The modern practice of sedation is the end result of a process of evolution in alteration of consciousness, likely starting with the discovery of the analgesic properties of ether. Recent technological advances have drastically changed the practice of sedation. One of the most significant was certainly the development of pulse oximetry during World War II by Glen Millikan. In 2002, the American Society of Anesthesiologists (ASA) appointed a task force to update practice guidelines for non-anesthesiologists administering sedation and analgesia. The Association of periOperative Registered Nurses (AORN) has produced guidelines for what every registered nurse should know about "conscious sedation". According to the AORN, moderate sedation/analgesia is produced by the administration of amnesic, analgesic, and sedative pharmacologic agents. With continued attention to a high standard of safety, many different professionals are able to provide sedation services to those patients who need them.

This chapter focuses on the pharmacology of the drugs commonly used to provide moderate and deep sedation and their available reversal agents. Intravenous sedative and analgesic drugs should be given in small, incremental doses titrated to desired end points of sedation and analgesia, with adequate time allowed between doses to achieve those effects. Preemptive analgesia is a treatment that is initiated before surgical procedure to reduce sensitization of pain pathways. Potential drug interactions require the clinician providing sedation to be cognizant of potential drug-drug effects, which can lead to morbidity and mortality. Opioids in combination with benzodiazepines provide adequate moderate and/or deep sedation and analgesia for many potentially painful procedures. Other drugs used for deep sedation include propofol, ketamine, dexmedetomidine, and etomidate. Local anesthetics (LA) have the potential to produce deleterious side effects. The choice of a local anesthetic and care in its use are the primary determinants of toxicity.

This chapter deals with important considerations with regard to pre-procedure, peri-procedure, and post-procedure patient assessment and pain management strategies. Practitioner training and experience in administering sedation is an important consideration. For most patients, pain assessments and establishment of pain treatment goals can be performed by a non-anesthesiologist. Appropriate assessment of pain increases caregiver awareness of pain status, allows for the delivery of appropriate interventions, provides for feedback, decreases both patient and caregiver frustration, and improves patient satisfaction. The chapter outlines the most common pain assessment tools in current use in general and special populations. In the general population, which includes mature children, adults, and the cognitively intact elderly, the use of self-report scales has been validated as the most reliable indicator of pain. With appropriate vigilance, planning, and continuous communication between team members, many of the barriers involved in planning and executing an effective pain management strategy can be overcome.

This chapter covers pre-screening, history and physical for evaluation of patients who are potential candidates for procedures under sedation, as well as instructions for patients. Patients for elective procedures may be referred by their primary care physician or may be self-referred. Screening, evaluation, and instruction of patients requires clinical experience, and clerical staff members should not be performing any more than simple initial screening or instructing patients as to time, location, and routine standard instructions. The scope of practice of the surgeon/practitioner/physician(s) involved and the individual facility determine the range of procedures possible. The setting may be quite flexible and general (an operating room) or very specifically designed and equipped. Procedures should be scheduled in locations equipped both for the procedure and for sedation and any contingencies that can be routinely expected as a result of either the procedure or the patient.

Adequate patient monitoring is essential for successful and safe practice of sedation. Monitoring must be performed by a designated healthcare provider and should be performed during all phases of the procedure. Healthcare providers should be familiar with monitoring equipment and be able to interpret the data obtained from it. Monitoring for sedation procedures primarily involves the observation of blood pressure, oxygenation, respiratory function, electrocardiography (ECG) and capnography tracings. Although patients undergoing sedation are not exposed to potent inhalation agents used for general anesthesia, the importance of temperature monitoring should not be underestimated. Patients undergoing minor surgical procedures are generally exposed to the ambient environment. The maximum concentration of carbon dioxide is reached at the end of exhalation, and then identified as end-tidal CO2 (ETCO2). During sedation, the use of crystalloid solutions is generally recommended for the intravenous replacement of fluids.

