Conscious Sedation: Reality or Myth?

Jeffrey L. Koh; Tonya Palermo

doi:10.1542/pir.28-7-243

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Jeffrey L. Koh, MD*
Tonya Palermo, PhD^†

^*Associate Professor and Chief, Division of Pediatric Anesthesia, Department of Anesthesiology and Peri-Operative Medicine, Oregon Health & Science University, Portland, Ore
^†Assistant Professor of Anesthesiology and Psychiatry, Department of Anesthesiology and Peri-Operative Medicine, Oregon Health & Science University, Portland, Ore

Objectives

After completing this article, readers should be able to:

Define conscious sedation in contrast to deep sedation and general anesthesia.
Know the recommended level of observation and monitoring for a patient undergoing conscious sedation and how to prepare for adverse events.
Name the indications and contraindications for conscious sedation.
Discuss the process for choosing pharmacologic or behavioral intervention options for procedural pain and distress.
Describe the indications and possible adverse effects for commonly used pharmacologic interventions.
Identify simple behavioral interventions for decreasing procedural distress and anxiety.

Introduction

Clinicians have differing definitions of conscious sedation. Many hope to benefit from the perceived safety of a conscious yet cooperative patient but actually expect a deeply sedated patient who does not move. It is important, therefore, to start with the definitions stated in the literature.

In 1992, the Committee on Drugs of the American Academy of Pediatrics (AAP) released its original “Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures.” In these guidelines, conscious sedation was defined as a stage of sedation that permits appropriate response by the patient to physical stimulation or verbal command. Although the intention of the Committee was for conscious sedation to be viewed as a minimal state of sedation, this concept was believed to be unclear. Therefore, in 2002, an addendum was published, in part, to clarify the continuum of sedation. In this addendum, the terminology of the American Society of Anesthesiologists’ (ASA) “Practice Guidelines for Sedation and Analgesia for Non-Anesthesiologists” was adopted, and conscious sedation was redefined as being moderate sedation/analgesia. At this level of sedation, the patient should have a decreased level of consciousness but be able to be aroused easily. An even lesser degree of sedation is acknowledged by both guidelines and has been given the term “minimal …