Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists

Developed by the Task Force on Sedation and Analgesia by Non-Anesthesiologists: Jeffrey B. Gross, M.D. (Chair), Farmington, Connecticut; Peter L. Bailey, M.D., Salt Lake City, Utah; Robert A. Caplan, M.D., Seattle, Washington; Richard T. Connis, Ph.D. (Methodologist), Woodinville, Washington; Charles J. Cote, M.D., Chicago, Illinois; Fred G. Davis, M.D., Burlington, Massachusetts; Burton S. Epstein, M.D., Washington, D.C.; Patricia A. Kapur, M.D., Los Angeles, California; John M. Zerwas, M.D., Houston, Texas; and Gregory Zuccaro, Jr., M.D., Cleveland, Ohio.Accepted for publication November 28, 1995. Supported by the American Society of Anesthesiologists, under the direction of James F. Arens, M.D., Chairman of the Committee on Practice Parameters. Approved by the House of Delegates, October 25, 1995. These guidelines received official endorsement by the Governing Board of the American Society for Gastrointestinal Endoscopy. A list of the references used to develop these guidelines is available by writing to the American Society of Anesthesiologists.Address correspondence to Dr. Gross: Department of Anesthesiology (M/C 2015), University of Connecticut School of Medicine, Farmington, Connecticut 06030-2015.Address reprint requests to the American Society of Anesthesiologists: 520 North Northwest Highway, Park Ridge, Illinois 60068-2573.Click on the links below to access all the ArticlePlus for this article.Please note that ArticlePlus files may launch a viewer application outside of your web browser.Key words: Analgesia. Practice guidelines: analgesia; sedation. Sedation: conscious.ANESTHESIOLOGISTS possess specific expertise in the pharmacology, physiology, and clinical management of patients receiving sedation and analgesia. For this reason, they are frequently called on to participate in the development of institutional policies and procedures for sedation and analgesia in nonoperating-room settings. To assist in this process, the American Society of Anesthesiologists developed these Guidelines for Sedation and Analgesia by Non-Anesthesiologists.Practice guidelines are systematically developed recommendations that assist practitioners in making decisions about health care. These recommendations may be adopted, modified, exceeded, or rejected according to clinical needs and constraints, and they are subject to periodic revision as warranted by the evolution of medical knowledge, technology, and practice. Practice guidelines are not intended as standards or absolute requirements, and their use cannot guarantee any specific outcome.The practice guidelines enumerated below have been developed using systematic literature summarization techniques. Results of the literature analyses have been supplemented by the opinions of the Task Force members and a panel of more than 60 consultants, drawn from a variety of medical specialties in which sedation and analgesia are commonly provided. In those instances when the literature does not provide conclusive data, there is an explicit statement that the guidelines are based on the opinion of the consultants or the consensus of the Task Force members. A detailed description of the analytic methods is included in appendix 1.A. Definition"Sedation and analgesia" describes a state that allows patients to tolerate unpleasant procedures while maintaining adequate cardiorespiratory function and the ability to respond purposefully to verbal command and/or tactile stimulation. The Task Force decided that the term "sedation and analgesia" (sedation/analgesia) more accurately defines this therapeutic goal than does the commonly used but imprecise term "conscious sedation." Note that patients whose only response is reflex withdrawal from a painful stimulus are sedated to a greater degree than encompassed by "sedation/analgesia."B. PurposeThe purpose of these guidelines is to allow clinicians to provide their patients with the benefits of sedation/analgesia while minimizing the associated risks. Sedation/analgesia provides two general types of benefit: First, sedation/analgesia allows patients to tolerate unpleasant procedures by relieving anxiety, discomfort, or pain. Second, in children and uncooperative adults, sedation/analgesia may expedite the conduct of procedures that are not particularly uncomfortable but require that the patient not move. Excessive sedation/analgesia may result in cardiac or respiratory depression that must be rapidly recognized and appropriately managed to avoid the risk of hypoxic brain damage, cardiac arrest, or death. Conversely, inadequate sedation/analgesia may result in undue patient discomfort or patient injury because of lack of cooperation or adverse physiologic response to stress.C. FocusThese guidelines have been designed to be applicable to procedures performed in a variety of settings (e.g., hospitals, free-standing clinics, physicians' offices) by practitioners who are not specialists in anesthesiology. The guidelines specifically exclude the following: (1) patients who are not undergoing a diagnostic or therapeutic procedure (e.g., postoperative analgesia, sedation for treatment of insomnia); (2) otherwise healthy patients receiving peripheral nerve blocks, local or topical