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Procedural Sedation and Analgesia

Last updated 1 Jun 2026 · Pain & analgesia

📋 Key Information Summary

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  • Procedural sedation and analgesia (PSA) is the use of sedative and/or analgesic agents to enable painful or distressing procedures while maintaining cardiorespiratory function.
  • Sedation exists on a continuum — minimal, moderate, deep, and general anaesthesia — and agents must be titrated to the minimum effective level.
  • Risk assessment before PSA includes ASA physical status, airway evaluation (Mallampati score, neck mobility), fasting status, allergy history, and concurrent medications.
  • Standard fasting guidelines (2 h clear fluids, 4 h breast milk, 6 h formula/solids) reduce aspiration risk but may be waived for emergency procedures with a risk–benefit discussion.
  • Minimum monitoring during PSA: continuous pulse oximetry (SpO₂), ECG, non-invasive blood pressure every 5 min, end-tidal CO₂ (capnography) for moderate-to-deep sedation, and visual assessment of respiratory effort.
  • A dedicated sedationist (separate from the proceduralist) must be present for moderate and deep sedation, with competency in airway management and resuscitation.
  • Midazolam (0.05–0.1 mg/kg IV, max 2.5 mg initial dose) and fentanyl (0.5–1 µg/kg IV, max initial 50 µg) are the most commonly used agents for moderate sedation in Australian EDs.
  • Propofol (0.5–1 mg/kg IV bolus, titrated) provides deep procedural sedation with rapid onset and offset but requires airway-management skills and is restricted to appropriately credentialed practitioners.
  • Ketamine (1–2 mg/kg IV or 4–5 mg/kg IM) is the preferred dissociative agent for paediatric procedural sedation, preserving respiratory drive and airway reflexes.
  • Penthrox (methoxyflurane) and Entonox (50% N₂O / 50% O₂) provide non-invasive analgesia suitable for brief painful procedures in the pre-hospital and ED setting.
  • Post-procedure monitoring must continue until discharge criteria are met (e.g., Aldrete score ≥ 9 or equivalent), with a minimum 30-minute observation for short-acting agents.
  • Adverse events during PSA — hypoxia, apnoea, hypotension, vomiting, laryngospasm — require immediate management with airway manoeuvres, bag-valve-mask ventilation, and reversal agents where appropriate.
  • Document sedation on a standardised procedural sedation form (ACSQHC-aligned), including agent, dose, time, monitoring parameters, adverse events, and discharge readiness.

Introduction & Australian Epidemiology

Procedural sedation and analgesia (PSA) encompasses the administration of sedative, dissociative, and/or analgesic medications to facilitate diagnostic and therapeutic procedures that would otherwise cause significant pain, discomfort, or anxiety. PSA is performed across Australian emergency departments (EDs), radiology suites, gastroenterology units, paediatric procedure rooms, dental clinics, and ambulatory care settings.

In Australian EDs, procedural sedation is one of the most commonly performed high-risk procedures. The Australasian College for Emergency Medicine (ACEM) estimates that over 250,000 episodes of procedural sedation occur annually across Australian and New Zealand emergency departments. Common indications include fracture and dislocation reduction, abscess incision and drainage, cardioversion, wound repair in children, foreign body removal, and lumbar puncture in paediatric patients.

The Australian Commission on Safety and Quality in Health Care (ACSQHC) National Safety and Quality Health Service (NSQHS) Standards mandate that facilities performing sedation have robust credentialing, monitoring, and recovery protocols. The Australasian Anaesthesia journal and ACEM guidelines provide the principal Australian clinical framework for safe PSA practice.

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Sedation is a continuum: Patients may unintentionally transition from moderate to deep sedation or general anaesthesia. The sedationist must be prepared to manage the next deeper level at all times. This is a core principle of ACEM and ANZCA guidance.

Sedation Levels

PSA is classified into four levels along a continuum of increasing central nervous system depression. Accurate classification determines the monitoring, staffing, and credentialing requirements for each episode.

Level Responsiveness Airway Reflexes Ventilation Cardiovascular Function
Minimal (Anxiolysis) Normal response to verbal stimulation Intact Unaffected Unaffected
Moderate (Conscious Sedation) Purposeful response to verbal ± tactile stimulation Intact Adequate independently Usually maintained
Deep Sedation Purposeful response after repeated or painful stimulation May be impaired May be inadequate; may require intervention Usually maintained
General Anaesthesia Unarousable even with painful stimulation Often lost Frequently inadequate; requires assistance May be impaired

Minimal Sedation (Anxiolysis)

Achieved with low-dose oral or intravenous benzodiazepines (e.g., midazolam 1–2.5 mg PO or 0.5–1 mg IV in adults). The patient remains fully conversant, protective reflexes are intact, and airway management is not required. Suitable for anxious patients undergoing minor procedures such as venepuncture, wound dressing changes, or simple imaging.

