This document provides guidelines for moderate sedation/analgesia (conscious sedation). It defines levels of sedation from minimal to general anesthesia. Moderate sedation involves patients responding purposefully to verbal commands with spontaneous breathing. The guidelines discuss patient evaluation, monitoring, personnel, equipment, drugs and discharge criteria for providing moderate sedation. Proper patient screening, credentialed practitioners and personnel, appropriate facilities and emergency equipment are emphasized to minimize risks while allowing benefits of sedation for certain medical procedures.

1. Moderate Sedation/
Analgesia (Conscious
Sedation)
Dr. Moataz Mohammed Ibrahim
Anesthesia Consultant
Al Meqaat Hospital Madinah

2. Introduction
These guidelines are designed to be applicable
to procedures performed in a variety of settings
by practitioners who are not specialists in
anesthesiology.The purpose of these is to allow
clinicians to provide their patients with the
benefits of sedation /analgesia, while minimizing
associated risks.These guidelines are intended
to be general in their application and broad in
scope.

3. Depth of Sedation
Minimal Sedation (Anxiolysis)
- is a drug induced state during which patients
respond normally to verbal commands.
Although cognitive function and coordination
may be impaired, ventilatory and
cardiovascular functions are unaffected.

4. Depth of Sedation
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.

5. Depth of Sedation
Deep Sedation/Analgesia
- is drug induced loss of consciousness during
which patients cannot be easily aroused but
respond purposefully* following repeated
stimulation. The ability to independently maintain
ventilatory function is often impaired.Patients
may require assistance in maintaining a patent
airway and positive pressure ventilation may be
required. Cardiovascular function may be
impaired.

6. Depth of Sedation
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 is often impaired. Patients
often require assistance in maintaining a patent
airway, and positive pressure ventilation may be
required. Cardiovascular function may be
impaired.

7. Depth of Sedation
• Protective airway reflexes-includes the ability of an
individual to counteract noxious events, especially to
defend breathing passages against foreign material.
• Reflex withdrawal from a painful stimulus is NOT
considered a purposeful response
• Sedation is a continuum, it is not always possible to
predict how an individual will respond.
• Practitioners intending to produce a given level of
sedation should be able to rescue patients whose level
of sedation becomes deeper than initially intended.

8. Locations of M.S./Analgesia
• Radiology
Department
• Medical Special
Procedures
• Dental Clinic
• Emergency
Department
• Critical Care Units
• Echocardiology Lab
• Cardiac
Catheterization Lab
• Clinics (Audiology,
Neurology)
• Pre-operative holding
area

9. Patient Evaluation
• History/ Physical exam
• Airway evaluation
• Abnormalities of the major organ systems
• Previous adverse experience with sedation
• Drug allergies, current meds.,potential
interaction
• Focused physical exam- vital signs,
auscultation of heart and lungs, evaluation of
the airway
• NPO status
• Lab data

10. Patient Evaluation
Airway Evaluation
Mallampati Classification
• Relates tongue size to pharyngeal size
• Performed with the patient in the sitting position, the
head held in a neutral position, the mouth wide open,
and the tongue protruding to the maximum
• May vary if the patient is in the supine position (instead
of sitting)
• If the patients phonates, this falsely improves the view.
•If the patient arches his or her tongue, the uvula is
falsely obscured.

11. Patient Evaluation
Airway
Evaluation
Mallampati Classification
Class I = visualization of the
soft palate, fauces, uvula,
anterior and posterior pillars.
Class II = visualization of the
soft palate, fauces and
uvula.
Class III = visualization of
the soft palate and the base
of the uvula.
Class IV = soft palate is not
visible at all.

12. ASA Physical Status
• Class I- normal, healthy
• Class II- mild systemic disease
• Class III- severe systemic disease, e.g. HTN
COPD,
• Class IV-severe systemic disease that is a
constant threat to life, e.g. unstable angina
• Class V- moribund patient not expected to
live with or without the procedure

13. Patient Evaluation
When an anesthesiologist or other specialist
may be needed.
• ASA class III or higher
• Airway abnormalities
• Morbid obesity
• Sleep apnea
• Previously failed
sedation
• Major allergy or
anaphylactic reaction
• Complex procedure
• Prolonged sedation
needed
• New procedure
• Unusual position
• Unusual location

14. Pre procedure preparation
• Informed consent
• Pre op fasting
– Clear liquids 2h
– Breast milk 4h
– Infant formula 6h
– Milk 6h
– Light meal 6h

15. Equipment
• Self inflating bag and mask
• Oxygen – 2 outlets
• Suction ( working )
• Pulse oximeter, ECG monitor, BP. Monitor
• ? Capnometer
• Pharmacologic antagonists
• Emergency equipment – airway kit (age
appropriate) crash cart, defibrillator

16. Monitoring and Documentation
• Pre-procedure
-V.S., SpO2
• Procedure
-Continuous SpO2, E.C.G.
-V.S. q 5 min.
-L.O.C. q 5 min.(level of consciousness)
• Post Procedure
-Continuous SpO2, V.S. q 5 min. for 15 min.,
then q 15 min. until discharge criteria met

17. Personnel
1. The minimal number of available personnel
should be two:
The operator (performs procedure)
The monitor (administers drugs,
monitors airway and vital signs.
The second individual may assist with minor
interruptible tasks.
Both personnel must be credentialed in
Moderate Sedation/ Analgesia

18. Personnel
Personnel who can administer Moderate
Sedation/ Analgesia or monitor a patient,
include:
- A physician, or dentist who has been
credentialed
Under the supervision of the above, the following
persons may administer M.S.
- resident physician or resident dentist
-registered nurse.

19. Training of Personnel
• Individuals responsible for patients should
understand the pharmacology of agents used
for sedation and antagonists for opiates and
benzodiazepines.
• Individuals monitoring patients should be able
to recognize associated complications.
• One individual capable of estabilishing a
patent airway and positive pressure
ventilation should be present.
• All personnel must be ACLS certified.

20. Discharge Criteria
Patients will be discharged according to
the Aldrete score. The patients must
have a score of ten.
Aldrete score is printed at the end of the Moderate
sedation/Analgesia record
Patients who receive reversal agents need
to remain in the procedure area for at least
one hour after the last dose.

21. Drugs
Drugs commonly used for M.S.
Meperidine (pethidine)
Fentanyl
Ketamine
Midazolam
Naloxone (Narcan)
Flumazenil (Anexate)

22. Doses:
• Midazolam 0.02-0.03 mg/kg Intranenous
70 kg patient 1.5 mg-2 mg
Given slowly IV over 1 min
Onset : 1-3 min
Duration : 20-40 min
• Fentanyl : 1 mic / kg IV
• Pethidine : 1 mg / kg IV
• Ketamine : 1 mg / kg IV

23. Antidotes:
• Naloxone: for Narcotic (pethidine –
fentanyl)
dose : 0.01 - 0.1 mg/kg IV according to
effect
duration : 0.5 h
• Flumazinl : for midazolam
dose : 0.2 – 1 mg
effect after 1-2 min max effect after 6-10
min

26. Thank you