Hi everyone,

There was a recent situation where a patient in the ER resuscitation room required an urgent closed reduction under procedural sedation. Due to a variety of circumstances including unstable hemodynamics, the ER physician felt this patient’s status was beyond the scope of their abilities to sedate the patient in the ER.

On this night , the junior orthopedic resident was tasked with coordinating with the evening IHA a plan to safely reduce the patient’s fracture.

As a result of this situation, based on my input, a communication was sent out to HSC ER doctors.

It is important to remember that the vast majority of procedural sedations are carried out in the ED without our involvement. This provides timely care to patients without using precious OR resources. The majority of these procedures will continue this way and I suspect we will be consulted a few times a year.

To make the process a bit easier, I have asked that ERPs to contact us directly, and don’t delegate to a trainee. This way we can get a better picture of the patient’s status and the rationale for our involvement so that we can determine the appropriate location of the reduction. There are times where it may be appropriate for us to go to resuscitation, but if the patient is truly unstable, an OR setting would be the appropriate location and the case would be triaged like any other surgical procedure. I corrected the false impression that the PACU is more appropriate than the resuscitation room for unstable patients.

I will leave the decision of where these procedures take place to the discretion of the IHA, as it truly is multifactorial. How many rooms are running, how sick the patients are, seniority of residents +/- ACA availability, time of day, PACU status… It’s impossible to protocolize these rare occurrences. Be sure to send me an email if you are consulted for a procedural sedation from the ED so that I can track the occurrences.

In the situation described, the evening IHA assessed the patient as stable and appropriate for out of OR sedation. Once it was appropriate for them to leave the OR complex, they went to resusc to sedate the patient while the ortho residents attempted the closed reduction. Unfortunately, the post procedure x-ray demonstrated the reduction failed requiring the IHA to return for a second time. I believe surgical attending supervision is warranted for closed reductions in hemodynamically unstable patients

From: Chau Pham <cpham1@hsc.mb.camailto:cpham1@hsc.mb.ca>

Subject: Process for Anesthesia Support with High-Risk Procedural Sedation

Hello Team,

In the uncommon situation where a patient meets ASA III/IV criteria and you are asked to provide procedural sedation in Resuscitation for a procedure that is not immediately life- or limb-saving—such as an orthopedic reduction—you may consult Anesthesia on call if you determine that the patient’s risk exceeds what can safely be managed in the ED.

To support clear, timely communication and an effective workflow, please follow this process:

1. Call the Anesthesia on-call phone directly at 204-583-2509. This phone is staffed 24/7. 2. Speak directly with the staff anesthesiologist on call. Please avoid routing the request through intermediary trainees, such as junior Orthopedic residents. 3. Discuss the safest and most appropriate location for sedation based on the patient’s condition and current capacity. This may be Resuscitation, PACU or the OR. 4. The anesthesiologist will be responsible for intra-procedural monitoring. Phase 1 recovery will be provided by the nursing team in the location where the procedure is performed. If sedation occurs in PACU or the OR, the patient’s ED bed must be held so that they can return for phase 2 recovery while awaiting their final disposition.

A few important considerations:

* PACU is more comparable to a step-down unit than a critical care environment, generally with a nursing ratio of one nurse to two patients. If a patient is too unstable for Resuscitation, they are unlikely to be appropriate for PACU and may require the OR or ICU. After hours, PACU has fewer nursing resources and no immediately available respiratory therapy or pharmacy support. There may also be fewer physicians present, with much of the support resting on a single anesthesiologist.

* During regular daytime hours, Anesthesia generally has more in-house staff available to assist. After hours, the anesthetist on-call may be working alone or scrubbed into an E1 case and unable to leave the OR complex. A senior resident may not always be available to provide relief. A clinical assistant is available until 23:00, and the backup anesthesiologist is approximately one hour from the site and is activated only for emergent situations. These factors should be considered during the discussion about the safest and most practical plan.

* If additional Anesthesia resources are engaged, please confirm with Orthopedics that appropriate attending supervision will be available for the reduction. This is important to maximize the likelihood of a successful procedure and avoid requiring Anesthesia to return for a second attempt. * Finally, Anesthesia has asked that we also use the on-call phone number when requesting assistance with a double setup for an anticipated difficult airway. Please do not call “Anesthesia 25”—we would prefer that no one have to run and trip on the way. 😉

Thank you, Chau

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