Procedural Sedation (PSA)

Question 1

Contraindications for PSA:

Answer 1

ASA 3 or above
High airway risk
High aspiration risk (eg. Lap band, drunk)
Unstable
Procedure not quick
Lack of resource/ personnel

Etc.

Question 2

ACEM position on fasting for PSA:

Answer 2

Don’t need to be fasted if EMERGENT procedure:
- Life/ limb/ sight saving
- Significant pain/distress

As per ANZCA.

Ideal fast: food 6 hours, fluid 2 hours

—> NONE OF THIS ACTUALLY EVIDENCE BASED. For emergency, or elective.

——————-

*** reduce risk of asp:
antiemetic
NGT +- asp
‘sedation spare’ with LA/regional

Question 3

Describe minimal, moderate and deep sedation. Example for when each used:

Answer 3

Minimal
- Anxiolysis only.
- Eg. Lumbar puncture

Moderate
- Depressed consciousness / dissociation
- Purposeful response to verbal, tactile
- Eg. Cardioversion

Deep
- Responds purposefully only with repeated or painful stimulus
- Eg. Hip relocation

• No validated formalised sedation score for PSA in ED. (RASS, Ramsay are for tubed/ICU)

Question 4

Process of preparing for and administering PSA:

Answer 4

Assess for INDICATION
- Brief, painful or unpleasant procedure

Assess for CONTRAINDICATION
- ASA (1 or 2)
- Airway risk (MOANS, LEMON, Mallampati)
- Fasting status

Choose AGENT:
- Fent/ propofol
- Ketamine (most)
*Consider adjunctive local or regional to ‘sedation spare’
Remember analgesia component.

PROCEDURE
- Consent
- 2 doc +1
- P’s (prep, position, preox, prep equip, pharmacy, procedure)
- TITRATE MEDS TO DESIRED DEPTH
- Monitoring until baseline consciousness/2h (EMU)
- Do not drive, DC in company
- Document
- Written post sed/ proc advice

Question 5

ASA score:

Answer 5

American Society Anaesthesiologists Physical Status Score:

Applies to KIDS and adults

Applies to PSA and GA

Question 6

Management of ketamine emergence phenomena:

Answer 6

Benzos- Midazolam