Procedural Sedation & Analgesia

Author: Demian Szyld, MD
Updated: 8/6/2010

Procedural Sedation and Analgesia

Airway Assessment: Predicting difficulty

Difficult Airway (LEMON) Difficult Ventilation (MOANS)
L ook externally: syndromic, obese, gestalt M ask seal (beard, trauma, prone)
E valuate 3-3-2 rule
(mouth opening, thyromental, hyomental)
O besity
(redundant upper airway, OSA, poor reserve)
M allampati
  • I: Uvula, tonsils, palate
  • II: Upper uvula, tonsils
  • III Base of uvula
  • IV: Hard palate only
A ge > 55 (Loss of airway tone)
O bstruction: OSA, PTA, epiglottis, mass N o teeth
N eck mobility: Rheum. arthritis, c-collar S tiffness (asthma, COPD, pregnant)


Assemble appropriate staffing and equipment (SOAPME):

  • S uction
  • O xygen
  • A irway adjuncts
  • P ersonnel
  • M edications
  • E quipment

Select sedative AND analgesic if both are required. Match duration of procedure to duration of drug.


SEDATION medications

Medication / Initial IV dose Advantage Side Effects
Midazolam 0.05 mg/kg Shortest benzodiazepine
Lorazepam 0.05 mg/kg Short benzodiazepine
Diazepam 0.1 mg/kg Muscle relaxation
Etomidate 0.15 mg/kg Short duration Myoclonus
Propofol 1-2 mg/kg Short duration Transient hypotension
Ketofol 0.5 mg/kg
1:1 ratio of
CV stable, amnesia, analgesia

ANALGESIC medications

Medication / Initial IV dose Advantage Side Effects
Fentanyl 1-2 mcg/kg Short duration Decreased respiratory rate
Hydromorphone 0.02 mg/kg | Decreased respiratory rate and blood pressure
Morphine 0.1-0.2 mg/kg | Decreased respiratory rate and blood pressure

DISSOCIATIVE medications

Medication / Initial IV dose Advantage
Ketamine 1-2 mg/kg
Dexamedetomidine 0.5-1 mcg/kg
over 10 min
No respiratory depression


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