Policies,Clinical,UW Health Clinical,General Care and Procedures,Procedures

Adult Procedural Sedation (2.3.29)

Adult Procedural Sedation (2.3.29) - Policies, Clinical, UW Health Clinical, General Care and Procedures, Procedures


Policy Title: Adult Procedural Sedation
Policy Number: 2.3.29
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: August 28, 2017


To provide a consistent standard of care that promotes safe and effective moderate and deep sedation for
adult patients receiving procedural sedation throughout UW Health.

For pediatric patients refer to UW Health clinical policy #2.3.30, Pediatric Procedural Sedation.


A. SEDATIVE DRUGS are medications which when used in commonly employed dose ranges are intended to
result in central nervous system depression. The use of these drugs may result in loss of protective reflexes
with subsequent respiratory and/or cardiac depression.
The effects of medications administered to achieve sedation are dose related and must be assessed
individually for each patient. Sedative drugs may be administered via enteral, intranasal, buccal, rectal,
parenteral, or by inhalation routes.
B. LEVELS OF SEDATION. The transition from moderate sedation to deep sedation and from deep sedation to
general anesthesia is a continuum, can be difficult to predict, and must be anticipated whenever sedation is
administered. If this transition is not appreciated and appropriate interventions taken immediately, the
patient's condition can rapidly deteriorate resulting in hypoxia, cardiogenic shock, respiratory arrest, anoxic
brain injury and even death. The transition along this continuum can be especially difficult to assess in many
patients especially the elderly, young, mentally disabled, aphasic and/or hearing impaired patient. Table 1
shows a comparison of levels of sedation by 3 scoring systems; for the purposes of this policy the Ramsay
Sedation Scale will be used.

Table 1: Levels of Sedation by Scoring System

C. QUALIFIED PERSONNEL will be responsible for directing and administering sedative drugs for moderate
sedation. Qualifications are as follows:
i. Attending Physician (Staff Physician) / Advanced Practice Provider
a. There is an attending (staff) physician/advanced practice provider (APP) who is privileged
for directing and administering moderate sedation and who is ultimately responsible for
ensuring that appropriate care is provided to the patient during all phases of sedation.
Privileges for sedation are administered by the UWH Credentials Committee and can be
found using the privilege internal site.
b. The attending (staff) physician/APP must be on site. On site means in the department or
on the unit where the patient is receiving moderate sedation. The intent is that the
attending (staff) physician/APP is immediately available.
c. If the attending (staff) physician/APP is not on site, another attending (staff) physician/APP
privileged in moderate sedation must be on site. That attending (staff) physician/APP must
accept the responsibility and be knowledgeable about the patient’s condition.
ii. Graduate Medical Education (GME) Trainees (Residents and Fellows)
Level of sedation
Level of Consciousness
Ramsey Score
RASS Score
Ability to protect
None Normal 1 or 2 0 Intact Intact Intact
Minimal Cooperative, oriented, tranquil 2 -1
Intact Intact
Sleepy, responds appropriately to verbal
commands and/or tactile stimulation
3 -1 or -2 Impaired Intact Intact
Moderate Sleeping, arouses easily to stimulation 4 -3 Impaired
Intact (should NOT
have to intervene)
Deep Sleeping, arouses only to painful stimulation 5 -4 Impaired Impaired Impaired
General Anesthesia
(Anesthesiologist only)
Not arousable even to painful stimulation 6 -5 Impaired Absent impaired

Policy Title: Adult Procedural Sedation
Policy Number: 2.3.29

a. Graduate Medical Education (GME) Trainees must be supervised by an attending (staff)
physician who is privileged in moderate sedation.
b. Graduate Medical Education (GME) Trainees must be trained at a minimum in Healthcare
Provider BLS.
iii. Registered Nurses
a. Nurses must be competent to administer and monitor sedation under the direction of a
physician/APP who is privileged in moderate sedation. This is achieved by successfully
completing the hospital approved core competency education.
iv. All staff (staff physician, APPs, Graduate Medical Education (GME) Trainees, and nurses) should be
knowledgeable of the pharmacodynamics of the sedative drugs given, as well as being skilled and
knowledgeable in the assessment and management of adverse effects of the sedative, which
include, but are not limited to, airway obstruction, respiratory insufficiency, cardiovascular
compromise, and neuropsychiatric complications.


In order to provide for a consistent standard of safe patient care, the following monitoring standards will
apply to all adult patients who receive in any setting, for any purpose, by any route, moderate sedation
during a procedure.

