This document provides an overview of procedural sedation in emergency medicine. It discusses the goals and benefits of procedural sedation, as well as considerations for patient selection and assessment. Commonly used sedative agents like propofol, fentanyl, midazolam, and ketamine are reviewed in terms of their mechanisms of action, dosing, pharmacokinetics, pros and cons. The document emphasizes the importance of airway assessment and having the skills and resources to manage complications from sedation.

1. Procedural sedation in
Emergency Medicine
Dr . Venugopalan. P.P
DA,DNB,MNAMS,MEM[GWU]
Director Emergency Medicine
PG Teacher in EM , NBE
Founder & Executive director ,ANGELS
Aster DM Health care
India

2. Objectives
What does it mean
What needs to be
considered.
What do we normally
use it for.
Review commonly
used agents
Briefly discuss
alternatives to PSA

3. Overview
DISCLAIMER….
This is a very simplified overview of a
complex topic.
It is not a substitute for in-depth research,
background knowledge and training.
Acknowledgement
Presentations by
Deon Stoltz ,
Dr Garry Clearwater and
Barnes-Jewish Hospital

4. What is
Procedural
Sedation?
To reduce patient anxiety
and awareness
To facilitate a painful
medical procedure
Patient maintains their
airway & breathing
“Conscious sedation”
“Deep sedation”

5. What is Procedural Sedation?
• Procedure (n) A series
of steps taken to
accomplish an end.
Examples: EGD,
bronchoscopy,
fracture/dislocation
reduction, cardiac
catheterization
• Sedation (n)
Reduction of anxiety,
stress, irritability, or
excitement by
administration of a
sedative agent or
drug.Procedural Sedation (n) Reducing anxiety or stress
with medications in order to perform a procedure.
These medications may include, but are not limited to
Opiates (e.g., morphine, fentanyl) and
Benzodiazepines (e.g., midazolam, lorazepam).

6. The goals of PS
Patient safety &
welfare the first
priority.
Adequate
analgesia,
anxiolysis,
sedation and
amnesia during the
performance of
painful diagnostic or
therapeutic
procedures in the
ED.
Minimize the
adverse
psychological
responses
Control motor
behaviour that
inhibits the provision
of necessary medical
care.
Return the patient to
a state in which safe
discharge is

7. Procedural
Sedation Positives
Avoids the discomfort
associated with local or
regional anaesthetic
techniques.
Doesn’t affect anatomy
Relatively simple
technique
Negatives
Consumes resources
General anaesthesia in
the
ED
is frowned upon…

8. How low should you go?
Depth of Procedural Sedation
Minimal Sedation (Anxiolysis)
Moderate Sedation/Analgesia
Deep Sedation/Analgesia
General Anaesthesia
Normal LOC

9. Sedation Continuum Moving from one state of conscious to
another is a dose-related continuum that depends on patient
response NOT type, dose or route of medication, or any other
external factors..
MINIMAL
SEDATION
(ANXIOLYSIS)
MODERATE
SEDATION
DEEP
SEDATION
ANESTHESIA
Response Normal
response to
verbal
stimulation
Purposeful
response to
verbal or
tactile
stimulation
Purposeful
response
following
repeated or
painful
stimulation
Unarousable
even with
painful
stimulus
Airway Unaffected No
intervention
required
Intervention
may be
required
Intervention
often required
Spontaneous
Ventilation
Unaffected Adequate May be
inadequate
Frequently
inadequate
Cardiovascular
Function
Unaffected Usually
maintained
Usually
maintained
May be
impaired

10. Uses Reduction of
dislocations:
 Shoulder, elbow, hip,
patella, ankle
Reduction of fractures:
 Wrist, ankle
 Washout compound
fracture
Paediatric injuries:
 Wound inspection,
closure, suturing
Abscess I&D

