Procedural Sedation

[dukes7779]

just wondering what everyone is using for procedural sedation at their EDs and what staff are involved (2nd provider, RN, Resp. Therapist, etc.).

[kargiver]

Depends on the procedure. We use it across the spectrum of patients from everything from reductions to lac repairs and just about everything in between the two. We can (and do) use everything except propofol. Our anesthesia groups (at both hospitals where I work) still hold out on it.

 

Ketamine is in and etomidate seens to be fading in popularity. I still use it for quick reductions (hips, shoulders) though. I rarely use fentanyl and versed as the degree of sedation needed to achieve some reductions just cannot be achieved with these.

 

With regards to personnel, Practitioner is always there plus a nurse. Usually have a second practitioner or RT as well. In a pinch we can get by with just a practitioner and nurse but is usually is etomidate as the drug of choice. Else it is a minimum 3 person affair. If an orthopod is doing a procedure then I will cover the other practitioner role. Either way it is still three people.

 

G

[True Anomaly]

Propofol is our sedative of choice, but that primarily comes from using it for several sedation studies in our ER.

 

An interesting discussion on the most recent EMRAP (the ER podcast for ER residents) made the case for remifentanill, which has a longer onset than propofol but a much more rapid offset, and side effect profile seems to be more favorable. For the anxious patient, it was mentioned that an anxiolytic would have to be used first though. Good luck finding that drug in your ER though....

[EMEDPA]

I work several different jobs.

#1 versed/fentanyl only for pa's. considered "moderate sedation" so only need 1 extra rn in room. use it for abscess I+D mostly in nervous adults. anything more serious have doc sign off for better drugs.

#2 (rural) in house crna's come down for every sedation but will use any med we want. with propofol or ketamine must have crna+ rn

#3 pa's can order anything. rn for moderate, rn+rt for ketamine/propofol.

 

speaking of which has anyone tried "ketophol". (ketamine + propofol). they use it at la county/usc and have it on their training site www.emrap.tv

the guy getting it in the video gets REALLY gorked but they reduce his ankle with zero problems....haven't tried it yet....

[dukes7779]

I have not tried Ketophol yet but it looks great. Emrap is a great site!!! In my ED (Critical Access Hospital - very rural) we typically use propofol for the dislocations and the versed/fentanyl cocktail for anxiolysis and analgesia for smaller procedures (I&D, lac. repairs on certain pt.s, etc.)

 

When using propofol we follow ACEP clinical policy guidelines with regards to monitoring (SpO2, EtCO2, cardiac, etc...). NY does not allow nurses to push the propofol so I will push the meds and when the patient is where I want them I will reduce the dislocation. the nurse monitors the patient and someone else assists me. This is a solo provider ED staffed by PAs with physicians on call for back up.

 

EMEDPA - I am working on developing a Policy and Procedure for propofol use in my ED. Could you PM me what your #3 job uses for a P&P as the work environ. sounds just like mine. I am trying to present P&Ps from other facilities to my Med. Staff so we can see what is a "standard" at similar facilities. Thanks.

[rcdavis]

E,

 

Have u had probes w/ ankle reductions?

 

Even w/ 3-m fx dislocate, a little versed, a little fentanyl, or at worse tom, and I cannot remember one I couldn't get in, or at least near enough (sometime fx fragment precludes complete reduction) to last overnight and to the OR.

 

I cannot see any need for ketamine plus proposal. I see no advantage over ketamine alone, or ( if worried about hallucinations, ket plus versed).

 

Tell what I am missing.

 

Propofol is soooo expensive.. I am not sure where it helps in short term procedures...

 

Just being contrary I guess.

[EMEDPA]

nope, no problems with the reductions. my last rural shift I did 3 in 1 shift( 1 with analgesics alone- a shoulder that hadn't been out long- and 2 with propofol- a shoulder out for hours and a prosthetic hip) I think the reason usc uses it is that they don't want to do a lot of titration like sometimes you have to do with propofol .many places don't use straight ketamine in adults due to emergence phenomenoa.

also re: expense; you can probably use less propofol if you mix with the (cheaper ) ketamine.

I was just curious because I hadn't tried it and wondered if anyone here had experience with it.

[wdtpac]

What ever happened to good old morphine and valium???

[kargiver]

Morphine and valium work just fine... assuming one deals with the histamine release associated with "allergy" people have to morphine. This means treating a subpopulation with benadryl, another sedating med that needs to be dealt with during the process. However, the more persuasive argument to not using them is that the half-life of both drugs are too long when trying to move people through the ER. I'd much rather use fentanyl and versed, both with a very short half-life, as compared to the morphine-valium combo. They achieve the same effect with a very short turn-around time.

 

G