ED sedation

[lakersbaby]

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Patient ate full meal 3 hours ago now has impaction. 10 weeks pregnant with hyperemesis, otherwise unremarkable history. ER physician states GI scopes done on full stomachs routinely in ED with moderate/deep sedation and stating General Anesthesia not indicated and is way overkill.

After telling the ED to go pound sand. Proceeded with GA with RSI, case went fine. After further discussion I realize now that ED does tons of procedures with moderate to deep sedation on full stomachs whether it be GI scopes, shoulder dislocations etc. Rant over..

 

[vector2]

EDs have been doing this for decades based on these kinda studies

NPO for sedation? Don't swallow the myth - First10EM

They have the concept so deeply rooted now that they turn their brains off even when a pt likely has a strong case for intubation

 

[Mman]

Patient ate full meal 3 hours ago now has impaction. 10 weeks pregnant with hyperemesis, otherwise unremarkable history. ER physician states GI scopes done on full stomachs routinely in ED with moderate/deep sedation and stating General Anesthesia not indicated and is way overkill.

After telling the ED to go pound sand. Proceeded with GA with RSI, case went fine. After further discussion I realize now that ED does tons of procedures with moderate to deep sedation on full stomachs whether it be GI scopes, shoulder dislocations etc. Rant over..

There is scant good evidence in any direction as to what NPO times should actually be so to some extent we are kinda stuck/limited by ASA guidelines. But how to get around that? Urgent/emergent procedures. If the person wanting our help doesn't want to abide by our guidelines, they just gotta document the harm to the patient if we wait.

As for another physician caring if I do moderate sedation vs GA, I'm the one doing it so I will do what I think is best. But in your particular case I wouldn't call GA overkill, I'd call sedation without a secured airway "kill" because that's what happens when that frequent puker starts vomiting with diminished airway reflexes.

 

[AdmiralChz]

Didn’t we just have this discussion in another thread?

The GI and ED peeps are welcome to do the case with moderate sedation. Without me.

 

[T-burglar]

probably comes from their lower comfort level with intubation and looking for studies to justify not having to do it

full stomach makes it onto my list of red flag conditions that you need to take seriously. Hypoxemia will always be the fastest and easiest way to kill someone and any condition that can create refractory critical hypoxemia needs to be carefully managed.

 

[lakersbaby]

Didn’t we just have this discussion in another thread?

The GI and ED peeps are welcome to do the case with moderate sedation. Without me.

Lol I just saw the post for esophageal food impaction. So yes we did just have this discussion. That is basically what I told them. If GI requests anesthesia support then stop talking to me about what you do down there.

 

[deleted875186]

Patient ate full meal 3 hours ago now has impaction. 10 weeks pregnant with hyperemesis, otherwise unremarkable history. ER physician states GI scopes done on full stomachs routinely in ED with moderate/deep sedation and stating General Anesthesia not indicated and is way overkill.

After telling the ED to go pound sand. Proceeded with GA with RSI, case went fine. After further discussion I realize now that ED does tons of procedures with moderate to deep sedation on full stomachs whether it be GI scopes, shoulder dislocations etc. Rant over..

Wow, pregnant lady with hyperemesis, even if she was NPO I’d be concerned. That sounds like an ED doctor who has made up his mind that no sedation requires any amount of NPO time or respect for aspiration. Makes me wonder if he/she ever had a case of aspiration, because I’m sure their opinion would change.

 

[Man o War]

I cannot even begin to count the number of times I’ve been called to bail out a GI or ED sedation/airway screw up.
Their opinion of how anything should be done with with regard to those 2 things means less than zero to me.
It got so bad at my previous place that we had to call emergency meetings and write an official policy that no doctor other than an anesthesiologist was allowed to use Propofol.

 

[anbuitachi]

The question is if they are doing these non npo cases with moderate or deep sedation and get away with it must mean they must not have too many messups or youd think the hospital would do something about it?