11. Considerations for PS in the
ED
Environmen
tal
Patient Agent

12. Patient

13. Case – Mr. F. B.

14. Case
A 40 yo
man
presents
with a
painful,
swollen
right wrist
after a fall.
You do an

15. So what about our patient?
Allergies:
Eggs
Medications:
Enalapril
Salbutamol
Flovent
Past Medical History:
Asthma
Obstructive sleep apnea
Hypertension
DM II
• Last Meal:
– 30 minutes ago
• Events:
– Patient came immediately to the
hospital after falling.
AMPL
E

16. To sedate or not to sedate…
86 yo female with a dislocated hip
Allergies: NKDA
Meds:
Metoprolol
Nitroglycerin patch
Enalapril
Lasix
ASA
Last meal:
NPO for 4 hours
• PMHx:
– MI x 2 (multi-vessel
CAD)
– Angina with minimal
activity
– PVD
– HTN
– CVA
– CRF
• Events:
– Pt felt a pop while
trying to get up from

17. To sedate or not to sedate…
22 yo intoxicated male with an ankle fracture
Allergies: NKDA
Meds: unknown
PMHx: unknown
Last meal:
Smells like EtOH
Unknown
Events:
No one really knows

18. To sedate or not to sedate…
28 yo female with a fractured wrist
What risks
are
associated
with sedation
during
pregnancy?

19. Patient
Assessment
 The AMPLE
history
Allergies
Medications
Past medical
history
Last meal
Events before &

after the incident
 Physical Exam
Airway
assessment
Respiratory
exam
Cardiovascular

20. ASA Physical Status
Classification
I. Healthy Patient
II. Mild systemic disease – no
functional limitation
III. Severe systemic disease –
definite functional limitation
IV. Severe systemic disease that is a
constant threat to life
V. Moribund patient that is not
expected to survive with the

21. ASA PS (physical status) classification
Definition Details Examples
ASA
PS 1
A
normal
healthy
patient
Healthy individual with no
systemic disease, undergoing
elective surgery. Patient not at
extremes of age. (Note: Age
is often ignored as affecting
operative risk; however, in
practice, patients at either
extreme of age are thought to
represent increased risk.)
Fit patient with inguinal
hernia.
Fibroid uterus in an
otherwise healthy woman
ASA
PS 2
A
patient
with
mild
systemic
disease
Individual with one system,
well-controlled disease.
Disease does not affect daily
activities. Other anesthetic
risk factors, including mild
obesity, alcoholism, and
smoking can be incorporated
at this level.
Non-limiting or only
slightly limiting organic
heart disease.
Mild diabetes, essential
hypertension, or
anemia.

22. ASA PS (physical status) classification continued
Definition Details Examples
ASA
PS 3
A
patient
with
severe
systemic
disease
Individual with multiple
system disease or well
controlled major system
disease. Disease status
limits daily activity.
However, there is no
immediate danger of
death from any
individual disease.
Severely limiting organic heart
disease. Severe diabetes with
vascular complications.
Moderate to severe degrees of
pulmonary insufficiency.
Angina pectoris or healed
myocardial infarction.
ASA
PS 4
A patient
with
severe
systemic
disease
that is a
constant
threat to
life
Individual with severe,
incapacitating disease.
Normally, disease state
is poorly controlled or
end-stage. Danger of
death due to organ
failure is always present
Organic heart disease showing
marked signs of cardiac
insufficiency, Persistent
anginal syndrome, or active
myocarditis. Advanced
degrees of pulmonary, hepatic,
renal, or endocrine
insufficiency.

23. ASA PS (physical status) classification continued
Definition Details Examples
ASA PS 5 A
moribund
patient not
expected to
survive (24
hrs)
Patient who is in
imminent danger of death.
Operation deemed to be a
last resort attempt at
preserving life. Patient not
expected to live through
the next 24 hours. In some
cases, the patient may be
relatively healthy prior to
catastrophic event, which
led to the current medical
condition.
Burst abdominal
aneurysm with
profound
shock.
Major cerebral
trauma with rapidly
increasing
intracranial
pressure.
Massive pulmonary
embolus.
ASA PS 6 A declared
brain-dead
patient /
organ
donor

24. “It’s only a little chest pain”
ASA Scores & PSA
• The ASA classification is not validated
outside of the OR.
• Malviya et al showed an increased risk
of adverse sedation-related events in
paediatric patients with an ASA > 2.

