SAFE SEDATION

(Moderate Sedation, Conscious Sedation)

A SELF STUDY GUIDE

Page Contents: Etomidate 18

Introduction/ overview ----------------------- 2 Ketamine 19
Sedation competency requirements---------- 2 Narcotics (Opioids) 20
Moderate Sedation (Safe Sedation) 3 Morphine 20
Definitions --------------------------------- ---- 3 Fentanyl (Sublimaze) 20
Equipments – 4444 4 Meperidine 20
Monitoring 5 Hydromorphone 21
Level of consciousness 5 Reversal Agents 21
Pulse Oximetry 6 Naloxone (Narcan) 22
End tidal CO2 6 Flumazenil (Anexate) 22
EKG 6 Special Consecrations 23
Noninvasive Blood Pressure Monitoring 6 Sedation for Pediatric Patient 24
Patient Care and Planning 6 Pediatric Anatomy and Physiology 24
Pre-sedation assessment 6 Complications of pediatric sedation 25
ASA classification 6 Contraindications to sedation 25
Airway assessment 7 Practicalities for Children 25
Consent 8 Sedation for Elderly Patient 26
Patient education 8 Physiologic Changes in the Elderly 26
NPO/ Fasting requirements 8 Sedation for Pregnant Patient 27
Patient care during conducting safe sedation 9 Lactating woman 28
Pre-induction events 9 Airway management 29
Oxygen administration 9 Airway Assessment 30
Responsibilities 9 Oxygen Therapy 30
Documentation 9 Airway Devices 31
Monitoring 10 Appendices 32
Post sedation care (Discharge Criteria) 10 Flowcharts for airway obstruction 32
Complications and emergency interventions 11 Flowcharts for laryngospasm 33
Over and under-sedation 12 Flowcharts for apnea 34
Respiratory Complications 12 References 35
Cardiac Complications 12
Sample Discharge Instructions 13
What to expect 13
Pharmacology of Sedatives & Analgesia 14
Pharmacology and drug administration 15
Administration of intravenous medications 15
Single dose injection "titration to effect 15
The bolus technique 15
Continuous infusions 15
Drug classes and medications 15
Benzodiazepines 16
Midazolam (Dormicum) 16
Diazepam (Valium) 17
Chloralhydrate 17
Other Sedative Hypnotics 18
Propofol 18
 SAFE SEDATION
(Moderate Sedation, Conscious Sedation)
A SELF STUDY GUIDE

INTRODUCTION/ OVERVIEW The course objectives are designed to enable the

Diagnostic and surgical procedures are being participant to:
performed in a variety of settings throughout the 1. Prepare patients for sedation, including performing
hospital. Safe Sedation (Moderate a pre-sedation assessment,
sedation/analgesia formerly known as conscious acquiring consent, and developing an individualized
sedation) was exclusively performed by plan for sedation;
anesthesiologists, but it is now a common practice 2. Perform procedural sedation safely and effectively
for non-anesthesiologists doctors & nurses. adhering to regulatory guidelines
However, it must be accepted that these techniques 3. Plan for and address special patients' needs and
also have the potential to cause life-threatening appropriately respond to emergency situations;
complications. 4. Monitor patients during post-sedation recovery to
ensure safe emergence from sedation, and
Moderate sedation allows a patient to tolerate an 5. Discharge patients appropriately after recovery.
unpleasant procedure while maintaining
consciousness and cooperation. Many of the sedation competency requirements
pharmacologic agents used will provide mood 1. Knowledge of safe sedation material
alteration and partial amnesia. The patient does not I. Pre-sedation Patient Care and instructions;
remember the majority of the procedure and indications and contraindications
awakens in a comfortable, composed state. The II. Post sedation Care and instruction; potential
choice of medications used depends on the complications/side effects
objectives desired; some medications will provide III. Patient selection, assessment, monitoring
an elevation in the patient's pain threshold, while IV. documentation
others have no analgesic properties. A number of 2. Written test with more than 80% pass score
procedures such as; repair of complex lacerations, 3. Licensure
reduction of fractures and casting, wound care, I. Current active, unrestricted HAAD license
abscess incision and drainage, lengthy,
II. Current BLS, and for physicians ACLS or PLAS
uncomfortable radiologic studies, such as
bronchoscopy, endoscopy, cardiac studies, and
pacemaker placement addition to local and
moderate sedation has been used with analgesics.

This course is designed to strengthen your

competence and confidence in administering
moderate sedation for both adult and pediatric
patients and also emphasis some flow flowcharts
for how to rescue patients at whatever level of
sedation is achieved either intentionally or
unintentionally.
This guide includes indications/contraindications
for safe sedation, accepted medications,
administration guidelines, and the hospital's Safe
Sedation Policy.
 SAFE SEDATION
(Moderate Sedation, Conscious Sedation)
A SELF STUDY GUIDE

Moderate SEDATION (SAFE SEDATION) Moderate sedation: describes a state where a

Who is a candidate? purposeful response to verbal commands either
Any patient undergoing an invasive or alone (conscious sedation), or accompanied by light
noninvasive Procedure that does not require tactile stimulation, is maintained. Moderate
general anesthesia but sufficiently unpleasant or sedation is generally achieved when there is an onset of
uncomfortable. slurred speech.
q Response to verbal stimulation purposefully.
There are exceptions and limitation for these procedures. q Airway is patent.
The approved exceptions by the American q Spontaneous ventilation is preserved.
Society of Anesthesiology (ASA) are: q Cardiovascular function unaffected.
q No or minimal intervention is required.
1. Patients receiving inhalational and or other Deep sedation: uses medication to induce a
anesthetics, administered by anesthesiologists. controlled state of more depressed consciousness in
2. Patients receiving analgesia for post-operative pain which the patient may experience partial or complete
control. loss of protective reflexes including the ability to
3. Patients received premedication ordered by an independently and continuously maintain a patent
anesthesiologist in preparation for an operative airway. The deeply sedated patients are not easily
procedure aroused and do not purposefully respond to verbal
commands or gentle touch but will response to
4. Patients intubated and or ventilated in intensive care
painful physical stimulation. It may be accompanied
units.
by clinically significant ventilatory depression. The
While there are some limitation including:
patient may require assistance maintaining a patent
1. Duration of the procedures, which should not
airway, and positive pressure ventilation. This deep
that last more than 60 minutes sedation may only administer by anesthesiologists.
2. Blood loss, procedures should be with minimal
q Patient is not easily aroused, needs repeated
blood loss
painful stimulation.
3. Procedure should not constitute any threat to
q Often require assistance to maintain airway.
patient life
q Spontaneous ventilation is inadequate and
often needs support.
Definition
The Joint Commission defines moderate q Cardiovascular function may require support.
sedation/analgesia as "a drug-induced depression of General anesthesia: the patient will not even respond
consciousness while patient still be able to respond to painful stimulation. Ventilatory function and
purposefully to verbal commands either alone or cardiovascular stability are often impaired and
accompanied by light tactile stimulation. No require support. The patient needs active assistance to
interventions are required to maintain a patent airway, maintain the airway patent and or positive pressure
and spontaneous ventilation is adequate. Cardiovascular ventilation.
function is usually maintained. q NO response even to painful stimulation.
The American Society of Anesthesiologists (ASA) q Airway is lost
defines three levels of sedation q Inadequate ventilatory function
Minimal sedation: is a drug-induced state during which q Ventilation needs assistance with positive pressure
the patient responds normally to verbal commands.
ventilation.
Cognitive function and physical co-ordination may be
impaired, but airway reflexes, and ventilatory and q Cardio-vascular support may be needed
cardiovascular functions are unaffected. Progress from one level of sedation to another
q Response to verbal stimulation. requires appropriate changes in monitoring and
observation of the patient.
q Cognitive function may be impaired.
In summary, passing along the sedation continuum
q Ventilatory and Cardiovascular functions are
from minimal through moderate to deep sedation,
preserved.
 SAFE SEDATION
(Moderate Sedation, Conscious Sedation)
A SELF STUDY GUIDE

and ultimately to general anaesthesia, increasing Hence, practitioners intending to produce a given
depression of physiological systems is seen. level of sedation should be able to rescue patients
It should be recognized that various degrees of sedation whose level of sedation becomes deeper than initially
occur on a continuum. A patient may progress from one intended. Individuals administering Moderate
degree of sedation to another depending on their Sedation/Analgesia (‘Conscious Sedation’) should be
underlying medical status, the medication(s) able to rescue patients who enter a state of Deep
administered, dosage and route of administration. Sedation/Analgesia, whilst those administering Deep
According to ASA ‘Because sedation is a continuum, it Sedation/Analgesia should be able to rescue patients
is not always possible to predict how an individual who enter a state of General Anesthesia
patient will respond.

