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How To Do Procedural Sedation and Analgesia
Contraindications
Absolute contraindications Urgent need for treatment (eg, hemodynamic instability) that cannot await sedation Hypersensitivity to one of the drugs or to the delivery vehicle* Particular toketamine: Age<3 months (increased risk of airway compromise) Particular to nitrous oxide: Pneumothorax, pneumomediastinum, bowel obstruction, or intraocular gas bubble (post-vitreoretinal surgery), which are sites of air accumulation into which nitrous oxide can expand * Allergy to eggs or soy are no longer a contraindication topropofol(the egg/soy allergens are different from the egg/soy moieties in thepropofolformulation). Relative contraindications Severe cardiopulmonary disease (increased risk of decompensation from respiratory depression)† Obstructive sleep apnea† Obesity or anatomic characteristics (eg, micrognathia, macroglossia, short neck, congenital anomalies) that suggest difficult intubation† Chronic liver or kidney disease: Some drugs will be metabolized slowly, leading to prolonged sedation. Patients>60 years of age (increased risk of decompensation): PSA drug doses should often be decreased. Acute alcohol/sedative drug intoxication (increased risk of respiratory complications): PSA drug doses should be decreased. Chronic alcohol or substance use disorder: PSA drug doses may need to be increased. Pre-procedural food or drink: Review institution-specific protocols regarding fasting before PSA‡ † If one of these contraindications is present, consult an anesthesiologist and/or consider use of a drug that does not depress respiration (eg,ketamine). ‡ Although some guidelines recommend delaying elective procedural sedation for a few hours after ingestion of clear liquids and 8 hours after ingestion of solids, no data establish the efficacy or necessity for doing so ( References ). 