Sedation and Anxiety Management

Pre-Procedure Preparation

The American Society of Anesthesiologists recommends having suction, supplemental oxygen, and airway management equipment immediately available, and ensuring at least one team member is trained in recognition and management of airway complications 1
Patients should rinse with chlorhexidine 0.12%-0.20% mouthwash for 3 minutes before the procedure, and topical anesthesia can be considered to reduce injection pain, as recommended by the American Dental Association 2
Vital signs should be checked before and during the procedure, as suggested by the American Heart Association 2

Oral diazepam is recommended at 5-10 mg, 30-60 minutes prior to the procedure, for adults requiring anxiety management, by the American Gastroenterological Association 3
Midazolam is an alternative, with a recommended dose of 0.5-1 mg/kg orally (max 15 mg), 30-60 minutes before the procedure, preferred for shorter procedures due to its shorter half-life, as suggested by the American Gastroenterological Association 3
Diazepam dosing is recommended at 0.1-0.8 mg/kg body weight, with no renal impairment adjustment, while midazolam dosing is 0.5-1 mg/kg, with a maximum of 15 mg, and reduced to 5 mg if eGFR <30 mL/minute, according to 2, 4
The maximum daily dose of lorazepam should not exceed 4 mg in 24 hours, as recommended by the British Medical Journal 4
Elderly or debilitated patients require lower doses of sedatives, with a recommended dose of 0.25-0.5 mg for lorazepam, due to increased sensitivity and risk of cognitive impairment, delirium, and falls, as recommended by the British Medical Journal 4
Long-acting benzodiazepines should be avoided in elderly patients or for outpatient procedures to prevent prolonged recovery, as advised against by the World Journal of Emergency Surgery guidelines 5
Elderly patients should use lower doses of benzodiazepines, reduced by 50%, due to increased sensitivity, as recommended by the American Geriatrics Society 6

Combining diazepam with opioids increases the risk of respiratory depression, as noted by the American Gastroenterological Association 3
Patients on opioids should avoid benzodiazepines due to a quadrupled overdose risk, as warned by the Centers for Disease Control and Prevention 6
Flumazenil should be available for emergency reversal of severe respiratory depression, as recommended by the American Academy of Pediatrics 7 and the Gastroenterology society 3
Benzodiazepine use is associated with a risk of dependence and should be limited to short-term use, as cautioned by the American Academy of Pain Medicine 6
Patients with a history of substance abuse require regular assessment for signs of misuse, as advised by the Substance Abuse and Mental Health Services Administration 6

Patients must not drive after receiving benzodiazepines, as warned by the National Highway Traffic Safety Administration
Creating a calm environment before and during procedures can help reduce anxiety, as suggested by the Journal of Travel Medicine 8
A quiet working environment with minimal interruptions is essential, as suggested by the American Heart Association 2
Psychological approaches, such as stress management and exposure therapy, can be useful for patients requiring multiple procedures, as recommended by the American Psychological Association 3 and the American Dental Association