Moderate Sedation

Previously referred to as conscious sedation, moderate sedation is a drug-induced depression of consciousness in which the patient responds purposefully to verbal commands, either spontaneously or with light tactile stimulation. With moderate sedation, the patient can maintain a patent airway, protective reflexes (such as the ability to handle secretions without aspiration), adequate spontaneous ventilations, and cardiovascular function without interventions. ¹^,²

Moderate sedation is commonly administered to relieve anxiety, discomfort, or pain so that patients can tolerate unpleasant procedures. ¹ In children and uncooperative adults, it may be used to expedite procedures that aren’t particularly uncomfortable but that require the patient to remain still.

Because predicting a patient’s response to sedation isn’t always possible, health care providers must have an understanding of the different levels of sedation. (See Levels of sedation.)

In addition to the health care practitioner administering moderate sedation, this procedure requires the presence of at least one other person capable of establishing a patent airway, administering positive pressure ventilation to the patient, and summoning additional assistance if necessary. A person with advanced life support skills should be immediately available. ¹^,⁴

A patient receiving moderate sedation requires sedation monitoring before the procedure, throughout the procedure, and during the recovery period. Health care practitioners who are permitted by their scope of practice to administer moderate sedation should receive special training. ²^,⁴^,⁵^,⁶ Those administering the sedation and who are responsible for the patient’s care should understand the pharmacology of the agents as well as the role of reversal agents. Those monitoring the patient receiving moderate sedation should be able to recognize associated complications, such as apnea and airway obstruction. ¹ The health care practitioner responsible for monitoring a patient receiving moderate sedation or analgesia shouldn’t have other responsibilities that would require leaving the patient unattended or that would compromise continuous monitoring during the procedure. ²^,⁴

Some patients who require a procedure may not be appropriate candidates for moderate sedation and may require anesthesia that’s monitored by an anesthesia care provider. The American Society of Anesthesiologists (ASA) devised the ASA physical status classification system to provide a uniform guideline for evaluating the severity of systemic diseases, physiologic dysfunction, and anatomic abnormalities to determine a patient’s risk of developing complications. ⁷ (See ASA physical status classification system.) Patients classified as ASA I, ASA II, and medically stable ASA III are commonly considered appropriate for registered nurse–administered moderate sedation. ⁴

Moderate sedation is commonly administered for procedures that are performed in many settings outside the operating room, including GI procedure units, interventional radiology suites, bronchoscopy suites, emergency departments, interventional cardiology suites, and critical care units. Regardless of the location, adequately trained staff and appropriate monitoring equipment must be available to ensure the patient’s safety.

Equipment

Facility-approved sedation scale • positive pressure oxygen delivery system • supplemental oxygen administration equipment¹ • suction apparatus • suction catheter • pulse oximeter and probe • vital signs monitoring equipment • capnometer • stethoscope • cardiac monitoring equipment • disinfectant pad • emergency equipment (code cart with emergency medications, defibrillator, handheld resuscitation bag with mask, and intubation equipment)¹^,² • prescribed medications and reversal agents • Optional: gloves and other personal protective equipment, IV catheter insertion equipment.

Preparation of equipment

Make sure the room where the patient will be receiving the sedation has all the necessary equipment, including emergency care supplies. ¹^,²^,⁶ Make sure all emergency equipment is readily available and functioning properly. ⁶ Inspect all equipment and supplies to ensure that they’re in proper working order before attaching them to the patient. ¹ If a product is expired, is defective, or has compromised integrity, remove it from patient use, label it as expired or defective, and report the expiration or defect as directed by your facility.

Implementation

Avoid distractions and interruptions when preparing and administering medication to prevent medication errors.⁹^,¹⁰
Verify the practitioner’s order for the prescribed medication. ¹¹^,¹²^,¹³^,¹⁴
Review the patient’s medical record and verify documentation of preexisting medical conditions; a history of tobacco, alcohol, or substance use or abuse; previous anesthesia and sedation experiences; history of a difficult airway; current medications; allergies; frequent or repeated exposure to sedation or analgesia agents; the last time the patient ate or had oral fluids; a recent height and weight (in metric units);¹⁵ and physical examination findings, including evaluation of the airway, cardiac and respiratory assessments, and vital signs. ¹^,²^,⁴^,⁶^,¹⁶^,¹⁷

NURSING ALERT Contact the anesthesia care provider if the patient has any of the following conditions: a history of respiratory or hemodynamic instability; one or more significant comorbidities; pregnancy; sleep apnea; inability to communicate or cooperate; multiple drug allergies; multiple medications with potential for drug interactions with sedative analgesia; or current substance abuse. Extra precautions may need to be taken with these patients, including additional monitoring and medication management. ⁴

NURSING ALERT Patients with obesity have special needs during moderate sedation because they’re at increased risk for complications owing to altered physiology. Consult with the anesthesia care provider. ¹

