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Learning outcomes
This lecture should enable you to:

Define conscious sedation

Indication of conscious sedation

Know what equipment is needed

Identify Who should do

Describe conscious sedation Levels

Describe minimal monitoring parameters established for the patient receiving

conscious sedation

Identify medications commonly administered to induce conscious sedation

 Definition
• Latin sedationem (nominative sedatio) "a quieting, a
calming,“to calm or to allay fear
• noun of action from past participle stem
of sedare (see sedate (adj.)
 Definition cont’d
A minimally depressed level of
consciousness, that retains the patient’s
ability to maintain an airway independently &
respond appropriately to physical stimulation
& verbal commands.
 Definition cont’d
• Conscious sedation is produced by the
administration of pharmacological agents
during a therapeutic or diagnostic
procedure. Conscious sedation allays the
patient’s fear and anxiety regarding the
planned procedure.
 OBJECTIVES
• To achieve sedation which allows patients to
undergo and tolerate unpleasant procedures
• To avoid deeper levels of sedation and the
related complications
– This cannot be completely avoided!
• In the uncooperative patient,
sedation/analgesia may facilitate those
procedures which are not uncomfortable but
which require that the patient not move
 Personnel

• “Personnel capable of rapidly identifying and treating

cardiorespiratory complications, including respiratory
depression, apnea, partial airway obstruction, emesis,
and hypersalivation. They must understand the
pharmacology of the sedatives they use and be proficient
at maintaining airway patency and assisting ventilation
if needed.”
• “At least two experienced healthcare providers
medicating the patient.
 Pre-sedation Assessment
• Screening for medical risk factors
– How will these alter response to sedation?
– Abnormalities of major organ systems?
– Previous adverse reactions with sedation/analgesia as well
as regional and general anesthesia?
• Allergies to drugs?
• Medications
• Past History
• Last meal
• Events

– NPO status
 The Spectrum of sedation

Normal
Anxiolysis
Deep
Conscious Sedation General
Sedation Anesthesia

1. Protective reflexes intact 3. Loss of protective

2. Partial loss of reflexes
Patient can independently
protective reflexes Inability to independently
and continuously maintain
Inability to maintain an airway
an airway
independently No pain sensation or reflex
Patient can respond
maintain an airway withdrawal from stimuli
appropriately to verbal
May not respond to Total unconsciousness
commands
verbal commands
1
0

The Spectrum of sedation

Minimal Moderate Deep General
Responsiveness Normal Purposeful
Purposeful Unarousable
response to
response to response to repeated verbal
verbal stim verbal stim or painful stim

Airway Normal Intervention

No
Intervention usually
intervention
may be req’d required
req’d

Ventilation Normal Adequate May be Usually

inadequate inadequate
CV fxn Normal Usually Usually May be
maintained maintained impaired

American Society of Anesthesiologists. Continuum of depth of sedation definition of general anesthesia and levels of
sedation/analgesia. October 27, 2004
The Spectrum of sedation cont’d
Minimal:
Normal response to verbal
stimulation with reduction
of anxiety. Cardio-
respiratory reflexes intact.
Moderate
Somnolence, responds to verbal
stimulation may need tactile stimulation.
Airway and protective reflexes are
protected.
MS is a medically controlled state of
depressed consciousness that
(1) allows protective reflexes to be
maintained
(2) retains the patients ability to
maintain a patent airway independently
and continuously
(3) permits appropriate response by the
patient to physical stimulation or verbal
command, e.g., “open your eyes
The Spectrum of sedation cont’d
Deep sedation General anesthesia
• Reduction in
consciousness. Pt not • a medically controlled
easily aroused by verbal state of unconsciousness
and noxious stimuli. accompanied by a loss of
Respond to painful stimuli protective reflexes,
including the ability to
• Airway and protective
maintain a patent airway
reflexes may be preserved
independently and
or compromised.
respond verbally to
• inability to maintain a patent physical stimulation or
airway independently and command.”
respond purposefully to
physical stimulation or
verbal command.”
 Ramsay Sedation Score
Level 1 Awake, anxious, agitated, restlessness

Level 2 Awake, cooperative, tranquil.

Level 3 Respond to commands.

Level 4 Asleep, brisk response to stimuli.

