ANE - 06 Role & Responsibility For Sedation Practice

Kingdom of Saudi Arabia
Ministry of Defense
ARMED FORCES HOSPITAL JAZAN
Hospital Policy
Controlled Document, Not to be Reproduced
Policy No: ANE - 06
Policy Title: Role & Responsibility for Sedation Practice
Version No: 01
Supersedes: New Effective Date: September 2019 Page:1 of 26
1.0 PURPOSE:
1.1 To outline specific roles and responsibilities with regards to sedation practice in
AFHJ
2.0 APPLICABILITY:
2.1 All Staff who provide sedation
3.0 RESPONSIBILITY:
3.1 Head of Anaesthesia
3.2 Medical Director
4.0 POLICY:
4.1 Clinical Director of anaesthesia
4.1.1 Responsibility for oversight of the sedation and anaesthesia care policy.
4.1.2 Assure that the anaesthesiologystaff are available for consultation
regarding moderate sedation and anaesthesia care practices
4.1.3 Provide training of persons involved in physiologic monitoring of sedated
patients
4.1.4 Other responsibilities as defined in the job description
4.2 Physician responsibilities
4.2.1 The physician must have Basic life support (BLS) certification, Advance
cardiac life support (ACLS) and complete a course of sedation practice
approved by the clinical director of anaesthesia
4.2.2 The role of the physician is:
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4.2.2.1 Prescribe sedation

4.2.2.2 To assure the level of monitoring required
4.2.2.3 Manage complications of the sedation
4.2.3 If a patient is deemed as having unusual airway problem or an ASA PS III
or IV class patient, an anaesthesiologist must be available to ensure
adequate airway management and additional monitoring.
4.3 Nurses responsibilities:
4.3.1 Other A nurse who is BLS and ACLS certified and has completed a course
of sedation practice approved by the clinical director of anaesthesiashall
be present. This nurse will be privileged for this specific function.
4.3.2 The nurse must be readily available to supervise the assessment and
monitoring of the patient.
4.3.3 The role of the nurse is to monitor record appropriate physiologic
parameters and to assist in any supportive or resuscitative measures as
required for sedated patients.
5.0 PROCEDURE:
5.1 Sedation Protocols:
5.1.1 All patients receiving sedation must have a patient identity wrist band
checked and attached prior to sedation commencing.
5.1.2 Sedation can be achieved by the administration of a number of different
medications and a variety of routes.
5.1.3 All patients receiving intravenous sedation must have secure intravenous
access throughout the procedure and recovery phase.
5.2 Patient Selection:
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5.2.1 Candidates for moderate and deep sedation are those patients who must
undergo painful or difficult procedures where cooperation and/ or comfort
will be difficult or impossible without pharmacologic support. Patients
must be screened for potential risk factors for any pharmacologic agents
selected. This decision on which agent to use must be based on the goals
of sedation, type of procedure and condition and age of the patient.
5.2.2 Patients suitable for moderate to deep sedation are those requiring short
diagnostic or therapeutic procedures.
5.3 Pre procedure Sedation Assessment:
5.3.1 Establish methods of patient evaluation and risk assessment before giving
sedation including:
5.3.1.1 ASA physical status classification.
5.3.1.2 Airway assessment.
5.3.1.3 Fasting interval.
5.3.1.4 Aspiration risk.
5.3.1.5 Criteria for Anesthesia Consultation.
5.3.1.6 Procedure considered appropriate for moderate and deep
sedation (ASA Class I and ASA Class II)
5.3.1.6.1 Short diagnostic and therapeutic procedure
5.3.1.6.2 Cardioversion
5.3.1.6.3 Colonoscopy
5.3.1.6.4 Gastroscopy
5.3.1.6.5 Sigmoidoscopy
5.3.1.6.6 Incision and Drainage of abscess
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5.3.1.6.7 Reduction and immobilization of fracture and

