1. All the agents listed in this table can cause sedation after a sufficient dose is administered. Sedation is a continuum and it is not always possible to predict how an individual patient will respond. Health care providers intending to induce a given level of sedation should follow the patient closely and have the skills necessary to support patients whose level of sedation becomes deeper than intended.

Levels of sedation commonly used, their clinical presentations and documentation required:

Minimal Sedation
(for anxiolysis)

Patient responds normally to verbal commands. (Documentation: pre and post sedation status, drug, dose, route and evidence of response)

Moderate Sedation
(formally conscious sedation)

Patient responds purposefully to verbal commands either alone or accompanied by light tactile stimulation. (Documentation: Pre and post sedation status, drug, dose, route, cardiac rate, rhythm, oxygen saturation, Ramsey or Aldrete score, +/- complications, use of reversal agents)

Deep Sedation

Patient cannot be easily aroused but responds purposefully following repeated or painful stimulation. Cardiovascular function is usually maintained. Ventilatory function may be impaired. (Documentation: Pre and post sedation status, drug, dose, route, cardiac rate, rhythm, oxygen saturation, Ramsey or Aldrete score, +/- complications, use of reversal agents)

General Anesthesia

Patient is not arousable, even by painful stimulation. Cardiovascular function may be impaired and ventilatory support is required. (Documentation: as per anesthesia protocol)

2. Initially attempt to sedate patients using only one agent. Continue using the single drug until one gets the desired response. Lower doses of an additional drug may be added if adequate sedation is not achieved.

3. Lower doses should be used when more than one agent is used for sedation - Benzodiazepines work synergistically with opioids, may cause excessive CNS, respiratory and cardiovascular depression in some patients. Dosage should be adjusted based on patient response and tolerance.

4. Lower doses should be initiated for mild to moderate agitation or in patients with increased risk for complications (see note 5 below). Dosage should be adjusted based on patient response and tolerance. KEY: Avoid rapid IV administration + Slow dose titration with careful patient assessment

5. In agitated delirious patients, lorazepam should be used in combination with haloperidol - Haloperidol, 2.5-5 mg IV/IM, followed by lorazepam, 0.5-1 mg IV/IM. Dosage should be adjusted based on patient response and tolerance.

6. Routine use of antidotes or reversal agents in patients with stable hemodynamic or respiratory status is not recommended.

7. Patients at increased risk for sedation-associated complications:

-Administration-related - high doses, multiple sedating agents, and rapid IV administration

- Extremes of age - young children and the elderly

- Morbid obesity

- Hemodynamic compromise - including hypotension, arrhythmias, severe underlying cardiac disease and metabolic derangements

- Severe hepatic or renal dysfunction

- Underlying neurologic abnormalities - including epilepsy

- Severe pulmonary diseases - including COPD, asthma or severe upper respiratory tract infection

- Severe gastroesophageal reflux disease

- History of multiple allergies

- History of sleep apnea

- History of gastroesophageal reflex, impaired GI motility or mechanical obstruction

- Coagulopathy

- Anatomical/ structural abnormalities in neck and face

REFERENCES

1. Krauss B, Green SM. Sedation and analgesia for procedures in children. N Eng J Med. 2000;342(13):938-45.

2. American College of Emergency Physicians: Clinical policy for procedural sedation and analgesia in the emergency department. Ann Emerg Med. 1998;31:663-77.

3. American Society of Anesthesiologists: Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology. 1996;84(2):459-71.

4. American College of Critical Care Medicine: Practice parameters for intravenous analgesia and sedation for adult patients in the intensive care unit: an executive summary.Crit Care Med. 1995;23(9):1596-605.

5. Cote CJ. Sedation for the pediatric patient. A review. Ped Clin N Am. 1994;41(1):31-58.

6. American Society of Health-System Pharmacists: American Hospital Formulary Services - Drug Information, 2000.

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