25. “The patient’s ASA status should be
determined. For non-emergent
procedures, ED sedation and
analgesia should be limited to ASA
class 1 or 2 patients.”
Class B, Level III
Procedural sedation and analgesia in the emergency department
Canadian Consensus Guidelines

26. The Last Supper
Fasting & PSA
ANZCA recommendations for healthy
elective GA patients:
2 h NPO for liquids
6 h NPO for solids
The risk of aspiration during PSA is
extremely low.
There is no evidence that fasting
improves outcome during procedural
sedation and analgesia.
One large paediatric study of ED procedural sedation showed
no increase in the number of adverse events in patients that

27. Starved for how long…?
Controversial.
Probably not as rigid as anaesthetic guidelines
for GA...
Depends on degree and duration of sedation
Starship CED paediatric guideline:
 Clear fluids: at least 2 hours
 Non-clear fluids and solids: at least 4 hours

28. Oral Intake
Guidelines
Age does not matter – what they
took orally is the issue.
Ingested Material
Minimum Fasting Period
Clear Liquids 2
hours
Breast Milk 4
hours
Infant Formula
6hours
Non-clear Liquids 6
hours
Light Meal 6
hours
Options for the patient not within
these guidelines:
Cancel the Procedure

29. Emergent
Procedures
Emergent
Procedures :
life- or organ
(i.e., CNS)
saving
procedures
(consult
anesthesiolog
y)
Urgent procedure are those
which need to be done
in 2-4 hrs
•Document why it is
urgent;
•Assess the need for
sedation and
preferably administer
none
•Consider postponing
or consult
anesthesiology
•Monitor the patient's
airway closely
•Look for active or
silent regurgitation
and aspiration.

30. PATIENT SELECTION
Can you hold the fort if something goes wrong?
BREATHING & CIRCULATION:
 Lung disease?
 Stable cardiac status?
 BP stable?
Medications
Allergies (e.g. watch out for soy, eggs: Propofol)

31. Airway Assessment
Can you bag?
Can you
Intubate?

32. Predictors of Difficult BVM Ventilation
Beard
Obesity
Old (age > 55 yrs)
Toothless
Snores
Langeron O, Masso E, Huraux C, et al. Prediction of difficult
mask ventilation. Anesthesiology. 2000; 92:1229-36.

33. The LEMON Method of Airway
Assessment
• Look for external characteristics known to causes
problems with BVM or intubation.
• Evaluate the 3-3-1 Rule:
Mouth opening > 3 fingers
Hyoid – chin distance > 3 fingers
Anterior low jaw subluxation > 1 finger
• Mallampati Score
• Obstruction – any pathology within or surrounding the
upper airway
• Neck Mobility - full flexion & extension

34. Considerations for PS in the
ED
Environmen
tal
Patient
Agent

36. Choosing appropriate
medications
• Agents should be chosen
based on the desired
pharmacological
response. Depending on
the particular agent one,
two or all three of these
below effects can be
achieved:
Adverse effects -
The potential side
effects of any
medication in a
particular patient
must by
considered.
Many sedative
agents can
produce cardiac
or respiratory
depression.
Analgesi
a
Amnesi
a

37. Pharmacokineti
c
Considerations
When selecting a sedative,
the following pharmacokinetic
parameters should be
considered to optimize
response in a given situation.
* Onset and Duration
* Elimination Route
* Accumulation
* Drug interactions /
potentiations
* Cross-Tolerance
e.g. patients with prior
opiate use may require higher
doses of opiates; those with
prior ethanol exposure may
require larger doses or
benzodiazepines, etc.
-

38. The Perfect
Drug
Provides adequate
sedation and analgesia
for:
Patient comfort
Easy completion of the
procedure
Maintains airway
reflexes
Does not affect
hemodynamics
Does not affect
respiratory function

