Procedural Sedation Manual

June 2020

Learning Objectives

• Non-pharmacological and pharmacological alternatives

• Adjuncts to pharmacological sedation
• Patient assessment
• Consent and parent/patient information
Pre procedure
• Environment
• Personnel required for procedural sedation including skill
level
• Equipment and drug preparation
• Observation and monitoring

• Drug administration
During
• Monitoring of patient including sedation and pain scores
procedure
• Ability to identify and respond to adverse events

• Monitoring of patient Discharge criteria Discharge advice

Post procedure
and discharge check list

Documentation • Legal and mandatory components of documentation

Special thanks to Caboolture Hospital who provided a template to prepare this manual

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POWH Procedural Sedation Package for Registrars and SRMOs
Principles of Procedural Sedation
Definitions
Procedural Sedation (PS) refers to a technique of administering sedatives or dissociative
agents, with or without analgesics, to intentionally suppress a patient’s level of
consciousness. This is used to induce a state that allows the patient to tolerate unpleasant
procedures while maintaining cardio respiratory function.

Ideally PS is intended to result in a depressed level of consciousness that allows the patient
to maintain oxygenation and airway control independently, with no compromise to
cardiovascular function.

It is important to recognize that procedural sedation is a continual spectrum from minimal

sedation to general anaesthesia. All agents used for procedural sedation can potentially
result in general anaesthesia if given in large enough doses.

As such, all practitioners administering PS should be competent to manage a patient at

levels greater than the intended level of sedation including cardiovascular support and
airway management as for general anaesthesia.

Minimal sedation (anxiolysis) is a drug-induced state during which patients respond

normally to verbal commands. Cognitive function and coordination may be impaired but
airway, ventilation and cardiovascular function are preserved.

Moderate Sedation previously referred to as ‘conscious sedation’ is defined as a drug-

induced depression of consciousness during which patients respond purposefully to verbal
commands either alone or accompanied by light tactile stimulation. No interventions are
required to maintain a patent airway and spontaneous ventilation is adequate.
Cardiovascular function is usually maintained.

Deep sedation is defined as a drug induced depression of consciousness during which

patients cannot be easily roused but respond purposefully after repeated or painful
stimulation. These patients may require assistance in maintaining airway patency and
respiratory effort. Cardiovascular function is usually maintained.

General anaesthesia is defined as a drug-induced loss of consciousness during which

patients are not rousable and may have an impaired cardio-respiratory function requiring
varying degrees of support. The patient under general anaesthesia is profoundly
compromised and does not exhibit movement or autonomic nervous system responses to a
standard surgical stimulus.

Dissociative sedation is a separate category of sedation which is used to better classify

and describe the effects of agents such as ketamine. It is described as a ‘‘trance-like
cataleptic state characterized by profound analgesia and amnesia, with retention of
protective airway reflexes, spontaneous respirations, and cardiopulmonary stability.’’ The
terms mild, moderate and deep sedation therefore do not apply to dissociative sedation.

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POWH Procedural Sedation Package for Registrars and SRMOs
Aims of procedural sedation
The aims for procedural sedation are to:-

• minimise physical discomfort or pain

• control behaviour and patient movement
• minimise psychological disturbance and distress
• maximise the potential for amnesia
• maximise patient safety.

These aims for safe and successful sedation can be maximised by:-

• correct patient selection (excluding patients at high risk for failure)

• ensuring that it is safe to perform PS
• preparing the patient and their family
• preparing the environment and staff
• ensuring adequate monitoring during the period of sedation
• ensuring discharge processes are safe

Prior to embarking on procedural sedation ask yourself 3 questions:-

1. Is this patient suitable for PS? (consider patient and procedure factors)
2. Is it safe to perform PS? (consider staff and environmental factors)
3. Is there a suitable alternative to PS?

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POWH Procedural Sedation Package for Registrars and SRMOs
Preparation for Procedural Sedation
1. Patient Selection

It is important that only suitable patients undergo PS and that those with a high
chance of failure or anticipated difficulty are excluded.

Procedural Sedation may NOT be suitable for:-

• Very young children and severely ill patients: these cases should only be
sedated in ED in extenuating emergency circumstances and require ED
consultant to be consulted and/or present during the sedation
• Very painful or prolonged procedures: these are unlikely to be managed
successfully with PS; GA should be considered
• Very anxious patients: difficult to achieve adequate sedation, GA should be
considered
• Patients unable to provide consent (unless in an emergency i.e. life or limb
threatening)

2 Safety Issues

As a general rule, procedural sedation should NOT be provided in ED:-

• when the required number of appropriately skilled staff are not available
• when appropriate staff cannot be dedicated to their roles due to other
demands in ED
• when an appropriate clinical area with resuscitation equipment cannot be
dedicated for the procedure to take place

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POWH Procedural Sedation Package for Registrars and SRMOs
To minimise risk associated with incorrect patient identification and comply with
mandatory national standards, the POWH standardised approach to patient
identification should be followed. This ensures confirmation of the correct identity,
correct procedure and correct site for patients receiving care.

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POWH Procedural Sedation Package for Registrars and SRMOs
3. Consider Alternatives to Procedural Sedation

Alternatives to PS include:-

• Non-pharmacological strategies
• Analgesia only: parenteral and/or oral
• Local anaesthesia (may be used as an adjunct)
• Regional anaesthesia (nerve blocks, Bier’s block)
• Procedure performed under general anaesthesia

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POWH Procedural Sedation Package for Registrars and SRMOs
4. Non-pharmacological adjuncts/alternatives to PS

Using non-pharmacological techniques for both children and adults will make
procedures less distressing for patients, family and staff. These are summarised in
the table below.

• Non-procedural talk and distraction

Coping promoting • Prompting children to use coping behaviours
behaviours • Breathing techniques (eg slow deep breathing)
• Humour

• Making reassuring or empathetic statements (thought to

be because it makes child focus on feelings rather than
Distress promoting coping)
behaviours • Apologising, criticising, bargaining with the child
• Providing explanation during the procedure
• Giving the child control over when to start the procedure
• Becoming agitated

5. Pharmacological adjuncts to PS

Any factors that decrease sedation needs are beneficial in the short and long term
and include:

Systemic pain relief:-

• Removal of pain will reduce anxiety and possibly the need for sedation.
• Simple and multimodal analgesia will help with the induction, maintenance
and recovery phases of PS
• Administration of simple analgesia (eg paracetamol, ibuprofen, codeine) can
compliment post procedural pain management.

Local pain relief:

• Laceraine (amethocaine 0.5%/lignocaine 4% /adrenaline 0.1%) applied to

open wounds to provide local anaesthesia. This is particularly beneficial prior
to suturing and may obviate the need for further local anaesthetic or may
reduce the pain with subsequent injected local anaesthetic.
• EMLA (Eutectic Mixture of Local Anaesthesia = Prilocaine 2.5%/lignocaine
2.5%) cream applied to cutaneous areas prior to IV insertion or blood taking.
Ensure the cream is covering the vein or area you wish to use. EMLA is
applied onto intact skin.
• Amethocaine 4% Topical gel is a more rapidly acting topical anaesthetic
than EMLA and causes venodilation.
• Local anaesthetic infiltration
• Regional nerve blocks

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POWH Procedural Sedation Package for Registrars and SRMOs
6. Patient assessment

Health evaluation prior to sedation includes:-

• Nature of the current condition

• General health
• Medications and allergies
• Past medical problems (esp. CVS, respiratory or CNS)
• Previous anaesthetics (and any problems)
• Family history of problems with anaesthesia
• Fasting status
• Baseline observations
• Patient weight (for dose calculations)
• Allergies

A risk assessment should be performed to identify patients at higher risk of

complications who might be unsuitable for sedation in ED. This identifies features
that may indicate a higher risk of airway complications and cardiovascular instability
during sedations.

