Sign Up
You are not currently logged in. Please log in to CEUfast to enable the course progress and auto resume features.

Course Library

Conscious Sedation (FL INITIAL Autonomous Practice - Pharmacology)

1 Contact Hour including 1 Advanced Pharmacology Hour
Only FL APRNs will receive credit for this course.
Listen to Audio
CEUfast OwlGet one year unlimited nursing CEUs $39Sign up now
This course is only applicable for Florida nurse practitioners who need to meet the autonomous practice initial licensure requirement.
This peer reviewed course is applicable for the following professions:
Advanced Practice Registered Nurse (APRN)
This course will be updated or discontinued on or before Friday, April 25, 2025

Nationally Accredited

CEUFast, Inc. is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's Commission on Accreditation. ANCC Provider number #P0274.


≥ 92% of participants will know how to improve their care by synthesizing new knowledge about common sedation drugs and pain scales to better monitor and predict patient responses.


After completing this continuing education course, the learner should be able to:

  1. Summarize the pathophysiology of breathing and the role of breathing in a sedated patient.
  2. Describe practical approaches and treatment for sedated patients.
  3. Explain the components of assessing sedation levels and pain.
  4. Outline the importance of patient safety and comfort with attentive care.
  5. Determine the healthcare professional's role for sedated patients.
CEUFast Inc. and the course planners for this educational activity do not have any relevant financial relationship(s) to disclose with ineligible companies whose primary business is producing, marketing, selling, re-selling, or distributing healthcare products used by or on patients.

Last Updated:
  • 0% complete
Hide Outline
Playback Speed

Narrator Preference

(Automatically scroll to related sections.)
Conscious Sedation (FL INITIAL Autonomous Practice - Pharmacology)
To earn of certificate of completion you have one of two options:
  1. Take test and pass with a score of at least 80%
  2. Reflect on practice impact by completing self-reflection, self-assessment and course evaluation.
    (NOTE: Some approval agencies and organizations require you to take a test and self reflection is NOT an option.)
Author:    Nick Angelis (CRNA, MSN)


Combining academic knowledge and practical experience is a challenge that requires critical thinking and teamwork with other healthcare professionals. A theoretical, policy-based approach may not be appropriate for the fluctuating nuances of patient needs, especially with sedated patients. However, more flexible models focusing on skill and experience depend on the practitioner's expertise (Varndell et al., 2015). Healthcare professionals may struggle to adequately perform conscious sedation if they lack experience with sedation. The precise, prescribed amount of sedation for two seemingly similar patients could result in comfort and tranquility for one and pain and trauma or hypotension and organ damage in the other. Rather than prolonged education about genetic variability in P450 enzyme systems, healthcare professionals are better served by concentrating on effective assessment, intervention, and plan of care to achieve various treatment goals for sedated patients.

The Basics of Ventilation

Patients who require respiratory assistance via an endotracheal tube or temporary devices such as laryngeal mask airways are considered intubated. These advanced airway devices stimulate the gag and other potent reflexes and initially require positive pressure ventilation. Patients receiving positive pressure via a tracheostomy may not require the same level of sedation to achieve adequate ventilation. Patients who require pressure support from specialized masks may not achieve adequate ventilation if heavily sedated, especially without a nasal or oral pharyngeal airway to decrease obstruction. Obstruction risks increase with obese patients, and medication doses should be adjusted, especially when calculating ideal body weight. Older adults also frequently present with comorbidities increasing sedation risks. When administering, sedation onset may be delayed. Remember, it is easier to give more sedation than it is to take back what has been administered.

Without a firm grasp of normal physiologic parameters, healthcare professionals may struggle to swiftly and correctly assess problems in ventilation and perfusion. For example, trauma patients requiring a chest tube often qualify for conscious sedation. Nurses must remember that air between the visceral pleura and the outer parietal pleura can worsen if a patient requires positive pressure ventilation through a bag and mask or endotracheal tube, resulting in a pneumothorax(Galvagno et al., 2020). Perfusion risks are not absent from scheduled, routine procedures, either. Although rare, exsanguination, or significant blood loss, can occur in many procedures, and sedation drugs may decrease blood pressure (Huei et al., 2017). To summarize, the conservative approach of too little sedation can increase blood pressure, bleeding, and patient movement. Too much sedation increases the risk of apnea in patients who may already be compromised.

