Guia Asa de Anestesia General y Sedación
Guia Asa de Anestesia General y Sedación
Guia Asa de Anestesia General y Sedación
*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, Mas-
sachusetts; 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.
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.
Copyright © 2018, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. All Rights Reserved. Anesthesiology 2018; 128:437–79
Copyright © 2018, the American Society of Anesthesiologists, Inc. Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
<zdoi;10.1097/ALN.0000000000002043>
Practice Guidelines
ese guidelines specically apply to the level of seda- are limited by federal, state, or municipal regulations or
tion corresponding to moderate sedation/analgesia (pre- statutes. Because it is not always possible to predict how
viously called conscious sedation), which is dened as a a specic patient will respond to sedative and analgesic
drug-induced depression of consciousness during which medications, practitioners intending to produce a given
patients respond purposefully† to verbal commands, level of sedation should be able to rescue patients whose
either alone or accompanied by light tactile stimulation. level of sedation becomes deeper than initially intended.
No interventions are required to maintain a patent airway For moderate sedation, this implies the ability to manage
when spontaneous ventilation is adequate.‡ Cardiovascu- a compromised airway or hypoventilation, and support
lar function is usually maintained. For these guidelines, cardiovascular function in patients who become hypoten-
analgesia refers to the management of patient pain or dis- sive, hypertensive, bradycardic, or tachycardic.
comfort during and after procedures requiring moderate
sedation. Focus
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PRACTICE PARAMETERS
Task Force Members and Consultants organizations, and manual searches of references located in
ese guidelines were developed by an ASA–appointed reviewed articles.
task force of 13 members, consisting of physician anesthe- Findings from the aggregated literature are reported in
siologists in both private and academic practices from vari- the text of these guidelines by evidence category, level,
ous geographic areas of the United States, a cardiologist, a and direction. Evidence categories refer specically to the
dentist anesthesiologist, an oral/maxillofacial surgeon, a strength and quality of the research design of the stud-
radiologist, an ASA sta methodologist, and two consult- ies. Category A evidence represents results obtained from
ing methodologists for the ASA Committee on Standards randomized controlled trials (RCTs), and category B
and Practice Parameters. Conict of interest documentation evidence represents observational results obtained from
regarding current or potential nancial and other interests nonrandomized study designs or RCTs without pertinent
pertinent to the practice guideline were disclosed by all task comparison groups. When available, category A evidence
force members and managed. is given precedence over category B evidence for any par-
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Practice Guidelines
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PRACTICE PARAMETERS
Recommendations for Patient Evaluation equivocal ndings for gastric volume and pH when fasting of
• Review previous medical records and interview the liquids for 0.5 to 3 h is compared with fasting times of greater
patient or family to identify: than 3 h (category B1-E evidence).29
◦ Abnormalities of the major organ systems (e.g., Survey Findings. e consultants, ASA members, AAOMS
cardiac, renal, pulmonary, neurologic, sleep apnea, members, and ASDA members strongly agree with the
metabolic, endocrine) recommendations to (1) consult with a medical special-
◦ Adverse experience with sedation/analgesia, as well ist, when appropriate, before administration of moderate
as regional and general anesthesia procedural sedation to patients with signicant underlying
◦ History of a dicult airway conditions; (2) when feasible before the procedure, inform
◦ Current medications, potential drug interactions, patients or legal guardians of the benets, risks, and limi-
drug allergies, and nutraceuticals tations of moderate sedation/analgesia and possible alter-
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Practice Guidelines
• On the day of the procedure, assess the time and Observational studies also indicate that electrocardiogra-
nature of last oral intake phy monitoring is eective in the detection of arrhythmias,
◦ Evaluate the risk of pulmonary aspiration of gastric premature ventricular contractions, and bradycardia (cat-
contents when determining (1) the target level of egory B3-B evidence).46,49,64
sedation and (2) whether the procedure should be e literature is insucient to determine the benets of
delayed contemporaneous recording of patients’ level of conscious-
ness, respiratory function, or hemodynamics. In addition,
• In urgent or emergent situations where complete gas- the literature is insucient to evaluate whether the presence
tric emptying is not possible, do not delay moderate of an individual dedicated to patient monitoring will reduce
procedural sedation based on fasting time alone adverse outcomes related to moderate sedation/analgesia.
