The document outlines the guidelines and standards for procedural sedation within hospitals, emphasizing the importance of uniform administration, qualified staff, and patient safety. It details pre-assessment requirements, monitoring protocols, and documentation necessary before, during, and after sedation, ensuring informed consent and addressing potential risks. The document also covers the various depths of sedation, sedation agents, and the responsibilities of healthcare providers in managing patient care during sedation procedures.

1. Conscious Sedation
Competency Training
Course
Joven Botin Bilbao, MAN
Chief Nursing Officer- Al Hayat National Hospital
Corporate Accreditation and Clinical Educator–Al Inma Medical
Services

2. Introduction
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 cardio respiratory
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 in order to facilitate a specific procedure, it is considered procedural
sedation. Procedural sedation is often performed in many areas of the hospital
outside of the operating theatre. Because procedural sedation, like
anaesthesia, poses significant potential risks to patients, the administration of
procedural sedation must be uniform throughout the hospital. The
qualifications of staff participating in the procedure, the medical equipment,
the supplies, and the monitoring must be the same wherever procedural
sedation is provided in the hospital. Thus hospitals must develop specific
guidelines for how and where procedural sedation may be used.

3. Standards Requirements
• Standard ASC.3
The administration of procedural sedation is standardized throughout the
hospital.
• Standard ASC.3.1
Practitioners responsible for procedural sedation and individuals responsible
for monitoring patients receiving procedural sedation are qualified.
• Standard ASC.3.2
Procedural sedation is administered and monitored according to professional
practice guidelines.
• Standard ASC.3.3
The risks, benefits, and alternatives related to procedural sedation are
discussed with the patient, his or her family, or those who make decisions
for the patient.

4. Qualified Provider
• The qualified provider requirement covers the training and credentials
of the provider who gives moderate sedation.
ACLS,PALS
Training and Competency
Privileging for Non anesthesia Physician
• A provider “qualified” to give moderate sedation must be trained in:
techniques and various modes of sedation;
pharmacology of sedation drugs and the use of reversal agents;
monitoring requirements; and
 response to complications.
• The ability to “rescue” patients from deep sedation includes training in:
How to manage an airway
How to give oxygen and ventilation
How to deliver appropriate reversal agents

5. CONTINUUM OF DEPTH
OF SEDATION

6. • Minimal Sedation (Anxiolysis) is a drug-induced state
during which patients respond normally to verbal commands.
Although cognitive function and physical coordination may
be impaired, airway reflexes, and ventilatory and
cardiovascular functions are unaffected.
• Moderate Sedation/Analgesia (“Conscious Sedation”) is a
drug-induced depression of consciousness during which
patients respond 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.

7. • Deep Sedation/Analgesia 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.
• General Anesthesia is a drug-induced loss of consciousness during
which patients are not arousable, 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 druginduced depression of neuromuscular function.
Cardiovascular function may be impaired.

10. Conscious Sedation
Pre-assessment

11. Health Assessment
• The purpose of the pre-procedure assessment is to determine baseline status
of the patient and identify factors that may increase the patient's risk during
the period of sedation.
• No patient shall receive sedation until a pre-sedation assessment has been
completed and documented, and the physician has attested to the patient's
appropriateness to receive sedation as evidenced by his/her signature on an
appropriate informed consent documentation form.
• The person administering the sedative agent shall verify that the required
documentation is completed prior to any sedation being given.
• A procedure will be delayed or cancelled until all pre-procedure
documentation is completed.
• Hospitals with obstetric or emergency services should be able to perform an
assessment quickly.
• These hospitals should be able to gather enough information to give
moderate sedation safely within 30 minutes after deciding to sedate the
patient.

12. • Minimal assessment required before sedation includes, but is not limited
to, the determination and documentation of:
 Age and weight.
 Drug allergies.
 Current medication use (including recent narcotics and sedatives within the past
24 hours).
 Previous problems with anesthesia/sedation.
 Heart rate, blood pressure, and respiratory rate.
 Oxygen saturation.
 Level of awareness (consider mental status/orientation)
 Time of last PO intake
 Respiratory and cardiovascular status which may include findings from heart
and lung auscultation and other physical findings as appropriate.
 Baseline assessment of pain, where appropriate.
 Baseline Modified Aldrete Sedation Score (minimum score of 8 recommended for
moderate sedation).
 Marking of surgical site involving right/left distinction, multiple structures
(such as fingers or toes) or levels (such as spine)

