Classification Restricted
Title: Procedural Sedation Policy
Ref. No: PP/ASC/001/07 Issue Date: October 2014
Version: 07 Last Reviewed: January 2024
Document Owner: Anesthesia Department Next Revision Date: January 2026
1. PURPOSE:
1.1 To ensure sedation services are available to meet patient needs, and all such services meet professional
standards and applicable local and national standards, laws, and regulations.
1.2 To ensure procedural sedation services are uniform and standardized throughout the hospital.
1.3 To define the process of providing and monitoring patients receiving procedural sedation.
2. POLICY STATEMENT:
2.1 Sedation services are available for elective & emergency procedures during and after normal hours of
operation.
2.2 Sedation services are under the direction of one or more qualified individuals in The Hospital
2.3 Administration of procedural sedation services are uniform and standardized throughout the hospital.
2.4 Emergency medical equipment and supplies are immediately available and customized to the type of
sedation being performed, the age and medical condition of the patient.
2.5 An individual with advanced life-support training appropriate for the age and history of the patient is
immediately available when procedural sedation is being performed.
2.6 Standardization of procedural sedation is supported by policies and procedures that are understood by
all practitioners permitted to administer procedural sedation and identifies:
2.6.1 Areas in the hospital where procedural sedation may occur,
2.6.2 Special qualifications or skills of staff involved in the procedural sedation process,
2.6.3 The differences between pediatric, adult, and geriatric populations or other special
considerations,
2.6.4 The immediate availability and use of specialized medical equipment, appropriate to the age
and history of the patient,
2.6.5 The informed consent process for both the procedure and the use of sedation
2.7 A qualified individual monitors the patient during the period of sedation and documents the
monitoring.
2.8 Established criteria are used and documented for the recovery and discharge from procedural sedation.
3 APPLICABILITY:
All clinical staff are privileged to provide procedural sedation.
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Classification Restricted
Title: Procedural Sedation Policy
Ref. No: PP/ASC/001/07 Issue Date: October 2014
Version: 07 Last Reviewed: January 2024
Document Owner: Anesthesia Department Next Revision Date: January 2026
4 RESPONSIBILITIES:
The responsibilities are detailed below in the procedure section.
5 PROCEDURE:
5.1 This policy applies to the areas of the Hospital where procedural sedation is administered:
5.1.1 Emergency Department
5.1.2 Radiology Department
5.1.3 High Dependency Unit (HDU)
5.1.4 Intensive Care Unit (ICU)
5.1.5 Operation Theater
5.1.6 Endoscopy Unit
5.1.7 Dental OPD
5.1.8 Cath Lab
5.1.9 Maternity ward
5.2 The individual responsible for procedural sedation must be competent in:
5.2.1 Techniques and various modes of sedation
5.2.2 Pharmacology of sedation drugs and the use of reversal agents
5.2.3 Monitoring requirements
5.2.4 Response to complications
5.3 Sedation services shall be provided by the Anesthesiologists, Intensivist, Pedodontist, ER physicians,
interventional cardiologist, midwives and privileged nurses.
5.4 Sedation in patients with Obesity class III (APPENDIX VII) difficult airway and ASA physical status
classification III and above (Appendix 1) shall be administered by the Anesthesiologist only.
5.5 Pedodontics and midwives are privileged to administer nitrous oxide sedation only.
5.6 All the patients shall be monitored with pulse oximeter, BP, ETCO2 and ECG when administering sedation
ensuring their vital signs remain stable throughout the procedure.
5.7 A crash cart equipped with life- saving medications, defibrillators, airway management tools, and cardiac
monitoring devices shall be accessible in all areas of the hospital where sedation will occur.
5.8 Non-Anesthesiologist administering sedation must have sedation privileges, and all necessary
qualifications, training, and credentials to perform sedation safely.
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Classification Restricted
Title: Procedural Sedation Policy
Ref. No: PP/ASC/001/07 Issue Date: October 2014
Version: 07 Last Reviewed: January 2024
Document Owner: Anesthesia Department Next Revision Date: January 2026
5.9 All Healthcare providers involved in the procedural sedation must have at least basic life support to
manage any emergency situations/events.
