Presedation Assessment

Conducting a complete pre-sedation history and physical exam is essential to identify high-risk patient populations and anticipate and reduce adverse sedation events. Pre-sedation preparation begins prior to patient arrival. Studies have shown that background knowledge and skills in resuscitation (particularly airway management), education in sedative pharmacology, and pre-sedation risk assessment reduce the frequency and severity of adverse events during sedation. All in all, the majority of preventable adverse sedation events tend to occur as a consequence of inadequate practitioner experience and skills (insufficient education) and violation of hospital policy and procedure (rule violation). Several general statements can be made regarding adverse events during sedation:

• The vast majority of adverse outcomes during sedation are preceded by a respiratory event.
• The greater the depth of sedation, the greater the risk of complications.
• The majority of poor outcomes related to adverse sedation events are due to a rule violation or insufficient education and skills of the practitioner.
• Adverse sedation events are not associated with either a specific sedative drug class or route of administration.

Important components of a pre-sedation history and exam include the following:

Pre-Sedation History

Past medical history

• Chronic conditions (e.g., cardiovascular, respiratory, neurological disorders)
• Birth history
• Sleep-disordered breathing (e.g., OSA or snoring)

Ongoing or recent acute illness

Assess for upper respiratory infection, wheezing, uncontrolled vomiting, or fever.

Surgical history

Note any previous surgeries.

Sedation/anesthesia history

Inquire about any previous experiences with sedation or anesthesia, including any adverse reactions.

Medications

List all current medications, including over-the-counter drugs and supplements.

Allergies

Document any known drug allergies and reactions.

Social history

Assess for smoking, alcohol, and substance use, as these can affect sedation and anesthesia.

Family history

Note any family history of anesthesia complications, such as malignant hyperthermia.

Labs

Review recent labs that may be relevant to the sedation or procedure.

Last oral intake

Current ASA guidelines recommend observing NPO guidelines prior to moderate and deep sedation.

Physical Examination

General assessment

• Vital signs: Baseline blood pressure, heart rate, respiratory rate, and oxygen saturation.
• General appearance: Assess the patient’s overall health status and level of distress.

Systemic examination

• Head/nose/airway: Evaluate the airway for potential difficulties with intubation or ventilation (e.g., Mallampati score, neck mobility, tonsil size, dental health, retrognathia, enlarged tongue, nasal congestion).
• Cardiovascular System: Perfusion, heart murmurs, irregular rhythms, or signs of heart failure.
• Respiratory System: Assess breath sounds, respiratory effort, and any signs of respiratory distress.
• Neurological System: Assess baseline neurological status, including mental status and any focal deficits.

Documentation and Risk Assessment

Risk stratification

• Use the information gathered to classify the patient’s risk level for sedation-related complications.
• Consider using standardized tools, such as the ASA Physical Status Classification System.

Informed Consent

• Discuss the risks, benefits, and alternatives of the sedation procedure with the patient.
• Obtain written/verbal informed consent per your institutional guidelines.