Clinical Policy for Procedural Sedation and Analgesia in the Emergency Department☆
Section snippets
PREFACE
Procedural sedation has received a great amount of attention in recent years. Several groups have produced documents covering its use, including the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), which has made it an area of intense review. Unfortunately, most of these promulgated advisory materials are not truly evidence-based. The following clinical policy, developed by the Clinical Policies Committee of ACEP, attempts to remove the bias from recommendations for
INTRODUCTION
The appropriate management of anxiety and pain is an important component of comprehensive emergency medical care for patients of all ages. Pain control often is not adequately provided for a variety of reasons, which include fear of oversedation, concern of altering physical findings, or underestimation of patient needs.1 However, proactively addressing pain and anxiety may improve quality of care and patient satisfaction by facilitating interventional procedures and minimizing patient
DEFINITION
“Procedural sedation” refers to a technique of administering sedatives or dissociative agents with or without analgesics to induce a state that allows the patient to tolerate unpleasant procedures while maintaining cardiorespiratory function. Procedural sedation and analgesia is intended to result in a depressed level of consciousness but one that allows the patient to maintain airway control independently and continuously. Specifically, the drugs, doses, and techniques used are not likely to
RATIONALE AND GUIDELINE DISCUSSION
Emergency physicians are trained in resuscitation and stabilization of critically ill patients, and in all aspects of patient management including airway assessment and interventions including rapid sequence intubation.3 The emergency department is a unique environment where a variety of patients with emergent and urgent conditions are managed; many of these conditions result in significant pain and are associated with varying degrees of anxiety, making the management of analgesia and sedation
INCLUSION AND EXCLUSION CRITERIA
This clinical policy is intended for hospital ED patients of all ages who have emergent or urgent conditions that require pain and/or anxiety management to successfully accomplish an interventional or diagnostic procedure. Patients with underlying cardiopulmonary disorders, multiple trauma, head trauma, or who have ingested a central nervous system depressant such as alcohol are included in this guideline. However, these patients are at increased risk of complications from procedural sedation
DESCRIPTION OF THE PROCESS
A MEDLINE search for articles published between January 1992 and August 1996 was performed using combinations of the key words conscious sedation, analgesia, sedation, standards, guidelines, and emergency department. A manual search was performed in the peer-reviewed emergency medicine literature from August 1996 through January 1997. Terms were exploded as appropriate. There were 124 references dealing with procedural sedation and analgesia in the primary care setting or in the ED that were
SCOPE OF APPLICATION
This guideline is intended for emergency physicians working in hospital-based EDs. Procedural sedation is a fundamental skill expected of a specialist in emergency medicine. It is expected that any emergency physician working in an ED will have procedural sedation within their scope of practice. Procedural sedation and analgesia is an identified core content area in emergency medicine training.11 All physicians who are working or consulting in the ED should coordinate all procedures requiring
PERSONNEL
Procedural sedation and analgesia requires personnel who have an understanding and experience with the drugs used; the ability to monitor the patient's condition and recognize changes in clinical status; and the skills necessary to manage a compromised airway and to perform CPR.
The literature does not provide clear evidence on the number of personnel necessary to safely provide procedural sedation and analgesia. The presence of a support person assumes increased importance when the physician is
PATIENT ASSESSMENT
Key components of the patient assessment include indications for procedural sedation and analgesia, past medical history, anesthetic history, medications, allergies, and drug reactions. The combination of vomiting and loss of airway protective reflexes is an extremely rare occurrence with procedural sedation and analgesia, making aspiration an unlikely event; however, potential for aspiration must always be considered in the timing and degree of procedural sedation and analgesia. There is lack
CONSENT
It is good medical practice to discuss with patients all medications and interventions that will be provided. The discussion should include the risks, benefits, potential side effects, and alternatives. There is no literature to support that the use of an informed/consent form separate from the general informed/ consent obtained at registration in the ED has an effect on patient satisfaction or on clinical outcome. In some cases, procedural sedation and analgesia is provided in situations when
EQUIPMENT AND SUPPLIES
Although rare, procedural sedation and analgesia may result in an allergic reaction, respiratory arrest, or cardiopulmonary arrest. The incidence of complications is dependent on the drugs used, rate and dose of administration, and patient sensitivities. Consequently, the appropriate protocols and equipment to monitor the patient's condition, and to manage airways, allergic reactions, drug overdoses, and to treat respiratory and cardiorespiratory arrest should be readily available; use of
