In the February 2014 issue of the Annals of Emergency Medicine, ACEP published a clinical policy focusing on procedural sedation and analgesia in the emergency department [PDF].¹ This is a revision of a 2005 clinical policy with the same name. The revised was accepted for abstraction on the National Guideline Clearinghouse website.

The clinical policy takes an evidence-based approach to answering four frequently encountered questions (see “Critical Questions and Recommendations”) with regard to decision making associated with procedural sedation and analgesia in the ED. Recommendations (Level A, B, or C) for patient management are provided based on the strength of evidence using the ACEP Clinical Policies Committee’s well-established methodology:

• Level A recommendations represent patient-management principles that reflect a high degree of clinical certainty
• Level B recommendations represent patient-management principles that reflect a moderate degree of clinical certainty
• Level C recommendations represent other patient-management strategies based on Class III studies or, in the absence of any adequate published literature, based on consensus of the members of the Clinical Policies Committee

During development, this clinical policy was reviewed and expert review comments were received from emergency physicians, pediatric emergency physicians, toxicologists, a pediatric anesthesiologist, and a pharmacist. Likewise, individual members of the American Academy of Pediatrics; the American College of Medical Toxicology; ACEP’s Emergency Medicine Practice Committee, Medical-Legal Committee, and Pediatric Emergency Medicine Committee; and ACEP’s Toxicology Section. ACEP’s Emergency Medicine Workforce Section also reviewed and commented. The draft  also was open to further comments through various ACEP communication pieces.

Critical Questions and Recommendations

Question 1: In patients undergoing procedural sedation and analgesia in the ED, does preprocedural fasting demonstrate a reduction in the risk of emesis or aspiration?

Level B recommendations: Do not delay procedural sedation in adults or pediatrics in the ED based on fasting time. Preprocedural fasting for any duration has not demonstrated a reduced risk of emesis or aspiration when administering procedural sedation and analgesia.

Question 2: In patients undergoing procedural sedation and analgesia in the ED, does the routine use of capnography reduce the incidence of adverse respiratory events?

Level B recommendations: Capnography—including all forms of quantitative exhaled carbon dioxide analysis—may be used as an adjunct to pulse oximetry and clinical assessment to detect hypoventilation and apnea earlier than pulse oximetry and/or clinical assessment alone in patients undergoing procedural sedation and analgesia in the ED.

Question 3: In patients undergoing procedural sedation and analgesia in the ED, what is the minimum number of personnel necessary to manage complications?