What is the protocol for conscious sedation?

Protocol for Conscious Sedation

Conscious sedation requires a systematic approach with continuous monitoring, dedicated personnel, and immediate availability of rescue equipment, using midazolam combined with fentanyl as the standard pharmacologic regimen. 1

Pre-Procedure Preparation (SOAPME Checklist)

Before initiating any sedation, systematically verify the following using the SOAPME acronym: 1

• S (Suction): Size-appropriate suction catheters and functioning Yankauer-type suction apparatus 1
• O (Oxygen): Adequate oxygen supply with functioning flow meters and delivery devices 1
• A (Airway): Size-appropriate nasopharyngeal/oropharyngeal airways, functioning laryngoscope blades, endotracheal tubes, stylets, face mask, and bag-valve-mask device 1
• P (Pharmacy): All basic resuscitation drugs including reversal agents (flumazenil for benzodiazepines, naloxone for opioids) 1, 2
• M (Monitors): Functioning pulse oximeter with appropriate probes, noninvasive blood pressure monitor, ECG, and stethoscope 1
• E (Equipment): Defibrillator and any procedure-specific equipment 1

Patient Assessment

Assess for predictors of difficult intubation or history of prior difficult intubation before proceeding. 1

Key patient factors to evaluate include: 1

• Age and health status
• Concurrent medications (particularly monoamine oxidase inhibitors, which contraindicate meperidine use) 1
• Renal function (significant renal insufficiency contraindicates meperidine due to neurotoxic metabolite accumulation) 1
• Preprocedural anxiety level
• Pain tolerance

Pharmacologic Protocol

Standard Regimen: Midazolam + Fentanyl

Fentanyl dosing: 3

• Initial dose: 50-100 μg IV over 1-2 minutes
• Onset of action: 1-2 minutes
• Duration: 30-60 minutes
• Supplemental doses: 25 μg every 2-5 minutes until adequate sedation achieved 1

Midazolam dosing: 1

• Titrate in small increments to achieve conscious sedation
• Allow adequate time between doses for peak effect assessment 1
• Reduce initial doses by 50% in elderly or debilitated patients 1

Alternative Opioid: Meperidine

Use only if fentanyl unavailable and patient has normal renal function: 1

• Initial dose: 25-50 mg IV over 1-2 minutes
• Onset: 3-6 minutes
• Duration: 1-3 hours
• Supplemental doses: 25 mg every 2-5 minutes
• Absolute contraindication: Patients on monoamine oxidase inhibitors (can cause life-threatening excitatory reactions including seizures and death) 1
• Relative contraindication: Renal insufficiency (accumulation of neurotoxic metabolite normeperidine causes myoclonus and seizures) 1

Critical Monitoring Requirements

A dedicated individual other than the proceduralist must continuously monitor the patient throughout sedation. 1

Continuous Monitoring Parameters

Monitor and document at regular intervals: 1

• Level of consciousness: Patient must respond purposefully to verbal commands or light tactile stimulation 1
• Respiratory rate and effort: Direct observation (pulse oximetry alone is insufficient as it delays detection of hypoventilation, especially with supplemental oxygen) 1
• Oxygen saturation: Continuous pulse oximetry 1
• Blood pressure: Noninvasive monitoring 1
• Cardiac rhythm: ECG monitoring 1
• Heart rate: Continuous assessment 1

Target Sedation Level: Moderate Sedation Definition

The goal is moderate sedation where the patient maintains all of the following: 1

• Responsiveness: Purposeful response to verbal commands alone or with light tactile stimulation (reflex withdrawal from pain does NOT count as purposeful) 1
• Airway: Patent without intervention required 1
• Spontaneous ventilation: Adequate without assistance 1
• Cardiovascular function: Usually maintained 1

Critical Safety Principle: Rescue Capability

Because sedation exists on a continuum, practitioners must be prepared to rescue patients who become one level deeper than intended. 1

This means: 1

• If providing moderate sedation, you must be able to manage deep sedation (including airway intervention and ventilatory support)
• Have immediate access to airway management equipment and reversal agents
• Maintain IV access throughout the procedure 1

Intravenous Access and Oxygen

• Establish a free-flowing IV line before administering any sedative 1
• Administer supplemental oxygen even without preexisting hypoxia to provide a safety margin 1
• Administer sedatives through a freely running IV infusion into a large vein to minimize injection site pain 2

Drug Administration Technique

Administer sedatives as a series of small incremental doses, NOT as single bolus injections. 2

This approach allows: 2

• Control of sedation reversal to the desired endpoint
• Minimization of adverse effects
• Assessment of peak effect before additional dosing 1

Recovery and Discharge

Recovery Monitoring

Continue monitoring in a dedicated recovery area until predetermined discharge criteria are met: 1

• Level of consciousness returned to safe baseline 1
• Oxygen saturation in room air returned to baseline (or similar oxygen requirement as pre-procedure) 1
• Vital signs stable 1
• Simple discharge criterion: Infant or child remains awake for at least 20 minutes when placed in quiet environment 1

Post-Sedation Observation

• After naloxone administration: Minimum 2 hours observation to ensure resedation does not occur 1
• After flumazenil administration: Monitor for resedation; may repeat doses at 20-minute intervals if needed (maximum 1 mg per dose, maximum 3 mg per hour) 2
• Some long-acting sedatives may require extended observation periods before discharge 1

Discharge Requirements

Patient must be discharged into the care of a responsible adult escort who has received written postoperative instructions. 1

Exception: Escort may not be required after nitrous oxide inhalation sedation alone 1

Reversal Agents

Flumazenil (for benzodiazepine reversal)

Dosing for conscious sedation reversal in adults: 2

• Initial: 0.2 mg (2 mL) IV over 15 seconds
• If inadequate response after 45 seconds: repeat 0.2 mg
• May repeat at 60-second intervals up to 4 additional times
• Maximum total dose: 1 mg (10 mL)
• Most patients respond to 0.6-1 mg total 2

Dosing for pediatric patients >1 year: 2

• Initial: 0.01 mg/kg (up to 0.2 mg) IV over 15 seconds
• May repeat 0.01 mg/kg at 60-second intervals up to 4 times
• Maximum: 0.05 mg/kg or 1 mg, whichever is lower

Naloxone (for opioid reversal)

Have immediately available with appropriate dosing protocols 1

Special Population Considerations

Elderly or High-Risk Patients

Reduce initial sedative and analgesic doses by 50% and titrate more slowly with smaller increments. 3

Consider ketamine instead of midazolam for hemodynamically unstable patients 3

Pediatric Patients

Use weight-based dosing and age-appropriate equipment 1, 2

Common Pitfalls to Avoid

• Do NOT rely solely on pulse oximetry for respiratory monitoring—it delays detection of hypoventilation, especially with supplemental oxygen 1
• Do NOT administer sedatives as single bolus injections—use incremental titration 2
• Do NOT use meperidine in patients on MAOIs (life-threatening interaction) or with renal insufficiency (neurotoxic metabolite accumulation) 1
• Do NOT proceed without a dedicated monitor separate from the proceduralist 1
• Do NOT discharge patients without appropriate recovery time and escort 1
• Avoid oversedation—the goal is conscious sedation where patients respond to verbal commands, not deep sedation requiring airway management 3

Documentation Requirements

Document throughout the procedure: 1

• Pre-procedure assessment and consent
• All medications administered with doses and times
• Vital signs and sedation level at regular intervals
• Any adverse events and interventions
• Recovery parameters
• Discharge time, condition, and instructions provided