Moderate (Conscious) Sedation

The most common level of PSA in Australian EDs. The patient retains the ability to maintain their own airway and respond purposefully to verbal or light tactile stimulation. Common agents include midazolam + fentanyl ("M&F"), low-dose ketamine, or nitrous oxide. Standard monitoring (SpO₂, NIBP, ECG) and a dedicated sedationist are required.

Deep Sedation

The patient cannot be easily aroused but responds purposefully to repeated or painful stimulation. Airway reflexes may be impaired and ventilatory support may become necessary. Agents include propofol, ketamine at higher doses, or combined midazolam–opioid titration. Requires capnography, advanced airway equipment at the bedside, and a practitioner proficient in bag-valve-mask ventilation and intubation. Deep sedation is typically restricted to ED consultants, proceduralists with FANZCA credentials, or intensivists in Australian practice.

Dissociative Sedation

A unique state induced by ketamine characterised by catalepsy, amnesia, and profound analgesia with preservation of airway reflexes, spontaneous respiration, and cardiovascular tone. Widely used for paediatric procedural sedation in Australian EDs. Dissociative sedation is generally classified between moderate and deep for regulatory purposes, though its clinical safety profile is more favourable than traditional deep sedation agents.

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Practice tip: Always document the intended level of sedation before commencing the procedure and have the equipment, drugs, and competency to manage the next deeper level if it occurs unintentionally.

Risk Assessment

A structured pre-procedure risk assessment is essential for every episode of PSA. This identifies patients at elevated risk of adverse events and determines the appropriate setting, staffing, and agent selection.

ASA Physical Status Classification

ASA Class Description PSA Suitability
I Healthy patient Standard PSA protocol
II Mild systemic disease (e.g., well-controlled asthma, BMI 30–40) Standard protocol with enhanced monitoring
III Severe systemic disease (e.g., poorly controlled diabetes, COPD, morbid obesity) Senior clinician, consider anaesthetic consultation, lower threshold for RSI equipment
IV+ Severe life-threatening disease or moribund PSA generally contraindicated in ED — pursue general anaesthesia in OT or discuss with anaesthetics

Airway Assessment

Assess for predictors of difficult airway management prior to PSA. Features associated with increased risk include:

  • Mallampati score III–IV (limited oropharyngeal view)
  • Short neck, neck immobility, or cervical spine injury
  • Morbid obesity (BMI > 40 kg/m²) — associated with difficult bag-mask ventilation, rapid desaturation, and obstructive sleep apnoea
  • Macroglossia, micrognathia, or craniofacial abnormalities
  • History of obstructive sleep apnoea (OSA) — increased sensitivity to sedatives and opioids
  • Stridor, hoarseness, or upper airway pathology

Fasting Status

Standard fasting guidelines for elective PSA in Australian facilities align with ANZCA recommendations:

Intake Minimum Fasting Period
Clear fluids (water, apple juice, black tea/coffee) 2 hours
Breast milk 4 hours
Formula, infant formula 6 hours
Light meal / solids 6 hours
Heavy / fatty meal 8 hours
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Emergency procedures: For urgent/emergent PSA in patients who have not fasted, fasting status alone is not an absolute contraindication. Weigh the urgency of the procedure against aspiration risk, use the lowest effective sedation depth, consider procedural topical/local anaesthesia where possible, and have suction and advanced airway equipment immediately available.

Medication and Allergy Review

  • Opioid- or benzodiazepine-tolerant patients: May require higher doses; consult with the treating team regarding home medication doses.
  • Concurrent sedating medications (antipsychotics, antihistamines, gabapentinoids, alcohol): Additive CNS depression; use reduced initial doses.
  • Opioid allergy vs. intolerance: True IgE-mediated opioid allergy is rare; pseudoallergy (histamine release) is more common with morphine — consider fentanyl or remifentanil as alternatives.
  • Egg/soy allergy and propofol: Current evidence supports that propofol (which contains egg lecithin, not egg protein) is safe in most egg-allergic patients. Consult ASCIA guidance for complex cases.
  • Malignant hyperthermia (MH) risk: Avoid succinylcholine and volatile agents (including methoxyflurane/Penthrox) in patients with personal or family history of MH.