anesthesia, and/or no more than 50% N2O with oxygen and no other sedative or analgesic agents administered by any route; (3) situations when it is anticipated that the required sedation will eradicate the purposeful response to verbal commands or tactile stimulation (as distinct from reflex withdrawal from a painful stimulus); such patients require a greater level of care than recommended by these guidelines; and (4) perioperative management of patients undergoing general anesthesia or major conduction anesthesia (spinal or epidural/caudal blockade).D. ApplicationThese guidelines are intended to be general in their application and broad in scope. The appropriate choice of agents and techniques for sedation/analgesia is dependent on the experience and preference of the individual practitioner, requirements or constraints imposed by the patient or procedure, and the likelihood of producing unintended loss of consciousness. Templates are provided as examples to illustrate principles; clinicians and their institutions have ultimate responsibility for selecting patients, procedures, medications, and equipment.Published data suggest and consultant opinion strongly supports the contention that appropriate preprocedure evaluation of patients' histories and physical findings reduces the risk of adverse outcomes. Additionally, consultant opinion supports the contention that an appropriate history, physical examination, and laboratory evaluation leads to improved patient satisfaction.Recommendations: Clinicians administering sedation/analgesia should be familiar with relevant aspects of the patient's medical history including: (1) abnormalities of the major organ systems, (2) previous adverse experience with sedation/analgesia, as well as regional and general anesthesia, (3) current medications and drug allergies, (4) time and nature of last oral intake, and (5) history of tobacco, alcohol, or substance use or abuse. Patients presenting for sedation/analgesia should undergo a focused physical examination including auscultation of the heart and lungs and evaluation of the airway (Table 1template 1). Preprocedure laboratory testing should be guided by the patient's underlying medical condition and the likelihood that the results will affect the management of sedation/analgesia.Patient Counseling: There is insufficient evidence in the literature to establish the benefit of providing the patient (or her/his guardian, in the case of a child or impaired adult) with preprocedure information about sedation/analgesia. However, the consultants strongly support the contention that appropriate preprocedure counseling improves patient satisfaction and reduces risks; they also support the view that costs may be reduced. The Task Force members concur that patients undergoing sedation/analgesia should be informed of the benefits, risks, and limitations associated with this therapy, as well as possible alternatives.Preprocedure Fasting: Because sedatives and analgesics tend to impair airway reflexes in proportion to the degree of sedation/analgesia achieved, members of the Task Force support the concept of preprocedure fasting before sedation/analgesia for elective procedures. However, the literature provides insufficient data to test the hypothesis that preprocedure fasting results in a decreased incidence of adverse outcomes in patients undergoing sedation/analgesia (as distinct from patients undergoing general anesthesia).Recommendations: Patients (or their legal guardians in the case of minors or legally incompetent adults) should be informed of and agree to the administration of sedation/analgesia before the procedure begins. Patients undergoing sedation/analgesia for elective procedures should not drink fluids or eat solid foods for a sufficient period of time to allow for gastric emptying before their procedure (Table 2template 2). In urgent, emergent, or other situations when gastric emptying is impaired, the potential for pulmonary aspiration of gastric contents must be considered in determining the timing of the intervention and the degree of sedation/analgesia.Level of Consciousness: The response of patients to commands during procedures performed with sedation/analgesia serves as a guide to their level of consciousness. Spoken responses also provide an indication that the patients are breathing. Patients whose only response is reflex withdrawal from painful stimuli are likely to be deeply sedated, approaching a state of general anesthesia, and should be treated accordingly. The consultants strongly support the contention that monitoring level of consciousness reduces risks and support the concept that overall costs may be reduced. The members of the Task Force believe that many of the complications associated with sedation/analgesia can be avoided if adverse drug responses are detected and treated in a timely manner (i.e., before the development of cardiovascular decompensation or cerebral hypoxia); this may pose a special risk to patients given sedatives/analgesics in unmonitored settings in of a is the opinion of the Task Force that a of associated with sedation/analgesia is respiratory The literature and consultant opinion strongly supports the that monitoring of function reduces the risk of adverse