Procedural Sedation and Analgesia

Aka: Procedural Sedation and Analgesia, Procedural Sedation, Procedural Anesthesia, Conscious Sedation, Deep Sedation, Sedative, PSAA

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II. Definitions

  1. Procedural Sedation and Analgesia (PSAA)
    1. Replaces the term Conscious Sedation
    2. Administer Sedatives (e.g. Propofol) or dissociative agents (e.g. Ketamine), with or without Analgesics (e.g. Fentanyl)
    3. Induce Altered Level of Consciousness while still preserving cardiopulmonary function
  2. Light Sedation (sedation score 1)
    1. Anxiolysis
    2. Normal response to verbal stimuli
      1. Near baseline level of alertness
      2. Coordination or cognition may be impaired
    3. No Ventilatory depression
    4. No cardiovascular depression
  3. Moderate Sedation (sedation score 2)
    1. Depressed Level of Consciousness
    2. Purposeful response to verbal commands or light stimulation
      1. Drooping Eyelids and slurred speech
      2. Delayed verbal response
      3. Often associated with Amnesia around the period of the procedure
    3. No airway compromise
    4. No Ventilatory depression
    5. No cardiovascular depression
  4. Dissociative Sedation (i.e. Ketamine)
    1. Trance state (cataleptic) induced by Ketamine
    2. Potent Analgesic and amnestic properties
    3. Maintains airway reflexes and spontaneous respirations
    4. Cardiovascular function maintained
  5. Deep Sedation (sedation score 3)
    1. Depressed Level of Consciousness
    2. Response only to repeated or painful stimuli
    3. Ensure airway protection
    4. Ventilatory depression may occur
    5. No cardiovascular depression
  6. General Anesthesia (sedation score 4)
    1. Depressed Level of Consciousness
    2. Not arrousable to painful stimuli
    3. Airway and Ventilatory support required
    4. Cardiovascular depression may occur

III. Background

  1. Painful surgical procedures have been documented for >2000 years
    1. However, painful procedures were limited to life-threatening conditions due to a lack of adequate Anesthesia
  2. Procedural Sedation, Anesthesia and analgesia are modern advances starting in the 1800s
    1. General Anesthesia (Ether, Nitrous Oxide and chloroform) was first introduced in the 1840s
    2. Lead to development of modern surgery, antiseptic techniques and ultimately to Advanced Airway management

IV. Indications

  1. Adult precedural sedation
    1. Fracture or dislocation reduction
    2. Significant Wound Debridement (e.g. extensive Burn Injury)
    3. Complicated Foreign Body Removal (e.g. Rectal Foreign Body)
    4. Deep Incision and Drainage procedures
    5. Endoscopy
    6. Bronchoscopy
    7. Electrical cardioversion
    8. Painful procedures intolerable due to patient specific factors (e.g. anxiety, Chronic Pain)
  2. Child Procedural Sedation
    1. Fracture or dislocation reduction
    2. Laceration Repair or Wound Debridement
    3. Abscess Incision and Drainage
    4. Advanced Imaging studies requiring a motionless patient (e.g. MRI)
    5. Ear Foreign Body
    6. Entrapment of penis in zipper

V. Contraindications

  1. Patient refusal
  2. Significant or unstable cormorbid illness (e.g. hemodynamic instability)
  3. ASA Physical Status Classification System 4-5 (caution in Class 3)

VI. History

  1. Last oral intake
  2. Medications
  3. Medication Allergies
  4. Prior reaction to Anesthesia or analgesia
  5. Conditions affecting the airway
    1. Stridor
    2. Obstructive Sleep Apnea
    3. Cervical Spine rhumatologic disorders with risk of C2 subluxation (e.g. Rheumatoid Arthritis, Ankylosing Spondylitis)
    4. Congenital disorders affecting the spine or airwar (e.g. Down Syndrome, dysmorphic facial features)
    5. Prior difficult Endotracheal Intubation
    6. Prior head and neck Radiation Therapy
    7. Acute respiratory infections (currently active)
  6. Serious medical conditions (affecting major organ systems)
    1. ASA Physical Status Classification System >=3
    2. Cerebrovascular Disease
    3. Coronary Artery Disease, Congestive Heart Failure or Arrhythmia
    4. COPD
    5. Chronic Kidney Disease
    6. Diabetes Mellitus
    7. Asthma or active Upper Respiratory Infection
      1. Increased risk of laryngospasm
  7. Perform consent
    1. Procedure intended under Deep Sedation

