Procedural sedation for adult and pediatric orthopedic fracture and joint reduction

SCOPE OF THE PROBLEM The closed reduction of fractures and dislocations presents an excellent situation in which to perform procedural sedation. Fracture and joint reductions involve a great deal more pain than the patient feels prior to or after the reduction. Procedural sedation should provide analgesia prior to and during the procedure, sedation, muscle relaxation, and procedural amnesia for these painful events. Proper sedation for these procedures has the additional benefit to the medical care provider(s) by optimizing patient relaxation to facilitate a successful reduction. Once a reduction has been completed, patients often have less pain than prior to the procedure owing to stabilization of the bone or joint. The use of long-acting sedative agents for procedural sedation, in combination with long-acting analgesics, may lead to patients who have unnecessarily extended periods of sedation particularly following the procedure when stimulus and pain are minimal. Such an extended period may lead to respiratory depression at a time when patient monitoring has been reduced. This concern, in addition to caregiver desires to shorten procedural sedation times in order to reduce the period of moderate or deep sedation and the duration of extensive staff patient monitoring, has led to significant changes in medical practice in favor of shortacting sedation agents. CLINICAL ASSESSMENT Both the urgency of the patient’s requirement for fracture or joint reduction and the patient’s current and preexisting medical conditions must be considered prior to procedural sedation. The depth and timing of sedation should achieve an optimal balance for the patient’s needs, risk of the procedure and/or delays to the procedure, and risk of sedation.