dislocation
5.3.1.6.8 MRI
5.3.1.6.9 CT Scan
5.3.1.6.10 EEG
5.3.1.6.11 Visual dental procedures moderate and deep sedation
must be administered in OR
5.3.1.6.12 As a part of monitored anesthesia care in OR
5.3.1.6.13 As a part of anesthesia care under regional in OR.
5.3.1.6.14 Labor and Delivery
5.3.1.6.15 Patients who fall into ASA Class III or Class IV
present special problems which may necessitate a
consultation by a member of the Anesthesia
department.
5.4 Mallampati Airway Classification System:
5.4.1 Classify the patient’s airway using this system. This system is used to
predict patients who may be prone to difficult intubation or prone to
difficult airway maintenance while sedated.
5.4.1.1 Mallampati Airway Classification:
5.4.1.1.1 Class I: Soft palate, uvula, anterior and posterior
tonsillar pillars. Class II: Soft palate, fauces, uvula.
5.4.1.2 Class III: Soft palate, base of uvula Class IV: Soft palate, not
visible at all.
5.4.2 Patient should sit upright with the head in a neutral position and asked to
open mouth as wide as possible and to produce the tongue as far as
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possible. Classification can then be made as follows per visualization of

the following structures in the oral cavity; uvula, faucial pillars, and soft
palate.
5.4.3 A difficult endotracheal intubation is predicted for Class III and IV
patients. Class III and IV require anesthesia consultation.
5.5 Fasting:
5.5.1 All patients undergoing sedation should be fasted according to guidelines
for fasting as developed by the Director of Anesthesia/ ASA fasting
Recommendations.
5.5.2 Instructions about fasting should include a question as to the last intake of
food and drink, which must be documented.
5.5.3 Information about, whether or not the patient should take their routine
medication, and contact details of an individual who can answer questions,
should be given to all out-patients prior to the procedure. Specific
instructions regarding diabetic medication and anticoagulation should be
given when necessary.
5.6 Anesthesia Consultation:
5.6.1 Formal consultation with the Department of Anesthesia should be
requested when the physicians and nurses caring for the patient are
uncertain about the patient’s ability to undergo the planned procedure and
sedation safely.
5.6.2 For patients with a significant risk of:
5.6.2.1 Airway compromise
5.6.2.2 Limited neck motion
5.6.2.3 Cervical Instability
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5.6.2.4 Abnormal Craniofacial Anatomy

5.6.2.5 Gastric content aspiration.
5.6.3 A history of complications or failure of prior sedation:
5.6.3.1 Inability of patient to cooperate
5.6.3.2 History of sleep apnea
5.6.4 ASA III or greater, mallampati>2 (difficult airway)
5.6.5 Morbid Obesity
5.6.6 Pregnant Patient
5.6.7 Sickle cell disease
5.6.8 Symptoms and signs of shock
5.6.9 History of malignant hyperthermia
5.6.10 CNS depression
5.6.11 Renal or hepatic failure
5.6.12 Patients on monoamine oxidase inhibitors
5.7 Equipment:
5.7.1 The sedating Location must provide: Oxygen source/wall oxygen and
suction sources/suction apparatus are most reliable and preferred. If tank
oxygen and/or portable suction machine are used, the attending trained
physician or anesthetist must ascertain that the oxygen supply is sufficient
and the suction apparatus is functioning properly before beginning the
procedure.
5.7.2 Standard fully equipped crash cart with equipment appropriate for the age
of the patient being sedated including a self-inflating positive pressure
oxygen delivery resuscitation bag, airways, laryngoscopes and
endotracheal tubes.
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5.7.3 Pulse oximeter, ECG monitor and Noninvasive blood pressure measuring
device.
5.7.4 A patient intravenous infusion for the duration of the procedure and during
recovery as deemed necessary.
5.7.5 Procedure rooms must be large enough to accommodate all appropriate
personnel and monitoring equipment including a resuscitation team should
it be required. In certain circumstances e.g. MRI where resuscitation close
to the magnet would endanger the resuscitation team, an appropriately
sized and resourced resuscitation area immediately adjacent must be
provided, together with means rapidly to transfer the patient there.
5.7.6 Dedicated recovery facilities must be available for patients who have
received sedation. Monitoring is continued until they are fit for discharge.
The recovery area should be adjacent to the treatment/investigation area;
quiet, warm and easily accessible to staff.
5.8 Personnel/Staffing
5.8.1 A minimum of two personnel must be involved in the care of patients
undergoing conscious sedation during the entire procedure and these
should be:
5.8.1.1 The physician or anesthetist
5.8.1.2 An individual whose sole responsibility is to monitor the patient
and observe their response to the medication and the procedure.
5.8.1.3 These individuals must have completed Basic Life Support and
qualified in Advanced Cardiac Life Support or Pediatric
Advanced Cardiac Life Support.
5.9 Timing of Procedure
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5.9.1 Procedures being carried out under sedation should be appropriately timed
to ensure that the fasting times are not excessive and that recovery from
sedative drugs can take place during routine working hours if at all
possible.
5.9.2 Only in exceptional circumstances should procedures carried out under
sedation take place out of hours. These are likely to be emergencies and
usually involve sicker and thus higher risk patients. It is essential that
daytime standards are not compromised, particularly in relation to an early
stage as out of hours there will be on call anesthetist only.
5.10 Intra-Operative assessment and monitoring
5.10.1 Patients must have baseline measurements recorded prior to administration
of sedation. Following administration of sedation observation of the
patient must be continuous. Monitoring should include:
5.10.1.1 Respiratory: Rate and depth of respirations, patency of airway –
most respiratory problems associated with sedation are caused by
the effect of medications, which decrease the rate and depth of
ventilations or impair airway patency. The patient should have a
minimal SpO2 of 95% on room air supplemental oxygen.
Measurement of respiratory rate (at least every 5 minutes).
5.10.1.2 Heart rate / Pulse: Periodically assess rate, skin temperature,
color, and capillary refill. Meperidine may cause an increase in
heart rate; all other narcotics tend to decrease the heart rate.
5.10.1.3 Blood Pressure: Use the appropriate sized cuff, assess every 5
minutes throughout the procedure; more frequently if aberrations
noted.
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5.10.1.4 Cardiac Monitoring: The patient will be monitored continuously

