This guideline is a brief summary of the RCEM 2012 Safe sedation in the ED and RCEM – Pharmacological Agents for Procedural Sedation and Analgesia in the Emergency Department – March 2019. Please read these documents in full or participate in RCEM learning elearning for further information.

 

Who can perform it?

• Senior medical staff (ST3+)
• Must have done at least 6 months of anaesthetics/ICU
• Must have at least 3 staff members – someone to perform sedation, someone to perform procedure, someone to monitor the patient
• Department must be safe – Senior ED clinician in department has final say over if it is appropriate to perform at any given time.

Where should it be performed?

• ED resus
• Full monitoring – 3 lead ECG, sats probe, BP cuff, CO2 monitoring

Levels of Sedation

• Analgesia: Relief of pain without intentionally producing a sedated state. Altered mental status may occur as a secondary effect of medications administered for analgesia.
• Minimal sedation (anxiolysis): The patient responds normally to verbal commands. Cognitive function and coordination may be impaired, but ventilatory and cardiovascular functions are unaffected.
• Moderate sedation and analgesia: The patient responds purposefully to verbal commands alone or when accompanied by light touch. Protective airway reflexes and adequate ventilation are maintained without intervention. Cardiovascular function remains stable.
• Deep sedation and analgesia: The patient cannot be easily aroused but responds purposefully to noxious stimulation. Assistance may be needed to ensure the airway is protected and adequate ventilation maintained. Cardiovascular function is usually stable.
• General anaesthesia: The patient cannot be aroused and often requires assistance to protect the airway and maintain ventilation. Cardiovascular function may be impaired.
• Dissociative sedation: Dissociative sedation is a trance-like cataleptic state in which the patient experiences profound analgesia and amnesia, but retains airway protective reflexes, spontaneous respirations, and cardiopulmonary stability. Ketamine is the pharmacologic agent used for procedural sedation that produces this state

Indications

• Any procedure that may cause pain and anxiety
  • Most commonly bone/joint manipulations
  • DC cardioversion

Contraindications

• Patient is clinically unwell/unstable – anaesthetic assistance should be sought
• Patient is assessed to have a potentially ‘difficult airway’ – anaesthetic assistance should be sought and procedure reconsidered – may be more appropriate to be done in theatre
• Allergy to the planned sedative agent
• Specific contraindications to each medication. See Appendix 3 of RCEM – Pharmacological Agents for Procedural Sedation and Analgesia in the Emergency Department – March 2019 for more information.

Fasting

• For an emergency procedure in a patient who has not fasted, balance the risks and benefits of the decision to proceed with sedation before fasting criteria are achieved, on the urgency of the procedure and the target depth of sedation..
• If safe and appropriate to wait until fully fasted, wait:
  • 2 hours for clear fluids
  • 6 hours for solids

Consent

• Patient MUST be consented appropriately
• Risks and benefits along with potential side effects should be explained
  • Common (nausea/vomiting, hypotension) and rare but serious (respiratory compromise, allergy) side effects/complications should be explained. These vary depending on the medications used. See Appendix 3 of RCEM – Pharmacological Agents for Procedural Sedation and Analgesia in the Emergency Department – March 2019 for more information.

Medications

DRUG	ROLE	ROUTE	INITIAL DOSE (elderly)	REPEAT DOSE (elderly)	INITIAL DOSE (adult)	REPEAT DOSE (adult)	ONSET (min)	PEAK EFFECT (min)
Propofol	Sedation/Amnesia	IV	10-20mg (slowly)	10-20mg (slowly)	0.5-1mg/kg	0.5mg/kg every 3-5min	0.5-1	1-2
Midazolam	Sedation/Amnesia	IV (over 1-2 min)	0.5mg	0.5mg	1-2mg (max 2.5mg as single dose)	After 2-5min	1-2	3-4
Ketamine	Sedation/Amnesia/Analgesia	IV (give over 30-60sec)	10-30mg		1mg/kg	0.25-0.5mg/kg every 5-10 min	0.5-1	1-2
Ketamine	Sedation/Amnesia/Analgesia	IM			4-5mg/kg	2-2.5mg/kg every 5-10min	0.5-1	1-2
Ketamine	Analgesia (sub-dissociative)	IV			0.3mg/kg		0.5-1	1-2
Fentanyl	Analgesia (with other sedation)	IV			up to 0.5µg/kg	up to 0.5µg/kg (every 2min)	1-2	3-5
Fentanyl	Sedation/Amnesia	IV			up to 0.5-1.0µg/kg	up to 0.5-1.0µg/kg (every 2min)	1-2	3-5
Ketofol	Sedation/Amnesia/Analgesia	IV			0.5-0.75mg/kg (of both agents)		0.5-1	1-2

RCEM – Pharmacological Agents for Procedural Sedation and Analgesia in the Emergency Department – March 2019 – see this document for the references numbered in the table. Only use medications that you are familiar with unless supervised by an experienced colleague.

Post sedation care

• Patient must be observed in a safe place until:
  • Observations returned to normal
  • The patient is fully awake with intact airway reflexes
  • Nausea, vomiting and pain have been fully addressed
• Patient must be advised not to drive for 24 hours.
• Advice leaflet should be given. – HERE
• Fill in adhoc form on EPR – this covers pre sedation airway assessment, drugs given and any complications
• Ensure any drugs used are prescribed and signed for. Controlled drugs should also be signed in the CD book by whoever administered them.