Sedation Training Using Simulation

Aims:

  • By the end of this teaching session the learner will be able to perform safe sedation including management of complications in a simulated environment.

Objectives:

To demonstrate safe patient preparation and adequate clinical assessment including:

  • Demonstration that risk / benefits considered for at risk patients: elderly, obese or significant medical history
  • Obtain fasting status
  • Perform airway assessment
  • Obtain informed consent for sedation and procedure in conscious patient
  • Where the procedure is an emergency considers the risk / benefit of sedating a non-fasted patient

To demonstrate safe preparation of the environment / choice of equipment

  • Start continuous monitoring of ECG, PR, Bp, RR and O2 sats
  • Ensures ALS medication, airway rescue equipment and reversal agents available

To demonstrate safe practice in drug administration

  • Pre-oxygenate patient for 3mins with highest FiO2 possible
  • If opiates given, this should be before any sedating drugs with sufficient time for full effect allowed
  • Propofol should be titrated slowly to a maximum of 1mg/kg….anticipate a reduced dose in the elderly
  • Give incremental top ups of propofol of 0.25mg/kg as required.
  • Apply the same principles to the administration of midazolam.
  • To recognise when adequate conditions for the procedure are not met, or complications have occurred and to stop the sedation

To recognise and manage complications of procedural sedation including

  • Over sedation with respiratory depression and hypoxia
  • Hypotension
  • Cardiac arrhythmia
  • Cardiac arrest
  • Vomiting and aspiration

Suggested Scenarios to Practice Above:

  1. Young fit healthy man with shoulder dislocation. (Use to demonstrate the ideal case, should be able to illustrate all the above show good practice. A chance to practice using propofol)
  2. Elderly lady with hypertension and diabetes, no airway issues with shoulder dislocation, respiratory depression post procedure
  3. Elderly gentleman with IHD, diabetes, hypertension, AF. Dislocated hip replacement. Ortho SHO gave a bolus of 5mg of midazolam and patient went into VT. Ed reg called in to rescue situation. Stops breathing shortly after ED reg arrives. Ortho SHO not prepared adequately, reversal agents not immediately available etc. Patient maintains pulse but hypotensive (80/40)
  4. 66yr old women. New onset AF. Amiodarone infusion running. Becomes hypotensive and requires DC cardioversion. Not starved. Vomits and aspirates on administration of sedation.
  5. Elderly women. VT with hypotension but conscious. Complaining of chest pain and SOB. Needs urgent DC cardioversion. Significant COPD on home nebulisers. No recent hospital admissions. VF following first shock.

 

Kit Required for All of these Scenarios:

SIMMAN will be set up wearing a gown and have a cannula in situ. This is the same for all the scenarios.

General Kit List

  • Bags of N.Saline plus drip attachments
  • A trolley set up like the one in A+E resus.
  • Grab board.
  • Boxes of fake propofol, naloxone, flumazenil and midazolone
  • Cardiac arrest drugs (minijets of adrenaline, atropine, amiodarone.
  • Sedation charts
  • Observation charts
  • Drug labels
  • Syringes
  • Consent forms
  • Defibrillator with pads

 

Scenario 1 – Instructor directions

The main objective of this scenario is to show competency in an uncomplicated propofol-induced procedural sedation of a patient with no pre-existing features to suggest a higher-risk procedure.

Scenario
A 24 year old man with no previous medical history presents to the ED with a first episode of anterior dislocation of the R shoulder.
Attempted reduction using entonox and morphine have been unsuccessful.
You decide he would be a good candidate for reduction under sedation.

Objectives
1. Candidate to demonstrate appropriate pre-procedural sedation preparation (the ED sedation chart should be used as a proforma and prompt)
a) Personnel
b) Pre-morbid health assessment
c) ASA grading
d) Airway assessment
e) Fasting state
f) Consent (use advice sheet)
g) Monitoring
h) Equipment
2. Candidate to demonstrate an understanding of the safe dosage and delivery of propofol including the use of labelled syringes
3. Procedure to be performed simply and easily by 1 of the instructors
4. Candidate to recognise the importance of close monitoring during the post-procedure period especially where a painful stimulus has been removed.
5. Candidate to recognise the requirements to stop close monitoring and acceptable discharge criteria and advice

 

Simman SetUp 

Pulse:        75 sinus rhythm
Bp:             130/70
RR:             14
O2 sats      98% moving to 100% with oxygen
Normal breath sounds and heart sounds
Normal pulses

There is no change with these observations during this scenario.