EQUIPMENTS
Patient support equipment, including oxygen and suction, should be tested to ensure proper
functioning. Monitoring equipment should be warmed up and calibrated.
 SAFE SEDATION
(Moderate Sedation, Conscious Sedation)
A SELF STUDY GUIDE

Monitoring:
Monitors are used to measure a certain physiological
parameter. But whatever technology had made
monitors so sophisticated a vigilant, well trained
health care provider remains the best monitor.
Monitoring has to be performed before, during and
after any procedure. An appropriate sound and safe
decisions are only taken by a human being and not
by machines.
There is a so-called minimum monitoring
requirement in order to guarantee patient safety.
Proper and adequate monitoring proved to prevent
complications and gives the Sedationist ample time
to interfere to correct any physiological
derangement. Essential monitors include:
1. Level of consciousness

A variety of monitors are available to monitor depth of

anesthetic like BIS, yet the best monitor of the level of
consciousness is maintain a verbal contact with the
patient.
Procedure
It is recommended to use a scoring system and record it
in the patient chart. Scoring systems proved to be safe 1. Observe patient. Is patient alert and calm (score 0)?
and ease communication among staff. Commonly used Does patient have behavior that is consistent with
scales include the Ramsay Sedation Scale and the restlessness or agitation (score +1 to +4 using the criteria
Richmond Agitation-Sedation Scale (RASS). listed above)?
The Ramsay Sedation Scale and Richmond Agitation- 2. If patient is not alert, in a loud speaking voice state
Sedation Scale (RASS) were developed for ICU patients patient’s name and direct patient to open eyes and look at
and is one of the scoring systems most widely used speaker. Repeat once if necessary.
during moderate sedation. The desirable level of I. Can prompt patient to continue looking at speaker.
sedation using the Ramsay Sedation Scale is a level of 2 Patient has eye opening and eye contact, which is
or 3; however, upon inspection of this scoring system, sustained for more than 10 seconds (score -1).
clarity is lacking between these two levels. II. Patient has eye opening and eye contact, but this is
not sustained for 10 seconds (score -2).
III. Patient has any movement in response to voice,
excluding eye contact (score -3).
3. If patient does not respond to voice, physically stimulate
patient by shaking shoulder and then rubbing sternum if
there is no response to shaking shoulder. Patient has any
movement to physical stimulation (score -4).
4. Patient has no response to voice or physical stimulation
(score -5).
Patients adequately sedated are those quiet, tranquil,
with slurred speech, easily arousal, and respond to
verbal commands. This means Ramsey score 2-3.
Once the desired level of sedation is achieved it has
to be maintained and regularly assessed.
 SAFE SEDATION
(Moderate Sedation, Conscious Sedation)
A SELF STUDY GUIDE

PULSE OXIMETRY: Patient Care and Planning:

Pulse oximeters are inexpensive and a valuable Pre-sedation and assessment:
monitor, easy to use. Pulse oximeter probes It is important to look for risk factors that may place
locations include fingers, toes, earlobes, nose, or the patient at increased risk of complications. This
forehead. can be done by recognition of pre-existing
Oxygen saturation is measured by pulse oximeter comorbidities, pre-procedure assessment may be done
were heart rate is also displayed in conjunction of days or weeks in advance; early assessment is
the percentage of hemoglobin saturation. essential for allowing time to make any necessary
changes, such as the discontinuation of certain
People tend to use it by mistake as a respiratory medications or herbal supplements.
monitor. Pulse oximeters are not a substitute for Questionnaire should have the following items:
monitoring of ventilation. • Whether the patient is pregnant or not,
limitations of pulse oximetry: • Is he/she a smoker.
Significant hypotension, Severe hypothermia, Anemia, • What medication he/she is on, drugs.
Vasoconstrictive drug use, Methemoglobinemia, • Allergies
Arterial compression, Intravascular dye use, ambient • previous anesthesia or sedation and possible
light, Nail polish and Henna. events.
END-TIDAL CARBON DIOXIDE MONITORING:
• Arrange for a responsible adult to drive
End-tidal carbon dioxide is a more sensitive indicator of
him/her to and from the hospital.
respiratory depression and provides information about
the patient's ventilation. Optional for minimal and
The components of pre- sedation assessment include:
moderate sedation but is a must for deep sedation and q Measurements, Vital signs
anesthesia. Monitors should be equipped with CO2 q Identifying patient at risk
monitoring possibility whether to use it or not. q ASA classification
EKG: q H & P history and physical examination
Allow us to monitor heart rate, regularity of the q NPO (Nil Per Mouth), patient education
cardiac rhythm and display arrhythmias q Availability of Equipment and place of
The most common lead to monitor the cardiac sedation
rhythm is lead 2 Baseline vital signs (including BP, pulse and oxygen
saturation prior to oxygen therapy), level of
– Right Red consciousness should be obtained.
– Left Yellow An electrocardiogram (ECG) may be indicated for
– Left leg Green patients with positive cardiac histories, but not for
everyone older than 40 years of age.
Advice is to look for: ASA CLASSIFICATION:
q Rate changes bradycardia, tachycardia The American Society of Anesthesiologists (ASA)
recommends that Patients in Class 1 and 2 considered
q Rhythm changes good candidates for moderate sedation procedure, as these
q Ischemic changes patients are the lowest risk. Patients classified as ASA
NONINVASIVE BLOOD PRESSURE MONITORING: Class III may require consultation and collaboration by the
It is important that the practitioner place the cuff health care team to determine if they are appropriately
appropriately and ensure that the appropriate size cuff is stable to go under selected procedure using moderate
used. A cuff that is too wide or too narrow will provide sedation, and/or if Anesthesia department suggest whether
a blood pressure reading that is inaccurately low or anesthesia assistance is needed. ASA Class IV & V
high. A proper cuff is approximately 40% of the patients must be involved of the Department of
circumference of the arm to which the cuff is applied. Anesthesiology.
 SAFE SEDATION
(Moderate Sedation, Conscious Sedation)
A SELF STUDY GUIDE

AIRWAY ASSESSMENT: noting the ability to visualize the fauces, anterior

and posterior pillars, soft palate, and uvula.
Clinical oropharyngeal view (modified Mallampati q Class 1: soft palate, fauces, uvula, pillars
scale). visible
The patient is placed in a comfortable sitting q Class 2: soft palate, fauces, uvula visible
position and asked to open his/her mouth and q Class 3: soft palate, base of uvula visible
protrude the tongue then assesses the airway, q Class 4: soft palate not visible at all.
 SAFE SEDATION
(Moderate Sedation, Conscious Sedation)
A SELF STUDY GUIDE

Consent and pre-sedation assessment form:

LEMON approach for airway evaluation Valid consent is an essential preliminary to
Þ L = Look: face, neck, chest sedation. Patient to be able to ask questions,
Þ E = Examine: mouth, thyromental, floor of understand the choices and risks before making
mouth to thyroid decision to sedate. Risks and benefits must be
Þ M = Mallampatti: huge tongue? back of clearly explained. Alternatives to sedation
throat? (typically general anaesthesia or local anaesthesia
Þ = Obstruction: tumor, epiglottitis with behavioral techniques) should be clearly
Þ N = Neck mobility: RA, syndromic explained.
Certain patient groups will require additional
bespoke information for example children,
pregnant and lactating women.
Pre-sedation assessment completion is
mandatory for all sedation procedures.

PATIENT EDUCATION
The patient should be told what he/she can
expect throughout the procedure. Certain
It has also been noted that obesity may contribute to condition and equipment can be explained
airway difficulties. In addition to visualization of during planning such as verbal stimulation,
the airway, neck circumference and body mass tactile stimulation asking them to take a deep
index should also be assessed preoperatively and
considered in the overall airway assessment.
breath, how they will assess the pain or during
Signs of Difficult Airway: recovery patient finger will be clipped to a
Protruding incisors special device (pulse oximeter) or blood
Small mouth opening pressure will be checked every few minutes
Narrow mandible therefore the patient may feel a cuff inflating.
Macrognathia Finally, discharge instructions should be
Macroglossia provided prior to the procedure; the patient
Short musculature
may not remember all that is told to him/her in
the post sedation period. Reinforcing these
Limited range of motion of the neck
instructions during the presedation period will
3 fingers role greatly enhance patient compliance in the post
3 fingers breadths of mouth opening sedation period.
3 fingerbreadths from mandible to thyroid NPO (Nil Per Mouth) fasting requirements:
Patients who receive moderate sedation
should not drink clear fluids for at least 2
hours, Breast Milk 4 hours, eat solid foods (a
light meal) for at least 6 hours, or heavy meals
for 8 hours prior to the procedure. Examples
of Solids/Non-clear Liquids: Milk, Formula,
Orange/Grapefruit or Pulp juices and Creamy
soup. Examples of Clear Liquids: Water,
Pedialyte, Apple juice.
 SAFE SEDATION
(Moderate Sedation, Conscious Sedation)
A SELF STUDY GUIDE

