What is sedation?
Sedation calms anxiety and dulls consciousness, but does not put the patient into a fully unconscious state. Sedation is used for minor procedures and also in many emergency trauma cases.
Sedation is inducing depression of consciousness with the use of sedative medications. Sedation is administered in different dosages to relax a patient or make them unconscious before a medical procedure that can cause pain or discomfort.
Sedation is generally accompanied by the administration of painkillers (analgesics) or neuromuscular blocks to prevent pain. Typically, minimal to moderate levels of sedation are maintained for minor procedures, while patients undergoing surgeries are administered general anesthesia which puts them in a deeply unconscious state.
The four types of sedation which produce varying levels of consciousness as required for a given procedure are as follows:
- Minimal sedation
- Moderate sedation
- Deep sedation
- General anesthesia
Why is sedation performed?
The primary goal of sedation is patient comfort. A patient comes to the emergency department in distress, and treatment of their anxiety and pain is as important as the treatment of the condition that affects them. Sedation helps the patient calm down and tolerate unpleasant medical procedures.
In addition to depressing consciousness, sedative agents are also used to produce:
- Anxiolysis: Relief from anxiety and agitation
- Amnesia: Lapse of memory of the procedure
- Analgesia: Pain relief
A combination of sedative medications is usually administered, because a single sedative agent may not be able to achieve all of the above effects.
What does sedation feel like?
Sedation effects may vary to some extent from person to person, but most people feel drowsy and relaxed within a couple of minutes. The patient may feel a tingling sensation and heaviness, especially in the arms and legs. Depending on the sedative dosage, the patient may be semi conscious or gradually slip into unconsciousness.
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How long does sedation last?
After sedation is withdrawn, the patient usually regains consciousness within 20 to 30 minutes. Some sedative agents have a very brief duration of activity, though others, especially those used for general anesthesia last longer. Doctors may use reversal medications to help speed up the recovery from sedation.
Residual sedative effects may last for up to 24 hours, during which the patient may have episodes of drowsiness and weakness. With minimal and moderate sedation most people will be able to resume normal activities the next day.
People who undergo major surgeries under general anesthesia may take longer to recover, because they may require continued use of sedative and analgesic medications for a longer period.
What are the important considerations for sedation?
The important considerations for sedation include the following:
- Determination of the level and duration of sedation required for a given procedure.
- Selection of the appropriate sedative agent based on the procedure, the type of patient (child or adult), and the patient’s condition.
- Determination of the route of administration. Sedation is usually intravenous in adults but in children it may be any one of the following:
- Oral
- Intranasal
- Intramuscular
- Intravenous
- Rectal
- Assessment of the patient’s medical history, health condition and dietary status.
- Fasting prior to elective procedures to prevent aspiration.
- Monitoring the patient’s vital signs during and after withdrawal of sedation until the patient is stable.
- Reversal agents to counter the effects of sedation, hastening recovery after the procedure, or reversing any adverse effects in patients.
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What are the common sedation regimens?
Different classes of drugs are used for sedation depending on the procedure, the patient’s condition, and the level and duration of sedation required. The drugs are often used in combinations in appropriate dosages to achieve adequate anesthesia and analgesia.
Medications that have only sedative and amnesic properties are combined with analgesic drugs. Some procedures may be performed with nerve blocks for analgesia. Finally, reversal agents may be used to bring certain patients out of sedation.
Some of the commonly used sedation and analgesia drug regimens are as follows:
- Midazolam/fentanyl
- Methohexital/morphine
- Propofol/morphine
- Etomidate/fentanyl
- Ketamine/propofol (known as ketofol) for procedural sedation
Reversal agents
An important part of the sedation regimen is safely bringing the patient out of sedation. Reversal agents are used to reverse the effects of the anesthetic drugs after completion of the procedure, or if the patient has adverse reactions to the sedative agent.
The two reversal agents used are:
- Naloxone: Reverses benzodiazepine class of drugs such as midazolam
- Flumazenil: Reverses barbiturate class of drugs such as methohexital