Sedation in the Emergency Department
Revised and approved by the ACEP Board of Directors January 2011 by replacing two rescinded policy statements, “Procedural Sedation in the Emergency Department” approved October 2004 and “The Use of Pediatric Sedation and Analgesia” originally approved March 1992; revised January 1997 and April 2008; and reaffirmed October 2001
Procedural sedation involves the use of sedative and analgesic agents to reduce the anxiety and pain suffered by patients during procedures. Procedural sedation decreases the length of time necessary to perform a procedure, increases the likelihood of success, and reduces the potential risk of injury to the patient or healthcare worker due to uncontrolled movements.
Procedural sedation encompasses a continuum of altered levels of consciousness including minimal, moderate, deep, and dissociative sedation levels.
Procedural sedation is a critically important component of comprehensive emergency care and a required core competency of emergency medicine residency training. This training includes rescue airway interventions for support of patient ventilation and oxygenation, as well as support and monitoring of patient cardiovascular status.
Evidence in the medical literature has established that procedural sedation, including light, moderate, and deep levels of sedation, can be safely and effectively performed in the emergency department by emergency physicians, both in the care of adult and pediatric emergency populations.
There is no single agent, or combination of agents that can be recommended for every patient or sedation procedure. Clinicians must weigh the relative needs for pain control (analgesia), sedation, and the potential risks, benefits, and alternatives when individualizing their plan for patient sedation.
Agents commonly used for sedation of patients in the emergency department include but are not limited to opioids, benzodiazepines, and barbiturates as well as other specific agents such as ketamine, propofol, remifentanil, dexmedetomidine, etomidate, and nitrous oxide.
Adjunctive techniques, such as distraction and visual imagery, should be used as needed to reduce patients’ fear, discomfort, and anxiety. Although physical restraints may be needed to prevent inadvertent movements, pharmacologic and nonpharmacologic techniques should be used to reduce pain- and fear-related movements whenever possible.
The American College of Emergency Physicians is the authoritative body for the establishment of guidelines for sedation of patients in the emergency setting. To promote the safe and effective use of sedation in emergency department patients, the American College of Emergency Physicians recommends the following:
- Emergency physicians who have received the appropriate training and skills necessary to safely provide procedural sedation should be eligible for credentialing in all levels of procedural sedation.
- The decision to provide sedation and the selection of the specific pharmacologic agents should be individualized for each patient by the emergency physician and should not be otherwise restricted.
- Emergency physicians and staff are expected to be familiar with the pharmaceutical agents they use and be prepared to manage their potential complications.
- To minimize complications, the appropriate drugs and dosages must be chosen and administered in an appropriately monitored setting, and a patient evaluation should be performed before, during, and after their use.
- Institutional and departmental guidelines related to the sedation of patients should include credentialing and verification of competency of providers, selection and preparation of patients, informed consent, equipment and monitoring requirements, staff training and competency verification, criteria for discharge, and continuous quality improvement.