CARE DURING SEDATION: behaviors are secondary to inadequate analgesia,

Pre-induction events: and further assessment should be performed. If
– Make sure that the informed consent is not hypoxemia considered as the primary cause of
expired, agitation the risk of further hypoxemia should be
– the NPO status is appropriate, eliminated.
– equipments are in working condition
checked and calibrated, Responsibilities of the physician include:
– finally, patient followed the instruction Þ Completion of history and physical
given earlier regarding medications and Þ Completion of informed consent
other concern condition. Þ Ordering of the medication, dosage and
Then establishing IV access, starts oxygenation for route of administration
all patients, attached monitor including heart rate,
Þ Directing and providing of emergency
blood pressure and oxygen saturation to be
interventions as necessary
continuously monitored in all patients undergoing
moderate sedation. Þ Dictation of operative note immediately
The results of all elements of the pre-procedure after completion of procedure
assessment should be clearly documented as pre-
sedation. Responsibilities of the RN include:
Throughout sedation, the two most important Þ Knowledge of the goals and objectives of
responsibilities are Monitoring and Documentation. IV safe Moderate sedation
During sedation period, the nurse taking care of Þ Patient assessment
monitoring and documentation should remain with Þ Administration of medications per
the patient at all times and there should be no other physician's orders
responsibilities for the nurse; assisting with the Þ Uninterrupted observation and monitoring
procedure should not be an expectation. Patency of of the patient from time of safe sedation
airway and adequate ventilation (without until time of discharge
intervention) of patient receiving and recovering
from sedation should be ensured from time patient Þ Documentation
enter the procedure room until he/she is discharged Þ Provision of appropriate emergency
to ward or home. Should the patient's level of intervention as necessary
consciousness deepen to the point that the airway is
compromised measures should be undertaken to Documentation:
reverse the effects of this untoward complication. Documentation provides other healthcare
The ASA guidelines note that supplemental oxygen practitioners with information regarding the
should be considered for moderate sedation. If the patient during the intervention. Additionally,
oxygen flow rate were less than 5 L/min, carbon chart reviews can be performed as a component
dioxide (CO2) could accumulate within the mask of quality monitoring.
and the patient would rebreathe this CO2. This
would lead to a respiratory acidotic state with Documentation should include:
further compromise of the patient's ventilatory Þ the pre-sedation assessment, the intra-sedation
status. record, and the post sedation record.
Þ Dosages, route, time of all drugs used
OXYGEN Administration:
Vital signs may be assessed as frequently as every Þ Type and amount of fluids administered,
5 minutes. During sedation, the patient will be including blood and blood products,
monitored for his/her response to the medications Þ monitoring devices or equipment used
used. If a patient demonstrates restlessness and Þ HR, BP, respiratory rate, oxygen saturation,
agitation the cause should be determined and and level of sedation
intervention starts to reverse any untoward events. Þ Interventions start and end times
Restlessness and agitation should always be
Þ Untoward or significant patient reactions and
considered signs of hypoxemia until proven
their resolution or outcome
otherwise. However, it is just as possible that these
 SAFE SEDATION
(Moderate Sedation, Conscious Sedation)
A SELF STUDY GUIDE

Patient Monitoring: the patient is an expectation. Many patients are

The patient must be continuously monitored from discharged home. Care of the patient should be
the start of safe sedation until the discharge criteria well-delineated so that both the patient and the
are met. caregiver are comfortable with the expectations of
Baseline vital signs, oxygen saturation, heart-rate, the remaining recovery period.
rhythm, and level of consciousness are the Home transfer should be done in 1 to 2 hours after
minimum assessment parameters obtained and the procedure.
documented prior to sedation. The patient should At home:
be monitored at 5-minute intervals during the Þ Patient should be able to return to everyday
procedure and at 5-15-minute intervals during the activities the next day.
recovery phase, and at any significant event in Þ Patient shouldn’t do the following for at least
either phase. 24 hours: driving, operating machinery,
The nurse monitoring the patient may not be drinking alcohol, and making legal decisions.
engaged in any other activity during the period of The most commonly used discharge scoring
safe sedation. The nurse should immediately report systems is the Modified Aldrete Score. The easy-
any unexpected response by the patient to the to-use, simple scoring mechanisms are very useful
physician. These include, but are not limited to: for patients undergoing moderate sedation. A
Ø variations from baseline ± 20 % HR or BP score of 18 or higher indicates a patient's readiness
Ø cardiac dysrhythmias (continuous); for discharge.
Ø 5 % below baseline of oxygen saturation • A typical time of 30 to 60 minutes after the
(continuous monitoring) last sedative dose and/or 2 hours after the last
Ø dyspnea, apnea, or hypoventilation reversal dose is required as criteria for
Ø diaphoresis (may signify myocardial discharge. Many healthy adult patients may
ischemia) awaken much faster than this. On the other
Ø inability to arouse the patient hand, elderly patients may need more time for
Ø or the need to maintain the patient’s airway monitoring, as circulation times are slower
mechanically. and the risk of slow release of sedative from
Once the patient's vital signs are at pre-sedation the fatty tissue may develop.
levels or at least 30 minutes have passed since the
• An additional discharge requirement may be
last sedating medication, monitoring of
to ensure that the patient has taken fluids
physiological parameters may be increased to every
orally. The requirement that all patients drink
15 minutes until the patient returns to pre-sedation
clear fluids prior to discharge has also been
level of safeness and stability.
eliminated for many patients. Guidelines
recommend that toleration of fluids should
POSTSEDATION CARE:
only be required for specific populations, such
The ASA recommends that monitoring continue
as diabetics. Patients who are discharged prior
until the patient is near the baseline level of pre-
to taking fluids should be advised to start
sedation consciousness and is no longer at
drinking clear liquids when they feel ready.
increased risk of cardiorespiratory depression. If
• The American Society of Anesthesiologists
the patient is to be transferred to a separate
states that the routine requirement for
recovery area, the personal administering the
urination before discharge should not be part
sedatives should accompany the patient to the
of a discharge protocol and may only be
recovery area and give a complete, concise report
necessary for selected patients. Assessment of
to the responsible for further patient care.
urine output is useful in detecting some
Generally, vital signs and pulse oximetry readings
postoperative complications, and patients who
are obtained on a 5-15-minute cycle until stable and
are at high risk of urinary retention are
then on a regular basis until the time of discharge.
generally required to void prior to discharge.
Discharge of the patient after sedation is a critical
This includes patients who have had pelvic or
part of post-sedation care.
genitourinary surgery, rectal or urological
Procedures performed under moderate sedation are
procedures, hernia repairs, perioperative
those in which rapid recovery and discharge of
urinary catheterization.
 SAFE SEDATION
(Moderate Sedation, Conscious Sedation)
A SELF STUDY GUIDE

Discharge Criteria: 2. Able to void.

Patients who have received safe sedation must go 3. Able to retain oral fluids.
to the PACU or another recovery area with 4. Discharged with a written physician's order
comparable monitoring capabilities post and follow up instructions.
procedure. Monitoring will be continued at 5-15- 5. Under observation of a responsible person
minute intervals. The patient must meet specific and have transportation from the hospital.
A physician must evaluate any patient(s) who
discharge criteria for the recovery area before
are unable to meet these criteria prior to
moving to another location such as, Lounge
discharge or at the time of transfer from the
Recovery (for outpatients), the floor (for
PACU.
inpatients), or home (as in the case of the The nurse is responsible for patient advocacy,
Emergency Department). Meeting these criteria patient and family education, drug
ensures that the patient has returned to a safe administration, documentation, preparedness,
physiological level of functioning. evaluation, and the overall monitoring of the
Use of the Aldrete scoring system is a helpful patient pre-, during, and post-sedation.
adjunct in determining the patient's ability to
follow commands, respiratory effort, circulatory Complications and emergency interventions:
status, safeness and ventilatory status. Complications are related to pre-existing
Patients to be discharged should be: comorbidities. With good pre-sedation
1. Stable out of bed for 30 minutes prior to assessment and selection, the incidence of
discharge. these problems can be kept to a minimum.
 SAFE SEDATION
(Moderate Sedation, Conscious Sedation)
A SELF STUDY GUIDE