39. Commonly
Used Agents Propofol
Fentanyl
Ketamine
Midazola
m

40. Commonly Used
Agents
Propofol
Category
Sedative-Hypnotic
What is it?
2,6-diisopropofol, an
alkylphenol oil in an
emulsion
How does it work?
Potentiates GABA
activity
How much do you
need?
Starting dose of 0.5 -
1 mg/kg

41. Commonly Used
Agents
Propofol
What else does it do?
CNS: Mild analgesic
properties; euphoria
CVS: Myocardial
depressant;
vasodilation
Resp: Respiratory
depressant
GI: Antiemetic
MSK: Myoclonus
What does the body do
with it?
Rapid redistribution
Hepatic and
extrahepatic
metabolism

42. Commonly Used
Agents
Propofol
Pros
Shown to be safe for
ED PSA use
Rapid onset and
recovery
Cons
Must be combined with
an analgesic agent
May cause apnea &
loss of airway reflexes
Myocardial depressant
and vasodilator

43. Commonly Used
Agents
Fentanyl
Category
Analgesic agent
What is it?
Synthetic opioid
How does it work?
Decreases
conduction along
nociceptive
pathways and
increases activity in
pain control
pathways in the
brain.
How much do you
need?
Starting dose of 1-2
mcg/kg

44. Commonly Used
Agents
Fentanyl
What else does it do?
CNS: Euphoria (or
dysphoria)
Resp: Respiratory
depressant; chest wall
rigidity
CVS: May decrease
HR
GI: Decreased motility
What does the body do
with it?
Hepatic metabolism
(inactive metabolite)
Renal excretion

45. Commonly Used
Agents
Fentanyl
Pros
Good hemodynamic
stability
Rapid onset and
recovery
Cons
Must be combined with
an amnestic agent
May cause bradycardia
May cause chest wall
rigidity
May cause apnea &
loss of airway reflexes

46. Commonly Used
Agents
Midazolam
Category
Amnestic
What is it?
Benzodiazepine
How does it work?
Bind to
benzodiazepine
receptors which up-
regulate GABA
activity
How much do you
need?
0.02 – 0.1 mg/kg IV

47. Commonly Used
Agents
Midazolam
What else does it do?
CNS: Anxiolysis
CVS: Slight decrease in
PVR & decreased
contractility.
Resp: Respiratory
depression
What does the body do
with it?
Hepatic metabolism
(active metabolite)
Renal excretion

48. Commonly Used
Agents
Ketamine
Category
Dissociative Amnestic
What is it?
Derivative of
phencyclidine with
some opioid properties.
How does it work?
Stimulates the limbic
system while inhibiting
the thalamus & cortex
(dissociation)
Binds to NMDA and
opioid receptors

49. Commonly Used
Agents
Ketamine
What else does it do?
CNS: Emergence
reactions
CVS: Increased
contractility, HR and
PVR through
sympathetic stimulation.
Direct myocardial
depressant.
Resp: Laryngospasm,
bronchodilation,
increased secretions
What does the body do with
it?
Hepatic metabolism

50. • Frequency is reported to
be anywhere from <1% to
50% in adults.
• Treatment with
benzodiazepines is the
most effective way to
prevent emergence
reactions.
But won’t it give him nightmares?
Ketamine & Emergence Reactions

51. Commonly Used
Agents
Ketamine How much do you
need?
1 – 2 mg/kg IV
How much
midazolam?
0.7 mg/kg given at
the time of
ketamine injection.

52. Mix & Match
Commonly used combinations:
Propofol + Fentanyl
Fentanyl + Midazolam
Propofol + Midazolam + Fentanyl
Ketamine + Midazolam
Ketamine + Propofol
“Ketofol”

53. If respiratory depression and/or hemodynamic instability
occurs, consider use of reversal agents.

54. Naloxone
(Narcan®)  Opioid antagonist
 Dosing: 0.4–2 mg q 2-3
min, up to 10 mg
 Onset time: 1-2 min
 Duration of effect: 30-60
min
 Adverse effects:
precipitate withdrawal,
pulmonary edema

