Procedural sedation is a practice to relieve pain, anxiety and suffering for patients undergoing painful medical procedures in Territorial Emergency-Urgency. It involves the administration of sedative or dissociative drugs with or without analgesic agents.
It is a practice performed by experienced personnel who have acquired skills in drug management, airway management and cardio-respiratory resuscitation, to cope with any complications.
The objective of procedural sedation through the administration of sedatives and / or analgesics is to achieve a decrease in the level of consciousness in order to tolerate pain and unpleasant procedures, maintaining preserved respiratory and cardiovascular functions.
The depth of sedation varies according to the type of patient and the procedure:
Minimal sedation: cognitive functions and coordination could be slightly impaired; respiratory and cardiovascular functions remain unharmed. It is used for minor procedures.
Moderate sedation: there is a depression of consciousness, the patient responds to verbal stimuli with or without tactile stimuli. Spontaneous ventilation and cardiovascular function are adequate.
Dissociative sedation: the patient is in a trance-like state of catalepsy characterized by analgesia and amnesia with maintenance of protective airway reflexes, spontaneous breathing and hemodynamic stability. The main drug for this condition is Ketamine.
Deep sedation: the patient has a depression of consciousness, he is not easily reawakened unless after prolonged and repeated painful stimuli. Respiratory function may be impaired and the patient may require ventilatory assistance. Cardiovascular function is maintained.
Fentanyl: 1 – 3 mcg / kg IV → can be used for procedures requiring minimal sedation with high analgesia
Midazolam: 0.05 – 0.1 mg / kg IV → can be used for procedures requiring minimal or moderate sedation
Ketamine: 0.5 – 1 mg / kg IV → can be used for procedures that require dissociative sedation, particularly in the pediatric setting
Propofol: 0.5 – 1 mg / kg IV → followed by 0.5 mg / kg every 3 minutes if necessary, can be used for procedures that require moderate or profound sedation.
MEOPA, Equimolar mixture of oxygen and nitrous oxide, used for inhalation, can be used for procedures that require minimal sedation but is not easily feasible on the territory.
Inhaled methossiflurane may be a valid alternative in moderate and severe pain (3 ml repeatable).
TERRITORIAL APPLICATION SCENARIOS 118
fentanyl 1 mcg / kg
followed by midazolam 1-2 mg every 2 min up to a maximum of 5 mg halving doses in the elderly
SUTURE from superficial injury:
MEOPA especially in children
alternatively Ketamine 0.5-1mg / Kg via MAD
REDUCTION from FRACTURE:
F.entanyl: 1-3 mcg / Kg IV Midazolam: 0.05 – 0.1 mg / Kg IV
REDUCTION from DISLOCATION:
Midazolam: 0.05 – 0.1 mg / Kg IV
alternatively Propofol: 0.5-1 mg / Kg IV
MANEUVERING AND PROCEDURES NOT RECOMMENDED
Sedation must be carried out by experienced operators since the individual response is very variable from individual to individual. For this reason, too fast intravenous administration of the drug chosen according to the required sedative level should always be avoided.
It goes also avoided the summation of several drugs acting on the central nervous system and on the state of consciousness, perhaps previously taken by the patient.
Always avoid sedation without the possibility of immediate assistance to the airways and ventilation.
RECOMMENDATIONS – BEST PRACTICE
x If possible, use the Ramsey scale to evaluate the sedative level by reporting the value in the rescue card.
x Whenever possible, carry out sedation inside the medical cabin of the rescue vehicle, having prepared for any assistance (and possible control) of the airways and ventilation.
x Always carry out instrumental monitoring, at least oximetry.
x Use drugs for which you are most familiar, associating opioid with benzodiazepine (also exploiting the amnesic effect of the latter) and remembering that the combination of the two drugs will certainly give respiratory depression, in most cases manageable with non-invasive positive pressure ventilation (Ambu connected to oxygen source).
x If patient oxygenation is not sufficient with this type of ventilation, consider advanced airway management, or (especially if the patient was not fasting) awakening with the respective antidotes of the recommended medications. Also remember to pre-oxygenate the patient in the mask during preparation for cardioversion, even if he does not show signs of hypoxia.