REVIEW ARTICLE Page | 11

Procedural sedation analgesia

Saad A. Sheta
A B S T R A C T
Oral Maxillofacial Department,
Dental College, King Saud The number of noninvasive and minimally invasive procedures performed outside of
University, KSA B.O. 80169 the operating room has grown exponentially over the last several decades. Sedation,
Riyadh 11545, Saudi Arabia analgesia, or both may be needed for many of these interventional or diagnostic
procedures. Individualized care is important when determining if a patient requires
procedural sedation analgesia (PSA). The patient might need an anti-anxiety drug,
pain medicine, immobilization, simple reassurance, or a combination of these
interventions. The goals of PSA in four different multidisciplinary practices namely;
emergency, dentistry, radiology and gastrointestinal endoscopy are discussed in this
review article. Some procedures are painful, others painless. Therefore, goals of PSA
vary widely. Sedation management can range from minimal sedation, to the extent
of minimal anesthesia. Procedural sedation in emergency department (ED) usually
requires combinations of multiple agents to reach desired effects of analgesia plus
anxiolysis. However, in dental practice, moderate sedation analgesia (known to the
Address for correspondence: dentists as conscious sedation) is usually what is required. It is usually most effective
Prof. Saad Sheta, with the combined use of local anesthesia. The mainstay of success for painless
Consultant Anaesthetist, imaging is absolute immobility. Immobility can be achieved by deep sedation or
Oral Maxillofacial Department, minimal anesthesia. On the other hand, moderate sedation, deep sedation, minimal
Dental College, King Saud anesthesia and conventional general anesthesia can be all utilized for management of
University, B.O. 6 0169
gastrointestinal endoscopy.
Riyadh 11545, Saudi Arabia.
E-mail: [email protected] /
[email protected] Key words: Conscious sedation, deep sedation, minimal anesthesia, procedural
sedation
www.saudija.org DOI: 10.4103/1658-354X.62608

• Minimizing patient’s motion during the procedure;

INTRODUCTION
• Maximizing the chance of success of a procedure; and
The number of noninvasive and minimally invasive returning the patient to presedation state as quickly as
possible
procedures performed outside of the operating room
has grown exponentially over the last several decades.[1]
The indications for procedural sedation can vary from
Sedation, analgesia, or both may be needed for many patient to patient, based on anxiety level and pain
of these interventional or diagnostic procedures. With associated with the procedure[3] [Table 1]. Individualized
the introduction of shorter-acting sedatives for sedation care is important when determining if a patient requires
and opioids for pain control, specific reversal agents for procedural sedation. The patient might need an anti-anxiety
both opioids and benzodiazepines, and the availability of drug, pain medicine, immobilization, simple reassurance,
noninvasive monitoring equipment, procedural sedation or a combination of these interventions.
can now be safely administered in many healthcare
settings.[2] The purpose of this mini-review is to substantially advance
our understanding of the goals of PSA in four different
Various procedures that require procedural sedation are multidisciplinary practices namely; emergency, dentistry,
better served by considering the goals of procedural radiology and gastrointestinal endoscopy. There, some
sedation and determining if a particular patient requires procedures are painful, others are painless. Therefore, goals
pharmacological intervention to meet the following goals of PSA vary widely. Sedation management can range from
during a procedure.[3] minimal sedation, to minimal anesthesia.

• Patient safety; Sedation and analgesia introduces an independent risk

• Minimizing pain and anxiety associated with procedure; factor for morbidity and mortality in addition to the