5.10 In the event of an emergency the sedation provider should follow ACLS protocol and directly contact an
anesthesiologist/ intensivist.
5.11 Procedural sedation competencies for all staff involved in sedation are documented in the personnel files.
5.12 Pre-sedation assessment of the patient will be done by the physician administering the sedation and
includes:
5.12.1 Relevant history & physical examination.
5.12.2 Airway assessment to identify any airway problems that may influence the type of sedation used.
5.12.3 BMI assessment to classify grade of Obesity if applicable
5.12.4 ASA classification
5.12.5 Laboratory Review.
5.13 Patients shall be instructed to remain NPO (Nothing Per Oral) according to the ASA guidelines (Appendix
II).
5.14 In emergency situations the risk of pulmonary aspiration should be weighed against the benefits of the
procedure. The decision to proceed with the sedation when the patient is inadequately fasted (according
to the guidelines – Appendix II) must be documented in the patient’s medical record with a clear
explanation as to the decision-making process.
5.15 Formulate the plan of care to meet patient’s identified needs which is discussed with the patient, family
and/or decision makers. This plan of care should be documented in patient medical records.
5.16 Informed Consent
5.16.1 The physicians involved in procedural sedation shall discuss with the patient, family and/or
decision makers to educate the concerned on the risks, benefits, and alternatives of procedural
sedation.
5.16.2 The physicians involved in procedural sedation shall further educate the patient, family and/or
decision makers about post-procedure analgesia.
5.16.3 The informed consent must be signed and documented in the medical record and presence of this
documentation must be verified before the sedation is administered.
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Classification Restricted
Title: Procedural Sedation Policy
Ref. No: PP/ASC/001/07 Issue Date: October 2014
Version: 07 Last Reviewed: January 2024
Document Owner: Anesthesia Department Next Revision Date: January 2026
5.16.4 The informed consent will be obtained after the above-mentioned criteria and signed by the
patient/ decision maker and a witness/translator (if applicable) and the physicians involved in
procedural sedation obtaining the consent.
5.17 Intra Procedure Care
5.17.1 Immediately prior to induction of sedation, the physician administering the sedation should
confirm the findings of the initial assessment and the fitness of the patient to undergo the
sedation. This information should be appropriately documented in the patient’s medical record.
5.17.2 Sign in, time out and sign out should be done as per policy Refer: PP/IPSG/004/05.
5.17.3 Patients undergoing procedural sedation shall require clinical monitoring of their level of
consciousness, ventilation, oxygenation and hemodynamic variables at a frequency based on the
type and amount of medication administered, the length of the procedure, and the type and
condition of the patient.
5.17.4 Appropriate equipment will be immediately available, including:
5.17.4.1 Electrocardiographic monitoring, including defibrillator
5.17.4.2 Oxygen availability by a system with positive pressure delivery
5.17.4.3 Oxygen saturation by Pulse Oximetry
5.17.4.4 End tidal CO2 monitoring.
5.17.4.5 Non-invasive blood pressure monitoring equipment
5.17.4.6 The continuous use of appropriately set audible alarms on all physiologic parameters
5.17.4.7 Age-specific emergency equipment
5.17.4.8 Crash cart, with appropriate intubation equipment
5.17.4.9 Emergency drugs including flumazenil and naloxone.
5.18 Monitoring and Documentation (time-based record of events)
During the procedure all medication administered to the patient and the patient’s vital signs must be
documented
5.19 Post-Procedure Care
5.19.1 Patients who have received safe sedation must be monitored post procedure until full recovery.
5.19.2 The Nurse involved in monitoring patients during post sedation period, should be competent in.
5.19.2.1 Monitoring requirements.
5.19.2.2 Response to complications.
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Classification Restricted
Title: Procedural Sedation Policy
Ref. No: PP/ASC/001/07 Issue Date: October 2014
Version: 07 Last Reviewed: January 2024
Document Owner: Anesthesia Department Next Revision Date: January 2026
5.19.2.3 Use of reversal agents
5.19.2.4 Recovery criteria
5.19.3 Recovering and discharging the patient after sedation is as per “Modified Aldrete Score” criteria.
5.19.4 Maintain time-based record of vital signs until full recovery.
5.19.5 The patient may be discharged from the recovery area to another location such as the ward, or
home as clinically indicated.
