Patient Care,

Clinical Hub,References,Adult Moderate Sedation Topics

Intra-Procedure Care

Intra-Procedure Care - Clinical Hub, References, Adult Moderate Sedation Topics


The patient's response to the procedure and the sedation used must be continually monitored and evaluated during the intra-procedure phase of care. The person monitoring the patient may assist with "minor interruptible tasks," but may not leave the patient's bedside.

Intra-procedure Phase

Qualified personnel will:

  1. Document medication used, including:
    • Dosage of all medications administered
    • Time, route and site of administration of all medications
    • Responsible party administering the medication, and
    • Type and amount of any fluids infused including blood and blood products. See UWHC Policy #8.17, Administration of Medications.
  2. Monitor and document patient status continuously throughout the procedure. Document patient status immediately prior to administration of sedation drugs, and at least every 15 minutes during the procedure including:
    • Heart rate, blood pressure and respiratory rate
    • Oxygen saturation
    • Sedation score/level of awareness
    • Level of pain, and
    • ECG findings where applicable
  3. Diagnose and immediately treat any adverse or unexpected events during the sedative period such as bradycardia, apnea, oxygen desaturation, hypotension, emesis, vasovagal reaction, diaphoresis, seizure, anaphylaxis or anaphylactoid reactions, and any other cardiopulmonary impairment. Document the event, any interventions, and subsequent patient response related to the event and interventions.

    Should a patient inadvertently become and remain unresponsive to painful stimuli, or exhibit evidence of significant cardiopulmonary compromise during a moderate sedation episode, the care providers shall institute appropriate therapy and call for immediate emergency assistance as needed.
  4. Document patient status upon completion of the procedure, including: heart rate, blood pressure, respiratory rate, oxygen saturation, level of awareness (sedation score) and level of pain.

    Allergic and adverse response (i.e., noxious and/or unintended) to any sedation medication should be reported to the Pharmacy and Therapeutics Committee according to UWHC Policy 8.20, Adverse Drug Experience Document.