Patients will use the chest, neck, and abdominal muscles when struggling to force air in and out of the lungs but quickly tire, as breathing is far more effective as a primarily passive exchange based on volume and pressure. Intubation prevents respiratory acidosis and subsequent respiratory failure from inadequate carbon dioxide elimination, sometimes due to excessive sedation. Once intubated, sedation allows the lungs and thoracic muscles to rest and the patient to tolerate mechanical ventilation(Galvagno et al., 2020).

During normal inspiration, the diaphragm and the external intercostal muscles contract slightly to enlarge the thoracic cavity, decreasing pressure so air will flow into the lungs until atmospheric pressure is reached. The chest and abdomen expand outward, and the diaphragm downward; this provides negative pressure ventilation instead of artificially forcing a specific volume and air pressure into the lungs. When the muscles are relaxed at the end of inspiration, the elastic lungs, and thoracic wall recoil, decreasing in volume to send deoxygenated air out of the lungs. The pressure within the pleural cavity remains negative due to the tendency of alveolar fluid surface tension and elastic lung tissue to pull the lung inward (Sieck et al., 2013). Also keeping the lungs inflated is the thoracic wall, which pulls away from the lung to enlarge the pleural cavity. The surface tension of the pleural fluid prevents actual separation. These opposing forces differentiate intrapleural and intrapulmonary pressures, which keep each lung inflated unless lung or thoracic injury obliterates the pressure gradient. Because of this interplay, the chest will rise and fall despite medication-induced relaxation of pharyngeal muscles, causing obstruction and decreased respiratory drive. The classic chin lift and jaw thrust taught in basic life support classes is often a simple remedy for obstruction.

graphic showing the diaphragm functions in breathing

Common Medications and Receptors

Both propofol and benzodiazepines, such as midazolam, depress the central nervous system and cause sedation and amnesia via the inhibitory neurotransmitter gamma-aminobutyric acid (GABA). These actions do not affect pain receptors, so a completely sedated patient may still require pain medication. Although effects are dose-dependent, propofol is preferred for anesthesia and has a quicker onset and recovery period. Midazolam does not decrease blood pressure, respiratory reflexes, or brain activity as much as propofol. Because of this added safety, nurses can "push" midazolam during conscious sedation procedures rather than just relying on an infusion. Individual variability requiring changes to the infusion rate is more pronounced in midazolam, as is also the case for opioids (NYSORA, 2023).

Opioids increase the anesthetic effect of sedation drugs but do not provide amnesia. Their primary action is analgesia due to mu receptor binding in the central nervous system. Sedation drugs combined with sufentanil or remifentanil infusions for the intubated and sedated patient may be encountered. However, the most common opioid for conscious sedation is fentanyl. Synergy is an important concept in pharmacology that healthcare professionals should be familiar with since multiple drugs acting on different receptors create various effects.

Table 1: Common Perioperative Opioids
MedicationRouteTime to EffectDurationRoutine Dosage
Morphine SulphateIV
5-10 min
15-30 min
30-60 min
3-6 hours
3-6 hours
3-6 hours
10 mg IV<
10 mg IM
30-60 mg PO
OxycodonePO10-15 min4-6 hours10-20 mg PO
HydrocodonePO30-60 min4-6 hours15-30 mg PO
FentanylIVImmediate1-2 hours50 mcg IV
15-30 min
15 min
15 min
4-6 hours
4-6 hours
4-6 hours
7.5 mg
1.5 mg
1.5 mg
CodeinePO30-60 min4-6 hours200 mg
NalbuphineIM15 min3-6 hours10 mg
IV = intravenous, IM = intramuscular, PO = orally
NYSORA, 2023; Gadsden, 2017

