light sedation and conscious sedation

[coffeebythelake]

hopping over from the anesthesiology forums.

from what i understand your official society guidelines regarding NPO status for procedural sedation is based on ASA guidelines - 2 hours clears/6 hours light meals/8 hours heavy meals. there does appear to be a number of journal articles and opinion pieces in the EM literature about the safety of performing light and conscious sedation on non-urgent/non-emergent procedures without following these guidelines. what's your opinion on this?

---

Members don't see this ad.

 

[gro2001]

hopping over from the anesthesiology forums.

from what i understand your official society guidelines regarding NPO status for procedural sedation is based on ASA guidelines - 2 hours clears/6 hours light meals/8 hours heavy meals. there does appear to be a number of journal articles and opinion pieces in the EM literature about the safety of performing light and conscious sedation on non-urgent/non-emergent procedures without following these guidelines. what's your opinion on this?

Not read up on the literature you refer to, but what do you mean by non-urgent/non-emergent in the EM setting? I never do non-urgent/non-emergent procedural sedation. I only do procedural sedations for things that need to happen now. Joint dislocation reductions, fracture reductions, cardioversion, lac repair in kids that can't be restrained and I can't glue or use other adjuncts in, etc. Actually, this applies to all procedures. I don't do elective intubations, or elective chest tubes, or elective anything. If it can wait till tomorrow, it gets done by somebody else, somewhere else.

 

[coffeebythelake]

Not read up on the literature you refer to, but what do you mean by non-urgent/non-emergent in the EM setting? I never do non-urgent/non-emergent procedural sedation. I only do procedural sedations for things that need to happen now. Joint dislocation reductions, fracture reductions, cardioversion, lac repair in kids that can't be restrained and I can't glue or use other adjuncts in, etc. Actually, this applies to all procedures. I don't do elective intubations, or elective chest tubes, or elective anything. If it can wait till tomorrow, it gets done by somebody else, somewhere else.

i don't mean non-urgent/non-emergent in the sense that it is elective. i mean in the sense that it could technically wait for appropriately NPO time. a joint dislocation is painful, but unless it's causing an issue with blood supply, it can technically wait 6 hours from the patient's last NPO time?

 

[Daedalus]

Procedural Sedation in the Emergency Department // ACEP

Here's the the actual policy statement from ACEP. From that statement, "Nothing by mouth (NPO) status has not been demonstrated to reduce risk of emesis or aspiration in ED procedural sedation."

I agree with this. I document last PO intake, but it generally does not affect my decision to perform sedation.

 

[BoardingDoc]

i don't mean non-urgent/non-emergent in the sense that it is elective. i mean in the sense that it could technically wait for appropriately NPO time. a joint dislocation is painful, but unless it's causing an issue with blood supply, it can technically wait 6 hours from the patient's last NPO time?

Even if it's not causing an issue with blood supply, the longer it's out the harder it can be to put back in. This means increased risk of iatrogenic injury and increased need to have it done in the OR instead of the ED. And as Daedalus noted above, it doesn't seem to matter anyway.

 

[link2swim06]

hopping over from the anesthesiology forums.

from what i understand your official society guidelines regarding NPO status for procedural sedation is based on ASA guidelines - 2 hours clears/6 hours light meals/8 hours heavy meals. there does appear to be a number of journal articles and opinion pieces in the EM literature about the safety of performing light and conscious sedation on non-urgent/non-emergent procedures without following these guidelines. what's your opinion on this?

"Our guidelines" are posted above. The data is fairly clear, waiting is not useful or indicated for what we do. The sedation should proceed as soon as possible. Now, granted I don't encourage my patient's to eat while waiting for their procedure.

I think general anesthesia guidelines are a bit different because you have to start considering the effect of your paralytic, inhaled gases, and positive pressure ventilation.

I haven't seen any of my patients have significant aspiration issues from my sedations (and I do about one sedation every other shift).

 

[Janders]

Agree with above. I do occasionally change my approach if they are coming straight from dinner (a common occurrence). For example I might leave them sitting upright while I re-locate their ankle, or I might go with a touch lighter sedation if appropriate and add-in local/regional.

