What are the recommended step‑by‑step guidelines for safe moderate (conscious) sedation in adults and children older than six months who are American Society of Anesthesiologists (ASA) physical status I‑III?

Sedation Guidelines for Moderate (Conscious) Sedation in Adults and Children >6 Months (ASA I-III)

For safe moderate procedural sedation in ASA I-III patients, you must ensure a dedicated monitoring person separate from the proceduralist, maintain continuous pulse oximetry and capnography, have immediate airway rescue capability including bag-valve-mask ventilation, and verify NPO status while recognizing that urgent procedures should not be delayed for fasting alone. 1

Pre-Procedure Assessment and Preparation

Patient Evaluation

• Verify ASA physical status (ideally I or II; ASA III acceptable but carries higher risk of oxygen desaturation and airway difficulties) 1, 2
• Assess airway anatomy for potential difficulties (Mallampati score, neck mobility, jaw opening, obesity) 1
• Document NPO status: Inform patients not to eat solids or drink fluids for sufficient gastric emptying time, but in urgent/emergent situations, do not delay sedation based on fasting time alone 1
• Obtain informed consent from patient or legal guardian regarding benefits, risks, limitations, and alternatives 1

Equipment Setup (SOAPME Checklist)

Use this systematic approach for every procedure 1:

• S (Suction): Size-appropriate suction catheters and functioning Yankauer-type suction 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 masks, bag-valve-mask device 1
• P (Pharmacy): Resuscitation drugs and antagonists (naloxone for opioids, flumazenil for benzodiazepines) 1, 3
• M (Monitors): Functioning pulse oximeter with size-appropriate probes, blood pressure monitor, capnography, ECG, stethoscope 1
• E (Equipment): Special equipment for specific cases (defibrillator, procedure-specific tools) 1

Personnel Requirements

The Practitioner

• Must be competent to use sedation techniques, provide guideline-level monitoring, and manage complications including rescue from deeper sedation 1
• Must be trained in bag-valve-mask ventilation at minimum to manage airway obstruction or apnea 1
• Requires advanced pediatric airway skills for pediatric patients, with regular skills reinforcement 1

Dedicated Monitoring Personnel

• A separate individual (not the proceduralist) must be present solely to monitor the patient throughout the procedure 1
• This person must be trained in recognition of apnea and airway obstruction, basic life support, and authorized to seek additional help 1
• May assist with brief interruptible tasks but primary responsibility is patient monitoring 1

Monitoring Requirements During Procedure

Continuous Monitoring (Uninterrupted)

• Pulse oximetry: Continuous throughout procedure with functioning alarms set 1
• Capnography: Recommended to detect respiratory depression earlier than pulse oximetry alone 1, 2
• Visual observation: Continual assessment of chest wall movement and respiratory effort 1

Intermittent Monitoring (Every 5 Minutes Minimum)

• Level of consciousness: Check response to verbal commands or light tactile stimulation (e.g., "thumbs up" sign) every 5 minutes, except when verbal response impossible (oral surgery, endoscopy) or movement detrimental 1
• Blood pressure and heart rate: Measure at 5-minute intervals unless monitoring interferes with procedure 1
• ECG monitoring: Use in patients with clinically significant cardiovascular disease or when dysrhythmias anticipated 1

Documentation Requirements

Record at minimum 1:

1. Before sedative/analgesic administration
2. After sedative/analgesic administration
3. At regular intervals during procedure
4. During initial recovery
5. Just before discharge

Medication Selection by Patient Population

Pediatric Patients (>6 Months)

First-line: Ketamine 2

• IV dose: 1-1.5 mg/kg over 30-60 seconds with atropine 0.01 mg/kg 2
• IM dose: 4-5 mg/kg if IV access unavailable 2
• Advantages: Provides both analgesia and sedation, maintains airway reflexes and respiratory drive, particularly useful for painful procedures 2
• Consider adding: Glycopyrrolate 5 μg/kg to reduce secretions 2
• Emergence reactions: More common in children >10 years; consider adding midazolam 0.05 mg/kg to reduce this risk 2
• Contraindications: Increased intracranial pressure, psychosis 2
• Rare but serious complication: Laryngospasm requires vigilant monitoring 2

Second-line: Midazolam 2

• IV dose: 0.05-0.1 mg/kg over 2-3 minutes (maximum single dose: 5 mg) 2
• Advantages: Shorter recovery time than pentobarbital 2
• Critical caveat: Provides NO analgesia; never use alone for painful procedures 2
• Risk: Paradoxical agitation in some patients; respiratory depression especially when combined with opioids 2

Not recommended first-line: Pentobarbital 2

• Decreased efficacy in patients ≥12 years or >50 kg 2
• Longer recovery time (up to 100 minutes) 2

Adults

Common effective agents include etomidate, ketamine, propofol, fentanyl/midazolam combinations 1, 4

Etomidate dosing (when used):

• Initial dose: 0.1-0.2 mg/kg IV over 30-60 seconds 5
• Maximum total dose: 0.3 mg/kg to minimize adverse effects 5
• Pre-treatment: Consider fentanyl or droperidol to reduce myoclonus (occurs in 4-38% of patients) 5
• Adverse effects: Respiratory depression in ~16% (usually manageable with oxygen and airway repositioning), oxygen desaturation in 5-39% (higher risk at doses ≥0.23 mg/kg) 5
• Caution: Use carefully in adrenal insufficiency 5

Critical principle: Provider familiarity with the chosen agent is paramount for safety—never use an unfamiliar agent simply because it seems theoretically ideal, as complications arise from inability to manage adverse events, not from the agent itself 3

Rescue Capability and Complication Management

Anticipate Deeper Sedation

• Patients may progress from moderate to deep sedation unpredictably 1
• Practitioners must be skilled to rescue patients who become deeply sedated, including providing bag-valve-mask ventilation 1
• Reflex withdrawal from painful stimulus is NOT a purposeful response and indicates general anesthesia, not moderate sedation 1

Common Adverse Events

• Hypoxia is most common adverse event with procedural sedation 6
• Pulmonary aspiration risk is low even in non-fasted patients 6
• Combining agents (e.g., fentanyl/midazolam) significantly increases respiratory depression risk: hypoxemia in 92%, apnea in 50% of volunteers 3

Immediate Availability Required

• Resuscitative drugs 3
• Age-appropriate airway equipment 3
• Personnel trained in airway management 3
• Specific antagonists (naloxone, flumazenil) if using opioids or benzodiazepines 3

Recovery and Discharge

Recovery Monitoring

• Continue monitoring until patient returns to age-appropriate baseline mental status and function 4
• Discharge criteria: Patient must meet predetermined recovery criteria before discharge 1
• Observation time: With appropriate short-acting agents (ketamine, propofol, methohexital, etomidate), patients can safely be discharged 2-4 hours post-procedure 7

Discharge Planning

• Traditional requirement for discharge with responsible adult is not pharmacologically necessary with appropriate short-acting agents and observation protocols 7
• Inform patients/guardians about post-procedure expectations and when to seek help 1

Quality Improvement

Track and analyze adverse events including desaturation, apnea, laryngospasm, need for airway interventions (jaw thrust, positive pressure ventilation), prolonged sedation, unintended reversal agent use, unplanned hospital admission, and unsatisfactory sedation 1