Synopsis
Plan and deliver adult procedural sedation within a defined target depth, with competent staffing, proportionate monitoring and immediate rescue capability if consciousness, airway control or ventilation deteriorates.
- Sedation is a continuum: if targeting moderate sedation, the team must be able to rescue a patient who becomes deeply sedated; deep sedation requires capability to rescue from general anaesthesia.
- For sedation deeper than minimal, use pulse oximetry, ECG, automated blood pressure and continuous waveform capnography, while directly observing airway, breathing, circulation and responsiveness.
- Stop drugs and rescue immediately when verbal responsiveness is lost unexpectedly, the airway obstructs or ventilation becomes ineffective; give oxygen and verify assisted breaths by chest movement and waveform capnography.
Key red flags
Loss of normal verbal response during intended moderate sedation means the patient has crossed into deeper sedation and needs immediate rescue assessment.
Snoring obstruction, paradoxical breathing, absent chest movement or a flat capnography trace requires prompt airway manoeuvres and confirmation of effective ventilation.
Apnoea, persistent desaturation, hypotension, arrhythmia or reduced responsiveness demands cessation of drug delivery and structured resuscitation.
Repeated small doses can accumulate, especially in older or frail adults and after opioids, alcohol or other central nervous system depressants.
A procedure cannot safely continue when the only person able to monitor and rescue the patient is occupied by the technical task.
Discharge before recovery of baseline consciousness, stable observations and safe mobility can expose the patient to recurrent drug effect away from monitoring.
Purposeful response requires repeated or painful stimulation, and airway intervention or ventilatory support may be needed.
Snoring, tracheal tug, paradoxical movement or absent airflow despite effort indicates obstruction and requires immediate airway action.
A falling respiratory rate, shallow movement or absent or changing carbon dioxide waveform may precede desaturation.
Reasoning priorities
Identify features that may make airway opening, bag-mask ventilation or tracheal intubation difficult.
Predicted difficulty changes personnel, location, technique and the threshold for anaesthetic involvement; it does not reliably predict every event.
Worked reasoning
A stable adult needs a painful procedure and is expected to retain purposeful response to voice.
- Define the intended moderate depth, assess patient and airway risk, explain alternatives and material risks, and confirm fasting and medicine history appropriate to the urgency.
- Allocate a trained dedicated monitor, prepare oxygen, suction, airway and resuscitation equipment, and attach pulse oximetry, ECG, automated blood pressure and waveform capnography.
- Titrate small drug doses with time for peak effect, assess verbal response and ventilation after each dose, and pause if the patient approaches a deeper level.
- Continue observation until baseline consciousness and stable physiology return, apply written discharge criteria and give escort and activity advice after ambulatory care.