Last time I refused to sedate someone was a person who was at an all-day outdoor festival consuming liters of dark rum, dislocated their elbow! and stopped for an entire bucket of fried chicken of which they were gnawing on the last piece (being held by their good arm) when I walked in the room. Even my die-hard nurses cocked an eyebrow when I started grousing about propofol-- they were correct, his ETOH-sedation was actually perfect for a near-painless elbow reduction, which he tolerated splendidly as demonstrated by the hugs given to myself and the PA immediately post-reduction.

YMMV.

 

[GonnaBeADoc2222]

Dunno about everyone else, but I personally wouldn't want to wait 6 hours with my joint out waiting for reduction.

Have never seen an aspiration event with any of my sedations. Rarely vomiting even.

Leaving hips out long term also increases risk of AVN.

 

[Psai]

Eveything here sounds rather reasonable

 

[TooMuchResearch]

hopping over from the anesthesiology forums.

from what i understand your official society guidelines regarding NPO status for procedural sedation is based on ASA guidelines - 2 hours clears/6 hours light meals/8 hours heavy meals. there does appear to be a number of journal articles and opinion pieces in the EM literature about the safety of performing light and conscious sedation on non-urgent/non-emergent procedures without following these guidelines. what's your opinion on this?

The paraphrased version of our guidelines is that as long as they don't have Cheetos in their mouth right now, we're good to go. I don't document a last NPO time.

 

[coffeebythelake]

• 
  

  "Our guidelines" are posted above. The data is fairly clear, waiting is not useful or indicated for what we do. The sedation should proceed as soon as possible. Now, granted I don't encourage my patient's to eat while waiting for their procedure.
  
  I think general anesthesia guidelines are a bit different because you have to start considering the effect of your paralytic, inhaled gases, and positive pressure ventilation.
  
  I haven't seen any of my patients have significant aspiration issues from my sedations (and I do about one sedation every other shift).

  
  
• The NPO guidelines established by ASA are not for just general anesthesia. They apply to all types of anesthesia whether it is a cataract surgery getting 1 mg versed or major surgery with general. I would disagree (as would most anesthesiologists) when you say that sedation has less risk of aspiration than general esp when you decide to forgo NPO considerations. In fact we would do a GA rapid sequence for urgent or emergent cases that cannot wait for NPO even if it is something we could normally do sedation for. How do you reconcile This? Are u thinking that ASA guidelines are too strict Then?

 

[KGflyboy]

• 
  
  
  
• The NPO guidelines established by ASA are not for just general anesthesia. They apply to all types of anesthesia whether it is a cataract surgery getting 1 mg versed or major surgery with general. I would disagree (as would most anesthesiologists) when you say that sedation has less risk of aspiration than general esp when you decide to forgo NPO considerations. In fact we would do a GA rapid sequence for urgent or emergent cases that cannot wait for NPO even if it is something we could normally do sedation for. How do you reconcile This? Are u thinking that ASA guidelines are too strict Then?

We reconcile it with the data that shows ED sedations are safe even when standard npo times are not met. As posted before, the data is pretty clear on this.

I had a similar conversation recently with an anesthesiologist who agrees with the ACEP guidelines. He offered a very reasonable and educated explanation as to why we consistently have safe sedations despite short npo times.

He suggested it might be due to the short duration of our procedures. Much of the time we are just giving one dose and reducing a shoulder. It's rare for us redose multiple times. Most procedures in the OR require ongoing sedation with combinations of drugs. This is much different than sedation in the ED.

Whether this explains why we have such good results in the ED or not, data supports our methods. It is now the standard of care in the ED.

 

[Janders]

Precisely as above. When was the last time you sedated someone for more than a handful of minutes in the ED, and didn't secure the airway? The sole exclusion to this in my personal practice are complex pedi lacerations which typically get ketamine not deep propofol.
As well most of my sedations are not laid flat.
As well most of my sedations don't involve an endoscopy pushing and pulling the esophagus for 20 minutes...
horses for courses.

