Submitted for publication September 1, 2017. Accepted for publication November 22, 2017.
Approved by the ASA House of Delegates on October 25, 2017. Approved by the American Association of Oral and Maxillofacial Surgeons on September 23, 2017; the American College of Radiology on October 5, 2017; the American Dental Association on September 21, 2017; the American Society of Dentist Anesthesiologists on September 15, 2017; and the Society of Interventional Radiology on September 15, 2017.
This article is featured in “This Month in Anesthesiology,” page 1A.
Supplemental Digital Content is available for this article. Direct URL citations appear in the printed text and are available in both the HTML and PDF versions of this article. Links to the digital files are provided in the HTML text of this article on the Journal’s Web site (www.anesthesiology.org).
A complete bibliography used to develop these guidelines, arranged alphabetically by author, is available as Supplemental Digital Content 1, https://links.lww.com/ALN/B594.
Address correspondence to the American Society of Anesthesiologists: 1061 American Lane, Schaumburg, Illinois 60173. jeffa@dacc.uchicago.edu. These updated Practice Guidelines, and all ASA Practice Parameters, may be obtained at no cost through the Journal Web site, www.anesthesiology.org.
Anesthesiology March 2018, Vol. 128, 437–479.Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018 : A Report by the American Society of Anesthesiologists Task Force on Moderate Procedural Sedation and Analgesia, the American Association of Oral and Maxillofacial Surgeons, American College of Radiology, American Dental Association, American Society of Dentist Anesthesiologists, and Society of Interventional Radiology . Anesthesiology 2018; 128:437–479 doi: https://doi.org/10.1097/ALN.0000000000002043
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toolbar search Update HighlightsIn October 2014, the American Society of Anesthesiologists Committee on Standards and Practice Parameters recommended that new practice guidelines addressing moderate procedural sedation and analgesia be developed.
These new guidelines:
New recommendations include:
PRACTICE guidelines are systematically developed recommendations that assist the practitioner and patient in making decisions about health care. These recommendations may be adopted, modified, or rejected according to clinical needs and constraints and are not intended to replace local institutional policies. In addition, these practice guidelines are not intended as standards or absolute requirements, and their use cannot guarantee any specific outcome. Practice guidelines are subject to revision as warranted by the evolution of medical knowledge, technology, and practice. They provide basic recommendations that are supported by a synthesis and analysis of the current literature, expert and practitioner opinion, open forum commentary, and clinical feasibility data.
This document replaces the “Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists: An Updated Report by the American Society of Anesthesiologists (ASA) Task Force on Sedation and Analgesia by Non-Anesthesiologists,” adopted in 2001 and published in 2002. 1
These guidelines apply to moderate sedation and analgesia before, during, and after procedures. Sedation and analgesia comprises a continuum of states ranging from minimal sedation (anxiolysis) through general anesthesia, as defined by the American Society of Anesthesiologists and accepted by the Joint Commission (table 1). 2,3 Level of sedation is entirely independent of the route of administration. Moderate and deep sedation or general anesthesia may be achieved via any route of administration.
Continuum of Depth of Sedation, Definition of General Anesthesia, and Levels of Sedation/Analgesia
Airway Assessment Procedures for Sedation and Analgesia
Summary of American Society of Anesthesiologists Recommendations for Preoperative Fasting and Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures
Emergency Equipment for Sedation and Analgesia
Recovery and Discharge Criteria after Sedation and Analgesia
Consultant Survey Responses
ASA Membership Survey Responses
American Association of Oral and Maxillofacial Surgeons Member Survey Responses
American Society of Dentist Anesthesiologists Member Survey Responses
These guidelines specifically apply to the level of sedation corresponding to moderate sedation/analgesia (previously called conscious sedation), which is defined as a drug-induced depression of consciousness during which patients respond purposefully † to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway when spontaneous ventilation is adequate. ‡ Cardiovascular function is usually maintained. For these guidelines, analgesia refers to the management of patient pain or discomfort during and after procedures requiring moderate sedation.
The purposes of these guidelines are to allow clinicians to optimize the benefits of moderate procedural sedation regardless of site of service; to guide practitioners in appropriate patient selection; to decrease the risk of adverse patient outcomes (e.g., apnea, airway obstruction, respiratory arrest, cardiac arrest, death); to encourage sedation education, training, and research; and to offer evidence-based data to promote cross-specialty consistency for moderate sedation practice.
Moderate sedation/analgesia provides patient tolerance of unpleasant or prolonged procedures through relief of anxiety, discomfort, and/or pain. If the patient response results in deeper sedation than intended, these sedation practices can be associated with cardiac or respiratory depression that must be rapidly recognized and appropriately managed to avoid the risk of hypoxic brain damage, cardiac arrest, or death. Conversely, inadequate sedation or analgesia can result in undue patient discomfort or patient injury, lack of cooperation, or adverse physiological or psychological responses to stress.
The appropriate choice of agents and techniques for moderate sedation/analgesia is dependent upon the experience, training, and preference of the individual practitioner, requirements or constraints imposed by associated medical issues of the patient or type of procedure, and the risk of producing a deeper level of sedation than anticipated. In some cases, the choice of agents or techniques are limited by federal, state, or municipal regulations or statutes. Because it is not always possible to predict how a specific patient will respond to sedative and analgesic medications, practitioners intending to produce a given level of sedation should be able to rescue patients whose level of sedation becomes deeper than initially intended. For moderate sedation, this implies the ability to manage a compromised airway or hypoventilation, and support cardiovascular function in patients who become hypotensive, hypertensive, bradycardic, or tachycardic.