until discharge criteria met. The monitoring RN will stay with
the patient continuously during a procedure. According to the
joint commission the art and monitoring the patient should not be
engaged in tasks that would compromise continuous monitoring.
Print a pre and post sedation rhythm strip and include any
arrhythmia activity or events.
5.10.1.5 Monitor continuously and record every 5 minutes as appropriate:
heart rate, respiratory rate an adequacy of pulmonary ventilation,
SpO2 by pulse oximetry, noninvasive blood pressure, level of
consciousness, ECG monitoring should be available and utilized
for patients with significant cardiopulmonary disease or when
dysrhythmias are anticipated or detected.
5.10.1.6 Level of Consciousness (LOC): It is important to assess and
document baseline LOC prior to the initiation of sedation.
During sedation and recovery, LOC will be documented at least
every 5 minutes.
5.10.2 Sedation scale may be used to document level of consciousness during the
sedation procedure and recovery.
5.10.2.1 Ramsey Sedation Scale:
5.10.2.1.1 Anxious, restless or agitated
5.10.2.1.2 Cooperation oriented and calm
5.10.2.1.3 Asleep with a brisk respond to comments
5.10.2.1.4 Asleep with a brisk response to light glabellar tap
5.10.2.1.5 Asleep with a slow response to light glabellar tap
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5.10.2.1.6 Asleep with no response to light glabellar tap

5.10.3 Monitoring and documentation of the following is also required:
5.10.3.1 The time, route, dose and effect of all medications including
oxygen therapy in liters/min. and by means delivered (e.g. nasal
prongs).
5.10.3.2 All doses of drugs must be titrated to the desired effect, allowing
sufficient time for circulation and observation of variables
responses.
5.10.4 Other aspects to monitor: Include anxiety, pain and/or restlessness.
Restlessness may indicate anxiety or pain; however, it might also be an
early indicator of hypoxemia or a pre-syncopal episode. Hence if your
patient becomes restless, assess for multiple causes.
5.10.5 For prolonged procedures attention should be given to:
5.10.5.1 Patient positioning
5.10.5.2 Hydration (IV fluids may be required)
5.10.5.3 Temperature control
5.10.5.4 Use of supportive / protective padding for pressure areas.
5.10.6 Conditions/observations that needs to be reported to the administering
physician: Restlessness, Cyanosis: a late sign of hypoxemia, Pallor,
Flushing: a possible sign of a developing allergic reaction, Diaphoresis,
Nausea.
5.10.7 Provide nursing support interventions during the procedure.
5.10.7.1 Talk to the patient using positive and reassuring language. Avoid
conversations in the room, which might be misinterpreted by a
sedated patient.
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5.10.7.2 Keep the patient informed of the progress of the procedure.

