Acil Serviste Prosedürel Sedasyon ve Analjezi
Özet
Acil serviste prosedürel sedasyon ve analjezi (PSA), tanısal veya terapötik girişimler esnasında hastanın kardiyopulmoner fonksiyonlarını koruyarak ağrı, anksiyete ve rahatsızlığı gidermeyi, aynı zamanda hasta konforu ile hareket kontrolünü sağlamayı hedefleyen standart bir yöntemdir. Sedasyon düzeyi; hastanın klinik yanıtı ile kardiyopulmoner durumuna göre minimal, orta dereceli, disosiyatif, derin sedasyon ve genel anestezi şeklinde sınıflandırılmaktadır. İşlem öncesinde hastaların mevcut komorbiditeleri, hava yolu açıklığı riski, madde kullanımı ve gebelik durumları değerlendirilmeli; işlem ve olası yan etkiler hakkında bilgilendirilerek aydınlatılmış onam alınmalıdır. Acil serviste yaygın olarak tercih edilen propofol, ketamin, etomidat, midazolam, fentanil ve nitröz oksit gibi sedatif ve analjezik ilaçlar; başlangıç süreleri, etki süreleri, hemodinamik stabiliteleri ile solunum depresyonu ve hipotansiyon gibi komplikasyon potansiyelleri göz önüne alınarak seçilmelidir. Ketofol gibi sinerjik ilaç kombinasyonları toplam doz ihtiyacını azaltarak yan etkileri dengeleyebilmektedir. Pediatrik yaş grubunda transmukozal yollar alternatif sağlarken, gebe hastalarda maternal hipotansiyon önlenmeli ve teratojenik ilaçlardan kesinlikle kaçınılmalıdır. PSA sırasında sürekli vital monitörizasyon ve resüsitasyon ekipmanının hazır bulundurulması zorunludur. İşlem sonrasında hastalar; koruyucu refleksleri, bilinç durumu ve solunum fonksiyonları tamamen düzelip taburculuk kriterlerini karşılayana kadar yakından izlenmelidir. Sonuç olarak, PSA uygulayan ekibin ileri yaşam desteği ve hava yolu yönetiminde deneyimli olması morbidite ve mortaliteyi azaltmada kritik rol oynar.
Referanslar
Godwin SA, Burton JH, Gerardo CJ, et al. Clinical policy: procedural sedation and analgesia in the emergency department. Ann Emerg Med, 2014;63: 247.
Green SM, Roback MG, Krauss BS, et al. Unscheduled procedural sedation: a multidisciplinary consensus practice guideline. Ann Emerg Med, 2019;73: e51.
Roback MG, Green SM, Andolfatto G, et al. Tracking and Reporting Outcomes Of Procedural Sedation (TROOPS): Standardized quality improvement and research tools from the International Committee for the Advancement of Procedural Sedation. Br J Anaesth, 2018;120:164.
American Society of Anesthesiologists. 2019. Continuum of depth of sedation: definition of general anesthesia and levels of sedation/analgesia. 29/01/2021 tarihinde, https://www.asahq.org/standards-and-guidelines/continuum-of-depth-of-sedation-definition-of-general-anesthesia-and-levels-of-sedationanalgesia adresinden ulaşılmıştır.
Green SM, Roback MG, Kennedy RM, et al. Clinical practice guideline for emergency department ketamine dissociative sedation 2011 update. Ann Emerg Med, 2011;57: 449.
Miner JR, Bachman A, Kosman L, et al. Assessment of the onset and persistence of amnesia during procedural sedation with propofol. Acad Emerg Med, 2005;12: 491.
Robbertze R, Posner KL, Domino KB. Closed claims review of anesthesia for procedures outside the operating room. Curr Opin Anaesthesiol, 2006;19: 436-442.
Schick A, Driver B, Moore JC, et al. Randomized clinical trial comparing procedural amnesia and respiratory depression between moderate and deep sedation with propofol in the emergency department. Acad Emerg Med, 2019;26: 364.
Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018: A Report by the American Society of Anesthesiologists Task Force on Moderate Procedural Sedation and Analgesia, the American Association of Oral and Maxillofacial Surgeons, American College of Radiology, American Dental Association, American Society of Dentist Anesthesiologists, and Society of Interventional Radiology. Anesthesiology, 2018;128:437-79.