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 Sheta: Procedural sedation analgesia
Page | 12
Moderate sedation: There is a depression of consciousness,
Table 1: Selected indications for procedural
sedation
but patients in this state can respond appropriately to
verbal commands, either alone or in conjunction with light
Dental procedures
tactile stimulation. The patient is able to maintain an airway
Flexible fiber optic laryngoscopy and bronchoscopy
Laceration repair in children
independently, ventilation is adequate, and cardiovascular
Bone marrow aspiration
function is usually unaffected by drugs administered
Burn debridement/major abrasion cleaning (“road rash”)
Deep sedation: Patients in this state are not easily awakened,
Cardiac catheterization
but they respond purposefully (they do not simply
Cardio version (elective)
withdraw) after repeated or painful stimulation. These
Endoscopy
patients may require assistance maintaining an airway and
Fracture reduction/dislocation reduction
adequate ventilation, but normal cardiovascular status is
Interventional radiology procedures
usually sustained as long as ventilation is appropriate
Thoracentesis
Thoracotomy/chest tube placement
These revised definitions replace the popular but misused
term “conscious sedation,” as this level of sedation (as
procedure itself.[4] An anesthetist-led service is ideal but is defined by the AAP in 1985)[10] is insufficient for most
a scarce resource. Safe protocols and sedation guidelines painful procedures, especially in children.
are beyond the scope of this review because these have
been covered extensively elsewhere.[5-10] Nonetheless, it is The term procedural sedation has emerged by The American
mandatory to emphasize that if anesthetists cannot provide College of Emergency Physicians (ACEP). Procedural
a service, then others will need training, support and sedation defines as “a technique of administering sedatives
monitoring, ideally from the local anesthetic department. or dissociative agents with or without analgesics to induce a
The Joint Commission on Accreditation of Healthcare state that allows the patient to tolerate unpleasant procedures
Organizations (JCAHO) recognizes the risks involved while maintaining cardio respiratory function. PSA is
with sedation and analgesia for procedures and mandates intended to result in a depressed level of consciousness
that sedation practices throughout an institution be that allows the patient to maintain oxygenation and
monitored and evaluated by the department of anesthesia. airway control independently.” [9] Understanding the
The American Society of Anesthesiologists (ASA) has various depths of sedation is essential to provide safe and
responded to this challenging responsibility by developing effective procedural sedation and analgesia. According
practice guidelines for non-anesthesiologists who provide to the ASA guidelines, most procedural sedation falls
sedation and analgesia.[8] within the level of moderate sedation/analgesia although
very painful procedures may require deep sedation/
analgesia. The current definition of deep sedation is
SEDATION DEFINITIONS
considered gray. There are, however, important aspects
Sedation is a technique where one or more drugs are used of sedation in uncooperative children that are not covered
to depress the central nervous system of a patient thus by the standard definitions and guidelines. With respect
reducing the awareness of the patient to his surroundings. to successful painless imaging, the essential element is
immobility and, in uncooperative children, the key status
Many professional organizations have published sedation is sleep. Therefore, the terms “sleep sedation” or “safe
definitions and guidelines, the most prominent being the sleep” was evolved and defined as ‘the patient is not
American Academy of Pediatrics (AAP),[5] the American easily roused but the technique has a safety margin wide
College of Emergency Physicians (ACEP),[6] the American enough to render the loss of airway and breathing reflexes
Society of Anesthesiologists (ASA),[8] and the American unlikely’.[11] Sedation drugs have a wide margin of safety, but
Academy of Pediatric Dentistry (AAPD).[7] The ASA are typically weak, and do not always succeed. Occasionally,
revised and updated its guidelines to include a definition of they cause prolonged unconsciousness usually because of
the continuum of sedation that occurs when sedative and excessive doses. Anesthesia drugs, in contrast, are ideal
analgesic medications are administered.[2,9] From lightest because they are potent and short acting, and doses can be
to deepest sedation, the levels are: gradually increased to achieve success. If anesthetic doses
are used to induce an unarousable sleep, lasting only a few
Minimal sedation (anxiolysis): In this state, the patient can minutes, subsequent doses could be used that are so low or
respond to verbal commands and may have some cognitive subanesthetic that, although the individual remains asleep,
impairment, but there is no effect on cardiopulmonary they may be indeed being rousable. Furthermore, in this
status state, appreciable effects upon vital reflexes are unlikely and

