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Anaesthesia - Procedural sedation

Indications

Analgesia and anaesthesia required for painful procedure, such as:

Cardioversion

Fracture or dislocation reduction

Incision and drainage of abscess

Foreign body removal

Suturing

Contraindications (absolute in bold)

Airway and aspiration risks:

Difficult airway (known or suspected on assessment)

Vomiting or risk of vomiting

Recent oral intake (food <6 hours, fluid <2 hours *see discussion)

Breathing risks:

Acute respiratory illness

Lung disease (known or suspected)

Obesity

Pregnancy

Circulation risks:

Haemodynamic compromise

Severe systemic disease (ASA >=4, LVEF <35%, aortic stenosis)

Department:

Safer or more appropriate alternative available (theatre, regional anaesthesia)

Area:

Resuscitation bay equipped for cardiopulmonary resuscitation and monitoring unavailable

Staff:

Fewer than three staff available (proceduralist, sedating provider, assistant)

No accredited sedation provider (emergency physician, accredited registrar or local equivalent)

Alternatives

General anaesthesia in theatre

Inhaled nitrous oxide

Local or regional anaesthesia

Informed consent

Medical emergency

Consent is not required if the patient lacks capacity or is unable to consent

Brief verbal discussion is recommended if the situation allows

Or

Written consent

More complex non-emergency procedure with higher risk of complications

Potential complications

Laryngospasm

Aspiration (vomiting or secretions)

Hypoxia

Hypotension

Prolonged or excessive sedation requiring intubation

Emergence phenomenon

Procedural hygiene

Standard precautions

PPE: non-sterile gloves

Pre-procedure assessment and risk stratification

History:

Allergies

Medication

Past medical and anaesthetic history

Last ate/drank

Events

Examination and airway assessment

Observations

ASA classification

LEMON airway assessment and MOANS bag valve mask assessment

Area

Resuscitation bay

Continuous pulse oximetry

ECG monitoring

Blood pressure recordings 3-5 minutely

Wave form capnography

Staff

Minimum three (procedural clinician, accredited procedural clinician with airway skills, assistant)

One clinician must remain a dedicated airway monitor throughout procedure

Equipment

Suction

Oxygen via NRM

BVM and airway equipment

2x IV access with 1l crystalloid primed on pump set

Positioning

Dictate by procedure (supine, 30 degrees head up)

Medication

No single sedative agent recommended for every patient, typically:

IV Pain relief prior to procedure, followed by

Bolus ketamine or propofol 1mg/kg (dose reduced to 0.3-0.5mg/kg if frail or elderly)

Further titrated 20mg boluses to minimum level required for patient comfort

Sequence

Use departments checklist or protocol for emergency sedation

Pre-procedure time out (confirm preparation, correct patient, consent)

Delivery of sedation, continual patient assessment and performance of procedure

Post-procedure care

Monitor in resuscitation bay until alert, obeying commands with pain controlled

Document procedure in departmental sedation chart and the patient notes

Safe criteria for discharge from the emergency department:

Observe in non-monitored bed for two hours post sedation

Vital signs and level of consciousness return to normal

Tolerate oral fluids with no vomiting

In the company of an appropriate person (longer observation required if unavailable)

Warning not to drive/operate heavy machinery for 24 hours

Post-sedation instruction sheet.

Tips

Difficult bag-mask ventilation (MOANS)

M: Mask seal (beards, liquid on the face, anatomy disruption)

O: Obesity or obstruction

A: Age >55

N: No teeth

S: Sleep apnoea or stiff lungs

Difficult laryngoscopy and intubation (LEMON)

L: Look externally (anatomy disruption, small mouth, blood etc)

E: Evaluate 3-3-2 (mouth opening, mental process to hyoid, hyoid to thyroid notch)

M: Mallampati score

O: Obstruction or obesity

N: Neck mobility

Discussion

The available evidence suggests that vomiting during procedural sedation in the emergency department is rare and preprocedural fasting of any duration has not demonstrated a reduction in the risk of emesis or aspiration.

Procedural sedation of unfasted patients is not contraindicated in emergency situations where a procedure will prevent severe injury or significant pain and distress. Often procedural sedation in the emergency department is performed immediately due to such indications. In other situations, ACEM support the Australian and New Zealand College of Anaesthetists guidelines on procedural sedation recommending no recent oral intake (food <6 hours, fluid <2 hours) prior to procedural sedation.

Peer review

This guideline has been reviewed and approved by the following expert groups:

Emergency Care Institute

Please direct feedback for this procedure to ACI-ECIs@health.nsw.gov.au.

References

Australian and New Zealand College of Anaesthetists. Guidelines on sedation and/or analgesia for diagnostic and interventional medical, dental or surgical procedures. PS09 2014. Melbourne, Vic: ANZCA; 2014. Available from: https://www.anzca.edu.au/documents/ps09-2014-guidelines-on-sedation-and-or-analgesia.

NSW Agency for Clinical Innovation. Minimum standards for safe procedural sedation. Sydney: ACI; 2015. 23pp. Available from: https://www.aci.health.nsw.gov.au/resources/anaesthesia-perioperative-care/sedation/safe-sedation-resources.

NSW Agency for Clinical Innovation. Procedural sedation: ED sedation procedure. Sydney: ACI; 2013. Available from https://aci.health.nsw.gov.au/networks/eci/clinical/clinical-resources/clinical-tools/procedural-sedation-ed.

Roberts JR, Custalow CB, Thomsen TW. Roberts and Hedges' clinical procedures in emergency medicine and acute care. 7th ed. Philadelphia, PA: Elsevier; 2019.

Dunn RJ, Borland M, O'Brien D (eds.). The emergency medicine manual. Online ed. Tennyson, SA: Venom Publishing; 2019.

American Society of Anesthesiologists. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Task Force on Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration. Anesthesiology 3 2017, Vol.126, 376-393. doi:https://doi.org/10.1097/ALN.0000000000001452

Godwin SA, Burton JH, Gerardo CJ, Hatten BW, Mace SE, Silvers SM, Fesmire FM, American College of Emergency Physicians . Clinical policy: procedural sedation and analgesia in the emergency department. Ann Emerg Med.

2014 Feb;63(2):247-58.e18. doi: 10.1016/j.annemergmed.2013.10.015.

Bell A, Taylor DM, Holdgate A, MacBean C, Huynh T, Thom O, Augello M, Millar R, Day R, Williams A, Ritchie P, Pasco J. Procedural sedation practices in Australian emergency departments. Emerg Med Australas. 2011 Aug;23(4):458-65. doi: 10.1111/j.1742-6723.2011.01418.x.

Brady M, Kinn S, Stuart P. Preoperative fasting for adults to prevent perioperative complications. Cochrane Database Syst Rev. 2003;(4):CD004423. doi: 10.1002/14651858.CD004423.

Nickson, C. Periprocedural fasting. Life in the fast lane. 2019 (cited July 2019). Available from https://litfl.com/peri-procedural-fasting/

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