VII. Exam

  1. Baseline Vital Signs
  2. Body weight and height
    1. Obesity
    2. Dosing (based on Ideal Body Weight)
    3. Tidal Volume if Ventilatory support needed (based on height)
  3. Assess for major factors contributing to difficult airway
    1. See Difficult Airway Assessment
    2. LEMON Mnemonic
    3. Mallampati Score
    4. Limited neck extension (<70 degrees, e.g. prior cervical fusion)
    5. Macroglossia
    6. Neck Mass
    7. Facial hair (may interfere with BVM seal)
  4. Facial features associated with more difficult airways
    1. Significant facial Trauma or facial anatomy distortion
    2. High arched Palate
    3. Small Mandible or Micrognathia
    4. Low Set Ears
    5. Short or large circumference neck

VIII. Preparation: Fasting

  1. Fasting is preferred but not required prior to urgent or emergent procedures
    1. Moderate aspiration risk factors AND urgent or emergent procedure
      1. Consider Ketamine sedation with Ondansetron
      2. Consider anesthesia Consultation
    2. Elective procedures, however, should follow Anesthesia guidelines
      1. See Aspiration risk factors below
      2. No major aspiration risk factors: No Fasting needed
      3. Mild aspiration risk factors: No food within 4 hours (but clear liquids may be taken before procedure)
      4. Moderate aspiration risk factors: Consult Anesthesia
    3. References
      1. Green (2020) Anaesthesia 75(3):374-85 +PMID: 31792941 [PubMed]
  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 (older Anesthesia guidelines pre-dating 2020 guidelines)
    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 pulmonary aspiration
    1. Mild Risk Factors
      1. Severe systemic disease
      2. Body Mass Index (BMI) 30-39
      3. Age <12 months
      4. Hiatal Hernia
      5. Upper endoscopy
      6. Bronchoscopy
    2. Moderate Risk Factors
      1. Life-threatening disease
      2. Body Mass Index (BMI) >=40
      3. Obstructive Sleep Apnea
      4. Micrognathia
      5. Macroglossia
      6. Airway disorders
      7. Achalasia
      8. Gastroparesis
      9. Small Bowel Obstruction
    3. Other factors with increased perioperative Vomiting risk
      1. Advanced age
      2. Pregnancy
      3. Ketamine is associated with peri-procedural Vomiting in up to 28% of children
      4. Full Stomach
  5. No evidence to support Vomiting prophylaxis
    1. May consider Nasogastric Tube at start of procedure (after sedation started)
    2. No evidence for pre-procedural Antacids, H2 Blockers or Anticholinergics
      1. However, H2 Blockers or Metoclopramide is often given prophylactically in pregnancy
    3. Pre-procedural Ondansetron may be considered if higher aspiration risk
      1. However, no consistent evidence of benefit
      2. Lee (2014) J Paediatr Child Health 50(7): 557-61 [PubMed]
      3. Lee (2008) Ann Emerg Med 52(10: 30-4 [PubMed]
  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]

IX. Preparation: Emergency Preparedness

  1. Requires provider experienced in sedation
    1. Knowledgeable about Sedatives and monitoring
    2. Skilled in ABC Management
    3. Assign one person to monitor and manage Anesthesia and respiratory status (e.g. clinician, RN, RT, Anesthesia)
      1. Other clinician focuses on the procedure
      2. Capnography (End-Tidal CO2) may be adequate for monitoring (without additional required staff)
      3. However, many organizations require one trained practitioner dedicated to monitoring Anesthesia
    4. Often simple maneuvers are effective for apneic periods
      1. Chin-lift with or without Jaw Thrust (often clears airway obstruction)
      2. Apneic Oxygenation (see below)
      3. Noxious stimulation may stimulate breaths
    5. Perform Time Out before procedure
      1. Verify patient name, date of birth, medical record number
      2. Verify type and location of procedure
  2. Monitoring during procedure
    1. Level of Consciousness
      1. Record every 5 minutes
    2. Blood Pressure Monitoring
      1. Automatic cuff cycled at least every 5 minutes
    3. Continuous waveform End-Tidal CO2 Monitoring (Capnography)
      1. Abnormal Findings
        1. Bradypneic Hypoventilation
          1. Increased ETCO2 >50 mmHg
          2. Decreased Respiratory Rate
        2. Hypopneic hypoventilation
          1. Decreased ETCO2 <30 mmHg (or >10 mmHg drop from baseline)
          2. Decreased respiratory effort, but normal Respiratory Rate
      2. Commonly used for emergency department Procedural Sedation
        1. Not required per ACEP guidelines as of 2014
      3. 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]
      4. May not alter outcomes compared with standard monitoring
        1. van Loon (2014) Anesth Analg 119(1): 49-55 [PubMed]
      5. Available as part of a Nasal Cannula type device
      6. 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
    4. Cardiac monitoring
    5. 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
        1. Decreases Incidence of Hypoxia and allows for brief periods of apnea during Procedural Sedation
        2. Supplemental O2 is controversial, as some argue it delays apnea recognition (if not on EtCO2)
      2. Consider High Flow Oxygen for Apneic Oxygenation
        1. Nasal Cannula 15 L or
        2. Non-Rebreather Mask
          1. Start at 15 L before sedation
          2. Turn to flush rate (50 L)
            1. Patient instructed to take 6 Vital Capacity breaths (clears nitrogen)
            2. Start sedation
            3. Continue flush rate (50 L) oxygen throughout the procedure
    2. Airway Suction equipment
    3. Nasopharyngeal Airway (Nasal Trumpet)
    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
        1. Only use if not on chronic Benzodiazepines (risk of acute withdrawal and Status Epilepticus)