Most common complications include the saturation still low encourage the patient to
following: take deep breaths and change the nasal cannula
o Over- and under sedation to facemask. For further oxygen supply
o Airway obstruction rebreathing facemask should be used.
o Hemodynamic instability *When patient airway becomes obstructed the
o Aspiration most effective way to open the airway is the
o Nausea and vomiting. head tilt-jaw lift. Often this maneuver alone is
The Physician and the RN must be ready to enough to improve ventilation and O2
intervene if these complications arise. Emergency saturation. If efforts remain unsuccessful, bag
interventions include, but are not limited to, airway the patient by connecting the non-rebreathing
management, reversal of sedating medications and 100% O2 facemask to an ambu-bag. Continue
other measures such basic life and advanced to bag the patient until the O2 saturation
cardiac life support. improves. Here you can use the oral or/and
OVER- AND UNDERSEDATION: nasal airway to elevate the relaxed tongue. If
Overdose or adverse drug reactions may cause the condition does not improve, intubate the
respiratory depression, hypotension, and impaired patient using LMA or EET (Endo Tracheal
cardiac function. Most complications occur Tube). See flowcharts below.
because of sedation becoming deeper than * If the patient is breathing and has adequate
intended (over-sedation), rather than not reaching O2 saturation but cannot maintain his or her
adequate sedation. This is especially important for own airway, an artificial airway is indicated. A
children, as studies have indicated that children nasal or oral airway may be used. The nasal
often reach a level of sedation that is deeper than airway may be more tolerable than an oral
intended. airway for a sedated patient. Apply lubricant
Another common complication of moderate and insert into one nostril. If resistance is
sedation is nonoptimal sedation (under sedation) of encountered, slight rotation of the tube will
the patient. The effects of undersedation can be facilitate insertion.
undesirable. The patient who is under sedated * Respiratory depression can progress to
experiences an increased amount of stress, leading respiratory arrest. If the patient is not
to an increased autonomic response. Patients with breathing, begin artificial respirations
high preprocedural levels of anxiety may also be at immediately intubate the patient.
risk; the heightened anxiety state can prevent the Other Respiratory Complication:
patient from achieving the full benefits of the drug Airway obstruction
administered. Laryngospasm & Bronchospasm
Patients at increased risk of over sedation and Apnea
under sedation are younger children, the elderly, Cardiac Complications and Hypotension:
the critically ill, the obese, and patients with liver Hypotension is another complication of safe
and/or renal disease. sedation. Hypotension may be easily corrected
Respiratory Depression and Hypoventilation: by placing the patient in "Trendelenburg" (head
Decreased or shallow respirations and decreased down) position and giving IV fluids. If this
oxygen saturation demonstrate respiratory intervention does not improve the blood
depression. pressure, more aggressive drug therapy is
Respiratory depression should be treated with needed. Call for help STAT before the situation
oxygen and airway management while overdosing gets worse.
can be treated by giving an antagonist. Another potentially lethal complication of safe
The proper position of the patient is a key for sedation is cardiac arrhythmias. Cardiac
further airway management. Every patient should arrhythmias must be recognized and treated
have oxygen via nasal cannula throughout the quickly for positive patient outcomes.
procedure. REMEMBER: IF YOU ARE IN DOUBT IT IS
*If the airway is patent and the patient is SAFER TO CALL FOR HELP!
breathing but the O2 saturation is low then the flow
of the nasal cannula may be increased. If O2
 SAFE SEDATION
(Moderate Sedation, Conscious Sedation)
A SELF STUDY GUIDE

SAMPLE DISCHARGE INSTRUCTIONS What to expect

Today you received medications to make you -You will remain conscious during this kind of
sleepy during your procedure. sedation.
Recommendations for your own safety for the next -You may experience a temporary loss of
24 hours. memory during the time that you are sedated.
1. Do not drive or operate heavy machinery for 8 Many patients have no memory of the
to 24 hours. procedure at all.
2. Do not consume any alcoholic beverages for 24 -You may feel unsteady on your feet for some
hours. hours after the procedure.
3. Do not make any important decisions for 24 -Your ability to think clearly and make
hours. judgements may be affected for the next 24
4. Describe pain management plan and medication hours.
use (if appropriate): You will experience pain for -Once you are sedated, the dentist can use local
the next few hours (or specific time frame). Your analgesia.
doctor provided you with the name of medication to -You will spend some time in the recovery area
Take for pain. following your treatment.
5. You may resume your regular diet unless -You will be checked by the dentist or the
instructed otherwise. If you feel sick to your person giving you the sedation before you can
stomach, you may begin with clear liquids and add go home.
items as you feel ready. -You must be accompanied by an able-bodied
6. It is best to rest the remainder of the day. adult who can take responsibility for you
7. Describe surgical site management (if following your treatment.
appropriate).
(Note: These should be provided in written format)
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PHARMACOLOGY AND DRUG ADMINISTRATION: Single dose injection "titration to effect."

The most common route of administration is The patient is given frequent, small doses of the
intravenous (IV), although medications may be medication, and the effects are monitored prior to
given orally (PO), Rectally (PR), intramuscular further drug administration. It requires that the
(IM), subcutaneously (SQ), or nasally. The agents practitioner monitor the patient's vital signs and
used depend on the type, duration and intensity of level of sedation after each drug dose and titrate
the procedure. subsequent doses based upon these responses.
Physicians and nurses who do not have privileges Therefore, it provides for better control of the
in anesthesiology should not administer drugs amount of drug delivered, although repeated doses
classified as anesthetic agents, including but not may prolong the patient's recovery time.
limited to, ketamine, Propofol, and etomidate for Additionally, it is one of the safest methods for
the intent of safe sedation. drug delivery. The risk of over sedation or
Differences in patients' health status with variable undersedation is minimal.
ability to metabolize medications should be The bolus technique: is the administration of the
considered when selecting and administering the entire dose, or a large percentage of the drug, all
medications. Medications frequently given for at once, causing a rapid onset of action and
safe sedation are listed in the hospital's (clinics) allowing the drug to reach a therapeutic level very
policy on safe sedation. quickly. Deep, rapid sedation is more common,
The nurse is responsible for validating the and the risk of respiratory depression increases.
physician's order, obtaining the medications, and The major disadvantage of this method is that the
assuring administration of medications according length of action of the drug may be shorter than
to the hospital's policy. This includes the right the procedural time, and that complications may
medication in the right dose, to the right develop with the bolus technique is faster.
patient, over the right time frame, through the Continuous infusions: are advantageous in that
right route. they provide a constant plasma level of the drug.
The nurse must adhere to all National, Adjacent Recovery time is often shorter, and the individual
and Hospital guidelines when administering any begins to awaken as soon as the drug is
IV medication. Inconsistencies between physician discontinued. This technique needs a special
orders and guidelines should be resolved prior to training and special equipment.
administering the medications. Finally, Drug combination therapy may be used.
Currently in the Operating Room, non-anesthesia Most commonly, opiates and benzodiazepines are
personnel may administer only benzodiazepines combined to achieve an appropriate level of
such as diazepam (Valium) and midazolam sedation and pain control. A possible
(Versed), and narcotics such as fentanyl, disadvantage of drug combinations is the
morphine, or meperidine (Demerol). This packet synergistic, cumulative effects of drugs,
will only address these medications and their producing the risk of profound deep sedation,
respective reversal agents. Information on other however with drug combination therapy, the goals
drugs may be found in the hospital's policy on and objectives of moderate sedation can be
safe sedation. achieved with proper drug dosing.

ADMINISTRATION OF INTRAVENOUS DRUG CLASSES AND MEDICATIONS

MEDICATIONS The medications used for moderate sedation
Methods of administration of IV medications provide a number of different actions. Medication
include: choice should be made with consideration of a
§ single-dose injection (titration to effect) number of factors, including the actions of the
§ bolus technique drugs, their relative length of action, and the
§ continuous infusion technique bioavailability of each drug.
Each method has distinct advantages and
disadvantages, and certain drugs can only be
administered by one technique.
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The two most common medications administered Pharmacology:

for moderate sedation are midazolam and 1. Short acting benzodiazepine.
fentanyl. These drugs, as well as many others, are 2. Share the same mechanism of action with
included in the following discussion. all other benzodiazepine on GABA
Benzodiazepines: receptors.
Benzodiazepines elicit beneficial effect for
3. Midazolam is water soluble in acidic
sedation. They have different pharmacological
solution and becomes lipid soluble at
properties including amnesia, anxiolytic and
physiologic pH.
anticonvulsant effect. Benzodiazepines are
classified by their half-lives as Dosage & Route:
§ short-acting (e.g., midazolam) It may be administered IV, IM, P0, rectally, or
§ intermediate-acting (e.g., lorazepam) nasally. The most common route of administration
§ long-acting (e.g., diazepam). is IV.
The medications used in the Operating Room in Midazolam is a potent sedative agent that must be
this category are midazolam (Dormicum) and given slowly. Administration over 2 or more
diazepam (Valium). minutes is prudent.
Mechanism of action: Benzodiazepines facilitate Never give it as a single large bolus dose. Rapid
the inhibitory action of gamma-aminobutyric acid or excessive IV doses may result in respiratory
(GABA) in the brain, thus reducing excitatory depression or arrest. If not recognized and treated
impulses. Therefore, Benzodiazepines have promptly, death or hypoxic encephalopathy may
antianxiety, anti-convulsant, sedation, mild central result.
muscle relaxation, and amnesic properties. The Adults:
patient may develop a depressed ventilatory The initial IV dose may be as little as 0.5-l.0 mg,
response due to increasing carbon dioxide levels but should not exceed 2.5 mg in a healthy adult. It
with subsequent falling levels of arterial should be titrated to the desired effect. Slurred
oxygenation. Benzodiazepines are said to reduce speech is an excellent indicator of an adequate
the body's response to rising carbon dioxide dose. (Do NOT exceed 2.5 mg as initial dose or 1.5
levels. Therefore, the patient's level of mg initially in elderly), Max 5 mg
consciousness decreases, the risk of respiratory depressants.
insufficiency increases greatly. Pediatric dose:
They may decrease peripheral vascular resistance IV: 0.1mg/kg
PO: 0.25–0.5 mg/kg
and a subsequent drop in blood pressure. Patients
IM: 0.1–0.15 mg/kg
with low cardiac output require slower loading Nasal: 0.2–0.4 mg/kg (not an approved route)
times for benzodiazepines to reduce a possible
Dose Adjustments:
cardio-respiratory depression.
Reduce dosage is required in geriatric patients,
Precautions should be taken for the very young,
debilitated patients, patients with COPD, Renal
elderly, and pregnant or lactating patient due to
failure, hepatic dysfunction, and concomitant
benzodiazepines are 97% to 98% protein bound.
administration of narcotics or another CNS.
This is an important consideration in many elderly
Adverse reactions:
patients with decreased protein stores the reason
from IV administration include hiccups, nausea,
of drug or drug metabolites accumulate and result
vomiting, over sedation, headache, coughing, and
in excessive sedation, cognitive impairment and
pain at the injection site.
falls. The less body proteins available, the more
free-circulating drug exists. Thus, the effects of Contradictions
action are potentiated. Ø Midazolam should not be used on patients
Midazolam (Dormicum) with known benzodiazepine
Midazolam is a CNS depressant. It is indicated for hypersensitivity
safe sedation prior to short diagnostic or surgical Ø acute narrow-angle glaucoma
procedures, either alone or with a narcotic.
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Chloral hydrate has not been approved by the