Midazolam and fentanyl are an adequate combination, while propofol and remifentanil may cause a decreased possibility of awareness. Except for remifentanil, opioids accumulate in the body to cause respiratory depression, constipation, and other side effects long after discontinuation. These side effects can complicate subsequent dosing, as can tolerance to initial infusion rates as liver enzymes process opioids more quickly. Traditionally, intravenous and inhaled medications are the gold standard for initially bypassing the liver, avoiding the variability dependent on the metabolizing ability of hepatic enzymes. Intranasal and buccal administration of fentanyl or dexmedetomidine is rising in popularity (NYSORA, 2023). Correct doses of oral non-steroidal anti-inflammatory drugs (NSAIDs) block cyclooxygenase (COX) and play an essential role in pain control. Antidepressants, gabapentin, and pregabalin, typically reserved for nerve disorders, are useful adjuncts. Multimodal and preemptive interventions decrease pain and the risk of respiratory depression, constipation, nausea, pruritus, and other unfavorable side effects associated with opioids that usually require reversal agents to attenuate. By using lesser amounts of multiple drugs, the risk of complications from any particular approach or class of medications will hopefully decrease.

Local anesthetics such as lidocaine prevent or relieve pain by binding to receptors on nerve sodium channels to stop nerve conduction. They pass through lipid-soluble nerve membranes but retain a partially ionic form to be active in the sodium channel. They are manufactured as water-soluble salts but do not work well in acidic environments like infected wounds. The influence of pH also means that adding sodium bicarbonate to a local anesthetic speeds onset while decreasing injection pain. Local anesthetists alter the function of all organs conducting or transmitting nerve impulses, so advanced cardiac life support (ACLS) may be needed if an overdose occurs. Plasma concentration depends on the dose, absorption, vascularization, and other properties of the site injected and metabolism by the body. Sensory disturbances such as tongue numbness and tinnitus typically precede life-threatening reactions. Large doses can be used with peripheral nerve blocks without the seizures, coma, and eventually, respiratory and cardiac failure that could follow the same dose in the bloodstream or spinal cord (Gadsden, 2017).

As opioid tolerance increases in the patient population, options are available to provide simultaneous sedation and analgesia. Ketamine targets the N-methyl-D-aspartate (NMDA) receptor to create a dissociative state, while dexmedetomidine stimulates alpha-2 receptors to provide sedation and suppress the release of pain-stimulating neurotransmitters. As in critically ill patients, parameters such as respiratory rate are no longer valid indicators of pain control. Epidural and regional nerve blocks can provide analgesia for the sedated and intubated patient. Intravenous acetaminophen and the non-steroidal anti-inflammatory ketorolac are useful adjuncts in select patients. The dysphoric effects of ketamine or the sedative and hypotensive side effects of alpha-2 agonists require adequate patient and healthcare professional education (NYSORA, 2023).

Table 2: Choice of Local Anesthetic for Peripheral Nerve Blockade
AnestheticOnset (min)Duration of Anesthesia (h)Duration of Analgesia (h)
3% 2-Chloroprocaine (+ HCO3)10-1512
3% 2-Chloroprocaine (+ HCO3 + epinephrine)10-151.5-22-3
1.5% Mepivacaine (+ HCO3)10-202-33-5
1.5% Mepivacaine (+ HCO3 + epinephrine)10-202-53-8
2% Lidocaine (+ HCO3 + epinephrine)10-202-53-8
0.5% Ropivacaine15-304-85-12
0.75% Ropivacaine10-155-106-24
0.5% Bupivacaine or levobupivacaine (+ epinephrine)15-305-156-30
Gadsden, 2017

Even if these drugs are rarely used outside surgery or the emergency department in some hospitals, nurses in other specialties require a basic knowledge of their duration and effect. Just as volatile anesthesia agents' physiologic and pharmacologic effects extend into the postoperative period, even short-acting drugs can accumulate and cause side effects much later. Potent drugs for intubation may wear off before sedation infusions reach therapeutic levels. The healthcare professional is responsible for understanding and anticipating potential risks and complications.

Healthcare Professional's Role

Nurses continually expand their roles as more and more patients require complex sedation and airway management. The number of critically ill patients seeking medical care has increased by a third over the last few decades. Still, research and education methods preparing nurses to sedate these patients safely are lacking (Varndell et al., 2015). Self-directed learning fails to teach the required skills, and supervision and educational materials insufficiently train nurses to care for these patients.