5.19.6 The patient may be discharged from the recovery area if Modified Aldrete score is 9 or more and
if Modified Aldrete Score (APPENDIX V) is 8 or less with the written order from the Physician
providing sedation.
5.19.7 Steps to be followed before the patient is discharged to Home:
5.19.7.1 Stable out of bed for 30 minutes prior to discharge.
5.19.7.2 Able to void.
5.19.7.3 Able to retain oral fluids, unless otherwise indicated
5.19.7.4 Discharged with a written order and follow up instructions.
5.19.7.5 Under observation of a responsible person at home and have transportation from the
hospital.
5.19.7.6 Utilize Aldrete scoring system as an objective discharge criterion (see APPENDIX V):
Patient must achieve a score of at least 9 (with no score of “0” in any category) before
discharge from hospital can be considered.
5.19.7.7 All patients would be advised not to drive/operate machine/ take any legally binding
decisions for 24 hours after discharge.
6 DEFINITIONS/ABBREVIATIONS:
6.1 Procedural sedation is defined as “the technique of administering sedatives or dissociative agents with or
without analgesics to induce an altered state of consciousness that allows the patient to tolerate painful
or unpleasant procedures while preserving cardiorespiratory function. “Regardless of the medication,
dose, or route of administration, when a medication is used for the purposes of altering the patient’s
cognitive state to facilitate a specific procedure, it is considered procedural sedation. The levels of
sedation are defined as:
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Classification Restricted
Title: Procedural Sedation Policy
Ref. No: PP/ASC/001/07 Issue Date: October 2014
Version: 07 Last Reviewed: January 2024
Document Owner: Anesthesia Department Next Revision Date: January 2026
6.1.1 Minimal sedation – drug induced state in which cognitive function and coordination may be
impaired, but airway protection and patency, ventilation and cardiovascular function are
unaffected.
6.1.2 Moderate Sedation – is a drug-induced depression of consciousness during which a patient
responds purposefully to verbal commands, either alone or accompanied by light tactile
stimulation. No interventions are required to maintain a patent airway and spontaneous
ventilation is adequate. Cardiovascular function is usually maintained.
6.1.3 Deep Sedation – is a drug-induced depression of consciousness during which patients cannot be
easily aroused but respond purposefully following repeated or painful stimulation. The ability to
independently maintain ventilatory function may be impaired. Patients may require assistance in
maintaining a patent airway and spontaneous ventilation may be inadequate. Cardiovascular
function is usually maintained.
6.1.4 General anesthesia – is a drug-induced loss of consciousness during which patients cannot be
aroused, even by painful stimulation. The ability to independently maintain ventilatory function
is often impaired. Patients often require assistance in maintaining a patent airway and positive
pressure ventilation may be required because of depressed spontaneous ventilation or drug-
induced depression of neuromuscular function. Cardiovascular function may be impaired.
6.2 Pediatric patient: A pediatric patient is considered as a child aged 12 years or less.
6.3 ACLS: Advanced Cardiac Life Support
6.4 ASA: American Society of Anesthesiologist
6.5 ED: Emergency Department
6.6 ICU: Intensive Care Unit
6.7 HDU: High Dependency Unit
6.8 NIBP: Non-Invasive Blood Pressure
6.9 PALS: Pediatric Advanced Life Support
6.10 PACU: Post Anesthesia Care Unit
7 APPENDICES:
7.1 Appendix I: ASA physical status classification
7.2 Appendix II: ASA Practice Guidelines for Preoperative Fasting for ELECTIVE PROCEDURES
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Title: Procedural Sedation Policy
Ref. No: PP/ASC/001/07 Issue Date: October 2014
Version: 07 Last Reviewed: January 2024
Document Owner: Anesthesia Department Next Revision Date: January 2026
7.3 Appendix III: Richmond Agitation Sedation Scale
7.4 Appendix IV: Home discharge criteria
7.5 Appendix V: Post Sedation Modified Aldrete Score
7.6 Appendix VI: Special Considerations for Pediatric Patients.
APPENDIX I
ASA (American Society of Anesthesiology) Physical Status Classification: The American Society of Anesthesiology
uses a classification of health status that relates concurrent illness to anesthesia risk. ASA I and II indicate low risk
whilst levels III and IV anticipate progressively higher risk from the anesthetic intervention, independent of any
associated surgical risk.
