Procedural Sedation and Analgesia (ASA 2018)

Algorithm Steps

1. ▶

   Start

   Procedural Sedation Required

   Patient requires sedation for procedure

   1. ●

      Action

      Pre-Sedation Assessment

      Evaluate patient suitability

      • ASA physical status (I-II preferred, III-IV higher risk)
      • Airway assessment (Mallampati, neck mobility, BMI)
      • Cardiopulmonary status
      • Current medications
      • Allergies
      • Previous sedation/anesthesia experience
      1. ◆

         Decision

         NPO Status Adequate?

         ASA fasting guidelines

         • Clear liquids: 2 hours minimum
         • Breast milk: 4 hours
         • Infant formula/light meal: 6 hours
         • Full meal/fatty food: 8 hours
         • Emergency: weigh risk vs benefit
         1. ●

            Action

            Delay or Risk Assessment

            If NPO not met, consider options

            • Delay procedure if elective
            • If urgent: document aspiration risk
            • Consider RSI precautions
            • Anesthesiology consult if high risk
            1. ●

               Action

               Consent & Equipment

               Prepare for sedation

               • Informed consent obtained
               • IV access established
               • MONITORING REQUIRED:
               • Pulse oximetry (continuous)
               • Capnography (moderate/deep sedation)
               • ECG (moderate/deep sedation)
               • BP (every 5 min minimum)
               • EQUIPMENT AT BEDSIDE:
               • Oxygen source and delivery device
               • Suction apparatus
               • BVM and airway adjuncts
               • Reversal agents (flumazenil, naloxone)
               • Emergency equipment
               1. ◆

                  Decision

                  Target Sedation Level?

                  Sedation continuum

                  • MINIMAL: anxiolysis only, responds normally
                  • MODERATE: depressed consciousness, responds purposefully
                  • DEEP: cannot be easily aroused, responds to repeated/painful stimuli
                  • GENERAL: unarousable even with painful stimulus
                  1. ●

                     Action

                     Minimal Sedation

                     Anxiolysis only

                     • Midazolam 0.5-2 mg IV or
                     • Oral anxiolytic (triazolam, diazepam)
                     • Patient remains conversant
                     • Airway reflexes intact
                     1. ●

                        Action

                        Continuous Monitoring

                        Throughout procedure

                        • Dedicated monitoring personnel (not doing procedure)
                        • Continuous pulse oximetry
                        • Continuous capnography
                        • BP every 5 minutes
                        • Level of consciousness
                        • Respiratory rate and pattern
                        • Document all at regular intervals
                        1. ◆

                           Decision

                           Adverse Event?

                           Desaturation, apnea, hypotension, oversedation

                           1. ●

                              Action

                              Manage Adverse Events

                              Immediate intervention

                              • APNEA/DESATURATION:
                              • Stop sedation, stimulate patient
                              • Open airway (jaw thrust, chin lift)
                              • Increase O2, bag-mask if needed
                              • OVERSEDATION:
                              • Flumazenil 0.2 mg IV (reverse benzos)
                              • Naloxone 0.04-0.4 mg IV (reverse opioids)
                              • HYPOTENSION:
                              • Fluid bolus, reduce sedation
                           2. ●

                              Action

                              Post-Procedure Recovery

                              Monitor until discharge criteria met

                              • Continue monitoring in recovery area
                              • Aldrete Score ≥9 for discharge
                              • Return to baseline mental status
                              • Stable vital signs for 30 min
                              • Ambulating without assistance
                              • Minimal nausea/pain
                              • Responsible adult for escort home
                              1. ✓

                                 Outcome

                                 Safe Discharge

                                 Written and verbal instructions provided

                  2. ●

                     Action

                     Moderate Sedation

                     Goal: purposeful response to verbal/tactile

                     • OPTION 1: Midazolam + Fentanyl
                     • Midazolam 0.5-2 mg IV titrated
                     • Fentanyl 25-50 mcg IV titrated
                     • OPTION 2: Propofol-based
                     • Propofol 0.5-1 mg/kg initial
                     • Then 10-20 mg boluses q1-2min PRN
                     • (Requires trained personnel)
                     • Supplemental O2 recommended
                     • Capnography REQUIRED
                  3. ⚠

                     Warning

                     ⚠️ Deep Sedation

                     Higher risk - anesthesia expertise recommended

                     • Propofol infusion or repeated boluses
                     • Ketamine for painful procedures
                     • Requires TRAINED personnel
                     • Capnography MANDATORY
                     • Airway intervention likely needed
                     • Consider anesthesia provider