Finally the ASA does something right, "FDA upholds ASA Stance on Propofol"

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It's about time the ASA did something right.

http://www.asahq.org/news/asanews081910.htm

Seems like the GI docs were trying to push their own studies showing their own non-anesthesia staff can safely sedate patients with propofol.
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I am really disappointed by this. Diprivan is one of the choice drugs that we use for procedural sedation in the ED. Every sedation, requires the presence of a board certified EM doc along w/ 2 nurses and an RT. I believe in an environment such as this it is perfectly safe to use.
 
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diphenyl said:
I am really disappointed by this. Diprivan is one of the choice drugs that we use for procedural sedation in the ED. Every sedation, requires the presence of a board certified EM doc along w/ 2 nurses and an RT. I believe in an environment such as this it is perfectly safe to use.
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The FDA isn't saying the ER doc or even the GI doc can't use it. It's saying the GI docs can't be doing the GI scopes while at the same time directing his own RN to give propofol.

The ER doc can use it for intubation or even sedation as long as he's not doing another procedure at the same time.
 
This ruling cuts both ways. A major reason why GI wanted to remove the anesthesiologist requirement because they wanted to make c-scopes more cost competitive with virtual colonoscopy which doesn't require sedation and is much cheaper. I believe that this will ruling will make virtual colonoscopies more and more appealing to insurance companies. It's just a matter of a few years before virtual colonoscopy will finally be approved by CMS for reimbursement and it will take off from there.
 
diphenyl said:
I am really disappointed by this. Diprivan is one of the choice drugs that we use for procedural sedation in the ED. Every sedation, requires the presence of a board certified EM doc along w/ 2 nurses and an RT. I believe in an environment such as this it is perfectly safe to use.
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Next time you open a bottle of propofol pull the package insert and take a look. The drug company has a nice disclaimer in there basically stating the only practitioners trained in general anesthesia should be administering propofol. As for my perspective, I have less of a problem with you guys using it in the ED than for the GI guys giving free reign to a "sedation nurse". Most ED folks can manage an airway. Most of the GI guys I have seen have no clue when it comes to an airway going bad. By the way, you are taking a risk using propofol in the ED. If something happens and you end up in court, you and the jurors will be seeing a big blown up copy of that disclaimer and you will be asked if you are trained to provide general anesthesia.
 
It's true that a certain number of ER physicians can manage an airway (which means they can most of the times intubate if the patient is about to die), but as we all know, managing an airway under anesthesia is not about being able to perform a rescue intubation after you lose the airway. When we (anesthesia trained professionals) administer anesthesia of any kind our airway management starts the moment we start our anesthetic and continues through out the procedure, we have an intimate relationship with the patient's airway, we constantly adjust our level of anesthesia and our level of airway support according to the depth of anesthetic we need and according to a number of parameters that we monitor continuously: breathing pattern, SPO2, HR, BP, signs of anesthetic depth, intensity of surgical stimulus...
We don't only manage the airway continuously but we also know how to monitor and correct the hemodynamic effects of anesthetics as well as how to provide the appropriate resuscitation required.
So, I find it laughable when an ER guy claims that he/she can administer GA (calling it procedural sedation) as safely as we do:rofl:
It is very difficult to explain to an outsider the real meaning of managing an airway under anesthesia and that is why it is very difficult to make these guys understand that it is an art that requires years of training and a different set of skills than simply being able to intubate if needed.
The only reasonable way for an outsider to understand what airway management under anesthesia means is for them to spend some time in the OR observing the delivery of anesthesia (not only visiting to learn how to intubate as most ER residents do).
 
Planktonmd said:
It's true that a certain number of ER physicians can manage an airway (which means they can most of the times intubate if the patient is about to die), but as we all know, managing an airway under anesthesia is not about being able to perform a rescue intubation after you lose the airway. When we (anesthesia trained professionals) administer anesthesia of any kind our airway management starts the moment we start our anesthetic and continues through out the procedure, we have an intimate relationship with the patient's airway, we constantly adjust our level of anesthesia and our level of airway support according to the depth of anesthetic we need and according to a number of parameters that we monitor continuously: breathing pattern, SPO2, HR, BP, signs of anesthetic depth, intensity of surgical stimulus...
We don't only manage the airway continuously but we also know how to monitor and correct the hemodynamic effects of anesthetics as well as how to provide the appropriate resuscitation required.
So, I find it laughable when an ER guy claims that he/she can administer GA (calling it procedural sedation) as safely as we do:rofl:
It is very difficult to explain to an outsider the real meaning of managing an airway under anesthesia and that is why it is very difficult to make these guys understand that it is an art that requires years of training and a different set of skills than simply being able to intubate if needed.
The only reasonable way for an outsider to understand what airway management under anesthesia means is for them to spend some time in the OR observing the delivery of anesthesia (not only visiting to learn how to intubate as most ER residents do).
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You are painting "ER physicians" with a broad brush. I have had minimal issues with EM trained physicians and airway management and sedation. In nearly 20 years of practice I can count on one hand the number of messes that I have had to clean up by an EM trained physician. Nearly All of the emergent calls from these folks have been extremely challenging. HOWEVER not all docs that work in an ER are EM trained. There are still plenty of internists and family practice docs picking up shifts in an ER. These individuals are an entirely different animal. Is their procedural sedation as safe as we do? NO. BUt they operate under a different standard of care than we do.
 