PATIENT MONITORING AND DOCUMENTATION—GENERAL
Monitoring the patient's condition involves visual observation and assessment of the level of consciousness and physiologic changes. The monitoring process should be documented (see Figure 1 for example). The components of monitoring may include level of consciousness, respiratory rate, blood pressure, oxygen saturation, percent of exhaled carbon dioxide, heart rate, blood pressure, and ECG rhythm. The patient's ability to follow commands is a method of monitoring level of consciousness. Except
PATIENT MONITORING AND DOCUMENTATION—PULSE OXIMETRY
The use of pulse oximetry in procedural sedation and analgesia has been extensively reviewed in the recent literature.18 Pulse oximetry provides continuous noninvasive estimates of arterial oxygen saturation and is a reliable tool in detecting early decreases in oxygen saturation and changes in the patient's heart rate. Under most circumstances, there is excellent correlation between the pulse oximeter saturation, measured by spectrophotometry, and arterial hemoglobin oxygen saturation measured
PATIENT MONITORING AND DOCUMENTATION—CAPNOMETRY
Capnometry is a technique used to monitor end-tidal CO2 (PETco2) and thus may detect early cases of inadequate ventilation before oxygen desaturation takes place.18 There is an excellent correlation between Paco2 and PETco2 even when the PETco2 is measured through a nasal cannula while the patient is receiving oxygen.25 It has been found that the combination of opioids and benzodiazepines results in decreased hypoxic ventilatory drive, and that hypoventilation may be detected by rising levels
DRUG ADMINISTRATION
A key to minimizing complications in procedural sedation and analgesia is the slow titration of drugs to the desired effect. Rapid administration of drugs may be associated with hypotension or respiratory depression. In addition, the combination of drugs may accentuate the potential side affects associated with each drug individually. In one study, use of benzodiazepines alone resulted in no significant respiratory depression, whereas use of an opioid alone caused hypoxemia in 50% of volunteers
Postprocedure and Discharge
The condition of all patients should be monitored in the immediate postprocedure period. It is during this period that all stimulation is removed, and pain and anxiety have been controlled, thus putting the patient at risk of complications from the medications used. In one study, the one case of apnea occurred after a shoulder was relocated.14 The duration of actions of all agents used, including reversal agents, must be taken into consideration before discharging the patient.
Discharge criteria
QUALITY ASSURANCE
A quality management program is a useful tool for monitoring the safety of procedural sedation and analgesia in the ED. Suggested indications for a quality management review include death, cardiopulmonary arrest, airway compromise, prolonged sedation, new neurologic deficit, significant hypoxemia, aspiration, significant hypotension, and significant bradycardia or tachycardia.
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Ann Emerg Med
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An evaluation of pulse oximetry in prehospital care
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Results from the American Society for Gastrointestinal Endoscopy/ US Food and Drug Administration collaborative study on complication rates and drug use during gastrointestinal endoscopy
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(1991) Procedural sedation and analgesia in the emergency department: The value of capnography and pulse oximetry
Ann Emerg Med
(1992)
Intramuscular ketamine, midazolam, and glycopyrrolate for pediatric sedation in the emergency department
J Oral Maxillofac Surg
Nasal versus oral midazolam for sedation of anxious children undergoing laceration repair
Ann Emerg Med
Emergence delirium in a child given oral midazolam for procedural sedation and analgesia
Ann Emerg Med
Arterial oxygen desaturation in adult dental patients receiving procedural sedation and analgesia
J Oral Maxillofac Surg
Respiratory arrest after intramuscular ketamine in a 2-year-old child
Am J Emerg Med
Efficacy of rectal midazolam for the sedation of preschool children undergoing laceration repair
Ann Emerg Med
Respiratory arrest following intramuscular ketamine injection in a 4-year-old child
Ann Emerg Med
Continuous intravenous infusion fentanyl for sedation and analgesia of the multiple trauma patient
Ann Emerg Med
Guidelines for sedation by nonanesthesiologists during diagnostic and therapeutic procedures
J Clin Anesth
Rapid-sequence intubation
Ann Emerg Med
Procedural sedation and analgesia
Critical Decisions in Emergency Medicine
Cited by (168)
Procedural sedation and analgesia with propofol (PSA) for gynecologic surgery: A systematic review of the literature
2023, European Journal of Obstetrics and Gynecology and Reproductive BiologySedation for Diagnostic and Therapeutic Procedures Outside the Operating Room
2019, A Practice of Anesthesia for Infants and ChildrenSedation for Diagnostic and Therapeutic Procedures Outside the Operating Room
2018, A Practice of Anesthesia for Infants and ChildrenAnesthesia in Pediatric Otolaryngology
2014, Cummings Pediatric Otolaryngology
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This clinical policy was developed by the ACEP Clinical Policies Committee and the Clinical Policies Subcommittee on Procedural Sedation and Analgesia.