Scenario 1 – Candidate directions

  • A 24 year old man with no previous medical history presents to the ED with a first episode of anterior dislocation of the R shoulder.
  • Attempted reduction using entonox and morphine have been unsuccessful.
  • You decide he would be a good candidate for reduction under sedation.

Task:

  • Sedate this patient for reduction of his dislocation

 

Scenario 1

Preparation

Adequate

Inadequate / Not attempted

Patient assessment

 

a)   Pre-morbid health

b)  Medications

c)   Allergies

d)  Weight

e)   Previous sedation/anaesthetic

f)    Fasting state

g)  ASA grade

h)  Airway assessment

 

 

 

Environment

 

a)   Equipment

b)   Monitoring

c)   Personnel

d)   Pre-oxygenation

 

 

 

Consent

 

 

 

Procedure

 

 

 

a)   Initial dose of propofol

b)   Supplemental dose

 

 

 

Post-procedure

 

 

 

a)   Show awareness of increased sedation risk immediately after painful stimulus removed

b)   Aware of when patient is safe to leave resus

c)   Aware of discharge criteria

d)   Provides patient and relative with sedation advice sheet

 

 

 

 

Scenario 2 – Instructor directions

The main objective of this OSCE is to show competency in propofol-induced procedural sedation of an ASA grade III patient who develops post-procedural respiratory depression.

Scenario
A 72 year old woman with a PMH of T2DM, hypertension and exertional angina with an exercise tolerance of 100 yards presents to the ED with a first episode of anterior dislocation of the R shoulder.
Attempted reduction using entonox and morphine have been unsuccessful.
You decide she would be a good candidate for reduction under sedation.

Clinical course
Following successful joint reduction the patient develops a period of apnoea

Objectives
1. Candidate to demonstrate appropriate pre-procedural sedation preparation (the ED sedation chart should be used as a proforma and prompt)
a) Personnel
b) Pre-morbid health assessment
c) ASA grading
d) Airway assessment
e) Fasting state
f) Consent (use advice sheet)
g) Monitoring
h) Equipment
2. Candidate to demonstrate an understanding of the safe dosage and delivery of propofol including the use of labelled syringes, and to recognise the need for a reduced dose in certain groups of patients
3. Procedure to be performed simply and easily by 1 of the instructors
4. Candidate to recognise the importance of close monitoring during the post-procedure period especially where a painful stimulus has been removed and to recognise that respiratory depression and even transient apnoea can occur in this phase
5. Candidate to manage propofol-induced respiratory depression

 

Simman Set Up

Pulse: 84 sinus rhythm
Bp: 180/100
RR: 14
Sats 96% rising to 100% with oxygen
Normal breath sounds and heart sounds
Normal pulses.
After shoulder relocated:
Pulse 96
Bp: 130/80
RR: 4
Sats: Sats fall to 92% over 5mins unless bag valve mask ventilation is commenced. Sats will then be maintained around 96% until patient wakes up.

Scenario 2 – Candidate directions

  • A 72 year old woman with a PMH of T2DM, hypertension and exertional angina with an exercise tolerance of 100 yards presents to the ED with a first episode of anterior dislocation of the R shoulder.
  • Attempted reduction using entonox and morphine have been unsuccessful.
  • You decide she would be a good candidate for reduction under sedation.