In recognition of the safety risks involved in caring for patients requiring any level of sedation, the Joint Commission, in the USA, has set specific standards around credentialing, competency assessment, and education. The six general competencies identified by the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties are cited by the Joint Commission as a framework for credentialing and ongoing competency assessment. The intent of procedural sedation education is to develop and validate knowledge, skills, and behavioral competency in the management of patients requiring pharmacologic intervention during procedures. Significant advances in technology over the past few decades have created opportunity for organizations to meet the challenges of competency development and validation for healthcare practitioners. Simulation-based education is an emerging learning and assessment modality that educates, provides practice experience, and validates the competencies required to manage procedural sedation.

The goal of a procedural sedation program is to provide the best standard of care, yielding the best outcome for the patient. The policy sets the framework for the practice. It is the presence of a strong quality and risk management structure that ensures the practices outlined in the policy are appropriately and consistently applied at the point of care. In the USA, several regulatory bodies have promulgated regulations or developed guidelines regarding the administration of procedural sedation, both at state and federal levels. The purpose of the quality and practice improvement program is to ensure best practice at the point of care through the review and evaluation of key care processes and patient outcomes, along with the oversight committee, to provide a systematic approach to safe, consistent practice. Risk management and quality are involved to varying degrees with most responses, working closely with local leadership and other expert practitioners.

The nurse plays a very important role in administering procedural sedation and monitoring the patient receiving it. Receiving specialized training and adhering to strict institutional standards helps to keep patients safe. The nurse's primary responsibility during procedural sedation is exclusively to that patient. The American Association of Nurse Anesthetists (AANA) suggests that the registered nurse managing and monitoring the patient receiving sedation and analgesia should have no other responsibilities during the procedure. One of the most important things the nurse can do to prevent complications is to avoid overmedication. Intravenous sedative and analgesic drugs should be given in small, incremental doses that are titrated to the desired end point of sedation and analgesia. The American Society of Anesthesiologists (ASA) agrees that continued observation, monitoring, and predetermined discharge criteria decrease the likelihood of adverse outcomes for both moderate and deep sedation.

Nurse practitioners (NPs) and physician assistants (PAs) are healthcare professionals committed to delivering high-quality health care, and they strive to meet the needs of their patients in an effective, caring, and efficient manner. There are several entities that govern how NPs and PAs can practice. These include but are not limited to the Centers for Medicare Systems (CMS), Medicare Conditions of Participation (CoP), the Joint Commission (TJC), state law, private payer policies, established institutional polices and medical staff bylaws and the defined scopes of practice of the NP or PA. This chapter provides clarification on each of the entities' policies regarding NPs and PAs providing moderate sedation and highlights the nuances of such language. All practitioners should have the ability to manage complications during moderate sedation and have the ability to activate the appropriate emergency response team for that practice area.

Certain patient populations provide challenging clinical situations for the sedation provider. Patients with cardiovascular disease, chronic obstructive pulmonary disease (COPD), chronic renal failure, obesity, or advanced age are considered high risk and possess a higher rate of procedural complications. This chapter discusses important features of these higher-risk patients and practice management when sedation is required. COPD is frequently found in patients with chronic bronchitis or emphysema. Common procedural complications in this patient population include hypoventilation (hypoxemia and hypercapnia) and bronchospasm. Bronchospasm manifests as wheezing, and it is commonly caused by an exacerbation of the patient's COPD, but an anaphylactoid reaction to a sedation medication should be ruled out. Patients with known coronary artery disease (CAD) who become oversedated experience cardiac complications related to hypotension and/or hypoxemia. Medication used for sedation should be titrated in slowly, carefully watching hemodynamic response to the medication.