diphenyl said:
I am really disappointed by this. Diprivan is one of the choice drugs that we use for procedural sedation in the ED. Every sedation, requires the presence of a board certified EM doc along w/ 2 nurses and an RT. I believe in an environment such as this it is perfectly safe to use.
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So, it's one of the nurses or the RT doing the procedure, right?

:D
 
dr doze said:
You are painting "ER physicians" with a broad brush. I have had minimal issues with EM trained physicians and airway management and sedation. In nearly 20 years of practice I can count on one hand the number of messes that I have had to clean up by an EM trained physician. Nearly All of the emergent calls from these folks have been extremely challenging. HOWEVER not all docs that work in an ER are EM trained. There are still plenty of internists and family practice docs picking up shifts in an ER. These individuals are an entirely different animal. Is their procedural sedation as safe as we do? NO. BUt they operate under a different standard of care than we do.
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My point is: Being able to intubate does not qualify you to administer General Anesthesia even if you call it "procedural sedation".
This is what most ER physicians are unable to understand and that's why this same argument keeps coming back: I can intubate so I should be allowed to induce GA!
 
Planktonmd said:
My point is: Being able to intubate does not qualify you to administer General Anesthesia even if you call it "procedural sedation".
This is what most ER physicians are unable to understand and that's why this same argument keeps coming back: I can intubate so I should be allowed to induce GA!
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those same ER docs will also give deep sedation bordering on GA all the time for closed reductions who ate a full meal two hours ago, hundreds if not thousands of times without incident. Because their standards are different than ours. They will do it with only rare complications. If we did the same, there would be no shortage of experts willing to crucify us.
 
dr doze said:
those same ER docs will also give deep sedation bordering on GA all the time for closed reductions who ate a full meal two hours ago, hundreds if not thousands of times without incident. Because their standards are different than ours. They will do it with only rare complications. If we did the same, there would be no shortage of experts willing to crucify us.
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I had this exact conversation with my brother (currently an ER resident). He and his department were annoyed that the hospital took propofol away from them, so now it's etomidate for just about everything. Occasionally ketamine.

Of course, this solves no problems. Using clear stuff instead of white stuff doesn't change the fact that they're inducing general anesthesia in people with full stomachs.
 
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pgg said:
I had this exact conversation with my brother (currently an ER resident). He and his department were annoyed that the hospital took propofol away from them, so now it's etomidate for just about everything. Occasionally ketamine.

Of course, this solves no problems. Using clear stuff instead of white stuff doesn't change the fact that they're inducing general anesthesia in people with full stomachs.
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To them this is not a problem.
 
Hamhock said:
Ann Emerg Med. 2003;42:647-650 and pages 636-646

HH
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They make some reasonable points in defense of propofol for ER general anesthesia sedation, but it doesn't exactly reassure me to read that in an article defending the practice they note a slew of studies with numbers like
- induction doses of 1 - 1.5 mg/kg
- 19-49% respiratory depression
- 12-31% hypoxia
At least there were no aspiration events documented.

I was however amused to read that one of their justifications for using propofol in people who aren't NPO is that it's an anti-emetic and thus vomiting is rare. Yet ERs promptly replace propofol with evomitate when the institution takes it away.


Anyway, exactly 100% of the ER aspirations I've personally witnessed were during attempts at intubation, usually multiply attempted intubations punctuated by lousy mask ventilation. I suspect the aspiration risk is probably overblown so long as an unskilled person isn't manhandling a laryngoscope as if he's drilling for oil, but it still isn't zero.

As dr doze noted, any one of us would be utterly alone and defenseless if a patient aspirated after we semi-electively induced GA in a non-NPO patient without immediately securing the airway with an ETT - it's clearly outside our standard of care.
 
