Propofol / Ketamine / Etomidate in ED

[Venko]

ER guys should not mess with anesthetics they don't understand.

You don't know what you don't know and an internet forum is not the right place to teach you anesthesia.

Thank you.

I can only imagine how I would feel and respond if I felt that someone felt they could learn and practice what I do as well as I do it from an internet forum and so I can understand how this may be your initial thought and response.

If I may, when I created this thread, I did hope to learn more about what I "don't know" even if it is an internet forum. I never hope to be an anesthesiologist, and believe the entirety of its knowledge is far too much to learn in an such a forum. With this said, I do hope to gain some knowledge that I may take to the bedside when I care for my patients within the scope of my emergency medicine practice. Because of the nature of the trauma, pain, and illnesses that my patients experience, I need to and desire to provide the best possible comfort and humane care that I can. Currently, this involves the practice of what my specialty calls and teaches in residency as procedural sedation, which I fully understand is a spectrum of anesthesia. This is very similar to how an anesthesiologist will surely read and interpret an EKG but is not a cardiologist or even how an physics professor may wish to learn some nuance of mathematics from a mathematics professor.

We are all colleagues whose training, knowledge and experience cross into each others expertise without implying that we ourselves are experts in all the fields. I consider myself an expert in the recognition and management of emergent conditions, resuscitation of all patients, and immediate prognostication. This is not to say that other physicians cannot do these things, but that by the nature of my specialty, training, and experience I am an expert in these areas. I hope through this thread to learn some nuances and thoughts about the use of medications such as propofol and ketamine so that I can provide better care for my patients. As I have read this forum, many people have provided helpful and honest comments. However, there have been others, whose posts seem to have little respect for other specialties...such posts look bad upon us all and do not help to further the care of all our patients.

I apologize for the diatribe, but if you still feel that these comments are the very best thing that can be said to colleagues who ask to learn more and have a discussion about a medical issue to which this group are the experts then....

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[Gimlet]

I have to also look at a regular vial and see what temp conditions it is recommended to store them at.

I've looked before...it's something like between 4-23 degrees C. Basically between refrigeration or room temp. The vials are stored at room temp at our main hospital, but come up cold from the pharmacy at the VA in our system.

 

[pgg]

planktonmd is abrasive, it's just the way he is, don't take it personally.

 

[Planktonmd]

planktonmd is abrasive, it's just the way he is, don't take it personally.

This same subject has been discussed numerous times on this forum and it is always the same old argument:
I can intubate (sometimes) so I should be able to give GA, call it something else (procedural sedation) and you guys should not object if I don't follow or understand the guidelines you follow, actually if you don't like what I do then you are being mean and territorial.
So, I might be abrasive but obviously this abrasiveness is based on the fact that there is no point to this discussion since it always ends up where it started.

 

[Venko]

This same subject has been discussed numerous times on this forum and it is always the same old argument:
I can intubate (sometimes) so I should be able to give GA, call it something else (procedural sedation) and you guys should not object if I don't follow or understand the guidelines you follow, actually if you don't like what I do then you are being mean and territorial.
So, I might be abrasive but obviously this abrasiveness is based on the fact that there is no point to this discussion since it always ends up where it started.

Thank you again Dr. Plankton.

I apologize if I told you I think I should be able to perform general anesthesia because I can intubate. I do not recall this being ever my point, but who knows...

Also, I did not feel that you were being mean or condescending because you disapprove of EM docs using these medications, but rather the tone and word choice that you continue to use is laced with disrespect to me and my colleagues. For example the parenthesis and "sometimes" being able to intubate is unnecessary as "sometimes" is applicable to all physicians including anesthesiologists. I know of airways that anesthesiologists are unable to intubate and that their colleagues in different specialties have assisted successfully (yes even EM docs getting an orotracheal airway after anesthesia has failed) or in cases for whom the patient has died. This is true just as cardiologists can misread an ECG, and surgeons can have sutures that come undone. The fact that you keep adding it in reference to my practice is unnecessary and is condescending. When the math professor explains or discusses calculus to a physicist it need not be condescending, but yet your every communication is laced with it and I personally do not appreciate it or see the added value it brings.

As for this being a repetition of a previous thread. I apologize for restarting it as it seems to have ruined your experience on SDN. My thinking is that I wished to approach it from a different perspective and hoped to learn from anesthesia where I am deficient. This is also specifically why I have not stated, "I can intubate therefore I am an anesthetist." I do not believe this and have not stated it. I do wish to learn from your colleagues and you if you can teach without irreverence. Also, in medicine, we constantly revisit topics, it is the way we refine and advance medical practice. What was true five years ago is not necessarily true today. If teaching and review are distasteful to you, maybe a professional reevaluation should be undertaken.

Lastly, being abrasive is not a necessary personality trait in any specialty or capacity of society. I see it employed by those who cannot convey their points effectively to others and use this as a means to force an opinion or idea without foundation being presented. Consider bringing a real contribution to this discussion or avoiding it altogether.

Thank you again,
TL

 

[Bertelman]

Lastly, being abrasive is not a necessary personality trait in any specialty or capacity of society. I see it employed by those who cannot convey their points effectively to others and use this as a means to force an opinion or idea without foundation being presented. Consider bringing a real contribution to this discussion or avoiding it altogether.

Thank you again,
TL

 

[sevoflurane]

FWIW... I like the fact Plankton and IN2B8R are back from sabbatical.

Nice.

 

[pgg]

So, I might be abrasive but obviously this abrasiveness is based on the fact that there is no point to this discussion since it always ends up where it started.

Virtually every topic on every forum, everywhere, is some manner of a rehash. But somehow the rest of us managed to get basically the same points across without the implied sneer.

Glad you're back, I like reading your clinical opinions as much as I like seeing urge's pentsuxtube perspective.

 

[dhb]

To steer the post back to a clinical perspective i would like to add that propofol is not this magical on/off switch that you can pull on everyone.
For instance i routinely induce GA with 30-40mg in eldery frail patients (in combination with potent opiods). So beware of what medication the patient has received previously : morphine for pain etc..
I often find that when used as a bolus for very short procedures like a cardioversion the effect can last longer that the theoretical half-life so obstruction/apnea should always be a concern.