X. Preparation: Resource Limited Environments (e.g. low and middle income countries)

  1. See Resource Limited Environment
  2. Consider alternatives to Conscious Sedation
    1. Defer non-emergent procedures to the most appropriate available local options
    2. Local or Regional Anesthesia is preferred
    3. Consider non-intravenous options as listed below
  3. Preparation
    1. Familiarize yourself with locally available medications
    2. Follow a pre-procedure checklist
    3. Prepare the evironment
      1. Adequate lighting
      2. Clean, organized work area
      3. Disrobe patient for adequate access
    4. Alert all staff to remain vigilant throughout procedure
      1. Assign one person dedicated solely to monitoring during the procedure
    5. Obtain IV Access
      1. Infuse crystalloid (NS or LR)
      2. Consider initial 500 cc or 10-20 cc/kg bolus
    6. Monitoring equipment as available
    7. Emergency airway and breathing equipment prepared and ready for use (ideally as above)
  4. Airway Monitoring
    1. Maintain airway with Jaw Thrust
    2. Monitor for airway obstruction
    3. Nasopharyngeal Airway, suction and intubation equipment should be ready
  5. Breathing monitoring
    1. Pulse Oximeter (preferred if available)
      1. If not available, continuously auscultate Respiratory Rate, volume, rhythm and observe chest rise
    2. Supplemental Oxygen
      1. If not available, use bag-valve mask to improve oxygenation by preventing Atelectasis
  6. Circulation monitoring
    1. Obtain Blood Pressure every 5 minutes
    2. Continuous Pulse Oximetry
      1. If not available, palpate pulse or auscultate heart sounds continuously
  7. References
    1. Acker, Koval and Leeper (2017) Crit Dec Emerg Med 31(4): 3-13

XI. Preparation: BiPAP or CPAP

  1. Indications
    1. Sleep Apnea patient with risk of airway compromise during procedure
    2. Obesity
    3. Elderly
  2. Starting setting (use patient's home settings if known)
    1. Inspiratory pressure: 10 cm H2O
    2. Expiratory pressure: 5 cm H2O
  3. Precautions
    1. Requires vigilant observation for apnea and aspiration risk
    2. Suction should be on with attached catheter (e.g. yanker)
      1. Remove mask immediately and suction for any signs of imminent Vomiting

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

  1. Obtain adequate analgesia with Opioids >20-30 minutes prior to Procedural Sedation (e.g. Dilaudid, Morphine or Fentanyl)
    1. Analgesics are given prior to Sedatives
    2. Increased complications when Opioids are given close to the time of sedation
  2. Administer Procedural Sedation (e.g. Propofol) without analgesia (e.g. Fentanyl)
  3. Analgesia persists through procedure, while not complicating respiratory status

XIII. Protocol: Difficult IV Access options

  1. Intranasal medications
    1. Fentanyl
    2. Midazolam (Versed)
    3. Lidocaine
    4. Dexmedetomidine (Precedex)
  2. Intramuscular Medications
    1. Ketamine
    2. Midazolam (Versed)
    3. Hydromorphone (Dilaudid)
  3. Rectal Medications
    1. Methohexital (Brevital)
    2. Diazepam (Valium)
    3. Midazolam (Versed)

XIV. Precautions

  1. Monitor patient response (grimace, whimper, withdrawal from pain) to procedure
    1. Maintain awareness of inadequate Anesthesia and analgesia, in addition to standard monitoring
  2. Consider Antiemetics prior to sedation
    1. Ondansetron 4 mg IV before procedure (esp. when Ketamine is used for sedation)
  3. Young children
    1. Higher risk of apnea (except with Ketamine)
  4. Comorbidities (e.g. elderly, debilitated or heart, lung, renal or liver disease)
    1. Decrease Sedative and Analgesic dosing to 50% of doses listed below
    2. Decrease dose and frequency in advanced liver disease (e.g. Cirrhosis) due to decreased metabolic clearance
  5. Risk of complications in emergency Procedural Sedation increases with level of sedation
    1. Moderate sedation related complications: 2.6%
    2. Deep Sedation related complications: 6.3%
    3. General Anesthesia related complications: up to 40%
    4. Sacchetti (2007) Acad Emerg Med 14(1):41-6 +PMID: 16946280 [PubMed]
  6. Pregnancy
    1. See Trauma in Pregnancy
    2. Pregnant patients are higher risk for cardiopulmonary compromise
      1. Decreased Functional Residual Capacity
      2. Increased oxygen demand and resting Respiratory Rate
      3. Baseline relative Hypotension
    3. Avoid Hypoxia, hypercapnia and Hypotension
      1. Risk of adverse fetal effects
    4. Measures to consider
      1. Supplemental Oxygen
      2. Intravenous crystalloid fluid (LR) infusion (and consider bolus)
      3. Vomiting and pulmonary aspiration prophylaxis (e.g. Metoclopramide or H2 Blocker)
      4. Left lateral decubitus position
        1. Increases uteroplacental flow and venous return
        2. Reduce aspiration risk
    5. Safer Anesthetics and Analgesics in pregnancy
      1. See Analgesic Medications in Pregnancy
      2. Avoid Benzodiazepines (e.g. Midazolam)
      3. Ketamine
        1. Avoid in maternal Hypertension
      4. Propofol
        1. Significant risk of Hypotension
      5. Other agents to consider
        1. Nitrous Oxide
        2. Remifentanil