13. ASA Physical Status Classification System
ASA 1
ASA 2
ASA 3
ASA 4
ASA 5
A normal healthy patient
A patient with mild systemic disease
A patient with severe systemic
disease
A patient with severe systemic
disease that is a constant threat to
life
A moribund patient who is not
expected to survive without the
operation
May have conscious sedation
without other consultation
Same as above
Consider medical consultation.
Mandatory involvement of
Anesthesiology Department
Same as above

14. Assessment for risk of airway compromise.
(Mallampati Classification)
The Mallampati classification relates tongue size to pharyngeal size and is an
important factor in determining the degree of difficulty of direct larynogoscopy. This
classification allows one to assess upper airway access based on visibility of the oral
pharynx ranging from complete visualization including tonsilar pillars to no
visualization with the uvula pressed against the tongue. This test is performed while
the patient is in the sitting position, awake and cooperative. Simply have the patient
open their mouth and stick out their tongue and assess based upon the pharyngeal
structures that are visible. This may not always be possible to accomplish in our
patients.
Class I: Visualization of the soft palate, fauces, uvula and pillars. No anticipated
difficulty.
Class II: Visualization of the soft palate, fauces, uvula. No anticipated difficulty.
Class III: Visualization of the soft palate and base of the uvula. Anticipate moderate
difficulty.
Class IV: Soft palate is not visible. Anticipate severe difficulty. The classification
assigned may vary if the patient is in the supine position (instead of sitting).

16. • The following fasting guidelines must be considered. Gastric emptying
may be influenced by many factors such that the guidelines below do not
guarantee that complete gastric emptying has occurred.

17. Conditions that will affect the use of moderate sedation
include:
•Indication for the procedure
•Altered mental status
•Atypical airway anatomy
•Obesity
•Pregnancy
•Sleep apnea
•Current medications
•Substance abuse
•Cardiovascular disease
•Respiratory disease
•Liver disease
•Kidney disease
•Central nervous system dysfunction

18. Discussion of Options & Risks
Sedation options and risks may be discussed with the patient and family before giving
moderate sedation.
Patients must give informed consent for any treatment. This includes moderate sedation.
Part of informed consent is a full understanding of the options and risks of treatment.
Discussing the sedation procedure can help to calm the patient fears.
Patient education also should include information on:
• Resuming activity
• Consciousness checks
• Dietary restrictions
• When medications can be resumed
• Potential post-procedural complications
• Whom to contact for asking for help

19. Medication and
Equipment

20. DRUG ACTION ROUTE DOSE
mg/Kg
ONSET DURATION COMPLICATION COMMENTS Reversal
Agents
Diazepam
Hypnotic
Anxiolytic
Amnestic
IV
PO
PR
0.1-0.4
0.1-0.2
0.2-0.5
2-5minutes
1-1½ hour
10minutes
1-2hours
<12hours
1-2hours
Respiratory
Depression
Hypotention
Blurred vision
Avoid IM; erratic
absorption
Reversible with Flumazenil
Flumazenil
Midazolam
Sedative
Analgesic
IV
IM
PO
PR
0.01-0.08
0.07-0.08
0.5-1.0
0.3-0.7
3-5minutes
10-20minutes
15-45minutes
10-20minutes
1-2hours
1-4hours
1-4hours
1-4hours
Respiratory depression
Hypotension
Paradoxical agitation
Use repeated small doses
given slowly
Short recovery time
IM: Painful
Flumazenil
Morphine
Sedative
Analgesic
IV
IM
0.1-0.2
0.1-0.2
2-5minutes (peak
20minutes)
20-60minutes
(peak 45-
60minutes)
3-5 hours
Respiratory depression
Hypotension
Histamine release
Slower onset longer
Duration than fentanyl
Efficacious
Some sedative properties
Naloxone
Fentanyl
Sedative
Analgesic
IV
IM
0.001-0.002
0.001-0.005
1-3minutes (peak
10-30minutes)
30-120minutes
Respiratory depression
(less than Morphine)
Apnea, Increased ICP
Facial Pruritis
Weak sedative
Rapid onset
Short duration
Naloxone
Pethidine
Anesthetic
Sedative
IV
IM
0.5-1
1-2
5 minutes
15-30minutes
(peak 45-
60minutes)
2-4hours
Respiratory depression
Hypotension
Seizures
Nausea & Vomiting
Increased ICP
Aivoid in renal faliure
If compined with
benzodiazepienes
Decrease the initial dose
Used with caution in elderly
Naloxone
List of Drugs Used in Conscious Sedation

