Procedural sedation and analgesia

Procedural sedation and analgesia
Intervention
MeSH	D016292

Procedural sedation and analgesia previously referred to as conscious sedation is defined as "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."^[1] It was previously referred to as conscious sedation.

Definitions

The American Society of Anesthesiologists defines the continuum of sedation as follows:^[2]

	Minimal Sedation	Moderate Sedation	Deep Sedation	General Anesthesia
Responsiveness	Normal to verbal stimulus	Purposeful response to verbal or tactile stimulus	Purposeful to repeated or painful stimulus	Unarousable, even to painful stimulus
Airway	Unaffected	No intervention required	Intervention may be required	Intervention often required
Ventilation	Unaffected	Adequate	May be inadequate	Frequently inadequate
CardioVasc Function	Unaffected	Usually maintained	Usually maintained	May be impaired

Medical uses

This technique is often used in the emergency department for the performance of painful or uncomfortable procedures. It has been used for setting fractures, draining abscesses, reducing dislocations, performing endoscopy, imaging procedures in patients unable to hold still, cardioversion^[3] and during dental procedures.

Agents used

Sedatives/dissociative agents

• Propofol^[4]
• Ketamine
• Etomidate
• Midazolam^[4]

Analgesics

• Fentanyl
• Morphine
• Ketamine: Small doses of ketamine have been found to be safer than fentanyl when used in combination with propofol.^[5]

Techniques

For most agents the person should have had nothing to eat for at least 6 hours. Clear fluids can be allowed up to two hours before the procedure. An exception to this may be with ketamine in children where fasting may be unnecessary.^[6]

Complications

Complications depend on the sedative agent that is used. Many commonly used agents can cause respiratory depression, hypoxia and hemodynamic effects. For some agents antagonists are available that can be used to reverse the effects.

Safety

Procedural sedation can be safely performed in an emergency department if structured sedation protocols are followed.^[7]

Electrocardiography, pulse oximetry, capnography and blood pressure monitoring are essential, as is the use of supplementary oxygen.

Protocols

Many institutions have protocols that are used during procedural sedation.

Controversies

Some resistance to sedation techniques used outside the operating room by non-anesthetists has been voiced.^[8]

History

Procedural sedation used to be referred to as conscious sedation.

References

1. ^ "Procedural Sedation: - eMedicine". http://emedicine.medscape.com/article/109695-overview. 
2. ^ [1]
3. ^ "Procedural Sedation for Cardioversion". http://www.bestbets.org/bets/bet.php?id=977. 
4. ^ ^{a b} Hohl, CM.; Sadatsafavi, M.; Nosyk, B.; Anis, AH. (Jan 2008). "Safety and clinical effectiveness of midazolam versus propofol for procedural sedation in the emergency department: a systematic review.". Acad Emerg Med 15 (1): 1–8. doi:10.1111/j.1553-2712.2007.00022.x. PMID 18211306. 
5. ^ Messenger DW, Murray HE, Dungey PE, van Vlymen J, Sivilotti ML (October 2008). "Subdissociative-dose ketamine versus fentanyl for analgesia during propofol procedural sedation: a randomized clinical trial". Acad Emerg Med 15 (10): 877–86. doi:10.1111/j.1553-2712.2008.00219.x. PMID 18754820. 
6. ^ "BestBets: Does the time of fasting affect complication rates during ketamine sedation". http://www.bestbets.org/bets/bet.php?id=866. 
7. ^ Ip U, Saincher A (January 2000). "Safety of pediatric procedural sedation in a Canadian emergency department". CJEM 2 (1): 15–20. PMID 17637112. http://caep.ca/template.asp?id=A657D85EDAE94D9E966CFD4DD617C281. 
8. ^ Krauss B, Green SM (March 2006). "Procedural sedation and analgesia in children". Lancet 367 (9512): 766–80. doi:10.1016/S0140-6736(06)68230-5. PMID 16517277. 

External links

• Guidelines to Conscious (Moderate) or Procedural Sedation
• American Family Physician: Procedural Sedation in the Acute Care Setting