XV. Medication: Sedatives - Ketamine

  1. Indications
    1. Preferred Sedative in children (do not use for age <3 months)
    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
    2. No Muscle relaxation (unlike Propofol)
  3. IV
    1. Onset in 1 min, peaks at 1-3 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, peaks at 5-20 min, dissociation for 15-30 min, and recovery over 90-150 min
    2. Initial: 2-5 mg/kg IM (adult and child)
    3. Repeat 2 mg/kg IM after 10 min for one dose if needed
  5. Intranasal Ketamine (not in mainstream use yet as of 2022)
    1. Analgesia
      1. Ketamine 1 to 1.5 mg.kg (1/2 in each nostril)
      2. Onset of action: 10 min
    2. Procedural Sedation
      1. Use Ketamine 100 mg/ml if available (maximal nasal dose volume 0.5 ml)
      2. Dose: 2 to 4 mg/kg intranasally
      3. Onset of action: 10 min
      4. Duration: 15-20 min
      5. Observe for 60 min after procedure
    3. Efficacy
      1. Not recommended intranasally for sedation
        1. Amount delivered intranasally is too low for Anesthesia dosing and onset varies widely
      2. Anecdotally not as affective as other routes of Ketamine, and Intranasal Fentanyl
        1. However prior dosing (1 mg/kg) was likely too low for Procedural Sedation
    4. References
      1. Graudins (2015) Ann Emerg Med 65(3): 248-54 [PubMed]
      2. Nordt, Poonai and Ramiakhan in Swadron (2022) EM:Rap 22(3): 5-6
  6. Adverse effects
    1. Peri-procedure Vomiting may occur in up to 28% of children
    2. Least adverse effects in children of the procedural Sedatives
      1. Bhatt (2017) Pediatr 171(10): 957-64 +PMID:28828486 [PubMed]
    3. Laryngospasm (0.3 to 0.4% of cases, especially children)
      1. See Laryngospasm on Induction
      2. See Laryngospasm Notch Maneuver
      3. Typically transient, but risk of airway obstruction
    4. Risk of emergence reaction in up to 10-20% (e.g. Agitation)
      1. Prepare the patient by "Setting the Dream" BEFORE dissociation
        1. Have the patient think of their happiest, most relaxing places
        2. "Close your eyes and in the next minute you will drift into a pleasant dream..."
        3. Prevents dissociation into a Nightmare
      2. Prepare parents of younger children
        1. Child may have eyes open with the procedure and seem to be in a trance or dissociative Fugue State
        2. Child may vocalize during the procedure
      3. Consider concurrent Midazolam in adults (0.03 mg/kg up to 2 mg) to counter emergence reaction
        1. Sener (2011) Ann Emerg Med 57(2):109-114 [PubMed]
    5. Older data recommends avoiding in Closed Head Injury (risk of Increased Intracranial Pressure)
      1. Newer data suggests safe in Head Injury
    6. Hypersalivation
      1. Anticholinergics (Atropine, glycopyrrolate) are not recommended to dry secretions
      2. Green (2009) Ann Emerg Med 54(2): 171-80 +PMID:19501426 [PubMed]
    7. Respiratory drive is typically preserved
      1. However, transient apnea (10-20 s) may occur with rapid infusion
      2. Infuse Ketamine slowly (over 1-2 minutes)

