Shoulder reduction

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When I give a small dose of propofol for a cardioversion, I insist that the patient is fasted. If not they can come back the next day.

There is no urgency to the procedure though.

A better question is if you had to do the cardioversion immediately which is which is lower risk RSI vs enough propofol moderate sedation for the shock.

I dont know the answer, but it is plausible to me that there isnt significant difference.

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When I give a small dose of propofol for a cardioversion, I insist that the patient is fasted. If not they can come back the next day.
Sure, for an Afib stable cardioversion. Maybe if you were called for a cardioversion for AF with ischemia or something …. But then again any unstable cardioversion I would give some fentanyl and not a dangerous SVR lowering drug like propofol.
 
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There is no urgency to the procedure though.

A better question is if you had to do the cardioversion immediately which is which is lower risk RSI vs enough propofol moderate sedation for the shock.

I dont know the answer, but it is plausible to me that there isnt significant difference.


Yeh, elective cardioversion was not the best example because they are reliably short. But we’ve all seen what is advertised as a 30 second shoulder reduction turn into a 20min struggle-thon. Those are the ones we remember and the proceduralists forget.
 
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Fine. Go ahead. But that’s not the standard in anesthesia and we would be crucified if a patient had a bad outcome.
It is the standard. Did you not read what the ASA said? Have you not looked at the reams of literature?
 
From your reference, 37% of the surveyed experts were either equivocal or disagreed with ignoring fasting guidelines. It’s still a controversial topic and not settled as you imply. View attachment 347766
Yes, it is settled. Its the consensus of the ASA and other major organizations. Disagree all you want but the fact remains that the ASA supports it. As does the huge amount of literature that also supports it. Those are the facts.
Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018 | Anesthesiology | American Society of Anesthesiologists (asahq.org)

The consultants, ASA members, AAOMS members, and ASDA members strongly agree with the recommendations to (1) consult with a medical specialist, when appropriate, before administration of moderate procedural sedation to patients with significant underlying conditions; (2) when feasible before the procedure, inform patients or legal guardians of the benefits, risks, and limitations of moderate sedation/analgesia and possible alternatives, and elicit their preferences; (3) before the day of the procedure, inform patients or legal guardians that they should not drink fluids or eat solid foods for a sufficient period of time to allow for gastric emptying; and (4) on the day of the procedure, assess the time and nature of the last oral intake. All four groups of survey respondents agreed with the recommendation that in urgent or emergent situations where complete gastric emptying is not possible, do not delay moderate procedural sedation based on fasting time alone.





This guideline has been organized by the American College of Emergency Physicians and has been endorsed by the American Academy of Emergency Medicine, the American Board of Emergency Medicine, the American College of Cardiology, the American College of Medical Toxicology, the American College of Osteopathic Emergency Medicine, the Association of Academic Chairs of Emergency Medicine, the Emergency Medicine Residents’ Association, the Emergency Nurses Association, the Society for Academic Emergency Medicine, and the Society for Pediatric Sedation







  • To date, only nine reports of aspiration-associated deaths have been reported in the post-1984 procedural sedation literature, of which eight were during upper gastrointestinal endoscopy. None of these occurred in children or in healthy adults.66 Currently, there is no evidence that non-compliance with elective fasting guidelines increases the risk of aspiration or other adverse events.23-31 Any concerns regarding aspiration vastly exceed the actual risk.31,66-69

  • ́ Providers of unscheduled procedural sedation should assess the timing and nature of recent oral intake. The urgency of the procedure will dictate the necessity of providing sedation without delay, regardless of fasting status. For patients with established risk factors for aspiration (eg, serious underlying illness,31,66 obstructive sleep apnea,31 obesity,70-73 age less than 12 months,31 upper endoscopy as the procedure,37,38,66,74,75 or bowel obstruction),31 consider the risks versus benefits of delaying procedural sedation after recent ingestion of a substantial meal. When such a delay is not feasible, consider the use of dissociative sedation, as unlike other sedatives ketamine helps preserve protective airway reflexes,5,32 and there have been no reported occurrences of aspiration (despite its association with vomiting and laryngospasm) in patients receiving this agent alone except in compromised neonates.5,66





The search yielded 2,046 titles for review.

́ Fifty-five articles were eligible, including 9,652 procedural sedations.


  • ́ Severe adverse events requiring emergent medical intervention were rare, with one case of aspiration in 2,370 sedations (1.2 per 1,000), one case of laryngospasm in 883 sedations (4.2 per 1,000), and two intubations in 3,636 sedations (1.6 per 1,000).


https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4755 157/






Studies


  • ́ A prospective observational trial looking at 1014 children undergoing procedural sedation in the ED, of whom 905 had data on fasting status available. More than half the patients (509) did not meeting fasting guidelines.