These guidelines focus specifically on the administration of moderate sedation and analgesia for adults and children. The guidelines exclude patients who are not undergoing a diagnostic or therapeutic procedure (e.g., postoperative analgesia). Because minimal sedation (anxiolysis) may entail minimal risk, the guidelines specifically exclude it. Examples of minimal sedation are (1) less than 50% nitrous oxide in oxygen with no other sedative or analgesic medications by any route and (2) a single, oral sedative or analgesic medication administered in doses appropriate for the unsupervised treatment of anxiety or pain. The guidelines do not apply to patients receiving deep sedation, general anesthesia, or major conduction (i.e., neuraxial) anesthesia. Additional interventions excluded from these guidelines include but are not limited to patient-controlled sedation/analgesia, sedatives administered before or during regional and central neuraxis anesthesia, premedication for general anesthesia, interventions without sedatives (e.g., hypnosis, acupuncture), new or rarely administered sedative/analgesics, new or rarely used monitoring or delivery devices, and automated sedative delivery systems. These guidelines do not address education, training, or certification requirements for practitioners who provide moderate procedural sedation.
These guidelines are intended for use by all providers who perform moderate procedural sedation and analgesia in any inpatient or outpatient setting including but not limited to hospitals, ambulatory procedural centers, hospital-connected or freestanding office practices (e.g., dental, urology, or ophthalmology offices), endoscopy suites, plastic surgery suites, radiology suites (magnetic resonance imaging, computed tomography), oral and maxillofacial surgery suites, cardiac catheterization laboratories, oncology clinics, electrophysiology laboratories, interventional radiology laboratories, neurointerventional laboratories, echocardiography laboratories, and evoked auditory testing laboratories. They are intended to serve as a resource for other physicians and patient care personnel who are involved in the care of these patients, including those involved in local policy development.
These guidelines were developed by an ASA–appointed task force of 13 members, consisting of physician anesthesiologists in both private and academic practices from various geographic areas of the United States, a cardiologist, a dentist anesthesiologist, an oral/maxillofacial surgeon, a radiologist, an ASA staff methodologist, and two consulting methodologists for the ASA Committee on Standards and Practice Parameters. Conflict of interest documentation regarding current or potential financial and other interests pertinent to the practice guideline were disclosed by all task force members and managed.
The task force developed these guidelines by means of a seven-step process. First, criteria for evidence associated with moderate sedation and analgesia techniques were established. Second, original published research studies relevant to the guidelines were reviewed and analyzed; only articles relevant to the administration of moderate sedation were evaluated. Third, a panel of expert consultants was asked to (1) participate in opinion surveys on the effectiveness and safety of various methods and interventions that might be used during sedation/analgesia and (2) review and comment on a draft of the guidelines developed by the task force. Fourth, survey opinions about the guideline recommendations were solicited from a random sample of active members of the ASA and participating medical specialty societies. Fifth, the task force held open forums at major national meetings to solicit input on its draft recommendations. § National organizations representing specialties whose members typically provide moderate sedation were invited to participate in the open forums. Sixth, the consultants were surveyed to assess their opinions on the feasibility of implementing the guidelines. Seventh, all available information was used to build consensus within the task force to finalize the guidelines.
Preparation of these updated guidelines followed a rigorous methodological process. Evidence was obtained from two principal sources: scientific evidence and opinion-based evidence
Scientific evidence used in the development of these guidelines is based on cumulative findings from literature published in peer-reviewed journals. Literature citations are obtained from healthcare databases, direct internet searches, task force members, liaisons with other organizations, and manual searches of references located in reviewed articles.
Findings from the aggregated literature are reported in the text of these guidelines by evidence category, level, and direction. Evidence categories refer specifically to the strength and quality of the research design of the studies. Category A evidence represents results obtained from randomized controlled trials (RCTs), and category B evidence represents observational results obtained from nonrandomized study designs or RCTs without pertinent comparison groups. When available, category A evidence is given precedence over category B evidence for any particular outcome. These evidence categories are further divided into evidence levels. Evidence levels refer specifically to the strength and quality of the summarized study findings (i.e., statistical findings, type of data, and the number of studies reporting/replicating the findings). In this document, only the highest level of evidence is included in the summary report for each intervention–outcome pair, including a directional designation of benefit, harm, or equivocality.
Observational studies or RCTs without pertinent comparison groups may permit inference of beneficial or harmful relationships among clinical interventions and clinical outcomes. Inferred findings are given a directional designation of beneficial (B), harmful (H), or equivocal (E). For studies that report statistical findings, the threshold for significance is P < 0.01.
The lack of sufficient scientific evidence in the literature may occur when the evidence is either unavailable (i.e., no pertinent studies found) or inadequate. Inadequate literature cannot be used to assess relationships among clinical interventions and outcomes because a clear interpretation of findings is not obtained due to methodological concerns (e.g., confounding of study design or implementation) or the study does not meet the criteria for content as defined in the “Focus” of the guidelines.
All opinion-based evidence (e.g., survey data, open forum testimony, internet-based comments, letters, and editorials) relevant to each topic was considered in the development of these guidelines. However, only the findings obtained from formal surveys are reported in the document.
Opinion surveys were developed by the task force to address each clinical intervention identified in the document. Identical surveys were distributed to expert consultants and a random sample of members of the participating organizations.
Survey findings from task force–appointed expert consultants, a random sample of the ASA membership, and membership samples from the American Association of Oral and Maxillofacial Surgeons (AAOMS) and the American Society of Dentist Anesthesiologists (ASDA) are fully reported in this document. Survey responses were recorded using a 5-point scale and summarized based on median values.
Open forum testimony obtained during development of these guidelines, internet-based comments, letters, and editorials are all informally evaluated and discussed during the formulation of guideline recommendations. When warranted, the task force may add educational information or cautionary notes based on this information.
