sedation represents a continuum of states ranging from minimal sedation ( anxiolysis ) to general anesthesia and may result in respiratory depression , loss of the patient 's protective reflexes , and cardiopulmonary impairment .
the need for sedation has markedly increased with the development of new invasive diagnostic and minor surgical procedures outside of the operating room setting , which makes it important to provide patients with the benefits of sedation while minimizing adverse responses .
safe sedation requires a systemic presedation evaluation , particularly for the airway , and a clear understanding of the medications used and skills in airway management , which the joint commission international ( jci ) standards pursue .
severance hospital has accepted the jci standards and has revised all sedation policies to the jci standards .
the jci standard states that the chief of the anesthesiology department is in charge of instituting the sedation practice policy and protocol .
a sedation committee must be established , which should consist of physicians from various departments in which sedation is performed as committee members and the chief of the anesthesiology department as the committee president .
this committee has the responsibility to determine the requirements for qualified individuals to sedate , obtain informed consent , conduct a presedation assessment , and procure the proper equipment and monitoring ( table 1 ) .
sedation in the jci standards is classified into four categories , including minimal sedation , moderate sedation , deep sedation , and anesthesia .
sedation policy usually does not apply to minimal sedation and anesthesia or for sedation used for mechanically ventilated patients , psychological management , and sometimes for direct management of the anesthesiologist , which can change according to the policies of different institutes .
the jci standards require that a qualified individual for sedation should have the ability to perform the various modes of sedation , monitor the patients , and manage the adverse responses , particularly those relating to the airway , as well as the medications , including reversal agents and basic life support ( bls ) .
the members of the education subcommittee should consider developing a physician and nurse education program .
the education program will consist of a lecture on sedation techniques , medications , responses to complications , and an appropriate monitoring and practice program for airway management techniques .
the institute will provide a vcr systemrather than a lecture for convenient access at anytime .
other institutes have held a sedation special week festival to increase the importance of sedation during the education process .
it is recommended that lectures will be provided on a departmental basis , because the necessary knowledge for sedation is slightly different in each department . practicing airway management technique
will be implemented by the education subcommittee or replaced by advanced cardiac life support ( acls ) or pediatric advanced life support ( pals ) , if these programs have been running regularly .
although jci has set the standards for sedation practice as at least bls , they require advanced airway management techniques . there is no rule in the jci standards as to whether anesthesiologists should be qualified for sedation without participation in an education program .
there is no definite standard for renewing the sedation qualification in the jci standards . at severance hospital
, physicians should renew their sedation qualification every 2 years , because practice programs such as bls , acls , and pals have 2-year validation period .
if your institute has its own practice program , you can determine the required time for renewing the qualification .
the sedation policy should be defined in terms of safety , so a qualified physician should consider consulting with an anesthesiologist prior to sedation in the following situations ; patient does not fulfill npo criteria , or has severe cardiopulmonary , neurological , or other organ system disease , which may present a significant hazard and lead to a potentially difficult airway . a pre - sedation assessment after obtaining informed consent should be performed in a private room prior to beginning sedation .
the sedation location and recovery room should be equipped with appropriate monitoring and emergency resuscitation systems .
end tidal co2 monitoring may be routine monitoring or not based on the sedation policy at your institute .
emergency equipment must be immediately available at every location where moderate or deep sedation is administered or recovery occurs and include at least the following : defibrillator , suction device , oxygen , airway management tools , emergency drugs , intubation equipment , and an ekg monitor .
informed consent , pre - sedation assessment , monitoring during the procedure , and recovery records should be documented .
informed consent for sedation includes the sedation method , necessities , alternatives , success rates , complications , and cautions .
a presedation evaluation and assessment will be performed by a physician and nurse and include a medical history and current medications , prior history of adverse reactions to sedation or anesthesia , airway status and npo time , and vital signs .
if the patient has a difficult airway , it is helpful to consult with the anesthesiology department .
the jci standards define documentation of the monitored parameters , but do not mention specific parameters .
