Conscious sedation, produced by the administration of certain medications, is an altered level of consciousness that still allows a patient to respond to physical stimulation and verbal commands, and to maintain an unassisted airway.
The purpose of conscious sedation is to produce a state of relaxation and/or pain relief by using benzodiazepine-type and narcotic medications, to facilitate performing a procedure such as a biopsy, radiologic imaging study, endoscopic procedure, radiation therapy, or bone marrow aspiration.
Sedation is used inside or outside the operating room . Outside the operating suite, medical specialists use sedation to calm and relax their patients.
If the patient is to undergo a minor surgical procedure, screening and assessment of medical conditions that may interfere with conscious sedation must be explored. These potential risk factors include advanced age, history of adverse reactions to the proposed medications and a past medical history of severe cardiopulmonary (heart/lung) disease.
Once it has been established that the patient would be a good candidate for conscious sedation, just prior to the surgery or procedure, the patient will receive the sedating drug intravenously. A clip-like apparatus will be placed on the patient's finger to monitor oxygen intake during the sedation. This oxygen monitoring is called pulse oximetry and is a valuable continuous monitor of patient oxygenation.
Dosing of medications that produce conscious sedation is individualized, and the medication is administered slowly to gauge a patient's response to the sedative. The two most common medications used to sedate patients for medical procedures are midazolam and fentanyl.
Fentanyl is a medication classified as an opioid narcotic analgesic (pain reliever) that is 50 to 100 times more potent than morphine. Given intravenously, the onset of action of fentanyl is almost immediate, and peak analgesia occurs with in 10 to 15 minutes. A single dose of fentanyl given intravenously can produce good analgesia for only 20 to 45 minutes for most patients because the drug's distribution shifts from the brain (central nervous system) to peripheral tissues. The key to correct dosage is titration, or giving the medication in small amounts until the desired patient response is achieved.
Midazolam is a medication classified as a short-acting benzodiazepine (sedative) that depresses the central nervous system. Midazolam is ineffective for pain and has no analgesic effect during conscious sedation. The drug is a primary choice for conscious sedation because midazolam causes patients to have no recollection of the medical procedure. In general, midazolam has a fast-acting, short-lived sedative effect when given intravenously, achieving sedation within one to five minutes and peaking within 30 minutes. The effects of midazolam typically last one hour but may persist for six hours (including the amnestic effect). Patients who receive midazolam for conscious sedation should not be allowed to drive home after the procedure.
Patient monitoring during conscious sedation must be performed by a trained and licensed health care professional. This clinician must not be involved in the procedure, but should have primary responsibility of monitoring and attending to the patient. Equipment must be in place and organized for monitoring the patient's blood pressure, pulse, respiratory rate, level of consciousness, and, most important, the oxygen saturation (the measure of oxygen perfusion inside the body) with a pulse oximeter (a machine that provides a continuous real-time recording of oxygenation). The oxygen saturation is the most sensitive parameter affected during increased levels of conscious sedation. Vital signs and other pertinent recordings must be monitored before the start of the administration of medications, and then at a minimum of every five minutes thereafter until the procedure is completed. After the procedure has been completed, monitoring should continue every 15 minutes for the first hour after the last dose of medication(s) was administered. After the first hour, monitoring can continue as needed.
The American Academy of Pediatrics (AAP) has established safe practice guidelines to manage conscious sedation without an anesthesiologist for minor procedures. These AAP criteria include (1) a full-time licensed clinician (nurse, physician, physician assistant, surgeon assistant, respiratory therapist) who is strictly and exclusively monitoring the patient's breathing, level of consciousness, vital signs, and airway; (2) standard procedures for monitoring vital signs; and (3) immediate availability (on site) of airway equipment, resuscitative medications, suction apparatus, and supplemental oxygen delivery systems.
If adverse reactions occur while using fentanyl, the antidote is a drug called naloxone. It provides rapid reversal of fentanyl's narcotic effect. The incidence of oversedation or decreased respiration is low using fentanyl if the medication is carefully titrated.
See also Pulse oximeter .
Behrman, R. Nelson Textbook of Pediatrics, 16th ed. Philadelphia: W. B. Saunders Company, 2000.
"Recommended Practices: Monitoring the Patient Receiving IV Conscious Sedation." Association of Operating Room Nurses 57, no. 4 (April 1993).
U. S. Department of Health and Human Services. Acute Pain Management: Operative or Medical Procedures and Trauma. Clinical Practice Guidelines. Department of Health and Human Services Pub. No AHCPR 92-0032.