Pre-procedure Checklist

1
Patient identification & consent
Confirm identity, procedure site/side, informed consent obtained (including discussion of risks of sedation).
2
Risk assessment complete
ASA class documented, airway assessed, fasting status confirmed (or risk accepted), allergies reviewed.
3
Equipment check
Monitoring connected, suction working, IV access secured, oxygen and bag-valve-mask available, reversal agents drawn up (flumazenil, naloxone), advanced airway adjuncts at bedside.
4
Team briefing
Roles assigned (sedationist vs. proceduralist), intended sedation level and agents discussed, rescue plan verbalised.
5
Time-out / WHO checklist
NSQHS-aligned time-out performed before first agent administered.

Monitoring Requirements

Monitoring during PSA must be continuous, documented at defined intervals, and appropriate to the depth of sedation. The ACSQHC and ACEM standards specify minimum requirements.

Minimum Monitoring by Sedation Level

Parameter Minimal Moderate Deep / Dissociative
Pulse oximetry (SpO₂) Continuous Continuous Continuous
ECG Not required Continuous Continuous
Non-invasive BP Baseline + post-procedure Every 5 min Every 5 min
Capnography (EtCO₂) Not required Recommended Mandatory
Visual respiratory assessment Continuous Continuous Continuous
Level of consciousness Continuous Continuous Continuous
Pain assessment Pre/post Pre/during/post Pre/post
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Capnography saves lives: End-tidal CO₂ monitoring detects apnoea and hypoventilation 30–60 seconds before pulse oximetry desaturation becomes apparent. ACEM and ANZCA endorse capnography as mandatory for all episodes of deep sedation and strongly recommend it for moderate sedation.

Monitoring Equipment

Essential
Pulse oximeter with audible alarm
Continuous SpO₂ and heart rate; functioning probe on patient throughout sedation and recovery.
Essential
Non-invasive blood pressure (NIBP) monitor
Appropriate cuff size; automated cycling every 5 minutes during moderate/deep sedation.
Essential
ECG monitor
Continuous cardiac rhythm monitoring for moderate and deep sedation; particularly important in patients >50 years or with cardiovascular comorbidities.
Essential
Capnograph / EtCO₂ monitor
Nasal prong or inline sampling; mandatory for deep sedation, strongly recommended for moderate sedation. Detects early apnoea and airway obstruction.
Available
Point-of-care blood glucose
For diabetic patients or when hypoglycaemia is a differential for altered consciousness.

Airway and Resuscitation Equipment

The following must be immediately available (within arm's reach) for all episodes of moderate or deeper sedation:

  • Supplemental oxygen (wall or cylinder) with delivery devices (nasal prongs, Hudson mask, non-rebreather mask)
  • Self-inflating bag-valve-mask (BVM) with oxygen reservoir — adult and paediatric sizes
  • Suction apparatus with Yankauer and flexible catheter tips
  • Oropharyngeal (Guedel) and nasopharyngeal airways — range of sizes
  • Supraglottic airway device (e.g., i-gel or LMA) — range of sizes
  • Laryngoscope (video preferred) with endotracheal tubes (size range) and stylet
  • Intravenous access equipment with fluids and pressor agents (metaraminol 0.5–1 mg IV bolus)
  • Reversal agents drawn up: naloxone 0.4 mg/1 mL ampoule (opioid reversal) and flumazenil 0.2 mg/2 mL ampoule (benzodiazepine reversal)
  • Emergency trolley with defibrillator accessible

Documentation

Use a standardised procedural sedation form documenting: date/time, patient demographics, procedure performed, pre-procedure assessment (ASA, airway, fasting, allergies), agent(s) and dose(s), sedation level achieved, vital signs at 5-minute intervals, adverse events, interventions required, post-procedure Aldrete score, time of discharge readiness, and responsible clinician signature.

Aftercare

Post-procedure care is a critical phase of PSA. Most adverse events (respiratory depression, vomiting, airway obstruction) occur during or immediately after the procedure, but delayed recovery and discharge complications also pose risks.

Recovery Phase Monitoring

All patients must be observed in a dedicated recovery area with continuous SpO₂ monitoring and intermittent vital sign assessment until they meet discharge criteria. Minimum observation periods:

  • Minimal sedation: 15–30 minutes or until baseline mental state returns
  • Moderate sedation: Minimum 30 minutes after last drug dose
  • Deep sedation: Minimum 60 minutes; longer if prolonged-acting agents used (e.g., morphine, diazepam)
  • Ketamine: Until purposeful, age-appropriate behaviour is restored (typically 60–120 minutes for IM ketamine in children)

Modified Aldrete Score for Discharge Readiness

Criterion Score 0 Score 1 Score 2
Activity Unable to move extremities Moves 2 extremities voluntarily Moves all 4 extremities
Respiration Apnoea Shallow or limited breathing Deep cough / normal breathing
Circulation BP ±50% of baseline BP ±20–50% of baseline BP within ±20% of baseline
Consciousness Unresponsive Arousable on calling Fully awake
SpO₂ <90% on O₂ Needs O₂ to maintain ≥90% ≥92% on room air

Discharge when Aldrete score ≥ 9 (out of 10). A score of 8 requires continued observation and reassessment.

