CLINICAL PRACTICE

GUIDELINE
PROFESSIONAL
PRACTICE
TITLE:
Sedation and Analgesia for Diagnostic or Therapeutic Procedures
DATE OF ISSUE:
2002, 11
PAGE
1
OF
11(Appendix)
NUMBER:
CPG 3-1
ISSUED BY:
SUPERCEDES:
2001, 12
1998, 01 TITLE:
Chief of Medical Staff
ISSUED BY:
TITLE:
President
Purpose:
To provide guidelines for the administration of sedation and analgesia to patients requiring a
diagnostic or therapeutic procedure.
Definitions:
The Sedation Continuum:
Sedation is a continuum, it is not always possible to predict how an individual will respond.
Conscious Sedation describes a state of sedation, tranquilization and amnesia, that allows a
patient to tolerate a painful diagnostic or therapeutic procedure while maintaining adequate
cardiorespiratory function and the ability to respond purposefully to verbal command and/or
tactile stimulation.
Protective Reflexes Maintained
Patent Airway
Responds Appropriately
Loss of Reflexes
Unable to Maintain Airway
Impaired Response
Conscious
Sedation
Sedation/
Analgesia
Awake Deep
Sedation
General
Anesthesia
Cardiopulmonary Arrest
CPG 3-1
Sedation and Analgesia for Diagnostic or
Therapeutic Procedures
Page 2 of 11
Deep Sedation is a state of unconsciousness from which the patient is not easily aroused,
which may be accompanied by impairment of airway protective reflexes and ventilatory drive.
General Anesthesia refers to a state of unconsciousness plus partial or complete loss of
protective reflexes including the inability to independently maintain an airway.
Selection Criteria:
Inclusion for All Sedation
For patients undergoing a procedure where sedation and analgesia is required to relieve
anxiety, discomfort or pain.
For children or uncooperative adults where sedation and analgesia may expedite the conduct
of procedures and require that the patient not move.
Those elective patients who have been fasting as outlined in the Fasting Protocol for
Sedation and Analgesia for Elective Procedures - Appendix 1.
In Urgent/Emergent situations where gastric emptying may be impaired due to anxiety and
pain, or when the patient has not been fasting, and the physician has decided there is a
greater risk to the patient if the procedure is delayed, the potential for pulmonary aspiration
of gastric contents must be considered in determining the timing of the intervention and the
degree of sedation/analgesia.
American Society of Anesthesiologists Classification (ASA) - Class I and II patients
Appendix 2
The availability of adequately trained professionals to provide intra and post procedure care.
Exclusion
American Society of Anesthesiologists Classification (ASA) - Class III and IV require
specialized care in the OR, ICU, ER or Special Procedures Room. Anesthetist/Internist should
be consulted. - Appendix 2
Situations where there are not adequately trained professionals to provide intra and post
procedure care.
Responsibilities:
Scope of Practice for use of Sedation and Analgesia:
Physicians and other regulated Health Professionals who will be administering and or monitoring
patients receiving sedation and analgesia are responsible for familiarizing themselves with the
agents administered and the role of pharmacologic antagonists for opioids and benzodiazepines
and are responsible for recognizing and responding appropriately to the associated complications.
A physician competent in advanced life support and airway management will be available during the
procedure and recovery period.
Patient Evaluation:
Prior to the administration of sedation and analgesia a history and physical examination will be
performed to assess:
abnormalities of the major organ systems
previous adverse experience with sedation/analgesia as well as regional and general anesthesia
medication and drug allergies
time and nature of last oral intake
history of tobacco, alcohol, or substance use or abuse
CPG 3-1
Sedation and Analgesia for Diagnostic or
Therapeutic Procedures
Page 3 of 11
physical examination including auscultation of the heart and lungs and evaluation of the airway
Pre Procedure Preparation:
Obtain informed consent according to the Consent policy
#
PP3.1.
Physician orders for:
- Intravenous access
- Medication administration
Ensure equipment and personnel are available
Initiate Sedation/Analgesia Flowsheet or Endoscopy Suite G.I. Procedure Record
Monitoring and Treatment:
Initiate medication administration according to the Guideline for Medication Administration
Appendix A
Monitoring according to the attached Standards for Monitored Care.
The physician will order the discharge of the patient according to the attached Sedation and
Analgesia Discharge Criteria.
