lecture given in NBE e learning session

1. Headline Text
Procedural Sedation &
Analgesia - Adult

2. Procedural sedation and Analgesia -PSA
Adult
Dr Venugopalan P P
DA,DNB,MNAMS,MEM-GW
PG-Teacher NBE
Senior Consultant and Director
Emergency Medicine ,Aster DM Healthcare

3. Background
The practice of acute care medicine often
requires the performance of procedures that
can cause pain and anxiety.
Procedural sedation reduces the discomfort,
apprehension, and potential unpleasant
memories associated with procedures
Facilitates performance of the procedure.
The practice of procedural sedation in adults,
Monitoring & Medications

4. Definition
Procedural sedation involves the use of short acting
analgesic and sedative medications to enable clinicians to
perform procedures effectively, while monitoring the
patient closely for potential adverse effects.
The process was previously (and inappropriately) termed
"conscious sedation"
Effective sedation often alters consciousness
Preferred term is now "procedural sedation and
analgesia" [PSA ]

5. Who can do it
The practice of providing sedation, once primarily the
domain of anaesthesia practitioners,
Now routinely performed by other specialists, such as
emergency clinicians, critical care specialists, and
various nurse specialists

6. Levels of Sedation
Joint Commission on Accreditation of Healthcare
Organizations in the United States has attempted to
define the levels of sedation, which range from
minimal sedation to general anaesthesia

10. Terminology
Analgesia
Relief of pain without intentionally producing a sedated state. Altered mental
status may occur as a secondary effect of medications administered for
analgesia.
Minimal sedation
The patient responds normally to verbal commands. Cognitive function and
coordination may be impaired, but ventilatory and cardiovascular functions are
unaffected.

11. Terminology
Moderate sedation and analgesia
The patient responds purposefully to verbal commands alone or when
accompanied by light touch. Protective airway reflexes and adequate
ventilation are maintained without intervention. Cardiovascular function
remains stable.

12. Terminology
Deep sedation and analgesia
The patient cannot be easily aroused but responds purposefully to
noxious stimulation. Assistance may be needed to ensure the airway
is protected and adequate ventilation maintained. Cardiovascular
function is usually stable.

13. Terminology
General anaesthesia
The patient cannot be aroused and often requires assistance to
protect the airway and maintain ventilation. Cardiovascular
function may be impaired.

14. Terminology
Dissociative sedation
Dissociative sedation is a trancelike cataleptic state in which the patient
experiences profound analgesia and amnesia but retains airway
protective reflexes, spontaneous respirations, and cardiopulmonary
stability .
Ketamine is the pharmacologic agent used for procedural sedation that
produces this state

15. Sedation
Sedation exists on a continuum, and it is
difficult to divide it into discrete clinical stages,
the definitions above notwithstanding
Many sedatives can cause rapid changes in the
depth of sedation.
Dissociative sedation stands apart from the
continuum of sedation due to its unique
characteristics.

16. Indication
Any procedure in which a patient's pain or anxiety
may be excessive and may impede performance.
Procedures where deep relaxation facilitates
performance (eg, closed reduction of a dislocated
joint).
PSA may be beneficial include electrical
cardioversion, closed joint reduction, complicated
laceration repair, abscess incision and drainage, and
lumbar puncture.

17. Relative contraindication
No absolute contraindications to procedural sedation and
analgesia (PSA).
Relative contraindications
Older age
Significant medical co-morbidities
Signs of a difficult airway.

18. Risk assessment

19. ASA grade

20. High risk cases- Caution
To reduce the risk of adverse events in the elderly and
patients with major co-morbid disease- follow a more
conservative approach to PSA medications
● Lower starting dose
● Slower rates of administration
● Less frequent intervals -repeat doses

21. Caution ..
PSA is relatively contraindicated in patients who are
likely to be difficult to ventilate or oxygenate should
respiratory difficulties arise while the patient is
sedated.
Alternatives to PSA may be preferable if signs
suggesting a difficult airway are identified.

