ANESTHETIC MANAGEMENT: PROCEDURAL SEDATION

LEARNING OUTCOME

After completing this chapter, the learner will be able to explain the concept of procedural
sedation.

CHAPTER OBJECTIVES

After completing this chapter, the learner will be able to:

1. Discriminate between minimal, moderate, and deep sedation and general anesthesia.
2. Identify the pharmacologic agents used to produce moderate sedation.

INTRODUCTION

Moderate, or procedural, sedation, sometimes referred to as monitored anesthesia care (MAC), is

a term used to describe a state of minimally depressed consciousness wherein the patient
independently maintains airway control and responds appropriately to physical stimulation and
verbal commands. It is a pharmacologically induced depression of consciousness, with or
without analgesia, which facilitates patient comfort and acceptance during appropriate surgical
procedures.

Most patients are concerned about pain and awareness during surgery under local anesthesia, yet
they would prefer not to undergo general anesthesia. With the judicious use of sedation and
analgesia, the patient objectives of relief of anxiety, prevention of pain, and enhanced
cooperation can be achieved with minimal risk.

Induced sedation is a continuum identified by four levels: minimal (anxiolysis), moderate

(procedural), deep, and general anesthesia (see Table 4-1). During minimal sedation, the patient
responds normally. During moderate or procedural sedation/analgesia, the patient responds
purposefully to verbal or tactile stimulation, and the airway and cardiovascular system are
maintained. In deep sedation/analgesia, the patient responds purposefully only following
repeated or painful stimulation, may lose protective reflexes, and may not be able to maintain the
airway. At the level of general anesthesia, consciousness and the ability to move are lost, the
patient is unable to respond even to painful stimulation, and he or she may not be able to
maintain the airway (American Society of Anesthesiologists, 2014a).

<TABLE 4-1 WILL BE VIEWABLE AFTER PURCHASE>

The medications, doses, and techniques used for procedural sedation are not intended to produce
unconsciousness; the goal is to use as little medication as possible to ensure the patient is as
comfortable as possible and to do so as safely as possible. Adequate sedation may be identified
by a calm demeanor, slurred speech, slowed heart rate, or reduced blood pressure. A sedated
patient whose only response is reflex withdrawal from painful stimuli is sedated beyond the level
of procedural sedation (American Society of Anesthesiologists, 2014a).

Deep sedation may be accompanied by a partial or complete loss of protective reflexes, the
inability to manage oropharyngeal secretions, or an inability to continuously maintain a patent
airway, leading to possible aspiration and hypoxia. Other complications of deep sedation include
hypotension, hypoventilation, respiratory depression, and apnea.

Used in conjunction with local or regional anesthesia, procedural sedation, when chosen
thoughtfully for appropriate surgical procedures and patients, may obviate the need for general
anesthesia and its associated physiologic effects. Patients with significant anxiety or previous
unpleasant general anesthetic experiences are candidates for this technique for ambulatory
surgery. In children and uncooperative adults, the use of procedural sedation may facilitate
diagnostic procedures that require the patient not to move. To achieve optimal patient safety and
comfort, effective communication with both the patient and surgeon is required, along with the
careful titration of sedative and analgesic drugs and the vigilant monitoring of the cardiovascular,
respiratory, and neurologic systems.

PROCEDURAL SEDATION MEDICATIONS

The desirable pharmacologic characteristics of procedural sedation include the rapid onset of
action, short duration of action, lack of cumulative effects, minimal side effects, and rapid
metabolization. Because sedation and analgesia may be required to achieve a relaxed, pain-free
state of detachment, a combination of medications is often necessary. Potential adverse effects of
these medications on airway patency, respiratory function, and hemodynamic balance should be
fully understood by the practitioner administering the medications. Adverse events during
procedural sedation may be prevented through appropriate preanesthesia assessment of the
patient, intraprocedural monitoring of physiologic function, and early intervention when adverse
effects are recognized (Tobias & Leder, 2011).

Benzodiazepines

Benzodiazepines produce dose-related sedation, anxiolytic effects, and amnesia.

