Propofol / Ketamine / Etomidate in ED

[Apollyon]

Many thanks for the informative replies. The idea of residual opiate hanging around is something I address in patients with concerns that they'll get addicted. As I tell them, as long as they have pain, they won't get high - if they're at -5, the pain meds take them back to plano. However, when the pain is gone, now they go to +5 and high.

I had the similar thing happen at my last gig - a shoulder reduction with something - I don't recall if it was Fentanyl or Dilaudid (that's what we had), and I wanted to reverse the patient - and the charge nurse lost her **** saying "Do you want the patient to be in pain?" - as I tried to tell her the shoulder was now reduced, and, as stated, the patient showed signs of opiate use; fortunately, she cleared it reasonably quickly. That charge nurse is THE WORST - if you wonder who or where, I'll tell you via PM.

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[Planktonmd]

I had the similar thing happen at my last gig - a shoulder reduction with something - I don't recall if it was Fentanyl or Dilaudid (that's what we had), and I wanted to reverse the patient - and the charge nurse lost her **** saying "Do you want the patient to be in pain?" - as I tried to tell her the shoulder was now reduced, and, as stated, the patient showed signs of opiate use; fortunately, she cleared it reasonably quickly. That charge nurse is THE WORST - if you wonder who or where, I'll tell you via PM.

I would be careful "reversing" opiates in a chronic opiate abuser.

 

[Apollyon]

I would be careful "reversing" opiates in a chronic opiate abuser.

Oh, I should have been clearer - she wasn't a chronic user - it was strictly the meds I put on board which were then manifesting after cessation of pain.

 

[jwk]

I would be careful "reversing" opiates in a chronic opiate abuser.

Use of naloxone and flumazenil following sedation or anesthesia in my facilities means an adverse drug reaction report has to be completed, because the assumption is they've been overdosed. That applies whether due to PCA on the floor, or sedation or anesthesia in the OR, GI, ER, or cath lab.

 

[dhb]

This is an honest question.

Here are some answers in this mythical post

 

[Venko]

Tap water and crazy glue are good for a mother's kitchen to wash a wound or for repairing wounds in the battle field during Vietnam war but they are not good enough for an emergency room today in the united states!
That is the point!
If you do it this way it might be OK but it's not what an expert under similar circumstances would have done.
The reason why I brought up the tap water and the crazy glue example is because they do work but they are NOT what is done by the majority of reasonable practitioners under similar circumstances.
It's funny when people attempt so hard to miss the point of an example and instead concentrate on meaningless details.

#1
Plankton, on this point, you are clearly wrong by the medical evidence. Many of the cleaning agents other than pressurized water have been shown to compromise cosmesis without adding any benefit in reduction of infection. Tap water has been shown in the evidence cited and others to have the greatest volume of water per injured tissue and to have the lowest rate of infection. You talk about today's hospitals...well at Mayo Clinic, GWU, VA in DC, UF Shands, and PG we used tap water on wounds and had fantastic results.

You are wrong.

#2
It seems that many anesthesiology posts focus on a concern of aspiration. If we as EM physicians have been doing this wrong for many years, why are there only a few anecdotes of harm (I have had one personal experience of vomiting and clinically significant aspiration during "sedation" as we call it or GA as you all do)?

After all, sedation (or general anesthesia as anesthesia would contend) is not an infrequent occurrence in Emergency Departments today. Also, if the rate of aspiration were to be 1% (I am selecting random cut point consistent with my experience in number of my known adverse events) with us performing "general anesthesia" in un prepped patients in high pressure situations and without training....we cannot be that far off from knowing how to use the medications right?

#3
I thought I answered this, but as for my practice, I never perform sedation and am the proceduralist. I am one or the other at all times period.

#4
The reason I brought this thread here is not to get your opinion and not listen. Since moving to DC, I experienced for the first time a hospital in which ED was not permitted to use these medications because Anesthesia placed the limitation. This is why I brought this thread up in this forum, because in that hospital anesthesia is governing my practice. So those of you who say you don't care I should do what I want to do and feel comfortable putting my license on the line with, I appreciate that, and wish I could. Unfortunately, I am not given this privilege by one of my hospitals at this time. It is not an evidence based decision, but rather a consensus opinion.

In any case, thank you all for your posts and commentary.

TL

 

[Planktonmd]

#1


You are wrong.

