Clinical Analgesia Pearls: Recap of Lecture given by Dr. Michael Cole
- Defining procedural sedation: giving an IV anxiolytic and an IV analgesic together does not necessarily always count as procedural sedation. Key point: It’s not the combination of medications you use, but rather the intent behind using them. A procedure is a painful event (cardioversion, shoulder reduction, etc.) followed by relief. Post-procedurally, there is diminished adrenergic drive once relief has been achieved, which can lead to a potential cardiovascular and respiratory collapse if drugs remain on board. Thus, following administration of medications for the purpose of performing the procedure, patients require continued monitoring for this. In contrast, giving an anxious patient with abdominal pain both ativan and dilaudid would not count as procedural sedation, as once these medications wear off, the patient is likely to continue to have pain.
- Hypoxia during procedural sedation is always an emergency that should be promptly addressed. A normal, healthy adult can maintain apneic oxygenation for ~7 minutes until desaturating to 90%. However, once desaturated to 90%, it takes only 2 minutes to get down to an oxygen saturation of 0%. Interventions include maneuvers to open the airway such as jaw thrust, BVM, and use of reversal agents such as narcan.Exert caution with using the benzodiazepine antagonist flumazenil in ALL patients. Although it is typically safe in pediatrics (used ONLY as rescue med for procedural sedation), we recommend that it NEVER be used in Adults in light of the constant uncertainty related to the practice of emergency medicine and the fact that the risk of inducing intractable seizures is too great. The answer for the patient with benzodiazepine related adverse event is typically supportive care with the potential need for intubation (and possibly vasopressors, in severe overdose).
- There are many options when it comes to analgesics. Tylenol is generally considered the safest first line pain relief medication and is good for most mild types of pain. Exert caution when using in patients with liver disease, renal disease, or on coumadin (tylenol dose > 2 g/day has been demonstrated to increase INR while on coumadin). NSAIDs work by inhibiting prostaglandins which leads to anti-inflammatory effects. Contraindications include PUD/gastritis, renal disease, Coumadin use (can exacerbate bleeding), allergy. Please click here for the latest FDA Warning on the cardiovascular risk related to NSAID use. There is no great evidence that NSAIDs inhibit bone healing, and use of NSAIDs in pediatric fractures is generally accepted at our institution by our orthopedic colleagues. A good practical rule of thumb (until we get better evidence on this topic) is the older and sicker the patient is (i.e. the more difficult it is for them to heal) the less likely it is that you should be plowing them with NSAIDs. Toradol is another option, but should only be used in the short term due to its increased side effect profile. Morphine, dilaudid and fentanyl are commonly used opiates in the ED. Use caution with morphine in ESRD patients as its metabolites are renally excreted, leading to an increased risk of side effects such as respiratory depression. Ketamine has gained increasing popularity as an analgesic when used at the appropriate dose, as it provides both analgesia and amnesia. It can be associated with an emergence reaction. Dr. Cole emphasized that it is better used in combination with other medications as it has an opiate sparing effect, rather than as a monotherapy, and suggested the dosage of 0.1-0.5 mg/kg bolus followed by a drip 0.05-0.4 mg/kg/hr.