Benzodiazepines have no analgesic properties. They may be used in conjunction with analgesic
medications, but the use of opioids prolongs recovery times. Patient response to this
pharmacologic category is widely variable, and drug dosage must be carefully titrated, as well as
reduced for elderly patients. When benzodiazepines are used to produce profound sedation,
amnesia may occur for events during the early postoperative recovery period. For this reason,
patient education should be provided before the procedure or given to the patient’s significant
other. It is customary for the surgeon to seek out the patient’s significant other and share the
patient’s outcomes because the surgeon knows the patient most likely will not remember any
discussions from the immediate postoperative period. Benzodiazepines can lead to adverse
effects on the respiratory system and hemodynamic function. These effects are dose dependent
and are amplified by comorbid diseases and the synergistic effect of coadministration with other
sedatives or analgesic agents such as the opioids.
Diazepam (Valium)

Diazepam has been widely used for procedural sedation and is particularly useful with regional
anesthesia because it exerts the strongest anticonvulsant effect of all the benzodiazepines by
increasing the seizure threshold for local anesthetics. When administered IV, the anesthesia care
provider should titrate the IV dosage to the desired sedative response, such as slurring of speech,
with slow administration immediately before the procedure (Hospira.com, 2015).

Diazepam should not be considered a drug of short duration. Following a period of apparent
recovery, patients can experience drowsiness for 6 to 8 hours. Ambulatory surgery patients
should be cautioned that they may feel tired for a day or more after receiving IV diazepam. With
large doses, impairment of coordination and reactive skills may persist for 10 hours. A
responsible adult should monitor the patient for at least 24 hours after surgery. The nurse should
advise the patient and significant other that the patient should not drive, operate heavy
machinery, cook, or use any apparatus that requires coordination. (For a complete description of
discharge instructions, see Chapter 9.) Pain during IV injection and possible postprocedure
phlebitis are some drawbacks patients may experience. Using larger veins and reducing the rate
of injection may help alleviate pain and sequelae.

Midazolam (Versed)

Because midazolam is prepared in an aqueous solution, it causes minimal venous irritation. It has
a faster onset of action (1 to 2 minutes) and provides more effective amnesia than diazepam.
Because midazolam does not undergo intrahepatic recirculation, drowsiness does not usually
recur after the patient recovers; however, large doses may cause prolonged drowsiness.

Midazolam’s rapid onset and redistribution have made it a popular choice for procedures
involving procedural sedation, but it should be given in small increments, with sufficient time
allowed for its effect to develop, until signs such as slurred speech and drooping eyelids occur.
Depending on the patient’s general condition, drug history, and alcohol use, response is variable.
Elderly patients may require lower doses. Respiratory depression is the most significant adverse
event associated with midazolam (Hospira.com, 2010). Renal disease or failure may lead to
prolonged sedation with midazolam due to the accumulation of a conjugated metabolite. See
Table 4-2 for more information.

Opioids

Opioids are administered for their analgesic properties. In the context of procedural sedation,
they are used to supplement other agents, such as sedative-hypnotics, to provide optimal
conditions for patients to tolerate painful procedures. Fentanyl, morphine, meperidine, and
hydromorphone may also be administered to patients during the recovery phase. Opioid selection
is often based on the medication’s onset and duration or its adverse effects (see Table 4-2).
Fentanyl (Sublimaze)

Fentanyl is widely used in ambulatory settings. After IV administration, response usually begins
immediately and lasts 30 to 60 minutes. With a redistribution half-life of 13.4 minutes, 98.6% of
the injected dose is cleared from the plasma in 60 minutes (Hospira.com, 2014, June). This rapid
clearance makes it useful for outpatient sedation.

Although fentanyl is considered appropriate for ambulatory surgery, it can produce marked
respiratory depression. Care should be taken to avoid a dosage sufficient to produce a sleeplike
state in which there is a lack of spontaneous verbalization. This sleeplike state has been
identified as one of the recurring problems found in unexpected cardiac arrests during spinal
anesthesia. Cyanosis frequently heralded the onset of cardiac arrest in patients exhibiting this
degree of sedation, which suggests that undetected respiratory insufficiency may have played an
important role.

Fentanyl is often given in combination with a benzodiazepine, which significantly increases

respiratory depression compared with either drug used alone. Appropriate monitoring is essential
for the patient’s safety. If fentanyl is injected too rapidly, chest rigidity may occur (Hospira.com,
2014, June).

Morphine Sulfate

Morphine sulfate is indicated for the relief of severe pain. An absolute contraindication to
morphine use is the presence of a pre-existing allergy or acute asthma. The most serious adverse
effects of morphine administration are related to the respiratory system and lead to
hypoventilation and hypercapnia. Other, less common adverse effects include central nervous
system (CNS) depression, psychosis, constipation, euphoria, and oliguria (Hicks, Hernandez, &
Wanzer, 2012).

