Definitions for the strength of evidence (Class I-III) and strength of recommendations (A-C) are repeated at the end of the "Major Recommendations" field.
What are the personnel requirements needed to provide procedural sedation and analgesia in the ED?
What are the key components of the patient assessment before initiating procedural sedation?
Is preprocedural fasting necessary before initiating procedural sedation?
- Level A recommendations. None specified.
- Level B recommendations. None specified.
- Level C recommendations. Recent food intake is not a contraindication for administering procedural sedation and analgesia, but should be considered in choosing the timing and target level of sedation.
What equipment and supplies are required to provide procedural sedation and analgesia?
What assessment and monitoring are required to provide procedural sedation in the ED?
- Level A recommendations. None specified.
- Level B recommendations. None specified.
- Level C recommendations. Obtain and document vital signs before, during, and after procedural sedation and analgesia. Monitor the patient's appearance and ability to respond to verbal stimuli during and after procedural sedation and analgesia.
How should respiratory status be assessed?
Can ketamine, midazolam, fentanyl, propofol, and etomidate be safely administered for procedural sedation and analgesia in the ED?
- Level A recommendations. Ketamine can be safely administered to children for procedural sedation and analgesia in the ED.
- Level B recommendations. Propofol can be safely administered for procedural sedation and analgesia in the ED.
Nondissociative sedation agents should be titrated to clinical effect to maximize safety during procedural sedation in the ED.
The combination of fentanyl and midazolam is effective for procedural sedation and analgesia in the ED.
- Level C recommendations. Etomidate can be safely administered for procedural sedation and analgesia in the ED.
Definitions:
Strength of Evidence
Class I - Interventional studies including clinical trials, observational studies including prospective cohort studies, and aggregate studies including meta-analyses of randomized clinical trials only
Class II - Observational studies including retrospective cohort studies, case-controlled studies, and aggregate studies including other meta-analyses
Class III - Descriptive cross-sectional studies, observational reports including case series and case reports, and consensus studies including published panel consensus by acknowledged groups of experts
Strength of Recommendation
Level A recommendations. Generally accepted principles for patient management that reflect a high degree of clinical certainty (i.e., based on strength of evidence Class I or overwhelming evidence from strength of evidence Class II studies that directly address all the issues)
Level B recommendations. Recommendations for patient management that may identify a particular strategy or range of management strategies that reflect moderate clinical certainty (i.e., based on strength of evidence Class II studies that directly address the issue, decision analysis that directly addresses the issue, or strong consensus of strength of evidence Class III studies)
Level C recommendations. Other strategies for patient management based on preliminary, inconclusive, or conflicting evidence, or in the absence of any published literature, based on panel consensus
There are certain circumstances in which the recommendations stemming from a body of evidence should not be rated as highly as the individual studies on which they are based. Factors such as heterogeneity of results, uncertainty about effect magnitude and consequences, strength of prior beliefs, and publication bias, among others, might lead to such a downgrading of recommendations.
