Procedural Sedation

Objectives

To outline the expected conduct of procedural sedation in the operational environment.

Scope

What preparation should be done prior to procedural sedation?

What equipment might be needed for procedural sedation?

What drugs might be used during procedural sedation in different situations?

How should procedural sedation be carried out?

Audience

This guideline is intended for use by registered healthcare professionals fulfilling a general role in forward medical locations or in an emergency department in a deployed hospital setting

Initial Assessment & Management

Decision to Undertake Procedural Sedation

Is procedural sedation required? Consider:

i. The urgency and complexity of the procedure

ii. Availability of appropriately-trained staff for the procedure and sedation

iii. Availability of appropriate space and equipment

iv. Patient Assessment (including fasting status)

v. Patient consent, where applicable

vi. Alternatives to sedation:

Analgesia: Pain should be assessed and managed with analgesia in accordance with appropriate guidelines (e.g. via alternative routes: inhalational, topical, intra-nasal or regional anaesthesia) rather than sedation. Consider the need for ongoing pain relief post-procedure.

Anxiolysis: Non-pharmacological methods of reducing anxiety (e.g. a calm environment and support/ distraction from family members or clinicians) are effective and may mitigate the need for sedation.

Preparing for Procedural Sedation

Preparation should include:

i. Patient Preparation

a. A full assessment of the patient should be conducted.

b. Patient consent should be obtained.

c. IV access obtained, supplementary oxygen provided and monitoring applied.

ii. Personnel:

a. Any clinician undertaking procedural sedation should have undergone appropriate training in the knowledge, skills and competencies. Regular clinical experience or appropriate refresher training should be documented as well as competency limits.

b. The minimum staffing should be: Sedationist (responsible solely for delivering sedation and monitoring the patient), Proceduralist (responsible solely for conducting the planned procedure), trained assistant (to assist either clinician or obtain additional equipment/ help).

c. In some circumstances, there will only be one available clinician who will have to deliver the sedation and perform the procedure. In this case, two trained assistants will be necessary: one with no other role or responsibility other than to monitor the patient and another as the assistant to the operator.

d. Team brief and checklist should be carried out prior to procedural sedation. This should include (not exhaustively): A discussion about the patient and the planned procedure; confirmation of the availability of drugs, monitoring and equipment; expected roles for team members; and back-up plans in the event of complications.

iii. Equipment:

Full resuscitation equipment should be immediately available and checked. This should include:

a. Airway adjuncts and equipment required for endotracheal intubation.

b. Appropriate method of oxygen delivery (oxygen mask and bag-valve-mask)

c. High pressure suction and appropriate suction catheters

d. Appropriate trolley/ stretcher to position the patient

e. Monitoring equipment (see below).

f. Sedation drugs (see below).

g. Emergency Drugs (including those appropriate for advanced life support, reversal of sedation and emergency intubation).

iv. Environment:

An appropriate location should be selected and where possible should be:

a. Well-lit

b. Quiet/ minimal interruptions or distractions

c. Adequately spacious

d. Protected from the elements (e.g. cold/ heat/ dust/ rain/ wind)

Selection of Procedural Sedation Agent

i. The choice of pharmacological agents for procedural sedation will depend upon:

a. The procedure being undertaken

b. The planned level of sedation

c. Training and familiarity of clinicians with potential agents

d. Patient factors (e.g. cardiovascular stability, fasting status, age)

e. The local environment

ii. The appendix lists potential pharmacological agents. In all cases, the appropriate drug needs to be titrated to the appropriate dose and speed of administration for the clinical effect required.

Monitoring During and After Procedural Sedation

i. Full monitoring during and after the procedure should be carried out. This should include:

a. 3 lead ECG,

b. Pulse oximetry,

c. Non-invasive blood pressure,

d. Continuous capnography,

ii. Alarms for monitoring equipment should be appropriately set and the continuously monitored by a nominated clinician.

Conducting Procedural Sedation

Final preparations

The patient should be appropriately positioned.

A Time-Out is carried out including:

Confirming the patient, any pertinent clinical details and planned procedure.

All personnel, equipment, monitoring and drugs are available.

Commence Sedation

Sedation drugs should be carefully titrated with regards to dose and careful consideration for time of onset and peak effect.

The required level of sedation may vary from minimal depression of consciousness to response to painful/ repeated stimulus to full loss of consciousness despite painful stimulus. This may correspond to additional interventions required for airway, breathing and cardiovascular system support.

Conduct the Procedure

The procedure should not be commenced until the sedationist has achieved the desired level of sedation.

The proceduralist should inform the team when a particularly stimulating/ painful component of the procedure is about to be carried out. Likewise, the team should also be informed when the procedure is complete.