21. DRUG ACTION ROUTE
DOSE
mg/Kg
ONSET Duration COMPLICATION COMMENTS Reversal Agents
Nitrous Oxide
Anesthetic
Sedative
Inhale 50:50 (02:N20) 3-5minutes 1-3minutes
Increased pressure of
trapped gases
Myocardial depression
Avoid in bowel
obstruction, head injury
None
Propofol
Anesthetic
Sedative
IV 1-2 µg/Kg 60 seconds 3-5 minutes
Hypersensitivity: Rush &
pruritus
Hypotension
Decreased ICP
Apnea possibly lasting
longer 60 seconds
Due to increase the risk of
hypotention and
bradycardia so it shoud
be used by an ICU doctor
or anethesiologist
None
Thiopental
Anesthetic
Sedative
IV
Child: 5-6mg/Kg
Adult: 3-5Kg
30-60 seconds 10-30 minutes
Myocardial depression,
cardiac arrhythmias
Respiratory depression
Hypersensitivity
None
Naloxone
SC/ IV/
IM
Child: 0.005-0.01
mg/Kg at 2-3 mins.
Interval
Adult: 0.4-2mg IV
Immediate 30-90 minutes
These doses are for
reversal of narcotic
depression only
None
Flumazenil
IV
0.3mg IV over 30
seconds
Repeat at 60 seconds
intervals to max. of 2
mg
Immediate 60 minutes
Limited experience in
children
Do not give with TCA
congestion
Do not give to patients
dependent to BZD
None

22. Equipments
• Oxygen
• Suction
• Airway management
• Monitors
– Pulse oximeter
– Cardiac monitor
– Automated blood pressure device
• Resuscitative equipment / medications
– Ambu bag
– Defibrillator with ECG recorder
– Emergency drugs
– Emergency drug card and ACLS protocols

23. Monitoring and
Documentation

24. Monitoring
Patients must be monitored during moderate sedation.
Physiological monitoring is the only way to ensure that patients
get the supportive treatment they need.
The following need to be monitored in some or all patients:
• Heart rate and oxygenation—should be continuously
monitored by pulse oximetry.
• Respiratory rate--& pulmonary ventilation should be
continuously monitored
• Blood pressure—should be measured at regular intervals.
• ECG—should be monitored:
– If the patient has significant cardiovascular disease
– If cardiac arrhythmias are expected or detected.
• Data from monitoring must be recorded in the patient’s
medical record.

25. Ramsay Sedation Score
One of the most commonly used measures of sedation is the Ramsay
Sedation Scale. It divides a patient's level of sedation into six categories
ranging from severe agitation to deep coma. Despite its frequent use,
the Ramsay Sedation Scale has shortcomings in patients with complex cases.
When the scale is applied at the bedside, many patients appear to conform to
more than one level of sedation. For example, patient may appear to be
asleep, with a sluggish response to the glabellar tap, and at the same time
may be restless and anxious.

26. Notify Medical Doctor
• Rise or fall in systolic pressure 30 mmhg from baseline.
• Tachycardia or bradycardia
• Rise or fall in respiratory rate
• Oxygen saturation less than 90% or significantly below pre-
sedation level.
• Marked decrease in patient responsiveness to verbal or
painful stimulation
• Signs or symptoms of medication intolerance or allergies
• Patient does not meet discharge criteria.

27. Documentation of Care
• Pre-procedure assessment
• Dosage, route, time, and effects of all medications
and fluids used.
• Type and amount of fluids administered, including
blood and blood products.
• Monitoring devices and equipment used.

28. Documentation of Care
• Physiologic data from continuous monitoring at 5 to
15 minute intervals and following significant events.
• Level of consciousness
• Nursing interventions and patient’s response
• Unwanted significant patient reactions and their
resolution.

29. Discharge assessment
and Instruction

30. Discharge Assessment
 Vital signs to pre-procedural baseline
 Gag reflex / able to swallow
 To pre-procedural level of awareness
 Documentation of modified aldert score will be
completed prior to patient discharge. The score
must return to the baseline assessment before
the patient may be release from the procedure
area.evidence that patient has met discharge
criteria must be clearly documented in the
medical record

32. Discharge Teaching
• Verbal and written discharge instructions.
• Instructions should be initiated in pre-procedure phase and
repeated in post-procedural phase.
• Documentation of modified aldert score will be completed
prior to patient discharge. The score must return to the
baseline assessment before the patient may be release from the
procedure area.evidence that patient has met discharge criteria
must be clearly documented in the medical record

33. Discharge Instructions
• Instructions should cover:
– Home medications administration
– Dietary requirements
– Limitations on activity
– Post-procedural care
– Signs and symptoms of complications
– Emergency numbers / physician numbers
– Follow-up appointment