Procedural Sedation in the Emergency Department

Reaffirmed February 2023

Revised June 2017 with current title

Revised January 2011 titled "Sedation in the Emergency Department", replacing two rescinded policy statements “Procedural Sedation in the Emergency Department” (approved October 2004) and “The Use of Pediatric Sedation and Analgesia” (revised April 2008, reaffirmed October 2001, revised January 1997, originally approved March 1992)

Procedural sedation is a technique of administering sedatives or dissociative agents with or without analgesics to induce a state that allows the patient to tolerate unpleasant procedures. Procedural sedation improves the quality and safety of patient care by decreasing the length of time necessary to perform a procedure, increasing the likelihood of success, and reducing risk of injury to the patient or health care worker due to uncontrolled movements.

Procedural sedation encompasses a continuum of altered levels of consciousness (including minimal, moderate, and deep), and dissociative sedation.

Procedural sedation is a critically important component of comprehensive emergency care and a required core competency of emergency medicine residency training. This training includes rescue airway interventions for support of patient ventilation and oxygenation, as well as support and monitoring of patient cardiovascular status.

Evidence in the medical literature has established that procedural sedation, including minimal, moderate, deep, and dissociative sedation, can be safely and effectively performed in the emergency department (ED) by emergency physicians, both in the care of adult and pediatric emergency populations.

There is no single agent or combination of agents that can be recommended for every patient or sedation procedure. Clinicians must weigh the relative needs for pain control (analgesia), sedation, and the potential risks, benefits, and alternatives when individualizing their plan for patient sedation.

Agents commonly used for sedation of patients in the ED include but are not limited to opioids, benzodiazepines, and barbiturates as well as other specific agents such as ketamine, propofol, remifentanil, alfentanil, dexmedetomidine, etomidate, and nitrous oxide.

In addition to pharmacologic agents, adjunctive techniques, such as regional, local, and topical anesthesia, and nonpharmacologic techniques should be used as needed to reduce patients’ fear, discomfort, and anxiety.

Nothing by mouth (NPO) status has not been demonstrated to reduce risk of emesis or aspiration in ED procedural sedation.

The American College of Emergency Physicians is the authoritative body for the establishment of guidelines for sedation of patients in the ED. To promote the safe and effective use of sedation in ED patients, the American College of Emergency Physicians recommends the following:

• Emergency physicians who have received the appropriate training and skills necessary to safely provide procedural sedation, such as board certification (ABEM/ABOEM) in emergency medicine or graduates of an ACGME accredited emergency medicine program, should be credentialed without additional requirements for procedural sedation.
• The decision to provide sedation and the selection of the specific pharmacologic agents should be individualized for each patient by the emergency physician and should not be otherwise restricted.
• Emergency physicians and staff are expected to be familiar with the pharmaceutical agents they use and be prepared to manage their potential complications.
• To minimize complications, the appropriate drugs and dosages must be chosen and administered in an appropriately monitored setting. Patient evaluation should be performed before, during, and after their use.
• Institutional and departmental guidelines related to the sedation of patients should include the selection and preparation of patients, informed consent, equipment and monitoring requirements, hospital staff training and competency verification, criteria for discharge, and continuous quality improvement.
• ED physician and nursing leadership should have ongoing collaboration to develop institutional policy regarding nursing roles in sedation and the ability of nurses to administer sedatives. Emergency nurses with demonstrated competencies are qualified and capable to safely administer propofol, ketamine, and other sedatives.