Procedural Sedation Required
Patient requires sedation for procedure
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AnesthesiologyManagement
Procedural Sedation and Analgesia (ASA 2018)
Procedural Sedation and Analgesia (ASA 2018): Procedural Sedation Required → Pre-Sedation Assessment → NPO Status Adequate? → Delay or Risk Assessment →...
Pathway Overview
14 steps
Algorithm Steps
14 total
01Start 02Action 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
03Decision 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
04Action 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
05Action 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
06Decision 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
07Action Minimal Sedation
Anxiolysis only
- Midazolam 0.5-2 mg IV or
- Oral anxiolytic (triazolam, diazepam)
- Patient remains conversant
- Airway reflexes intact
08Action 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
09Decision Adverse Event?
Desaturation, apnea, hypotension, oversedation
10Action 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
- Path rejoins step 08Shared downstream outcome
11Action 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
12Outcome Safe Discharge
Written and verbal instructions provided
13Action 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
- Path rejoins step 08Shared downstream outcome
14Warning ⚠️ 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
- Path rejoins step 08Shared downstream outcome
- Path rejoins step 05Shared downstream outcome
Guideline Source
Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Intended for non-anesthesiologist use of moderate sedation
- Deep sedation/GA requires anesthesiology expertise
- Pediatric considerations differ
- Emergency procedures may modify NPO requirements
Contraindicated Populations
uncontrolled_airway_risk
Applicable Regions
USEUglobal
EU: Compatible with ESA recommendations
US: Based on ASA 2018 Guidelines
Version 1Next review: 2027-01-01
Next steps
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Related Resources
Frequently Asked Questions
What is the Procedural Sedation and Analgesia (ASA 2018)?
The Procedural Sedation and Analgesia (ASA 2018) is a management clinical algorithm for Anesthesiology. It provides a structured decision tree to guide clinical decision-making, based on Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018.
What guideline is the Procedural Sedation and Analgesia (ASA 2018) based on?
This algorithm is based on Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018 (DOI: 10.1097/ALN.0000000000002043).
What are the limitations of the Procedural Sedation and Analgesia (ASA 2018)?
Known limitations include: Intended for non-anesthesiologist use of moderate sedation; Deep sedation/GA requires anesthesiology expertise; Pediatric considerations differ; Emergency procedures may modify NPO requirements. Individual patient factors may require deviation from these recommendations.
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