Decision
Is the patient a candidate for procedural sedation?
- ASA score <3
- No anatomical abnormality
- Age >3 months
- Hemodynamically stable
Yes
Patient meets criteria for ED procedural sedation
- Discuss risks, benefits, side effects.
- Obtain written consent for sedation and procedure
No
Consider alternative options:
- Local aesthetics
- Operating room with anesthesia
Background
Determine patients risk:
“To date, no outcome-based studies have demonstrated clear benefit from patient evaluation beyond vital signs, mental status, airway patency, and cardiopulmonary assessment prior to sedation. Despite this, consensus guidelines suggest that there is an increased risk for adverse events in patients who are at the extremes of age; have difficult neck, pharyngeal, or facial anatomy; and who have significant underlying diseases. The ASA Physical Status Classification System has been used for more than 60 years to classify a patient’s physical status based on pre-anesthesia comorbidities. It specifies classes ranging from class I (patient is normal and healthy) to class VI (patient is declared brain-dead)”
ASA Classification System
Class | Description | Examples |
1 | Healthy | Minimal alcohol use, No smoking |
2 | Mild disease | Controlled DM or HTN, Social alcohol use, Smoker, Pregnancy, Obesity |
3 | Severe disease | Poorly controlled disease, BMI>40, ESRD on dialysis |
4 | Severe disease with “constant life threat” | Recent (<3 months) MI, CVA, Coronay stenting, Shock, Sepsis |
5 | Moribund, not expected to live without surgery | Ruptured AAA, Massive transfusion for trauma, Intracranial hemorrhage with midline shift |
6 | Brain dead, undergoing organ procurement |
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