Discharge Criteria and Instructions

Patients may be discharged when ALL of the following are met:

  • Modified Aldrete score ≥ 9
  • Baseline mental status restored (oriented, age-appropriate behaviour in children)
  • Able to ambulate without assistance (age-appropriate)
  • Pain controlled (verbal pain score ≤ 4/10 or equivalent)
  • No nausea/vomiting or adequately controlled
  • No active bleeding from the procedure site
  • Tolerating oral fluids (in paediatric patients, able to keep down clear fluids)

Discharge Instructions for Patients / Carers

  • A responsible adult must escort the patient home and supervise for a minimum of 12 hours (24 hours for paediatric patients or after deep sedation).
  • Do not drive, operate heavy machinery, make important legal decisions, or consume alcohol for at least 24 hours following sedation.
  • Resume normal medications as directed by the treating team.
  • Take prescribed analgesia (e.g., paracetamol, ibuprofen) as directed for post-procedure pain.
  • Seek emergency care if persistent drowsiness, vomiting, difficulty breathing, or worsening pain occurs.

Reversal Agents

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Naloxone
Narcan® · Opioid reversal agent
Adult dose 40–100 µg (0.4–1 mL of 400 µg/mL) IV titrated every 2–3 min; repeat until respiratory depression reversed. IM: 0.4–2 mg if IV access unavailable.
Paediatric dose 1–10 µg/kg IV titrated every 2–3 min; neonatal: 10 µg/kg IV/IM/SC.
Onset / Duration IV onset 1–2 min, duration 20–45 min (shorter than most opioids — risk of re-sedation).
Renal adjustment No adjustment required.
Hepatic adjustment No specific adjustment; use with caution in severe hepatic impairment.
PBS status ✔ PBS General Benefit
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Flumazenil
Anexate® · Benzodiazepine reversal agent
Adult dose 200 µg IV over 15 sec; repeat 100 µg every 60 sec as needed to a max of 1 mg (total).
Paediatric dose 10 µg/kg IV (max initial 200 µg); repeat 10 µg/kg every 60 sec to max 40 µg/kg or 1 mg, whichever is lower.
Onset / Duration IV onset 1–2 min, duration 45–90 min. Re-sedation possible with long-acting benzodiazepines (e.g., diazepam).
Renal adjustment No adjustment required.
Hepatic adjustment Clearance reduced; lower doses and extended monitoring in hepatic impairment.
PBS status ✔ PBS General Benefit
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Caution with reversal agents: Naloxone and flumazenil have shorter durations of action than the agents they reverse. Patients must be monitored for re-sedation for at least 30–60 minutes after administration. Flumazenil is contraindicated in patients with long-term benzodiazepine dependence (risk of seizures) and in mixed overdose with pro-convulsant agents (e.g., tricyclic antidepressants). Reversal agents are not a substitute for adequate monitoring and airway management.

Pharmacological Agents for Procedural Sedation

Agent selection depends on the intended sedation level, procedure type and duration, patient factors, and clinician competency. The following agents are most commonly used in Australian practice.