Patient Monitoring Survey Findings. e consultants, ASA members, AAOMS
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PRACTICE PARAMETERS
Monitoring Patient Ventilation and Oxygenation Availability of an Individual Responsible for Patient
• Continually*** monitor ventilatory function by obser- Monitoring
vation of qualitative clinical signs • Assure that a designated individual other than the
• Continually monitor ventilatory function with cap- practitioner performing the procedure is present to
nography unless precluded or invalidated by the monitor the patient throughout the procedure
nature of the patient, procedure, or equipment
◦ e individual responsible for monitoring the
◦ For uncooperative patients, institute capnography patient should be trained in the recognition of
after moderate sedation has been achieved apnea and airway obstruction and be authorized to
• Continuously monitor all patients by pulse oximetry seek additional help
with appropriate alarms ◦ e designated individual should not be a member
of the procedural team but may assist with minor,
Monitoring Hemodynamics interruptible tasks once the patient’s level of seda-
• Determine blood pressure before sedation/analge- tion/analgesia and vital signs have stabilized, pro-
sia is initiated unless precluded by lack of patient vided that adequate monitoring for the patient’s
cooperation level of sedation is maintained
• Once moderate sedation/analgesia is established,
continually monitor blood pressure (e.g., at 5-min Supplemental Oxygen
intervals) and heart rate during the procedure unless Literature Findings. Meta-analysis of RCTs indicate that the
such monitoring interferes with the procedure (e.g., use of supplemental oxygen versus no supplemental oxygen
magnetic resonance imaging where stimulation from is associated with a reduced frequency of hypoxemia‡‡‡ dur-
the blood pressure cu could arouse an appropriately ing procedures with moderate sedation (category A1-B evi-
sedated patient) dence).65–71 e literature is insucient to examine which
• Use electrocardiographic monitoring during moderate methods of supplemental oxygen administration (e.g., nasal
sedation in patients with clinically signicant cardio- cannula, face mask, or specialized devices) are more eective
vascular disease or those who are undergoing proce- in reducing hypoxemia.
dures where dysrhythmias are anticipated
Survey Findings. e consultants, ASA members, AAOMS
members, and ASDA members strongly agree with the rec-
##A response limited to reex withdrawal from a painful stimu-
lus is not considered a purposeful response and thus represents a ommendation to use supplemental oxygen during moderate
state of general anesthesia. procedural sedation/analgesia unless specically contraindi-
***The term continual is dened as “repeated regularly and cated for a particular patient or procedure.
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. †††For rare uncooperative patients (e.g., children with autism
Approved by the ASA House of Delegates October 21, 1986, and spectrum disorder or attention decit disorder), recording oxy-
last amended October 28, 2015. Available at: http://www.asahq. genation status or blood pressure may not be possible until after
org/quality-and-practice-management/practice-guidance-resource- sedation.
documents/standards-for-basic-anesthetic-monitoring. Accessed on ‡‡‡Reported by authors as oxygen desaturation to at most 95%
August 21, 2017). or oxygen desaturation more than 5 or 10% below baseline.
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Practice Guidelines
Recommendations for Supplemental Oxygen able to recognize the need for additional support and know
• Use supplemental oxygen during moderate procedural how to access emergency services from the procedure room.
sedation/analgesia unless specically contraindicated
for a particular patient or procedure Recommendations for Emergency Support §§§
• Assure that pharmacologic antagonists for benzodi-
Emergency Support azepines and opioids are immediately available in the
Emergency support strategies include (1) the presence of procedure suite or procedure room║║║
pharmacologic antagonists; (2) the presence of age and • Assure that an individual is present in the room who
weight appropriate emergency airway equipment (e.g., dif- understands the pharmacology of the sedative/analge-
ferent types of airway devices, supraglottic airway devices); sics administered (e.g., opioids and benzodiazepines)
(3) the presence of an individual capable of establishing a and potential interactions with other medications and
patent airway and providing positive pressure ventilation and nutraceuticals the patient may be taking
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PRACTICE PARAMETERS
unitrazepam, lorazepam, or temazapam) and dexmedeto- ndings for sedation time, duration of the procedure, and
midine. Analgesics administered with sedatives include opi- the frequency of rescue doses of midazolam administered
oids such as fentanyl, alfentanil, remifentanil, meperidine, (category A3-E evidence).93
morphine, and nalbuphine. is section of the guidelines One RCT comparing titration (i.e., administration of
addresses the following topics: (1) benzodiazepines and small, incremental doses of intravenous midazolam com-
