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Procedural sedation and analgesia

Last updated: June 24, 2021

Summarytoggle arrow icon

Procedural sedation and analgesia (PSA) can be used to reduce pain and awareness during painful or distressing procedures performed outside of the operating room. The level of awareness is typically adjusted according to patient risk factors and the type of procedure. In contrast to patients under general anesthesia, patients undergoing PSA typically maintain airway reflexes and spontaneous respiration. While the risk to patients undergoing PSA is low, both oversedation and adverse effects from the medication are possible. Therefore, PSA should only be performed by trained providers and in patients who have been screened for conditions that are high risk for complications. The choice of sedatives and analgesics should be adapted to the procedure and the patient's physiological parameters, and patients should be monitored closely both during and after the procedure. Patients may be discharged after PSA once they return to their baseline level of functioning.

Recommendations in this article are consistent with the 2018 American Society of Anesthesiologists (ASA) guidelines, the 2019 American College of Emergency Physicians (ACEP) guideline, and the 2014 ACEP clinical policy statement relating to PSA. [1][2][3]

  • Procedural sedation [3]
    • Administration of sedatives and/or analgesics to reduce pain, anxiety, and awareness
    • Applied during diagnostic or therapeutic procedures outside of the operating room
    • Cardiorespiratory function is typically maintained with minimal external support.
  • General anesthesia
    • Administration of sedatives and/or analgesics to induce a loss of consciousness and complete unresponsiveness
    • Applied in the operating room
    • Typically leads to loss of airway patency and spontaneous respiration requiring intubation and mechanical ventilation
    • Cardiovascular function may also be impaired, occasionally requiring fluids and pressors.
  • Monitored anesthesia care
    • Sedation provided by an individual (typically an anesthesiologist) who is exclusively responsible for sedating and monitoring the patient
    • Used in patients at a high risk of adverse events or if it is likely that procedural sedation will need to be converted to general anesthesia [4]

Levels of sedation

PSA typically requires a moderate, deep, or dissociative level of sedation. For most agents used in PSA (except those used in dissociative sedation), the level of sedation follows a dose-response relationship.

Levels of sedation [2][3]
Responsiveness Airway, breathing, and circulation
Minimal sedation (anxiolysis)
  • Normal to verbal commands
  • No assistance is required
  • No monitoring is required
Moderate sedation [2]
  • Purposeful reaction to verbal commands
  • Usually, no assistance is required
  • Monitoring is necessary.
Deep sedation
  • Purposeful reaction to repeated or painful stimuli
  • Airway and breathing may require interventions.
  • Circulation is usually adequate.
General anesthesia
  • Absent
Dissociative anesthesia
  • Absent
  • Usually, no assistance is required.
  • Monitoring is necessary.

Practitioners administering moderate or deep sedation should be experienced in airway management, as the level of sedation may become deeper than anticipated.

Goals

Types of procedures that often require PSA [3][5]

Situations in which PSA may be harmful [1][2][5]

Any form of sedation must be used with caution in patients with hypotension and those at risk of developing shock, as most sedating agents further reduce blood pressure.

Approach

  • Evaluate the patient and consider if an alternative to procedural sedation may be more appropriate.
  • Obtain informed consent from the patient or legal guardian.
  • Determine the most appropriate regimen and prepare medications.
  • Assemble the team and necessary equipment.
  • Set up monitoring. [1]

Always consult local protocols for procedural sedation, as they may vary between institutions!

Preprocedural patient evaluation [1][2]

For nonurgent sedation, a full patient history is appropriate. For emergency procedures in unstable patients, focus evaluation on conditions that may predispose the patient to potentially life-threatening complications (e.g., anaphylaxis, laryngospasm, aspiration, cardiorespiratory compromise) and airway assessment.