Level 5 Asleep, sluggish(slow) response to

stimuli.
Level 6 Asleep, no response
 Sedation – Monitoring/Equipment
• Oxygen
• • Suction
• Airway adjuncts :
 Ambu-bag adult &
pediatric
 Airways all sizes
 Laryngoscope – all
size blades
 • Endotracheal tubes
• IV access
• Crash cart with AED
 Sedation – Monitoring/Equipment
• Sedation medications
• Reversal agents
• Monitoring devices
• Pulse oximeter
• Non-invasive blood
pressure
• ECG monitor
• End-tidal CO2
monitor
• Suction machine
• Resuscitation
medications and
equipment
• •IV access
• •Reversal agents
 RECORDS
• Vital signs and level of consciousness
– Document at baseline
– Regular, frequent intervals during the
procedure
– Regular, frequent intervals during recovery
– Prior to discharge
1
8

Procedural Sedation – Fasting

• Fasting
– ASA guidelines - consensus based
• Two hours for clear liquids
• Four hours for breast milk
• Six hours for formula, non-human milk, and solids
» Practice guidelines for preoperative fasting and the
use of pharmacologic agents to reduce the risk of
pulmonary aspiration: application to healthy patients
undergoing elective procedures: a report by the
American Society of Anesthesiologist Task Force on
Preoperative Fasting. Anesthesiology 1999; 90:896.
 Indication
• Foreign body removal
• endoscopy or bronchoscopy;
• ENT surgeries such as
myringoplasty,( closure of the perforation of
pars tensa of the tympanic membrane)
• Supplement to local or regional anesthesia
2
0
Indication cont’d
 Orthopedic procedure
such as reduction of
displaced distal radius
fracture.

Source undetermined
2
1

Indication cont’d
• radiological
procedures like
computerized
tomography
(CT) or magnetic
resonance imaging
(MRI)

Seth Rossman, Wikimedia Commons

Indication cont’d
• ICU for respiratory
support
 Contraindications
• There are few absolute contraindication for
conscious sedation however, relative
contra-indications are important and can
only be considered following a full
assessment.
 Contraindications cont’d
• Chronic obstructive pulmonary disease
• (COPD), epilepsy, & bleeding disorders.
• Uncooperative or unwilling patients.
• Unaccompanied patients..
• Prolonged surgery.
• Lack of equipment or inadequate
personnel.
 RECOVERY PERIOD
• Requires monitoring as during procedure
• Patients may be at increased risk after
removal of painful stimulus
• Various criteria available such as Aldrete
– Consciousness Activity
– Respiration Saturation
– Circulation
– Consider pain and nausea
 AFTERCARE
• Responsible accompanying person for 24
hours
• Written detailed instructions for dealing
with complications
• Medical assistance readily available
• Should have means to be contacted
• No major life decisions, driving or alcohol
for 24 hours
 Discharge Criteria
• Vitals are appropriate for age
• If Child, has appropriate
activity for age?
• Appropriately responds to
verbal stimuli
• Oxygen saturation returns to
normal baseline
• Maintains airway appropriately
• Modified Aldrete score of > 13
 Discharge Criteria
• Fully conscious
• Respond appropriately
• Walk unassisted
• Pain, nausea and vomiting,
bleeding all under control
• Must have accompanying
responsible person
Modified Aldrete Score

• Should have a score of

greater than or equal to
13, before discharge
 Medication

Hypnosis Analgesia

No Muscle
Relaxation
 Benzodiazepines
Diazepam
• Respiratory effects – Respiratory depression, apnea
• Cardiovascular effects – Bradycardia, hypotension
• CNS effects – Agitation, confusion, diplopia
• GI effects – hiccups
• Special Considerations – Phlebitis at site of injection, rash, urticaria, avoid
extravasation as drug is caustic to tissue.
• May be diluted with normal saline only. Do not mix with any other drug.
• Midazolam is generally preferable to Diazepam due
to Midazolam’s decreased duration and easier titratability.
 Benzodiazepines
Diazepam
• Administer in 1-2mg increments every 2
minutes IV until desired effect is achieved.
(Slurred speech).
• Generally 10 to 20 mg in 60 minutes.
• Pediatric Dose: 0.1 – 0.3 mg/kg.
 Benzodiazepines
• Midazolam (Versed)
• The most commonly used sedation agent in children and adults
• Excellent safety record
• Provides potent sedation, anxiolysis, and amnesia
• Shorter acting than other benzodiazepines
• Water soluble, so eliminates burning on administration IV
• May be given in different routes
 Benzodiazepines
• Midazolam oral
– Dose is 0.5 to 0.75 mg/kg orally
– Maximum doses are the same as for IV
– Onset: 15-20 minutes
– Duration : 60-90 minutes
– Not easily titrated, may cause oversedation
– Now formulated as a oral syrup 2mg/ml
• Midazolam, with a half-life of 2 hours, has limited
• cardiovascular effects, allows for quick recovery and
• has no postoperative sequelae such as nausea and
 Benzodiazepines
• Midazolam - Intranasal/Sublingual
– Dose is 0.2 -0.5 mg/kg intranasal or sublingual of IV
formulation
– Onset: 10-15 minutes
– Duration: 60 minutes
– Similar side effects as oral route
– Intranasal route burns when administered, and children
generally do not cooperate with administration.
– Sublingual has same problem with bitter taste as oral
 Benzodiazepines