 

[GaseousClay]

The question is if they are doing these non npo cases with moderate or deep sedation and get away with it must mean they must not have too many messups or youd think the hospital would do something about it?

Yea all those studies from that link above are pretty compelling. I’m sure the risk is pretty low when selected for right patient and they probably have had success doing it. That being said I’d still ignore them and do what we normally do even if we’re more conservative than them.

 

[Lexdiamondz]

probably comes from their lower comfort level with intubation and looking for studies to justify not having to do it

full stomach makes it onto my list of red flag conditions that you need to take seriously. Hypoxemia will always be the fastest and easiest way to kill someone and any condition that can create refractory critical hypoxemia needs to be carefully managed.

It's more a question of the amount of time and resources intubating someone takes. If you're an EM doc with a busy department, intubating and subsequently extubating a patient for a procedure will destroy your workflow - if they need to be tubed and it's not emergent they should go to the OR.

 

[drmwvr]

Patient ate full meal 3 hours ago now has impaction. 10 weeks pregnant with hyperemesis, otherwise unremarkable history. ER physician states GI scopes done on full stomachs routinely in ED with moderate/deep sedation and stating General Anesthesia not indicated and is way overkill.

After telling the ED to go pound sand. Proceeded with GA with RSI, case went fine. After further discussion I realize now that ED does tons of procedures with moderate to deep sedation on full stomachs whether it be GI scopes, shoulder dislocations etc. Rant over..

Consider the source...they think endotracheal intubation is just short of spinal cord transplant...

 

[BeatriZZ]

FWIW an er friend of mine told me it's exactly this
comes down to workflow...they can't afford to board a patient for 6 or 8 hours to meet ASA NPO guidelines.
Medicolegally, the standard of care for an ER doc doing sedation on a full stomach is different than an anesthesiologist doing the very same thing..so weird

It's more a question of the amount of time and resources intubating someone takes. If you're an EM doc with a busy department, intubating and subsequently extubating a patient for a procedure will destroy your workflow - if they need to be tubed and it's not emergent they should go to the OR.

 

[deleted126335]

The consensus of expert opinion of what is appropriate care for ER physicians regarding IV sedation and NPO conflicts with the consensus of expert opinion of what constitutes appropriate care for Anesthesiologists. Both have peer reviewed literature and lots of recommendations from their professional societies. I don’t judge fellow physicians for following their own guidelines. I expect the same from them when I follow my guidelines.

 

[lakersbaby]

The consensus of expert opinion of what is appropriate care for ER physicians regarding IV sedation and NPO conflicts with the consensus of expert opinion of what constitutes appropriate care for Anesthesiologists. Both have peer reviewed literature and lots of recommendations from their professional societies. I don’t judge fellow physicians for following their own guidelines. I expect the same from them when I follow my guidelines.

Well yea this ED doc definitely judged me for following ASA guidelines. I could care less what they do down there.

 

[K31]

probably comes from their lower comfort level with intubation and looking for studies to justify not having to do it

I think this is not exactly the right explanation--most emergency physicians love to intubate. For reference, my training is emergency medicine and critical care. I think there's a couple of factors at play here.

1) Hospital credentialing--everywhere that I've worked, only anesthesiologists can perform general anesthesia. You put in an ET tube for a procedure and it is by definition general anesthesia, which is limited to anesthesiologists only (at the behest of the anesthesia department).

2) Lower comfort level with extubation. I run into this frequently with patients intubated for the ED to facilitate workup (ie the "intubated for combativeness" patient). The ED then will not extubate downstairs so the patient has to come take up an ICU bed for extubation. This is a combination of two factors, I think. First, the ED does not extubate frequently. And second, it requires time to extubate a patient and that is difficult with multiple other patients requiring your attention.

 

[deleted162650]

I think this is not exactly the right explanation--most emergency physicians love to intubate. For reference, my training is emergency medicine and critical care. I think there's a couple of factors at play here.

