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Key Points

  • Procedural sedation is the administration of analgesic and sedative agents to induce a depressed level of consciousness so that a medical procedure can be performed without patient movement or memory.

  • Procedural sedation should maintain cardiorespiratory function without requiring advanced airway adjuncts.

  • Preprocedure patient assessment and proper selection of pharmacologic agents are the keys to patient safety.


Procedural sedation is a clinical technique that creates a decreased level of awareness, but allows maintenance of protective airway reflexes and adequate spontaneous ventilation. The goals of procedural sedation are to provide analgesia, amnesia, and anxiolysis during a potentially painful or frightening procedure. Pharmacologic agents used in procedural sedation are of 3 general classes: sedatives, analgesics, and dissociative agents. The use of such medications in the emergency setting is common and has been shown to be safe. Before the procedure, the physician should assess the patient for systemic disease and for a potential difficult airway. The patient's fitness for sedation can be quantified using the American Society of Anesthesiologists (ASA) physical status classification system (Table 4-1). The risk of a complication from emergency department (ED) procedural sedation and analgesia in ASA class I and II patients is low, usually <5%.

Table 4-1.

The American Society of Anesthesiologists physical status classification.

Examples of clinical scenarios appropriate for procedural sedation include painful or anxiety-provoking situations such as joint or fracture reduction, lumbar puncture, pediatric radiologic studies, incision and drainage, or cardioversion.


Contraindications include ASA class III/IV, altered mental status, hemodynamic instability, known medication allergy, and lack of equipment or qualified personnel. Oral intake within 3 hours is a relative contraindication. Higher risk cases may be more safely performed with anesthesia consultation or in the operating room.


Patients should be closely monitored to recognize any change in vital signs and avert complications, most notably respiratory depression. Continuous pulse oximetry, cardiac monitor, and end-tidal CO2 capnography (if available) should be applied. Intravenous (IV) access, an oxygen source and delivery method (eg, nasal canula), suction, airway management equipment (ie, bag-valve-mask, supraglottic airway, laryngoscope, endotracheal tube), resuscitation cart, and reversal drugs should be readily available. Personnel should be skilled in airway management and patient monitoring and recovery.


Appropriate preprocedure history includes allergies to or adverse effects from anesthetic agents, medical conditions, and time of last oral intake. Physical exam should include a thorough ...

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