“These guidelines are intended for use by all providers who perform moderate procedural sedation and analgesia in any inpatient or outpatient setting …”
That is to say, effectively by fiat, if you perform procedural sedation, these guidelines apply to YOU.
This is a publication by the American Society of Anesthesiologists, and sponsored by various dental and radiology organizations. This replaces a 2012 version of this document – and it has changed for both better and worse.
Falling into the “better” column of this document, this guideline no longer perpetuates the myth of requiring a period of fasting prior to an urgent or emergent procedure. Their new recommendation:
“In urgent or emergent situations where complete gastric emptying is not possible, do not delay moderate procedural sedation based on fasting time alone”
However, some things are definitely “worse”. By far the largest problem with these guidelines – reflecting the exclusion of emergency medicine and critical care specialties from the writing or approving group – is their classification of propofol and ketamine as agents intended for general anesthesia. They specifically differentiate practice with these agents from the use of benzodiazepines or adjunctive opiates by stating:
“When moderate procedural sedation with sedative/ analgesic medications intended for general anesthesia by any route is intended, provide care consistent with that required for general anesthesia.”
These guidelines do not describe the care of patients receiving general anesthesia, but, obviously, we are not performing general anesthesia in the Emergency Department – and, I expect most hospitals do not credential their Emergency Physicians for general anesthesia. The impact of these guidelines in a practical sense on individual health system policy is unclear, particularly in the context of safe use of these medications by EPs for decades, but it’s certainly just one more pretentious obstacle to providing safe and effective care for our patients.
“Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018”
http://anesthesiology.pubs.asahq.org/article.aspx?articleid=2670190
“The Newest Threat to Emergency Department Procedural Sedation”
Thanks Ryan.
Steve Green’s comments in Annals of EM are (as usual) brilliant. But his 5 page rebuttal could have been nicely summarized to, “the ASA can get f*##*!”
keep up the good work