1. Procedural Sedation
and Analgesia
Paleerat Jariyakanjana, MD
Faculty of Medicine
Naresuan University
31 Jan 2013

2. Procedural sedation
 administration of sedatives or dissociative
anesthetics
 induce depressed level of consciousness
 maintaining cardiorespiratory function
 little or no patient reaction or memory
Procedural sedation and analgesia (PSA)
 addition of agents to reduce or eliminate pain

3. Sedation Level

5. Sedation Level
Minimal sedation
procedures that require patient cooperation and
those in which pain is controlled by local or
regional anesthesia
Procedures: lumbar puncture, sexual assault
examinations, simple fracture
reductions, abscess I&D
Agents: nitrous
oxide, midazolam, fentanyl, pentobarbital, low-
dose ketamine

6. Sedation Level
Moderate sedation
procedures in which detailed patient cooperation
is not necessary, and diminished pain reaction
and muscular relaxation is desired
Procedures: reduction of shoulder
dislocation, thoracostomy tube
insertion, synchronized cardioversion
Agents:
propofol, etomidate, ketamine, methohexital, an
d combination of fentanyl and midazolam

7. Sedation Level
Deep sedation
procedures that are painful and require muscular
relaxation with minimal patient reaction
Procedures: reduction of dislocated hip
Agents: same as moderate sedation, but with
larger doses

8. PATIENT EVALUATION

9. History and Comorbidities: ASA
Patient Assessment
Procedural Urgency

10. Patient Assessment
Hx: fasting state, prior experiences with PSA or
anesthesia, current medications, and allergies
PE: potentially difficult airway or
cardiorespiratory problems

11. Patient Assessment
Routine laboratory studies: not necessary
Directed ancillary testing
 airway abnormalities, infections, advanced
age, hepatic or renal
disease, dehydration, fever, or hypovolemia

12. RISKS AND PRECAUTIONS

13. Fasting State

14. Number of Physicians Needed
2 physicians
1. perform sedation and monitor patient
2. perform procedure
minimal & moderate levels of sedation
 1 emergency physician
 administering sedation and performing procedure

15. Equipment
equipment for airway management and
resuscitation
defibrillator
reversal agents
IV access
 not required for minimal sedation
 equipment for IV access should be immediately
available

16. PROCEDURAL SEDATION
MONITORING

17. Interactive Monitoring: by dedicated observers
Mechanical Monitoring

18. Mechanical Monitoring

19. STEP-BY-STEP
TECHNIQUE

20. Preprocedure Pain Management
The administration of morphine or fentanyl for
pain control before the start of PSA will provide
the patient with analgesia during PSA.

21. Preprocedure Pain Management
PSA should begin after last dose of analgesic
has been given and has reached its peak affect
 3-5 minutes for IV morphine
 2-3 minutes for IV fentanyl

22. Supplemental Oxygen during Procedural
Sedation and Analgesia
administration of supplemental oxygen can
delay recognition of hypoventilation

23. Sedation Management
1. patient has been evaluated
2. appropriate sedation target level is selected
3. monitoring modalities are applied
4. preparations are made for possible adverse
events
5. PSA

24. Sedation Management
Once the patient has achieved the target
sedation level, the actual procedure may begin.

25. SEDATION AGENTS

26. Nitrous Oxide
can be used alone for minimal sedation or as
adjunct with IV medications for moderate
sedation

27. Midazolam
sole agent for minimal sedation
can be combined with opioid for moderate or
deep PSA
Adverse side effects
mild cardiovascular depression, and
hypotension can arise when this agent is given
to patients who are hypovolemic
paradoxical agitation

28. Fentanyl
easily titratable when used alone for minimal
sedation
can be used in combination with midazolam for
moderate and deep PSA

29. Methohexital
best used for brief moderate and deep sedation
 joint dislocation reduction
Adverse side effects
respiratory depression

30. Pentobarbital
excellent agent for minimal sedation for
neuroimaging in children

31. Ketamine
state of dissociation
 profound analgesia, sedation, and amnesia
both analgesic and anxiolytic properties
only sedative agent that typically preserves
patient's ventilatory effort and has minimal effect
on blood pressure

32. Ketamine
Adverse side effects
hypersalivation
laryngospasm, vomiting
emergence reactions
 mild agitation to recurrent nightmares and
hallucinations
increases intracranial pressure
 avoid in patients with head injuries
increase intraocular pressure
 avoided in patients with eye injuries or glaucoma

33. Etomidate
rapid onset and short duration of effect
Adverse side effects
less cardiovascular depression but similar
respiratory depression
myoclonic jerking
suppression of adrenal-cortical axis

34. Propofol
frequently used for moderate and deep PSA

35. Propofol
Adverse side effects
associated with fewer complications than
etomidate or methohexital in patients who
received multiple doses and is much easier to
titrate
most serious adverse effect: sudden respiratory
depression and apnea
hypotension
C/I: allergic to eggs or soy protein

37. Follow-Up and Patient Instructions
At the completion of the PSA procedure, patients
are monitored until a return to baseline mental
status.
Return to a preprocedure baseline score or a
score of at least 18 indicates the patient is safe
for discharge.

39. ANY QUESTIONS?