Unplanned escalation of sedation is a significant clinical risk. Sedation practices must proactively avoid progression to deep sedation or general anaesthesia, especially in environments not equipped to manage such escalation.
A comprehensive sedation plan must be established before the procedure to assess whether the intended level of sedation is achievable in the chosen clinical setting, and with the available resources and staff.
Before the procedure
Reactive or ad hoc escalation of sedation increases the likelihood of unintentionally crossing into deep sedation or general anaesthesia.
This can lead to complications outside the skillset of the immediate clinical team or capacity of the facility. It can be particularly dangerous in settings where advanced airway support may be limited or delayed, e.g. settings other than an operating theatre.
A structured approach to contingency planning reduces the need for reactive sedation.
Before starting sedation, the sedation provider and proceduralist must agree on the following:
- An action plan if the patient does not tolerate the procedure at the planned level of sedation.
- A contingency for patient movement impacting procedural safety.
- Options such as repositioning, increasing sedation (within an agreed ceiling), calling for additional support, or pausing or ending the procedure.
All facilities where sedation is administered should have timely access to emergency services and resuscitation equipment.
Sedation plan
Develop a sedation plan with all members of the clinical team before the procedure.
Consider:
- sedative agent(s) and dosage to be used
- anticipated patient response and potential complications
- clearly defined ceiling doses
- parameters and protocols for escalation.
The plan should specify a maximum allowable dose or ceiling to prevent excessive drug administration, which may lead to unintentional deep sedation and airway compromise.
Clear escalation parameters should be agreed before the procedure begins to ensure team readiness and rapid response to changing patient conditions.
Anticipating critical events and planning an appropriate response must occur before a procedure during Team Time Out. NSW Health provides guidance in the Clinical Procedure Safety Policy (PD2025_006).
When plans change
If a procedure cannot be performed safely, postpone and rebook it for another day under sedation led by an anaesthetist or critical care physician.
Considerations for escalating patients to more specialised sedation providers:
- Patient and proceduralist needs.
- Escalation of drug therapy – determining appropriate ceiling limits.
- De-escalation of drug therapy – determining when the procedure should pause or end.
- In rural settings, virtual care models should be available to support escalation.
- In rural and remote areas, awareness of statewide escalation support services, e.g. virtual rural generalist services and helicopter emergency medical services.
- Physical accessibility to the patient in the case of an emergency for paramedics or other healthcare workers.