Green SM, Pershad J. Should Capnographic Monitoring Be Standard Practice During Emergency Department Procedural Sedation and Analgesia? Pro and Con. Ann Emerg Med, 2010;55:265-7.
Dewdney C, MacDougall M, Blackburn R, et al. Capnography for procedural sedation in the ED: a systematic review. Emerg Med J, 2017;34:476-84.
Williams MR, McKeown A, Dexter F, et al. Efficacy Outcome Measures for Procedural Sedation Clinical Trials in Adults: An ACTTION Systematic Review. Anesth Analg, 2016;122:152-70.
Frenzel D, Greim C-A, Sommer C, et al. Is the bispectral index appropriate for monitoring the sedation level of mechanically ventilated surgical ICU patients? Intensive Care Med, 2002;28:178-83.
Baker SN, Weant KA. Procedural sedation and analgesia in the emergency department. J Pharm Pract, 2011;24: 189.
Miller KA, Andolfatto G, Miner JR, et al. Clinical practice guideline for emergency department procedural sedation with propofol: 2018 update. Ann Emerg Med, 2019;73:470.
Nathanson MH, Gajraj NM, Russell JA. Prevention of pain on injection of propofol: a comparison of lidocaine with alfentanil. Anesth Analg, 1996;82:469.
U.S. Food and Drug Administration: Product Information: KETALAR [Ketamine Hydrochloride] Injection. Chestnut Ridge, NY 10977. Reference ID: 4089409. 29/01/2021 tarihinde https://www.accessdata.fda.gov/drugsatfda_docs/label/2017/016812s043lbl.pdf adresinden ulaşılmıştır.
Riddell J, Tran A, Bengiamin R, et al. Ketamine as a first-line treatment for severely agitated emergency department patients. Am J Emerg Med, 2017;35:1000-4.
Newton A, Fitton L. Intravenous ketamine for adult procedural sedation in the emergency department: a prospective cohort study. Emerg Med J, 2008;25:498-501.
Tzimas P, Samara E, Petrou A, et al. The influence of anesthetic techniques on postoperative cognitive function in elderly patients undergoing hip fracture surgery: General vs spinal anesthesia. Injury, 2018;49:2221-6.
Green SM, Andolfatto G, Krauss BS. Ketofol for procedural sedation revisited: pro and con. Ann Emerg Med, 2015;65: 489.
Vinson DR, Bradbury DR. Etomidate for procedural sedation in the emergency medicine. Ann Emerg Med, 2002;39: 592-598.
Ruth WJ, Burton JH, Bock AJ. Intravenous etomidate for procedural sedation in emergency department patients. Acad Emerg Med, 2001;8:13-8.
Lameijer H, Sikkema YT, Pol A, et al. Propofol versus midazolam for procedural sedation in the emergency department: a study on efficacy and safety. Am J Emerg Med, 2017;35:692.
Becker DE. Pharmacodynamic considerations for moderate and deep sedation. Anesth Prog, 2012;59:28-42.
U.S. Food and Drug Administration 2013. Precedex (dexmedetomidine hydrochloride) Injection. https://www.accessdata.fda.gov/drugsatfda_docs/label/2013/021038s021lbl.pdf adresinden 29/01/2021 tarihinde ulaşılmıştır.
Chawla N, Boateng A, Deshpande R. Procedural sedation in the ICU and emergency department. Curr Opin Anaesthesiol, 2017;30:507.
Tobias JD, Leder M. Procedural sedation: A review of sedative agents, monitoring, and management of complications. Saudi J Anaesth, 2011;5:395-410.
Bahn EL, Holt KR. Procedural sedation and analgesia: a review and new concepts. Emerg Med Clin North Am, 2005;23:503.
Kost S, Roy A. Procedural sedation and analgesia in the pediatric emergency department: A Review of sedative pharmacology. Clinical Pediatric Emergency Medicine, 2010;1:233-43.
McMorrow SP, Abramo TJ. Dexmedetomidine sedation: uses in pediatric procedural sedation outside the operating room. Pediatr Emerg Care 2012;28:292-96.
Neuman G, Koren G. Safety of procedural sedation in pregnancy. J Obstet Gynaecol Can, 2013;35:168-73.
Newman DH, Azer MM, Pitetti RD, et al. When is a patient safe for discharge after procedural sedation? The timing of adverse effect events in 1367 pediatric procedural sedations. Ann Emerg Med 2003;42:627-35.
