Procedural Sedation Summary

Key Components

Analgesia - Treat pain first
Anxiolysis - Reduce anxiety
Sedation - Moderate to deep level
Amnesia - Minimize unpleasant memories

Drug Comparison

Propofol: Fast onset, hypotension risk
Midazolam: Reversible with flumazenil
Ketamine: Maintains airway, dissociative

Critical Safety Points

Assess pain before sedation
Adjust doses for elderly/obese
Monitor for respiratory depression
Have reversal agents available

Dosing Guidelines

Propofol: 0.5-1 mg/kg initial
Midazolam: 1-2 mg initial
Ketamine: 1 mg/kg IV, 4-5 mg/kg IM

Special Considerations

Ketamine: Emergence phenomena
Propofol: Profound hypotension
Midazolam: Accumulates in obese
All: Enhanced effects with opioids

Ketamine Contraindications

Airway instability
Severe cardiovascular disease
Psychotic illness
Globe injury/glaucoma

Procedural Sedation

Comprehensive guide to pharmacological agents for effective and safe procedural sedation

Effective Sedation Requirements

Analgesia

Pain should be treated with analgesia rather than sedation
Assess and manage pain prior to starting sedation using WHO pain ladder principles
Consider need for ongoing pain relief post-procedure
If opiates given pre-sedation, adjust sedative doses accordingly

Anxiolysis

Non-pharmacological methods often most effective
Consider environment and patient comfort
Environment crucial for children, dementia, learning difficulties
Family members provide support and distraction
Most painful procedures best performed supine

Sedation

For most ED procedures: moderate to deep sedation required
Determine required level in advance
Tailor to procedure complexity and duration

Amnesia

Degree of amnesia minimizes unpleasant memories
Particularly important for traumatic procedures
Enhances patient satisfaction and cooperation

Note: Ketamine is the only pharmacological agent that provides analgesia, sedation, anxiolysis and amnesia simultaneously.

Choice of Sedation Agents

Appropriate choice depends on: procedure nature, planned sedation level, practitioner familiarity, patient factors, and local environment.

Key Considerations

Tailor drug doses to individual patient requirements
Great care needed due to:
- Slow and variable onset time
- Inter-patient variability in dose requirement
- Synergistic action between drugs
Always have reversal agents available
Continuous monitoring essential

Common Pharmacological Agents

Midazolam

Properties

Fast-acting water-soluble benzodiazepine
Used in ED for ~30 years
No analgesic properties
Important safety feature: reversible with flumazenil

Important Notes

Flumazenil should not be used routinely
Flumazenil may have shorter duration than sedative
Risk of re-sedation after flumazenil wears off
Accumulates in adipose tissue (elderly, obese, hepatic/renal disease)

Propofol

Properties

Lipophilic agent enhancing GABA inhibitory neurotransmission
Rapid onset and recovery
Complication rates comparable to midazolam
Useful for brief procedures

Significant Risks

Profound hypotension
Respiratory depression
Frequent induction of deep sedation/general anesthesia
Enhanced effects when combined with opioids

Important: When opiate analgesia is required, give it first and allow time to become maximally effective before administering sedatives.

Ketamine

Properties

Dissociative anesthetic and analgesic
Produces trance-like state
Patients appear awake with little cortical depression
Unique: maintains respiration and airway reflexes

Side Effects & Considerations

Emergence phenomena (related to pre-sedation agitation)
Sympathetic stimulation: tachycardia and hypertension
Benzodiazepines for emergence phenomena prolong recovery
Minimize stimulation during recovery

Ketamine Contraindications

Airway instability or tracheal pathology
High predisposition to laryngospasm or apnea
Severe cardiovascular disease
CSF obstructive states
Previous psychotic illness
Hyperthyroidism or thyroid medication use
Globe injury or glaucoma
Porphyria

Drug Comparison Table

Parameter	Propofol	Midazolam	Ketamine
Mode of Action	Positive modulation of GABA inhibitory neurotransmission	Short-acting benzodiazepine	NMDA-receptor antagonist
Effects	Sedation and amnesia	Sedation and amnesia	Dissociative sedation, amnesia, analgesia
Side Effects	Hypotension, respiratory depression, pain at injection site	Respiratory depression, hypotension, paradoxical disinhibition, accumulates in adipose tissue	Tachycardia, hypertension, laryngospasm, hallucinations, nausea/vomiting, hypersalivation, increased ICP/IOP
Route	IV	IV	IV, IM
Initial Onset Time	30 sec - 1 min	1 - 2 min	30 sec - 1 min
Peak Effect Time	1 - 2 min	3 - 4 min	1 - 2 min

Dosing Guidelines

Drug	Initial Dose	Repeat Dose	Special Populations
Propofol	Adult: 0.5 - 1 mg/kg Elderly: 10 - 20 mg	Adult: 0.5 mg/kg every 3-5 mins Elderly: 10 - 20 mg	Reduce dose in elderly, hemodynamically unstable
Midazolam	Adult: 1 - 2 mg Elderly: 0.5 mg	Adult: 1 - 2 mg after 2-5 mins Elderly: 0.5 mg	Reduce dose in elderly, obese, hepatic/renal impairment
Ketamine	Adult IV: 1 mg/kg Elderly IV: 10 - 30 mg IM: 4 - 5 mg/kg	IV: 0.25 - 0.5 mg/kg every 5-10 min IM: 2 - 2.5 mg/kg every 5-10 min	Multiple contraindications - check carefully

Critical Safety Points:

Always titrate to effect - start low, go slow
Consider reduced doses in elderly, obese, and those with comorbidities
Have resuscitation equipment and reversal agents immediately available
Continuous monitoring of vital signs essential
Never leave patient unattended during sedation

Practical Considerations

Pre-procedure Assessment

Airway assessment
Cardiorespiratory status
Fasting status (if applicable)
Allergies and contraindications
Previous sedation/anesthesia history

Monitoring Requirements

Continuous pulse oximetry
Blood pressure monitoring
ECG for at-risk patients
Capnography if available
Level of consciousness assessment

Equipment Checklist

Airway management equipment
Oxygen supply and delivery devices
Suction apparatus
Reversal agents (flumazenil, naloxone)
Emergency drugs
Defibrillator

Recovery Protocol

Monitor until fully alert
Assess vital signs regularly
Check for adequate pain control
Provide post-procedure instructions
Arrange appropriate discharge