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Joint Trust Guideline for the Safe use of Intravenous Conscious Sedation in Adult
Patients undergoing Procedures
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All areas using intravenous conscious sedation
All staff involved in the care of patients
receiving intravenous conscious sedation
Patients requiring reduction of discomfort
during a procedure not requiring general
anaesthesia
Surgical Division
Intravenous Conscious Sedation, Midazolam,
Opioids, Flumazenil, Naloxone
Dr Nicholas Saunders
Consultant Anaesthetist (NNUH)
Dr David Spackman
Clinical Director, Department of Anaesthetics
(NNUH)
Dr Dhiraj Ail, Consultant Anaesthetist (JPUH)
Clinical Guidelines Assessment Panel
(CGAP)
If approved by committee or Governance
Lead Chair’s Action; tick here 
06/10/2016
Clinical Standards Group and Effectiveness
Sub-Board
This document remains current after
this date but will be under review
06/10/2019
To be reviewed by:
Reference and / or Trust Docs ID No:
Version No:
Description of changes:
Compliance links:
If Yes - does the strategy/policy
deviate from the recommendations of
NICE? If so why?
Dr Nicholas Saunders, Consultant Anaesthetist
JCG0004 - 1311
2
Appendix 4 added
None
N/A
This guideline has been approved by the Trust's Clinical Guidelines Assessment Panel as an aid to the diagnosis and management of relevant
patients and clinical circumstances. Not every patient or situation fits neatly into a standard guideline scenario and the guideline must be
interpreted and applied in practice in the light of prevailing clinical circumstances, the diagnostic and treatment options available and the
professional judgement, knowledge and expertise of relevant clinicians. It is advised that the rationale for any departure from relevant guidance
should be documented in the patient's case notes.
The Trust's guidelines are made publicly available as part of the collective endeavour to continuously improve the quality of healthcare through
sharing medical experience and knowledge. The Trust accepts no responsibility for any misunderstanding or misapplication of this document.
Joint Trust Clinical Guideline: for the Safe use of Intravenous Conscious Sedation in Adult Patients undergoing Procedures
Author/s: Dr Nicholas Saunders Author/s title: Consultant Anaesthetist (NNUH)
Approved by: CGAP
Date approved: 06/10/2016
Review date: 06/10/2019
Available via Trust Docs
Version: 2
Trust Docs ID: JCG004 - 1311
Page 1 of 11
Joint Trust Guideline for the Safe use of Intravenous Conscious
Sedation in Adult Patients undergoing Procedures
Joint Trust Clinical Guideline: for the Safe use of Intravenous Conscious Sedation in Adult Patients undergoing Procedures
Author/s: Dr Nicholas Saunders Author/s title: Consultant Anaesthetist (NNUH)
Approved by: CGAP
Date approved: 06/10/2016
Review date: 06/10/2019
Available via Trust Docs
Version: 2
Trust Docs ID: JCG004 - 1311
Page 2 of 11
Joint Trust Guideline for the Safe use of Intravenous Conscious
Sedation in Adult Patients undergoing Procedures
Quick reference Guideline

All departments using IV conscious sedation should have a named lead
clinician responsible for the use of IV sedation and a departmental protocol.

All staff involved in the administration of IV drugs for conscious sedation and
patient care should have recent and current resuscitation training and also
have training in conscious sedation.

All patients should have a comprehensive pre procedural assessment of their
medical history and medication. Vital signs should be recorded. Consent for
conscious sedation should be taken.

Procedures should only take place in areas prepared for sedation, eg
endoscopy, A&E, radiology and theatres. All areas should be equipped with
oxygen, resuscitation equipment and full monitoring.

Capnography is not mandatory for conscious sedation but is desirable and
should be considered a developmental standard 10.

A trained staff member should be responsible for monitoring the patient
during the procedures.

Records should be made including pre procedural information and vital signs,
and observations during the procedure.

Benzodiazepines and opioids depress the central nervous system and have
the potential to impair respiration or circulation or both.

Extra care should be taken when sedating the elderly and frail, or combining
an opioid with a benzodiazepine.

Antagonist should be available and practitioners should be trained in
administration. (Appendix 2)

Patients should be monitored in a recovery area with a fully trained nurse until
discharge criteria met. (Appendix 4)

Patients must be accompanied by a competent adult for the next 24 hours.
They should be given comprehensive post sedation instructions.