Check the patient’s medical record for pregnancy test results, if applicable. ⁴
Confirm that written informed consent has been obtained and that the signed consent form is in the patient’s medical record. ²^,⁴^,⁶^,¹⁸^,¹⁹^,²⁰^,²¹
Conduct a preprocedure verification to make sure that all relevant documentation, related information, and equipment are available and correctly identified to the patient’s identifiers.²²^,²³
Verify that the laboratory studies have been completed as ordered and that the results are in the patient’s medical record to evaluate whether the results will affect the management of moderate sedation. Notify the practitioner of any unexpected results. ¹
Compare the medication label with the order in the patient’s medical record. ¹¹^,¹²^,¹³^,¹⁴
Check the patient’s medical record for allergy or a contraindication to the prescribed medication. If an allergy or a contraindication exists, don’t administer the medication, and notify the practitioner. ¹¹^,¹²^,¹³^,¹⁴
Check the expiration date on the medication. If the medication is expired, return it to the pharmacy and obtain new medication. ¹¹^,¹²^,¹³^,¹⁴
Visually inspect the solution for particles or discoloration or other loss of integrity; don’t administer the medication if its integrity is compromised. ¹¹^,¹²^,¹³^,¹⁴
Discuss any unresolved concerns about the medication with the patient’s practitioner. ¹¹^,¹²^,¹³^,¹⁴
Perform hand hygiene. ²⁴^,²⁵^,²⁶^,²⁷^,²⁸^,²⁹
Confirm the patient’s identity using at least two patient identifiers. ³⁰
Provide privacy. ³¹^,³²^,³³^,³⁴
Verify the scheduled invasive procedure and the correct site as stated by the patient, and compare it with the medical record. ²²
Reinforce the practitioner’s explanation of the sedation administration procedure to the patient and family (if appropriate) according to their individual communication and learning needs to increase their understanding, allay their fears, and enhance cooperation.³⁵ Answer their questions. Teach the patient and family about potential adverse reactions or other concerns related to the medication. ¹¹^,¹²^,¹³^,¹⁴
If the patient is to be discharged after receiving sedation within a time frame determined by your facility (up to 24 hours after completion of the procedure), verify that arrangements have been made to transport the patient home, and that an adult will be available in case complications arise. ¹^,²
Confirm the patient’s nothing-by-mouth status before the procedure;⁶ if the procedure is not an emergency, minimum fasting recommendations include 2 hours for clear liquids, 6 or more hours for a light meal or nonhuman milk, and 8 or more hours for fried or fatty foods or meat. If the need for the procedure is an emergency, collaborate with the practitioner to compare the risks and benefits of the procedure, considering the amount and type of liquids or solids ingested. ³⁶
Assess the patient for conditions that might make ventilation difficult, such as significant obesity, history of snoring or sleep apnea, facial hair, missing teeth, and stridor. ⁴
When the patient is in the room where sedation will be administered, perform hand hygiene. ²⁴^,²⁵^,²⁶^,²⁷^,²⁸^,²⁹
Put on gloves and other personal protective equipment as needed to comply with standard precautions.³⁷^,³⁸
Attach the patient to a pulse oximeter to monitor the patient’s oxygen saturation level. Make sure that the alarm limits are set appropriately for the patient’s current condition, and that the alarms are turned on, functioning properly, and audible to staff. ⁴^,³⁹^,⁴⁰^,⁴¹^,⁴²^,⁴³
Attach the patient to a cardiac monitor to monitor heart rate and rhythm.⁴^,³⁹ Make sure that the alarm limits are set appropriately for the patient’s current condition, and that the alarms are turned on, functioning properly, and audible to staff. ¹^,⁴⁰^,⁴¹^,⁴²^,⁴³
Attach the patient to a capnometer to continuously monitor exhaled carbon dioxide during the procedure. Make sure that the alarm limits are set appropriately for the patient’s current condition, and that alarms are turned on, functioning properly, and audible to staff. ¹^,⁴^,⁶^,³⁹^,⁴⁰^,⁴¹^,⁴²
Obtain the patient’s pulse, blood pressure, respiratory rate, exhaled carbon dioxide level by capnography, and oxygen saturation level, and assess level of consciousness (LOC), pain level, and anxiety level to use as a baseline for comparison during and after the procedure.⁴^,¹⁶
Ensure that the patient has patent IV access. If a patent IV catheter isn’t present, insert one. ¹^,⁶ (See the "IV catheter insertion and removal" procedure.)
Confirm that the procedure site has been marked appropriately by the practitioner, if indicated. Involve the patient in the process if possible. ²³^,⁴⁴
Confirm the medication dosage calculations based on the patient’s weight or body surface area.
If your facility uses a bar-code technology, use it as directed by your facility.
After the patient is prepared and draped for the procedure, conduct a time-out immediately before starting the procedure to perform a final assessment that the correct patient, site, positioning, and procedure are identified and, as applicable, all relevant information and necessary equipment are available.⁴⁵

NURSING ALERT Medications used for moderate sedation are considered high-alert medications because they can cause significant patient harm when used in error.⁴⁶^,⁴⁷

