Sedation and Anxiolysis Protocols

CONSCIOUS SEDATION

PREPROCEDURAL AND INTRAPROCEDURAL CARE

At our institution, conscious sedation is administered by either two registered nurses or anesthesia technologists under the supervision of a physician. The goals of conscious sedation are to depress only minimally the level of the patient’s consciousness, to maintain a patent airway, and to allow the patient to respond to commands. Generally, emergency equipment such as oxygen, suction, monitors, Ambu bag, mask, and resuscitation drugs should be readily available. The patient should have an empty stomach (adults: NPO 4 to 6 hours before sedation, children: NPO 2 hours before sedation). During sedation, continuous monitoring of vital signs and oxygen saturation (normally above 95%) is needed. We record vital signs and oxygen saturation every 15 minutes. The level of consciousness of a patient is also continuously evaluated and recorded every 15 minutes according to a sedation scale as follows:

Fully awake	5 points
Arouses easily	4 points
Arouses with tactile stimuli	3 points
Arouses with vigorous stimuli	2 points
Arouses with painful stimuli	1 point
Unresponsive	0 points

The following is a list of the most common drugs used for conscious sedation at our institution. This list details drugs administered intravenously. All drugs should be given slowly.

Parenteral Drugs

Pentobarbital Sodium (Nembutal)

This medication is used for sedation. It is probably the medication we use most. It results in rapid sedation given via either IV or IM routes. Its side effects include respiratory and cardiovascular depression. It should be avoided in patients with hepatic insufficiency. If given IV, its onset is immediate; when given IM, its onset is within 10 to 15 minutes. Its effect lasts 15 to 20 minutes. We do not use it in children <6 months of age.

Age

Dose

Children

2 mg/kg/dose IV (repeat dose of 1 mg/kg up to maximum of 7 mg/kg, not to exceed total of 500 mg)

2-6 mg/kg IM (maximum dose of 100 mg)

Adults

100 mg IV (repeat in equal increments up to maximum of 500 mg)

150-200 mg IM

Morphine Sulfate

This medication is used for sedation and/or severe pain. It may result in nausea/vomiting and respiratory depression. Its antagonist is naloxone. It should not be given to patients with increased intracranial pressure or respiratory depression. Its effects peak between 20 and 60 minutes and may last 3 to 5 hours.

Age	Dose
Neonates	0.05 mg/kg IV
Infants/children	0.05-0.1 mg/kg/dose (may be repeat up to maximum of 15 mg)
Adolescents	3-4 mg IV (may be repeated up to maximum of 15 mg, increments of 1.2 mg)
Adults	10 mg IV (may be repeated up to maximum of 20 mg, increments of 1-2 mg)

Fentanyl

This medication is used for pain and/or sedation. It may result in similar side effects as morphine and its antagonist is naloxone. Its onset is immediate and its effects last 30 to 60 minutes.

Age	Dose
Infants/children	1-2 µg/kg IV (may be repeated up to maximum dose of 5 mg/kg, increments of 1 µg/kg)
Adults	0.5-1 µg/kg IV

Demerol

This medication is used for patients with moderate-to-severe pain. Its side effects are similar to those of morphine and its antagonist is naloxone. Its onset is within 5 minutes of administration and its effect lasts 2 to 4 hours.

Age	Dose
Children	1-1.5 mg/kg/dose IV (maximum initial dose of 100 mg, maximum total dose of 150 mg, increments of 1 mg/kg)
Adults	50-150 mg/dose IV

Midazolam (Versed)

The medication is used for sedation. It may result in cardiac and respiratory depression. Its antagonist is Flumazenil. Its onset of action is within 1 to 5 minutes after administration and its effect lasts 2 to 6 hours.

Age	Dose
Children	0.05 mg/kg/dose IV (maximum initial dose of 2 mg, maximum total dose of 5 mg)
Adults	0.5-2 mg IV (repeat every 3 min for maximum dose of 5 mg)