Author: Mary Jagim, RN, BSN, CEN, FAEN

Section Editor: Kathleen A. Ream

Mary Jagim is Consultant, Senior Health Care Analyst, E SuiteConsulting, Fargo, ND.

For correspondence, write: Mary Jagim, RN, BSN, CEN, FAEN,6030 23rd Street South, Fargo, ND 58104;E-mail: mmjagim@cableone.net.

J Emerg Nurs 2007;33:488-91.

0099-1767/$32.00

Copyright n 2007 by the Emergency Nurses Association.doi: 10.1016/j.jen.2007.06.012

tion. He asks the emergency nurse to begin preparations

Procedural Sed

Emergency Depa

Do We Draw

E M E R G E N C Y N U R S I N G A D V O C A C Y488short with 1.3 to 4.1 minutes (compared with 30 minutes

for midazolam.) This results in a rapid decline of propofol

concentrations to levels below those required for hypnosis,for the administration of procedural sedation. The phy-

sician selects propofol as his drug of choice due to several

characteristics that render it superior to other sedatives

in terms of side effects and duration. Its high lipid solu-

bility results in a very fast onset of action (30 to 60 sec-

onds), and the plasma half life (tO distribution) is veryAmale patient presents to triage in severe pain

and is placed in a treatment bed by an emergency

nurse. The patient had been playing softball and

dislocated his shoulder sliding into base. The emergency

physician sees the patient and tells him that he will need to

reduce the shoulder dislocation and that it can be done in

the emergency department.

The Dilemma

The emergency physician is planning to use sedation to

make the patient comfortable during the shoulder reduc-

ation in the

rtment: Where

the Line?and permits a rapid awakening and shorter recovery times

even after prolonged administration.1

In these types of situations, the administration of

procedural sedation, in particular propofol, could be a

challenge. In some states, medical and nursing anesthesia

specialty organizations have been seeking to limit the ability

of those who are not trained in general anesthesia to ad-

minister certain medications such as propofol. The concern

being brought forward by these organizations is that they

feel medications such as propofol have the ability to take

a patient to level of deep sedation, rather than the desired

JOURNAL OF EMERGENCY NURSING 33:5 October 2007

can respond purposefully to verbal commands and inde-

pend lar

func ion

is ad

nts

airw art

of t can

under the direct supervision of an emergency physician.

plications related to sedation and analgesia sedation

4. R al-

g ed.

5. P in-

te ute

a or

in

6. Show competency, through ACLS or pediatric life sup-

EMERGENCY NURS ING ADVOCACY / J a g imCollege of Emergency Physicians (ACEP) Clinical Policy

on Procedural Sedation and Analgesia in the Emergency

Department published in 2005, proper administration of

sedative medications is a continuum and it is often diffi-

cult to predict how an individual will respond to a specific

sedative agent. Therefore, practitioners should possess the

skills required to rescue a patient 1 level greater than the

intended level of sedation. Should deep sedation be re-

quired to carry out a procedure, the practitioner is ex-

pected to be competent in skills involving cardiovascular

support and airway management as in general anesthesia.

These competencies are now considered core skills for all

board-certified emergency physicians.3

In these types of situations, theadministration of procedural sedation,in particular propofol, could bea challenge.

ENA and ACEP Position

Based on these expected competencies, the Emergency

Nurses Association (ENA) and ACEP contend that proce-

dural sedation can be safely administered in the emer-

gency department. In a joint position statement issued in

March 2005, ENA and ACEP stated that they support

the delivery of medications used for procedural sedation

and analgesia by credentialed emergency nurses workingOctoently maintain a continuous airway. Cardiovascu

tion is usually maintained and spontaneous ventilat

equate.

Deep sedation, therefore, may compromise a patie

ay and necessitate airway management on the p

he emergency physician.2 As noted in the Ameristate of moderate sedation. Deep sedation is a medication-

induced depression of consciousness during which patients

cannot be easily awakened, but can respond purposefully

after repeated or painful stimulation. Cardiovascular func-

tion is usually maintained, but spontaneous ventilation may

not be adequate and airway patency may require assistance.

Moderate sedation, on the other hand, is a medication-

induced depression of consciousness during which patientsber 2007 33:5port, in airway management and resuscitation appro-

priate to the age of the patient.5JOURecognize potential complications of sedation and an

esia sedation for each type of agent being administer

ossess the competency to assess, diagnose, and

rvene in the event of complications and instit

ppropriate interventions in compliance with orders

stitutional protocols.and medications.

2. Assess the total patient care requirements before and

during the administration of sedation and analgesia, in-

cluding the recovery phase.

3. Understand the principles of oxygen delivery, transport

and uptake, respiratory physiology, as well as under-

stand and use oxygen delivery devices.These agents include but are not limited to etomidate,

propofol, ketamine, fentanyl, and midazolam.4

Therefore, practitioners should possessthe skills required to rescue a patient1 level greater than the intended levelof sedation.

Certainly, the practice of procedural sedation is not one

to be under-recognized for the risks involved and potential

compromise to a patients airway. If emergency nurses and

physicians are advocating for the ability to administer these

medications in the emergency department, then we must

assure the level of competency expected as well as carry out

the procedure in a safe manner.

Safe Administration

Recommended competencies as outlined by the American

Association of Nurse Anesthetists (AANA) for the registered

nurse administering sedative and analgesic drugs under the

direct supervision of an emergency physician include:

1. Show the acquired knowledge of anatomy, physiology,

pharmacology, cardiac arrhythmia recognition, and com-NAL OF EMERGENCY NURSING 489

lay o ills

of a ist.

