Practice Guidelines for Moderate Procedural Sedation

Moderate procedural sedation is a depressed level of consciousness during which patients respond purposefully to verbal commands and light tactile stimulation. Their airway reflexes, spontaneous ventilation and cardiovascular function are usually maintained without interventions.

This depth of sedation is usually used for procedures that require muscular relaxation with minimal patient recoil (e.g. hip relocation).

Anaesthetic Management

Surgical, diagnostic, and therapeutic procedures often require patients to undergo sedation to minimize pain or discomfort. Procedural sedation techniques should be administered by trained personnel and monitored for safety and appropriateness following nursing standards.

Moderate sedation is a type of sedation characterized by the use of pharmacologic agents that reduce consciousness but do not impair independent respiration and cardiovascular function. Depending on the physician and the procedure, moderate sedation may be a primary form of anaesthesia or used with general or regional anaesthesia.

Anaesthetic management is a critical element of moderate procedural sedation. It includes pre-sedation evaluations, administration of sedative medications and monitoring of cardiorespiratory function.

Pre-Sedation Assessment

A pre-sedation assessment is a critical component of safe and effective sedation. Policies and procedures for moderate and deep sedation must define the scope and content of this pre-sedation assessment.

A pre-sedation assessment aims to ensure that the patient is appropriately prepared and that sedation goals are met. This includes conducting a physical examination, tabulating risk factors, and choosing medications to produce the desired level of sedation.

It also involves recognizing complications and responding to emergencies. These include reversal agents, oxygenation, respiratory support and monitoring.

Because sedation is a continuum, predicting how a patient will respond is not always possible. Therefore, practitioners intending to produce a given level of sedation should be able to rescue* patients whose level of sedation becomes deeper than intended. The qualified practitioner corrects adverse physiologic consequences of the deeper-than-intended level of sedation (such as hypoventilation, hypoxia and hypotension) and returns the patient to the originally intended level of sedation.

Patient Monitoring

Moderate sedation is used during office procedures to provide patient comfort and cooperation. This level of sedation is achieved with oral or injectable medications that depress the patient’s consciousness, ease pain and anxiety, and provide amnesia.

However, this level of sedation can also trigger serious complications, such as airway and cardiovascular events. Closed malpractice cases demonstrate that respiratory and cardiovascular function is often compromised during moderate sedation, requiring intervention from medical professionals or resulting in significant morbidity.

Continuous monitoring of blood pressure, heart rate, respiratory rate and oxygen saturation is recommended for every patient undergoing moderate sedation. It is possible to use blood pressure changes to titrate sedation, but this method requires detailed knowledge of baseline and pre-procedure medication history.

Unless patient conditions make this unadvisable, it is recommended that a pulse oximeter be used to measure oxygenation and end-tidal CO2. For ASA Physical Status Class I or II patients, continuous EKG monitoring may be considered during moderate sedation.

Post-Sedation Care

Patients should be monitored continuously and without interruption from the moment, medications are administered until the sedation wears off. This monitoring includes cardiac and pulse-oximetry monitoring.

The onset of sedation may vary from patient to patient depending on their physical status and the speed of administration but typically occurs within 2 to 3 minutes. The maximum effect is achieved in about 5 to 10 minutes.

Sedation exists along a continuum from minimal sedation to general anaesthesia. Moderate procedural sedation aims to provide a patient with minimal consciousness, control behaviour and movement, and support cardiovascular function.

Moderate procedural sedation can be performed in various settings, including emergency departments and outpatient surgery. Before a patient receives sedation, they should be thoroughly reevaluated to ensure they are in the best physical condition for the procedure. Presentation assessment should include a thorough physical examination and patient history. The clinician should follow a prescribed assessment format to gather patient data, order laboratory tests, and implement a sedation plan of care.