Task:

  • Sedate this patient for reduction of her dislocation

 

Scenario 2

Preparation

Adequate

Inadequate / Not attempted

Patient assessment

 

a)   Pre-morbid health

b)  Medications

c)   Allergies

d)  Weight

e)   Previous sedation/anaesthetic

f)    Fasting state

g)  ASA grade

h)  Airway assessment

 

 

 

Environment

 

a)   Equipment

b)   Monitoring

c)   Personnel

d)   Pre-oxygenation

 

 

 

Consent

 

 

 

Procedure

 

 

 

a)   Reduced initial dose of propofol

b)   Reduced supplemental dose

 

 

 

Post-procedure

 

 

 

a)   Show awareness of increased sedation risk immediately after painful stimulus removed

b)   Recognise respiratory depression

c)   Manage with airway manoeuvres, BVM +/- naloxone

d)   Recognise transient nature of effect and avoid intubation / RSI

 

 

 

 

Scenario 3 – Instructor directions

The main objective of this OSCE is to show competency in the management of the major complications of procedural sedation in a man with ASA grade IV. An additional objective is to demonstrate the ability to recognise when sedation is and is not appropriate and to understand that GA may be appropriate.  

Scenario
An 80 year old man presents to the ED with a first episode of dislocation of his prosthetic THR.
He has a PMH of IHD, T2DM, hypertension, congestive heart failure and permanent AF currently treated with a battery of drugs including a β-blocker, nitrates and an ACEI. His exercise tolerance is 20 yards at best.
He is in severe pain despite IV morphine. You decide he would be a good candidate for reduction under sedation. Unfortunately despite excellent sedation using propofol the rest of the team were unable to reduce the dislocation. You have referred the patient to the Orthopedic team for reduction under GA.
30 minutes later you are called urgently back to resus and find the patient comatose after having been given a 5 mg midazolam bolus by the orthopaedic team ….

Clinical course

  1. On arrival:
  • RR 4
  • O2 sat 90% on 15l/min NRB
  • AE minimal
  • PR 130
  • BP 70/40
  • Broad complex tachycardia on ECG monitor (VT)

2. The patient will rapidly deteriorate to a respiratory arrest

3. There is no flumazenil immediately available

4. Post-cardioversion respiratory effort will resume

 Objectives

  1.  Candidate to demonstrate ability to rapidly assess patient and recognise respiratory depression and VT
  2. Candidate to manage respiratory depression  
  3. Candidate to ensure reversal agents are made available
  4. Candidate to DC cardiovert patient safely
  5. Candidate to recognise post-cardioversion hypotension may be related to myocardial stunning, sedating agents and /or myocardial ischaemia.
  6. Candidate to recognise management of sedation-induced hypotension largely depends on the short t1/2  but may require IVI crystalloids and occasionally inotropes (1:100000 adrenaline or metaraminole)
  7. Candidate to  demonstrate post-arrhythmia management using ABC principles
  8. Candidate to recognise the importance of a clinical governance framework for procedural sedation and the risks associated with uncontrolled use of sedating agents
  9. Candidate to recognise the risks in repeated attempts at procedural sedation and to recognise that the need to elect for a GA in certain situations does not reflect a failure of the team

Simman SetUp 

Pulse:        130 Ventricular tachycardia
Bp:             70/40
RR:             4
Sats:          90% (High flow O2 is already in place)
Normal breath sounds and heart sounds
Normal femoral and carotid pulse
Weak radial pulse

Shortly after candidate enters room SIMMAN stops breathing

 

Post DC Cardioversion 

Pulse:        70 sinus rhythm
Bp:             70/40
RR:             8
Sats:          Gradually rise to 94% (over 5mins)

Scenario 3 – Candidate directions

  • An 80 year old man presents to the ED with a first episode of dislocation of his prosthetic THR.
  • He has a PMH of IHD, T2DM, hypertension, congestive heart failure and permanent AF currently treated with a battery of drugs including a β-blocker, nitrates and an ACEI. His exercise tolerance is 20 yards at best. 
  • He is in severe pain despite IV morphine. You decide he would be a good candidate for reduction under sedation. Unfortunately despite excellent sedation using propofol the rest of the team were unable to reduce the dislocation. You have referred the patient to the Orthopedic team for reduction under GA
  • 30 minutes later you are called urgently back to resus….