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Midazolam
Hypnodorm® · Generic · Benzodiazepine
Indication Anxiolysis / minimal-to-moderate sedation; amnesia adjunct
Adult dose IV: 0.5–1 mg initially, titrate by 0.5 mg every 2–3 min (max single dose 2.5 mg; total max 5–7.5 mg). PO: 3.75–7.5 mg 30–60 min pre-procedure. IM: 0.05–0.1 mg/kg (max 5 mg).
Paediatric dose IV: 0.05–0.1 mg/kg (max 2.5 mg initial). PO: 0.25–0.5 mg/kg (max 20 mg). IN: 0.2–0.3 mg/kg (max 5 mg/dose).
Onset / Duration IV onset 1–3 min, peak 3–5 min, duration 15–60 min. PO onset 15–30 min.
Renal adjustment Active metabolite accumulates in renal impairment — use lower doses and monitor for prolonged sedation.
Hepatic adjustment Reduced clearance; reduce dose by 50% in moderate–severe hepatic impairment.
PBS status ✔ PBS General Benefit
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Fentanyl
Sublimaze® · Generic · Opioid analgesic
Indication Analgesic adjunct for moderate sedation (commonly combined with midazolam)
Adult dose IV: 0.5–1 µg/kg initially, titrate by 25 µg every 2–3 min (max initial dose ~50 µg). IN: 1.5 µg/kg per nostril.
Paediatric dose IV: 0.5–1 µg/kg (max initial 25 µg). IN: 1.5–2 µg/kg (max 75 µg per nostril).
Onset / Duration IV onset 1–2 min, peak 3–5 min, duration 30–60 min. IN onset 5–10 min.
Renal adjustment No specific adjustment; use with caution (reduced clearance in ESRD).
Hepatic adjustment Reduced clearance in severe hepatic disease; use lower doses.
PBS status ✔ PBS General Benefit
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Ketamine
Ketalar® · Generic · Dissociative anaesthetic
Indication Dissociative sedation for paediatric procedures; also used in adults; preferred agent for short painful paediatric procedures in Australian EDs
Adult dose IV: 0.5–1 mg/kg over 60 sec, titrate with 0.25–0.5 mg/kg increments. IM: 4–5 mg/kg.
Paediatric dose IV: 1–1.5 mg/kg over 60 sec. IM: 4–5 mg/kg (most common route in paediatric ED). Supplemental doses: 1–2 mg/kg IV or 2–4 mg/kg IM.
Onset / Duration IV onset 30–60 sec, duration 10–20 min. IM onset 3–5 min, duration 20–40 min.
Renal adjustment No specific adjustment; active metabolites may accumulate in severe renal impairment.
Hepatic adjustment Metabolised hepatically; reduced clearance in severe hepatic impairment — use lower doses.
PBS status ✔ PBS General Benefit
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Propofol
Diprivan® · Generic · Intravenous anaesthetic
Indication Deep procedural sedation (e.g., cardioversion, complex ED reduction, colonoscopy); requires airway-management competency
Adult dose 0.5–1 mg/kg IV bolus over 30–60 sec, titrate with 0.25–0.5 mg/kg increments. Infusion: 25–75 µg/kg/min if prolonged procedure.
Paediatric dose 1–2 mg/kg IV bolus; titrate. Typically used only by anaesthetists or credentialed emergency physicians for paediatric sedation.
Onset / Duration IV onset 15–30 sec, peak 60 sec, duration 3–10 min per bolus. Rapid recovery.
Renal adjustment No adjustment required.
Hepatic adjustment No specific adjustment; high hepatic extraction ratio.
PBS status ✔ PBS General Benefit (injection)
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Methoxyflurane
Penthrox® · Non-opioid inhalational analgesic
Indication Short-term analgesia for acute procedural pain (burns dressing, wound repair, fracture immobilisation, IM injections); pre-hospital and ED use
Adult dose Self-administered via Penthrox inhaler: 3 mL in device, patient inhales as needed. Typically 1 device = up to 1 hour analgesia. Second device may be used if activated charcoal scavenger attached.
Paediatric dose Approved ≥5 years in Australia. Same dosing. Child must be able to self-administer and follow instructions.
Onset / Duration Onset 6–10 breaths (approximately 1–2 min). Duration of effect ceases rapidly once inhalation stops.
Contraindications Malignant hyperthermia (personal/family history), hepatic impairment, renal impairment, concurrent nephrotoxic drugs, pregnancy (Category B3).
PBS status ✘ Not PBS
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Nitrous Oxide / Oxygen
Entonox® (50% N₂O / 50% O₂) · Inhalational analgesic
Indication Procedural analgesia and anxiolysis for brief painful procedures; dental procedures; labour analgesia; pre-hospital pain management
Adult dose Self-administered via demand-valve mask: continuous flow 10–15 L/min. Patient breathes mixture for 2–5 min before procedure; continues as needed.
Paediatric dose Approved ≥2 years in Australian facilities with appropriate scavenging. Concentration can be titrated (30% N₂O to 50% N₂O) in paediatric units.
Onset / Duration Onset 2–5 min. Offset within 3–5 min of cessation (rapid elimination via lungs).
Contraindications Pneumothorax, bowel obstruction, middle-ear occlusion, pneumocephalus, severe COPD, concurrent bleomycin therapy, pregnancy (first trimester — relative).
PBS status ⚑ Authority Required (hospital use; some community settings)