The thing that rubs us the wrong way as anesthesiologist is the way people with less experience justify the use of medication with a narrow therapeutic index by semantic tricks like "procedural sedation" and "moderate to deep sedation".
When you induce a patient to the point that he won't react to a noxious stimulus you are by definition giving a general anesthetic no matter how you want to call it.

 

[jwk]

To steer the post back to a clinical perspective i would like to add that propofol is not this magical on/off switch that you can pull on everyone.
For instance i routinely induce GA with 30-40mg in eldery frail patients (in combination with potent opiods). So beware of what medication the patient has received previously : morphine for pain etc..
I often find that when used as a bolus for very short procedures like a cardioversion the effect can last longer that the theoretical half-life so obstruction/apnea should always be a concern.

The thing that rubs us the wrong way as anesthesiologist is the way people with less experience justify the use of medication with a narrow therapeutic index by semantic tricks like "procedural sedation" and "moderate to deep sedation".
When you induce a patient to the point that he won't react to a noxious stimulus you are by definition giving a general anesthetic no matter how you want to call it.

Exactly. I gave propofol to a 59y/o lady today for a cardioversion. 40mg and we're still chit-chatting away, 10mg more and she starts batting her eyes at me - that's generally my stopping point. We waited 30sec, and shocked. She converted on the first try, and then slept for 10 more minutes. The cardiologist asked me when I was going to reverse her - hmmmm, oops, sorry it's not a reversible drug. She maintained her SaO2 and respirations throughout. And yes, she was NPO per our requirements.

 

[Planktonmd]

Thank you again Dr. Plankton.

I apologize if I told you ........
TL

I appreciate the lengthiness of your response and I am sorry if I offended you.
I never said that I don't respect you personally or your specialty in general.
My point is very simple: You want to give anesthesia then you have to follow the same guidelines and provide the same level of care an anesthesiologist provides.
If you chose to do something different or create your own guidelines then this would be equivalent to me saying: I want to practice Emergency medicine but since I don't have the training I will do it my way and ask you to endorse what I do, and If you don't I accuse you of protecting your turf and being mean.

 

[IN2B8R]

FWIW... I like the fact Plankton and IN2B8R are back from sabbatical.

Nice.

Hiya, Bro' Been busting my rear working and trying to take some time off with family. Did some traveling actually. Thrilling to go to South America and forget about it all... Wanted to go to Egypt to see the pyramids, but....lol, my luck: a freakin' revolution!

 

[Apollyon]

Here is a thread from almost three years ago that developed into a similar discussion. Plank assiduously and stridently posited one thought without apparently reading anyone else's response. JetPropPilot actually was in the real world; jwk only piped in peripherally.

Then, as now, it came out to (although it's more one sided now):

1. Only anesthesiologists and paramedical anesthesia providers should use virtually all meds for sedation.
2. Anesthesia providers do NOT want to come to the ED - AT ALL.
3. Anesthesia providers want patients sent to the OR for 5 minute, painful procedures.
3a. Sending all patients needing sedation to the OR is not reasonable, and does not occur in the vast majority of hospitals in the US (I don't even have anesthesia in my hospital overnight, even though the hospital has active transplant services, both above and below the diaphragm - only on-call), and would not be supported by administration.

Completely candidly, I would LOVE any buzz words or things I could say that would get ortho to take a shoulder reduction or a surgeon a facial lac in a child to the OR, both to the provider and the anesthesia provider. Honestly, the viewpoint stated by some does not leave a clear solution, and I ask for one that administration would support, along with the providers credentialed to work in the OR (which I'm not).

Yes, see JPP's comments in the other thread regarding propofol. Enlightening!

 

[Planktonmd]

Here is a thread from almost three years ago that developed into a similar discussion. Plank assiduously and stridently posited one thought without apparently reading anyone else's response. ......

Good that you brought that thread back since it shows exactly my point of view which happens to be the ASA's point of view as well.
As for the repetition of the same idea, it was inevitable since that was one idea that many people did not want to understand: If you want to assume the role of an anesthesiologist then you have to adhere to the same standards and provide the same level of care.
So there, I repeated it one more time for you!

 

[pgg]

Apollyon, if you want different answers from us, you should ask different questions.

 

[Apollyon]

Apollyon, if you want different answers from us, you should ask different questions.

I did - I asked, honestly, for what would be the right things to say to anesthesia providers and specialists that would get them to do the right thing, as has been heavily stated by anesthesiologists and paramedical anesthesia providers, for these patients. Anesthesia providers are saying "X", while the world is at "Y"; it sounds clearly like "X" is correct, but the anesthesia providers are ONLY saying that - there has been NOTHING to say how "X" gets to "Y". To say "do an anesthesia residency" is not reasonable.

When I look all over the internet, local rules for moderate/procedural/conscious sedation for non-anesthesia personnel are in place, with anesthesia department input/approval/authorship. As such, if it is the ASA position, as Plank states, there are many, many places where the constituents of the ASA aren't following what their group says.

Is it a utopian ideal that is being stated?

 

[Planktonmd]

I did - I asked, honestly, for what would be the right things .....
Is it a utopian ideal that is being stated?

Here is a link to the ASA's guidelines on sedation by non anesthesiologists look at it and pay special attention to the NPO section and to the section that addresses the administration of induction agents (Propofol, Ketamine...) by non anesthesiologists.

http://journals.lww.com/anesthesiol...delines_for_sedation_and_analgesia_by.31.aspx

 

[pgg]

Is it a utopian ideal that is being stated?

No, not really.

We know what goes on in the real world.

What a lot of EM guys do in the real world is induction of general anesthesia for procedures in patients with full stomachs. As I've said a bunch of times before, we're fully aware that EM physicians have been mostly getting away with doing so (our ICUs are not full of patients who aspirated during closed reductions in the ER) and that there is even some data in the EM literature regarding the apparent low risk.

