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Procedural sedation by advanced care paramedics for emergency gastrointestinal endoscopy

  • Hana M. Wiemer (a1), Michael B. Butler (a2), Patrick C. Froese (a1), Allan Lapierre (a1), Chris Carriere (a1), Glen R. Etsell (a1), Dana Farina (a3), Jennifer Jones (a3), Jock Murray (a1) and Samuel G. Campbell (a1)...

Abstract

Objectives

At the QEII Health Sciences Centre Emergency Department (ED) in Halifax, Nova Scotia, advanced care paramedics (ACPs) perform procedural sedation and analgesia (PSA) for many indications, including orthopedic procedures. We have begun using ACPs as sedationists for emergent upper gastrointestinal (UGI) endoscopy. This study compares ACP-performed ED PSA for UGI endoscopy and orthopedic procedures in terms of adverse events, airway intervention, vasopressor requirement, and PSA medication use.

Methods

A data set was built from an ED PSA quality control database matching 61 UGI endoscopy PSAs to 183 orthopedic PSAs by propensity scores calculated using age, gender, and the American Society of Anesthesiologists (ASA) classification. Outcomes assessed were hypotension (systolic BP<100 mm Hg or a 15% decrease from baseline), hypoxia (SaO2<90%), apnea (>30 sec), vomiting, arrhythmias, death, airway intervention, vasopressor requirement, and PSA medication use.

Results

UGI endoscopy patients experienced hypotension more frequently than orthopedic patients (OR=4.11, CI: 2.05-8.22) and required airway repositioning less often (OR=0.24, CI: 0.10-0.59). They received ketamine more frequently (OR=15.7, CI: 4.75-67.7) and fentanyl less often (OR=0.30, CI: 0.15-0.63) than orthopedic patients. Four endoscopy patients received phenylephrine, and one required intubation. No patient died in either group.

Conclusions

In ACP-led sedation for UGI endoscopy and orthopedic procedures, adverse events were rare with the notable exception of hypotension, which was more frequent in the endoscopy group. Only endoscopy patients required vasopressor treatment and intubation. We provide preliminary evidence that ACPs can manage ED PSA for emergent UGI endoscopy, although priorities must shift from pain control to hemodynamic optimization.

Objectif

Les paramédicaux en soins avancés (PSA), au service des urgences (SU) du Queen Elizabeth II Health Sciences Centre, à Halifax, en Nouvelle-Écosse, pratiquent déjà la sédation-analgésie interventionnelle (SAI) dans de nombreuses indications, dont des interventions orthopédiques. Maintenant, ils ont commencé à travailler comme sédationistes en vue d’une endoscopie digestive haute (EDH) d’urgence. L’étude décrite ici visait à comparer la SAI pratiquée par des PSA au SU pour une endoscopie digestive haute ou pour des interventions orthopédiques quant aux événements indésirables, aux interventions sur les voies respiratoires, au besoin de vasopresseurs et aux médicaments utilisés pour la SAI.

Méthode

Un ensemble de données a été constitué à l’aide d’une base de données sur le contrôle de la qualité de la SAI, au SU, dans lequel 61 SAI pour une EDH ont été comparées à 183 SAI pour une intervention orthopédique, suivant la méthode des coefficients de propension calculés en fonction de l’âge, du sexe et de la classification de l’état des patients selon l’American Society of Anesthesiologists. Les résultats cliniques évalués étaient l’hypotension (PA systolique<100 mm Hg ou baisse de 15 % de la PA initiale), l’hypoxie (SaO2<90 %), l’apnée (>30 sec), les vomissements, l’arythmie, la mort, les interventions sur les voies respiratoires, le besoin de vasopresseurs et les médicaments utilisés pour la SAI.

Résultats

Les patients ayant subi une EDH ont souffert plus souvent d’hypotension que les patients en orthopédie (risque relatif approché [RRA]=4,11; CI:2,05-8,22) mais ont eu besoin moins souvent qu’eux de manœuvres de dégagement des voies respiratoires (RRA=0,24; IC:0,10-0,59). Les premiers ont reçu plus souvent de la kétamine (RRA=15,7; IC:4,75-67,7) mais moins souvent du fentanyl (RRA=0,30; IC : 0,15-0,63) que les seconds. Quatre patients dans le groupe de l’EDH ont reçu de la phényléphrine et un patient a dû être intubé. Aucun des patients dans l’un ou l’autre des groupes n’est mort.

Conclusions

Les événements indésirables liés à la sédation effectuée par des PSA en vue d’une endoscopie digestive haute ou d’une intervention orthopédique étaient rares, à l’exception notable de l’hypotension observée dans le groupe de l’EDH, qui a nécessité l’administration de vasopresseurs ou l’intubation. Les résultats préliminaires démontrent que les PSA peuvent pratiquer la SAI au SU en vue d’une EDH d’urgence, mais la priorité doit alors être accordée à l’équilibre hémodynamique plutôt qu’au soulagement de la douleur.

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Copyright

Corresponding author

Correspondence to: Dr. Hana M. Wiemer, Department of Emergency Medicine, Dalhousie University, 1796 Summer Street, Halifax Infirmary, Suite 355, Halifax, NS B3H 3A7, Canada; Email: hana.wiemer@dal.ca

References

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Procedural sedation by advanced care paramedics for emergency gastrointestinal endoscopy

  • Hana M. Wiemer (a1), Michael B. Butler (a2), Patrick C. Froese (a1), Allan Lapierre (a1), Chris Carriere (a1), Glen R. Etsell (a1), Dana Farina (a3), Jennifer Jones (a3), Jock Murray (a1) and Samuel G. Campbell (a1)...

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