Sedation/Pain Control/Anesthesia 1: Procedural Sedation
Pain is a common in many Emergency Departments (EDs). Age, gender, socioeconomic class and ethnicity do not limit pain or define an individual’s tolerance for pain. Patients often judge their caregivers on how well their pain was treated. Many procedures performed in the ED are painful and require medication to alleviate the discomfort.
Oligoanalgesia means inadequate treatment of pain. Practitioners inadequately treat pain for many reasons, including:
- Fear of over-sedation
- Fear of adverse effects
- Inadequate inquiry
- Inadequate knowledge
- Inadequate dose/route
- Underestimation of patient’s need
- Pain relief not seen as high priority
- Insufficient time and resources
New standards* to define the levels of sedation follow:
Level 1: Minimal sedation (anxiolysis). There is no significant effect on cardiorespiratory function. Patient responds normally to verbal commands, but cognitive function and coordination may be impaired.
Level 2: Moderate sedation. Cardiorespiratory function is usually maintained. (This level most closely correlates with what was previously termed conscious and is now procedural sedation). Patient responds purposefully to verbal commands and may require light tactile stimulation.
Level 3: Deep sedation. Respiratory function is often impaired; cardiac function may be impaired. Patient cannot be easily aroused, responds purposefully after repeated or painful stimulation.
Level 4: Anesthesia. There is a significant depressive effect on cardiorespiratory function. Patients are not arousable even by painful stimulation.
Progression from Level 1 through Level 4 exists as a continuum, determined by the maintenance or loss of protective airway reflexes, a patent airway, adequate ventilation and oxygenation, and response to verbal and physical stimuli. These may be controlled by dose-dependent titration of one or more classes of drugs.
In the rules set forth by the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), there is strong emphasis on sedation being administered by qualified personnel who can respond to problems associated with the patient slipping into a deeper level of sedation than intended. The personnel should have competency-based education, training, and experience. These rules also include:
- Pre-sedation assessment
- Sedation must be planned
- Informed consent
- Physiological monitoring
- Assessment post-procedure
- Assessment at discharge
Definition of Procedural Sedation
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.
Purpose/Indications
- Provide sedation, analgesia, and/or immobilization of an anxious or uncooperative patient during a diagnostic study or therapeutic procedure causing pain or requiring immobilization and cooperation.
- Procedure producing anxiety/pain or requiring immobilization/cooperation: Treat with sedative only (eg, head CT of an uncooperative, confused, anxious, or intoxicated patient)
- Procedure producing anxiety and pain: Treat with sedative and analgesic (eg, fracture/dislocation reduction, intubation, abscess I&D, cardioversion, chest tube placement, burn debridement, multi-system trauma requiring multiple diagnostic imaging studies, PEDS complex facial laceration/repair)
Preprocedural Fasting
Recent oral intake has historically been considered a contraindication to elective procedural sedation. While preprocedural fasting is still preferred and should be considered according to expert opinion, the weight of this recommendation has shifted and is now considered Level C evidence. The combination of vomiting and loss of airway reflexes is an extremely rare occurrence with procedural sedation and analgesia, making aspiration an unlikely event. Much of the aspiration data had previously been extrapolated from general anesthesia literature where intubation and extubation greatly increase the aspiration risk. Multiple studies in emergency department patients failed to demonstrate that gastric emptying had any impact on the incidence of complications or outcomes in procedural sedation and analgesia.
Absolute Contraindication
- Unstable patient requiring immediate intervention
- Refusal by competent patient
- Inexperienced or inadequate number of staff
- Inadequate monitoring equipment
Relative Contraindication
- Hemodynamic or respiratory compromise
- Altered LOC
-
Significant past medical history (eg, atherosclerotic heart disease,
chronic obstructive pulmonary disease, procedures lasting > 1
hour
or better performed in the operating room).