What we're saying the EM guys should do with their full stomach urgent/emergent procedures is either put the brakes on at conscious sedation (moderate sedation, by definition a verbally responsive patient) or secure the airway if it's GA they need or want.

The problem is that lots of EM guys say "sedation" when what they're actually doing is "general anesthesia" ... Propofol, etomidate, and ketamine are induction agents that can be very difficult to titrate to the level of conscious sedation and what I see all the time in the ED are people who think they're doing conscious sedation but usually fly right through deep sedation into general anesthesia. They think that because the patient wakes up 4 minutes later that it was just a touch of sedation.


Yes, a closed reduction under conscious sedation is harder for the reducer and less enjoyable for the patient than it would be under general anesthesia. Yes, we know this is why EM guys prefer general anesthesia.

But you keep asking us why we have a problem with the way you induce general anesthesia in full stomach patients. What do you want us to say?

It's your license, your house, your procedure, your patient - it's not my place to tell you what to do. But if you ask my opinion, however you phrase the question and however many times you ask the question, I'm still going to tell you that induction of general anesthesia in a full stomach with an unprotected airway is a bad idea.


The real world truth is that you have options that we'd endorse:
1) stop at moderate sedation
2) general anesthesia with a RSI and intubation (when appropriate)

You've made the decision that the benefits of some combination of patient satisfaction, procedural ease, and efficiency outweigh the risk of aspiration. That's your call to make.

 

[Birdstrike]

I find this whole ED sedation topic frankly quite amusing. I (and all board certified ED physicians) have been doing sedation in the ED for emergencies for years with propofol and other agents with virtual no issues whatsoever. Everybody knows this, its not a secret. Its 100% political games and its totally obvious. I don't even like sedating people. Its much quicker and easier if I can do a procedure without sedating someone. The paperwork and whole "protocol" is totally annoying and I avoid it for that reason, not to mention the risks to the patient and impact on department flow. If I was an anesthesiologist, I would have no desire to go into the ED at 2 in the morning to titrate propofol for 30 seconds and then wait 5 minutes for the patient to wake up for a procedure that takes 60 seconds. Its sorta like "whack-a-mole": ban propofol, we'll use etomidate; ban etomidate, we'll use fentanyl/versed, ban fentanyl/versed, we'll use ketamine, ban ketamine and we'll go back to brevital, and so on.

 

[jwk]

No, not really.

We know what goes on in the real world.

What a lot of EM guys do in the real world is induction of general anesthesia for procedures in patients with full stomachs. As I've said a bunch of times before, we're fully aware that EM physicians have been mostly getting away with doing so (our ICUs are not full of patients who aspirated during closed reductions in the ER) and that there is even some data in the EM literature regarding the apparent low risk.

What we're saying the EM guys should do with their full stomach urgent/emergent procedures is either put the brakes on at conscious sedation (moderate sedation, by definition a verbally responsive patient) or secure the airway if it's GA they need or want.

The problem is that lots of EM guys say "sedation" when what they're actually doing is "general anesthesia" ... Propofol, etomidate, and ketamine are induction agents that can be very difficult to titrate to the level of conscious sedation and what I see all the time in the ED are people who think they're doing conscious sedation but usually fly right through deep sedation into general anesthesia. They think that because the patient wakes up 4 minutes later that it was just a touch of sedation.


Yes, a closed reduction under conscious sedation is harder for the reducer and less enjoyable for the patient than it would be under general anesthesia. Yes, we know this is why EM guys prefer general anesthesia.

But you keep asking us why we have a problem with the way you induce general anesthesia in full stomach patients. What do you want us to say?

It's your license, your house, your procedure, your patient - it's not my place to tell you what to do. But if you ask my opinion, however you phrase the question and however many times you ask the question, I'm still going to tell you that induction of general anesthesia in a full stomach with an unprotected airway is a bad idea.


The real world truth is that you have options that we'd endorse:
1) stop at moderate sedation
2) general anesthesia with a RSI and intubation (when appropriate)

You've made the decision that the benefits of some combination of patient satisfaction, procedural ease, and efficiency outweigh the risk of aspiration. That's your call to make.

Best common sense post of the whole thread.

 

[Apollyon]

Is it a utopian ideal that is being stated?

We don't sedate GI cases if they're not NPO either, so why would we do it in the ER? If they require our expertise, they come to the OR.

Good to hear this side of view. Do you take all the food bolus patients to the OR 24/7? and the patients who need a traction pin placed? elbow and shoulder reductions etc...

You didn't answer this.

Here is a link to the ASA's guidelines on sedation by non anesthesiologists look at it and pay special attention to the NPO section and to the section that addresses the administration of induction agents (Propofol, Ketamine...) by non anesthesiologists.

6h is the max in that chart, and I've waited for that long. Even so, as the position paper states, that's still no guarantee against aspiration and other events:

The literature does not provide sufficient evidence to test the hypothesis that preprocedure fasting results in a decreased incidence of adverse outcomes in patients undergoing either moderate or deep sedation.

As to Ketamine and Propofol, the paper is in contravention to statements made by physician and non-anesthesiologist anesthesia providers in this thread:

The literature suggests that, when administered by non-anesthesiologists, propofol and ketamine can provide satisfactory moderate sedation, and suggests that methohexital can provide satisfactory deep sedation. The literature is insufficient to evaluate the efficacy of propofol or ketamine administered by non-anesthesiologists for deep sedation. There is insufficient literature to determine whether moderate or deep sedation with propofol is associated with a different incidence of adverse outcomes than similar levels of sedation with midazolam. The consultants are equivocal regarding whether use of these medications affects the likelihood of producing satisfactory moderate sedation, while agreeing that using them increases the likelihood of satisfactory deep sedation.

One thing that is clear is that this paper is due for updating; they rely heavily on literature, and this statement was released almost 9 years ago. Evidence-based medicine is "what have you done for me lately?", and, 9 years ago, I was finishing med school.

I'm an inclusionist, not a separator. I don't hold to the Hippocratic idea of "keeping information secret", nor do I let personal biases affect patient care (to the best of my knowledge and ability) - I strive to do the right thing. That's why I ask and make the statements I do. I am not trying to inflame or troll or agitate. I'm looking for "win-win".

