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Procedural
Sedation

Hesham Youssef
PGY1, Anesthesia

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Procedural Sedation/Analgesia.
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.

Godwin SA, Caro DA, Wolf SJ, et al. Clinical policy: procedural sedation and
analgesia in the emergency department. Ann Emerg Med. 2005; 45(2):177196.

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Goals of Sedation and
Analgesia

Maintain patient safety and welfare.

Minimize physical discomfort and pain.

Control anxiety, minimize psychological trauma,

maximize amnesia.

Control behaviour and/or movement to allow safe

performance of procedures.

Return the patient to a state in which safe discharge

from medical supervision is possible.

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Indications

Diagnostic Imaging (requiring sedation only)

a. CT
b. MRI

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Indications

Painful Diagnostic (requiring both sedation and

analgesia), including:
a. Lumbar puncture

b. Sexual assault examination with forensic evidence

collection

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Indications

Painful Therapeutic (requiring both sedation and

analgesia), including:
a. Fracture/ dislocation reduction
b. Complex laceration repair
c. Foreign body removal
d. Abscess incision and drainage

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Patient Assessment
History:
a.
b.

Concurrent medical illnesses.

Medications.

c.

Allergies .

d.

History of sleep disordered breathing or snoring .

e.

Major medical illnesses

f.

Previous adverse reactions to anesthetic/ sedative agents

g.

Family history of an adverse reaction to sedation,

analgesia, or GA

h.

Last oral intake

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Patient Assessment
Fasting:

ER literature:

No correlation found between fasting status and incidence

of aspiration in procedural sedation outside the OR

Analgesia, anesthesia, and procedural sedation. In: Tintinalli JE,

Stapczynski JS, Cline DM, Ma OJ, Cydulka RK, Meckler GD,
eds.Tintinalli's emergency medicine.Seventh ed. The McGraw-Hill
Companies, Inc.; 2011.

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Patient Assessment
Fasting:

ACEP:

procedural sedation may be safely administered to pediatric patients

in the ED who have had recent oral intake.

However, theoretical risk of aspiration should still be considered

ASA Fasting Guidelines

Green SM, Roback MG, Miner JR, Burton JH, Krauss B. Fasting and emergency
department procedural sedation and analgesia: a consensus-based clinical
practice advisory. Ann Emerg Med. 2007; 49(4):454-461.

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Patient Assessment

Physical Exam:

a.

Cardio-respiratory status & Neurological Status.

b.

Airway Assessment.

Features of difficult BMV/intubation

Previous history of difficult airway

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Exclusion criteria

Difficult airway abnormal face, mouth, dentition or neck

Sleep apnea, stridor, airway obstruction, severe asthma

Tracheal abnormalities

Severe cardiorespiratory disease

Severe GERD

Severe obesity

Raised intracranial pressure

Severe neurological impairment and/ or bulbar dysfunction

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ASA

Cot CJ, Wilson S. Guidelines for monitoring and management of pediatric

patients during and after sedation for diagnostic and therapeutic
procedures: an update. Pediatrics. 2006; 118(6):2587-2602.

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Personnel

Physicians

should be competent in:

a. Pediatric airway management and resuscitation

b. Patient assessment & preparation
c. Patient monitoring
d. Pharmacology of PSA
e. Recognition and treatment of the complications of
PSA

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Personnel

Nurses

& ancillary personnel (i.e. RT) should be :

a. Comfortable with basic airway management and

resuscitation
b. Knowledgeable of patient preparation and monitoring
procedures
c. Familiar with proper documentation of PSA technique
d. Able to prepare a time-based record of the treatment
procedure

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Consent

Written consent.

proposed benefits (performing procedure effectively

while minimizing pain/anxiety/psychological trauma).

possible risks (Air Way compromise, hypoxia, vomiting),

Drug: options - potential routes - Alternatives

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Equipment and Monitoring
(SOAPME).

S (suction)

O (oxygen)

A (airway)

P (pharmacy)

M (monitors)

E (extra equipment) - (e.g., defibrillator)

Cot CJ, Wilson S. Guidelines for monitoring and management of pediatric

patients during and after sedation for diagnostic and therapeutic procedures:
an update. Pediatrics. 2006; 118(6):2587-2602.

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Pharmacology

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Ketamine

Ketamine is a dissociative anasthetic with sedative,

analgesic and amnestic properties

Administration

IV 1 mg/kg, repeat 0.5-1 mg/kg q10min prn

Onset: 1-2 min

Duration: 10-15 min

Recovery: 60 min.