  • Focused history
    • Determine the patient's ASA class based on past medical history; review medical records if available.
    • Ask the patient if they have had any previous experiences of anesthesia and/or sedation.
    • Note any relevant allergies, current medication, and any prior or current tobacco, alcohol, or recreational drug use. [8]
    • Ask the patient when they last consumed food and liquids. [3][6][9]
      • Planned or nonurgent procedures: no solid food for > 6 hours and no liquids for > 2 hours prior to the procedure (see also “Preoperative preparation”)
      • Emergency procedures should not be delayed because the patient has eaten within the previous 6 hours.
      • Patients at high risk of aspiration (e.g., those with obesity): Involve anesthesiology early and consider dissociative sedation. [1][9]
    • Review laboratory studies and order additional tests as required (see “Preoperative assessment” for further information).
  • Focused physical examination

LEMON airway assessment: Look for concerning features, Evaluate mouth opening and larynx position, assess oral accessibility using the Mallampati score, evaluate for Obesity and conditions that can cause airway Obstruction, and assess Neck mobility. [5]

In unscheduled sedation, routinely evaluate the patient for intoxication. Alcohol and recreational drugs can have an additive effect on sedation and, therefore, lower induction doses may be indicated.

Team [1][2][3]

A minimum of two practitioners are required to perform procedural sedation, at least one of whom should be trained in safe sedation. Additional team members (e.g., an anesthesiologist, emergency physician) may be required depending on local protocols, the complexity of the patient's health needs, and the procedure.

Procedural sedation team
Team member Qualifications and skills Responsibilities
Sedation provider
  • Oversees and is responsible for the sedation
  • Monitors the level of sedation
  • Performs resuscitation if required
Sedation monitor
  • Can perform clinical monitoring and interpret instrument-based monitoring parameters
  • Can identify excessive or inadequate sedation
  • Can recognize apnea and airway obstruction
  • Is familiar with the resuscitation equipment and its location
  • Is familiar with the drugs used for sedation and their adverse effects
  • Monitors the patient's airway and ventilation continuously
  • Can administer sedative drugs as ordered by the sedation provider
  • Should not participate in the procedure
  • Assists the provider during resuscitation and seeks additional help if there are complications

Equipment [2]

Trained personnel and devices required for ACLS should be readily available. The following equipment should be present in the room where the procedure is being performed:

Before procedural sedation, remember to review the SOAP ME checklist: Suction, Oxygen, Airway equipment, Pharmacy, Monitoring, and Equipment for resuscitation (e.g., defibrillator).

Monitoring [2][3]

Monitoring intensity depends on the level of sedation.

Clinical observation during moderate sedation or deep sedation is essential, as it may help to detect apnea earlier than monitoring devices alone.

General principles

  • Medications commonly used for PSA: [1]
    • May have sedating and/or analgesic effects
    • May be used as single agents or in combination.
  • Short-acting agents have a better safety profile for PSA compared to long-acting ones since they allow for: [3]
    • More responsive titration
    • Less time under sedation
  • IV administration is preferred in adults. [5]
    • IV titration is generally well-tolerated, predictable, and has the most rapid onset of action compared with other routes of administration.
    • Other routes of administration may be chosen in select patients, e.g., if venous access cannot easily be obtained.
  • Principles of titration [2]
    • Agents are given in small doses intravenously followed by a saline flush, or by IV infusion.
    • The effect of the previous dose must be assessed before the next dose is administered.
  • For nonintravenously administered drugs, there must be sufficient time for absorption before the next dose is administered.

Follow all IV doses of a sedating agent with a saline flush. Failing to flush can cause the medication to accumulate in the IV tube, which can lead to undersedation, or oversedation if the buildup is dislodged.

Choice of regimen [1][5]

The type of procedure (painful and/or anxiety-inducing), the duration, and other procedural requirements (e.g., immobility for radiographic studies) must be taken into account when selecting a regimen, alongside patient factors (e.g., alcohol use, comorbidities, current clinical condition) and clinician experience and comfort with the medications.

Not all sedatives have analgesic properties! Both sedation and analgesia are required for painful procedures.

