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Sedation Full Guideline

Sedation Full Guideline - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Clinical Practice Guidelines, Nursing Practice Guidelines, Related

Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Last Revised: 05/2016EArsenaultknudsen@uwhealth.org
Patients may receive sedative drugs for short-term therapeutic indications (e.g. stabilization
of the intensive care patient, nausea, anxiety, pain relief, muscle spasticity, insomnia, and
agitation) in non-procedural settings, or as non-intravenous preoperative medications. This
guideline excludes sedation administered in surgical services and/or associated with alcohol
The scope of this guideline includes procedures requiring sedation in the ambulatory setting,
on inpatient units, in procedural areas, and in the emergency department.
Clinical Specialty
Intended Users
The intended users are nurses who provide sedation (minimal, moderate, deep) to adult and
pediatric patients in both the inpatient and outpatient settings.
Target Population
Adult and pediatric patients undergoing procedures receiving minimal, moderate and/or
deep sedation; including patients who become sedated beyond (or in excess of) original
intent, as a result of sedative agents.
Nursing Practice Guideline Objective(s)
The main objective is to provide an evidence-based guideline for inpatient and outpatient
assessment and monitoring of patients who receive sedation (minimal, moderate, deep).
Clinical Questions Considered
1. How do I prepare a patient and the environment for minimal, moderate and/or deep
2. What are the risk factors for adverse events such as over-sedation or airway
3. How should I assess and monitor my patient before, during, and after sedation?
Unive rsity o f Wisc onsin
Hospitals a nd C linic s
Nursing Practice Guidelines

May 2016

Copyright © 201� University of Wisconsin Hospitals and Clinics Authority
Contact: Last Revised: 05/2016EArsenaultknudsen@uwhealth.org
Major Outcomes Considered
Provide evidence-based individualized, quality, standardized and safe care to our patients
receiving sedation.
Description Of Methods Used To Collect/Select the Evidence
• Hand-searches of published literature (primary sources)
• Hand-searches of published literature (secondary sources)
• Hand searches of selected articles’ reference list
• Searches of electronic databases: Cochrane, National Guideline Clearinghouse,
Agency for Healthcare Research and Quality, Joanna Briggs Institute
Methods Used To Assess The Quality And Strength Of The Evidence
Weighting according to a rating scheme (scheme provided below)
Rating Scheme For The Strength Of The Evidence
Strongest (I) – Weakest (VII) as follows:
Level of Evidence A:
Data derived from multiple randomized clinical trials or meta-
Level of Evidence B:
Data derived from a single randomized trial or nonrandomized
Level of Evidence C:
Only consensus opinion of experts, case studies, or standard-of-
Description Of The Methods Used To Analyze The Evidence
The guideline recommendations were originally based on published guidelines specific to
the care of patients undergoing gastrointestinal procedures. Sparse research trial evidence
and expert opinion was used to develop practice recommendations for patients receiving
deep sedation. The best available evidence available on the care of the patient receiving
moderate sedation in the inpatient setting is expert opinion and regulatory standards.
Description Of Methods Used To Formulate The Recommendations
Review of the data from research literature. Review of nursing literature and its
• Expert consensus
• National guideline
• Meta-analyses
• Systematic review
• Literature review