  • ́ There was no difference in adverse events between the fasting and non- fasting groups. There was no difference in vomiting between the fasting and non-fasting groups. There were no cases of aspiration.





Agrawal D, Manzi SF, Gupta R, Krauss B. Preprocedural fasting state and adverse events in children undergoing procedural sedation and analgesia in a pediatric emergency department. Annals of emergency medicine. 2003; 42(5):636-46. PMID: 14581915


 
From your reference, 37% of the surveyed experts were either equivocal or disagreed with ignoring fasting guidelines. It’s still a controversial topic and not settled as you imply. View attachment 347766








  • This as a prospective observational study of 2623 patients undergoing emergency department procedural sedation looking at adverse events. There was only 1 aspiration event (0.05%), and that patient had been fasting for 24 hours.

  • ́ There was no association between time of last oral intake and vomiting (which overall occured 1.6% of the time) or any other adverse event.





  • Taylor DM, Bell A, Holdgate A. Risk factors for sedation-related events during procedural sedation in the emergency department. Emergency medicine Australasia : EMA. 2011; 23(4):466-73. PMID: 21824314




  • This is a retrospective analysis of prospectively gathered observational data. They looked at 2085 procedural sedations, for which fasting time was documented in 1555 cases. The incidence of adverse events was the same whether fasting was less than 2 hours, 2-4 hours, 4-6 hours, 6-8 hours, or over 8 hours.

  • There were no clinically apparent aspiration events among these 2000 patients.

    Roback MG, Bajaj L, Wathen JE, Bothner J. Preprocedural fasting and adverse events in procedural sedation and analgesia in a pediatric emergency department: are they related? Annals of emergency medicine. 2004; 44(5):454-9. PMID: 15520704
 
Yes, it is settled. Its the consensus of the ASA and other major organizations. Disagree all you want but the fact remains that the ASA supports it. As does the huge amount of literature that also supports it. Those are the facts.
Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018 | Anesthesiology | American Society of Anesthesiologists (asahq.org)

The consultants, ASA members, AAOMS members, and ASDA members strongly agree with the recommendations to (1) consult with a medical specialist, when appropriate, before administration of moderate procedural sedation to patients with significant underlying conditions; (2) when feasible before the procedure, inform patients or legal guardians of the benefits, risks, and limitations of moderate sedation/analgesia and possible alternatives, and elicit their preferences; (3) before the day of the procedure, inform patients or legal guardians that they should not drink fluids or eat solid foods for a sufficient period of time to allow for gastric emptying; and (4) on the day of the procedure, assess the time and nature of the last oral intake. All four groups of survey respondents agreed with the recommendation that in urgent or emergent situations where complete gastric emptying is not possible, do not delay moderate procedural sedation based on fasting time alone.





This guideline has been organized by the American College of Emergency Physicians and has been endorsed by the American Academy of Emergency Medicine, the American Board of Emergency Medicine, the American College of Cardiology, the American College of Medical Toxicology, the American College of Osteopathic Emergency Medicine, the Association of Academic Chairs of Emergency Medicine, the Emergency Medicine Residents’ Association, the Emergency Nurses Association, the Society for Academic Emergency Medicine, and the Society for Pediatric Sedation







  • To date, only nine reports of aspiration-associated deaths have been reported in the post-1984 procedural sedation literature, of which eight were during upper gastrointestinal endoscopy. None of these occurred in children or in healthy adults.66 Currently, there is no evidence that non-compliance with elective fasting guidelines increases the risk of aspiration or other adverse events.23-31 Any concerns regarding aspiration vastly exceed the actual risk.31,66-69

  • ́ Providers of unscheduled procedural sedation should assess the timing and nature of recent oral intake. The urgency of the procedure will dictate the necessity of providing sedation without delay, regardless of fasting status. For patients with established risk factors for aspiration (eg, serious underlying illness,31,66 obstructive sleep apnea,31 obesity,70-73 age less than 12 months,31 upper endoscopy as the procedure,37,38,66,74,75 or bowel obstruction),31 consider the risks versus benefits of delaying procedural sedation after recent ingestion of a substantial meal. When such a delay is not feasible, consider the use of dissociative sedation, as unlike other sedatives ketamine helps preserve protective airway reflexes,5,32 and there have been no reported occurrences of aspiration (despite its association with vomiting and laryngospasm) in patients receiving this agent alone except in compromised neonates.5,66





The search yielded 2,046 titles for review.

