> Half an hour of obtundation is perhaps, a little long, but I agree that
> Propofol in the right hands would have some advantage.
>
And for some patients. As an example I recently did an overweight lady with
COPD. I was keen to use a technique that would get her back to her normal
breathing pattern as quickly as possible. Propofol worked well.
> All of which goes to show that sedation is a very personal thing. One
> must have a feel for the drug, its effects and duration of action in
> each patient. It does not come out of a book.
>
Agreed.
> The null hypothesis is that all of these techniques are much of a
> muchness and it all depends on the individual practitioner's skills,
> preferences and experience. Is this view acceptable to our EBM obsessed
> specialty? ;-)
> --
The decision as to what we actually do with an individual patient should be
based on more than just the published evidence:-
1. the patient
2. the experience/skill of the doc
3. the cost
4. the evidence
The weighting of the above 4 factors determines our decision. We did
describe this as a decision box a while back in the JAEM (see attachment).
So in answer to your question - yes its right in line with ebm!
NB there are a variety of other decision boxes for other specialities:-
Orthopaedics - is not so much a box, as a dot that says "because I say so"
etc.
etc.
etc.
Simon
Simon Carley
SpR in Emergency Medicine
Manchester Royal Infirmary
England
[log in to unmask]
Evidence based Emergency Medicine
http://www.bestbets.org
----- Original Message -----
From: S A Hughes <[log in to unmask]>
To: <[log in to unmask]>
Sent: Monday, December 04, 2000 8:56 PM
Subject: Re: Sedation in A&E
> In message <03a701c05dd9$dc6ea8e0$b52a073e@tinypc>, Simon Carley
> <[log in to unmask]> writes
> >I have been fairly unsatisfied with the midaz/opiate sedation technique
in
> >A+E
> >for quite a while. Problems:-
> >1. Usually given too quickly (people dose stack because they don't wait
long
> >enough for titrated effects leading to peak effect after the procedure)
> >2. midax/morphine is considered "safe" as it is "not an anaesthetic" -
> >rubbish really, this is a dose related effect and I have certainly seen
and
> >recently rescued my medical collegues from several midazolam
anaesthetics.
> >3. Relatively long acting (in terms of sedation/respiratory depression
etc).
> >4. We often give relatively poor training and supervision for this
> >technique.
> >
> Point 4 is the key. Training, supervision and experience. Once one is
> familiar with the technique and is good with airway management, then
> there is a lot to be said for Midazolam/Opiate sedation.
>
> >I went through a stage of opiate + 70%N2O/30%O2 via an anaesthetic
machine
> >which has worked well. This technique has a fairly quick onset/offset and
is
> >pretty safe (assuming you know how to work the gas machine).
> >
> ....Doubtless a disaster in the hands of others!
>
> >I am now inreasingly using Propofol + IV NSAID +/- the morphine they have
> >already been given.
> >The propofol is given in 10-20mg boluses to achieve a state of sedation
(not
> >anaesthesia). This works really well. Taking the disclocated shoulder as
an
> >example, instead of being left with a obtunded patient for half an hour,
the
> >patient is pretty much back to normal after 5-10 minutes
>
> >Propofol is only used by those of us with fairly significant anaesthetic
> >experience (i.e. about one year) so we are pretty familiar with its use.
>
> Half an hour of obtundation is perhaps, a little long, but I agree that
> Propofol in the right hands would have some advantage.
>
> All of which goes to show that sedation is a very personal thing. One
> must have a feel for the drug, its effects and duration of action in
> each patient. It does not come out of a book.
>
> The null hypothesis is that all of these techniques are much of a
> muchness and it all depends on the individual practitioner's skills,
> preferences and experience. Is this view acceptable to our EBM obsessed
> specialty? ;-)
> --
> S A Hughes
>
>
|