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Rating Scheme For The Strength Of The Recommendations
Category Description
Class I Conditions for which there is evidence and/or general agreement that a given
procedure or treatment is beneficial, useful, and effective.
Class II Conditions for which there is conflicting evidence and/or a divergence of opinion
about the usefulness/efficacy of a procedure or treatment
Class IIa Weight of evidence/opinion is in favor of usefulness/efficacy.
Class IIb Usefulness/efficacy is less well established by evidence/opinion.
Class III Conditions for which there is evidence and/or general agreement that a
procedure/treatment is not useful/ effective and in some cases may be harmful.
Cost Analysis
None completed
Description Of Method Of Guideline Validation
The original version of this guideline included internal peer review by multiple
representatives of nursing units and clinics from University of Wisconsin Hospital and Clinics
and American Family Children’s Hospital.
Revision version (2016) was reviewed by the Sedation Committee.
The following definitions are extracted from the America’s Society of Anesthesiologists’
Continuum of Depth of Sedation: Definition of General Anesthesia and Levels of
Sedation/Analgesia (click here for more details).
Minimal Sedation (anxiolysis): A drug induced state during which patients are quiet,
drowsy and respond normally to verbal commands. Although cognitive function and
coordination may be impaired, ventilatory and cardiovascular functions are unaffected. Level
of awareness for minimal sedation correlates with a Ramsey sedation score of 1, 2 or 3 on
the adult sedation scale or Pediatric sedation score of 1, 2, 3.
Moderate Sedation/analgesia ("conscious sedation"): A drug-induced depressed level of
consciousness during which patients respond appropriately to verbal commands, either
alone or accompanied by light tactile stimulation. The ability to independently maintain
ventilatory and cardiovascular function is retained. No interventions are required to maintain
an adequate airway and pulmonary ventilation. Level of awareness for moderate sedation
correlates with a Ramsey sedation score of 4 on the adult sedation scale or score on
Pediatric sedation score of 4.
Deep sedation/analgesia: A drug-induced depressed level of consciousness during which
patients cannot be easily aroused but respond appropriately to painful stimulation. The
ability to independently maintain ventilatory and cardiovascular function may be impaired.
Patients may require assistance in maintaining an adequate airway, but ventilatory drive is
usually sufficient to avoid the need for positive pressure ventilation. Level of awareness for
deep sedation correlates with a Ramsey sedation score of 5 on the adult sedation scale or
score on Pediatric sedation score of 5.

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General Anesthesia: A drug-induced loss of consciousness during which patients are not
arousable, even by painful stimulation. The ability to independently maintain ventilatory
function is often impaired. Patients often require assistance in maintaining a patent airway,
and positive pressure ventilation may be required because of depressed spontaneous
ventilation or drug- induced depression of neuromuscular function. Cardiovascular function
may be impaired. This correlates with pediatric sedation score of 6 and Ramsey sedation
score of 6.
Inadequate-sedation-analgesia: Increased arousal/change in level of consciousness as a
response to stress and may result in undue patient discomfort.
Over-sedation: A level of sedation that is deeper or lasts longer than intended. It occurs as
a result of accumulation of sedative and analgesic medications and is associated with
prolonged ventilatory monitoring and/or assistance.
This guideline provides information for nurses who care for adult and/or pediatric patients
receiving minimal, moderate, or deep sedation as well as any patient who reaches a
sedation level after receiving medication.
The goals of sedation include:
• minimizing physical discomfort and pain,
• minimizing physical response to the procedure and sedation (intact protective
reflexes, relaxation, comfort, cooperation, appropriate level of consciousness, patent
airway with adequate ventilatory exchange and easy arousal from sleep),
• controlling behavior and/or movement to allow for the safe completion of the
• maximizing the potential for amnesia,
• minimizing psychological trauma,
• controlling anxiety, and
• returning the patient to a state, as determined by recognized criteria, in which they are
deemed safe to be discharged from medical supervision.
Sedation and analgesia are on a continuum ranging from minimal sedation to general
anesthesia. Patients who have received minimal sedation generally require only
observation and intermittent assessment of their level of sedation.
I. General Recommendations for Procedure-Related Moderate and Deep Sedation
(C IIa)
A. Nursing Considerations
1. Moderate and deep sedation procedures may cause cardiovascular and respiratory
depression and therefore require more frequent assessments.
2. Nurses should be able to recognize changes in the continuum of sedation and
rescue the patient from the various sedation levels.
3. Level of sedation goal should be based on clinical circumstances such as anticipated
pain of procedure, need for immobility, and patient anxiety.
4. Nurses administering moderate sedation should be trained to administer medications
and monitor the patient during intra-procedure, phase 1 and 2.

