Identify what the procedure requires: pain relief, anxiety control, immobility, and duration.
Local / regional anesthesia may avoid or reduce systemic sedation.
Plan analgesia and sedation separately. Choose the depth needed for comfort and procedural success—not deep sedation for every patient. See Assessment.
02 Assess Risk
Assess airway anatomy, baseline breathing, and circulation. Review prior sedation reactions and opioids / sedatives already administered.
Identify what changes the plan: difficult airway, cardiopulmonary compromise, frailty, or aspiration risk. Adjust the regimen, staffing, or setting accordingly.
Record recent intake, but do not delay urgent sedation for fasting time alone. Assess the full aspiration risk rather than applying elective fasting intervals automatically. See Fasting.
03 Prepare
Confirm consent, the procedure, intended sedation depth, and team roles. Identify the qualified monitor and clinician responsible for airway rescue.
Establish appropriate access and monitoring: pulse oximetry, serial BP, ECG, and capnography for moderate, deep, or dissociative sedation whenever feasible.
Check oxygen, suction, bag-mask equipment, and advanced-airway equipment. Prepare to manage deeper-than-intended sedation before medications begin. See Preparation.
04 Sedate / Reassess
Match the agent to the procedure and patient. Reduce doses for frailty, hemodynamic compromise, or other depressants.
Allow each dose to reach its expected effect before redosing. Reassess pain and sedation separately; titrate to procedural comfort rather than a fixed total dose. See Medications.
Follow airway patency, chest movement, capnography, oxygenation, and BP throughout. Normal SpO₂ on oxygen does not exclude hypoventilation.
05 Recognize / Treat Complications
Obstruction / hypoventilation: Pause medications and the procedure; reposition, open the airway, and suction as needed.
Apnea / inadequate ventilation: Begin bag-mask ventilation promptly. Persistent obstruction or ineffective ventilation requires advanced-airway rescue.
Hypotension: Pause sedation, assess ventilation and perfusion, and treat the cause. Reversal agents are selective adjuncts—not substitutes for respiratory support. See Complications.
06 Recover / Disposition
Continue monitoring after the procedure ends; sedation may persist after painful stimulation stops.
Confirm baseline consciousness and stable airway, ventilation, and circulation. Longer-acting medications or reversal may require extended observation.
Discharge: Appropriate recovery, responsible supervision, and written instructions. Readiness depends on recovery—not a fixed timer or mandatory oral-fluid challenge. See Disposition.
02Procedure / Patient Assessment
Sedation Needed?
Match the plan to pain, anxiety, and movement control. Reductions, cardioversion, drainage, and imaging do not all require the same depth.
Local / regional anesthesia and nonpharmacologic support may reduce the need for systemic medication.
Sedation and analgesia are separate needs. Amnesia does not mean pain is controlled. AAP/AAPD — Goals Of Sedation.
Sedation Depth
Sedation Depth — Response And Airway
State
Clinical Description
Minimal:
Normal response to verbal stimulation; ventilation unaffected.
Baseline mental status, respiratory effort, oxygen requirement, BP, and perfusion.
Review opioids, sedatives, alcohol, and other depressants already present. Frailty and impaired drug clearance affect dosing and recovery. Midazolam Labeling.
Check airway patency, mouth opening, dentition, neck mobility, and how difficult mask ventilation may be.
Discuss the procedure, alternatives, sedation risks, and consent. Plan for procedure duration and recovery needs. ACEP 2014.
Fasting / Aspiration Risk
Record recent intake and assess vomiting, gastrointestinal disease, and procedural urgency.
Urgent ED sedation should not be delayed solely for elective fasting intervals. Fasting does not eliminate aspiration risk. ACEP 2014.
GLP-1 medications: Assess gastrointestinal symptoms; adult use alone does not require cancellation. Higher-risk presentations call for an individualized plan. Consensus 2026.
03Preparation / Monitoring
Team / Equipment
Confirm the proceduralist, sedation clinician, and qualified monitor; roles must satisfy the intended depth and local credentialing.
A qualified person monitors the patient in addition to the proceduralist. Pediatric deep sedation has additional staffing requirements. ACEP 2014.
Confirm medications, concentrations, calculated doses, reversal agents, and vascular access appropriate to the regimen. AAP/AAPD 2025.
Monitoring
Observe airway patency, chest movement, respiratory rate, and depth of sedation continuously.
