Procedural Sedation Clinical Pathway — Emergency Department

Indications for Admission
Sedation related:
- Less than 28 days (FT)
- Less than 60 weeks post-conceptual age
- Need for further monitoring
Other medical/surgical reason for admission

Discuss with Anesthesia
Call Board Runner at 54444 or Anesthesia Attending on Call. Generally not appropriate for ED Sedation, discuss specifics with Anesthesia.

ASA 4/5
Age less than 6 months for moderate sedation, less than 1 year for deep sedation
Known or suspected difficult airway based on exam or syndrome, history of or active airway obstruction (severe OSA, active croup)
Clinical concern for increased intracranial pressure with urgent procedure
Length of procedure > 30-45 min or need for motionless anesthesia

Consider Anesthesia Consult
Call Board Runner at 54444 or Attending Anesthesiologist on call
ED team to assess patient and consider Anesthesia consult for the following scenarios

ASA 3
Chronic lung disease
C-collar in place
Impending OR for other procedure
Status epilepticus or poorly controlled seizure disorder
Acute asthma exacerbation requiring frequent bronchodilators
Autism/behavioral issues
Resource requirement
Complexity of procedure, pain, amount of sedation medication required
Ongoing emesis; impaired GI motility syndromes

Cardiology Consult

Generally safe for ED sedation
- Repaired isolated PDA, ASD, VSD, coarctation with no hemodynamic or electrophysiologic compromise
Generally not appropriate for ED sedation
- Pulmonary Hypertension
- Heart failure
- Cardiomyopathy
- Single ventricle physiology
- Dysrhythmia
For all other cardiac patients requiring procedural sedation, consult Cardiology for assistance on determination of appropriateness for ED sedation. Cardiac Anesthesia can be consulted for additional guidance.

Posted: July 2020
Revised: December 2020
Authors: J. Del Pizzo, MD; J. Fein, MD, MPH; K. Crescenzo, RN; S. Jarrett, MD; F. McGowan, MD; B. Blowey PharmD; H. Huang, PharmD

Evidence

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.