 

[pgg]

The literature suggests that, when administered by non-anesthesiologists, propofol and ketamine can provide satisfactory moderate sedation, and suggests that methohexital can provide satisfactory deep sedation.

Your bold, my underline. The disconnect is this - what you guys tend to call "moderate sedation" isn't what we call moderate sedation. When patients get sedated in the ED for painful procedures, they're typically either non-responsive or respond only to painful stimuli. This by definition is either general anesthesia or deep sedation, not moderate sedation / analgesia.

These phrases have very specific meanings.

The ASA guidelines you skimmed suggest have the following to say about patients not meeting NPO guidelines:

In urgent, emergent, or other situations in which gastric emptying is impaired, the potential for pulmonary aspiration of gastric contents must be considered in determining (1) the target level of sedation, (2) whether the procedure should be delayed,or (3) whether the trachea should be protected by intubation.

This is pretty clear - if the procedure can't be reasonably delayed, the patient should either be intubated or the target level of sedation be more conservative than what would otherwise be appropriate.

You seem to think there's some kind of impossible inconsistency between what we keep writing on this forum and what we really do in the real world. There isn't - we either tube the patient or we limit sedating & analgesic drugs such that the patients can continue protecting their own airways.

 

[pgg]

I (and all board certified ED physicians) have been doing sedation in the ED for emergencies for years with propofol and other agents with virtual no issues whatsoever.

[...]

Its sorta like "whack-a-mole": ban propofol, we'll use etomidate; ban etomidate, we'll use fentanyl/versed, ban fentanyl/versed, we'll use ketamine, ban ketamine and we'll go back to brevital, and so on.

As I've said a bunch of times before, we're fully aware that EM physicians have been mostly getting away with doing so (our ICUs are not full of patients who aspirated during closed reductions in the ER) and that there is even some data in the EM literature regarding the apparent low risk.

[...]

It's your license, your house, your procedure, your patient - it's not my place to tell you what to do.

So, you think it's safe, and you're going to do what you want.

I think the actual risk is low, and have no interest in telling you what to do.

What's the problem again? Oh, right ... you guys keep asking our opinions and our answers aren't changing with every thread ...

 

[Planktonmd]

As I said initially: This discussion always ends exactly where it started.

 

[jwk]

You didn't answer this.

All our food bolus patients come to our GI lab where we provide sedation/general anesthesia as indicated. We have an anesthesia machine on hand for just that reason.

And again, we do not sedate/anesthetize patients in the ER, and, by hospital policy, propofol, etomidate, ketamine and brevital (no more pentothal available ) are anesthesia-only drugs. So if a patient needs a brief orthopedic procedure for example that cannot be managed with MODERATE sedation with versed/fentanyl, then yes they are brought to the OR to have it done.

 

[Hamhock]

Post #68 - EM guys: read it again...and again

I am an extremely opinionated EM guy who firmly believes that anesthesiologists restricting our access to a drug (propofol, etomidate, ketamine, whatever) is inappropriate, hurts patient care, and limits education.

However, I must sadly admit that one of the biggest problems here is that too many (I want to say 'most', but I don't have the data to support it) EM docs have very little idea about what defines moderate sedation vs. deep sedation vs. induction of general anesthesia...or if they do, they don't want to admit it because they are intentionally inducing general anesthesia; and don't want to get into some ridiculous political fight with hospital admin and - for some reason anesthesiology - over it.

If we were honest with ourselves (EM and anesthesiology), we would all admit that these "contentious" drugs (see list above) WILL be used everyday in the ED by EM docs and they WILL be used for at least deep sedation and most likely general anesthesia -- whether we continue to fight about it or not.

The sooner we admit that and the sooner EM docs don't feel the need (for fear of "loosing access" to drugs) to mislabel deep sedation/GA as moderate sedation, the sooner we can develop our procedural sedation knowledge and skills and the sooner we can develop guidelines for the use of procedural sedation in the ED (guidelines that must certainly be distinct from - but probably similar to - anesthesiology's guidelines for sedation in their domain/OR).

The scope of EM is constantly changing and will continue to do so...it WILL be defined by emergency medicine and it INHERENTLY includes aspects of other specialties. Just like closed reduction of a bimalleolar fracture-dislocation is now defined by EM (not defined by orthopedics) as within our scope and clearly the open reduction and fixation is not, the use of many induction agents WILL be defined by EM (not anesthesiology) as within our scope of practice and the use of most inhaled anesthetics will not be.

We did not need the "approval" of orthopedics to define the closed reduction of many fractures within our scope and we do not need the "approval" of anesthesiology to use propofol and fentanyl for procedural sedation (and all physicians should be behind this). EM will define this as within our scope of practice.

It is now our (EM's) responsibility to learn about these agents and use them appropriately. Ideally, this improved use (vs. suboptimal, clandestine general anesthesia of patients with full stomachs under the guise of "moderate sedation") will be supported by anethesiology.

HH

 

[Planktonmd]

We did not need the "approval" of orthopedics to define the closed reduction of many fractures within our scope and we do not need the "approval" of anesthesiology to use propofol and fentanyl for procedural sedation (and all physicians should be behind this). EM will define this as within our scope of practice.



HH

Nice post mostly but one correction:
When you do the closed reduction the same way an orthopedic surgeon does then you don't need approval, but if you decide to do it differently and in a way that the majority of orthopedic surgeons consider inappropriate then you actually need approval which you won't get.
That is exactly what is going to happen with giving anesthesia:
If you do it the same way an anesthesiologist does it you don't need approval, but if you do it differently then from our prospective you are violating the guidelines and won't be supported.

 

[jwk]

... and we do not need the "approval" of anesthesiology to use propofol and fentanyl for procedural sedation (and all physicians should be behind this). EM will define this as within our scope of practice.

This is the other bugaboo.

WARNINGS
For general anesthesia or monitored anesthesia care (MAC) sedation, DIPRIVAN Injectable Emulsion should be administered only by persons trained
in the administration of general anesthesia...