Meperidine (Demerol)

Meperidine is a synthetic narcotic analgesic and is indicated for relief of moderate to severe pain.
Compared to morphine, this medication peaks faster but also dissipates faster, resulting in a
shorter duration. The most common adverse effects of meperidine include respiratory depression,
light-headedness, vertigo, sedation, nausea, vomiting, euphoria, biliary tract spasm, and urinary
retention (Hicks, Hernandez, & Wanzer, 2012).

Hydromorphone (Dilaudid)

Hydromorphone is a pure opioid agonist used for analgesia. A contraindication is gastrointestinal

obstruction because this medication decreases peristalsis. Therefore, the presence of biliary tract
or pancreatic tract disorders may preclude its use. Adverse effects of hydromorphone include
respiratory depression, hypotension, flushing, constipation, and urticaria. Hydromorphone is not
often used to treat the elderly patient population due to an increased risk for respiratory
depression. See Table 4-3 for more information.
Alfentanil (Alfenta)

The opioids alfentanil, sufentanil, and remifentanil are typically administered by an anesthesia
provider in a monitored anesthesia care situation. Their potency and potentially lethal side effects
if improperly administered or monitored make these drugs dangerous in less skilled hands.

Alfentanil is a short-acting fentanyl analog with one-quarter the potency and one-third the
duration of fentanyl. Nevertheless, large doses may result in prolonged sedation and respiratory
depression. Compared with fentanyl, alfentanil produces more hypotension and more muscular
rigidity if administered too rapidly, although fentanyl, sufentanil, and alfentanil may cause
rigidity severe enough to prevent sufficient ventilation (Hospira.com, 2004).
Sufentanil (Sufenta)

Sufentanil is shorter acting than alfentanil and extremely potent. When used in balanced general
anesthesia, sufentanil is 10 times as potent as fentanyl (Hospira.com, 2014, August). When
administered by continuous IV infusion for procedures of intermediate duration, recovery should
occur almost 50% more rapidly. However, compared with maintenance by intermittent boluses,
IV infusion may result in episodes of hypoxemia (Hospira.com, 2014, August).

Agonist-Antagonist Opioids

In an attempt to achieve analgesia with fewer side effects, agonist-antagonists such as

butorphanol (Stadol) and nalbuphine (Nubain) were developed. Administered independently, this
class of drugs produces opioid effects but antagonizes the effects of full agonists if given with
them. These agents may trigger withdrawal symptoms in patients with a history of drug abuse.

Butorphanol has an analgesic potency five times that of morphine, whereas nalbuphine is
considered equipotent to morphine. Both drugs have sedative effects as well. Their onsets of
action occur within 2 minutes after IV administration, but their durations, like those of morphine,
are long. Some studies document the recovery time of butorphanol as 1 to 2 hours and consider
the postoperative analgesia an asset. Realistically, their monitored recovery time should be 3 to 4
hours, and their use should be restricted to procedures in which considerable postoperative pain
is anticipated.

Sedative-Hypnotic Agents

These drugs, also referred to as rapid-acting IV induction agents, may be more applicable to
monitored anesthesia care (MAC). Although the term MAC is sometimes used interchangeably
with procedural sedation, as the name implies, an anesthesia provider monitors the patient, ready
to institute general anesthesia if necessary.

Propofol (Diprivan)

Propofol is classified as a sedative-hypnotic without analgesic effect or amnesic properties when

given in doses that do not produce unconsciousness. It has gained popularity because it results in
rapid recovery with few side effects. Patients quickly appear alert and clearheaded; some
experience a significant sense of well-being. Propofol is also believed to have some antiemetic
effects, and the incidence of postoperative nausea and vomiting is low.

Propofol causes less postoperative sedation, drowsiness, and confusion than midazolam, yet
when given alone, it may cause dysphoria. When midazolam is given preoperatively or at the
start of the procedure with propofol, it does not delay rapid recovery or cause additional side
effects. This combined usage allows for the rapid recovery associated with propofol as well as
midazolam’s ability to provide relief from anxiety and amnesia during the procedure.

It should be noted that propofol solution provides an excellent medium for bacterial growth.
Failure to use aseptic technique when handling propofol-injectable emulsion has been associated
with microbial contamination that led to patient harm, including fever, infection and sepsis, and
death. Propofol manufacturers state that at the end of the procedure or at 12 hours, whichever is
the soonest, both the reservoir of propofol and the infusion line must be discarded and replaced
as appropriate.

