To provide anxiolysis, analgesia, sedation, and motor control during unpleasant diagnostic or therapeutic procedures. Decisions regarding appropriate sedation practices depend on:

    Type of procedure or treatment

    Age and medical condition of the patient

    Skill and experience of practitioner

    Available staff

    Policies and procedures of the institution

CONTRAINDICATIONS

 No absolute contraindications to analgesia other than significant allergies

    Pain control is an essential component of good emergency care

    Choice of agent depends on level of pain, speed of action, medical condition, and age of patient

 Relative Contraindications

    Presence of acute or chronic conditions which make the patient American Society of Anesthesiologists (ASA) class III or higher (anesthesiology should be involved in the care of these patients; general anesthesia in the operating room [OR] may be indicated)

    Inadequate personnel available

       Except for mild anxiolysis (oral benzodiazepines) or analgesia without sedation, person administering sedation cannot be the same person performing the procedure

       The Centers for Medicare and Medicaid Services (CMS) recommends two physicians (one to manage sedation, one to perform procedure) and a nurse be present for the duration of the sedation. The American College of Emergency Physicians (ACEP) Clinical Policy on Procedural Sedation and Analgesia in the Emergency Department recommends one physician (performing the procedure) and one nurse be present for the sedation.

RISK/CONSENT ISSUES

 Inadvertent deep sedation or general anesthesia

 Hypoxia/hypoventilation

 Nausea and vomiting

 Medication reactions

    Fentanyl: Respiratory depression, rigid chest (more likely with rapid delivery)

    Morphine: Histamine release and hypotension

    Benzodiazepines, barbiturates: Paradoxical reaction of restlessness or agitation

    Ketamine: Laryngospasm, emergence reactions, and hypertension

    Propofol: Hypotension

CLASSIFICATION

 Often, moderate sedation is the goal for emergency department procedural sedation; however, the depth of sedation should be determined by the procedure being performed and the patient characteristics. One must be aware of the possibility of the patient passing into a state of deep sedation and be able to manage this occurrence. Advanced airway management skills are required for anyone performing procedural sedation.

    Minimal/mild sedation: Impaired cognitive function and coordination but unaffected ventilatory and cardiovascular functions; able to respond to verbal commands

    Moderate sedation: Blunted anxiety/pain responses but intact airway reflex; normal cardiovascular function; patient should respond to verbal commands (possibly with addition of light tactile stimulation).

    Dissociative sedation: Profound analgesia and amnesia with retention of airway reflexes, spontaneous respirations, and cardiovascular function

       State induced by ketamine

    Deep sedation: Difficult to arouse; can respond purposefully to repeated or painful stimulation; partial or complete loss of airway reflexes is possible; cardiovascular function usually intact

PRESEDATION CONSIDERATIONS

All patients should have a presedation assessment, which includes the following:

 Consider type and severity of underlying medical conditions; consult anesthesiology for patients of ASA class III and higher (TABLE 90.1)

 Consider current medications and allergies especially regarding previous adverse experiences with analgesia/anesthesia

 Inspect airway for abnormalities or limited neck mobility that may impair rescue airway intervention (short neck, obesity, large tonsils/tongue, small mandible)

 Determine time and nature of last meal: Fasting recommendations for elective procedures are 2 to 3 hours for liquids and 4 to 8 hours for solids; in an emergency situation, these guidelines are often not realistic; document the time of last intake and the need for emergent treatment.

 Perform a general physical examination, concentrating on cardiac and lung auscultation, presence of active upper respiratory infection (URI) or asthma exacerbation, and baseline neurologic state

 Assemble all equipment you may need for sedation and potential complications:

    Suction

    Oxygen delivery system (face mask or nasal cannula of appropriate size)

    Airway equipment

    Monitors (pulse oximeter, electrocardiography, blood pressure, capnography)

    Medications, including reversal agents

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