Clinical Policy for Procedural Sedation and Analgesia in the Emergency Department

https://doi.org/10.1016/S0196-0644(98)70216-1Get rights and content

Abstract

[American College of Emergency Physicians: Clinical policy for procedural sedation and analgesia in the emergency department. Ann Emerg Med May 1998;31:663-677.]

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.

References (43)

  • J Pruitt et al.

    Intramuscular ketamine, midazolam, and glycopyrrolate for pediatric sedation in the emergency department

    J Oral Maxillofac Surg

    (1995)
  • K Connors et al.

    Nasal versus oral midazolam for sedation of anxious children undergoing laceration repair

    Ann Emerg Med

    (1994)
  • W Doyle et al.

    Emergence delirium in a child given oral midazolam for procedural sedation and analgesia

    Ann Emerg Med

    (1994)
  • A Hovagim et al.

    Arterial oxygen desaturation in adult dental patients receiving procedural sedation and analgesia

    J Oral Maxillofac Surg

    (1989)
  • R Mitchell et al.

    Respiratory arrest after intramuscular ketamine in a 2-year-old child

    Am J Emerg Med

    (1996)
  • S Shane et al.

    Efficacy of rectal midazolam for the sedation of preschool children undergoing laceration repair

    Ann Emerg Med

    (1994)
  • J Smith et al.

    Respiratory arrest following intramuscular ketamine injection in a 4-year-old child

    Ann Emerg Med

    (1993)
  • M Walsh et al.

    Continuous intravenous infusion fentanyl for sedation and analgesia of the multiple trauma patient

    Ann Emerg Med

    (1991)
  • R Holzman et al.

    Guidelines for sedation by nonanesthesiologists during diagnostic and therapeutic procedures

    J Clin Anesth

    (1994)
  • American College of Emergency Physicians

    Rapid-sequence intubation

    Ann Emerg Med

    (1997)
  • J Rose et al.

    Procedural sedation and analgesia

    Critical Decisions in Emergency Medicine

    (1996)
  • Cited by (168)

    • Sedation for Diagnostic and Therapeutic Procedures Outside the Operating Room

      2019, A Practice of Anesthesia for Infants and Children
    • Sedation for Diagnostic and Therapeutic Procedures Outside the Operating Room

      2018, A Practice of Anesthesia for Infants and Children
    • Anesthesia in Pediatric Otolaryngology

      2014, Cummings Pediatric Otolaryngology
    View all citing articles on Scopus

    This clinical policy was developed by the ACEP Clinical Policies Committee and the Clinical Policies Subcommittee on Procedural Sedation and Analgesia.

    View full text