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.
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.
In addition, the prior Level C recommendation regarding preprocedural fasting is now a Level B recommendation and advises that providers “not delay procedural sedation in adults or pediatrics in the ED based on fasting time.”
In the years since the last policy, there has been increasing evidence published on the use of capnography with procedural sedation and analgesia. As a result, a Level B recommendation states that providers may use capnography as an adjunct to pulse oximetry and clinical assessment to detect hypoventilation earlier than pulse oximetry and/or clinical assessment alone.
As a call for future research, the policy authors note that ED studies on this topic should focus on patient-centered outcomes as a core principle in study design. They further suggest that studies should investigate best practices for procedural sedation, analgesia monitoring, and performance in high-risk patient subgroups.
In conclusion, ACEP’s revised policy provides supporting evidence for the unique expertise of emergency physicians regarding the performance of procedural sedation and analgesia, and can serve as a resource for emergency physicians to use within their home institutions and demonstrate recognition at a national level of this distinctive and specialized skill set.
Dr. Godwin is professor, chair, and chief of service for the department of emergency medicine and assistant dean of simulation education at the University of Florida College of Medicine at Jacksonville.