Procedural sedation and analgesia
|Procedural sedation and analgesia|
Procedural sedation and analgesia, previously referred to as conscious sedation, is defined as "a technique of administering sedatives or dissociative agents with or without analgesics to induce a state that allows the patient to tolerate unpleasant procedures while maintaining cardiorespiratory function."
The American Society of Anesthesiologists defines the continuum of sedation as follows:
|Minimal Sedation||Moderate Sedation||Deep Sedation||General Anesthesia|
|Responsiveness||Normal to verbal stimulus||Purposeful response to verbal or tactile stimulus||Purposeful to repeated or painful stimulus||Unarousable, even to painful stimulus|
|Airway||Unaffected||No intervention required||Intervention may be required||Intervention often required|
|Ventilation||Unaffected||Adequate||May be inadequate||Frequently inadequate|
|CardioVasc Function||Unaffected||Usually maintained||Usually maintained||May be impaired|
This technique is often used in the emergency department for the performance of painful or uncomfortable procedures. Common purposes include:
- setting fractures
- draining abscesses
- reducing dislocations
- performing endoscopy
- for cardioversion
- during various dental procedures
- during transesophageal echocardiogram
- and certain imaging or minor procedures where the patient is unable (or unwilling) to keep still—especially children
- Remifentanyl continue infusion
- Ketamine: Small doses of ketamine have been found to be safer than fentanyl when used in combination with propofol.
For most agents the person should have had nothing to eat for at least 6 hours. Clear fluids can be allowed up to two hours before the procedure. An exception to this may be with ketamine in children where fasting may be unnecessary. However, in the emergency room setting, conscious sedation is usually administered without waiting the full 6 hours unless there is clear evidence that the patient may not be able to maintain his/her airway on their own. The most common drug combination used is Versed (midazolam) for sedation (due to its potency and its ability to induce temporary amnesia, which can be beneficial because the unpleasantness of the procedure and any related sights, sounds, or smells) and Fentanyl for analgesia. Despite this being the most frequently used drug combination, variations are not uncommon due to factors such as patient allergies or clinician preference.
Complications depend on the sedative agent used. Some agents are more likely to cause complications than others, but all sedative agents can cause complications if not used properly. Titration is a common technique used to reduce complications. Many commonly used agents can cause respiratory depression, hypoxia and hemodynamic effects. For some agents antagonists are available that can be used to reverse the effects.
Procedural sedation can be safely performed in an emergency department if structured sedation protocols are followed.
Electrocardiography, pulse oximetry, capnography and blood pressure monitoring are essential, as is the use of supplementary oxygen.
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Some resistance to sedation techniques used outside the operating room by non-anesthetists has been voiced.
Procedural sedation used to be referred to as conscious sedation. When the patient is adequately sedated this is known as a (+)Ruiz sign.
- Procedural Sedation at eMedicine
- "Continuum of Depth of Sedation; Definition of General Anesthesia and Levels of Sedation/Analgesia". American Society of Anesthesiologists (ASA). 2009.
- "Procedural Sedation for Cardioversion".
- Hohl, CM.; Sadatsafavi, M.; Nosyk, B.; Anis, AH. (January 2008). "Safety and clinical effectiveness of midazolam versus propofol for procedural sedation in the emergency department: a systematic review.". Acad Emerg Med. 15 (1): 1–8. PMID 18211306. doi:10.1111/j.1553-2712.2007.00022.x.
- Messenger DW, Murray HE, Dungey PE, van Vlymen J, Sivilotti ML (October 2008). "Subdissociative-dose ketamine versus fentanyl for analgesia during propofol procedural sedation: a randomized clinical trial". Acad Emerg Med. 15 (10): 877–86. PMID 18754820. doi:10.1111/j.1553-2712.2008.00219.x.
- "BestBets: Does the time of fasting affect complication rates during ketamine sedation".
- Ip U, Saincher A (January 2000). "Safety of pediatric procedural sedation in a Canadian emergency department". CJEM. 2 (1): 15–20. PMID 17637112.
- Krauss B, Green SM (March 2006). "Procedural sedation and analgesia in children". Lancet. 367 (9512): 766–80. PMID 16517277. doi:10.1016/S0140-6736(06)68230-5.