Methohexital (Brevital)

Methohexital is an ultra-short-acting barbiturate also of the group known as IV anesthetics.

Widely used as an IV induction agent to produce unconsciousness quickly, it may also be
administered by continuous infusion, which results in a reasonably short recovery period.
Because it is strongly alkaline, methohexital should be given cautiously to avoid extravasations.
Methohexital is closely related to thiopental (Pentothal), but despite its shorter recovery profile,
methohexital is more potent. Methohexital is also associated with hiccupping and muscle
twitching (Monarch Pharmaceuticals, 2007).

Ketamine (Ketalar)

Ketamine is unique because it can be administered by the intramuscular (IM) or IV route, which
makes it useful in situations in which IM administration before the procedure may be an
advantage. However, ketamine produces a dissociative state with undesirable emergent side
effects (especially in adults), such as disorientation, hypersensitivity, vivid dreams, and
tachycardia. When combined with a benzodiazepine, these psychomimetic reactions and
cardiostimulatory effects may be attenuated.

Droperidol (Inapsine)

Droperidol, a butyrophenone derivative, has been used for many years as a supplement to
surgical and diagnostic procedures. Droperidol is not recommended for any use other than
treatment of perioperative nausea and vomiting in which other treatments are known to be
ineffective or inappropriate for the patient (PDR.net, n.d.b). It provides sedation and a sense of
detachment with minimal amnesia. When combined with a narcotic, neuroleptanalgesia (i.e.,
dissociative analgesia) results. Although it does not cause significant respiratory depression,
droperidol in large doses may cause hypotension, extrapyramidal effects, and confusion.
Droperidol carries a black box warning – the most serious warning for a U.S. Food and Drug
Administration (FDA) approved drug – because of its association with fatal cardiac
dysrhythmias.

Additionally, although clinical recovery from droperidol occurs after 25 minutes, tiredness or
drowsiness persists, and tests of coordination and attention remain significantly abnormal after
10 hours. Droperidol is a potent antiemetic, and small doses may be used prophylactically to
reduce the incidence of postoperative vomiting in adults and children. Large doses, alone or in
combination with fentanyl, are generally considered inappropriate for ambulatory patients. The
sedation far outlasts the effect of the narcotic component. See Table 4-4 for more detail.
Antagonists

Naloxone (Narcan)

Naloxone reverses the central nervous system (CNS) and respiratory depressant effects of
narcotics in a dose-dependent manner by displacing opioid binding at receptor sites in the brain
and spinal column. It is usually administered IV in small, repeated doses until the desired effect
is achieved. CNS effects may be seen in 1 to 2 minutes. Naloxone is an emergency drug and
should be immediately available wherever opioids are administered.

However, the reversal procedure should be done cautiously because abrupt reversal may result in
sudden pain perception, causing hypertension and tachycardia. Caution should also be used with
patients who have cardiac disease or suspected or known narcotic dependence.

Flumazenil (Romazicon)
Flumazenil works by displacing benzodiazepines at their receptor sites. Therefore, it does not
reverse the effects of drugs that bind elsewhere, such as barbiturates, antidepressants, alcohol, or
general anesthesia. Given IV, flumazenil’s onset of action occurs in 1 to 2 minutes, with peak
effect in 6 to 10 minutes.

The half-life of flumazenil is 40 to 80 minutes (Genentech, 2010). Except for midazolam, most
benzodiazepines have a longer half-life than flumazenil, so patients should be monitored for
resedation for up to 2 hours. Pain at the injection site sometimes occurs, and flumazenil has been
associated with thrombophlebitis.

Flumazenil is effective in reversing drug-induced sedation and respiratory depression when only
benzodiazepines have been administered. In patients who have received both opioids and
benzodiazepines, flumazenil is known to reverse benzodiazepine-induced sedation; however, its
effectiveness in reversing respiratory depression under these circumstances is unclear. See Table
4-5 for more information.

SUMMARY

The ambulatory surgery nurse is familiar with pharmacologic agents used to induce and reverse
procedural sedation. Ambulatory surgery patients need education regarding expectations when
receiving procedural sedation because they may experience some level of awareness during the
procedure. This education will allow the patient to anticipate each step in the surgical care
encounter and be prepared for common effects and their duration. The use of procedural sedation
assists the patient and the ambulatory surgery team in relieving anxiety, preventing pain, and
enhancing cooperation with minimal risk.