Subject: Re: Flumazenil, Sedation and Fits
Getting back to the original thread now, I was fascinated to note one of my
junior's approach to a sedation case the other night. It was a shoulder, and
I used 200mcg fentanyl followed by the "Belsham" technique. As frequently
happens the fentanyl produced apnoea, which can be easily dealt with either
by prodding the patient, by speaking to him, or by starting the procedure!
My concern about the junior's approach were as follows.
Firstly she didn't even spot the apnoea, was too busy watching the pulse
oximeter. This concerns me, there's a whole generation of doctors out there
who have lost vital clinical skills because of pulse oximetry. Many of them
can't even spot airway obstruction! They all seem to think obstruction is
noisy, but it is rarely noisy in the sedated patient, it is almost
exclusively silent. By simply watching the monitor, they miss the clinical
signs for several minutes. When the sats then do plummet they're not
entirely sure why and frequently then panic, which leads me to the next
When I pointed out the apnoea, long before the sats altered, my junior's
first reaction was to ask for naloxone! Again no concept of how to deal with
apnoea simply, either by the three techniques described earlier or by
bagging the patient. In the event I simply started the procedure which
produced just enough stimulus to produce a nice respiratory pattern. The
fentanyl was so short acting that the patient "woke up" immediately
following the procedure, no naloxone required, and was "street ready" for
discharge 45 minutes later.
I am concerned that sedation as an artform is rapidly disappearing from our
armamentarium. Maybe I'm just old fashioned, but when you learned to work
without pulse oximetry you had to keep your wits about you. Aren't airline
pilots still taught to fly without ILS, or certainly with a limited
instrument panel? I think modern trainees should have trials of working
without oximetry (perhaps visible to their trainer only) so that these
clinical skills can be relearned.
By the way, the junior I speak of is an excellent doctor, but like so many
of her era, she just hasn't had much sedation/anaesthesia experience yet.