 

[coffeebythelake]

Tbh, I've always considered the ASA guideline for NPO in light sedation (anxiolysis, midazolam and light fentanyl) to be exceedingly strict. For instance with a cataract surgery where topical lidocaine jelly is used and essentially no sedatives are needed. It' always good to have the backing of your society and hospital policy though so we're stuck with waiting 6 hours for a cataract patient who had lunch on day of surgery

 

[gro2001]

At the risk of exposing my ignorance: I always thought the NPO recommendations were applicable to sedation because of the risk of over sedation, resulting in the risk of general anesthesia. Basically, any time you plan for sedation, you should be aware that there is a chance it may result in general anesthesia and be ready to intubate, so keep them NPO as if you were planning for an elective intubation from the start. Which is why I thought the EM world isn't that married to the NPO guidelines for sedation, since our reflex would be to RSI people anyway, mitigating a lot of that risk.

 

[Arch Guillotti]

The ER gets away with it (mostly) because the procedures are usually short, airways are rarely instrumented and the patients maintain spontaneous ventilation throughout.

 

[RoyBasch]

The ER gets away with it (mostly) because the procedures are usually short, airways are rarely instrumented and the patients maintain spontaneous ventilation throughout.

I have no data to back me up, but I think this is what it comes down to (as others in this thread have implied as well).

 

[gro2001]

The ER gets away with it (mostly) because the procedures are usually short, airways are rarely instrumented and the patients maintain spontaneous ventilation throughout.

You don't think that most of the procedures we do are emergent and therefore outside of the NPO guidelines?

 

[UKEMdoc]

The whole rationale for fasting involves hoping that the stomach has emptied itself. Post injury you can't assume there's any gastric emptying and just because the patients not eaten for 6 hours doesn't indicate the stomachs now empty and aspiration isn't a risk. Keeping someone with a dislocation in pain for six hours isn't going to magically make the stomach empty itself.


Every patient we sedate in the ED should be treated as if they MAY have a full stomach and we should be prepared to deal with the consequences (tipping trolley, suction, ability to intubate quickly) for every sedation. Regardless from orthodoxy handed down by another speciality performing different procedures, on different patients in a different place we know that careful sedation in the ED is safe.

 

[WilcoWorld]

You don't think that most of the procedures we do are emergent and therefore outside of the NPO guidelines?

I think that Arch Guillotti meant that our patients don't aspirate because of those reasons. Not that we are excused for those reasons.

I also think you're correct that NPO guidelines are meant to optimize safety in elective procedures, thus they shouldn't apply to non-elective procedures (most to all of ours in the ED).

 

[deleted109597]

I have no data to back me up, but I think this is what it comes down to (as others in this thread have implied as well).

There's plenty of safety data out there.

 

[gamerEMdoc]

I dont wait for npo. I also wouldnt call what we do “conscious” sedation. For most ED docs, we do deeper sedation. We use etomidate, propofol, or ketamine. I havent given doses of fentanyl/versed for a “conscious” sedation in like 10 years.

We do procedural sedation. And its a deep sedation. Though, ketamine may be considered a deep sedation drug, I always argue its not really since you maintain your airway reflexes.

If a patient had a full stomach that needed sedated, I generally use ketamine on all those patients since they maintain airway reflexes.

 

[TooMuchResearch]

The whole rationale for fasting involves hoping that the stomach has emptied itself. Post injury you can't assume there's any gastric emptying and just because the patients not eaten for 6 hours doesn't indicate the stomachs now empty and aspiration isn't a risk. Keeping someone with a dislocation in pain for six hours isn't going to magically make the stomach empty itself.


Every patient we sedate in the ED should be treated as if they MAY have a full stomach and we should be prepared to deal with the consequences (tipping trolley, suction, ability to intubate quickly) for every sedation. Regardless from orthodoxy handed down by another speciality performing different procedures, on different patients in a different place we know that careful sedation in the ED is safe.

What's a tipping trolley?

 

[RoyBasch]

There's plenty of safety data out there.

I'm not saying there IS no data, just that I cannot personally quote it.