Preprocedure patient evaluation consists of the following strategies for reducing sedation-related adverse outcomes: (1) reviewing previous medical records for underlying medical problems (e.g., abnormalities of major organ systems, obesity, obstructive sleep apnea, anatomical airway problems, congenital syndromes with associated medical/surgical issues, respiratory disease, allergies, intestinal inflammation); sedation, anesthesia, and surgery history; history of or current problems pertaining to cooperation, pain tolerance, or sensitivity to anesthesia or sedation; current medications; extremes of age; psychotropic drug use; use of nonpharmaceuticals (e.g., nutraceuticals); and family history; (2) a focused physical examination; and (3) preprocedure laboratory testing (where indicated).
Although it is well accepted clinical practice to review medical records, conduct a physical examination, and review laboratory test results, comparative studies are insufficient to evaluate the periprocedural impact of these activities. Observational studies indicate that some adverse outcomes (e.g., unintended deep sedation, hypoxemia, # ** or hypotension) may occur in patients with preexisting medical conditions when moderate sedation/analgesia is administered. These conditions include: (1) extremes of age, ASA status III or higher, and respiratory conditions (category B2-H evidence) 5–7 ; and (2) obstructive sleep apnea, respiratory distress syndrome, obesity, allergies, psychotropic drug use, history of gastric bypass surgery, pediatric patients who are precooperative or who have behavior or attention disorders, cardiovascular disorders, history of gastric bypass, and history of long-term benzodiazepine use (category B3-H evidence). 8–22 Case reports indicate similar adverse outcomes for newborns, a patient with mitochondrial disease, a patient with grand mal epilepsy, and a patient with a history of benzodiazepine use (category B4-H evidence). 23–26
The consultants, ASA members, AAOMS members, and ASDA members strongly agree with the recommendations to (1) review previous medical records and interview the patient or family, (2) conduct a focused physical examination of the patient, and (3) review available laboratory test results. The consultants and ASA members agree with the recommendation to, if possible, perform the preprocedure evaluation well enough in advance (e.g., several days to weeks) to allow for optimal patient preparation; the AAOMS members and ASDA members strongly agree with this recommendation. Finally, consultants, ASA members, AAOMS members, and ASDA members strongly agree with the recommendation to reevaluate the patient immediately before the procedure.
Preprocedure patient preparation consists of (1) consultation with a medical specialist when needed; (2) patient preparation for the procedure (e.g., informing patients of the benefits and risks of sedatives and analgesics, preprocedure instruction, medication usage, counseling); and (3) preprocedure fasting from solids and liquids.
The literature is insufficient regarding the benefits of consultation with a medical specialist or providing the patient (or legal guardian, in the case of a child or impaired adult) with preprocedure information about sedation and analgesia. A nonrandomized comparative study reported equivocal outcomes (e.g., emesis, apnea, oxygen levels) when preprocedure fasting (i.e., liquids or solids) is compared to no fasting (category B1-E evidence). 27 Another nonrandomized comparison of fasting for less than 2 h versus fasting for greater than 2 h reported equivocal findings for emesis, oxygen saturation levels, and arrhythmia for infants (category B1-E evidence). 28 Finally, a third nonrandomized comparison reported equivocal findings for gastric volume and pH when fasting of liquids for 0.5 to 3 h is compared with fasting times of greater than 3 h (category B1-E evidence). 29
The consultants, ASA members, AAOMS members, and ASDA members strongly agree with the recommendations to (1) consult with a medical specialist, when appropriate, before administration of moderate procedural sedation to patients with significant underlying conditions; (2) when feasible before the procedure, inform patients or legal guardians of the benefits, risks, and limitations of moderate sedation/analgesia and possible alternatives, and elicit their preferences; (3) before the day of the procedure, inform patients or legal guardians that they should not drink fluids or eat solid foods for a sufficient period of time to allow for gastric emptying; and (4) on the day of the procedure, assess the time and nature of the last oral intake. All four groups of survey respondents agreed with the recommendation that in urgent or emergent situations where complete gastric emptying is not possible, do not delay moderate procedural sedation based on fasting time alone.
Many of the complications associated with moderate sedation and analgesia may be avoided if adverse drug responses are detected and treated in a timely manner (i.e., before the development of cardiovascular decompensation or cerebral hypoxia). Patients given sedatives or analgesics in unmonitored settings may be at increased risk of these complications. Patient monitoring includes strategies for the following: (1) monitoring patient level of consciousness assessed by the response of patients, including spoken responses to commands or other forms of bidirectional communication during procedures performed with moderate sedation/analgesia ‖‖ ; (2) monitoring patient ventilation and oxygenation, including ventilatory function, by observation of qualitative clinical signs, capnography, and pulse oximetry; (3) hemodynamic monitoring, including blood pressure, heart rate, and electrocardiography; (4) contemporaneous recording of monitored parameters; and (5) availability/presence of an individual responsible for patient monitoring.
The literature is insufficient to determine whether monitoring patients’ level of consciousness improves patient outcomes or decreases risks. Also, the literature is insufficient to evaluate whether observation of the patient, auscultation, chest excursion, or plethysmography are associated with reduced sedation-related risks.
Meta-analysis of RCTs indicate that the use of continuous end-tidal carbon dioxide monitoring (i.e., capnography) is associated with a reduced frequency of hypoxemic events (i.e., oxygen saturation less than 90%) when compared to monitoring without capnography (e.g., practitioners were blinded to capnography results) during procedures with moderate sedation (category A1-B evidence). 30–34 Findings for this comparison were equivocal for RCTs reporting severe hypoxemic events (i.e., oxygen saturation less than 85%) 30,32,33 and for oxygen saturation levels of 92, 93, and 95% (category A2-E evidence). 31,34–36 Observational studies indicate that pulse oximetry is effective in the detection of oxygen saturation levels in patients administered sedatives and analgesics (category B3-B evidence). 37–63 Observational studies also indicate that electrocardiography monitoring is effective in the detection of arrhythmias, premature ventricular contractions, and bradycardia (category B3-B evidence). 46,49,64
The literature is insufficient to determine the benefits of contemporaneous recording of patients’ level of consciousness, respiratory function, or hemodynamics. In addition, the literature is insufficient to evaluate whether the presence of an individual dedicated to patient monitoring will reduce adverse outcomes related to moderate sedation/analgesia.