The American Society of Anaesthetists (ASA) classification of health parameters,

whilst not directly applicable to procedural sedation, has been shown to correlate
with morbidity and mortality of general anaesthesia and can assist in the
performance of risk assessment. The classes are defined as:

Class 1: Normal healthy patient

Class 2: Patient with mild systemic disease with no functional limitation.

Class 3: Patient with severe systemic disease with definite functional limitation

Class 4: Patient with severe systemic disease that is a constant threat to life.

Class 5: Moribund patient who is not expected to survive without the operation

This is a commonly used and understood classification which may aid in

communication between health professionals.

Other risk components are:

Increased risk of airway compromise leading to obstruction

• History of snoring, stridor, sleep apnoea

• Craniofacial abnormalities
• History of airway difficulties
• Children < 1 year

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POWH Procedural Sedation Package for Registrars and SRMOs
Increased risk of hypoventilation

• Patients with reduced sensitivity to CO2 retention – chronic lung disease,

neuromuscular disorders
• Abnormalities of the respiratory centre – brainstem tumours

Increased risk of aspiration

• Vomiting, bowel obstruction, history of aspiration previously

• History of gastro-oesophageal reflux, hiatus hernia, congenital abnormalities,
Cerebral palsy, pregnancy, obesity
• Altered mental status

Increased risk of bronchospasm or laryngospasm

• Asthma, recent upper or lower respiratory tract infection

Increased risk of cardiovascular compromise

• Cardiac disease, hypovolemia, sepsis

Drug specific contraindications need to be considered as part of a sedation plan. For

more details on different drugs used refer to the appendix.

7. Fasting status

Current literature fails to support an association between fasting status and adverse
events during procedural sedation in children or adults.

The ASA guidelines for fasting in relation to elective general anaesthesia are not
applicable to patients requiring procedural sedation in the ED.

The American College of Emergency Physicians (2014) states, “Do not delay
procedural sedation in adults or paediatrics in the ED based on fasting time.
Preprocedural fasting for any duration has not demonstrated a reduction in the risk of
emesis or aspiration when administering procedural sedation and analgesia.

Step 1: Patient risk of aspiration (higher or standard risk)

Higher-risk patients are those with one or more of the following present to a degree
individually or cumulatively judged clinically important by the treating physician:-

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POWH Procedural Sedation Package for Registrars and SRMOs
 • Potential for difficult or prolonged assisted ventilation should an airway
complication occur (e.g., short neck, small mandible, large tongue,
tracheomalacia, laryngomalacia, history of difficult intubation, congenital
anomalies of the airway and neck, sleep apnoea)
• Conditions predisposing to oesophageal reflux (e.g. oesophageal disease,
hiatus hernia, bowel obstruction, ileus, tracheoesophageal fistula, raised ICP,
pregnancy, obesity)
• Extremes of age (eg, >70 years or <6 months)
• Severe systemic disease with definite functional limitation (i.e. ASA physical
status 3 or greater)
• Other clinical findings leading the emergency physician to judge the patient to
be at higher than standard risk (eg, altered level of consciousness, frail
appearance)

Step 2: Nature and timing of recent oral intake (within last 4 hours)

• Nothing
• Clear liquids only
• Light snack (includes breast milk and cow’s milk)
• Heavier snack or meal

Step 3: Urgency of the Procedure

• Emergent eg, cardioversion for life-threatening dysrhythmia, reduction of

markedly angulated fracture or dislocation with soft tissue or vascular
compromise, intractable pain or suffering.
• Urgent e.g., care of dirty wounds and lacerations, animal and human bites,
abscess incision and drainage, fracture reduction, hip reduction, lumbar
puncture for suspected meningitis, arthrocentesis, neuroimaging for trauma
• Semi-urgent e.g., care of clean wounds and lacerations, shoulder reduction,
neuroimaging for new-onset seizure, foreign body removal, sexual assault
examination
• Non-urgent or elective eg, non-vegetable foreign body in external auditory
canal, chronic embedded soft tissue foreign body, ingrown toenail

Step 4: Determine the Prudent Limit of Targeted Depth and Length of PS

The following sedation levels and durations are listed in the order
representing the lowest to highest potential aspiration risk.

1. Minimal sedation
2. Dissociative sedation or brief/intermediate length moderate sedation
3. Extended moderate sedation
4. Brief deep sedation
5. Intermediate or extended length deep sedation

Duration of sedation

• Brief <10 minutes

• Intermediate 10-20mins

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POWH Procedural Sedation Package for Registrars and SRMOs
 • Extended > 20mins

By considering the elements described in Steps 1 – 4, a reasonable assessment of

the risk of aspiration during PS for the individual patient may be made, which can
then be balanced against the urgency of the procedure.

8. Consent and patient/parent information

It is essential to give patients and carers information and discuss the procedure and
risks of the procedure prior to starting. The information may be in verbal, written or
audio visual form.

Informed consent must be obtained from the patient or their carers prior to any
procedural sedation. Written informed consent is recommended and the most
important part of this process is the dissemination and comprehension of the
information prior to the signature on the dotted line. The “procedural consent form”
may be used for this purpose.

9. Environment

Sedation with ketamine, propofol, midazolam and nitrous oxide can be performed in
the resuscitation area or in a specifically equipped procedural sedation area with
resuscitation equipment immediately available.

Sedation with inhalational agents or oral/IN midazolam can be performed in the

procedure room or cubicles provided that equipment to provide ventilatory support,
oxygen and suctioning and clearance of the airway is checked and immediately
available.

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POWH Procedural Sedation Package for Registrars and SRMOs
10. Staff requirements for procedural sedation

Minimum STAFF NEEDED

MEDICATION

Sedation Procedure

• 1 Doctor
• One Doctor
Ketamine • 1 RN (PS credentialed and
• Any other staff
Propofol orientated to resus/procedural
required e.g.
IV Midazolam sedation area)
physio
Also Senior Emergency Doctor on
shift notified and available

However, in situations where a single Dr and RN ONLY are available, the

following applies:

• Consider the urgency of the procedure and patient risk assessment.

• Consider deferring the procedure until 2 doctors are present.
• Consider using nitrous + / - opiates only.
• Consider whether there is another Dr on site who may be able to perform the
procedure, leaving the credentialed Dr to provide the sedation and careful
monitoring

11. Equipment and drug preparation

Equipment and drugs for the management of any adverse events must be prepared
prior to intravenous procedural sedation, including:-

Airway and ventilation equipment

• Oxygen source
• Suction working
• Airway adjuncts (OP and NP airways) of appropriate sizes
• BVM with appropriate mask size
• Intubation Equipment: ET tubes (not opened), introducers, working
laryngoscopes, lubricating gel, syringe, tube tie.

