A World Without Propofol

Emergency department procedural sedation does not begin and end with propofol. Ketamine, etomidate, dexmedetomidine, midazolam, and methohexital each fit different procedures, sedation depths, and hemodynamic profiles, while safe practice still hinges on consent, staffing, and capnography.

Non-Propofol Procedural Sedation

• Sedation privilege barriers: Deep sedation is often constrained by CMS-style hospital privileging, with anesthesia controlling access and a two-provider requirement that can block single-physician ED settings.
• Sedation planning essentials: Drug choice should match procedure length and onset time, and patients should be consented for deep sedation up front because moderate sedation can easily progress further.
• Monitoring that matters: Pulse oximetry lags behind apnea, especially on oxygen, so end-tidal CO2 with supplemental oxygen and 3-lead ECG is the real safety floor for moderate, deep, and dissociative sedation.
• Ketamine tradeoffs: Ketamine is hemodynamically stable and preserves airway reflexes, but it provides no muscle relaxation and often needs redosing with recovery monitoring that extends beyond 30 minutes.
• Etomidate sweet spot: Etomidate is a strong choice for brief deep procedures like cardioversion or joint reduction, with myoclonus or fasciculations seen in about 30% of cases.
• Dexmedetomidine niche: Dexmedetomidine offers moderate sedation with an unusually low apnea risk, making it useful for less painful procedures, though the setup and timing details are worth hearing in the episode.

Procedure-Specific Sedation Choices

• Recent meal hip reduction: For prosthetic hip dislocation soon after eating, ketamine is attractive because airway reflexes are maintained, but aspiration-risk documentation still matters if deep sedation is chosen.
• Pediatric facial laceration repair: Ketamine is particularly well suited for children needing painful facial repair, with a track record of good pediatric tolerability and titratable dissociation for longer work.
• Atrial fibrillation cardioversion: Etomidate is the default non-propofol option when cardioversion needs to happen fast, especially if the patient is hemodynamically unstable.
• Anxious lumbar puncture: Midazolam fits anxiolysis for a terrified lumbar puncture patient, but its slow onset makes it a poor standalone choice for moderate or deep procedural sedation. We get into the escalation options in the chapter.
• Fentanyl limitations: Fentanyl has a role as pre-procedure analgesia, but using it alone for sedation or stacking it with other sedatives raises the hypoxemia risk.

References:

1. Grégoire C, De Kock M, Henrie J, et al. Procedural Sedation With Dexmedetomidine in Combination With Ketamine in the Emergency Department. J Emerg Med. 2022;63(2):283-289. PMID: 35550843. 
2. Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018: A Report by the American Society of Anesthesiologists Task Force on Moderate Procedural Sedation and Analgesia, the American Association of Oral and Maxillofacial Surgeons, American College of Radiology, American Dental Association, American Society of Dentist Anesthesiologists, and Society of Interventional Radiology. Anesthesiology. 2018;128(3):437-479. PMID: 29334501
3. Green SM, Roback MG, Miner JR, Burton JH, Krauss B. Fasting and emergency department procedural sedation and analgesia: a consensus-based clinical practice advisory. Ann Emerg Med. 2007;49(4):454-461. PMID: 17083995
4. Godwin SA, Burton JH, Gerardo CJ, et al. Clinical policy: procedural sedation and analgesia in the emergency department [published correction appears in Ann Emerg Med. 2017 Nov;70(5):758]. Ann Emerg Med. 2014;63(2):247-58.e18. PMID: 24438649