5.10.7.3 Touch the patient gently when assessing ventilations, skin
temperature, LOC, or when reassuring them.
5.10.7.4 Attend to basic comfort needs of the patient, such as
repositioning.
5.10.7.5 Observe the patient for nonverbal indicators of pain and anxiety.
5.11 Post-procedure monitoring:
5.11.1 It should include the following:
5.11.1.1 Vital signs
5.11.1.1.1 Every 5 minutes for the 1st 15 minutes the every
until discharge criteria are met.
5.11.1.2 Airway
5.11.1.2.1 Position patient for airway observation and
maintenance of clear airway. If patient’s face must
be under drapes, be sure there is a flow of fresh air
to prevent buildup of CO2.
5.11.1.3 Breathing
5.11.1.3.1 Assess and document rate, depth and character of
respirations. Monitor and document oxygen
saturation. SpO2 should remain at a constant of
95% or greater regardless of oxygen delivery status.
Record administered oxygen flow and its delivery
device (by face mask or nasal prongs).
5.11.1.4 Circulation
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5.11.1.4.1 Monitor pulse rate from oximeter and ECG. Good

to get baseline pulse character by palpating pulse
prior to procedure and PRN during procedure.
Monitor ECG for rate and rhythm. Print a pre-
procedure strip, and print a strip for any abnormal
rhythms. If change is noted in ST segments, obtain
a 12-lead ECG. Assess BP with vital signs. Alert
physician for sustained drop of 20% to 30% below
Patient’s baseline.
5.11.1.5 Consciousness
5.11.1.5.1 Level of consciousness is documented every 5
minutes during procedure and in the recovery phase
until patient meets discharge criteria.
5.11.1.5.2 Use of Aldrete Post-Anesthesia Scoring System to
document patient LOC. Discharge documentation
should compare the patient’s discharge LOC with
pre-procedure LOC.
5.11.1.6 The patient may be transferred from the procedure area to a
recovery area when: Able to maintain a patent airway with intact
reflexes (swallow, cough, gag) Responsive to verbal and tactile
stimuli as appropriate vital signs are stable with satisfactory
SpO2.
5.11.2 If the recovery area is remote from the procedure area, the patient must be
monitored in transit by the monitoring person with a pulse oximeter. If the
patient is sedated in an area remote from the procedure area, the patient
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must be transported to the procedure area by a monitoring person with a

pulse oximeter.
5.11.3 The patient should be transferred to a recovery area where monitoring
should be continued by trained staff.
5.11.4 Recover area must have the appropriate drugs and equipment for
resuscitation as detailed above as for the sedation area.
5.11.5 Monitoring and recording of observations should be continued into the
recovery period every 5 minutes for the first 15 minutes; reduced
stimulation may allow level of sedation to increase during this period.
Subsequently observations should be recorded every 15 minutes until
discharge criteria are met.
5.12 Discharge criteria:
5.12.1 The patient maybe discharges from the hospital when:
5.12.1.1 Fully awake with an ALDRETE SCORE of 9/10. No category
with a score of 0, Hydration is adequate, able to walk unassisted,
accompanied by a responsible adult escort, advised regarding
after care with written and verbal instructions. The responsible
attending physician must write the discharge order and write a
discharge note including patient status.
5.12.1.2 Once patient meets the discharge criteria they may be discharged
home, with an accompanying adult or transferred to the ward
accompanied by a member staff.
5.13 Post Procedure Patient Instructions:
5.13.1 All patients should receive written instructions at the time of discharge
detailing what they can expect to happen in the next 24 hours, that they
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should not drive, operate machinery or make important decisions, and

what to do should they feel unwell with the relevant contact details.
5.14 Drugs
5.14.1 The most frequently prescribed sedation/analgesia medications/drugs
available for use are:
5.14.1.1 BENZODIAZEPAM- Specific agents: Midazolam (Dormicum)
and Diazepam (Valium)
5.14.1.1.1 Patients who chronically take Cimetidine (Tagamet)
or Ranitidine (Zantac) are especially to
Benzodiazepine overdose… these H-2 blocking
drugs may dramatically increase the sedative effect
of even small doses of Benzodiazepines.
5.14.1.2 Narcotics (when given in conjunction with Benzodiazepines are
great potentiators of respiratory depression (great synergistic
effect)
5.14.1.3 Diazepam (valium)
5.14.1.3.1 Adult dose: Administer in 1-2mg increments in
every 2 minutes IV until desired effect is achieved.
(Slurred speech). Generally, 10 to 20mg in 60
minutes.
5.14.1.3.2 Pediatric dose: 0.1- 0.3mg/kg
5.14.1.3.3 Potential Adverse Reactions: Phlebitis at site of
injection, bradycardia, hypotension, respiratory
depression and apnea, agitation, confusion, hiccups,
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diplopia, rash, urticaria. Avoid extravasation as