- Recent meal (< 2 hours) in patient at risk for aspiration
Caution
- Geriatric patients
- PEDS: Pediatric patients
- High-risk patients: possible difficult intubation/ventilation, previous adverse experience with sedation or anesthesia, potential for aspiration
Risk Reduction
- Informed, written consent for elective conscious sedation
- Pre-sedation evaluation to identify high-risk patient
- Aspiration risk factors: recent oral intake, obese, pregnant, alcohol/prescription/elicit drug use
- Prepare for difficult airway or bag-valve-mask ventilation: Assess for short stocky neck, large tongue (Mallampati score), dental prosthesis, airway disease, previous neck surgery, bearded patient, neck immobility (eg, cervical collar, cervical spine fusion)
- Past medical history, past psychiatric history (eg, psychosis)
- Responsible adult to accept/monitor discharged patient
Equipment Preparation
Oxygen, suction, reversal agents and advanced life support medications and
equipment should be available when procedural sedation and analgesia is
used. Due to this necessity, many hospitals should consider limiting
procedural sedation and analgesia to areas where this equipment and
medication is normally stocked and readily available, such as the
emergency department, critical care units, or surgical areas.
Monitoring
- Two-person task: one monitors patient/administers drugs; one performs procedure
- Two types: interactive and mechanical
Goals
- Ensure adequate sedation/analgesia
-
Detect adverse effects: most common=
bradypnea/apnea
hypoxia
Interactive Monitoring
- Contact between patient and person monitoring patient/administering drugs
-
Initial and ongoing assessment with
vital signs/LOC recorded:
- Every 5 minutes
- For 20 minutes after last drug administered or procedure completed (in studies using fentanyl and diazepam, all episodes of oxygen desaturation occurred within 20 minutes of last drug dose)1,2
- Through recovery phase
- Recovery phase: every 5 to 10 minutes until patient is awake, alert, and conversant
- Observe 1 hour or more after patient awake, alert, and conversant.
Mechanical Monitoring
- Auto blood pressure, heart rate, respiratory rate, continuous pulse oximetry or capnography, cardiac rhythm - with alarms set
- Nasal end-tidal CO2 capnography detects increased CO2 levels due to apnea or hypopnea often several minutes before hypoxia occurs. Many providers of procedural sedation are now utilizing capnography to detect hypopnea and respond before hypoxia or other problems develop; however, no proven outcomes advantage over continuous SaO2 monitoring have been reported. The latest guidelines on procedural sedation for the American Academy of Pediatrics recommends the use of capnography for sedated children.3
-
Pulse oximetry:
- Must register heart rate to provide accurate SaO2
- On extremity opposite auto blood pressure cuff for uninterrupted readings
- With supplemental O2, SaO2 may reach > 100% and pulse oximetry may not be accurate - patient may become apneic for as many as 5 minutes before desaturation detected by pulse oximetry
Initial and Ongoing Assessment
- Obtain informed, written consent.
- Monitoring equipment: auto blood pressure, heart rate, respiratory rate, continuous pulse oximetry/capnography, cardiac monitor
- Airway equipment: suction, nasal/oral airways, bag-valve-mask (BVM), intubation equipment
- Monitor/record: see protocol sample (this portal)
- Vital signs: blood pressure, heart rate, respiratory rate, continuous pulse oximetry/capnography, cardiac rhythm
-
Pain:
- Scale 0 to 10
- > 3 = Treat with analgesia
-
LOC: based on stimulus required to
evoke 1 of 3 responses:
- Awake and talking
- Drowsy but responsive to verbal/painful stimuli
- Unresponsive to any stimuli
Pharmacology
Ideal Drug
Has
rapid onset, short duration is titrateable and reversible, produces
desired effect, with little or no untoward side effects (eg,
cardiorespiratory, gastrointestinal)
Drug Selection
- Determined by procedure performed:
- Duration: short vs. long/repetitive (eg, simple dislocated shoulder reduction vs. complex displaced fracture requiring reduction/immobilization/x-ray)
- Painful vs. painless: requiring analgesia and sedation vs. sedation alone (eg, peri-anal abscess I&D vs. PEDS head CT)
- Immobilization/cooperation: eg, uncooperative patient requiring head CT, PEDS complex facial laceration/repair
Route
- Types: IV, IM, PO, transmucosal (nasal, rectal), inhalation
- IV: preferred route allowing rapid, safe titration of repeat doses to predictable desired effect
-
IM
- Preferred route if no IV access
- Preferred route with PEDS receiving ketamine if no IV access
- No more effective than transmucosal or oral with drugs other than ketamine
- Does not allow rapid onset, known duration, predictable effects, titration.