although the american society of anesthesiology ( asa ) guidelines recommend that vital signs , respiratory rate , and patient response to verbal commands should be routinely monitored and recorded , your institute can select the routine monitoring parameters for procedure and recovery .
end tidal co2 monitoring may be beneficial for deep sedation and for infants with a difficult airway , particularly when a procedure room , such as the magnetic resonance imaging ( mri ) room is remotely located .
monitoring and documentation will continue every 10 min during the procedure and for 30 min after entering the recovery room .
the patient should be discharged from the recovery area by a qualified individual using established criteria .
the aldrete score has been used at severance hospital as the discharge criteria . if discharged , the patient must be provided with written instructions regarding diet , medications , activities , and signs or symptoms of complications when they occur .
if the patient is transferred to the intensive care unit , they should receive an equal level of patient care ( table 2 ) .
sedation is applied to both children and adults in many fields , such as endoscopy , mri , and bronchoscopy .
sedation of an infant differs from sedating an adult in terms of the drugs used , npo time , and discharge criteria .
this difference should be stated in the sedation policy , so a separate policy will be developed for the pediatric and adult sedation populations .
the definition of a pediatric patient is a critical issue that may provoke conflict among medical departments .
another difference is that the requirement of the qualified physician for sedation is different between pediatric and adult sedation .
usually , the physician in charge of pediatric sedation should be skilled in pals , whereas the physician in charge of adult sedation shouldbe skilled in adult advanced life support .
a child 's ability to control his or her own behavior and to cooperate during a procedure depends on their chronological and developmental age .
children < 6 years or those with a developmental delay often require a deeper level of sedation to control their behavior .
indications for pediatric sedation include endoscopy , liver and kidney biopsy , an electrophysiological study , angiography , bone marrow study , and mri .
midazolam and propofol are mainly used for loss of consciousness , whereas fentanyl , ketamine , remifentanil , or pethidine are given additionally for painful procedures .
this combination can reduce the safety range , so a reduced dosage should be used .
ketamine increases the incidence of laryngospasm during an upper endoscopy   but can be an alternative to lower gi endoscopy .
chloral hydrate , ketamine , midazolam , propofol , and dexmedetomidine are useful for sedation during non painful procedures such as computed tomography and mri . although chloral hydrate is safe , it is not recommended , because the failure rate is up to 20% , which is economically costly .
midazolam is not suitable for mri imaging because the sedation duration is approximately 30 min or longer .
ketamine is not suitable for mri sedation because hypertonicity , hypertension , and re - emergence phenomenon occur more frequently .
but , in patients with difficult airways or in cardiac patients , ketamine has the advantage of airway patency and hemodynamic stability .
propofol has a rapid onset and short duration , which is effective for edating children undergoing an mri procedure .
dexmedetomidine is a selective alpha-2 agonist , which is recommended by the asa as a sedative that can be used by non - anesthesiologists .
some investigators have found no differences in successful mri scanning between patients sedated with dexmedetomidine or propofol .
dexmedetomidine can be injected intramuscularly , which is an advantage when administering a sedative to an infant with no intravenous line . as access to the patient
is limited in an mri setting and respiratory movement can not be seen directly , the physician should consider the risks and must be very experienced in airway management , particularly when testing disabled children or newborns .
it is recommended that supplemental oxygen be used and end tidal co2 be monitored to increase safety .
adult sedation for mris , patients with claustrophobia or a movement disorder , as well as the cardiac catheterization lab , endoscopy , and bronchoscopy .
midazolam is used frequently for adult endoscopy throughout the world , because it has a rapid onset of action within 2 min , but the elimination half life is between 1 and 2.8 hours .
propofol cause hypnosis within 40 seconds and has an antiemetic effect with a shorter duration of action .
a meta - analysis demonstrated that propofol provides significant advantages over benzodiazepines to induce and maintain adequate sedation during endoscopic procedures .
when a recovery room is not large enough for a sedation procedure , propofol is preferred because the effect of propofol wears off more rapidly than that of midazolam .