Sedatives and analgesics for PSA

The following example dosages are based on adult patients. For pediatric dosages, see “Medication for PSA in children.”

Sedatives

Sedatives for procedural sedation [3][5]
Agent Dosing Benefits and general considerations Adverse effects and cautions [5]
Propofol [10]
  • Route: IV
  • Dosages
    • Initial dose: 0.5–1.0 mg/kg
    • Additional dosages: 0.25–0.5 mg/kg every 1–3 minutes until the desired level of sedation has been reached
    • Continuous infusion dosage: 3–9 mg/kg/hour
  • Onset and duration
    • Onset: < 1 minute
    • Duration: 8–10 minutes
Etomidate [11]
  • Route: IV
  • Dosages
    • Initial dose: 0.1–0.15 mg/kg
    • Additional dosages: 0.05–0.1 mg/kg every 2–3 minutes until the desired level of sedation has been reached
  • Onset and duration
    • Onset: < 1 minute
    • Duration: 5–10 minutes
  • Minimal effect on cardiovascular stability
  • Cerebroprotective
Ketamine [13]
  • Route: IV
  • Dosage
    • Initial dose: 1–2 mg/kg
    • Additional doses: 0.5–1.0 mg/kg
      • Repeat doses should only be given to prolong the duration of action or if the initial dose did not achieve dissociation.
      • Additional doses do not increase the depth of sedation. [13]
  • Onset and duration
    • Onset: 1 minute
    • Duration: 5–15 minutes
  • Causes profound analgesia and amnesia
  • Bronchodilation
  • Maintenance of:
    • Protective airway reflexes
    • Spontaneous respiration
    • Cardiovascular function
  • Route: IM
  • Dosage
    • Initial dose: 4–5 mg/kg
    • Repeat at full or half dose if the initial dose does not achieve dissociation after 5–10 minutes, or to prolong sedation.
  • Onset and duration
    • Onset: 5 minutes
    • Duration: 15–30 minutes
Midazolam
  • Route: IV
  • Dosage
    • Initial dose: 0.5–2 mg over 2 minutes or 0.05 mg/kg
    • Repeat every 2–5 minutes as needed
  • Onset and duration
    • Onset: 1–2 minutes
    • Duration: 30–60 minutes

Dexmedetomidine

  • Route: IV
  • Dosage
    • Initial dose: 1 mcg/kg over 10 minutes
    • Additional dosages: continuous infusion of 0.2–0.7 mcg/kg/hour
  • Onset and duration
    • Onset: 10–15 minutes
    • Half-life: 5–8 minutes
  • Anxiolytic and analgesic
  • Induces sleep-like sedation with a quick transition to alertness after the procedure [14]
  • Minimal effect on ventilation

Analgesics

Analgesics for procedural sedation [3][5]
Agent Dosing Benefits and general considerations Adverse effects and cautions [5]
Fentanyl
  • Route: IV
  • Dosage
    • Initial dose (prior to sedative): 1–2 mcg/kg
    • Titration (alongside sedative)
      • Start with 1 mcg/kg
      • Administer additional smaller doses every 1–2 minutes
      • 1–3 mcg/kg is typically sufficient
  • Onset and duration
    • Onset: 1–2 minutes
    • Duration: 30–40 minutes
  • Route: intranasal
  • Dosage
    • Single dose: 1–2 mcg/kg (half administered into each nostril)
    • Max. dose: 100 mcg
  • Onset and duration
    • Onset: 10–30 minutes
    • Duration: 60–120 minutes
Alfentanil
  • Route: IV
  • Dosage
    • Starting dosage: 3–8 mcg/kg over 3 minutes
    • Additional dosages: 3 mcg/kg every 5–20 minutes
  • Onset and duration
    • Onset: immediate
    • Duration: 10–15 minutes
  • Analgesic
  • Minimal effect on cardiovascular stability
  • Respiratory depression

Combination regimens [2][3][5]

Potential benefits of combination regimens include lower dose requirements of individual drugs, lower risk of adverse effects, and greater ability to tailor regimens to individual patient needs and harness synergistic drug effects . Commonly used combinations include:

Combinations of certain sedatives, especially opioids and benzodiazepines, can exacerbate adverse effects on cardiorespiratory function.

