Deep conscious sedation

[VJV]

We are looking at having ED Dr do deep sedation with anesthesia induction agents (propofol, etomidate, etc). Are there many programs that do this and what sort of educational training do you receive to be credentialed?

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[spyderdoc]

More current term is "procedural sedation". Most EM docs are trained extensively during residency to do this with all the meds (etomidate, ketamine, propofol, fentanyl/versed, etc).

There was a recent article/policy statement in the annals, either this or last month. Look it up and get some good info!
Mark

 

[DocWagner]

We do this as well, our primary conscious (deep) sedation technique is etomidate...works like a friggin charm...love it.
No special training except for attending-resident training.

 

[VJV]

We do this as well, our primary conscious (deep) sedation technique is etomidate...works like a friggin charm...love it.
No special training except for attending-resident training.

As an anesthesiologist and Wright State grad I ask why would you choose etomidate over propofol? Is is because the hospital P&T committee wont let you use propofol. I have never used etomidate for sedation.

 

[spyderdoc]

As an anesthesiologist and Wright State grad I ask why would you choose etomidate over propofol? Is is because the hospital P&T committee wont let you use propofol. I have never used etomidate for sedation.

I too love to use etomidate. Our P&T comittee currently does not let us use propofol in the ED, but we are working on changing that...Hopefully soon.

I think etomidate is favorable, since it is easier to dose than propofol, just give 0.15mg/kg (usually 10mg) and the pt goes out like a light for a few minutes. Just long enough to do a procedure. Occasionally get myoclonic ticks, but that's about it....With propofol, it seems like you spend more time titrating the dose until the patient is out....Just my opinion though....
Mark

 

[Sessamoid]

As an anesthesiologist and Wright State grad I ask why would you choose etomidate over propofol? Is is because the hospital P&T committee wont let you use propofol. I have never used etomidate for sedation.

I don't know about DocWagner, but at the last hospital I worked at they wouldn't let us use propofol. At the hospital I worked at before that, we could use it but the nurses weren't allowed to push it. They would draw it up and we would have to push it ourselves. I've used both and have gotten pretty comfortable with either.

I've had two cases of suboptimal response to etomidate, both in pediatric patients (neither were infants). In one case, the drug had practically no effect on the patient's sensorium, an 8 or 9 year old male. I gave him what amounted to essentially an intubation dose of the drug spread over two doses. Barely fazed the kid. He became a little fuzzy for maybe 5 seconds, then was back to normal. He responded fantastically to a relatively small dose of fentanyl, on the other hand. Everybody's different, so I like have a wide variety of drugs in the armamentarium.

I've never had such a problem with propofol, but for the reasons noted above I haven't used it nearly as much as etomidate.

 

[paisley05]

I was told that we didn't use propofol in my home ED because it needs to be refrigerated and was thus just more inconvenient to use.

 

[docB]

I too love to use etomidate. Our P&T comittee currently does not let us use propofol in the ED, but we are working on changing that...Hopefully soon.

I think etomidate is favorable, since it is easier to dose than propofol, just give 0.15mg/kg (usually 10mg) and the pt goes out like a light for a few minutes. Just long enough to do a procedure. Occasionally get myoclonic ticks, but that's about it....With propofol, it seems like you spend more time titrating the dose until the patient is out....Just my opinion though....
Mark

Ditto the extra time neded to titrate the dose compared to etomidate. Consequently I use etomidate almost exclusively now. We did have propofol but lost it after some doc tried to use it for sedating a violent psych pt and caused apnea. I don't know what kind of doc tried this.

For kids I use ketamine. I've used IM ketamine with good success but I don't anymore because the nursing protocols where I work won't let you do sedation on a pt without an IV. Whatever.

 

[Sessamoid]

For kids I use ketamine. I've used IM ketamine with good success but I don't anymore because the nursing protocols where I work won't let you do sedation on a pt without an IV. Whatever.

Yeah, that's the way I feel about those kinds of rules. I get around that by using fentanyl lollipops and calling it "analgesia" rather than "sedation." Works for me.

 

[DrQuinn]

Have any of you tried Etomidate for your sedation for cardioversion?

I've only cardioverted two patients that went from stable -> unstable. First time we didn't use any sedation cause he was out, but a week or two ago I had this patient who was in WC-Tachy who was stable at home for 8 hours before he came into the ED. Within 20-30 minutes he started feeling woozy, but his BP was still 85-95. Anywho, tried the Etomidate, waited about a minute and then pulled the trigger. He most definately felt it. Wonderin' if I shoulda used something else.

BTW, he deteriorated into polymorphic VT... quite the scary case but it was a lot of fun. Man I love EM. (Apollyon, saw it with your old homeboy HS).