sedation in the jci standards is classified into four categories , including minimal sedation , moderate sedation , deep sedation , and anesthesia .
sedation policy usually does not apply to minimal sedation and anesthesia or for sedation used for mechanically ventilated patients , psychological management , and sometimes for direct management of the anesthesiologist , which can change according to the policies of different institutes .
the jci standards require that a qualified individual for sedation should have the ability to perform the various modes of sedation , monitor the patients , and manage the adverse responses , particularly those relating to the airway , as well as the medications , including reversal agents and basic life support ( bls ) .
the members of the education subcommittee should consider developing a physician and nurse education program .
the education program will consist of a lecture on sedation techniques , medications , responses to complications , and an appropriate monitoring and practice program for airway management techniques .
the institute will provide a vcr systemrather than a lecture for convenient access at anytime .
other institutes have held a sedation special week festival to increase the importance of sedation during the education process . it is recommended that lectures will be provided on a departmental basis , because the necessary knowledge for sedation is slightly different in each department . practicing airway management technique
will be implemented by the education subcommittee or replaced by advanced cardiac life support ( acls ) or pediatric advanced life support ( pals ) , if these programs have been running regularly .
although jci has set the standards for sedation practice as at least bls , they require advanced airway management techniques . there is no rule in the jci standards as to whether anesthesiologists should be qualified for sedation without participation in an education program .
there is no definite standard for renewing the sedation qualification in the jci standards . at severance hospital
, physicians should renew their sedation qualification every 2 years , because practice programs such as bls , acls , and pals have 2-year validation period .
if your institute has its own practice program , you can determine the required time for renewing the qualification .
the sedation policy should be defined in terms of safety , so a qualified physician should consider consulting with an anesthesiologist prior to sedation in the following situations ; patient does not fulfill npo criteria , or has severe cardiopulmonary , neurological , or other organ system disease , which may present a significant hazard and lead to a potentially difficult airway .
a pre - sedation assessment after obtaining informed consent should be performed in a private room prior to beginning sedation .
the sedation location and recovery room should be equipped with appropriate monitoring and emergency resuscitation systems .
end tidal co2 monitoring may be routine monitoring or not based on the sedation policy at your institute .
emergency equipment must be immediately available at every location where moderate or deep sedation is administered or recovery occurs and include at least the following : defibrillator , suction device , oxygen , airway management tools , emergency drugs , intubation equipment , and an ekg monitor .
informed consent , pre - sedation assessment , monitoring during the procedure , and recovery records should be documented .
informed consent for sedation includes the sedation method , necessities , alternatives , success rates , complications , and cautions . a presedation evaluation and assessment
will be performed by a physician and nurse and include a medical history and current medications , prior history of adverse reactions to sedation or anesthesia , airway status and npo time , and vital signs .
if the patient has a difficult airway , it is helpful to consult with the anesthesiology department .
the jci standards define documentation of the monitored parameters , but do not mention specific parameters .
although the american society of anesthesiology ( asa ) guidelines recommend that vital signs , respiratory rate , and patient response to verbal commands should be routinely monitored and recorded , your institute can select the routine monitoring parameters for procedure and recovery .
end tidal co2 monitoring may be beneficial for deep sedation and for infants with a difficult airway , particularly when a procedure room , such as the magnetic resonance imaging ( mri ) room is remotely located .
monitoring and documentation will continue every 10 min during the procedure and for 30 min after entering the recovery room .
the patient should be discharged from the recovery area by a qualified individual using established criteria .
the aldrete score has been used at severance hospital as the discharge criteria . if discharged , the patient must be provided with written instructions regarding diet , medications , activities , and signs or symptoms of complications when they occur .
if the patient is transferred to the intensive care unit , they should receive an equal level of patient care ( table 2 ) .
sedation is applied to both children and adults in many fields , such as endoscopy , mri , and bronchoscopy .
sedation of an infant differs from sedating an adult in terms of the drugs used , npo time , and discharge criteria .
this difference should be stated in the sedation policy , so a separate policy will be developed for the pediatric and adult sedation populations .