Compatibility:
FDA in the United States or the EMA in the
Solution compatibility & dilution: D5w, NS, European Union for any medical indication
lactated Ringer's and sterile water for and is on the list of unapproved drugs that are
injection. Midazolam can be mixed in the still prescribed by clinicians. Usage of the
same syringe with morphine, meperidine, drug as a sedative or hypnotic may carry
atropine, and scopolamine. some risk given the lack of clinical trials.
Patient/Family education: Indications:
The patients should not be involved in any Chloral hydrate is used for the short-term
activity that require fine motor or cognition treatment of insomnia and as a sedative before
skills (i.e. driving, cooking) during the next minor medical, dental treatment, or EEG
12 hours after its administration. procedures. It was largely displaced in the
Advise patient to avoid alcohol or other CNS mid-20th century by barbiturates and
depressants for 24hrs following subsequently by benzodiazepines.
administration of midazolam. Dosage:
Sedation: 50–75 mg kg−1 orally (maximum 2
Diazepam (Valium) g)
Has been replaced for the most part by 20–30 min pre-procedure, Chloral hydrate
midazolam but is still used occasionally. may be
Diazepam IM administration is very painful given by mouth or per rectum
and not recommended. Onset is within 15 min, Peak effect 30-60 min
and duration can be as long as 2 h.
The IV dose may range from 2-20 mg in a
Recently challenged and its use is discouraged
healthy adult, although 10mg or less is
for its
usually sufficient. It should be administered in
• Unpredictable effect.
1-2 mg increments every 2 minutes until the
desired effect is achieved. As with • May cause nausea and vomiting.
midazolam, slurred speech is an excellent • Safety in neonates.
indicator of an adequate dose. Lower doses • Paradoxical hyperactivity.
should be used for elderly or debilitated • It has a very narrow therapeutic window
patients. making this drug difficult to use. Higher
This drug cannot be mixed with other doses can depress respiration and blood
medications or diluted due to precipitation. It pressure.
should be injected as close to the IV cannula The metabolite of chloral hydrate exerts its
pharmacological properties via enhancing the
as possible.
GABA receptor complex and therefore is
Adverse reactions include venous thrombosis, similar in action to benzodiazepines, and
phlebitis, apnea, and hypotension. barbiturates. It can be moderately addictive, as
chronic use is known to cause dependency and
Chloral hydrate withdrawal symptoms.
It was discovered through the chlorination Contraindications:
(halogenation) of ethanol in 1832. It has Ø Gastric disease, severe hepatic, or renal
limited use as a sedative and hypnotic dysfunction.
pharmaceutical drug. Ø Obstructive sleep apnea (OSA)
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OTHER SEDATIVE HYPNOTICS: k. Prone to bacterial contamination due to the

Sedative hypnotics as a class encompass many use of intralipid as a solvent. It needs careful
agents, Propofol, etomidate and Ketamine are handling to avoid contamination
also used in moderate sedation. These ultra-Dosage:
short-acting agents restricted to be used bySingle injection:
ICU, ED and anesthesiologist. Increments of 0.25 - 1.5 mg/kg, titrated to the
Propofol: desired effect.
Infusion:
Propofol is an ultra-short acting non-barbiturate
intravenous anesthetic induction agent. After a bolus dose, start an infusion of 1.5 -
a. A diethyl phenol derivative suspended in 3mg/kg /h titrated to the desired effect.
Target controlled infusion where the operator set
lipid emulsion. a pharmacokinetically programmed infusion
b. Metabolized in the liver to non-active pump to a desired plasma level 0.5-1.5 mcg/ml.
metabolites. Levels above 4 mcg is associated with anesthesia
c. Preserve spontaneous breathing if it is
given in small doses and with the absence Etomidate:
of opiate on board. Is another ultra-short-acting sedative hypnotic
d. Has no analgesic effect. with no analgesic properties can be used to
e. Should only be used by ICU, ED, or presence induce moderate sedation.
of an anesthesiologist. o An Imidazole derivative.
Advantages: o Pain on injection.
f. Rapid onset and smooth and rapid and o Associated with high incidence of nausea
complete recovery. and vomiting.
g. Antiemetic properties o Characterized by its cardiovascular stability.
Disadvantages: o No analgesic properties.
h. Pain on injection (which can be reduced by o Administration of etomidate via
being mixed with Xylocaine). continuous infusion has been associated
i. Potent respiratory depression when with increased morbidity and mortality
combined with opiates. as a result of its adrenal suppression
j. Significant cardiovascular depression.
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Ketamine:
Is a dissociative agent that "dissociates" the q Saliva and mucus production are increased,
thalamus from the limbic system. especially in the pediatric patient. These
Ø Derivative of Phencyclidine. effects are usually tolerable in the adult, but
Ø Ketamine acts as a selective antagonist of the child may require the administration of
the NMDA receptor. an anti-sialagogue or an anticholinergic
Ø The patient is dissociated from his agent to help dry these secretions.
surrounding, looks awake, eye opening is Contraindications:
maintained, may have involuntary § Patients with open eye injury.
movement or even produce sounds. § Patients with head injury.
Ø The drug provides both analgesia and § Severe cardiovascular disorders where
amnesia. increase in blood pressure and heart rate is a
Disadvantages: disadvantage.
q The main disadvantage that limits its use in § History of psychological disorder.
adults is high incidence of emergence Dosage:
reactions: o 0.5-1 mg/kg Intravenously.
o Hallucination (The concomitant use of o 2.5-5 mg/kg Intramuscularly.
midazolam may help reduce this risk). o Doses from 0.1-0.5mg /kg are often utilized
o Confusion as analgesic dose.
o Excitement and irrational behavior.
o Emergence delirium. Drug used for continuous infusion technique
o Night mares or vivid dreams. or as a single dose
q Undesirable skeletal muscle movement can Ø Remifentanyl
occur in some patients. A patient who is Ø Dexmedetomidine
required to lie completely still, like those Ø Clonidine
undergoing MRI, should in most cases not Ø Propofol
receive ketamine for sedation. Their discussion is behind our scope of
moderate sedation
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Narcotics (Opioids): the vascular system. Therefore, the patient should
Opioids, referred here as narcotics, bind with be continually assessed during administration for
specific receptors in the central nervous system. profound cardiovascular depression. With slow
These receptors include the mu, kappa, delta, titration of the drug, these effects can be negligible
and sigma subtypes. Opioids act on these ´ Metabolized primarily in the liver.
receptors to provide analgesia, sedation, and o Its active metabolite, morphine-6-
elevate the pain threshold. glucuronide, produces analgesia and
They may be classified as by their activity at the ventilatory depression by way of agonism of
opioid receptors. the mu receptors
o agonists o Thus, elimination of morphine in patients with
o mixed agonists-antagonists renal failure may be impaired, causing an
o partial agonists accumulation of metabolites and unexpected
They share common side effect of variable depression of ventilation even with small
degree doses of opioids.
´ The cardiovascular system is significantly Precautions
affected o Elderly and debilitated patients.
a. All narcotics produce bradycardia except o Increase ICP
Meperidine. o Pulmonary disease.
b. Blood pressure decreases by slower heart o Hepatic or renal diseases
rate.
´ Respiratory depression: most serious adverse Fentanyl (Sublimaze):
effects o A synthetic opioid that is indicated for
a. Opioids reduce alveolar ventilation in a dose- analgesic action of short duration procedures
dependent manner. such as endoscopies.
b. They slow the respiratory rate and may cause o Fentanyl has an immediate response and
periodic breathing or apnea. provides excellent analgesia.
c. Shift the alveolar ventilatory response to co2 o If given alone, dosage should begin at 1-2
curve down and to the right µg/kg, which is about 75- 150µg for an average
d. Opioids also impair the hypoxic ventilatory size adult. If given in conjunction with a
drive benzodiazepine a smaller dose should be used.
´ Sedation and drowsiness The average patient usually requires 50-l00µg.
´ Nausea and vomiting o Chest wall rigidity is an uncommon, that can
´ Itching occur with the rapid intravenous administration
´ Constipation of fentanyl. The chest wall muscles become
´ Addiction potential tight, and the patient is unable to be breath. This
´ Histamine release effect may be reversed with naloxone (Narcan)
Commonly used opiates: or may require a depolarizing muscle relaxant
o Morphine and intubation.
o Meperidine Meperidine:
o Fentanyl Meperidine is about one-tenth as potent as
o hydromorphone morphine.
Meperidine was previously used for its analgesic
Morphine: properties. However, the American Pain Society
Morphine is one of the most popular of all the and Institute for Safe Medication Practices (ISMP)
medications used for moderate sedation. do not recommend the use of meperidine for its
´ Morphine is the prototype opioid agonist analgesic properties because it carries an equal
with which all other opioids are compared. risk of addiction like other opioids (Morphine),
´ Morphine produces analgesia, euphoria, and and due to its toxic metabolite norpethidine is
sedation. more toxic than other opioids—especially during
´ Untoward complications can be avoided long-term use.
with proper administration. The risk of If the patient experiences acute pain in those
hypotension is great with morphine patients who does not tolerate other opioids, it is
secondary to the action of histamine upon recommended that treatment with meperidine be
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limited and used with caution in patients with o Unlike morphine, it is metabolized to inactive
liver and renal diseases. compounds and results in less histamine
Side effects /Precautions: release.
o It shares with opiates the common side o The analgesic properties are the best of any of
effects. It has also a myocardial depressant the drugs used in sedation, and whenever a
effect painful procedure is initiated, these drugs
o Meperidine should not be used in patients should be at the top of the consideration list.
moderate to severe pain, and can be o The usual adult parenteral I.V.: Initial: 0.05-0.1
administered via oral, intramuscular, or mg every 2-3 q 10 minutes.
intravenous routes, among others.
Metabolism/ Excretion: Reversal Agents (Antagonists):
´ on monoamine oxidase (MAO) inhibitors, Reversal agents are drugs that counteract the
it may precipitate serotonin syndrome effects of other drugs by acting on to same
(autonomic instability with hypertension, receptors. The reversal agent used for
tachycardia, diaphoresis, hyperthermia, benzodiazepines is flumazenil (Romazicon), and
agitation, and hyperreflexia) for narcotics is naloxone (Narcan) both are
´ In addition, meperidine may cause seizures counteracting the effect in the central nervous
in patients with renal insufficiency or a system.
history of seizures, or when used in repeated Generally, their length of action is short, usually
or high doses. shorter than the length of action of the drug being
Hydromorphone: reversed. Thus, administration requires repeat
o Hydromorphone is an opioid analgesic and is dosing. The advantage of the antagonists is that
a semisynthetic derivative of morphine with they can be administered in small doses, with a
5– 6 times the potency of morphine. goal of reversing deep sedation and respiratory
Hydromorphone can be used to relieve moderate depression. By administering the drugs in this
to severe pain, and can be administered via oral, manner, the patient's respiratory drive increases
intramuscular, or intravenous routes, among but the effects of the sedative are not completely
others. reversed. In other words, the intervention can
proceed and the patient can remain, by definition,
moderately sedated.
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Naloxone (Narcan): requires subsequent doses. Flumazenil is