Guideline for Medication Administration
See Appendix A: Guideline for Drug Administration to obtain the following:
Recommended dosages
Onset, peak affect and duration
Precautions, contraindications and adverse affects
This is only a brief overview. For additional information the following sources are available:
Computer access: Manuals/Manual: MOX Library: Medication/Parenteral Manual
Compendium of Pharmaceutical and Specialties (CPS)
Pharmacist
1. Intravenous sedative/analgesic drugs should be given in small, incremental doses that are
titrated to the desired endpoints of analgesia and sedation with sufficient time allowed between
dosing to permit assessment of the effect before additional drug is given.
2. The propensity for combinations of sedative and analgesic agents to potentate respiratory
depression emphasizes the need to appropriately reduce the dose of each component.
3. It is often difficult to achieve true conscious sedation without the potential for the patient to
become deeply sedated, either because of delayed drug absorption or because the stimulus of
the procedure is no longer present. Adherence to monitoring guidelines is critical.
4. Reversal agents will be readily available whenever opioid analgesics or benzodiazepine
sedatives are administered.
5. In the majority of instances, intravenous drug administration will be the route utilized, although,
in children, oral/rectal or IM administration of sedation and analgesia are acceptable. In these
CPG 3-1
Sedation and Analgesia for Diagnostic or
Therapeutic Procedures
Page 4 of 11
cases intravenous access is not considered essential, however intravenous administration sets,
fluids and a selection of intravenous catheters need to be readily available.
6. Oxygen administration may increase oxygen saturation in the face of hypoventilation and
undetected CO
2
retention may occur.
7. Drugs administered, dosage and time of administration will be recorded in the patients record.
Response to sedation and analgesia will be assessed using the sedation score and pain scale.
Adverse drug reactions or complications will be documented in the progress notes.
Standards for Monitored Care:
A. Administration of Oral/Rectal or Intramuscular Agents (Excluding IM Ketamine)
Intra Procedure:
1. Required equipment: The following equipment will be at the bedside and functioning prior to
administration of "sedation and analgesia":
- Oxygen setup
- Suction setup
2. Readily available equipment:
- Emergency Measures Code Blue Cart
3. Pulse oximeter attached to each patient to monitor oxygen saturation.
4. There will be a record of vital signs (heart/respiratory rate/blood pressure, oxygen saturation
and sedation score) pre procedure and q 15 minutes during the sedation period. The patient
will be observed for signs of deep sedation. Based on clinical judgement, the frequency of BP
monitoring may be adjusted so that the patient is not disturbed during crucial periods of the test
or procedure.
If additional sedation is given or the patient becomes deeply sedated (sedation score of 3)
continuous monitoring of vital signs (heart/respiratory rate), oxygen saturation and constant
observation by monitoring personnel are required until the patients sedation score is 1 or 0.
5. For intramuscular agents the sedating physician will be immediately available until the patient is
assessed to be awake. For oral and rectal agents the sedating physician is not required to be
immediately available.
Post Sedation Recovery:
1. There will be a record of vital signs (heart/respiratory rate/blood pressure) and sedation score
post procedure and the patient will be observed every 15 minutes until awake. The discharge
criteria must be met prior to discharge.
B. Administration of Intravenous Agents and IM Ketamine
Intra Procedure:
1. Required equipment: The following equipment will be at the bedside and functioning prior to
administration of "sedation and analgesia":
- Oxygen setup
- Suction setup
CPG 3-1
Sedation and Analgesia for Diagnostic or
Therapeutic Procedures
Page 5 of 11
- Self inflating resuscitation bag and airway
- Intubation tray in the Emergency Department, Endoscopy Clinic and Fracture Clinic.
2. Readily available equipment:
The following equipment located on the Emergency Measures Code Blue Cart will be readily
available and functioning prior to administration of "sedation and analgesia".
- A selection of appropriate sized endotracheal tubes
- Functioning laryngoscope and blades both adult and paediatric
- EKG monitoring
- Cardiac defibrillator
- Emergency drugs
- Intravenous administration sets and fluids and a selection of intravenous catheters both
adult and paediatric.
Emergency equipment will be obtained, in the event of a respiratory or cardiac arrest, by
initiating the Emergency Measures Code Blue.
