On-line version ISSN 2078-5135
SAMJ, S. Afr. med. j. vol.101 n.3 Cape Town Mar. 2011
Procedural sedation in the emergency centre
M StanderI; L A WallisII
IMB BCh, MMed (EM). Division of Emergency Medicine, Stellenbosch University, Tygerberg, W Cape
IIMB ChB, MD, DIMCRCSEd, Dip Sport Med, FRCS (Ed) (A&E), FCEM, FCEM (SA). Division of Emergency Medicine, Stellenbosch University, Tygerberg, W Cape
BACKGROUND: The performance of safe and effective procedural sedation in the emergency centre has become a core competency in emergency medicine internationally. However, in South Africa clear guidelines are lacking and this guideline attempts to set out the standard for the routine safe use of procedural sedation by clinical staff in emergency centres.
METHOD: The Emergency Medicine Society of South Africa (EMSSA) appointed a task group to analyse the international literature and guidelines, and a draft document was produced which was revised by consensus input from an expert panel.
RESULTS AND CONCLUSION: A simple and clear practice guideline has been developed for health professionals working in emergency centres in South Africa. This guideline will help to improve the provision of emergency procedural sedation, which is an important component of the care provided in emergency centres.
A proportion of patients presenting to emergency centres need to undergo procedures that can be unpleasant and painful. The provision of safe and effective analgesia and procedural sedation is a critical aspect of the provision of care in an emergency centre. Given the nature of an emergency centre, which is often overwhelming and noisy and appears chaotic to patients, the entire clinical experience for the patient and ultimately outcome can be improved if appropriate and effective procedural sedation is provided. The Emergency Medicine Society of South Africa (EMSSA) recognised the lack of uniformity on this topic1 and set up an expert panel responsible for the drafting of this practice guideline.
This document is intended as a guide for emergency medicine specialists and all medical practitioners involved in the provision of emergency procedural sedation in emergency centres in South Africa.
Procedural sedation definition
Procedural sedation refers to a technique of administering sedatives or dissociative agents, with or without analgesics, to induce a state that allows patients to tolerate unpleasant procedures while maintaining cardiorespiratory function and retaining the ability to respond purposefully to verbal commands and/or tactile stimulation.2-4 This technique is appropriate for both adult and paediatric patients.5
3. Levels of sedation2,6-8
3.1 Minimal sedation (anxiolysis) is a drug-induced state during which patients respond normally to verbal commands. Cognitive function and co-ordination may be impaired, but ventilatory and cardiovascular systems are unaffected.
3.2 Moderate sedation (previously referred to as conscious sedation) is a drug-induced depression of consciousness during which patients respond purposefully to verbal or light tactile stimulation. The techniques and drugs (in the doses used) are not likely to produce loss of protective airway reflexes.
3.3 Deep sedation is a drug-induced depression of consciousness during which patients cannot be aroused easily but respond purposefully after repeated or painful stimulation. These patients may require assistance in maintaining a patent airway and may need ventilatory support.
3.4 General anaesthesia refers to a state of drug-induced loss of consciousness during which patients are not rousable and may have impaired cardiorespiratory function requiring varying degrees of support.
3.5 Dissociative sedation is a trance-like cataleptic state characterised by profound analgesia and amnesia with retention of protective airway reflexes, spontaneous respiration and cardiopulmonary stability. Ketamine is the only approved dissociative agent.
Progression from one stage to the next is a continuum, and it is often difficult to predict how a patient will respond to a specific sedative agent. It is essential that practitioners possess the skills necessary to rescue a patient from one level deeper than the desired level of sedation.
Recommendations in this guideline are not intended to represent the only diagnostic and management options that emergency practitioners can apply. The individual physician's judgement is of utmost importance. However, procedural sedation is the recognised and validated standard of practice for painful and intimidating procedures.
4. Scope of practice guideline6-8
This practice guideline:
applies to the administration of dissociative agents, sedative agents or sedative and analgesic agents together
does NOT apply to:
administration of agents to facilitate airway management or tracheal intubation
patients who have already undergone tracheal intubation and ventilation
refers to the use of moderate sedation and analgesia, and deep sedation and analgesia, in order to facilitate diagnostic or therapeutic procedures
refers to the use of sedative, analgesic and dissociative agents in the emergency centre
refers to adult and paediatric patients.
5. Objectives of procedural sedation4
The objectives are:
to provide adequate analgesia, anxiolysis, sedation and amnesia during the performance of painful diagnostic or therapeutic procedures
to minimise variations in patients' cardiovascular and respiratory physiological parameters
to maintain the patient's protective airway reflexes.
