD and can only usually manage to walk ab0ut 15-20 metres without getting out of breath. He is starved at the moment. His ECG is unremarkable and he is cardiovascularly stable with an SaO2 of 92% on 2L by nasal cannula. It’s clear that his ankle needs repositioning but even when examining the ankle it’s clear that he is in a fair bit of pain. Theatre is full and there is no chance of getting a slot for at least a couple of hours.

What did we do? OK. This is a tricky one and if you said that you were just going to crack on and apologise for the pain later I think that’s OK. The foot needs to get back into position and you cannot wait until theatre is ready. Similarly if you wanted to phone a friend (our anaesthetists are great) then sure go right ahead, this is not straightforward, but what did we do?

We evaluated the patient and reviewed his meds, past medical hx and obs. As this was going to be a fairly quick procedure to reduce the fracture and to apply a POP we did not need a long acting agent. So

Analgesia – Yes, needed, but probably not huge amounts. Already has long acting opiate on board, and you don’t really want to give him lots of additional long acting opiate as pretty soon he will hopefully be in a a POP with less pain (and more reason to suffer resp depression effects of the opiate). He doeshave a requirement for some additional short acting increased analgesia though.

Sedation – minimal requirement has to be cardiovascularly stable

Anxiolysis – not a major problem

Amnesia – would be nice.

So our choice was Ketamine IV. Short acting with rapid onset and combined sedation and analgesic qualities. Good CVS stability and unlikely to cause respiratory problems (if anything likely to improve them). A total of 30mg Ketamine gave good sedation and excellent amnesia. Job done :-) .

A 22 year old chap is brought to the ED following a nasty tackle on the football pitch (that’s rugby not soccer by the way). He has a deformed, swollen, tented fracture dislocation of the ankle. He is in agony and is crying and generally whimpering in the way that normally brave young men sometimes do in the ED. It’s pretty clear that you need to crack on and relocate the ankle but he is scared, anxious and in pain. You’re not going to be doing this with entonox!

This is a scenario where you can really put the principles of balanced sedation into action. Clearly this chap is in a lot of pain and you need to get on top of that first, and before you start with any sedation. If you just used propofol here you would be heading towards an OD. So with a fair bit of pain here and a painful procedure to come you want something that is going to work fairly quickly. Fentanyl is a good choice in this situation and so 100mcg of Fentanyl with some IV paracetamol and some 30mg IV Ketoralac (NSAID) will get you well on the way to good analgesia. Next up is arguably the anxiolysis and amnesia elements. A smidge (technically 1-2mg Midazolam in a fit healthy chap – beware the elderly) can go a long way to reducing the amount of stimulation this man is currently experiencing (might help with a bit of amnesia too). That then gives you time to ensure that you are ready to proceed to sedation with incremental doses of propofol until he is deep enough to facilitate manipulation and POP application.

Job done :-)

At this point there will be at least one person saying….’Ketamine does all of this, that is the one agent I need, and to be honest it’s all 4 elements of sedation in one’. I would say yes…, but also no. Sure, if you are out in the sticks and you are limited in terms of time, facility, access, support, drugs I think you can make a reasonable argument that Ketamine is a pretty god agent. However, it’s not as elegant a solution to the one described above in achieving a balance. Having said that in our second patient if you were insistent on giving them just one agent then I would be happier if you used Ketamine than if you tried to kill them will with Propofol. Well maybe not kill them, but you really must understand the drug if you are going to use it, start with listening to the Propofol assassins.

Key to getting the balance right is to control pain first. There is no doubt that you will need to use less sedative agents if you control pain first. Then consider anxiolysis, often this is linked to pain so it may not be an issue once that is sorted, then, and only then is it worth embarking on sedation. Amnesia will hopefully follow as a natural consequence of the first three elements, but you may have to specifically address in rare cases.

If you are an anaesthetist who has reached this point with a systolic blood pressure of >200, chill. This is a blog post and not a textbook. The blog is here to raise the concept and to get docs to reflect on their practice. Relax and enjoy the discussion that I hope will follow.

