Same here. Problem is when you combine ketamine with propofol. Here ketamine is considered "moderate " sedation. and just the use of propofol makes it deep, whether or not the dose used would invoke deep sedation.
FOr example when I set fractures using ketofol, I have a problem with the sedation protocol. Am I rendering deep sedation or moderate? Can I set the fracture, as long as the patient is monitored by a properly credentialed nurse or do I have to gt another physician who is credentialed to render deep sedation ( or conversely set the fracture) to assist? We "single staff" so finding another doc is a logistic problem. Also if I am supervising a resident and teaching them how to set the fracture, is that adequate to say we have 2 docs? or is it that because I am supervising the resident, I am technically performing the reduction and so can't be the sedationist??
Aother issue has to be the depth of sedation is not defined by the drug alone..Example--I use propofol in very low doses to break migraine headaches ( start with 0.5 mg/kg and repeat q 5 minutes till headache breaks. average is 1.7 mg/kg. according the studies I have read. SO is this deep sedation??even though the patient can answer questions??
Martin Herman, M.D.
Pediatric Emergency Medicine
Sacred Heart Children's Hospital
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> Date: Wed, 19 Nov 2014 11:53:24 -0500
> From: [log in to unmask]
> Subject: Re: Deep (Procedural) Sedation in the Pediatric ED, one vs two physician presence
> To: [log in to unmask]
> In our institution, for deep sedation, the person doing the procedure cannot be the person providing deep sedation. Meticulous attention needs to be paid to airway/respiratory management at all times and this is best done by a physician who is expert in this so that subtle changes can be identified and managed before the patient deteriorates. This is particularly true in that the threshold between deep sedation and gen anesthesia can be crossed inadvertently.
> We have a nurse also who primarily documents and does some monitoring and is there to help out in the event there is a significant event related to the sedation.
> Elise W. van der Jagt, MD, MPH, FAAP, SFHM
> Professor of Pediatrics and Critical Care
> Pediatric Sedation Officer
> Chief, Pediatric Hospital Medicine
> University of Rochester Medical Center
> 601 Elmwood Ave., Box 667
> Rochester, NY 14642
> Tele: 585-275-8138/585-276-4113
> Fax: 585-276-1128
> Golisano Children's Hospital
> -----Original Message-----
> From: Pediatric Emergency Medicine Discussion List [mailto:[log in to unmask]] On Behalf Of Bernard Dannenberg
> Sent: Tuesday, November 18, 2014 7:09 PM
> To: [log in to unmask]
> Subject: Deep (Procedural) Sedation in the Pediatric ED, one vs two physician presence
> A straw poll to all members
> We have written a new policy for deep sedation in our Pediatric Emergency Department.
> The following sentence has raised significant resistance by our anesthesia department:
> > The physician administering deep sedation may also perform the procedure if a qualified ED registered nurse (RN) is present to continuously monitor the patient.
> Their argument is that not one academic institution they contacted would permit this.
> Naturally I am suspicious. CMS guidelines appear to allow that one provider can administer the sedation if a qualified nurse is present to monitor the patient.
> The California Department of Public Health has issued the following clarification in July 2013 https://urldefense.proofpoint.com/v2/url?u=http-3A__www.cdph.ca.gov_certlic_facilities_Documents_LNC-2DAFL-2D13-2D17.pdf&d=AAIFaQ&c=4sF48jRmVAe_CH-k9mXYXEGfSnM3bY53YSKuLUQRxhA&r=U8mD137vcSlcKJYPnZ2lgpiN1pKg9W8j4g606YTHprDbGeReCmYTGhJOFWn9rqv-&m=nAJc9v539AzNX6PTrjik2nVyHLg8AdmP-MQiy0rthzc&s=eos1ZIVa3Prq-_oQ4gAvwTw-eB-NwpF62CMB2lD60wE&e=
> Can you respond to me directly what your institution is allowing you to do.
> A. 2 physicians need to be present: One performs the sedation, the other performs the procedure
> B. 1 physician can administer the sedation and perform the procedure if a qualified RN is monitoring the patient
> I will tabulate the answers and distribute them back to the group.
> Thank you for your assistance
> Bernard Dannenberg, MD, FAAP, FACEP
> Clinical Associate Professor
> Davies Family Director, Pediatric Emergency Medicine Division of Emergency Medicine Department of Surgery Stanford University School of Medicine Lucile Packard Children’s Hospital
> 300 Pasteur Drive
> Alway Building M-121
> Stanford, CA 94305
> (650) 721 2450 FAX: (650) 723-0121
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