II. Definitions

  1. Procedural Sedation and Analgesia (PSAA)
    1. Replaces the term Conscious Sedation
  2. Minimal Sedation
    1. Anxiolysis
    2. Normal response to verbal stimuli
    3. No Ventilatory depression
    4. No cardiovascular depression
  3. Moderate Sedation
    1. Depressed Level of Consciousness
    2. Purposeful response to verbal commands or light stimulation
    3. No Ventilatory depression
    4. No cardiovascular depression
  4. Deep Sedation
    1. Depressed Level of Consciousness
    2. Response only to repeated or painful stimuli
    3. Ventilatory depression may occur
    4. No cardiovascular depression
  5. General Anesthesia
    1. Depressed Level of Consciousness
    2. No arrousable
    3. Airway and Ventilatory support required
    4. Cardiovascular depression may occur
  6. Dissociative Sedation
    1. Trance state (cataleptic) induced by Ketamine
    2. Potent Analgesic and amnestic properties
    3. Maintains airway reflexes and spontaneous respirations
    4. Cardiovascular function maintained

III. Indications

  1. Adult precedural Sedation
    1. Fracture or dislocation reduction
    2. Significant Wound Debridement
    3. Rectal foreign body
    4. Ketamine is usually preferred in children
  2. Child Procedural Sedation
    1. Fracture or dislocation reduction
    2. Laceration Repair or Wound Debridement
    3. Abscess Incision and Drainage
    4. Imaging studies
    5. Ear Foreign Body
    6. Entrapment of penis in zipper

IV. Contraindications

  1. Significant or unstable cormorbid illness

V. History

  1. Last oral intake
  2. Medications
  3. Medication Allergies
  4. Serious medical conditions (affecting major organ systems)
    1. See ASA Physical Status Classification System
    2. Cerebrovascular Disease
    3. Coronary Artery Disease, Congestive Heart Failure or arrhythmia
    4. Obstructive Sleep Apnea, COPD or Asthma
    5. Chronic Kidney Disease
    6. Diabetes Mellitus

VI. Exam: Airway

VII. Preparation: Fasting

  1. Fasting is preferred but not required prior to procedure
  2. Food intake is not absolute contraindication
    1. Aspiration is less likely with Fasting
    2. Urgent procedures may be performed without Fasting
  3. Formal guidelines for elective procedures (per anesthesia)
    1. No clear liquids in last 2 hours
    2. No Breast Milk in 4 hours (or infant formula in 6 hours)
    3. No food, milk, solids in last 6 hours
  4. Consider risk factors for aspiration
    1. Advanced age
    2. Comorbid medical conditions
    3. Gastroesophageal Reflux risks (e.g. Hiatal Hernia, Bowel Obstruction, ileus, Peptic Ulcer Disease)
  5. No evidence to support prophylaxis
    1. No evidence for pre-procedural antacids, H2 Blockers or Anticholinergics
  6. Emergency department guidelines for NPO prior to Procedural Sedation
    1. Evidence does not support the same NPO guidelines in Emergency Department as for elective procedures
    2. ACEP guidelines note that recent food intake is not a contraindication to Procedural Sedation
      1. Godwin (2014) Ann Emerg Med 63(2): 247-58 +PMID:24438649 [PubMed]
    3. NPO duration prior to Procedural Sedation does not appear to impact risk of Vomiting or aspiration
      1. Molina (2010) Int J Evid Based Healthc 8(2): 75-8 [PubMed]
      2. Bell (2007) Emerg Med Australas 19(5): 405-10 [PubMed]