3. Pulse oximeter attached to each patient to monitor oxygen saturation.
4. There will be continuous monitoring of vital signs (heart/respiratory rate) and oxygen saturation
during the procedure. Blood pressure and sedation score will be assessed q 15 min (minimum),
more frequently if indicated. Frequency of blood pressure monitoring and assessment of the
sedation score will be adjusted based on clinical judgement so that the patient is not disturbed
during crucial periods of the test or procedure. Monitoring parameters will be recorded every 5 -
15 minutes (minimum). Constant observation by monitoring personnel is required until the
patients sedation score is 1 or 0.
5. The sedating physician will be immediately available until the patient is assessed to be awake.
Post Sedation Recovery:
1. There will be a record of vital signs (heart/respiratory rate/blood pressure) and sedation score
every 15 minutes for a minimum of 1 hour and until fully recovered. The discharge criteria must
be met prior to discharge.
2. Pulse oximetry monitoring will be maintained until the patient is awake, and the patient is able to
maintain O
2
saturations greater than 93% while breathing room air. Patients with saturations
less than 93% should receive oxygen by mask.
Sedation and Analgesia Discharge Criteria:
The nurse will assess the patient against the criteria. All criteria will be met prior to discharge. If the
criteria are not met, physician assessment is required prior to discharge.
1. The patient will meet the following discharge criteria.
Airway patent and stable
Cardiovascular function stable
Return to baseline level of consciousness
Able to sit (age appropriate)
Able to talk (age appropriate)
Taking oral fluids; not vomiting
Accompanied by a responsible adult
2. Sufficient time (up to 2 hours) is required after the last administration of reversal agents to
ensure that patients do not become resedated after reversal effects have abated. The
duration of the sedation/analgesia and reversal agent will need to be considered when
evaluating this criteria.
CPG 3-1
Sedation and Analgesia for Diagnostic or
Therapeutic Procedures
Page 6 of 11
3. The patient will be given written adult or paediatric post sedation instructions. These
instructions will be explained to both the patient and accompanying adult. The patient will be
instructed to not drive a vehicle, operate hazardous machinery or consume alcohol for a
minimum of 18 hours, or longer if drowsiness or dizziness persists.
4. A discharge order is required.
Appendix 1. Fasting Protocol for Sedation and Analgesia for Elective Procedures
It is important that the patient have an empty stomach to reduce the chances of vomiting and
aspirating after sedation and analgesia is given.
Fasting Recommendations (1)
Ingested Material
Minimum Fasting Period (2)
Clear Liquids (3) 2 hours
Breast Milk 4 hours
Infant Formula 6 hours
Non-human Milk (4) 6 hours
Light Meal (5) 6 hours
1. These recommendations apply to healthy patients who are undergoing elective procedures.
They do not guarantee complete gastric emptying has occurred.
2. The fasting period noted above apply to all ages.
3. Examples of clear liquids include water, fruit juices without pulp, carbonated beverages, clear
tea, and black coffee.
4. Since non-human milk is similar to solids in gastric emptying time, the amount ingested must be
considered when determining an appropriate fasting period.
5. A light meal typically consists of toast and clear liquids. Meals that include fried or fatty foods or
meat may prolong gastric emptying time. Both the amount and type of foods ingested must be
considered when determining an appropriate fasting period.
Appendix 2. American Society of Anesthesiologists (ASA) Classification
I. Healthy patient
II. Mild systemic disease - no functional limitation
III. Severe systemic disease - definite functional limitation
IV. Severe systemic disease that is a constant threat to life
V. Moribund patient not expected to survive without the operation
Appendix 3. Sedation Score
1) Awake
2) Mild - Arousable with verbal stimulation
3) Moderate - Arousable with tactile stimulation
4) Severe - Not arousable by tactile stimulation
CPG 3-1
Sedation and Analgesia for Diagnostic or
Therapeutic Procedures
Page 7 of 11
Evaluation Criteria:
Monitoring will be done through the high-risk case review process. Each
department/programme will be responsible for evaluating outcome and compliance.
An audit of Ketamine and Propofol use for procedural analgesia and sedation will be done to
assess utilization and outcome.
References:
1. American Society of Anesthesiologists. Practice guidelines for sedation
and analgesia by non-anesthesiologists. Anesthesiology 1996:84;459-71.