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POWH Procedural Sedation Package for Registrars and SRMOs
Drugs

• cardiac arrest drugs available in minijet form

• reversal agents as appropriate
• paediatric drug doses calculated and written on the white board
• drugs for the procedure including adjuncts drawn up and doses double
checked

IV access

• checked and flushing adequately

• IV crystalloids available (consider using as flush for titrated medications)

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POWH Procedural Sedation Package for Registrars and SRMOs
12. Drugs for Procedural sedation

Drugs Dose Physiology

Clinical
Onset Sedation Analgesia
Offset
50% N2O
Entonox /50% 1-3min 5 min Stable + ++
oxygen
Up to 70%
Quantiflex N2O /30% 1-3 min 5 min Stable ++ ++
oxygen
↓ RR, HR and BP,
0.05 – 0.1
Morphine 5mins 3 hours histamine release, + ++
mg/kg IV
N&V
1-3 mcg/kg
IV
↓ RR and chest
Fentanyl 2 min 60min + ++
wall rigidity
1.5 mcg/kg
IN
0.1mg/kg
IV 1-5
Midazolam 1-2hrs ↓ RR, HR and BP ++ none
0.4mg/kg mins
IN
0.5 -
Propofol 30sec 4-8min ↓ RR and BP +++ none
3mg/kg IV
1-2mg/kg
IV 5-10min
↑BP, HR
IV
1min IV laryngospasm +++
Ketamine 2-4mg/kg +++
5minIM myoclonic jerks dissociative
IM 20-25
and nystagmus
min IM

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POWH Procedural Sedation Package for Registrars and SRMOs
13. Guidelines for Procedural Sedation using Intravenous
Medication

• Examination by MO
• Inform senior medical officer on shift that a patient is going to be sedated
• 2 doctors one with skills to PS
• RN
• Parents/patients informed consent
• Medication prescribed on medication chart (dose to be filled in later)
• Medication prepared (consider continuous IV infusion of saline)
• O2, suction, bag valve mask and airway equipment checked and in working
order
• IVC in place – secured and patent
• Emergency and intubation drugs immediately available
• Oximetry monitoring and capnography in place
• Cardiac monitoring in place if applicable
• Baseline observations documented especially BP
• Supplemental oxygen should be applied for all procedures
• Titrated boluses of sedation medication during procedure
• Constant monitoring of blood pressure, heart rate, SPO2 and level of
consciousness (sedation score)
• Provide airway support when required
• Definitive care
• Continue monitoring until fully awake and continue recording on the PSR 3
minutely during the procedure, 5 minutely until fully awake and then 15
minutely for up to 1 hour post procedure
• Documentation throughout

Do not leave patient unattended at any time until GCS returns to pre-sedation
score.

14. Observations and monitoring

A set of observations must be obtained immediately prior to the administration of the

sedation and should be documented. If the patient is agitated and unsettled prior to
the procedure, consider the accuracy of observations due to distress.

Observations include but are not limited to:

• Weight – mandatory for children

• Temperature, Pulse, Respiratory rate, Oxygen saturation,
• Blood pressure (in children only with IV sedation)
• Capnography
• Pain Score.
• Conscious state (AVPU or sedation score)

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POWH Procedural Sedation Package for Registrars and SRMOs
Monitoring must be applied prior to any IV medications being administered. This
includes a minimum of:-

• Continuous O2 saturation and heart rate monitoring

• NIV blood pressure monitoring (every 3-5 mins).
• Continuous nasal capnography
• Continuous ECG monitoring (if any history of CVS disease or compromise )

DURING PROCEDURE
1. Drug administration

All medications must be recorded. This does not require a specific dose prior to the
procedure as the medication will be titrated and then totalled for recording but a
record must be kept

Titrated medications should be entered at the time given

All drugs are to be administered in accordance with the Medication Act. Nitrous can
be administered by credentialed nurses.

Oxygen should be administered in all intravenous sedation

2. Monitoring of the patient

As noted previously, all patients are to have a complete set of relevant

observations recorded immediately prior to the procedure, including pain
score.

• Pulse oximetry should be continuously monitored with IV sedation until 1 hour

after the procedure has finished and for 15 min after IN or inhaled sedation
has finished
• Cardiac monitoring is required if any history of heart disease or arrhythmia or
in patients >50 years
• NIBP monitoring should be performed every 3 minutes during sedation

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POWH Procedural Sedation Package for Registrars and SRMOs
 • NIBP, Oxygen saturations, capnography, HR and RR should be recorded for
IV sedation
• Every 3 mins post the administration of IV medication until the end of
the procedure
• After the end of the procedure 5 minutely until the patient has regained
pre sedation consciousness.
• Once regained pre sedation consciousness recorded every 15mins for
up to the next hour
• Sedation score or AVPU– should be documented at these intervals
also to obtain a rapid determination of conscious level

Sedation score (Wisconsin score)

This scoring system is often used to document level of sedation. Deeper sedation
has been shown to carry a higher risk of adverse events than lighter sedations.

Ketamine, as a dissociative agent, does not fit into this schema and is addressed
separately in the ketamine module.

Inadequate 6 Anxious, agitated, or in pain

Minimal-conscious 5 Spontaneously awake without stimulus

Conscious-moderate 4 Drowsy, eyes open or closed, but easily arouses to

consciousness with verbal stimulus

Moderate-deep 3 Arouses to consciousness with moderate tactile or

loud verbal stimulus

Deep 2 Arouses slowly to consciousness with sustained

painful stimulus

1 Arouses, but not to consciousness, with painful

stimulus

Anaesthesia 0 Unresponsive to painful stimulus

Communication between all staff involved with the procedure is essential to ensure
safe practice and detection of possible complications. The treating doctor must be
informed of any variances in vital signs and observations to ensure appropriate
interventions.

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POWH Procedural Sedation Package for Registrars and SRMOs
ADVERSE EVENTS
Adverse events are associated with procedural sedation and can be classified into:-

Major: laryngospasm, hypoxia, apnoea, pulmonary aspiration, hypotension, severe

emergence agitation, seizures, arrhythmias, emesis during sedation.

Minor: transient rash, post procedure emesis, nausea, dizziness, hypertonicity,

minor airway obstruction, salivation.

The actual incidence varies considerably in reported studies from 2% up to 17% in

some studies. The incidence of adverse events highlights the need to ensure PS
must only be administered and monitored by staff knowledgeable in the identification
and management of adverse events and who possess the requisite skills to manage
these.

Adverse events should be recorded in the patient medical notes.

Management of Adverse Events

Airway and Breathing

1. Airway obstruction

• Complete obstruction: cessation of airflow, no respirations and marked

paradoxical rocking of the chest (chest descends as the abdomen rises)
• Partial obstruction – sonorous breathing,

Management

1. Call for help

2. Basic manoeuvres (head tilt/chin lift or jaw thrust)
3. Supplemental O2 (maximal FiO2)
4. Clear airway using suction if required
5. Try airway adjuncts: oropharyngeal or nasopharyngeal airway
6. Consider adrenaline if thought to be allergic reaction
7. If still no clear airway proceed to advanced airway management: laryngeal
mask (LMA) or endotracheal tube (ETT)
8. Last resort surgical airway management

2. Hypersalivation
• Suction – with care (deep suction may trigger laryngospasm)
• Positioning manoeuvres e.g. lateral position /head down
• Atropine 20mcg/kg (0.02mg/kg) to maximum dose of 0.6mg

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POWH Procedural Sedation Package for Registrars and SRMOs
 3. Laryngospasm

Laryngospasm is spasm of the vocal cords secondary to airway trauma,

instrumentation or secretions in the airway.