outcomes associated with sedation/analgesia. function can be by of respiratory or auscultation of In patients are from the the consultants support and the Task Force members concur that monitoring of or other may risks; the consultants suggest that such monitoring will not overall The Task Force practitioners that may to airway data suggest and the consultants strongly support the view that of the use of during sedation/analgesia the likelihood of adverse such as cardiac and death. The literature the consultants strongly and Task Force members agree that during sedation and analgesia is more likely to be detected by than by clinical The Task Force that is not a for monitoring there is insufficient data to a it is the opinion of the Task Force that sedative and analgesic agents may the appropriate for and of in patients' heart and may practitioners to and in a timely the risk of cardiovascular The consultants support the concept that monitoring of reduces risks and suggest that it the literature provides no the consultants suggest the use of monitoring in patients with and strongly support use in patients with cardiovascular or the consultants suggest that monitoring is not required in patients cardiovascular of patient response to verbal commands should be in patients who are to respond appropriately (e.g., impaired or uncooperative or during procedures in which be procedures in which a verbal response is not possible (e.g., oral the ability to a or other indication of consciousness in response to verbal or tactile stimulation that the patient will be to airway and if Note that a response to reflex withdrawal from a painful stimulus a greater degree of sedation/analgesia than by this function should be by and/or cannot be is a to these patients undergoing sedation/analgesia should be by with appropriate the which a indication of the oxygen may be should be before sedation/analgesia is sedation/analgesia is should be during the procedure, as well as during the monitoring should be used in patients with cardiovascular as well as during procedures in which are the literature and consultant opinion suggest that of patients' level of respiratory and reduces the risk of adverse outcomes. consultant opinion that of this information may not patient or the consultants suggest that it may costs from adverse The consultants strongly support of and respiratory before sedation/analgesia, administration of medications, during the procedure, on of and before is the opinion of the Task Force that or of patient data provides information that in determining the of any adverse that Additionally, that an individual for the patient is of in patient in a timely and and should be a to be by the and of administered as well as the of the procedure and the general condition of the a this should (1) before the of the procedure, (2) administration of (3) on of the procedure, (4) during and (5) the time of is performed should be to the care to in patient there are insufficient data in the literature to provide on this the Task Force that it is for the individual a procedure to be of the patient's condition during sedation/analgesia. The consultants support the contention that the of an individual other than the the procedure to the patient's improves patient and they also strongly support the view that risks are reduced. The consultants support the that this not overall is the consensus of the Task Force members that the individual monitoring the patient may assist the with of the patient's level of sedation/analgesia and have provided that adequate monitoring is A other than the the procedure, should be to the patient procedures performed with sedation/analgesia. individual may assist with there is insufficient literature to the of on patient the consultants strongly support the that providing appropriate in clinical for administering medications reduces the risk of adverse they also support the that patient is improved and overall costs are reduced. (1) of respiratory depression by administered (2) inadequate time of sedative or analgesic in a and (3) inadequate with the of for sedative and analgesic the complications of sedation/analgesia are to respiratory or cardiovascular it is the consensus of the Task Force that the individual for monitoring the patient should be in the of complications associated with sedation/analgesia. In of a airway and maintaining and should be during the for patients receiving sedation/analgesia should the of the agents that are as well as the of for and monitoring patients receiving sedation/analgesia should be to the associated individual of a airway and as well as a for should be sedation/analgesia is is recommended that an individual with be literature and the consultants strongly support the view that the of appropriately reduces the risk of sedation and analgesia. The consultants also support the contention that overall including those associated with adverse may be reduced. The literature does not the for cardiac during sedation/analgesia. The consultants strongly support the of a sedation/analgesia is as well as appropriately for a airway and providing with oxygen should be sedation/analgesia is airway and medications should be available (Table A should be available when sedation/analgesia