1) Hospital credentialing--everywhere that I've worked, only anesthesiologists can perform general anesthesia. You put in an ET tube for a procedure and it is by definition general anesthesia, which is limited to anesthesiologists only (at the behest of the anesthesia department).

2) Lower comfort level with extubation. I run into this frequently with patients intubated for the ED to facilitate workup (ie the "intubated for combativeness" patient). The ED then will not extubate downstairs so the patient has to come take up an ICU bed for extubation. This is a combination of two factors, I think. First, the ED does not extubate frequently. And second, it requires time to extubate a patient and that is difficult with multiple other patients requiring your attention.

The definition of general anesthesia has nothing to do with what kind of (if any) airway is present.

 

[nimbus]

I’ve been doing anesthesia for a while now and I still don’t understand the difference between general anesthesia and deep sedation. To me they are the same. Can someone explain this to me? Is it just a duration thing?

 

[Psai]

Deep sedation is when the patient moves. I know this because that's when the surgeon is biching that the patient is light.

Also extubation takes less time than intubation. Literally just drop the cuff and pull the tube. It's so easy a caveman can do it.

 

[K31]

The definition of general anesthesia has nothing to do with what kind of (if any) airway is present.

True, but at most facilities emergency physicians are only credentialed for up to moderate sedation, and if they have loss of airway reflexes requiring intubation then the sedation level is beyond moderate sedation. Whether the typical ED sedation goes beyond moderate sedation is a separate issue (eg the usual orthopod griping if the patient so much as grimaces when they're yanking on a fracture).

 

[K31]

Also extubation takes less time than intubation. Literally just drop the cuff and pull the tube. It's so easy a caveman can do it.

I agree. I do it every day. But most emergency physicians don't and thus aren't comfortable with it.

Some of it is a nursing issue too. The typical ER nurse has 2-3 other patients of varying acuity and asking them to intensively monitor a freshly extubated patient frequently isn't realistic.

 

[Groove]

ER doc here. Yes, we don’t extubate very much in the ED. If the pt required intubation in the first place, better for pt safety to transfer to the ICU for further management and extubation. My nurses routinely are 1:4 or 1:5 and I’m actively managing up to 12 pts at the same time. If I’m pulled to the room for too long, that’s when people start having MIs and strokes in the waiting room while it continues to back up. It’s unsafe. You have to realize we are taking a lot other things into consideration.

In the particular case you’re describing there’s no reason that needs to happen in the ED. What a ridiculous waste of resources. At my shop that would go to GI lab with anesthesia and out of the ED. I’m not sedating a non NPO pregger hyperemesis in the ED for a GI procedure. Good grief. I’d be stuck in that room forever. Not to mention the aspiration risk. She needs to go to a more controlled environment and I’d prefer anesthesia to handle that one. I’m not saying I haven’t done it on very rare occasions but it’s never a good idea.

 

[anbuitachi]

I’ve been doing anesthesia for a while now and I still don’t understand the difference between general anesthesia and deep sedation. To me they are the same. Can someone explain this to me? Is it just a duration thing?

what? GA is when patient doesn't move. a lot of endoscopies are GA without tubes

 

[vector2]

 

[anbuitachi]

The more confusing term is MAC. Seems like the definition is different depending on whos using it ha!

Some people equate mac to sedation (some articles define MAC as such as well). ASA only says MAC is a anesthesiologist led service which also includes preop and post op care. Doesn't really say level of sedation. some people say mac is sedation with anesthesiologist. other people say MAC is anything with anesthesiologist present since it doesn't depend on level of sedation/anesthesia (thus include sedation, GA, neuraxial, regional, everything)

 

[narcotics999]

FWIW an er friend of mine told me it's exactly this
comes down to workflow...they can't afford to board a patient for 6 or 8 hours to meet ASA NPO guidelines.
Medicolegally, the standard of care for an ER doc doing sedation on a full stomach is different than an anesthesiologist doing the very same thing..so weird

So if aspiration does happen and bad outcome occurs, ER MD can get away with it and Anesthesiologists can't??? The lawyers will be OK with it?

