Standard operating procedure

Sedation Procedure

The step-by-step procedure for the safe delivery of conscious sedation for procedures at the clinic, covering patient selection, consent, the trained team and monitoring required, titration to effect, recovery, objective discharge and the management of complications.

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What's inside

This standard operating procedure is fully drafted and structured, ready to brand and complete for your service. It covers:

  • 1. Purpose
  • 2. Scope
  • 3. Definitions and abbreviations
  • 4. Responsibilities
  • 5. Equipment and monitoring
  • 6. Procedure
  • 7. Discharge criteria
  • 8. Records
  • 9. Related documents
  • 10. Review and version control
  • 11. Disclaimer

Legislation & standards it maps to

  • Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 12 (Safe care and treatment)
  • Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 9 (Person-centred care) and Regulation 11 (Need for consent)
  • Academy of Medical Royal Colleges, Safe Sedation Practice for Healthcare Procedures: Standards and Guidance (2013)
  • Resuscitation Council UK, Quality Standards for cardiopulmonary resuscitation practice and training, and the current Adult Advanced Life Support and Immediate Life Support guidance
  • General Medical Council, Decision making and consent (2020)
  • Mental Capacity Act 2005
  • Human Medicines Regulations 2012 (SI 2012/1916, as amended) and the Misuse of Drugs Regulations 2001 (SI 2001/3998, as amended)

Who it applies to

All sedationists, operators, registered nurses, operating department practitioners and healthcare assistants at [Organisation Name] who assess patients for, deliver, monitor, recover or discharge patients receiving conscious sedation, together with any locum, bank or agency staff working in these roles.

Glossary

Plain-English explanations of the technical terms and legislation used in this document.

