potential difficult airway. The patient's fitness for sedation
can be quantified using the American Society of
Anesthesiologists (ASA) physical status classification sys
tem (Table 4-1). The risk of a complication from emer
gency department (ED) procedural sedation and analgesia
in ASA class I and II patients is low, usually <So/o.
Examples of clinical scenarios appropriate for procedural
sedation include painful or anxiety-provoking situations s uch
as joint or fracture reduction, lumbar puncture, pediatric
radiologic studies, incision and drainage, or cardioversion.
Contraindications include ASA class III/IV, altered mental
status, hemodynamic instability, known medication
allergy, and lack of equipment or qualified personnel. Oral
• Procedural sedation should maintain cardiorespiratory
function without requiring advanced airway adjuncts.
• Preprocedure patient assessment and proper selection
of pharmacologic agents are the keys to patient safety.
Table 4-1. The American Society of Anesthesiologists
physical status classification.
II. Mild systemic disease-no functional limitation
111. Severe system disease-definite functional limitation
IV. Severe systemic disease-constant threat to life
v. Moribund patient-not expected to survive without the
Data from American Society of Anesthesiologists. ASA Physical Status
Classification System. http:/ jwww.asahq.org
intake within 3 hours is a relative contraindication. Higher
risk cases may be more safely performed with anesthesia
consultation or in the operating room.
Patients should be closely monitored to recognize any
change in vital signs and avert complications, most notably
respiratory depression. Continuous pulse oximetry, cardiac
monitor, and end-tidal C02 capnography (if available)
should be applied. Intravenous (IV) access, an oxygen
source and delivery method (eg, nasal canula), suction,
airway management equipment (ie, bag-valve-mask,
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