ASA I: The patient has no systemic disease.
Example: Fit, healthy patient for hernia repair
ASA II: The patient has mild to moderate systemic disease which does not limit activities. This
may be caused either by the condition to be corrected by surgery or by some other
pathophysiological process
Examples: Mild diabetes controlled essential hypertension or anemia. Significant obesity
and chronic bronchitis may be included in this category.
ASA III: The patient has severe systemic disease-causing functional limitation.
Examples: organic heart disease, diabetes with vascular complications, moderate to
severe pulmonary insufficiency, angina pectoris or recovered myocardial infarction.
ASA IV: The patient has severe systemic disease which is a constant threat to life.
Examples: Organic heart disease showing signs of cardiac decompensation, persistent
angina, active myocarditis, advanced degrees of pulmonary, hepatic, or endocrine
insufficiency and chronic bronchitis may be included in this category.
ASA V: The patient is moribund and unlikely to survive more than 24 hours with or without
surgery. The surgical interventions are directed toward improving the patient’s chances
of survival.
Examples: Ruptured abdominal aneurysm with profound shock, massive pulmonary
embolism. The surgical intervention is part of the “last resort” resuscitation effort.
APPENDIX II
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Title: Procedural Sedation Policy
Ref. No: PP/ASC/001/07 Issue Date: October 2014
Version: 07 Last Reviewed: January 2024
Document Owner: Anesthesia Department Next Revision Date: January 2026
ASA Practice Guidelines for Preoperative Fasting for Elective Procedures
Minimum fasting times
1. 2 hours clear fluids (including water, apple juice and tea without milk)
2. 4 hours breast milk
3. 6 hours
I. infant formula and non-human milk (e.g. cow’s milk)
II. fruit cocktail and mango juice
III. fizzy drinks (e.g. coca cola, sprite)
IV. fresh fruit
V. non-fatty meal (e.g. clear fluid and toast without butter or margarine)
4. 8 hours fatty meal
5. In emergency situations the risk of pulmonary aspiration shall be weighed against the benefits of the
procedure. The decision to proceed with the sedation when the patient is inadequately fasted (according
to the guidelines – Appendix II) must be documented in the patient’s medical record with a clear
explanation as to the decision-making process.
APPENDIX III
Richmond Agitation Sedation Scale:
Score Term Description
+4 Combative Overtly combative, violent, immediate danger to staff
+3 Very agitated Pulls or remove tube(s) or catheter(s); aggressive
+2 Agitated Frequent non-purposeful movement, fights ventilator
+1 Restless Anxious but movements not aggressive vigorous
0 Alert and calm
-1 Drowsy Not fully alert, but has sustained awakening
(eye-opening/eye contact) to voice (≥ 10 seconds)
-2 Light sedation Briefly awakens with eye contact to voice (≥ 10 seconds)
-3 Moderate sedation Movement or eye opening to voice (but no eye contact)
-4 Deep sedation No response to voice, but movement or eye opening to physical stimulation
-5 Unarousable No response to voice or physical stimulation
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Title: Procedural Sedation Policy
Ref. No: PP/ASC/001/07 Issue Date: October 2014
Version: 07 Last Reviewed: January 2024
Document Owner: Anesthesia Department Next Revision Date: January 2026
APPENDIX IV
Post sedation Modified Aldrete score
ACTIVITY Able to move 4 extremities spontaneously or on command 2
Able to move 2 extremities spontaneously or on command 1
Unable to voluntarily move extremities 0
CONSCIOUSNESS Fully conscious 2
Responding to verbal command 1
Not responding 0
Respiration Able to breathe deeply and coughing 2
Tachypnea, dyspnea, or shallow breathing 1
Apnea 0
Circulation Blood pressure ± 20% of pre-anesthesia Value 2
Blood pressure ± 20-50% of pre-anesthesia Value 1
Blood pressure > 50% of pre-anesthesia Value 0
OXYGEN SATURATION Maintains value >92 % on room air 2
Requires oxygen to maintain >92% 1
Saturation< 90% with oxygen therapy. 0
TOTAL 10
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Version: 07 Last Reviewed: January 2024
Document Owner: Anesthesia Department Next Revision Date: January 2026
APPENDIX V
Home discharge criteria: Patient must achieve a score of at least 9 (with no score of “0” in any category)
before discharge from hospital can be considered.
