Moderate Sedation/Analgesia

Purpose

This document provides guidance for care of the patient receiving moderate sedation/analgesia administered 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, pre-sedation patient assessment (eg, airway, difficult mask ventilation, obstructive sleep apnea), intraoperative continual patient monitoring, staffing, medication administration, and postoperative discharge criteria.

The aim of moderate sedation/analgesia is to achieve a drug-induced, mild depression of consciousness 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 so that they can tolerate diagnostic, therapeutic, and invasive procedures. The patient can experience some degree of amnesia.^1,2 

Moderate sedation produces a condition in which the patient exhibits a mildly depressed level of consciousness and an altered perception of 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 protective reflexes and is able to communicate verbally.

• The patient maintains adequate, spontaneous ventilation.

• There are minimal variations in the patient’s vital signs.^1,2 

Depth of sedation occurs across a continuum from minimal sedation to moderate sedation/analgesia, to 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 need to be able to rescue a patient who enters deep sedation/analgesia.^1,2 

The 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, fospropofol, etomidate, chloral hydrate, nitrous oxide, RN-administered continuous infusion of sedatives, 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), surgical or procedural techniques, target-controlled infusion, and computer-assisted personalized sedation. 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.

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

Evidence Review

A medical librarian with a perioperative background conducted a systematic search of the databases Ovid MEDLINE, Ovid Embase, EBSCO CINAHL, and the Cochrane Database of Systematic Reviews. The search was limited to literature published in English from January 2015 through May 2020. At the time of the initial search, weekly alerts were created on the topics included in that search. Results from these alerts were provided to the lead author until September 2020. The lead author requested additional articles that either did not fit the original search criteria or were discovered during the evidence appraisal process. The lead author and the medical librarian also identified relevant guidelines from government agencies, professional organizations, and standards-setting bodies.

Search terms included airway management, airway obstruction, Aldrete recovery score, antianxiety/anti-anxiety agents, ASA Continuum of Sedation Scale, ASA Physical Status Classification System, assess*, Berlin questionnaire, bispectral index, capnography, computer assisted personalized sedation, conscious sedation, consciousness monitors, depth of sedation, dexmedetomidine, difficult airway, difficult mask ventilation, discharge readiness criteria, fasting guidelines, fentanyl, flumazenil, ketamine, Mallampati classification, Mallampati score, Mallampati test, midazolam, moderate analgesia, moderate sedation, Modified Observer's Assessment of Alertness/Sedation Scale, naloxone, nitrous oxide, NPO, nurse-administered sedation, obstructive sleep apnea, obstructive sleep apnea assess*, post-anesthetic discharge scoring system, preoperative fasting, preprocedural fasting, propofol, Ramsay Sedation Scale, sleep apnea (obstructive), Sedasys, sedation plan, STOP-Bang, tracheobronchomalacia, and thyromental distance test.

Included were research and non-research literature in English, complete publications, and publications with dates within the time restriction when available. Historical studies were also included. Excluded were non-peer-reviewed publications and older evidence within the time restriction when more recent evidence was available. Editorials, news items, and other brief items were excluded. 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

Adapted from Moher D, Liberati A, Tetzlaff J, Atman DG; The PRISMA Group. Preferred reporting items for systematic reviews and meta-analyses: The PRISMA Statement. PLoS Med. 2009;6(6):e1000097.

Articles identified in the search were provided to the project team for evaluation. The team consisted of the lead author and one evidence appraiser. The lead author and the evidence appraiser reviewed and critically appraised each article using the AORN Research or Non-Research Evidence Appraisal Tools as appropriate. A second appraiser was consulted in the event of a disagreement between the lead author and the primary evidence appraiser. 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.

Each recommendation rating is based on a synthesis of the collective evidence, a benefit-harm assessment, and consideration of resource use. The strength of the recommendation was determined using the AORN Evidence Rating Model and the quality and consistency of the evidence supporting a recommendation. The recommendation strength rating is noted in brackets after each recommendation.

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