Planktonmd said:
...
So, I find it laughable when an ER guy claims that he/she can administer GA (calling it procedural sedation) as safely as we do:rofl:
...
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Procedural sedation (what I do) and GA (what you do) are NOT the same, as you assert. The ASA says so.

http://www.asahq.org/publicationsAndServices/standards/35.pdf

I have no desire to administer GA. I do know that I can and do safely conduct procedural sedation.

pgg said:
I was however amused to read that one of their justifications for using propofol in people who aren't NPO is that it's an anti-emetic and thus vomiting is rare. Yet ERs promptly replace propofol with evomitate when the institution takes it away.
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With that concern for vomiting in mind, what would be your suggested alternative to propofol for a SHORT (<5 min) procedure?
 
NateintheED said:
Procedural sedation (what I do) and GA (what you do) are NOT the same, as you assert. The ASA says so.

http://www.asahq.org/publicationsAndServices/standards/35.pdf

I have no desire to administer GA. I do know that I can and do safely conduct procedural sedation.



With that concern for vomiting in mind, what would be your suggested alternative to propofol for a SHORT (<5 min) procedure?
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Let's be honest. There's no such thing as procedural sedation. It's a continuum from awake to general anesthesia and different procedures produce different levels of nociception which require different levels depression of consciousness.

The policy statement you've quoted also states:

Due to the strong likelihood that “deep” sedation may, with or without intention, transition to general anesthesia, the skills of an anesthesia provider are necessary to manage the effects of general anesthesia on the patient as well as to return the patient quickly to a state of “deep” or lesser sedation.

You, and countless other EPs, induce GA in practice. It's done in patients at high risk of adverse events. The actual depth and risks of anesthesia produced doesn't change if it's an EM trained physician or anesthesiologist pushing the drug.
 
NateintheED said:
Procedural sedation (what I do) and GA (what you do) are NOT the same, as you assert. The ASA says so.

http://www.asahq.org/publicationsAndServices/standards/35.pdf

I have no desire to administer GA. I do know that I can and do safely conduct procedural sedation.
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I know that this is what you think but unfortunately what you do most of the time IS general anesthesia but you just can't recognize it (or don't want to).
When you tell a nurse to give a random dose of Propofol then you pull on a dislocated joint and the patient does not flinch this is General anesthesia my friend.
 
NateintheED said:
With that concern for vomiting in mind, what would be your suggested alternative to propofol for a SHORT (<5 min) procedure?
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He did not say that there is a better drug to use if you want to anesthetize a patient who is full stomach!
He is saying that the standard we are held to (Anesthesia professionals) requires us to secure the airway with RSI and ETT if the patient is full stomach and requires an intervention regardless of how short that intervention might be.
ER guys regularly ignore that standard and they only kill a small number of people which is not too bad I guess!
 
NateintheED said:
With that concern for vomiting in mind, what would be your suggested alternative to propofol for a SHORT (<5 min) procedure?
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It doesn't matter.

NPO patient - use your favorite drug, I don't care who uses it

not NPO patient - use your favorite drug + RSI/ETT, I don't care who does it


I think it's silly to 'take away' propofol from ERs, because the issue we generally get anxious about isn't what agent they're using but how they're using it.


Also, I wasn't making the claim that using etomidate increased the patient's risk for aspiration, just that citing propofol's antiemetic properties as an aspiration-risk-reducer while the patient is obtunded is ******ed. It's a silly contrived argument, and the authors surely know it's a silly contrived argument, because the instant propofol is 'taken away' the goto drug is etomidate.
 
Its not just the ER where it can be an issue. Intensivits including pulmonolgists have the abilty to use GA. In training i rescued a good number of pulmonary failed intubations. I still remember the time they let a 1 hour extubated patient eat and then when the patient failed extubation they pushed propofol and nimbex. Needless to say the 10mg of nimbex they used in a 150kg pt did not work and the patient aspirated during an intubation attempt. Then they called me.

Thank god in private practice the pulmonolgists dont even try.
 
proman said:
Let's be honest. There's no such thing as procedural sedation. It's a continuum from awake to general anesthesia and different procedures produce different levels of nociception which require different levels depression of consciousness.

The policy statement you've quoted also states:

Due to the strong likelihood that “deep” sedation may, with or without intention, transition to general anesthesia, the skills of an anesthesia provider are necessary to manage the effects of general anesthesia on the patient as well as to return the patient quickly to a state of “deep” or lesser sedation.

