Procedural sedation is when analgesic or low-dose anaesthetic medications are used to allow patients to tolerate uncomfortable or painful procedures.
Sedatives may be given orally, via inhalation, intranasally (IN), intravenously (IV) or intramuscularly (IM).
As a greater number of complex procedures are being performed outside operating theatres, the need for safe procedural sedation continues to increase.
Ideal safe sedation journey
- Patient is assessed.
- Risk stratification establishes whether an anaesthetist should be consulted.
- Patient is sedated by a trained clinician.
- Patient is monitored during the procedure by clinician (not the proceduralist).
- Clinician is present with bag-mask ventilation skills.
- Responsibility and accountability for the patient is handed over.
- Patient is monitored during recovery phase.
- Patient is assessed for discharge and follow-up arranged.
- Patient is discharged and accompanied by responsible adult.
Safety
Patient safety is underpinned by individual patient risk assessments, risk stratification and management, safe medication use, and access to life support skills and resources.
Anaesthetists, including rural generalist anaesthetists and critical care physicians (CCPs) are specifically trained to manage patients under sedation; however, they are not required or available for every sedation episode, especially for low-risk patients.
All clinicians who administer and support procedural sedation must be appropriately trained to manage potential complications.
In NSW public hospitals, there are several specialty areas where sedation is routinely administered by non-critical care clinicians.
Levels of sedation
Sedation is classified into three levels: mild, moderate and deep.1,2
The Australian and New Zealand College of Anaesthetists (ANZCA) define these as follows:3
- Mild: a drug-induced state of diminished anxiety, during which patients are conscious and respond purposefully to verbal commands or light tactile stimulation.
- Moderate: a drug-induced state of depressed consciousness during which patients retain the ability to respond purposefully to verbal commands and tactile stimulation.
- Deep: a drug-induced state of depressed consciousness during which patients are not easily roused and may respond only to noxious stimulation.
In contrast, general anaesthesia renders a reversible state in which a patient is unrousable and unconscious.
The transition between levels of sedation, particularly between deep sedation and general anaesthesia, can be subtle, with a potentially narrow margin of safety. Progression from deep sedation to general anaesthesia can be rapid and unpredictable.3 Clinicians administering sedation must be equipped with the skills and training to safely rescue a patient who enters a deeper level of sedation than intended.
Intentional deep sedation should only be administered by an anaesthetist, CCP or other medical practitioner trained and credentialed to deliver deep sedation within their scope of practice.
Who provides sedation
There are four categories of sedation providers.
| Category 1 | Proceduralist prescribed and administered |
|---|---|
| Category 2 | Proceduralist prescribed, nurse administered |
| Category 3 | Sedationist: Non-anaesthesia/CCP prescribed and administered, e.g. nurses, dentists, career medical officers |
| Category 4 | Sedationist: Anaesthesia/CCP – includes trainees under supervision and other appropriately trained and credentialed clinicians, e.g. GP anaesthetists, rural generalist anaesthetists. We acknowledge that in the future, training and courses may be developed which allow for other clinicians to provide this category of sedation. |
All sedation providers, including nurses, dentists, career medical officers, rural generalist anaesthetists, specialist anaesthetists, CCPs, paramedics and their supervised trainees must be appropriately trained, assessed and credentialed within the facility, working within their scope of practice and indemnified for complications arising from sedation.
Summary of recommendations
Mild sedation
Level of consciousness: patient is awake.
Appropriate for: mildly or briefly uncomfortable procedures, e.g. prior to local anaesthesia.
Unsuitable for: moderate or prolonged discomfort.
Fasting: usually unnecessary.1
Consent: verbal. Patient cooperation and acceptance that they will likely have recall.
Suitable for: nearly all stable, cooperative patients. Not for those with critical conditions or unstable vital signs.2
Escalation (help): no requirement for medical emergency team (MET) on site. Standard escalation appropriate.3
Typical drugs: oral benzodiazepines or opioids, methoxyflurane and N2O.4
Examples: minor surgery prior to local anaesthesia, simple angiography and cataracts.
Sedation clinicians: all appropriately trained and credentialed, working within their scope of practice for the facility and indemnified.5
Staffing: as described in the Safe Procedural Sedation Matrix.
Access: easy access to paramedics or hospital staff.
Moderate sedation
Level of consciousness: patient has depressed consciousness, responds purposefully to verbal commands or tactile stimulation, maintains own airway.
Appropriate for: procedures with moderate discomfort.
