The top two reasons for emergency department visits in the United States in 2013 were abdominal pain and chest pain. Back pain and headache also appeared among the top 10 reasons.([FOOTNOTE=Rui P, Kang K, Albert M. National Hospital Ambulatory Medical Care Survey: 2013 Emergency Department Summary Tables. U.S. Department of Health and Human Services.],[ANCHOR=],[LINK=])
Patients who need immediate care and sedation for diagnostic or therapeutic procedures can present their own set of challenges.
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
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
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=])
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.
Aspiration during procedural sedation is rare but potentially fatal when it occurs. Clinicians can assess risk in individual patients, balancing oral intake against the urgency of the procedure and determining the lightest level of sedation appropriate.([FOOTNOTE=Green SM, Roback MG, Miner JR, Burton JH, Krauss B. Fasting and emergency department procedural sedation and analgesia: a consensus-based clinical practice advisory. Ann Emerg Med. 2007;49(4):454-61],[ANCHOR=],[LINK=])
Using capnography, clinicians detect respiratory depression before hypoxia occurs. Because clinicians can intervene sooner, the rate of hypoxic events with capnography decreases by 17 percent, compared to standard monitoring (pulse rate and rhythm, respiratory rate, blood pressure, and pulse oximetry).4
Patients received either 100% oxygen or compressed room air at 15 L/minute by a nonrebreather mask for five minutes before and during procedural sedation.6
Patients receiving high-flow oxygen experienced significantly less (23%) hypoxia than patients receiving compressed room air.6
In a study, undergoing orthopedic procedures and receiving pre-sedation opioids decreased patient satisfaction, while deeper sedation levels during the operation increased it.7
There is no single agent or combination of agents for every patient or sedation procedure. Emergency physicians and staff are expected to be familiar with the pharmaceutical agents they use and be prepared to manage their potential complications, including converting to intubation and general anesthesia if necessary.([FOOTNOTE=American College of Emergency Physicians. Policy Statement: Sedation in the Emergency Department. January 13, 2011. Retrieved May 2, 2017.],[ANCHOR=],[LINK=]),3 The American College of Emergency Physicians recommends capnography for patients receiving procedural sedation in the emergency department.10