procedural sedation, what are you comfortable with?

[badasshairday]

Everyone has their comfort level with providing procedural sedation.

At my current community hospital the IR department isn't really comfortable with giving any type of sedation.

The floor/icu RN accompanies the patient to special procedures and subsequently calls up the ordering doctor (me the intern) for orders. I.e., "the patient is not sitting still and agitated and will not tolerate the procedure, what do you want to do doctor?" And I say give some haldol or ativan or whatever. I think it is pretty bizarre that I have to do this and the rads don't.

Anyways I had a situation like that in which a patient needed venous access (could not draw labs or admin meds). Patient super agitated, delirium, personally went down to the special procedure area after the RN called me. Gave orders for haldol, and double the dose if still agitated. Never got another call for another hour. Than at 4:45pm I get a call from the RN saying the pt did not tolerate the procedure, they had 7 techs holding the patient down. All I could think was "WTF, why didn't they call me or anesthesia instead of holding the patient down with 7 people."

On the other hand when I was in med school it was common to see the IR guys tell the sedation nurse to give rounds of fentanyl and midazolam if needed for dialysis access. Something like I described above wouldn't happen, especially for a PICC.

What are you comfortable giving? What is the standards at your hospital?

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[irwarrior]

That is somewhat surprising. Usually hospitals have different types of privileging for sedation. ie conscious sedation vs deep sedation vs general anesthesia etc.

Most IR physicians have conscious sedation privileges.

conscious sedation has certain hospital policy for timing of clears or solids (usually NPO for 8 hours) and most IR feel comfortable giving sedation (versed, fentanyl, morphine, dilaudid, benadryl ) and the reversal agents.

It is atypical for fellowship trained IR not to feel comfortable with conscious sedation as some of what we do can require a fair amount of sedation (including transhepatic biliary drains, TIPS, fistula work, nephrostomy, ablations ). I guess at some places the anesthesia department can provide support, but that may become an additional barrier.

 

[irwarrior]

Deep sedation is a bit trickier as that entails propofol etc and requires the potential need for aggressive airway management (chin tilt/ jawthrust/ oral airway etc) as needed and this is difficult to manage if you do not have nursing that is comfortable with this and you are heavily focused on a complex intervention. So, though you can get deep sedation privileges it adds an extra thing (specifically airway compromise) that you have to worry about. I think in these case it makes sense to have a dedicated anesthesia service provide help.

But, basic conscious sedation should be something any fellowship trained IR should feel comfortable with and that entails knowledge of ACLS and airway management .

 

[omarsaleh66]

That is somewhat surprising. Usually hospitals have different types of privileging for sedation. ie conscious sedation vs deep sedation vs general anesthesia etc.

Most IR physicians have conscious sedation privileges.

conscious sedation has certain hospital policy for timing of clears or solids (usually NPO for 8 hours) and most IR feel comfortable giving sedation (versed, fentanyl, morphine, dilaudid, benadryl ) and the reversal agents.

It is atypical for fellowship trained IR not to feel comfortable with conscious sedation as some of what we do can require a fair amount of sedation (including transhepatic biliary drains, TIPS, fistula work, nephrostomy, ablations ). I guess at some places the anesthesia department can provide support, but that may become an additional barrier.

I am surprised you guys do TIPS under conscious sedation. Is this pretty common?

We do many things with concious sedation but have been doing TIPS, ablations, sclerotherapy under GETA.

Personally, I am cool with giving versed and fentanyl but am very careful with patient isnt responding and I have given up to 6-7 mg versed and 400-500 fenatnyl. Some of these patients are on pain meds all the time and have developed a tolerance and may be better suited for general anesthesia or MAC by anethesiologist.

 

[irwarrior]

Only on occasion, but if anesthesia is available it is preferable for TIPS as it makes it a much more controlled environment. Most centers do TIPS with anesthesia. I agree that I worry about conscious sedation in certain populations especially the elderly and those that have big necks or OSA as they are more likely to have complications of sedation.