ASA guidelines: sedation

Except as noted, guidelines apply to both moderate and deep sedation.

1. Preprocedure evaluation Relevant history (major organ systems, sedation–anesthesia history, medications, allergies, last oral intake). Focused physical examination (to include heart, lungs, airway. Laboratory testing guided by underlying conditions and possible effect on patient management. Findings confirmed immediately before sedation.
2. Patient counseling Risks, benefits, limitations, and alternatives
3. Preprocedure fasting Elective procedures—sufficient time for gastric emptying. Urgent or emergent situations—potential for pulmonary aspiration considered in determining target level of sedation, delay of procedure, protection of trachea by intubation.

   See ASA Guidelines for Preoperative Fasting2

4. Monitoring Data to be recorded at appropriate intervals before, during, and after procedure. Pulse oximetry. Response to verbal commands when practical. Pulmonary ventilation (observation,auscultation, exhaled carbon dioxide monitoring considered when patients separated from caregiver. Blood pressure and heart rate at 5-min intervals unless contraindicated. Electrocardiograph for patients with significant cardiovascular disease.

   For deep sedation: Response to verbal commands or more profound stimuli unless contraindicated. Exhaled CO₂ monitoring considered for all patients. Electrocardiograph for all patients.

5. Personnel Designated individual, other than the practitioner performing the procedure, present to monitor the patient throughout the procedure. This individual may assist with minor interruptible tasks once patient is stable.

   For deep sedation: The monitoring individual may not assist with other tasks.

6. Training Pharmacology of sedative and analgesic agents. Pharmacology of available antagonists Basic life support skills—present. Advanced life support skills—within 5 min.

   For deep sedation: Advanced life support skills in the procedure room.

7. Emergency Equipment Suction, appropriately sized airway equipment, means of positive-pressure ventilation. Intravenous equipment, pharmacologic antagonists, and basic resuscitative medications. Defibrillator immediately available for patients with cardiovascular disease.

   For deep sedation: Defibrillator immediately available for all patients

8. Supplemental Oxygen Oxygen delivery equipment available Oxygen administered if hypoxemia occurs

   For deep sedation: Oxygen administered to all patients unless contraindicated

9. Choice of Agents Sedatives to decrease anxiety, promote somnolence. Analgesics to relieve pain.
10. Dose Titration Medications given incrementally with sufficient time between doses to assess effects Appropriate dose reduction if both sedatives and analgesics used. Repeat doses of oral medications not recommended.
11. Use of anesthetic induction agents (methohexital, propofol) Regardless of route of administration and intended level of sedation, patients should receive care consistent with deep sedation, including ability to rescue from unintended general anesthesia.
12. Intravenous Access Sedatives administered intravenously—maintain intravenous access. Sedatives administered by other routes—case-by-case decision. Individual with intravenous skills immediately available
13. Reversal Agents Naloxone and flumazenil available whenever opioids or benzodiazepines administered.
14. Recovery Observation until patients no longer at risk for cardiorespiratory depression. Appropriate discharge criteria to minimize risk of respiratory or cardiovascular depression after discharge.
15. Special Situations Severe underlying medical problems—consult with appropriate specialist if possible. Risk of severe cardiovascular or respiratory compromise or need for complete unresponsiveness to obtain adequate operating conditions—consult anesthesiologist

‡This is a summary of the Guidelines. The body of the document should be consulted for complete details