• Complete: silent, paradoxical movement of chest

• Partial: stridor (high-pitched crowing noise)

Management

1. Cease procedure
2. Call for help
3. Clear airway/suction hypopharyngeal secretions
4. Give Supplemental O2 (maximal FiO2)
5. Jaw thrust with BVM held on firmly, give gentle breaths if required
6. Pressure on Larsons point (laryngospasm notch)
7. Prepare for emergency drug assisted intubation
8. Deepen sedation eg with low dose propofol
9. If no response consider administering suxamethonium. A dose of only 0.1-0.5
mg/kg may be sufficient, but in severe laryngospasm administer a full dose (1-
2 mg/kg IV) and perform intubation.

4. Hypoventilation/apnoea

Signs may include slowed respirations, shallow or irregular respirations or cessation

of respirations. Detected much earlier by use of nasal capnography, and identified by
rising level of ETCO2 or decreased breathing rate (hypoventilation) or complete loss
of CO2 trace (apnoea)

Most commonly due to over sedation but may be secondary to airway obstruction
(see above).

Management

1. Call for help

2. Try to rouse patient
3. Ensure adequate clear airway(as above)
4. Supplemental O2 (maximal FiO2)
5. Assist ventilation with BVM few small breaths if other measures fail
6. If prolonged consider chemically reversing sedatives
7. If still hypo-ventilating despite above measures proceed to advanced airway
and ventilation measures

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POWH Procedural Sedation Package for Registrars and SRMOs
5. Aspiration of stomach contents

Usually identified easily with the presence of vomiting and coughing during sedation.

Management

• Stop the procedure

• Head down/ lateral position to potentiate drainage
• Suction and clear airway
• Give Supplemental O2 (maximal FiO2)
• Assist ventilation with BVM after airway toilet if inadequate ventilation
• May need NIV BIPAP/IPPV and PEEP
• After the procedure is finished may need admission for further management.

Desaturation (SaO2 < 94%)

1. Ensure adequate wave form on monitor, move probe if required.

2. Ensure adequate and clear airway (as above)
3. Give supplemental O2 (maximal FiO2)
4. Assist ventilation with BVM if required
5. Identify and treat potential causes:-

• airway obstruction or laryngospasm

• aspiration
• anaphylaxis

6. Ensure adequate circulation-check pulse, BP and capillary refill and manage if

inadequate
7. Reverse sedatives if necessary

6. Allergy and anaphylaxis

Allergy and anaphylaxis are part of the same spectrum. Manifestations may include

• Skin – generalised erythematous or macular rash, itchy and warm

• Airway – swelling of lips/tongue, evidence of angioedema of the floor of the
mouth and pharynx and plate, stridor
• Bronchospasm (greater if patient is asthmatic)
• CVS – hypotension
• ENT – rhinitis
• Eyes – conjunctivitis
• GIT – nausea, vomiting and diarrhoea

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POWH Procedural Sedation Package for Registrars and SRMOs
Management

1. Stop procedure
2. Assess and resuscitate using ABCDE approach
3. Specific treatment depends on what is manifesting

• Rash only: may be just histamine release e.g. with morphine or propofol.
Consider adopting “wait and see” approach. May require an anitihistamine
• Wheeze only: nebulised salbutamol and hydrocortisone
• Angio-oedema or stridor
• Consider nebulised adrenaline if isolated angio-oedema
• IM adrenaline 0.5mg (adult) or 0.01mg/kg (child)
• IV adrenaline 1mg in 100ml of Normal saline titrated to effect
• IV hydrocortisone
• Hypotension:
• IM adrenaline 0.5mg (adult) or 0.01mg/kg (child)
• IV fluid bolus (up to 50ml/kg)
• IV Adrenaline as above
• IV Hydrocortisone
• Consider H1 and H2 Blockers

Circulation
1. Cardiac Arrest (Asystole/pulseless VT/VF):Follow usual protocols

2. Bradycardia

• Treat underlying cause – may do nothing more

• Drugs - atropine (use ARC guidelines)
• Pacing and dopamine, isoprenaline if resistant

3. Tachycardia

• Usually due to pain resulting from inadequate sedation: manage by increasing

sedation and analgesia
• Maybe iatrogenic secondary to medication e.g. ketamine
• Primary arrhythmias rarer: manage as per usual protocols

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POWH Procedural Sedation Package for Registrars and SRMOs
4. Hypotension

• Fluid challenge
• Treat underlying cause:-

• Iatrogenic secondary to sedation medication: allow sedation to wear off

• Consider bleeding or other fluid loss: give further fluid
• Anaphylaxis: IM or IV adrenaline (as above)

5. Hypertension

Treat the cause

• Commonly pain secondary to inadequate sedation: increase sedation and

analgesia
• May be iatrogenic e.g. ketamine
•
• Monitor patient - usually doesn’t require further management

Neurological
1. Pain, distress and agitation

• Pause procedure
• Ensure adequate ABC
• Psychological support: distraction and reassurance
• Drugs: consider increasing analgesia and sedation
• Gentle but firm physical restraint

2. Emergence reaction

Ketamine can stimulate hallucinatory reactions during recovery, which may be either
pleasant or unpleasant. Although these so-called ‘‘emergence reactions’’ are rarely
unpleasant in children (1.6% incidence of reactions judged more than ‘‘mild’’) their
incidence in adults is highly variable, with reported incidences ranging from 0% to
30%. When Ketamine is administered in adults, clinicians should be aware of the
potential for pronounced reactions, including nightmares, delirium, excitation, and
physical combativeness.

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POWH Procedural Sedation Package for Registrars and SRMOs
Management

• Low noise, dimmed lights may lessen chance of reaction

• Reassure patient
• Talk them through it
• Allow patient to fuss with mask etc
• Consider small dose of midazolam if patient is otherwise unmanageable

3. Paradoxical reactions

Instead of acting as a sedative medication in about 10% of cases patients will

become paradoxically excited. This is not uncommon with midazolam and
occasionally occurs with N2O

Management

1. Opioid prior to sedation often prevents

2. Ensure adequate analgesia
3. Firm “gentle” restraint
4. If due to midazolam–consider reversal with flumazenil IV – consider
contraindications- eg benzodiazepine dependence, seizure disorder

4. Vomiting

1. Lateral position/suction

2. Drugs

• First line metoclopramide 0.2-0.5 mg/kg (not in patients <20yrs)

• Second line ondansetron 0.1 mg/kg
• Third line dexamethasone 0.15 mg/kg
• Use all 3 for severe nausea and vomiting
• If still refractory can trial droperidol 10mcg/kg or Promethazine 0.5 mg/kg
• Manage aspiration see above

5. Drug induced muscle rigidity

Identify cause and treat accordingly:

• Secondary to tramadol, fentanyl, morphine: treat with naloxone

• Secondary to extrapyramidal effects of drugs (dystonia, akathisia: treat with
benztropine 0.01-0.02 mg/kg
• Neuroleptic malignant syndrome(NMS) IV fluids +/- bromocriptine
• Malignant hyperthermia(MH): treat with IV fluids and dantrolene

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POWH Procedural Sedation Package for Registrars and SRMOs
6. Seizures

• Position on side
• Ensure adequate brain perfusion: check and manage ABC, give oxygen,
check BSL
• Medications if doesn’t resolve spontaneously
1. IV Midazolam
2. IV propofol (unless secondary to this)
3. IV Levetiracetam
• If prolonged and resistant–rapid sequence induction and intubate

7. Myoclonus

Mild and brief – no specific management needed

POST PROCEDURE
The patient must be observed by a member of nursing staff until full recovery to pre
sedation state.