Drug dosage, use of antagonists and adverse events should be an integral
part of the written record and audited regularly.
Objective
These guidelines are designed to guide the safe use of intravenous (IV) conscious
sedation used to reduce discomfort and anxiety of a procedure not requiring a general
anaesthetic (including sedation in theatres but not using an anaesthetist).
Rationale
Sedation is used to make uncomfortable and painful procedures more acceptable to
patients but has the potential to cause life threatening complications. The National
Patient Safety Agency (NPSA) rapid response alert 1 highlighted that the use of
midazolam for conscious sedation has been responsible for 3 deaths, and the 2004
Joint Trust Clinical Guideline: for the Safe use of Intravenous Conscious Sedation in Adult Patients undergoing Procedures
Author/s: Dr Nicholas Saunders Author/s title: Consultant Anaesthetist (NNUH)
Approved by: CGAP
Date approved: 06/10/2016
Review date: 06/10/2019
Available via Trust Docs
Version: 2
Trust Docs ID: JCG004 - 1311
Page 3 of 11
Joint Trust Guideline for the Safe use of Intravenous Conscious
Sedation in Adult Patients undergoing Procedures
National Confidential Enquiry into Patient Outcome and Death (NCEPOD) report 2
showed that elderly patients are particularly vulnerable.
Broad Recommendations
Definition of Conscious Sedation
A technique in which the use of drug or drugs produces a state of depression of the
central nervous system enabling treatment to be carried out, but during which verbal
contact with the patient is maintained throughout the period of sedation. The drug and
techniques used to provide conscious sedation should carry a margin of safety wide
enough to render loss of consciousness unlikely.
Deeper levels of sedation, where verbal contact is lost, have the potential to
cardiovascular and or respiratory depression as well as loss of airway reflexes. This
may result in significant morbidity and mortality 9
Drugs preferred for sedation
The preferred drugs to be used for sedation are midazolam and fentanyl. These are
both short acting drugs with an onset of 1-2 minutes and a peak effect of 3-5 minutes.
The analgesic effects of fentanyl last about 30-60 minutes therefore occasionally
morphine is needed for a more prolonged analgesic effect after the procedure.
Morphine has a longer onset with a peak intravenous effect of 20 minutes, therefore the
patients should be observed for at least 10-15 minutes before the midazolam is
administered. See appendix 2 for further information about dosing, side effects and
cautions. Propofol should not be used by non-anaesthetists for sedation.
Staff training
All departments using IV conscious sedation should have a named lead clinician
responsible for the use of IV sedation and a departmental protocol including the points
covered in this general guideline specific to their department and the procedures it is
being use for.
The doctors supervising conscious sedation should be up to date with current
ALS protocols and regularly attend mandatory resuscitation training. All other staff
involved in the administration of IV drugs for conscious sedation, including operator and
observer, should have recent and current resuscitation training e.g. Intermediate Life
Support training. They should also have training in the administration and actions of the
drugs being used and be able to recognise and deal with the complications of
administration. Training can be either completion of a course on conscious sedation,
such as is provided by NANIME for the dentists, or similar external course and/or a
suitable period of training with an experienced sedationist until considered competent.
Pre procedural assessment
Joint Trust Clinical Guideline: for the Safe use of Intravenous Conscious Sedation in Adult Patients undergoing Procedures
Author/s: Dr Nicholas Saunders Author/s title: Consultant Anaesthetist (NNUH)
Approved by: CGAP
Date approved: 06/10/2016
Review date: 06/10/2019
Available via Trust Docs
Version: 2
Trust Docs ID: JCG004 - 1311
Page 4 of 11
Trust Guideline for the Management of Safe use of Intravenous
Conscious Sedation in Adult Patients undergoing Procedures
All patients should have an assessment covering previous medical history, drug history,
allergies, smoking and alcohol history, previous anaesthetic history including
