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Easing the pain in older adults – practical pearls and a few words of warning.

An 84-year old woman presents to your ED with a traumatic, left-sided posterior hip dislocation. You need to reduce the hip, but how should you sedate her? Procedural sedation is an important component of ED care. It allows us to more comfortably perform otherwise painful procedures such as fracture or dislocation reductions, endoscopies, large laceration repairs, and I&Ds. But how safe is procedural sedation in older adults?

Sedation for any patient requires preparation, airway assessment, and close monitoring. The physician has to be prepared in case of adverse medication reaction, respiratory depression, need for airway protection, and cardiovascular side effects of the medications. Do patients 65 and older present any unique challenges? Are any other preparation needed prior to sedation? Are the commonly used medications safe? Are older patients at increased risk of side effects? 

There are few studies of procedural sedation specifically in older adults in the ED setting. However, we can also learn from studies in the anesthesiology and dental literature, as many older patients receive sedation for colonoscopies and dental work. Let’s look at a few agents that are commonly used.

Opioids and Benzodiazepines

This is a popular combination, and is generally tolerated well in older adults. There is a body of dental literature on sedation for older patients who undergo extractions and other dental procedures. Some of these studies used diazepam. However, in general midazolam is strongly preferred for short ED sedations because of its more rapid onset and shorter-lived effect.

In one study1 in which sequential doses of diazepam were titrated, the authors found lower doses were required to reach the same level of sedation in older patients. Oxygen saturation declined slightly more in older patients, and this occurred within the first few minutes following administration of the medication.

In another study with 200 patients (age 65 and over) undergoing brief dental procedures, there were no serious complications seen when fentanyl was added to diazepam or midazolam. Mean doses given included 100 mcg of fentanyl, 9.2 mg diazepam and 3.9 mg of midazolam.  The authors also used small boluses of methohexital for amnesia, with a mean dose of 60.3 mg.2

Comparing patients under 60 years old, who received 0.05 mg/kg of midazolam, with those over 60 years old who received 0.025 mg/kg midazolam for colonoscopy, even with the lower dose, the older patients experienced more frequent desaturation.3

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Propofol

Propofol is also generally well tolerated in older adults, and is the preferred first-line agent in many EDs. As with any patient, pay attention to the blood pressure, and an alternative agent may be preferable for those with hypotension.

In an ED study of sedation with propofol with or without an opioid or midazolam with an opioid, there were no statistically significant differences in complication rates (which included hypotension, apnea, hypoxia, aspiration, need for rescue maneuvers, bradycardia and death) between patients age 18-49 (5.2%), 50-64 (5.4%) and ≥65 (8%), p=0.563.   However, the dose of sedative medications used decreased with both age and ASA score.4

Another study found that for patients receiving propofol alone, older patients required a lower dose. There were three age groups: 18-40, 41-64, and ≥65 years. The median induction doses were 1.4 mg/kg, 1 mg/kg, and 0.9 mg/kg, and the median total doses required were 2 mg/kg, 1.7 mg/kg, and 1.2 mg/kg.5

Finally, a study that included patients up to age 60 years noted those who were 50-60 years old experienced airway complications more frequently than younger patients. Airway complications such as obstruction, desaturation, or hypoventilation requiring an intervention (stimulation, chin-lift, bag-valve mask, or OPA) occurred at a rate of 31% in the 50-60 year age-group, compared with 21% overall. Furthermore, there were more airway events if the level of sedation was deep (odds ratio doubled for a sedation level of 6 compared with sedation level 4). However, the interventions were relatively minor, and no patients required intubation during the procedure (one patient aspirated and was intubated later).6

Ketamine

While ketamine has become a favorite agent in many EDs and has been used successfully in children for many years, it is probably not the best first choice in certain older adults, at least until more research is available.

There are a number of older, small studies of ketamine used as the sole agent in the OR to perform open reduction and intern fixations of hip fractures in older adults7. In a study with an average patient age of 83 years, during ketamine administration, patients experienced increased blood pressure and cardiac index, but there were no serious adverse events8. Another small study comparing ketamine and propofol found that ketamine increased myocardial oxygen demand.9 In general, there is a higher prevalence of hypertension and coronary artery disease among older patients. Increasing the myocardial oxygen demand could present a risk with ketamine use.  Some recent studies have combined ketamine and propofol (“ketofol”), with a goal of minimizing the side effects of both agents, but retaining their therapeutic properties. However these studies enrolled few older patients10,11. This combination may be safe in older adults, but more research is needed.

Etomidate

Etomidate is not often used as a first-line agent for procedural sedation due to its high incidence of myoclonus. However, it is otherwise generally well-tolerated in older adults, and is still a common first-line medication for rapid sequence induction and intubation.