dexmedetomidine, (2) sedative/opioid combinations, (3) bined with meperidine until the desired level of sedation
intravenous versus nonintravenous sedatives/analgesics not and/or analgesia is achieved) of midazolam combined with
intended for general anesthesia,### and (4) titration of seda- an opioid compared with a single, rapid bolus reports higher
tives/analgesics not intended for general anesthesia. total physician times, medication dosages, frequencies of
hypoxemia, and somnolence scores for titration (category
Literature Findings. Meta-analysis of RCTs comparing A3-H evidence).94
midazolam combined with opioids versus midazolam alone
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Practice Guidelines
• In patients receiving intravenous medications for seda- RCTs comparing propofol versus benzodiazepines combined
tion/analgesia, maintain vascular access throughout with opioid analgesics report shorter sedation and recovery
the procedure and until the patient is no longer at risk times for propofol alone (category A2-B evidence),105,106
for cardiorespiratory depression with equivocal ndings for pain, oxygen saturation levels,
• In patients who have received sedation/analgesia by and blood pressure (category A2-E evidence).107–109 (3) RCTs
nonintravenous routes or whose intravenous line has comparing propofol combined with benzodiazepines versus
become dislodged or blocked, determine the advis- propofol alone report equivocal ndings for recovery and
ability of reestablishing intravenous access on a case- procedure times, pain with injection, and restlessness (cat-
by-case basis egory A2-E evidence).110–112 One RCT comparing propo-
• Administer intravenous sedative/analgesic drugs in fol combined with midazolam versus propofol alone reports
small, incremental doses, or by infusion, titrating to deeper sedation levels and more episodes of deep sedation
the desired endpoints for the combination group (category A3-H evidence).112
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PRACTICE PARAMETERS
depth of sedation for ketamine (category A3-B evidence), midazolam reports equivocal ndings for sedation time,
with equivocal ndings for recall, pain scores and frequency recovery agitation, and duration of the procedure (category
of hypoxemia (category A3-E evidence).146 (4) RCTs com- A3-E evidence).148
paring ketamine combined with midazolam versus ketamine Observational studies reporting titrated administra-
alone or midazolam alone report equivocal ndings for seda- tion of sedatives intended for general anesthesia report
tion scores, sedation time, recovery, and recovery agitation the frequency of hypoxemia ranging from 1.7 to 4.7% of
(category A2-E evidence).143,147,148 (5) One RCT comparing patients,14,160–163 with oversedation occurring in 0.13%-
ketamine combined with midazolam versus midazolam com- 0.2% of patients.14,161
bined with alfentanil reports a lower frequency of hypoxemia
(category A3-B evidence) and increased disruptive move- Survey Findings. e consultants, ASA members, AAOMS
ments, longer recovery times, and longer times to discharge members, and ASDA members strongly agree with the
for ketamine combined with midazolam (category A3-H recommendations to (1) provide care consistent with that
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Practice Guidelines
• When drugs intended for general anesthesia are • If patients develop hypoxemia, signicant hypoventi-
administered by nonintravenous routes (e.g., oral, rec- lation or apnea during sedation/analgesia: (1) encour-
tal, intramuscular, transmucosal), allow sucient time age or physically stimulate patients to breathe deeply,
for absorption and peak eect of the previous dose to (2) administer supplemental oxygen, and (3) provide
occur before supplementation is considered positive pressure ventilation if spontaneous ventilation
is inadequate
Reversal Agents: Naloxone and Flumazenil • Use reversal agents in cases where airway control,
Literature Findings. One placebo-controlled RCT reports spontaneous ventilation or positive pressure ventila-
that naloxone eectively reverses the eects of meperidine tion are inadequate
as measured by increasing alertness scores and respiratory ◦ Administer naloxone to reverse opioid-induced
rate (category A3-B evidence).164 Reversal of respiratory sedation and respiratory depression║║║║
depression, apnea, and oxygen desaturation after naloxone ◦ Administer umazenil to reverse benzodiazepine-
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PRACTICE PARAMETERS
Recommendations for Recovery Care • Review previous medical records and interview the
patient or family to identify:
• After sedation/analgesia, observe and monitor patients
in an appropriately staed and equipped area until ◦ Abnormalities of the major organ systems (e.g.,
they are near their baseline level of consciousness and cardiac, renal, pulmonary, neurologic, sleep apnea,
are no longer at increased risk for cardiorespiratory metabolic, endocrine)
depression ◦ Adverse experience with sedation/analgesia, as well
• Monitor oxygenation continuously until patients are as regional and general anesthesia
no longer at risk for hypoxemia ◦ History of a dicult airway
• Monitor ventilation and circulation at regular inter- ◦ Current medications, potential drug interactions,