VIII. Preparation: Emergency Preparedness

  1. Requires provider experienced in Sedation
    1. Knowledgeable about sedatives and monitoring
    2. Skilled in ABC Management
    3. Assign one person (e.g. clinician, RN, RT, anesthesia) to monitor and manage anesthesia and respiratory status
      1. Capnography (End-Tidal CO2) may be adequate for monitoring (without additional required staff)
      2. However, many organizations require one trained practitioner dedicated to monitoring anesthesia
  2. Monitoring during procedure
    1. Continuous waveform End-Tidal CO2 Monitoring (Capnography)
      1. Commonly used for emergency department Procedural Sedation
        1. Not required per ACEP guidelines as of 2014
      2. Significantly increases early detection of repiratory depression and apnea
        1. Decreased Hypoxia risk by 10-20%
        2. Alerts to apnea 4-8 minutes before Oxygen Saturation changes
        3. Supplemental Oxygen delays oxygen desaturation during apnea
        4. Deitch (2010) Ann Emerg Med 55(3): 258-64 [PubMed]
      3. May not alter outcomes compared with standard monitoring
        1. van Loon (2014) Anesth Analg 119(1): 49-55 [PubMed]
      4. Available as part of a Nasal Cannula type device
      5. Technique for attaching to face mask
        1. Insert a 14 gauge angiocatheter through holes in face mask outflow
        2. Attach 14 gauge catheter to Capnography
    2. Cardiac monitoring
    3. Pulse Oximetry
      1. Not useful for timely diagnosis of apnea if Supplemental Oxygen used
      2. Identifying apnea during Sedation may be delayed as much as 4 minutes using Oxygen Saturation alone
      3. Use end tidal CO2 for patients on Supplemental Oxygen
  3. Emergency equipment
    1. Oxygen Delivery
      1. Apply Supplemental Oxygen to all patients undergoing Procedural Sedation
      2. Consider High Flow Oxygen for Apneic Oxygenation
    2. Airway Suction equipment
    3. Nasal Cannulas (see below)
    4. Bag-valve mask
      1. Administer a few breaths initially to assure that patients may be supported with with bag-valve mask
      2. Be ready for airway collapse (e.g. Sleep Apnea patient with a large Tongue)
        1. Jaw Thrust alone can significantly open the airway
        2. Assistant may be required to perform Jaw Thrust, while a second provider provides bag-valve-mask
        3. Consider inserting 2 Nasal Airways (and an Oral Airway may be inserted if no Gag Reflex)
    5. Intubation equipment
    6. Resuscitation cart
    7. Reversal agents
      1. Naloxone
      2. Flumazenil

IX. Preparation: BiPAP

  1. Indications
    1. Sleep Apnea patient with risk of airway compromise during procedure
    2. Elderly
  2. Starting setting
    1. Inspiratory pressure: 10 cm H2O
    2. Expiratory pressure: 5 cm H2O

X. Protocol: Two phase Approach (Hennepin protocol, per Jim Miner, MD)

  1. Obtain adequate analgesia with Opioids 20 minutes prior to Procedural Sedation
  2. Administer Procedural Sedation (e.g. Propofol) without analgesia (e.g. Fentanyl)
  3. Analgesia persists through procedure, while not complicating respiratory status