And I never got a clear answer to my earlier question to ThymeLess, so maybe you can tell me.

When you're doing these closed reductions and other procedures, I will assume someone else gives the sedation while you do the procedure. Who does the sedating? And I ask, because in many states, propofol may not be administered by RN's except by infusion to ventilated patients in the ICU. So for those EM docs who want to use propofol in such a state, is another EM doc adminstering the propofol?

 

[Hamhock]

Nice post mostly but one correction:
When you do the closed reduction the same way an orthopedic surgeon does then you don't need approval, but if you decide to do it differently and in a way that the majority of orthopedic surgeons consider inappropriate then you actually need approval which you won't get.
That is exactly what is going to happen with giving anesthesia:
If you do it the same way an anesthesiologist does it you don't need approval, but if you do it differently then from our prospective you are violating the guidelines and won't be supported.

Yes, in some ways...

...but I can give you multiple examples where this isn't true; some simple, some complex. A couple:

Lac repair: I don't need a plastic surgeon's approval to repair a 3cm lac over a kid's eyebrow. Yet, I am going to do it differently. Many surgeons will pour betadine in that wound to "clean" or something. I certainly won't (and I think most EM folks won't).I will clean/irrigate the wound and clean the edges, but NO betadine, even if the surgeon next door tells me it is standard of care. This is within the scope of EM and I will do it my way - without approval.

RSI in trauma and the ACS's ATLS guidelines: Older editions (to the best of my knowledge, without access to anything but the 7th edition right now) have stated RSI should not be used in the trauma patient (and even the 7th edition states something along the lines of most cases don't need sedation or NMB prior to ETT). However, despite these guidelines, the great majority of the time (only rare exceptions), I am going to use RSI in trauma...and if I was practicing back when those editions were out, I would still use RSI and I bet many anesthesiologists (including, I bet, many on this board) would too...and of course this would be done "differently and in a way that the majority of ... surgeons would consider inappropirate" (as defined by their "college's" guidelines).

Yes, I may not get approval from the surgeon's, but my arguement is that I don't need the surgeon's approval. It is within the scope of EM and defined by EM.

I bet most anesthesiologist's feel similarly regarding getting approval from surgeons for intubation in trauma.

Yes, it is/was against the "guidelines" but I don't think it matters if those guidelines are from another specialty...did you follow the ACS guidelines or ASA guidelines? I think the guidelines from another specialty should be considered and analyzed, but approval from another specialty is not required just because they have guidelines regarding an aspect of patient care that overlaps your specialty.

HH
HH

 

[Apollyon]

So if a patient needs a brief orthopedic procedure for example that cannot be managed with MODERATE sedation with versed/fentanyl, then yes they are brought to the OR to have it done.

Now THAT is utopian - closed reduction under anesthesia in the OR.

I guess what colors my thoughts is the recollections I have of sedations in the past; there are three with propofol, with 1 for shoulder dislocation reduction by me, one for fracture reduction by me, and one for shoulder dislocation reduction in the ED by ortho (who used to be a tight end for a pro football team in Pennsylvania). All the patients fit criteria for moderate sedation - all were verbal, none were responsive to pain only, and withdrawal at that, none lost consciousness, there was no emesis, and there was amnesia.

What it rounds out to is what I said a few posts ago: anesthesia doesn't want us using these meds, they don't want to come to the ED, and the consultants and administration (in the vast majority of cases) won't support taking these patients to the OR. Then, with the ASA guidelines, if EM docs (as I don't know of anywhere where mid-level providers (PAs and NPs) in the ED can perform procedural sedation) can indeed perform procedural (moderate) sedation, then there is no issue.

That leads to another question to the anesthesiologists (and paramedical anesthesia providers): how are all of you aware of this general anesthesia being induced in the ED, when patients are not going to the ICU or being admitted with iatrogenic aspiration pneumonia? I mean, honestly (as I've been this entire thread), I can't name even one anesthesiologist at my current hospital, and, at my last system, I met one once, when he came down to the ED and had a question about what to do with his son, who'd suffered a mild concussion, and I talked to one once on the telephone, who had a Chinese name, and a pronounced accent - that's all I recall. Do you review charts, and deduce that deep sedation has been passed by, or do you co-incidentally happen to be in the ED when sedations occur, or what?

 

[pgg]

I guess what colors my thoughts is the recollections I have of sedations in the past; there are three with propofol, with 1 for shoulder dislocation reduction by me, one for fracture reduction by me, and one for shoulder dislocation reduction in the ED by ortho (who used to be a tight end for a pro football team in Pennsylvania). All the patients fit criteria for moderate sedation - all were verbal, none were responsive to pain only, and withdrawal at that, none lost consciousness, there was no emesis, and there was amnesia.

That's great. Well done.

What it rounds out to is what I said a few posts ago: anesthesia doesn't want us using these meds,

Most of us don't care what meds you use.

jwk quoted the package insert warning regarding use (for sedation) only by persons trained in the administration of general anesthesia. I haven't seen any of you guys comment on that.

Perhaps your gripe should be with the FDA and the manufacturer of propofol, not us?

they don't want to come to the ED, and the consultants and administration (in the vast majority of cases) won't support taking these patients to the OR. Then, with the ASA guidelines, if EM docs (as I don't know of anywhere where mid-level providers (PAs and NPs) in the ED can perform procedural sedation) can indeed perform procedural (moderate) sedation, then there is no issue.

Agreed, there's no issue with that from the ASA.

So are you saying that it's unusual, unexpected, or unintended when ED patients get sedation that goes beyond responsiveness to verbal stimuli?

Because that'd be nice, but it doesn't seem to jive with reality.

That leads to another question to the anesthesiologists (and paramedical anesthesia providers): how are all of you aware of this general anesthesia being induced in the ED, when patients are not going to the ICU or being admitted with iatrogenic aspiration pneumonia?

I remember how things were done when I was a med student and intern rotating through the ED. At the time I thought it was really cool how you could drill a screw through a tibia to put a femur fx in traction while the patient dozed.