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Practice Guidelines
• Before the procedure, inform patients or legal guard- • Continually monitor ventilatory function with cap-
ians of the benets, risks, and limitations of moderate nography unless precluded or invalidated by the
sedation/analgesia and possible alternatives, and elicit nature of the patient, procedure, or equipment
their preferences‡ ◦ For uncooperative patients, institute capnography
• Inform patients or legal guardians before the day of after moderate sedation has been achieved
the procedure that they should not drink uids or eat
solid foods for a sucient period of time to allow for • Continuously monitor all patients by pulse oximetry
gastric emptying before the procedure§ with appropriate alarms
• On the day of the procedure, assess the time and
nature of last oral intake Monitoring Hemodynamics
◦ Evaluate the risk of pulmonary aspiration of gastric • Determine blood pressure before sedation/analge-
contents when determining (1) the target level of sia is initiated unless precluded by lack of patient
‡This may not be feasible for urgent or emergency procedures. Availability of an Individual Responsible for Patient
§See table 3 and/or refer to: American Society of Anesthesiolo- Monitoring
gists: Practice guidelines for preoperative fasting and the use of
pharmacologic agents to reduce the risk of pulmonary aspiration: • Assure that a designated individual other than the
Application to healthy patients undergoing elective procedures: An practitioner performing the procedure is present to
updated report. ANESTHESIOLOGY 2017; 126:376–93
monitor the patient throughout the procedure
║A response limited to reex withdrawal from a painful stimu-
lus is not considered a purposeful response and thus represents a ◦ e individual responsible for monitoring the
state of general anesthesia. patient should be trained in the recognition of
#The term “continual” is dened as “repeated regularly and fre- apnea and airway obstruction and be authorized to
quently in steady rapid succession” whereas “continuous” means
“prolonged without any interruption at any time” (see Standards for seek additional help
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:// **For rare uncooperative patients (e.g., children with autism spec-
www.asahq.org/quality-and-practice-management/standards-and- trum disorder or attention decit disorder) recording oxygenation
guidelines/search?q=basic anesthesia monitoring). status or blood pressure may not be possible until after sedation.
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PRACTICE PARAMETERS
◦ e designated individual may assist with minor, Sedative or Analgesic Medications Not Intended for
interruptible tasks once the patient’s level of seda- General Anesthesia
tion/analgesia and vital signs have stabilized, pro- • Combinations of sedative and analgesic agents may be
vided that adequate monitoring for the patient’s administered as appropriate for the procedure and the
level of sedation is maintained condition of the patient‡‡
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Practice Guidelines
• In patients who have received sedative/analgesic medi- • Monitor ventilation and circulation at regular intervals (e.g.,
cations intended for general anesthesia by nonintra- every 5 to 15 min) until patients are suitable for discharge
venous routes or whose intravenous line has become • Design discharge criteria to minimize the risk of central
dislodged or blocked, determine the advisability of nervous system or cardiorespiratory depression after
reestablishing intravenous access on a case-by-case basis discharge from observation by trained personnel║║
• Administer intravenous sedative/analgesic medications
intended for general anesthesia in small, incremental Creation and Implementation of Patient Safety Processes
doses, or by infusion, titrating to the desired endpoints • Create and implement a quality improvement process based
◦ Allow sucient time to elapse between doses so the upon established national, regional, or institutional report-
peak eect of each dose can be assessed before sub- ing protocols (e.g., adverse events, unsatisfactory sedation)
sequent drug administration
◦ Periodically update the quality improvement process
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PRACTICE PARAMETERS
▪ Patients who do not respond purposefully to verbal ▪ Oral and maxillofacial surgery suite
or tactile stimulation (e.g., stroke victims, neonates) ▪ Cardiac catheterization laboratory
▪ Patients in whom determining the level of seda- ▪ Oncology clinics
tion interferes with the procedure ▪ Electrophysiology laboratory
▪ Interventional radiology laboratory
Procedures ▪ Neurointerventional laboratory
• Inclusion criteria: ▪ Echocardiology laboratory
◦ Elective and urgent/emergent procedures ▪ Evoked auditory testing laboratory
◦ Diagnostic and therapeutic procedures • Exclusion criteria: (none indicated)
▪ Principal procedures (e.g., upper endoscopy, colo-
noscopy, radiology, ophthalmology, cardiology, Providers
dentistry, plastics, orthopedic, urology, podiatry)
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Practice Guidelines
▪ Focused physical examination (e.g., heart, lungs, ◦ Sedative or analgesic medications not intended for
airway) general anesthesia
