What's your favorite conscious sedation technique?

[DrQuinn]

I'm pretty bored since I started my toxicology rotation, and am reflecting upon my last month in the ED. I tried the majority of the different conscious sedation techniques... luckily at TGH we have the ability to choose whatever medication we want... just curious to see what you guys in residency as well as practice like to use...

I prefer Etomidate. Super easy, .15 mg/kg. Only had one patient with the spasms.

Q

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[spyderdoc]

I'm pretty bored since I started my toxicology rotation, and am reflecting upon my last month in the ED. I tried the majority of the different conscious sedation techniques... luckily at TGH we have the ability to choose whatever medication we want... just curious to see what you guys in residency as well as practice like to use...

I prefer Etomidate. Super easy, .15 mg/kg. Only had one patient with the spasms.

Q

I agree. I love to use Etomidate for pretty much all of my adult sedations. Watch for vomiting (~5%) and myoclonic ticks (these are not seizures, just a common side effect of the med)...
Propofol is another good choice for short procedures, such as DCCV.
I almost never give fentanyl/versed anymore due to the longer recovery time (keeping the RN tied up too long) compared to Etomidate or Propofol.

For kids, special K is the drug of choice (given w/ atropine to control secretions). I prefer to use it IM, but our hospital sedation protocols requires IV access for all sedations. There is plenty of research to show that K is safe to use IM...I am trying to get this policy changed...

 

[Sessamoid]

Ketamine is great for procedures where anxiety is a big issue, especially. I've had good luck with fentanyl lollipops for merely painful procedures in children (finger dislocations, short lacerations).

 

[margaritaboy]

I'm pretty bored since I started my toxicology rotation, and am reflecting upon my last month in the ED. I tried the majority of the different conscious sedation techniques... luckily at TGH we have the ability to choose whatever medication we want... just curious to see what you guys in residency as well as practice like to use...

I prefer Etomidate. Super easy, .15 mg/kg. Only had one patient with the spasms.

Q

I'm glad there are some people out there that like Etomidate too. Quick in, quick out. It seems to be a strong prefrence among our residents to use propofol.

 

[docB]

I used to use brevital but since that's no longer available I have grown to like etomidate. I've been using it almost exclusively (I do ketamine on kids) with no complications except for 2 cases where the myoclonic jerks made it impossible to do the procedure. I have used propofol with success but in my system it's frowned on because someone had a problem with it in the past.

BTW I really like fentanyl/versed but you need to give yourself time to titrate up to good sedation. If you have a consultant they always get impatient and want to start too early. I find it takes about 10 - 15 minutes to get someone really well sedated on F&V.

 

[anonymousEM]

It's tough to use Propofol for conscious sedation at my place due to issues with the nurses pushing it, so we tend not to do it though I saw a lot of success with it as a med student. I tend to do etomidate/fentanyl. 1 time had the myoclonus but not so significant that it effected the procedure.

 

[unk_fxn]

Etomidate Etomidate Etomidate

Joint reductions become an effortless thing.

Easy down, Easy up.

Love it.

Diprivan (propofol- the "milk of amnesia") is nice also. The anesthesia guys love that here.

Anyone ever seen an allergic rxn with diprivan in someone who was allergic to eggs or soy?

 

[roja]

We aren't allowed to use etomidate in our institution. If we were, it would be my drug of choice.

Instead, I am becoming quite creative at trying to avoid full concious sedation because I hate versed/fentanyl becaseu of the long recovery time and high nursing needs..

I like ketamine in kids.

 

[leviathan]

Ketamine is great for procedures where anxiety is a big issue, especially. I've had good luck with fentanyl lollipops for merely painful procedures in children (finger dislocations, short lacerations).

Ah, I remember as a child getting a finger dislocation. The ED doc just gave me two injections of lido (or some anaesthetic) RIGHT into the finger. That was one of the most painful things I ever endured. Do you think he should have given me some sort of sedation first? I sure wish I had received some.

 

[rh]

We use propofol for most of our sedations. It's easy to titrate. Quick down and quick up. Brevital is good and is becoming avaliable again. We use etomidate almost exclusively in our RSI's, but never for sedation. I'll have to try it out moonlighting.

