>From: Adrian Fogarty <[log in to unmask]>
>Reply-To: The list will be of relevance to all trainees including
> undergraduates and <[log in to unmask]>
>To: [log in to unmask]
>Subject: Re: Sedation in A&E
>Date: Thu, 30 Nov 2000 13:26:21 -0000
>
>
>Furthermore one would often use a short acting opioid, e.g.
>fentanyl, to spare your propofol dose i.e. balanced anaesthesia. It's
>probably dangerous to conduct a blinded trial when comparing different
>classes of drugs, i.e. induction agent versus sedation/analgesic agent.
>
I think this is where a lot of trouble regarding using various drugs in ED
comes from, the class distinction you make is all dose relative and using
terms like balanced anaesthesia - we are not giving a propofol balanced
anesthesia - we a using a titrated reduced dose for procedural sedation -
immediately gets anaesthetic back up.
Propofol - 10-20 mg boluses given every 2 minutes to an end point of
sedation / titrated slowly up (with a dose range of 20-150 mg required for
sedation = a sedation dose
Propofol - 2.5 mg /kg IV push = induction dose
Midazolam - 0.05-0.1 / mg kg = sedation dose
Midazolam - -0.3-0.4 / mg kg = induction dose
Its because some of our anaesthetic collegues can only see the effects of
induction doses of drugs that we have so much trouble with these agents (
Ketamine is another similar dose situation ). Because they only use them for
one purpose they miss their other uses. Its compounded by how badly some
ED's practice procedural sedation ( no guidelines, poor monitoring ) and the
fact we let SHO's with 3 weeks in the job do it unsupervised - because this
myth has crept into practice that benzo/opiate cocktail is safe for anyone
to do, and its ok if the same person gives the drugs then does the
procedure. So is it any surprise some anaesthetic departments want to keep
us away from their newer agaents.
But coming back to a comparison trial - I have to aggree with Adrian, that
the best approach is observational audit, but on the backgroud of a
comprehensive sedation policy. Its imposible to safely blind given the
different drug profiles
Craig
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