XI. Protocol: Difficult IV Access options

  1. Fentanyl and Versed intranasally
  2. Ketamine intramuscularly
  3. Methohexital (Brevital) rectally

XII. Preparations: Sedatives

  1. Ketamine
    1. Indications
      1. Preferred sedative in children
      2. Sedation in a patient with a potentially difficult airway
      3. Sedation in critically ill patient (where Hypotension risk with Propofol)
      4. ASA Physical Status Score 2 and 3
    2. Effects
      1. Analgesic and anesthetic properties
    3. IV
      1. Onset in 1 min, dissociation for 15 min, and recovery over 60 min
      2. Initial
        1. Adult: 1.0 mg/kg slow IV over 1-2 min
        2. Child: 1.5 mg/kg slow IV over 1-2 min
      3. Next
        1. Administer 1/2 of intial dose every 10 minutes as needed
    4. IM
      1. Onset in 3-5 min, dissociation for 15-30 min, and recovery over 90-150 min
      2. Initial: 4-5 mg/kg IM (adult and child)
      3. Repeat 4-5 mg/kg IM after 10 min for one dose if needed
    5. Adverse effects
      1. Laryngospasm (0.4% of cases, especially children)
        1. Typically transient, but risk of airway obstruction
      2. Risk of emergence reaction (e.g. agitation)
        1. Consider concurrent Midazolam in adults (0.03 mg/kg) to counter emergence reaction
        2. Sener (2011) Ann Emerg Med 57(2):109-114 [PubMed]
      3. Older data recommends avoiding in Closed Head Injury (risk of Increased Intracranial Pressure)
        1. Newer data suggests safe in Head Injury
      4. Hypersalivation
        1. Anticholinergics (Atropine, glycopyrrolate) are not recommended to dry secretions
        2. Green (2009) Ann Emerg Med 54(2): 171-80 +PMID:19501426 [PubMed]
  2. Propofol
    1. Indications
      1. Preferred sedative in adults
      2. Indicated for ASA Physical Status Score 2 (non-hypotensive, stable)
        1. Use Ketamine or Etomidate instead in patients at risk of Hypotension
    2. Adverse Effects
      1. Risk of Hypotension
    3. Effects
      1. Propofol is primarily anesthetic
      2. Administer concurrent Analgesics (e.g Fentanyl 50 mcg increments)
    4. Intravenous
      1. Adult
        1. Initial: 1 mg/kg IV over 20-30 seconds (typically given as smaller increments)
          1. Obese patients: Consider 0.7 to 0.8 mg/kg for starting dose
          2. Thin patients: Consider 1.5 mg/kg for starting dose
        2. Next: 0.5 mg/kg IV as needed (as often as every 90 seconds)
      2. Child
        1. Initial: 1 mg/kg IV (up to 40 mg) over 20-30 seconds (typically given as smaller increments)
        2. Next: 0.5 mg/kg IV (up to 20 mg) as needed
      3. Typically no respiratory depression at 1 mg/kg dose
        1. Amnesia occurs at this dose
        2. However, apnea may occur when Propofol is combined with Opioids
      4. Perform painful procedures immediately following infusion
        1. Amnestic effect wears off prior to Sedation
  3. Etomidate
    1. Indications
      1. Indicated for ASA Physical Status Score 2 and 3
      2. Consider for Sedation in hypotensive adult patient
        1. Otherwise Propofol is preferred adult sedative due to greater efficacy and less Myoclonus than Etomidate
        2. Miner (2007) Ann Emerg Med 49(1): 15-22 [PubMed]
    2. Adverse Effects
      1. Myoclonus (20-40% of cases)
        1. Administer Etomidate slowly over 90 seconds
        2. Pretreatment
          1. Fentanyl (or Alfentanil or Sufentanil)
          2. Alternatively, Magnesium Sulfate or Midazolam may be used as pretreatment
      2. Adrenal suppression
        1. Typically associated with continuous infusion
        2. Avoid in Sepsis
      3. Respiratory depression (10% of cases)
    3. Pharmacokinetics
      1. Onset: <1 minute
      2. Duration: 5-15 minutes
    4. Dosing
      1. IV: 0.15 to 0.2 mg/kg
        1. Repeat 0.05 mg/kg every 3-5 minutes as needed
  4. Pentobarbital
    1. Indicated in brief Sedation
      1. Ideal for CT Head (brief action, Seizure Prophylaxis)
      2. May be accompanied to CT with RN (low risk of respiratory depression, or other serious adverse effects)
    2. Observe for Hypotension
    3. Dose: 2.5 mg/kg IV (may repeat additional 1.25 mg/kg as needed twice)
  5. Methohexital (Brevital)
    1. Indications
      1. Propofol is preferred over Methohexital
      2. Consider methohexital where unable to obtain Intravenous Access (can be given rectally)
    2. Barbiturate with rapid onset of action
    3. Paradoxically lowers Seizure threshold (in contrast to other barbiturates which are used to a abort Seizures)
    4. In case of laryngospasm, give a full dose (additional Methohexital) to fully supersaturate GABA receptors
  6. Ketaphol (Ketamine with Propofol)
    1. Postulated to reduce risk of Hypotension and apnea of Propofol by cutting dose with Ketamine
      1. Initial studies recommended ratio of 4:1 Propofol to Ketamine for adequate effect
      2. Some protocols start 1:1 ratio Propofol to Ketamine 0.5 then add Propofol to effect
    2. Variable efficacy: Some studies show no significant benefit over Propofol alone
      1. Andolfatto (2012) Ann Emerg Med 59(6): 504-12 [PubMed]
      2. Nejati (2011) Acad Emerg Med 18(8): 800 [PubMed]
    3. Typical protocol
      1. Start: Administer mix of Propofol 0.5 mg/kg AND Ketamine 0.5 mg/kg
      2. Next: Administer additional Propofol 0.5 mg/kg every 90 seconds as needed to adequate effect
  7. Midazolam (Versed)
    1. Intravenous (onset 2-3 min and lasts 45-60 min)
      1. Age 6 months to 5 years
        1. Initial: 0.05 to 0.1 mg/kg IV
        2. Titrate: Up to 1 mg increments IV every 3 min to max of 0.6 mg/kg
      2. Age 6 to 12 years
        1. Initial: 0.025 to 0.05 mg/kg IV
        2. Titrate: Up to 1 mg increments IV every 3 min to max of 0.4 mg/kg
      3. Adults (and over age 12 years)
        1. Initial: 0.02 mg/kg IV (1-2 mg IV)
        2. Titrate: 1 mg increments IV every 3 min
    2. IM (onset 10-20 min and lasts 60-120 min)
      1. Child: 0.1 to 0.15 mg/kg
      2. Adult: 0.07 mg/kg up to 5mg
    3. Oral: 0.5 mg/kg
    4. Nasal: 0.2 to 0.5 mg/kg intranasal (1/2 in each nostril) using 5 mg/ml up to 10 mg
    5. Rectal 0.25 to 0.5 mg/kg per Rectum
    6. Commonly used in combination with Fentanyl
      1. When combined with Opioids (e.g. Fentanyl), use lower Midazolam dose
    7. Unpredictable at increased doses (risk of respiratory and cardiovascular depression)
      1. Best delivered in incremental doses (e.g. 1 mg increments)
      2. Exercise extra caution in elderly, debilitated and children
    8. Reversal: Flumazenil