▪ Consultation with a medical specialist (e.g., physi- ▪ Sedatives (all routes of administration)
cian anesthesiologist, cardiologist, endocrinologist, ▫ Benzodiazepines
pulmonologist, nephrologist, obstetrician) ▫ Dexmedetomidine versus other sedatives or
▪ Preparation of the patient (e.g., preprocedure analgesics
instruction, medication usage, counseling, ▪ Sedative/opioid combinations (all routes of
fasting) administration)
◦ Patient monitoring ▫ Benzodiazepines combined with opioids ver-
▪ Level of consciousness (e.g., responsiveness) sus benzodiazepines
▪ Breathing/ventilation ▫ Benzodiazepines combined with opioids ver-
sus opioids
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PRACTICE PARAMETERS
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Practice Guidelines
▪ Hemodynamic support or rescue required Results for each pertinent outcome were summarized, and
▪ Assistance request when sucient numbers of RCTs were found, study grading
▪ Neurologic injury and meta-analyses were conducted. e literature relating to six
▪ Death evidence linkages contained enough studies with well dened
experimental designs and statistical information to conduct for-
Evidence Collection mal meta-analyses. ese seven evidence linkages are: (1) cap-
• Literature inclusion criteria: nography versus blinded capnography, (2) supplemental oxygen
◦ Randomized controlled trials versus no supplemental oxygen, (3) midazolam combined with
◦ Prospective nonrandomized comparative studies opioids versus midazolam alone, (4) propofol versus midazolam,
(e.g., quasiexperimental, cohort) (5) umazenil versus placebo for benzodiazepine reversal, and
◦ Retrospective comparative studies (e.g., (6) umazenil versus placebo for reversal of benzodiazepines
case-control) combined with opioids (table 6). Fixed and random-eects
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PRACTICE PARAMETERS
Consultants were asked to indicate which, if any, of the 5. Müller S, Prolla JC, Maguilnik I, Breyer HP: Predictive factors
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Practice Guidelines
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PRACTICE PARAMETERS
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Practice Guidelines
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Rochat T, Diaper J, Bridevaux PO, Tschopp JM: Titrated azolam and propofol, titrated to moderate sedation, for
sedation with propofol or midazolam for exible bronchos- colonoscopy: A randomized controlled trial. Dig Dis Sci
copy: A randomised trial. Eur Respir J 2009; 34:1277–83 2012; 57:2385–93
97. Hari Keerthy P, Balakrishna R, Srungeri KM, Singhvi N, 113. Holas A, Krafft P, Marcovic M, Quehenberger F: Remifentanil,
John J, Islam M: Comparitive evaluation of propofol and propofol or both for conscious sedation during eye sur-
midazolam as conscious sedatives in minor oral surgery. J gery under regional anaesthesia. Eur J Anaesthesiol 1999;
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PRACTICE PARAMETERS
128. Kuyrukluyıldız U, Binici O, Onk D, Ayhan Celik S, Torun pediatric dental patients: A triple blind randomized cross-
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129. Lee CK, Lee SH, Chung IK, Lee TH, Park SH, Kim EO, Lee 2001; 18:30–3
SH, Kim HS, Kim SJ: Balanced propofol sedation for thera- 145. Lee JH, Kim K, Kim TY, Jo YH, Kim SH, Rhee JE, Heo CY,
peutic GI endoscopic procedures: A prospective, random- Eun SC: A randomized comparison of nitrous oxide ver-
ized study. Gastrointest Endosc 2011; 73:206–14 sus intravenous ketamine for laceration repair in children.
130. Levitzky BE, Lopez R, Dumot JA, Vargo JJ: Moderate seda- Pediatr Emerg Care 2012; 28:1297–301
tion for elective upper endoscopy with balanced propofol 146. Jamal SM, Fathil SM, Nidzwani MM, Ismail AK, Yatim FM:
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Practice Guidelines
for post-procedure physiologic monitoring. Emerg Med 174. Holloway AM, Logan DA: The use of umazenil to reverse
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PRACTICE PARAMETERS
Table 1. Continuum of Depth of Sedation, Denition of General Anesthesia, and Levels of Sedation/Analgesia
Moderate
Minimal Sedation Sedation/Analgesia Deep
(Anxiolysis) (Conscious Sedation) Sedation/Analgesia General Anesthesia
Responsiveness Normal response to Purposeful* response to Purposeful* response Unarousable, even with
verbal stimulation verbal or tactile after repeated or painful stimulus
stimulation painful stimulation
Airway Unaffected No intervention required Intervention may be Intervention often
required required
Spontaneous ventilation Unaffected Adequate May be inadequate Frequently inadequate
Cardiovascular function Unaffected Usually maintained Usually maintained May be impaired
Minimal Sedation (Anxiolysis) indicates a drug-induced state during which patients respond normally to verbal commands. Although cognitive function
Positive pressure ventilation, with or without tracheal intubation, may be necessary if respiratory compromise develops during seda-
tion/analgesia. This may be more difcult in patients with atypical airway anatomy. Also, some airway abnormalities may increase the
likelihood of airway obstruction during spontaneous ventilation. Some factors that may be associated with difculty in airway manage-
ment are listed below.
