ESA Guidelines on Procedural Sedation and Analgesia in Adults

ESA Guidelines on Procedural Sedation and Analgesia in Adults

  • Issue 71

Massimo Lamperti

During Euroanaesthesia 2017 in Geneva, the members of the Taskforce created by the ESA Guidelines Committee and the European Board of Anaesthesiology Council presented the guidelines on procedural sedation and analgesia in adults. The need to have evidence-based guidelines grew from two main issues: first, the reported incidence of adverse events, mainly related to the administration of propofol by non-anaesthesiologists, leading to too-deep levels of sedation and potentially life-threatening events without the ability to manage these complications;[1] second, the increasing demand for providing sedation for different procedures performed in the operating rooms as nerve blocks or in settings outside the operating rooms when the actual and future number of anaesthesiologists in most of the European countries is declining and the allowed working hours have been reduced to increase patients’ safety.

The main goal of these guidelines was not to publish a detailed legal document that could applied in the different European countries defining which drugs can or cannot be used by non-anaesthesiologists or who can be considered privileged to deliver this kind of sedation.

These guidelines took a long time before their final publication as they are based on an extensive number of scientific papers that have been analysed according the GRADE method[2] or whenever the evidence was poor according a RAND-Delphi[3] consensus among the taskforce members.

The Taskforce clarified the definition of procedural sedation and analgesia (PSA) as it involves the use of a hypnotic and/or analgesic drug to allow the performance of a diagnostic or therapeutic procedure, whilst the patient is closely monitored for potential adverse effects as his/her consciousness is impaired in this period. Only understanding the potential risks related to this procedure could we select the patients properly and allow the use of certain drugs and provide the privileges to whoever is involved or is required to perform PSA. The real gap in the literature was to consider the potential risks of sedation related to specific drugs and in particular propofol, while these guidelines are focusing on how to deliver PSA in a safe way considering the overall process.

The main topics examined in the guidelines are: a) proper selection of patients, providing specific and overall risk scores that will guide the choice of drugs and sometimes could also contraindicate the procedure itself if the airways or the haemodynamics of the patient can be compromised, b) mandatory requirements necessary to perform PSA, c) how to recover patients after sedation before discharging them home, and d) a syllabus on how to train and then evaluate non-anaesthesiologists before licensing them with the privileges for performing PSA independently.

The mandatory requirements do not include only the minimal monitoring that needs to be in place when performing PSA but also the need for a specific and adequate location where PSA needs to be done and the mandatory supplies to manage potential adverse events including a code blue tray and a difficult airway cart. The advanced skills to help during resuscitation manoeuvers required from the personnel involved during PSA are essential to avoid medico-legal and clinical consequences in case of unpredicted adverse events.

The Taskforce clearly stated in these guidelines that the person in charge for PSA cannot be the same person performing the procedure as, in case of an emergency, there will be no one in charge for the emergency as the proceduralist could still be busy.

There is no detailed description of which drugs can or cannot be suggested for PSA. All drugs used during PSA can potentially cause adverse events such as over-sedation or respiratory depression if the personnel involved are not specifically trained on their use.

The guidelines not only refer to procedural sedation are related to endoscopic procedures even if most of the literature comes from this area, but they are valid for any procedure requiring reduction of consciousness for any reason.

The aim of these guidelines is to inform and alert that PSA is safe if handled in the proper way and to create a professional training path that will be able to certify and provide privileges to perform PSA to non-anaesthesiologists whenever they are asking or are already providing PSA. The role of the anaesthesiologist is to not only advise anaesthesia trainees on the potential risks related to PSA, but also training and tutoring non-anaesthesiologists on how to manage patients before, during, and after the sedation. Placing barriers to who is privileged to perform PSA is not protecting our profession but it could impair patients’ safety.

1. Bhananker SM, Posner KL, Cheney FW, et al. Anesthesiology 2006;104:228–34.
2. Guyatt G, Rennie D, Meade M, et al. Brit Med J 2008;336:924–6.
3. Fitch K, Bernstein SJ, Aguilar MD, et al. The RAND/UCLA appropriateness method user’s manual. Santa Monica, CA: RAND Corporation; 2001. Available at: