A Suggested Protocol

RCEM has published guidance on the use of procedural sedation in the emergency department. Please also refer to your own departments sedation policy prior to performing sedation.

An example protocol is as follows:

• Perform a focussed assessment, with emphasis on current medications and allergies, airway, fasting status, and any previous adverse experience or reactions with sedation or anaesthesia.
• Consider the indication for propofol sedation, and alternate strategies that may be employed. It is important not only to consider the individual patient, but also the wider department are resources currently available to deliver sedation safely?
• Consent the patient for sedation. Explain the procedure, the rationale for the use of sedation, and any alternative strategies that could reasonably be used. It is important to inform the patient that they will not be able to drive for 24 hours post sedation. It is also important to inform them of the risks of awareness/recall of the procedure being performed, post-sedation drowsiness and nausea, drug reaction, aspiration and the (very rare) requirement for intubation and ventilatory support.
• Move the patient to the resuscitation area. They should be made comfortable on a trolley. Raising the head of the bed may help to protect against passive regurgitation of gastric contents (and therefore aspiration) whilst improving V/Q matching (and thus protecting against hypoxia), though at an increased risk of cerebral hypoperfusion if hypotension develops.
• Gain and secure good IV access.
• Identify staff: one seditionist, one proceduralist, and at least one other staff member to act as a runner/scribe.
• Check that appropriate equipment is available, including (but not necessarily limited to) working suction, facemask and Mapleson C circuit, airway adjuncts and intubation equipment.
• Draw up appropriate drugs (propofol +/- opioid). If hypotension is likely, consider a bolus of fluid prior to sedation, and make sure that a vasopressor such as metaraminol is quickly available. Staff should be aware of the location of emergency drugs, including muscle relaxant, should they be required.
• Apply high flow oxygen via a non-rebreathe mask, and monitoring (SaO2, ECG, NIBP and capnography).
• Give sedative drugs. Propofol should be carefully titrated to effect. It is recommended to give an initial bolus of 0.5 1mg/kg (typically 50mg) in younger patients, and under 0.5mg/kg (typically 20mg) in older/frail patients, and then supplementary boluses of 10 20mg until the desired level of sedation is achieved.
• The proceduralist should perform the procedure whilst the sedationist continually monitors the patient, providing further boluses of sedation if needed. The total amount of propofol that may be required can vary widely, from just 10 20mg to well over 300mg!
• Following completion of the procedure, the patient should be allowed to wake to full consciousness before oxygen and monitoring is removed and they leave the resuscitation area.