• Every Emergency Department should have a procedural sedation policy that is regularly reviewed, and audited.

• The procedural sedation policy should provide guidelines for pharmacological agents that are routinely used in the Department.

• A form should be used for procedural sedation and analgesia (PSA) as a checklist and as an auditable record of the procedure.

• Adverse events should be reported using a standardized reporting tool.

Effective procedural sedation requires: 

1. Analgesia:
   Pain experienced by the patient should be treated with analgesia rather than sedation. Pain should be assessed and managed prior to starting sedation using the World Health Organization (WHO) pain ladder principles and the need for ongoing pain relief post-procedure considered. Where opiate pain relief has been given prior to procedural sedation and analgesia (PSA), doses of sedatives should be adjusted accordingly.

2. Anxiolysis:
   Non-pharmacological methods of reducing anxiety are often the most effective and include consideration of the environment and patient comfort. Environment is particularly important for children and patients with dementia or learning difficulties. Family members often provide invaluable support and distraction. Most painful procedures are best performed with the patient supine.

3. Sedation:
   The Joint Commission on Accreditation of Healthcare Organizations in the United States has attempted to define the levels of sedation. For most procedures in the ED, the level of required sedation will be moderate to deep, this should be determined in advance. 

4. Amnesia:
   A degree of amnesia will minimize unpleasant memories associated with the procedure. In most circumstances a combination of short acting analgesics and sedatives are required as the only pharmacological agent that has the potential to provide analgesia, sedation, anxiolysis and amnesia is ketamine.

1. Analgesia
   Relief of pain without intentionally producing a sedated state. Altered mental status may occur as a secondary effect of medications administered for analgesia.

2. Minimal sedation (anxiolysis)
   The patient responds normally to verbal commands. Cognitive function and coordination may be impaired, but ventilatory and cardiovascular functions are unaffected.

3. Moderate sedation and analgesia
   The patient responds purposefully to verbal commands alone or when accompanied by light touch. Protective airway reflexes and adequate ventilation are maintained without intervention. Cardiovascular function remains stable.

4. Deep sedation and analgesia
   The patient cannot be easily aroused, but responds purposefully to noxious stimulation. Assistance may be needed to ensure the airway is protected and adequate ventilation maintained. Cardiovascular function is usually stable.

5. General anesthesia
   The patient cannot be aroused and often requires assistance to protect the airway and maintain ventilation. Cardiovascular function may be impaired.

6. Dissociative sedation
   Dissociative sedation is a trance-like cataleptic state in which the patient experiences profound analgesia and amnesia, but retains airway protective reflexes, spontaneous respirations, and cardiopulmonary stability. Ketamine is the pharmacologic agent used for procedural sedation that produces this state.

Sedation exists on a continuum, and is difficult to divide into discrete clinical stages. Many sedatives can cause rapid changes in the depth of sedation. Dissociative sedation is considered to be separate from the continuum of sedation.

Related drugs:

• Propofol

• Etomidate

• Ketamine

• Midazolam

• Fentanyl

Additional suggested reading

• Godwin SA, Burton JH, Gerardo CJ, et al. Clinical policy: procedural sedation and analgesia in the emergency department [published correction appears in Ann Emerg Med. 2017 Nov;70(5):758]. Ann Emerg Med. 2014;63(2):247-58.e18. doi:10.1016/j.annemergmed.2013.10.015
  ACEP (Open Access)

• Bellolio MF, Gilani WI, Barrionuevo P, Murad MH, Erwin PJ, Anderson JR, Miner JR, Hess EP. Incidence of Adverse Events in Adults Undergoing Procedural Sedation in the Emergency Department: A Systematic Review and Meta-analysis. Acad Emerg Med. 2016 Feb;23(2):119-34. doi: 10.1111/acem.12875. Epub 2016 Jan 22. PMID: 26801209; PMCID: PMC4755157.
  AEM (Open Access)

• Bellolio MF, Puls HA, Anderson JL, et al. Incidence of adverse events in paediatric procedural sedation in the emergency department: a systematic review and meta-analysis. BMJ Open. 2016;6(6):e011384. Published 2016 Jun 15. doi:10.1136/bmjopen-2016-011384
  BMJ Open (Open Access)

• The Royal College of Emergency Medicine Best Practice Guideline. Ketamine Procedural Sedation for Children in the Emergency Department, February 2020. Accessed April 14, 2023.
  RCEM (Open Access)