drug is caustic to tissue.
5.14.2 Midazolam: Dormicum
5.14.2.1 Midazolam is very potent short – acting drug that must be
given slowly by IV administration over two minutes is
recommended.
5.14.2.2 Dilution. May dilute to desired concentration with D5W
or NS. Recommended concentration of 0.25mg/ml, with
administration rate no faster than 0.5 mg over 2 minutes.
5.14.2.3 Dosage Recommendation for Sedation:
5.14.2.4 Adult: Initial dose of 1-2 mgs IV over 2 minutes just
before beginning of the procedure. Must titrate to effect
(slurred speech) by giving additional IV doses over 2
minutes. In general, do not exceed total dose of 3.0 mg,
however you may continue to titrate high doses if needed
to obtain effect. Wait at least 2 minutes after each
administration of medication to determine effect.
5.14.2.5 Geriatric or patients with impaired pulmonary/hepatic
function:
Route Onset of Action Peak Effect Duration of Action
IV 1-5 minutes 3-5 minutes 2-4 hours
Oral 15-60 minutes 60 minutes 3-6 hours
5.14.2.6 Initial dose 0.25mg-0.5mg IV over 2 minutes. Maximum
total dose is 2.0 mg. Titrate to effect.
5.14.2.7 Pediatric: 0.025 – 0.05 mg/kg IV over 2 minutes.
Maximum total dose 0.1 mg/kg. Titrate to effect.
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5.14.2.8 Contraindications: Do not give midazolam to persons

with known hypersensitivities to the drug. Do not give to
patients with acute narrow – angle glaucoma and shock.
Reduce dosage for patients with alcohol intoxication, or
history of COPD.
5.14.2.9 Adverse Reactions: Respiratory depression, apnea,
cardiac arrest, coughing, bronchospasm, laryngospsam.
Hypotension, PVC’s, tachycardia, bradycardia, hiccups,
nausea, vomiting, urticaria, pain at infusion site.
5.14.3 Reversal Agent for Benzodiazepines – Diazepam and Midazolam
Flumazenil
Route Onset of Action Peak Effect Duration of
Action
IV(bolus or 1-2 minutes 6-10 minutes (but 80% of the
infusion) maximum response is seen
within 3 minutes.)Call
anesthesia if there is no
desired clinical response with
the administration of the
initial 1 mg.
5.14.3.1 Specific benzodiazepine antagonist, used for complete or

partial reversal of the sedative effects of benzodiazepines;
management of benzodiazepine overdose.
5.14.3.2 Administration Technique:
5.14.3.3 IV bolus:
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5.14.3.4 Phase One: Initially 0.2 mg IV over 15 seconds to one

minute. If patient does not reach desired level of
consciousness after 45 seconds.
5.14.3.5 Phase Two: Repeat dose at one minute intervals until a
cumulative dose of 1 mg has been administered (includes
initial dose in phase one). If no response to treatment is
noted, call anesthesia for assistance.
5.14.3.6 IV infusion:
5.14.3.6.1 30-60 ug/minute (0.5 – 1 ug/kg/min). Total dose
does not exceed 3 mg/hour.
5.14.3.7 Individualized dosage is required. Manufacturer does not
recommend the administration of flumazenil to patients
under the age of 18.
5.14.3.8 Flumazenil: induced seizures have been reported in
patients with chronic physical dependence to
benzodiazepines or patients recently undergoing multiple
procedures requiring multiple large doses of
benzodiazepines.
5.14.3.9 Patients who have responded to flumazenil should be
carefully monitored (up to 120 minutes) for re – sedation.
5.14.3.10 To avoid pain and inflammation at the site of injection,
administration of flumazenil via a large vein is
recommended.
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5.14.3.11 Adverse Effects: Respiratory – return of respiratory

