Conscious Sedation

[fuegofrio17]

I found everyone's personal practice regimens for treating migraines/HA to be very interesting and educational. What regimens do you use for conscious sedation in adults and in kids in the ED? I've seen a wide variation of practices in my limited EM experiece.

Just a suggestion, but similar to the journal club sub-forum, maybe a ED clinical practice sub-forum would be a helpful longterm reference for students and residents.

Thanks for any input!

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[The White Coat Investor]

I use a lot of propofol and ketamine. I'm not as a big of fan of etomidate, except for intubating, but even that may be changing soon (if you're following the intensivist literature, you know what I'm talking about.) I've done a little fentanyl and versed as well, but I like the more predictable effects of propofol and ketamine.

Propofol you have to be a bit more cautious with. I only use propofol for short procedures, and I set up to intubate prior to giving the drug. I always make sure it is a separate person doing the sedation from the one doing the procedure. I always use full monitoring (including ETCO2) when I use it.

Ketamine is much safer and I have used it with success in both adults and kids.

 

[southerndoc]

Desperado, what is the intensivist literature saying about etomidate?

We do not use etomidate for conscious sedation because of the risk of laryngospasm (1%) and trismus (15%).

 

[12R34Y]

At my institution JACHO came in last year and said that ketamine cannot be adminstered anymore in the ED unless staff anesthesia faculty is present. And you cannot do it by yourself meaning that one physician has to be present for the sedation and the other to do the procedure. it is ridiculous, but the rules at my university. all of the EM attendings hate it because they used ketamine for years, but not now.

also curious about etomidate?

later

 

[Arch Guillotti]

Probably etomidate and adrenal suppression.

 

[GeneralVeers]

My attendings use Etomidate almost exclusively during conscious sedation. It's been quite effective from what I've seen.

 

[edinOH]

I use so much etomidate that I expect a nice steak dinner from them any day now.

Kids I let fly on Special K.

Anesthesia still gets their panties in a wad about propofol in the ED. Funny how I can put someone on a vent and order a propofol drip in the ED but it won't get hung until they hit the unit, then I can order it by the truckload (one pallet of propofol to bedside qd). Funny too when you board pts. for a few hours/days in the ED. It always seems to miraculously appear after the 8th ativan order.

 

[DrQuinn]

Probably etomidate and adrenal suppression.

Those studies with etomidate and prolonged adrenal suppression were on patients with either multiple doses or on continuous drips of etomidate. Its true that a single dose of etomidate does cause a minimal drop in cortisol level but it returns to normal after 4 hours.

Q

 

[NinerNiner999]

Agreed, a single does of etomidate has minimal effects on adrenal suppression. We frequently use Etomidate 20mg/dose in adults for relatively short procedures (orthopedic reductions, etc). Elderly adults may benefit from a smaller dose. For longer procedures or ones that may require extensive pain management, I have found that Fentanyl and Versed is a fairly reliable combination and titratable to effect. That being said, respiratory depression is always a concern with this method (I've only needed to put in one nasal trumpet in over 50 sedations with this combination). Propofol is also useful from what I've read, again because it is easily turned off, but in our institution only anesthesia can administer this drug. Ketamine is wonderful in children (and pretty cool when the nystagmus kicks in). I try to consider why I need conscious sedation (what is the procedure being performed) and tailor my drug choice accordingly.

 

[Arch Guillotti]

Those studies with etomidate and prolonged adrenal suppression were on patients with either multiple doses or on continuous drips of etomidate. Its true that a single dose of etomidate does cause a minimal drop in cortisol level but it returns to normal after 4 hours.

Q

I may be wrong (esp. since I am post call) but I think there may be some new studies coming out in this area.

 

[bartleby]

Aside from the amnestic properties of propofol and its quick on/off action, it really knocks patients' muscle tone down which is helpful for shoulder reductions in the guy who fell leaving the gym after his usual 6 hour workout

For kids, it's special K all the way. It's hard to imagine any reasonable justification for restricting this drug in the ED setting given the only infinitesimal risk of serious respiratory depression compared with fentanyl & midazolam.