The goal of sedation/analgesia for procedures is to minimize the patient's discomfort and anxiety
experienced while undergoing invasive or other procedures. The specific objectives of sedation are mood
alteration, maintenance of consciousness and cooperation, improved management of pain with minimal
changes in vital signs, and a prompt, safe return to activities of daily living.

Procedures utilizing sedation are done in both inpatient and outpatient departments. Procedures with
sedation may include, but are not limited to minor surgery, endoscopy, muscular/skeletal trauma
assessment and repair, imaging, cardioversion, and other invasive and non-invasive therapies.

This policy is intended to address sedation management for procedures only. 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, agitation, etc.) in non-procedural settings, or as non-intravenous
preoperative medications. Sedative drugs ordered for these reasons are not intended to produce
anesthesia. They are to be used in a manner and in a dose, which may be reasonably expected not to result
in the loss of protective reflexes; therefore, the following guidelines do not apply in these situations.

Regardless of purpose or intent of medication administration, the monitoring standards of this sedation
policy will apply to patients who remain sedated at the moderate level per the sedation scale during
procedures, with the exception of mechanically ventilated patients.

This policy is intended to encourage appropriate patient care during procedural sedation, but cannot
guarantee any specific patient outcome. The policy is not intended as a standard order, nor to replace
clinical judgment, but shall be considered minimum requirements when sedative medications are used for
procedural management. It is subject to revision and clinical application as warranted by evolution of
technology, practice, and specific clinical situations.


The following policy will apply during procedures for all patients receiving moderate sedation. Any
reason for variation in use of this policy will be recorded in the patient record (e.g., emergent case
where patient unable to attest to medication history).

A. Identifying Patients at Risk for Respiratory Depression
i. A PATIENT AT RISK includes, but is not limited to, any patient meeting one or more of the
following criteria:
a. The patient is unable to handle secretions without aspiration.
b. The patient is unable to maintain a patent airway independently (excludes
mechanically ventilated patients).
c. The patient has severe systemic disturbance or disease which limits activity.

Policy Title: Adult Procedural Sedation
Policy Number: 2.3.29

d. The patient has received opioids, benzodiazepines, or initiated therapy with any CNS
depressant within the past 6 hours.
e. The patient has begun extended release opioids or received methadone or
intraspinal/epidural narcotics within the past 24 hours.
f. The patient has begun receiving opioids via an implantable pump within the past 72 hours.
g. The sedative drug is administered IV regardless of drug or dose used.
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
ii. HIGH RISK CASES are those which may require consultation with or support from the
Anesthesiology Department when performing procedures with sedation. The responsible qualified
physician will exercise medical judgment to determine when such consultation is required.
Characteristics that indicate a patient may not be an appropriate candidate to undergo moderate
sedation include:
a. The patient has cardiac and/or respiratory status that makes risk of cardiac or pulmonary
compromise likely.
b. The patient's mental status makes assessment of level of awareness, pain, and response
to medications used difficult.
c. The patient has had previous adverse experience with sedation.
d. The patient is allergic or sensitive to sedative or analgesic drugs.
e. The patient is allergic to products that may be used during the procedure (e.g., latex
products or iodine).
f. The patient has a baseline Modified Aldrete score less than 8 (see Appendix E).
i. Dosage requirements for sedation generally decrease in elderly patients, in debilitated patents, and
in patients with significant cardiac, pulmonary or CNS disease. Therefore, consider reducing initial
doses in these patient populations and titrate to desired clinical effect. Total doses and/or
frequency of administration may also need to be reduced in patients with renal and/or hepatic
ii. The combination of CNS depressants may produce synergistic cardiorespiratory depression. When
using these agents in combination, reduce the initial dose by 50% and titrate to patient response.
iii. Special consideration should be given to the patient who has received opioids, benzodiazepines, or
initiated therapy with any CNS depressant within the past 6 hours of planned sedation; started
extended release opioids or received methadone or intraspinal/epidural narcotics within the past 24
hours; or started opioids via an implantable pump within the past 72 hours.
iv. Dosage adjustments may also need to be considered when 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.
v. Sedative medications used in a manner, or in a dose that is intended to or may reasonably be
expected to result in the loss of protective reflexes, may result in deep sedation. Use of such
medications in this manner shall require additional assessments, equipment, monitoring,
documentation, outcome evaluation, and staff competencies beyond those required for moderate
sedation. (See Appendix A for guidelines on medication prescribing)
ii. A qualified physician (Graduate Medical Education (GME) Trainee- resident or fellow)/APP
(privilege not required but under the auspices of a privileged provider) will:
a. Re-evaluate the patient immediately prior to sedation administration as evidenced by
his/her signature on the appropriate sedation form prior to the administration of any
sedative drugs.
b. Assess and document a patient's appropriateness to receive sedation as evidenced by
his/her signature on the appropriate sedation form prior to receiving any sedative drugs.
c. Order and direct the administration of sedation based on findings of the pre-procedure
d. Be on site and able to respond to changing patient status and treat complications of
sedation that may occur.
e. Be able to rescue patients that unavoidably slip into a level of deep sedation.
f. Have immediate (STAT response) access to support from Anesthesiology or the Code