Effo im-

prac nd,

in fa ent

suffe nd

shou

EMERGENCY NURS ING ADVOCACY / J a g imThere is a growing body of literature supporting the

safe use of a large variety of agents for procedural seda-

tion and analgesia in the emergency department. Keta-

mine, midazolam, fentanyl, propofol, and etomidate are

just a few of the agents in common usage. Although serious

side effects may occur, they are no more common than

with other medications and may be appropriately managed

by a multidisciplinary team including an appropriately quali-

fied registered nurse. Professional nursing organizations and

health care facilities are expected to support patient safety

by developing credentialing standards, prerequisites, and

criteria for nurses commensurate with current and accepted

standards of practice in a manner that will meet the goals

established by professional licensing boards.6

Scientific Evidence and Consensus-Based

Clinical Guidelines

What happens when emergency nurses and physicians can-

not administer conscious sedation in the emergency depart-

ment? Well, a different and perhaps less effective medicationAdditional safeguards include:. The registered nurse who monitors the patient should

have no other duties to carry out during the sedation

and recovery process that would compromise her/

his ability to adequately monitor the patient.7

. Monitoring should continue post-procedure until the

patient returns to his or her baseline level of function

and is ready for discharge.. Oxygen, suction, reversal agents, and advanced life

support medication and equipment should be avail-

able when procedural sedation and analgesia is pro-

vided. Intravenous access may not be necessary when

procedural sedation and analgesia are provided by

other routes.3

Evidence-BasedRecommended assessment and monitoring of the pa-

tients physiologic parameters during sedation may include

but are not limited to: level of consciousness and physio-

logic changes observed, blood pressure, respiratory rate,

oxygen saturation by pulse oximetry, electrocardiographic

monitoring, and capnometry.3490 JAdvocacy Resources

ENA has developed an advocacy packet for use by its

state councils to address the administration of procedural

sedation and analgesia with their state boards of nursing.

This advocacy packet can be found on the ENA websiteOURrts to restrict the use of specific medications are

tical and not in the best interests of patient care a

ct, could significantly delay care and prolong pati

ring. Safe and efficient patient care has been a

ld always remain our overarching goal.sedation and analgesia with their stateboards of nursing.

The ENA Position Statement on Procedural Sedation

and Analgesia in the Emergency Department recommends

instead that the professional scope of practice be based on

scientific evidence and consensus-based clinical guidelines.f care, increased pain, and inefficient use of the sk

certified registered nurse anesthetist or anesthesiolog

ENA has developed an advocacy packetfor use by its state councils to addressthe administration of proceduralThere is a growing body of literaturesupporting the safe use of a large varietyof agents for procedural sedation andanalgesia in the emergency department.

Restricting registered nurses from administering a cer-

tain classification of sedating medication creates a structure

that is overly restrictive and difficult for nurses and health

care facilities to understand and apply. It may result in de-could be administered. Or the emergency physician could

contact an anesthesiologist or nurse anesthetists to admin-

ister the propofol. This would of course be ideal, but in

most hospitals are these individuals always available? What

if they are not or their response is delayed? Patient care

is delayed.NAL OF EMERGENCY NURSING 33:5 October 2007

(www.ena.org/government/Advocacy/default.asp). Components

EMERGENCY NURS ING ADVOCACY / J a g imAccessed on May 13, 2007.

Contributions for this column are welcomed and encouraged. Sub-missions may be sent to:

Kathleen A. Ream

Washington RepresentativeEmergency Nurses Association6534 Marlo DriveFalls Church, Virginia 22402

703-241-3947 . kathiream@aol.comtion statement.

REFERENCES

1. Green SM. Editorial: Research advances in procedural sedationand analgesia. Ann Emerg Med 2007;49:15-22.

2. American Society of Anesthesiologists. Continuum of depth ofsedation: Definition of general anesthesia and levels of sedation/analgesia. Available at: http://www.asahq.org/publicationsAndServices/standards/20.pdf. Accessed May 13, 2007.

3. Mace SE, Barata IA, Cravero JP, Dalsey WC, Godwin SA,Kennedy RM, et al. Clinical policy: Evidence-based approach topharmacologic agents used in pediatric sedation and analgesia inthe emergency department. Ann Emerg Med 2004;44:342-77.

4. ENA and ACEP Joint Position Statement. Delivery of agents forprocedural sedation and analgesia by emergency nurses. Availableat: http://ena.org/about/position/ACEP/ProceduralSedation.asp .Accessed May 13, 2007.

5. AANA Practice Policy. Considerations for policy guidelines forregistered nurses engaged in the administration of sedation andanalgesia. Available at: http:www.aana.com/resources.aspx?ucNavMenu_TSMenuTargetID=51&ucNavMenu_TSMenuTargetType=4&ucNavMenu_TSMenuID=6&id=706. AccessedMay 13, 2007.

6. Joint Commission on Accreditation of Healthcare Organizations.Comprehensive accreditation manual for hospitals: The officialhandbook. Oakbrook Terrace, IL: Author; 2005.

7. ENA Position Statement. Procedural sedation and analgesia inthe emergency department. Available at: http://ena.org/about/position/PDFs/DF08CCBA0E46430288A9EB30B835E350.pdf.of the packet include such items as:. How to checklist;. Template letter activating ENA members;. Issue brief for ENA members;. Detailed bibliography and background articles

and information;. Template letter and issue brief for state board of

nursing; and. Model language for state board of nursing posi-October 2007 33:5 JOURNAL OF EMERGENCY NURSING 491

Procedural Sedation in the Emergency Department: Where Do We Draw the Line?The DilemmaENA and ACEP PositionSafe AdministrationEvidence-BasedScientific Evidence and Consensus-Based Clinical GuidelinesAdvocacy ResourcesReferences