the definition of a pediatric patient is a critical issue that may provoke conflict among medical departments .
another difference is that the requirement of the qualified physician for sedation is different between pediatric and adult sedation .
usually , the physician in charge of pediatric sedation should be skilled in pals , whereas the physician in charge of adult sedation shouldbe skilled in adult advanced life support .
a child 's ability to control his or her own behavior and to cooperate during a procedure depends on their chronological and developmental age .
children < 6 years or those with a developmental delay often require a deeper level of sedation to control their behavior .
indications for pediatric sedation include endoscopy , liver and kidney biopsy , an electrophysiological study , angiography , bone marrow study , and mri .
midazolam and propofol are mainly used for loss of consciousness , whereas fentanyl , ketamine , remifentanil , or pethidine are given additionally for painful procedures .
this combination can reduce the safety range , so a reduced dosage should be used .
ketamine increases the incidence of laryngospasm during an upper endoscopy   but can be an alternative to lower gi endoscopy .
chloral hydrate , ketamine , midazolam , propofol , and dexmedetomidine are useful for sedation during non painful procedures such as computed tomography and mri . although chloral hydrate is safe , it is not recommended , because the failure rate is up to 20% , which is economically costly .
midazolam is not suitable for mri imaging because the sedation duration is approximately 30 min or longer .
ketamine is not suitable for mri sedation because hypertonicity , hypertension , and re - emergence phenomenon occur more frequently .
but , in patients with difficult airways or in cardiac patients , ketamine has the advantage of airway patency and hemodynamic stability .
propofol has a rapid onset and short duration , which is effective for edating children undergoing an mri procedure .
dexmedetomidine is a selective alpha-2 agonist , which is recommended by the asa as a sedative that can be used by non - anesthesiologists .
some investigators have found no differences in successful mri scanning between patients sedated with dexmedetomidine or propofol .
dexmedetomidine can be injected intramuscularly , which is an advantage when administering a sedative to an infant with no intravenous line . as access to the patient
is limited in an mri setting and respiratory movement can not be seen directly , the physician should consider the risks and must be very experienced in airway management , particularly when testing disabled children or newborns .
it is recommended that supplemental oxygen be used and end tidal co2 be monitored to increase safety .
adult sedation for mris , patients with claustrophobia or a movement disorder , as well as the cardiac catheterization lab , endoscopy , and bronchoscopy .
midazolam is used frequently for adult endoscopy throughout the world , because it has a rapid onset of action within 2 min , but the elimination half life is between 1 and 2.8 hours .
propofol cause hypnosis within 40 seconds and has an antiemetic effect with a shorter duration of action .
a meta - analysis demonstrated that propofol provides significant advantages over benzodiazepines to induce and maintain adequate sedation during endoscopic procedures .
when a recovery room is not large enough for a sedation procedure , propofol is preferred because the effect of propofol wears off more rapidly than that of midazolam .
sedation under the jci standards is mainly based on the asa recommendations . however , because the mission of the jci standard is to improve the quality and safety of care in the international community , jci defines the minimum requirements . following
this standard will provide your hospital with the most efficient , safe , and economically efficient policy .
 the practice of anesthesia and sedation continues to expand beyond the operating room and now includes the gastroenterology suite , magnetic resonance imaging suites , and the cardiac catheterization laboratory . 
 non - anesthesiologists frequently administer sedation , in part because of a lack of available anesthesiologists and economic aspect , which emphasizes the safety of sedation . the joint commission international ( jci ) set a standard responding to this issue indicating that qualified individuals who have drug and monitoring knowledge as well as airway management skills can only administer sedating agents . in korea , 
 the ministry of health and welfare developed new sedation standards for hospital evaluation , which is similar to the jci standards . 
 this review intends to help with the understanding of the jci sedation standard and compare it to the korean sedation standard . 
Introduction
Sedation Policy
Scope of sedation
Requirements of a qualified individual to practice sedation
Sedation location, equipment and monitoring
Documentation
Sedation guidelines
Conclusion