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5. Nurses prepping the patient and recovering the patient should be knowledgeable
regarding medication side effects and potential complications of moderate sedation.
6. Nurses involved in moderate sedation need to have access to emergency equipment
and personnel with advanced airway skills.
7. Nurses should be knowledgeable about the risk factors for over-sedation such as:
a. patient is unable to handle secretions without aspiration
b. patient is unable to maintain a patent airway independently or independent
ventilation (excludes mechanically ventilated patients)
c. patient has severe systemic disturbance or disease which limits activity
d. patient has received opioids, benzodiazepines, or initiated therapy with any
central nervous system (CNS) depressant within the past 6 hours
e. patient has begun extended release opioids, received methadone, or
intraspinal/epidural opioids within the past 24 hours
f. patient has begun receiving opioids via an implantable pump within the past
72 hours
g. sedative drug is administered intravenously (regardless of drug or dose
h. two or more sedative drugs are administered concomitantly or sequentially
such that there is an overlap in the duration of action, which places the
patient at increased risk for airway compromise
8. Any complications or sudden change in condition should be reported immediately to
the provider.
a. Conduct a rapid assessment of patient and equipment to determine
possible cause(s)
b. Consider the use of reversal agents, if needed
c. Nurses should be knowledgeable about the special considerations when
using reversal agents:
i. Patients who receive reversal agents need to be recovered for
minimum of 2 hours after reversal agents are given to assure the
patient doesn't become re-sedated once the reversal agents wear off
ii. Initially, reversal medication should be intended to reverse the last
dose of sedative
iii. Careful consideration should be given to reversal agents in patients
with seizure disorders, chronic opioid or benzodiazepine use, or
complex medical history. The reversal agent may have an impact on
their condition and usually last shorter than the benzodiazepine or
iv. When reversal agents are administered to patients with respiratory
depression, abrupt reversal can cause pain, hypertension, tachycardia
or pulmonary edema
v. Whenever a reversal agent is administered, organizational
requirements specific to safety reporting should be followed
9. The nurse should be aware of and abide by organizational policies regarding
provider credentialing to perform sedation and to direct airway management and
cardiopulmonary resuscitation.
B. Considerations for Specific Patient Populations
1. Additional considerations for patients receiving sedation: Some patient populations
such as pediatrics, pregnant and lactating women, patients with sleep diagnosis that
require the use of CPAP, BiPAP, or other forms of ventilation, elderly and/or those
with previous problems with anesthesia or sedation, as well as patients scored to be

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“at risk” for sleep apnea, with co-morbidities and anatomic variants, may need
special consideration related to their sedation plan.
2. Anesthesia should be consulted for severely compromised or medically unstable
patients (difficult airway, severe COPD, severe heart disease) or in situations where
the patient will need to be sedated past the point of responsiveness. Note that this
list is not all inclusive for situations when anesthesia might be needed.
II. Assessment and Monitoring (C IIb)
A. Preparation
1. Nurses should follow organizational policy requirements related to verification of
provider credentials. Refer to I.A.9 above.
2. Nurses should prepare the environment and ensure that appropriate equipment is in
procedure room with patient prior to the sedation initiation.
a. The following equipment will be available in the procedure setting: oxygen
delivery devices, suction apparatus (setup and ready to use), noninvasive
blood pressure cuff, EKG (if required), pulse oximetry, opioid and sedative
reversal agents, and an Intravenous line.
b. Oxygen equipment should be immediately available.
3. The nurse should review patient’s pertinent history, laboratory values, NPO status
and allergies. Additional assessments include:
a. Pre-sedation assessment of patient’s current level of sedation
b. A baseline assessment of patient's ability to communicate with the nurse
and develop a plan during the procedure
c. Review all medications (including over-the-counter and herbal remedies)
taken and the time of the last dose
d. Review health history and systems assessment with special focus on
abnormalities that may alter expected responses to sedation and analgesic
i. Such concerns may include respiratory abnormalities, such as the use
of CPAP or BiPAP, sleep apnea, or screened “at risk” for sleep apnea
ii. Other concerns may include, facial deformities, increased intracranial
pressure or cardiac abnormalities
4. An approved tool for assessing level of sedation should be utilized for intra-
procedure monitoring of patient’s sedation level.
5. Pre-procedure fasting is necessary because of the risk of respiratory depression and
possible aspiration. If fasting was not done prior to procedure, may need to re-
evaluate the urgency of the procedure and possibly delay the procedure.
6. Ensure that patient meets NPO requirements; except in extenuating circumstances
that should be approved by the credentialed sedation provider (e.g. emergency
department) and dependent on the urgency of procedure.
a. For adults patients, use the following guidance:
i. Solids (including tube feeding) and non-clear liquids: 6-8 hours prior
to procedure schedule time
ii. Clear liquids minimum of 2 hours prior to procedure schedule time
b. For pediatric patients
i. Solids/milk/formula: NPO for 6 hours
ii. Breast milk all ages: 4 hours