 

[Hamhock]

Should we be intubating full stomachs?
Then just extubate afterwards.
HH

 

[deleted109597]

Should we be intubating full stomachs?
Then just extubate afterwards.
HH

N

 

[Hamhock]

Ninja:
Why not?
I can't believe the amount of time and paperwork procedural sedation takes. And, in some cases, it takes two docs (one for the procedure and one for the sedation).
And all of that with the risk of apnea, aspiration (very rare but often catastrophic when it occurs), unstable vitals.
Except for quick procedures (eg cardioversion), it is pretty nice to have complete pain control and airway control.
RSI - procedure (eg reduction, splinting, films) - recovery extubation.
I suspect it would be even faster than the procedural sedation. And with less stress in single doc situations.
HH

 

[RoyBasch]

Ninja:
Why not?
I can't believe the amount of time and paperwork procedural sedation takes. And, in some cases, it takes two docs (one for the procedure and one for the sedation).
And all of that with the risk of apnea, aspiration (very rare but often catastrophic when it occurs), unstable vitals.
Except for quick procedures (eg cardioversion), it is pretty nice to have complete pain control and airway control.
RSI - procedure (eg reduction, splinting, films) - recovery extubation.
I suspect it would be even faster than the procedural sedation. And with less stress in single doc situations.
HH

I've never done it personally, but the logic to me is sound. Anybody ever RSI, do a quick tube, procedure, then extubate in the ER?

 

[gamerEMdoc]

I've never done it personally, but the logic to me is sound. Anybody ever RSI, do a quick tube, procedure, then extubate in the ER?

Im not sure how you’d get away with doing this in the ED from a credentialling standpoint. What you are describing, intubating someone to perform a procedure on them, is general anesthesia. Ive never been at a hospital that credentials the ED to perform general anesthesia for procedures. And the idea of doing general anesthesia AND the procedure itself seems pretty unlikely to be ok with any hosptial sedation committee.

 

[Hamhock]

Im not sure how you’d get away with doing this in the ED from a credentialling standpoint. What you are describing, intubating someone to perform a procedure on them, is general anesthesia. Ive never been at a hospital that credentials the ED to perform general anesthesia for procedures. And the idea of doing general anesthesia AND the procedure itself seems pretty unlikely to be ok with any hosptial sedation committee.

You may be right from a technical standpoint. However, we are already credentialed for each of the components: IV analgesia, RSI, starting mechanical ventilation, propofol sedation, the procedures.

The sedation committees may not be thrilled at first and it will be certainly a different way of thinking about things...but I am really starting to wonder if it would be a better way in some cases, for us and the patients. (even consulting proceduralists, who would no longer have to coordinate with us for the sedation)

The paper work and inflexible thinkers/committees might have to adjust; similar to when sedation committees thought propofol in the ED was unacceptable.

Remember that nonsense?

HH

 

[MechEDoc]

I've never done it personally, but the logic to me is sound. Anybody ever RSI, do a quick tube, procedure, then extubate in the ER?

Yes, as a resident. I wasn't sure if it was kosher, but I went along with it as I was pretty junior. Working in some rural EDs where I am the only physician and anesthesia can take significant amounts of time to arrive doing a RSI (or placing an LMA) + procedure can be pretty tempting sometimes. A very muscular person with a hip dislocation will come to mind, succinylcholine would help immensely in that situation. However, I'm worried that people get pretty bent out of shape if I tried that trick.

 

[MechEDoc]

Of course, one could always intubate for pain control - address the pain - and then extubate. But that seems to cute x 2 and would be pretty obvious what was going on..!

 

[Janders]

I have intubated and done sedation once--- GI started doing moderate sedation on an esophageal food impaction, got the scope in, realized it was a massive amount of shredded chicken at the UES, teetering over the epiglottis. They came running out worried she was imminently going to aspirate prior to waking up from their versed.

So we decided to keep the patient propped at 45 degrees, added a whiff of propofol, intubated her, then just kept a propofol drip running while GI spent an hour removing shredded chicken. It was about the easiest hour I've had 😉

But honestly If I think I need them so deep for so long or that they are so high risk that they need an ETT, I typically am calling anesthesia to do an OR case...