XVI. Medication: Sedatives - Propofol

  1. Indications
    1. Preferred procedural Sedative in adults for brief procedures
      1. Rapid "on" and rapid "off" sedation
    2. Indicated for ASA Physical Status Score 2 (non-hypotensive, stable)
      1. Use Ketamine or Etomidate instead in patients at risk of Hypotension
  2. Relative Contraindications
    1. Age <6 months or weight <5 kg
    2. Age >75 years old
    3. ASA Physical Status Class 3 and above
  3. Adverse Effects
    1. Transient Hypotension
    2. Respiratory depression with Hypoxia or apnea (higher doses, esp. adults)
    3. Appears safe in pregnancy and Lactation (limited data)
    4. Safe in soybean and egg allergy
  4. Effects
    1. Peak effect reached in 30-60 seconds with 5-6 minute duration
  5. Propofol is primarily Anesthetic without analgesia
    1. Administer analgesia prior to sedation
    2. May be combined with Ketamine for longer procedures (Ketamine does provide analgesia)
    3. Fentanyl 0.5 mcg/kg IV (or 50 mcg in adults) PRIOR to procedure
      1. Avoid if possible during procedure (e.g. cardioversion) due to higher adverse effects
      2. Adding Fentanyl to Propofol increases adverse events (Hypotension, apnea and Hypoxia)
        1. Butler (2017) World J Emerg Med 8(3):165-9 +PMID: 28680511 [PubMed]
        2. Desai (2015) Ann Card Anaesth 18(3):306-11 +PMID: 26139733 [PubMed]
  6. Propofol Dosing
    1. Adult
      1. Initial: 0.5 to 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. Young patients 1 mg/kg (with 0.5 mg/kg repeat doses)
        3. Thin young patients: Consider 1.5 mg/kg for starting dose (risk of respiratory depression)
        4. Frail elderly patients: Consider 20-30 mg IV for starting dose (or 100 - Age)
      2. Next: 0.25 to 0.5 mg/kg (or 20 mg) IV every 1 to 3 minutes
      3. Decrease dose in older patients (cummulative required total dose decreases with age)
        1. Age 18-40 years old: 2 mg/kg total dose
        2. Age 41-64 years old: 1.7 mg/kg total dose
        3. Age >64 years old: 1.2 mg/kg total dose
        4. Patanwala (2013) J Emerg Med 44(4): 823-8 +PMID:23333181 [PubMed]
    2. Child
      1. Initial: 1 mg/kg IV (up to 40 mg) over 20-30 seconds (typically given as smaller increments)
        1. Dose per kilogram typically higher in children than adults for adequate sedation
        2. Age <3 years: 2 mg/kg
        3. Older children and teens: 1.5 mg/kg
      2. Next: 0.5 to 1 mg/kg IV (up to 20 mg) every 1 to 3 minutes 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
  7. Propofol Infusion
    1. Adult: 100 to 150 mcg/kg/min (6 to 9 mg/kg/h)
    2. Child: 100 to 250 mcg/kg/min (6 to 15 mg/kg/h)

XVII. Medication: Sedatives - Etomidate

  1. Indications
    1. Indicated for ASA Physical Status Score 2 and 3
    2. Consider for sedation in hypotensive adult patient (or Ketamine)
      1. Otherwise Propofol is preferred adult Sedative with greater efficacy, less Myoclonus than Etomidate
      2. Miner (2007) Ann Emerg Med 49(1): 15-22 [PubMed]
  2. Etomidate provides NO analgesia (similar to Propofol)
    1. Administer analgesia prior to sedation
    2. Fentanyl 0.5 mcg/kg (or 50 mcg in adults) IV PRIOR to procedure
      1. Avoid if possible during procedure (e.g. cardioversion) due to higher adverse effects
      2. Adding Fentanyl to Etomidate increases adverse events (Hypotension)
        1. Butler (2017) World J Emerg Med 8(3):165-9 +PMID: 28680511 [PubMed]
        2. Desai (2015) Ann Card Anaesth 18(3):306-11 +PMID: 26139733 [PubMed]
  3. 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. Adrenal suppression is typically associated with continuous infusion
      2. Appears safe for single dose
      3. Avoid in Sepsis
    3. Respiratory depression or Apnea (10% of cases)
    4. Nausea and Vomiting (at emergence)
      1. Risk for aspiration!
    5. Seizure threshold lowered (avoid in Seizure Disorder)
  4. Pharmacokinetics
    1. Onset: 30-60 seconds
    2. Duration: 3-8 min (up to 15 min)
  5. Dosing: IV
    1. Initial: 0.1 mg/kg IV (maximum sedation dose 0.2 mg/kg)
    2. Repeat 0.05 mg/kg IV every 3-5 minutes as needed

XVIII. Medication: Sedatives - 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)

XIX. Medication: Sedatives - Methohexital (Brevital)

  1. Indications
    1. Propofol is preferred over Methohexital (but consider as substitute when Propofol is unavailable)
    2. Consider Methohexital where unable to obtain Intravenous Access (can be given rectally)
    3. Safe in pregnancy
  2. Pharmacokinetics
    1. Barbiturate with rapid onset of action, and with IV dosing same as IM dosing
    2. Onset within 30-60 minutes
    3. Duration 3-5 minutes
  3. Adverse Effects
    1. Cardiopulmonary depression
      1. Follow same precautions as for Propofol
    2. Respiratory depression (10-22%)
    3. Hypotension (1-3%)
    4. Paradoxically lowers Seizure threshold (avoid in Seizure Disorder)
      1. Contrast to other Barbiturates which are used to a abort Seizures
    5. Laryngospasm
      1. Give a full dose (additional Methohexital) to fully supersaturate GABA Receptors
      2. Otherwise similar management to Ketamine laryngospasm
      3. See Laryngospasm on Induction
    6. Other adverse effects
      1. Vomiting
      2. Cough
      3. Hiccups

