2. Key Principles of Procedural Sedation
and Analgesia
• Determine appropriate level of sedation
desired
• Have appropriate monitoring and rescue
equipment
• Administer analgesic before sedative
• Titrate agents to desired level of sedation
• Observe and monitor until recovery to
baseline mental status
5. Procedural Sedation Monitoring
• Interactive monitoring:
Direct observation of patient to access
- Depth of sedation
- Respiratory function & Hemodynamics
Unobstructed view of the
patient’s face, mouth,
chest wall
6. In patients undergoing procedural sedation and
analgesia in the emergency department,
what is the minimum number of personnel
necessary to manage complications?
7. • Mostly, one clinician performs the
procedure while another (usually a
nurse) observe and continuously
monitor the patient
Level C recommendations
Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department
Ann Emerg Med. 2014;63:247-258.
8. Monitoring Depth of sedation
• Check response to verbal commands
• If verbal response is not possible, “thumbs up”
• Deep sedation: response to a more profound
stimulus
• Response limited to reflex withdrawal from a
painful stimulus is not considered a
purposeful response
9. Scale monitoring depth of sedation
Moderate sedation: Do not exceed level 4
Deep sedation score: Level 5
11. Bispectral Index monitoring
• uses processed electroencephalogram signals
to measure the depth of sedation
• 100 = complete alertness,
• 0 = no cortical activity at all
• 40 - 60 is believed to be consistent with GA
14. Arterial oxygenation
• Pulse oxymetry is not a substitute for
monitoring ventilation
• Hypoventilation or apnea develop before
oxygen saturation decreases especially
“Patient who receive supplemental oxygen”
15. Ventilation
• Capnography
• ETco2 correlates with arterial Pco2
• ETco2 > 50 mmHg or ↑>10 mmHg
indicates hypoventilation
16.
17. In patients undergoing procedural sedation and
analgesia in the emergency department,
Does the routine use of capnography
reduce the incidence of adverse
respiratory events?
18. Level B recommendation
• Capnography* may be used as an adjunct to
pulse oximetry and clinical assessment to
detect hypoventilation and apnea earlier than
pulse oximetry and/or clinical assessment
alone in patients undergoing procedural
sedation and analgesia in the ED.
• Capnography includes all forms of quantitative
exhaled carbon dioxide analysis.
19. Vital Signs
• Before the procedure
• After each dose of sedative
• Regular intervals during the procedure
• During initial of recovery period
• Before discharge
20. Recommendations
Level of
Sedation
LOC Heart Rate Respiratory
Rate
BP O2
Saturation
Capno
graphy
Minimal Observe
frequently
q 15 min q 15 min q 15 min
and after
sedative
boluses
Continuously -
Moderate
or
Dissociative
Observe
constantly
Continuously Continuous
direct
observation
q 5 min
& after
sedative
boluses
Continuously Consider
continuously
Deep Observe
constantly
Continuously Continuous
direct
observation
q 5 min
& after
sedative
boluses
Continuously Recommend
continuously
If recording is performed automatically,
Device alarms should be set to alert
21. Cardiac monitoring
Recommended for:
• Preexisting cardiac disease
• Dysrhythmias
• During procedures in which the cardiac
rhythm is of interest
22. Post-Sedation Recovery
• Recovery and discharge under supervision of
operating practitioner or a licensed physician.
• A nurse or other individual should monitor
until appropriate discharge criteria are
satisfied
• Preparation for management of complications.
23. Observation Duration
• In most cases, prolong observation beyond 30
min is unlikely to be necessary
• Longer duration in patients who receive
reversal agents
24. Discharge Criteria
• Low risk procedure that additional monitoring is
un necessary.
• Symptoms should be well-controlled.
• Stable V/S and respiratory and cardiac function
• Alert and oriented or returned to baseline
• A reliable person who can provide support and
supervision at least a few hours.
• Scoring systems may assist in documentation.
• Patient instruction
28. Pediatric Discharge Criteria
• Young infants or children who are
handicapped should return to the level of
responsiveness observed before sedation
• Because of the significant risk of apnea after
sedation, term infants with postconceptual
ages (PCA) ≤45 weeks and former premature
infants with PCA <60 weeks should undergo
prolonged observation of respiratory status
prior to discharge
29. Minimum Duration of Observation for
Infants
• All infants with PCA ≤45 weeks – 12 hours
• Pre-term infants with PCA 46 to 60 weeks and
significant comorbidities – 12 hours
• Healthy pre-term infants with PCA 46 to 60
weeks – 6 hours (12 hours if given opioids or
other medications with significant respiratory
depressant effects)
30. • Patients, who develop apnea during
observation, warrant prolonged observation
until they are free of apnea for at least 12
hours.
• In some patients with frequent apneic
episodes, caffeine administration may be
appropriate.
Level C recommendation
Clinical Policy: Procedural Sedation and Analgesia in the Emergency Department
Ann Emerg Med. 2005;45:177-196
Phase I: At the start of exhalation, CO2 concentration in the exhaled gas is essentially zero, representing gas from the anatomic dead space that does not participate in gas exchange. Phase II: As the anatomic dead space is exhaled, CO2 concentration rises as alveolar gas exits the airway. Phase III: For most of exhalation, CO2 concentration is constant and reflects the concentration of CO2 in alveolar gas. Phase IV: During inhalation, CO2 concentration decreases to zero as atmospheric air enters the airway. [Reproduced with permission from Brauss B, Hess DR: Capnography for procedural sedation and analgesia in the emergency department. Ann
Capnography allows continuous measurement of exhaled
carbon dioxide and displays the resulting waveform graphically. It
provides an advantage over pulse oximetry alone by identifying
respiratory depression more consistently. Capnometry is the
numeric display of exhaled carbon dioxide concentrations.
ETCO2 is the highest value of carbon dioxide measured during
the end of expiration of each breath