PARAMETERS OF CARE

Practice Guidelines for Intravenous Conscious Sedation in
Dentistry (Second Edition, 2017)
Developed By The Japanese Dental Society ofAnesthesiology for Dentists Practicing Sedation in JapanI

ntravenous sedation is a method of intravenously
administering a sedative so that a patient can receive
dental treatment safely and comfortably; it is a patientmanagement method that reduces or eliminates fear andanxiety during treatment.1,2 This method is a specialized
treatment that is used worldwide and responds to theneed to prevent medical complications, underlying
disease exacerbation, and stress during oral/dental
surgical treatment under local anesthesia in patientswith dental phobia or medical compromise.3,4Dental treatment is characterized by the fact that thesurgical field and the airway are the same site; the use ofa mouth prop narrows the airway, and water stored in
the oral cavity easily flows into the pharynx/larynx due
to the use of dental rotary and cutting equipment.
Maintaining consciousness, swallowing and upper respiratory tract reflexes, and sufficient respiration during
dental treatment is extremely important in preventing
airway obstruction and aspiration.1,5 Conscious sedation is a procedure in which the level of sedation isregulated so that consciousness is maintained. Anxiety
and fear of dental treatment and oral surgical procedures are frequently eliminated; calm is maintained, andthe patient can respond to verbal command or lightphysical stimuli.5,6 The term conscious sedation that isused in Japan is equivalent to the term minimal tomoderate sedation in the American Dental Association(ADA) guidelines7 and minimal to moderate sedation/
analgesia in the American Society of Anesthesiologists(ASA) guidelines.8
However, in clinical dentistry, there are cases in which
behavioral management is performed with sedation todeliberately cause a loss of consciousness for a period oftime.9 This state is called ‘‘deep sedation.’’ Deep
sedation is associated with more side effects andcomplications, such as airway obstruction and aspiration, compared with conscious sedation. Moreover,because advanced knowledge and techniques are required, it is necessary to perform perioperative management similar to that for general anesthesia.6,10
The ASA statement regarding monitored anesthesia
care notes that providers of moderate sedation must be
qualified to recognize deep sedation, manage its
consequences, and adjust the level of sedation to amoderate or lesser level.11 In Japan, several clinicians
fail to understand the difference between ‘‘conscious
sedation’’ and ‘‘deep sedation’’ in terms of the common
practices, concepts, and indications. The reason is that
there are no comprehensive guidelines on proper
management under ‘‘conscious sedation,’’ which is abasic technique of intravenous sedation. Therefore, inthese guidelines, similar to the first edition, standard
guidelines have been presented, so that management of
intravenous conscious sedation can be performed safely
and effectively in adults.
The first edition of these guidelines was issued in
September 2009. It was decided that a revised version ofthat report should be issued, since the first publication
was issued 7½ years ago. Since evidence regarding
relatively new sedative drugs in dental practice islacking, these new drugs are not covered in this revised
edition. However, evidence indicating the utility of
propofol, a conventionally used sedative, has beenreported and was added to this revised edition. In our
principle of conscious sedation, no analgesic drugs were
included, and benzodiazepine and propofol were included when used alone or in combination. Intravenous
sedation with propofol should be performed only byappropriately trained practitioners.
We should explain the legal status of the provision of
sedation/general anesthesia in Japan. General anesthesia
can be legally provided by any dentist in Japan. Dental
students receive more than 50 hours of lectures onanesthetic management in dental school, with the totalvarying between universities. The faculties in Departments of Dental Anesthesiology are responsible fortraining in dental anesthesia. Thus, the national examination for licensing of dentists includes the field ofanesthetic management. Undergraduate education qual-

Address correspondence to Toshiaki Fujisawa, Chief of theWorking Group on Guidelines Development for Intravenous
Sedation in Dentistry, the Japanese Dental Society of Anesthesiology, Department of Dental Anesthesiology, Faculty of Dental
Medicine and Graduate School of Dental Medicine, Hokkaido
University, North-13, West-7, kita-ku, Sapporo 060-8586 Japan;
fujitosi@den.hokudai.ac.jp.
Anesth Prog 65:e1–e18 2018 j DOI 10.2344/anpr-65-04-15w! 2018 by the American Dental Society of Anesthesiology12

