Emergency Sedation and Pain Management
Burton JH, Miner J, eds. New York: Cambridge University Press, 2008. ISBN 978-521-87086-3. 282 pages, $85.00.
Over the past 20 years, the specialty of emergency medicine has rapidly and enthusiastically embraced the application of anesthetic agents to their patient population (“… one of the great advances in the maturation of emergency medicine …” according to this book’s foreword) such that administration of these medications by emergency department physicians (EDPs) is now viewed as the standard of care practice around the country. This evolution has largely occurred with minimal involvement of anesthesiologists, since most EDPs view their clinical environment as so diametrically different from the operating room that anesthesiologists’ training, education, and experience routinely utilizing these drugs is dismissed as not applicable to the Emergency Department (ED).
The editors and chapter authors of this book are almost exclusively EDPs and attempt to concentrate information on ED administration of induction agents, analgesics, sedatives, neuromuscular blockers, and local anesthetics into a “comprehensive medical text” utilizing an “informative, authoritative, and concise format.” The book is divided into 5 major sections (overview/principles, analgesia, procedural sedation, topical/local/regional anesthesia, and special considerations) and 39 chapters, with an average chapter length of 5–7 pages. Individual chapters are consistently arranged in a “Cliff’s Notes” style in an effort to succinctly summarize the most clinically relevant points of sedation and analgesia for a specific population (e.g., analgesia for the emergency headache patient), procedure (e.g., sedation for cardioversion), or process (e.g., monitoring for procedural sedation) for the busy EDP.
While the chosen format makes for easy reading, it also results in excessive redundancy (e.g., 4 separate chapters on various orthopedic and musculoskeletal topics; 6 discrete chapters referable to the pediatric patient) that significantly detracts from the editors’ stated goal of being “concise.” In addition, the book’s utilization of chapter bibliographies rather than specific references makes it difficult for the reader to independently confirm the accuracy of chapter contents and leads to frequent unreferenced overstatements (such as the implication on page 266 that nondepolarizing neuromuscular blockers administered in rapid sequence intubation dosages can be acutely reversed with cholinesterase inhibitors), multiple misinterpretations (“… deep sedation … response to verbal commands is substantially impaired with … preservation of airway protective reflexes” on page 7), and use of outdated bibliography citings (such as the 1992 American Academy of Pediatrics sedation guidelines in Chapter 2 rather than the revised guidelines recently published in 2006). A final format curiosity was inclusion of the color figures for Chapters 3 and 32 between Chapters 19 and 20 as an apparent last-minute replacement for the identical black-and-white figures found within the respective chapters. This book is organizationally challenged, producing multiple hurdles between the reader and acquisition of accurate, clinically useful knowledge.
This reviewer was very disappointed that the book failed to initially establish an appropriate pharmacologic framework upon which to anchor its following clinically based chapters by not incorporating succinct chapters on basic pharmacokinetics and pharmacodynamics, the pertinent pharmacology of the specific drug classes/individual agents mentioned throughout the book, and basic pain mechanisms. This led to the same drugs, descriptions, and doses being reproduced ad nauseum (i.e., fentanyl 1–2 μg/kg IV) while making little to no mention of many important clinical points (e.g., apnea and bradycardia spells in neonates, sensitivity of the elderly to centrally acting agents, pregnancy and its sedation/analgesia implications, methemoglobinemia from topical benzocaine administration, sedation and recovery of the patient with obstructive sleep apnea). This lack of a systematic pharmacologic approach over the course of 39 individually authored chapters subsequently creates a milieu where numerous pharmacologic errors are transmitted (e.g., droperidol as an analgesic for coronary ischemia pain in Chapter 16, IV fentanyl trade name as Duragesic® in Chapter 17, fentanyl half-life of 20 minutes in Chapter 37, hypertension from dexmedetomidine in Chapter 38). Also puzzling was the complete absence of a chapter on the implications of acute/chronic substance abuse (alcohol intoxication, drug-seeking behavior, etc.) on ED sedation and analgesia given the significant incidence of such populations presenting for ED care.
As can be inferred from the comments above, this book lacks adequate editorial oversight and contains a plethora of typographical errors, misspellings, spacing deficiencies, and unnumbered pages. Even straightforward, commonplace information well known to practicing EDPs was overlooked (e.g., no statement proscribing epinephrine-containing local anesthetic solutions for digital blocks on page 209). More disturbingly, the book also contains misleading, inaccurate, and potentially lethal information regarding sedative, analgesic, and intravenous anesthetic drug dosages (i.e., Table 25-3, where the “suggested pediatric combination” for sedation and analgesia is “midazolam 0.02 mg/kg IV when combined with 1 mg/kg fentanyl” and Table 38-2, where the rapid sequence induction dose of fentanyl for children ages 3–16 is 2.5–3.5 mg/kg). The implications of such egregious doses being administered by relatively inexperienced, less sophisticated EDPs (as is the case in some rural hospitals staffed by non-emergency medicine residency-trained physicians, moonlighting resident trainees from a variety of specialties, or midlevel providers) following such recommendations are frightening and raise legitimate liability concerns.
On a more positive note, the book does shed some light on facets of ED sedation and analgesia with which the average EDP may be relatively unfamiliar. Reference is made early in the book regarding the Joint Commission for Accreditation of Healthcare Organizations (JCAHO) standards for moderate and deep sedation and how such standards are applicable to ED settings. Similarly, there is a reasonably coherent summary of noninvasive capnography as a useful monitor of airway patency and ventilation. Dexmedetomidine also received some mention (albeit incomplete), and this drug’s absence of respiratory depression, preservation of the patient’s ability to follow commands, and short duration of action make it an appealing agent to consider for ED sedation (particularly for imaging procedures). A few chapters are especially well written, contained sound content, and would prove useful to the practicing EDP. In particular, the chapters on regional anesthesia for dental pain and sedation and analgesia for the critical care patient stand out.
As a former EDP, this reviewer believes the book’s intended subject has important clinical care and patient safety ramifications that are highly relevant to current ED practice. While the book’s editors and authors are to be commended for their attempt to synthesize the broad topic of ED sedation and analgesia into a single, focused text, the book’s multiple and significant deficiencies far outweigh its limited benefits. This reviewer cannot in good conscience recommend it to any of my former colleagues still actively practicing emergency medicine. Hopefully the editors will address the shortcomings identified above in subsequent editions and produce a more complete, tightly organized, and factually accurate text.
Jeffrey S. Kelly, MD, FACEP
Section on Critical Care
Department of Anesthesiology
Chairman, Medical Center Procedural Sedation Committee
Wake Forest University Baptist Medical Center