Continuous pulse oximetry and cardiac rhythm monitoring, with serial BP, for moderate, deep, and dissociative sedation whenever feasible.
Capnography: Routine for moderate, deep, and dissociative sedation whenever feasible. If initially limited by cooperation or the procedure, maintain direct observation and apply monitoring as soon as possible. Consensus 2026.
Normal SpO₂ on oxygen does not establish adequate ventilation. Record medication times, physiologic changes, and interventions. ACEP 2014.
Guidelines differ on routine preventive oxygen: ASA recommends supplemental oxygen during moderate sedation unless contraindicated; the 2026 unscheduled-sedation consensus considers it optional. Follow patient needs and local protocol. ASA 2018 · Consensus 2026.
04Agent Selection / Titration
Adult doses below are examples, not automatic boluses. Reduce doses for frailty, hemodynamic compromise, or other depressants.
Wait for the previous dose to reach its expected effect before redosing. Reassess pain, sedation, and ventilation separately. ASA 2018.
Propofol
Brief, titratable sedation with rapid recovery; no intrinsic analgesia.
Initial: 0.5–1 mg/kg IV. Repeat: 0.25–0.5 mg/kg every 1–3 minutes as needed, after reassessment. Smaller doses for higher-risk patients; use lean body mass for weight-based dosing in obesity. Propofol 2019.
Apnea and hypotension remain important risks. Reliable IV access and hemodynamic rescue must be available; routine saline does not ensure stability. Diprivan Labeling.
Egg / Soy Allergy
Food allergy alone is not equivalent to propofol allergy; AAAAI supports use in egg / soy allergy without special precautions.
Previous propofol reaction requires separate assessment. Diprivan labeling still lists a history of egg / soy anaphylaxis as a contraindication; recognize this discrepancy and follow local policy. AAAAI · Diprivan — Contraindications.
Ketamine
Dissociation with analgesia and amnesia; useful for painful procedures.
IV: 1–2 mg/kg slowly over at least one minute. Additional 0.5 mg/kg increments may maintain dissociation after reassessment. CorePendium — Ketamine.
IM alternative: 4–5 mg/kg when IV delivery is impractical; less titratable, with longer recovery.
Breathing and airway reflexes are usually preserved—not guaranteed. Laryngospasm, apnea, vomiting, and emergence symptoms remain possible. Ketamine Guideline 2011.
Cautions / Adjuncts
Avoid ketamine when a significant BP rise would create a serious hazard. Cardiovascular stability is not guaranteed; airway procedures and acute globe injury require particular caution. Ketamine Labeling · Ketamine 2011.
Intracranial pathology alone is not an automatic contraindication. Reassuring ICP evidence mainly concerns mechanically ventilated ICU patients and is limited in quality. ICP Review 2020.
Quiet recovery; suction for problematic secretions. No routine atropine / glycopyrrolate.
Midazolam may reduce adult recovery agitation; routine pediatric benefit is unproven. Consensus 2026.
Etomidate
Short-acting adult option; no analgesia.
0.1 mg/kg IV initially; titrate additional small doses only after reassessment. CorePendium.
Myoclonus, nausea / vomiting, respiratory depression, and adrenal suppression remain relevant. Relative hemodynamic stability is not guaranteed. Etomidate — Adverse Effects · Pharmacology.
Midazolam
Anxiolysis and anterograde amnesia; no analgesia. It does not reliably erase earlier painful events. Midazolam — Pharmacology.
1 mg IV over at least two minutes is a reasonable initial adult increment; allow at least another two minutes before reassessment / redosing.
Older, frail, or premedicated patients may need less. Avoid treating 0.1 mg/kg as a routine starting bolus. Midazolam — Dosing.
Fentanyl
Analgesia; not reliable amnesia or complete procedural sedation.
50 mcg IV over 1–2 minutes is an adult starting option; smaller doses for higher-risk patients. Reassess before additional increments. Fentanyl — Dosing.
Respiratory depression may peak several minutes later and outlast analgesia. Rapid / high doses may cause rigidity; benzodiazepines and other sedatives intensify respiratory depression. Fentanyl Labeling.
Ketofol
Ketamine + propofol is an alternative regimen; use a defined protocol and track each drug’s dose separately.
Not protection against apnea. POKER found no significant reduction in respiratory interventions versus propofol alone; less hypotension but more severe emergence delirium. POKER 2016.