Practice Guidelines for Intravenous Conscious Sedation in Dentistryifies a dentist in Japan to provide anesthetic care,including general anesthesia, for dental treatment. It is,however, obvious that further coursework is required toensure the safe provision of anesthetic care in dentistry.
The Japanese Dental Society of Anesthesiology is
responsible for overseeing such training courses. In
1977, the Japanese Board of Dental Anesthesiologists
was established as a qualifying examination for anesthesia providers. Most anesthesia providers in dentistry havetaken specific residencies in a Department of Dental
Anesthesiology and have passed a board examination
after approximately 3 years of full-time training. As
dental anesthesiologists, we generally advise trainee
dentists, including oral surgeons and general practitioners, who are willing to learn dental anesthesia that theyshould provide intravenous sedation by themselves in a
private office only after they obtain certification by theJapanese Board of Dental Anesthesiologists (ie, completed residency training in dental anesthesiology). However,some oral surgeons and general practitioners train inproviding intravenous sedation under previously trainedoral surgeons or medical anesthesiologists who are skilled
at sedation management. Even though serious adverse
events related to dental anesthesia are quite rare in
Japan, our society continues to provide education andcontinuing education in safe anesthetic practices forhealth care providers in this field. Thus, this guideline is
one of the methods our society uses to promote safe
dental anesthesia management.
To introduce this revised version to dental practitioners around the world who perform sedation, we hereby
publish an English version. It should be noted that somenewer guidelines of other organizations were notavailable at the time of the Japanese publication.
Therefore, reference is made to the most recent
guidelines of other organizations as of 2017, when thisguideline was published in Japanese.
These guidelines were prepared in accordance with theprocedure manual of ‘‘evidence-based medical care’’12
by the Working Group of the Japanese Dental Societyof Anesthesiology consisting of board-certified dental
anesthesiology specialists and reviewed by six societies
in related fields (Japanese Society of Oral and Maxillofacial Surgeons, Japanese Society for Disability andOral Health, Japanese Society of Oral Implantology,
Japanese Society of Pediatric Dentistry, JapaneseSociety of Gerodontology, Japanese Society of Dentistry for Medically Compromised Patients).
Details concerning the targets of the literature search,evidence levels, and recommendation levels are described, as follows.
1. We clarified the clinical questions (CQs) regarding
intravenous conscious sedation that are performed at

Anesth Prog 65:e1–e18 2018present and searched the literature concerning each
CQ.
2. To select relevant references, working group members were divided to perform searches of theliterature, mainly using Igaku Chuo Zasshi(ICHUSHI) and PubMed. Independently collected
papers were also used as references. The evidence
levels and recommendations extracted from thereference literature were discussed among the working group members, and a final draft was created.
3. The recommendations and evidence levels used inthese guidelines are shown below.

Degree of recommendation
Grade A: Strongly recommended to be performed
Grade B: Recommended to be performed
Grade C: The evidence for recommendation is unclear
Grade D: Not recommended to be performed
Evidence level
Level I:
Systematic review/meta-analysis
Level II:
One or more randomized controlled trials
Level III: Nonrandomized controlled trial/prospective
clinical trial
Level IV: Analytical epidemiological study (cohort study
or case-control study)
Level V:
Descriptive study (case report or case series)
Level VI: Opinion of technical committees and experts;
not based on patient data

Evidence Levels I and II are classified as degree ofrecommendation A, evidence level III as degree ofrecommendation B, and evidence Levels IV to VI as
degree of recommendation C. When reports that met
level I and II criteria could not be found, if the items
were determined to be highly or moderately recommended by the working group members, they weremarked as ‘‘degree of recommendation A or B evaluatedby the Working Group on Guidelines Development.’’
When a quoted statement was not derived fromevidence-based medicine, although it was from asystematic review, it was classified as ‘‘Level VI in I’’
and Grade B. In practice, there were some CQs forwhich it was difficult to find evidence, and they wereconsolidated as the opinion of the working group.
The purpose of these guidelines is to support medical
treatment, but they do not restrict the discretion of thedentist/physician or limit medical treatment. How theseguidelines are used in the clinical setting should bedetermined by the patient’s needs and the expert
knowledge and experience of the dentist/physician.
It is our hope that patients who cannot receive
standard dental treatment will be able to receive
appropriate dental treatment by undergoing safe andeffective intravenous conscious sedation and that theseguidelines contribute to the progress of dental care andpatient health.

Anesth Prog 65:e1–e18 2018

No financial assistance from a company or other entity
was provided to create these guidelines. The members of
the guidelines working group have no conflicts ofinterests to declare at the time of publication.
The various clinical issues are addressed in a question
and answer format.

