Chapter 159: Procedural Sedation and Analgesia (Conscious Sedation)

INTRODUCTION

Procedural sedation and analgesia (PSA) techniques are an essential skill for any Emergency Physician. The daily practice of Emergency Medicine employs painful and anxiety-provoking measures to perform diagnostic testing or therapeutic interventions. PSA is a skill that may require a credentialing process at some institutions. It probably has evoked a written procedural guide in most hospitals and Emergency Departments, with or without the input from a hospital-wide PSA committee or the Department of Anesthesiology. PSA certification may require annual competency assessments in the form of a written examination or practical scenarios. PSA is a technique that probably receives a great deal of attention from the continuous quality improvement committee because of The Joint Commission’s directive. It is a skill that, with proper training and well-designed application principles, will provide the patient and their families with a sense of compassion and caring for their physical and emotional distress.^1,2 PSA is a skill that may result in horrific outcomes when performed without anticipation of complications, appropriate training, knowledge, and risk-benefit analysis.³

An extensive spectrum of painful and anxiety-provoking clinical presentations is seen in an Emergency Department on any given day. There may be a dislocation reduction, a fracture reduction, a diagnostic lumbar puncture, a sexual assault examination on a child, or neuroimaging on a combative, head-injured patient. Each presentation has a separate subset of variables to consider prior to PSA. While Anesthesiologists are still considered the “experts” in sedation, they are not readily available to the Emergency Department’s beck and call. Multiple guidelines for the use of PSA account for these limitations and are followed to ensure that safe effective care can be rendered to their patient populations.^4-10

The environment of the Emergency Department is unique in many facets of PSA with situations being nonelective. Procedures are relatively brief and make Operating Room time neither timely nor cost effective. Intrinsic to PSA is the core training and frequent exposure. Who better to handle an untoward cardiopulmonary complication of a procedure than a specialist of airway management and resuscitation?

It is critical to the technique of PSA, including drug selection, to take a variety of parameters into consideration before the first medication is administered.¹¹ The potency and effectiveness of today’s agents are a double-edged sword. They are invaluable with the correct selection and administration.³ They are a recipe for disaster if risks are not appropriately identified and minimized. Monitoring techniques (e.g., pulse oximetry and capnography) are effective adjuncts to procedural monitoring. They are no substitute for a trained and dedicated observer.

TERMINOLOGY

Textbooks and review articles use various definitions to define components of PSA, formerly known as conscious sedation.¹² Terms such as light and deep sedation are often applied to the extremes of the sedation continuum. The important thing to realize is that sedation is a continuum.^5,...