Academy of Medical Royal Colleges
The body that brings together the UK's medical royal colleges and sets shared standards, including the national guidance on safe sedation.
Advanced Life Support (ALS)
An advanced level of resuscitation training covering the management of cardiac arrest and the seriously deteriorating patient.
Airway
The passage from the mouth and nose to the lungs through which a person breathes; keeping it open and clear is essential during sedation.
Anaesthetist
A doctor specially trained to give anaesthesia and to manage breathing, consciousness and vital functions during procedures.
Anaphylaxis
A severe, life-threatening allergic reaction needing immediate emergency treatment.
Apnoea
A pause or stop in breathing.
ASA grade
The American Society of Anesthesiologists physical status score, a simple grading of how fit a patient is, used to judge whether sedation is suitable.
Aspiration
Breathing stomach contents, fluid or other material into the lungs, which can cause serious harm.
Bag-valve-mask
A hand-held device with a mask and squeezable bag used to push oxygen into the lungs of a patient who is not breathing adequately.
Baseline observations
A patient's vital sign readings taken before sedation, used as the reference point to compare later readings against.
Benzodiazepine
A class of sedative medicine (for example midazolam) commonly used for conscious sedation; its effect can be reversed by flumazenil.
Body mass index
A measure of body weight in relation to height, used here as one indicator of sedation risk.
Capnography
Continuous measurement of the carbon dioxide a patient breathes out, used to detect breathing problems early.
Cardiopulmonary resuscitation (CPR)
Emergency chest compressions and rescue breaths given when a person's heart or breathing has stopped.
Care Quality Commission (CQC)
The independent regulator of health and social care services in England.
Central nervous system
The brain and spinal cord; sedatives work by reducing its activity, which calms the patient and can slow breathing.
Conscious sedation
A light, controlled level of sedation that keeps a patient relaxed and able to respond to speech while their breathing and reflexes are maintained.
Contemporaneous
Recorded at the time something happens, rather than written up later from memory.
Controlled drug
A medicine whose supply, storage and records are tightly restricted by law because of its potential for misuse.
Decision making and consent
General Medical Council guidance (2020) on how clinicians should share information with patients and obtain valid consent.
Deep sedation
A deeper level of sedation in which a patient is hard to rouse and their breathing may be at risk; it is outside the scope of this procedure.
Defibrillator
A device that delivers a controlled electric shock to the heart to restore a normal rhythm in certain cardiac arrests.
Discharge criteria
The set of objective checks a patient must pass before it is safe for them to leave after sedation.
End-tidal carbon dioxide
The level of carbon dioxide measured at the end of a breath out; a rising level can be an early sign of inadequate breathing.
Endpoint
The intended level of sedation aimed for during titration, here a calm, cooperative patient who still responds to speech.
Escort
A responsible adult who takes the patient home after sedation and stays with them.
Fasting status
Whether and for how long a patient has gone without food or drink before sedation, checked to reduce the risk of breathing in stomach contents.
Flumazenil
The reversal medicine that counteracts the effect of benzodiazepine sedatives.
General anaesthesia
A drug-induced, controlled state of unconsciousness for surgery, requiring an anaesthetist and full anaesthetic facilities; it is outside the scope of this procedure.
General Medical Council (GMC)
The body that registers doctors in the UK and sets the standards they must follow.
Health and Social Care Act 2008 (Regulated Activities) Regulations 2014
The regulations setting the fundamental standards that providers of regulated care must meet, enforced by the Care Quality Commission.
Hepatic impairment
Reduced liver function, which can affect how the body handles sedative drugs.
Human Medicines Regulations 2012
The main law governing how medicines are authorised, supplied and used in the UK.
Hypoxia
A lower-than-normal level of oxygen reaching the body's tissues.
Immediate Life Support (ILS)
A level of resuscitation training covering initial management of a cardiac arrest until an advanced team arrives.
Informed consent
Agreement to treatment given freely after the risks, benefits and alternatives have been clearly explained.
Intravenous
Given directly into a vein.
Local anaesthesia
Numbing of a specific part of the body for a procedure, without making the patient unconscious.
Mallampati score
A quick check of how much of the back of the mouth and throat can be seen, used to predict whether managing a patient's airway may be difficult.
Mental Capacity Act 2005
The law that protects and supports people who may be unable to make particular decisions for themselves.
Misuse of Drugs Regulations 2001
The law controlling how controlled drugs may be possessed, stored, supplied and recorded.
Naloxone
The reversal medicine that counteracts the effect of opioids, used for opioid-induced slowed breathing.
Nasopharyngeal airway
A soft tube passed through the nose to help keep a sedated patient's airway open.
Obstructive sleep apnoea
A condition in which the airway repeatedly narrows or closes during sleep, increasing the risk of breathing problems under sedation.
Operating department practitioner
A registered healthcare professional trained to support patients and the clinical team before, during and after procedures and anaesthesia.
Operator (proceduralist)
The clinician who actually carries out the procedure on the patient.
Operator-sedationist
A clinician who both performs the procedure and gives the sedation; in this situation a separate trained person must monitor the patient throughout.
Opioid
A class of strong pain-relieving medicine that can also slow breathing; its effect can be reversed by naloxone.
Oropharyngeal airway
A curved device placed in the mouth to help keep a sedated patient's airway open.
Over-sedation
Sedation that is deeper than intended, putting breathing, the airway and consciousness at risk.
Oxygen saturation
The percentage of oxygen carried in the blood, measured continuously during sedation.
Pulse oximetry
A painless clip-on monitor that measures oxygen levels in the blood and the pulse rate.
Registered Manager
The person registered with the regulator as responsible for the day-to-day running of a service.
Regulated activity
A type of care or treatment the law requires a provider to register with the regulator to deliver.
Renal impairment
Reduced kidney function, which can affect how the body handles sedative drugs.
Respiratory depression
Breathing that becomes too slow or too shallow to keep oxygen levels safe.
Resuscitation Council UK
The UK body that sets the standards and guidance for resuscitation practice and training.
Reversal agent
A medicine that counteracts a sedative or opioid to help manage over-sedation or slowed breathing.
Safe Sedation Practice for Healthcare Procedures
The Academy of Medical Royal Colleges standards and guidance setting out how sedation should be delivered safely.
Sedationist
The competent clinician responsible for planning and delivering the sedation.
Standard Operating Procedure (SOP)
A written, step-by-step instruction setting out how a particular task is to be carried out consistently and safely.
Suction
Equipment used to clear fluid, secretions or vomit from a patient's mouth and airway.
Synergistic
When two drugs together produce a greater combined effect than expected, here a stronger depression of consciousness and breathing.
Titration
Giving a drug in small steps, waiting for each to take effect, until the right level is reached, rather than one large dose.
Venous thromboembolism (VTE)
A blood clot that forms in a vein, which can travel to the lungs and become life-threatening.
Vital signs
Key measurements of body function such as pulse, blood pressure and oxygen levels.
Yankauer sucker
A rigid suction device used to clear the mouth and throat quickly.

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