History
• Previous problems with anesthesia or sedation
• Stridor, snoring, or sleep apnea
• Advanced rheumatoid arthritis
• Chromosomal abnormality (e.g., trisomy 21)
Physical examination
• Habitus: signicant obesity (especially involving the neck and facial structures)
• Head and neck: short neck, limited neck extension, decreased hyoid-mental distance (< 3 cm in an adult), neck mass, cervical
spine disease or trauma, tracheal deviation, dysmorphic facial features (e.g., Pierre–Robin syndrome)
• Mouth: small opening (< 3 cm in an adult); edentulous; protruding incisors; loose or capped teeth; dental appliances; high, arched
palate; macroglossia; tonsillar hypertrophy; nonvisible uvula
• Jaw: micrognathia, retrognathia, trismus, signicant malocclusion
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Practice Guidelines
Table 3. Summary of American Society of Anesthesiologists Table 4. Emergency Equipment for Sedation and Analgesia
Recommendations for Preoperative Fasting and Use of
Pharmacologic Agents to Reduce the Risk of Pulmonary Intravenous equipment (age- and size-appropriate)
Aspiration: Application to Healthy Patients Undergoing Elective • Gloves
Procedures • Tourniquets
• Alcohol wipes
Recommendation
• Sterile gauze pads
Ingested material • Intravenous catheters
Clear liquids† 2-h minimum fasting period* • Intravenous tubing
Breast milk 4-h minimum fasting period* • Intravenous uid
Infant formula 6-h minimum fasting period* • Assorted needles for drug aspiration, intramuscular injection
Nonhuman milk‡ 6-h minimum fasting period* • Intraosseous access kit
Light meal§ 6-h minimum fasting period* • Appropriately sized syringes
Fried foods, fatty foods, Additional fasting time (e.g., 8 h or • Tape
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PRACTICE PARAMETERS
General principles
• Medical supervision of recovery and discharge after moderate sedation is the responsibility of the operating practitioner or a
licensed physician.
• The recovery area should be equipped with or have direct access to age and size appropriate monitoring and resuscitation equipment.
• Patients receiving moderate sedation should be monitored until appropriate discharge criteria are satised. The duration and fre-
quency of monitoring should be individualized depending upon the level of sedation achieved, the overall condition of the patient,
and the nature of the intervention for which sedation/analgesia was administered. Oxygenation should be monitored until patients
are no longer at risk for respiratory depression.
• Level of consciousness, vital signs, and oxygenation (when indicated) should be recorded at regular intervals.
• A nurse or other individual trained to monitor patients and recognize complications should be in attendance until discharge criteria
are fullled.
• An individual capable of managing complications (e.g., establishing a patent airway, administering a reversal medication when
appropriate, and providing positive pressure ventilation) should be immediately available until discharge criteria are fullled.
Each patient-care facility in which sedation/analgesia is administered should develop recovery and discharge criteria that are suitable for its specic patients
and procedures. Some of the basic principles that might be incorporated in these criteria are enumerated in the table.
*Drugs with long durations of action (e.g., chloral hydrate, intramuscular pentobarbital, phenothiazines) will require longer periods of observation even after
the child achieves currently used recovery and discharge criteria. This concept is particularly important for infants and toddlers transported in car safety
seats who are at risk of resedation after discharge because of residual prolonged drug effects with the potential for airway obstruction.
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Practice Guidelines
Odds Odds
Evidence Linkages* N† Ratio (CI)‡ Z Value P Value Ratio (CI)§ Z Value P Value Heterogeneity‖
Patient monitoring
(capnography versus
blinded capnography)
Hypoxemia (O2 < 90%)30–34 6 0.68 (0.51–0.90) –3.53 < 0.001 0.70 (0.47–1.02) –2.44 0.015 0.110
Supplemental oxygen
(supplemental oxygen
vs. placebo)
Hypoxemia (O2 < 95%)65–71 7 0.15 (0.09–0.24) –10.49 < 0.001 0.24 (0.07–0.81) –3.01 < 0.001 < 0.001
Sedative/analgesics not
intended for general
Statistics for individual studies and forest plots are available as supplemental digital content 4, http://links.lww.com/ALN/B596.
*Evidence linkage with references for included studies.
†Number of studies included in the meta-analysis.
‡Mantel–Haenszel or Peto xed-effects analysis (99% CI); using Comprehensive Meta-analysis software, version 3.3.070, November 20, 2014. Licensed to
Richard T. Connis, Ph.D., March 20, 2017.