55. Flumazenil
(Romazicon®)  Benzodiazepine
antagonist
 Dosing: 0.2 mg q 1 min,
up to 1 mg
 Onset time: 1-2 min
 Duration of effect: 30-90
min
 Adverse effects: seizures
 Reversing BZD-induced
hypoventilation

56. How low should you go?
Depth of Procedural Sedation
Minimal Sedation (Anxiolysis)
Moderate Sedation/Analgesia
Deep Sedation/Analgesia
General Anaesthesia
Normal LOC

57. Considerations for PS in the
ED
Environmen
tal
Patient
Agent

58. Environmenta
l

59. PREPARATIO
N
Prepare for the worst….
What can go wrong?
 Unexpected drug
reaction or anaphylaxis
 Vomit and aspirate
 Obstructed airway (e.g.
laryngospasm, tongue)
 Apnoea, respiratory
arrest
 Profound hypotension

60. PREPARATIO
N
Not quite the worst …
What can go wrong?
 Disinhibition / agitation
 Terrors, nightmares
 Unexpected drug
reactions: dystonias
 Inadequate sedation
 Unsuccessful
procedure… still needs
GA

61. PREPARATIO
N
ACEM POLICY
DOCUMENT -
USE OF
INTRAVENOU
S SEDATION
FOR
PROCEDURE
S IN THE
EMERGENCY
DEPARTMENT
© ACEM. 5 December

62. PREPARATION
Environment
 Separate space
to perform the
procedure
 A recovery
space: ideally
quiet, available
for 1-2 hours,
easily observed.

63. PREPARATIO
N
ENVIRONMENT
The procedure must be
performed in a
suitable clinical area
with facilities for:
 Monitoring,
 Oxygen
 Suction
 Immediate access to
emergency
resuscitation
equipment, drugs and

64. PREPARATIO
N
ENVIRONMENT
Readily
available
equipment
must
include:
 Resuscitatio
n trolley
 Defibrillator
 Bag-Valve-
Mask device
for

65. PREPARATIO
N
MONITORING
Cardiac rhythm,Non-
invasive blood
pressure, Pulse
oximetry must be
monitored “throughout
the procedure and
recovery period”

66. PREPARATIO
N
PERSONNEL
The involvement of at least
two clinical staff is
required:
 PERSON PERFORMING
PROCEDURE
must understand the
procedure and its potential
complications.
 PERSON GIVING DRUGS
AND MONITORING PATIENT
- must have training and
experience of resuscitation,
emergency drugs and ….
(details of) the drugs used.
This person is not involved in
the performance of the
procedure but is dedicated to

67. PREPARATIO
N
PATIENT PREPARATION
Explanation
Consent
Secure IV access
is mandatory.

68. Informed Consent
* The person performing the procedure (clinician) is to review objectives,
risks, benefits and alternatives of Procedural Sedation (informed consent)
* This can be done at the same time as the procedure is explained
* Informed consent for the sedation does not require a patient signature.
Rather there is a check box on the Pre-Procedure/Pre-Sedation Assessment
form. If paper forms are not available, it is the responsibility of the clinician
to document this in the pre- procedure note.
* If the person who will monitor the patient (assistant) finds that the patient has
additional questions, the person performing the procedure (clinician) will be
contacted to answer these questions before sedation is given.

69. Assistant Responsibilities
– Patient assessment and
appropriate documentation
throughout the procedure
– Reassure patient and monitor
patient awareness.
– Provide comfort measures as
needed
– Notify clinician of changes /
concerns.
– Documentation of required
parameters.
The Assistant is not to leave patient bedside for any
reason during the procedure (although may assist
the clinician with short, interruptible tasks) The
assistant must be able to drop those tasks if the
patient needs attention)

70. Documentations
Don’t forget …..
Must ….

71. Pre-Procedure/Pre-Sedation Assessment form (required
for all procedural sedation) includes documentation of the
following:
Review of Systems:
*Can be completed by nursing or medical staff. If completed by nursing,
must
be reviewed by the clinician completing the pre-procedure
assessment.
Focused Assessment:
Must be completed by a licensed independent practitioner according
to
Medical Staff Bylaws. It includes procedure-specific parameters, and
addresses any new or pertinent data seen on the Review of Systems.
Airway Assessment:
* Aim is to plan for airway management if that would be necessary.
* Assessment parameters may include
* Assessing dentures, loose teeth, partials, etc.
* When the patient opens his/her mouth, how easily can the cords
and
pharynx be visualized should intubation be necessary.
* Are there physical limitations, which would impede proper