Following the procedure observations should be recorded every 5 -15 minutes

depending on how much the patient has recovered from sedation. If patients remain
difficult to rouse then close visual observation should be maintained and
observations recorded every 5 minutes. As the patient recovers the frequency of
observations can be reduced to 15 minutely.

Keep the patient nil by mouth until fully alert then offer clear fluids prior to discharge.

DISCHARGE CRITERIA
The patient cannot be discharged until discharge criteria are met. It is essential to
assess each patient individually by using the following discharge criteria:

• Resumption of pre-sedation level of consciousness

• Resumption of purposeful neuromuscular activity
• Ability to ambulate (if appropriate) or able to sit without support
• Ability to verbalise appropriate for age
• Final set of vital signs are returned to pre procedure status.
• Ability to tolerate oral fluids - initial fluids offered can include water, cordial,
juice, tea, coffee or ice block
• Pain score less than 4

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POWH Procedural Sedation Package for Registrars and SRMOs
 For a very young or intellectually disabled child or adult, the aim is to achieve the
pre-sedation level of responsiveness or as close as possible to the normal level
of functioning for the particular patient. This should be achieved by
communicating with the parent/guardian/carer to establish what is normal for the
patient.

In addition, a responsible adult needs to be available to accompany the patient

home.

DOCUMENTATION
All notes relating to the procedure performed, procedural sedation technique,
adverse events and management and discharge / follow-up plans must be recorded
in the patient’s medical records.

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POWH Procedural Sedation Package for Registrars and SRMOs
APPENDICES
Appendix A: Drugs Used in Procedural Sedation

NITROUS OXIDE
Background

Nitrous oxide is an anaesthetic gas, which provides analgesia and sedation and is
delivered in variable concentration with oxygen. The exact mechanism of action of
nitrous oxide is unknown however it is thought to work by stabilising neuronal as well
as other membranes and therefore causing general depression of the whole CNS.
The gas is non allergenic and not flammable or explosive.

1. Entonox: a 50-50 premix nitrous oxide and oxygen.

2. Quantiflex: a device allowing delivery of a variable quantity of nitrous mixed
with Oxygen up to 70% Nitrous concentration

Indications

N2O has both analgesic and sedative properties. Its quick onset of action and
recovery makes it ideal for use in the emergency department.

It is useful in such interventions as:

• Suturing and wound management

• IV insertion – particularly in acutely painful conditions e.g. burns
• Removal of foreign bodies from ear/soft tissue
• Fracture manipulation
• Reduction of digit dislocations
• Simple moulding of plaster of Paris casts to fractures
• Burns dressings
• Injection of local anaesthetic
• Abscess incision and drainage
• Other painful/uncomfortable procedures

It is less useful for:

• Very painful or prolonged procedures

• Facial (perioral) lacerations
• Procedures requiring immobility

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POWH Procedural Sedation Package for Registrars and SRMOs
Pharmacology

Nitrous oxide has a short duration of action. It takes approximately 1-3 minutes to
induce these effects with a nitrous oxide-oxygen mixture and about 4-5 minutes for
them to wear off. There are no drug interactions – nitrous is eliminated unchanged
from the lungs.

Adverse events and Contraindications

Nitrous oxide is usually well tolerated by patients in the emergency department. Most
patients only have mild side effects such as vomiting, nausea, dizziness, light-
headedness and occasionally nightmares and some patients will not be able to
tolerate the mask. Some side effects are further outlined below.

Vomiting: Patients should be warned that vomiting may occur both during and after
the procedure and even after arrival home. Post procedure nausea and vomiting has
recently been cited as a reason for decreasing or stopping the use of nitrous oxide.
Although vomiting is unpleasant it is not usually dangerous as cough and gag
reflexes are maintained. The exception to this is if patients have had previous or
simultaneously administered opiates or benzodiazepines. Because the combination
will result in deeper sedation there is a potential for aspiration if vomiting occurs.

Over sedation: The precautions of mandatory co-administration of oxygen and self-

administration prevent over sedation. If a mask or mouthpiece is held on by another
person there is a possibility of over-sedation so this should be avoided unless the
patient has monitoring and staffing requirements as per intravenous sedation and if
the operator feels that the patient is becoming too sedated then they should remove
the mask

Desaturation with respiratory difficulties. This is rare. In patients with concurrent

URTI or history or airways disease or asthma there is an increase risk therefore care
should be taken with these patients

Increased pressure – intracranial, intraocular and Pulmonary vascular

Pressure: Nitrous oxide is therefore contraindicated in patients with pulmonary
hypertension, glaucoma or anyone with known increased ICP or with ALOC after
head injury

Increased volume in closed air spaces: Nitrous oxide is 35 times more soluble in
blood than nitrogen causing it to diffuse into a closed air-containing cavity faster than
nitrogen diffuses out. If the cavity does not have rigid walls, the volume increases. It
should not be used in patients in whom there is a the possibility of closed air spaces
such as pneumothorax , bowel obstruction, middle ear infection, or after SCUBA
diving (12hours of a normal dive or 24hours of repeated or deep dives) or if any
signs of decompression sickness.

History of Malignant hyperthermia: Nitrous oxide is possibly associated with

malignant hyperthermia and should not be used in patients who are susceptible to
this.

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POWH Procedural Sedation Package for Registrars and SRMOs
Fasting state prior to procedure

There is no evidence that fasting state is related to adverse events – in particular

there is no reported difference in vomiting or aspiration rates in patients given N20
whether they have fasted or not.

Equipment

Nitrous Oxide administration requires the preparation of the following equipment:

Separate oxygen source with mask other than the nitrous oxygen source and also
Bag valve mask available

Observations

• Documentation of vital signs and findings throughout the administration of

nitrous oxide
• Oxygen saturation needs to be monitored constantly and for five minutes post
procedure
• Respiratory rate needs to be constantly monitored
• Conscious state must be constantly monitored by the administrator
• On completion of the procedure and administration of nitrous the patient
needs to be monitored until their conscious state returns to the baseline. (if
developmentally delayed, carers can aid in the assessment of baseline)

Administration

Trained nursing or medical staff are required to supervise the administration of

nitrous oxide.