§DerSimonian–Laird random-effects analysis (99% CI), using Comprehensive Meta-analysis software version 3.3.070, November 20, 2014. Licensed to
Richard T. Connis, Ph.D., March 20, 2017.
‖Statistical signicance values for homogeneity/heterogeneity of effect size; a P value of < 0.01 indicates that the studies are signicantly heterogeneous.
#Double-blind studies only.
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PRACTICE PARAMETERS
Strongly Strongly
N* Agree Agree Equivocal Disagree Disagree
Patient evaluation
1. Review previous medical records and interview the patient or family 129 87.6* 10.1 2.3 0.0 0.0
2. Conduct a focused physical examination of the patient 129 86.0* 13.2 0.8 0.0 0.0
3. Review available laboratory test results and order additional labo- 129 71.3* 21.7 6.2 0.8 0.0
ratory tests when needed
4. If possible, perform the preprocedure evaluation well enough in 129 35.7 35.7* 19.4 4.7 4.7
advance (e.g., several days to weeks) to allow for proper patient
preparation
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Practice Guidelines
Table 7. (Continued).
Strongly Strongly
N* Agree Agree Equivocal Disagree Disagree
22. The individual responsible for monitoring the patient should be 127 87.4* 11.8 0.0 0.8 0.0
trained in the recognition of apnea and airway obstruction and be
empowered to seek additional help
23. The designated individual may assist with minor, interruptible 127 47.2 30.7* 10.2 9.4 2.4
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
Supplemental oxygen
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PRACTICE PARAMETERS
Table 7. (Continued)
Strongly Strongly
N* Agree Agree Equivocal Disagree Disagree
42. Assure that practitioners administering these drugs are able 122 87.7* 9.8 0.8 0.8 0.8
to reliably rescue patients from unintended deep sedation or
general anesthesia
43. For patients receiving intravenous sedatives intended for general 123 85.4* 9.8 1.6 1.6 1.6
anesthesia, maintain vascular access throughout the procedure
and until the patient is no longer at risk for cardiorespiratory
depression
44. In patients who have received sedatives intended for general anesthe- 121 51.2* 24.8 4.1 13.2 6.6
*N = the number of consultants who responded to each item. An asterisk beside a percentage score in the columns to the right indicates the median.
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Practice Guidelines
Strongly Strongly
N* Agree Agree Equivocal Disagree Disagree
Patient evaluation
1. Review previous medical records and interview the patient or 444 91.0* 7.0 1.4 0.5 0.2
family
2. Conduct a focused physical examination of the patient 445 85.2* 13.5 0.9 0.2 0.2
3. Review available laboratory test results and order additional 441 77.6* 19.0 2.7 0.2 0.5
laboratory tests when needed
4. If possible, perform the preprocedure evaluation well enough 441 37.6 34.7* 18.4 7.0 2.3
in advance (e.g., several days to weeks) to allow for proper
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PRACTICE PARAMETERS
Table 8. (Continued)
Strongly Strongly
N* Agree Agree Equivocal Disagree Disagree
22. The individual responsible for monitoring the patient should be 416 93.8* 5.0 0.2 0.0 1.0
trained in the recognition of apnea and airway obstruction and
be empowered to seek additional help
23. The designated individual may assist with minor, interruptible 418 32.5 28.0* 12.0 17.0 10.5
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
Supplemental oxygen
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Practice Guidelines
Table 8. (Continued)
Strongly Strongly
N* Agree Agree Equivocal Disagree Disagree
42. Assure that practitioners administering these drugs are able to 404 94.1* 4.5 0.5 0.0 1.0
reliably rescue patients from unintended deep sedation/general
anesthesia
43. For patients receiving intravenous sedatives intended for 399 93.7* 5.8 0.0 0.0 0.5
general anesthesia, maintain vascular access throughout the
procedure and until the patient is no longer at risk for cardi-
orespiratory depression
44. In patients who have received sedatives intended for general 401 57.4* 20.2 2.7 9.5 10.2
*N = the number of consultants who responded to each item. An asterisk beside a percentage score in the columns to the right indicates the median.