 

[RoyBasch]

I have intubated and done sedation once--- GI started doing moderate sedation on an esophageal food impaction, got the scope in, realized it was a massive amount of shredded chicken at the UES, teetering over the epiglottis. They came running out worried she was imminently going to aspirate prior to waking up from their versed.

So we decided to keep the patient propped at 45 degrees, added a whiff of propofol, intubated her, then just kept a propofol drip running while GI spent an hour removing shredded chicken. It was about the easiest hour I've had 😉

But honestly If I think I need them so deep for so long or that they are so high risk that they need an ETT, I typically am calling anesthesia to do an OR case...

I do not do sedation for any EGD procedure. GI has asked me before and I always differ to anesthesia. I think doing a sedation with direct complex instrumentation of the patient's airway is a totally different animal.

 

[deleted109597]

Ninja:
Why not?
I can't believe the amount of time and paperwork procedural sedation takes. And, in some cases, it takes two docs (one for the procedure and one for the sedation).
And all of that with the risk of apnea, aspiration (very rare but often catastrophic when it occurs), unstable vitals.
Except for quick procedures (eg cardioversion), it is pretty nice to have complete pain control and airway control.
RSI - procedure (eg reduction, splinting, films) - recovery extubation.
I suspect it would be even faster than the procedural sedation. And with less stress in single doc situations.
HH

Procedural sedation has better safety stats than RSI. Not that either of them should be that dangerous to begin win.
But you run the risk of vocal cord injury, dental injury, etc.
Plus you would have to consent them the same for RSI as you would for Proc Sed. And they would have to have the same wakeup time. So you're not really saving much of anything, except for the 2 doc thing (which is only sort of maybe a policy for TJC with propofol only apparently now).

 

[gamerEMdoc]

I find it odd that some places require two docs for a sedation, but if you intubate and do general anesthesia, then it can just be you. That makes absolutely no sense to me.

 

[gro2001]

I find it odd that some places require two docs for a sedation, but if you intubate and do general anesthesia, then it can just be you. That makes absolutely no sense to me.

The two doc requirement is for one to do the sedation and the other to do the procedure. The reason being that if you are sedating someone without securing their airway, you want someone to be watching them very closely. The doc doing the procedure does not count, since they will probably be paying attention to the procedure and might not notice early signs of deterioration or be optimally positioned to intervene. If the airway is secure though, you probably don't need to watch it as closely, as most of the things that could go wrong at that point can be monitored by listening to the beeping of the monitor.

 

[sum dude]

• 
  
  
  
• The NPO guidelines established by ASA are not for just general anesthesia. They apply to all types of anesthesia whether it is a cataract surgery getting 1 mg versed or major surgery with general. I would disagree (as would most anesthesiologists) when you say that sedation has less risk of aspiration than general esp when you decide to forgo NPO considerations. In fact we would do a GA rapid sequence for urgent or emergent cases that cannot wait for NPO even if it is something we could normally do sedation for. How do you reconcile This? Are u thinking that ASA guidelines are too strict Then?

Their recommendations for light/moderate/deep(procedural) sedation are based on committee opinions, which are low levels of evidence. NPO status for procedural sedation has been studied ad nauseum, and the 2/6/overnight thing doesn't hold water to actual real studies (aka higher level of evidence)

http://www.acepnow.com/article/proc...c-patients-emergency-department/?singlepage=1

• Primary outcome: No statistical association between NPO status and major complications or aspiration was shown.

Adult Study w/ propofol:
"Seventy per cent of patients undergoing ED procedural sedation are not fasted. No patient had a clinically evident adverse outcome. "

From anecdotal, I don't wait for npo status, and (knock on wood) have never had a bad outcome. I dare say purposefully waiting 6hrs for npo status for a painful dislocation/fx/etc is practicing sub-standard of care and causing unnecessary pain.

