Overview of procedural sedation and analgesia

For advice on managing preprocedural and postprocedural pain, see General principles of acute pain management.

This topic focuses on managing the pain anticipated during a painful procedure. Painful procedures are expected to be brief (ie minutes not hours) with a peak in pain or distress during the procedure. Pain should resolve once the procedure is completed. Examples of painful procedures include lumbar puncture, upper gastrointestinal endoscopy, paediatric wound repair, and fracture manipulation.

Adequate analgesia is a priority for all painful procedures because inadequate analgesia can increase a patient’s anticipation of pain and distress during subsequent medical care, and result in adverse psychological outcomes (eg acute traumatic stress, needle phobia, posttraumatic stress disorder). This is particularly true for young children.

Sedation may be required in addition to analgesia to manage a painful procedure, but must not be used to compensate for inadequate analgesia.

Procedural sedation and analgesia is the co-administration of sedative and analgesic drugs, which allows a patient to tolerate an uncomfortable or painful diagnostic or interventional procedure. Depressed consciousness is intended, but the patient must be able to independently and continuously maintain airway control—see here for the different levels of consciousness associated with procedural sedation and analgesia.

Optimal procedural sedation and analgesia:

• provides adequate analgesia for the duration of the procedure
• minimises preprocedure anxiety, distress during the procedure and unpleasant postprocedure recall
• facilitates safe and effective performance of the procedure
• meets the patient’s expectations.

Procedural sedation and analgesia must be performed by appropriately trained and credentialed staff, within their scope of practice, in settings where appropriate monitoring and equipment are available; see Requirements for procedural sedation and analgesia.

Before procedural sedation and analgesia is undertaken, a preprocedural risk assessment must confirm that it can be safely used in the individual patient (eg they are not at high risk of airway compromise or cardiorespiratory complications); see Managing complications of procedural sedation and analgesia for advice.

Procedural sedation and analgesia is not required if the pain and distress associated with the procedure can be adequately managed with nonpharmacological techniques. These might include distraction, distress minimisation, local or regional anaesthesia, or sucrose (for infants).

Nonpharmacological techniques should always be used in addition to procedural sedation and analgesia. They can reduce drug requirements and limit the likelihood of adverse psychological outcomes associated with the procedure. The use of nonpharmacological techniques, local or regional anaesthesia, or sucrose (for infants) for painful procedures is not addressed in this topic.