Guidelines for administration of Nitrous Oxide

• Familiarise patient especially children with the equipment prior to the

procedure – this increases effectiveness and compliance
• Appropriate mask to be attached to the circuit or mouthpiece if older
• Filter is needed in the Entonox circuit
• Use a new mouthpiece and filter for each administration
• Check level in the bottle – if less than 1⁄4 then must be replaced
• Turn on the cylinder
• Allow patient to self-administer Entonox – a “Darth Vader” or hissing sound
indicates the patient is activating the valve
• Administration should start 3 minutes prior to the procedure
• Sedation score of 4 is the aim – if the patient becomes excessively drowsy,
remove the mask if it doesn’t automatically fall away.
• At the end of the procedure 100% oxygen should be delivered for 3 minutes
and the cylinder turned off and mouthpiece and filter discarded
• Continue observations 15 minutely until the patient meets discharge criteria

Equipment assembly and check prior to procedure

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POWH Procedural Sedation Package for Registrars and SRMOs
 • Check that the O2 and N2O hoses are connected to the cylinders and both
cylinders are turned on
• Check the gauges to ensure that there is an adequate supply of oxygen and
nitrous oxide (1⁄4 % full minimum)
• Check the reservoir bag inflates with no leak
• Select the appropriate size face mask.
• Check the scavenging device is connected
• Prescribe on medication chart

During procedure

• Set the flow of O2/ N2O to desired concentration (usually 50-70% N2O)
• Apply face mask ensuring adequate seal
• Observe the reservoir to ensure there is a supply of nitrous oxide for the
patient to breathe and to ensure that the bag does not overextend
• Nitrous oxide/oxygen mix should be applied for 3 minutes PRIOR to
procedure to ensure sufficient analgesic effect is present.
• The patient should continue to breathe nitrous/oxygen mix for the duration of
the procedure.
• The dose may be titrated upwards by increasing the nitrous flow by 1 l/min. -
or by 10 % increase in nitrous to a maximum of 70% N2O
• Administration should be temporarily discontinued if the patient becomes
excessively drowsy. Frequent communication with the patient allows titration
of the N2O dose for effect.
• Monitor sedation levels and adjust % of N2O versus O2 as required
• Continuous monitoring and assessment of vital signs throughout the
procedure (see observation recommendations)
• Administer 100% oxygen for 4-5 minutes after the procedure is finished to
avoid diffusion hypoxia

Post Procedure

• Turn off nitrous machine

• Discard face mask and tubing
• Monitor patient until their conscious state returns to baseline

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POWH Procedural Sedation Package for Registrars and SRMOs
BENZODIAZEPINES
Benzodiazepines have been used in children and adults as adjuncts in procedural
sedation. They are anxiolytic, sedative and result in amnesia for the procedure. They
have no analgesic effects therefore for painful procedures they should only be used
in conjunction with an opiate for analgesia.

Benzodiazepines act at the gamma amino butyric acid receptor (GABA). GABA
receptor stimulators such as benzodiazepines potentiate the GABA effects of
calming the patient, relaxing smooth muscle and producing sleep.

The prototypical benzodiazepine, diazepam, has been replaced in procedural

sedation by midazolam due to its shorter half-life and water solubility.

Midazolam can be administered IV, IM, orally, rectally and nasally. Absorption varies
with route of administration. In addition oral dosages are in part metabolised by the
liver (first pass effect).

Effects of benzodiazepines can be reversed by Flumazenil, a benzodiazepine

antagonist although this should not be administered to patients who have a history of
chronic benzodiazepine use as they are at risk of seizures with reversal

Formulation of Midazolam

• ORAL/BUCCAL: The oral route is the most convenient and easiest route of
administration. However, the IV preparation used is bitter and children
sometimes refuse it or spit it out. The taste can be disguised by using 5-
15mls of undiluted cordial/other flavouring.
• INTRAVENOUS: The advantage of IV midazolam is ease of administration
and titration. Disadvantage is insertion of an IV line.
• INTRANASAL: IN midazolam has a rapid onset and may be used however
children may become upset because the formulation stings the mucosa. One
drop of 5mg/ml solution contains about 0.3mg of midazolam – one drop per
nostril over 15sec until full dose applied. A single spray of Intranasal
lignocaine spray per nostril administered immediately prior to the IN
midazolam solution has been found to reduce the discomfort.
• RECTAL and INTRAMUSCULAR: Rectal and IM administration of
midazolam are generally not recommended for procedural sedation in the
emergency department. Blood levels after rectal administration are variable.
The onset is slower than with intranasal route.

o The main problem with IM midazolam is the pain associated with injection.

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POWH Procedural Sedation Package for Registrars and SRMOs
Indications for use

Relieve anxiety regarding procedures and in conjunction with opiates to achieve

sedation for procedures

Benzodiazepines have no analgesic effect

Adverse reactions

Major side effects are:

1. Cardiorespiratory depression (hypotension, bradycardia and respiratory

depression)

2. Paradoxical excitement (10-15%)

3. Emergence delirium

Side effects are dose related and vary with route of administration.

• The highest risk of major side effects is IV administration. 13 Rapid IV

administration simultaneously with opioids increases the risk of respiratory
depression.
• Higher doses of intranasal midazolam can lead to prolonged elimination,
delayed recovery and respiratory depression. All patients receiving this
sedative intra-nasally must be monitored closely.
• No serious respiratory depression has been reported in oral administration at
0.5mg/kg except if other sedative drugs are co-administered.

Considerations for use

• Patients with previous adverse events to midazolam sedation – this is the only
true contraindication. Also should not be used in children aged less than 1
year due to increased risk of airway complications.
• Patients with swallowing difficulties, airway difficulties or sleep disorders can
develop airway obstruction and hypoxemia from relaxation of upper airway
muscles
• Consider reduced doses in renal hepatic and cardiac impairment
• Consider reduced doses in the elderly
• Myasthenia gravis.
• Acute glaucoma

Equipment, staffing and set up are as per general module see previous

Doses

• Oral midazolam: 0.5mg/kg with sedation in 30-45 minutes (max 15mg).

Higher doses of 0.75-1mg/kg are associated with increased side effects.

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POWH Procedural Sedation Package for Registrars and SRMOs
 • Buccal Midazolam: 0.3mg/kg of IV formulation – onset 10-15mins but may
be earlier.
• IV Midazolam: 0.05-0.1mg/kg with onset 1 minute. IV midazolam should be
given slowly and titrated to effect in adults <5mg is recommended regardless
of weight dosing.
• IN Midazolam: 0.2-0.4mg/kg of IV formulation (max 10mg) intra-nasally
sedation is usually within 10-15 minutes but may be earlier and may last up to
2 hours

Reversal agent Flumazenil

Overdose symptoms of midazolam can be reversed by flumazenil, a benzodiazepine

antagonist. Flumazenil is administered IV. It has a short duration of action and might
require several doses or an infusion. It should never be required if careful titrated
sedation is undertaken.

• Children: 5mcg/kg every 60 seconds to a total dose of 40mcg/kg (max 1mg)

• Adult dose: 300-600mcg repeat as necessary up to a total of 2mg
Maintenance dose if indicated – half the dose required to waken the patient
given every hour by continuous infusion

KETAMINE
Background

Ketamine is an analgesic and a dissociative anaesthetic agent. It is fundamentally

different from other procedural sedation and analgesia agents. Ketamine exerts its
effect by ‘‘disconnecting’’ the thalamo-neocortical and limbic systems (through
simultaneous depression of the cortex and stimulation of the limbic system),
effectively dissociating the central nervous system from outside stimuli (e.g., pain,
sight, sound). The resulting ‘‘sensory isolation’’ of this trance like cataleptic state is
characterized by potent analgesia, sedation, and amnesia while cardiovascular
stability is maintained and spontaneous respirations and protective airway reflexes
are usually preserved.