You, and countless other EPs, induce GA in practice. It's done in patients at high risk of adverse events. The actual depth and risks of anesthesia produced doesn't change if it's an EM trained physician or anesthesiologist pushing the drug.
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Completely agree re: the fact that sedation is a spectrum. And therefore by your and Planktonmd's definition, we do induce GA from time to time. And you're absolutely right - the risks don't change based on who's responsible.

HOWEVER, a few points:
1) We do not give "random" doses of propofol, as someone mentioned. And we often have to push it ourselves due to state limitations on RN scope of practice. Everyone I work with is acutely aware of the dose of anything we're giving, not just Propofol.

2) As far as I know, there is no magic involved in allowing a patient to return from a very brief period of GA to "deep or lesser sedation", especially when using something as short-acting as Propofol. Its all supportive - wait, don't give any more drug, give O2, and perhaps a jaw thrust if needed.

3) It is inappropriate for one specialty to dictate another's scope and standard of practice. I'm the one taking the risk and assuming the liability, not you. If you want to be in every ED 24/7 to manage every patient that needs sedation or anesthesia, be my guest. Bottom line: I'm not going to wait hours for the shoulder dislocation or the screaming kid with the grossly angulated forearm fracture to be NPO for 8 hours, let alone the rapid a-fib with chest pain that needs shocking or the grossly deformed trimalleolar fracture with no DP pulse. Its unnecessary suffering for the patient, wasted time in the ED, and may entail a probability of damage to life or limb that outweighs the risk of sedation. And good luck getting Ortho or someone else to come in and take any of these to the OR.

4) Remember, just like I don't call surgery for every belly pain, cardiology for every chest pain, peds for every child, or OB for every pregnant patient that shows up, when I call you, its because something has gone bad or its something I can't handle. So that is ALL you are going to see. If you're seeing ED sedations go bad and kill people as often as you suggest, you must have some of the worst ER doctors around.
 
NateintheED said:
1) We do not give "random" doses of propofol, as someone mentioned. And we often have to push it ourselves due to state limitations on RN scope of practice. Everyone I work with is acutely aware of the dose of anything we're giving, not just Propofol.
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This statement is a confirmation of what I said earlier (random doses)!
Could you kindly tell us the dose of propofol you use to achieve "procedural sedation" while maintaining airway reflexes and spontaneous ventilation??
NateintheED said:
2) As far as I know, there is no magic involved in allowing a patient to return from a very brief period of GA to "deep or lesser sedation", especially when using something as short-acting as Propofol. Its all supportive - wait, don't give any more drug, give O2, and perhaps a jaw thrust if needed.
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Wrong again! There is magic involved and it is called the art of giving general anesthesia.
NateintheED said:
3) It is inappropriate for one specialty to dictate another's scope and standard of practice. I'm the one taking the risk and assuming the liability, not you. If you want to be in every ED 24/7 to manage every patient that needs sedation or anesthesia, be my guest. Bottom line: I'm not going to wait hours for the shoulder dislocation or the screaming kid with the grossly angulated forearm fracture to be NPO for 8 hours, let alone the rapid a-fib with chest pain that needs shocking or the grossly deformed trimalleolar fracture with no DP pulse. Its unnecessary suffering for the patient, wasted time in the ED, and may entail a probability of damage to life or limb that outweighs the risk of sedation. And good luck getting Ortho or someone else to come in and take any of these to the OR.
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No one is dictating how you practice and we are all happy that you are not calling us for these cases but we can not lie to you and tell you that the way you are giving GA with unprotected airway and full stomach is appropriate.
But you are right, you can do whatever you want!
NateintheED said:
4) Remember, just like I don't call surgery for every belly pain, cardiology for every chest pain, peds for every child, or OB for every pregnant patient that shows up, when I call you, its because something has gone bad or its something I can't handle. So that is ALL you are going to see. If you're seeing ED sedations go bad and kill people as often as you suggest, you must have some of the worst ER doctors around.
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Trust me, we appreciate not getting called for every ER sedation, but again this does not mean we should agree with the way you are doing things just because you are a nice guy!
 