As a resident the anesthesia trauma call team would go to the ED to 'stand by' and be available to help. Kind of a silly arrangement as the EM resident took the airway, so I spent a lot of time standing around.

These days, I go to the ED all the time to see urgent or emergent surgical patients headed for the OR, and it's not like I'm snooping around, but I see what happens.

 

[NateintheED]

That's great. Well done.

jwk quoted the package insert warning regarding use (for sedation) only by persons trained in the administration of general anesthesia. I haven't seen any of you guys comment on that.

I'll comment on that.

This is possibly the statement most often taken out of context. You say the warning is regarding use "for sedation" only by anesthesia-trained people.

The package insert states, as jwk quoted "For general anesthesia or monitored anesthesia care (MAC) sedation, DIPRIVAN Injectable Emulsion should be administered only by persons trained
in the administration of general anesthesia..."

Note the bolded segment. Package insert says nothing about moderate or even deep sedation, which I know the ASA specifically defines as different from MAC or GA, since we're into definitions. It says nothing regarding use of propofol for moderate or deep sedations.

 

[Planktonmd]

It seems I need to say this to you one more time!
Listen carefully now because I won't say it again:
What you are doing in your ER is GENERAL ANESTHESIA with FULL STOMACH and UNPROTECTED AIRWAY.
Calling it moderate sedation, procedural sedation or whatever else you like to call it does not change anything, it will still be general anesthesia!
You don't know how to give general anesthesia and you don't even know how to define it, so you should not do it.
But you are a grownup and you can do whatever you want.
So, have at it, but don't ask us to endorse you.

I'll comment on that.

This is possibly the statement most often taken out of context. You say the warning is regarding use "for sedation" only by anesthesia-trained people.

The package insert states, as jwk quoted "For general anesthesia or monitored anesthesia care (MAC) sedation, DIPRIVAN Injectable Emulsion should be administered only by persons trained
in the administration of general anesthesia..."

Note the bolded segment. Package insert says nothing about moderate or even deep sedation, which I know the ASA specifically defines as different from MAC or GA, since we're into definitions. It says nothing regarding use of propofol for moderate or deep sedations.

 

[Planktonmd]

OK, I will play:
The plastic surgeons will not object to how you suture as long as it makes sense but if you say that you will use crazy glue to close wounds they might not agree to endorse you.

The surgeons might not abject to you not washing with Betadine but if you say you will use tap water instead they probably won't like it.

The trauma surgeon might not understand why we would intubate a patient in a certain manner but he can not really tell us how to intubate because we are the airway experts.
So, as you see, the experts on certain things in medicine tend to define what the standard should be.
We are the experts on anesthesia, so we define what is acceptable and what is not.

Yes, in some ways...

...but I can give you multiple examples where this isn't true; some simple, some complex. A couple:

Lac repair: I don't need a plastic surgeon's approval to repair a 3cm lac over a kid's eyebrow. Yet, I am going to do it differently. Many surgeons will pour betadine in that wound to "clean" or something. I certainly won't (and I think most EM folks won't).I will clean/irrigate the wound and clean the edges, but NO betadine, even if the surgeon next door tells me it is standard of care. This is within the scope of EM and I will do it my way - without approval.

RSI in trauma and the ACS's ATLS guidelines: Older editions (to the best of my knowledge, without access to anything but the 7th edition right now) have stated RSI should not be used in the trauma patient (and even the 7th edition states something along the lines of most cases don't need sedation or NMB prior to ETT). However, despite these guidelines, the great majority of the time (only rare exceptions), I am going to use RSI in trauma...and if I was practicing back when those editions were out, I would still use RSI and I bet many anesthesiologists (including, I bet, many on this board) would too...and of course this would be done "differently and in a way that the majority of ... surgeons would consider inappropirate" (as defined by their "college's" guidelines).

Yes, I may not get approval from the surgeon's, but my arguement is that I don't need the surgeon's approval. It is within the scope of EM and defined by EM.

I bet most anesthesiologist's feel similarly regarding getting approval from surgeons for intubation in trauma.

Yes, it is/was against the "guidelines" but I don't think it matters if those guidelines are from another specialty...did you follow the ACS guidelines or ASA guidelines? I think the guidelines from another specialty should be considered and analyzed, but approval from another specialty is not required just because they have guidelines regarding an aspect of patient care that overlaps your specialty.

HH
HH

 

[Apollyon]

What you are doing in your ER is GENERAL ANESTHESIA with FULL STOMACH and UNPROTECTED AIRWAY.
Calling it moderate sedation, procedural sedation or whatever else you like to call it does not change anything, it will still be general anesthesia!

Definitions: by definition, moderate sedation and procedural sedation are NOT general anesthesia. You're hung up on definitions, but this one you skate over. Deep sedation is defined as withdrawal to painful stimulus. Moderate sedation is response to verbal stimulus. Absent both of these, it's general anesthesia. Isn't it? Or is simply giving someone one of these meds general anesthesia to you?

 

[Planktonmd]

Or is simply giving someone one of these meds general anesthesia to you?

Actually in the hands of inexperienced people this statement tends to be true.

 

[Birdstrike]

Game over.

From your own American Society of Anesthesiologists website:

"Q4: Why is there a particular mention in the IG on the emergency department’s (ED’s) sedation policies?

A4: The ED is a unique environment where patients present on an unscheduled basis with often very complex problems that may require several emergent or urgent interventions to proceed simultaneously to prevent further morbidity or mortality. In addition, emergency medicine- trained physicians have very specific skill sets to manage airways and ventilation that is necessary to provide patient rescue. Therefore, these practitioners are uniquely qualified to provide all levels of analgesia/sedation and anesthesia (moderate to deep to general)."

http://www.asahq.org/Home-Page/ASA-News-and-Alerts/Whats-New/~/media/For%20Members/Advocacy/ASA%20in%20Washington/2011%20FAQ%20for%20CMS%20Revised%20Hospital%20Interpretive%20Guidelines.ashx

Also very nicely described here:

http://www.epmonthly.com/features/current-features/cms-and-deep-sedation-a-win-for-em/

 

[Hamhock]

It seems I need to say this to you one more time!
Listen carefully now because I won't say it again:
What you are doing in your ER is GENERAL ANESTHESIA with FULL STOMACH and UNPROTECTED AIRWAY.
Calling it moderate sedation, procedural sedation or whatever else you like to call it does not change anything, it will still be general anesthesia!
You don't know how to give general anesthesia and you don't even know how to define it, so you should not do it.
But you are a grownup and you can do whatever you want.
So, have at it, but don't ask us to endorse you.

