Risk Reduction in Sedation and Analgesia - PowerPoint PPT Presentation

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Risk Reduction in Sedation and Analgesia

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... essential pieces of equipment basic interpretation of ECG understand pulse oximetry and know the limitations of use capnography reliable oxygen source, ... – PowerPoint PPT presentation

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Title: Risk Reduction in Sedation and Analgesia


1
Risk Reduction in Sedation and Analgesia
  • Rowland P. Wu, MD
  • Adapted from Glynne D. Stanley, MD

2
Overview
  • Complications occur because of
  • Inappropriate patient selection
  • Unanticipated responses from patient or equipment
  • Over-medication
  • Wrong patient/wrong site/wrong procedure

3
Strategies to reduce risk,patient selection
  • Improve patient selection
  • ASA Classification
  • airway assessment and history
  • identify other factors e.g. pregnancy, obesity

4
Patient Selection
  • Important baseline assessments are
  • actual or estimated weight
  • vital signs including baseline oxygen saturation
  • cardiopulmonary status
  • general neurological status
  • previous adverse responses to medication (not
    just allergy detection)_
  • ASA classification
  • (Baseline airway evaluation)

5
ASA Classification
  • ASA 1 Normal, healthy patient
  • ASA 2 Stable mild systemic disease
  • ASA 3 Severe systemic disease with functional
    impairment
  • ASA 4 Severe disease, constant threat to
    life, not necessarily to be improved by
    surgery
  • ASA 5 Moribund patient, not expected to
    survive without surgery
  • ASA 6 Brain-dead donor
  • Emergency (E)

6
Patient Selection
  • All patients should be carefully evaluated by the
    MD. Some ASA Class III, and most ASA Classes IV
    and V will not be suitable for sedation
    administered by non-anesthesiologists.

7
Mallampati classification
8
Airway Assessment
  • Mallampati classification
  • Neck extension
  • Thyromental distance (?short neck)
  • Interincisor distance (?poor mouth opening)
  • Concurrent obesity
  • (History of airway problems)
  • Letters and bracelets

9
Patient Selection
  • Anesthesia consultation should also be considered
    under the following circumstances
  • patient has limited neck motion or cervical
    instability
  • patient has abnormal craniofacial anatomy
  • patient is morbidly obese
  • patient has a history of sleep apnea
  • pregnant patients
  • patient has not been NPO

10
Strategies to reduce risk,unanticipated events
  • Have available and be familiar with essential
    pieces of equipment
  • basic interpretation of ECG
  • understand pulse oximetry and know the
    limitations of use
  • capnography
  • reliable oxygen source, equipment for positive
    pressure ventilation
  • know how to quickly and reliably get help

11
Ideal Patient Positioning
12
Obstructed Airway
13
Oral Airway
14
Nasal Airway
15
Mask Ventilation
16
EtCO2 Apparatus
17
EtCO2 Tracing
18
Unanticipated events
  • Cardiac instability/dysrhythmia
  • Respiratory depression and/or airway obstruction
  • Neurological disconnection
  • Equipment malfunction

19
Unanticipated cardiovascular events
  • Cardiovascular instability
  • Hypotension
  • Tachycardia
  • PVCs
  • atrial arrhythmias
  • ventricular arrhythmias
  • cardiac arrest!
  • Possible causes
  • hypovolemia
  • allergic reaction
  • overmedication
  • hypoxemia
  • ischemia
  • hypercarbia
  • bleeding

20
Unanticipated respiratory events
  • Respiratory complications
  • depression
  • airway obstruction
  • bronchospasm
  • Possible causes
  • overmedication
  • relative
  • absolute
  • patient position
  • foreign material
  • allergic reaction

21
Unanticipated neurological events
  • Possible causes
  • overmedication
  • Hypoxemia
  • hypercarbia
  • cerebral ischemia
  • hypoxemia
  • cerebral hypoperfusion
  • undermedication?
  • Neurological Disconnection
  • drowsiness
  • unresponsiveness
  • uncooperative
  • combative
  • disinhibition

22
Unexpected eventsThe catastrophe!
  • Call for help/Code Blue
  • Discontinue sedative therapy, infusions
    /transfusions etc
  • Begin BCLS/ACLS if appropriate
  • prepare emergency equipment, drugs
  • try to anticipate resuscitation needs

23
Equipment problemsE.C.G.
  • Problems
  • No trace/loss of trace
  • Poor quality
  • Intermittent trace
  • Interference
  • Possible causes
  • ASYSTOLE!!
  • loose leads
  • incorrect placement
  • dry electrodes!
  • greasy skin
  • respiratory variation
  • electrical interference