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PRACTICE PARAMETERS
Table 9. American Association of Oral and Maxillofacial Surgeons Member Survey Responses
Strongly Strongly
N* Agree Agree Equivocal Disagree Disagree
Patient evaluation
1. Review previous medical records and interview the 68 82.4* 16.2 1.5 0.0 0.0
patient or family
2. Conduct a focused physical examination of the patient 68 80.9* 17.6 1.5 0.0 0.0
3. Review available laboratory test results and order addi- 68 76.5* 17.6 5.9 0.0 0.0
tional laboratory tests when needed
4. If possible, perform the preprocedure evaluation well 67 53.7* 28.4 9.0 9.0 0.0
enough in advance (e.g., several days to weeks) to allow
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Practice Guidelines
Table 9. (Continued)
Strongly Strongly
N* Agree Agree Equivocal Disagree Disagree
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PRACTICE PARAMETERS
Table 9. (Continued)
Strongly Strongly
N* Agree Agree Equivocal Disagree Disagree
38. In patients receiving intravenous medications for seda- 64 85.9* 14.1 0.0 0.0 0.0
tion/analgesia, maintain vascular access throughout the
procedure and until the patient is no longer at risk for
cardiorespiratory depression
39. In patients who have received sedation/analgesia by 63 66.7* 31.7 1.6 0.0 0.0
nonintravenous routes or whose intravenous line has
become dislodged or blocked, determine the advisabil-
ity of establishing or reestablishing intravenous access
(Continued )
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Practice Guidelines
Table 9. (Continued)
Strongly Strongly
N* Agree Agree Equivocal Disagree Disagree
Recovery care
55. After sedation/analgesia, observe and monitor patients 63 84.1* 15.9 0.0 0.0 0.0
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
56. Monitor oxygenation continuously until patients are no 63 85.7* 14.3 0.0 0.0 0.0
longer at risk for hypoxemia
57. Monitor ventilation and circulation at regular intervals 64 73.4* 21.9 4.7 0.0 0.0
*N = the number of consultants who responded to each item. An asterisk beside a percentage score in the columns to the right indicates the median.
Strongly Strongly
N* Agree Agree Equivocal Disagree Disagree
Patient evaluation
1. Review previous medical records and interview the 104 89.4* 10.6 0.0 0.0 0.0
patient or family
2. Conduct a focused physical examination of the patient 104 87.5* 12.5 0.0 0.0 0.0
3. Review available laboratory test results and order addi- 104 72.1* 24.0 3.8 0.0 0.0
tional laboratory tests when needed
4. If possible, perform the preprocedure evaluation well 104 55.8* 30.8 9.6 2.9 1.0
enough in advance (e.g., several days to weeks) to allow
for proper patient preparation
5. Re-evaluate the patient immediately before the procedure 104 83.7* 16.3 0.0 0.0 0.0
Preprocedure patient preparation
6. Consult with a medical specialist, when appropriate, 104 81.7* 13.5 4.8 0.0 0.0
before administration of moderate procedural sedation to
patients with signicant underlying conditions
7. When feasible before the procedure, inform patients or 104 85.6* 12.5 1.9 0.0 0.0
legal guardians of the benets, risks, and limitations of
moderate sedation/analgesia and possible alternatives,
and elicit their preferences
8. Before the day of the procedure, inform patients or legal 104 94.2* 5.8 0.0 0.0 0.0
guardians that they should not drink uids or eat solid
foods for a sufcient period of time to allow for gastric
emptying
9. On the day of the procedure, assess the time and nature 104 93.3* 6.7 0.0 0.0 0.0
of last oral intake
10. In urgent or emergent situations where complete gastric 103 16.5 35.0* 21.4 13.6 13.6
emptying is not possible, do not delay moderate proce-
dural sedation based on fasting time alone
(Continued )
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PRACTICE PARAMETERS
Strongly Strongly
N* Agree Agree Equivocal Disagree Disagree
(Continued )
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Practice Guidelines
Strongly Strongly
N* Agree Agree Equivocal Disagree Disagree
27. Assure that appropriately sized equipment for establish- 94 92.6* 7.4 0.0 0.0 0.0
ing a patent airway is available
28. Assure that at least one individual capable of establish- 93 95.7* 3.2 0.0 0.0 1.1
ing a patent airway and providing positive pressure
ventilation is present in the procedure room
29. Assure that suction, advanced airway equipment, posi- 94 94.7* 4.3 1.1 0.0 0.0
tive pressure ventilation, and supplemental oxygen are
immediately available in the procedure room and in good
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PRACTICE PARAMETERS
Strongly Strongly
N* Agree Agree Equivocal Disagree Disagree
45. Administer intravenous sedative/analgesic drugs 90 65.6* 12.2 5.6 5.6 11.1
intended for general anesthesia in small, incremental
doses, or by infusion, titrating to the desired endpoints
Reversal agents
46. Assure that specic antagonists are immediately available 90 82.2* 14.4 1.1 2.2 0.0
in the procedure room whenever opioid analgesics or ben-
zodiazepines are administered for moderate procedural
sedation/analgesia regardless of administration route
*N = the number of consultants who responded to each item. An asterisk beside a percentage score in the columns to the right indicates the median.
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