Vital Signs
Within 15% of preoperative level 2
Within 15% to 30% of preoperative level 1
Less than 30 % of preoperative level 0
Activity Level:
Steady gait, no dizziness or meets preoperative level 2
Requires assistance 1
Unable to ambulate 0
Nausea and Vomiting
Nil/minimal: Successfully treated with oral mediation 2
Moderate: Successfully treated with intramuscular medication 1
Severe: Continues after repeated treatment 0
Pain Level:
No or minimal pain (0-3) 2
Moderate pain (4-7) 1
Severe pain (8-10) 0
Surgical Bleeding
Nil/Minimal: no dressing change required 2
Moderate: Up to two dressing changes required 1
Severe: More than three dressing changes required 0
TOTAL 10
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Title: Procedural Sedation Policy
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Version: 07 Last Reviewed: January 2024
Document Owner: Anesthesia Department Next Revision Date: January 2026
APPENDIX VI
Dosing Recommendations for Adult and Pediatric Patients
DRUG DOSAGE COMMENTS ONSET DURATION
PEDIATRIC
PO 0.5 mg/kg.
INTRANASAL0.2-0.3mg/kg..
Preferred
IV 0.05 – 0.15mg/kg.
benzodiapine
IM 100 mcg/kg
agent.
ADULT
a) IV Initial dose should be 1mg;
PO30- 30 min –
MIDALOZAM additional doses of <2mg may be given
45 min 2 hours
at intervals of >2 mins. Usual dose
<5mg.
Infuse bolus
b) Initial dose should be reduced to
over 2 – 3
0.5mg for patients >60years of age or
minutes.
patients who are debilitated or
chronically ill; additional doses of
<1mg. may be given in these patients.
IV
DIAZEPAM ADULT Give IV slow
1-5 6-8 hour
(VALIUM) IV 0.3-0.7 mg/kg. over 3 minutes
min.
PEDIATRIC
FENTANYL IV 0.5-2mcg/kg
Slow IV over 2-3 IV 30min-1 hr
ADULT
mins. 3-5min
IV 1-2mcg/kg
Max 2-4mcg/kg
Continuous
ADULT infusion started 1-3
REMIFENTANIL 3-10 min
IV 0.01-0.1 mcg/kg/min 1-3 mins before min
procedure
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Title: Procedural Sedation Policy
Ref. No: PP/ASC/001/07 Issue Date: October 2014
Version: 07 Last Reviewed: January 2024
Document Owner: Anesthesia Department Next Revision Date: January 2026
PEDIATRIC
MORPHINE IV over at IV
IV 0.05-0.1mg/kg 2-4 hours
least 5min. 10 min
ADULT: IV 2.5mg-10mg
IM 15-
PEDIATRIC
Infuse over at 20min
MEPERIDINE IV 0.5 - 1 mg/kg
least 5 2-4 hour
(PETHIDINE) ADULT
minutes IV 3-5
IM/IV 1mg/kg
min
The maintenance dose should be 25% of the dose required to reach sedation. Reduce the dose by 30% if a concomitant
narcotic or CNS depressant is given. Recommendations are guidelines only and should not substitute for Physician
judgment or specific patient safety requirements.
