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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.
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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
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)
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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.
CME Objectives
CME Information
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.
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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.
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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.
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