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PHARM PODCAST 101 : ED sedation -towards best practice

 

 

Hi Folks

On today’s show, we have Dr Reuben Strayer of EMergency Medicine Updates, Dr Nicholas Chrimes of ClinicalCred and Dr Andy Buck of EDExam discuss and debate the topic of best practice in ED procedural sedation. Nick argues the concerns of aspiration risk in emergency patients with likely full stomachs. Reuben discusses the ED literature around safety of procedural sedation as well as his best practice approach. Andy provides some clinical context with examples from his own ED work.

What do you do in the ED for procedural sedation? Do you think RSI is safer? Do you think ED sedation without RSI is safer? Post your comments!

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2 Comments Post a comment
  1. edexam #

    Hi Minh
    Great talking with you. I’m not sure I made the point clearly about risk assessment and risk tolerance for procedural sedation in the ED.

    Nick makes the great point that clinical urgency determines when the procedure is done, and things like fasting should determine how it’s done, and implies that if the patient is not fasted, RSI with a cuffed tube in the trachea is, in theory at least, safer from an aspiration point of view. Whilst it sounds good on paper, I’m not sure that RSI for a procedure in a busy ED is (currently) as safe as it is in the hands of a skilled anaesthetist and anaesthetic nurse, in the controlled environment of theatre, so I’m not sure we can draw the same risk conclusion. As I mentioned, we need to factor several other issues in to our risk assessment in ED before starting the procedure, including patient factors (age, co-morbidities, difficult airway predictors), staff factors (medical and nursing skill mix, ability to perform an RSI and extubation, distraction/interruption), and department factors like resus room availability, preparing for expected/transferred patients, (and leaving a buffer for the unexpected resus arrivals – I have had a violent patient requiring physical and chemical restraint brought in to the next cubicle whilst doing a ketamine sedation on a child before, the emergence was not great), department load, time of day, shift changeovers, and availability of help/backup should things go wrong.

    Whether we should or not, we have a different risk tolerance in ED, due to the aforementioned factors, as well as things like throughput pressure and access block, and having done a couple of RSI’s in ED for procedures now that didn’t go smoothly, I think we need to weigh up what is clearly a relatively (key word, “relatively”) safe procedure (sedation with an unprotected airway), as documented by the available “evidence” (admittedly of variable quality) that often saves an admission (and we know that patients who get admitted are exposed to a whole new set of risks like hospital acquired infections & drug errors), against performing a procedure that will often allow the patient to be discharged directly from ED in a relatively short space of time.

    I think ED practitioners who perform procedural sedation need to figure out their own risk assessment and risk tolerance, that aligns with what’s considered acceptable by their department, and their hospital, (and possibly their medical defence association!) when performing sedation with an unprotected airway, and weigh this up against the risks of performing a procedure we’re not skilled at (RSI & intubation for procedures), that carries its own set of significant risks, that may be higher when done in the ED setting, and if they’re not happy with that calculation, tube them in ED, and if they’re not happy with the risks involved in that, push for the patient to be admitted and have it done in theatre. I’m not sure it’s as simple as “a cuffed tube is the safest option, all the time, in every setting”.

    July 23, 2014
    • thanks ANdy! great comments! I agree..we must remember sedation is a form of anaesthesia and it carries all the risks and benefits. I think the key is careful patient selection and this includes factoring in what is going on in ED at the time. So yes the risk assessment and management is on a case by case basis!

      July 23, 2014

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