XX. Medication: Sedatives - Ketaphol or Ketafol (Ketamine with Propofol)

  1. Indications
    1. Muscle relaxation (e.g. joint dislocation) when Ketamine is the primary Sedative (see sequential sedation below)
    2. Postulated to reduce risk of Hypotension and apnea of Propofol by cutting dose with Ketamine
  2. Combined Ketamine and Propofol
    1. Initial studies recommended ratio of 4:1 Propofol to Ketamine for adequate effect
      1. Some protocols start 1:1 ratio Propofol to Ketamine 0.5 then add Propofol to effect
    2. Most studies show no significant benefit over Propofol alone (similar efficacy and safety)
      1. Andolfatto (2012) Ann Emerg Med 59(6): 504-12 [PubMed]
      2. Nejati (2011) Acad Emerg Med 18(8): 800 [PubMed]
      3. Ferguson (2016) Ann Emerg Med 86(5): 574-82 [PubMed]
    3. Typical protocol
      1. Prepare 1:1 mix of Propofol (10 mg/ml) 0.75 mg/kg AND Ketamine (10 mg/ml) 0.75 mg/kg
      2. Adminster 2-3 ml IV of the mix every 1-3 minutes as needed
      3. Next: Administer additional Propofol 0.5 mg/kg every 90 seconds as needed to adequate effect
    4. Effects
      1. Peak onset at 20-60 min with a 15 min duration
  3. Sequential Ketamine then Propofol (e.g. Muscle relaxation)
    1. Start with Ketamine 0.75 mg/kg IV over 1-2 minutes
    2. Add Propofol titrated in small boluses (0.25 to 0.5 mg/kg up to 0.75 mg) over 1 min and repeat as needed

XXI. Medication: Sedatives - Midazolam (Versed)

  1. Indications
    1. Ideal for procedural anxiolysis rather than sedation (e.g. Lumbar Puncture, Nasogastric Tube placement)
    2. Other agents are preferred for moderate Procedural Sedation in most cases
    3. Intranasal Versed in children may allow for imaging, Intravenous Access, Laceration Repair
    4. Benzodiazepines do NOT provide analgesia and are typically combined with Analgesics (e.g. Opioids)
      1. Give analgesia BEFORE the Benzodiazepine
  2. Intravenous (onset 2-3 min and lasts 20-30 min, up to 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
      3. Common procedural anxiolysis dose: 1 to 2 mg IV
  3. 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 5 mg
  4. Oral (onset 10-20 min, peak 20-50 min, duration 60 min)
    1. Dose: 0.5 to 0.75 mg/kg
    2. Peaks at 15-30 min, duration 60-90 min
  5. Other routes
    1. Nasal: 0.2 to 0.5 mg/kg intranasal (1/2 in each nostril) using 5 mg/ml up to 10 mg
      1. Peaks at 10-15 min, duration 45-60 min
      2. May cause burning Sensation on spraying into nose
    2. Rectal 0.25 to 0.5 mg/kg per Rectum
  6. Precautions
    1. Contraindicated in pregnancy (Category D), and wait at least 4 hours for Breast Feeding
    2. Commonly used in combination with Fentanyl
      1. When combined with Opioids (e.g. Fentanyl), use lower Midazolam dose
      2. Risk of Deep Sedation with cardiopulmonary depression
    3. Unpredictable at increased doses (risk of respiratory and cardiovascular depression)
      1. Unreliable sedation for painful procedures
      2. Best delivered in incremental doses (e.g. 1 mg increments)
      3. Exercise extra caution in elderly, debilitated, children, hepatic insufficiency, Dementia
      4. Paradoxical Agitation and disinhibition occurs in 2-6%
    4. Comorbidities (e.g. elderly, debilitated or heart, lung, renal or liver disease)
      1. Decrease Sedative and Analgesic dosing to 50% of doses listed below
      2. Decrease dose and frequency in advanced liver disease (e.g. Cirrhosis) due to decreased metabolic clearance
  7. Reversal
    1. Reverse Opioid first (Naloxone is far safer than Flumazenil)
    2. Flumazenil 0.01 mg/kg up to 0.2 mg (over 15 seconds) every 1 min as needed (max: 1 mg)
      1. Do not use if on longterm Benzodiazepines or history of Seizure Disorder (risk of Status Epilepticus)

