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.
How would you manage these patients? Subscribe for evidence-based best practices and to discover the outcomes.
Subscribe to access the complete flowchart to guide your clinical decision making.
Subscribe for full access to all Tables and Figures.
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
Subscribe to get the full list of 93 references and see how the authors distilled all of the evidence into a concise, clinically relevant, practical resource.
Keywords: procedure, sedation, analgesia, anesthesia, pain, OSA, airway, laryngospasm, capnography, fasting, oximetry, oxygen, opioids, anticholinergic, antiemetic, benzodiazepine, propofol, ketamine, ketofol, etomidate, naloxone, flumazenil
Dr. Ashoo is a practicing emergency physician, board-certified in emergency medicine and clinical informatics. Join him as he takes you through the June 2022 issue of Emergency Medicine Practice: Procedural Sedation and Analgesia in the Emergency Department (Pharmacology CME)
Joshua Kern, MD; Alexander Guinn, MD; Prayag Mehta, MD
Jennifer Maccagnano, DO, FACEP, FACOEP; Mark Silverberg, MD
June 1, 2022
June 30, 2025
4 AMA PRA Category 1 Credits™, 4 ACEP Category I Credits, 4 AAFP Prescribed Credits, 4 AOA Category 2-A or 2-B Credits. Specialty CME Credits: Included as part of the 4 credits, this CME activity is eligible for 2 Pharmacology CME credits.
Date of Original Release: June 1, 2022. Date of most recent review: May 10, 2022. Termination date: June 1, 2025.
Accreditation: EB Medicine is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians. This activity has been planned and implemented in accordance with the accreditation requirements and policies of the ACCME.
Credit Designation: EB Medicine designates this enduring material for a maximum of 4 AMA PRA Category 1 CreditsTM. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
Specialty CME: Included as part of the 4 credits, this CME activity is eligible for 2 Pharmacology CME credits, subject to your state and institutional requirements.
ACEP Accreditation: Emergency Medicine Practice is approved by the American College of Emergency Physicians for 48 hours of ACEP Category I credit per annual subscription.
AAFP Accreditation: The AAFP has reviewed Emergency Medicine Practice, and deemed it acceptable for AAFP credit. Term of approval is from 07/01/2021 to 06/30/2022. Physicians should claim only the credit commensurate with the extent of their participation in the activity.
AOA Accreditation: Emergency Medicine Practice is eligible for 4 Category 2-A or 2-B credit hours per issue by the American Osteopathic Association.
Needs Assessment: The need for this educational activity was determined by a practice gap analysis; a survey of medical staff, including the editorial board of this publication; review of morbidity and mortality data from the CDC, AHA, NCHS, and ACEP; and evaluation responses from prior educational activities for emergency physicians.
Target Audience: This enduring material is designed for emergency medicine physicians, physician assistants, nurse practitioners, and residents.
Goals: Upon completion of this activity, you should be able to: (1) identify areas in practice that require modification to be consistent with current evidence in order to improve competence and performance; (2) develop strategies to accurately diagnose and treat both common and critical ED presentations; and (3) demonstrate informed medical decision-making based on the strongest clinical evidence.
Discussion of Investigational Information: As part of the activity, faculty may be presenting investigational information about pharmaceutical products that is outside Food and Drug Administration approved labeling. Information presented as part of this activity is intended solely as continuing medical education and is not intended to promote off-label use of any pharmaceutical product.
Faculty Disclosure: It is the policy of EB Medicine to ensure objectivity, balance, independence, transparency, and scientific rigor in all CME activities. All faculty participating in the planning or implementation of a CME activity are expected to disclose to the participants any relevant financial relationships and to assist in resolving any conflict of interest that may arise from the relationship. In compliance with all ACCME accreditation requirements and policies, all faculty for this CME activity were asked to complete a full financial disclosure statement. The information received is as follows: The authors, Dr. Joshua Kern, Dr. Alexander Guinn, and Dr. Prayag Mehta; the peer reviewers, Dr. Jennifer Maccagnano and Dr. Mark Silverberg; the Editor-in-Chief, Dr. Andy Jagoda; the Associate Editor-in-Chief, Dr. Kaushal Shah; the Planning Peer Reviewer, Dr. Daniel Egan; and the Research Editors, Dr. Aimee Mishler and Dr. Joseph Toscano report no relevant financial relationships with ineligible companies.
Commercial Support: This issue of Emergency Medicine Practice did not receive any commercial support.
Earning Credit: (1) Go online to www.ebmedicine.net/CME and click on the title of the test you wish to take. When completed, a CME certificate will be emailed to you.
Hardware/Software Requirements: You will need a Macintosh or PC with internet capabilities to access the website.
Additional Policies: For additional policies, including our statement of conflict of interest, source of funding, statement of informed consent, and statement of human and animal rights, visit https://www.ebmedicine.net/policies.