The consultants, ASA members, AAOMS members, and ASDA members agree with the recommendations to (1) periodically monitor a patient’s response to verbal commands during moderate sedation, except in patients who are unable to respond appropriately or during procedures where movement could detrimental clinically; and (2) during procedures where a verbal response is not possible, check the patient’s ability to give a “thumbs up” or other indication of consciousness in response to verbal or tactile (light tap) stimulation. The consultants, ASA members, AAOMS members, and ASDA members strongly agree with the recommendations to (1) continually monitor ventilatory function by observation of qualitative clinical signs; (2) continually monitor ventilatory function with capnography unless precluded or invalidated by the nature of the patient, procedure, or equipment; (3) monitor all patients by pulse oximetry with appropriate alarms; (4) determine blood pressure before sedation/analgesia is initiated unless precluded by lack of patient cooperation; (5) once moderate sedation/analgesia is established, continually monitor blood pressure and heart rate during the procedure unless such monitoring interferes with the procedure; (6) use electrocardiographic monitoring during moderate sedation in patients with clinically significant cardiovascular disease or those who are undergoing procedures where dysrhythmias are anticipated; (7) record patients’ level of consciousness, ventilatory and oxygenation status, and hemodynamic variables at a frequency that depends on the type and amount of medication administered, the length of the procedure, and the general condition of the patient; (8) set device alarms to alert the care team to critical changes in patient; (9) assure that a designated individual other than the practitioner performing the procedure is present to monitor the patient throughout the procedure; and (10) the individual responsible for monitoring the patient should be trained in the recognition of apnea and airway obstruction and be authorized to seek additional help. The consultants, ASA members, and ASDA members agree that the designated individual may assist with minor, interruptible tasks once the patient’s level of sedation/analgesia and vital signs have stabilized, provided that adequate monitoring for the patient’s level of sedation is maintained; the AAOMS members strongly agree with this recommendation.
Meta-analysis of RCTs indicate that the use of supplemental oxygen versus no supplemental oxygen is associated with a reduced frequency of hypoxemia ‡‡‡ during procedures with moderate sedation (category A1-B evidence). 65–71 The literature is insufficient to examine which methods of supplemental oxygen administration (e.g., nasal cannula, face mask, or specialized devices) are more effective in reducing hypoxemia.
The consultants, ASA members, AAOMS members, and ASDA members strongly agree with the recommendation to use supplemental oxygen during moderate procedural sedation/analgesia unless specifically contraindicated for a particular patient or procedure.
Emergency support strategies include (1) the presence of pharmacologic antagonists; (2) the presence of age and weight appropriate emergency airway equipment (e.g., different types of airway devices, supraglottic airway devices); (3) the presence of an individual capable of establishing a patent airway and providing positive pressure ventilation and resuscitation; (4) the presence of an individual to establish intravenous access; and (5) the availability of rescue support.
Although it is established clinical practice to provide access to emergency support, the literature is insufficient to assess the benefits or harms of keeping pharmacologic antagonists or emergency airway equipment available during procedures with moderate sedation and analgesia. The literature is insufficient to assess whether the presence of an individual capable of establishing a patent airway, positive pressure ventilation, and resuscitation will improve outcomes. In addition, the literature is insufficient to determine the benefits of keeping an individual present to establish intravenous access during procedures with moderate sedation/analgesia. Finally, the literature is insufficient to determine the benefits of rescue support availability during moderate procedural sedation/analgesia.
The consultants, ASA members, AAOMS members, and ASDA members strongly agree with the recommendation to assure that (1) pharmacologic antagonists for benzodiazepines and opioids are immediately available in the procedure suite or procedure room; (2) an individual is present in the room who understands the pharmacology of the sedative/analgesics administered and potential interactions with other medications and nutraceuticals the patient may be taking; (3) appropriately sized equipment for establishing a patent airway is available; (4) at least one individual capable of establishing a patent airway and providing positive pressure ventilation is present in the procedure room; (5) suction, advanced airway equipment, positive pressure ventilation, and supplemental oxygen are immediately available in the procedure room and in good working order; (6) a member of the procedural team is trained in the recognition and treatment of airway complications, opening the airway, suctioning secretions, and performing bag-valve-mask ventilation; (7) a member of the procedural team has the skills to establish intravascular access; (8) a member of the procedural team has the skills to provide chest compressions; (9) a functional defibrillator or automatic external defibrillator is immediately available in the procedure area; (10) an individual or service is immediately available with advanced life support skills; and (11) members of the procedural team are able to recognize the need for additional support and know how to access emergency services from the procedure room.
For these guidelines, sedatives not intended for general anesthesia include benzodiazepines (e.g., midazolam, diazepam, flunitrazepam, lorazepam, or temazapam) and dexmedetomidine. Analgesics administered with sedatives include opioids such as fentanyl, alfentanil, remifentanil, meperidine, morphine, and nalbuphine. This section of the guidelines addresses the following topics: (1) benzodiazepines and dexmedetomidine, (2) sedative/opioid combinations, (3) intravenous versus nonintravenous sedatives/analgesics not intended for general anesthesia, ### and (4) titration of sedatives/analgesics not intended for general anesthesia.