22. Airway difficulties
Assess airway properly - LEMON
Apply various Airway algorithms
appropriately

23. Fasting guideline
ASA guidelines recommend that patients undergoing PSA for
"elective procedures" fast according to the standards used for
general anaesthesia.
It requires that patients not eat or drink for Two hours
after drinking clear liquids and Six hours after ingesting
solid foods or cow's milk
If the standards cannot be met, the guidelines recommend
1- delaying the procedure 2-reducing the level of
sedation3-protecting the airway with endotracheal
intubation.

24. Fasting guidelines- issues in ED
It is rare that patients requiring emergent PSA
meet these fasting criteria.
Emergent procedures cannot be delayed.
Although fasting to reduce the risk of aspiration
during PSA or elective surgery makes intuitive
sense, there is little evidence to support this
approach

25. What evidences say?
According to one review, patients who fast for two hours have the same gastric
volume and pH as those who fast for longer periods .
No clear evidence that a relationship exists among fasting time, gastric volume,
gastric pH, depth of sedation, and the likelihood of aspiration
Green SM, Krauss B. Pulmonary aspiration risk during emergency department
procedural sedationan examination of the role of fasting and sedation depth. Acad
Emerg Med 2002; 9:35.

26. What evidences say?
Clinically significant aspiration during emergency department PSA appears to
be rare
Endotracheal intubation may not protect the patient from aspiration
Aspiration can occur despite the presence of an endotracheal tube
Airway manipulation involved in performing intubation appears to increase
the risk of aspiration.
Green SM, Krauss B. Pulmonary aspiration risk during emergency department
procedural sedationan examination of the role of fasting and sedation depth.
Acad Emerg Med 2002; 9:35.

27. ACEP
American College of Emergency Physicians policy statement
on PSA states:
“Recent food intake is not a contraindication for
administering procedural sedation and analgesia but should
be considered in choosing the timing and target of
sedation"

29. Perform PSA

30. Informed consent
Clinician must discuss the risks, benefits, and
alternatives of the procedure and the planned
sedation with the patient and answer any
questions.
A printed informed consent form may be used
Implied consent is acceptable in some cases
where the patient is unable to provide explicit
consent due to severe pain or altered mental
status

31. Pre-requisites
Clinicians providing PSA should have in
depth knowledge of the relevant drugs
Knowledge of mechanism of action, doses,
side effects, and reversal agents
Clinicians must also be well versed in
advanced cardiovascular life support,
including airway management

32. Prerequisites
Residents must utilise their
anaesthesia posting to become well
versed in PSA
EP may receive a special training on
PSA[ NABH standard]

33. Prerequisites
Number of clinicians needed to perform PSA
and the procedure safely may vary according
to the patient and the procedure.
One clinician performs the procedure while
another (usually a nurse) administers the
sedative agents and monitors and records
the patient's vital signs and clinical status.
Whenever possible , make sure that this
minimum standard to be met

34. Prerequisites
Guidelines from the American Society of
Anesthesiologists (ASA)
Call for someone with "advanced life
support skills" to be immediately
available (within five minutes) for PSA
He must be “Present” in the procedure
room whenever deep sedation is being
performed

35. Equipment
To perform the procedure and manage the airway should be available at the
bedside during the performance of PSA.
Suction to manage vomiting or oral
secretions
Oxygen
Airway adjuncts, such as a bag valve
mask and oral and nasal airways
Equipment to perform endotracheal
intubation

36. Equipment
Intravenous access should be established.
Resuscitation medications, including advanced
cardiac life support medications
Reversal agents - Naloxone , Flumazenil

38. Monitoring and Pre-oxygenation
Blood pressure
Heart rate
Respiratory rate
measured at frequent,
regular intervals

39. Monitoring and Pre-oxygenation
Oxygen saturation (SpO2)
End tidal carbon dioxide (EtCO2)
Cardiac rhythm
should be monitored
continuously

