Procedural Sedation and Analgesia in the Emergency Department (Pharmacology CME)

Table of Contents

 

About This Issue

When performing a painful procedure is necessary in the ED, making sure each patient receives the safest and most effective procedural sedation and analgesia (PSA) will improve the chances for success of the procedure as well as ensuring patient comfort and satisfaction. In this issue, you will learn:

How the history and physical examination will point to potential risks with particular PSA drugs and procedures.

What the most current evidence is on how many clinician providers are needed for safety.

Why preprocedural fasting is no longer required.

How to use the algorithm for airway rescue.

Capnography, pulse oximetry, and oxygen administration: how they can work together to minimize adverse events.

Which of the preprocedural treatments—opioids, anticholinergics, and antiemetics—are useful, and which are not.

The pros and cons of PSA agents: opioids, benzodiazepines, nitrous oxide, propofol, ketamine, ketofol, and etomidate.

Which reversal agents are helpful, and which are not recommended.

1. About This Issue
2. Abstract
3. Case Presentations
4. Introduction
5. Overview of Sedation Levels
6. Critical Appraisal of the Literature
7. Prehospital Care
8. Emergency Department Evaluation
   1. Patient Assessment
9. Procedural Technique
   1. The Two-Physician Model Versus the One-Physician Model for Procedure Personnel
   2. Preprocedural Fasting
   3. Capnography
   4. Pulse Oximetry and Oxygen Administration
   5. Preprocedural Treatments and Adjuncts
      1. Preprocedural Opioids
      2. Preprocedural Sedatives
      3. Anticholinergics
      4. Antiemetics
10. Treatment
    1. Opioids
    2. Benzodiazepines
    3. Nitrous Oxide
    4. Propofol
    5. Ketamine
       1. Contraindications for Ketamine
    6. Ketamine-Propofol or “Ketofol”
       1. Ketofol Use in Children
    7. Etomidate
    8. Reversal Agents
       1. Naloxone
       2. Flumazenil
11. Special Populations
    1. Pediatric Patients
    2. Pregnant Patients
    3. Elderly Patients
    4. Patients With ASA Physical Status Class ≥III
12. Controversies and Cutting Edge
    1. Dexmedetomidine
    2. Target-Controlled Infusion
    3. Bispectral Index System
    4. Peripheral Tissue Oxygen Saturation Monitoring
13. Disposition
14. Summary
15. Time and Cost-Effective Strategies
16. 5 Things That Will Change Your Practice
17. Risk Management Pitfalls for Procedural Sedation and Analgesia in the Emergency Department
18. Case Conclusions
19. Clinical Pathway for Procedural Sedation and Analgesia in the Emergency Department
20. Tables and Figures
21. References

Abstract

Procedural sedation is a common procedure performed in the emergency department and is a fundamental skill for emergency clinicians. With a wide variety of procedures and patient populations, procedural sedation can be systematically tailored to individual patients‘ needs, in order to optimize safety and efficacy. This evidence-based review distinguishes the various levels of sedation, provides insight on which patients are appropriate for procedural sedation, lists adjuncts that should be used, and reviews considerations for special populations. The differences between the most frequently utilized medications are presented, as well as a discussion of documentation requirements and discharge criteria.

Case Presentations

A 30-year-old man with no past medical history presents to the ED after falling off a ladder, landing on his right shoulder…

• You perform a 3-view shoulder x-ray and find that his right shoulder is anteriorly dislocated.
• The patient states that he had eaten lunch just prior to this event. The patient is in pain and very resistant to any manipulation.
• You know that procedural sedation will be needed, but you wonder if he is eligible since he just ate . . .

An 80-year-old man with a past medical history of congestive heart failure, hypertension, and diabetes presents to the ED with chest pain…

• His initial ECG demonstrates ventricular tachycardia. He has lower extremity edema with bibasilar rales on exam. He is hypotensive, with a blood pressure of 85/52 mm Hg.
• You make the decision that cardioversion with procedural sedation is indicated, but you wonder what would be the best drug(s) to use, given his comorbidities, and whether his ASA physical status class impacts your decision . . .