PREOPERATIVE MANAGEMENT
1. CQ: How should the general status of the patient beassessed?
Recommendation. Although it is desirable to follow theguidelines for general anesthesia, it is important to focus
on the detailed medical interview (medical interview) andrecording of vital signs (degree of recommendation: A
evaluated by the Working Group on Guidelines Development). If the patient has or is suspected to have asystemic illness, it is advisable to consult with theattending physician (medical inquiry) via medical records(degree of recommendation: B evaluated by the Working
Group on Guidelines Development). Comprehensive
evaluation should be carried out by the attending dentist
or dentist in charge who is knowledgeable and skilled(degree of recommendation: A evaluated by the Working
Group on Guidelines Development).
Refer to: CQ 2–6). What education and training arenecessary for intravenous sedation?
Scientific Basis. In general, patients with ASA
physical status classification I or II are consideredappropriate for intravenous sedation in dentistry. It isnecessary to verify whether or not medical treatment isbeing performed based on the latest guidelines for eachdisease (refer to Medical Information Network Distribution Service). Moreover, it is also necessary toconfirm whether or not adequate medical management
is being performed.13,14
Perform a detailed verbal examination (medical
interview), which covers disease history, current
disease state, medications taken, family history,
discomfort level during past dental treatments, andany allergies to food, medicine, etc (level IV).5,15,16
After the medical interview and measurement of vital
signs, preoperative screening tests and comprehensive
assessment of the patient’s general status should be
performed, and, if necessary, written inquiries to thetreating physician (medical information request form)should be made. This is relatively acceptable if there is
only one complicating factor and medical management
is sufficient; however, there are cases in which thepatient visits multiple medical institutions for multiple
systemic or chronic diseases or is administered
medication for long periods, and it is appropriate to

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3

evaluate the general status of the patient based on allof his or her information. Furthermore, the goal ofpatient evaluation should be determined by how well
the patient can tolerate the planned dental treatment,
which sedation method is optimal for the patient, andso on (level IV).17,18
Explanation. Particularly in cases of intravenous sedation in outpatients, it is necessary to perform more detailed
preoperative interviews before surgery (interviews of family
members or accompanying persons may be necessary insome cases) and measure vital signs. It is important toaccurately perform preoperative evaluations, since management after patients return home is not possible.

2. CQ: What are the indications/contraindications of
intravenous sedation?
Recommendation. Indications/contraindications of intravenous sedation are considered to include thefollowing (degree of recommendation: B).
1. Indications
1) Patients with dental phobia2) Patients in whom vasovagal reflex, hyperventilation syndrome, panic disorder, and so on arelikely to develop from dental treatment
3) Patients with a strong vomiting reflex or abnormal gag reflex4) Patients who require stabilization of intraoperative circulatory dynamics (patients with hypertension, heart disease, etc)
5) Persons with disabilities who require sedation(see note)(1) Patients with cerebral palsy who have severe
athetosis or spasticity(2) Patients with Parkinson’s disease who havesevere tremor(Note) The purpose of intravenous sedation is torelieve stress. It is necessary to differentiate this fromdeep sedation for the purpose of behavior modification in persons with disabilities and uncooperative
children. In the case of patients with cerebral palsy,
muscle tension and involuntary movements are frequently worsened by stress and can be relieved byintravenous sedation. In patients with Parkinson’s
disease, tremor at rest can be reduced by intravenous
sedation.
6) Patients undergoing highly invasive treatment
2. Contraindications
1) Patients in early stages of pregnancy

4Practice Guidelines for Intravenous Conscious Sedation in Dentistry2) Patients who have an allergy to the sedative
3) Patients who are using a contraindicated drug
(1) Patients with myasthenia gravis (diazepam,
flunitrazepam)(2) Patients who are using a protease inhibitor(eg, ritonavir) for treatment of HIV (diazepam)(3) Patients with acute angle-closure glaucoma(diazepam, flunitrazepam)
3. Patients who require special care when undergoing
intravenous sedation
1) Patients with diseases associated with upper
airway obstruction (eg, severe obesity, micrognathia, tonsillar hypertrophy, obstructive sleep
apnea syndrome, severe cerebral palsy)
2) Patients who are thought to have residual
stomach contents
3) Patients with severe systemic illness, especiallythose with decreased respiratory or cardiovascular reserve capacity
4) Patients who have previously experienced anadverse event due to intravenous sedation
5) Patients receiving oral long-term psychotropic or
antipsychotic drug administration
6) Patients with muscular dystrophy
Scientific Basis. The application of intravenous
sedation is wide ranging, and it can be used in mostpatients (level VI).5 However, care is especially needed
when performing intravenous sedation in patients who
require special care (level VI, level IV in level I).8,19
Explanation. The incidence of complications during
intravenous sedation, especially respiratory complications, such as respiratory depression and airway obstruction, is high; in some cases, intraoperative airway
management by mask ventilation and endotracheal
intubation may be necessary. Therefore, caution is neededwith intravenous sedation in patients in whom airway
management is difficult (eg, severe obesity, short neck,
neck tumor, cervical spine injury, mandibular micrognathia, trismus, tonsillar hypertrophy, cerebral palsy).

