I did a primer episode on the 2026 ACEP Sedation Guidelines a few days ago. I promised a follow-up with on the of the guideline’s authors:
Mark Roback, MD
Dr. Mark Roback is a Professor of Pediatrics at the University of Colorado School of Medicine and performs Leadership Development and Coaching services in the Section Head of Emergency Medicine at Children’s Hospital Colorado (CHCO). He spends his clinical time caring for ill and injured children in the Emergency Departments of CHCO. Dr. Roback’s primary academic interest is procedural sedation. His sedation research has focused on developing best practice for ketamine sedation for children, on defining and identifying risk factors for sedation-related adverse events as well as developing benchmarks for outcomes of procedural sedation. As a member of the multidisciplinary International Committee for the Advancement of Procedural Sedation (ICAPS) and ACEP Procedural Sedation Writing Group, Dr. Roback also participates in consensus-based procedural sedation policy statement development. He is a frequent national and international speaker on procedural sedation for children.
Questions we Covered
- Where was the ASA in all of this?
- Was adopting the fasting guideline from ICAPS a step backwards?
- ICAPS has done enormous work in this space, but do you worry that emergency medicine and critical care are being lumped together with proceduralists who do not have the same airway and resuscitation skill set?
- When your guidelines discuss removing things like ASA status, I say great, but then the hospital guidelines never change–how do we move the needle?
- What should we actually be asking or examining for to screen for obstructive sleep apnea? — scores?
- Supplemental O2 is a difficult ?. The evidence doesn’t clearly support a practice that clinically gives an attractive safety margin before having to ventilate pts–how did you folks walk that line.
- You and I have both watched the field struggle with the artificial distinction between deep sedation and general anesthesia. Is it time to admit that emergency physicians sometimes (often) intentionally provide general anesthesia for procedures?
- What do you think about intentionally incorporating noninvasive ventilation into procedural sedation for selected high-risk patients?
- Same question for high-flow nasal cannula.
- What do you think about planned pharmacologic reversal as part of the sedation strategy? For example, deliberately using an opioid or benzodiazepine with the expectation that you may reverse it at the end of the procedure.
- Does TROOPS allow for any of these?
- For long procedures, should we move away from repeated boluses and toward targeted infusions?
- Where does planned procedural intubation fit into all this? Are there cases where the safest sedation strategy is simply to induce anesthesia, intubate, perform the procedure, and extubate afterward if possible?
- How do you think FDA labeling interferes with rational procedural sedation practice? Are there medications whose labels are badly out of sync with how we know they can be safely used?
- What should a modern hospital sedation governance structure actually look like? Who should own it?
- If you could change one regulatory barrier around procedural sedation tomorrow, what would it be?