́ Fifty-five articles were eligible, including 9,652 procedural sedations.


  • ́ Severe adverse events requiring emergent medical intervention were rare, with one case of aspiration in 2,370 sedations (1.2 per 1,000), one case of laryngospasm in 883 sedations (4.2 per 1,000), and two intubations in 3,636 sedations (1.6 per 1,000).


https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4755 157/






Studies


  • ́ A prospective observational trial looking at 1014 children undergoing procedural sedation in the ED, of whom 905 had data on fasting status available. More than half the patients (509) did not meeting fasting guidelines.

  • ́ There was no difference in adverse events between the fasting and non- fasting groups. There was no difference in vomiting between the fasting and non-fasting groups. There were no cases of aspiration.





Agrawal D, Manzi SF, Gupta R, Krauss B. Preprocedural fasting state and adverse events in children undergoing procedural sedation and analgesia in a pediatric emergency department. Annals of emergency medicine. 2003; 42(5):636-46. PMID: 14581915




That is fine. Sedate them yourself. I personally do over 1000 cases/year. An aspiration every 2-3 years would be too much for me, especially if I could have prevented it. I’m not sedating some unfasted patient without a protected airway when it’s easy for me to protect it. I work at a very busy level 1 trauma center so I anesthetize unfasted patients all the time but I take care to protect the airway and prevent aspiration.
 
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Yes, it is settled. Its the consensus of the ASA and other major organizations. Disagree all you want but the fact remains that the ASA supports it. As does the huge amount of literature that also supports it. Those are the facts.
Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018 | Anesthesiology | American Society of Anesthesiologists (asahq.org)

The consultants, ASA members, AAOMS members, and ASDA members strongly agree with the recommendations to (1) consult with a medical specialist, when appropriate, before administration of moderate procedural sedation to patients with significant underlying conditions; (2) when feasible before the procedure, inform patients or legal guardians of the benefits, risks, and limitations of moderate sedation/analgesia and possible alternatives, and elicit their preferences; (3) before the day of the procedure, inform patients or legal guardians that they should not drink fluids or eat solid foods for a sufficient period of time to allow for gastric emptying; and (4) on the day of the procedure, assess the time and nature of the last oral intake. All four groups of survey respondents agreed with the recommendation that in urgent or emergent situations where complete gastric emptying is not possible, do not delay moderate procedural sedation based on fasting time alone.





This guideline has been organized by the American College of Emergency Physicians and has been endorsed by the American Academy of Emergency Medicine, the American Board of Emergency Medicine, the American College of Cardiology, the American College of Medical Toxicology, the American College of Osteopathic Emergency Medicine, the Association of Academic Chairs of Emergency Medicine, the Emergency Medicine Residents’ Association, the Emergency Nurses Association, the Society for Academic Emergency Medicine, and the Society for Pediatric Sedation







  • To date, only nine reports of aspiration-associated deaths have been reported in the post-1984 procedural sedation literature, of which eight were during upper gastrointestinal endoscopy. None of these occurred in children or in healthy adults.66 Currently, there is no evidence that non-compliance with elective fasting guidelines increases the risk of aspiration or other adverse events.23-31 Any concerns regarding aspiration vastly exceed the actual risk.31,66-69

  • ́ Providers of unscheduled procedural sedation should assess the timing and nature of recent oral intake. The urgency of the procedure will dictate the necessity of providing sedation without delay, regardless of fasting status. For patients with established risk factors for aspiration (eg, serious underlying illness,31,66 obstructive sleep apnea,31 obesity,70-73 age less than 12 months,31 upper endoscopy as the procedure,37,38,66,74,75 or bowel obstruction),31 consider the risks versus benefits of delaying procedural sedation after recent ingestion of a substantial meal. When such a delay is not feasible, consider the use of dissociative sedation, as unlike other sedatives ketamine helps preserve protective airway reflexes,5,32 and there have been no reported occurrences of aspiration (despite its association with vomiting and laryngospasm) in patients receiving this agent alone except in compromised neonates.5,66





The search yielded 2,046 titles for review.

́ Fifty-five articles were eligible, including 9,652 procedural sedations.


  • ́ Severe adverse events requiring emergent medical intervention were rare, with one case of aspiration in 2,370 sedations (1.2 per 1,000), one case of laryngospasm in 883 sedations (4.2 per 1,000), and two intubations in 3,636 sedations (1.6 per 1,000).


https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4755 157/






Studies


  • ́ A prospective observational trial looking at 1014 children undergoing procedural sedation in the ED, of whom 905 had data on fasting status available. More than half the patients (509) did not meeting fasting guidelines.