Task:

  •  Manage this patient

 

Scenario 3

Interventions

Adequate

Inadequate / Not attempted

ABC + high flow oxygen via NRB

 

 

 

Airway manoeuvres / OP airway and BVM ventilation

 

 

 

Recognises VT

 

 

 

Immediate DC cardioversion

 

 

 

Post-cardioversion reassessment of ABC

 

 

 

Post-cardioversion hypotension treated with bolus of crystalloid

 

 

 

Early recognition of need for flumazenil +/- naloxone

 

 

 

ECG, CXR and ABG obtained

 

 

 

ITU referral – for review and to arrange reduction of dislocation

 

 

 

Incident reported and team debriefed

 

 

 

 

Scenario 4 – Instructor directions

The main objective of this scenario is to show competency in a propofol-induced procedural sedation of an unstable patient who requires immediate management. The additional objective is to demonstrate the ability to manage the rare complication of sedation-induced emesis with aspiration.

Scenario
A 60 year old woman with no previous medical history presents to the ED with a first episode of atrial fibrillation with a rapid ventricular response. This is well-tolerated. You elect to aim for cardioversion and treat her with an IV flecainide infusion covered with LMW heparin.
During the infusion she becomes hypotensive (70/55) and develops chest tightness. Her ECG is unchanged.
You decide she requires emergency synchronised DC cardioversion reduction under sedation.

Clinical course
Following successful DC cardioversion with a 100J DC synch shock the patient vomits profusely. After management of the primary problem the patient is referred to ITU. A clinical incident form is completed suggesting the patient should either have been fasted prior to the procedure or cardioverted under GA

Objectives

1. Candidate to demonstrate appropriate pre-procedural sedation preparation (the ED sedation chart should be used as a proforma and prompt)
a) Personnel
b) Pre-morbid health assessment
c) ASA grading (E = Emergency status. This is added to the ASA designation if the patient is undergoing an emergency procedure.)
d) Airway assessment
e) Fasting state
f) Consent (use advice sheet)
g) Monitoring
h) Equipment
2. Candidate to demonstrate an understanding of the safe dosage and delivery of propofol including the use of labelled syringes
3. Candidate to recognise the need for a reduced dose of any sedating drug in a haemodynamically unstable patient and to allow additional time for the maximum effect of each bolus
4. Cardioversion to be performed simply and easily by 1 of the instructors
5. Candidate to demonstrate management of sedation-associated emesis with possible aspiration and to recognise that recovery of ventilation post-sedation does not guarantee gas exchange
6. Candidate to recognise the rarity of sedation associated emesis with aspiration – only one case reported ever
7. Candidate to understand:
a) The evidence for fasting in emergency patients is limited. In emergency patients gastric emptying may be impaired and even if time allows, following the ASA elective guidelines does not guarantee complete gastric emptying.
b) Although fasting before elective surgery is traditional there is no good evidence to associate fasting time, gastric volume or gastric acidity with risk of aspiration and no evidence that fasting has an impact on the incidence of complications or outcome of procedural sedation.
c) An ASA consensus document (2002) and an ACEP advisory document (2007) states that in urgent, emergent, or other situations in which gastric emptying is impaired, recent food intake is not a contra-indication but should be considered in choosing the timing and target level of sedation. In emergency procedures in all risk groups, all levels of sedation are acceptable provided the risk of not proceeding outweighs the benefits.
d) With less urgency ACEP suggests that the potential aspiration risk is considered but that a 3 hour risk period, for any intake, is used rather than the ASA elective recommendations.