In summary, if you are going to be good at procedural sedation you need to evaluate the needs of the patient assess their needs and then select the appropriate drugs to tailor their effects to what the patient requires.

Remember

  1. Analgesia
  2. Sedation
  3. Anxiolysis
  4. Amnesia

 

 

Comments

  1. says

    Great post. I AM an anaesthesiologist, and I think you’ve made a number of valid points. We’d love to think that procedural sedation never happens outside the hallowed halls of theatre, but its use is practical and necessary in a resource constrained environment (I put it to you that all hospitals are resource constrained whether you are in Manchester or Johannesburg)

    My BP did rise when you mentioned muscle relaxation but careful reading of your point made it clear that you were not advocating use of non depolarisers or scoline. :-)

    I think the point that must be made strongly is that procedural sedation is not to be undertaken lightly. In our state hospitals ED units are generally staffed by very junior doctors armed with huge egos and little practical knowledge. This combination spells disaster often with patients receiving huge doses of inappropriate agents, often 15:15 Midaz/morphine. The implications of this are easy to see. I think the balanced approach is ideal. We’ve know for ages that 2+2 is closer to 5 than 4 when it comes to multiple agents.

    I’d would have liked to have seen more emphasis on appropriate monitoring and personnel but I appreciate that in a first world regulated environment these are taken as a given.

    I love the emphasis on choosing appropriate cocktails for the right patient.

    Very good post, thanks very much!

    • says

      Cheers, although the post was not about monitoring and procedural sedation in general your point about monitoring, preparation and skills is really important so thanks for reinforcing that.

      15:15 midaz-morphine…..don’t you mean 15:15:0.2 as the Flumazenil gets added ;-) Seriously, I’ve seen this too often (not in my department) and it’s rather terrifying.

      Thanks again

      S

  2. Traumagasdoc says

    I am honoured that I inspired to this blog, as it’s a very good analysis of the requirements for good sedation/anaesthesia in the emergency department.

    I use the terms sedation and anaesthesia almost interchangeably, as the border between the two is at best ill-defined. Simon’s point that the control of pain must be the first priority is entirely true. Most of the time the reason we are sedating these patients is that the procedure we are about to start is painful. Therefore it makes complete sense to control pain first.

    I hate the term muscle relaxation in the way that anaesthetists use it. It creates confusion, and to people who are not in them though they think muscle relaxation just like a nice massage where you feel a bit relaxed. We should not refer to Rocuronium as a muscle relaxant, we should refer to it as a muscle paralysing agent. Says on the tin what it does, no confusion.

    I think the main difference between my approach as anaesthetist and Simon’s approach as an emergency medicine doctor is the likelihood of the patient stopping breathing. I freely admit that when I sedate people, there is probably a much higher likelihood of them becoming apnoeic for a short period than when Simon sedates them. To an anaesthetist stopping breathing is no big disaster, and I would simply support the patient’s airway, avoid obstruction, and assist breathing for the short period of apnoea. I say “to an anaesthetist” but probably mean anyone who is able to deal with apnoea completely in the comfort zone. My point is that anyone who administers this sort of sedation, which is deeper than simply giving 2 mg of midozalam, Should be happy to deal with the side effects of the sedation. I refer to apnoea as being a side effect rather than a complication, because it does not cause harm as long as it is treated properly.

    I’m looking forward to more debate on this.

    • says

      Yep, agree with pretty much all of that. As a general rule if you are doing a procedure you should be able to manage the procedure in question AND the procedure one step beyond if it goes wrong.

      Think intubation – means you must be able to sort out what to do if you cannot. It’s a principle I learned some time ago from the military who train their commanders to manage one step above their normal role. It’s a good principle in medicine too.

      Apnoea is a known complication and sedationists need to be able to spot it (most importantly!) and manage it.

      So, thanks for the comments, they improve the blog.