Unsuitable for: procedures with prolonged moderate or severe discomfort.
Fasting: essential.1
Consent: verbal or written depending on the procedure. Understanding and acceptance they may have recall.
Suitable for: stable, ASA 1–3, cooperative patients. Not for those with critical conditions or unstable vital signs.2
Escalation (help): senior trained clinicians available to intervene quickly or MET for non-anaesthetist/CCP providers.3
Typical drugs: intravenous (IV) midazolam, fentanyl and methoxyflurane.4
Examples: endoscopy, colonoscopy, implantable devices, renal biopsies, bone marrow biopsies, angioplasty, flexible cystoscopy and bronchoscopy.
Sedation clinicians: clinicians who are trained and credentialed, working within their scope of practice for the facility and indemnified for moderate sedation.5
Staffing: as described in the Safe Procedural Sedation Matrix.
Access: easy access to paramedics and hospital staff including internal transfer.
Deep sedation
Level of consciousness: patient has depressed consciousness, not easily roused, respond to noxious stimulation, requires airway support or an airway adjunct. If they don’t respond, this qualifies as general anaesthesia.
Appropriate for: uncooperative patients, painful procedures, severe discomfort.
Fasting: essential.1
Consent: written.
Escalation (help): refer to notes.3
Typical drugs: propofol6, remifentanil4, dexmedetomidine, ketamine, IV midazolam, fentanyl and dexmedetomidine
Examples: endoscopy, colonoscopy, automated implantable cardioverter defibrillator testing, endoscopic retrograde cholangiopancreatography, cardioversion and endoscopic ultrasound.
Sedation clinicians: anaesthetists/CCPs and those trained in deep sedation, credentialed, and working within their scope of practice for the facility and indemnified.5
Staffing: as described in the Safe Procedural Sedation Matrix.
Access: easy access to hospital staff including internal transfer.
Notes
- Fasting is recommended for patients with targeted moderate sedation as escalation to deep sedation is possible. Follow Sip-Til-Send or standard protocols. Risk assessment detects patients with delayed gastric emptying, e.g. on Ozempic, who should be referred to anaesthetist or CCP.
- Red flags indicate patients who should not be sedated by non-anaesthetists/CCPs. See Standard 1 for list of red flags.
- Escalation must be available for all patients where moderate or deep sedation is targeted. This can be via and available anaesthetist/CCP or via a MET, clinical emergency response system or rapid response team.
- Drugs used for sedation can be used by many routes. Commonly oral, IV, IM, IN, inhaled. The key is the sedation achieved (mild, moderate or deep) and not the drug used. In general, lower doses of a drug will cause milder levels of sedation; however, there is wide variability in patient response to standard doses. Low doses in some can produce a deeper level of sedation than expected.
- All anaesthetists, CCPs, their supervised trainees and rural generalist anaesthetists are credentialed for all three levels of sedation. If other clinicians, e.g. dentists and nurses, have been trained and assessed, they can also provide the appropriate level of sedation, as per their facility credentialing. All providers must be indemnified for complications arising from sedation.
- Propofol can be used for all three levels of sedation; however, use should be limited to anaesthetists and CCPs, unless an individual has been specifically credentialed in its use.
References
- Kim SH, Moon YJ, Chae MS, et al. Korean clinical practice guidelines for diagnostic and procedural sedation. Korean J Anesthesiol. 2024;77(1):5-30. DOI: 10.4097/kja.23745
- Benzoni T, Cascella M. Procedural sedation. Treasure Island, Florida: StatPearls Publishing; Jan 2024 [cited 5 December 2024].
- Australian and New Zealand College of Anaesthetists. PG09(G) Guideline on procedural sedation 2023. Melbourne, Australia: ANZCA; 2023 [cited 5 December 2024].
- Salas E, Sim DE, Burke CS. Is there a “Big Five” in Teamwork? Small Group Research 2005; 36:555. DOI: 10.1177/1046496405277134
- Dobson G, Chong MA, Chow L, et al. Procedural sedation: a position paper of the Canadian Anesthesiologists' Society. Can J Anaesth. 2018;65(12):1372-84. DOI: 10.1007/s12630-018-1230-z
- Tran TT, Beutler SS, Urman RD. Moderate and deep sedation training and pharmacology for nonanesthesiologists: recommendations for effective practice. Curr Opin Anaesthesiol. 2019;32(4):457-63. DOI: 10.1097/aco.0000000000000758