Before administering moderate sedation, have another nurse perform an independent double-check to verify the patient’s identity and to make sure that the correct medication is being administered in the prescribed concentration, the medication’s indication corresponds with the patient’s diagnosis, the dosage calculations are correct and the dosing formula used to derive the final dose is correct, and the route of administration is safe and proper for the patient.⁴⁸
Compare the results of the independent double-check with the other nurse and, if no discrepancies exist, begin administering the medication. If discrepancies exist, rectify them before administering the medication. ⁴⁸
Administer each medication separately in incremental doses and titrate it to the desired effect following safe medication administration practices to decrease the risk of overdose and respiratory and circulatory depression.⁴^,¹¹^,¹²^,¹³^,¹⁴
Continuously monitor the patient’s heart rate and rhythm (using a cardiac monitor), oxygenation (using pulse oximetry), and respiratory rate and adequacy of ventilation (using continual observation of clinical status and capnography).¹^,⁴^,⁶^,⁴⁹
Determine and evaluate the patient’s blood pressure and heart rate at least every 5 minutes. ¹^,³⁹^,⁴⁹
Monitor the patient’s LOC (by checking response to verbal commands when practical), depth of sedation (using a facility-approved sedation scale), comfort level, and skin condition at regular intervals. ¹^,⁴^,⁴⁹
Administer supplemental oxygen, as ordered, unless specifically contraindicated for the patient’s condition or the procedure. ¹ Determine the method and rate of flow using the patient’s optimal oxygen saturation level according to pulse oximetry. ⁴ Hypoxemia may cause cardiopulmonary complications.⁴
Monitor the patient’s temperature when clinically significant changes in body temperature are intended, anticipated, or suspected. ³⁹^,⁴⁹
Monitor the patient for complications; intervene as indicated. ²^,⁴⁹
When sedation administration is complete, use the same monitoring parameters used during the procedure and monitor the patient until discharge criteria are met. The patient should remain awake for at least 20 minutes without stimulation before being considered ready for discharge. The duration and frequency of monitoring should be individualized, depending on the level of sedation achieved, the patient’s overall condition, and the nature of the procedure for which sedation was administered. If a reversal agent was given, monitor the patient for a sufficient time interval (for example, 2 hours) after the last administration of an antagonist to make sure that the patient doesn’t become resedated after the reversal effects have worn off.¹^,⁴
Remove and discard your gloves and other personal protective equipment, if worn. ³⁷
Perform hand hygiene. ²⁴^,²⁵^,²⁶^,²⁷^,²⁸^,²⁹
Clean and disinfect your stethoscope using a disinfectant pad. ⁵⁰^,⁵¹
Perform hand hygiene. ²⁴^,²⁵^,²⁶^,²⁷^,²⁸^,²⁹
Document the procedure. ⁵²^,⁵³^,⁵⁴^,⁵⁵^,⁵⁶

Special considerations

The State Board of Nursing may have guidelines about the registered nurses’ role in administering moderate sedation or caring for a patient who has received moderate sedation. Check the regulations in your state.
Use a recovery and discharge criteria scoring system, such as the Aldrete Post-Anesthesia Recovery Score and the Post-Anesthesia Discharge Scoring System, to monitor the patient’s status and to help determine when the patient is ready for discharge; tailor use of the scoring system to the patient’s specific needs. ⁴
Before discharge, the patient should meet certain criteria, which may include a return to preprocedural baseline LOC and stable vital signs; a sufficient time interval (for example, 2 hours) since the last administration of an antagonist; the use of an objective patient assessment scoring system; absence of protracted nausea; intact protective reflexes (for example, gag or cough reflex); adequate pain control; and return of sensory and motor control. ⁴

Complications

The patient can become oversedated during moderate sedation. Other complications of moderate sedation include aspiration of gastric contents, respiratory depression or failure, and adverse reactions to the medication. Observe the patient for airway obstruction, respiratory depression, hypotension, and drug-specific complications.

Age and general health, in addition to such preexisting respiratory conditions as chronic obstructive pulmonary disease and asthma, and hepatic or renal dysfunction can increase the patient’s risk of adverse reactions. In general, older adults, because of decreased renal and hepatic function and relative loss of muscle, are at greater risk. Drug interactions may occur; opioids when used in combination with sedatives may produce a synergistic effect. (See Responding to complications of sedation.)

Documentation

Document according to your facility’s documentation system and stated parameters, including preprocedure assessment findings, procedure and site verification, and time-out procedure; the name, dose, route, time, and effects of all medications administered; the patient’s LOC, ventilation, and oxygenation status; and the procedure start and end times. Documentation should also include vital signs at intervals determined by the type and quantity of medication administered and the patient’s condition. ⁴ Record any adverse reactions, the date and time a practitioner was notified, prescribed interventions, and the patient’s response to the interventions. Document teaching provided to the patient and family (if applicable), their understanding of that teaching, and any need for follow-up teaching.

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section name header

Introduction ⬇

Equipment ⬆ ⬇

Preparation of Equipment ⬆ ⬇

Implementation ⬆ ⬇

Special Considerations ⬆ ⬇

Complications ⬆ ⬇

Documentation ⬆ ⬇

References ⬆