 

Simman SetUp
Pulse: 180 atrial fibrillation
Bp: 70/55
RR: 22
Sats: 92%

Normal breath sounds and heart sounds
Normal carotid and femoral pulses.
Weak radial pulses

Following cardioversion while patient still drowsy…..profuse vomiting:

Pulse: 78 sinus rhythm
Bp: 90/50
RR: 10
Sats: 90%

Scenario 4 – Candidate directions

  • A 60 year old woman with no previous medical history presents to the ED with a first episode of atrial fibrillation with a rapid ventricular response. The episode started immediately after a large meal.
  • The arrhythmia is initially well-tolerated. You elect to aim for cardioversion and treat her with an IV flecainide infusion (2mg/kg) over 1 hour covered with LMW heparin.
  • During the infusion she becomes hypotensive (70/55) and develops chest tightness. Her ECG is unchanged.
  • You decide she requires emergency synchronised DC cardioversion reduction under sedation.

Task:

  • Sedate and cardiovert this patient

Scenario 4

Preparation

Adequate

Inadequate / Not attempted

Patient assessment

 

a)   Pre-morbid health

b)  Medications

c)   Allergies

d)  Weight

e)   Previous sedation/anaesthetic

f)    Fasting state

g)  ASA grade – recognise emergency grading

h)  Airway assessment

 

 

 

Environment

 

a)   Equipment

b)   Monitoring

c)   Personnel

d)   Pre-oxygenation

 

 

 

Consent

 

 

 

Procedure

 

 

 

a)   Reduced initial dose of propofol

b)   Delayed and reduced supplemental dose

 

 

 

Post-procedure

 

 

 

a)   Manage emesis and possible aspiration

b)   Turn on side and suction

c)   High flow oxygen

d)   Consider airway manoeuvre / OPA

e)   Consider RSI

f)    Assess ventilation and oxygenation

 

 

 

Scenario 5 – Instructor directions

The main objective of this OSCE is to show competency in preparation for procedural sedation. An additional objective is to demonstrate the ability to recognise when sedation is not appropriate and to understand that GA may be required.

Scenario
A 43 year old man presents to the ED with an open #/dislocation of his L ankle. He is alcohol dependent and is currently alcohol intoxicated.
He has no other PMH and is on no medication.
You give him some IV morphine and antibiotics and decide to sedate him with midazolam for manipulation into a POP.

Clinical course
The patient will become increasingly agitated despite treatment. Sedation will have to be abandoned and urgent GA arranged

Objectives

1. Candidate to demonstrate appropriate pre-procedural sedation preparation (the ED sedation chart should be used as a proforma and prompt)
a) Personnel
b) Pre-morbid health assessment
c) ASA grading
d) Airway assessment
e) Fasting state
f) Consent (use advice sheet)
g) Monitoring
h) Equipment
2. Candidate to demonstrate an understanding of the safe dosage and delivery of midazolam including the use of labelled syringes
3. Candidate to recognise that midazolam carries a risk of paradoxical hyperagitation.
4. Candidate to recognise that the half-life of both midazolam and propofol is reduced in alcohol-dependence which can make sedation using normal doses difficult
5. Candidate to recognise that in some situations it is safest to stop attempted sedation and seek an alternative

 

Simman SetUp
Use patient actor (me or Stacy) attached to SIMMANs monitoring.
May be best to do this one last:
Pulse: 95 sinus rhythm
Bp: 130/80
RR: 16
Sats: 98%

As midazolm is given, patient gets steadily more agitated.
Over 5 mins:
Pulse: 110
Bp: 160/90
RR: 22
Sats: 98%

 

Scenario 5 – Candidate directions

  • A 43 year old man presents to the ED with an open #/dislocation of his L ankle. He is alcohol dependent and is currently alcohol intoxicated.
  • He has no other PMH and is on no medication. 
  • You give him some IV morphine and antibiotics and decide to sedate him with midazolam for manipulation into a POP.

Task:

  • Manage this patient

 

Scenario 5

Preparation

Adequate

Inadequate / Not attempted

Patient assessment

 

a)   Pre-morbid health

b)  Medications

c)   Allergies

d)  Weight

e)   Previous sedation/anaesthetic

f)    Fasting state

g)  ASA grade – recognise emergency grading

h)  Airway assessment

 

 

 

Environment

 

a)   Equipment

b)   Monitoring

c)   Personnel

d)   Pre-oxygenation

 

 

 

Consent

 

 

 

Procedure

 

 

 

a)   Initial dose of propofol

b)   Supplemental dose

c)   Abandon procedure as too agitated

d)   Arrange anaesthetic review for GA

 

 

 

 

Scenario 6 – Instructor directions

The main objective of this scenario is to show competency in propofol-induced procedural sedation of a patient where there is no alternative to immediate treatment despite the patients poor pre-morbid health, lack of fasting and haemodynamic instability. The additional objective is to recognise the need for additional external support at certain times of the day.

