Emergency Department Clinical Pathway
for Procedural Sedation
for Procedural Sedation
Related Pathways
- Burn Injury, ED
- Cellulitis/Abscess, ED
- Dental Trauma or Infection, ED
- Fracture, Extremity, ED
- Fracture, Open Long Bone, ED
- Laceration, ED
- Neck Space Infection, Deep, ED
- Preparing Children for Anesthesia/
Sedation, ED and Inpatient - Septic Arthritis, ED
- Ventricular Shunt Obstruction/Infection,
ED, ICU, Inpatient
Related Order Set
- ED Sedation Order set
- Determine Sedation Regimen
- Consider appropriate sedation level
- Obtain verbal consent
- Policy: ED Procedural Sedation
- Procedural Sedation Drug Information
- Anxiolysis Only
- Sedation Only, No Pain Control
- Sedation and Pain Control
- Pain Control Only
- Resources for Sedation Emergencies
- Sedation Procedure
- Time out
- Monitor patient
- Recover Patient
- Phase 1 recovery
- Phase 2 recovery
- 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.
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
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 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.
- Generally safe for ED sedation
- Repaired isolated PDA, ASD, VSD, coarctation with no hemodynamic or electrophysiologic compromise
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
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
- Association of Preprocedural Fasting With Outcomes of Emergency Department Sedation in Children
- Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures: Update 2016
- Clinical Practice Guideline for Emergency Department Ketamine Dissociative Sedation: 2011 Update.
- Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018: A Report by the American Society of Anesthesiologists Task Force on Moderate Procedural Sedation and Analgesia, the American Association of Oral and Maxillofacial Surgeons, American College of Radiology, American Dental Association, American Society of Dentist Anesthesiologists, and Society of Interventional Radiology
- The Newest Threat to Emergency Department Procedural Sedation
- An International Multidisciplinary Consensus Statement on Fasting Before Procedural Sedation in Adults and Children