Adverse Events and Complications of Procedural Sedation
Angela Stone
Mark Freedman
Overview
The complication rate of procedural sedation is estimated to be <1% in the hospitals and specialties routinely practicing procedural sedation and analgesia.
Adverse event rate is estimated at 2%–3% in pediatric patients.
The most common complication is respiratory depression and airway obstruction.
Medication errors.
Many of the complications related to PSA can be prevented by:
Appropriate monitoring and recognition of respiratory depression or arrest.
Adequate monitoring.
Ensuring the correct dose of medications (avoid drug calculation error).
Careful titration of medications.
Appropriate patient assessment.
Avoiding drug–drug interactions.
Personnel present who are trained in airway management and resuscitation.
Management of potential complications requires early recognition. Therefore, clinical observation and appropriate monitoring during the procedure is essential in order to identify and treat possible adverse effects (see Chapter 5).
Most complications during procedural sedation can be managed noninvasively.
Propofol
Respiratory Depression
Propofol causes dose-related apnea and respiratory depression.
No clinically significant events reported in studies with PSA, with most cases managed by bag-valve mask ventilation.
Recognition of respiratory depression is essential.
Managed with jaw thrust, repositioning of the airway, or assisted ventilation for a brief period.
The need for intubation after the use of propofol in the emergency department (ED) has not been reported.
Propofol is reported to have the lowest rate of respiratory depression when compared with methohexital, fentanyl/midazolam, and etomidate.
Hypotension
Propofol commonly results in a drop in blood pressure, which is often transient.
More commonly seen with rapid bolus, for example patients who are hypovolemic, or have poor cardiovascular reserve.
When compared with etomidate, propofol has been found to induce greater hypotension, although this is transient and of unknown clinical significance.
Can be treated with Trendelenburg positioning, fluid bolus, or short-acting vasopressor (phenylephrine).
Injection Pain
Injection pain has been reported in up to 70% of patients.
Warning the patient often alleviates anxiety when pain is felt with the injection.
Lidocaine, either mixed with propofol (1 mL of 1% lidocaine in 19 mL propofol) or given with a rubber tourniquet in place 30–120 s before injection (0.5 mL/kg) has been found to prevent injection pain.
Ketamine
Laryngospasm
Rare but potentially life-threatening side complication.
Unrelated to age, sex, underlying medical condition, or dose.
Associated with procedures that stimulate hyperactive gag reflex through direct instrumentation or secretions appear to represent a higher risk.
Risk factors include:
Upper airway infection.
Age between 3 and 12 months.
Active pulmonary disease including asthma.
Laryngospasm often manifests as hypoxia and decreased chest wall movement not responsive to maneuvers to open the upper airway.
Consider bag-valve mask and positive pressure ventilation as first line approach – breaks most cases of laryngospasm.
In severe circumstances may require urgent paralysis and intubation.
Hypersalivation
Ketamine stimulates salivary and tracheobronchial secretions.
In children, coadminister with atropine (0.01 mg/kg; min 0.1 mg, max 0.5 mg) or glycopyrrolate (0.005 mg/kg; max 0.25 mg).
The use of atropine appears to be unnecessary in adult patients in the ED.
Nausea and Vomiting
Vomiting occurs in 0%–9% of patients receiving ketamine.
In children, the incidence appears to be age-related, with a higher risk in patients aged 5 years and older.
Vomiting most often occurs during the late recovery phase when the patient is awake and alert.
Protective airway reflexes are maintained during dissociative anesthesia with ketamine, therefore, significant aspiration is extremely rare.
Ketamine is therefore preferred over other agents for urgent or emergent procedures when fasting is not assured.
Delayed vomiting may occur after discharge, and patients should be informed about this (see Chapter 4 on discharge instructions).Related posts:
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