XIII. Preparations: Analgesics

  1. Fentanyl
    1. Nasal: 2 mcg/kg intranasal (1/2 in each nostril)
    2. Nebulized: 4 mcg/kg in breath activated neb
      1. As effective as IV morphine using ultrasonic nebulizer with tight fitting mask
      2. Farahmand (2014) Am J Emerg Med 32(9):1011-5 +PMID:25027194 [PubMed]
    3. IV (onset in 3-5 min, lasting 30-60 min)
      1. Adult: 50 mcg/dose every 3 minutes, titrating to effect
      2. Child: 1 mcg/kg/dose IV every 3 minutes, titrating to effect
        1. Age 1-3 years old: 2-3 mcg/kg/dose every 30-60 minutes as needed
        2. Age 3-12 years old: 1-2 mcg/kg/dose every 30-60 minutes as needed
        3. Age >12 years old: 0.5-1 mcg/kg/dose every 30-60 minutes as needed
    4. Reversal: Naloxone
    5. Use lower doses in combination with Midazolam (Versed)
  2. Morphine
    1. IV/IM/SC: 0.05 to 0.2 mg/kg every 2-4 hours up to 15 mg (typically given in 2-4 mg increments)
    2. Reversal: Naloxone
  3. Oxycodone (immediate release)
    1. Oral route (better than IM opiods, without significant delay)
      1. Adults (and over age 12 years) 5-10 mg every 4-6 hours as needed
      2. Child: 0.05 to 0.3 mg/kg/dose (up to 10 mg) every 4-6 hours as needed
    2. Reversal: Naloxone
  4. Hydrocodone-Acetaminophen (Vicodin or Lortab) 2.5 mg/5 ml elixir
    1. Oral: 0.2 mg/kg (up to 1.25 mg if under age 2 years, and up to 5 mg if age 2-12 years)
    2. Reversal: Naloxone
  5. Ketorolac (Toradol)
    1. IV/IM: 0.5 mg/kg (up to 30 mg)
  6. Nitrous Oxide
    1. Mixed with 40% oxygen (pre-set)
    2. Dose is self administered by patient breathing through demand valve mask
    3. Onset within 5 minutes and duration <5 minutes after discontinuing
    4. Activity is similar to Opioids
    5. Consider for IV Access start

XIV. Preparations: Older agents to avoid (replaced by other agents above)

  1. Chloral Hydrate
    1. Older oral Sedation agent similar to Ethanol with GABA-receptor mediated effects
    2. Rapidly metabolized to the active form, trichloroethanol
    3. Agitation and Nausea are common
    4. Common use among pediatric dentists (with case reports of outpatient pediatric deaths)
    5. Ketamine or oral/intranasal Midazolam are far preferred over oral Chloral Hydrate

XV. Management: Disposition

  1. Continue monitoring until no risk of respiratory depression
  2. Observe for at least 2 hours if any reversal agent used (e.g. Naloxone, Flumazenil)
  3. Discharge after patient is alert and back to baseline mental status
  4. Give discharge instructions
    1. Family or friend should observe the patient for several hours after discharge
    2. Patients may expect Nausea, Fatigue or light headedness for up to 24 hours after discharge

XVI. References

  1. Braude in Herbert (2013) EM:Rap 13(11): 14
  2. Kay (2015) Crit Dec Emerg Med 29(8): 11-17
  3. Lester and Braude in Herbert (2014) EM:Rap 14(5): 5-6
  4. Weingart in Majoewsky (2012) EM:RAP 12(2): 8
  5. Miner (2012) APLS Lecture, HCMC, Minneapolis
  6. Hamilton (2012) Tarascon Pharmacopeia, Jones and Bartlett, Burlington
  7. Rispoli (2002) Tarascon Pocket Orthopedics, Loma Linda, p. 115
  8. Singh in Blaivas (2012) Emergency Medicine - an International Perspective, p. 199-208
  9. University Minnesota Childrens - Pediatric Emergency Drug Card
  10. Becker (2012) Anesth Prog 59:28-42 [PubMed]
  11. Brown (2005) Am Fam Physician 71:85-90 [PubMed]
  12. Godwin (2014) Ann Emerg Med 63(2): 247-58 [PubMed]