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Ketamine

Ketamine is a dissociative anasthetic with sedative,

analgesic and amnestic properties

Advantages

Anesthetic and Analgesic

Short-acting

Maintain airway protective reflexes, spontaneous

respirations, and cardiopulmonary stability

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Ketamine

Ketamine is a dissociative anasthetic with sedative,

analgesic and amnestic properties

Disadvantages

Emesis

Laryngospasm

Agitation/Emergence reaction

Increases salivation

Increase ICO & IOP

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Ketamine

Ketamine is a dissociative anasthetic with sedative,

analgesic and amnestic properties

Contraindications:

Age < 3 months

Psychosis

Intraocular trauma or glaucoma

Systemic hypertension

Thyrotoxicosis

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Propofol

Propofol is a short acting sedative hypnotic which,

due to its potency, has been used for both painful and
painless procedures

Administration

IV 1-2 mg/kg, repeat 0.5 mg/kg q3-5 min

IV Infusion: start at 25-50 mcg/kg/min

Onset seconds

Duration minutes

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Propofol

Propofol is a short acting sedative hypnotic which,

due to its potency, has been used for both painful and
painless procedures

Advantages

Rapid onset, short recovery time, easy titratability.

reliable potency to induce deep sedation

Mild anti-emetic properties

Decreases CMRO2 and CBF, as well as ICP

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Propofol

Propofol is a short acting sedative hypnotic which,

due to its potency, has been used for both painful and
painless procedures

Disadvantages

Anesthetic, with NO analgesia

Pain on IV Administration

Respiratory and cardiovascular depressant

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Ketofol

Advantage:
a.

Shorter recovery time

b.

Decreases dose for both agents - minimize side

effects (resp + cardiac depression, emesis,
emergence reaction)

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Ketofol

Administration:

In 2010, Andolfatto and Willman published a series of

219 pediatric patients who received a 1:1 mixture of 10
mg/ml ketamine and 10 mg/ml propofol in a single
syringe .

Another 2007 study by Sharieff et al described a

different method of ketofol administration, ketamine
0.5 mg/kg followed 1 minute later by propofol 1 mg/kg.
Additional doses of ketamine 0.25 mg/kg and/ or
propofol 0.5 mg/kg were given as deemed necessary
by the ED physician.

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Midazolam

Midazolam is a short-acting benzodiazepine that

provides sedation, amnesia and anxiolysis.

Administration

IV/IM 0.05-0.1 mg/kg (max single dose 2 mg), repeats q2-5

min

Routes: PO, PR, IV, IM, IN

Onset: IV 1-2min, IM 5-10 min

Duration: IV 45-60min, IM 60-120min

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Midazolam

Midazolam is a short-acting benzodiazepine that

provides sedation, amnesia and anxiolysis.

Advantages

Rapid onset

Anxiolytic, amnestic, sedative

Many routes of administration

Rare resp depression when used as sole agent

Effective reversal agent (Flumazenil)

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Midazolam

Midazolam is a short-acting benzodiazepine that

provides sedation, amnesia and anxiolysis.

Disadvantages

No analgesia

Respiratory depression/Apnea (Specially when combined

with opioids)

Paradoxical reactions (hyperactivity, aggressive behaviour)

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Fentanyl

Fentanyl is a potent synthetic opioid.

Administration:
IV: 1.0 mcg/kg, repeat dose every 3 minutes as needed

Onset: IV: 3-5 minutes

Duration: IV: 30-60 minutes

Advantage: Rapid onset, short duration, less N/V

Disadvantage: resp depression, chest wall rigidity,

facial pruritus

Reversal: Naloxone

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Other Medications

Nitrous Oxide. 50-70 %.

Etomidate. 0.1-0.3 mg/kg.

Pentobarbital. (IV, IM, PO).

a.
b.

<4 years: 3-6 mg/kg PO

>4 years: 1.5-3 mg/kg PO.

. Chloral

Hydrate. 50-75 mg/kg/dose 30 to 60 minutes

prior to procedure; may repeat 30 minutes after initial
dose if needed.

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Emergency States During
Sedation
Airway

Obstruction (Pharyngeal)

Laryngospasm
Hypoventilation/Apnea
Aspiration
Cardiovascular

instability

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Recovery & Discharge

Airway patency, Resp, cardiovascular function, and

hydration are satisfactory.

The patients level of consciousness has returned to

baseline .

The patient can sit unassisted.

The patient can take oral fluids without vomiting;

The patient, or a responsible person who will be with

the patient, can understand the discharge instructions.

Thank You