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B. Pre-Sedation (C I)
The nurse who is administering the sedation medications (the sedation nurse) and
monitoring the patient intra-procedure through Phase I should complete the assessments
Pre-sedation assessment increases the likelihood of satisfactory sedation and decreases
the likelihood of adverse outcomes for sedation.
1. The sedation nurse should verify procedural and emergency equipment availability.
2. Assess the patient’s history of receiving sedation for a procedure and the dose and
medications received. Assess patient’s tolerance of sedation and any adverse
3. Prior to beginning sedation, establish a system of responding to questions during the
procedure for the patient and/or family.
a. Monitoring of patient's verbal response during sedation is important during
the sedation, except in procedures where movement could be detrimental
or when patients are unable to respond.
b. During procedures where verbal responses are not possible, an alternative
method for patient acknowledgment of verbal/tactile stimulation should be
4. A “time out” will be done by all personnel in the room prior to sedation initiation and
procedure. Final verification to confirm the correct patient, correct procedure,
correct site, correct position and correct implants or equipment using a "time out” is
carried out.
5. An organizationally approved sedation assessment tool will be used to assess any
changes from pre-sedation/procedure through Phase I.
C. Intra-Procedure (CII)
1. The frequency of assessment and documentation for the vital signs is determined by
patient’s age, level of sedation (deep vs. moderate) and any changes in the patient’s
2. The sedation nurse should assess the patient’s respiratory effort including depth of
respiration, use of accessory muscles, signs of hypoxemia and any sign indicating
that the patient is having difficulty breathing.
a. Oxygen does not need to be placed on the patient at the time of the
sedation procedure. If signs of hypoxemia occur, oxygen may be
administered according to physician orders.
3. The sedation nurse should assess the patient's ability to respond purposefully to
verbal and/or tactile stimulation.
4. The sedation nurse will monitor the patient’s tolerance to the procedure and
sedation. Patient’s level of sedation/analgesia is continuously monitored to maintain
the desired level of sedation.
5. The sedation nurse should take into consideration the medication pharmacokinetics
and the individual’s response (or anticipated response) to the medication to prevent
respiratory depression.
a. Each medication should be administered individually to allow each
medication to achieve desired effect. If medications are given in
combination or in multiple doses, caution should be taken to ensure doses
are not given too close together (e.g. need to avoid “stacking”).
D. Post-Procedure Monitoring (CI)
1. Phase I post-procedure monitoring:

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a. Only nurses who are considered competent in performing moderate
sedation will monitor the patient during this phase.
b. Patient’s blood pressure, heart rate, ventilatory function should be closely
monitored; oxygen can be administered as needed.
c. Phase I monitoring requires continuous monitoring by a moderate sedation
competent nurse and documentation at least every 15 minutes.
2. To discharge from Phase 1 criteria Aldrete Score should be greater than 8 and
commensurate with baseline Aldrete score.
3. Phase II monitoring should be a minimum of 30 minutes with assessment and
documentation occurring at least every 15 minutes by a nurse. This can be
performed on any general care, IMC or ICU area.
4. Patients should meet all Phase I and II criteria to discontinue sedation monitoring or
be discharged from sedation monitoring.
5. Discharge instructions should be provided to the patient and support person(s) both
in writing and verbally.
6. Ensure patient safety as patients receiving sedation are at higher risk for falls due to
the procedure, medications and potential co-morbidities.
7. Outpatients should be able to eat and drink prior to discharge. NPO status for
hospitalized patients will be evaluated by the primary team and revised when
8. Patients should be discharged with a responsible adult who will provide
transportation home.
III. Deep Sedation (C IIa)
A. General Considerations
1. Sedative drugs may result in deep sedation. When these drugs are used as intended
or result in deep sedation, additional requirements and precautions are necessary
related to assessments, equipment, monitoring, documentation, outcome evaluation,
and staff competencies that are beyond those required for moderate sedation.
2. Nurses require successful completion of ACLS and PALS courses (as applicable to
their patient populations) to care for patients under deep sedation.
3. The nurse should be aware of and abide by organizational policies regarding
provider credentialing to perform deep sedation and to direct airway management
and cardiopulmonary resuscitation.
B. Assessment and Monitoring
1. Deep sedation for adult patients requires etCO2 monitoring, pulse oximetry, and
EKG monitoring in addition to blood pressure, heart rate, respiratory rate, level of
consciousness, level of pain and any signs of complications (respiratory depression,
hypotension, aspiration and procedure specific).
2. Deep sedation for pediatric patients may use etCO2 monitoring or pre-tracheal
stethoscope monitoring, pulse oximetry, blood pressure, respiratory rate, pulse rate,
level of consciousness, level of pain and any signs of complications (respiratory
depression, hypotension, aspiration and procedure specific). Pediatric patients may
have EKG monitoring.
3. Oxygen should be administered unless contraindicated.
4. The frequency of assessment and documentation for the vital signs is determined by
patient’s age, level of sedation (deep vs. moderate) and any changes in the patient’s
5. Testing the patient's response to more profound stimuli is necessary, unless
contraindicated, in order to assure the patient has not become oversedated and is
under general anesthesia.