is administered to patients with cardiovascular literature supports the use of oxygen during There is a decreased incidence and of sedation/analgesia patients given oxygen as to those However, it must be by the of oxygen will the of by the of monitoring pulmonary by other opinion supports the view that oxygen patient while that use of oxygen may to oxygen should be when sedation/analgesia is is anticipated or during sedation/analgesia, oxygen should be literature supports the that of agents may be more than agents in However, the data also suggest and consultant opinion supports the that of sedatives and may the likelihood of adverse including depression and not in the it is the consensus of the Task Force that of sedative and analgesic agents may not allow the individual of sedation/analgesia to be appropriately to the individual requirements of the patient and of sedative and analgesic agents should be administered as appropriate for the procedure performed and the condition of the should be administered to the (e.g., analgesic to sedative to or The for of sedative and analgesic agents to respiratory depression the to appropriately the of as well as the to respiratory literature that the administration of of the level of sedation and/or analgesia is is to a based on patient or The consultants support the concept that drug administration improves patient and they strongly support the contention that the potential risks associated with are should be given in that are to the of analgesia and sedation. time must to allow the of to be before drug are administered by (e.g., should be for the time required for drug before is data suggest in patients, administration of agents by the improves patient and The consultants strongly support the of access in patient risks. In situations when medications are to be administered it is the consensus of the Task Force that maintaining access the patient is no risk for cardiorespiratory depression improves patient In those situations when sedation is by (e.g., the for access is not in the However, of access the sedation allows and to be administered if In patients receiving medications for sedation/analgesia, access should be the procedure and the patient is no risk for cardiorespiratory In patients who have received sedation/analgesia by or whose or practitioners should the of or access on a In all an individual with the to establish access should be agents are available for the (e.g., and (e.g., The literature supports the ability of to sedation and depression during sedation/analgesia. However, the Task Force practitioners that of analgesia may result in or pulmonary The literature supports the ability of to sedation and in depression in patients who have received In patients who have received and data support the ability of to there are insufficient data to establish the of in depression under these The consultants strongly support the contention that the of agents is associated with decreased is the consensus of the Task Force that respiratory depression should be treated with oxygen if by should be available analgesics or are administered for sedation/analgesia. and/or may be administered to in patients who have received or may be in in which airway and are or with patients who or during sedation/analgesia (1) be or to (2) if is and (3) patients should be to that cardiorespiratory depression does not may to be risk for complications their procedure is drug oral or and may to cardiorespiratory sedation/analgesia is administered to must there will be no medical the patient the medical there is not sufficient literature to the of monitoring on patient the consultants suggest that appropriate monitoring of patients during the period will patient and strongly support the view that adverse outcomes may be reduced. is the consensus of the Task Force that should be that the risk for cardiorespiratory depression patients are from by sedation/analgesia, patients should be they are no risk for cardiorespiratory and respiratory function should be patients are for should be designed to the risk of or cardiorespiratory depression from by (Table literature the consultants strongly and the Task Force members concur that of patients (e.g., uncooperative of or drug or are risk for complications to sedation/analgesia special are However, the consultants support the view that risks may be by preprocedure with appropriate specialists (e.g., before administration of sedation/analgesia to these The consultants support the concept that patient is improved and risks are by with an before administering sedation/analgesia to patients who are likely to develop complications (e.g., inadequate loss of airway cardiovascular or in sedation/analgesia is not to provide adequate (e.g., uncooperative However, the consultants also support the contention that such will not appropriate medical specialists should be before administration of sedation/analgesia to patients with underlying The choice of specialists on the nature of the underlying condition and the of the For patients (e.g., pulmonary heart or if it likely that sedation to the of or general anesthesia will be to adequate practitioners who are not specifically to provide these should an of these guidelines based on the or evidence