complications. Baseline vital signs including heart rate, blood pressure, oxygen
saturation, weight. Consent for sedation and procedure should be taken. American
Society of Anesthesiologists (ASA) grade should be noted (see Appendix 1).
Procedures carried out on elderly patients who may have significant co-morbidity and
even in younger patients. The presence of heart disease, cerebrovascular disease,
insulin dependant diabetes, lung disease, liver failure, anaemia, shock and morbid
obesity are risk factors. The possible effect of any concurrent medication should be
assessed as to its possible effects on the sedation process. 4
Consent for conscious sedation and the procedure should be taken at this time and
information should be given on oral intake and post procedural requirements.
Equipment
Equipment should be available in both procedural areas and recovery areas. This
should include full monitoring equipment including ECG, Blood pressure, oxygen
saturation monitoring; resuscitation equipment including defibrillator and resuscitation
drugs; oxygen and oxygen delivery systems; suction; a tipping trolley; intravenous
access devices and fluids. The use of continuous capnography is recommended
wherever conscious sedation is planned.
Management of sedation
A period of starvation of 6 hours for food and 2 hours for clear fluids would
reduce the risk of aspiration should over-sedation occur. In the case of upper
gastrointestinal haemorrhage, light sedation is preferable to pharyngeal local
anaesthesia which can lead to loss of gag reflex.
The drugs used for IV conscious sedation are benzodiazepines and opioids. These
drugs depress the central nervous system and have the potential to impair
respiration or circulation or both, particularly in the presence of disease or old age.3
When used together there is a synergistic effect which can increase the risk of
cardiorespiratory events. Dosage of benzodiazepines and opiates should be kept to a
minimum to achieve sedation and should be within the manufacturer’s guidelines. 4
If a combination of drugs is considered necessary the opioids should, whenever
possible, be given before benzodiazepines and their effect observed before proceeding 4
to give any sedative. Each drug should be flushed with sterile 0.9% sodium chloride
after each administration. Verbal contact should be kept with the patient at all times.
In patients over 70 years no more than 2 mg of midazolam should be drawn up into a
syringe. In most instances the maximum dose should be 2 mg of midazolam, but it may
be necessary to exceed this dose.2 Further doses should be kept to small increments.
Reversal agents should be available at all times and staff should know how and when to
administer the drugs and recognise the complications. (Appendix 2)
Joint Trust Clinical Guideline: for the Safe use of Intravenous Conscious Sedation in Adult Patients undergoing Procedures
Author/s: Dr Nicholas Saunders Author/s title: Consultant Anaesthetist (NNUH)
Approved by: CGAP
Date approved: 06/10/2016
Review date: 06/10/2019
Available via Trust Docs
Version: 2
Trust Docs ID: JCG004 - 1311
Page 5 of 11
Joint Trust Guideline for the Safe use of Intravenous Conscious
Sedation in Adult Patients undergoing Procedures
The use of oxygen via face mask or nasal prongs during sedation will reduce the risk of
hypoxia.5
A suitably trained member of staff should be responsible for monitoring the patient
throughout the procedure. Level of sedation, oxygen saturations (SpO 2) and blood
pressure should be recorded at regular intervals. ECG monitoring should be added for
patients with cardiac risk factors.5
Recovery and Post Procedure Monitoring
The patients should be recovered in a dedicated recovery area, equipped with
resuscitation equipment, full monitoring and oxygen. There should be a fully trained
member of staff in attendance at all times and monitoring should be continued until the
level of consciousness and other vital signs have returned to pre-procedural baseline
levels. The patients should be discharged into the care of a competent adult and should
not drive, operate machinery or sign legal documents for the next 24 hours.
Patients should be given written instructions about common after effects of their