      S

  3. says

    Hi folks. Good post Simon. Procedural sedation is a form of anaesthesia..along a spectrum. the goal should always be a balance depending upon a number of patient variables. Like any anaesthetic, it requires a formal approach. Fasting, ASA risk assessment, airway assessment, Medical review, setup of monitoring and rescue equipment, consent etc. It is very true that if you provide procedural sedation, you need to be prepared to rescue the situation if it goes deeper than you expect ..just relying upon the drugs to wear off is not good enough..you need the full range of acute anaesthesia skills.
    Now there is emergency procedural sedation and elective. If it can wait, it should be done like any formal anaesthetic. If it cant you need to do a risk assessment and decide whether sedation with uncontrolled airway is appropriate or not,
    In my local ED, you need to undertake a formal credentialling program to perform procedural sedation. Am not sure if this is standard around the world but it does help here to highlight the minimum standard required for a safe approach, in the ED.

    When I deliver procedural sedation in the aircraft or in prehospital setting, its always setup like for a RSI. We use ketamine a lot..its not perfect but its effective and very forgiving. For the occasional anaesthetist its much safer across a wide age range…than say propofol. There is a tendency to regard propofol like super midazolam and folks can run into trouble. Personally I find, if someone is in pain then they need a quick acting potent analgesic like fentanyl, adding ketamine in combination to an opioid has been proven in prehospital setting to be more effective with less problems. the ketamine provides sedation and amnesia. now propofol and fentanyl will provide reasonable balanced sedation/ analgesia, just has higher incidence of resp complications which is not a big deal if you are prepared to handle them. But at climb into 18000ft in back of vibrating aircraft, I will go the K.

    • says

      Great stuff Minh, would agree with all of that and in the prehospital environment I’m also a great fan of ketamine. In the resus room where there is time, space and more people then I try to gof for a more refined and elegant approach. What you arwe describing is an assessment of the patient and a risk balanced choice of agents. I absolutely agree with that.

      Think of the resus room as a cocktail bar with an expert barman providing the perfect blend of herbs, spices and drugs (balanced sedation). Quite happy for us to sup some stubbies (I believe this to be the Australian term) when out in the wilderness (plain old ketamine).

      vb

      S

  4. says

    This is gold Simon, many thanks.

    Totally agree with the comments made already. I use ketamine frequently and I think this trend is echoed in the speciality as a whole. Sometimes ketamine isn’t the right drug, and propofol is a useful drug to have in the cupboard. It is of course, not without it’s risks.

    The issue I see with propofol is a lack of understanding of its effects. It is NOT an analgesic. See the tears in your intubated patient’s eyes? That’s cause you haven;t given them any analgesia. Wonder why your young fit shoulder dislocation patient needed 100mg of propofol? Because you haven’t given them any analgesia. And guess what’s going to happen when you reduce that shoulder and take away their pain? Got your BVM to hand?

    Sedation is not analgesia. If pain is controlled, less sedation is needed. Better for the patient, better for us.

    Thanks again Simon. I may print this out and stick it to the door of our resus drug cupboard….

    Gareth

  5. Andy Webster says

    Excellent blog Simon, raising the bar of EM bloggers.

    Agree one size does not fit all. Probably don’t use cocktails to the extent that is outlined here. Mainly because the patient often has opiates on board, so tend to choose just propofol/ketamine depending on age/procedure/amount of alcohol on board.
    Personally don’t think there is one right way, but plenty of wrong ways. Using a single agent, only had to ventilate one patient briefly post cardioversion, not had complaints of pain…..must have given sufficient amnesia agents.

    As an EM physician though if done well it is one of the most satisfying parts of our work. Currently for shoulders though, trying to follow the example of Dr Cunningham and getting the majority of my shoulders back in with entonox in a relaxed environment. One of our ST3 2 weeks ago had never seen a reduction without sedation. After doing one with me, the next 4/5 managed without.

    • says

      Good point Andy – patients often have a baseline of morphine on board before they hit the resus room. It’s great to have a baseline so that you can then just manage the pain blip during the procedure itself. Sometimes that would mean using a short acting agent such as Alfentanyl. Again, it’s about matching the drug to the need.

