Anaesthesia - Procedural sedation
Analgesia and anaesthesia required for painful procedure, such as:
Fracture or dislocation reduction
Incision and drainage of abscess
Foreign body removal
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)
Acute respiratory illness
Lung disease (known or suspected)
Severe systemic disease (ASA >=4, LVEF <35%, aortic stenosis)
Safer or more appropriate alternative available (theatre, regional anaesthesia)
Resuscitation bay equipped for cardiopulmonary resuscitation and monitoring unavailable
Fewer than three staff available (proceduralist, sedating provider, assistant)
No accredited sedation provider (emergency physician, accredited registrar or local equivalent)
General anaesthesia in theatre
Inhaled nitrous oxide
Local or regional anaesthesia
Consent is not required if the patient lacks capacity or is unable to consent
Brief verbal discussion is recommended if the situation allows
More complex non-emergency procedure with higher risk of complications
Aspiration (vomiting or secretions)
Prolonged or excessive sedation requiring intubation
PPE: non-sterile gloves
Pre-procedure assessment and risk stratification
Past medical and anaesthetic history
Examination and airway assessment
LEMON airway assessment and MOANS bag valve mask assessment
Continuous pulse oximetry
Blood pressure recordings 3-5 minutely
Wave form capnography
Minimum three (procedural clinician, accredited procedural clinician with airway skills, assistant)
One clinician must remain a dedicated airway monitor throughout procedure
Oxygen via NRM
BVM and airway equipment
2x IV access with 1l crystalloid primed on pump set
Dictate by procedure (supine, 30 degrees head up)
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
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
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.
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
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.
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.
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/