72. Pre-Procedure/Pre-Sedation Assessment form
(required for all procedural sedation) includes
documentation of the following:
Risk Assessment (ASA PS Score)
*To be completed by clinician, even if you’re not Anesthesia
personnel
Risks/Benefits/Alternatives for Sedation
*Required discussion with patient should be documented
either on outpatientforms, or in procedure note
Risks/Benefits/Alternatives for Procedure
*As above, with the addition of signature on procedural
consent
Sedation Plan:
*The level of sedation that was presented to, and accepted by
the patient. This must be documented before initiation of the
procedure.

73. Prevent wrong site / wrong patient / wrong
limb / wrong equipment
• Site Verification / Marking “YES” on the procedure site
– Must be completed before the procedure starts
– Is the responsibility of the person performing the procedure
(clinician)
– Should be a process which includes patient input / verification /
understanding
• TIME OUT!
– To be completed immediately before the first dose of sedation /
start of the procedure.
– Is the responsibility of the clinician, although may be
documented by the assistant
– Should be a group interaction (clinician, assistant, others
present in the room)
– Includes four questions:
1. Is this the Correct Patient?
2. Is this the Correct Procedure?
3. Is this the Correct Site?
4. Is this the Correct Equipment?

74. Intra-procedure Monitoring requirements
*BP, Pulse, Respiratory Rate, SpO2
Immediately before the procedure / first dose of sedation, monitored
frequently and documented every 10 minutes throughout the
procedure and recovery period.
*Mechanical noninvasive blood pressure is preferred, however may
use manual (cuff) method.
*Continuous Pulse Oximetry
*Sedation
*Assessed and documented with vital signs
*RASS Sedation Scale

75. Richmond Agitation Sedation Scale (RASS)
Score Term (not included
on documentation
forms)
Description
+4 Combative Overtly combative, violent, immediate danger to staff
+3 Very agitated Pulls or removes tube(s) or catheter(s), aggressive
+2 Agitated Frequent, non-purposeful movement. Fights ventilator
+1 Restless Anxious, but movements not aggressive, vigorous
0 Alert and Calm
-1 Drowsy Not fully alert, but has sustained awakening
(Eye-opening/eye-contact) to voice, ≥ 10 seconds
-2 Light sedation Briefly awakens with eye-contact to voice, <10 seconds
-3 Moderate sedation Movement or eye-opening to voice, (but no eye
contact)
-4 Deep sedation No response to voice, but movement or eye opening to
physical stimulation
-5 Unarousable No response to voice or physical stimulation

76. Intra-procedure Monitoring requirements
EKG monitor
*Assistants may not be able to perform rhythm
interpretation
*Identify when more in depth patient assessment
is required
1). For example: heart rate drops, assistant
may stimulate
patient, check BP, or other
2). Another example: heart rate accelerates,
assistant may ask patient about comfort level.
*Assistants should notify the clinician for any
noticeable changes in rhythm, rate, or other
concerns noted on monitor for further medical

77. Intra-procedure Monitoring
requirements
Capnography?
*Although not essential this indicates if
patient is ventilating
adequately.
*This will indicate hypoventilation
before pulse oximetry.
*Currently available to intubated
patients only

78. Responsible Individual
for discharge planning
• The person who will provide the patient’s ride home and be
available to the patient after the procedure will be identified
before the procedure begins.
• This person may be an adult, or someone in their late teens that
the patient feels comfortable with.
• If the patient is an outpatient, this person frequently
accompanies the patient to the hospital
• If the responsible individual is not present, hospital staff need to
verify the individual by telephone.
• If the patient is an inpatient, it may not be necessary to identify
this individual pre-procedure.
• If the inpatient is discharged within 24 hours of the
procedure, the patient must be discharged to a responsible
individual.