24
Equipment problemsNon-invasive BP
  • Problems
  • no reading
  • repetitive cycling
  • very low/high BP
  • ??Arterial line
  • Possible causes
  • HYPOTENSION!
  • HYPERTENSION!
  • cuff leak
  • wrong size cuff
  • arrhythmia e.g. AF
  • tubing kinked
  • patient/MD movement

25
Equipment problemsPulse oximetry
  • Possible causes
  • no pulse!
  • hypoxemia!
  • decreased perfusion
  • dye injection
  • electrical interference
  • inappropriate sat/pulse settings
  • incident light/nail polish
  • Problems
  • no reading
  • low reading
  • intermittent trace
  • frequent alarm

26
Equipment problemsPulse oximetry
  • REMEMBER!
  • Oximetry does not measure respiration
  • there may be a lag phase, depending on probe
    site
  • as with all the equipment
  • if it isnt working at the beginning it will not
    suddenly get better, it is likely to let you down
    when you need it most.

27
Strategies to reduce risk,over-sedation
  • Have an understanding of the pharmacology
    involved in conscious sedation
  • Titrate drugs carefully to patient weight but
    especially to effect.
  • Have appropriate reversal agents readily
    available and know how to use them
  • Know where other emergency drugs can be found

28
Commonly Used Medications
  • Midazolam
  • intravenous/oral/intramuscular/intranasal
  • Initial dose 0.5-2mg iv over 2 min
  • Onset 1minute, peak 3-5 mins
  • Wait full 2 mins between doses with 0.5-1mg
    increments
  • Duration 1-2 hours

29
Commonly Used Medications
  • Valium
  • Initial dose 2-5 mg iv
  • Onset 1-5 mins
  • Wait full 5 mins between doses with 1 mg
    increments
  • Duration 3-4 hours

30
Commonly Used Medications
  • Fentanyl
  • Onset 1-3 min peak-effect at 3-5 minutes
  • Initial dose 25-50 mcg iv
  • titrated in 25mcg doses
  • low dose drug is short acting
  • Duration of effect 30-60 mins

31
Commonly Used Medications
  • Morphine
  • Onset 1-6 min
  • Initial dose 2-5 mg iv
  • titrated in 2 mg doses but wait 3-5 mins between
    doses
  • Duration of effect 3-5 hours

32
Commonly Used Medications
  • Meperidine
  • Initial dose 25-50 mg iv
  • Onset 2-8 mins, peak 20 mins
  • Mild vagolytic and antispasmodic
  • Normeperidine is pro-convulsant
  • Dose titration 12.5-25mg Duration 2-3hrs
  • Interaction with MAOIs

33
Overmedication
  • Why does overmedication occur?
  • Excessive dose
  • Overly sensitive patient,
  • concurrent medications or disease states
  • Inadequate time for effect before more drug
    administered
  • Abnormal response such as hyperactivity leading
    to more medication

34
Overmedication
  • What problems does overmedication cause?
  • Airway obstruction
  • Hypoxemia and hypercarbia
  • Loss of protective reflexes
  • Loss of contact with the caregiver
  • Hemodynamic instability
  • Interferes with the procedure

35
Overmedication
  • How may overmedication be managed?
  • stop medicating!
  • open airway and stimulate to breathe
  • ensure adequate oxygen supply
  • call for help early, especially if hemodynamic
    instability
  • consider reversal of medication
  • have suction immediately available

36
Overmedication
  • How may medication be reversed?
  • Opiates and benzodiazepines are the only drugs
    with specific antagonists
  • REMEMBER once reversal agents are used this
    MUST lead to a longer period of post-procedure
    monitoring.

37
Reversal Agents
  • NALOXONE, 40mcg - 400mcg slow I.V.
  • Onset 1-3 minutes, duration 45 minutes
  • will reverse analgesia
  • may cause pulmonary edema
  • beware withdrawal effects if long term narcotic
    use
  • may need repeating or infusion

38
Reversal Agents
  • FLUMAZENIL,
  • 0.1mg - 0.2 mg I.V. for partial reversal
  • 0.4mg - 1.0mg I.V. for complete reversal
  • Onset 1-2 minutes, duration 45 minutes
  • may precipitate withdrawal seizure
  • not to be used routinely
  • half life of benzodiazepine may be long so
    flumazenil may need to be repeated

39
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42
Summary
  • Choose your patients carefully.
  • Check and understand your equipment
  • Use medication judiciously, you cant take it out
    but you can always give more!
  • Have reversal agents available but remember basic
    airway techniques.
  • Be vigilant and prepare for the unexpected.
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