Planktonmd said:
This statement is a confirmation of what I said earlier (random doses)!
Could you kindly tell us the dose of propofol you use to achieve "procedural sedation" while maintaining airway reflexes and spontaneous ventilation??
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Personally, I start with 0.5mg/kg and titrate to effect from there. Patients come in random weights and metabolisms, so I guess that means weight-based dosing and titration is "random" dosing as you put it. What fixed dose would you use? Obviously, I know if they have spontaneous ventilation, but no, I'll never know with absolute certainty if they still have airway reflexes, and don't intend to test for them!
Wrong again! There is magic involved and it is called the art of giving general anesthesia.
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I honestly don't know how to respond to this. Unless you can give me something specific that you can do in this situation by virtue of your training that I can't, I maintain that I can monitor and support someone in this situation (recovering from very brief unintentional GA). Come to think of it, I regularly see patients who induce their own GA prior to arrival. They're called drunks, and we watch them WAY longer than we would need to watch anyone recovering from propofol or etomidate.
No one is dictating how you practice and we are all happy that you are not calling us for these cases but we can not lie to you and tell you that the way you are giving GA with unprotected airway and full stomach is appropriate.
But you are right, you can do whatever you want!
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Here is where you are wrong. Who in the hospital is the driving force behind taking Propofol out of the ED? Anesthesia. By doing that, you are dictating how I practice.
Trust me, we appreciate not getting called for every ER sedation, but again this does not mean we should agree with the way you are doing things just because you are a nice guy!
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This is where we will have to respectfully agree to disagree. I respect that you don't agree with my practice; that's your professional opinion. But if you don't want to be called for every one of these cases, please respect my ability to recognize the patients that I can safely sedate patients in the vast majority of cases.

I appreciate the collegial discussion.
 
NateintheED said:
Completely agree re: the fact that sedation is a spectrum. And therefore by your and Planktonmd's definition, we do induce GA from time to time. And you're absolutely right - the risks don't change based on who's responsible.

HOWEVER, a few points:
1) We do not give "random" doses of propofol, as someone mentioned. And we often have to push it ourselves due to state limitations on RN scope of practice. Everyone I work with is acutely aware of the dose of anything we're giving, not just Propofol.

2) As far as I know, there is no magic involved in allowing a patient to return from a very brief period of GA to "deep or lesser sedation", especially when using something as short-acting as Propofol. Its all supportive - wait, don't give any more drug, give O2, and perhaps a jaw thrust if needed.

3) It is inappropriate for one specialty to dictate another's scope and standard of practice. I'm the one taking the risk and assuming the liability, not you. If you want to be in every ED 24/7 to manage every patient that needs sedation or anesthesia, be my guest. Bottom line: I'm not going to wait hours for the shoulder dislocation or the screaming kid with the grossly angulated forearm fracture to be NPO for 8 hours, let alone the rapid a-fib with chest pain that needs shocking or the grossly deformed trimalleolar fracture with no DP pulse. Its unnecessary suffering for the patient, wasted time in the ED, and may entail a probability of damage to life or limb that outweighs the risk of sedation. And good luck getting Ortho or someone else to come in and take any of these to the OR.

4) Remember, just like I don't call surgery for every belly pain, cardiology for every chest pain, peds for every child, or OB for every pregnant patient that shows up, when I call you, its because something has gone bad or its something I can't handle. So that is ALL you are going to see. If you're seeing ED sedations go bad and kill people as often as you suggest, you must have some of the worst ER doctors around.
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Agree with all.
 
Planktonmd said:
You agree that he should give GA with unprotected airway on full stomach patients just because he does not want to call someone?
:rolleyes:
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I agree that EM docs using these drugs have an excellent record of safety.

I agree that anesthesiology has no business dictating to EM physicians standards or practice guidelines.
 
NateintheED said:
Here is where you are wrong. Who in the hospital is the driving force behind taking Propofol out of the ED? Anesthesia. By doing that, you are dictating how I practice.
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FWIW, I'm not really comfortable with any specialty imposing rigid limits on any other. There is a point though within an institution when borderline or crazy stuff done by one group has the potential to impact another.

You may be board certified by your own society, and your literature may support what you're doing, but you're credentialed to practice at a given institution by that institution. Beyond credentialing, other hospital committees may have substantial influence and power to regulate how certain things are done there. Those committees are made up of people, people who may include anesthesiologists, people whose purpose (among other things) is to attempt to minimize both the risk of harm to patients and legal risk to the hospital.

I've had such committee duty inflicted on me, and when a proposal or adverse event report reaches me for my opinion the only thing I can do is make judgments and recommendations based on my experience in my own field. I can't imagine and apply another specialty's standard of care.

I suspect that inducing general anesthesia in full-stomach patients for brief painful procedures (as is often done in the ER) probably has very low risk. Obviously our ICUs are not full of ARDS patients who aspirated during their propofol-facilitated shoulder reductions in the ER. I suspect that the fact that you generally aren't mask ventilating them or instrumenting their airways contributes to the low incidence of aspiration. But I don't know.

What I do know is that I have seen full-stomach patients regurgitate large volumes into their mouths immediately after induction in the OR, before any airway instrumentation or procedure was done ... and I do know that my own society has NPO guidelines and if I step outside those guidelines, I do so at my own peril (to say nothing of the risk assumed by the patient).

