The Emergency Department

Rethinking preprocedural fasting

Under normal circumstances, fasting recommendations for procedural sedation are like those for general anesthesia: two hours of fasting for clear liquids and six hours for solids. But these recommendations can be impractical in an emergency room setting.([FOOTNOTE=Lingappan, A. Sedation. Medscape. Aug 13 2015. Retrieved May 2, 2017 from http://www.medscape.com/viewarticle/738074.],[ANCHOR=],[LINK=]) The American College of Emergency Physicians recommends not delaying procedural sedation for adults or children based on fasting time.([FOOTNOTE=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.],[ANCHOR=],[LINK=])

Emergency clinicians can balance patient comfort against aspiration risk to safely sedate patients who have not fasted.²

Making pain management decisions

Procedural sedation plays a vital part in managing pain and anxiety during acute emergency care.([FOOTNOTE=Deitch K, Miner J, Chudnofsky C, Dominici P, Latta D. Does End Tidal CO2 Monitoring During Emergency Department Procedural Sedation and Analgesia With Propofol Decrease the Incidence of Hypoxic Events? A Randomized, Controlled Trial. Ann Emerg Med. 2010;55:258–64. doi:10.1016/j.annemergmed.2009.07.030],[ANCHOR=],[LINK=]) But sedation can also cause respiratory depression, which can lead to adverse events such as hypoxia.⁴

With advance warning, clinicians have the time to address respiratory depression and potentially avert hypoxia.⁴ 

Reducing hypoxia

Hypoxia, defined as oxygen saturation less than 93%, is one of the most common adverse respiratory events that occurs during emergency procedural sedation, occurring 40.2 times per 1,000 sedations.([FOOTNOTE=Bellolio MF, Gilani WI, Barrionuevo P, Murad MH, Erwin PJ, Anderson JR, Miner JR, Hess EP. Incidence of Adverse Events in Adults Undergoing Procedural Sedation in the Emergency Department: A Systematic Review and Meta-analysis. Acad Emerg Med. 2016 Feb;23(2):119-34.],[ANCHOR=],[LINK=])

Emergency clinicians can reduce hypoxia with supplemental oxygen.([FOOTNOTE=Deitch K, Chudnofsky CR, Dominici P, Latta D, Salamanca Y. The utility of high-flow oxygen during emergency department procedural sedation and analgesia with propofol: a randomized, controlled trial. Ann Emerg Med. 2011 Oct;58(4):360-364.e3.],[ANCHOR=],[LINK=])

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A better emergency department experience

Are patients satisfied with procedural sedation in the emergency department? One study showed that they are, giving a median score of 2.7 on a scale of -3 (poor satisfaction) to +3 (very satisfied).([FOOTNOTE=Johnson OG, Taylor DM, Lee M, Ding JL, Ashok A, Johnson D, Peck D, Knott J, Weinberg L. Patient satisfaction with procedural sedation in the emergency department. Emerg Med Australas. 2017 Mar 29.],[ANCHOR=],[LINK=])

Emergency clinicians can use this knowledge to help improve patient experience.

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