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Archive for the ‘Sedation & Analgesia’ Category

Deep Sedation

The Sedation/Analgesia (“Conscious Sedation”) Policy
The Sedation/Analgesia Policy was amended to delete the section on Deep Sedation.  Deep Sedation has been reclassified by CMS as “Anesthesia.”  Physicians and Dentists performing Deep Sedation must be credentialed specifically to perform deep sedation by their Chief of Service and maintain standards of care and documentation that are equivalent to the Department of Anesthesiology standards.  (Policy # A2-307)

Written by phil

July 14th, 2010 at 5:34 pm

HipStat Hip Fracture Study: Improving Pain and Function in Hip Fracture – page 917.205.8474

with 2 comments

Step by step instruction sheet for performing the block here.

The Mount Sinai School of Medicine’s Departments of Geriatrics, Emergency Medicine and Anesthesiology are collaborating on a study examining the efficacy and effects of 2 regional anesthesia techniques, femoral nerve blocks (FNB) and fascia iliaca blocks (FIB), on the treatment of peri-operative acute hip (femoral neck, intertrochanteric) fracture pain.

Patients age 60 years and over presenting to two New York City emergency departments (MSMC or Beth Israel)  with hip fracture will be randomized to receive the intervention or usual care.  The intervention includes single injection FNB in the ED followed by insertion of a continuous FIB catheter within 24 hours of the single injection FNB plus “as needed” non-opioid/opioid analgesia.  Usual care patients will receive conventional therapy with regularly scheduled intravenous or oral opioids plus “as needed” non/opioids/opioids. We will examine the impact of the intervention on patients’ self reported pain intensity; systemic opioid requirements; post-operative function; incidence of delirium, treatment related side effects; and hospital length of stay and participation in physical therapy.

Inclusion criteria:

  • Ages 60 and over
  • Male or female
  • Presenting to the emergency departments at MSMC ED from 8:00 to 20:00 with   radiographically confirmed hip fracture (femoral neck, intertrochanteric, or peri-capsular).

Exclusion criteria:

  • History of advanced dementia
  • Presence of multiple trauma, pathological fractures, bilateral hip fractures, or previous fracture or surgery at the currently fractured site
  • Patients transferred from another hospital
  • Patients with cirrhosis or liver failure

Dr. Sean Morrison is the PI on this study. For more information or questions, please contact the project manager, Taja Ferguson, or one of the study coordinators, Carla Foster, or Lauren Greenberg

If you have a hip fracture, page the study coordinator (917-205-8474).

Management of Severe Local Anesthetic Toxicity

Written by reuben

April 13th, 2009 at 4:31 pm

Corrective Action Plans

We have had several ED cases with poor outcomes over the past year that triggered root cause analysis and resulted in corrective action plans.  The following corrective actions directly or indirectly involve our ED practice. The department may be monitored by the state for compliance with these plans.

• New onset adult seizures, syncope, and chest pain will all be treated as if potential cardiac ischemia:  ECG within 15 minutes.

• Initial dosing of hydromorphone is 0.5 -1.4 mg, initial dosing of Morphine is 4 mg.

• Higher doses of pain medications may be given if there is a note in the chart documenting the medical reasoning for choosing a higher dose.

• More than 3 doses of IV pain medication in 3 hours should prompt a pain consult for consideration of PCA pump, or medical reasoning why there is no consult.

• All transfers of patients with thoracic aneurysm or dissection should be discussed with the MSH ED attending before transfer from another institution.

• CT surgery will use AMION for on call and chain of command contacts.  Non-compliance should be reported to Scot Hill.

• Consultants should respond by phone within 10 minutes, and be present within 30 minutes.  Non-response should trigger a call to the next higher level in the chain of command.

Written by phil

April 8th, 2009 at 7:16 pm

Pain Policy

This policy outlines the MSSM ED pain protocol.

Written by reuben

September 16th, 2008 at 10:09 pm


Propofol has been approved for use in the ED for post-intubation sedation and may be ordered in IBEX by all attendings.

It should not be used as a continuous infusion for patients under age 18.

The starting dose is 5 mcg/kg/min, titrated upwards by 5 mcg/kg/min every 10 minutes until desired sedation level is reached.

An infusion chart is available on the EHCED site:

I spoke with Robert Asselta today and he reported that all nurses should be able to hang and deliver propofol as a standard infusion, effective immediately.