40. Monitoring and Pre-oxygenation
Monitor sedation level using Sedation scales
Richmond Agitation Sedation Scale
Ramsay Score

43. Monitoring and Pre-oxygenation
Alertness
Depth of respiration
Response to painful stimuli (eg, fracture
reduction)
Important in determining subsequent
medication doses

44. Monitoring and Pre-oxygenation
Supplemental oxygen is often recommended during PSA to
maintain oxygen reserves and prevent hypoxemia caused by
hypoventilation
Close attention to pulse oximetry readings remains critical
when monitoring patients breathing room air during PSA.

45. Monitoring and Pre-oxygenation
High flow oxygen by face mask be given to patients
undergoing PSA
Reduce the likelihood of hypoxic episodes,
particularly with prolonged procedures
Easy to perform,
Unlikely to cause harm.

46. Monitoring and Pre-oxygenation
Recommend pulse oximetry and EtCO2
monitoring for all patients undergoing PSA
EtCO2 measurements correlate closely with
arterial CO2
Provide an early sign of hypoventilation or
apnea, especially if supplemental oxygen is
used

47. Monitoring and Pre-oxygenation
Bi-spectral analysis monitoring
(BIS)
Technology developed to monitor
the level of general anaesthesia
Does not appear to be useful for
monitoring the depth of
procedural sedation

48. Pregnancy - Special consideration
Pre-procedural administration of medications
To improve gastroesophageal sphincter tone and
reduce gastric volume (eg, metoclopramide)
Decrease stomach acidity (eg, H2 antagonists,
sodium citrate)
Medications may reduce the risk of vomiting and
aspiration

49. Pregnancy - Special consideration
Pre- procedural hydration
Left lateral displacement of the uterus (in the late second and the third
trimester)
Reduce the risk of hypotension, utero -placental insufficiency, and
resultant foetal hypoxemia.
Foetal monitoring is not required but should be considered for
women in the third trimester.

50. Pregnancy - Special consideration
Oxygen by face mask is
administered because of the risk
of sedation related maternal
desaturation

52. PSA - Complications
Respiratory depression
Hypoxia
Hypercarbia
Cardiovascular instability

53. PSA Complications
Vomiting and aspiration
Emergence reactions
Inadequate sedation
preventing completion of the
procedure

55. PSA - Complications
Adverse events are more common in
Older age
Presence of multiple medical conditions (ie, higher ASA class)
Performance of esophagoscopy or cardioversion.

56. How to prevent complications ?
Appropriate selection of
patients
Proper use of sedative
medication
Careful monitoring of
sedation.

57. How to prevent complications ?
Attention should be paid to patients in whom
oxygenation and ventilation may be
difficult, should the need for airway
management arise.
Such patients may not be appropriate
candidates for PSA.

58. How to prevent complications ?
Oxygen desaturation can be minimized by
cautious, unhurried medication administration

59. How to prevent complications ?
Hypoventilation and apnea are usually short -
lived due to the brief duration of the drugs.Can
be managed by
Patient stimulation,
Supplemental oxygen,
Positioning of the airway
Brief ventilatory support using a bag valve
mask

60. How to prevent complications ?
Reversal agent naloxone or
flumazenil may be necessary
with more severe or prolonged
respiratory depression during PSA
using opioids or
benzodiazepines
Nausea and vomiting occur in about 5 percent of patients

61. How to prevent complications ?
Hypotension and bradycardia
Significant cardiac morbidity
Cardio- depressant
medications (eg, beta
blockers)
Hemodynamically neutral sedatives (eg, etomidate) may be preferable
for patients at risk from changes in blood pressure or heart rate.