79. Responsible individual?
• For outpatients: If either the clinician (person performing
the procedure) or the assistant (person monitoring the
patient) feels the individual present would not be
appropriate in this role, or the patient has no one
identified, the clinician needs to determine:
– Can the procedure be cancelled (or postponed) until a
responsible individual is available?
– Should the procedure be completed and the patient
kept an additional 4 hours after discharge criteria are
reached, then released with appropriate
transportation?

80. Discharge to Responsible Person
Guidelines:
Best Practice: Patient accompanied by Responsible
Adult
If no responsible adult present at patient admission,
staff should
-Verify via phone the responsible adult who will be
present at discharge
-Or
-Identify a responsible individual to whom the patient
can be reasonably transported after the procedure
-Or
-Cancel the Procedure!
How do I know the
person is
responsible?
Use your
professional
judgment.
If no responsible adult present after the procedure is completed,
observe the patient for 4 hours after completion of the recovery
period, then discharge (patient must not drive for 24 hours after
sedation).

81. READY TO GO…
Explain
Pre-oxygenate
IV Access and IV fluid running
Splints or plaster or equipment all
ready to go
Hand over your phone or pager…

82. ALDRETE POST PROCEDURE RECOVERY SCORE
Aldrete Post Procedure Recovery Score Base
Line
Post
Procedure D/C
Activity Moves 4 Extremities voluntarily or on command
Moves 2 Extremities voluntarily or on command
Moves 0 Extremities voluntarily or on command
2
1
0
2
1
0
2
1
0
Circulation SBP ± 20 mmHg of Preprocedure Level
± 20-50 mmHg of Preprocedure Level
± 50 mmHg of Preprocedure Level
Preprocedure BP / .
2
1
0
2
1
0
2
1
0
Respirations Able to deep breath or cough freely
Dyspnea, shallow, or limited breathing
Apneic or Mechanical Vent
2
1
0
2
1
0
2
1
0
Consciousness Awake (oriented, answers questions approp.)
Arousable on calling (responds to voice)
Non-responsive
2
1
0
2
1
0
2
1
0
Color Normal
Pale, dusky, mottled, jaundiced, other
Cyanotic
2
1
0
2
1
0
2
1
0
Discharge score must be a minimum of pre-procedure score minus
one, with stable vital signs to meet discharge criteria.
TOTAL:
Baseline must be done before sedation initiated. This
is what post-procedure Aldretes are compared to.
Post Procedure is done at the end of the procedure, then every 10 minutes until patient
meets recovery criteria. A minimum of 3 aldrete scores must be completed before the
patient can be identified as “recovered” When recovery criteria are met, the last
(frequently the third) Aldrete can be the D/C score.

83. Recovery criteria
*A minimum of two consecutive Aldrete scores are baseline minus one
with stable vital signs
*The patient’s room air oxygen saturation must be back to baseline
*Sufficient time (i.e., a minimum of 1 hour) should have elapsed after the
last administration of reversal agents (naloxone, flumazenil) to ensure
that
the patient does not become resedated after reversal effects have
abated.
* Patients who will be discharged to home and receive IV
medications for relief of pain, nausea, vomiting etc. must be
observed no less than two consecutive Aldrete / vital sign
assessments following administration of such medication

84. Discharge criteria
Vital signs stable (Vital signs include BP, HR, R,& O2 Sat. The VS are
determined to be stable if they are consistent with the patient’s age and with the
patient’s pre-operative VS)
Swallow, cough present (patient demonstrates ability to swallow fluids and
is able to cough
Able to ambulate (patient demonstrates ability to ambulate at pre-procedure
level)
Nausea, vomiting, dizziness is minimal
Absence of respiratory distress (patient’s respiratory effort consistent
with pre-procedure status)
State of consciousness (patient is alert, oriented to time, place and person
consistent with pre-procedure level of consciousness).
Level of comfort (Pain controlled as per BJH pain policy)
Post-procedure (oral and written) discharge instructions are
given to the patient and/or significant other regarding the following: purpose and
expected effects of sedation, patient’s care, emergency phone number,
medications, dietary or activity restrictions, and necessary precautions (e.g., no
driving for 24 hours, avoid alcohol and use of power tools, etc.).