Policy Title: Adult Procedural Sedation
Policy Number: 2.3.29

Blue Team, OR if the sedation is performed at an offsite location, must be able to
demonstrate competency to provide continuing respiratory and cardiac life support
measures (e.g., Active certification in Advanced Cardiac Life Support (ACLS)).
g. Have immediate access to obtain additional assistance for transport to an appropriate
care area.
iii. RESUSCITATIVE AND MONITORING EQUIPMENT. A qualified nurse will verify that the following
is immediately available:
a. Suction apparatus with appropriate suction catheters.
b. Oxygen delivery system capable of 15 L/min flow for greater than 60 minutes.
c. Appropriately sized masks, and oral and nasal airways.
d. Resuscitation bag.
e. Pulse oximeter, and blood pressure monitoring equipment.
f. Emergency medications including reversal agents.
g. Capnography when indicated (mandatory for deep sedation).
h. ECG monitor when indicated (patient at risk for cardiac arrhythmia and/or ischemia).
iv. EDUCATION. A qualified nurse will:
a. Educate the patient and/or family prior to administration of sedative medication. This would
include information about what the patient can anticipate before, during, and after sedation
including symptoms and side effects to report. When possible, work out a pre-established
signaling system for pain. Where applicable, pre-sedation instruction will be given to the
patient (i.e., medication adjustments, NPO requirements, designated driver post procedure,
b. Strongly recommended that patients have arranged adult supervision throughout the night
after the procedure.
c. Outpatients need to be instructed to have a responsible adult to review post procedure
instructions and take them from the facility after they have met discharge criteria.
v. CONSENT. A qualified provider will obtain consent for both the procedure and sedation and
document if given verbally. (See Hospital Administrative policy 4.17-Informed Consent.)
Documented consent is part of the physician sedation attestation statement.
a. An attending (staff) physician/APP must supervise the performance and documentation of a
health assessment of the patient. The purpose of the pre-procedure assessment is to
determine baseline status of the patient and identify factors that may increase the patient's
risk during the period of sedation.
b. No patient shall receive sedation until a pre-sedation assessment has been completed and
documented, and the physician has attested to the patient's appropriateness to receive
sedation as evidenced by his/her signature in the medical record.
c. The person administering the sedative agent shall verify that the required documentation is
completed prior to any sedation medication being administered.
d. A procedure will be delayed or canceled until all pre-procedure documentation is
completed. Minimal assessment required before sedation includes, but is not limited to, the
determination and documentation of:
1. Age and weight.
2. Drug allergies.
3. Current medication use (including recent narcotics and sedatives and over the
counter medication within the past 24 hours).
4. Previous problems with anesthesia/sedation/chronic pain.
5. Heart rate, blood pressure, and respiratory rate.
6. Oxygen saturation.
7. Level of awareness (consider mental status/orientation).
8. Time of last PO intake (see Appendix B).
9. Respiratory and cardiovascular status which may include findings from heart and
lung auscultation and other physical findings as appropriate.
10. Assessment for risk of airway compromise/difficulty of endotracheal intubation
(including Mallampati Classification).
11. Baseline assessment of pain, where appropriate.
12. Baseline Modified Aldrete Sedation Score (minimum score of 8 recommended for
moderate sedation).
13. Marking of surgical site involving right/left distinction, multiple structures (such as
fingers or toes) or levels (such as spine). Teeth do not require marking.
vii. The moderate and deep sedation privileged provider will complete and sign an attestation statement
to be included in the patient’s medical record