Scenario
An 82 year old man presents to the ED at 0300 hrs with angina, presyncope and palpitations. He is conscious but his BP is only 60/-. He has a background history of advanced COPD with an exercise tolerance of a few yards at best. He continues to smoke. He has no home O2. His ECG is consistent with VT. You decide he needs urgent DC cardioversion under sedation.

Clinical course
Following successful DC cardioversion the patient remains hypotensive and becomes apnoeic.

Objectives
1. Candidate to demonstrate appropriate pre-procedural sedation preparation (the ED sedation chart should be used as a proforma and prompt)
a) Personnel
(i) Recognise that with only 1 ED middle grade for a complex procedure anaesthetic support would be useful
(ii) Recognise this patient will be very difficult to manage both in terms of ventilation/oxygenation and his arrhythmia and anaesthetic support will be useful
(iii) Recognise immediate DC cardioversion is required
b) Pre-morbid health assessment
(i) Recognise the possibility of chronic T2RF with the risk of oxygen-induced apnoea
c) ASA grading - IV-E
d) Airway assessment
e) Fasting state
f) Consent (use advice sheet)
g) Monitoring
h) Equipment
2. Candidate to demonstrate an understanding of the safe dosage and delivery of propofol including the use of labelled syringes
3. Candidate to recognise the need for a reduced dose of any sedating drug in a haemodynamically unstable patient and to allow additional time for the maximum effect of each bolus
4. Procedure to be performed simply and easily by 1 of the instructors
5. Candidate to recognise that oxygen-induced apnoea is a possibility
6. Candidate to recognise post-cardioversion hypotension may be related to myocardial stunning, sedating agents and /or myocardial ischaemia.
7. Candidate to recognise management of sedation-induced hypotension largely depends on the short t1/2 but may require IVI crystalloids and occasionally inotropes (1:100000 adrenaline or metaraminole

Simman SetUp
Pulse: 200 ventricular tachycardia
Bp: 60/30
RR: 28
Sats: 88%

Normal heart sounds.
Wheezes both lungs
Weak pulses

The changes in obs will depend on what the candidate does. Will need to wing it.

 

Scenario 6 – Candidate directions

  • An 82 year old man presents to the ED at 0300 hrs with angina, presyncope and palpitations.
  • He is conscious but his BP is only 60/-.
  • He has a background history of advanced COPD with an exercise tolerance of a few yards at best. He continues to smoke. He has no home O2.
  • His ECG is consistent with VT.

Task:

  • Manage this patient

 

Scenario 6

Preparation

Adequate

Inadequate / Not attempted

Patient assessment

 

a)   Pre-morbid health - ?  chronic T2RF

b)  Medications

c)   Allergies

d)  Weight

e)   Previous sedation/anaesthetic

f)    Fasting state

g)  ASA grade

h)  Airway assessment

 

 

 

Environment

 

a)   Equipment

b)   Monitoring

c)   Personnel – Call anaesthesia/ITU

d)   Pre-oxygenation

 

 

 

Consent

 

 

 

Procedure

 

 

 

a)   Reduced initial dose of propofol

b)   Delayed and reduced supplemental dose if required

 

 

 

Post-procedure

 

 

a)   Recognise respiratory depression

b)   Manage with airway manoeuvres, BVM +/- naloxone

c)   Consider if RSI may be required even if only temporarily to apply pressure support and allow ventilation with reduced FiO2

d)   Manage hypotension with fluids  and consider inotropes

e)   Recognise patient requires transfer for ongoing critical care management

 

 

 

 

This page was last updated November 12th 2014 (10 years ago)