Naloxone possesses the ability to antagonize all indicated for reversal of procedural sedation, a
types of opioid receptors. However, it shows reversal of sedation in the Intensive Care Unit,
high affinity for µ receptors. The drug is management of BZD overdose. For this purpose,
metabolized in the liver primarily by in adults 0.2 mg/dose, to a total of 3 mg, over 30
conjugation with glucuronic acid. The half-life s followed by 0.3 and 0.5 mg at 1 min intervals
of naloxone is about 1 h. It acts in 1–2 min to a maximum dose of 3 mg can be given. In
when it is given intravenously (IV). In patients children 0.01 mg/kg IV per dose, to a total of
with respiratory depression, an increase in 0.05 mg/kg or 1 mg is administered. A total of 1
respiratory rate is seen within 1-2 min. Primary mg flumazenil given over 1–3 min usually is
indications are to reverse respiratory depression sufficient to abolish the effects of therapeutic
due to intraoperative opioid overdose (0.1–0.2 doses of BZDs such as the sedative, anxiolytic,
mg IV). It can be used as an agent to decrease anticonvulsant, ataxic, anesthetic and muscle
neonatal respiratory depression secondary to relaxant effects of BZDs. The sublingual
the intravenous or intramuscular administration approach would allow convenient and better
of opioids to the mother. In the neonate, the treatment availability for patients with hepatic
initial dose is 10 µg/kg given IV, encephalopathy as well as for reversing the
intramuscularly or subcutaneously. Rebound residual hypnotic effect after a surgical
release of catecholamines may cause procedure.
hypertension, tachycardia, ventricular Adverse effects: dizziness, facial erythema,
arrhythmias and pulmonary oedema and hence anxiety and headache which are often mild and
nausea, vomiting, tremors, sweating, seizures disappear within several minutes. Additionally,
and cardiac arrest can flumazenil has been noted to precipitate seizures
occur. To prevent these, diluting the drug (0.4 in epileptic patients who are on BZDs for seizure
mg) to 10 ml (0.04 mg/ml) and injecting 1–2 control. It should also be avoided in patients who
ml every 1–2 min is recommended. have consumed a combination of Tricyclic anti-
Flumazenil (Anexate): depressants and BZDs.
Flumazenil is administered IV.
Flumazenil is a Benzodiazepines (BZP)
receptor competitive antagonist, it is used as a
reversal agent for BZDs.
On intravenous administration, flumazenil has
a half-life of about 1 h and the duration of
clinical effects usually are only 30–60 min. It is
eliminated via liver to inactive products and
excreted renally. Therefore, re-sedation is a
possibility with longer acting BZDs and may
occur within 1–2 h after administration, which
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Sedation for pediatric Patients: § Neonates preferentially breathe through

their nose. Their narrow nasal passages are
Regardless of the intended level of sedation or easily blocked by secretions and may be
route of drug administration, the sedation of a damaged by a nasogastric tube or a nasally
pediatric patient may result in life threatening placed endotracheal tube.
events. § The neonate and infant have limited
Many brief procedures may be respiratory reserve.
accomplished with behavioural modalities, Cardiovascular System:
such as, careful preparation, parental § Cardiac output is rate dependent. The
presence, hypnosis, distraction, topical infant behaves as with a fixed cardiac
output state.
local anesthetics, electronic devices with
§ Bradycardia is associated with reduced
age-appropriate games or videos.
cardiac output. Bradycardia associated with
However, longer procedures that require
hypoxia should be treated with oxygen and
immobility involving children younger ventilation initially. External cardiac
than 6 years or those with developmental compression will be required in the neonate
delay often require an increased depth of with a heart rate of 60 beats per minute or
sedation to gain control of their behavior less, or 60-80 beats per minute with
(immobility). Children younger than 6 adequate ventilation.
years (particularly those younger than 6 § Sinus arrhythmia is common in children
months) may be at greatest risk of an and all other irregular rhythms are
adverse event. abnormal.
When the procedures performed under deep Renal System:
sedation for pediatric age group it is preferable Dehydration is poorly tolerated. Premature
that an anesthesiologist be in charge of infants have increased insensible losses as that
providing the sedation. have a large surface area relative to weight.
Temperature Control:
PAEDIATRIC ANATOMY AND Babies and infants have a large surface area to
PHYSIOLOGY: weight ratio with minimal subcutaneous fat.
Children are not small adults they have their Hypothermia may develop quickly.
own anatomical & physiological Hypothermia causes respiratory depression,
characteristics. acidosis, decreased cardiac output, increases
Pediatric patients involve a wide spectrum of the duration of action of drugs, decreases
different age groups: platelet function and increases the risk of
Ø Neonates: a baby within 44 weeks of age infection.
from the date of conception Central Nervous System:
Ø Infants: 1- 12 months of age It was believed for some time that children do
Ø Child: 1 to 12 years not feel pain like adults and they do not
o The Toddler 1-3 years remember painful events similar to adults. This
o The Preschooler 4-5 years myth led to performing a lot of procedures for
o School Aged Child 6-12 years kid, without giving them any sedative or even
Ø Adolescent – 13 to 16 years any analgesic. Neonates can appreciate pain
Airway and Respiratory System: and this is associated with increased heart rate,
§ Large head, short neck, and the tongue is blood pressure and a neuro-endocrine response.
relatively large. Narcotics depress the ventilation response to a
The larynx is high and anterior, at the level rise in PaCO2. The blood brain barrier is poorly
of C3 - C4. The epiglottis is long, stiff and formed. Drugs such as opioids, cross the blood
U-shaped. brain barrier easily causing a prolonged and
§ The ‘sniffing the morning air’ position will variable duration of action.
not help bag mask ventilation or to Psychology:
visualize the glottis. The head needs to be Children up to 6 months-4 years of age are
in a neutral position. upset by the separation from their parents and
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the unfamiliar people and surroundings.

