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Associated DocumentsProcedural Sedation Record and Checklist- Dunstan Hospital Rapid Sequence Intubation: RSIProcedural Sedation in ED MIDAS doc :66982Ketamine Sedation ED MIDAS doc: 85725IndicationShort duration painful/distressing procedures that are not suitable for regional anaesthesia.Patient SelectionGeneral Assessment. The sedationist should know the background medical history of the patient. In particular, history of specific diseases that are likely to complicate sedation should be enquired about and examined for.These should include:GORDAortic StenosisOther significant cardiac disease: e.g. Heart failure/ uncontrolled IHDObstructive sleep apnoeaAsthma/COPDRecent Respiratory illnessMedications and allergies should be known and ones relevant to sedation documented on the sedation record.General Health StatusASA 1-2: generally appropriate for procedural sedation at Dunstan Hospital.ASA 3: The risk of procedural sedation at Dunstan need to be balanced against the risks of delayed procedure and transfer.ASA 4: Not appropriate for sedation at Dunstan unless procedure is time-critical and life/limb preserving.ASA 5: In rare circumstances sedation may be appropriate if ceiling of care is Dunstan Hospital.Previous Anaesthetic/SedationPrevious adverse reaction to sedation/analgesia should be considered a contra-indication to sedation at Dunstan Hospital unless it is mild (e.g.: brief and easily managed apnoea) or avoidable/minimizable with an alternate plan.Airway AssessmentDeep sedation should be avoided in those who have markers that predict a possible difficult airway. If possible regional anaesthesia should be used or at least agents such as ketamine that are more likely to preserve airway reflexes and spontaneous ventilationMarkers of difficult airway:Difficult BVM: beard, obese, no teeth, OSA/snoringDifficult Laryngoscopy: L.E.M.O.N.Difficult rescue airway (LMA, Cric): abnormal neck anatomy, previous surgery, radiation.EquipmentFull intubation equipment available as per RSI checklist, does not necessarily need laid out, but resus trolley must be readily available and contents checked/known to be immediately availableIn addition, below equipment should be out and at the patient bed space:OPA/NPA sized to patientBVM with PEEP valve checkedSuctionStaffingAt absolute minimum there must be one person able to monitor the patient throughout the sedation and not involved in the procedure. This person must be able to recognise apnoea and institute basic airway manoeuvres. If they do not have advanced airway skills the proceduralist must have advanced airway skills and the procedure must be able to be immediately interrupted. In this setting a drug given a single bolus with fairly predictable effect is required, e.g.: Ketamine. In specific circumstances a senior nurse with airway experience may fulfil this airway monitoring role.Whenever possible there should be one doctor for procedure, plus one for sedation, plus a nurse available for the duration of sedation and recovery to assist. Any sedations involving propofol or drugs titrated to effect should have a dedicated sedationist.From the ANZCA guidelines 2014:5.6 In situations other than those when an anaesthetist, or other trained and credentialed medical practitioner within his/her scope of practice, must be present (noted in 4.2 and 5.5), administration of sedation and/or analgesia and monitoring of the patient should be performed by another practitioner working with the proceduralist and whose training complies with the requirements outlined in section 13. If such an appropriately trained medical or dental practitioner is not present solely to administer sedation and/or analgesia and monitor the patient, there must be another health practitioner present during the procedure, who is trained in observation and monitoring of sedated patients and in resuscitation. The primary responsibility of this other practitioner is to monitor the level of consciousness and cardiorespiratory status of the patient. This practitioner must be immediately available to manage the patient should there be any need. This person may, if appropriately trained, administer sedative and/or analgesic drugs under the direct supervision of the proceduralist, who must have advanced life support skills and training (see item 5.4). Propofol, thiopentone and other anaesthetic agents must not be used in these circumstances. If loss of consciousness, airway obstruction or cardiorespiratory insufficiency occur at any time, all staff must devote their entire attention to treating and monitoring the patient until recovery, or until such time as another medical or dental practitioner becomes available to take responsibility for the patient’s care.MonitoringNIBP (set to auto Q3-5mins), ECG, SpO2, ETCO2 (via CO2 sampling nasal prongs).Most guidelines do not mandate ETCO2 for ketamine, however to standardise sedation procedures this is recommended for all sedations.PreparationConsent: written consent obtained whenever time/patient condition allows.Fasting: In general the risks of delaying an urgent procedure outweigh the benefits of fasting.Previously widely accepted timeframes for ‘being ‘fully fasted’ have been brought into question and are largely arbitrary. On the whole aspiration is a rare event. Clinician judgement weighing the clinical risk of delaying a procedure versus the small reduction in risk of aspiration is more important than absolute time-frame.Antiemetic: pre-med ondansetron or other anti-emetic is appropriate if the patient nauseous. If the patient is vomiting the procedure should be delayed, where possible to control this.Analgesia: Usually controlling pain prior to the procedure is useful and reduces the dose of sedative required, however if the procedure is expected to resolve the cause of pain it may be more appropriate to precede straight to sedation. Where pain is expected to be controlled or reduced by the procedure, a short acting opiate such as fentanyl should be used.Patient Position: Ideally 30 degrees head up, head in sniffing position if procedure allows i.e.: base of neck flexed and extended at atlanto-occipital joint resulting in external auditory meatus anterior to sternal notch. This will maximise the likelihood of the patient’s airway remaining patent and optimise ventilation.Pre-oxygenation: 3 minutes tidal breathing with high flow O2 via NRB.Apnoeic oxygenation: CO2 monitoring nasal prongs, 10-15L/min, maintain airway patency.Medications and safety checksIV access; line checked. IV fluids up and running well.Sedation drugs chosen and drawn up in standard formulations:Using the standardised formulation below aims to familiarise nursing staff with the medications and reduce the chances of drug error.