American Association of Nurse Anesthetists. 222 South Prospect Avenue Park Ridge, IL 60068-4001. Telephone: (847) 692–7050. Fax: (847) 692–6968. E-mail: info@ aana.com.
Laith Farid Gulli, M.D.,M.S. Alfredo Mori, MBBS
Conscious sedation is administered by medical or pediatric specialists performing a procedure that may be diagnostic and/or therapeutic. It may be used in a hospital, outpatient care facility, or doctor's office.
It was great. Absolutely no side effects and do not remember procedure. Unfortunately, my Cardiologist informed me that this can not be used for many other procedures, otherwise, would have administered with ANY procedure.
Anesthesiology 2002;96:1004-17.
The kids get conscious sedation however, as my son had this. It's very gentle and he can obey instructions to move, etc. He seems sleeping but can open his eyes and even answer questions. When the doctor is done I tell him to go to sleep and he sleeps for two hours at least (unless they need his bed).
I am taking 10mg Paroxine daily.
Is it possible that the sedative did not work?? On reflexion, that it what it felt like. The consultant did not speak to me afterwards so I had no opportunity to ask questions. I intend asking for an appointment with her to discuss this, as now a barium enema is planned (according to the write up that was given to me afterwards)
For example: "A 49-yr old female sedated with midazolam developed severe aggressive behavior during insertion of implants, which increased with further increments of midazolam. This paradoxical reaction was terminated by the injection of flumazenil, after which the patient calmly underwent the procedure." Reports are few and these effects seem rather short-lived and/or reversible. I find it odd that any lengthy paradoxical effects would last enough to be prescribed meds. Indeed, Versed (aka midazolam) is useful for treating agitated or combative behaviors (as well as seizures - muscle relaxant).
I did see an about.com article on Versed (and I dislike about.com because I've found quite a few things that are flat-out wrong on there by so-called experts) that said "a small minority of patients feel agitated, hyperactive or combative when taking Versed, rather than the anxiety relief and relaxation that is intended." But while it doesn't say so, this seems to be based on reports of in-procedure reactions, not prolonged after surgery. For those experiencing these, I would definitely suggest having further work-up. I also acknowledge that adverse effects are very likely under reported, but I couldn't find anything on lasting behavioral changes so I hope that means that those experiencing these problems will only have to deal with them temporarily. But get checked out!
But to be sure, I did have a "Twilight" sedation many years prior (~15yrs) that was awful. I have no idea what they used but I remember some of the procedure, then later trying to wake up, unable to see (I assume because I couldn't figure out how to open my eyes), scratching the wall beside my bed, and begging for help. I could hear a nurse come in and she ignored me, until I finally got her to answer about how the procedure went. She was brusque and rude. My t1houghts are that they likely did not do a good job of titrating the meds they used on me because they either didn't care, use the same amount for every patient whether or not it was effective, and/or were in a hurry. I was rather rushed and pushed into having the procedure done, I was distraught, and not well informed at the time. I have gone into the medical profession since and will always remember how I was treated and felt. It was not acceptable.
I think it is best to vet the staff at whatever facility you use for whatever procedure you are having. If they don't care or take the time to answer your questions then you aren't getting good care. It can make all the difference!
I have since had a colonoscopy with NO drugs...I was warned the doc who did it that "Most patients can't tolerate the pain," which I think was a scare tactic to get me to ask for the sedation. The "pain" was just a few seconds of bad, crampy gas here and there as he inflated the colon at the flexures to advance the scope.
Conscious sedation does NOTHING for pain. Unless you are so anxious that you cannot otherwise tolerate the procedure you're having, there is absolutely no reason for it, other than to potentially make the provider's job easier. If you don't want it, discuss this ahead with both your primary care provider and the specialist who will be doing the procedure. If you feel someone is trying to talk you into something you don't want, find another provider.
I really feel for you. I went through a very painful colonoscopy 3 years ago. Now I am a chronic pain patient of 16 years and have to take some heavy duty pain meds. I always have had a very high tolerance as well.
I was given the max dose of fentanyl, versed and benadryl. Was awake and in excruciating pain throughout. This cocktail worked before quite well. It is possible that they did not get the I.V. in clean.
Have and upcoming lumbar injection and do not like propofol as I wake with a massive headache in which more pain meds. are needed. I will try the fent/versed again hoping it worked great like the first time.
God bless. Hope you have better outcome if you need another procedure.
The information leaflet I was given prior to the procedure said I might experience 'some discomfort'.