Common Agent Combinations

Fracture / dislocation reduction (adult)
Fentanyl 1 µg/kg + Midazolam 0.05 mg/kg IV; or Proceduralist-directed propofol
Single procedure
Hematoma block / regional anaesthesia as adjunct
Paediatric laceration / minor procedure
Ketamine 4–5 mg/kg IM; or IN fentanyl 1.5 µg/kg + topical local anaesthesia (EMLA / LMX4)
Single procedure
Ketamine preferred for uncooperative children
Burns dressing change
Entonox self-administered; or Penthrox inhaler; ± oral paracetamol + ibuprofen pre-medication
Throughout dressing change
Intranasal fentanyl may be added for paediatric burns
Cardioversion (ED)
Propofol 0.5–1 mg/kg IV (single bolus usually sufficient); or Etomidate 0.15 mg/kg IV
Single bolus — brief procedure
Deep sedation / GA level — full airway team required

Adverse Events & Management

Adverse events during PSA are common but usually minor if detected early and managed promptly. The most frequent adverse events are oxygen desaturation, hypotension, nausea/vomiting, and emergence reactions.

Adverse Event Common Cause Immediate Management
Hypoxia (SpO₂ <93%) Apnoea, airway obstruction, hypoventilation Increase FiO₂, jaw thrust/chin lift, NP airway, BVM ventilation, consider reversal agents
Apnoea Opioid or propofol overdosing; rapid IV push Bag-valve-mask ventilation, naloxone (if opioid), reduce/stop sedative infusion
Hypotension Vasodilation (propofol), relative hypovolaemia IV fluid bolus (250–500 mL NaCl 0.9%), Trendelenburg, metaraminol 0.5 mg IV
Laryngospasm Secretions, airway manipulation, light anaesthesia Positive-pressure ventilation with BVM (CPAP 20 cmH₂O), suction, deepen sedation, IV lidocaine 1 mg/kg; succinylcholine 1 mg/kg if refractory
Nausea / Vomiting Opioids, ketamine, gastric distension Lateral (recovery) position, ondansetron 4 mg IV (adults) or 0.1 mg/kg IV (paeds)
Emergence reaction Ketamine (particularly in adults >16 years) Reassurance in calm environment; midazolam 0.5–1 mg IV if severe; reduce external stimulation
Bradycardia Vagal response (paediatrics), hypoxia Oxygenation, atropine 10–20 µg/kg IV (min 100 µg, max 600 µg paediatric; 500–600 µg adult)
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Failed airway during PSA: If bag-valve-mask ventilation is inadequate and SpO₂ falls below 90% despite optimal positioning and airway adjuncts, activate the failed airway protocol: call for anaesthetic assistance, insert a supraglottic airway device, and prepare for emergency intubation or surgical airway. This is a rare but life-threatening complication that requires pre-planned escalation.

Special Populations

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Pregnancy

Fasting: Physiologically higher aspiration risk from 20 weeks gestation (reduced lower oesophageal sphincter tone, delayed gastric emptying). Treat as full stomach for PSA purposes.
Positioning: Left lateral tilt (15°) from 20 weeks to prevent aortocaval compression.
Agent selection: Midazolam (Category C — avoid in first trimester if possible), fentanyl (no established teratogenic risk), ketamine (avoid if raised intracranial pressure risk). Propofol is considered safe for short procedures.
Penthrox: Category B3 — avoid in pregnancy.
Monitoring: Continuous fetal monitoring for viable pregnancies (≥23 weeks) if the procedure is of sufficient duration; at minimum, document fetal heart tones pre- and post-procedure.
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Paediatrics

Preferred agent: Ketamine IM (4–5 mg/kg) is the gold standard for paediatric procedural sedation in Australian EDs — preserves airway reflexes, predictable dosing, and avoids the need for IV access.
IV access not required: IN fentanyl (1.5–2 µg/kg), IN midazolam (0.2–0.3 mg/kg), or IM ketamine are first-line in children to avoid distressing cannulation.
Dose calculation: Always calculate doses on actual body weight. Use Broselow tape or age-based emergency dosing charts as a safety check. Double-check with a second clinician before administration.
Emergence reactions: Rare in children (<5 years). More common in adolescents — consider co-administering midazolam 0.05 mg/kg IV to reduce incidence.
Monitoring: Same minimum standards as adults. Use paediatric-sized BP cuffs, pulse oximeter probes, and airway equipment. Capnography nasal cannulae are available in paediatric sizes.
Discharge: Children require a responsible adult carer for 24 hours post-sedation and must not return to school/childcare on the same day.
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Elderly (≥65 years)