      I also agree with you about shoulders. I’m increasingly putting them back in with not a lot, which makes me wonder why I (and others) have been flattening them with sedation for many years.

      Hmm, need to think about that one.

      There are arguably two reasons to do any procedure.
      1. The patient needs it.
      2. You want to do it.

      Only the first is acceptable :-)

      S

  6. says

    Great Post.
    In my ED we are doing more and more paeds sedation due to lack of theatre time, and there is definitely heavy reliance on ketamine, which does have a proven track record of safety. But I frequently have to remind myself that paediatric anaesthetists have a fair bit of extra training, experience and knowledge than I do as a general ED Physician. I have knocked back a few cases recently that were more for convenience than life/limb threat, and am so much more cautious than I used to be the more I think about potential complications, and the fact that I managed about 5 paediatric cases in total in my 3-month anaesthetic rotation when I was training, as I think we need to be really careful about taking on more than we are specifically trained for in ED due to system pressures. Litigation is far less common in Australia but I can just hear the lawyers voice on the stand “so Dr Buck, can you please tell the court about your post-graduate qualifications in paediatric anaesthesia?”…. “ummmm…..ummmmm…everyone uses ketamine, it’s really safe…”

    I’ll add my voice to the “one size doesn’t fit all” approach, and add the point that lack of theatre time is not a reason to practice outside your sphere of expertise. If someone’s limb is really at threat, and you’re not 100% confident, don’t take a risk you wouldn’t take with your own child, or do make-do job in ED… make them make theatre time, or get an anesthetist down to help you.

  7. Ed Valentine says

    Excellent post! Completely agree with all the points you make. It drives me mad as well when people just use a single agent to manage all patients, without considering their individual problem, background and co-morbidities.

    Pre-hospital, ketamine nearly always ‘gets the job done’ safely, but in the ED we should definitely be striving to provide a more tailored, reasoned and balanced procedural sedation approach.

    I have to admit that in the past I’ve often turned to ketamine for procedural sedation in the ED (as I’m very familiar with it) and it’s only in the last year or so that I’ve really started thinking about how to individualise procedural sedation to the needs of the patient.

    Ed

  8. Traumagasdoc says

    Interestingly during my lecture yesterday I put up the RCOA definition of sedation (maintain verbal contact etcetc) and asked the audience (mostly ED consultants) to put their hand up if they frequently lost verbal contact. Almost everyone did. I followed it up by asking how many ‘frequently’ had the patient go apnoeic for a short period. Fewer, but still around 50% of the hands went up.

    I think we anaesthetists must accept that deep sedation bordering on GA is being given without anaesthetic support all the time. Pretending it doesn’t exist stops us improving safety and expertise in the ED.

    Tanks Simon for starting this thread!

    H

  9. says

    Might I bring another can of worms? If patient 1 later goes for an ORIF, I think it’s a reasonable punt that he will have it done under epidural or spinal anaesthesia, so that should be available in the ED…..discuss! (Or at least some consideration of a regional technique).

    • Hildy says

      I did an ORIF with sciatic/femoral nerve block… it’s not fun (due to lack of tourniquet).

      What do you think of the use of ultrashortacting TIVA opioids (eg remifentanyl) in that situation? maybe with a touch of midazolam.

      As for the statement “I never use Midazolam” I have met an anaesthetist who says that because he believes that it is a daterape drug.

  10. Tom Leckie says

    Balanced sedation tailored to the patient and the emergency environment is one area where Emergency Medicine can claim a body of expertise. I think most most with experience in emergency sedation would share the choice of agents made in Virchester.

    As my practice in this area evolved it was informed more by my anaesthetic and critical care experience than by input from the Emergency Medicine consultants I worked with. Now our trainees are given enough anaesthetic training to have a healthy respect for the agents but little confidence. Our challenge is to pass on the safe use of strong opiods, ketamine, propofol, midazolam etc for sedation to those joining us in the speciality.

    A good summary of the thought processess required – thanks Simon.