 

[pgg]

So if aspiration does happen and bad outcome occurs, ER MD can get away with it and Anesthesiologists can't??? The lawyers will be OK with it?

The short answer is yes.

Malpractice, by definition, includes a deviation from the standard of care, which is established by one's peers. The standard of care with regard to NPO status and management of sedation, is different for EM physicians than it is for us.

Now, the truth is that anything can happen when lawyers and lawsuits and juries get involved, but you're not going to find an anesthesiology expert witness that will ever agree that these GA "sedation" procedures on non-NPO patients are OK. You'll have no such trouble finding an EM expert witness who says it's OK.

 

[Groove]

This is very true regarding NPO status. Standard of care is different for us because most of the procedures are “emergent”. Open ankle fx/dislocation with cold foot? The ankle has to be reduced, like yesterday... Chances are I’m going to risk sedation regardless of NPO status or either shove an NGT down and place it to suction. There’s no time to waste and we are trained for these procedures. HTN emergency with flash pulmonary edema who just at a Big Mac (or four) an hour ago requiring intubation? Emergency. Shoulder, knee, hip, etc.. dislocations? Emergency procedures. Traumatic emergencies requiring airway management? I wish I could cancel these for 24 hours or handle in a more controlled setting. That’s not the world we live in down there. The hyper agitated, combative patient who tried to strangle one of my nurses and then hang himself in his room using bedsheets, high on bath salts with the strength of 10 men requiring sedation? (True story) Emergency. To hell with NPO status on that one. (He actually is one of the few that got intubated and extubated later in my shift.) The list goes on...

However, for the case at hand I would argue that it’s a non “emergent” procedure and thus has no business being done by me in the ER. We get lots of food bolus impaction pts in the ED and I can’t remember the last one that required an emergent sedation. Urgent? Sure, but not emergent. Hand these people an emesis spit bag for their secretions and they do just fine until GI and anesthesia is ready. If I was forced to do it in the ED, she would get a tube, I don’t care what GI wants. I would also be livid that GI required me to do the procedure for him in the ED in the first place when GI lab resources and anesthesia could easily be mobilized to handle the pt in a more controlled setting and not utilize ED resources that would be better served elsewhere. I probably would be so pissed I’d report it for peer review and escalate it up to the c-suite. I did sedation for a GI friend in the ED on a very slow night a couple years back for an EGD and I was stuck in the room for at least 30 minutes paranoid the entire time about what was about to come through the ambulance bay doors and I swore I would never do it again after that. Most of the GI procedures just aren’t emergent and let’s be honest, you guys do a lot more of those than us. The exception might be the variceal bleeders who have already been tubed by me for airway protection and are hypotensive and GI can’t mobilize enough staff for the EGD in the GI lab at 2a.m. so they bring everything down to the resus bay. Those cases are once in a blue moon.

Same goes for hungry Sally weighing in at 200kilos who swallowed an entire rotisserie chicken and now has a chicken bone stuck in her esophagus. Non emergent. Sally can spit in an emesis bag until GI and anesthesia are ready for her. Anybody telling you that these food bolus cases are emergent and absolutely need to happen in the ED are angling for convenience, plain and simple. Most of our departments are already operating on skeleton crews these days due to hospital restrictions on nursing/ancillary FTE hours and it’s an egregious misuse of resources.

