Procedural Sedation and Analgesia

The performance of painful diagnostic and therapeutic procedures is common in emergency care. Many of these are associated with significant anxiety, especially in children. Procedural sedation and analgesia (PSA) has therefore become a fundamental and required skill for emergency physicians and an integral part of the core training of emergency medicine residents. PSA improves the quality of patient care and satisfaction through relief of pain and anxiety and by facilitating the timeliness and success of therapeutic or diagnostic procedures. These include fracture or joint reduction, incision and drainage of abscesses, cardioversion, tube thoracostomy, lumbar puncture, complex wound repair, and imaging studies in young or uncooperative patients. Many of the agents used for PSA have the potential to cause significant respiratory, cardiovascular, or central nervous system (CNS) depression. The Joint Commission (TJC), the Centers for Medicare and Medicaid Services (CMS), the American College of Emergency Physicians (ACEP), and the American Society of Anesthesiologists (ASA) have produced expert consensus or evidence-based documents concerning its use (Box 4-1). Although significant controversy continues with respect to credentialing and oversight of PSA outside the operating room, the advent of these guidelines has led to PSA becoming a safe, common, and practical emergency department (ED) procedure. It has been further improved by the development of shorter-acting, more effective drugs and the use of noninvasive monitoring devices. With the wide variety of procedures and patient populations, the ability to individualize PSA and maximize the risk-benefit ratio for each unique situation is a necessary skill. This can be best achieved through a detailed understanding of: the preprocedural patient assessment, the protocols delineating the required personnel and their roles, the supplies and equipment required, the specific drugs used (including their routes of administration, dosages, effects, interactions, and complications), consideration for special populations and patient monitoring, recovery, and discharge criteria.