# Minimal vs Moderate Sedation



## brockorama01 (Mar 5, 2010)

This thread goes out to everyone in Indiana, Michigan, Ohio and New York...the states that I know where physicians who perform anesthesia in their office need to be accredited.

In Indiana, physicians must be accredited if they perform 'moderate' sedation.  No accreditation is needed for 'minimal' sedation.  I work with many pain management physicians who perform procedures in an office-based procedure room, and (surprise) there does not seem a consensus on what is 'minimal' and what is 'moderate'.

The Indiana law stipulates that minimal sedation/anxiolysis" means a drug-induced state during which a patient responds normally to verbal commands. Although cognitive function and coordination may be impaired, ventilatory and cardiovascular functions are usually not affected.

"Moderate sedation/analgesia" (also sometimes called "conscious sedation") means a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation.
The following are conditions that a patient under moderate sedation may experience:
(1) No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate.
(2) Cardiovascular function is usually maintained.

In most situations, pt's are given IV Versed or Fentanyl under the direction of the pain specialist.  Pt's walk out of the procedure room on their own after their procedure/sedation.

Questions:  Both Fentanyl and Versed affect respiration and cardiovascular functions.  However, in small doses the affect is small.  Can small doses of Versed/Fentanyl still be minimal sedation?  What is small?  If you read the definition of 'minimal' one way, it sounds like only things like oral Valium would be allowed.  If IV sedation can be considered 'minimal', where is the line and how would we document it?  How do you document "normal" versus "purposeful" conversation...other than 'normal' versus 'purposeful'?

The only thing at stake is $15,000, hundreds of man hours and six months of delay.

Your assistance is greatly appreciated.


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## hgolfos (Mar 5, 2010)

I found an article by the ASA to be very informative on the subject of recognizing levels of sedation and definitions of moderate sedation.  I don't believe the dose amount is the determining factor, because it may take a small amount for one person while another may require a larger dose to obtain the same effect.  The determining factor is level of consciousness.  This article is dated 2002, but it is the latest guidance that the ASA gives on the subject.  

https://www.asahq.org/publicationsAndServices/sedation1017.pdf

Hope it helps,


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