The American College of Emergency Physicians (ACEP) just published a new clinical policy on procedural sedation and analgesia in the emergency department, which revised the previous policy from 2005.1 Procedural sedation (conscious sedation) is extremely common in the ED and can be performed safely and improve the patient and provider experience during difficult procedures.
This new clinical policy addressed some critical questions about procedural sedation that I will summarize below:
1. Procedural sedation can be performed in adults or children regardless of the preprocedural fasting time. The policy states that, “Preprocedural fasting for any duration has not demonstrated a reduction in the risk of emesis or aspiration when administering procedural sedation and analgesia.” The policy cites studies performed in both children and adults using agents as varied as midazolam, fentanyl, ketamine, and propofol as monotherapy and combined.
2. Capnography may be used as an adjunct to pulse oximetry and clinical assessment to detect hypoventilation and apnea earlier than pulse oximetry monitoring alone. Several studies clearly demonstrate that the use of capnography decreases the incidence of hypoxia and respiratory events, but there is still insufficient evidence that capnography decreases the incidence of “serious adverse respiratory events.”
3. The minimum number of personnel necessary to manage procedural sedation and analgesia is two. A nurse should be present for continuous monitoring of the patient in addition to the procedural operator.
4. The policy states that ketamine, propofol, etomidate, and alfentanil can all be safely administered in the ED for procedural sedation and analgesia. More data are needed for remifentanil and dexmedetomidine before any definitive statement can be made about its use.
Godwin SA et al. Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department. Annals of Emerg Med. 2014; 63 (2):247-258.