The goal is to provide safe, timely and humane care in treating painful conditions and performing painful and/or anxiety-provoking procedures. There are a number of approaches, each with advantages and disadvantages in certain clinical circumstances.

The best choice for PSA depends on the clinical circumstances. Considerations include: 

1. Procedural factors:

• Sedation depth required;
• Amount of pain associated with procedure;
• Length of the procedure;

2. Patient factors:

• Patient’s cardiorespiratory reserve (co-morbid conditions);
• Patient’s anxiety level;
• Fasting status;

3. Clinical environment:

• Ability to provide required monitoring;
• The skill set and comfort of available staff with PSA and associated pharmacologic agents

Based on the factors above, clinicians may choose to either proceed with or delay the procedure, consult with additional staff, or consider transfer of the patient to a more appropriate facility.

Absolute contraindications to PSA:

• Lack of personnel experienced in airway management and advanced life support;
• Lack of familiarity with the medications being used;
• Lack of appropriate monitoring equipment (minimum of continuous cardiac and oxygen saturation monitoring with intermittent BP; end-tidal CO2 recommended if using deep sedation);
• Inability to monitor the patient during the procedure and the recovery period;
• An allergy to relevant medications.

1. Potential airway compromise:

• Patients with facial / dental / airway factors that might inhibit or preclude bag-mask ventilation or tracheal intubation.
• In this circumstance choose agents with less potential for respiratory depression (e.g., ketamine) and / or sedate to a lighter endpoint. Consider not doing the sedation, or consulting anesthesia colleagues if possible.

2. Potential cardiovascular insufficiency:

• Patients with potential cardiovascular complications (elderly/history of heart failure/concurrent serious illness) should be considered for sedation regimens that are less likely to produce hypotension (e.g., ketamine/ketofol).
• Pre-treat with intravenous fluids if not in CHF and consider delay or abandonment of the procedure or consult anesthesia if possible.

3. Potential for aspiration:

• No clear relationship demonstrated between fasting status and aspiration.
• Manage the potential risk (i.e. lateral position/gravity with suction).
• While procedures need not be delayed due to unknown or short fasting times, we recommend using brief-acting agents with anti-emetic effects (e.g. propofol or ketofol) rather than agents known to cause emesis (e.g., opiates, ketamine).
• Similar caution should be exercised in patients with ileus, bowel obstruction, and morbid obesity.

Use what you are most comfortable with – when using a new drug or combination recommend you consult with a colleague who has experience with them if possible.

1. Painful procedures

• Choose a regimen with strong analgesia as well as sedation (e.g. ketofol or ketamine), particularly if there will be pain after the procedure (e.g. fracture reduction, I+D).
• If using propofol alone you should administer an analgesic unless the procedure is particularly short (e.g. cardioversion).
• Opiates in conjunction with propofol lead to more respiratory adverse events.
• Ketamine can provide analgesia with no increased respiratory depression.

2. Short recovery

• Choose shorter-acting agents such as propofol or ketofol (separate syringes or 20:80 / 30:70 mixtures to limit the amount of ketamine given).
• Advantageous where fasting may be inadequate or when personnel and space resources are in demand.
• Etomidate is also an effective option.

3. Post procedure agitation

• In patients with a known history of psychosis, or those with extreme anxiety it may be prudent to avoid the use of ketamine and ketofol as they are associated with more psychomimetic effects than propofol alone.
• Alternatively, be prepared to provide a small dose of midazolam (e.g. 2mg IV in an adult) if necessary.
• Fentanyl / Midazolam Combination: an effective option if there are no concerns regarding airway compromise or prolonged recovery.

4. Impaired cardiovascular status

• In older patients or in patients with known history of congestive heart failure, choose a regimen known to support blood pressure (e.g., ketamine or ketofol) and avoid using propofol alone.

5. Other drug regimens

• Etomidate: This can be used effectively but myoclonus is often a problem. For this reason, it is considered an inferior option to propofol or ketofol.
• Fentanyl / Midazolam Combination: an effective combination but increased respiratory adverse events and prolonged recovery time.

Capnography

Capnography can be very handy with limited resources as it improves the detection of respiratory depression and apnea. Many clinicians find this advantageous however clinical outcomes are equally excellent with close clinical observation as outcomes are most dependent on clinical vigilance rather than technology.

High-Risk Patients

Be extremely cautious in the very young and the very old, as well as those with relevant co-morbid conditions (e.g. cardiorespiratory disease, morbid obesity).

1. Podcast by Dr Andolfatto on ketamine use (NursEM)   Part One  discusses dosing, myths, pain control and procedural sedation (33:34).

   Part Two discusses intubation, behavioural control, physiologic effects and other important info (34:49).

   
   

2. International Committee for the Advancement of Procedural Sedation (ICAPS); A multidisciplinary, international, independent consensus committee dedicated to advancing optimal, evidence-based practices for procedural sedation and analgesia.

   
   

3. Current Guidelines for Sedation and Analgesia by Non-Anesthesiologists. A review of current practice standards. Anesthesiology. 2002;96(4):1004-1017.

   
   

4. American College of Emergency Physicians clinical and practice management resource on procedural sedation.

   
   

5. Procedural sedation checklist (EMCrit)