  • ́ There was no difference in adverse events between the fasting and non- fasting groups. There was no difference in vomiting between the fasting and non-fasting groups. There were no cases of aspiration.





Agrawal D, Manzi SF, Gupta R, Krauss B. Preprocedural fasting state and adverse events in children undergoing procedural sedation and analgesia in a pediatric emergency department. Annals of emergency medicine. 2003; 42(5):636-46. PMID: 14581915




ASA may have been swayed by ACEP concern for throughput, you know, move the meat!
 
On second thought, if we strictly adhere to moderate sedation where patient still has purposeful response to verbal or tactile stimuli, then they are probably still protecting their airway and it sounds reasonable. However, in the real world, the proceduralist will often say, “the patient is moving” or “ the patient is fighting” and you move beyond moderate sedation to deep sedation or general anesthesia. The alternative is to say “sorry bud, that’s as deep as we’re going right now.” I’d have no problem giving a little versed and ketamine to an unfasted patient, so long as they can still talk to me. But I wouldn’t give them a big slug of propofol.
 
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On second thought, if we strictly adhere to moderate sedation where patient still has purposeful response to verbal or tactile stimuli, then they are probably still protecting their airway and it sounds reasonable. However, in the real world, the proceduralist will often say, “the patient is moving” or “ the patient is fighting” and you move beyond moderate sedation to deep sedation or general anesthesia. The alternative is to say “sorry bud, that’s as deep as we’re going right now.” I’d have no problem giving a little versed and ketamine to an unfasted patient, so long as they can still talk to me. But I wouldn’t give them a big slug of propofol.
Yes this is the main issue. Provided deep or GA to an unprotected airway with a full stomach is still considered malpractice.
 
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Yep. Plenty of grey areas in my mind. Most of our ED docs will sedate and try to reduce whatever they can. If they had to consult ortho and ortho calls me, then it’s a no brainer. I follow asa npo guideline.
1. It’s not “emergent” - it has been putz around already, if it was emergent, come to the OR with ortho
2. If you “need” propofol, (for whatever reason) you are no longer in “moderate” sedation territory.

In essence I am following your guideline as well. If someone tells me it’s emergent (limb losing, emergent). I will do it in the OR.
If you cannot sedate with drugs that you have access to, then I assume the procedure needs to be deeper than fent/versed/ketamine/etomidate. And let’s be honest, if you cannot manage with those drugs, which we all know can get you to GA, then what are you really saying, if you “need” anesthesia to be there?

If you have a conversation/call with me directly to convince me otherwise, I am open to change my mind.
 
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Again, there is a huge amount of literature on the subject supporting procedural sedation. It's why ER providers do it and do you ever hear of aspiration? Down many thousands of times every day in EDs across the country.
Three comments -

1) The ASA document you're citing specifically references "moderate sedation" which has a definition at odds with what you guys actually do in the ER. Moderate sedation is to a depth of consciousness at which purposeful response to verbal commands is maintained. When you "sedate" patients in the ER, you're either doing deep sedation (purposeful response to painful stimulus) or you're inducing general anesthesia (unarousable even with painful stimulus). I have never ever once in my life seen an ER sedation regimen that fit the ASA definition of moderate sedation. And when you call us for help, it's not moderate sedation you're asking for.

2) I agree, the general anesthetics and deep sedation you are providing for your "procedural sedation" in the ER generally aren't causing a lot of aspiration injuries. My suspicion based on personal experience is that this is mainly because you aren't instrumenting airways in these patients. Aspiration happens, mostly, when an object (laryngoscope, oral airway, LMA, etc) is shoved into a patient's mouth when they are lightly anesthetized - though it has to be acknowledged that some people will regurgitate stomach contents the instant they're asleep and their tone relaxes. This is a high risk in patients with FULL full stomachs (e.g. small bowel obstructions) and a lower risk in trauma patients, but that risk isn't zero.

3) I've got nothing, absolutely nothing, to gain by playing loose games with NPO guidelines on those occasions when I set foot in the ER. I'm happy to RSI and intubate patients who need an indicated procedure prior to meeting NPO times, for whom the ER sedation nurse's bit of fentanyl or midazolam won't serve. If you want my help you get it on my terms.
 
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I wonder what enpdoc means
is it like emedpa where the "globaldoc" is actually not a real doctor?
 
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