I am not debating if it is better or worse to clean a wound with tap water, I am saying it is not what the experts (surgeons) would do under similar circumstances, which makes your practice, if you chose to do it, not the standard practice of the community.
As a result, if you have a complication, let's say an infection, you will have a hard time defending your practice.
But, you are a licensed physician and you can do whatever you want, just don't expect endorsement from the surgeons.
I understand that you really want this example to become the issue in this discussion but it is not, the issue here: You want to do something and you expect the experts in that field to endorse you then you need to do it their way. I can give you many other examples on that but obviously I will be wasting my time.

#2
It seems that many anesthesiology posts focus on a concern of aspiration. If we as EM physicians have been doing this wrong for many years, why are there only a few anecdotes of harm (I have had one personal experience of vomiting and clinically significant aspiration during "sedation" as we call it or GA as you all do)?

You might very well be right on that aspiration is not such an important issue, but until there is solid evidence confirming that inducing GA in a full stomach patient with unprotected airway is safe, then you either need to follow the existing guidelines or do whatever you like on your own, and in that case you don't really need us to agree with you.

After all, sedation (or general anesthesia as anesthesia would contend) is not an infrequent occurrence in Emergency Departments today. Also, if the rate of aspiration were to be 1% (I am selecting random cut point consistent with my experience in number of my known adverse events) with us performing "general anesthesia" in un prepped patients in high pressure situations and without training....we cannot be that far off from knowing how to use the medications right?

The fact that you are getting away with something with only occasional disasters that mostly go unreported or under-reported does not make it the right thing to do.

#3
I thought I answered this, but as for my practice, I never perform sedation and am the proceduralist. I am one or the other at all times period.

In the overwhelming majority of cases, sedation/GA in the ER is done by the nurse acting on the ER physician's orders while the ER physician is attempting to do a procedure on the patient.
Actually I am not sure how many ER's have 2 ER physicians present at all times so one of them would do the anesthetic and the other does the procedure. Maybe it is the case in big university hospitals but what about real world community hospitals?

 

[periopdoc]

if the rate of aspiration were to be 1% (I am selecting random cut point consistent with my experience in number of my known adverse events) with us performing "general anesthesia" in un prepped patients in high pressure situations and without training....we cannot be that far off from knowing how to use the medications right?

A complication rate of one percent might or might not say anything about the physician's knowledge of the medication, but it would certainly say volumes about his or her judgement of appropriate situations for applying the medication. That is a horrible complication rate for a procedure like this, one that an anesthesiologist simply would not accept. I would be appalled if you believe that to be a reasonable cut off. Perhaps that is the difference between the way that emergency physicians and anesthesiologists view the issue. We are much more risk averse.

It is not the place of one specialty to endorse restrictions on other specialties. Neither should the members of one specialty be expected to endorse practices by other specialties that are viewed as unsafe by the experts in the endorsing specialty.

The depth of sedation/ anesthesia is not defined by the plane that the patient experiences for the majority of the time. It is the deepest plane achieved by the patient at any point in the procedure. It is extremely difficult to titrate propofol/ etomidate/ ketamine to deep sedation without, at some point, crossing the line into general anesthesia. I rarely code for monitored anesthesia care or sedation any more because unless the patient is lightly sedated and responsive, I am most likely doing general anesthesia without airway control. Acceptable in low risk, fasted patients, but I would be crucified if I tried it in the kinds of patients you are describing.


- pod


oh, and if we aren't the experts, then why are you asking for our endorsement/ opinion.

 

[periopdoc]

If I were on a hospital's credentialing committee, deciding who is and is not allowed to utilize these anesthetic agents, I would be significantly less laissez faire about the issue.

ED docs who want to be credentialed in sedation with anesthetic agents would have to prove that they had specific, continuing training in anesthetic medications and in airway management. I can understand why a hospital would want to protect itself by restricting all non-anesthesiologists from using anesthetic drugs. Unless you and all of your colleagues in the emergency department can demonstrate specific and continuing training, I would vote for restriction to avoid the inappropriate use by untrained or poorly trained physicians who are riding on the credentialing coat-tails of the better trained physicians. e.g. the family docs referred to in post #25.

- pod

 

[Apollyon]

If I were on a hospital's credentialing committee, deciding who is and is not allowed to utilize these anesthetic agents, I would be significantly less laissez faire about the issue.