depression which has exceeded the therapeutic effects
of flumazenil.
5.14.3.12 Cardiovascular – cutaneous vasodilation, sweating,
flushing, dysrhythmias, bradycardia, tachycardia and
hypertension.
5.14.3.13 CNS – dizziness, headache, abnormal or blurred vision,
confusion and convulsions.
5.14.4 Pethidine:
5.14.4.1
IV 3-5 minutes 5-20 minutes 1-3 hours
IM 1-5 minutes 30-50 minutes 2-4 hours
Oral 15-45 minutes 60 minutes 2-4 hours
Dosage/Administration:
5.14.4.2 Adult: 25 mg slow IV. Slowly titrate in 25 mg increments to individual patient
response. Total dose for nursing administration, 100 mg in 60 minutes.
5.14.4.3 Reduce dosage and rate of administration in patients who are
elderly, debilitated, having renal or hepatic disease, or who have
hypothyroidism.
5.14.4.4 Contraindicated in patients on Monoamine oxidase
inhibitors(MAO). Isocarboxazid(Marplan), Phenelzine (Nardil),
Selegiline(Emsam,Eldepryl,Zelapar),Tranylcypromine(Parnate).
5.14.4.5 Severe and even fatal reactions have been known to occur.
5.14.4.6 Pediatric: 1- 1.5 mg/kg. Titrate dose to individual response. Max
dose 100 mgs.
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5.14.5 Fentanyl Citrate –Binds with opiate receptors in CNS, altering perception
and emotional response to pain.
IV <1 minute 5-15 minutes 30-60 minutes
IM 5-8 minutes 15-20 minutes 1-2 hours
Transmucosal 5-15 minutes 20-30 minutes 1-2 hours
5.14.5.1 Dosage/Administration: Adults:25-100 mcg slow IV injection
into IV infusion line over 1-2 minutes is required. Titrate 25 mcg
at a time. Total recommended dose for nursing administration,
200 mcg for healthy young adult. Reduce dose and rate of
administration in patients who are elderly, debilitated or have
renal or hepatic disease.
5.14.5.2 Pediatric: 0.5- 2 mcg/kg. Titrate to individual response.
5.14.5.3 Special considerations: Fentanyl must be titrated to effect and
administered slowly to prevent the occurrence of adverse
reactions. DO NOT mix with barbiturates.
5.14.6 Morphine: Narcotic analgesic:
IV 5 Minutes 5-15 minutes 2-4 hours
5.14.6.1 Adult doses: 2.5-10mg/dose may repeat every 10 min. Total dose
does not greater than 15 mg.
5.14.6.2 Pediatric Dose: 0.05 to 0.1mg/kg/dose may repeat every 10
minutes.
5.14.6.3 Special considerations: Administer slowly to avoid respiratory
depression and apnea use small dose in debilitated chronically ill
or patients with decreased cardio pulmonary reserve can cause
respiratory depression when combined with benzodiazepines.
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5.14.6.4 Reversal Agent: Nalaxone(Narcan)will reverse the respiratory

and cardiovascular effects of Fentanyl overdose. Reversal
brought on too rapidly may cause nausea, sweating and
hypertension.
5.14.7 Naloxone Hydrochloride
5.14.7.1 Dosage /Administration:
5.14.7.2 Naloxone injection is available as sterile solution for intravenous,
intramascular and subcutaneous administration in three: 0.02mg,
0.4mg and 1mg of naloxone hydrochloride per ml. pH is adjusted
to 3.5 + 0.5 with hydrochloride acid.
5.14.7.3 Adult: Initial Dose: 0.04mg-2mg titrated in small increments.
Dilute 0.4mg amp of Naloxone to 10cc total volume. This will be
0.04mg of 40mcg per cc. Give this reversal 1cc at a time with at
least 2-3 minutes between doses. This titration will allow one to
bring the patient up to a safe respiratory rate without reversing
analgesia or causing severe CV problems. If no response is
observed after 2mg has been administered, the diagnosis of
narcotic induced toxicity should be questioned. Total dosage for
nursing administration -2 mg.
5.14.7.4 0.01 mg initial dose. If initial dose does not result in desired
clinical reversal, administer a subsequent dose of 0.01 mg. If this
does not result in desired effect, administer 0.1 mg/kg. Total
dosage for nursing administration in pediatric patients is
0.2mg/kg.
5.14.7.5 Anesthesia medications should only be used by Anesthetist.
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5.14.8 Propofol