62. PSA Medications

63. Medications
Procedural sedation and analgesia (PSA)
typically involves the intravenous (IV)
administration of sedative or
dissociative agents, sometimes in
combination with short acting opioids

64. Medications
Ideal drugs for PSA - Rapid
onset ,Short duration of action, Hemo-
dynamic stability, and Do not cause
major side effects
Several medications are commonly
used
No Single drug is ideal for all
situations.

65. Propofol
Phenol derivative , effective PSA for
emergent procedures
Propofol is highly lipophilic , crosses the
blood brain barrier rapidly.

66. Propofol
Drug takes effect within
approximately 40 seconds,
Duration of action is
approximately 6 minutes
Sedative and amnestic
No analgesia

67. Propofol
Slow injection
Initial loading dose of 0.5 to 1 mg/kg IV
Followed by doses of 0.5 mg/kg IV every three to five minutes
Titrate necessary until the appropriate level of sedation is
achieved

68. Propofol
One reasonable approach to
administration
20 mg every 10 seconds (eg, a 50 mg dose
would be given over 25 seconds)
No direct evidence demonstrating
improved efficacy or safety using this
regimen.

69. Propofol
Pharmacokinetics
Unchanged in patients with impaired
kidney or liver function
Plasma levels appear to be increased in
elder patients
Prolonged sedation and more
pronounced cardiorespiratory
depression[ Old age ]

70. Propofol-caution
Patients over 55 are particularly sensitive .
The manufacturer recommendations
Doses in elders be reduced by 20 percent
Drug be given more slowly (over three to five
minutes)
Reductions from 20 to 60 percent of the dose
used in a healthy young adult are reasonable

71. Soya bean &
Egg Lecithin
Propofol -Preparation

72. Propofol
Contains egg lecithin and soybean oil
Contraindicated in a sensitivity to either of
these substances
Hypotension (due to myocardial depression)
Respiratory depression.

73. Propofol
Hypotension causes complications in
patients with severe medical problems (eg,
sepsis, cardiac dysfunction) or hypovolemia
Respiratory depression usually manifests
as a mild oxygen desaturation.
Co-administration with other sedatives or
analgesics (eg, fentanyl) can exacerbate
respiratory problems

74. Propofol
No analgesia and can cause pain during injection through an intravenous
catheter.Prevention
1. Injecting into an antecubital vein rather than a hand vein (relative risk [RR]
0.14; 95% CI 0.070.30)
2. Lidocaine pretreatment while occluding the vein (RR 0.29; 95% CI 0.220.38)
3. Pretreatment with lidocaine propofol admixture (RR 0.40; 95% CI 0.330.48)
4. Lidocaine pretreatment without vein occlusion (RR 0.47; 95% CI 0.400.56)
5. Opioid pretreatment (RR 0.49; 95% CI 0.410.59)
6. Ketamine pretreatment (RR 0.52; 95% CI 0.460.57)
7. Pain during injection can also be reduced by using larger catheters placed in
larger veins.

75. Propofol Pain on injection
1.Effective approach is to place a tourniquet on the arm proximal to the injection
site and then give 0.5 mg/kg of lidocaine IV 30 to 120 seconds before propofol is
injected
2.Pretreatment with short acting opioids (eg, fentanyl). Unfortunately, the
addition of opioids increases the likelihood of respiratory complications.
3.Pretreatment with short acting opioids is to use sub dissociative doses of
ketamine (0.3 mg/kg). Ketamine appears to provide comparable analgesia with
less risk of respiratory depression

76. Etomidate
Imidazole derivative
IV over 30 to 60 seconds in doses of 0.1
to 0.15 mg/kg
Less than the dose used for rapid
sequence intubation.
Re-dosed approximately every three to
five minutes as needed.
Onset of action is almost immediate
Duration of effect is 5 to 15 minutes

77. Etomidate
More profound and prolonged effects in the
elderly and patients with renal or hepatic
dysfunction
Lower dosing range should be used.
Important benefit - maintains
cardiovascular stability.