6. Contraindications to procedural sedation4
lack of appropriate monitoring equipment, or inability to monitor patient during procedure
lack of personnel experienced in airway management or interpretation of monitoring equipment
lack of resuscitation and airway management equipment
children under the age of 2 years should not receive procedural sedation unless under the care of an emergency medicine physician experienced in paediatric emergency medicine
allergy or sensitivity to the prescribed medication (refer to the listed contraindications to specific medications as described in the latest edition of the South African Medicines Formulary (SAMF)).
6. Relative contraindications
Relative contraindications include:
facial, dental or airway abnormalities that would preclude tracheal intubation
patients at high risk of vomiting and aspiration
haemodynamically or neurologically unstable patients.
7. Patient evaluation4,8,9
Obtain a history and perform a physical examination to identify medical illnesses, medications, allergies and anatomical features that may affect procedural sedation and airway management. The time and nature of last oral intake must be documented.
7.1 Medical history and examination6,7,10
The medical history and formal physical examination to be performed before administering sedation are to include the following:
health and risk assessment history, including allergies, current medications, current health problems, previous hospitalisations, previous sedation and anaesthetic history
vital signs and weight
mental health status
assessment of airway opening and patency
the airway should also be assessed for potential difficulties to bagmask ventilate as well as difficult laryngoscopy
respiratory status cardiovascular status
nil per os (NPO) status
developmental status (in paediatric cases).
As part of the consent process, staff members must clearly explain the proposed treatment or procedure. The explanation should include the following:
potential benefits and drawbacks
any possible adverse affects of treatment
any significant/reasonable alternatives
the likelihood of success.
Informed consent for sedation and the procedure is to be obtained by documentation on a formal consent form.
7.3 High-risk patients6
Patients at high risk for complications due to procedural sedation include individuals with:
upper airway obstruction (stridor when awake)
sleep apnoea or significant snoring
mandibular hypoplasia, craniofacial abnormalities or history of difficult airway during anaesthesia or sedation
active vomiting, delayed gastric emptying
significant gastro-oesophageal reflux, particularly with history of aspiration
pre-existing significant neurological dysfunction or depressed level of consciousness
hypovolaemia, cardiac disease or other potential for alteration in perfusion
pneumonia, reactive airway disease or other disorder of gas exchange or pulmonary mechanics
history of sedation failure
patients who have ingested a central nervous system depressant such as alcohol.
7.4 High-risk techniques6
Sedation techniques with higher risk for complications include:
deep sedation, regardless of intended depth or drugs administered
combination drug therapy, particularly opioids and hypnotics
medications administered in large doses instead of titrated to effect
use of opioids for sedation instead of analgesia.
The planned sedation process will be developed on the basis of the assessment information including patient risk documentation, assignment of an American Society of Anesthesiologists (ASA) physical status score, risk of procedure, and risk of planned sedative techniques. Patients with ASA classifications of IV and V should NOT be considered for procedural sedation (refer to Appendix 1 for ASA classifications).
8. Pre-procedure preparation and equipment
The procedure should be performed in a clinical environment where monitoring can be done and where access to resuscitative drugs and equipment is immediately available. The relevant reversal agents must also be available.
The following equipment should be present:11
oxygen and delivery devices (nasal cannula and face mask)
suction and suction catheters
resuscitation trolley and defibrillator and intubation equipment
vital signs monitor (including blood pressure, cardiac monitor and saturation)
positive-pressure breathing device>
oral airways of appropriate size
advanced cardiac life support medications.
Intravenous (IV) access must be established and maintained, except when using an intramuscular technique for the administration of ketamine in children.
9. Fasting before procedural sedation2
There is no evidence to show that patients need to be fasted, and recent food intake is not a contraindication. The risks and benefits of performing procedural sedation on each individual patient need to be considered carefully in choosing the timing and target level of sedation.
Sedation and performance of a procedure require at least two appropriately qualified staff (a doctor and a nurse or two doctors): one to perform the procedure, and one to be solely responsible for the administration of medication, monitoring and documentation.
Observation and monitoring should be done from the start of
sedation until discharge criteria have been met.
The staff responsible for administering the IV analgesia and sedation should be trained in the recognition of complications associated with IV sedation. Personnel providing procedural sedation and analgesia must have an understanding of the drugs administered, ability to monitor the patient's response to the medications given, and the skills necessary to intervene in managing all potential complications.
11. Monitoring and documentation6,7
Assessment of the patient should be done at baseline and every 5 minutes once the first analgesia/sedation dose has been administered.
The following should be documented:
vital signs (blood pressure, heart rate, respiratory rate)
use (or not) of supplemental oxygen
level of consciousness
medications given, including route, dose and person administering.