Increased sensitivity: Reduced volume of distribution, decreased hepatic/renal clearance, and increased blood–brain barrier permeability lead to prolonged and exaggerated sedative responses.
Dose reduction: Reduce all sedative and opioid doses by 30–50%. Titrate slowly (small increments with longer observation between doses).
Preferred agents: Short-acting agents preferred (fentanyl over morphine, midazolam over diazepam). Propofol titrated carefully; avoid bolus dosing in frail elderly.
Falls risk: Prolonged sedation and ataxia increase post-discharge falls risk. Extended observation and a supervised discharge plan are essential.
Comorbidities: Higher prevalence of cardiac disease, COPD, and renal impairment — all influence agent choice and monitoring intensity.
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Renal Impairment

Midazolam: Active metabolite (α-hydroxymidazolam glucuronide) accumulates in renal failure — prolonged sedation expected. Use reduced doses; avoid in CKD stage 5 if alternatives available.
Morphine: Active metabolite (M6G) accumulates — avoid in eGFR <30 mL/min. Use fentanyl (no active metabolites) as the preferred opioid.
Ketamine: No significant renal adjustment required for single-dose procedural use.
Propofol: Safe in renal impairment; no adjustment needed.
Penthrox: Contraindicated in significant renal impairment (nephrotoxic potential).
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Hepatic Impairment

General principles: Reduced hepatic blood flow and enzyme activity prolong the half-life of most sedatives and opioids. Use lower doses and longer observation.
Midazolam: Clearance significantly reduced in cirrhosis — reduce dose by 50% and extend monitoring.
Propofol: High hepatic extraction ratio — generally safe as a single bolus for short procedures.
Fentanyl: Preferred opioid in hepatic impairment (short-acting, less affected than morphine). Use reduced doses.
Coagulopathy: If INR >1.5, consider haematology review before invasive procedures requiring sedation; ensure reversal agents (vitamin K, prothrombin complex concentrate) are accessible if needed.
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Immunocompromised

Neutropenic patients: Use strict aseptic technique for IV access; febrile neutropenic patients should not receive elective PSA without haematology/infectious-disease input.
Drug interactions: Calcineurin inhibitors (ciclosporin, tacrolimus) may interact with sedatives — monitor levels peri-procedure. Azole antifungals inhibit CYP3A4 — increased midazolam and fentanyl levels.
Pneumocystis/immunosuppression: Patients on long-term corticosteroids or biologics may have suppressed cortisol response — consider stress-dose hydrocortisone if deep/prolonged sedation is planned.
Infection control: Single-use equipment preferred. If reusable devices are used, ensure high-level disinfection per AS/NZS 4187.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health
Cultural safety & communication
Use Aboriginal and Torres Strait Islander health practitioners and interpreters when available. Explain the procedure, sedation process, and monitoring equipment in plain language. Obtain culturally appropriate informed consent, respecting the patient's right to involve family and community Elders in decision-making. Be aware of the significance of "sorry business" and gender sensitivity — same-gender clinicians may be preferred for intimate procedures.
Remote and rural access
Many Aboriginal and Torres Strait Islander peoples live in remote communities where specialist anaesthetic support, recovery facilities, and advanced airway equipment may be limited. The Royal Flying Doctor Service (RFDS) and Retrieval Services Queensland/Northern Territory coordinate aeromedical retrieval when deep sedation or general anaesthesia is required. In remote clinics, moderate sedation with midazolam/fentanyl or dissociative sedation with ketamine is often the highest level available; practitioners must be credentialled in the agents they use and confident in airway rescue.
Pharmacogenomics & metabolism
There is limited published data on pharmacogenomic differences specific to Aboriginal and Torres Strait Islander populations for sedative agents. Clinical practice should emphasise standard weight-based dosing with careful titration. Avoid assumptions about alcohol tolerance or drug metabolism; individual assessment is essential.
Chronic disease burden
Aboriginal and Torres Strait Islander Australians experience higher rates of chronic kidney disease (CKD), rheumatic heart disease, type 2 diabetes, and chronic liver disease — all of which affect sedative agent choice and monitoring. Pre-procedure renal and hepatic function should be reviewed where time permits. Patients with rheumatic heart disease undergoing procedural sedation require antibiotic prophylaxis considerations if endocarditis risk is present.
Children & paediatric sedation
Aboriginal and Torres Strait Islander children have higher rates of ear disease, dental caries, and skin infections requiring procedural intervention. Ketamine IM remains the preferred agent for paediatric procedural sedation in remote and regional settings. Ensure families/carers are fully informed and present during the recovery phase where culturally appropriate.
Alcohol & substance use considerations
Some patients may present with concurrent alcohol intoxication or withdrawal, affecting sedation depth, aspiration risk, and the need for higher sedative doses. Assess blood alcohol level and signs of withdrawal (CIWA-Ar). Alcohol withdrawal can mimic and compound sedation-related complications; manage with benzodiazepine protocols as indicated. Always use a non-judgemental, trauma-informed approach.

