From the Guidelines
The recommended medication regimen for procedural sedation typically involves a combination of sedatives and analgesics tailored to the specific procedure and patient characteristics, with propofol, midazolam, and fentanyl being commonly used agents, as supported by the most recent evidence 1.
Medication Options
- For most adult procedural sedations, midazolam (1-2 mg IV initially, with additional 0.5-1 mg doses as needed) combined with fentanyl (25-50 mcg IV initially, with additional doses as needed) provides effective anxiolysis, sedation, and pain control.
- For deeper sedation, propofol (0.5-1 mg/kg IV initial bolus, followed by 0.25-0.5 mg/kg increments) may be used, often with reduced doses when combined with other agents, as it can be safely administered for procedural sedation and analgesia in the ED 1.
- Ketamine (0.5-1 mg/kg IV or 4-5 mg/kg IM) is particularly useful for painful procedures in children or hemodynamically unstable patients, with a study showing that a ketamine and midazolam combination was safer and more efficacious than a fentanyl and midazolam combination for sedation in orthopedic procedures 1.
Key Considerations
- The choice of medications should be based on procedure duration and intensity, patient comorbidities, and desired depth of sedation.
- Continuous monitoring of vital signs, oxygen saturation, and sedation level is essential, and resuscitation equipment must be immediately available.
- Providers should be prepared to manage potential adverse effects including respiratory depression, hypotension, or paradoxical reactions, with studies highlighting the importance of titrating nondissociative sedation agents to clinical effect to maximize safety during procedural sedation in the ED 1.
From the FDA Drug Label
When used for sedation/anxiolysis/amnesia for a procedure, dosage must be individualized and titrated. Midazolam should always be titrated slowly; administer over at least 2 minutes and allow an additional 2 or more minutes to fully evaluate the sedative effect. For intubated, mechanically ventilated adult patients, Intensive Care Unit (ICU) sedation should be initiated slowly with a continuous infusion in order to titrate to desired clinical effect and minimize hypotension.
The recommended medication regimen for procedural sedation involves the use of medications such as midazolam and propofol.
- Midazolam should be titrated slowly, with a recommended dose of 1-2.5 mg for healthy adults below the age of 60, administered over at least 2 minutes.
- Propofol should be initiated slowly with a continuous infusion, with a recommended starting dose of 5 mcg/kg/min (0.3 mg/kg/h) for intubated, mechanically ventilated adult patients. It is essential to individualize and titrate the dosage of these medications to the desired clinical effect, taking into account factors such as the patient's age, medical history, and concomitant medications 2 3.
From the Research
Medication Regimens for Procedural Sedation
The recommended medication regimen for procedural sedation can vary depending on the specific procedure, patient characteristics, and institutional preferences. Some common medication regimens used for procedural sedation include:
- Propofol and fentanyl: This combination has been shown to be effective and safe for procedural sedation in the emergency department 4, 5.
- Midazolam and fentanyl: This combination is also commonly used for procedural sedation, but may have a higher incidence of respiratory depression compared to propofol and fentanyl 6, 7.
- Ketamine and midazolam: This combination may be superior due to synergistic traits, but may also have a higher incidence of respiratory depression 6, 8.
- Etomidate and propofol: These agents are relatively recent additions to procedural sedation and have been shown to be highly effective 8.
Key Considerations
When selecting a medication regimen for procedural sedation, it is essential to consider the following factors:
- Patient characteristics, such as age, medical history, and comorbidities
- Procedure-specific requirements, such as level of sedation and analgesia needed
- Institutional preferences and availability of medications
- Monitoring and rescue equipment available
Monitoring and Safety
Monitoring and safety are crucial components of procedural sedation. Capnography can serve as a useful monitoring tool in the evaluation of ventilation during sedation or sedation/analgesia 6, 7. Supplemental oxygen may not reduce the incidence of hypoxia in patients moderately sedated with midazolam and fentanyl, but blinded capnography can frequently identify respiratory depression undetected by the treating physicians 7.