Post Procedural Sedation Care

The patient should be monitored until return to full consciousness

Ensure adequate, effective post-procedure analgesia

Documentation and handover to following clinical teams

Discharge advice to the patient and family, provide (if available) and information leaflet

Record and report any complications

Paediatric Considerations

See accordion section on Paediatric dosing

Commonly used pharmacological agents for Procedural Sedation (Adapted from RCEM Best Practice Guideline Procedural Sedation in the Emergency Department August 2022)

 

Propofol

Properties: Phenol derivative, highly lipophilic, crosses blood brain barrier rapidly. Action thought to be through positive modulation of GABA inhibitory neurotransmission. Used widely for induction and maintenance of anaesthesia.

Uses: Sedation and amnesia.

Administration: Much smaller doses are required for sedation than for general anaesthesia, with initial doses as low as 10 mg in the elderly or those with significant co-morbidities although the initial action may be seen within 30 s, the peak effect may take 2 min or more, particularly in the elderly. An alternative technique is to use a computer-controlled infusion, which estimates the administration profile required for a target plasma concentration, normally 0.5-1.5 μg/ml for sedation.

Children: Propofol is not licensed for use in sedation in children, however the NICE Guideline Development Group recommend off-license use of propofol for sedation in children

Side effects: Hypotension, respiratory depression, pain at site of injection

Midazolam

Properties: Short-acting benzodiazepine metabolised in the liver commonly used for sedation, it is also a powerful amnesic.

Uses: Sedation and amnesia

Administration: Can be administered orally, buccally, or as an IV infusion.

Children: Midazolam is not licensed for use in children under 6 months or for sedation either via the oral or buccal route in children. There is no UK marketing authority currently for oral or intranasal midazolam use in sedation.

Side effects: respiratory depression, hypotension, paradoxical disinhibition and agitation at low doses in children. Accumulates in adipose tissue, which can significantly prolong sedation. The elderly, obese and patients with hepatic or renal disease are at risk of prolonged sedation.

Ketamine

Properties: Phencyclidine derivative that produces a dissociative state and profound analgesia with superficial sleep. Ketamine does not display a dose-response continuum as seen with other analgesic and sedative agents. There is a threshold dose for dissociation after which additional doses are required only to maintain the dissociative state. Sub-dissociative doses provide analgesia with disorientation rather than dissociation. The big advantage of ketamine is that airway reflexes are maintained and that it does not cause hypotension.

Uses: 1. dissociative state, amnesia, and analgesia 2. analgesia

Administration: Can be administered as a slow IV bolus titrated to effect or intramuscularly.

Side effects: tachycardia, hypertension, laryngospasm, unpleasant hallucinations (reduced by pre-medication with a benzodiazepine), nausea and vomiting, hyper-salivation, increased intracranial and intraocular pressure.

Contraindications: Absolute contraindications: age less than 3 months, known or suspected schizophrenia. Relative contraindications: age less than 1 year, active pulmonary disease or infection, known or suspected cardiovascular disease (including angina, hypertension and heart failure), CNS masses, abnormalities or hydrocephalus, globe injury or glaucoma.

Ketofol

Properties: Combination of Ketamine and 1% Propofol used at a 1:1 ratio in the same syringe in the belief that the lower doses reduce side-effects (hypotension and vomiting and emergence phenomena respectively) of the agents and that the agents act synergistically.

Uses: sedation, amnesia and analgesia.

Administration: 1:1 mixture in the same syringe.

Side effects: as for propofol and ketamine

Fentanyl

Properties: A synthetic opioid with 72-125x potency of morphine. Rapid onset (2-3 minutes) duration of effect 30-60mins.

Uses: analgesia and sedation

Administration: Best given a few minutes before sedation to maximise analgesic effect. Doses of no more than 0.5 mcg/kg with other sedation agents.

Side effects: Respiratory depression potentiated by sedatives (e.g. propofol). Patients with renal or hepatic disease and the elderly may experience more profound or prolonged effects.

Methoxyflurane

Properties: An inhalational anaesthetic agent that has been repurposed as an inhaled analgesic. Initially licensed for analgesia, it has also found use for sedation of patients. It has a very rapid onset of action (seconds).

Uses: analgesia and sedation

Administration: Methoxyflurane is self-administered using the hand held PENTHROX Inhaler.

Side effects: Contraindicated in patients who are known to be or genetically susceptible to malignant hyperthermia, patients who have a history of showing signs of liver damage after previous methoxyflurane use or halogenated hydrocarbon

anaesthesia. It should not be used in patients with clinically significant renal impairment, cardiovascular instability or respiratory depression.

 

REVERSAL AGENTS

Flumazenil

Properties: Competitive antagonist at central benzodiazepine receptors

Use: Reversal of respiratory depression following benzodiazepine use.

Administration: 100-200mcg over 15 seconds, every minute. Maximum dose 1mg (adults), acts 30-60 seconds.