XXII. Medication: Sedatives - Lorazepam (Ativan)

  1. Similar indications and precautions as for Midazolam (see above)
  2. When Benzodiazepines are used for Procedural Sedation, Midazolam is often preferred for shorter duration
  3. Adult Dosing
    1. IV (onset 2-3 min, peak 5 min, duration 6-8 hours)
      1. Start: 2 mg IV
      2. Subsequent: 1-2 mg IV every 3-5 min
    2. Oral (onset 20-30 min, peak 60-90 min, duration 6-8 hours)
      1. Start: 2 mg oral

XXIII. Medication: Sedatives - 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

XXIV. Medication: Sedatives - Dexmedotomidine (Precedex)

  1. Background
    1. Selective alpha-2 Agonist with strong Sedative properties but no Analgesic properties (See Dexmedotomidine)
    2. Typically used for IV sedation in the Intensive Care unit (e.g. Mechanical Ventilation, severe Alcohol Withdrawal)
    3. May be particularly useful in autistic patients who may be refractory to Benzodiazepines
  2. Intranasal
    1. Dose: 2-3 mcg/kg
    2. Onset in 13-25 minutes and duration for 85 minutes (longer in adults)
    3. Intranasal use rarely causes Bradycardia or Syncope
    4. Oriby (2019) Anesth Pain Med 9(1): e85227 +PMID:30881910 [PubMed]
  3. Intravenous combination with Ketamine
    1. Indications
      1. Procedural Sedation in adults and children
    2. Advantages
      1. No respiratory depression
      2. Fewer hemodynamic effects, Hypersalivation or emergence reactions (as compared with Ketamine alone)
      3. Decreased Vomiting episodes
    3. Efficacy
      1. Similar to Ketofol (but moire expensive)
    4. Protocol
      1. First: Dexmedetomidine 1 mcg/kg IV over 1 min
      2. Next: Ketamine 1 mg/kg IV over 30 seconds
      3. Next: Ketamine 0.5 to 1 mg/kg IV as needed
    5. References
      1. Tobias (2012) Pediatr Crit Care Med 13(4):423-7 +PMID: 22067985 [PubMed]

XXV. Medication: Analgesics - Fentanyl

  1. Nasal: 2 mcg/kg intranasal (1/2 in each nostril) up to a maximum of 100 mcg
    1. Onset of analgesia within 10 minutes and duration of 30 minutes
    2. 2 mcg/kg is equivalent to 0.1 mg/kg Morphine
    3. Bioavailability: 70%
  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 1-3 min, lasting 30-60 min, MME 100)
    1. Adult (and children age >12 years)
      1. Initial: 0.5-1 mcg/kg (or 50 mcg)
      2. Subsequent: 0.25-0.5 mcg/kg (or 25-50 mcg) IV every 3 minutes as needed
    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
  4. Reversal
    1. Naloxone 0.01 mg/kg (or 0.1 mg every 30-60 sec)
  5. Adverse effects
    1. Less Histamine release than with Morphine
    2. Respiratory depression
      1. Supplemental Oxygen, Jaw Thrust maneuver, bag-valve mask
      2. Use lower doses in combination with Midazolam (Versed)

XXVI. Medication: Analgesics - Morphine

  1. IV (onset 5 min, duration 2-4 hours)
    1. Dose: 0.05 to 0.2 mg/kg every 2-4 hours up to 15 mg
    2. Adults: 2-4 mg IV every 3 minutes as needed
  2. IM/SC
    1. Doses are similar as IV, but with decreased dosing frequency
    2. Intramuscular onset of activity may be delayed as long as 30 minutes
  3. Adverse Effects
    1. Nausea or Vomiting
      1. Consider pretreatment with Antiemetic (e.g. Ondansetron)
    2. Hypotension
      1. Consider pretreatment bolus of crystalloid (500 cc or 10-20 cc/kg NS)
    3. Pruritus and/or rash
      1. Typically not Allergic Reaction
      2. Morphine may result in Histamine release
  4. Reversal
    1. Naloxone 0.01 mg/kg (or 0.1 mg every 30-60 sec)

XXVII. Medication: Analgesics - Hydromorphone (Dilaudid)

  1. IV (onset 5 min, duration 3-5 hours, MME 10)
  2. Adult dose
    1. Initial: 0.5 to 1 mg IV (or 2 mg orally)
    2. Subsequent: 0.1 to 0.2 mg IV every 3 minutes

XXVIII. Medication: Analgesics and Anesthetics - Miscellaneous Agents

  1. See Nitrous Oxide
  2. 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
  3. 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
  4. Ketorolac (Toradol)
    1. IV/IM: 0.5 mg/kg (up to 30 mg)
  5. Topical anesthestics (prior to venipuncture, peripheral IV, Lumbar Puncture, Laceration Repair)
    1. See Topical Anesthetic
    2. Lidocaine-Epinephrine-Tetracaine
    3. EMLA cream
    4. Lidocaine 4% in liposomal matrix (LMX or ELA-Max)
    5. J-Tip (transdermal Lidocaine device)