Policy Title: Adult Procedural Sedation
Policy Number: 2.3.29

viii. The nurse will complete the preprocedure sedation documentation.
ix. TIME-OUT. As per UWHC policy# 8.48, Operative, Invasive & Other Procedures, final
verification/time-out will be performed prior to the start of the procedure.
x. VENOUS ACCESS. Venous access will be established for the administration of intravenous
sedation and ready access should additional medications or IV fluids are required during or after the
procedure. See Nursing Patient Care policy #1.23AP, Continuous Peripheral Intravenous Therapy
(Adult & Pediatric).
xi. QUALIFIED PERSONNEL for the procedure. Qualified personnel will be present to monitor the
patient from the time of administration of sedative drugs until the patient returns to baseline status.
Qualified personnel responsible for monitoring the patient:
a. May administer sedative drugs under the direction and supervision of the responsible
b. Shall continuously assess and respond to the patient's condition.
c. Shall document assessments and findings as outlined by policy. Monitoring personnel
may assist with minor, interruptible tasks during procedures, but shall not leave the
patient's side. At least one qualified person, with appropriate equipment and supplies,
shall accompany a patient requiring any transfer during the sedative period. Patient
transport personnel may transport patients who are fully recovered (i.e., discharged from
Phase II monitoring). If a patient has not completed Phase II monitoring, they must be
accompanied by a nurse or other qualified medical personnel.
D. INTRA-PROCEDURE PHASE. Qualified personnel will:
a. Dosage of all medications administered.
b. Time, route, and site of administration of all medications.
c. Responsible party administering the medication.
d. Type and amount of any fluids infused including blood and blood products. See UWHC
policy #8.17, Administration of Medications.
ii. MONITOR PATIENT STATUS continually throughout the procedure. Re-evaluate and document
patient status immediately prior to administration of sedation drugs, and at least every 15 minutes
during the procedure including:
a. Heart rate, blood pressure, and respiratory rate.
b. Oxygen saturation.
c. Sedation score / level of awareness.
d. ECG findings where applicable.
e. Capnography monitoring is encouraged, particularly for patients who are at risk or at high
risk and for deeper levels of moderate sedation.
iii. 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, anaphylactic or anaphylactoid reactions, and any other
cardiopulmonary impairment. Document the event, any interventions, and subsequent patient
response related to the event and interventions. (See Section V.)
a. Should a patient 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.
rate, blood pressure, respiratory rate, oxygen saturation, level of awareness (Ramsey sedation
score), and level of pain.
E. POST-PROCEDURE PHASES MONITORING. Qualified personnel will:
i. Transfer of a patient from the sedation team to other personnel responsible for Phase I, Phase II,
or post-sedation care requires a handoff with the active acceptance of the responsibility for care
by the personnel assuming responsibility for the patient.
a. PHASE I: Continuously observe and monitor the patient, documenting every 15 minutes
(heart rate, blood pressure, respiratory rate, oxygen saturation, sedation score, level of
pain, Modified Aldrete Score). Using the Modified Aldrete scoring system, proceed to
Phase II monitoring once a minimum score of 8 is achieved or the patient returns to
baseline, with no category scoring 0. (see Appendix E). Exceptions to this score are per
MD order only. There is no minimum monitoring time requirement for phase I, and this
can occur in the procedure room, designated recovery area, or inpatient room. Patients
who meet Phase I discharge criteria immediately upon completion of the procedure may
proceed to Phase II.
b. PHASE II - monitoring and documentation of vital signs (heart rate, blood pressure,

Policy Title: Adult Procedural Sedation
Policy Number: 2.3.29

respiratory rate, oxygen saturation, sedation score, level of pain) continues every 15
minutes. Monitoring and documentation must continue for a minimum of 30 minutes
during phase II and can be performed in designated recovery areas, or upon return to the
inpatient unit. Phase II is complete when the patient meets discharge criteria (See
Appendix E) and at least 30 minutes of Phase II monitoring is completed. Regardless of
where Phase II occurs, continue documentation on the procedural sedation record.
Document any unusual events or post-procedure complications, the management of
those events, and the patient's response to those interventions
received reversal agents and/or have not returned to baseline Modified Aldrete score after 60
minutes are considered to have prolonged phase II monitoring. The responsible physician will
determine the plan of care and when needed will direct patient transfer to an appropriate care area
until baseline condition returns.
a. Any patient who receives naloxone or flumazenil following sedation/analgesia shall have
continued monitoring with documentation every 15 minutes. Monitoring shall include
heart rate, blood pressure, respiratory rate, capnography, and pulse oximetry, following
administration of the reversal agent for a minimum of 2 hours AND until Phase II criteria
are met.
iii. DISCHARGE PATIENTS or discontinue monitoring when Phase II criteria are met, having returned
to the baseline or Modified Aldrete score of 8. (See Appendix E )
iv. PROVIDE INSTRUCTIONS, verbal and written, to the discharged patient and/or responsible person
regarding diet, medications, activities, need for responsible adult, potential complications and course
of action if a complication develops.
v. COMMUNICATE INFORMATION during handoff to the qualified staff member assuming the
patient's care, if the patient is transferred to another care area
i. The requirements for deep procedural sedation include all of the requirements for moderate
sedation as listed in Section IV above.
ii. Deep sedation must be supervised by an attending physician who is specifically privileged for deep
sedation. Deep sedation requires a physician who is solely responsible for the administration of
deep sedation and is separate from the physician or provider who is performing the procedure that
requires the sedation.
iii. Nurses assisting in caring for deep sedation patients must have completed core hospital education.
iv. The administration of deep sedation requires adherence to the monitoring standards for general
anesthesia adopted by the Department of Anesthesiology and modeled after the monitoring
standards of the American Society of Anesthesiologists (2011). Monitoring for deep sedation must
include continuous capnography.
v. Deep sedation locations include: Emergency Department, critical care units, operating rooms, or
equivalent locations.