-
Transmucosal
- Preferred routes vs. oral with PEDS
- Variable onset but can be rapid for some medications. Makes titration more difficult. Compared with IV, less predictable duration and effects. Different dosing ranges compared with IV.
- Examples: Intranasal fentanyl for pre-procedural pain control and intranasal Versed for anxiolysis/sedation often used for pediatric cases or when IV access is difficult.
- With intranasal route, use of mucosal atomizer is important for effective drug delivery.
-
PO
- Affected by GI absorption/motility/emptying time, produces delayed onset, unpredictable effects/duration, increased aspiration risk
- Decreased effect due to first pass hepatic metabolism
- Does not allow rapid onset, known duration, predictable effects, titration.
- Inhalation: nitrous oxide only inhalation drug available in the ED
Dosing
Sedative/Analgesic
- Preferred order of drug administration is sedative then analgesic. This order is best for procedures becoming increasingly more painful.
- The order in which drugs are given is not as important as achieving the desired effect with one drug before administering another.
- Administer independently until the desired effect is achieved with one drug before administering another.
- Avoid alternating between doses of sedative and analgesic.
- Titrate in small incremental doses with enough elapsed time between doses to assess effect. Stacking doses too quickly increases risk of respiratory depression and hypoxia so dosing intervals and recommendations should be monitored closely, especially if combining medications.4
- Dose ranges listed in the following drug table are those most commonly effective. However, appropriate dose is that which produces desired effect without major side effects. Some patients may require lower or higher doses than the range listed in this drug table.
- Patients may moan, wince, or complain of pain even though adequately sedated and anesthetized.
- Nausea, severe pruritus, decreased blood pressure may occur at any dose. Discontinue drug.
- Mild nasal pruritus is common with narcotics
Desired Effective Endpoints
- Sedation: somnolence (drowsy), ptosis, gaze alteration, slurred speech
- Analgesia: somnolence (drowsy), miosis, decreased response to verbal stimulus, minimally impaired speech, decreased pain (< 3)
Reversal Agents
- Routine reversal of sedation/analgesia not recommended (reviewed by JCAHO as marker for inappropriate procedural sedation)
-
Reversal of sedation and/or analgesia required if:
- Prolonged unconscious sedation unresponsive to stimulation
- Cardiorespiratory depression unresponsive to stimulation
- Occurrence of hypoxia/apnea requiring assisted ventilation
- Perform procedure before reversing. Stimulation procedure often improves patient's status without need for reversal agent. After procedure, also may attempt verbal or physical stimulation of patient to reduce need for reversal.
- Sedation reversed initially allowing continued analgesia if possible
- Reverse benzodiazepines with flumazenil
- Reverse opioids with naloxone - only if reversal of sedative does not improve patient's status. Note that naloxone may be administered IV, IM, SQ, ET, SL, and IN. IN administration is a needleless alternative to the injected route and can save lives while avoiding the need for intubation and reducing the risk to providers of needlestick injuries.5
- Patient must be monitored for recurrence of unconscious sedation, cardiorespiratory depression, hypoxia/apnea requiring repeat dosing of reversal agent(s) until sedative/analgesic effects are over. For example, effects of morphine or hydromorphone will outlast the reversal effects of naloxone.
