Procedural Sedation and Analgesia

Procedural Sedation and Analgesia in the Emergency Department (October 2013)

Scope of Application

This guideline is intended for physicians working in emergency departments.

Inclusion Criteria

This guideline is intended for patients of all ages in the emergency department who have emergent or urgent conditions that require pain and/or anxiety management to successfully accomplish an interventional or diagnostic procedure and for high-risk patients (eg, those with underlying cardiopulmonary disorders, multiple trauma, head trauma, who have ingested a central nervous system depressant such as alcohol), with the understanding that these patients are at increased risk of complications from procedural sedation and analgesia.

Exclusion Criteria

This guideline is not intended for patients receiving inhalational anesthetics, patients who receive analgesia for pain control without sedatives, patients who receive sedation solely for the purpose of managing anxiolysis and behavioral emergencies, and patients who are intubated.

Critical Questions

  • In patients undergoing procedural sedation and analgesia in the emergency department, does preprocedural fasting demonstrate a reduction in the risk of emesis or aspiration?

    Recommendations
    Level A Recommendations

    None specified.

    Level B Recommendations

    Do not delay procedural sedation in adults or pediatrics in the ED based on fasting time. Preprocedural fasting for any duration has not demonstrated a reduction in the risk of emesis or aspiration when administering procedural sedation and analgesia.

    Level C Recommendations

    None specified.

    Level A Recommendations

    None specified.

    Level B Recommendations

    Do not delay procedural sedation in adults or pediatrics in the ED based on fasting time. Preprocedural fasting for any duration has not demonstrated a reduction in the risk of emesis or aspiration when administering procedural sedation and analgesia.

    Level C Recommendations

    None specified.

  • In patients undergoing procedural sedation and analgesia in the emergency department, does the routine use of capnography reduce the incidence of adverse respiratory events?

    Recommendations
    Level A Recommendations

    None specified.

    Level B Recommendations

    Capnography* may be used as an adjunct to pulse oximetry and clinical assessment to detect hypoventilation and apnea earlier than pulse oximetry and/or clinical assessment alone in patients undergoing procedural sedation and analgesia in the ED. *Capnography includes all forms of quantitative exhaled carbon dioxide analysis.

    Level C Recommendations

    None specified.

    Level A Recommendations

    None specified.

    Level B Recommendations

    Capnography* may be used as an adjunct to pulse oximetry and clinical assessment to detect hypoventilation and apnea earlier than pulse oximetry and/or clinical assessment alone in patients undergoing procedural sedation and analgesia in the ED. *Capnography includes all forms of quantitative exhaled carbon dioxide analysis.

    Level C Recommendations

    None specified.

  • In patients undergoing procedural sedation and analgesia in the emergency department, what is the minimum number of personnel necessary to manage complications?

    Recommendations
    Level A Recommendations

    None specified.

    Level B Recommendations

    None specified.

    Level C Recommendations

    During procedural sedation and analgesia, a nurse or other qualified individual should be present for continuous monitoring of the patient, in addition to the provider performing the procedure. Physicians who are working or consulting in the ED should coordinate procedures requiring procedural sedation and analgesia with the ED staff.

    Level A Recommendations

    None specified.

    Level B Recommendations

    None specified.

    Level C Recommendations

    During procedural sedation and analgesia, a nurse or other qualified individual should be present for continuous monitoring of the patient, in addition to the provider performing the procedure. Physicians who are working or consulting in the ED should coordinate procedures requiring procedural sedation and analgesia with the ED staff.

  • In patients undergoing procedural sedation and analgesia in the emergency department, can ketamine, propofol, etomidate, dexmedetomidine, alfentanil, and remifentanil be safely administered?

    Recommendations
    Level A Recommendations

    Ketamine can be safely administered to children for procedural sedation and analgesia in the ED. Propofol can be safely administered to children and adults for procedural sedation and analgesia in the ED.

    Level B Recommendations

    Etomidate can be safely administered to adults for procedural sedation and analgesia in the ED. A combination of propofol and ketamine can be safely administered to children and adults for procedural sedation and analgesia.

    Level C Recommendations

    Ketamine can be safely administered to adults for procedural sedation and analgesia in the ED. Alfentanil can be safely administered to adults for procedural sedation and analgesia in the ED. Etomidate can be safely administered to children for procedural sedation and analgesia in the ED.

    Level A Recommendations

    Ketamine can be safely administered to children for procedural sedation and analgesia in the ED. Propofol can be safely administered to children and adults for procedural sedation and analgesia in the ED.

    Level B Recommendations

    Etomidate can be safely administered to adults for procedural sedation and analgesia in the ED. A combination of propofol and ketamine can be safely administered to children and adults for procedural sedation and analgesia.

    Level C Recommendations

    Ketamine can be safely administered to adults for procedural sedation and analgesia in the ED. Alfentanil can be safely administered to adults for procedural sedation and analgesia in the ED. Etomidate can be safely administered to children for procedural sedation and analgesia in the ED.

Findings and Strength of Recommendations

Clinical findings and strength of recommendations regarding patient management were made according to the following criteria:
Level A recommendations
Generally accepted principles for patient care that reflect a high degree of clinical certainty (eg, based on evidence from 1 or more Class of Evidence I or multiple Class of Evidence II studies).
Level B recommendations
Recommendations for patient care that may identify a particular strategy or range of strategies that reflect moderate clinical certainty (eg, based on evidence from 1 or more Class of Evidence II studies or strong consensus of Class of Evidence III studies).
Level C recommendations
Recommendations for patient care that are based on evidence from Class of Evidence III studies or, in the absence of adequate published literature, based on expert consensus. In instances in which consensus recommendations are made, “consensus” is placed in parentheses at the end of the recommendation.
There are certain circumstances in which the recommendations stemming from a body of evidence should not be rated as highly as the individual studies on which they are based. Factors such as heterogeneity of results, uncertainty about effect magnitude, and publication bias, among others, might lead to a downgrading of recommendations.
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