Dr. Khaled Khreisat
Conscious Sedation
Conscious Sedation
(Introduction)
Good Morning my dear nurses, before I start let me introduce myself, I’m (Dr. Khaled Khreisat , …etc.),
I hope all of you doing good and are safe with your families.
Today my presentation is going to be about conscious sedation, I have divided my presentation into 5
main parts,
 First we will go into the definition of sedation, and conscious sedation.
What is conscious sedation? (ask this question)…,
 in the second part we will discuss the Patient Assessment Prior To Conscious Sedation, which
includes medical history and diseases, drug history, and airway assessment
 In the third part of this presentation we will talk sedation techniques
 In the fourth part we will move to drugs, their effects and their doses
 And finally, my last part will be about pre and post sedation instructions and notes
Dr. Khaled Khreisat
Conscious Sedation
FIRST PART
According to the degree of Central Nervous System depression:
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◦ Conscious Sedation
◦ Deep Sedation
◦ General Anesthesia
 What is conscious sedation?
It is a technique where one or more drugs are used to depress the Central Nervous System of a patient
thus reducing the awareness of the patient to his surroundings.
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How is conscious sedation different from deep sedation?
 Goals of conscious sedation
 Provision of safe analgesia, anxiolysis, sedation, and amnesia during stressful procedures.
 Safely decreasing adverse psychological responses associated with stressful procedures.
 The return of patients to their pre-procedural level of functioning.
 What are the levels of conscious sedation?
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Sedation Score 0 = Fully awake
Sedation Score 1 = Light sedation, largely aware of self/surroundings. Mildly sleepy.
Dr. Khaled Khreisat
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Conscious Sedation
Sedation Score 2 = Moderate sedation, slightly aware of self/surroundings; somnolent but
easily aroused with stimulation.
Sedation Score 3 = Deeply sedated; unaware of self/surroundings.
Sedation Score 4 = General anesthesia; patient is unconscious
SECOND PART
Patient Assessment Prior To Conscious Sedation
The physician, dentist, or independent practitioner responsible for overall conduct of the conscious
sedation is generally required to do the following:
 Perform a history and physical exam
 Assign an American Society of Anesthesiologist (ASA) health class
 Document a sedation plan
 Document NPO status
Note Exam History should focus on factors that may increase:
 Patient sensitivity to sedatives/analgesics
 Patient risk of respiratory/cardiopulmonary complications
Note Take care of the following medical conditions:
 Cardiopulmonary disease may accentuate hemodynamic/respiratory depression caused by
sedatives and analgesics. May require decreased drug dosages; EKG monitoring warranted.
 Hepatic or renal abnormalities may impair drug metabolism, causing altered sensitivity and
duration of action when sedatives/analgesics are administered.
Dr. Khaled Khreisat
Conscious Sedation
 Medication interactions between a patient’s routine medications & sedatives/analgesics
may alter normal drug responses.
 Patient allergies must be known and documented.
 Alcohol abuse may increase tolerance to sedatives/analgesics while acute use prior to
conscious sedation will be additive or synergistic with medication effects.
 Tobacco use increases airway irritability and risk of bronchospasm during sedation. Prior
adverse reaction to anesthesia/sedation may increase risk during subsequent procedures
Airway assessment;
The patient undergoing conscious sedation should have a thorough airway assessment focusing on :
 Airway class ;
 Mouth opening ; Normal mouth opening should be 3 to 4 cm, anything less than 2 cm is
considered a small mouth opening,
Example of this; is a case of trismus or known as lockjaw, may be caused by spasm of the
muscles of mastication, patient is unable to open his mouth.
PART 3
Sedation techniques
Dr. Khaled Khreisat
Conscious Sedation
1. Non - Titrable Technique;
 Oral Sedation
 Rectal Sedation
 Intramuscular Sedation
 Submucosal Sedation
 Intranasal Sedation
2. Titrable Technique
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Inhalational Sedation
Intravenous Sedation
3.Combination of the two techniques
1.Oral Sedation;
By far, it is the most universally accepted and easiest method of sedation administration.
