What are the dosing guidelines for procedural sedation and analgesia (PSA) in adults?

Updated: Sep 21, 2020
  • Author: Alma N Juels, MD; Chief Editor: Erik D Schraga, MD  more...
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Answer

Answer

   Table 1. Commonly Used Drugs for Procedural Sedation and Analgesia in Adults (Open Table in a new window)

Drug

Adult Dose

Onset of Action

Duration of Action*

Comments

Midazolam

 

0.02-0.1 mg/kg IV initially; if further sedation is required, may repeat with 25% of initial dose after 3-5 min; not to exceed 2.5 mg/dose (1.5 mg for elderly persons) and 5 mg cumulative dose (3.5 mg for elderly persons)

1-2 min

30-60 min

Respiratory depression or hypotension may occur, particularly when rapidly administered or combined with fentanyl (may need to decrease midazolam dose); does not provide analgesia; action reversed by flumazenil

Fentanyl

1-2 mcg/kg slow IV push (over 1-2 min); may repeat dose after 30 min

1-2 min

30-60 min

May cause chest wall rigidity, apnea, respiratory depression, or hypotension; elicits minimal cardiovascular depression; may cause dysphoria, nausea, vomiting, or EEG changes; action reversed by naloxone

Etomidate

(Amidate)

0.1-0.2 mg/kg slow IV push over 30-60 sec

< 1 min

3-5 min

Commonly causes myoclonus, pain upon injection, adrenal suppression (typically no clinical significance unless repeated doses are used within a limited time span); may cause nausea, vomiting, and lower seizure threshold; does not alter hemodynamics; causes a slight to moderate decrease in intracranial pressure that only lasts for several minutes; does not cause histamine release; useful for patients with trauma and hypotension

Propofol

(Diprivan)

0.5-1 mg/kg IV loading dose; may repeat by 0.5-mg/kg increments q3-5min. An infusion can be started at 20mg/kg/hour.

< 1 min

3-10 min

Provides rapid onset and recovery phase, and brief duration of action; has anticonvulsant properties; can rapidly cause deepening sedation;

causes cardiovascular depression and hypotension

Ketamine  1-2mg/kg IV, 3-5mg/kg IM                        < 1 min    5-10 min for IV, 25 min IM Can cause delirium and hallucinations; hypertension and tachycardia can occur; need to pretreat with glycopyrrolate due to excessive a salivation

Dexmedetomidine

(precedex)  

bolus IV 1mcg/kg and/or infusion 0.2-1mcg/kg/h, IM 1-4mcg/, intranasal 1-2 mcg/kg < 1min     5min 

Good sedation without taking away respiratory drive, short acting; can cause severe bradycardia/heart block       

*Duration of action based on normal drug elimination (ie, nonelderly adult with normal renal and hepatic function)