I really hate to do this, but I have to agree with and qft Planktonmd.

Please fellow EMers, let's at least admit we frequently cross from deep sedation to general anesthesia (I intentionally do it frequently!).

Until we admit that, we can't take an academic/investigative look at the safety of deep sedation or general anesthesia in the ED without an ETT. We will never be able to develop our own NPO guidelines for GA, which I think the evidence will show (may have already shown) to be much less than required in the ASA guidelines.

...and we will still continue to have stupid arguements about using select drugs for moderate sedation (which, we are NOT doing most of the time).

HH

 

[Hamhock]

OK, I will play:
The plastic surgeons will not object to how you suture as long as it makes sense but if you say that you will use crazy glue to close wounds they might not agree to endorse you.

The surgeons might not abject to you not washing with Betadine but if you say you will use tap water instead they probably won't like it.

It is interesting that you use these examples, as it is "known" in the ED tap water is fine (better than Betadine!) and we frequently crazy glue (eg Dermabond) wounds shut.

No "endorsement" from some surgeon needed. We have our own guidelines and evidence and standard of care to back us up. No permission needed, especially for something which the "experts" don't have much evidence for...which brings me back to sedation/airway and NPO guidelines from the ASA (?evidence for them and don't really need the ASA's endorsement).
HH

 

[Planktonmd]

It is interesting that you use these examples, as it is "known" in the ED tap water is fine (better than Betadine!) and we frequently crazy glue (eg Dermabond) wounds shut.

No "endorsement" from some surgeon needed. We have our own guidelines and evidence and standard of care to back us up. No permission needed, especially for something which the "experts" don't have much evidence for...which brings me back to sedation/airway and NPO guidelines from the ASA (?evidence for them and don't really need the ASA's endorsement).
HH

So you think that crazy glue and Dermabond are the same?
And you actually wash wounds with tap water?

Can you you PM me what ER you work in?

 

[Planktonmd]

I am not sure what you are talking about but it appears that you think that a document addressed at insurance carriers by the ASA to facilitate reimbursement for emergency physicians defines the practice guidelines of anesthesiology.
If that's what you think then I can't help you.

Game over.

From your own American Society of Anesthesiologists website:

"Q4: Why is there a particular mention in the IG on the emergency department's (ED's) sedation policies?

A4: The ED is a unique environment where patients present on an unscheduled basis with often very complex problems that may require several emergent or urgent interventions to proceed simultaneously to prevent further morbidity or mortality. In addition, emergency medicine- trained physicians have very specific skill sets to manage airways and ventilation that is necessary to provide patient rescue. Therefore, these practitioners are uniquely qualified to provide all levels of analgesia/sedation and anesthesia (moderate to deep to general)."

http://www.asahq.org/Home-Page/ASA-News-and-Alerts/Whats-New/~/media/For%20Members/Advocacy/ASA%20in%20Washington/2011%20FAQ%20for%20CMS%20Revised%20Hospital%20Interpretive%20Guidelines.ashx

Also very nicely described here:

http://www.epmonthly.com/features/current-features/cms-and-deep-sedation-a-win-for-em/

 

[Hamhock]

OK, I will play:
The trauma surgeon might not understand why we would intubate a patient in a certain manner but he can not really tell us how to intubate because we are the airway experts.
So, as you see, the experts on certain things in medicine tend to define what the standard should be.
We are the experts on anesthesia, so we define what is acceptable and what is not.

First, see my post above regarding wound repair and "expert" surgeons telling other folks how to do things because they are the "experts". They are called the experts, but it turns out they are wrong and had no evidence to back up to back up what they 'define as acceptable'.

I suspect the same is going to be found (or already has been found to be; I am going to go back over that literature soon) with procedural sedation (which you know I think includes DS/GA) and the relationship between the "expert" anesthesiologists and EM.

I still believe surgeons are wound repair experts and I still believe the anesthesiologists are sedation experts, but I do NOT believe they are the only experts and I certainly don't believe they define what is acceptable in the emergency department.

HH

 

[Birdstrike]

I am not sure what you are talking about but it appears that you think that a document addressed at insurance carriers by the ASA to facilitate reimbursement for emergency physicians defines the practice guidelines of anesthesiology.
If that's what you think then I can't help you.

Why would the ASA work to "facilitate reimbursement for emergency physicians" as you admit, for "analgesia/sedation and anesthesia (moderate to deep to general)" as quoted from your own web site's link, if this argument was about anything other than money, politics and turf? I'm glad to hear that the ASA is helping facilitate reimbursement for the same "moderate to deep to general" sedation that we're supposedly not qualified to practice.

 

[Hamhock]

So you think that crazy glue and Dermabond are the same?
And you actually wash wounds with tap water?

Can you you PM me what ER you work in?

Acad Emerg Med. 2007 May;14(5):404-9.

better yet:

Cochrane Database Syst Rev. 2008 Jan 23;(1):CD003861

AUTHORS' CONCLUSIONS: There is no evidence that using tap water to cleanse acute wounds in adults increases infection and some evidence that it reduces it.

And I would like to point out that I didn't even bring up the "crazy" idea of tap water - you did!

I stand by my previous posts.

"I still believe surgeons are wound repair experts and I still believe the anesthesiologists are sedation experts, but I do NOT believe they are the only experts and I certainly don't believe they define what is acceptable in the emergency department."

especially without any evidence!...?"expert opinon"...don't even get me going on "guidelines" by experts

HH

 

[Apollyon]

So you think that crazy glue and Dermabond are the same?
And you actually wash wounds with tap water?

Can you you PM me what ER you work in?

