Synopsis
Select an appropriate sedation plan, prepare personnel and rescue equipment, titrate medicines safely and verify recovery before discharge.
- Sedation can become deeper than intended; the team must be able to recognise and rescue airway or cardiovascular compromise.
- Use a dedicated sedation clinician, a separate procedural clinician and a trained nurse in an appropriately equipped area.
- Assess the airway, physiological reserve, aspiration risk, prior drug doses and the procedure’s urgency before selecting an agent.
Investigation priorities
Establish suitability, consent and the safest setting.
Management branches
A healthy adult undergoing shoulder reduction has received titrated propofol with a separate sedation clinician present. The capnography waveform disappears and there is no visible respiratory effort, while SpO2 is still 98% on oxygen.
- Treat the absent effort as apnoea. Stop propofol and pause the reduction immediately; ask for help while the sedation clinician maintains responsibility for the airway.
- Open the airway, use appropriate adjuncts and provide bag-mask ventilation with oxygen. Check the capnography line in parallel, but do not let an equipment check delay ventilating a non-breathing patient.
Key medicines
Propofol for adult procedural sedationThe UK 1% product describes 0.5–1 mg/kg IV over 1–5 minutes for onset, titrated to response. RCEM recommends substantially smaller, slowly given 10–20 mg increments in older adults; allow effect before additional dosing.It provides no analgesia and can cause apnoea and hypotension. Reduce dose and speed with frailty, poor cardiac reserve or prior opioids; stop dosing at excessive depth or physiological compromise. Check product-specific allergy contraindications.
Midazolam for conscious sedationUsing 1 mg/mL injection, the UK SmPC starts adults under 60 at 2–2.5 mg IV, given slowly, with 1 mg increments if needed. In older, debilitated or chronically ill adults start 0.5–1 mg and titrate cautiously in 0.5–1 mg increments.Allow time for the evolving effect; the SmPC places initial administration 5–10 minutes before the procedure. It is not an analgesic. Opioids, renal or hepatic impairment and respiratory disease increase risk of prolonged or excessive sedation.