ACEP Unscheduled Sedation Guidelines

June 11, 2019

Written by Clay Smith

Spoon Feed
This guideline for unscheduled sedation is based on good evidence and authoritatively states some key aspects of emergency sedation that apply to our patients and fit the needs of our setting.

Why does this matter?
Unscheduled sedation is categorically different than elective scheduled sedation and needs a separate guideline. We manage acute illness leading to urgent, time-sensitive sedation. Fasting may not be an option. Patients may or may not be completely stable or have definitive diagnosis yet. Goals are often different. Regulatory standards for elective sedation don’t apply.

Don’t fall asleep reading about sedation
This was a long paper, with a ton of information. Here are the highlights:

• Patient and family centered: “Delaying procedural sedation for reasons not supported by evidence [such as NPO status] may result in extended periods of unremitting pain and anxiety with a negligible decrease in risk and must be avoided.”

• Sedation is a continuum, except for dissociative sedation – which is especially useful when not NPO, in children, and those with comorbidities.

• Sedation committees should be multidisciplinary.

• They state that to monitor sedation, it is better to use airway patency and effectiveness of ventilation, using SpO2 and EtCO2, rather than the older model of assessing depth of sedation by verbal or tactile responsiveness.

• The depth of sedation is more important, rather than a focus on excluding certain drugs (i.e. propofol or ketamine) as “restricted” for use by only certain specialists. Any opiate or sedative is capable of producing general anesthesia in high enough doses, so the decision to exclude certain drugs is arbitrary.

• If a clinician has the training and skill set, this is what should determine sedation privileges, not speciality.

• Recording of “adverse events” should only consider those requiring an intervention. If a patient has 30 seconds of apnea but no change in any physiologic parameter and requires no intervention, is this an adverse event? The authors would say no.

• Recognize that the evidence base and clinical practice has far outstripped the FDA, and almost all of the sedation medications are off-label per the FDA for the indications for which we use them.

• They advocate for a two person team for sedation: the sedation provider and sedation monitor, who may be a trained nurse or RT. EM gives us all the requisite skill to be a sedation provider.

• They do not think a separate person is needed to provide sedation and perform the procedure, as long as there is a sedation monitor. This has been done safely for years, and the evidence does not support an increase in safety having two separate people – one to sedate, one to do the procedure.

• They strongly advocate for nurse administration of sedative drugs. State licensure barriers should be lifted.

• Competency in providing sedation is generally met by providers who regularly perform a number of sedations per year.

• A pre-sedation assessment should be performed to determine target depth, agent, duration, and risk. This includes a brief H&P, Rx, allergies, prior sedation problems, airway assessment – obese, cancer, etc. High risk patients should go to the OR. Consent should be obtained. ASA I and II patients are very low risk.

• NPO – “Currently, there is no evidence that non-compliance with elective fasting guidelines increases the risk of aspiration or other adverse events.” There are only 9 cases of death following aspiration during sedation since 1984, 8 of which were in patients undergoing upper GI endoscopy.

• Drug regimen is tailored to the patient and situation. Combinations are acceptable.

• Oxygen, suction, airway, ventilation, IV, and monitoring equipment must be available.

• A pre-procedure time-out should verify identifiers, procedure, agents, doses, allergies, surgical site and side (R or L).

• Most sedations should be monitored with pulse oximeter, cardiac monitor, and capnography.

• High-flow oxygen should be avoided if not using capnography.

• There is no need to assess toleration of oral intake during recovery prior to discharge.

• Departments should maintain QI. TROOPS is a way to track sedation outcomes.

Source
Unscheduled Procedural Sedation: A Multidisciplinary Consensus Practice Guideline. Ann Emerg Med. 2019 May;73(5):e51-e65. doi: 10.1016/j.annemergmed.2019.02.022.

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Reviewed by Thomas Davis