The complete analgesia typical of the dissociative state permits extremely painful
procedures to be performed that would otherwise be difficult using traditional
moderate or deep sedation with benzodiazepines and opioids. Rather than
displaying the dose-response continuum observed with all other procedural sedation
and analgesia agents, Ketamine dissociation is either present or absent with a
narrow transition zone. This dissociative state, once achieved, has no observable
progressive depth or level, and administration of additional Ketamine to an already
dissociated patient does not enhance or deepen sedation, as would be the case with
opioids, sedative-hypnotics, or inhalational agents. For non-dissociative agents, the
more drug given, the more the patient progresses along the sedation continuum, with
increasing probability of impaired independent airway function and respiratory
control. In contrast, the absolute amount of Ketamine given has no clinically

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POWH Procedural Sedation Package for Registrars and SRMOs
important impact on respirations and airway integrity within the range of clinically
administered doses and using standard administration methods. Accordingly,
dissociative sedation can be readily begun by administration of a single intravenous
or intramuscular loading dose, and the only need for titration, in marked contrast to
other sedatives, is to maintain the dissociative state over time.

Ketamine is an ideal agent to facilitate short painful procedures, especially in

children, which might otherwise require general anaesthesia. It has many features
that are attractive in the outpatient setting: rapid onset (less than 5 minutes IM or IV
and up to 25min Oral or IN), consistently effective analgesia and amnesia, airway
stability and acceptable recovery duration (70 –140 minutes depending on route of
administration).

Its safe use in children has been documented in numerous series14,15,16 and the
literature supports the safety and efficacy of ketamine for a large variety of brief,
painful or emotionally disturbing procedures – most typically fracture reduction and
laceration repair in children. Its use in adults has been increasing in recent years and
evidence is appearing that it is safe and effective in this age group also.

It is also used extensively in developing countries for major and minor surgery and in
disaster and battlefield settings where no anaesthetist or facilities are available.

Adverse Reactions and Contraindications

Previous allergy or anaphylaxis to ketamine

Ketamine use is obviously contraindicated in this case

Respiratory depression

Ketamine uncommonly causes respiratory depression. Severe respiratory

depression is rare but is increased in frequency if ketamine is pushed by rapid IV
bolus achieving rapid peak CNS levels, or when CNS abnormalities are present or in
young infants. Neonates and small infants have greater difficulty maintaining a
patent airway with any sedative agent. Therefore, in the Emergency Department,
ketamine is contraindicated in infants less than 3 months of age and relatively
contraindicated between 3-12 months of age.

Airway malposition

Occasional malposition of the airway can occur especially if the patient exhibits
random purposeless motion. It is critical to continuously pay attention to airway
patency and reposition head or jaw if snoring respirations or stridor develop.

Hypersalivation

Ketamine stimulates salivary and tracheobronchial secretions. Some experts

recommend concurrent use of an anticholinergic such as atropine (0.01-0.02/kg, max

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POWH Procedural Sedation Package for Registrars and SRMOs
dose 0.6mg) to inhibit these secretions, particularly when the procedure may involve
the mouth and airway. Newer studies have failed to show a benefit from co
administered atropine and its use in combination with ketamine is dropping. Can be
used if developed excessive secretions.

Laryngospasm

Generally with anaesthesia young age and respiratory infections increase the risk of
laryngospasm. Clinicians need to be prepared to treat laryngospasm with oxygen
and assisted ventilation until the episode subsides.

Ketamine is relatively contraindicated for use in conditions with increased risk of

laryngospasm. These include

• Procedures involving laryngeal stimulation

• History of Airway instability, stenosis, tracheomalacia, trachea surgery
• Active asthma, current upper respiratory tract infection

Cardiovascular stimulation

Ketamine is sympathomimetic and can produce mild to moderate increases of blood

pressure, heart rate, cardiac output and oxygen consumption. Therefore it is
relatively contraindicated in patients with significant cardiovascular disease.

Musculoskeletal effects and Ataxia

Skeletal muscle hypertonicity and random movement of head and extremities are
often observed. Ataxia can be pronounced during recovery. Ambulation must be
avoided until full equilibrium is restored. Also need to be aware if need full muscle
relaxation eg for joint relocations it may not be the agent of choice

Intracranial pressure elevation

Ketamine may increase intracranial pressure especially in patients with pre-existing

neurological conditions such as hydrocephalus and CNS lesions.

Whilst ketamine had previously been contraindicated in head trauma, a recent

review has challenged the basis for this. Recent studies have shown it to be safe
prehospital. ICU studies have found it to be a safe sedative agent in already
intubated patients with head injury.

Intraocular pressure elevation

Ketamine may increase intraocular pressure so is contraindicated in cases of

glaucoma or penetrating eye injury

Recovery reactions

Emergence Reactions and issues

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POWH Procedural Sedation Package for Registrars and SRMOs
Ketamine can stimulate hallucinatory reactions during recovery, which may be either
pleasant or unpleasant. Although these so-called ‘‘emergence reactions’’ are rarely
unpleasant in children their incidence in adults is highly variable, with reported
incidences ranging from 0% to 30%. When Ketamine is administered in adults,
clinicians should be aware of the rare potential for pronounced reactions, including
nightmares, delirium, excitation, and physical combativeness. Titrated
benzodiazepines appear to consistently and rapidly pacify such reaction.

Recovery agitation without an apparent hallucinatory component is not uncommon

after dissociative sedation. It appears to be a separate entity from the Ketamine
specific hallucinatory reactions and is also associated with Midazolam
administration. Mild recovery agitation occurs more frequently in children aged less
than 5 years of age and in patients with underlying medical problems.

Also, in contrast to all other sedative drugs, when a patient who is agitated prior to
the drug has a sedated CNS and awakes gradually, ketamine is a dissociative drug
and when the dissociative effect wears off the patient awakes as agitated as before
the sedation. It is therefore essential to ensure the patient is calm and relaxed,
thinking pleasant thoughts and to focus on what vivid dreams they would like to have
before administering ketamine.

Although evidence is insufficient to mandate it, whenever possible provide a well

monitored location with muted lighting, noise, and physical contact until wakefulness
is well established.

When Ketamine is administered without prophylactic benzodiazepines and rare

unpleasant recovery reactions do occur, titrated benzodiazepines appear rapidly and
consistently effective in alleviating or substantially mitigating such reactions.

Vomiting

When vomiting occurs, it is typically late during the recovery phase when the patient
is alert and can clear the airway without assistance. It occurs more frequently in
older children, compared with younger children and may also be dose related as it
has recently been reported to occur more frequently following IM administration –
which is typically a higher dose of 4 mg/kg compared with an IV dose of 1.5 mg/kg.

Length of sedation

Length of sedation is significantly longer in IM group compared to the IV group.

The trance like state, open eyes and occasional random movements seen during
ketamine administration can be frightening for parents. Therefore it is important to
explain the effects of ketamine to the parent. The sedation handout provides good
talking points in the discussion with parents about the expected events during the
sedation and possible sequelae after the procedure.

Ketamine Doses and routes of Administration

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POWH Procedural Sedation Package for Registrars and SRMOs
Ketamine may be safely and effectively administered by either the intramuscular or
intravenous route, and the choice should be based on practical considerations. The
following table summarises the main features of the two methods of administration.
Note that if IM ketamine is to be used then expertise to promptly achieve IV access
must be present until full recovery of the patient. There is no reversal agent for
ketamine.

