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What Agent Should I Use For Procedural Sedation?

Humanely performing painful procedures is one of the most satisfying aspects of emergency medicine. Over the last decade, we have emerged from the shadows of fentanyl/midazolam to enter the golden age of procedural sedation pharmacology. Most of us have a variety of better agents at our disposal so we don’t have to choose between agony and apnea. Ketamine, etomidate and propofol will give great results for just about every procedure about every time. To choose between them, you need to get to know them.

This came into being in the 1960s when pharmacologists recognized the potential of dissociative anesthesia. The first commonly available agent in this class was phencyclidine (initially…

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 Mastering Procedural Sedation in the Emergency Department

Procedural sedation, which is not called conscious sedation given the goal is to ensure the patient is not fully conscious, comes in a variety of flavors. Propofol, ketamine, or “ketofol” (the two used together) are typically preferred by emergency physicians, yet there are other options that may be more appropriate depending on the circumstances.

 Procedural Sedation Medications

Routinely available agents and dosages for emergency department procedural sedation.

Articles of Interest

Adult: Pharmacological Agents for Procedural Sedation and Analgesia

This document provides guidelines for the use of common pharmacological agents in sedation in the Emergency Department in the UK. It provides guidelines for the use of these agents for adults and children (excluding neonates).

Midazolam, Etomidate, Propofol, Fentanyl, Ketamine, and Propofol/Ketamine for Procedural Sedation and Analgesia Among Adults in the Emergency Departments: A Systematic Review

As the results of the retrieved articles indicated, propofol is the most common medication used for PSA in EDs due to the shorter time of induction, rapid recovery of consciousness, and fewer side effects. Etomidate and ketamine were also identified as other common sedatives applied for PSA.

Procedural Sedation - Medications

In this systematic review, when propofol and ketamine were combined, the incidence of agitation, apnea, hypoxia, bradycardia, hypotension, and vomiting were lower compared to each medication separately. ACEP established this evidence as Level A recommendation for the use of propofol, Level B for the combination of propofol and ketamine, and Level C for the use of ketamine alone.

Procedural Sedation in the ED: Agents

In this two part series, we are delving into a few of the many controversies regarding procedural sedation and explore how to reduce resource utilization and ED length of stay. Traditionally, ED procedural sedations have been described as Moderate Sedation or “Conscious Sedation”. However, I would argue that according to the ASA categorization above, the majority of contemporary ED sedations lie in the Deep Sedation or General Anesthesia category.

Procedural sedation: A review of sedative agents, monitoring, and management of complications

The greatest threat to the safety of a sedated patient is airway compromise and/or respiratory arrest. To decrease the risk of airway and respiratory complications, careful attention must be directed toward the appropriate selection of medications, adherence to dosing recommendations, and most importantly the identification of the high-risk patient.

What Drugs Are Used for Conscious Sedation?

Many of the conscious sedation drugs are common for children and adults, though dosages may vary. Sedation is usually administered intravenously for adults...