Benzodiazepine Reversal
- Preferred method=partial reversal with reversal agent(s) administered in small doses titrated to desired effect (eg, increased LOC, increased respiration rate)
-
May induce:
- Seizure - reverse with caution in patient with:
- seizure controlled with benzodiazepines
- tricyclic antidepressant overdose
- increased intracranial pressure/head injury
- Anxiety: sympathetic nervous system stimulation
- Seizure - reverse with caution in patient with:
Opioid Reversal
- Preferred method=partial reversal with reversal agent(s) administered in small doses titrated to desired effect (eg, increased LOC, increased respiratory rate)
- Will not induce opioid withdrawal in patients without preexisting dependence
- Will allow recurrence of pain - Treat with NSAIDS prn
- May induce nausea, anxiety
Discharge Criteria
-
Return to
- Normal vital signs relative to age and injuries
- Baseline mental status and verbal skills
- Baseline motor function:
- infant: sits unattended
- child/adult: ambulates unassisted
- Tolerating oral fluids
- Pain controlled with oral analgesia
- Discharged to responsible adult who understands and can comply with discharge instructions
Sample Discharge Instructions
Adult
- During the next 8 hours you may experience drowsiness, nausea, dizziness or mild changes in the ability to think clearly.
-
During the next 24 hours:
- Do not drive; operate heavy machinery, dangerous equipment, or tools; or engage in physically dangerous activities requiring clear thought and physical coordination.
- Do not make any important decisions or sign important documents.
- Eat a light diet (clear liquids if nauseous or vomiting).
- Remain in the presence of a responsible adult.
- Take only prescribed medications.
- Do not drink alcohol.
- Return to the ED or call 911 if you develop shortness of breath or persistent nausea and vomiting.
PEDS: Infants/Children
Your child has been given medications for sedation and/or pain. These medications may cause him or her to be sleepy and less aware of his or her surroundings, making it easier for accidents to occur as your child walks or crawls. Nausea and vomiting is also common after sedating and/or pain medications. This is generally self limiting, but if persistent they should be reevaluated. Because of these side effects, watch your child closely for the next 8 hours. If you notice anything unusual about your child, or he or she cannot take oral fluids within the next 4 to 6 hours, please call the Emergency Department.
We also recommend:
No oral food/fluids for the next 2 hours. (If your child is an infant, he or she may resume half normal feedings in 1 hour.)
Over the next 8 hours, adult supervision is required for activities such as baths, showers, cooking, use of dangerous appliances/tools/toys, playing, etc.
Over the next 24 hours, no activity requiring normal physical coordination (eg, biking, climbing swinging, etc.)
Protocol Sample
- Attach monitoring equipment: blood pressure, heart rate, respiratory rate, pulse oximetry/capnography, cardiac rhythm.
- Assemble airway equipment: suction, oral/nasal airways, BVM, intubation equipment.
- Assess LOC and pain.
- Attach O2 at 4 to 6 LPM per nasal cannula.
- Establish IV of normal saline @ TKO for flushes and volume bolus prn.
- Select sedative, analgesic, and reversal agents.
-
Administer drugs:
- Sedative
- Analgesic
- Accessory drugs (eg, atropine)
- Local anesthetic prn
- Monitor/record parameters listed in numbers 1 and 2 every 5 to 10 minutes.
- Perform procedure: titrate additional doses prn.
-
If reversal agents indicated:
- Perform procedure before reversing drug. Stimulation of procedure often improves patient's status without need for reversal agent.
- Assist with BVM and O2
- Reverse benzodiazepines with flumazenil.
- Reverse opioids with naloxone (only if reversal of sedative does not improve patient's status).
- Monitor closely for 1.5 to 2 h.
- Discharge to responsible adult who understands and can comply with instructions.