Serious complications from PSA are very rare. [3]

Troubleshooting complications of procedural sedation [2][5]
Event Potential sequelae Management
Oversedation
Nausea and vomiting
Agitation and emergence phenomena
Allergic reaction
Hypoventilation and apnea
Aspiration [9][16]
Laryngospasm [8]
Bronchospasm
Hypotension
Bradycardia
Acute coronary syndrome
Cardiac arrest

Airway repositioning and mask ventilation are the most important skills for the sedation provider. Intubation should only be attempted by experienced providers, and only when necessary. [1]

Recovery and discharge criteria may vary between institutions and local protocols should be consulted. In general, patients should be monitored in a suitable environment until they are alert, with stable vital signs that are within their normal parameters. The duration of monitoring also depends on the drugs used during sedation and the patient's health status.

Monitoring during recovery [2]

  • Location: conducted in an area with access to resuscitation equipment where constant observation is possible
  • Monitoring parameters
    • Continuous saturation monitoring until the patients is alert and has reached their target SpO2
    • Intermittent (every 5–15 minutes) monitoring of ventilation and blood pressure until their cardiorespiratory status and level of consciousness are at or near baseline
  • Additional consideration: If reversal agents were administered, sufficient time must have passed since the last administration before observation ends.

Serious complications from PSA most commonly occur at the end of the procedure after the painful stimulus has been removed (e.g., reduction of a dislocated joint).

Requirements for discharge [2][5]

  • Patient requirements
    • Vital signs should be stable and the airway patent.
    • Patients should be at their baseline level of:
      • Consciousness
      • Mobility
      • Communication
  • Discharge of outpatients
    • Address postprocedural pain and nausea before discharge.
    • Ensure that the patient is accompanied by a responsible adult.
    • Provide the patient with discharge instructions, including those for the presenting complaint.
    • Ask the patient to return to the hospital if they experience confusion or respiratory symptoms.
    • Instruct the patient to avoid driving for 24 hours after discharge.

The general procedural steps are the same for all patients who require PSA. Only divergences from standard procedures for children and pregnant patients are outlined in this section.

Children [17][18]

General principles

  • Common clinical applications
    • The applications are similar to those for adults, but young children may also require sedation for imaging and minor procedures such as suturing or the removal of foreign bodies.
    • Sedation during painful procedures, e.g., the management of burns or lumbar puncture, helps to reduce trauma and anxiety around future procedures.
  • Preparation
    • Perform a similar preprocedural assessment as for adult patients. In addition, ask whether the child was born prematurely.
    • Try to establish a positive rapport with the child and caregivers to reduce anxiety. If successful, some patients may be able to tolerate the procedure without sedation.
    • Delay sedation and obtain anesthesiology consult if there is a high risk of adverse events (e.g., ASA ≥ III, patients with an intellectual disability, anticipated difficult airway).
    • Ensure that correctly sized equipment is available (e.g., child-sized masks and supraglottic devices).
    • Ensure that a clinician experienced in pediatric life support is available.
    • Perform the necessary dose calculations based on age and/or weight to avoid dosage errors.
  • Procedure and monitoring
    • Topical anesthetic should be applied in addition to sedation whenever possible for painful procedures.
    • Perform age-appropriate interventions to reduce anxiety (e.g., distracting the patient with videos). [1]
    • If possible, parents or guardians should be allowed into the procedure room.
    • Avoid immobilization devices if possible. [1]
    • Ventilation monitoring via capnography or stethoscope is required for children who are not able to communicate appropriately.
  • Recovery and discharge
    • Children are not required to be able to ambulate unassisted or drink fluids before discharge.
    • They should, however, be able to sit unassisted, have stable vital signs, and be alert and talking.