Images: Related links to external sites (from Bing)

Related Studies (from Trip Database) Open in New Window

Ontology: Conscious Sedation (C0079159)

Definition (MSH) A drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway. (From: American Society of Anesthesiologists Practice Guidelines)
Concepts Therapeutic or Preventive Procedure (T061)
MSH D016292
SnomedCT 314271007
LNC LP97904-4
English Conscious Sedation, Sedation, Conscious, Moderate Sedation, Sedation, Moderate, Conscious sedation (procedure), Induction of conscious sedation, Induction of conscious sedation (procedure), Moderate sedation, conscious sedation, conscious sedation (medication), sedation conscious, Conscious sedation
Swedish Sedering
Portuguese Sedação Moderada, Sedação Consciente
Spanish inducción de sedación consciente, sedación consciente (procedimiento), inducción de sedación consciente (procedimiento), Sedación Moderada, sedación consciente, Sedación Consciente
Finnish Sedaatio
French Sédation consciente, Sédation modérée
Russian OBEZBOLIVANIE PRI SOKHRANENII SOZNANIIA, ОБЕЗБОЛИВАНИЕ ПРИ СОХРАНЕНИИ СОЗНАНИЯ
Italian Sedazione moderata, Sedazione cosciente
Croatian SEDACIJA S OČUVANJEM SVIJESTI
Polish Sedacja płytka, Uspokojenie polekowe z zachowaniem przytomności, Sedacja z zachowaniem świadomości, Umiarkowana sedacja
Japanese 意識下鎮静法, 意識下鎮静
Norwegian Sedering, bevisst, Moderat sedering, Våken sedasjon, Sedasjon, bevisst, Moderat sedasjon
Czech sedace při zachování vědomí, sedace při vědomí, analgosedace
German Analgosedierung, Sedierung, bewußte
Dutch Analgosedatie, Sedatie, analgo-

Ontology: Sedation procedure (C0344106)

Definition (NCI) The process of allaying nervous excitement or the state of being calmed. (Taber's)
Concepts Therapeutic or Preventive Procedure (T061)
ICD10 1911
SnomedCT 408498008, 72641008
Spanish administración de sedante, administración de sedante (procedimiento), procedimiento de sedación, sedación (procedimiento), sedación, Terapia de sedación
Italian Terapia sedativa
Japanese 鎮静療法, チンセイリョウホウ
English Sedation procedure, sedation, sedation [procedure], Sedative therapy (procedure), SEDATION, Sedation, Administration of sedative (procedure), Administration of sedative, Sedative therapy, Sedation procedure, NOS, Sedation, NOS, Sedation (procedure)
Czech Léčba sedativy
Hungarian Sedativ kezelés
Portuguese Terapia sedativa
Dutch sedatietherapie
French Traitement sédatif
German Therapie mit Beruhigungsmitteln

Ontology: Deep Sedation (C1956064)

Definition (MSH) Drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposely following repeated painful stimulation. The ability to independently maintain ventilatory function may be impaired. (From: American Society of Anesthesiologists Practice Guidelines)
Concepts Therapeutic or Preventive Procedure (T061)
MSH D054810
English Deep Sedation, Sedations, Deep, Sedation, Deep, Deep Sedations
Portuguese Sedação Profunda
Spanish Sedación Profunda
Finnish Syvä sedaatio
French Sédation profonde
German Tiefe Sedierung, Sedierung, Tiefe
Italian Sedazione profonda
Russian СЕДАТИВНЫЙ ЭФФЕКТ ГЛУБОКИЙ, УСПОКОЕНИЕ ГЛУБОКОЕ, USPOKOENIE GLUBOKOE, SEDATIVNYI EFFEKT GLUBOKII, ГЛУБОКАЯ СЕДАЦИЯ, GLUBOKAIA SEDATSIIA
Swedish Djup sedering
Czech hluboká sedace, hluboké zklidnění
Polish Sedacja głęboka
Japanese 深鎮静法, 深い鎮静, 鎮静法-深
Norwegian Dyp sedasjon, Dyp sedering