5.14.8.1 IV 40 seconds 1 minute 5-10 minutes
Dosage/Administration:
5.14.8.2 Adult dose: 25-50 mg(0.5-1mg/kg) IV, administered in 10 mg
increments over several minutes. Pain on injection is decreased
with IV lidocaine, 0.1 mg/kg, added to the propofol emulsion.
Strict aseptic technique must be maintained in handling, as
propofol is preservative free and will support bacterial growth.
Propofol injection should be prepared for single patient use only,
just prior to the initiation of each procedure. Discard after opened
for 6 hours.
5.14.8.3 Pediatric dose: 0.5-1.0 mg/kg infused slowly and titrated to
desired effect.
5.14.8.4 Special considerations: Propofol must be titrated to effect and
administered slowly to prevent the occurrence of adverse
reactions. Reduce dose in elderly, hypovolemic, and high-risk
patients. Potentiation occurs when combined with narcotic
analgesics and CNS depressants. There is no pharmacologic
reversal agent for propofol.
5.14.9 Ketamine
5.14.9.1 Ketamine hydrochloride(Ketalar) –Medication used especially
for deep sedation in pediatric patients. Not a primary use drug.
Administer drug only with previous experience or under the
direction of an anesthesia provider familiar with its use. Package
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Ministry of Defense
Hospital Policy
Policy No: ANE - 06
Version No: 01
insert “Ketamine should be used by or under the direction of

physicians experienced in administering general anesthesia and
in maintenance of an airway and in control of respiration.
5.14.9.2 Mechanism of Action – Selectively interrupts cerebral pathways,
causing dissociative anesthesia.
5.14.9.3 Dosage and Administration – usually 0.25 to 1.0 mg/kg.
Dose is based on patient response to medication. Rate of
infusion should not exceed 50 mcg/kg/min.
5.14.10 Other sedating Medications:
5.14.10.1 Chloral Hydrate: Drug is used primarily in pediatric patients.
5.14.10.2 Description: A pure sedative hypnotic with no analgesic
properties. It may produce a state of disinhibition with
agitated response to noxious stimuli. It is used as an adjunct
for painful therapeutic procedures. Most effective in children
less than 4 years of age.
5.14.10.3 Dose and Route of Administration: Oral: 25-100 mg/kg up to
1 g dose (max of 2g in divided doses).
5.14.10.4 Onset/Peak effect
5.14.10.5 Onset: 15-30 minutes
5.14.10.6 Peak effect:30-60 minutes
5.14.10.7 Duration:60 minutes (residual sedation may persist for 10 or
more hours in toddlers, but 20 hours or more in neonates.
5.14.10.8 Drug interactions:
5.14.10.8.1 Cautions use with other sedatives or opioids – may
increase the risk of respiratory complications.
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Ministry of Defense
Hospital Policy
Policy No: ANE - 06
Version No: 01
5.14.10.8.2 May alter the rate of metabolism of warfarin or