Sedation is described as a continuum, and it is often categorized according to the patient's level of consciousness as minimal, moderate, and deep sedation. Intravenous sedation can potentially cause numerous complications. The clinicians should therefore have a thorough knowledge of these possible complications and understand their management strategies. There are several scoring systems used to document the patient's mental status and depth of sedation, such as the Richmond Agitation-Sedation Scale (RASS) and the Inova Health System Sedation Scale (ISS). Prevention of complications starts with a thorough pre-procedural patient assessment. This chapter discusses, among other things, some of the patient-related risk factors and procedure-related risk factors. Among all the complications induced by intravenous sedation, respiratory complications are the most common. Moderate and deep sedation may have varying degrees of depressive effects on cardiovascular function, depending on the patient's physiological status and the dosage of sedatives administered.

The incidence of sedation-related complications for procedures is unknown, as mandatory reporting of outcomes is lacking. However, two sources of information are available that can shed light on the risks of sedation encountered in non-operating-room locations. The American Society of Anesthesiologists (ASA) changed the standards for monitoring of ventilation during moderate or deep sedation to require capnography to measure exhaled carbon dioxide unless precluded or invalidated by the nature of the patient, procedure, or equipment. Sedation-induced respiratory depression may cause brain damage and/or death. Brain function monitoring may have a beneficial role for procedural sedation in the future, but requires more investigation. The major controversies in procedural sedation are the choice of sedative agents and the administration of propofol by non-anesthesia providers. Future drugs include potential use of fospropofol and dexmedetomidine for sedation, patient-controlled sedation and analgesia (PCSA), and computer-assisted personalized sedation (CAPS).

Simulators are very effective in healthcare education, and they can be used for teaching the safe administration of sedation and/or analgesia. There are several classifications of simulators. One of them is based on the media used in simulation. This classification divides all simulators into two major categories: computer screen-based simulators and mannequin-based simulators. The following are the main high-fidelity mannequin-based computer-driven simulators utilized for teaching procedural sedation and analgesia: Laerdal SimMan simulators; Medical Education Technologies (METI) simulators; and Gaumard simulators. METI simulators have the most elaborate design, with built-in physiologic and pharmacologic systems that can be used for modeling different clinical conditions, and they have a sophisticated scenario editor/player. Laerdal SimMan simulators have advanced programming features that allow them to run preprogrammed scenarios as well as to be used on the fly. Any simulator is capable of delivering an exciting and valuable educational experience to both the trainees and instructors.

The number of minimally invasive procedures and diagnostic imaging examinations requiring moderate sedation has increased greatly in the radiology department. Many procedures in radiology are performed with the use of iodinated contrast media, and safe use of contrast media is important to everyday radiology practice. Providing moderate sedation in the magnetic resonance imaging (MRI) suite presents both patient and environmental challenges. The most common need for moderate sedation in MRI arises from severe anxiety from claustrophobia while in the scanner. It is important to limit patient movement to acquire clear diagnostic images, and in some instances patients require deep sedation or general anesthesia administered by an anesthesiologist. The American College of Radiology and the Joint Commission have published safety guidelines and alerts, and all personnel working in the MRI environment must review these guidelines and receive facility-specific safety training and screening prior to caring for patients in the environment.

An integral part of the practice of gastrointestinal endoscopy is adequate sedation and analgesia. The choice of the appropriate sedation modality is always a balance between optimizing the benefits of sedation and minimizing the potential risks. The American Society of Anesthesiologists (ASA) agrees that appropriate pre-procedure evaluation increases the likelihood of satisfactory sedation and decreases the likelihood of adverse outcomes. A vast majority of endoscopic procedures are diagnostic in nature and performed on relatively healthy patients with an ASA status of 1 or 2. Diagnostic and therapeutic endoscopic interventions include esophagogastroduodenoscopy (EGD), proctoscopy/sigmoidoscopy/colonoscopy, and endoscopic retrograde cholangiopancreatography (ERCP). Sedation for gastrointestinal endoscopy is particularly challenging because of variability during most procedures, characterized by long nonstimulating periods interspersed with significantly stimulating events. Use of a medication reconciliation tool is associated with significant improvements in patient safety.