2. The Journal of Emergency Medicine. Emergency Pain Management: A Canadian
Association of Emergency Physicians (CAEP) Consensus Document Vol 12,No
6,pp 855-866,1994.
3. The Journal of Emergency Medicine. Procedural Sedation and Analgesia in
the Emergency Department. Canadian Consensus Guidelines. Vol 17,No.1,pp.
145-156,1999.
4. American College of Emergency Physicians: Use of pediatric sedation and
analgesia. Ann Emerg Med June 1997;29:834-835.
5. Berkowitz C. Conscious Sedation. A primer. RN 1997: Feb. pg 32-36.
6. Morton NS, Oomen GJ: Development of a selection and monitoring protocol
for safe sedation of children. Pediatric Anesthesia 1998;8:65-68.
7. Lowrie L, Weiss AH, Lacombe C: The Pediatric Sedation Unit: A Mechanism
for Pediatric Sedation. Pediatrics Vol. 102 No. 3 September 1998.
http://www.pediatrics.org/cgi/content/full/102/3/e30
8. Bauman LA, Kish I, Baumann RC, Politis GD: Pediatric Sedation with
Analgesia. Am J Emerg Med 1999;17:1-3.
9. Hillier SC. Chapter 47. Monitored Anesthesia Care. Clinical
Anesthesia (3/e) 1996
10. Kost M. Conscious sedation: Guarding your patient against complications.
Nursing 1999, April pp. 34-39. http://www.springnet.com
11. Dlugose D. Risk Management Considerations in Conscious Sedation. Critical
Care Nursing Clinics of North America. Vol.9, No. 3, Sept 1997, pp.
429-440.
12. Guidelines for Sedation. The Hospital for Sick Children 1994 Formulary
pages 163-166.
13. Pediatric Dosage Handbook 5th Edition 1998-99 American Pharmaceutical
Association and Lexi-Comp.
14. (c) 1974-2000 Micromedex Inc. Vol. 106. 17. AHFS Drug Information 2000
ASHP
15. Trissel LA. Handbook on Injectable Drugs. 9th Edition. American Society
of Health System Pharmacists Inc. 1996.
16. Sedation Protocol, Department of Anaesthesia and Sedation Subcommittee.
The Hospital for Sick Children.
17. American Society of Anesthesiologists: Practice Guidelines for
Preoperative Fasting and the Use of Pharmocologic Agents to Reduce the
Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing
Elective Procedures http://www.asahq.org/practice/npo/npoguide.html
18. Green SM, Nakamura R, Johnson NE: Ketamin Sedation for Pediatric
CPG 3-1
Sedation and Analgesia for Diagnostic or
Therapeutic Procedures
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Prodedures: Part 1, A Prospective Series. Ann Emerg Med
1990;19:1024-1032.
19. Green SM, Johnson NE: Ketamine Sedation for Pediatric Procedures: Part 2,
Review and Implications. Ann Emerg Med 1990;19:1033-1045.
20. Green SM, Rothtrock SG, Lynch EL. Intramuscular Ketamine for Pediatric
Sedation in the Emergency Department: Safety Profile in 1022 Cases. Ann
Emerg Med 1998;31:688-697.
21. White PF, Way LW, Trevor AJ. Ketamine-Its Pharmacology and Therapeutic
Uses. Anesthesiology 1982,56:119-136.
22. Gale DW, Grissom TE, Mirenda JV. Titration of intravenous anesthetics for cardioversion: A
comparison of propofol, methohexital, and midazolam. Crit Care Med 1993; 21:1509-1513.
23. Wilbur K, Zed PJ. Is propofol an optimal agent for procedural sedation and rapid sequence
intubation in the emergency department? CJEM 2001;3(4):302-10.
24. Ducharme J. Propofol in the emergency department: another interpretation of the evidence.
CJEM 2001; 3(4): 311-12.
Approval:
Emergency Programme Steering Committee: June 18, 2002
Paediatric Programme Steering Committee: October 9, 2002
General Medicine Steering Committee: June 20, 2002
Surgery Steering Committee: September 18, 2001
Ambulatory Care Steering Committee: September 19, 2001
Pharmacy and Therapeutics Committee: September 10, 2002
Professional Practice Committee: November 25, 2002
Clinical Quality Care Committee: October 16, 2002
Medical Advisory Committee: November 4, 2002
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