Nurses need training in the clinical environment and preceptorships with experienced practitioners caring for these patients. It takes time to develop confidence when managing sedated and intubated patients. With experience, nurses realize that clear communication with the physician or nurse anesthetist is integral to best practice. Parameters for vital signs and level of sedation differ considerably depending on the situation (Varndell et al., 2015, Marthur et al., 2022).

Without defined goals and written orders for sedation, healthcare professionals must spend even more time carefully titrating infusions. Titrating can be especially difficult in emergency departments and other parts of the hospital that accept patients with unique situations. Visual cues are an important theme for nurses caring for sedated patients, but those cues need to come from vital signs—and occasionally, brain monitoring for awareness (Mathur et al., 2022). Unlike the other drugs mentioned thus far, ketamine is rarely administered as an infusion, making brain monitoring less accurate. Volatile anesthetics and sedation drugs increase GABA and depress cortical activity in the brain, but ketamine increases theta brain wave activity.

The most common monitor to interpret electroencephalogram readings into numeric values related to alertness is the Bispectral Index (BIS) monitor. Some companies use separate algorithms that do not correlate exactly to the values the BIS uses, such as between 40 and 60 for general anesthesia, especially during propofol infusions (Mathur et al., 2022). The utility of these monitors in the emergency department and intensive care unit may be limited to patients needing constant paralysis, such as in severe respiratory conditions.

Assessing Sedation and Pain

The Glasgow Coma Scale and the Richmond Agitation and Sedation Scale are among the instruments that provide a fuller picture for healthcare workers to evaluate the level of consciousness of critically ill patients before, during, and after sedation. Scales provide an objective method to avoid giving too much or subtherapeutic doses of drugs, which can cause unstable vital signs and iatrogenic harm to the patient. Assessing sedation and pain is a practical and immediate measure to titrate sedation.

If sedation is temporarily halted to assess neurological status, some patients can motion with their fingers to indicate pain intensity on a numeric scale; this is the default method until educated about more reliable alternatives for nonverbal patients. Charts that the patient can point to or write on agreed signals for "yes" and "no" if the patient cannot nod or speak and other nonverbal signaling should complement observational pain scales whenever possible to procure the patient's report of pain (UFHealth, n.d.).

Many pain instruments are appropriate for the sedated patient. Most take into account oxygen saturation and other variables continuously monitored in sedated patients. One example is the Non-Verbal Pain Scale (NVPS), derived and validated as a more specific, adult version of the Face, Legs, Activity, Cry, Consolability (FLACC) tool. Researchers compared the NVPS to the Behavioral Pain Scale (BPS), which researchers specifically developed to provide nurses with the ability to differentiate noxious from non-noxious stimuli in sedated and mechanically ventilated patients. Observation of the face and upper limbs and respiratory factors such as compliance with the ventilator is the only parameters measured by the BPS (UFHealth, n.d.). The simplicity is a distinct advantage because one of the purposes of comparing pain scales is to determine whether staff nurses can use the tools as effortlessly and reliably as trained nurse investigators. But can't nurses determine pain needs by observing patient vital signs? Chronic pain rarely causes increased pulse rate and blood pressure, like acute pain, and many patients requiring conscious sedation are in acute pain situations. The problem is that respiratory rate and other physiologic parameters in acute care settings are influenced by the disease process and the multiple medications required to keep these patients stable.

NVPS and BPS pain scores do not show objective data to indicate increased pain for the patient. With this in mind, nurses should be aware of preconceived notions about anesthesia and analgesia. Generally, pain scores are low for patients who receive continuous sedation or analgesia, but nurses rarely find a consensus value at which most patients require pharmacologic intervention.

Improving Care

Nurses' amount of time communicating with sedated patients also lacks consensus. In one study, nurses spoke to patients for a maximum of 2 minutes per 3-minute encounter, and the worse the patient scored on sedation and consciousness scales, the less time they spent trying to ascertain their needs (Parida et al., 2018). Training in the perception of communication is one method to improve care for sedated patients. Nurses test much better after receiving education about how communication is perceived. However, quality indicators such as the need for physical restraints and heavy sedation did not change after nurse education, nor did pain score documentation or the prevalence of hospital-acquired pressure sores. Information about receptor sites with pharmacologic action or better ways to assess patients does not improve care alone. As mentioned earlier, nurses need a combination of education and supervised clinical training to better care for these complex patients. Misplaced caution from lack of knowledge can lead to inadequate sedation. Conversely, misinterpreting movement as justification to administer more anesthesia or analgesia can lead to overdosing the patient (Parida et al., 2018).