Capnometry can be considered to provide additional information
regarding the early identification of hypoventilation, but is not an essential requirement of procedural sedation.2,12
Documentation should include the date and time of start of sedation, start of procedure and time of conclusion of post-procedure care. Adverse events that should be recorded include apnoea or airway obstruction requiring intervention, vomiting, aspiration, and over-sedation, inadequate sedation, sedation failure or need for reversal agents.
12. Drugs administered4,5,8,13,14
Ketamine, midazolam, fentanyl, propofol and etomidate can all safely be administered for procedural sedation and analgesia in the emergency centre. Morphine can safely be used as an analgesic adjunct (refer to Appendix 2 for drugs and dosages).
Medication doses must be calculated, drawn up and labelled before commencement of the procedure. Appropriate antagonists must be available and only used if absolutely necessary. Antagonists should not be given directly after the procedure in order to 'reverse' the patient's sedation and analgesia.
Drugs should be given slowly and in small incremental doses. Analgesic agents should generally be administered before sedative agents, as over-sedation may result if analgesic medications are given after sedation.
The therapeutic affect should be assessed before the next incremental dose is determined and the patient should be observed for the following:
decrease in oxygen saturation
ability to maintain patent airway
appropriate response to physical stimulation and/or verbal command
significant changes in vital signs.
Adjust doses according to patient's age, level of debilitation, drug combinations, tolerance, pulmonary reserve, previous narcotic use and length of procedure.
13. Post-procedure care and discharge criteria7,10
The patient should not be left alone at any stage. A trained staff member should remain with the patient until discharge.
13.1 Post-procedure assessments
Post-procedure assessments should be documented:
every 15 minutes for 1 hour
then every 30 minutes for 1 hour
then hourly or until discharge criteria have been met.
If the patient receives a reversal agent, they should be observed after the procedure for a minimum of 1.5 additional hours.
13.2 Discharge criteria
The following criteria need to be fulfilled before the patient can be discharged:
Vital signs, level of consciousness, cardiovascular and respiratory status have returned to pre-sedation levels.
A responsible, designated adult is able to accompany patient and transport is available.
The patient/caregiver has received appropriate verbal and written discharge instructions.
Discharge forms are completed and discharge medication has been dispensed.
Pain is adequately controlled.
Nausea/vomiting is controlled.
Oxygen saturation is at pre-intervention status.
No signs or symptoms that may jeopardise the safety of recovery (bleeding, swelling, extreme pain, dizziness, etc.).
Follow-up for extended care has been provided.
For children: age-appropriate responses are present.
All patients MAY NOT DRIVE home and should not drive for up to 24 hours following discharge. The same precaution would apply to patients who operate heavy machinery.
Patients with special handicaps, including the blind with or without a guide dog, the deaf and mute, and patients with mental illness and/ or mental handicap, may need extra precautions on discharge at the discretion of the attending doctor.
The authors wish to acknowledge the input into this document of Drs Mike Wells, Peter Hodkinson, Lara Goldstein and William Lubinga.
The authors declare that there are no conflicts of interest.
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8. Yale-New Haven Hospital Clinical Administrative Policy and Procedure Manual. Manual Code C: C-11. Conscious Sedation for Diagnostic and Surgical Procedures Multi Disciplinary Protocol. Dated 21/04/1998. Latest revised 29/10/2007. http://www.ynhh.org/medstaff/document/Reading_Materials_ for_Conscious_Sedation.pdf (last accessed on 19 May 2010). [ Links ]
9. Australian and New Zealand College of Anaesthetists, Faculty of Pain Medicine, Joint Faculty of Intensive Care Medicine Australian and New Zealand College of Anaesthetists and Royal Australian College of Physicians and Australasian College for Emergency Medicine. Statement on Clinical Principles for Procedural Sedation. JFICM/ANZCA Policy document PS48. ACEM Policy Document P29. 2003. http://www.emed.net.nz/wellington/docu/Journals/ProcSed/P29_ANZCA.pdf (last accessed 27 May 2010). [ Links ]
10. Massachusetts General Hospital policy on conscious sedation for non-anesthesiologists. [ Links ]
11. http://www.massgeneralimaging.org/PDF/rad_section.pdf%20/consciousSedation.pdf (last accessed 15 May 2010). [ Links ]
13. Green SM. Research advances in procedural sedation and analgesia. Ann Emerg Med 2007;49(1):31-36. [ Links ]
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15. Vardy JM, Dignon N, Mukherjee N, et al. Audit of the safety and effectiveness of Ketamine for procedural sedation in the emergency department. Emerg Med J 2008;25:579-582. [ Links ]
Accepted 2 August 2010.
Corresponding author: M Stander (firstname.lastname@example.org)
On behalf of the Emergency Medicine Society of South Africa (EMSSA)