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 Sheta: Procedural sedation analgesia
Page | 13
recovery is rapid. The terms ‘light anesthesia’[12] or ‘minimal management. All dentists should be able to communicate
anesthesia’[13,14] may be appropriate for such techniques. well with their patients. If sedation deemed necessary,
moderate sedation analgesia (known to the dentists as
PROCEDURAL SEDATION ANALGESIA IN THE EMERGENCY conscious sedation) is usually what is required.[7,20] It is
DEPARTMENT usually most effective with the combined use of local
anesthesia. In dentistry, sedation techniques are not pain-
The success of the physician in management of several control techniques and are often overridden when the
painful procedures that may present to emergency patient experiences intraoperative pain.[7] To overcome
department (ED) can be hindered by patient discomfort. these circumstances with sedative agents alone requires
Value exists in techniques that allow for alleviating the use of very high doses or the addition of a narcotic to
pain and anxiety of the patient undergoing a low-risk the regimen thus producing deeper levels of sedation than
procedure while minimizing adverse effects and recovery might be required together with the increasing possibility
time; therefore procedural sedation can be a useful tool in of side effects. Techniques should not be used simply to
emergency department. escape the need to inject a local anesthetic.[7,20]

Procedural sedation in ED usually requires combinations Dental sedation can be provided in the office sitting, to
of multiple agents to reach desired effects of analgesia the patient and he/she allowed home in the same day of
plus anxiolysis. Various drugs are available to provide surgery and they are commonly performed in a facility away
procedural sedation.[4] A short-acting benzodiazepine (e.g., from the proper hospital setting.
midazolam), either alone or in combination with an opioid
analgesic (e.g., fentanyl, morphine), is commonly selected With the exception of extensive oral and maxillofacial
for procedural sedation.[15] Evidence in the literature is surgery, most dental procedures are minimally invasive,
emerging that also supports the use of other sedatives generally result in little blood loss, and at most elicit pain that
(e.g., etomidate, propofol) for procedural sedation.[16-18] can be adequately controlled with oral analgesics.[7] Common
Etomidate is gaining popularity because it elicits minimal indications for office-based sedation are; young children,
hemodynamic effects and has a very reliable onset of
stressful procedures (such as third molar extraction (most
action[16]. Ketamine results in a dissociative state, and
common), complex periodontal procedures, recently dental
patients may not be able to speak or respond purposefully
implants), behaviorally and medically challenged patients.[7]
to verbal commands.[16,18] Ketamine is typically not used
in adults because of frequent association with emergence
The use of drugs to help patients deal with their fears has
delirium; however, ketamine is used frequently in the
been extensively researched and a number of techniques
pediatric population, where this effect is not typically
have become established in dental practice throughout the
elicited.[9] The use of propofol and ketamine as single agents
for procedural sedation and analgesia in the ED has grown world. These are, first, oral sedation with benzodiazepines;
in popularity.[18] The reasonable premise behind ketofol is second, inhalational sedation with nitrous oxide; and third,
that the two agents ketamine and propofol are theoretically intravenous sedation with midazolam alone or with an
synergistic. The sympathomimetic properties of ketamine analgesic.[7]
should mitigate propofol-induced hypotension, whereas at
the same time propofol might counteract the nauseant and A number of more innovative sedation techniques have
psychic recovery effects of ketamine.[18] been investigated in recent years, including polypharmacy,[21]
intravenous sedation in children,[22,23] inhalational sedation
Fospropofol (Aquavan; MGi Pharma, Bloomington, Minn) with sevoflurane,[24,25] trans-mucosal or intranasal sedation,[26]
is a water-soluble prodrug of propofol currently in clinical intravenous sedation with propofol and dental sedation
trials for mild to moderate sedation. However, its clinical with dexmedetomidine.[27] New concepts in sedation for
use in procedural sedation and analgesia remain to be seen, dentistry include enhanced mechanisms for drug delivery
as it exhibits a longer elimination half-life, larger volume of such as target controlled minfusion (TCI) and Patient
distribution, and slower onset of action than propofol.[19] controlled sedation (PCS).[28]

PROCEDURAL SEDATION ANALGESIA IN DENTISTRY PROCEDURAL SEDATION ANALGESIA FOR

(OFFICE-BASED DENTAL SEDATION) GASTROINTESTINAL ENDOSCOPY

The main goal of sedation in dentistry is to combat anxiety. Goals of procedural sedation for management of
The mainstay of the treatment of anxiety is behavioral gastrointestinal endoscopy vary from one case to another.

