Procedural sedation and analgesia

Procedural sedation is defined as "a technique of administering sedatives or dissociative agents with or without analgesics to induce a state that allows the patient to tolerate unpleasant procedures while maintaining cardiorespiratory function." It was previously referred to as conscious sedation.

Indications
This technique is often used in the emergency department for the performance of painful or uncomfortable procedures. It has been used for setting fractures, draining abscesses, reducing dislocations, performing endoscopy, imaging procedures in patients unable to hold still, cardioversion and during dental procedures.

Sedatives/dissociative agents

 * Propofol
 * Ketamine
 * Etomidate
 * Midazolam

Analgesics

 * Fentanyl
 * Morphine
 * Ketamine: Small doses of ketamine have been found to be safer than fentanyl when used in combination with propofol.

Techniques
For most agents the person should have had nothing to eat for at 6 hours. Clear fluids can be allowed up to two hours before the procedure. An exception to this may be with ketamine in children where fasting may be unnecessary.

Complications
Complications depend on the sedative agent that is used. Many commonly used agents can cause respiratory depression, hypoxia and hemodynamic effects. For some agents antagonists are available that can be used to reverse the effects.

Safety
Procedural sedation can be safely performed in an emergency department if structured sedation protocols are followed.

Electrocardiography, pulse oximetry, capnography and blood pressure monitoring are essential, as is the use of supplementary oxygen.

Protocols
Many institutions have protocols that are used during procedural sedation.

Controversies
Some resistance to sedation techniques used outside the operating room by non-anesthetists has been voiced.

History
Procedural sedation used to be referred to as conscious sedation.