78. Etomidate
No analgesic properties
Requires the co-administration of a
short acting opioid, such as fentanyl,
Increases the risk of respiratory
depression

79. Etomidate -Side effects
Pain during injection into peripheral veins
Myoclonus
Respiratory depression
Adrenal suppression
Nausea and vomiting

80. Etomidate Adrenal suppression

81. Etomidate -Myoclonus

82. Etomidate
The degree of myoclonus may be dose
dependent and ranges from mild and transient
to severe enough to prevent completion of the
procedure
Immediate airway support
Treatment with midazolam, 1 to 2 mg IV
approximately every 60 seconds until
myoclonus abates

83. Myoclonus -Evidences
Strategies to prevent myoclonus vary and there is insufficient evidence
to support any one approach:
1.According to one small randomized trial, a pretreatment dose of 0.03 to
0.05 mg/kg of etomidate given 50 seconds before the PSA dose reduces
myoclonus
2.Small randomized trial in patients undergoing cardioversion found that a
small dose of midazolam (0.015 mg/kg) given at the same time as etomidate
prevents myoclonus
3.Randomized trial, magnesium sulfate administered 90 seconds prior to
etomidate was found to reduce myoclonus
Guler A, Satilmis T, Akinci SB, et al. Magnesium sulfate pretreatment reduces
myoclonus after etomidate. Anesth Analg 2005; 101:705.

84. Benzodiazepines
Sedation
Anxiolysis
Amnesia
No analgesic properties.

86. Midazolam
Benzodiazepine used most often for PSA.
Lipophilic - closed ring
Penetrates the blood brain barrier
quickly.
Midazolam alone for anxiolysis
Combination with short acting opioids
(eg, fentanyl) for deeper levels of
sedation and analgesia.
Time of onset is 2 to 5 minutes
Duration of action is 30 to 60 minutes
Water
Soluble

87. Midazolam
IV over one to two minutes in doses of 0.02 to 0.03 mg/
kg
0.5 or 1 mg at a time and titrated to effect
No single dose should exceed 2.5 mg.
Repeat doses may be given every 2 to 5 minutes as
necessary.

88. Midazolam
Repeated doses, midazolam accumulates in adipose tissue
and significantly prolong sedation
The elderly, obese, and those with renal or hepatic
disease are at greater risk of prolonged sedation.
In such patients, the use of lower doses, longer dosing
intervals, and smaller total amounts reduces risk.
Horn E, Nesbit SA. Pharmacology and pharmacokinetics of sedatives and
analgesics. Gastrointest Endosc Clin N Am 2004; 14:247.

89. Midazolam
Adequate sedation depends
Patient Size & Age
Medication tolerance
Co-morbidities
Duration of the procedure
Other benzodiazepines, such as lorazepam and diazepam, are less suited for
PSA due to their relatively prolonged onset and duration of action

90. Short acting opioids
Opioids are often given alone or in
combination with sedatives for PSA.
Short acting agents, such as fentanyl,
alfentanil, and remifentanil, are used.

91. Fentanyl
Synthetic opioid
Frequently used in combination with midazolam
Provide analgesia during PSA before propofol
and Etomidate
Widely available.
75 to 125 times the potency of morphine
Rapid onset of action (two to three minutes)
Short duration of effect (30 to 60 minutes)
No amnestic properties

92. Fentanyl
Slow IV push in doses of 0.5 to 1 mcg/kg every two
minutes until an appropriate level of sedation and
analgesia is achieved
Maximum total dose is generally 5 mcg/kg or
approximately 250 mcg, but higher doses may be
needed in some instances.
Bahn EL, Holt KR. Procedural sedation and analgesia: a review and new concepts.
Emerg Med Clin North Am 2005; 23:503.

93. Fentanyl
Rarely causes hypotension
Does not stimulate histamine release
Primary side effect is respiratory depression, which is
potentiated by the co-administration of sedatives.
Renal or hepatic disease and the elderly can experience
more prolonged or profound effects.
Such patients, the use of lower doses, longer dosing
intervals, and smaller total amounts reduces risk.