procedure and sedation. A contact number should be provided in case of any problems.
Clinical audit standards
Audit should be an integral part of the written record of sedation. Drug dosage, use of
antagonists and adverse events should be audited regularly.
Summary of development and
registration and dissemination
consultation
process
undertaken
before
The authors listed above reviewed this guideline on behalf of the Anaesthetic
department who has agreed the final content.
This version has been endorsed by the Clinical Guidelines Assessment Panel.
Distribution list/ dissemination method
All A&E staff, Radiology staff, Endoscopy staff, Theatre staff and Dental staff. Available
on the Trust Intranet.
References/ source documents
1. Reducing risk of overdose with midazolam injection in adults. Rapid Response
report. NPSA/2008/RRR011
2. Elderly patient vulnerable to sedative overdose. Gray A, Bell GD. National
Patient Safety Agency. Patient Safety Bulletin: Number 3, January 2007.
www.npsa.nhs.uk/patientsafety/patient-safety-incident-data/bulletins-andnewsletters/archive Accessed 4 April 2009
3. Implementing and ensuring Safe Sedation Practice for Healthcare Procedures in
adults. Report of an Intercollegiate Working Party chaired by the Royal College
of Anaesthetists, November 2001
http://www.rcoa.ac.uk/docs/safesedationpractice.pdf Accessed 25 March 2009
4. Safety and sedation during endoscopic procedures. British Society of
Gastroenterology. September 2003 www.bsg.org.uk
Joint Trust Clinical Guideline: for the Safe use of Intravenous Conscious Sedation in Adult Patients undergoing Procedures
Author/s: Dr Nicholas Saunders Author/s title: Consultant Anaesthetist (NNUH)
Approved by: CGAP
Date approved: 06/10/2016
Review date: 06/10/2019
Available via Trust Docs
Version: 2
Trust Docs ID: JCG004 - 1311
Page 6 of 11
Trust Guideline for the Management of Safe use of Intravenous
Conscious Sedation in Adult Patients undergoing Procedures
http://www.bsg.org.uk/images/stories/docs/clinical/guidelines/endoscopy/sedation
.doc Accessed 04 April 2009
5. Local Anaesthesia and Sedation: managing the risk. May 2007 Published by
Association for Perioperative Practice.
6. British National Formulary. Available at http://bnf.org/bnf/ Accessed 26 August
2009
7. Safe sedation of adults in the emergency department. RCoA and CEM, London
2012 (www.rcoa.ac.uk/node/10214).
8. The use of capnography outside the operating theatre. Updated statement from
the Association of Anaesthetists of Great Britain and Northern Irelend (AAGBI).
May 2011
9. General Provision of Anaesthetic Practice (GPAS 2015).
www.rcoa.ac.uk/gpas2015
10. Practice for Healthcare Procedures: Standards and Guidance. AoMRC, London
2013 (www.rcoa.ac.uk/node/15182).
Joint Trust Clinical Guideline: for the Safe use of Intravenous Conscious Sedation in Adult Patients undergoing Procedures
Author/s: Dr Nicholas Saunders Author/s title: Consultant Anaesthetist (NNUH)
Approved by: CGAP
Date approved: 06/10/2016
Review date: 06/10/2019
Available via Trust Docs
Version: 2
Trust Docs ID: JCG004 - 1311
Page 7 of 11
Joint Trust Guideline for the Safe use of Intravenous Conscious
Sedation in Adult Patients undergoing Procedures
Appendix 1
ASA grade
ASA Grade
Description
1
Normal healthy individual
2
Mild systemic disease that does not limit activity
3
4
5
Severe systemic disease that limits activity but is not
incapacitating
Incapacitating systemic disease which is constantly life
threatening
Moribund, not expected to survive 24 hours with or without
surgery
Appendix 2
Joint Trust Clinical Guideline: for the Safe use of Intravenous Conscious Sedation in Adult Patients undergoing Procedures
Author/s: Dr Nicholas Saunders Author/s title: Consultant Anaesthetist (NNUH)
Approved by: CGAP
Date approved: 06/10/2016
Review date: 06/10/2019
Available via Trust Docs
Version: 2
Trust Docs ID: JCG004 - 1311
Page 8 of 11
Trust Guideline for the Management of Safe use of Intravenous
Conscious Sedation in Adult Patients undergoing Procedures
Table of Preferred Drugs - list including safe dosages
Sedative
Dose
Midazolam Healthy adult: 12mg bolus.
Titrate further
small boluses
with at least 2
minutes
between doses.
Usually max
5mg required.
Elderly or
unwell: 0.5-1mg
bolus. Titrate
further small
boluses with at
least 2 minutes
between doses.
Often no more
than 2 mg