For now, only use Propofol on intubated patients being monitored with continuous ETCO2 and automated, repeating blood pressure checks. Although propofol offers minimal if any benefit in most intubated patients when compared to midazolam, we must demonstrate a safe record of use before we petition the P&T committee to allow us to use it for RSI and procedural sedation, where it does offer significant advantages in certain situations. Propofol’s rapid offset of action does have particular utility in the patient intubated for CNS lesions, as the patient’s neurological status can be quickly re-evaluated after discontinuing the infusion.

Propofol causes respiratory depression, which is not an issue in an intubated patient, and hypotension, which can be. Be mindful of hypotension in susceptible patients.

I have pasted the summary I sent out months ago below for further information.

Thanks to all the MSSM attendings for suffering through the preliminary steps, thanks to Haru and Ruben for their efforts. Looking forward to seeing the milk-colored infusions.


* Propofol is a potent sedative-hypnotic that is structurally
different than but behaves similarly to the barbiturate class. It
produces dose-related sedation and amnesia, up to and including deep
sedation, in which case patients are unresponsive to painful stimuli
and may be apneic.

* Propofol has become popular for use in emergency medicine because
of its unique pharmacokinetics. When given as a bolus, onset of
action is generally within 1 minute, and duration of action is
generally not longer than several minutes. Patients are generally
completely alert within 15 minutes.

* Propofol may be used as an infusion to maintain sedation in
intubated patients. The recommended starting dose is 5 micrograms /
kg / minute, to be titrated to effect every 10 minutes. Note that 5
mcg/kg/min is a very small dose. Propofol is particularly well-suited
for this purpose if following the patient’s neurological exam is
important, as the effect wears off completely within 15 minutes of
holding the infusion.

* Propofol may be used to facilitate painful procedures. The
recommended dose is 1 mg/kg bolus, but experienced providers use
anywhere from .5 to 1.5 mg/kg as their starting doses. Repeat dosing,
usually at .5 mg/kg, must be provided quickly if needed, every 3
minutes at the longest, as the effect is so short-lived.

* Propofol is the most popular agent among anesthesiologists for RSI,
and may also be used to treat refractory delerium tremens and status
epilepticus. We can discuss these indications later as need and
interest warrant.

* Propofol is contraindicated in patients with egg or soy allergy, as
both of these ingredients are in the vehicle.

* Propofol causes pain at the injection site. This pain can be
reduced by adding lidocaine, .5 mg/kg, to the syringe. This is
routinely done in the OR and rarely done in the ED.

** Propofol routinely, reliably produces respiratory depression,
including apnea, as well hypotension. However, the clinical relevance
of these effects is greatly reduced by propofol’s ultrashort duration
of action.

-When end-tidal capnography is utilized (and it should be, if
available), there is no benefit to withholding supplemental oxygen.
In a healthy adult, adequate preoxygenation allows for periods of
apnea much greater than is routinely encountered with bolus propofol,
without desaturation. My experience is that the bolus is delivered,
the patient becomes unconscious, stops breathing, and starts
breathing within about a minute, without the saturation moving from

– Hypotension is to some degree prevented by pretreatment with
fluids; in any case the drop in blood pressure is brief and rarely of
clinical significance. In patients where hypotension is a particular
concern, it can be abolished with phenylephrine 100 microgram boluses.

** Though propofol has been demonstrated to be safer than
alternatives many of us are more comfortable with ( e.g. fentanyl /
midazolam), those who use it must anticipate its side effects and be
prepared to support blood pressure and ventilation as needed.

Written by phil

August 15th, 2008 at 2:21 pm

Acute Pain Services Available

1. The Faculty Practice Associates Anesthesiology Pain Management Division provides coverage at all times.  As of November 2007, the service established a 20 minute benchmark from the time that a page is received until a practitioner arrives at the patient’s bedside (pager 2738).

2. The FPA Palliative Care Consultative Team provides services for patients with pain who can benefit from the comprehensive interdisciplinary approach to medical management of co-morbidities.  Their team of MDs, NPs,  social workers, massage therapists and chaplain is available for consultation on weekdays (pager 9399).  At all other times, Palliative Care can be contacted for support by pager (917-632-6096).

Written by reuben

March 6th, 2008 at 1:44 am