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6. The nurse monitoring the patient should not perform any tasks other than
administering medications and monitoring the patient's response.
Availability Of Companion Documents
Companion documents are available on the Nursing Practice Guidelines Webpage housed
in U-Connect.
Patient Resources
Health Facts for You:
• Moderate Sedation for Adult and Pediatric Patients: HFFY # 5821
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Continuous Sedation for Adults)
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49. Regula, J., & Sokol-Kobielska, E. (2008). Sedation in endoscopy: When and how. Best
Practice & Research. Clinical Gastroenterology, 22(5), 945-957.

50. Rex, D. K., Overley, C., Kinser, K., Coates, M., Lee, A., Goodwine, B. W., Strahl, E., Lemler,
S., Sipe, B., Rahmani, E., & Helper, D. (2002). Safety of propofol administered by registered

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nurses with gastroenterologist supervision in 2000 endoscopic cases. The American Journal
of Gastroenterology, 97(5), 1159-1163.

51. Rex, D. K., Heuss, L. T., Walker, J. A., & Qi, R. (2005). Trained registered
nurses/endoscopy teams can administer propofol safely for endoscopy. Gastroenterology,
129(5), 1384-1391.

52. Slagelse, C., Vilmann, P., Hornslet, P., Hammering, A., & Mantoni, T. (2011). Nurse-
administered propofol sedation for gastrointestinal endoscopic procedures: First Nordic
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53. Society of Gastroenterology Nurses and Associates, Inc. (2012). Position statement:
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54. Vargo, J. J., DeLegge, M. H., Feld, A. D., Gerstenberger, P. D., Kwo, P. Y., Lightdale, J. R.,
Nuccio, S., Rex, D. K., & Schiller, L. R. (2012). Multisociety sedation curriculum for
gastrointestinal endoscopy. Gastrointestinal Endoscopy, 76(1), e1-e25.

55. Society of Gastroenterology Nurses and Associates, Inc. (2013). Position statement:
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Potential Benefits
The benefit of implementing this guideline is to establish consistent evidence-based practice
recommendations for pre-, intra-and post- sedation care for patients of all ages receiving sedation.
When nurses follow these guidelines it is anticipated that fewer sedation related complications will
occur and/or will be optimally managed.
Potential Harms
There are no potential harms associated with implementing this guideline.
Description Of Implementation Strategy
The hospital based policies and procedures are aligned with this nursing practice guideline.
Ongoing implementation is completed through onboarding training of new employees and
through periodic sedation courses. In the Spring of 2016, all nurses at University Hospital
received updated information about the process for moderate sedation via computer based

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Contact: Last Revised: 05/2016EArsenaultknudsen@uwhealth.org
Implementation Tools
Utilization of the Evidence-Based Practice Implementation Model copyright by Laura Cullen
and The University of Iowa Hospital & Clinics; see full article: Cullen, L. & Adams, S. (2012).
Planning for implementation of evidence-based practice. Journal of Nursing Administration,
42(4), 222-230. doi: 10.1097/NNA.0b013e31824ccd0a
Date Released (Revised)
2009; revised 2009; revised 2016
Guideline Sponsor
UWHC Nursing
Guideline Authors
Clinical Nurse Specialist, Cardiac Surgery
Clinical Nurse Specialist, Trauma Life Support Center
Clinical Nurse Specialist, Pain
Clinical Nurse Manager, Nursing Diagnostic/Therapy Center
Clinic Manager, Gastro/Bronchoscopy Procedures
Nursing Education Specialist, ED, Psychiatry, Med Flight/CHETA
Guideline Status
May, 2016
Guidelines are designed to assist clinicians by providing a framework for the evaluation and
treatment of patients. This guideline outlines the preferred approach for most patients. It is not
intended to replace a clinician’s judgment or to establish a protocol for all patients. It is understood
that some patients will not fit the clinical condition contemplated by a guideline and that a guideline
will rarely establish the only appropriate approach to a problem.