In a small, retrospective comparison of older and younger adults who received etomidate for procedural sedation, there was no statistically significant difference between the complication rate in older (20%) and younger (14.8%) adults, with a mean dose of 0.14 mg/kg12.  Of the 45 elderly patients included in their study, 3 had emesis without aspiration, 2 suffered hypoxia that resolved within 5 minutes with supplemental oxygen, 1 had bradycardia that resolved, 3 had asymptomatic hypertension, and 1 had fasciculations.

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Take Home Pearls

  1. Procedural sedation is generally safe in older adults, though they may be at higher risk for oxygen desaturation.
  2. Older patients usually require lower doses of medications. They tend to be more sensitive to medications, with slower metabolism, less physiologic reserve to handle side effects, and a smaller volume of distribution.
  3. Patients receiving non-analgesic medications such as etomidate or propofol may benefit from pre-treatment with a short-acting opioid (eg 0.5mcg/kg of fentanyl). However, risks of complications can increase when multiple agents are used, and doses of the sedative needed may be lower.
  4. Physicians should take all the usual precautions, and consider any co-morbidities that could make the patient more at risk for adverse reactions or complications, more difficult to bag or intubate, or more at risk of decompensation.

 

EPM + ROSH REVIEW Question: Which of the following is true regarding procedural sedation in the elderly? >>Go to Question

 

 

Dr. Shenvi is a geriatrics emergency medicine fellow in the department of emergency medicine at the University of North Carolina.

Michelle Lin, MD is Editor-in-Chief of Academic Life in Emergency Medicine

 

References

  1. Kitagawa E, Iida A, Kimura Y, Kumagai M, Nakamura M, Kamekura N, Fujisawa T, Fukushima K. Responses to intravenous sedation by elderly patients at the Hokkaido University Dental Hospital. Anesth Prog. 1992;39(3):73-8.
  2. Campbell RL, Smith PB. Intravenous sedation in 200 geriatric patients undergoing office oral surgery. Anesth Prog. 1997 Spring;44(2):64-7.
  3. Yano H, Iishi H, Tatsuta M, Sakai N, Narahara H, Omori M. Oxygen desaturation  during sedation for colonoscopy in elderly patients. Hepatogastroenterology. 1998 Nov-Dec;45(24):2138-41.
  4. Weaver CS, Terrell KM, Bassett R, Swiler W, Sandford B, Avery S, Perkins AJ. ED procedural sedation of elderly patients: is it safe? Am J Emerg Med. 2011 Jun;29(5):541-4.
  5. Patanwala AE, Christich AC, Jasiak KD, Edwards CJ, Phan H, Snyder EM. Age-related differences in propofol dosing for procedural sedation in the Emergency Department. J Emerg Med. 2013 Apr;44(4):823-8.
  6. Taylor DM, Bell A, Holdgate A, MacBean C, Huynh T, Thom O, Augello M, Millar R, Day R, Williams A, Ritchie P, Pasco J. Risk factors for sedation-related events during procedural sedation in the emergency department. Emerg Med Australas. 2011 Aug;23(4):466-73.
  7. Wickström I, Holmberg I, Stefánsson T. Survival of female geriatric patients after hip fracture surgery. A comparison of 5 anesthetic methods. Acta Anaesthesiol Scand. 1982 Dec;26(6):607-14.
  8. Stefánsson T, Wickström I, Haljamäe H. Hemodynamic and metabolic effects of ketamine anesthesia in the geriatric patient. Acta Anaesthesiol Scand. 1982 Aug;26(4):371-7.
  9. Maneglia R, Cousin MT. A comparison between propofol and ketamine for anaesthesia in the elderly. Haemodynamic effects during induction and maintenance. Anaesthesia. 1988 Mar;43 Suppl:109-11.
  10. Andolfatto G, Abu-Laban RB, Zed PJ, Staniforth SM, Stackhouse S, Moadebi S, Willman E. Ketamine-propofol combination (ketofol) versus propofol alone for emergency department procedural sedation and analgesia: a randomized double-blind trial. Ann Emerg Med. 2012 Jun;59(6):504-12.e1-2.
  11. Willman EV, Andolfatto G. A prospective evaluation of “ketofol” (ketamine/propofol combination) for procedural sedation and analgesia in the emergency department. Ann Emerg Med. 2007 Jan;49(1):23-30.
  12. Cicero M, Graneto J. Etomidate for procedural sedation in the elderly: a retrospective comparison between age groups. Am J Emerg Med. 2011 Nov;29(9):1111-6.
  13. Frank RL, Procedural Sedation in Adults, www.uptodate.com updated 10/16/2013, accessed 12/09/2013
 

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