Procedural Sedation

Savithiri Ratnapalan

Suzan Schneeweiss

Introduction

Procedural Sedation

Procedural sedation in the emergency setting allows patients to:
- Tolerate unpleasant procedures while maintaining cardiorespiratory function
- Maintain airway independently and continuously
- Maintain protective airway reflexes

Levels of Sedation

Sedation Guidelines for Non-Anesthesiologists

Patient Selection

Only ASA I and II status
Consider other risk factors such as obesity, nonfasting status, previous sedation complications

Facilities

Dedicated space with appropriate resuscitation equipment
Equipment: oxygen, bag-valve-mask setup, suction, monitoring equipment, emergency cart, drugs for sedation and resuscitation including reversal agents

Table 65.1 Levels of Sedation

Minimal sedation	Impaired cognitive function and coordination with:
	•	Normal response to verbal commands
	•	Normal cardiorespiratory function
Moderate sedation	Depressed state of consciousness associated with:
	•	Maintenance of protective airway reflexes
	•	Ability to maintain patent airway
	•	Appropriate responses to stimulation/verbal commands
Deep sedation	Depressed state of consciousness/unconsciousness from which patient is not easily aroused:
	•	Partial or complete loss of protective reflexes
	•	May not maintain a patent airway independently
	•	Inability to appropriately respond to physical stimulation or verbal commands
General anesthesia	State of unconsciousness associated with:
	•	Loss of protective reflexes
	•	Inability to independently maintain a patent airway
	•	Inability to appropriately respond to physical stimulation or verbal commands
Dissociative state	Trancelike cataleptic state induced by ketamine and characterized by:
	•	Profound analgesia and amnesia
	•	Usually with retention of protective airway reflexes
	•	Spontaneous respiration and cardiopulmonary stability

Personnel

Preparation of Patient/Family

Consent
Verbal explanation of drug(s) to be used, expected behavior, and potential complications
Written discharge instructions and 24-hour contact number

Table 65.2 American Society of Anesthesiology Classification

ASA CLASS	DESCRIPTION
I	Healthy, no underlying organic disease
II	Mild or moderate systemic disease that does not interfere with daily routines (e.g., well-controlled asthma, essential hypertension)
III	Organic disease with definite functional impairment (e.g., severe steroid dependent asthma, IDDM, uncorrected congenital heart disease)
IV	Severe disease that is life threatening (e.g., head trauma with increased ICP)
V	Moribund patient, not expected to survive
E (suffix)	Physical status classification appended with an “E” connotes a procedure undertaken as an emergency (e.g., an otherwise healthy patient presenting for fracture reduction is classified as ASA status I E)

Pre-Sedation Assessment

Age, weight, fasting status, ASA status
Bromage sedation score
Consent and assent
History
- Underlying medical conditions, allergies
- Current medications
- Past experience with anesthesia or sedation
- Family history of anesthesia problems
Exam
- Baseline vital signs including temperature, saturation
- Cardiorespiratory exam
- Focused airway assessment: face shape, facial trauma, large central incisors, loose or absent teeth, receding mandible, size and configuration of palate, evidence of upper airway obstruction such as stridor, voice change, neck mobility
- Mallampati classification

Table 65.3 Bromage Sedation Score

0	Awake and alert
1	Occasionally drowsy, easy to arouse
2	Frequently drowsy, easy to arouse
3	Somnolent, difficult to arouse, inappropriate response to physical stimulation or verbal command
4	Unresponsive to verbal command or physical stimulation
S	Asleep, easy to arouse
Sedation score 0-2 = minimal to moderate sedation
Sedation score 3 = red flag, bordering on deep sedation
Sedation score 4 = deep sedation/general anesthesia

NPO Guidelines for Children

Elective Non-Emergency Procedures

Emergency Procedures

Jun 22, 2016 | Posted by drzezo in EMERGENCY MEDICINE | Comments Off

Anesthesia Key