Mastering procedural sedation can make your shifts safer, more efficient, and more comfortable for your patients. But what defines a sedation? What and who do I need? Does my patient need to be fasting? How should I choose and dose my medications? Below is a brief guide to help you be more confident in your definitions, preparation, and medications. Included is a guide card you can print out and clip behind your badge! Read on and be a pro for your next on-shift sedation.

Definitions

The level of sedation is defined by the patient’s responsiveness and ventilation pattern, not by the medications used. Procedural sedation in the emergency department starts when your intent is dissociative, moderate, or deep sedation.

Does my patient need to be fasting?

Guidelines regarding fasting vary depending on your practice setting, so make sure you check before you perform any sedation. However, the 2018 ACEP consensus states that you should assess the risk, but there is no evidence that non-compliance with mandatory fasting guidelines increases risk of aspiration.​1​

Patient preparation

ACEP recommended that all patients are evaluated for American Society of Anesthesiologists (ASA) score prior to sedation, and you will need to document your assessment.1 You do not formally need to assess Mallampati1  but have a look and plan how you would position, bag or intubate this patient if needed. Take 5 minutes and consent the patient for both sedation and procedure, review allergies, and any medications they recently received.

Who do I need?

  • Respiratory therapy – Your best friend, a no brainer.
  • Nursing – You need a sedation certified nurse, and although local/state laws vary by location, ACEP states that similar to intubations – a qualified nurse can push medications at the direction of the physician.
  • Another provider – In an ideal world you have separate providers for the sedation and the procedure and some hospitals require this. However, you often have to balance the urgency of the procedure with available resources. ACEP again has your back here, saying that there is a long track record of single providers safely performing both.1 Keep in mind that the deeper the sedation the larger the risk, and if alone you should be able to stop the procedure and resuscitate if needed.

Set up

There are a lot of things to prepare, so keep it organized and separated by category. Key tips – have the blood pressure cuff on the opposite arm of the IV. Open up your fluids and make sure that IV flows well before getting started. End-tidal CO2 is now standard of care,​2​ as it can help you recognize changes in ventilation well before your patient starts dropping their O2 saturation. Draw up more medications than you expect to use. You do not want to be stuck waiting for someone to fetch more medications while your patient is waking up in pain.

Medications and dosing

Consider your goal depth and duration of sedation as well as patient characteristics when choosing your medication(s) of choice. Everyone has their own preferred medications, but it is good to be comfortable with a few strategies. The table below outlines doses, side effects, and dosing tips for the most common choices. Keep in mind that the dose you will need for a desired level of sedation will vary for each patient – and the dose you give should be based on your desired depth of sedation. Many of the strategies include pushing small maintenance doses given during the procedure to keep the desired response to stimuli while monitoring chest rise and EtCO2 waveform.

Procedural Sedation

Read more about the Ketofol Mixed 1 syringe method.​3,4​

Know your reversal agents if using opioids or benzodiazepines. Interested in opioid reversal? Check out our trick of the trade for naloxone dilution. Want to know more about flumazenil?​5​ The Canadian Medical Journal reviews five things to know about flumazenil in benzodiazepine reversal, and check out EMpharmD’s review of flumazenil usage.

Procedural Sedation Card PDF Printout

Cut out this procedure sedation reference pocket card. Fold on the dotted line, laminate, hole punch, and put on a badge clip. 

References

  1. 1.
    Stephen M Green et al. Unscheduled Procedural Sedation: A Multidisciplinary Consensus Practice Guideline. American College of Emergency Physicians. https://www.acep.org/patient-care/policy-statements/unscheduled-procedural-sedation-a-multidisciplinary-consensus-practice-guideline/. Published February 2019. Accessed September 26, 2019.
  2. 2.
    American S. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology. 2002;96(4):1004-1017. https://www.ncbi.nlm.nih.gov/pubmed/11964611.
  3. 3.
    Green S, Roback M, Kennedy R, Krauss B. Clinical practice guideline for emergency department ketamine dissociative sedation: 2011 update. Ann Emerg Med. 2011;57(5):449-461. https://www.ncbi.nlm.nih.gov/pubmed/21256625.
  4. 4.
    Krauss B, Green S. Procedural sedation and analgesia in children. Lancet. 2006;367(9512):766-780. https://www.ncbi.nlm.nih.gov/pubmed/16517277.
  5. 5.
    An H, Godwin J. Flumazenil in benzodiazepine overdose. CMAJ. 2016;188(17-18):E537. https://www.ncbi.nlm.nih.gov/pubmed/27920113.
Mac Chamberlin, MD

Mac Chamberlin, MD

Emergency Medicine Resident
Highland Hospital