Meta-analysis of RCTs comparing midazolam combined with opioids versus midazolam alone report equivocal findings for pain and discomfort, 72–77 hypoxemia, **** 74,75,77–80 and patient recall of the procedure. 72–74,77,80–83 (category A1-E evidence). When midazolam combined with opioids are compared with opioids alone, RCTs report equivocal findings for patient recall, pain during the procedure, frequency of hypoxemia, ### hypercarbia and respiratory depression (category A2-E evidence). 75,78,83–85
One RCT comparing dexmedetomidine with midazolam reports equivocal outcomes for recovery time, oxygen saturation levels, apnea, and bradycardia (category A3-E evidence). 86 Another RCT reports a longer recovery time for dexmedetomidine compared with midazolam (category A3-H evidence), with equivocal findings for analgesia scores, oxygen saturation levels, respiratory rate, blood pressure, and pulse rate (category A3-E evidence). 87 One RCT reports a lower frequency of hypoxemia when dexmedetomidine is combined with an opioid analgesic compared with midazolam combined with an opioid analgesic (category A3-B evidence). 88 One RCT reports deeper sedation (i.e., higher sedation scores) and a lower frequency of hypoxemia when dexmedetomidine combined with midazolam and meperidine is compared with midazolam combined with meperidine (category A3-B evidence). 89
One RCT comparing intravenous midazolam with intramuscular midazolam reports equivocal findings for oxygen saturation levels, respiratory rate, and heart rate (category A3-E evidence). 90 One RCT comparing intravenous midazolam with intranasal midazolam reports equivocal findings for sedation efficacy (category A3-E evidence), but discomfort from the nasal administration was reported for all intranasal patients with no nasal discomfort from the intravenous patients (category A3-B evidence). 91 One RCT comparing intravenous diazepam with rectal diazepam reports lower recall for the intravenous method (category A3-B evidence); findings were equivocal for sedative effect, anxiety, and crying (category A3-E evidence). 92 One RCT comparing intravenous with intranasal dexmedetomidine reported equivocal findings for sedation time, duration of the procedure, and the frequency of rescue doses of midazolam administered (category A3-E evidence). 93
One RCT comparing titration (i.e., administration of small, incremental doses of intravenous midazolam combined with meperidine until the desired level of sedation and/or analgesia is achieved) of midazolam combined with an opioid compared with a single, rapid bolus reports higher total physician times, medication dosages, frequencies of hypoxemia, and somnolence scores for titration (category A3-H evidence). 94
The consultants, ASA members, AAOMS members, and ASDA members strongly agree with the recommendation that combinations of sedative and analgesic agents may be administered as appropriate for the procedure and the condition of the patient. The consultants, ASA members, and ASDA members agree that dexmedetomidine may be administered as an alternative to benzodiazepine sedatives on a case-by-case basis; the AAOMS members are equivocal regarding this recommendation. The consultants, ASA members, AAOMS members, and ASDA members strongly agree with the recommendation that in patients receiving intravenous medications for sedation/analgesia, maintain vascular access throughout the procedure and until the patient is no longer at risk for cardiorespiratory depression. The consultants agree and the ASA members, AAOMS members, and ASDA members strongly agree that in patients who have received sedation/analgesia by nonintravenous routes or whose intravenous line has become dislodged or blocked, determine the advisability of reestablishing intravenous access on a case-by-case basis. Finally, the consultants, ASA members, AAOMS members, and ASDA members strongly agree with the recommendation to administer intravenous sedative/analgesic drugs in small, incremental doses, or by infusion, titrating to the desired endpoints.
For these guidelines, sedatives intended for general anesthesia include propofol, ketamine and etomidate. ‡‡‡‡ Sedatives not intended for general anesthesia (e.g., benzodiazepines, nitrous oxide, chloral hydrate, barbiturates, and antihistamines) are included either as comparison groups or in combination with sedatives intended for general anesthesia. Analgesics (e.g., opioids, nonsteroidal antiinflammatory drugs, and local anesthetics) are included either in comparison groups or in combination with sedatives intended for general anesthesia. This section of the guidelines addresses the following topics: (1) propofol versus other sedative/analgesics, (2) ketamine versus other sedative/analgesics, (3) etomidate versus other sedative/analgesics, (4) combinations of sedatives intended for general anesthesia versus other sedatives/analgesics, alone or in combination, (5) intravenous versus nonintravenous sedatives/analgesics intended for general anesthesia, ‖‖‖ and (6) titration of intravenous sedatives/analgesics intended for general anesthesia.
