Anesthesia in the emergency room (ER) plays a vital role in facilitating painful procedures while ensuring patient comfort and cooperation. However, balancing between sedation and maintaining patient safety under the additional time pressures of emergent cases requires a multidisciplinary approach, compliance with safety guidelines, anticipation of complications, and diligent monitoring.
The American College of Emergency Physicians (ACEP) and the American Society of Anesthesiologists (ASA) have established guidelines to ensure the safe practice of anesthesia in the ER (1). Key recommendations include pre-procedure assessment, appropriate fasting status, availability of resuscitation equipment, continuous monitoring of vital signs, and provision of supplemental oxygen. However, emergent cases requiring anesthesia often mean that standard pre-procedure preparation is not possible. As a result, special protocols and techniques are necessary in emergency medicine and critical care.The selection of pharmacologic agents for anesthesia depends on the patient’s age, medical history, procedure type, and desired level of sedation. Commonly used medications include benzodiazepines (e.g., midazolam), opioids (e.g., fentanyl), and dissociative agents (e.g., ketamine) (2). Benzodiazepines provide anxiolysis and amnesia but carry a risk of respiratory depression, especially when combined with opioids. Opioids offer potent analgesia but may cause respiratory depression and hypotension. Ketamine provides dissociative anesthesia with minimal respiratory depression but may cause emergence reactions and hallucinations.
Sedation scales, such as the Richmond Agitation-Sedation Scale (RASS) and the Ramsay Sedation Scale, guide clinicians in assessing and titrating sedation levels (3). These scales classify patients’ level of consciousness on a numerical scale, ranging from agitation to deep sedation. Regular assessment ensures adequate sedation while minimizing the risk of oversedation and respiratory compromise. Continuous monitoring of vital signs, including heart rate, blood pressure, respiratory rate, and oxygen saturation, is essential during anesthesia, whether in the ER or for an elective procedure (1).
Despite meticulous planning, complications may arise, including respiratory depression, hypotension, airway obstruction, and allergic reactions (4). Prompt recognition and management of these complications are critical to prevent adverse outcomes. Emergency physicians and/or anesthesiologists should be prepared to intervene with airway maneuvers, administration of reversal agents (e.g., naloxone for opioid-induced respiratory depression), and initiation of cardiopulmonary resuscitation if necessary.
References
- Miner JR, Burton JH. Clinical Practice Advisory: Emergency Department Procedural Sedation with Propofol. Ann Emerg Med. 2007;50(2):182-7.
- Green SM, Roback MG, Krauss B, et al. Predictors of Airway and Respiratory Adverse Events With Ketamine Sedation in the Emergency Department: An Individual-Patient Data Meta-analysis of 8,282 Children. Ann Emerg Med. 2009;54(2):158-68.e1-4.
- Sessler CN, Gosnell MS, Grap MJ, et al. The Richmond Agitation-Sedation Scale: Validity and reliability in adult intensive care unit patients. Am J Respir Crit Care Med. 2002;166(10):1338-44.
- Godwin SA, Caro DA, Wolf SJ, et al. Clinical policy: procedural sedation and analgesia in the emergency department. Ann Emerg Med. 2005;45(2):177-96.