It is difficult to rationalize with a child of this
age. The behaviour of this group is more
unpredictable.
School age children are more upset by the
procedure, its mutilating effects and the
possibility of pain.
Complications of pediatric sedation:
Procedural sedation of pediatric patients has
serious associated risks such as:
respiratory depression, laryngospasm, impaired
airway patency or airway obstruction, apnea,
loss of the patient’s protective airway reflexes,
pulmonary aspiration and cardiovascular
instability. Other sedation related
complications including: anaphylaxis,
vomiting, delayed recovery and failure of
sedation.
These adverse responses during and after
sedation for a diagnostic or therapeutic
procedure may be minimized, but not
completely eliminated, by a careful pre-
procedure review of the patient’s underlying
medical conditions and consideration of how
the sedation process might affect or be affected Practicalities for Children
by these conditions: for example, children with q Weight (kg) up to 10 years of age can be
developmental disabilities have been shown to estimated by: (age + 4) x 2.
have a threefold increased incidence of q RR = 24 – age/2
desaturation compared with children without q A parent may join their child at the time of
developmental disabilities. induction. It is not compulsory but can be
Close monitoring and continuous observation useful in many instances.
of the patient leads to accurate and rapid q Warm the theatre and prepare any warming
diagnosis of complications and initiation of devices. Keeping children warm can be a
appropriate rescue interventions simple thing to do to improve post-
operative wellbeing and outcomes.
Contraindications to sedation:

Problem Risk
Abnormal airway air way obstruction &
hypoxia
Sleep apnea hypoxia
Respiratory / cardiac life threatening
failure respiratory depression
Bowel obstruction Aspiration
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Sedation for the elderly: preferred opioid titrated to the lowest dose for
Physiologic Changes in the Elderly: painful interventions or for diagnostic
Homeostatic mechanisms deteriorate with procedures. In general midazolam is strongly
aging; there is variability in this dysfunction. preferred for short ED sedations because of its
Changes in compliance of cardiovascular more rapid onset and shorter-lived effect.
structures seem to be the primary defect in the Comparing patients under 60 years old,
CVS. The implication of this change affects who received 0.05 mg/kg of midazolam,
many aspects of the circulation. There also with those over 60 years old who received
seem to be some alterations within the 0.025 mg/kg midazolam for colonoscopy,
autonomic nervous system. All these changes even with the lower dose, the older patients
affect how elderly patients respond to experienced more frequent desaturation.
anesthesia. Propofol:
The respiratory system undergoes both Propofol is also generally well tolerated in
functional and structural changes with aging. older adults, and is the preferred first-line agent
These can be considered under 4 main in ED and ICU. As with any patient, pay
headings: reduction in muscle mass and power, attention to the blood pressure, and an
changes in compliance, reduction in diffusion alternative agent may be preferable for those
capacity, and a decline in control of breathing. with hypotension.
All of these changes have a profound influence Ketamine:
on the response to anesthesia. Ketamine has become a favorite agent in ED,
Age-related changes take place in kidney ICU and anaesthesia and has been used
structure, blood flow, and function. These successfully for many years. There are some
renal changes have effects on the elimination studies suggesting a very low dose as low as
of anesthesia drugs, and on water and 0.1-0.5mg/kg additional to opioid and
electrolyte metabolism. benzodiazepines. It is probably not the best first
Temperature control is impaired in the elderly. choice in certain older adults, at least until
Anesthesia has a much more profound effect more research is available.
on temperature control in geriatric patients Etomidate:
than in younger adults. Etomidate is not often used as a first-line
Easing the pain in older adults (practical pearls agent for procedural sedation due to its
and a few words of warning) high incidence of myoclonus. However, it is
Understanding physiologic differences otherwise generally well-tolerated in older
between elderly age group guides us in adults, and is still a common first-line
sedation management. Sedation for any medication for rapid sequence induction
patient requires preparation, airway and intubation. Its use is still limited to ED
assessment, and close monitoring. The and ICU.
physician has to be prepared in case of Take Home Pearls:
adverse medication reaction, respiratory 1.Procedural sedation is generally safe in older
depression, need for airway protection, adults, though they may be at higher risk for
and cardiovascular side effects of the oxygen desaturation.
medications. 2.Older patients usually require lower doses of
Do patients 65 and older present any unique medications. They tend to be more sensitive to
challenges? medications, with slower metabolism, less
Is any other preparation needed prior to physiologic reserve to handle side effects, and a
sedation? smaller volume of distribution.
Are the commonly used medications safe? 3.Patients receiving non-analgesic medications
Are older patients at increased risk of side such as Etomidate or Propofol may benefit
effects? from pre-treatment with a short-acting opioid
Opioids and Benzodiazepines: (e.g. 0.5mcg/kg of fentanyl). However, risks of
This is a popular combination, and is generally complications can increase when multiple
tolerated well in older adults. Fentanyl is a agents are used, and doses of the sedative
needed may be lower.
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4.Physicians should take all the usual Benzodiazepines (category D):
precautions, and consider any co-morbidities Diazepam: should not be used for sedation in
that could make the patient more at risk for pregnant women. Sustained use of diazepam
adverse reactions or complications, more during pregnancy has been associated with cleft
difficult to bag or intubate, or more at risk of palate and, when used later in pregnancy,
decompensation. neurobehavioral disorders.
SEDATION FOR THE PREGNANT Midazolam (category D) has not been
PATIENT: associated with congenital abnormalities. It is
Sedation in pregnant patients is risky because the preferred benzodiazepine when sedation
the fetus is particularly sensitive to maternal with meperidine alone is inadequate.
hypoxia and hypotension. Other risks to the Midazolam should be avoided in the first
fetus include teratogenesis (medications and/or trimester, if possible.
ionizing radiation exposure) and premature Flumazenil (category C) little is known of the
birth. Sedation should be avoided in the first safety profile of this benzodiazepine antagonist
trimester as possible. in pregnancy. Although it is not teratogenic in
Maternal over-sedation can result in rats and mice, it does produce subtle
hypoventilation or hypotension. neurobehavioral changes in male offspring of
In late pregnancy, patients should not be rats exposed to the drug in utero.
placed supine or prone. Maternal positioning Lidocaine (category B):
precipitating inferior vena cava compression No fetal abnormalities associated with drug in
can lead to decreased uterine blood flow and one study.
fetal hypoxia. Antibiotic Safety in pregnancy: Avoid in first
Caution should be used when administering trimester and in the third trimester.
higher level of sedation to a pregnant patient TIPS
because of the increased risk of aspiration and Procedures under Sedation should be deferred
potentially difficult airway. to the second trimester whenever possible and
A pregnancy-induced physiologic change such should always have a strong indication with a
as cardiopulmonary systems as well as careful assessment of risk versus benefit
anatomic changes in the airway (swelling of Every procedure requires a preoperative
the oropharyngeal tissues) mandates a proper consultation with an obstetrician, regardless of
examination, investigation and monitoring. the gestational age of the fetus.
Narcotic analgesics: Use lowest effective dose of sedative
Meperidine:(category B) does not appear to be medications.
teratogenic, and it is preferred over morphine Use category B drugs whenever possible.
(category C), which crosses the fetal blood- Minimize procedure time.
brain barrier more rapidly. Meperidine may Position patient in left pelvic tilt or left lateral
cause loss of fetal beat-to-beat cardiac position to avoid vena cava or aortic
variability that can last up to 1 hour after drug compression.
administration, but this does not indicate fetal The decision to monitor fetal heart rate should
distress. be individualized and will depend on
Fentanyl: (category C) has a rapid onset of gestational age of the fetus and available
action and shorter patient recovery time than resources.
meperidine. It is not teratogenic. Although Before 24 weeks of fetal gestation, it is
fentanyl appears safe in humans when given in sufficient to confirm the presence of the fetal
low doses typical for endoscopy, meperidine is heart rate by Doppler pre and post sedation,
preferred over fentanyl in pregnancy. after 24 weeks, continuous fetal heart rate and
Naloxone: (category B) this rapidly acting uterine contraction monitoring advisable.
opiate antagonist crosses the placenta within 2 Ideally, procedures should be done at an
minutes of I.V administration. It does not institution with neonatal and pediatric services
appear to be teratogenic. It should be used only if possible with obstetrician awareness or
in respiratory depression, hypotension, or presence.
unresponsiveness in a closely monitored Procedures under sedation are contraindicated
setting. in placental abruption, imminent delivery,
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ruptured membranes, or uncontrolled Fentanyl:
eclampsia. Fentanyl is excreted in breast milk, but the
Lactating woman: concentrations are too low to be
The role of doing procedure (Diagnostic and pharmacologically significant and fall to
therapeutic) in lactating women does not vary undetectable levels by 10 hours. No
from that in pregnant women in terms of interruption of breastfeeding is recommended.
indications/contraindications, pre-procedure Meperidine:
preparation, procedural monitoring and Meperidine is concentrated in breast milk, and
radiation exposure. Caution should be may be detected up to 24 hours after
exercised in the use of certain medications administration and may have neurobehavioral
because these drugs may be transferred to the effects. Advisable to use an alternative drug
infant through breast milk. In situations where such as fentanyl whenever possible, especially
there is a concern regarding medication or when the patient is nursing a newborn or
metabolite transfer to the infant, the woman preterm infant.
should be advised to pump her breast milk and Propofol:
discard it as indicated for the individual Propofol is excreted in breast milk with
medication after the procedure is complete. maximum concentrations at 4 to 5 hours. The
Midazolam: effects of small oral doses of Propofol on the
Midazolam is excreted in breast milk. infant are unknown, so no interruption of
However, midazolam and its metabolite breastfeeding is recommended.
hydroxy midazolam were minimal as 10nmol/l Reversal agents:
or undetectable after 4-7 hours. It is advisable The safety of naloxone and flumazenil in this
to recommend withholding nursing of the setting is unknown. Naloxone is not orally
infant for at least 4 hours following bioavailable, so it is unlikely to affect the
administration of midazolam. breastfed infant.
 SAFE SEDATION
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 SAFE SEDATION
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A SELF STUDY GUIDE
Patients under sedation are at potential risk of position and asked to open his/her mouth and
significant airway obstruction and respiratory protrude the tongue then assesses the airway,
depression. Airway problems that arise under noting the ability to visualize the fauces,
sedation may potentially lead to life threatening anterior and posterior pillars, soft palate, and
complications of hypoxia and if not managed uvula.
appropriately may lead to hypoxic brain damage q Class 1: soft palate, fauces, uvula, pillars
and or death. visible
Sedation state is not a static one but, it is a q Class 2: soft palate, fauces, uvula visible
continuum spectrum where patients may be q Class 3: soft palate, base of uvula visible
either fully awake or adequately sedated state, or q Class 4: soft palate not visible at all.
may go in deep sedation.
The most common respiratory complications we
may encounter:
Ø Respiratory or ventilatory depression
Ø Altered protective reflexes
Ø Pulmonary aspiration
Ø Hypoxaemia
Ø Airway obstruction
Ø Laryngospasm & Bronchospasm
Ø Apnea CLINICAL SIGNS OF A COMPROMISED
These problems may be evident either during or AIRWAY INCLUDE:
after the procedure. The awareness of them and Some clinical signs mentioned her may help in
mastering basic skills in airway management the diagnosis of a compromised airway, but
with timely and prompt intervention well when in doubt call for help
safeguard the majority of patients against q Noisy respiration, snoring or stridor.
devastating and life-threatening consequences of q Respiratory effort with no chest expansion
hypoxia. or air movement.
The first step in proper airway management will q Cyanosis or low oxygen saturation.
q Dyspnea, sternal notch or intercostal
be an adequate airway assessment.
retraction, nasal flaring and use of
Airway Assessment: accessory muscles during breathing.
History: q Restlessness and or agitation.
I. Previous problems with sedation or q Tachycardia and hypertension.
anesthesia q Coughing.
II. Obstructive sleep apnea
III. Dysmorphic facial features OXYGEN THERAPY:
Physical examination: o Oxygen must be available for all levels of
1. Obesity sedation.
2. Limited neck mobility o The ASA guidelines note that supplemental
3. Thyromental distance less than 6cm oxygen should be considered for moderate
4. Mouth opening less than 3cm sedation.
5. Neck mass o Choose the appropriate oxygen delivery
6. Tracheal deviation system.
7. Edentulous o In case of severe respiratory depression or
8. Protruding incisors apnea start positive pressure ventilation by
9. Loose anterior teeth mask – bag
10. High arched palate o Oxygen is a drug that needs to be
11. Micro And micrognathia administered correctly.
12. Narrow mandible o Get yourself familiar with the available of
Clinical oropharyngeal view (modified oxygen delivery systems before starting
Mallampati scale). sedation.
The patient is placed in a comfortable sitting o Make sure that adequate supply of Oxygen
is available
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A SELF STUDY GUIDE

