Procedural Sedation Errors

Procedural Sedation Errors

Error #1: Delaying deep sedation until fasting times are met

Error #2: Believing PSA carries less risk than endotracheal intubation

Error #3: Minimizing risk of airway and breathing complications while using ketamine

Error #4: Not having full intubation setup nearby

Error #5: Responding to hypoventilation or apnea with early and/or aggressive use of the bag-valve mask (BVM)

Error #6: If the oxygen saturation is ok, then the patient is breathing ok

Error #7: Withholding ketamine sedation on adults

Error #8: Adding an opioid with ketamine for sedation

Error #9: Using the same dosing strategy for propofol sedations as with fentanyl/midazolam

Error #10: Using the same PSA dosing strategy for the elderly

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IV Iron

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Indication:

  • Severe iron-deficiency anemia (Hb <9 g/dL) especially if there is ongoing bleeding
  • Rate of bleeding too brisk for oral iron
  • Time-sensitive pressures (eg, an urgent surgical procedure; observational studies of the use of IV iron preoperatively for patients with anemia have shown a reduced rate of red cell transfusion being required)
  • Severe anemia of chronic disease and evidence of iron deficiency (eg, ferritin <30 ug/L)
  • Oral iron being poorly tolerated or the failure of an oral trial
  • Poor oral absorption (due to conditions including gastric bypass, celiac disease, and gastritis)

Dose:

IV iron is given as iron sucrose (brand name Venofer) in an infusion of 300 mg in 250 mL of normal saline over two hours. After IV iron, and with ongoing oral supplementation, a patient’s hemoglobin will start to rise in three to seven days. You can expect a 0.1- to 0.2-point rise in the hemoglobin per day; after two to four weeks, the hemoglobin will have risen 2 to 3 g/dL. Ferrous sulfate (300 mg) contains 60 mg of elemental iron, and one tablet can be taken each night on an empty stomach at least two hours after meals with 500 mg of vitamin C to improve absorption. Patients should be counseled to avoid taking iron with calcium or magnesium supplements as they decrease iron absorption.

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Good Medicine

Good Medicine

  • ALWAYS SIT DOWN during a consultation! Patient will perceive your presence as being greater than it is.
  • Always introduce yourself. Acknowledge everyone in the room.
  • Remember that you are always on stage and you need to put on a good show!
  • Patients want to be “treated like a person”… which is always reasonable.

LFTs explained

LFTs Explained

  • LFTs = ‘hepatocellular’ or ‘cholestatic’ arrangement based on the pattern of elevation.
    • Hepatocellular pattern = transaminases >  ALK
  • ALT is generally considered to be more specific to liver damage
  • Magnitude of aminotransferase elevation => guide initial diagnosis: mild (<5x), moderate (5-10x), or marked elevation (>10x)
    • Mild = NAFLD, Drug Induced Liver Injury, Alcohol Induced Liver Injury
    • Moderate = Alcoholic Hepatitis, Biliary Tract Disease
    • Severe = Acute Viral Hepatitis, Ischemic Injury, Acetaminophen Toxicity

 

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Bronchiolitis guidelines

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Bronchiolitis Treatment

What are the cornerstones for bronchiolitis treatment? Supportive care! This means ensuring adequate hydration and oxygenation. A limited amount of suctioning to clear the nares might be beneficial. Supplemental oxygen may be necessary if oxygen saturations are < 90% persistently. Antipyretics (acetaminophen or ibuprofen) for infants with high fever are often useful adjuncts for treatment and can reduce irritability.

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How to call a consult

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5 C’s Model of Calling a Consult

Contact – Introduce yourself and confirm who you are speaking to e.g. ‘This is Dr. Njoroge, I am calling you from the Emergency Department. Dr Odhiambo we have you listed as our on call surgeon today, is this correct?’

Communicate – Give a concise complete story, ideally a one sentence delivery to ‘hook’ the listener e.g.We have a 23 year old patient, Mr. Mumo, with a diagnosis of an acute appendicitis confirmed on CT.

Core question –  Have a specific question or request of the consultant (why you called them) e.g. can we admit the patient to the ward?

Collaboration – Is there anything else you can do for the patient e.g. order additional labs

Closing the loop – Ensure that both parties are on the same page regarding the plan and maintain proper communication about any change in the patients status.

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