Literature comparing propofol with other sedative/analgesic medications, either alone or in combination, report the following findings: (1) Meta-analysis of RCTs report faster recovery times for propofol versus midazolam after procedures with moderate sedation (category A1-B evidence), 95–99 with equivocal findings for patient recall, 95,100–103 and frequency of hypoxemia (category A1-E evidence). 96,100,102,103 One RCT reports shorter sedation time, a lower frequency of recall and higher recovery scores for propofol versus diazepam (category A3-B evidence). 104 (2) RCTs comparing propofol versus benzodiazepines combined with opioid analgesics report shorter sedation and recovery times for propofol alone (category A2-B evidence), 105,106 with equivocal findings for pain, oxygen saturation levels, and blood pressure (category A2-E evidence). 107–109 (3) RCTs comparing propofol combined with benzodiazepines versus propofol alone report equivocal findings for recovery and procedure times, pain with injection, and restlessness (category A2-E evidence). 110–112 One RCT comparing propofol combined with midazolam versus propofol alone reports deeper sedation levels and more episodes of deep sedation for the combination group (category A3-H evidence). 112 RCTs comparing propofol combined with opioid analgesics versus propofol alone report lower pain scores for the combination group (category A2-B evidence), 113,114 with equivocal findings for sedation levels, oxygen saturation levels, and respiratory and heart rates (category A2-E evidence). 113–116 (4) One RCT comparing propofol combined with remifentanil versus remifentanil alone reports deeper sedation, less recall (category A3-B evidence), and more respiratory depression (category A3-H evidence) for the combination group. 117 (5) RCTs comparing propofol combined with sedatives/analgesics not intended for general anesthesia versus combinations of sedatives/analgesics not intended for general anesthesia report equivocal findings for outcomes including sedation time, patient recall, pain scores, recovery time, oxygen saturation levels, blood pressure, and heart rate (category A2-E evidence). 118–136 (6) RCTs comparing propofol with ketamine report equivocal findings for sedation scores, pain during the procedure, recovery, oxygen saturation levels, respiratory rate, blood pressure, and heart rate (category A2-E evidence). 137,138 (7) One RCT comparing propofol versus ketamine combined with midazolam reports equivocal findings for recovery agitation, oxygen saturation levels, respiratory rate, blood pressure, and heart rate (category A3-E evidence). 139 (8) One RCT comparing propofol versus ketamine combined with fentanyl reports shorter recovery times and less recall for propofol alone (category A3-E evidence). 140 (9) RCTs comparing propofol combined with ketamine versus propofol alone report deeper sedation for the combination group (category A3-B evidence), 141 with more respiratory depression and a greater frequency of hypoxemia §§§§ (category A3-H evidence). 142
Literature comparing ketamine with other sedative/analgesic medications, either alone or in combination, report the following findings: (1) RCTs comparing ketamine with midazolam report equivocal findings for sedation scores, recovery time, and oxygen saturation levels (category A2-E evidence). 87,143,144 (2) One RCT comparing ketamine versus nitrous oxide reports longer sedation times and higher levels of sedation (i.e., deeper sedation levels) for ketamine (category A3-H evidence). 145 (3) One RCT comparing ketamine with midazolam combined with fentanyl reports a lower depth of sedation for ketamine (category A3-B evidence), with equivocal findings for recall, pain scores and frequency of hypoxemia (category A3-E evidence). 146 (4) RCTs comparing ketamine combined with midazolam versus ketamine alone or midazolam alone report equivocal findings for sedation scores, sedation time, recovery, and recovery agitation (category A2-E evidence). 143,147,148 (5) One RCT comparing ketamine combined with midazolam versus midazolam combined with alfentanil reports a lower frequency of hypoxemia (category A3-B evidence) and increased disruptive movements, longer recovery times, and longer times to discharge for ketamine combined with midazolam (category A3-H evidence). 149 (6) RCTs comparing ketamine with propofol report equivocal findings for sedation scores, pain during the procedure, oxygen saturation levels, and recovery scores (category A2-E evidence). 137,138 RCTs comparing ketamine with etomidate report less airway assistance required and lower frequencies of myoclonus with ketamine (category A2-B evidence). 150,151 (7) RCTs comparing ketamine combined with propofol versus propofol combined with fentanyl report equivocal findings for recovery times, oxygen saturation levels, respiratory rate, and heart rate (category A3-H evidence). 152–154
Literature comparing etomidate with other sedative/analgesic medications, either alone or in combination, report the following findings: (1) One RCT comparing etomidate with midazolam reports shorter sedation times for etomidate (category A3-B evidence), with equivocal findings for recovery agitation, oxygen saturation levels, and apnea (category A3-E evidence). 155 (2) One RCT comparing etomidate with pentobarbital reports shorter sedation times for etomidate (category A3-B evidence), with equivocal findings for recovery agitation and hypotension (category A3-B evidence). 156 (3) One RCT comparing etomidate combined with fentanyl versus midazolam combined with fentanyl reports deeper sedation (i.e., higher sedation scores) for the combination group (category A3-B evidence), with equivocal findings for sedation times, recovery times, frequency of oversedation, and oxygen saturation levels (category A3-E evidence), and a higher frequency of myoclonus (category A3-H evidence). 157 (4) One RCT comparing etomidate combined with morphine and fentanyl versus midazolam combined with morphine and fentanyl reports shorter sedation times for the etomidate combination (category A3-B evidence), with equivocal findings for oxygen saturation levels, apnea, hypotension, and recovery agitation (category A3-E evidence), and a higher frequency of patient recall and myoclonus (category A3-H evidence). 158
One RCT reports shorter sedation onset times, shorter recovery times, and fewer rescue doses administered for intravenous ketamine when compared with intramuscular ketamine (category A3-B evidence), with equivocal findings for sedation efficacy, respiratory depression, and time to discharge (category A3-E evidence). 159 One RCT comparing intravenous versus intramuscular ketamine with or without midazolam reports equivocal findings for sedation time, recovery agitation, and duration of the procedure (category A3-E evidence). 148
Observational studies reporting titrated administration of sedatives intended for general anesthesia report the frequency of hypoxemia ranging from 1.7 to 4.7% of patients, 14,160–163 with oversedation occurring in 0.13%-0.2% of patients. 14,161
The consultants, ASA members, AAOMS members, and ASDA members strongly agree with the recommendations to (1) provide care consistent with that required for general anesthesia when moderate procedural sedation with sedative or analgesic medications intended for general anesthesia by any route is intended; (2) assure that practitioners administering these drugs are able to reliably rescue patients from unintended deep sedation or general anesthesia; (3) maintain vascular access throughout the procedure and until the patient is no longer at risk for cardiorespiratory depression for patients receiving intravenous sedatives intended for general anesthesia; (4) determine the advisability of reestablishing intravenous access on a case-by-case basis in patients who have received sedatives intended for general anesthesia by nonintravenous routes or whose intravenous line has become dislodged or blocked; and (5) administer intravenous sedative/analgesic drugs intended for general anesthesia in small, incremental doses, or by infusion, titrating to the desired endpoints.