These about sedation/analgesia by and clinical A preprocedure patient evaluation (i.e., history, physical examination, laboratory improves patient clinical benefits, and reduces adverse Preprocedure of the patient (e.g., improves patient clinical benefits, and reduces adverse monitoring (i.e., level of pulmonary improves patient clinical benefits, and reduces adverse of (e.g., level of respiratory improves patient clinical benefits, and reduces adverse of a to patient monitoring and improves patient clinical benefits, and reduces adverse and of (sedation/analgesia) improves patient clinical benefits, and reduces adverse of appropriately and airway including improves patient clinical benefits, and reduces adverse of oxygen improves patient clinical benefits, and reduces adverse of agents improves patient clinical benefits, and reduces adverse of medications to the improves patient clinical benefits, and reduces adverse of agents by the improves patient clinical benefits, and reduces adverse of agents (e.g., improves patient clinical benefits, and reduces adverse monitoring (e.g., during of improves patient clinical benefits, and reduces adverse for patients with special (e.g., uncooperative of or drug or and airway improves patient clinical benefits, and reduces adverse evidence from including literature when and other For of literature relevant clinical and of the The a from from than that to the evidence of the not provide evidence and by the included the pharmacology, pulmonary and result for by the (1) a (2) a or (3) The results to a of support for The literature to and and to to and to with with well and information to conduct when data, and an procedure to as (1) the producing based on of the from the and (2) the providing of the by of the by the of the A procedure based on the for results using used when sufficient information level and of for of the to the To for potential a for for and no for results of the are in from the for clinical for for for and for from to from the for outcomes for two and for adverse outcomes for not from to data available to conduct analyses for and in the of by patients oxygen those The of an adverse for agents to be for of and in all and to with that the of provided of and for the The two for may be to a variety of (e.g., the or other Task Force members and two by using a for as (1) of (2) of (3) evidence and (4) literature for (1) (2) (3) and (4) literature These to of findings of the literature analyses supplemented by the opinions of Task Force members and of the opinions of a panel of consultants drawn from the specialties in which sedation/analgesia are commonly oral and pharmacology, pulmonary and in of the (i.e., that they in of patient risk of adverse overall and for the guidelines to given on a from strongly to strongly support for a as the of consultants or to a given The of consultants support for is in responses from consultants are as (1) of consultants monitoring of of patients for all patients, patients with patients with cardiovascular and patients with cardiac (2) of consultants the of a for of patients for all patients, patients with patients with cardiovascular and patients with and (3) of consultants of and respiratory the before sedation during procedure, of during and before of these guidelines clinical practice by an opinion of those from the consultant panel who for of of the guidelines as of these consultants that of the guidelines not result in the to or the who that be the anticipated costs and (e.g., the of a during procedures, access as a procedure, monitoring more to preprocedure needs (e.g., and time during consultants to if of the evidence their clinical if the guidelines of consultants no associated with as preprocedure history, of the monitoring of cardiovascular and of and preprocedure with an of the that the guidelines have no on the of time on a that the guidelines the of time For all the in the of time on a case the of who an anticipated in time on a the with special in the analyses used in these guidelines can information by writing Jeffrey B. Gross, M.D., Department of Anesthesiology (M/C University of Connecticut School of Medicine, Farmington, Connecticut these the are used to the of the evidence and the associated There are insufficient data to provide an indication of the intervention and There is evidence in the of case or but there is insufficient evidence to establish a intervention and data a intervention and and data are based on a from to with a of The of or the or 50% or more of the responses or 50% or more of the responses physical examination testing when benefits, and time for gastric or of sedation/analgesia must be the potential risk of and aspiration of gastric to be appropriate and to verbal commands when other and heart appropriate for patients with cardiovascular other than the the procedure, to the patient the of sedative and analgesic of available support support appropriately airway of and administered if of to anxiety, to given with sufficient time to if sedatives and analgesics are administered administered by other patients are no risk for cardiorespiratory underlying medical with appropriate of cardiovascular or respiratory or for anesthesia to adequate is a of the The of the should be for