📚 References

  1. 1. Australian and New Zealand College of Anaesthetists (ANZCA). PS09: Guidelines on Sedation and/or Analgesia for Diagnostic and Interventional Medical, Dental or Surgical Procedures. Melbourne: ANZCA; 2023.
  2. 2. Australasian College for Emergency Medicine (ACEM). Guideline on Procedural Sedation in the Emergency Department. Melbourne: ACEM; 2023.
  3. 3. Australian Commission on Safety and Quality in Health Care (ACSQHC). National Safety and Quality Health Service (NSQHS) Standards. 2nd ed. Sydney: ACSQHC; 2021.
  4. 4. Bell A, Treston G, Cardwell R, Schabort W, Chand D. Optimization of procedural sedation in emergency departments. Emerg Med Australas. 2014;26(4):343–350.
  5. 5. Green SM, Roback MG, Kennedy RM, Krauss B. Clinical practice guideline for emergency department ketamine dissociative sedation: 2011 update. Ann Emerg Med. 2011;57(5):449–461.
  6. 6. Coté CJ, Wilson S; American Academy of Pediatrics; American Academy of Pediatric Dentistry. Guidelines for monitoring and management of pediatric patients before, during, and after sedation for diagnostic and therapeutic procedures. Pediatrics. 2019;143(6):e20191000.
  7. 7. Australasian Society of Clinical Immunology and Allergy (ASCIA). Adverse Reactions to Drugs and Biologicals — Position Paper. Sydney: ASCIA; 2023.
  8. 8. Healthdirect Australia. Penthrox (methoxyflurane) — Consumer Medicine Information. Canberra: Australian Government Department of Health; 2023.
  9. 9. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary Report. Canberra: AIHW; 2023.
  10. 10. Royal Australian College of General Practitioners (RACGP). Procedural Skills Guide for General Practice. Melbourne: RACGP; 2022.
  11. 11. Godwin SA, Burton JH, Gerardo CJ, et al. Clinical policy: procedural sedation and analgesia in the emergency department. Ann Emerg Med. 2014;63(2):247–258.e18.
  12. 12. Bhatt M, Johnson DW, Chan J, et al. Risk factors for adverse events in emergency department procedural sedation for children. JAMA Pediatr. 2017;171(10):957–964.
  13. 13. Thomsen MM, Rasmussen LS. Capnography during procedural sedation in the emergency department: a systematic review. Scand J Trauma Resusc Emerg Med. 2021;29(1):13.
for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.
Preventive health
Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction
Paracetamol ± NSAID; manual therapy
2–6 weeks
Provocable on palpation; no red flags
Thoracic compression fracture
Paracetamol; ± calcitonin; DXA + osteoporosis Rx
6–12 weeks healing
Elderly; osteoporosis; acute onset
ACS (posterior MI)
Aspirin 300 mg, GTN, heparin; urgent PCI
Time-critical
ECG, troponin; CV risk factors
Aortic dissection
IV labetalol; urgent CT aortogram; surgery (Type A)
Time-critical
Tearing pain; BP differential >20 mmHg
Vertebral osteomyelitis
IV antibiotics (vancomycin + ceftriaxone initially); ID consult
6 weeks IV antibiotics
Fever, elevated CRP, IV drug use
Biliary colic / cholecystitis
Paracetamol ± morphine; lap cholecystectomy
Surgical within 72 h (cholecystitis)
RUQ/infrascapular; post-prandial; RUQ US

📚 References

  1. 1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
  2. 2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
  3. 3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
  4. 4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
  5. 5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
  6. 6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
  7. 7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
  8. 8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
  9. 9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
  10. 10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
  11. 11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
  12. 12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.
for PBS-listed medicines at participating pharmacies.
Cultural safety
Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.
Medication adherence
Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.
Specific conditions
Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.
Referral pathways
Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

  1. 1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
  2. 2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
  3. 3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
  4. 4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
  5. 5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
  6. 6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  7. 7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
  8. 8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
  9. 9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
  10. 10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
  11. 11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
  12. 12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
  13. 13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).
for PBS-listed medicines at participating pharmacies.
Cultural safety
Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.
Medication adherence
Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.
Specific conditions
Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.
Referral pathways
Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

  1. 1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
  2. 2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
  3. 3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
  4. 4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
  5. 5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
  6. 6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  7. 7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
  8. 8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
  9. 9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
  10. 10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
  11. 11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
  12. 12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
  13. 13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).