85. Phone a friend…
Consider sending the at-risk patient
to the OR.

86. Questions?

87. Key Points
Be
prepared
Know
your drugs
and your
drug
interactions
Consider
all your
options
Thank you so muc

89. Procedural Sedation Post Test
1. Which treatment is an example of procedural sedation?
A. Preventing anxiety prior to treatment without
altering the
patient’s level of consciousness.
B. Providing comfort measures to the patient.
C. Performing a simple dressing change.
D. Administering medication to alter the level of
consciousness prior to a procedure.
2. A Physician prescribes a one-time dose of Morphine and
Ativan to
reduce the patient’s pain and anxiety during a dressing
change.
This is considered procedural sedation.

90. Procedural Sedation Post Test
3. To prepare for procedural sedation, the RN must:
A. Obtain patient consent for both the procedure and the sedation.
B. Confirm auscultation of heart, lungs, and airway assessment was
performed by MD
C. Be aware of sedation plan
D. Perform patient identification and a “Time-Out”
E. Perform a baseline PASS assessment.
F. All of the above
4. To perform procedural sedation, the RN must:
A. Have age-specific resuscitative equipment.
B. Have a physician privileged in Procedural Sedation present in the
room.
C. Receive age specific advanced life support certification.
D. Provide a cardiac monitor, O2 monitoring, and ET CO2 monitoring.

91. Procedural Sedation Post Test
5. When performing procedural sedation, it is satisfactory to have the
physician be available by pager during the procedure.
A. True
B. False
6. The nurse providing moderate sedation should remain with the patient
at all times.
A. True
B. False
• 7. Before a procedural sedation patient can be discharged, they need to
be observed for a minimum of 30 minutes after the last dose of sedative
or analgesic was administered. Longer periods of observation are
required if reversal agents are used.
A. True
B. False

92. Procedural Sedation Post Test
8. To discharge a patient following procedural sedation, a post-procedural
assessment must be conducted (by a credentialed practitioner
privileged in this
procedure), the patient needs to receive written discharge instructions,
and a
responsible adult/driver must be identified.
A. True
B. False
9. A “time-out” is performed prior to the start of the procedure and
typically includes:
A. A description of the nature of the procedure, the patient’s condition,
details of any abnormal history or condition, and any special patient
needs.
B. Use of two patient identifiers – patient name and medical record on
arm band.
C. Verification of the site, both physically and verbally, and if required,
marking of the site.
D. A review of the expected course of the procedure and recovery.
E. All of the above

93. Procedural Sedation Post Test
10. Development of chest wall rigidity (“wooden chest”) may result in
serious respiratory compromise and is most often seen with the rapid
administration of:
A. Fentanyl (Sublimaze)
B. Morphine
C. Ketamine (Ketalar)
D. Flumazenil (Romazicon)
11. The reversal agent and initial dose preferred for a 300-pound 18
year-old who has had Diazepam, Midazolam, and Lorazepam
during a procedure is:
A. Flumazenil (Romazicon) 0.2 mg, repeat every 1-2 minutes as
needed
B. Naloxone (Narcan) 0.4 mg, repeat every 2-3 minutes as needed
C. Both a and b

94. Procedural Sedation Post Test
12. A 60 year-old male patient with coronary artery disease undergoes a
pacemaker implant under IV sedation. During the procedure, the
patient’s oxygen saturation decreases to 84%. The patient is snoring
and responds to vigorous stimulation. You should:
A. Lift the chin and jaw, attempt to provide a better airway, notify the
physician immediately after the change in the patient's condition,
increase oxygen delivery, call for assistance and consider reversal
agents.
B. Continue to monitor for further changes; reduce the next dose of
sedation medication by half.
C. Document the patient's status on the assessment form; notify the
MD at the conclusion of the procedure.