 

[anbuitachi]

I don tthink the issue is emergent or not, cause no one is expecting you to wait 8 hours, but the issue is to tube or not. Yes standard of care is different per the 2 societies but i can EASILY see a knowledgeable lawyer pull off a 'so anesthesiologists, doctors who specialize in anesthetizing patients, would put a tube, but you would not?'. And they'd ask for what reason would you not put a tube? and if your answer would be.. b/c it disrupts my workflow.. i can't imagine that sounding very good to the jury

 

[Groove]

I don tthink the issue is emergent or not, cause no one is expecting you to wait 8 hours, but the issue is to tube or not. Yes standard of care is different per the 2 societies but i can EASILY see a knowledgeable lawyer pull off a 'so anesthesiologists, doctors who specialize in anesthetizing patients, would put a tube, but you would not?'. And they'd ask for what reason would you not put a tube? and if your answer would be.. b/c it disrupts my workflow.. i can't imagine that sounding very good to the jury

Agree and in the original case, she needed a tube for all the reasons discussed. That’s my personal opinion. But hey, I don’t speak for everyone.

However, as someone else already mentioned, I’m not held to your standard of care. I’m held to the standard of care in my specialty. “What would an anesthesiologist do?” Are rarely part of a litigation strategy with us. It’s more along the lines of what would a reasonable emergency doctor do as standard of care for this case. A better approach would be “Doctor what about this case was an emergency requiring you to sedate this pt in the ED”? “Doctor, where are most EGDs for food bolus impactions performed in your hospital and who usually handles sedation during these procedures”? “Ah, so anesthesia handles most EGD sedations...sir, did you attempt to consult anesthesia for this particular case”?

Again, we just don’t routinely do sedation in the ED for EGDs because they are usually not true emergencies. If the ED doc in question is having to do a bunch of these in the ED for GI, he needs to go find another job. That’s sounds like a nightmare.

 

[pgg]

It's not a matter of urgency at all - it's a matter of either you put a tube in an airway that is at elevated risk for aspiration, or you don't.

We never delay urgent or emergent cases for NPO reasons. Acuity is not the issue.

Where the anesthesia-EM disconnect lies, mostly, is in our assessment of that aspiration risk. I can't deny that the EM literature is full of people saying the risk is low, and that you guys aren't doing M&Ms every week. My opinion is that the biggest inducer of aspiration events is airway instrumentation (not necessarily DL but rather LMAs or OP airways or EGD scopes being manhandled by GI) in patients who are moderately or deeply sedated. Harassing the gag reflex in someone whose reflexes are impaired is where the danger lies, and the ER simply doesn't touch the airway at all in 99% of their "sedations" even if a lot of those "sedations" are objectively general anesthesia.

I think that's why the ER gets away with loose/no NPO rules, and I don't throw stones at their methods. I just can't do my job that way. 🙂

 

[Groove]

We never delay urgent or emergent cases for NPO reasons.

I think that's why the ER gets away with loose/no NPO rules, and I don't throw stones at their methods. I just can't do my job that way. 🙂

All we do in the context of airway are emergent/“urgent” procedures so what’s the disconnect? You just said you guys don’t delay for emergent cases. Neither do we.

If this is all about pissing on the ER for this one docs decision not to place a tube, just keep in mind this is one guy. It’s certainly not reflective on all of us, nor would I say his management in this case reflects standard of care within EM.

 

[lakersbaby]

All we do in the context of airway are emergent/“urgent” procedures so what’s the disconnect? You just said you guys don’t delay for emergent cases. Neither do we.

If this is all about pissing on the ER for this one docs decision not to place a tube, just keep in mind this is one guy. It’s certainly not reflective on all of us, nor would I say his management in this case reflects standard of care within EM.

its not one guy/gal. as shown above there is a lot of evidence that ED docs refer to to justify doing procedural sedation whether it be deep/moderate or essentially GA minus tube/LMA without waiting NPO. The ED physician stated that everyone there does these type of cases regularly thats the whole jist of the discussion. Im not trying to diss ED at all I just find it interesting at the differing guidelines and if thats how their guidelines/practice dictates then so be it but nobody should dictate how each others specialty should do things without superior evidence.

 

[pgg]

All we do in the context of airway are emergent/“urgent” procedures so what’s the disconnect? You just said you guys don’t delay for emergent cases. Neither do we.