DOSAGE COMMENTS ON SET DURATION
MISCELLANEOUS
1mg/kg Administer over 1- IV 1min IV 15min
PROPOFOL IV Continuous infusion: 4-8 2 mins
mg/kg/hr Titrate to effect
Adults: 1-2 mg/kg IV given over Subsequent doses of 1-2 min 10-20 min
1-2 minutes 0.25 to 1 mg/kg may
KETAMINE Pediatric: 4-5 mg/kg IM, be repeated every 5
1-2 mg/kg IV given over 1-2 to 10 minutes
minutes
CHLORAL PEDIATRIC PO/PR 30- 4 hours
HYDRATE PO/PR 25-75mg/kg.max 0.5 -1gm. 60 min
REVERSAL AGENTS
DRUG DOSAGE COMMENTS ONSET DURATION
PEDIATRIC: 0.005-0.1 mg IV/IM/SC: ET (2-3 times IV dose) IV 2- 20-60 min
NALOXONE
repeat q2-3 min PRN based on dilute in 1-2 ml. NS. 3min
(NARCAN)
response (Max 0.1mg/kg)
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Classification Restricted
Title: Procedural Sedation Policy
Ref. No: PP/ASC/001/07 Issue Date: October 2014
Version: 07 Last Reviewed: January 2024
Document Owner: Anesthesia Department Next Revision Date: January 2026
ADULT: 0.04 – 0.4 mg IV/IM/SC initially, Repeated doses usually IM/SC
may repeat until desired response necessary. /ET
achieved (Max 0.8 mg) 2-5
min
PEDIATRIC Infuse over 15 seconds. IV 1-3 Usually, < 1 hr
FLUMAZENIL IV 5 mcg/kg, repeat up to 40 mcg/kg Reversal effects may min
(ANEXATE) ADULT wear off before effects
IV 0.2mg. may repeat to maximum 1 mg. of benzodiazepines
APPENDIX VII
World Health Organization Classification of obesity
Body Mass Index; Kg.m2 Classification
<18.5 Underweight
18.5- 24.9 Normal
25.0- 29.9 Overweight
30.0-34.9 Obese 1
35.0- 39.9 Obese 2
>40.0 Obese 3 (Previously morbid obesity)
8 CROSS REFERENCES
8.1 Joint Commission International accreditation standards for hospitals (7th ed.), USA: JCR.
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Classification Restricted
Title: Procedural Sedation Policy
Ref. No: PP/ASC/001/07 Issue Date: October 2014
Version: 07 Last Reviewed: January 2024
Document Owner: Anesthesia Department Next Revision Date: January 2026
9 REVISION HISTORY:
Record Revised Date Revisions Done
Version 1.0 October 2014 Initial Version
Version 1.1 October 2015 Updated contents to ensure applicability and alignment to
regulatory requirements
Version 2.0 July 2017 Updated logo, format, organizational structure terms and
contents to ensure applicability and alignment to ASC 3 and 5.1
of JCIA Standards for Hospitals 6th Edition
Version 03 September 2018 Updated logo, format, organizational structure terms and
contents to ensure applicability and alignment to JCIA Standards
for Hospitals 6th Edition. Responsibility added as main Heading
no 4.
Version 04 September 2019 Document Classification updated as per ADHICS Regulation
Asset Classification
Version 05 March 2021 Updated with new logo and JCIA 7th Edition Standards
Version 06 April 2023 Updated with new logo and approval page
Version 07 January 2024 Updated with new logo
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Title: Procedural Sedation Policy
Ref. No: PP/ASC/001/07 Issue Date: October 2014
Version: 07 Last Reviewed: January 2024
Document Owner: Anesthesia Department Next Revision Date: January 2026
10 APPROVAL:
Name Designation Signature Date
03/01/2024
Prepared By: Dr. Sayed Kazmi Specialist Anesthesia
03/01/2024
Reviewed by: Mr. Benjamin John Senior Quality Officer
03/01/2024
Reviewed by: Mr. Ahmad Alyounes Chief Nursing Officer
03/01/2024
Reviewed By: Dr. Abdulla Almarzooqi Medical Director
GM/Director of 03/01/2024
Approved By: Mr. Jayaprakash Kalijavedu
Operations
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