Environment, equipment, monitoring and documentation

Whilst the use of 50% nitrous oxide/oxygen mixtures +/- opioids is generally safe throughout the ED you should ensure procedural sedation takes place in either the resuscitation room or another area with advance life support equipment. Such facilities are outlined in table 7.

Table 7: Resuscitation room facilities (as per RCoA/RCEM joint document)
  • Full resuscitation equipment for the administration of basic and advanced life support. Equipment and drugs should be checked daily, and after each use. That such checks have occurred should be routinely recorded
  • Difficult airway equipment
  • Continuous high flow oxygen with appropriate devices for administration
  • High pressure suction with appropriate suction catheters
  • A trolley capable of being tipped head down
  • Monitoring: Pulse oximeter, ECG, NIBP and continuous quantitative capnography
  • Appropriate range of intravenous cannulae
  • An appropriate range of intravenous fluids and infusion devices
  • Manual handling devices

ACEP policy5 would suggest that your staff record the patient’s vital signs (pulse rate, blood pressure, respiratory rate and oxygen saturations) before, during and after the procedure. There is no guidance in the literature as to how often; every five minutes is probably practical. Several exemplar charts are available on the RCEM website, click here for an example. Capnography monitoring and supplementary oxygen is recommended for patients in which conscious sedation or beyond is targeted. Perform a ‘timeout’ before starting the procedure: a checklist of right patient, right side, monitoring, equipment, personnel, plan A, plan B etc.