Airway Devices
Oral Airway Ø The oropharyngeal airway may be used to maintain
airway patency
Ø Oral airway size is determined by measuring the
distance from the corner of the patient's mouth to the
earlobe.
Ø The oral airway is inserted with the point towards the
roof of the mouth and then inverted as the pharynx is
reached

Nasopharyngeal Airway • The nasal airway may be more tolerable than an oral
airway for a sedated patient.
• The appropriate size nasal airway should be selected
by measuring the distance from the tip of the patient's
nose to the earlobe.
• Apply lubricant and insert into one nostril.

Laryngeal Mask Airway(LMA) o They comprise a tube with an inflatable cuff

that is inserted into the pharynx.
o Laryngeal mask airways are used in
anesthesia and in emergency medicine for
airway management.
o They cause less pain and coughing than an
endotracheal tube, and are much easier to
insert.

airway is patent and the patient q Increase flow of the nasal cannula
is breathing but the O2 q If O2 saturation still low encourage the patient to take deep breaths
saturation is low and change the nasal cannula to facemask.
q rebreathing facemask can be used
airway obstruction Ø Simulating the patient may be enough to retain a patent airway Open
Ø Head tilt-jaw lift.
Ø Oral or/and nasal airway may help to maintain a patent airway.
Ø Suctioning: removal of secretions obstructing the airway.
Ø If the condition does not improve, intubate the patient using LMA or
Tracheal Tube.
If the patient is breathing and An artificial airway is indicated.
has adequate O2 saturation but A nasal or oral airway may be used
cannot maintain his or her own Advanced airway management: Laryngeal mask, Intubation.
airway
respiratory arrest bag the patient by connecting the non-rebreathing 100% O2 facemask to
an ambu-bag.
Consider the use of antagonists.
Call for help
 SAFE SEDATION
(Moderate Sedation, Conscious Sedation)
A SELF STUDY GUIDE

Appendices
Flowcharts for airway management airway obstruction, apnea, and laryngospasm
 SAFE SEDATION
(Moderate Sedation, Conscious Sedation)
A SELF STUDY GUIDE
 SAFE SEDATION
(Moderate Sedation, Conscious Sedation)
A SELF STUDY GUIDE
 SAFE SEDATION
(Moderate Sedation, Conscious Sedation)
A SELF STUDY GUIDE

References:
n NetCE is accredited as a provider of continuing nursing education by the American Nurses
Credentialing Center's Commission on Accreditation. NetCE is approved by the California
Nursing Home Administrator Program as a provider of continuing education
http://www.netce.com/coursecontent.php?courseid=1072&scrollTo=BEGIN
n Debra G. Wechter, MD, FACS, general surgery practice specializing in breast cancer, Virginia
Mason Medical Center, Seattle, WA. Also reviewed by David Zieve, MD, MHA, Isla Ogilvie,
PhD, and the A.D.A.M. Editorial team
Indian J Anaesth. 2015 Oct; 59(10): 664–669. doi: 10.4103/0019-5049.167484,
PMCID: PMC4645356, Reversal agents in anaesthesia and critical care, Nibedita Pani, Pradeep A
Dongare,1 and Rajeeb Kumar Mishra,
n http://www.asahq.org/quality-and-practice-management/standards-and-guidelines
Taken from Safe Sedation A Self Study Guide, Chet I. Wyman, M.D.
Chair, Department of Anesthesiology, Franklin Square Hospital Center,
Clinical Instructor, University of Maryland School of Medicine
Baltimore, U.S.A
n Practice Guidelines for Sedation and Analgesia by Non-Anaesthesiologists Anesthesiology, V84,
Nol, Feb 1996
n Ketamine - Midazolam versus Meperidine- Midazolam for Painful Procedures in Pediatric
Oncology Patients J. Clin Oncology Vol IS; Nol: jan 1997. pp94102 .
n Anaesthesia and Analgesia in the Emergency Department
n Can J Anaesth 1997; 44: 5, pp R52-59
n Conscious Sedation of Pediatric Oncology Patients for Painful Procedures
n J Pediatric Oncology Nursing Vol 14; No 1: (Jan) 1997, pp3342\