Saudi J Anaesth Vol. 4, Issue 1, January-April 2010

 Sheta: Procedural sedation analgesia
Page | 14
Moderate sedation, deep sedation, minimal anesthesia and sedation or minimal anesthesia.
conventional general anesthesia can all be utilized.
Natural sleep is only sufficiently reliable in infants under
Moderate sedation is possible[29] again, if the child is not 6 months old who will often sleep after a feed and if they
cooperative, deeper sedation is necessary. Combinations of are warm (the ‘feed and wrap’ technique).[13] Older children
midazolam, fentanyl and ketamine are useful but must be may sleep naturally after melatonin, but this is probably not
used with caution.[30] Even with good judgment, there is a reliable enough to be practical.[40]
risk of laryngospasm[31] and hypoxia.[32] Recovery is usually
prolonged and naloxone and flumazenil are often needed.[29] Regardless of potential side effects,[41] large doses of oral
chloral hydrate or triclofos (50- 100 mg/kg, maximum dose
General anesthesia, favored by anesthetists, has been shown 1 g) reliably causes sleep lasting 30-60 minutes in 95% of
to provide safer operating conditions than sedation.[33] but children below 15 kg and are effective for MR imaging.[42]
is perceived, by endoscopists, as being expensive because it Deep sedation for uncooperative children over 15 kg can
requires specialized personnel.[32] However, the short-acting be difficult. The volume of chloral required often causes
nature of propofol[34,35] and sevoflurane.[36] can reduce costs vomiting and benzodiazepines alone are usually insufficient
for scans that need prolonged sleep. Dexmedetomidine
because recovery time is shorter. Anesthesia avoids the
shows promise because it seems to preserve rousability.
considerable expense of sedation failure. Colonoscopy
It has to be infused intravenously and has been combined
causes pain from bowel distension, which may serve to
with either midazolam[43] or chloral.[44]
warn of colonic perforation. Anesthesia reduces colonic
tone and therefore deep sedation may be safer in this Propofol is the ideal intravenous ‘minimal’ anesthetic. After
respect. a standard induction dose, maintains an immobile sleep in
almost all children.[14] Appreciable airway effects occur in
Minimal anesthesia with an initial bolus of propofol 1-2% but these should only need simple support measures.
(2-3 mg/kg)) will suppress the gag reflex in upper Occasionally, propofol alone does not suppress involuntary
gastrointestinal endoscopy sufficiently for insertion of the movements,[45] but a recent report confirms that propofol
scope and smaller bolus doses or an infusion are effective does not trigger epileptiform cortical electric activity in
thereafter.[35,37] Supplementary opioids are not usually epileptic children.[46]
necessary. Anesthesia for upper endoscopy may not require
tracheal intubation as diagnostic procedures can take less Pentobarbital (up to 5 mg/k) is regarded as a safe
than 10 min and do not cause appreciable unpleasant after intravenous sedative in North America; however, significant
effects. Two safety points need emphasis: the endoscope numbers of children have airway obstruction or paradoxical
can compress and obstruct the trachea (especially in excitement.[47] Thiopentone is a reliable drug for short
infants)[37,38] and achalasia is very dangerous (the esophageal scans.[48] Sevoflurane and other vapors can be given so
residue should be drained before any sedation or anesthesia that, after induction, the children can be positioned so
is given). Tracheal intubation is much safer in these two that airway support is unnecessary.[13,14] Control of inspired
situations. Also anesthesia for endoscopy, lasting 15-30 min, concentrations is imprecise, but endtidal concentrations
may be easier with an airway device; facemasks or laryngeal guide vaporizer settings. Scavenging could be achieved via
masks are available that have a port for the endoscope.[39] a transparent plastic hood. Ketamine can cause involuntary
movements that spoil the images; it also causes vomiting
In literature, reports discussed providing minimal and distressing hallucinations.[13,14]
anesthesia in gastrointestinal endoscopy are mostly
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Source of Support: Nil, Conflict of Interest: None declared.
2006;61:1040-7.

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