3) CQ: Are routine preoperative screening tests (ie,hematologic tests, chest radiography,
electrocardiography) necessary?
Recommendation. For intravenous sedation, routine
preoperative screening tests not based on specificindications are not necessary (degree of recommendation:
A). However, after recording the patient’s medical history
and performing a physical examination, if necessary, apreoperative evaluation should be performed similar to

Anesth Prog 65:e1–e18 2018

one performed before surgery with general anesthesia(degree of recommendation: A evaluated by the Working
Group on Guidelines Development).
Scientific Basis. There were no significant differences in
the rate of complications between the group who received
and the group who did not receive a routine preoperative
screening test (level II).20,21 In the absence of specificindications, routine preoperative laboratory tests contribute little to patient care (level IV).22 Medical history
evaluation and careful physical examination are important for the preoperative evaluation of patients, and basedon this information, it must be determined whether
further preoperative evaluation is necessary (level VI).23

4) CQ: How to provide a description of the procedure andobtain consent (informed consent) from patients?
Recommendation. The attending anesthesiologist
should provide a description of the procedure to thepatient and obtain consent (informed consent) after
distributing the descriptive pamphlet in advance (degreeof recommendation: B). A description by an anesthesiologist with extensive experience and knowledge is more
effective in relieving anxiety of intravenous sedationcompared with one by an inexperienced anesthesiologist(degree of recommendation: B).
Scientific Basis. After the information describing theanesthetic procedure was given to patients in advance, they
could deepen their understanding of the procedure with theanesthesiologist’s description (level III).24 Compared witha description by an anesthesiologist with less experienceand less knowledge, a description by an anesthesiologist
with extensive experience and deep knowledge significantly
reduced patients’ anxiety (level III).25

5) CQ: Is preoperative oral intake restriction necessary?
If so, what type of restriction is necessary?
Recommendation. It is recommended that preoperative oral intake restriction be implemented for intravenous sedation (degree of recommendation: A evaluatedby the Working Group on Guidelines Development).
Even for subjects who undergo conscious sedation, oral
intake restriction is necessary because if the patient
unintentionally enters a deep state of sedation, thepossibility of aspiration cannot be ruled out.
The following are recommended as oral intake
restrictions (degree of recommendation: B).
!

Up to 2 hours before: intake of clear liquids (water,
fruit juice containing no pulp, carbonated beverages,

Anesth Prog 65:e1–e18 2018

tea, functional soft drinks such as sports drinks, blackcoffee) acceptable! Up to 6 hours before: milk and light meals (toast andclear liquids) acceptable! Up to 8 hours before: intake of normal meals
acceptable
Scientific Basis. In the ‘‘Practice Guidelines for
Sedation and Analgesia by Non-anesthesiologists’’ ofthe ASA, it is recommended that preoperative oral
intake restriction be implemented (level IV in level I).8
However, evidence on oral intake restriction for
intravenous sedation during dental treatment is poor,and no conclusion has been reached. One reportsuggests that if the level of sedation is similar to thatof conscious sedation, there is no need for preoperative
oral intake restriction (level V).26,27 However, there isalso an opinion that even under conscious sedation,
intake restriction should be applied similar to deep
sedation and general anesthesia (level IV).28
When performing intravenous sedation, some formof oral intake restriction was implemented in 21 out of
23 university hospital dental anesthesiology departments in Japan (level VI).29 The results of a questionnaire on intravenous sedation from 70 institutions
showed that some type of absolute fasting was
implemented in 50 to 60% of facilities. However,
10% of facilities did not implement any type of fasting(level VI).5
The ASA guidelines list recommended preoperative
oral intake restriction methods (level I).8 According
to a study by Kurozumi et al,29 the mean fasting timewas 8.3 6 2.3 hours, and the mean liquid fasting timewas 6.8 6 3.1 hours (level VI). In a report byCampbell and Smith,30 200 patients older than 65
years who underwent an oral surgical procedure wereallowed to ingest solid food up to 8 hours before anddrink clear liquids up to 3 hours before intravenous
sedation was performed. No intraoperative or postoperative nausea, vomiting, aspiration, or dehydration was noted. Morse et al31 administered a survey
to Japanese dentistry departments and dental university hospitals; they found that the mean fasting time
was 5.5 6 3.0 hours (0–12 hours), and the meanliquid fasting time was 3.7 6 2.4 hours (0–9 hours;
level VI).
Explanation. There are no reliable data on theincidence of vomiting and aspiration during dental
procedures under intravenous sedation. However, severe
aspiration has been reported in endoscopic surgery
under intravenous sedation. As various dental procedures can induce vomiting, it is important to adhere topreoperative oral intake restriction.

