• Procedural sedation reduces the pain and anxiety that certain procedures can cause

• Loss of verbal contact with a patient (deep sedation) requires the same level of care as that needed for general anaesthesia

• This guideline is for procedural sedation delivered by anaesthetists and is adapted from the RCOA GPAS document¹

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Abbreviations

There are increasing numbers of therapeutic and diagnostic procedures that can cause pain and anxiety. Procedural sedation reduces discomfort and apprehension and facilitates performance of these procedures effectively. They are often performed in the non-theatre environment.

1.1 If deep procedural sedation is required in a non-theatre environment, the standards for equipment and monitoring should be the same as for the provision of general anaesthesia in a theatre environment. This also applies to pre-, intra - and post-procedural care.

1.2 The patient should be fasted for any procedural sedation, as for general anaesthesia.

1.3 Sedation by non-anaesthetists is not within the scope of this guideline.

Where sedation services are not provided by the department of anaesthesia, those professionals are advised to follow the guidance of their own College and the Academy of Royal Medical Colleges’ publication Safe Sedation Practices for Healthcare Procedures 2013.²

Minimal sedation – Is a drug-induced state during which the patient responds normally to verbal commands. Cognitive function and physical coordination may be impaired, but airway reflexes, and ventilatory and cardiovascular functions are unaffected.

Moderate sedation – Describes a state where a purposeful response to verbal commands either alone (~ conscious sedation), or accompanied by light tactile stimulation, is maintained.

Deep sedation – Describes a state where the patient cannot easily be roused but responds purposefully to repeated or painful stimulation. It may be accompanied by clinically significant ventilatory depression. The patient may require assistance maintaining a patent airway, and positive pressure ventilation.

2.1 The RCoA recognises the definitions of minimal, moderate and deep sedation as outlined in the Academy of Medical Royal Colleges’ guidance on safe sedation.² Deep sedation equates to anaesthesia and the recommendations outlined in chapters 2-5 of GPAS should be followed. ¹

2.2 A named anaesthetist should be responsible for liaising with consultants in other departments with responsibility for sedation, to establish local guidelines and training for the provision of safe sedation by non-anaesthetists.

2.3 Guidelines for the management of rare emergencies must be prominently displayed at all sites where sedation is administered.

2.4 All institutions where sedation is practised should have a sedation committee. In most institutions, the sedation committee should include an anaesthetist, at least in an advisory capacity.

2.5 Midazolam over-sedation during sedation is defined as a ‘never event’ by the Department of Health. Hospitals should report these incidents to the National Reporting and Learning System.

3.1 PSA may be used for any procedure in which a patient's pain or anxiety may be excessive and may impede performance.

3.2 Special considerations - Use with caution in patients who have:

• Respiratory problems (severe COPD)

• Confused or patients with mental health problems

• Drug sensitivities

• Severe cardiac problems

• Renal failure, renal and biliary colic

• Bowel obstruction or risk factors for aspiration

• Patients taking GLP-1 Receptor Agonists

4.1 Staffing

4.1.1 A dedicated, skilled anaesthetic assistant should be available in all locations where PSA is undertaken.

4.1.2 Patients recovering from PSA in an isolated unit should receive the same standard of care as that required in an operating theatre post anaesthetic care unit (PACU).

4.2 General equipment

4.2.1 Environments in which patients receive PSA should have full facilities for resuscitation available, including a defibrillator, suction, oxygen, airway devices and a means of providing ventilation.

4.2.2 All anaesthetic equipment should be checked before use in accordance with the Association of Anaesthetists guidelines. ³

4.2.3 Facilities to allow access to online information, such as electronic patient records, local guidelines and clinical decision aids, should be available.

4.3 Medication

A full range of emergency drugs including specific reversal agents such as naloxone and flumazenil should be made available.

4.4 Monitoring and oxygen administration

For patients receiving PSA, oxygen should be given and they should have full monitoring, as for GA, including continuous waveform capnography

4.5 Support services

4.5.1 A contemporary record of drugs administered during sedation, with times and doses, together with vital signs, must be recorded and stored in the patient notes whenever patients receive sedation.

4.5.2 Compliance with WHO Safe Surgery checklist is mandatory.

4.5.3 Intravenous cannulae must be flushed with 0.9% saline at end of the procedure.

5.1 Paediatric sedation

5.1.1 Children should always be managed in accordance with RCoA and Association of Paediatric Anaesthetists of Great Britain and Ireland recommendations.^4,5

5.1.2 The standard of care provided to children during sedation outside of theatre should be delivered to the same standards of care as applied to procedures performed in theatre.

5.2 The Emergency Department

Procedural sedation and analgesia in the ED should follow the recommendations from the RCoA and the RCEM.⁴

5.3 The Radiology Department

Exposure to ionising radiation should be kept to a minimum by the use of screens or lead gowns; remote slave monitors in screened viewing areas should be provided and staff should remain as distant from the imaging source as possible if they must remain in the x-ray environment.

5.4 Gastrointestinal Procedures

The complexity of endoscopic techniques is increasing and patient comorbidities are challenging to operator delivered sedation. Anaesthetic involvement may be requested for high-risk patients, or complex procedures.

High flow nasal oxygen should be available for anaesthesia -delivered sedation or general anaesthesia for endoscopic procedures.

5.5 Cardiology Procedures

Patients requiring direct current (DC) cardioversion may present as an emergency or be elective cases. The disturbance of physiological rhythm, the reduction in cardiac performance and the risk of embolic phenomena all place these patients at risk of serious complications when undergoing both anaesthesia and DC cardioversion.

6.1 All anaesthetists performing PSA should be able to demonstrate continued competency through maintenance of an appropriate level of experience, and ongoing participation in relevant continuing professional development.

6.2 Sedation techniques are frequently used in the non-theatre environment along with anaesthetic techniques. Sedation is regarded as a core competency for anaesthetic practice and training/exposure should be provided to current standards at basic, intermediate and higher levels.

Audit should be under regular review by a clinical lead and be coordinated by the Trust sedation committee.

8.1 Information regarding planned procedures and the requirement for sedation should be given to the patient in advance of their admission. Details on fasting times and medications to continue or omit should be included.

8.2 Patients meeting discharge criteria following sedation should be discharged into the care of a responsible third party. Verbal and written instructions for post-procedural care should be provided.