Today I am joined by James Miner, MD; chief of emergency medicine at Hennepin and an amazing, prolific researcher on procedural sedation.
The Procedural Sedation Series
- Procedural Sedation – Part I
- EMCrit Podcast 29 – Procedural Sedation, Part II
- EMCrit Podcast 151 – Procedural Sedation Part 3 with Jim Miner
Some of Jim's Procedural Sedation Studies
- [cite source='pubmed']25441247[/cite]
- [cite source='pubmed']23701339[/cite]
- [cite source='pubmed']20624140[/cite]
- [cite source='pubmed']19845550[/cite]
- [cite source='pubmed']16997421[/cite]
- [cite source='pubmed']15692132[/cite]
Some of the Points on Jim's Method for Short Procedures in Stable Patients
- Pre-procedural analgesia rather than peri-procedural
- He uses preoxygenation and ETCO2
- In stable patietnts, he gives 1-1.5 mg/kg of propofol up front
- 30-90 sec retrograde amnesia
- Can do painful things as propofol is coming on, but not coming off
Are there patients who will need different dosing?
- The elderly may need less, especially if they have opioids on board
- Volume depleted patients will need less
- Thin patients will need more, obese patients will need less (if we dose by actual weight)
- (IBW + 1/3 of remaining weight) may be the better way to dose with the 1.5 mg/kg
The biggest mistakes
- People ignore how long it takes for the propofol to kick in, need to wait 60 sec before a 2nd dose
Cardioversion
- Jim (and I) uses Etomidate
Nasal CPAP for Procedural Sedation
- [cite source='pubmed']25455053[/cite]
Alfentanil for Procedural Sedation
Stay Tuned
Update
An article demonstrating that supplemental oxygen impairs pulse ox detection of hypoventilation (Chest 2004;126:552)
And an article on Fasting (Ann Emerg Med. 2014;63(2):247-58. PMID: 24438649)
Additional New Information
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I really enjoyed this podcast, thanks gents! My role in procedural sedation is typically being a dedicated set of eyes and hands for airway management and vital signs monitoring. Keeping the pt safe while the doc pokes, prods and pulls. Knowing more about the idiosynchronies of these drugs for amnesia, apnea and hypotension helps me communicate more wisely in this role. One question: I have seen mixed success with Ketamine monotherapy for PSA as more docs seem to be trying it. The problem being the pt dissociates but does not necessarily relax, and sometimes squirm around quite a bit… Great… Read more »
Thanks for an excellent podcast! One thing i think anaesthetics do well and in emergency we do relatively poorly is giving “pre-med” prior to procedural practice. Previously, i have given single agent one time dosing. Recently I ahve changed to universally giving low dose analgesic and anxiolytic 5-10 mins before starting (eg 1mg Midazolam, 50mcg fentanyl)and assessing response. I usually repeat it about 2 mins before starting depending on response to initial dose . I find this has significant benefits 1. It reduces the dose needed to overcome the inevitable anxiety component – which may be significant, resulting in decreased… Read more »
I am an Anesthesiologist and enjoy listeining to these ED podcasts. I have a couple points based on my understanding. Retrograde amnesia (lack of recall of events that occur before the medication is given) is controversial and not thought to occur regularly with any medication. Head injury will do it though. Antegrade amnesia is produce by propofol and midazolam. Deep sedation is purposeful response to painful or repeated stimulus, where genereal anesthesia is no purposeful response (see ASA sedation continuum). It seems you prefer no response to painful procedures such as chest tube insertion, so you are aiming for general… Read more »
thanks, Brad. Yes clearly what we want for a hip dislocation or similar is general anesthesia; but we are precluded from calling it that for the reasons of politics.
Dear Scott, Javad Keyhani Rural ER from western Minnesota. I was the person who saw Jim Minor speak and suggested the interview. Thank you so much for doing it! You are awesome. What did you think of his response? It was similar to the lecture I attended. I took it as “in critically ill patients, when you need to do a procedure, focus on the perfusion over the pain and sedation. If you make perfusion the goal then they are more likely to survive.” That is not to say that you ignore it but make it the second goal after… Read more »
Well, not quite. Jim and I actually parsed what sparked your original comment during the lecture you had heard. Nothing to do with opioids; Jim’s comments revolved around post-intubation sedation, primarily propofol but analgesics as well immediately post-tube. Here is our discussion of the topic.
See section at 4:30. You refer to absence of recall early after bolus propofol and describe this as retrograde amnesia. This is antegrade amnesia. No pharmaceuticals give reliable retrograde amnesia – absence of recall of events that occur before the medication is given.
Brad, I think you are looking at the email, but not understanding threading comments. Go to https://emcrit.org/podcasts/procedural-sedation-3/ and I think you’ll immediately get it
I think we may be referring to two different areas of his research. I was referring to a part in his lecture talking about procedures in the critically ill patient where he said that aggressive pain control sometimes lead to worse perfusion and possibly worse outcomes. I will try to see my if he would clarify that and I hope I am misquoting him. This is pretty far afield for me coming from very rural ER but we do get the occasional critical patient and the teaching that you and Jim do is very helpful. Thanks again!
Thanks for this podcast. I really enjoyed it. I actually came back and listened to it again after an event in the ED. I have been practicing 16 years, and ketamine has been part of my practice for children this entire time. I have only recently started using it in adults, preferring propofol as my go to agent in most settings. I use intermittently for pain control as well. I had an episode of apnea in an adult who I gave ketamine to for a wrist reduction (I avoided propofol because he was already in an Aspen collar). Things were… Read more »
it is a relatively unexplored topic. we know if you slam it in, pts get apneic–other than that–we really don’t know.