• Midazolam -IV
– Dose: 0.05-0.1 mg/kg IV
– Onset: 1 to 3 min
– Duration: 10 to 30 min
 Benzodiazepines

• Midazolam - Important Considerations

– Has NO analgesic effect!

– May be reversed with flumazenil(0.01mg/kg IV)

– Contraindicated with narrow angle glaucoma and shock

 Hypnotics
Barbiturates
• Pentobarbital-Nembutal and Propofol – Diprivan
Side effects:
– Myocardial depression
– Hypotension
– Respiratory depression
– Bronchospasm- stimulate histamine release
Hypnotics
Pentobarbital - Nembutal

• Barbituate that is commonly used for

radiologic procedures like CT scans
which require children to be still.
• Dose:
– 2-6 mg/kg/dose PO/IM/PR (By rectum)
– 1-3 mg/kg/dose IV
– Max dose is 150mg
 Hypnotics
• Propofol
– highly lipophilic
– Can be painful on injection
– Rapidly metabolized in liver with high plasma
clearance
– Onset within 40 seconds with duration 8 - 10
minutes
– Causes peripheral vasodilatation and
respiratory depressant(Must be monitored
extremely closely
 Hypnotics
Propofol

– Has anti-emetic effects

– Sedative and amnestic not analgesic
– No reversal agent
– Difficult to titrate in some cases, can cause very
deep sedation
• cause postoperative shivering.
• Dose:
– 2.5-3.5 mg/kg IV
Propofol – Important concerns
• Profound respiratory depressant, and
causes apnea.
• May depress cardiac output and cause
severe hypotension
• IV site pain –requires mix of lidocaine.
 Hypnotics