And so, regardless of what your literature shows and what anecdotal information I hear from the ER, I can't get behind the kind of heavy handed sedation/GA you do in full-stomach patients. In time, perhaps your continued event-free ER general anesthetics will produce data and change my mind, but for now all I can think is "that's a really bad idea" ...

And again, when the question of who can sedate who and how and where comes before the hospital committee I'm a member of, all I can say to the rest of the committee is "that's a really bad idea" ...


All that said, imposing a propofol ban upon an ER is dumb. It solves nothing and unfortunately corners you into using an inferior drug for something you're going to do anyway.
 
dr doze said:
I agree that EM docs using these drugs have an excellent record of safety.

I agree that anesthesiology has no business dictating to EM physicians standards or practice guidelines.
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You don't know their safety record because it has never really been studied and because many mishaps go unreported.

Anesthesiology is not dictating how they should practice, Anesthesiology dictates how anesthesia should be done and that's what every specialty does!
(Surgeons dictate how surgery is done, ER physicians dictate how emergency medicine should be practiced...).
 
Planktonmd said:
You don't know their safety record because it has never really been studied and because many mishaps go unreported.

Anesthesiology is not dictating how they should practice, Anesthesiology dictates how anesthesia should be done and that's what every specialty does!
(Surgeons dictate how surgery is done, ER physicians dictate how emergency medicine should be practiced...).
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I have to say, we can never do the right thing by you guys. Are you saying a pulseless trimal fracture shouldn't be reduced until the patient's been NPO some silly number of hours dictated by anesthesia (with very little actual evidence behind those numbers, as you are no doubt aware) while his/her foot becomes necrotic, then gangrenous, and eventually requires amputation? Are you saying that you'd rather be called in from home or called into an emergent case so that the pulseless trimal fracture can be reduced in the OR? Should we just screw it all and reduce it - no pain medication, just a good old bullet to bite on so that you can tell everyone how much the ED sucks at pain management?
 
SoCuteMD said:
I have to say, we can never do the right thing by you guys. Are you saying a pulseless trimal fracture shouldn't be reduced until the patient's been NPO some silly number of hours dictated by anesthesia (with very little actual evidence behind those numbers, as you are no doubt aware) while his/her foot becomes necrotic, then gangrenous, and eventually requires amputation? Are you saying that you'd rather be called in from home or called into an emergent case so that the pulseless trimal fracture can be reduced in the OR? Should we just screw it all and reduce it - no pain medication, just a good old bullet to bite on so that you can tell everyone how much the ED sucks at pain management?
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No, we're saying that if we were asked to provide the "sedation" for this case and more than a touch of your favorite short-acting benzo or opiate was needed to help an awake patient through the procedure - ie you wanted general anesthesia briefly - we'd intubate the patient, pass an OG tube, and extubate them awake.

We wouldn't wait for 8 hours NPO, we'd intubate the patient after a rapid sequence induction if the plan called for general anesthesia.


I suspect you guys are correct with your repeated assertion that a few minutes of GA in the ER carries minimal aspiration risk - again, we all know that North American ICUs aren't loaded with ventilated ARDS patients who got fractures reduced in the ER. But I don't know, and when people solicit our opinions on the matter, all we can do is reply in the context of our own standard of care, and that standard of care is that a full stomach + GA = tube. Don't let it hurt your feelings.
 
I'm glad SDN has ER residents that can educate Anesthesiology ATTENDINGS about the safety of administering propofol/etomidate for conscious sedation; regardless of NPO status.

After all, they are the airway experts, right???
 
dutchmaster said:
I'm glad SDN has ER residents that can educate Anesthesiology ATTENDINGS about the safety of administering propofol/etomidate for conscious sedation; regardless of NPO status.

After all, they are the airway experts, right???
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Point taken. However, I didn't say I would ignore NPO status (and I don't). Just that I am aware of the ASA guidelines for NPO status and unaware of what the evidence behind them. From my conversations with my anesthesia colleagues, I'm certainly not the only PGY2 who is a little unclear on what and where the evidence is for them. So hey, here's your chance to educate me!

To be fair - at my current institution the trimal fracture would go to the OR quickly and I wouldn't have to deal with it. That still leaves me wondering what I'd do if I were somewhere that didn't have ortho or anesthesia 24/7 (unfortunately, we get very little experience with extubation in the ED). As for the way to handle it - I appreciate the input.
 
