Procedural Sedation and Anesthesia Guidelines

Airway Management and Sedation

For high-risk procedures, procedural sedation should be used when possible, with general anesthesia reserved for cases where deep sedation would be unsafe or when medications intended for general anesthesia are required, as recommended by the American Society of Anesthesiologists 1
Patients with difficult airways, significant respiratory disease, or high aspiration risk may require general anesthesia with endotracheal intubation, and ASA physical status 3-4 patients often benefit from general anesthesia, according to the American Society of Anesthesiologists and other guidelines 2
Procedural sedation has a lower risk of aspiration compared to general anesthesia, with a reported incidence of 1:13,914 in pediatric sedation vs 1:7,103 in general anesthesia, according to the American Society of Anesthesiologists and other guidelines 2
Intravenous administration of sedatives provides shorter onset times and recovery times compared to intramuscular route, as recommended by the American Society of Anesthesiologists 1

Continuous monitoring of SpO2, ECG, NIBP, and capnography is recommended, especially for deeper levels of sedation, and availability of emergency equipment and personnel trained in airway management is essential, as stated by the American Society of Anesthesiologists 1
Standard monitoring should include ECG, SpO2, NIBP, and capnography throughout anesthesia, as recommended by the American Society of Anesthesiologists 3
Additional monitoring such as quantitative neuromuscular monitoring and processed EEG monitoring may be necessary when using certain anesthetic techniques, as suggested by the Society of Cardiovascular Anesthesiologists 3

For procedures with high risk of complications, performance in an optimal medical setting, such as an operating room or PACU, with availability of skilled personnel, including an anesthesiologist and respiratory therapist, and ICU availability for post-procedure management is recommended, according to guidelines from the American College of Chest Physicians 4

When using sedatives intended for general anesthesia, care should be consistent with general anesthesia standards, and administration of IV sedatives in small, incremental doses, allowing sufficient time between doses to assess peak effect, is recommended, as stated by the American Society of Anesthesiologists 1
Recognition that drug combinations may increase the likelihood of adverse outcomes is crucial, as reported in the European Respiratory Journal 5
Maximize non-opioid analgesics (NSAIDs, paracetamol) as part of a multimodal approach, as recommended by the American Pain Society 6
Patients with opioid dependence may require higher doses of anesthetic agents due to cross-tolerance, and should be monitored closely for respiratory depression, especially when combined with other sedatives, according to the American Society of Addiction Medicine 6

Ketamine causes a dose-dependent increase in heart rate, blood pressure, and cardiac output by stimulating the sympathetic nervous system, and generally maintains respiratory drive at standard doses, as noted by the American Society of Anesthesiologists and the American Heart Association 7, 8
Ketamine preserves protective airway reflexes better than benzodiazepine/opioid combinations, as stated by the American Academy of Emergency Medicine 7
Patients with severe hypertension, recent myocardial infarction, angina, aneurysms, or cerebrovascular disease/recent stroke should avoid ketamine due to the risk of blood pressure elevation, and those with congestive heart failure or coronary artery disease should be carefully evaluated before ketamine administration, according to the American Heart Association and the European Society of Cardiology 9, 8
Emergence reactions, including floating sensations, vivid dreams, hallucinations, and delirium, occur in 10-30% of adults and can be prevented with co-administration of midazolam, according to the National Institute of Mental Health 8

For patients with a history of intravenous drug use, alternative routes of administration such as intramuscular ketamine should be considered when intravenous access is difficult, followed by establishing peripheral, central, or intraosseous access once sedated, as recommended by the American Society of Anesthesiologists and the American College of Surgeons 10
Consider ultrasound guidance for vascular access in patients with difficult veins, as suggested by the Society of Cardiovascular Anesthesiologists 10
Maintain detailed records of all drugs administered, including name and dosage, using standardized documentation forms that conform to institutional policies, as recommended by the Joint Commission 8
Consider longer PACU observation for patients with history of substance use, and be prepared to manage acute withdrawal symptoms and potentially higher analgesic requirements, according to the American Society of Anesthesiologists 8

Report and analyze all adverse events and near-misses to improve safety, as recommended by the National Patient Safety Foundation 8
Avoiding judgment and maintaining professional care is essential for optimal outcomes in patients with a history of substance use, as emphasized by the American Medical Association 8