Deep conscious sedation in ED

[VJV]

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We are looking at having ED MDs do deep sedation in ED with induction agents (etomidate, propofol) and was wondering what was happening at other institutions. This is not currently done in our medical community and we are a little hesitant.

 

[UTSouthwestern]

We are looking at having ED MDs do deep sedation in ED with induction agents (etomidate, propofol) and was wondering what was happening at other institutions. This is not currently done in our medical community and we are a little hesitant.

Unfortunately, it is a very complicated situation that doesn't have one cookie cutter answer. Clinical situations, availability of resuscitative equipment and personnel, etc. will determine the success or failure of an ER's sedation protocol.

If you could provide more information on what the sedation is being proposed for, it would give us more to look at to provide some answers.

 

[jwk]

We are looking at having ED MDs do deep sedation in ED with induction agents (etomidate, propofol) and was wondering what was happening at other institutions. This is not currently done in our medical community and we are a little hesitant.

You're wise to be a little wary. This debate is raging in many different areas.

Who is actually doing the sedation? Who is monitoring the patient? Who is doing the procedure and what is being done? It's a little different giving an induction dose for an urgent intubation than trying to titrate sedation for a closed reduction of a wrist. And your statement that it's "deep sedation" makes it that much more of a concern. If you can't manage the next level beyond deep sedation, which is general anesthesia, the consensus from most anesthesia providers is that you simply shouldn't be using propofol.

Although probably more restrictive than most hospitals, our hospital has a strict policy that ONLY anesthesia may give propofol, ketamine, etomidate, pentothal or brevital. (infusions on ventilated patients are OK) That means closed reductions, cardioversions, colonoscopies, etc. ANYTHING requiring use of these drugs and anesthesia has to give them, no exceptions.

And like it or not, the manufacturer clearly states that propofol is to be given only be those trained in general anesthesia. Any mishaps involving propofol being given by non-anesthesia personnel and that's the first piece of evidence a plaintiff's attorney will be using.

 

[2ndyear]

I routinely see peds intensivists here (no anes residency) give propofol for procedural sedation. I know they're not anesthesiologists but they are quite competent.

On another note we also have an outcomes based survey that goes in the chart for any sedative/hypnotic used by non-anesthesia personnel. It asks questions about any adverse events, etc. This is mainly for things like caths, bronchs, other scopes, etc.

There has been a few adverse outcomes, so far I've seen it in peds patients, where you don't want to wait for the peds sedation team as you have to schedule about a week in advance, the anesthesiologists are tied up in the OR, so someone slips them too much versed and they code in the CT scanner.

 

[jwk]

I routinely see peds intensivists here (no anes residency) give propofol for procedural sedation. I know they're not anesthesiologists but they are quite competent.

On another note we also have an outcomes based survey that goes in the chart for any sedative/hypnotic used by non-anesthesia personnel. It asks questions about any adverse events, etc. This is mainly for things like caths, bronchs, other scopes, etc.

There has been a few adverse outcomes, so far I've seen it in peds patients, where you don't want to wait for the peds sedation team as you have to schedule about a week in advance, the anesthesiologists are tied up in the OR, so someone slips them too much versed and they code in the CT scanner.

Same questions - who gives it, who monitors, who does the sedating?

Your last paragraph, and particularly your last line, says a lot!

 

[deleted6669]

we give all of these agents in the ed I work at(busy west coast trauma ctr) without anesthesia present. it involves a lot of paperwork and a conscious sedation team composed of at least 1 provider ( md/do or pa),1 resp therapist, and 1 rn. all pts constantly monitored. all members of the team acls certified and credentialed in a conscious sedation course.
that being said, I have never needed to give propofol as ketamine usually does the trick for kids and either fentanyl/versed or etomidate does it for adults.

 

[kungfufishing]

propofol is great stuff though, and I would say if you are going to choose an agent for deep conscious sedation in an ED setting *most* of the time, it is a great choice - short half life, effective, fat calorie source if your patient is a malnourished alkie frequent flyer

 

[jwk]

propofol is great stuff though, and I would say if you are going to choose an agent for deep conscious sedation in an ED setting *most* of the time, it is a great choice - short half life, effective, fat calorie source if your patient is a malnourished alkie frequent flyer

"Deep Conscious Sedation" is an oxymoron - it doesn't exist.

 

[ICUDOC]

Just remember...propofol titrated to lack of response to stimuli is general anesthesia with no airway protection......most ED docs get away with this because of the short half life of propofol...

 

[Brass_Monkey]

......most ED docs get away with this because of the short half life of propofol...

And because they are stupid

 

[DrDre']

You don't want to be labeled as inferior because you are a DO but it is ok to label all EM docs as stupid?


There is so much I would love to comment on. Must refrain...

 

[Brass_Monkey]

You don't want to be labeled as inferior because you are a DO but it is ok to label all EM docs as stupid?

Yes.