• PENTOTHAL/ thiopentone
• IV barbiturate, induction agent
• Hypnotic, sedatives, anticonvulsants
• Undergoes hepatic metabolism
• Recovery after bolus comparable to propofol
because of redistribution to inactive tissue sites
 PENTOTHAL
• CNS depressant
• “Anti-analgesic” properties
• May reduce pain threshold
• ↓BP due to peripheral vasodilation
• Transient as compensatory ↑ HR
• Respiratory depressant
• ↓ TV and ↓ RR – transient apnea
 Hypnotics
• Ketamine
• Agent of choice as an analgesic in conscious
sedation.
• Produces dissociated anesthesia. Psychotic
reactions
• such as hallucination, serious cardiovascular
adverse
• effects, seizures and postoperative shivering have
beenreported.
• Dose:1- 2 mg/kg IV
 Narcotics
Gold standard for pain management
Commonly used in combination with a benzodiazepine
(sedative-hypnotic), i.e., Versed, to potentiate effect and
provide both amnesia and analgesia
• High degree of variability in dose response
• Inter-individual variation
• Analgesia, euphoria, sedation, ↓ concentration
• Clearance primarily hepatic metabolism
• May be active metabolites
 Fentanyl
• A rapidly-acting narcotic analgesic, with
little sedative
• effect. May cause depression of
respiratory function.
• The patient may experience postoperative
NV
 Fentanyl - IV
• Preferred opioid because of rapid onset,
elimination, and lack of histamine release
• Dose is 1-2mcg/kg over 3-5 minutes for analgesia
• 0.25 to 0.5 µcg/kg q 3 to 5 minutes fro sedation
• Boluses of 25-50 μg increments for analgesia
• Titrate to effect every 3-5 minutes
• Onset: 1-2 minutes
• Peak effect: 10 minutes
• Duration: 30-60 minutes
 Fentanyl - IV
• Rapid IV administration can cause chest wall
rigidity and apnea
• Combination with benzodiazepines can cause
respiratory depression and dosage should be
reduced
• Respiratory depression may last longer than the
period of analgesia
• 75 to 125 times more potent than morphine
• More lipid soluble than morphine – crosses BBB
• May be reversed with Narcan
 Morphine Sulfate
• Better for procedures that have a longer
duration(30 minutes or greater)
• Morphine dose is 0.1-0.2 mg/kg IV with a
max of 15 mg/dose slow IV push. Titrate to
effect slowly.
• Onset: 5-10 minutes
• Duration: 2-4 hours
• Same dose may given IM or
SQ(subquitaneous )
 ALFENTANIL
• 1/5 to 1/10th potency fentanyl
• More rapid onset and shorter duration
• 1.4 minutes
• 0.1 to 0.4 µcg/kg/min by infusion
 REMIFENTANIL
• Short acting, titratable, rapid onset and
offset, rapid recovery aft infusion
• Boluses excellent for short painful
procedures
• Doses 0.25 to 1 µcg/kg
• Infusions for sedation
• Doses 0.05 to 0.2 µcg/kg/min
 COMPLICATIONS
• Serious complications rare
• All sedatives and narcotics will cause adverse
reactions in some patients even within
recommended doses
• Extremes of age most at risk
• Most sedatives cause dose dependent respiratory
depression
– Risk of desaturation up to 11% with propofol, even with
supplemental oxygen
– Hypoventilation and apnea usually easily treated
 COMPLICATIONS
• Treat respiratory
complications with patient
stimulation, oxygen, airway
positioning or brief
ventilatory support
• Cardiovascular instability
uncommon
– More likely to occur if
significant cardiac morbidity
– Hypotension and bradycardia
may develop in patients on
CV depressants
– Usually transient
 COMPLICATIONS
• Vomiting
– More common if narcotics given
– Little evidence regarding prophylaxis
• Inadequate sedation preventing
completion of procedure
• Over sedation
• Agitation
• Allergic reactions
Sedation vs. General Anesthesia
• While both sedation and general
anesthesia are forms of anesthesia, and
sedation is a component of general
anesthesia, they are different in several
respects. Patients under general
anesthesia have a complete loss of
consciousness. This means that the
patient will not feel, hear or remember
anything
Sedation vs. General Anesthesia
• In contrast, a state somewhere between
being very sleepy, being relaxed in
consciousness, and yet not unconscious,
characterizes sedation. The patients will
not feel pain, but are aware of what is
going on around them.
Sedation vs. General Anesthesia
• As an advantage, the adverse effects that may
be associated with general anesthesia are
avoided with sedation. Moreover, patients
maintain their natural physiological reflexes and
are capable of breathing on their own.
• This does not mean, however, that respiratory
support may not be needed in some instances
with sedation.
Sedation vs. General Anesthesia
• Nonetheless, the recovery period from sedation
is typically quicker than with general anesthesia.
• Cardiovascular function is usually unaffected or
maintained throughout the various stages of
sedation. In contrast, it is usually impaired with
general anesthesia and careful monitoring is
mandatory. In both cases, patients are required
to fast several hours prior to their operation. The
standard fasting duration is six hours. Clear
fluids may be consumed no later than two hours
prior to surgery.
Sedation vs. General Anesthesia
• Technically, light sedation may be given
after a two-hour fast, but this is not
recommended, especially in instances
where the duration of the surgical
procedure is unpredictable and may last
for considerably longer than planned and
general anesthesia becomes necessary
 Summary – take home smg
• Sedation is semi awake
• The maintenance of
awareness does not
mean, however, that
respiratory support may
not be needed in some
instances with sedation.
• Remember , Sedation
can be risky with certain
patient populations
• NPO should maintained
• Rescuci equip/drugs
readily available
 Summary – take home smg
• Always second hand
closer
• Monitoring does not end
with procedure
• Patient must be
monitored until defined
criteria for discharge are
met.
• Admission for observation
may be indicated if a
patient is over-sedated or
has significant
complications from the
sedation
Summary – take home smg
 REFERENCES
• Practice Guidelines for Sedation and
Analgesia by Non-Anesthesiologists - ASA
• Basics of Anesthesia 5th edition – Stoelting
• UNC Adult Moderate Sedation Policy:
http://intranet.unchealthcare.org/policies/u
nc-hcs-policies-pdf-new-
format/ADMIN0160%20pdf.pdf