Level C recommendations: In addition to the provider performing the procedure, a nurse or other qualified individual should be present for continuous monitoring of the patient during procedural sedation and analgesia. Physicians who are working or consulting in the ED should coordinate procedures requiring procedural sedation and analgesia with the ED staff.

Question 4: In patients undergoing procedural sedation and analgesia in the ED, can ketamine, propofol, etomidate, dexmedetomidine, alfentanil, or remifentanil be safely administered?

Level A recommendations: Ketamine can be safely administered to children and propofol can be safely administered to both children and adults for procedural sedation and analgesia in the ED.

Level B recommendations: Etomidate can be safely administered to adults for procedural sedation and analgesia in the ED. A combination of propofol and ketamine can be safely administered to both children and adults for procedural sedation and analgesia.

Level C recommendations: Ketamine and alfentanil can be safely administered to adults, and etomidate can be safely administered to children for procedural sedation and analgesia in the ED.
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An Ongoing Topic

Procedural sedation and analgesia continues to attract a great deal of attention within medical specialties and regulatory agencies. Guidelines, as well as multiple reviews, have been developed and written to provide guidance in the safe and effective delivery of sedation and analgesia. Given its frequent use by emergency physicians, as well as the continued development of research and clinical evidence for this practice, the ACEP Clinical Policies Committee revised its clinical policy.

Since ACEP released its previous clinical policy on procedural sedation and analgesia, a great deal of literature has been published on the topic both within the field of emergency medicine and by other specialties. The Centers for Medicare & Medicaid Services (CMS) has issued revised interpretive guidelines for hospital anesthesia services that address the broad categorization of anesthesia and analgesia while noting that the level of sedation for special sedation agents may vary in accordance with dosing, patient selection, and route of administration.

The mounting literature focused on the administration and delivery of sedative agents in the ED has served to further strengthen previous recommendations. For instance, the use of propofol was added to ketamine under Level A recommendations. This seems fitting given these medications are the best studied of the agents and therefore comprise the highest-quality studies. Etomidate and a combination of propofol and ketamine have been added to Level B recommendations for safe use, with etomidate for safe use in adults and a combination of propofol and ketamine for both children and adults.