94. Remifentanil
Remifentanil and alfentanil are opioids similar in
structure to fentanyl
Rapid onset
Duration of action of approximately five minutes,
and both are used for PSA
Potency of Remifentanil and Fentanyl are
comparable,
Alfentanil is one fifth to one tenth as potent.
Remifentanil can be given in combination with
propofol for PSA

95. Remifentanyl
Combination with propofol for PSA - Remifentanil - dose of 0.5
mcg/kg (and propofol 0.5 mg/kg) over one minute
Subsequent doses of Remifentanil 0.25 mcg/kg and Propofol 0.25
mg/kg may be given approximately every one to two minutes.
Remifentanil -ALONE for PSA - initial dose is 0.5 to 3 mcg/kg and
subsequent doses of 0.25 to 1 mcg/kg may be given approximately
every two minutes as needed
Dunn MJ, Mitchell R, Souza CD, Drummond G. Evaluation of propofol and remifentanil
for intravenous sedation for reducing shoulder dislocations in the emergency
department. Emerg Med J 2006; 23:57.

96. Alfentanyl
Alfentanil may be used as an
adjunct for PSA with propofol
Dose of 2.5 mcg/kg (along with
propofol 0.5 mg/kg).

97. Midazolam plus Fentanyl
Midazolam and Fentanyl - Problems
Hypoxia
Apnea
Increases the need for airway intervention
Medication reversal compared with PSA using ultra-short acting agents
In settings where ultra short acting agents are unavailable, the combination of
Midazolam and Fentanyl is sometimes used for PSA

98. Midaz - Fentanyl
Give midazolam first: 0.02 mg/kg (maximum 2 mg)
Wait two minutes and observe patient response;
Give second dose of midazolam if necessary
Give fentanyl: 0.5 mcg/kg
Observe patient
Repeat fentanyl dose every two minutes as necessary
Titrate to effect
Use smaller doses and longer intervals between doses in the elderly
and patients with compromised hepatic or renal function

99. Ketamine
Phencyclidine derivative
Acts as a dissociative sedative
Produces a trance like state and provides sedation,
analgesia, and amnesia
Preserving upper airway muscle tone, airway
protective reflexes, and spontaneous breathing

101. Ketamine
Rapid onset
Relatively short duration of action
Excellent sedative
Analgesic properties
Useful for brief, painful procedures, such as
fracture reduction or laceration repair

102. Ketamine
Generally given IV
Enables immediate onset
It can be given intramuscularly
Duration of effect is 10 to 20 minutes
PSA dose of 1 to 2 mg/kg is given IV over one to two
minutes
Doses of 0.25 to 0.5 mg/kg may be repeated every 5 to 10
minutes thereafter

103. Ketamine -Evidence
According to a systematic review of 87 studies involving over 70,000
patients, significant adverse reactions rarely occur when ketamine is used
for PSA in adults [91].
The authors emphasize that ketamine has proven to be an extremely safe
drug despite being used frequently in "austere, poorly monitored settings."
Strayer RJ, Nelson LS. Adverse events associated with ketamine for procedural
sedation in adults. Am J Emerg Med 2008; 26:985.

104. Side effects

105. Ketamine -Side effects
Tachycardia
Hypertension
Laryngo spasm
Emergence reactions
Nausea and vomiting
Increased intracranial pressure
Intraocular pressure
Hyper salivation
Exacerbate schizophrenia
Recent evidences are not supportive of raised ICP with Ketamine

106. Ketamine
The risk of laryngospasm may be greater in patients
with anatomic abnormalities of the upper airway (eg,
tracheal stenosis, tracheomalacia) or those undergoing
procedures involving significant or prolonged
stimulation of the oropharynx.

