The emergency department wants to use Etomidate for sedation ...

Pediatric Anesthesiology 2006PBLThe emergency department wants to use Etomidate for sedation:Should we let them?Jeffrey L. Galinkin MD, FAAPThe Children's Hospital, DenverJeana E. Havidich MDMedical University of South CarolinaObjectives:1. Understand the role of anesthesia departments in hospital sedation committees and currentnational sedation guidelines.2. Discuss the utility or lack of utility of capnography and the BIS monitor for sedation outside ofthe operating room.3. Develop a group consensus on the use of Etomidate by non-anesthesiologist for sedation.4. Build a group consensus on whether and how these should be conducted by nonanesthesiologists.Stem Case:As the anesthesia representative to the sedation committee you are approached by the hospitals IRB toreview a protocol evaluating the use of Etomidate for Emergency room sedation. In summary, the study isdescribed below:The authors of the study plan to look at patients aged 1 to 18 years who present to the emergencydepartment (ED) and require a procedure of short duration for which procedural sedation is necessary.Such procedures will include: acute closed fracture reductions with minimally displaced, angulatedfractures; joint reductions; abscess drainages; arthrocentesis; and qualifying lumbar punctures. NPO statuswill be per ED guidelines (>2 hours). Subjects are to be monitored by pulse oximetry, non-invasive bloodpressure, electrocardiogram and nasal capnography. Intravenous access will be achieved prior to sedation.For sedation each subject will be given 0.2mg/kg Etomidate IV and then be allowed to receive up to 2additional 0.1mg/kg IV dose increments. Additionally, subjects can receive 2mcg/kg fentanyl IV.Discharge criteria following study are as follows: 1) airway patent with adequate oxygenation; 2) awakeand easily aroused, but minimal tactile or vocal stimulation may be necessary; 3) swallowing reflexpresent demonstrating ability to swallow clear liquids while protecting the airway; 4) pre-sedation level ofresponsiveness should be achieved. Readiness for discharge will be documented using the VancouverSedation Recovery Scale (VSRS).As a consultant, you are asked to evaluate the safety and merit of this study.

Pediatric Anesthesiology 2006PBLQuestions:1. Discuss the role of the anesthesia department as an institutional “gatekeeper” for the use ofsedative agents.a. Qualifications of the provider: are all of the physicians trained in ER or are some of thephysicians pediatricians. Do they have the same airway management skills?b. How do you credential these individuals for deep sedation? (What policies exist forsedation/anesthesia by non-anesthesiologists and do they apply to children).c. Should competency be determined by the anesthesiologists?d. Does simulation play a role in competency?e. Who is responsible for the managing the airway? (Nurse or ER physician)?f. How should these providers be trained to be able to recognize and manage a difficultairway or provide sedation in children with complex medical problems (ASA PS III orgreater).2. NPO statusa. Is 2 hours (for solids and liquids) sufficient for procedural sedation?b. What is an acceptable NPO status and does waiting make any difference on outcome?c. Does your department have any jurisdiction over this area?3. Standard of care for monitoring children in the ERa. What do the published guidelines state?b. According to some of the ER literature capnography is not routinely utilized. Whenshould capnography be required when administering sedation?4. Can the individual performing an invasive procedure also be responsible for administration ofsedation?5. Resuscitative carea. Is there immediate availability of resuscitative drugs?b. Availability of reversal agents/emergency airway equipment (including the use ofLMAs).6. BIS guided sedation outside of the operating room.a. Is this a valid technique in children?b. Is this a useful technique in children?c. Would use of this provide a false sense of security to providers?7. Etomidate as a sedative agent.a. Evaluate the use of etomidate as a sedative agent.b. Would propofol or ketamine a better choice than etomidate?c. Is there any role for benzodiazepines?d. What about opioids?8. Discuss a design for a protocol using Etomidate in an emergency room setting.a. Is it possible to make this study safe?b. Does this protocol require the presence of an anesthesiologist or assigned designee?

Pediatric Anesthesiology 2006PBLReferences:1. Agrawal D, Feldman, Krauss B et al. Bispectral index monitoring quantifies depth of sedation duringemergency department procedural sedation and analgesia in children. Ann Emerg Med 2004;43:247-255.2. Committee on Drugs, American Academy of Pediatrics. Guidelines for monitoring and managementof pediatric patients during and after sedation for diagnostic and therapeutic procedures. Pediatrics1992;89:1110-5.3. Dickinson R, Singer AJ, Wesley C. Etomidate for pediatric sedation prior to fracture reduction.Acad Emerg Med 2001;8:74-7.4. Falk J, Zed PJ. Etomidate for procedural sedation in the emergency department. Ann Pharmacother2004;38:1272-7.5. Hoffman GM, Nowakowski R, Troshynski TJ, et al. Risk reduction in pediatric procedural sedationby application of an American Academy of Pediatrics/American Society of Anesthesiologists processmodel. Pediatrics 2002;109:236-43.6. Mace SE, Barata IA, Cravero JP, et al. Clinical policy: Evidence-based approach to pharmacologicagents used in pediatric sedation and analgesia in the emergency department. Ann Emerg Med 2004;44:342-77.7. McDermott NB, VanSickle T, Motas D et al. Validation of the bispectral index monitor duringconscious and deep sedation in children. Anesth Analg 2003;97:39-43.8. Motas D, McDermott NB, VanSicle T et al. Depth of consciousness and deep sedation attained inchildren as administered by nonanaesthesiologists in a children’s hospital. Pediatr Anesth2004;14:256-260.9. Roback MG, Wathen JE, Bajaj L, Bothner JP. Adverse events associated with procedural sedation andanalgesia in a pediatric emergency department: A comparison of common parenteral drugs. Acad EmergMed. 2005;12:508-513.10. Ruth WJ, Burton JH, Bock AJ. Intravenous etomidate for procedural sedation in emergencydepartment patients. Acad Emerg Med 2001;8:13-8.11. Vinson DR, Bradbury DR. Etomidate for procedural sedation in emergency medicine. Ann EmergMed 2002;30:592-8.12. Schenarts CL, Burton JH, Riker RR. Adrenocortical dysfunction following etomidate induction inemergency department patients. Acad Emerg Med 2001;8:1-7.