 

[Sessamoid]

Ah, I remember as a child getting a finger dislocation. The ED doc just gave me two injections of lido (or some anaesthetic) RIGHT into the finger. That was one of the most painful things I ever endured. Do you think he should have given me some sort of sedation first? I sure wish I had received some.

For a simple finger dislocation, I don't use sedation. It's generally quickly reduced. For young kids I might give 'em a fentanyl lollipop beforehand though, great for pain relief. I've had a couple kids to whom I gave fentanyl transmucosal for just such a dislocation. One of them laughed through the whole procedure. For adults, I just tell 'em to grin and bear it for 5-10 sec. It rarely takes longer than that.

 

[leviathan]

For a simple finger dislocation, I don't use sedation. It's generally quickly reduced. For young kids I might give 'em a fentanyl lollipop beforehand though, great for pain relief. I've had a couple kids to whom I gave fentanyl transmucosal for just such a dislocation. One of them laughed through the whole procedure. For adults, I just tell 'em to grin and bear it for 5-10 sec. It rarely takes longer than that.

Right, fair enough...I was about 10 years old at the time, I think. I definitely wasn't in any major pain beforehand, so maybe that's why he didn't consider fentanyl or anything else. But I remember when he pierced my finger with those two needles of anaesthetic, it was the most intense shearing pain I had ever experienced.

 

[Sessamoid]

Right, fair enough...I was about 10 years old at the time, I think. I definitely wasn't in any major pain beforehand, so maybe that's why he didn't consider fentanyl or anything else. But I remember when he pierced my finger with those two needles of anaesthetic, it was the most intense shearing pain I had ever experienced.

That's exactly why I don't do digital blocks for simple finger dislocations. The pain of the anesthetic is probably equal to or greater than the reduction itself.

 

[leviathan]

That's exactly why I don't do digital blocks for simple finger dislocations. The pain of the anesthetic is probably equal to or greater than the reduction itself.

I was going to mention that in my last post...I would have almost rather preferred him to reduce it without anesthetics. Hindsight is 20/20, though.

 

[Chris_Topher]

I do like etomidate for the already listed reasons - easy on/easy off, few AE, single medication, etc. But I have had some difficulty with joint reductions (hips, mostly) in that I do not get enough muscle relaxation and we eventually transition over to propofol.

Fentanyl lollipops? Never heard of this. (sounds tasty) Available at the local Kwik-E-Mart?

 

[Sessamoid]

I do like etomidate for the already listed reasons - easy on/easy off, few AE, single medication, etc. But I have had some difficulty with joint reductions (hips, mostly) in that I do not get enough muscle relaxation and we eventually transition over to propofol.

I've had better luck with propofol as well for hip dislocations for precisely this reason.

Fentanyl lollipops? Never heard of this. (sounds tasty) Available at the local Kwik-E-Mart?

They're the bees knees for treating small kids who need painful procedures. I've never tasted one, but they must taste pretty good 'cause the little kids suck those things down pretty quickly.

 

[docB]

They're the bees knees for treating small kids ...

I'd assume anyone who says "the bees knees" would be using leeches, ladunum and absinth.

 

[Sessamoid]

I'd assume anyone who says "the bees knees" would be using leeches, ladunum and absinth.

You don't?

 

[docB]

You don't?

Wellllllll..... Yeah, I do.

 

[Sessamoid]

Wellllllll..... Yeah, I do.

The laudanum part anyway. Right?

 

[Apollyon]

I'd assume anyone who says "the bees knees" would be using leeches, ladunum and absinth.

Saw leeches used for the first time by PlasticSx two weeks ago on a flap - in the morning, to paraphrase "Wayne's World" - "They REALLY suck!"

A couple escaped, but we didn't have to salt them.

Laudanum and absinthe? Count me in!

 

[docB]

The laudanum part anyway. Right?

Actually no. I find the laudanum makes my heroin too much.

 

[Sessamoid]

What's your favorite conscious sedation technique?

Good beer, and plenty of it.

Oh... you meant for the patient?