Fujisawa

56) CQ: What education and training are necessary for
intravenous sedation?
Recommendation. To safely perform intravenous
sedation, it is necessary to receive training in anesthetic
pharmacology, anesthesia technique, systemic physicalmanagement, and emergency resuscitation (degree ofrecommendation: A evaluated by the Working Groupon Guidelines Development).
Scientific Basis. According to the ‘‘Practice Guidelines
for Sedation and Analgesia by Non-anesthesiologists’’of the ASA (level VI in I),8 when sedation is performed
by a nonanesthesiologist, it is strongly recommended
that the practitioner receive training in anesthetic
pharmacology, anesthesia technique, systemic management, and emergency resuscitation. In addition, in the‘‘Policy Statement: Use of Sedation and General
Anesthesia by Dentists’’ (level VI),32 ‘‘Guidelines for
the Use of Sedation and General Anesthesia by
Dentists’’ (level VI),7 and ‘‘Guidelines for Teaching
Pain Control and Sedation to Dentists and Dental
Students’’ (level VI),33 the ADA provides guidance on
education and training and recommends practitioners
undergo this training before performing sedation.
Explanation. In predoctoral (dental student) dental
education in Japan, the following classes are offered for
dental anesthesiology: ‘‘anesthesia and the nervous
system,’’ ‘‘anesthesia and the respiratory system,’’ ‘‘anesthesia and the circulatory system,’’ ‘‘anesthesia and theendocrine system,’’ ‘‘anesthesia and the urinary system,’’‘‘anesthesia and circulatory disorders,’’ ‘‘anesthesia andimmunity,’’ ‘‘action of anesthetics,’’ ‘‘application andpharmacokinetics of drugs,’’ ‘‘side effects and adverse
effects of drugs,’’ ‘‘preoperative examination and systemic
diseases,’’ ‘‘vital signs and systemic complications,’’‘‘sedation technique,’’ and ‘‘cardiopulmonary resuscitation; basic life support and advanced life support.’’34

7) CQ: What are the skills needed to administer sedatives
intravenously?
Recommendation. Sedatives are administered continuously or intermittently during intravenous sedation.
In addition, in some cases, administration of an
inotrope or emergency drugs may be required during
patient management. Therefore, during sedation, it isnecessary to pay attention to complications that arise
from venous access itself and acquire the necessary
skills to prevent them (degree of recommendation: A
evaluated by the Working Group on Guidelines
Development).

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Practice Guidelines for Intravenous Conscious Sedation in Dentistry

Scientific Basis. According to the results of aquestionnaire survey on intravenous sedation administered to 77 institutions, including dental universities anddental schools throughout Japan, the actual treatment
time during intravenous sedation was as follows: within
1 hour, 37.8%; within 1 to 2 hours, 34.9%; within 2 to 3
hours, 16.9%; within 3 to 4 hours, 7.6% (level IV).5
Cases of seizures, hyperventilation syndrome, andcardiac arrest following severe vasovagal reflex caused
from the establishment of intravascular access inintravenous sedation have been reported (level V).35,36
There have also been reports of vasovagal reflex with
suppression of the circulation requiring use of circulatory agonists and/or emergency treatment (level V).37,38
Explanation. During intravenous sedation, it isnecessary to secure venous access over a relatively long
period of time; it is desirable to select an indwelling
catheter to avoid vascular injury or fluid leak when body
movements occur and to select a large blood vessel toprevent vascular pain or postoperative phlebitis. Furthermore, it is necessary to have humane and appropriate puncture technique.

