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10 Procedural Sedation Errors in the Emergency Department

Procedural sedation and analgesia (PSA) is a core skill set of the emergency physician (EP). It improves patient satisfaction by providing amnesia, anxiolysis and analgesia. Sedation also makes our consultants happier as it facilitates an easier and faster procedure...

10 Common PSA Errors

Error #1: Delaying deep sedation until fasting times are met

The American Society of Anesthesiologists (ASA) states that the current fasting guidelines are based on insufficient evidence but still “strongly recommend” the following (2): ◦2 hours for clear liquids, 6 hours for a solid light meal and 8 hours for a fatty or fried meal.

ASA…

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 Unsure about sedating your patient? Ask a Child Life Specialist

To sedate or not to sedate… That is the question you may want to ask Child Life. For me, sedation encompasses oral or intranasal midazolam and IV ketamine. There are a variety of other options out there including dexmedetomidine and propofol. Because the majority of what we use here is midazolam and ketamine, that’s where I’ll focus my efforts. Choosing sedation is tricky, and there is overall a lack of research on which agent is best at which age, which procedures, and at what dose. There is good data, however, showing both midazolam and ketamine are safe in kids. So you have options! I enlisted the help of a few different EM Attendings and Child Life staff to offer some advice.

Articles of Interest

Procedural Sedation and Analgesia

Adequate preparation is key to providing safe, reliable delivery of PSA. Any sedation targeting moderate, deep, or dissociate sedation can have significant respiratory or cardiovascular effects, so preparation should be aimed at managing and minimizing these effects.

ACEP Revises Clinical Policy on Procedural Sedation and Analgesia in the Emergency Department

Do not delay procedural sedation in adults or pediatrics in the ED based on fasting time. Preprocedural fasting for any duration has not demonstrated a reduced risk of emesis or aspiration when administering procedural sedation and analgesia...

Complications of Procedural Sedation

The incidence of serious adverse events during procedural sedation and analgesia in the ED are rare, but shared decision making and informed consent should still be used as this is not a completely benign procedure.

NPO for sedation

How long do you really need to keep a patient NPO prior to moderae/procedural sedation in the ED? Let’s look at this issue form a few different angles and explore the evidence since there is such a significant degree of practice variation.

Procedural Sedation

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. In this article, we will provide a brief overview of the basics of procedural sedation, then dive deeper to provide more information about the specific agents that can be used for procedural sedation, including the pros and cons of each.

Procedural Sedation and Analgesia in Children: Perspectives from Paediatric Emergency Physicians

The common medications for sedation in the emergency departments include ketamine, midazolam, fentanyl, morphine, oral chloral hydrate and nitrous oxide inhalation. Propofol and etomidate are used widely in some of the paediatric emergency departments internationally

Resources

Core EM

PSA is the use of analgesics, sedatives, and dissociative agents to perform urgent painful and emotionally challenging procedures on patients in a humane, safe and controlled fashion. What makes PSA possible in the ED is the comfort of EM docs with a host of sedative agents and the ability to prepare for and handle any complications stemming from sedation. For quick reference we’ve distilled the most commonly used PSA meds their doses and some of their nuances.

IntraNasal.net

This web site offers health care and consumers information about nasal drug therapy: medical research, expert testimonial opinion and protocol suggestions. Major topics reviewed include intranasal midazolam for sedation and seizures, intranasal fentanyl and intranasal sufentanil for acute and chronic pain control, intranasal naloxone for opiate overdoses and intranasal glucagon for hypoglycemia.

Life in the Fastlane

ACEP guideline 2014 •Do not delay PSA in adults based on fasting time •Fasting has not demonstrated reduction in the risk of emesis/aspiration

Pediatric Procedural Sedation

In this EM Cases episode on Pediatric Procedural Sedation with Dr. Amy Drendel, a world leader in pediatric pain management and procedural sedation research, we discuss how best to manage pain and anxiety in three situations in the ED: the child with a painful fracture, the child who requires imaging in the radiology department and the child who requires a lumbar puncture.

PemBlog

It’s the beginning of a new academic year – and whether or not you are entering the ED for the first time, or returning after a hiatus it’s a good time to catch up on the basics. That’s what these “Starter Packs” are about. I have collated a number of different posts to give you an idea of what I’ve shared over the past few years on a number of common conditions. This one focuses on procedural sedation with ketamine.

Procedural Sedation & Analgesia in the ED

Consideration of pharmacological agents in the setting of procedural sedation should account for patient age, comorbid conditions, level of sedation necessary to perform the procedure, and desired duration of sedation.

Procedural Sedation Part 3 with Jim Miner

Today I am joined by James Miner, MD; chief of emergency medicine at Hennepin and an amazing, prolific researcher on procedural sedation.

Procedural Sedation – Part I

It seems the government and other specialties are trying hard to make sedation as difficult as possible in the ED. We must persevere to provide the best procedural sedation for the maximal comfort and safety for our patients. This brief lecture was originally posted on the defunct EMCrit Lecture Site on 8/7/2009.

Procedural Sedation, Part II

It seems the government and other specialties are trying hard to make sedation as difficult as possible in the ED. We must persevere to provide the best procedural sedation to allow maximal comfort and safety for our patients. This continues the discussion started in Part I, where we discussed etomidate, ketamine, and versed/fentanyl. In this podcast, I discuss propofol, ketofol, and dexmedetomidine.

Society for Pediatric Sedation

This blog is intended as a resource for both sedation practitioners, as well as, non-sedation practitioners that may refer their patients for sedation. True to the SPS Mission the topics presented here are multidisciplinary and aimed at improving the sedation care of children. The Blog is divided into 10 different categories, which broadly cover sedation practice.