 

[Arcan57]

The two doc requirement is for one to do the sedation and the other to do the procedure. The reason being that if you are sedating someone without securing their airway, you want someone to be watching them very closely. The doc doing the procedure does not count, since they will probably be paying attention to the procedure and might not notice early signs of deterioration or be optimally positioned to intervene. If the airway is secure though, you probably don't need to watch it as closely, as most of the things that could go wrong at that point can be monitored by listening to the beeping of the monitor.

ACEP does not maintain a two doc policy for sedation. Some hospitals do. It would be incredibly rare that we would be doing a procedure that couldn’t be immediately discontinued if the nurse or RT noticed VS abnormalities (which at least at my shop include EtCO2).

 

[Psai]

I find it odd that some places require two docs for a sedation, but if you intubate and do general anesthesia, then it can just be you. That makes absolutely no sense to me.

That makes sense to me. I'd feel a lot more comfortable with some pvc in the throat than an unsecured airway and no knowing what's going to happen. But if you're doing general the patient probably belongs in the OR.

 

[gamerEMdoc]

The two doc requirement is for one to do the sedation and the other to do the procedure. The reason being that if you are sedating someone without securing their airway, you want someone to be watching them very closely. The doc doing the procedure does not count, since they will probably be paying attention to the procedure and might not notice early signs of deterioration or be optimally positioned to intervene. If the airway is secure though, you probably don't need to watch it as closely, as most of the things that could go wrong at that point can be monitored by listening to the beeping of the monitor.

Then why do they need anesthesia in the OR? Why cant surgeons just listen for the beeping monitor?

Im not saying we couldnt intubate people, do anesthesia on them, do a procedure, then extubate and recover the patient in the ED. Of course we could, and it’d probably be safe. But it’s grossly outside the scope of what needs to be happening in an ED. We are not the OR or the PACU. This would be tying up resources unnecessarily in the ED. If a patient needs to be intubated for a procedure, it should be done in the OR IMO. We need to stop trying to do consultants jobs for them, more and more and more stuff keeps getting done in the ED and we wonder why we are so overcrowded.

Re: two docs for sedation, Ive never done two doc sedation/procedure setup, I think thats a ridiculous requirement for procedural sedationnin the ED. If any procedure is kind of lengthy, drugs of deep sedation like propofol and etomidate arent the right choices anyways. Ketamine lasts a decent amount of time and the patient protects their airway. Its my go to drug for sedation for any procedure that isnt like a minute long.

 

[deleted109597]

The two doc requirement is for one to do the sedation and the other to do the procedure. The reason being that if you are sedating someone without securing their airway, you want someone to be watching them very closely. The doc doing the procedure does not count, since they will probably be paying attention to the procedure and might not notice early signs of deterioration or be optimally positioned to intervene. If the airway is secure though, you probably don't need to watch it as closely, as most of the things that could go wrong at that point can be monitored by listening to the beeping of the monitor.

Very few (and colossally ****ty) hospitals require 2 docs. They require 2 people, one doing the procedure, and one who is a trained observer. All they have to do is keep their eyes on the monitor and let you know when to stop. We generally aren't doing long, drawn out procedures like colonoscopies. I can stop reducing the hip and protect the airway if need be. And I often don't keep them as out for lacerations as I do for reductions.

 

[gro2001]

Then why do they need anesthesia in the OR? Why cant surgeons just listen for the beeping monitor?

Im not saying we couldnt intubate people, do anesthesia on them, do a procedure, then extubate and recover the patient in the ED. Of course we could, and it’d probably be safe. But it’s grossly outside the scope of what needs to be happening in an ED. We are not the OR or the PACU. This would be tying up resources unnecessarily in the ED. If a patient needs to be intubated for a procedure, it should be done in the OR IMO. We need to stop trying to do consultants jobs for them, more and more and more stuff keeps getting done in the ED and we wonder why we are so overcrowded.

Re: two docs for sedation, Ive never done two doc sedation/procedure setup, I think thats a ridiculous requirement for procedural sedationnin the ED. If any procedure is kind of lengthy, drugs of deep sedation like propofol and etomidate arent the right choices anyways. Ketamine lasts a decent amount of time and the patient protects their airway. Its my go to drug for sedation for any procedure that isnt like a minute long.

