Skip to Content

Introduction

The Guideline for Care of the Patient Receiving Moderate Sedation/Analgesia has been approved by the AORN Guidelines Advisory Board. It was presented as a proposed guideline for comments by members and others. The guideline is effective December 15, 2015. The recommendations in the guideline are intended to be achievable and represent what is believed to be an optimal level of practice. Policies and procedures will reflect variations in practice settings and/or clinical situations that determine the degree to which the guideline can be implemented. AORN recognizes the many diverse settings in which perioperative nurses practice; therefore, this guideline is adaptable to all areas where operative or other invasive procedures may be performed.

Purpose

This document provides guidance for care of the patient receiving moderate sedation/analgesia provided by a registered nurse (RN) in the perioperative practice setting. Guidance is provided for determining the scope of nursing practice related to administration of moderate sedation/analgesia, patient selection criteria, presedation patient assessment (eg, airway, difficult mask ventilation, obstructive sleep apnea), intraoperative sedation assessment, staffing, monitoring, medication administration, and postoperative discharge criteria.

The goal of moderate sedation/analgesia is drug-induced, mild depression of consciousness achieved with the use of sedatives or a combination of sedatives and analgesic medications, most often administered intravenously, and titrated to achieve a desired effect. The primary goal of moderate sedation/analgesia is to reduce the patient’s anxiety and discomfort. Moderate sedation also can facilitate cooperation between the patient and care providers. Moderate sedation produces a condition in which the patient exhibits a mildly depressed level of consciousness and an altered perception of pain but retains the ability to respond appropriately to verbal or tactile stimulation. The patient maintains protective reflexes and may experience some degree of amnesia.1 

The desired effect is a level of sedation with or without analgesia that enables the patient to tolerate diagnostic, therapeutic, and invasive procedures through relief from anxiety and pain. The four distinct characteristics of moderate sedation/analgesia are the following:

  • The patient is able to respond purposefully to verbal commands or light tactile stimulation.

  • The patient maintains his or her protective reflexes and is able to communicate verbally.

  • The patient maintains adequate, spontaneous ventilation.

  • There are minimal variations in the patient’s vital signs.1 

Depth of sedation occurs across a continuum from minimal sedation to moderate sedation/analgesia, deep sedation/analgesia, and finally general anesthesia. Patients’ responses to the medications for moderate sedation/analgesia are unpredictable. The patient may slip into a deeper level of sedation than intended; therefore, practitioners who administer moderate sedation/analgesia should be able to rescue a patient who enters deep sedation/analgesia.1 

This following topics are outside the scope of this document: local anesthesia, local monitored anesthesia care, general anesthesia, regional anesthesia (eg, spinal, epidural), total intravenous anesthesia, minimal sedation, deep sedation, endotracheal intubation, laryngoscopy, awake intubation, dental office procedures, fospropofol, etomidate, propofol administration in the emergency room and intensive care unit, sedation for intubated and mechanically ventilated patients, palliative care, premedication for general anesthesia, pain management following discharge from the postanesthesia care unit (PACU), and proceduralist techniques. It is not the intent of this guideline to address situations that require the services of an anesthesia professional or to substitute the services of a perioperative RN in those situations that require the services of an anesthesia professional.

Moderate sedation/analgesia may be referred to as moderate sedation, conscious sedation, nurse-administered procedural sedation, nurse-administered propofol sedation, or procedural sedation and analgesia. The term moderate sedation/analgesia is used throughout this document in the recommendations, interventions, and activities. Other terms may be seen in the rationales if the cited literature refers to moderate sedation/analgesia by another term.

Evidence Review

A medical librarian conducted systematic searches of the databases MEDLINE®, CINAHL®, and the Cochrane Database of Systematic Reviews in April 2013 and November 2014, and limited results to meta-analyses, systematic reviews, randomized and non-randomized trials and studies, reviews, and guidelines. The librarian also conducted a non-systematic search of the Scopus® database. The searches were limited to literature published in English between 2006 and November 2014. At the time of the initial searches, the librarian established weekly alerts on the search topics and until April 2015, presented relevant alert results to the lead author.

During the development of this guideline, the lead author requested supplementary literature searches and additional literature that either did not fit the original search criteria or was discovered during the evidence-appraisal process. Finally, the lead author and the medical librarian identified relevant guidelines from government agencies, professional organizations, and standards-setting bodies.

Although the lead author’s original search request encompassed both moderate sedation and local anesthesia, only literature relevant to the care of patients receiving moderate sedation/analgesia was considered for inclusion in this document. Search terms included conscious sedation, anti-anxiety agents, flumazenil, naloxone, propofol, midazolam, fentanyl, drug hypersensitivity, risk assessment, sleep apnea syndromes, continuous positive airway pressure, modified Mallampati test, thyromental distance test, bispectral index, airway management, and patient discharge. Other key words were included to address the concepts of patient assessment, sedation scales, risk factors, patient monitoring, and tools and methods for predicting difficult mask ventilation. The complete search strategies are available upon request.

Inclusion criteria were research and non-research literature in English, complete publications, relevance to the key questions, and publication dates within the time restriction unless none was available.

Excluded were non-peer-reviewed publications and literature that examined local anesthesia, local monitored anesthesia care, general anesthesia, regional anesthesia (eg, spinal, epidural), total intravenous anesthesia, minimal sedation, deep sedation, endotracheal intubation, laryngoscopy, awake intubation, dental office procedures, fospropofol, etomidate, propofol administration in the emergency room and intensive care unit, sedation for intubated and mechanically ventilated patients, palliative care, premedication for general anesthesia, pain management following discharge from the PACU, and proceduralist techniques. Low-quality evidence was excluded when higher quality evidence was available, and literature outside the time restriction was excluded when literature within the time restriction was available (Figure 1).

Figure 1.
Flow Diagram of Literature Search Results

Flow Diagram of Literature Search Results

Articles identified by the search were provided to the lead author and evidence reviewers for review and critical appraisal using the AORN Research or Non-Research Evidence Appraisal Tools as appropriate. The literature was independently evaluated and appraised according to the strength and quality of the evidence. Each article was then assigned an appraisal score. The appraisal score is noted in brackets after each reference as applicable.

The evidence supporting each intervention and activity statement within a specific recommendation was summarized, and the AORN Evidence Rating Model was used to rate the strength of the collective evidence. Factors considered in the review of the collective evidence were the quality of the evidence, the quantity of similar evidence on a given topic, the consistency of evidence supporting a recommendation, and the potential benefits and harms. The assigned evidence rating is noted in brackets after each intervention and activity statement.

 

Note: The evidence summary table is available at http://www.aorn.org/evidencetables.

 

Editor’s note: MEDLINE is a registered trademark of the US National Library of Medicine’s Medical Literature Analysis and Retrieval System, Bethesda, MD. CINAHL, Cumulative Index to Nursing and Allied Health Literature, is a registered trademark of EBSCO Industries, Birmingham, AL. Scopus is a registered trademark of Elsevier B.V., Amsterdam, The Netherlands.

Read MoreShow Less

Access Options

If you would like to learn more about purchasing a subscription to this content, please click the appropriate button below.

Learn about facility access

Learn about individual access