Policies
Ideally each institution develops guidelines specific to their ED setting and patient population with input from emergency medicine physicians, anesthesiologists, pediatricians, pharmacists, emergency medicine physician assistants, nurse practitioners, and nurses within the institution. These policies should consider state-specific regulations regarding nursing or physician practice with regard to administration of narcotics and/or sedating medications used in procedural sedation.
JCAHO’s standards include:
- Written informed consent specific for conscious sedation
- Pre-anesthesia patient assessment
- Anesthesia plan: drugs selected, dosages, routes
- Flow sheet to document procedure/recovery
- Appropriate monitoring
- Appropriate disposition
References
- Newman DH, Azer MM, Pitetti RD et al. When is a patient safe for discharge after procedural sedation? The timing of adverse effect events in 1,367 pediatric procedural sedations. Ann Emerg Med. 2003;42:627-635.
- Bailey PL, Pace NL, Ashburn MA, et al. Frequent hypoxemia and apnea after sedation with midazolam and fentanyl. Anesthesiology. 1990;73:826-830.
- American Academy of Pediatrics: Clinical Report: 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.
- American College of Emergency Physicians: Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department. Ann Emerg Med. 2005; 45:2:177-196.
- Koenig KL. Intranasal naloxone is effective for opioid overdose. Journal Watch Emergency Medicine. October 30, 2009.
- Arora S. Combining Ketamine and Propofol (“Ketofol”) for Emergency Department Procedural Sedation and Analgesia: A Review. West JEM. 2008; 9:20-23.
- Andolfatto G, Willman E; A Prospective Case Series of Single-Syringe Ketamine-Propofol (Ketofol) for Emergency Department Procedural Sedation and Analgesia in Adults. Acad Emergency Medicine. 2011; 18(3):237-45.
- Procedural Sedation Consensus Statement. Signed by: American Academy of Emergency Medicine, American Association of Critical Care Nurses, American College of Emergency Physicians, American Radiological Nurses Association, American Society for Pain Management Nursing, Emergency Nurses Association, National Association of Children’s Hospitals and Related Institutions and Air & Surface Transport Nurses Association. Feb. 2008.
- Cline David, et al. Emergency Medicine: A Comprehensive Study Guide: Companion Handbook. 4th ed. New York: McGraw-Hill; 1996.
- Goodman-Gilman Alfred, et al. The Pharmacologic Basis Of Therapeutics. 8th ed. New York: Pergamm Press, 1990.
- Kauffman, Ralph E, et al. American Academy of Pediatrics Committee on Drugs: Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation For Diagnostic and Therapeutic Procedures. Pediatrics. 1992;89:6:1110-1115.
- McEvoy Gerald K, et al. American Hospital Formulary Service. Bethesda, MD: American Society of Health-System Pharmacists, 1998.
- Joint ENA/ACEP Statement: Delivery of Agents for Procedural Sedation and Analgesia by Emergency Nurses. March 2005.
- Roberts James R, et al. Clinical Procedures In Emergency Medicine. 3rd ed. Philadelphia: WB Saunders; 1998.
- Rosen Peter, et al. Emergency Medicine: Concepts & Clinical Practice. St. Louis: Mosby-Year Book Inc.; 1997.
- Sacchetti, Alfred, et al. “Pediatric Analgesia and Sedation.” Ann Emerg Med. 1994;23:237-250.
- Strange Gary R, et al. Pediatric Emergency Medicine: A Comprehensive Study Guide, New York: McGraw-Hill; 1996.
- Tintinalli Judith E, et al. Emergency Medicine: A Comprehensive Study Guide. 4th ed. New York: McGraw Hill; 1996.
- Mace SE, Barata IA, Cravero JP, et al. EMSC Grant Panel Writing Committee on Pharmacologic Agents Used in Pediatric Sedation and Analgesia in the Emergency Department. Clinical policy: evidence-based approach to pharmacologic agents used in pediatric sedation and analgesia in the emergency department. Ann Emerg Med. 2004;44:342-377.