The most variable (non-titrable) technique
We should be familiar with the effects of oral sedation, such as ;
 Recovery time prolonged
 Difficult to reverse unwanted effect
 No repeated doses
Advantages of Oral Sedation
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Universal acceptability Ease of administration
Low cost
Incidence of adverse reactions less than some other techniques
No needles, syringes or special techniques
Various drugs, dosage forms available
Allergic reactions less severe than seen in parenteral administration
No specialized training
2. Inhalational Sedation Nitrous Oxide/Oxygen Inhalation Sedation ;
Nitrous oxide/oxygen (N²O/O²) sedation is a combination of these gases that the patient inhales to help
eliminate fear and to help the patient relax, usually used in dentistry and maternity
Dr. Khaled Khreisat
Conscious Sedation
Administration of Inhalation sedation
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Start with pure oxygen while establishing the patient’s tidal volume.
Slowly titrate the nitrous oxide until the desired results are achieved.
Patients should refrain from talking or mouth breathing.
The N²O/O² analgesia should end with the administration of 100% O² for 3 to 5 minutes.
Obtain postoperative vital signs and compare them to the preoperative recordings.
3. Intravenous Sedation
Antianxiety drugs that are administered intravenously continuously throughout the procedure at a
slower rate, providing a deeper stage I analgesia.
The most rapid technique; onset is approximately 20 to 25 seconds.
In children under 6 years, the incidence of untoward effects is increased.
PART 4
Drugs for sedation:
Either one drug or combinations of IV drugs
Most Common combinations :
 Benzodiazepines & opioids
 Propofol & opioids
1.Diazepam (Valium)
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Benzodiazepine
Produces sleepiness and relief of apprehension
Onset of action 1-5 minutes
Half-life is 30 hours
Average sedative dose is 10-12 mg
2.Ketamine
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Benzodiazepine
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Effects:
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Sedation
Hipnosis
Amnesia
Analgesia
Dr. Khaled Khreisat
Conscious Sedation
 Halisunation!!
 IMPORTANT: Do not use on Adults and psychiatric patients
3.Midazolam (Versed)
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Short acting benzodiazepine
4 times more potent than Valium
Produces sleepiness and relief of apprehension
Onset of action 3-5 minutes
Half-life is 1.2-12.3 hours
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Average sedative dose 2.5-7.5 mg
4.Fentanyl (Sublimaze)
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Narcotic/Opiod agonist 100 times more potent than Morphine
Pain attenuation and some sedation
Onset of action around 1 minute
Half-life 30-60 minutes
Average dose 0.05 – 0.06 mg
5.Propofol (Diprivan)
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Intravenous anesthetic/sedative hypnotic
Sedative, anesthetic and some antiemetic properties
Onset of action within 30 seconds
Half-life 2-4 minutes
Average sedative dose: Variable
6.Robinul (Glycopyrrolate)
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Anticholinergic
Heart rate increases
Salivary secretions decrease
Dose 0.1-0.2 mg
Onset of action within 1 minute
7.Naloxone (Narcan)
Dr. Khaled Khreisat
Conscious Sedation
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Narcotic antagonist!!!
Fentanyl reversal agent
Initial dose – 0.4mg May repeat every 2-3 minutes at doses of 0.4-2mg
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Monitor for re-sedation
List of generic and proprietary drug names is as below;
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Alprazolam = Xanax
Diazepam
= Valium
Flumazinil = Romazicon
Lorazepam = Ativan
Methohexital = Brevital
Midazolam = Versed
Naloxone
= Narcan
Propofol
= Diprivan
Sodium Thiopental = Sodium Pentothal
PART 5
Pre-Procedure Fasting (“NPO”)
The patient must be fasted minimum 2-3 hours for clear liquids and 6 hours for solid food to prevent
vomiting causing suffocation and aspiration pneumonia.
Discharge Criteria
1. Vital signs normal (within 20% baseline)
2. Airway patency uncompromised
3. Patient awake, or awake on command
4. Can breathe deeply
5. Protective reflexes intact
6. Adequate hydration, able to drink
7. Patient can speak normally
8. Patient can sit unaided
9. Patient can walk with minimal assistance
10. Responsible, “vested,” adult is available
11. No pain, no nausea or vomiting
Post-sedation Instructions
Verbal and written instructions must be given to the adult upon discharge from the office
Should include:
Dr. Khaled Khreisat
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Conscious Sedation
Potential and anticipated post-sedation effects
Limitation of activity (driving, machinery) for 24 hrs
Dietary precautions and suggestions
No other sedatives for 24 hrs
24-hour contact number for practitioner