XXIX. Medication: 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

XXX. 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

XXXI. Complications: Common

  1. Hypoxia (40.2 per 1000 sedations)
    1. Highest risk with Profol or with combined Midazolam with Opiate
    2. Open airway with Jaw Thrust
    3. Supplemental Oxygen
    4. Tactile and verbal stimulation
  2. Vomiting (16.4 per 1000 sedations)
    1. Highest risk with Ketamine
    2. Consider prophylactic Antiemetic in those at higher risk but evidence is lacking (see above)
    3. Suction airway
    4. Place patient in left lateral decubitus position
    5. Maintain airway management and consider definitive airway (i.e. Endotracheal Intubation)
    6. Administer Antiemetic (e.g. Ondansetron)
  3. Hypotension (15.2 per 1000 sedations)
    1. Highest risk with Propofol or combined Midazolam with an Opiate
    2. Typically resolves spontaneously
    3. Consider crystalloid fluid (NS or LR) bolus of 500 ml (or 10-20 ml/kg)
    4. Consider Push Dose Pressor (e.g. Phenylephrine) for refractory Hypotension
  4. Apnea (12.4 per 1000 sedations)
    1. Highest risk with Midazolam with or without an Opiate
    2. Capnography allows for earlier recognition (contrast with delayed recognition with Oxygen Saturation)
    3. Supplemental Oxygen
    4. Bag-Valve-Mask Ventilation
    5. Consider Endotracheal Intubation
    6. Consider reversal agents (e.g. Naloxone or Flumazenil)
  5. References
    1. Bellolio (2016) Acad Emerg Med 23(2): 119-34 [PubMed]

XXXII. Complications: Uncommon

  1. Pulmonary aspiration (1.2 per 1000 sedations)
    1. Suction airway
    2. Supplemental Oxygen
    3. Maintain airway management and consider definitive airway (i.e. Endotracheal Intubation)
    4. Consider Antibiotic coverage for Aspiration Pneumonia
  2. Agitation
    1. More common with Ketamine-related emergence reactions
    2. Also Agitation occurs paradoxically in children with Benzodiazepines (up to 15% of cases)
    3. Consider Benzodiazepine (e.g. Versed), unless of course the Benzodiazepine was causative
    4. Calm redirection can help patients more calmly emerge
  3. Sinus Bradycardia
    1. Typically resolves spontaneously
    2. Atropine may be dosed if needed
  4. Laryngospasm (3-4 per 1000 sedations with Ketamine)
    1. More common with Ketamine (esp. if comorbid Asthma or acute URI)
    2. May respond to Laryngospasm Notch Maneuver
    3. Deliver High Flow Oxygen
    4. Attempt bag valve ventilation
    5. Consider Paralytic Agent (e.g. Succinylcholine or Rocuronium) and intubation
  5. References
    1. Bellolio (2016) Acad Emerg Med 23(2): 119-34 [PubMed]

XXXIII. References

  1. (2025) Procedural Sedation, Hospital Procedures Course
  2. Acker, Koval and Leeper (2017) Crit Dec Emerg Med 31(4): 3-13
  3. Braude in Herbert (2013) EM:Rap 13(11): 14
  4. Claudius and Behar in Herbert (2019) EM:Rap 19(12): 15-6
  5. Kay (2015) Crit Dec Emerg Med 29(8): 11-17
  6. Koshy, Meta and Kern (2025) Crit Dec Emerg Med 39(8): 30-41
  7. Lester and Braude in Herbert (2014) EM:Rap 14(5): 5-6
  8. Weingart in Majoewsky (2012) EM:RAP 12(2): 8
  9. Miner (2012) APLS Lecture, HCMC, Minneapolis
  10. Hamilton (2012) Tarascon Pharmacopeia, Jones and Bartlett, Burlington
  11. Rispoli (2002) Tarascon Pocket Orthopedics, Loma Linda, p. 115
  12. Shahbaz and Kivlehan (2018) Crit Dec Emerg Med 32(8): 19-28
  13. Singh in Blaivas (2012) Emergency Medicine - an International Perspective, p. 199-208
  14. Strayer in Herbert (2017) EM:Rap 17(12): 17-9
  15. University Minnesota Childrens - Pediatric Emergency Drug Card
  16. Weingart and Swaminathan in Swadron (2023) EM:Rap 23(3): 7-10
  17. Becker (2012) Anesth Prog 59:28-42 [PubMed]
  18. Brown (2005) Am Fam Physician 71:85-90 [PubMed]
  19. Godwin (2014) Ann Emerg Med 63(2): 247-58 [PubMed]
  20. Miller (2018) Ann Emerg Med 73(5): 470-80 +PMID: 30732981 [PubMed]

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