An induction agent such as etomidate or ketamine and a paralytic drug to facilitate intubation should be considered when a patient is unstable. Paralytics do not have amnestic or analgesic effects but affect the skeletal muscle receptors for acetylcholine. Cardiac and smooth muscle remain unaffected, but the diaphragm is a skeletal muscle, so breathing will cease. Succinylcholine or rocuronium are common paralytics but have differing onsets and duration. Like rocuronium, atracurium and cisatracurium can be titrated for long-term use but have the added benefit of reliable elimination independent of kidney and liver function. If the patient cannot maintain adequate oxygen saturation, the nurse may need to rely on ACLS skills and ventilate the patient with a bag and mask while waiting for intubation or reintubation (Bittner, 2021). Additional sedation should be administered at the discretion of the physician or nurse anesthetist intubating the patient.

Case Study: Bronchoscopy

Scenario/Situation/Patient Description

Jim is sedating a sick patient for a bronchoscopy. The pulmonologist is struggling, and the patient is coughing and moving quite a bit despite maximum doses of aerosolized lidocaine to numb the airway. An additional five milligrams of midazolam is pushed into the intravenous line. Oxygen delivery is from a simple face mask instead of a nasal cannula with end-tidal carbon dioxide monitoring, and oxygen saturation has decreased to 93% for several moments now. The physician asks Jim to give 100 micrograms of fentanyl immediately, so he does. Within moments, the patient stops breathing, despite the stimulation and opened airway from an aggressive jaw thrust.


What indicators are present?

Depending on the exact nature of their pathology, ill patients may take shorter or longer to exhibit the effects of medications. Familiarity with drug onset and synergistic effects is necessary. Frustration can cause short-sightedness, and the lack of carbon dioxide tracing makes it more challenging to make informed decisions during the fluctuations inherent in restorative procedures. Also, fixing 93% as a "safe" value, unlike 92%, could have been an issue. Not questioning the physician's order and the fact that opioids like fentanyl are supposed to decrease stimulation and respiratory drive is another indication of trouble. Maximum oxygen and a patent airway are useless without ventilation.

Is there reasonable cause to treat this as an emergency? Yes.

What are your next steps?

Typically, the next step is immediately giving reversal agents for the midazolam and fentanyl (flumazenil and naloxone, respectively) while breathing for the patient with a bag-mask device. Current vital signs will deteriorate rapidly, so fixing the problem is the priority rather than looking at the monitor. The presence of backup assistance and the skill set of Jim and the pulmonologist matter, especially if the pulmonologist makes the "point of no return" decision to paralyze the patient for better airway control without the risk of laryngospasm. They first should call for backup. Since the problem will not be fixed without oxygen entering the lungs, the pulmonologist may slide an endotracheal tube onto the bronchoscope and immediately intubate the patient.

Discussion of Outcomes

  • This situation could have been prevented by recognizing that the patient's respiratory status was deteriorating. Still, deciding to give more sedation or let current drugs "wear off" a bit will always be challenging. Recognizing the problem (no ventilation) and immediately focusing on solutions rather than simply increasing oxygen flows or wasting time hoping for improvement is critical in these situations.
  • If Jim had questioned giving the 100 micrograms of fentanyl at once, a smaller dose might have diminished coughing while maintaining ventilation.

Strength and Weaknesses

  • Rapid transition to solutions is vital.
  • Attempts to stimulate the patient and open the airway by thrusting the jaw forward and lifting the chin can solve many conscious sedation problems. A trained healthcare professional inserting a lubricated nasal or an oral pharyngeal airway when inadequate ventilation also maintains airway patency.
  • Impatience, the desire to be compliant, and forgetting the onset time and synergistic effects of medications are weaknesses.

