What is procedural sedation?

From the Guidelines

Procedural sedation should be performed by emergency physicians who have received the appropriate training and skills necessary to safely provide procedural sedation, and the decision to provide sedation and the selection of the specific pharmacologic agents should be individualized for each patient. When it comes to procedural sedation, the goal is to reduce the anxiety and pain experienced by patients during procedures, and this can be achieved through the use of sedative and analgesic agents 1. The key to successful procedural sedation is to choose the right pharmacologic agents and to administer them in an appropriately monitored setting, with the ability to manage potential complications 1. Some of the key pharmacologic agents used in procedural sedation include midazolam, fentanyl, propofol, ketamine, and dexmedetomidine.

• Midazolam is often used for its anxiolytic and amnestic effects, with an initial dose of 1-2 mg IV.
• Fentanyl is a potent opioid analgesic, typically administered in doses of 50-100 mcg IV.
• Propofol is a rapid-onset sedative, often used for deeper sedation, with an initial bolus of 0.5-1 mg/kg IV.
• Ketamine is particularly useful for painful procedures in children or when hemodynamic stability is crucial, with doses ranging from 1-2 mg/kg IV or 4-5 mg/kg IM.
• Dexmedetomidine provides sedation without respiratory depression, with a typical dose of 1 mcg/kg over 10 minutes, followed by 0.2-0.7 mcg/kg/hr. Before administering sedation, patients should undergo a pre-procedure assessment, including airway evaluation, and have IV access established 1. Continuous monitoring of oxygen saturation, heart rate, blood pressure, and respiratory rate is essential, and resuscitation equipment and reversal agents should be immediately available 1. The sedation provider should be skilled in airway management and able to rescue patients from deeper levels of sedation than intended 1. By following these guidelines and using the right pharmacologic agents, procedural sedation can be safely and effectively performed in the emergency department, reducing the length of time necessary to perform a procedure, increasing the likelihood of success, and reducing the potential risk of injury to the patient or health care worker 1.

From the FDA Drug Label

Maintenance by infusion of propofol injectable emulsion should immediately follow the induction dose in order to provide satisfactory or continuous anesthesia during the induction phase. When propofol injectable emulsion is administered for MAC sedation, rates of administration should be individualized and titrated to clinical response In most patients, the rates of propofol injectable emulsion administration will be in the range of 25 mcg/kg/min to 75 mcg/kg/min. For maintenance of sedation, a variable rate infusion method is preferable over an intermittent bolus dose method. With the variable rate infusion method, patients will generally require maintenance rates of 25 mcg/kg/min to 75 mcg/kg/min (1.5 mg/kg/h to 4.5 mg/kg/h) during the first 10 minutes to 15 minutes of sedation maintenance.

Procedural Sedation with Propofol:

• The recommended rate of administration for MAC sedation is 25 mcg/kg/min to 75 mcg/kg/min.
• A variable rate infusion method is preferred over an intermittent bolus dose method for maintenance of sedation.
• The dosage of propofol injectable emulsion should be titrated to clinical response and reduced in elderly, debilitated, or ASA-PS III or IV patients to approximately 80% of the usual adult dosage 2.
• Slow infusion or slow injection techniques are preferable over rapid bolus administration during initiation of MAC sedation.

From the Research

Procedural Sedation Overview

• Procedural sedation is a medical procedure that uses sedatives to relax patients during medical procedures, reducing anxiety and pain.
• Various sedatives are used, including midazolam, propofol, and fentanyl, which can be administered through different routes, such as intravenous, oral, or intranasal.

Sedation Comparison Studies

• A study comparing patient-controlled sedation (PCS) with radiologist-controlled sedation (RCS) using midazolam and fentanyl found that PCS was safe and effective, with no significant difference in dosage given or degree of sedation 3.
• Another study compared propofol with midazolam for procedural sedation and analgesia in the emergency department, finding that both were equally safe and effective, but propofol resulted in a shorter length of stay 4.
• A study comparing midazolam/fentanyl with propofol infusion for aesthetic surgery found that both sedation protocols were similar in terms of patient safety, outcomes, and satisfaction, but propofol infusion resulted in more nausea in the recovery room 5.

Midazolam Sedation Studies

• A systematic review update on midazolam for sedation before procedures in adults and children found that midazolam resulted in a higher level of sedation than placebo, but the evidence was uncertain due to concerns about imprecision and risk of bias 6.
• A study on the hemodynamic characteristics of midazolam, propofol, and dexmedetomidine in healthy volunteers found that midazolam did not affect blood pressure or heart rate, while dexmedetomidine and propofol resulted in a dose-dependent reduction in blood pressure 7.

Sedation Route and Dosing

• The route and dosing of sedatives can affect their efficacy and safety, with intravenous administration often used for procedural sedation.
• Patient-controlled sedation, where patients self-administer sedatives, has been shown to be safe and effective, allowing patients to control their level of sedation during procedures 3.