Patients who present to the emergency department often do so seeking relief
from painful injuries or conditions. Proactively addressing pain and anxiety not
only facilitates interventional procedures and provides relief of suffering, it
also improves patient satisfaction and quality of care. Procedural sedation and
analgesia is a routine occurrence in emergency medicine. Arguments exist,
however, on where, how, and who should be involved in performing sedation in the
emergency department. For this reason, procedural sedation has received a great
amount of attention in recent years. The Joint Commission on Accreditation of
Healthcare Organization (JCAHO) has set forth general standards regarding the
issue, and multiple other organizations and publications have added their
discussion on the appropriate medications and dosages to be used. Not to be left
out, each individual institution adds its own policies and guidelines.
Contributing to the confusion is the fear that many of the medications used for
sedation and analgesia have significant negative side effects, such as
depression of the respiratory, cardiac and central nervous systems. As a result,
the American College of Emergency Physicians formed a committee to review the
literature and determine an official clinical policy regarding procedural
sedation and analgesia in the emergency department. For the purposes of this
article, this clinical policy will be summarized. According to ACEP's clinical
policy, physicians should attempt to minimize complications as best they can by
following JCAHO's advice. In addition, prior to procedural sedation, physicians
should discuss with patients the risks and benefits of, as well as the
alternatives to each case. As always, ACEP's clinical policy is meant to provide
strategies for physicians to use in practice. It is important to remember that
these are recommendations only and physicians should use their own judgment in
each individual situation.
Definitions:
Procedural sedation involves administering sedatives or dissociative agents with
or without analgesics to induce a depressed level of consciousness while
maintaining cardiorespiratory function. Moderate sedation, formerly known as
conscious sedation, is defined as a “drug-induced depression of consciousness
during which patients respond purposefully.” Protective airway reflexes should
be maintained throughout. Deep sedation is defined as a “drug-induced depression
of consciousness during which patients cannot easily be aroused but respond
purposefully after repeated or painful stimulation.” These patients may require
assistance in maintaining airway patency and ventilatory effort. General
anesthesia is defined as a “drug-induced loss of consciousness during which
patients are not arousable and may have an impaired cardiorespiratory function
requiring varying degrees of support.” The most important thing to remember
concerning sedation is that each level exists on a continuum and each individual
patient will respond differently to sedative medication. Therefore, physicians
must possess the skills to rescue a patient from one level greater than the
intended level of sedation. Another category of sedation, which does not fit in
the continuum, is dissociative sedation. This form is defined as a “trancelike
cataleptic state characterized by profound analgesia and amnesia, with retention
of protective airway reflexes, spontaneous respirations and cardiopulmonary
stability.”
Methodology:
In attempt to answer specific queries set forth by the committee, a MEDLINE
search was performed of peer-reviewed original research on sedation and
analgesia from January 1992 to January 2004. The articles were then reviewed by
committee members, and the pertinent ones were selected and graded into one of
three categories based on the perceived strength of evidence. The committee
recommendations regarding patient management were made according to the
following criteria: Level A: Generally accepted principles for patient
management that reflect a high degree of clinical certainty. Level B:
Recommendations for patient management that may identify a particular strategy
or range of strategies that reflect moderate clinical certainty. Level C: Other
strategies for patient management based on preliminary, inconclusive, or
conflicting evidence, or in the absence of any published literature, based on
panel consensus.
Critical Questions for procedural sedation:
I. Personnel requirements:
No level A or B recommendations were specified. Level C recommendations are that
individuals performing moderate and deep sedation must have an understanding of
the drugs administered, and must be able to recognize and manage respiratory and
hemodynamic emergencies. In the event that the physician involved in the
procedure will not be able to continually monitor the patient's clinical status,
a qualified support person should be present for this task. Procedural sedation
and analgesia in the ED must be supervised by an emergency physician or other
appropriately trained and credentialed specialist.
II. Preprocedural patient assessment
No level A or B recommendations were specified. Level C recommendations are
that prior to sedation, the physician should obtain a history and perform a
physical examination to identify medical illnesses, medications, allergies and
anatomic features that may affect procedural sedation and analgesia and airway
management. No routine diagnostic testing is required before procedural
sedation.
III. Is fasting necessary?
No level A or B recommendations were specified. Level C recommendations are that
recent food intake is not a contraindication for administering procedural
sedation and analgesia, since vomiting and loss of airway protective reflexes is
an extremely rare occurrence. Much of the data available has been extrapolated
from general anesthesia literature where the potential of aspiration is
increased with manipulation of the airway. Thorough reviews of this topic
demonstrate a lack of evidence that gastric emptying has any impact on the
incidence of complications or on outcome in procedural sedation and analgesia.
The physician must weigh the risk of aspiration and the benefits of providing
sedation and analgesia in accordance with the needs of each
individual patient.
IV. Equipment and supplies
No level A or B recommendations were specified. Level C recommendations are that
oxygen, suction, reversal agents and advanced life support medications and
equipment should be available when procedural sedation and analgesia is used.
Intravenous access should be maintained when intravenous sedation and analgesia
is provided. Intravenous access may not be necessary when procedural sedation
and analgesia is provided by other routes.
V. Assessment and monitoring
No level A or B recommendations were specified. Level C recommendations are that
the patient's vital signs should be documented before, during and after
procedural sedation and analgesia. The physician must monitor the patient's
appearance and ability to respond to verbal stimuli during and after procedural
sedation and analgesia.
VI. Respiratory status
No level A recommendations were specified. Level B recommendations are that
pulse oximetry should be used in patients at increased risk of developing
hypoxemia, such as when high doses of drugs or multiple drugs are used, or when
treating patients with significant comorbidity. Level C recommendations are that
when the patient's level of consciousness is minimally depressed and verbal
communication can be continually monitored, pulse oximetry may not be necessary.
Consider capnometry to provide additional information regarding early
identification of hypoventilation.
VII. Can ketamine, midazolam,
fentanyl, propofol and etomidate be safely administered for procedural sedation
and analgesia in the ED?
Level A recommendations are that ketamine can be safely
administered to children for procedural sedation and analgesia in the ED. Level
B recommendations are that propofol can be safely administered for procedural
sedation and analgesia in the ED. Nondissociative sedation agents should be
titrated to clinical effect to maximize safety during procedural sedation in the
ED. The combination of fentanyl and midazolam is effective for procedural
sedation and analgesia in the ED. Level C recommendations are that etomidate can
be safely administered for procedural sedation and analgesia in the ED.
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