If this is all about pissing on the ER for this one docs decision not to place a tube, just keep in mind this is one guy. It’s certainly not reflective on all of us, nor would I say his management in this case reflects standard of care within EM.

I don't really know how else to phrase this and I'm certainly not pissing on your specialty.

When we have an urgent case in a non-NPO patient, we don't delay, we do a RSI, intubate, pass an OG tube, and then extubate fully awake.

When you have an urgent case in a non-NPO patient, you don't delay, you just "sedate" the patient, where "sedate" can mean anything from actual by-definition sedation to general anesthesia.

These things are different. Your way is consistent with your standard of care when done by you. Your way is not consistent with our standard of care.

 

[deleted171991]

The more confusing term is MAC. Seems like the definition is different depending on whos using it ha!

Some people equate mac to sedation (some articles define MAC as such as well). ASA only says MAC is a anesthesiologist led service which also includes preop and post op care. Doesn't really say level of sedation. some people say mac is sedation with anesthesiologist. other people say MAC is anything with anesthesiologist present since it doesn't depend on level of sedation/anesthesia (thus include sedation, GA, neuraxial, regional, everything)

MAC is Monitored Anesthesia Care. It is anything that involves an anesthesiologist where the main anesthetic is not GA or a block.

It can be anything, from our mere presence to deep sedation. Again, it does NOT include general anesthesia, or regional anesthesia as the main anesthetic.

 

[Groove]

Don’t disagree with either of you guys, I just think this is a bad example of the point you are trying to make. No ED should be regularly employing mod sedation for an EGD. I’ve worked in more EDs than any of you and trust me when I say this is not the norm. No ED doc wants to get caught up in that procedure. The department would come to a screeching halt. If any of you has an ER that is regularly doing this, that’s not only dangerous but a misuse of resources. That’s my only point. I don’t disagree that we are more lax on NPO guidelines depending on the procedure at hand. It’s consistent with our guidelines and evidence based. Here’s our guidelines.

Procedural Sedation in the Emergency Department

That being said, I’ve refused to sedate many pts that were high risk and insisted in the specialist taking them to the OR with anesthesia. The ER doc in question sounds more the exception than the norm based on my experience working with many ER docs.

That being said, If an ER doc consults you for the sedation then just take over and insist in taking the pt to the OR or endo, it should be as simple as that.

Back to the point being made in here..yes it is a bit odd that our guidelines are so diff regarding NPO.

 

[Groove]

Another problem I run into when you guys describe an ER docs behavior is that I never know if they are ABEM (boarded in EM?), an FM doc with some experience in the ED? IM doc? Hell, I’ve worked with a cardiologist and surgeon who moonlighted in the ED. Practice habits are all over the place depending on who you’re talking about.

 

[lakersbaby]

Don’t disagree with either of you guys, I just think this is a bad example of the point you are trying to make. No ED should be regularly employing mod sedation for an EGD. I’ve worked in more EDs than any of you and trust me when I say this is not the norm. No ED doc wants to get caught up in that procedure. The department would come to a screeching halt. If any of you has an ER that is regularly doing this, that’s not only dangerous but a misuse of resources. That’s my only point. I don’t disagree that we are more lax on NPO guidelines depending on the procedure at hand. It’s consistent with our guidelines and evidence based. Here’s our guidelines.

Procedural Sedation in the Emergency Department

That being said, I’ve refused to sedate many pts that were high risk and insisted in the specialist taking them to the OR with anesthesia. The ER doc in question sounds more the exception than the norm based on my experience working with many ER docs.

That being said, If an ER doc consults you for the sedation then just take over and insist in taking the pt to the OR or endo, it should be as simple as that.

Back to the point being made in here..yes it is a bit odd that our guidelines are so diff regarding NPO.

I respect that and I definitely respect the ED. This shouldn't be about crapping on another specialty but a good discussion on what flies in the OR setting and the ED setting. Thanks for the info.