INTRAOPERATIVE MANAGEMENT
1) CQ: Can the practitioner performing intravenous
sedation also perform the dental treatment?
Recommendation. If the level of sedation is within therange of conscious sedation, the practitioner performing
the dental treatment can also perform intravenous
sedation. However, the practitioner needs to acquireconsiderable knowledge and skills concerning sedationand emergency treatment. It is also necessary to have 1
or more assistants devoted to monitoring patient status(degree of recommendation: C).
Scientific Basis. Although there are little data on thesubject, in principle, intraoperative sedation management should be performed by a person who is not
performing the dental treatment (level VI).5 However,there are no studies that form the basis for therecommendations in the ‘‘Guidelines for Sedation andAnalgesia by Non-anesthesiologists’’ of the ASA8 andthe sedation guidelines of the American Academy of
Pediatrics/American Academy of Pediatric Dentistry.39
Therefore, the expert committee determined who should
perform intravenous sedation according to the target
level of sedation. That is, if the target sedation level ismoderate (conscious sedation), the practitioner performing the dental procedure may also perform
intravenous sedation, but the practitioner must be a
person with expert knowledge and skill who cansufficiently handle emergencies. In addition, one assis-

Anesth Prog 65:e1–e18 2018

tant assigned to monitor the condition of the patient isnecessary. However, it has been noted that when
implementing deep sedation, the specialist devoted topatient management must be assigned separately fromthe surgeon (level VI).
Rodgers investigated 2889 patients who underwent
intravenous sedation that was performed by an oral
surgeon during the 7-year period from December 1994
to November 2001; the reported incidence of complications was 2.67% (77/2889; level V).40 In this study, theoral surgeon who performed intravenous sedation was
knowledgeable about anesthesia practices (National
Dental Board of Anesthesiology certified) and received
advanced cardiovascular life support training every 2
years. Intraoperative patient monitoring was performed
by a dental assistant who had taken a course on
anesthesia practices. In addition, Rodgers and colleagues conducted a similar study from December
2001 to November 2008 and reported that the incidenceof complications was 1.80% (60/3320; level V).41 The
sedation level ranged from moderate to deep sedation inmost patients, but no patients received intravenous
general anesthesia.
Lee et al reported that there was no difference in theincidence of intraoperative complications (0.4 and
0.25%, respectively) when intravenous sedation was
performed by the oral surgeon performing dental
treatment or when performed by an anesthesiologist or
a nurse anesthetist (level V).42
Explanation. During sedation, continuous monitoring of the patient’s breathing status, circulatory
dynamics, and so forth must be performed. It is also
necessary to respond appropriately to the degree ofsedation, which constantly changes because of theconditions of the surgery. Furthermore, when there is asudden change in the condition of the patient, prompt
response is required. When the person performing thedental treatment also performs intravenous sedation, it
is difficult to fully understand the status of the patientunder sedation; conversely, when the practitioner
concentrates on patient management, the progress ofthe dental treatment is hindered. Based on the abovefindings, it is the authors’ opinion that it is desirable
for intravenous sedation to be implemented by adifferent person from the one performing the dental
treatment. In recent years, it has been reported that
intravenous sedation, including deep sedation performed by the oral surgeon who is performing thedental treatment, has been performed safely; however,in such cases, it was also essential to have a well-trained
nurse familiar with intravenous sedation and methodsof evaluating the general status of the patient toconcentrate on patient monitoring during the procedure.

Anesth Prog 65:e1–e18 2018

2) CQ: How long is the treatment duration under
intravenous sedation?
Recommendation. It is preferable that the duration oftreatment under intravenous sedation is less than 2hours (degree of recommendation: B evaluated by theWorking Group on Guidelines Development).
Scientific Basis. In the questionnaire survey, thepercentage of cases according to actual treatment
duration during intravenous sedation was as follows:
within 1 hour, 37.8%; from 1 to 2 hours, 4.9%; from 2
to 3 hours, 16.9%; from 3 to 4 hours, 7.6%.5
However, the percentage of procedures that wereconsidered to have appropriate treatment durations
were as follows: within 30 minutes, 1%; within 1 hour,
25.7%; within 1.5 hours, 14.3%; within 2 hours,
44.3%; within 3 hours, 14.3% (level VI).5 In a study of
intravenous sedation in 200 elderly patients (mean age:72 6 4.2 years) who received oral surgical treatment,
the treatment duration ranged from 6 to 129 minutes(level VI).30 Lepere and Slack-Smith43 performed
dental procedures under intravenous sedation in 85
patients in private dental clinics. Treatment duration
was 8 to 185 minutes (mean time: 71.4 6 37.5 minutes;
median time: 64 minutes). Messieha et al44 performed
independent intravenous sedation (using fentanyl,
midazolam, propofol, etc) in 100 patients and retrospectively investigated the treatment duration andcomplications. The mean treatment duration was 97.5
6 42.39 minutes, and complications occurred in 6
cases.
Explanation. There are no highly reliable studies thathave examined the length of treatment time, quality ofsedation, and incidence of complications during intravenous sedation. However, when the treatment time
under intravenous sedation is prolonged, the patient
often becomes agitated, making it difficult to maintainsedation. In an investigation of the treatment duration
under intravenous sedation, most cases were completed
within 2 hours, and there were few reports of serious
complications. Therefore, it is considered reasonable toset the guideline for treatment duration under intravenous sedation to 2 hours.