While age-appropriate interventions for anxiety are important and can reduce the need for sedation in children, pharmacological interventions for anxiolysis and sedation should not be avoided in procedures that may cause trauma.

Commonly used sedatives and analgesics

Weight-based dosing for a single agent can differ between children of different age groups and adults.

Commonly used medication for procedural sedation in children
Agent Common routes of administration and dosages Considerations
Ketamine [13]
  • Intravenous
    • Initial dose: 1.5–2.0 mg/kg
    • Additional doses for prolonged sedation: 0.5–1 mg/kg
  • Intramuscular
    • Single dose: 4–5 mg/kg
    • Repeat at full or half dose after 5–10 minutes if sufficient sedation has not been achieved with the initial dose.
Propofol [10]
  • Intravenous
    • Children ≤ 3 years of age: 2 mg/kg
    • Children > 3 years of age: 1.5 mg/kg
    • Additional dosages: 0.5–1 mg/kg every 1–3 minutes as needed
  • Very commonly used in pediatric sedation
  • Commonly causes pain on injection, which children may be unable to tolerate
Midazolam [3][19]
  • Oral
    • Single dose for children > 6 months of age: 0.25–0.5 mg/kg (max. dose 20 mg)
  • Intranasal
    • Infants < 6 months of age: single dose of 0.2 mg/kg
    • Children ≥ 6 months of age
      • Starting dose: 0.2–0.3 mg/kg
      • Repeat after 5–15 minutes as needed
      • Max. dose
        • Children < 20 kg: 0.5 mg/kg
        • Children ≥ 20 kg: 10 mg
  • Rectal
    • Single dose for children > 6 months of age: 0.25–0.5 mg/kg
    • Max. dose: unknown (oral max. dose 20 mg)
  • Intramuscular
    • Single dose: 0.05–0.15 mg/kg, 30–60 minutes prior to the procedure
    • Max. dose: 10 mg
  • Intravenous
    • Children 6 months – 5 years of age
      • Initial dose: 0.05–0.1 mg/kg
      • May be repeated up to a max. dose of:
        • Children <10 kg: 0.6 mg/kg
        • Children ≥ 10 kg: 6 mg
    • Children 6–12 years of age:
      • Initial dose: 0.025–0.05 mg/kg
      • May be repeated to a max. dose of:
        • Children < 25 kg: 0.4 mg/kg
        • Children ≥ 25 kg: 10 mg
    • Children > 12 years of age: See adult dosages in “Sedatives for procedural sedation.”
  • Can be used as a single agent for anxiolysis, as premedication before PSA, or in combination with other agents
  • Intranasal application irritates the nasal mucosa.
Dexmedetomidine [20]
  • Intranasal
    • Children ≥ 6 months of age: 2–3 mcg/kg, 30–60 minutes prior to the procedure
  • Intravenous: IV administration is possible, however, intranasal administration is more common.
  • Used for nonpainful or minimally painful procedures
  • May result in a longer time to discharge than other sedatives

Pregnant women [21]

Hypoxemia, hypercapnia, and hypotension affect the fetus and the pregnant patient.

Preprocedural checklist

Procedure checklist

  • Administer analgesia before sedation, if required.
  • Titrate sedating agents until the desired level of sedation has been reached (apart from ketamine).
  • Ensure all procedural requirements (analgesia, anxiolysis, immobilization) are met.
  • Conduct continuous pulse oximetry and clinical monitoring; Measure EtCO2 if available.
  • Measure BP at regular intervals.

Recovery and discharge checklist

  • Transfer the patient to a suitable recovery area.
  • Continue continuous pulse oximetry and intermittent BP measurements.
  • Ensure the following prior to discharging outpatients:
  • Provide outpatients with discharge instructions and ensure they are accompanied by a responsible adult.
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  9. Lee S. Dexmedetomidine: present and future directions. Korean J Anesthesiol. 2019; 72 (4): p.323-330. doi: 10.4097/kja.19259 . | Open in Read by QxMD
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