107. Emergence reaction
Emergence - disorientation, dream like experiences, or
hallucinations that may be frightening.
20 percent of adults and prevented or treated by giving a small
dose of Midazolam
Prevention- midazolam, approximately 0.05 mg/kg (typical adult
dose 2 to 4 mg), may be given slowly (over about two minutes)
by IV prior to administering ketamine.

108. Ketamine - Nausea and Vomiting
Prophylactic treatment with Midazolam has met
with mixed results in pediatric populations
Pretreatment with Ondansetron or comparable
agents may be helpful.

109. Ketamine
Hypersalivation
Reduced by pretreating with
glycopyrrolate or atropine
The benefit of such pretreatment is
unclear

110. Barbiturates
Barbiturates suppress the reticular
activating center in the brainstem and
cerebral cortex, thereby causing
sedation.
Methohexital is the most commonly used
barbiturate for PSA but has largely been
supplanted by etomidate and propofol.

112. Methohexital
Immediate onset
Duration of action less than 10 minutes
Provides sedation
Amnesia
No analgesia.

113. Methohexital
Combination with opiates, which
can potentiate respiratory
depression.
Initial dose of methohexital is
0.75 to 1 mg/kg given
intravenously;
Repeat doses of 0.5 mg/kg IV can
be given every two minutes.

114. Methohexital
Myocardial depression, which can lead to
hypotension and tachycardia
Precipitate or exacerbate seizures and should
be avoided in patients with a seizure disorder
The Barbiturate causes seizures

115. Barbiturates
Thiopental is a barbiturate used for
induction of general anaesthesia, and
rarely used in the performance of PSA

116. Ketofol

117. Ketofol
"Ketofol" is a combination of ketamine and propofol being
studied for use in PSA.
The concept of ketofol is that the benefits of the two
medications are synergistic and allow lower doses of each
to be used.
Lower doses purportedly reduce the risk for potential
side effects ie, propofol induced hypotension and
ketamine induced vomiting and emergence reactions

118. Ketofol- Evidences
A systematic review of six randomized trials performed in emergency
departments, patients treated with a ketamine propofol combination for
procedural sedation experienced fewer adverse respiratory events
compared with those treated with propofol alone (29.0 versus 35.4
percent; RR 0.82, 95% CI 0.68 0.99) .
However, many of these adverse events were not clinically important (eg,
brief oxygen desaturation), and the review found no significant
difference in the overall rate of adverse events or in the time required
to complete procedures.
Yan JW, McLeod SL, Iansavitchene A. KetaminePropofol Versus Propofol Alone for
Procedural Sedation in the Emergency Department: A Systematic Review and Meta-
analysis. Acad Emerg Med 2015; 22:1003.

120. Nitrous Oxide
Nitrous oxide (N2O) is an ultrashort acting agent used for PSA
Inhaled as a 30 to 50 percent mixture, with 30 percent oxygen to avoid
hypoxemia.
N2O has an immediate onset of action and provides analgesia, anxiolysis,
and sedation.
N2O also obviates the need for an intravenous line.
The major disadvantage to N2O is that it must be administered in a well
ventilated room with a scavenging system to prevent clinician exposure .
Bahn EL, Holt KR. Procedural sedation and analgesia: a review and new concepts.
Emerg Med Clin North Am 2005; 23:503.

121. Future medications
New drugs are being developed that may have a future role in PSA.
Fospropofol is a propofol prodrug that may provide more sustained and
consistent clinical effects at lower plasma levels than equivalent doses of
propofol.
Dexmedetomidine is an alpha 2 agonist similar to clonidine that has
sedative and analgesic effects

122. How to choose?
Factors to consider when choosing between Propofol and Etomidate
● Etomidate provides greater hemodynamic stability
● Propofol can cause hypotension.
● The fall in blood pressure from propofol is generally small and
transient
● Difference may be of importance in patients with hypovolemia or
hypotension who undergo PSA
● Etomidate can cause myoclonus, which appears to reduce the rate of
procedural success

123. How to choose?
Etomidate can cause myoclonus, which appears to reduce the rate of
procedural success
Etomidate causes dose dependent adrenal suppression, which may be
harmful in patients with severe disease (eg, sepsis, multiple trauma).
Such patients may not be suitable for PSA.
This effect is unlikely to be important in otherwise healthy patients.
Respiratory depression occurs at comparable rates during PSA with both
drugs, although this rarely causes harm to the patient.

