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Re: Time for Emergency Physicians to all become experts in sedation

Dear Editor,

I welcome this reivew by Duncan et al (1) that adds further support to the use of sedation by emergency physicians (EPs) when performed according to safe sedation guidelines. I have previously completed a systematic review of the use of midazolam and propofol by non- anaesthetists for procedural sedation with similar conclusions to the review by Symington and Thakore (2) published in the EMJ earlier this year. I carried out my review whilst doing an anaesthetics secondment and asked my supervising consultant (an anaesthetist) for his views on sedation by non-anaesthetists. He likened my request to asking a gynaecologist for his opinion of backstreet abortions! Whilst this comment was said in jest, I think it is important that we as EPs remember that the literature contains overwhelming evidence that sedation by EPs can be both safe and effective.

As a secondary point, in the previous response to this article ("Sedate with caution" by Lutz and de Mello) the correspondents call for all patients undergoing sedation to have end-tidal CO2 monitoring. Whilst this may well be the gold standard for bedside ventilatory monitoring, its use in all sedated patients is not supported by the 2001 Intercollegiate working party report on Safe sedation practice (3) who only advocate the use of pulse oximetry, together with BP and ECG monitoring in older patients.

This report also made the following recommendations: "Royal Colleges, in association with the relevant sub-specialty organisations, should develop guidelines on sedation methods appropriate to clinical practice in their sphere of influence... [and] ...incorporate the necessary instruction and assessment into training and revalidation programmes of those specialties that use sedation techniques." I therefore call upon the College of Emergency Medicine to heed this call and I believe that the imminent changes in emergency medicine training are the perfect opportunity to ensure that all future EPs might be experts in procedural sedation.

(1) Duncan RA, Symington L, Thakore S. Sedation practice in a Scottish teaching hospital emergency department. Emerg Med J 2006;23:684- 686

(2) Symington L, Thakore S. A review of the use of propofol for procedural sedation in the emergency department. Emerg Med J 2006;23:89-93

(3) Intercollegiate Working Party chaired by the Royal College of Anaesthetists. U.K. Academy of Medical Royal Colleges and their faculties - implementing and ensuring safe sedation practice for healthcare procedures in adults. London Royal College of Anaesthetists, 2001.

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Re: Sedate with caution

We would like to comment on the sedation practice in the emergency department as described by Duncan et al. (1)

We feel there is too much reliance on SpO2 in patients undergoing sedation whilst receiving supplementary oxygen. This creates a false sense of security. The end-tidal CO2 is a better indicator of adequacy of ventilation although it is seldom used during sedation. Monitoring of respiratory rate, respiratory effort and end-tidal CO2 may identify those patients at risk of hypoventilation from over-sedation.

Another concern is the use of different opioids in a single patient journey, as there are potential interactions in terms of analgesic efficacy and side-effect profile (2).

The dose of midazolam should be reduced in the elderly and in those patients with significant co-morbidity. Although reversal of midazolam is possible with flumazenil (Anexate -R-), this may be associated with patients experiencing dysrhythmias, hypertension and even convulsions. For sedation in the elderly patient we use 0.5 to 1 mg midazolam intravenously plus fentanyl by titration and wait for a couple of minutes. We then use small boluses of intravenous propofol or inhalation of a low concentration of sevoflurane in an air / oxygen mixture to maintain sedation. We monitor the ECG, blood pressure, Sp02 and the end tidal CO2. We occasionally add nitrous oxide both as an analgesic and as an hypnotic agent.

We understand the service need for sedation to be provided by non- anaesthetists. However a multi-modal, tailor-made approach to sedation of a patient will provide the best outcome especially in the frail and the elderly. These patients would be better off under monitored anaesthetic care.

(1) Duncan RA, Symington L, Thakore S. Sedation practice in a Scottish teaching hospital emergency department. Emerg Med J 2006;23:684- 686