​Although procedural sedation is a bread and butter component of emergency medicine, it is an area where we can introduce significant harm to our patients. Preparation and being facile with all components of the process if key to doing this safely and efficiently.
 
Level of Sedation

• Minimal Sedationis characterized by anxiolysis but with normal, although sometimes slowed, response to verbal stimuli. The person will be awake but relaxed.  Good for procedures that require patient cooperation and those in which pain is controlled by local or regional anesthesia. (Lac Repair, Abscess I+D)
• Moderate Sedation is characterized by a depressed level of consciousness and a slower but purposeful motor response to simple verbal or tactile stimuli. Patients at this level generally have their eyes closed and respond slowly to verbal commands. Dissociative Sedation is one type.   Moderate sedation can be used for procedures in which detailed patient cooperation is not necessary, and muscular relaxation with diminished pain reaction is desired. (dislocation reductions, chest tube insertions and cardioversions)
• Deep Sedation is characterized by a profoundly depressed level of consciousness, with a purposeful motor response elicited only after repeated or painful stimuli, so we might use it for procedures that are painful and require muscular relaxation with minimal patient reaction like burn wound care or open fracture reductions.

Prepare for Complications

• Hypotension and apnea are not uncommon when using the sedative agents discussed below
• Be prepared to emergently manage an airway or resuscitate a patient with fluids/pressors if needed
• Consider having airway cart, BVM, end tidal CO2, defibrillator and any other equipment you would need to take care of a crashing patient

 
Know Your Patient

• Detailed History: Experience with anesthesia, NPO time, current meds and allergies can help you choose right agent
• Focused Exam: ASA classification can help predict complications (Class III-V have much higher complication rate), Mallampati score can help you prepare for emergent intubation.

 
Choose Your Agent

• There are many agents to choose from, each with advantages and disadvantages
• Try to master as many as you can and become facile with all of your options

​During and Post Procedure

• Need two qualified professionals; one to administer drugs and/or do procedure, and another to watch vital signs for signs of complications
• Watch until patient can ambulate, eat and has mentally returned to baseline

Background:

• Lupus is more common than you think – 1/2000 people have it
• We will rarely diagnose lupus in ED – diagnostic criteria is intense and involves a blood test that takes days to come back.
• Must have 4/11 of the following
  • Malar rash, discoid rash, photosensitivity, oral ulcers, serositis, arthritis, renal involvement, neurological findings, hematological abnormality, AND at least one of the 4/11 must be a positive autoantibody.
• Lupus can affect every organ system in your body

 
Understanding Lupus – The Big Picture:

• People are constantly between Lupus flairs and remission
• Lupus medications have a ton of side effects
  • Steroids and Immunomodulators
• People are very pro-coagulableand immunocompromised
• Benign presentations may be more serious in patients with Lupus, even if they are taking their medications

 
Organ specific problems: Cardiac

• Patients with Lupus are 10x more likely to have ACS. Can present at younger ages too.
• Libman Sachs endocarditis gives you an increased risk of acute valve rupture
• Increased risk cardiac effusion, pericarditis, CHF, RHF

 
Organ specific problems: Respiratory

• Diffuse alveolar hemorrhage – very rare. 
• Increased risk pleural effusions, PE, PNA, pulmonary HTN, interstitial lung disease

 
Organ specific problems: Neuro

• Stroke, dural venous sinus thrombosis
• Seizure that may not respond to benzos – intubate and paralyze
• PRES - posterior reversible encephalopathy syndrome from immunomodulators
• Peripheral neuropathy with strange distributions – not a stocking glove presentation

 
Organ specific problems: Vasculitis
– resuscitate and give 1g methylprednisone, and suggest to the admitted team they should consider IVIG and/or plasmapheresis!

• Can cause any vessels to be inflamed/bleed
• Mesenteric = hematemesis, hematochezia, bowel necrosis, perforation 
• Lung = hemoptysis 
• Catastrophic antiphospholipid syndrome (CAPS) – presents with multiple arterial occlusions, cold clammy body parts. Do same as above plus add heparin.

 
Organ specific problems: Many others random presentations
​– if someone has Lupus and a weird problem it can likely be attributed to Lupus, but rule out other causes first.