One placebo-controlled RCT reports that naloxone effectively reverses the effects of meperidine as measured by increasing alertness scores and respiratory rate (category A3-B evidence). 164 Reversal of respiratory depression, apnea, and oxygen desaturation after naloxone administration in other practice settings is also reported by observational studies (category B3-B evidence) 165,166 and case reports (category B4-B evidence). 167–170
Meta-analysis of double-blind placebo-controlled RCTs indicates that flumazenil effectively antagonizes the effects of sedation within 15 min for patients who have been administered benzodiazepines (category A1-B evidence). 171–178 Placebo-controlled RCTs also indicate that flumazenil administration is associated with shorter recovery times for benzodiazepine sedation (category A2-B evidence). 176,179–181 Meta-analysis of placebo-controlled RCTs indicate that flumazenil effectively antagonizes the effects of benzodiazepines when combined with opioids (category A1-B evidence). 182–186
The consultants, ASA members, AAOMS members, and ASDA members strongly agree with the recommendations to (1) assure that specific antagonists are immediately available in the procedure room whenever opioid analgesics or benzodiazepines are administered for moderate procedural sedation/analgesia, regardless of route of administration; (2) encourage or physically stimulate patients to breathe deeply if patients become hypoxemic or apneic during sedation/analgesia; (3) administer supplemental oxygen if patients become hypoxemic or apneic during sedation/analgesia; (4) provide positive pressure ventilation if spontaneous ventilation is inadequate when patients become hypoxemic or apneic during sedation/analgesia; (5) use reversal agents in cases where airway control, spontaneous ventilation, or positive pressure ventilation is inadequate; (6) administer naloxone to reverse opioid-induced sedation and respiratory depression; (7) administer flumazenil to reverse benzodiazepine-induced sedation and respiratory depression; (8) after pharmacologic reversal, observe and monitor patients for a sufficient time to ensure that sedation and cardiorespiratory depression does not recur once the effect of the antagonist dissipates; and (9) not use sedation regimens that include routine reversal of sedative or analgesic agents.
Patients receiving moderate procedural sedation may continue to be at risk for developing complications after their procedure is completed. Decreased stimulation from the proceduralist delayed drug absorption after nonintravenous administration, and slow drug elimination may contribute to residual sedation and cardiorespiratory depression during the recovery period. When sedation/analgesia is administered to outpatients, medical supervision may not be available once the patient leaves the medical facility. This section of the guidelines addresses the following recovery care topics: (1) continued observation and monitoring until discharge and (2) predetermined discharge criteria.
Although it is well accepted clinical practice to continue patient observation until discharge, the literature is insufficient to evaluate the impact of postprocedural observation and monitoring. The literature is also insufficient to evaluate the effects of using predetermined discharge criteria on patient outcomes.
The consultants, ASA members, AAOMS members, and ASDA members strongly agree with the recommendations to (1) observe and monitor patients in an appropriately staffed and equipped area until they are near their baseline level of consciousness and are no longer at increased risk for cardiorespiratory depression, (2) monitor oxygenation continuously until patients are no longer at risk for hypoxemia, (3) monitor ventilation and circulation at regular intervals until patients are suitable for discharge, and (4) design discharge criteria to minimize the risk of central nervous system or cardiorespiratory depression after discharge from observation by trained personnel.
Patient safety processes include quality improvement and preparation for rare events.
Regarding quality improvement, one observational study reported that use of a presedation checklist compared to no checklist use may improve safety documentation in emergency department sedations (category B1-B evidence). 187
The consultants, ASA members, AAOMS members, and ASDA members strongly agree with the recommendations to (1) create and implement a quality improvement process based upon established national, regional, or institutional reporting protocols; (2) strengthen patient safety culture through collaborative practices; and (3) create an emergency response plan.
Support was provided solely from institutional and/or departmental sources in the American Society of Anesthesiologists.
The authors declare no competing interests.
Updated by the American Society of Anesthesiologists Committee on Standards and Practice Parameters: Jeffrey L. Apfelbaum, M.D. (Committee Chair and Task Force Co-Chair), Chicago, Illinois; Jeffrey B. Gross, M.D. (Task Force Co-Chair), Farmington, Connecticut; Richard T. Connis, Ph.D. (Chief Methodologist), Woodinville, Washington; Madhulika Agarkar, M.P.H., Schaumburg, Illinois; Donald E. Arnold, M.D., St. Louis, Missouri; Charles J. Coté, M.D., Boston, Massachusetts; Richard Dutton, M.D., Dallas, Texas; Christopher Madias, M.D., Boston, Massachusetts; David G. Nickinovich, Ph.D., Bellevue, Washington; Paul J. Schwartz, D.M.D., Dunkirk, Maryland; James W. Tom, D.D.S., M.S., Los Angeles, California; Richard Towbin, M.D., Phoenix, Arizona; and Avery Tung, M.D., Chicago, Illinois.
Reflex withdrawal from a painful stimulus is NOT considered a purposeful response.
However, as stated in the American Academy of Pediatrics–American Academy of Pediatric Dentistry guidelines on the monitoring and management of pediatric patients during sedation (2016), “in the case of procedures that may themselves cause airway obstruction (e.g., dental or endoscopic), the practitioner must recognize an obstruction and assist the patient in opening the airway.” 4
American Dental Association Council on Dental Education and Licensure: Anesthesia Committee Meeting, April 20, 2017; 2017 Combined Annual Meeting of the Southwest Society of Oral and Maxillofacial Surgeons, the Texas Society of Oral and Maxillofacial Surgeons, the Midwestern Chapter of Oral and Maxillofacial Surgeons, and the Oklahoma Society of Oral and Maxillofacial Surgeons, April 21, 2017, Scottsdale, Arizona; the Society for Ambulatory Anesthesia 32nd Annual Meeting, May 5, 2017, Scottsdale, Arizona; International Anesthesia Research Society 2017 Annual Meeting; and the International Science Symposium, Washington, D.C., May 8, 2017.