Treatment Goals

When it comes to conscious sedation, healthcare professionals may err on one side of the sedation continuum more than the other. To provide the best care for a sedated patient, the healthcare professional must understand why the patient receives the medications and the goal. Pathophysiology and proper understanding of the medication action on the body are crucial for maintaining the patient's safety.

Is communicating with the patient during conscious sedation a priority, or is the patient on vasopressors and barely tolerating any sedation? Has the patient's cervical spine been cleared, and are they at risk of serious injury if writhing in the bed? With education and critical thinking, healthcare professionals can rapidly answer these questions and provide continuity of care throughout a patient's stay, rather than a shortsighted approach that views the patient's progress one procedure at a time.


Conscious sedation is often used to perform procedures not tolerated in a conscious state. Sedation, combined with an analgesic, also helps when pain is unmanageable. Different agents can be used to induce sedation, each with different dosages and effect times. Because of the potential risk for subtherapeutic doses or overdoses, it is essential to understand variability and synergistic effects within medications.

Select one of the following methods to complete this course.

Take TestPass an exam testing your knowledge of the course material.
No TestDescribe how this course will impact your practice.

Implicit Bias Statement

CEUFast, Inc. is committed to furthering diversity, equity, and inclusion (DEI). While reflecting on this course content, CEUFast, Inc. would like you to consider your individual perspective and question your own biases. Remember, implicit bias is a form of bias that impacts our practice as healthcare professionals. Implicit bias occurs when we have automatic prejudices, judgments, and/or a general attitude towards a person or a group of people based on associated stereotypes we have formed over time. These automatic thoughts occur without our conscious knowledge and without our intentional desire to discriminate. The concern with implicit bias is that this can impact our actions and decisions with our workplace leadership, colleagues, and even our patients. While it is our universal goal to treat everyone equally, our implicit biases can influence our interactions, assessments, communication, prioritization, and decision-making concerning patients, which can ultimately adversely impact health outcomes. It is important to keep this in mind in order to intentionally work to self-identify our own risk areas where our implicit biases might influence our behaviors. Together, we can cease perpetuating stereotypes and remind each other to remain mindful to help avoid reacting according to biases that are contrary to our conscious beliefs and values.


  • Bittner, E. (2021). Use of Neuromuscular blocking agents in critically ill patient: Use, agent selection, administration, and adverse effects. UpToDate. Visit Source.
  • Gadsden, J. (2017). Local anesthetics: Clinical pharmacology and rational selection. Anesthesia Key. Visit Source.
  • Galvagno Jr, S., Steurer, A., & Grissom, T. (2020). Anesthesia for Trauma. In: Miller, R., Miller's Anesthesia. (9th ed., pp. 2115-2155). Philadelphia: Elsevier.
  • Huei, T. J., Mohamad, Y., Lip, H. T. C., Md Noh, N., & Imran Alwi, R. (2017). Prognostic predictors of early mortality from exsanguination in adult trauma: a Malaysian trauma center experience. Trauma surgery & acute care open, 2(1), e000070. Visit Source.
  • Mathur, S., Patel, J., Goldstein, S., & Jain, A. Bispectral Index. (2022). In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. Visit Source.
  • Parida, S., Kundra, P., Mohan, V. K., & Mishra, S. K. (2018). Standards of care for procedural sedation: Focus on differing perceptions among societies. Indian journal of anaesthesia, 62(7), 493–496. Visit Source.
  • Sieck, G. C., Ferreira, L. F., Reid, M. B., & Mantilla, C. B. (2013). Mechanical properties of respiratory muscles. Comprehensive Physiology, 3(4), 1553–1567. Visit Source.
  • The New York School of Regional Anesthesia (NYSORA). (2023). Intravenous Anesthetics. The New York School of Regional Anesthesia (NYSORA). Visit Source.
  • University of Florida Health (UFHealth). (n.d). Pain Assessment Scales/Tools. University of Florida Health (UFHealth). Visit Source.
  • Varndell, W., Fry, M., & Elliott, D. (2015). Emergency nurses' perceptions of sedation management practices for critically ill intubated patients: a qualitative study. Journal of clinical nursing, 24(21-22), 3286–3295. Visit Source.