Chapter 4

GENERAL CONSIDERATIONS

Procedural sedation and analgesia has proven safe and effective in the emergency department, and should be utilized when patients undergo painful procedures. In addition to facilitating painful procedures, a number of agents are utilized in pediatrics to facilitate diagnostic studies (CT, MRI, lumbar punctures). The most important step in addition to monitoring the patient involves extensive preparation and, at conclusion of sedation, the patient should return to mental and physiologic baseline. In scenarios where the patient’s severity of illness questions the applicability of emergency department sedation, the physician must review the risks, and consider consultation with the anesthesiologist. Although degrees of sedation can at times be ambiguous, observation of the patient’s progression, and remaining vigilant for respiratory depression can diminish untoward effects and facilitate successful recovery and disposition.

The nomenclature “procedural sedation and analgesia” (PSA) has replaced the previous term “conscious sedation” following recent guideline recommendations, and is defined by The American College of Emergency Physicians (ACEP) as the “administration of 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 ACEP clinical policy states: “Procedural sedation and analgesia is intended to result in a depressed level of consciousness that allows the patient to maintain oxygenation and airway control independently.” Patients can progress to each successive stage of sedation to the point of apnea and respiratory arrest. The practitioner’s goal is to avoid progressive unconsciousness in the patient, and to remain capable in managing their cardiopulmonary function when necessary.

PROCEDURAL SEDATION & ANALGESIA STAGES

The PSA spectrum involves minimal, moderate, deep, and general anesthesia levels necessitating that the practitioner recognizes the levels of sedation, and be prepared to rescue the next level of sedation if necessary. Several experts have recommended a separate category for dissociative anesthetics such as ketamine because the performance and adverse effect profile differs widely from other forms of sedation. Each degree of sedation increases risk of cardiopulmonary instability with likely need for aggressive intervention.

• Minimal sedation (anxiolysis): a drug-induced state during which the patient responds normally to verbal commands. Although cognitive function and physical coordination may be impaired, airway reflexes, and ventilatory and cardiovascular functions are unaffected.

• Moderate sedation/analgesia (conscious sedation): a drug-induced depression of consciousness during which the patient responds purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.

• Deep sedation/analgesia: a drug-induced depression of consciousness during which the patient cannot be aroused easily but responds purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. The patient may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.

• General anesthesia: a drug-induced loss of consciousness during which the patient cannot be ...

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