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
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