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SoCuteMD said:
I have to say, we can never do the right thing by you guys. Are you saying a pulseless trimal fracture shouldn't be reduced until the patient's been NPO some silly number of hours dictated by anesthesia (with very little actual evidence behind those numbers, as you are no doubt aware) while his/her foot becomes necrotic, then gangrenous, and eventually requires amputation? Are you saying that you'd rather be called in from home or called into an emergent case so that the pulseless trimal fracture can be reduced in the OR? Should we just screw it all and reduce it - no pain medication, just a good old bullet to bite on so that you can tell everyone how much the ED sucks at pain management?
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-Don't lump us all together.
-When this issue came up at our credentialing discussions, our anesthesiology chairman stood by our ER colleagues when pharmacy raised the question of EM physicians use of this drug.

-Now if you could just return the favor by making sure all patients coming from ER to the OR have good vascular access :rolleyes:
 
SoCuteMD said:
I have to say, we can never do the right thing by you guys.
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I'm a fellow PGY-2. I've read the NPO guidelines, and I know they're not backed by a great deal of evidence. But, further thought should reveal that'd it'd be extremely difficult to gather such evidence. I'd just as well follow the guidelines of the experts in my field which have allowed us to steer clear of trouble for a long time. The ASA NPO guidelines are pretty detailed and informative.

I'd also direct you to the ASA page that differentiates standards, guidelines, and statements. http://www.asahq.org/publicationsAndServices/sgstoc.htm

In short, guidelines are not intended as standards or requirements, and their use can't guarantee outcome. Standards are minimum requirements for clinical practice. So for anesthesia, if I'm treating your patient I'll follow my guidelines and put on ASA standard monitors, followed by RSI-->ETT-->OG tube. If I had your patient and didn't follow my guidelines or standards, I'd be hung out to dry in the case of an adverse event.

But your society doesn't hold you to the same standards or guidelines, and they also don't seem to be in a rush toward changing your current practice. So go ahead, induce 'conscious sedation' in the full stomach patient in which you have to urgently reduce their fracture. You may never see an adverse event in your entire career. But if you do, I have to wonder, if you'll ask yourself if you did right by that patient who entrusted you to do the right thing. And the right thing, by the expert in the field, is RSI-->ETT. And if you called me in the middle of the night for help in this scenario, I'd be glad to help out.

And fwiw, I don't care if you use propofol. You obviously want it badly, and think you use it as well as the experts, so go ahead.
 
1st case this am. 75 y/o male with post laminectomy syndrome l-spine for scs implant. MAC with propofol so rapid reversal can be done for intra op testing to make sure electrodes were in best position. Propofol off and 2 min later, no change. Then 5 min. CRNA running case gives a little flumazenil as patient ha a little versed at start of case. Zip. At 15 min the attending Amesthesiologist called in. Vitals fine, patient in no distress, just cannot wake up. Intra op neurostim testing cancelled and leads and battery implanted to match fluoro pics from scs trial. 45 min from infusion stop until he woke up in PACU.

A compelling reason why I would never allow non anesthesia personnel to use diprivan in an outpt setting. It could have gone bad to worse real quick.
 
The one thing almost every anesthesiologist ignores is the setting of Emergency Medicine. It's actually a mistake most specialties make. You cannot blindly apply standards from the OR to the ER (or the cath lab to the ER or the clinic to the ER, etc, etc). I wouldn't doubt that total number of complications by EM is higher than if an anesthesiologist did every sedation. The difference, however, is likely exceedingly small and is going to be nearly impossible to power a study to detect any significant difference. It also would fail to capture the negative outcomes of having anesthesia be present for every sedation. Unless anesthesia at every private hospital in the country can ensure that they will present to the ER within 30 minutes of being called (and faster if the situation necessitates it) then the negative outcomes of delayed sedation will far, far outweigh the minimally increased risk of EM doing the sedation. It also completely ignores cost effectiveness. How much money would we as a country spend if we sent every open fracture to the OR for reduction and splinting? Would it be the safest venue? Yes, but there is no way it would be cost effective.

This is the reason specialties should not dictate scope of practice to each other. If this comes to fruition is it going to set a standard that will be applied to other medications? Will hematology need to be involved every time a heparin drip is started? Will cardiology need give their blessing every a amiodarone drip is started? Will an intensivist need to be consulted every time levophed is ordered? Does cardiology need to take away intra-operative TEE from anesthesia unless they are present since they define the standards of echo?
 