You're French, right? I can point you to anecdotal evidence, although vast - there are millions of kids in the US whose mothers washed their wounds and abrasions under the tap in the kitchen or bathroom and they didn't get infected. Granted, the plural of anecdote is not data, but that's pretty wide. Beyond that, it has been studied with tap water, and, as stated prior, tap water in the US is at least as good as sterile water and normal saline.

As for Krazy Glue and Dermabond, the Krazy Glue is cyanoacrylate, and the Dermabond is 2-octyl cyanoacrylate. Indermil is Butyl cyanoacrylate. Cyanoacrylate was reported by it's creator to have been used in Viet Nam in a spray form by US medics to help stop bleeding in patients en route to more advanced medical care. What you are doing is quibbling. As for quibbling:

Actually in the hands of inexperienced people this statement tends to be true.

This is weak sauce. Compared to what you've put even in this thread, the above statement is beneath you.

However, I have another question: if an agent provides amnesia, is it ethical to use that agent only, if a painful condition is rendered painless after a procedure? I mean, if you don't remember it (as I tell patients that are about to get Propofol, "The first thing you are going to say to me afterwards is 'When are we going to start?', and my answer is 'We're done already'."), does the pain count? This is an honest question.

 

[pgg]

And you actually wash wounds with tap water?

Tap water is fine for wound irrigation.

 

[Planktonmd]

Tap water and crazy glue are good for a mother's kitchen to wash a wound or for repairing wounds in the battle field during Vietnam war but they are not good enough for an emergency room today in the united states!
That is the point!
If you do it this way it might be OK but it's not what an expert under similar circumstances would have done.
The reason why I brought up the tap water and the crazy glue example is because they do work but they are NOT what is done by the majority of reasonable practitioners under similar circumstances.
It's funny when people attempt so hard to miss the point of an example and instead concentrate on meaningless details.

 

[bullard]

It's not just ethical, it's the correct thing to do. If you gave the patient propofol for sedation and fentanyl for analgesia and then quickly take away the painful stimulus, the fentanyl will still be around and potentially hurt you by inducing respiratory depression and could set you up for aspiration, although I guess you guys don't worry about that (JUST KIDDING).

However, I have another question: if an agent provides amnesia, is it ethical to use that agent only, if a painful condition is rendered painless after a procedure? I mean, if you don't remember it (as I tell patients that are about to get Propofol, "The first thing you are going to say to me afterwards is 'When are we going to start?', and my answer is 'We're done already'."), does the pain count? This is an honest question.

 

[BLADEMDA]

Thank you again Dr. Plankton.

I apologize if I told you I think I should be able to perform general anesthesia because I can intubate. I do not recall this being ever my point, but who knows...

Also, I did not feel that you were being mean or condescending because you disapprove of EM docs using these medications, but rather the tone and word choice that you continue to use is laced with disrespect to me and my colleagues. For example the parenthesis and "sometimes" being able to intubate is unnecessary as "sometimes" is applicable to all physicians including anesthesiologists. I know of airways that anesthesiologists are unable to intubate and that their colleagues in different specialties have assisted successfully (yes even EM docs getting an orotracheal airway after anesthesia has failed) or in cases for whom the patient has died. This is true just as cardiologists can misread an ECG, and surgeons can have sutures that come undone. The fact that you keep adding it in reference to my practice is unnecessary and is condescending. When the math professor explains or discusses calculus to a physicist it need not be condescending, but yet your every communication is laced with it and I personally do not appreciate it or see the added value it brings.

As for this being a repetition of a previous thread. I apologize for restarting it as it seems to have ruined your experience on SDN. My thinking is that I wished to approach it from a different perspective and hoped to learn from anesthesia where I am deficient. This is also specifically why I have not stated, "I can intubate therefore I am an anesthetist." I do not believe this and have not stated it. I do wish to learn from your colleagues and you if you can teach without irreverence. Also, in medicine, we constantly revisit topics, it is the way we refine and advance medical practice. What was true five years ago is not necessarily true today. If teaching and review are distasteful to you, maybe a professional reevaluation should be undertaken.

Lastly, being abrasive is not a necessary personality trait in any specialty or capacity of society. I see it employed by those who cannot convey their points effectively to others and use this as a means to force an opinion or idea without foundation being presented. Consider bringing a real contribution to this discussion or avoiding it altogether.

Thank you again,
TL

I enjoy your posts but let me share an anecdotal story.

Board Certified E.R. attending calls me down to the E.R. STAT. I get there and he is trying to intubate a 350 pound patient with a MAC 3 blade. The patient is BLUE, Saturation was 54%. I immediately bag the patient but very difficult to mask. I urgently grab a Miller 3 and 8.0 et tube and intubate him. (positive etcCo2, BBS, etc.).

E.R. Doc starts the "code" on him but alas he expires. I asked what he gave the patient for the intubation. Answer- Etomidate/Sux. The nurse recorded the time of "sedation" on her chart and it was 8 minutes prior to my arrival.

Be careful in the E.R. with whom you decide to "sedate."

 

[Planktonmd]

However, I have another question: if an agent provides amnesia, is it ethical to use that agent only, if a painful condition is rendered painless after a procedure? I mean, if you don't remember it (as I tell patients that are about to get Propofol, "The first thing you are going to say to me afterwards is 'When are we going to start?', and my answer is 'We're done already'."), does the pain count? This is an honest question.

Now this is a good question!
Amnesia alone is not what you are trying to achieve during a painful procedure because pain will trigger a physiologic response that will produce hemodynamic changes and an inflammatory reaction that could be very harmful especially in patients with severe comorbidities.
And although amnesia is an integral part of general anesthesia, analgesia, muscle relaxation and hypnosis are equally as important.
In the real world when you give a large dose of an induction agent you will achieve amnesia, hypnosis and some degree of muscle relaxation. Analgesia is not really achieved directly but if you suppress the brain activity enough you might decrease the central component of pain while the peripheral response might still be intact and capable of causing an acute response.
Again, the majority of patients will tolerate a short painful procedure without any specific analgesic given but some patients with significant comorbidities might require the pain to be treated to avoid complications.