3) CQ: What intraoperative complications may occur?
Recommendation. During intravenous sedation, caution is needed regarding the occurrence of the following
complications (degree of recommendation: A).
1) Respiratory complications! Hypoxia (decreased SpO2)! Airway obstruction/glossoptosis/snoring

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7

Respiratory depression/respiratory arrest
Cough (cough reflex)! Aspiration pneumonia
2) Cardiovascular complications! Hypertension/hypotension! Tachycardia/bradycardia! Cardiac arrest! Arrhythmia! Vasovagal reflex3) Other complications! Nausea/vomiting! Restless/excited state (agitation)! Vascular pain/phlebitis! Anaphylaxis!
!

Scientific Basis. During intravenous sedation, respiratory complications, such as respiratory depression andglossoptosis, frequently occur (level VI).5 According to
one study that analyzed the causes of intravenous
sedation failure, the most common reason why thescheduled treatment could not be performed was patient
disturbance/excitement (agitation; level V).45 Refer tothe section on medication and the side effects caused byeach drug that is used in intravenous sedation.
Explanation. In implementing intravenous sedation, it
is important to recognize the possibility of thesecomplications, and practitioners must adequately monitor patients and prepare countermeasures against thesecomplications.

4) CQ: When establishing intravenous access, what are
the points to consider to avoid nerve damage?
Recommendation. The puncture sites for intravenous
access include the dorsum of the hand, radial side of thewrist joint, antecubital fossa, and so on. When selecting
the cephalic vein, it is recommended to avoid puncturing
at a site close to the wrist joint (degree of recommendation: C). If puncturing at the antecubital fossa, it isdesirable to select a cutaneous vein on the radial side of
the antecubital fossa (degree of recommendation: C). If
the patient feels an abnormal sensation or numbness inthe punctured area, remove the needle promptly. Care isalso necessary when removing the needle (degree ofrecommendation: C). Although the incidence of nerve
injury and tissue damage accompanying venipuncture issmall, it should be performed after fully understanding
the anatomy of the surrounding region of the puncturesite (degree of recommendation: A evaluated by theWorking Group on Guidelines Development).
Scientific Basis. The nerves that may be damaged
from intravenous puncture include the antebrachialcutaneous nerve in the antecubital fossa, the superficial

8Practice Guidelines for Intravenous Conscious Sedation in Dentistrybranch of the radial nerve at the wrist, and the dorsal
sensory branches in the hand (level V).46–48 Whenpuncturing the cephalic vein of the wrist, it has beenreported that puncturing should be performed on thecentral side at 12 cm or further from the styloid process
to avoid nerve damage to the superficial branch of theradial nerve (level V).49 It has been reported that, when
performing venous puncture at the cubital fossa, themedian basilic vein should be avoided.48
The incidence of nerve damage accompanying venipuncture is rare. When minor cases were included, theincidence was 1 out of 6300, and when limited topatients with a recovery period of 1 month or longer, theincidence was 1 out of 20,500 cases50; 3 out of 560,000
patients took more than a year until fully healed51 (level
V).
Although it is impossible to completely prevent
peripheral nerve damage during vascular puncture, thenecessity of avoiding puncture at sites with a high risk ofnerve damage and prompt response when neurologicalsymptoms occur has been previously stressed (level
V).47,48 In addition, cases have been reported in which
nerve damage occurred not only during venous puncture
but also during removal of the catheter (level V).52
Explanation. Although the incidence of peripheral
vascular injury due to venipuncture is rare, when
performing vascular access via the cephalic vein,sufficient anatomical knowledge is necessary to avoid
complications, such as the possibility of radial nerve
damage. Furthermore, when radiating pain or numbness
occurs during needle insertion, stop immediately andremove the needle.

