Procedural sedation and analgesia

Procedural sedation and analgesia (PSA) is a technique in which a sedating/dissociative medication is given, usually along with an analgesic medication, in order to perform non-surgical procedures on a patient. The overall goal is to induce a decreased level of consciousness while maintaining the patient's ability to breathe on their own. PSA is commonly used in the emergency department, in addition to the operating room. While PSA is considered safe and has low rates of complication, it is important to conduct a pre-procedural assessment, determine any contraindications to PSA, choose the most appropriate sedative agent, and monitor the patient for potential complications both during and after the procedure.

Medical uses

This technique is often used in the emergency department for the performance of painful or uncomfortable procedures. Common purposes include:

laceration repair

setting fractures

draining abscesses

reducing dislocations

performing endoscopy

for cardioversion

during various dental procedures

during transesophageal echocardiogram

and certain imaging or minor procedures where the patient is unable (or unwilling) to keep still—especially children

Contraindications

There are no absolute reasons that immediately disqualify a patient from receiving PSA. However, a patient's age, medical comorbidities, or evidence of a difficult airway are important considerations.

Age

Although there is no age limit for PSA, the elderly have a greater chance of complications such as longer than intended sedation time, increased sensitivity to medications, adverse effects of medications, and higher than expected drug levels due to difficulty clearing the drugs. To help reduce risk of complications, consider a less aggressive approach to PSA, including starting with a smaller dose than given for non-elderly patients, giving the medication slowly, giving repeat doses of the medications less often.

Comorbidities

Patients with serious medical conditions are at greater chance for negative side effects after receiving PSA. Examples of comorbidities include heart failure, COPD, neuromuscular disease. Use the ASA Classification to predict a patient's risk for serious complications from PSA, such as hypotension or respiratory depression.