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Procedural sedation is the administration of sedatives or dissociative anesthetics to induce a depressed level of consciousness while maintaining cardiorespiratory function so that a medical procedure can be performed with little or no patient reaction or memory.1 Procedural sedation and analgesia (PSA) is the addition of agents to reduce or eliminate pain.1 Levels of PSA are defined by the patient’s level of responsiveness and cardiopulmonary function, not by the agents used (Table 41-1).2 By definition, patients receiving PSA do not require routine airway protection with endotracheal intubation or other airway adjuncts, as compared with general anesthesia that typically requires airway protection. Procedural sedation is commonly done for scheduled outpatient medical procedures by a variety of non-anesthesiology physicians.3,4 Protocols and procedures developed for these elective procedures emphasize patient assessment and preparation to minimize the risk of PSA to the lowest level possible, and if the patient does not satisfy all the criteria for proceeding, the procedure can be rescheduled. Procedural sedation performed in the ED presents different issues to the practitioner (Table 41-2).1

Table 41-1 Definition of General Anesthesia and Levels of Sedation/Analgesia
Table 41-2 Comparison of Outpatient and ED Procedural Sedation

The first step in performing PSA is to determine the depth of sedation needed for the procedure, guided by two important principles (Box 41-1).1,2 The first principle is that the lightest appropriate level of sedation should be used because complications from sedation increase with deeper levels. The second principle is that despite careful planning and performance, the depth of sedation needed or achieved during PSA cannot always be predicted, so plan for producing deeper levels of sedation, if needed, and plan for managing levels deeper than anticipated.

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