A 56-year-old obese woman with a history of alcohol abuse, obstructive sleep apnea, and diabetes presents with multiple deep lacerations…

• She states that she was intoxicated and trying to jump over a wire fence when her leg got caught on the edge and she fell backwards, suffering large lacerations on her right leg as well as her face.
• Both wounds appear to be contaminated. She is hysterical and unable to cooperate with your attempts to irrigate and repair her wounds. She asks for medication to help reduce her pain and anxiety, so you decide to perform procedural sedation.
• Given her comorbidities and presentation, what agent(s) would be safest to use in this patient? What adjuncts would be best for these procedures? What are some expected complications and how can you best prepare for them?

How would you manage these patients? Subscribe for evidence-based best practices and to discover the outcomes.

Clinical Pathway for Procedural Sedation and Analgesia in the Emergency Department

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Tables and Figures

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Key References

Following are the most informative references cited in this paper, as determined by the authors.

2. American Society of Anesthesiologists Committee on Quality Management and Departmental Administration. Continuum of depth of sedation: definition of general anesthesia and levels of sedation/analgesia. 2019. Accessed May 10, 2022. (Clinical practice statement)

3. U.S. Department of Health and Human Services; Centers for Medicare and Medicaid Services. State Operations Manual; Appendix A - Survey Protocol, Regulations and Interpretive Guidelines for Hospitals. 2020. Accessed May 10, 2022. (HHS hospital guidelines)

4. * Godwin SA, Burton JH, Gerardo CJ, et al. Clinical policy: procedural sedation and analgesia in the emergency department. Ann Emerg Med. 2014;63(2):247-258. (Practice guidelines) DOI: 10.1016/j.annemergmed.2013.10.015

10. American Society of Anesthesiologists Committee on Economics. ASA Physical Status Classification System. 2020. Accessed May 10, 2022. (Consensus guidelines)

15. * Miller KA, Andolfatto G, Miner JR, et al. Clinical practice guideline for emergency department procedural sedation with propofol: 2018 update. Ann Emerg Med. 2019;73(5):470-480. (Practice guidelines) DOI: 10.1016/j.annemergmed.2018.12.012

17. * Stewart RJ, Strickland CD, Sawyer JR, et al. Hunger games: impact of fasting guidelines for orthopedic procedural sedation in the pediatric emergency department. J Emerg Med. 2021;60(4):436-443. (Retrospective; 2674 patients) DOI: 10.1016/j.jemermed.2020.10.038

24. * Wall BF, Magee K, Campbell SG, et al. Capnography versus standard monitoring for emergency department procedural sedation and analgesia. Cochrane Database Syst Rev. 2017;3(3):CD010698. (Cochrane review; 3 trials, 1272 participants) DOI: 10.1002/14651858.CD010698.pub2

38. * Bhatt M, Johnson DW, Chan J, et al. Risk factors for adverse events in emergency department procedural sedation for children. JAMA Pediatr. 2017;171(10):957-964. (Prospective; 6295 patients) DOI: 10.1001/jamapediatrics.2017.2135

50. * Bellolio MF, Puls HA, Anderson JL, et al. Incidence of adverse events in paediatric procedural sedation in the emergency department: a systematic review and meta-analysis. BMJ Open. 2016;6(6):e011384. (Systematicic review and meta-analysis; 41 studies, 13,883 sedations) DOI: 10.1136/bmjopen-2016-011384

51. * Bellolio MF, Gilani WI, Barrionuevo P, et al. Incidence of adverse events in adults undergoing procedural sedation in the emergency department: a systematic review and meta-analysis. Acad Emerg Med. 2016;23(2):119-134. (Systematic review and meta-analysis; 55 studies, 9652 sedations) DOI: 10.1111/acem.12875

64. * Jalili M, Bahreini M, Doosti-Irani A, et al. Ketamine-propofol combination (ketofol) vs propofol for procedural sedation and analgesia: systematic review and meta-analysis. Am J Emerg Med. 2016;34(3):558-569. (Systematic review and meta-analysis) DOI: 10.1016/j.ajem.2015.12.074

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Keywords: procedure, sedation, analgesia, anesthesia, pain, OSA, airway, laryngospasm, capnography, fasting, oximetry, oxygen, opioids, anticholinergic, antiemetic, benzodiazepine, propofol, ketamine, ketofol, etomidate, naloxone, flumazenil