Side Effects: Use with caution in those on long tem benzodiazepines. Hypertension, dysrhythmias and vomiting.

Naloxone

Properties: Competitive antagonist at opiate receptors

Use: Reversal respiratory depression secondary to opioid administration

Administration: Adults:100-200mcg every 1-2 minutes; Children 11month-11yrs 1- 10mcg/kg (max 200mcg per dose, total max dose 2mg); children 12-17yrs 100-200mcg every 1-2 minutes (max dos 2mg). Acts within 2 minutes and lasts approximately 20 minutes. Titrate to reverse respiratory depression without reversing analgesia.

Side Effects: Precipitation of withdrawal in chronic opiate use. Arrhythmias, nausea vomiting.

Pharmacological agents for procedural sedation

 

Agent Role Route Initial dose - Elderly Repeat Dose Elderly Initial Dose Adult Repeat dose Adult Initial onset time (min) Peak Effect time (Min)
Propofol Sedation/Amnesia IV 10-20mg (given slowly) 10-20mg (given slowly) 0.5-1.0 mg/kg 0.5mg/kg every 3-5 mins 0.5-1 1-2
Midazolam Sedation/Amnesia IV over 1-2 mins 0.5mg 0.5mg 1-2mg (max single dose 2.5mg) After 2-5 mins 1-2 3-4
Ketamine Sedation/Analgesia/Amnesia IV give over 30-60 secs 10-30mg   1mg/kg 0.25-0.5mg/kg every 5-10 mins 0.5-1 1-2
Ketamine Sedation/Analgesia/Amnesia IM     4-5mg/kg 2-2.5mg/kg every 5-10 mins 0.5-1 1-2
Ketamine Analgesia (sub-dissociative) IV     0.4mk/kg   0.5-1 1-2
Fentanyl Analgesia with other sedatives IV     Up to 0.5mic/kg Up to 0.5mic/kg every 2 mins 1-2 3-5
Fentanyl Sedation/Analgesia IV     Up to 0.5-1mic/kg 0.5-1mic/kg every 2 mins 1-2 3-5
Ketofol (ketamine and propofol) Sedation/Analgesia/Amnesia IV     0.5mg/kg-0.75mg/kg of both agents   0.5-1 1-2
                 

Pharmacological agents for procedural sedation - Paediatric

Agent Role Route Age Initial dose Max dose Repeat dose Max dose Initial onset time (min) Peak effect Time (min)
Propofol Sedation/amnesia IV 6 months-2 years 1-2mg/kg*   0.5mg/kg every 3-5 mins 3mg/kg* 0.5-1 1-2
      >2 years 0.5-1mg/kg*          
Midazolam Sedation/Amnesia IV 6 months-5 years 0.025-.05mg/kg** 2mg (single dose) up to 0.2mg/kg after 2-5 mins total 6mg 1-2 3-4
      6-12 years 0.025-0.5mg/kg 2mg single dose 0.1mg/kg total 10mg    
Ketamine Sedation/Amnesia/analgesia IM >3 months only 4-5mg/kg (many authorities guidelines suggest 2-2.5mg/kg)   Half of first dose: 2-2.5mg/kg (1mg/kg if using first dose). IM after 5-10 mins   0.5-1 1-2
Ketamine Sedation/Amnesia/Analgesia IV (0ver 30-60 secs) >3 months only 1.0mg/kg***     0.5mg/kg after 5-10 mins   0.5-1 1-2
Ketofol (ketamine and propofol) Sedation/Amnesia/Analgesia IV >6 months only 0.5mg/kg propofol and ketamine       0.5-1 1-2

*reduce dose significantly in patient who are debilitated or have decreased cardiac function

**This is the BNF dosing regime, many sources suggest higher dosing range of 0.05-0.1mg/kg required

***See RCEM Ketamine Procedural Sedation for Children in EDs (Feb 2020)

Last reviewed: 21/05/2026

Next review date: 21/05/2027

Related resources

Safe Sedation Procedures in Adults - RCEMLearning https://www.rcemlearning.co.uk/reference/adult-procedural-sedation

Procedural sedation in Emergency Medicine 2024 - RCEMLearning https://www.rcemlearning.co.uk/reference/procedural-sedation-emergency-medicine-2018/

References

The Royal College of Emergency Medicine (RCEM) Best Practice Guideline, Procedural Sedation in the Emergency Department, August 2022.

Association of Anaesthetists. Recommendations for standards of monitoring during anaesthesia and recovery, May 2021 Academy of Medical Royal Colleges, Safe Sedation Practice for Healthcare Procedures. Standards and Guidance. 2013: London, UK. Academy of Medical Royal Colleges. Safe sedation practice for healthcare procedures, An update. Feb 2021.