-Ketamine 10mg/mL in 2x10mL syringes (2 smaller syringes minimises the chances of accidental overdosing in the drug most commonly used in our paediatric population)-Propofol 200mg in 20mL -Midazolam 1mg/mL: 5mL-Fentanyl 10mcg/mL: 10mLThe choice of agent will remain up to individual practitioner’s preference and patient characteristics. If combinations such as ‘ketafol’ are to be used, the preference is not to mix drugs in the same syringe but stick to standard preparations above.Push dose pressorThere are many different recipes available for these. We have aimed to minimise variation and standardise this to simplify the draw up process for nurses.The two options below give a mixed alpha+ beta effect in adrenalin and a predominantly alpha effect in metaraminolAdrenalin 10mcg/mL (1mL) or Metaraminol 500mcg/mL 10mg in 20mL (1-2mL)These formulations correspond with those on the RSI checklist, again for standardisation. Metaraminol at this dose can also be used as an infusion if required.Reversal Agent - should be available if using opioids or benzodiazepinesPlan to manage emergence phenomenon if using Ketamine; low dose midazolam or propofol.Paralysis (suxamethonium) should be readily available (and dose calculated for children) to manage laryngospasm that doesn’t respond to non-pharmacological strategies.In this setting Rocuronium is best avoided as the patient should be able to be woken up as soon as paralysis has worn off. If propofol has been used, ensure adequate sedation is continued while the patient remains paralysed.Escalating Airway/Apnoea interventionsETCO2 will assist early detection of apnoea. Initial management of apnoea should consist of airway opening manoeuvres. If apnoea persists in the setting of an open airway, it can be tolerated briefly if a short acting agent such as propofol has been used and oxygen saturations are maintained. Apnoea in the setting of a longer acting agent such as midazolam with generally require reversal or ventilation.Airway Management Flow Chart:Detect hypoventilationStop drugsOpen the Airway: Chin lift; Jaw thrust, Suction if required, NPA/OPAVentilate with BVM If the above interventions are unsuccessful announce Cannot VentilateABANDON PROCEDUREManage Laryngospasm:Laryngospasm notch pressureCPAP via BVMParalyse (suxamethonium)LMAIntubateSurgical AirwayRecovery:Sedation provider to remain in the room until the patient is rousable to light simulation and be stable from a haemodynamic and ventilatory point of view.Should remain having Q15mins obs and close nursing supervision until the patients scores 7 on the discharge criteria scoring below:Activity0Unable to lift head or move extremities voluntarily or on command1Lifts head spontaneously and moves extremities to command2Able to ambulate without assistanceBreathing0Apnoeic1Dyspnoea or shallow irregular breathing2Able to breathe deeply and cough on commandCirculation0Systolic BP below 80mmHg1Systolic BP below 100mmHg2Systolic BP within normal limits for patients – age appropriateConsciousness0Not responding or responding only to painful stimuli1Responds to verbal stimuli but falls asleep readily2Awake, alert and orientated to time person or place (recognises parent)If Ketamine has been used they should meet the criteria below:Ketamine Sedation Discharge Criteria?Obtains pre-sedation level of consciousness?Exhibits purposeful neuromuscular activity?Verbalises appropriately for age?Final set of vital signs are within normal limits?Able to ambulate if developmentally appropriate (with assistance if necessary)?Able to sit without support?Able to tolerate oral fluidsDocumentation:Procedural sedation should be documented on the procedural sedation checklist and record sheet. grades:Healthy person.Mild systemic disease without significant limitationsSevere systemic disease that is not incapacitatingSevere systemic disease that is a constant threat to life.A moribund person who is not expected to survive without the operation.A declared brain-dead person whose organs are being removed for donor purposes.Modified Mallampati Scoring: HYPERLINK "" [3]Class I: Soft palate, uvula, fauces, pillars visible.Class II: Soft palate, major part of uvula, fauces visible.Class III: Soft palate, base of uvula visible.Class IV: Only hard palate visible.The LEMON rule allows us to remember to look externally and to look at those parameters that will make the intubation simple or difficult.LEMON stands for:L – Look externally – Is the patient obese, do they have a high arched palate, a short neck, facial or neck trauma?E – Evaluate the 3:3:2 rule – 3cm mouth opening, 3cm thyromental distance, 2cm between hyoid bone and thyroid notch. If unsure as to how much a cm is, just use the 3 fingers or 2 fingers approachM – Mallampati Score – remember a Mallampati 4 is associated with a >10% chance of difficult airwayO – Obstruction – Is there a tumour, epiglottitis, recent neck surgery?N – Neck mobility – Is the patient in a cervical collar, are they elderly? ................
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