124. Patient at risk for Hypotension
Patients at risk of hypotension due to recent illness and dehydration,
cardiac disease, or some other condition, either Etomidate or
Ketamine be used for PSA;
Propofol has a greater blood pressure lowering effect

125. Patients at Risk for Airway or Respiratory
complications
Patient wit potentially difficult airway or compromised respiratory function -
Ketamine be used for PSA.
Ketamine allows the patient to maintain protective airway reflexes
Ketamine does not cause respiratory depression.

126. Elderly at increased risk of complications
Sedatives regardless of the agent, should be given
1.Lower starting dose
2.Lower rates of administration
3.Less frequent dosing intervals.
Elderly patients without major co-morbidities or hemodynamic instability
may use an ultra short acting sedative, such as Propofol.
Procedures in elderly patients with major co-morbidities are probably best
performed in the operating room.

127. Discharge criteria
"Neuromuscular and cognitive preprocedure baseline"
1. The procedure should be of sufficiently low risk
that additional monitoring for complications is
unnecessary.
2. Symptoms, such as pain, lightheadedness, and
nausea should be well controlled.

128. Discharge criteria
3.Vital Signs and respiratory and cardiac function
should be stable.
4.Mental status and physical function should have
returned to a point where the patient can care for
himself or herself with minimal to no assistance.
5.A reliable person who can provide support and
supervision should be present at the patient's home for
at least a few hours.

131. Discharge criteria
6.Clearly written discharge instructions should be
given and explained to the patient and to the family
member or friend who will be assisting with the patient's
care following PSA.
7.Clinician should explain
A. What was done
B. Expected course
C. Potential problems
D. What to do if problems arise
E. When and where to follow up
F. When to return to normal activities.

132. Summary &

139. Procedural sedation and analgesia (PSA) involves the use of short-acting
analgesic and sedative medications to enable clinicians to perform procedures,
while monitoring the patient closely for potential adverse effects
PSA may be used for any procedure in which a patient's pain or anxiety may
be excessive and may impede performance
No absolute contraindications to PSA
Relative contraindications include: older age, significant medical co-
morbidities, and signs of a difficult airway

140. The number of clinicians needed to perform PSA and the procedure safely may vary
according to the patient and the procedure
Proper monitoring during PSA is crucial.
Blood pressure, heart rate, and respiratory rate should be measured at frequent,
regular intervals
Oxygen saturation (SpO2), end-tidal carbon dioxide (EtCO2) level, and cardiac
rhythm should be monitored continuously.
Give high flow oxygen

141. Adverse outcomes- Respiratory depression with hypoxia or hypercarbia,
cardiovascular instability, vomiting and aspiration, and inadequate sedation
preventing completion of the procedure.
Several medications are commonly used and no single drug is ideal for all
situations

142. Patients at risk of hypotension, use either Etomidate or Ketamine for PSA
Patients with potentially difficult airway or have compromised respiratory
function, use Ketamine
Follow check list in each PSA
Follow criteria for safe discharge
Older patients are at increased risk of complications during PSA.
Sedatives administered to older patients for PSA, regardless of the agent,
should be given using a lower starting dose, slower rates of administration,
and less frequent dosing intervals

143. Thank you so much
drvenugopalpp@gmail.com
9847054747
www.drvenu.blogspot.in
Procedural sedation in adults outside the operating room Author: Robert L Frank, MD, FACEP
Section Editor: Allan B Wolfson, MD ,Deputy Editor: Jonathan Grayzel, MD, FAAEM