required.
Fentanyl
50mcg initial
bolus then
incremental
boluses of 2550mcg to a
maximum of
100mcg.
Reduce dose in
elderly or
debilitated.
Morphine
0.05mg-0.1mg
initial
intravenous
bolus then
observe for
minimum 1015min before
addition of
benzodiazepine.
Reduce dose in
elderly
Onset
3-5
minutes for
peak
effect.
Half life
1.5-3.5
hours.
Side effects
CARDIORESPIRATORY
DEPRESSION especially
associated with opioids.
Gastro-intestinal
disturbances,
anaphylaxis,
drowsiness,
confusion, ataxia,
amnesia, headache,
paradoxical
excitement and
aggression (especially
in children and
elderly), dysarthria;
injection-site
reactions. For
complete list see BNF
Cautions
Cardiac disease;
hepatic
impairment; renal
impairment;
(increases plasma
half life x2-2.5)
respiratory
disease;
myasthenia gravis;
history of drug or
alcohol abuse; risk
of severe
hypotension in
hypovolaemia,
vasoconstriction,
hypothermia;
pregnancy and
breast-feeding
Onset 1-2
minutes,
peal effect
3-5
minutes.
Lasts 3060 mins
General opioid side
effects.
Nausea and vomiting (less
with fentanyl), constipation,
dry mouth; larger doses
produce muscle rigidity,
hypotension, and
respiratory depression.
Other common side-effects
include bradycardia,
tachycardia, palpitations,
postural hypotension,
euphoria, dysphoria,
dizziness, confusion,
drowsiness, flushing, rash,
urticaria, and pruritus.
See BNF for complete list
Impaired
respiratory function
(avoid in chronic
obstructive
pulmonary
disease) and
asthma (acute
attack),
hypotension,
shock, myasthenia
gravis.
Reduced dose is
recommended in
hepatic impairment
and renal
impairment, in
hypothyroidism,
and in
adrenocortical
insufficiency.
Pregnancy and
breast-feeding
Onset 1015 mins,
peak effect
at 20mins.
Half life
1.7-4.5
hours.
Joint Trust Clinical Guideline: for the Safe use of Intravenous Conscious Sedation in Adult Patients undergoing Procedures
Author/s: Dr Nicholas Saunders Author/s title: Consultant Anaesthetist (NNUH)
Approved by: CGAP
Date approved: 06/10/2016
Review date: 06/10/2019
Available via Trust Docs
Version: 2
Trust Docs ID: JCG004 - 1311
Page 9 of 11
Joint Trust Guideline for the Safe use of Intravenous Conscious
Sedation in Adult Patients undergoing Procedures
Appendix 36
Treatment of over sedation
Sedative
Antagonist Dose
drug
Midazolam Flumazenil O.2mg IV
boluses up to
max 1mg
Infusion may
be required.
Onset
Side effects
Cautions
1-2 minutes,
peak 6-10
minutes.
Lasts 15140min
Short acting,
benzodiazepi
ne
dependence
(seizures),
prolonged
treatment of
convulsions
(seizures),
head injury,
elderly,
children,
hepatic
impairment,
pregnancy,
breast
feeding.
Opioid
2 minutes.
Lasts 20
minutes
Nausea,
vomiting, and
flushing;
agitation,
anxiety, and
fear; transient
increase in
blood pressure
and heart-rate;
very rarely
convulsions
(particularly in
those with
epilepsy),
hypersensitivit
y reactions
including
anaphylaxis.
Hypotension,
hypertension,
ventricular
tachycardia or
fibrillation,
cardiac arrest,
hyperventilatio
n, dypnoea,
pulmonary
hypertension,
agitation.
Naloxone
0.1mg-0.2mg
IV boluses.
Repeat
doses at 23min. 0.42mg can be
used if
required up
to max
10mg.
Infusion may
be required.
Cardiovascul
ar disease or
cardiotoxic
drugs,
physical
dependence
on opioids –
acute
withdrawal,
short acting,
pregnancy.
Joint Trust Clinical Guideline: for the Safe use of Intravenous Conscious Sedation in Adult Patients undergoing Procedures
Author/s: Dr Nicholas Saunders Author/s title: Consultant Anaesthetist (NNUH)
Approved by: CGAP
Date approved: 06/10/2016
Review date: 06/10/2019
Available via Trust Docs
Version: 2
Trust Docs ID: JCG004 - 1311
Page 10 of 11
Trust Guideline for the Management of Safe use of Intravenous
Conscious Sedation in Adult Patients undergoing Procedures
Appendix 47
Criteria for discharge
The patient has returned to their baseline level of consciousness
Vital signs are within normal limits for that patient
Respiratory status is not compromised
Pain and discomfort have been addressed
Joint Trust Clinical Guideline: for the Safe use of Intravenous Conscious Sedation in Adult Patients undergoing Procedures
Author/s: Dr Nicholas Saunders Author/s title: Consultant Anaesthetist (NNUH)
Approved by: CGAP
Date approved: 06/10/2016
Review date: 06/10/2019
Available via Trust Docs
Version: 2
Trust Docs ID: JCG004 - 1311
Page 11 of 11