I actually agree with you that we shouldn't be doing general anesthesia in the ER for these kinds of procedures.

However, in regards to your point of why don't the surgeons just listen for the beeping while we can:

1) A lot of surgeons aren't really trained in how to manage complications of mechanical ventilation or general anesthesia. Not hating on the orthopods at all, but what are they going to do about a an alarming vent?

2) The duration and nature of the procedure probably matters too. OR procedures are going to be much longer on average.

3) Different expectations of safety in elective and emergent procedures. Some of our practices wouldn't really be acceptable outside of the emergency situation. Guess it's a good thing we are ER docs.

 

[shookwell]

Not sure if you guys have read these yet

Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018:A Report by the American Society of Anesthesiologists Task Force on Moderate Procedural Sedation and Analgesia, the American Association of Oral and Maxillofacial Surgeons, American College of Radiology, American Dental Association, American Society of Dentist Anesthesiologists, and Society of Interventional Radiology* | Anesthesiology | ASA Publications

http://www.annemergmed.com/article/S0196-0644(17)31970-4/pdf


When I was doing more locums, I've been to multiple anesthesia moderate sedation "training" or "credentialing" sessions and they have all been terrible and useless. It's the same as ACLS, ATLS, PALS, etc. It's a huge waste of our time and demonstrably useless but hospitals where EM is not well respected/established require it because the surgeons, anesthesiologists, etc. insist on it and someone is making money on it.

It's come to the point where I will not credential at any ED that requires ACLS, PALS, or any anesthesia credentialing for sedation. Board certification in emergency medicine trumps all of those things. ATLS is similarly useless but ACS has a huge financial hold on the hospitals though their trauma center verification process in most states so it's a little more complicated.

 

[anbuitachi]

Not sure if you guys have read these yet

Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018:A Report by the American Society of Anesthesiologists Task Force on Moderate Procedural Sedation and Analgesia, the American Association of Oral and Maxillofacial Surgeons, American College of Radiology, American Dental Association, American Society of Dentist Anesthesiologists, and Society of Interventional Radiology* | Anesthesiology | ASA Publications

http://www.annemergmed.com/article/S0196-0644(17)31970-4/pdf


When I was doing more locums, I've been to multiple anesthesia moderate sedation "training" or "credentialing" sessions and they have all been terrible and useless. It's the same as ACLS, ATLS, PALS, etc. It's a huge waste of our time and demonstrably useless but hospitals where EM is not well respected/established require it because the surgeons, anesthesiologists, etc. insist on it and someone is making money on it.

It's come to the point where I will not credential at any ED that requires ACLS, PALS, or any anesthesia credentialing for sedation. Board certification in emergency medicine trumps all of those things. ATLS is similarly useless but ACS has a huge financial hold on the hospitals though their trauma center verification process in most states so it's a little more complicated.

I mean that's just a credentialing thing. Same reason as to why you need BLS and ACLS certification.. one would think if you have ACLS you know your BLS..

And I agree that ASA's NPO guidelines are too strict for the ED like what most posters said. ED procedures tend to be very short, and are usually not very invasive procedures to begin with. It's similar to giving people those medications on the floor.. Inpatients get opioids and or benzos all the time but do not need to be fasted. Aspiration is not a common event, but the standards for safety for anesthesia is the highest among all fields, that's why people say it's similar to flying a plane.

 

[deleted109597]

ATLS is similarly useless but ACS has a huge financial hold on the hospitals though their trauma center verification process in most states so it's a little more complicated.

The ACS itself states that one time teaching in ATLS and BC in EM preclude any further merit badging.

 

[Pudortu]

The ACS itself states that one time teaching in ATLS and BC in EM preclude any further merit badging.

I looked through the ACS website but couldn't find where they say this. Would you happen to know where the statement is? Have to re-do some merit badges soon and would love to avoid this.

 

[shookwell]

https://www.facs.org/~/media/files/...apter_23 new criteria reference guide v1.ashx

in #7