ED docs who want to be credentialed in sedation with anesthetic agents would have to prove that they had specific, continuing training in anesthetic medications and in airway management. I can understand why a hospital would want to protect itself by restricting all non-anesthesiologists from using anesthetic drugs. Unless you and all of your colleagues in the emergency department can demonstrate specific and continuing training, I would vote for restriction to avoid the inappropriate use by untrained or poorly trained physicians who are riding on the credentialing coat-tails of the better trained physicians. e.g. the family docs referred to in post #25.

- pod

Well, I hear you, but, with my anecdotal experience with several credentialing boards and P&T committees, they have leaned towards us using these meds - not against. Is it because the anesthesiologists don't have enough political juice, is it because they think differently, something else, or, most likely, a combination?

 

[periopdoc]

Or you have been lucky enough to work in ED's with all good EM boarded docs?

It is certainly a combination of factors plus the high likelihood that there were no anesthesiologists even interested in being on those committees.

Of course, my post wasn't claiming to represent what I think credentialing committees do/ would do in general, it was simply a reflection of how my attitude would change if I shared some degree of responsibility for the use of these meds by non-anesthesiologists. Currently, I share none of that responsibility, thus my laissez faire attitude.

- pod

 

[Apollyon]

It is certainly a combination of factors plus the high likelihood that there were no anesthesiologists even interested in being on those committees.

That is something that EM and anesthesiology have in common - it's our boat, so, if it sinks, it's our fault that we didn't try to be part of the crew.

Alternately, when someone of our respective professions is represented on such committees, it's remarkable the successes we can claim.

 

[NEATOMD]

When you're doing these closed reductions and other procedures, I will assume someone else gives the sedation while you do the procedure. Who does the sedating? And I ask, because in many states, propofol may not be administered by RN's except by infusion to ventilated patients in the ICU. So for those EM docs who want to use propofol in such a state, is another EM doc adminstering the propofol?

JCAHO mandates that a trained provider monitor the sedation and another does the procedure. Documentation wise, you have to list two separate providers.

Now, where this gets hairy is in who is able to be that provider. In my hospital, it has to be a physician or midlevel provider (CRNA) certified in administering and monitoring the patient. I've heard that some places use respiratory therapists who are trained to intubate and monitor the patient's vital signs, but nurses are not able to.

So, for any JCAHO institution your assumption is true.

As an aside, JCAHO also mandates that providers assess and document risk though means such as last oral intake, airway class, etc in addition to level of sedation goal for any sedation (operating room or not).

 

[Venko]

A complication rate of one percent might or might not say anything about the physician's knowledge of the medication, but it would certainly say volumes about his or her judgement of appropriate situations for applying the medication. That is a horrible complication rate for a procedure like this, one that an anesthesiologist simply would not accept. I would be appalled if you believe that to be a reasonable cut off. Perhaps that is the difference between the way that emergency physicians and anesthesiologists view the issue. We are much more risk averse.

It is not the place of one specialty to endorse restrictions on other specialties. Neither should the members of one specialty be expected to endorse practices by other specialties that are viewed as unsafe by the experts in the endorsing specialty.

The depth of sedation/ anesthesia is not defined by the plane that the patient experiences for the majority of the time. It is the deepest plane achieved by the patient at any point in the procedure. It is extremely difficult to titrate propofol/ etomidate/ ketamine to deep sedation without, at some point, crossing the line into general anesthesia. I rarely code for monitored anesthesia care or sedation any more because unless the patient is lightly sedated and responsive, I am most likely doing general anesthesia without airway control. Acceptable in low risk, fasted patients, but I would be crucified if I tried it in the kinds of patients you are describing.


- pod


oh, and if we aren't the experts, then why are you asking for our endorsement/ opinion.

Very well put.

 

[JackBauERfan]

So you think that crazy glue and Dermabond are the same?
And you actually wash wounds with tap water?

Can you you PM me what ER you work in?

Yes dermabond is used frequently for lacerations that are not gaping, but need some approximation, and studies have shown better cosmetic results in certain types of wounds.

More interesting is that studies done show that the main thing that decreases wound infection is high pressure irrigation, and in this particular study tap water was used. Now, I dont' use tap water, I just saline, but just saying.

thats why there is a residency in emergency medicine, just like there is a residency in anesthesia.....