Other Options
Methohexital: Short-acting alternative where familiar; plan analgesia separately. Apnea, hypotension, and laryngospasm require standard monitoring and airway rescue. Brevital Labeling.
Nitrous Oxide — N₂O: Titrate using an appropriate delivery system. Avoid with trapped-gas conditions, such as pneumothorax / bowel obstruction, or untreated vitamin B12 deficiency. Higher concentrations or added sedatives may require deeper-sedation safeguards. AAPD — Nitrous Oxide · ASA — Nitrous.
Pregnancy: Nitrous is used in labor; this does not establish suitability for every pregnant patient or procedure. Use an obstetric-specific assessment rather than a blanket prohibition. ASA — Nitrous In Labor.
05Complications / Rescue
Obstruction / Hypoventilation / Apnea
Stop dosing and pause the procedure. Reposition, open the airway, suction, and use airway adjuncts as needed.
Inadequate ventilation: Bag-mask ventilation promptly. Do not wait for profound desaturation.
Stop stimulation, call for help, apply jaw thrust, and attempt positive-pressure oxygenation.
Persistent obstruction may require deeper anesthesia or neuromuscular blockade / intubation by an experienced clinician.
Do not delay rescue while repeating an ineffective maneuver.AAP/AAPD — Rescue.
Hypotension
Pause sedatives; reassess ventilation, rhythm, perfusion, and the underlying cause.
Treat volume depletion when present; persistent compromise may require vasoactive support. Reconsider further dosing. Diprivan Labeling.
Reversal
Naloxone: Opioid-related respiratory depression.
Flumazenil: Selected benzodiazepine-related depression after contraindication and seizure-risk assessment. Dependence increases seizure risk; avoid when benzodiazepines treat a life-threatening condition, such as status epilepticus, or with serious cyclic antidepressant poisoning. Flumazenil Labeling.
Support ventilation first. Continue monitoring for recurrent sedation; do not use routine reversal to accelerate discharge. ASA 2018 — Reversal.
06Pediatric Safeguards
Use age-, weight-, route-, and agent-specific doses—not the adult examples above.
Assess developmental baseline, airway anatomy, respiratory illness, and comorbidities. Young infants require a separate high-risk assessment.
Deep sedation requires at least two personnel with current Pediatric Advanced Life Support (PALS) or Advanced Pediatric Life Support (APLS) certification and pediatric rescue skills, including a dedicated independent observer. AAP/AAPD 2025.
Continuous ECG and capnography for deep sedation; document vital signs at least every five minutes and any limitation preventing capnography. AAP/AAPD 2025.
Age-sized equipment and recovery monitoring continue until the child returns to baseline. AAP/AAPD — Reaffirmed 2025.
07Recovery / Disposition
Continue observation after procedural stimulation ends. Longer-acting combinations or reversal may require prolonged monitoring. ASA 2018.
ICU Admission
Persistent airway / respiratory failure or hemodynamic instability requiring advanced support. See Complications / Rescue.
Monitored Observation / Admission
Delayed recovery, recurrent respiratory depression, new or increased oxygen need, or another complication requiring observation.
Unsafe discharge arrangements or an underlying condition requiring admission.
Document medications, adverse events, interventions, and recovery status at handoff. AAP/AAPD — Recovery.
Discharge
Baseline consciousness; stable airway, ventilation, oxygenation, and circulation, with oxygen needs returned to baseline. AAP/AAPD 2025.
Function appropriate to age, baseline, and injury. A lower-extremity injury does not mean the patient must walk.
Responsible adult, written instructions, activity restrictions, and return precautions.
No routine oral-fluid challenge. Judge recovery by clinical criteria rather than a routine timer; reversal or long-acting drugs require longer observation. Follow agent-specific guidance and local protocol. Consensus 2026 · ASA 2018.
08In The Pit
Airway / Ventilation: Stop dosing, open the airway, ventilate; escalate promptly if ineffective.
Procedure: Match analgesia and sedation to the task; amnesia is not pain control.
Preparation: Qualified monitor, capnography, suction, and rescue equipment ready.
Dosing: Small, deliberate doses; allow effect before repeating. Reduce for frailty and drug combinations.
Fasting: Assess aspiration risk; fasting time alone should not delay urgent care.
Recovery: Baseline function, stable physiology, and no recurrent sedation; follow agent-specific observation requirements. See Disposition.