Airway Corner - Procedural Sedation

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Reuben Strayer (@emupdates) -

terrific discussion, thanks to darren, jim and rob. minor clarification re: "some use a rising end tidal CO2 as an indicator of hypoventilation."

end tidal CO2 can rise _or fall_ in hypoventilation, depending on the type of hypoventilation - in PSA, it usually falls. I discuss this explicitly in part two of errors in PSA.

Patrick B. -

At ACEP (can't remember the session) heard talk of a new approach that may be superior to EtCO2 monitoring....tracheal vibration monitoring coming down the pipeline.....

Pierre M., M.D. -

Excellent talk but I am not sold on a few things:

(1) I agree personally that treating the pain before the procedure makes sense and decreases risks during procedures but I don't think a study on catecholamines proves this in any way as that is not really a patient oriented outcome. Hypothesis generating maybe......

(2) I also initially loved the idea of ketofol because as an ED doc we are cutting edge, or like to think we are. But despite a large number of studies now on the use of this combination I have yet to see one that shows an advantage for a patient oriented outcome that matters. I think one of the times we are most vulnerable to medical errors is when we are mixing drugs. In the absence of clear benefit, I would choose ONE drug, sometimes it will be ketamine and sometimes propofol depending on the clinical scenario.

It was an excellent talk and the research you guys are doing seems very cool. Thanks.

James E., dr -

Thank you for the thought provoking discussion

I would interested in Darren and Jim's approach to sedation for electrical cardioversion?

Analgesia is not required prior to cardioversion but the procedure is moderately painful.... although typically of very brief duration
My approach is fentanyl for analgesia with propofol for the sedation. Is the fentanyl required?

Robert D. -

I have never heard you talk about methohexital for procedural sedation. It has the beneficial effects of etomidate and propofol without the adrenal suppression and myoclonus of the former and it seems to have less hypotension than the latter.

michael s. -

Dr Miner, I'd like to pick your brain about the transition from Er to anesthesia; do you have a professional email?



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