A. Each clinical service will be responsible for implementation of this policy, and may establish additional
written policies, consistent with this policy, for the care of patients receiving sedation that are procedure or
population specific. Key aspects of care required by this policy shall be monitored and reported annually to
the Patient Safety Committee or designee (see Appendix C).
B. A quality review process for complications shall be completed according to UWHC policy #8.48,
Operative, Invasive and Other Procedures.
C. Adverse drug event documentation shall be completed according to UWHC policy #8.20, Adverse Drug
Event Documentation.


Appendix A: Medication Guidelines for Short Term Procedural Sedation in Adults
Appendix B: Adult Fasting Protocol for Elective Procedures with sedation
Appendix C: Adult Sedation Documentation Requirements
Appendix D: Related Guidelines, Protocols, Policy & Procedures, and Forms
Appendix E: Modified Aldrete Scoring System
Appendix F: Procedural Moderate Sedation Adverse Events sedation

Policy Title: Adult Procedural Sedation
Policy Number: 2.3.29


Author: Sedation Steering Committee Co-Chairs
Senior Management Sponsor: Sr. VP for Medical Affairs
Reviewers: Pharmacy, Clinical Nurse Specialist
Approval Committees: Sedation Steering Committee; UW Health Clinical Policy Committee; Medical Board
UW Health Clinical Policy Committee Approval: July 17, 2017

UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.


Peter Newcomer, MD
Chief Clinical Officer

J.Scott McMurray, MD
Chair, UW Health Clinical Policy Committee


1. Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists, Anesthesiology 2002; 96:1004–

2. Ramsay MAE, Savege TM, Simpson BRJ, Goodwin R. Controlled Sedation with Alphaxalone-Alphadolone.
BMJ. 1974; 2:656-659.

3. The Richmond Agitation Sedation Scale, Am J Respir Crit Care Med 2002; 166:1338–1344.

4. The Joint Commission (TJC). Comprehensive accreditation manual for hospitals.

5. American Society of Anesthesiologists. Standards for Basic Anesthetic Monitoring. American Society of
Anesthesiologists, Inc. Park Ridge, 2011.

6. American Society of Post anesthesia Nurses.Practice Recommendation 7: The role of the registered nurse
in the management of patients undergoing sedation for short-term therapeutic, diagnostic, or surgical
procedures. In: Standards of Perianesthesia Nursing Practice. American Society of Post anesthesia Nurses;

7. Online Education Materials for Physicians - Adult Moderate Sedation Education and Credentialing.

8. Pediatric Moderate Sedation Nursing Materials.

9. Modifications to the Post anesthesia Score for Use in Ambulatory Surgery by J.Antonio Aldrete, MD, MS,
Journal of PeriAnesthesia Nursing, Vol. 13, No 3, 1998:148-155.

10. Fasting and emergency department procedural sedation and analgesia: a consensus- based clinical practice
advisory. Ann Emerg Med 49:454, 2007

Nursing Patient Care policy #1.23 AP, Continuous Peripheral Intravenous
Therapy (Adult & Pediatric)
UWHC policy #4.17, Informed Consent
UWHC policy #8.17, Administration of Medications
UWHC policy #8.20, Adverse Drug Event Documentation
UWHC policy #8.48, Operative, Invasive, and Other Procedures

Policy Title: Adult Procedural Sedation
Policy Number: 2.3.29


Version: Revision
Last Full Review: August 28, 2017
Next Revision Due: August 2020
Formerly Known as: UWHC policy #8.38, Adult Sedation Policy