warfarin- related anticoagulants.
5.14.10.9 Contraindications:
5.14.10.9.1 Preterm or term neonate (repeat dosing)
5.14.10.9.2 Should not be used on chronic basis
5.14.10.9.3 Idiosynchacy and hypersensitivity to drug
5.14.10.9.4 Oral dose contraindicated in gastritis
5.14.10.9.5 Porphyria
5.14.10.9.6 Significant hepatic disease
5.14.10.9.7 Dysrhythmias
5.14.10.9.8 Antogonist: not available
5.15 Maintenance of an adequate range of analgesic, sedative and resuscitative drugs
should be the responsibility of a specified individual within the department where
sedation is undertaken.
5.16 Expiry dates of drugs should be checked.
5.17 Drugs cupboards should be easily accessible in areas where drugs are to be
administered.
5.18 Clear labeling of syringes containing drugs is required.
5.19 Specific antagonists for intravenous sedatives should be immediately accessible.
These must not be used to facilitate excessive dosing or to enhance rapid recovery
prior to discharge.
5.20 Documentation
5.20.1 Documentation of all care administered is essential. The clinical records
should contain the following:
5.20.1.1 Details of the pre-procedure assessment
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Ministry of Defense
Hospital Policy
Policy No: ANE - 06
Version No: 01
5.20.1.2 Details of the consent process and a copy of the consent form
5.20.1.3 Records of all medication administered
5.20.1.4 Records of all observations – baseline, intra and post –procedure
5.20.1.5 Records of any adverse event occurring during the procedure or
as a result of the administration of sedation.
5.20.1.6 A record of the discharge process and the fact that the patient has
fulfilled the criteria for discharge.
5.21 Complications:
5.21.1 All sedative drugs depress the central nervous system and patients may
become unresponsive to command and mild stimulation. When loss of
consciousness occurs (defined as failure to respond to verbal command
and only responding to purposeful physical stimulation-), the state of
sedation has been lost and anesthesia induced with all its attendant risks. If
this occurs, then the procedure should be halted and the requirement for
the assistance of anesthetist considered urgently.
5.21.2 Patients exhibit excessive restlessness, confusion or signs of airway
obstructions are at high risk and on no account should further sedation be
administered until anesthetic assistance has been obtained. Some sedative
agents may produce a paradoxical response i.e. excitement, particularly in
young children and the elderly; if this occurs further medication should
not without assistance from an anesthetist.
5.21.3 In patients who do not have chronically low oxygen saturations, an oxygen
saturation of 90% or less represents a dangerously low level of
oxygenation. Immediate action should be taken.
102-03-05
Ministry of Defense
Hospital Policy
Policy No: ANE - 06
Version No: 01
5.21.4 In patients with chronically low oxygen saturations (for ex. Severe chronic
lung disease, a fall of 5% below their stable baseline oxygen saturation
represents a serious desaturation requiring intervention. I f measures to
improve oxygenation are not immediately effective an anesthetist should
be called.
5.21.5 All staff should be fully aware of how to access assistance in an
emergency, the location of call buttons and where resuscitation equipment
is kept.
5.21.6 All staff should be aware of the particular problems that may occur in the
environment in which they work and how to manage them in the arrest
situation, e.g. extracting a patient from an MRI scanner.
5.22 Monitoring
5.22.1 All adverse events associated with the administration of sedation should
be reported.
6.0 REFERENCES:
6.1 JCI/ASC 2
6.2 Continuum of Depth of sedation: Definition of general anesthesia and levels of
sedation/analgesia. ASA, USA 2009 (http://bit.ly/11iGlax)
6.3 Clinical Practice Guideline: Perioperative fasting in adult and children (full).
RCN, London 2005
(www.rcn.org.uk/_data/assets/pdf_file/009/78678/002800.pdf)
6.4 Recommendation for standards of monitoring during anesthesia and recovery (4th
edition).AAGBI London 2007
(www.aagbi.org/sites/default/files/standardsofmonitoring07.pdf)
102-03-05
Ministry of Defense
Hospital Policy
Policy No: ANE - 06
Version No: 01
6.5 WHO Surgical Safety Checklist. January 2009 (www.nrls.npsa.nhs.uk/alerts/?

entryid45=45860)
7.0 APPROVALS:
Compiled by: Signature: Date:
Lt. Col. Dr. Ihtisham Ul-Haq
Head of Anaesthesia
Reviewed by: Signature: Date:
Dr. Wagih Ghnnam
Head of Surgery

Lt. Col. Dr. Ali Al Fageeh
Medical Director

Mr. Bahae’e Mahmoud Saleh
Director of CQI&PS
Authorized by: Signature: Date:

Brig. Gen Dr. Mohammad
Jureibi
Assistant Director for Health
Affairs
Approved by: Signature: Date:
Maj. Gen. Dr. Ahmad
Hussein Al Hamidhi
Hospital Director
Date of Next Review:
102-03-05

ANE - 06 Role & Responsibility For Sedation Practice

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Kingdom of Saudi Arabia

4.2.2.1 Prescribe sedation

5.3.1.6.7 Reduction and immobilization of fracture and

possible. Classification can then be made as follows per visualization of

5.6.2.4 Abnormal Craniofacial Anatomy

5.10.1.4 Cardiac Monitoring: The patient will be monitored continuously

5.10.2.1.6 Asleep with no response to light glabellar tap

5.10.7.2 Keep the patient informed of the progress of the procedure.

5.11.1.4.1 Monitor pulse rate from oximeter and ECG. Good

must be transported to the procedure area by a monitoring person with a

should not drive, operate machinery or make important decisions, and

diplopia, rash, urticaria. Avoid extravasation as

5.14.2.8 Contraindications: Do not give midazolam to persons

5.14.3.1 Specific benzodiazepine antagonist, used for complete or

5.14.3.4 Phase One: Initially 0.2 mg IV over 15 seconds to one

5.14.3.11 Adverse Effects: Respiratory – return of respiratory

5.14.6.4 Reversal Agent: Nalaxone(Narcan)will reverse the respiratory

Route Onset of Action Peak Effect Duration of Action

insert “Ketamine should be used by or under the direction of

5.14.10.8.2 May alter the rate of metabolism of warfarin or

6.5 WHO Surgical Safety Checklist. January 2009 (www.nrls.npsa.nhs.uk/alerts/?

Reviewed by: Signature: Date:

Reviewed by: Signature: Date:

Authorized by: Signature: Date:

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