Recognising and managing a deteriorating patient

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The ability to recognise and manage complications is fundamental to providing safe sedation.

Providers must be suitably trained and competent to identify, prevent and manage complications that arise during episodes of procedural sedation.

Potential risks

The sedation continuum describes a dose-dependent depression of the patient’s level of consciousness and cardiorespiratory systems. Sedative and analgesic medications should be administered at the lowest effective dose necessary to achieve patient comfort while minimising the risk of adverse events.

Some patients are particularly susceptible to the effects of sedative or analgesic medications, and different medications have different margins of safety. Sedative and analgesic medicines work synergistically, i.e. one drug may exacerbate the intended and adverse effects of the other.

Transition from sedation to deep unconsciousness, with the risk of losing protective reflexes, may occur rapidly and unexpectedly.1

Clinicians who administer sedative or analgesic drugs, and who supervise recovery from sedation, must be prepared to manage the following potential risks:

  • Depression of protective airway reflexes and loss of airway patency.
  • Depression of respiration or hypoxaemia.
  • Depression of the cardiovascular system.
  • Adverse drug reactions including anaphylaxis.
  • Unexpectedly extreme sensitivity to the drugs used for procedural sedation or analgesia resulting in unintentional loss of consciousness, and respiratory or cardiovascular depression.

All staff must comply with pre-procedure and post-procedure requirements as outlined in the NSW Health Clinical Procedure Safety Policy (PD2025_006).

Warning signs

Red flags for action by the team include:

  • unexpected reduction in the patient’s conscious state beyond the target sedation level
  • snoring or noisy breathing – these are signs of partial obstruction and can rapidly progress to complete obstruction
  • signs of regurgitation of gastrointestinal contents
  • hypoxaemia – detected by pulse oximetry
  • complete airway obstruction – may be silent
  • paradoxical chest movement – may indicate partial or complete obstruction
  • unexpected patient agitation
  • hypotension
  • cyanosis is a late sign of deterioration.

Clinical emergency response system

The clinician monitoring the airway should be trained to recognise patient deterioration, and must be able to activate the local clinical emergency response system (CERS).

In NSW, the need for emergency assistance should align with the NSW Health Standard Observation Charts and local CERS as outlined in Recognition and management of patients who are deteriorating (PD2025_014). If emergency trigger observation levels need to be changed, document the variations before the procedure and ensure the proceduralist and nominated patient monitor agree on them.

Any patient deterioration outside prescribed or agreed limits will trigger the local CERS. All team members must be aware the procedure needs to pause or cease in the event of patient deterioration. The team member with bag-mask ventilation skills will attend the patient’s airway until the arrival of the CERS team.

The process for escalating to the CERS should be determined by local operating procedures.

Skills required

In addition to the clinical skills outlined above, non-technical and teamwork skills are essential:

  • Team briefings and structured communication skills, including effective handover. Conduct team huddles or briefings at the start of procedure lists or individual procedures. Led by the senior clinician, they should include overt permission for all staff to speak up if any issue is perceived. This also provides an opportunity to clarify roles.
  • Closed loop communication. This is especially relevant for the administration of drug doses where both the amount (in milligrams and micrograms) and volume of drugs should be requested by one team member and confirmed to be given by another.
  • Mutual performance monitoring and shared mental models to maintain situational awareness. This is especially important should an adverse event occur.
  • Speaking up techniques such as graded assertiveness. Models such as PACE (probe, alert, challenge, emergency action) or CUSS (concern, unsure, safety, stop) should be available.
  • Role clarity.
  • Use of protocols and cognitive aids.2

More about access to support and training

References

  1. Australian and New Zealand College of Anaesthetists. PG09(G) Guideline on procedural sedation 2023. Melbourne, Australia: ANZCA; 2023 [cited 5 December 2024].
  2. Salas E, Sim DE, Burke CS.  Is there a “Big Five” in Teamwork? Small Group Research 2005; 36:555. DOI: 10.1177/1046496405277134
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