Adult procedural sedation: an update

The increasing request for procedural sedation will create in the upcoming future the need for a specific training in delivering care to patients in a continuum of sedation, whose effects and adverse events are unpredictable. The main debate in the past years has been focused on using drugs that could have few adverse effects and could be considered well tolerated when administered by a nonanaesthesiologist. Propofol remains the most used drug for procedural sedation, but given its side-effects, its administration is limited and suggested only when an anaesthesiologist is available. The main studies recently appearing in the literature are focusing on the use of alternative drugs such as dexmedetomidine, remifentanil, fospropofol, ketofol and remimazolam. The current study is an overview of the different fields of procedural sedation, describing the evidence from the published studies and some upcoming studies.

Propofol is still considered as the drug of choice, and a recent study on its administration in the emergency department by nonanaesthesiologists has revealed a reduced number of adverse events. Dexmedetomidine is considered, at present, the most commonly used alternative to propofol, given its greater safety in terms of haemodynamic stability and lack of respiratory depression. Remifentanil has been suggested as the 'solo' drug during procedural sedation by target-controlled infusion, but it needs a controlled environment and skilled practitioners. Fosprofol and ketofol are new alternatives, but convincing studies that could support their wider use are absent. Remimazolam is another alternative whose efficacy is still to be determined. Most of the studies in the literature are debating on the training that the 'proceduralist' should undergo to deliver sedation safely and to manage any kind of adverse effect caused by it.

Recent studies on procedural sedation are still debating on the use of propofol by nonanaesthesiologists and are exploring the use of other sedatives and analgesics. The main goal in the future should be to have a clear curriculum on the role of the 'sedationalist' outside the operating room.