All meta-analyses are conducted by the ASA methodology group. Meta-analyses from other sources are reviewed but not included as evidence in this document. A minimum of five independent RCTs are required for meta-analysis.
Unless otherwise noted in this document, hypoxemia is reported in the literature to be oxygen desaturation to at most 90%.
This may not be feasible for urgent or emergency procedures, interventional radiology, or other radiology settings.
See table 2 for additional information related to airway assessment.
This may not be feasible for urgent or emergency procedures.
See table 3 and/or refer to: American Society of Anesthesiologists: Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: Application to healthy patients undergoing elective procedures: An updated report. A nesthesiology 2017; 126:376–93.
Patients whose only response is reflex withdrawal from painful stimuli are deeply sedated, approaching a state of general anesthesia, and should be treated accordingly.
A response limited to reflex withdrawal from a painful stimulus is not considered a purposeful response and thus represents a state of general anesthesia.
The term continual is defined as “repeated regularly and frequently in steady rapid succession,” whereas continuous means “prolonged without any interruption at any time” (see Standards for Basic Anesthetic Monitoring, American Society of Anesthesiologists. Approved by the ASA House of Delegates October 21, 1986, and last amended October 28, 2015. Available at: http://www.asahq.org/quality-and-practice-management/practice-guidance-resource-documents/standards-for-basic-anesthetic-monitoring. Accessed on August 21, 2017).
For rare uncooperative patients (e.g., children with autism spectrum disorder or attention deficit disorder), recording oxygenation status or blood pressure may not be possible until after sedation.
Reported by authors as oxygen desaturation to at most 95% or oxygen desaturation more than 5 or 10% below baseline.
Refer to table 4 for examples of emergency support equipment and pharmaceuticals.
“Immediately available in the procedure room” refers to easily accessible shelving, cabinetry, and other measures to assure that there is no delay in accessing medications and equipment during the procedure.
All routes of administration were considered, including oral, nasal, intramuscular, rectal, transdermal, sublingual, iontophoresis, and nebulization.
Reported by authors as oxygen desaturation to less than 94, 93, or 90%.
The propensity for combinations of sedative and analgesic agents to cause respiratory depression and airway obstruction emphasizes the need to appropriately reduce the dose of each component, as well as the need to continually monitor respiratory function. Knowledge of each drug’s time of onset, peak response, and duration of action is important. Titration of drug to effect is an important concept; one must know whether the previous dose has taken full effect before administering additional drug.
Note that these guidelines do not address education, training, or certification requirements for practitioners who provide moderate procedural sedation with these drugs.
Reported by author as oxygen desaturation to less than 94%.
Practitioners are cautioned that acute reversal of opioid-induced analgesia may result in pain, hypertension, tachycardia, or pulmonary edema.
Discharge criteria examples are noted in table 5.
See table 2 for additional information related to airway assessment.
This may not be feasible for urgent or emergency procedures, interventional radiology or other radiology settings.
This may not be feasible for urgent or emergency procedures.
See table 3 and/or refer to: American Society of Anesthesiologists: Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: Application to healthy patients undergoing elective procedures: An updated report. A nesthesiology 2017; 126:376–93
A response limited to reflex withdrawal from a painful stimulus is not considered a purposeful response and thus represents a state of general anesthesia.
The term “continual” is defined as “repeated regularly and frequently in steady rapid succession” whereas “continuous” means “prolonged without any interruption at any time” (see Standards for Basic Anesthetic Monitoring, American Society of Anesthesiologists. Approved by the ASA House of Delegates October 21, 1986, and last amended October 28, 2015. Retrieved May 9, 2017, from http://www.asahq.org/quality-and-practice-management/standards-and-guidelines/search?q=basic anesthesia monitoring).
For rare uncooperative patients (e.g., children with autism spectrum disorder or attention deficit disorder) recording oxygenation status or blood pressure may not be possible until after sedation.
“Immediately available in the procedure room” refers to accessible shelving, unlocked cabinetry, and other measures to assure that there is no delay in accessing medications and equipment during the procedure.
The propensity for combinations of sedative and analgesic agents to cause respiratory depression and airway obstruction emphasizes the need to appropriately reduce the dose of each component as well as the need to continually monitor respiratory function. Knowledge of each drug’s time of onset, peak response, and duration of action is important. Titration of drug to effect is an important concept; one must know whether the previous dose has taken full effect before administering additional drug.
Practitioners are cautioned that acute reversal of opioid-induced analgesia may result in pain, hypertension, tachycardia, or pulmonary edema.
Discharge criteria examples are noted in table 5.
Preferred reporting items of systematic reviews and meta-analyses.
Consultants were drawn from the following specialties where moderate procedural sedation/analgesia are commonly administered: anesthesiology, cardiology, dentistry, emergency medicine, gastroenterology, oral and maxillofacial surgery, pediatrics, radiology, and surgery.
All participating organizations were invited to participate in this survey.
American Dental Association Council on Dental Education and Licensure: Anesthesia Committee Meeting, April 20, 2017; 2017 Combined Annual Meeting of the Southwest Society of Oral and Maxillofacial Surgeons, the Texas Society of Oral and Maxillofacial Surgeons, the Midwestern Chapter of Oral and Maxillofacial Surgeons, and the Oklahoma Society of Oral and Maxillofacial Surgeons, April 21, 2017, Scottsdale, Arizona; the Society for Ambulatory Anesthesia 32nd Annual Meeting, May 5, 2017, Scottsdale, Arizona; International Anesthesia Research Society 2017 Annual Meeting; and the International Science Symposium, Washington, D.C., May 8, 2017.