Q

 

[Apollyon]

(Apollyon, saw it with your old homeboy HS).

Q

Have you asked him about Nathan Bedford Forrest, or Cleopatra (who was a Ptolemy)? He'll think you're all that if you know the Cleopatra/Greek thing.

Oh, and, is he still wearing that green tie with the frogs on it?

 

[docB]

Have any of you tried Etomidate for your sedation for cardioversion?

I've only cardioverted two patients that went from stable -> unstable. First time we didn't use any sedation cause he was out, but a week or two ago I had this patient who was in WC-Tachy who was stable at home for 8 hours before he came into the ED. Within 20-30 minutes he started feeling woozy, but his BP was still 85-95. Anywho, tried the Etomidate, waited about a minute and then pulled the trigger. He most definately felt it. Wonderin' if I shoulda used something else.

BTW, he deteriorated into polymorphic VT... quite the scary case but it was a lot of fun. Man I love EM. (Apollyon, saw it with your old homeboy HS).

Q

Yeah, I've used etomidate for emergent cardioversions. I've had good luck with it. The thing about emergent cardioversion is that almost everyone is hypotensive so your options are limited. You usually can't use opiates or benzos because of the BP and the time involved.

 

[ERMudPhud]

Have any of you tried Etomidate for your sedation for cardioversion? ...


... Anywho, tried the Etomidate, waited about a minute and then pulled the trigger. He most definately felt it. Wonderin' if I shoulda used something else.

Q

I think you probably didn't use enough etomidate. I've used it plenty for cardioversion and never had anyone say they remembered the zap. Just don't rush, give them plenty, and make sure they are really out just like you would if you were relocating a hip or whaterver.

Why do you think he went into v-tach after the shock? Did you sync? I've seen people forget to hit sync in the rush to cardiovert and that has the potential for some bad dysrythmia.

As for the etomidate vs propofol question. I think at many institutions propofol wasn't readily available in the ER for a variety of reasons; cost, politics, storage issues. We have it now and I will probably start trying it. I think one other issue is the potential for pretty profound hypotension with propofol which is supposed to be much less of an issue with etomidate.

 

[12R34Y]

I think you probably didn't use enough etomidate. I've used it plenty for cardioversion and never had anyone say they remembered the zap. Just don't rush, give them plenty, and make sure they are really out just like you would if you were relocating a hip or whaterver.

Why do you think he went into v-tach after the shock? Did you sync? I've seen people forget to hit sync in the rush to cardiovert and that has the potential for some bad dysrythmia.

As for the etomidate vs propofol question. I think at many institutions propofol wasn't readily available in the ER for a variety of reasons; cost, politics, storage issues. We have it now and I will probably start trying it. I think one other issue is the potential for pretty profound hypotension with propofol which is supposed to be much less of an issue with etomidate.

Academic Emergency Medicine just had a study comparing fentanyl/versed combo and propofol for anterior shoulder reduction in the ED........Conclusion was that propofol was just as effective as fentanyl/versed for reduction. They commented on propofol's shorter wakening time, but also stated that vomiting and respiratory depression were the major adverse effects with propofol in this particular study.

Interestingly hypotension did not occur in any of the 48 subjects who received propofol, but it did occur in fentanyl/versed group (not statistically different though). respiratory depression occured in 6 out of the 48 in propofol group compared to only 1 patient in the fentanyl/versed group.

Is the drop in pressure associated with hypotension transient or does it require fluid boluses etc...

later

 

[DrQuinn]

Why do you think he went into v-tach after the shock? Did you sync? I've seen people forget to hit sync in the rush to cardiovert and that has the potential for some bad dysrythmia.

Not sure why. I talked to the attending cardiologist who admitted him and he thought he was in VT when he came in, which I agree with. He went into polymorphic VT after the first shock at 100 J, which was synchronized. Pretty scary. It took 3 shocks to get him back. I will probably scan the rhythm strip and post it here, it was a pretty cool case... especially since I did my lecture this year as a PGY2 on Tachydsyrhythmias.

When we got him back into NSR, his QT was normal, and his Mag was normal as well. Weird.
Q

 

[Freeeedom!]

NEVER had a problem with etomidate and have had no reasons to choose anything else. Propofol has dropped pressures (for me) when etomidate has not, and etomidate is just so quick on and off.
I would marry etomidate if she would have me.

 

[DocWagner]

To answer an earlier question, I use etomidate primarily because it has worked so well for me. Propofol is an option at 2 of our 3 main hospitals.
I have also dorked around with versed and fentanyl...don't like it anywhere near as much.