Procedural Sedation Summary

Sedation Levels

  • Level 1: Minimal sedation (anxiolysis)
  • Level 2: Moderate sedation
  • Level 3: Deep sedation
  • Level 4: General anesthesia

Staffing Requirements

  • Minimal sedation: 1 physician or ENP
  • All other sedation: Sedationist + Operator + Nurse
  • Location: Resuscitation room for Level 2+

Monitoring

  • Minimal: Pulse oximetry
  • Moderate+: ECG, NIBP, SpO₂
  • Deep/Dissociative: Capnography mandatory

Fasting Guidelines

  • Minimal/Moderate: No fasting required
  • Deep/Dissociative: 2h clear fluids, 6h solids
  • Emergency: Risk-benefit assessment

Key Drugs

  • Minimal: Entonox
  • Moderate: Opioids/Benzodiazepines
  • Deep: Propofol
  • Dissociative: Ketamine

Discharge Criteria

  • Baseline consciousness
  • Stable vital signs
  • Respiratory status adequate
  • Symptoms controlled
  • Responsible escort required

Critical Points

  • Sedation is a continuum
  • Must be able to rescue from deeper level
  • Ketamine = deep sedation category
  • Capnography detects apnea early

Procedural Sedation

Comprehensive guide to sedation levels, requirements, and safety protocols in emergency settings

Depths of Sedation and Definitions

Sedation is a continuum which extends from normal alert consciousness to complete unresponsiveness.

Important Boundary: Once verbal contact with the patient is lost, it becomes difficult to determine the level of unconsciousness, and over-sedation with associated risk of airway and cardiorespiratory complications is possible.

Sedation Continuum

Sedation Level Response Airway Reflexes Ventilatory Function Cardiovascular Function Examples
Minimal sedation (anxiolysis) Level 1 Normal response to verbal commands Maintained Maintained Maintained Entonox
Moderate sedation/analgesia (conscious sedation) Level 2 Purposeful response to verbal commands (± light stimuli) Maintained Usually maintained Maintained Opioids/benzodiazepines
Deep sedation/analgesia Level 3 Not easily aroused but purposeful response to repeated or painful stimuli May be impaired May be impaired Usually maintained Propofol
General anesthesia Level 4 Patient unrousable, even by painful stimulation Impaired Usually impaired May be impaired General anesthetics

Rescue Principle: Practitioners intending to produce a given level of sedation must be able to 'rescue' patients from a deeper level of sedation than intended.

Dissociative Sedation

Definition

A trance-like cataleptic state characterized by profound analgesia and amnesia, with retention of protective airway reflexes, spontaneous respirations, and cardiopulmonary stability.

Ketamine Considerations

  • Does not fit standard sedation definitions
  • Loss of verbal contact with patients
  • Grouped with deep sedation/general anesthesia
  • Significant complications can occur unpredictably

Requirements for ED Sedation

Minimum Staffing Levels

Minimal Sedation (Entonox)

  • One physician OR emergency nurse practitioner (ENP)

All Other Sedation

  • One physician as sedationist AND
  • One physician or ENP as operator AND
  • One nurse

Location and Facilities

Minimal Sedation (Entonox)

  • Anywhere within the Emergency Department (ED)

All Other Sedation

  • Resuscitation room facilities
  • Full monitoring equipment available
  • Airway management equipment accessible

Required Competencies

Sedation Practitioner Competencies
  1. ASA grading assessment
  2. Pre-procedural assessment including prediction of difficulty in airway management
  3. Pre-procedural fasting and risk-benefit assessment
  4. Consent and documentation
  5. Drug selection and preparation: Safe use of benzodiazepine/opioid combinations, propofol, and ketamine; intervals between increments and reversal drugs
  6. Monitoring, complications (e.g., hypoxia, hypotension) and rescue strategies
  7. Governance and audit

Required Monitoring

Sedation Level Minimum Monitoring Additional Recommendations
Minimal sedation (Entonox) Pulse oximetry -
All other sedation ECG, NIBP, pulse oximetry Continuous capnography recommended for conscious sedation
Deep and dissociative sedation ECG, NIBP, pulse oximetry Continuous capnography MANDATORY

Fasting Prior to ED Sedation

General Rule: Fasting is not needed for minimal sedation, sedation with nitrous oxide alone, or moderate sedation where verbal contact is maintained.

Elective Procedures

Deep/Dissociative Sedation

  • Clear fluids: 2 hours fasting
  • Solids: 6 hours fasting
  • Same as general anesthesia guidelines

Moderate Sedation

  • No fasting required if verbal contact maintained
  • If verbal contact might be lost, apply deep sedation rules

Emergency Procedures

For emergency procedures in non-fasted patients, base the decision to proceed on:

  • The urgency of the procedure
  • The target depth of sedation
  • Risk-benefit analysis

Risk Assessment Factors

Procedure Factors

  • Urgency: Life or limb threatening situations may not allow delay
  • Depth and duration: Longer and deeper sedation increases risk
  • Airway interventions: May stimulate reflexes leading to aspiration

Patient Factors

  • Raised intracranial pressure
  • Hiatus hernia
  • Gastrointestinal obstruction
  • Recent injury or opioid use
  • Pregnancy
  • Morbid obesity
  • Upper GI surgery history

Risk Mitigation Strategies

Approaches to Reduce Aspiration Risk
  1. Delay procedure if clinically appropriate
  2. Alternative techniques:
    • Rapid sequence induction with tracheal intubation (gold standard)
    • Regional anesthesia with minimal sedation
  3. Reduce sedation depth and duration (increases procedural failure risk)
  4. Pharmacological preparation:
    • Ranitidine or proton pump inhibitors
    • Metoclopramide
    • Sodium citrate

Other Considerations for ED Sedation

Oxygen Administration

Protocol: Oxygen should be given to sedated patients from the start of sedative administration until the patient is ready for discharge from the recovery area.

Capnography

Mandatory Use

  • Deep sedation
  • Dissociative sedation
  • General anesthesia
  • Rapid sequence induction
  • Whenever verbal contact with patient will be lost

Recommended Use

  • Lighter levels of sedation
  • Expected to become routine practice
  • Early detection of apnea

Documentation

Required Documentation
  1. Standard forms for pre-assessment, consent, monitoring, discharge
  2. Past medical history and medications
  3. Allergies
  4. Physical examination: vital signs, airway, cardiopulmonary status
  5. Written consent for procedure and sedation technique

Post-procedure Monitoring and Discharge

Recovery Requirements

All patients should continue to be managed in a clinical area that provides the same level of facilities and monitoring as during the procedure, until returning to baseline.

Discharge Criteria

Clinical Status

  • Returned to baseline level of consciousness
  • Vital signs within normal limits for that patient
  • Respiratory status not compromised
  • Adequate control of nausea, vomiting, pain and discomfort

Discharge Planning

  • Formal assessment for discharge suitability
  • If criteria not met: transfer to appropriate clinical environment
  • Home discharge: responsible third party escort required
  • Verbal and written instructions provided