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.

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).

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.

An alternative that I have heard of, but not used is a propofol/fentanyl PCA
pump (or should that be PCSedation). I suspect that it may represent the
ideal method of achieving safe and true sedation. Anybody interested at
doing a trial might consider it as an arm for the trial (it was someone from
Scotland telling me about its use in A+E - ?Aberdeen?)..

There is a BET in progress by one of the North West SpR's (Rupert Jackson)
looking at
propofol vs benzos for procedural sedation. There is quite a lot of work out
there showing benefit to propofol, though not so much in the A+E setting.
You can see the BET in progress at
http://www.bestbets.org/cgi-bin/bets.pl?record=00256  It's not finished yet
which is why it appears as a white dot on the database.

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: <[log in to unmask]>
To: <[log in to unmask]>
Sent: Thursday, November 30, 2000 10:52 AM
Subject: Sedation in A&E


> I am interested that you use Propofol for sedation in the A&E dept. Dr.
Ellis.
>  My experience is of considerable resistance (mostly from Anaesthetic
colleagues)
> against its use by "non-anaesthetists". Some A&E colleagues have said that
"it
> is an anaesthetic drug so we cant use it".
> I have felt that it is a suitable drug when used for sedation for
manipulations,
> by an experienced operator - an emergency physician with advanced airway,
and
> resuscitaion skills, with appropriate monitoring and resus facilities.
Also,
> do we not use other dangerous "anaesthetic" drugs with apparent lack of
criticism
> - opiates, benzodiazepines, general anaesthetics for RSI?
> I proposed a randomised blinded trial of propofol against opiate/midazolam
for
> manipulations in A&E, to look at times to recovery and safe discharge
home,
> as well as safety.....and it was thrown back in my face by the Anaesthetic
dept.
>
> I would be interested to know list members views and current practice.
> Sorry for the long email - but this is an area I am interested in!
>
>
> Marten C. Howes
> SpR
> Blackpool
>