Route of Administration Intramuscular (IM) Intravenous (IV)

Ease of repeat dosing,

Advantages No IV necessary
faster recovery

Clinical onset 5 minutes 1-2 minutes

Duration of effective
20-25 minutes 5-10 -minutes
dissociative sedation

70 – 100 - minutes
Recovery time 100 – 140 minutes

Initial dose 2-4mg/kg 0.5 - 1mg/kg

Subsequent dose
Insert IV and give further doses
0.25 – 0.50 mg/kg
0.25 – 0.50 mg/kg IV
Maximum dose 5 mg/kg 2 mg/kg

Warning

IV administration must always be given over a period of greater than 60 seconds.

Rapid IV administration is associated with transient respiratory depression including
apnoea

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POWH Procedural Sedation Package for Registrars and SRMOs
PROPOFOL
Background

Propofol is an intravenous ultra-short acting sedative/hypnotic agent used for the

induction and maintenance of sedation and anaesthesia. The amassed emergency
medical experience using Propofol to induce deep sedation has shown this agent to
be relatively safe and without serious sequelae. This ultra-short agent can
occasionally transiently overshoot deep sedation but this appears to lack clinical
significance. Adverse reactions can be reduced by slower induction titrating to the
lowest dose producing optimal sedation. Transient cardio-respiratory depression can
be safely managed in clinical practice.

It has no analgesic action thus mandating co-administration of opioid analgesics for

painful procedures. It has the advantage of being a known antiemetic with minimum
emergence reactions.

Propofol use for procedural sedation in paediatrics has been increasing in recent
years with a number of published studies indicating its safety and efficacy in this age
group.

Combination of propofol with ketamine in a 1:1 mix “ketafol” or as combination

therapy can be used in procedural sedation in emergency. Preliminary studies
appear to show reduction of overall dose required when the drugs are used in
combination with minimal adverse events.

Pharmacology

A therapeutic dose of Propofol produces hypnosis with minimal excitation in

approximately forty seconds from the start of the injection. As with other rapidly
acting IV anaesthetic agents, the half time blood-brain equilibration is approximately
1 to 3 minutes, this accounts for the rapid induction of sedation/anaesthesia.
Elimination can be 2 – 24 hours.

Indications for use

Short term for moderate and deep procedural sedation e.g.

• Removal of foreign bodies

• Cardioversion
• Relocation of joint e.g. shoulder or hip
• Fracture manipulation
• Short laceration repair

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POWH Procedural Sedation Package for Registrars and SRMOs
Adverse Reactions

Possible adverse events outlined below

Bradycardia/asystole

Propofol has been associated with reports of bradycardia (occasionally profound)

and asystole. Atropine must be rapidly available to treat these adverse effects.

Hypotension

Cardiovascular effects range from minimal reduction in blood pressure to significant

arterial hypotension. Slow induction and minimising dose requirements reduces the
incidence of these untoward side effects. IV fluids should be available for
management. Inotropes are not usually required as propofol is short acting and
hypotension usually resolves with ceasing of further infusion of propofol however
they should be available. Metaraminol should be available at the beside to manage
this complication if required.

Pain on injection / thrombophlebitis

Often pain on injection. Good practive to warn the patient. Pain on injection can be
reduced by adding lignocaine to the Propofol. The addition of lignocaine significantly
decreases the incidence of excitatory side-effects. This is an OFF LABEL use of
lignocaine but is a widespread practice in emergency departments and by
anaesthetists.

Excitatory side-effects

Epileptiform movements, including convulsions & opisthotonos can occur.

Anaphylactoid reactions

Propofol has been reported to occasionally cause severe allergic reactions with
angioedema, bronchospasm, erythema and hypotension. These reactions respond
to adrenaline.

Flushing / rash

This is a not uncommon reaction and is due to histamine release. It is usually self
limiting.

Contraindications

Propofol has been found to be relatively safe however the following contraindications
should be noted.

• Anaphylaxis is rare but should not be used in patients with propofol, egg,
lecithin, glycerol, and soya oil allergies.
• Pregnancy (no direct harm to foetus but increased rate of maternal death)

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POWH Procedural Sedation Package for Registrars and SRMOs
 • CVS instability – other agents are more CVS stable
• Relative contraindications

O Epilepsy : the following details should be considered prior to using propofol

for epileptic patients

• Epileptic patients were thought to have had an increased risk of seizure

in the recovery phase. This is currently being challenged in the
literature.
• There may be some increase in seizures in the subsequent weeks
which is thought to be due to a proconvulsant metabolite.
• Status epilepticus is treated with propofol.

Propofol dose

• Adults Induction for deep sedation 0.5-1.0 mg/kg bolus (titrate

slowly) and 0.5 mg/kg subsequent boluses. Suggested dose up to
3mg/kg and should be titrated to effect.
• Children >2 Induction for deep sedation NB An emergency
consultant must be present for any sedation of children with propofol
• Initial dose IV Propofol 0.5- 1mg/kg (max 40mg) over 1 min

OPIOIDS
Introduction

Opioid analgesics are excellent agents for procedural sedation especially for patients
who have significant pain before, during and after a procedure e.g. relocation of a
dislocated shoulder. Analgesics are often given in the pre-hospital environment prior
to presentation to the ED and the sedationist needs to consider this when giving
other subsequent sedating medications. Morphine and fentanyl are used in
combination with N2O, benzodiazepines and Propofol. Multimodal use of procedural
sedation and analgesic (PSA) agents allows creation of a better sedation experience
while reducing the dose of each agent.

Indications

Analgesia for any painful procedure especially where the sedative agent has no
analgesic properties

Considerations

• Myasthenia gravis
• Opioid hypersensitivity usually alternative opioid is available.

Precautions

Using combinations of opioid and other agents have accumulative effects on the
depth of sedation and care must be taken to avoid adverse side effects.

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POWH Procedural Sedation Package for Registrars and SRMOs
 Reduced doses are needed with the elderly, debilitated & patients with renal &
hepatic dysfunction. Atopic patients may have increase histamine release.

Adverse Reactions

• Respiratory depression
• Histamine release
• Local rash
• Urticaria/wheeze
• Nausea/vomiting
• Muscle rigidity (High dose fentanyl in infants)

Dosage of Common agents

• Panadeine forte (codeine is a pro-drug of morphine) 30mg codeine with 500mg

paracetamol usual dose for adult is 2 tablets
• Morphine 0.05-0.15 mg/kg IV
• Fentanyl 1-2 mcg/kg IV
• Fentanyl 1.5 mcg/kg Intra nasal (IN) (see protocol for subsequent doses)

Reversal Agent
Naloxone is a pure antagonist. This agent should not be needed if appropriate dose
regimens are used. Abrupt reversal can cause sudden emergence with severe pain
and massive catecholamine output which can precipitate ischaemic chest pain,
arrhythmias and acute heart failure in the elderly. It can also cause seizures in
patients who take regular doses of opiates including codeine and may cause
pulmonary oedema in larger doses.

Dosage of Naloxone ADULTS:

Aliquots of 0.1-0.2mg should be given IV every 2-3 minutes until rousable with an
adequate respiration rate.

An infusion at 2/3 the initial resuscitation dose / hour should then be implemented of
more than 2 bolus’s are required

CHILDREN

• Initial dose of 0.01mg/kg IV

• Repeat every 2-3 minutes

40
POWH Procedural Sedation Package for Registrars and SRMOs
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POWH Procedural Sedation Package for Registrars and SRMOs