The one thing almost every anesthesiologist ignores is the setting of Emergency Medicine. It's actually a mistake most specialties make. You cannot blindly apply standards from the OR to the ER (or the cath lab to the ER or the clinic to the ER, etc, etc). I wouldn't doubt that total number of complications by EM is higher than if an anesthesiologist did every sedation. The difference, however, is likely exceedingly small and is going to be nearly impossible to power a study to detect any significant difference. It also would fail to capture the negative outcomes of having anesthesia be present for every sedation. Unless anesthesia at every private hospital in the country can ensure that they will present to the ER within 30 minutes of being called (and faster if the situation necessitates it) then the negative outcomes of delayed sedation will far, far outweigh the minimally increased risk of EM doing the sedation.

This is the reason specialties should not dictate scope of practice to each other. If this comes to fruition is it going to set a standard that will be applied to other medications? Will hematology need to be involved every time a heparin drip is started? Will cardiology need give their blessing every time amiodarone is started? Will an intensivist need to be consulted every time levophed is ordered? Does cardiology need to take away intra-operative TEE from anesthesia unless they are present since they define the standards of echo?
 
KYTNOH said:
The one thing almost every anesthesiologist ignores is the setting of Emergency Medicine. It's actually a mistake most specialties make. You cannot blindly apply standards from the OR to the ER (or the cath lab to the ER or the clinic to the ER, etc, etc).
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Your point is well taken however I doubt you are going to convert too many of us, if at all. We are trained differently and we have different standards for care. We are going to do things the way we were trained to. Part of this is driven by medicolegal fears, part is dogma. We are conform our practice patterns to the vast majority of our colleauges.
 
Arch Guillotti said:
Your point is well taken however I doubt you are going to convert too many of us, if at all. We are trained differently and we have different standards for care. We are going to do things the way we were trained to. Part of this is driven by medicolegal fears, part is dogma. We are conform our practice patterns to the vast majority of our colleauges.
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I don't necessarily think you or I need to be converted to the other's opinion because I don't think there is that much difference. You said it yourself: you're trained differently and have a different standard of care. What EM docs don't want anesthesiologist to do is apply your standards for something to us without walking in our shoes.

It is interesting that you mention dogma as well. No one here has yet to provide any data that says Emergency Physicians cannot provide safe and effective sedation with propofol. I've read personal opinion and references to package inserts, but no actual evidenced based medicine. Is it anesthesia dogma that propofol is an extremely dangerous drug that only they can administer? Of course, I have no evidence to that compares EM propofol sedations with anesthesia propofol sedations in regards to safety either. However, in the absence of any definitive data either way should one specialty in the house of medicine be dictating to another how they should practice? I personally don't think so.

In an ideal world we would have every eye complaint seen by an ophthalmologist, every chest pain or arrhythmia seen by a cardiologist, every headache seen by a neurologist, and every sedation run by an anesthesiologist. Of course, we don't live in an ideal world. We don't have the manpower or resources to staff hospitals like that, so we have created a specialty that can cross disciplines and provide high quality, adequate care for the bread and butter of these disciplines in addition to the unparalleled care in regards to medical and trauma resuscitation.

Sedations aren't going anywhere in the ER. There's no way the system could support taking sedation out of the ER. I don't see many community anesthesiology groups taking 24/7 call and being subject to EMTALA by being on call lists which would be what would happen if sedations are taken out of the hands of EM docs.
 
I find it very interesting that everyone thinks ED docs are sedating a bunch of people who just ate. Every ED where I have worked as strict NPO sedation rules for non-emergent procedures. I consider a stable shoulder non-emergent, but urgent. If this guy just ate a Happy Meal, I'm likely using local. If he ate 3-4 hrs ago, ok, now we are talking sedation. Just like anesthesia is a continuoum, so is NPO status in my mind. If their ankle is sideways and pulseless, I wouldn't care much about their NPO status, as I think the benefit outweighs the risk. That being said, if I didn't have immediate OR capeability, I would consider RSI intubation with reduction immediately following the intubation (hoepfully using the same induction meds).
 
dhb said:
Well then you have different NPO guidelines too.
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Yep. And yet we don't have high aspiration numbers in ED studies. As mentioned above, maybe it's because of the lack of instrumentation, maybe it is something else. But PSA is safe in the 4-6 hour range in our literature, and for clears, it is 2 hours.

pd4emergence said:
Next time you open a bottle of propofol pull the package insert and take a look. The drug company has a nice disclaimer in there basically stating the only practitioners trained in general anesthesia should be administering propofol.
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Yeah, and Chloraprep says
It should also not be used on open skin wounds, broken or damaged skin, for lumbar puncture or in children less than 2 months of age. In addition, contact with the brain, meninges and middle ear must be avoided.
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However, there are countless groups that use it for spinal, LP, epidural, and gasp neurosurgical procedures.
 
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