Patient assessment and preprocedure considerations

SCOPE OF THE PROBLEM Procedural sedation and analgesia (PSA) has three essential components: the initial presedation assessment, sedation during the procedure, and postprocedure recovery and discharge from the ED. The most important initial step is togather sufficient information to make an informed risk-benefit analysis. If the risks of sedation outweigh the benefits and the procedure is nonemergent, then the procedure should be postponed or managed in a more controlled environment of an operating room. If the procedure is emergent or the situation is life threatening, then the procedure should be undertaken with recognition of the critical nature of intervention. The risks, benefits, and limitations of PSA should be discussed with the patient (or their parent or guardian) in advance and verbal agreement obtained. Written consent is not required (unless a local institutional requirement), though documentation of this process should be routine whether a verbal or written consent is obtained. PSA enhances patient cooperation and facilitates the successful completion of diagnostic or therapeutic procedures that cause stress and pain. Anxiety alleviation and amnesia are additional benefits particularly important for children, who may perceive even simple procedures as terrifying. There are many factors that influence the decisionmaking process surrounding PSA, especially in children, and include age and temperament of the patient, type of procedure, amount of pain involved, movement control required, and patient/parental anxiety level (Figure 23-1).