Conscious Sedation in ED

Usually procedural sedation is one to one with cardiac monitoring along with everything else. As far as the drugs they use that can be doctor preference. In my experience the docs I've worked with prefer dilaudid and propofol. Propofol has a short half life so the pt is alert faster and out of the room faster, which is the goal of every ER.

Our protocol for procedural sedation: pt on cardiac monitor/pulse ox, crash cart in room, suction hooked up, monitor capnography.

Procedural sedation is not just to relax someone nor is it something we use over the long term to relieve pain. It is done for a procedure (reducing a dislocation for example).

Opioid + Benzo does not necessarily equal procedural sedation--in most cases it is not procedural sedation. There is a big difference between putting a pt "out" for a painful procedure versus giving them meds to reduce pain and anxiety.

FWIW, Propofol is definitely our most popular med for procedural sedation. I have seen etomidate used as well.

To be more specific - We do have a policy for Conscious Sedation, that clarifies how to manage a pt under sedation - but it does not clarify the combinations of medications that require the conscious sedation policy be implemented. It does however describe what the desired outcome of sedation is - to reduce loc in order to tolerate a procedure.

To be more specific - yesterday we had a pt come in with a shoulder dislocation. He was a big guy 30ish and obviously very uncomfortable. 1mg of IV dilauded and 5mg IV valium was ordered. The question arose that giving this combo together was actually a conscious sedation (opiod+benzo), and the policy should have been followed.

The patient was barely phased by these meds - the shoulder was reduced after xray and there were no complications. No decrease in loc, respirs, or bp. I have done conscious sedations that prop or versed is used, and obviously the policy is followed.

So my question is more this - What do you do? If you gave those 2 meds would a prudent ED RN have asked the MD to obtain consent, recorded a Mallampatti score and monitored ETCO2 etc.

So my question is more this - What do you do? If you gave those 2 meds would a prudent ED RN have asked the MD to obtain consent, recorded a Mallampatti score and monitored ETCO2 etc.

I would say that it depends on the intent of the meds. If the meds were given just to reduce pain and relax muscles/reduce anxiety (I'm thinking more than anything, the valium is being used to relax muscles and make the reduction easier), then, no, I would say you do not have to get special consent for that. If the goal was actually to do procedural/moderate/conscious sedation, then you would need a consent.

If we did etCO2 on every pt. that got narc + benzo, it would get quite annoying...just another (unnecessary) alarm to fatigue us.

To be more specific - We do have a policy for Conscious Sedation, that clarifies how to manage a pt under sedation - but it does not clarify the combinations of medications that require the conscious sedation policy be implemented. It does however describe what the desired outcome of sedation is - to reduce loc in order to tolerate a procedure.

To be more specific - yesterday we had a pt come in with a shoulder dislocation. He was a big guy 30ish and obviously very uncomfortable. 1mg of IV dilauded and 5mg IV valium was ordered. The question arose that giving this combo together was actually a conscious sedation (opiod+benzo), and the policy should have been followed.

The patient was barely phased by these meds - the shoulder was reduced after xray and there were no complications. No decrease in loc, respirs, or bp. I have done conscious sedations that prop or versed is used, and obviously the policy is followed.

So my question is more this - What do you do? If you gave those 2 meds would a prudent ED RN have asked the MD to obtain consent, recorded a Mallampatti score and monitored ETCO2 etc.

You didn't do conscious sedation. The patient was not sedated. He was given a pain killer and muscle relaxant.

About the equivalent of 2.5 percocets, and a bit less than a 1 mg po ativan. Some people drive to work on more than that.

I have worked where opioid + benzo has been defined in policy as conscious sedation. As well as where any IVP benzo meant that the patient could not leave the unit for a period of time (e.g., go for MRI) without accompanying monitoring equipment and staff.

Make sure you understand your policies. What the OP describes, in the context of a procedure, (shoulder reduction) would have been intuitively understood as procedural sedation where I work, and no one would have even attempted to not go the full conscious sedation monitoring/consent/documentation route.

Thank you all for the feedback. I didn't feel like we did a sedation. However this has opened up conversation in

my department - and we clearly need to come up with a better definition of conscious sedation. A few are stuck on benzo+opiate = conscious sedation, yet this is not written anywhere and this combo is used frequently.

Are you trying to say that giving a certain drug combination = conscious sedation and any other drug combination does not? I don't think it is that simple at all. I have given Valium & opioid to do conscious sedation in the past as that is the drug combination the provider performing the procedure wanted. I have also given a benzo to alleviate anxiety and a opioid to alleviate pain and not had it be a conscious sedation, the difference is in the procedure, and the dose.

Maybe in your case, the question is was the dose too little (although the answer to that is did the pt feel like he was under medicated and was the procedure successful) to properly sedate the patient, but if the patient was having his shoulder reduced and the doc wanted medication to knock him out during the procedure it was a conscious sedation and the procedure should have been followed. I don't believe a list of medications should be listed on the protocol.

I would say that considering the intent was for a reduction of a shoulder dislocation, regardless of medication administration, a consent would need to be obtained for that procedure (closed joint reduction of (left/right) shoulder dislocation). The provider would need to explain the procedure in detail identifying risks and benefits, and possible complications to patient, and then obtain informed consent from client.

What if the patient had a neurovascular injury and decided to say that he was fine until the doctor began yanking on his arm. Patient now has permanent injury and pain to the extremity with loss of sensation, maybe even paralysis (brachial plexus, anyone? OUCH!). Patient obtains a lawyer who finds no documentation that the patient was informed of the risks vs benefits or obtained informed consent for said procedure. I know I wouldn't want to have my name in that chart if that went down.

Just remember, its better to be safe than sorry, if you have any doubt, obtain a consent anyway. It won't hurt or complicate anything and you and your license are covered.

Sedation levels

Also, be careful when trying to differentiate conscious sedation and deep sedation. Back when I was in orientation, I was apparently doing conscious sedation charting with propofol and deep sedation protocols. That was nipped in the bud quickly. Know your conscious sedation medications versus your deep sedation medications so that you are fully aware as soon as the provider tells you what they want to use for the procedure.

Our Procedural Sedation policy is very specific. Defines Anxiolysis/Moderate/Deep sedation differences, including required monitoring, and gets into each drug, and the specific routes/doses that constitute each level of sedation. For example, nasal versed up to 0.2mg/kg is Anxiolysis, but any higher dose is sedation, etc. it's a pain, in that out Ad Locum docs *****, that the dose ranges are too low, but at least for my sake it's all very cut n dry, and eliminates needing to interpret gray areas. I know things are probably different for kids, but I would see how your policy lays it out, and maybe you can help spur a change if needed. =)