5) CQ: Is it possible to improve the safety of intravenous
sedation through monitoring?
Recommendation. Consciousness, ventilation, oxygenation, and circulation (pulse rate and blood pressure)should be monitored continuously (intermittently insome cases; degree of recommendation: A evaluated by
the Working Group on Guidelines Development).
Monitoring of consciousness with a bispectral index(BIS) monitor and monitoring of ventilation by
expiratory gas analysis is recommended to enhance thesafety of intravenous sedation (degree of recommendation: A). Electrocardiography should be considered inpatients with cardiovascular or respiratory disease(degree of recommendation: B evaluated by the Working Group on Guidelines Development).
1. Consciousness! A BIS monitor is useful for maintaining anappropriate sedation depth.

Anesth Prog 65:e1–e18 2018

! Intermittently evaluate response to verbal contact.
2. Ventilation! An end-tidal CO2 monitor is useful for theprevention and early detection of respiratory
depression.
! Intermittently observe the chest movements! Evaluate ventilatory state through respiratory
sound auscultation and conversation with patient.
3. Oxygenation! Continuously monitor SpO2 level.
! Intermittently assess the color of mucosa, skin,and blood.
4. Circulation! Continuously monitor pulse rate.
! Intermittently assess blood pressure.
! For cardiovascular and respiratory diseases, consider the use of electrocardiography.

Scientific Basis. By monitoring consciousness with a
BIS monitor during sedation, appropriate sedation
depth can be maintained with a lower drug dose (level
II, III).53–55 During sedation with midazolam andpropofol, protective reflexes were significantly inhibitedwhen the BIS score was maintained below 75 (level
III).56 Monitoring of ventilation by analysis of expiratory carbon dioxide during sedation significantly inhibited the incidence of respiratory depression and hypoxia(level II).57,58 Respiratory sound auscultation is useful tomeasure respiration rate during sedation of healthy
adults, but it is less reliable during sedation of patientswith disabilities (level III).59,60 All complications thatwere reported in the multicenter survey on intravenous
sedation (Ramsay score 2–3) using midazolam comprised cases of mildly decreased oxygen saturation (level
V).61
According to the ‘‘Practice Guidelines for Sedation
and Analgesia by Non-anesthesiologists’’ published by
the ASA (level VI in I),8 sedation guidelines of the ADA(level VI),7 and ‘‘Guidelines for Safe Performance ofIntravenous Sedation’’ commissioned by the Japanese
Dental Association (level VI),5 consciousness, oxygenation, ventilation, and circulation (pulse rate, bloodpressure, and electrocardiography, if necessary) should
be monitored continuously (intermittently in somecases). However, in the ASA’s ‘‘Practice Guidelines for
Sedation and Analgesia by Non-anesthesiologists’’ (level
VI in I),8 there is no guideline on the use of BIS
monitoring during sedation, and the efficacy of end-tidal
CO2 monitoring has not been established.
Explanation. The need for monitoring during intravenous sedation is not based on sufficient evidence but
rather should be based on the patient’s consciousness,
ventilation, oxygenation, and circulation (pulse rate andblood pressure) metrics. Other forms of monitoringAnesth Prog 65:e1–e18 2018

Fujisawa

should also be considered depending on the general
status of the patient.

6) CQ: Is it useful to select drugs according to the purposeof performing intravenous sedation?
Recommendation. For patients with dental phobia, thepractitioner should administer benzodiazepine or propofol monotherapy or both in combination (degree ofrecommendation: A). For suppression of abnormal gag
reflex, use propofol alone or propofol in combination
with benzodiazepine (degree of recommendation: B).
For patients with a comorbid disease, intellectual or
physical disabilities, or undergoing minor oral surgery,use benzodiazepine or propofol alone or in combination(degree of recommendation: C). For patients withintellectual disabilities, general anesthesia may beconsidered when behavior management is too difficultfor intravenous sedation (degree of recommendation: B
evaluated by the Working Group on Guidelines
Development). Furthermore, because midazolam, propofol, or their combination can increase bite forces,
caution is needed at the time of conscious sedation inpatients, such as those with intellectual disabilities, who
intensely bite during treatment (degree of recommendation: A).
Scientific Basis. When mental stress was applied
during intravenous sedation with midazolam or propofol, midazolam inhibited sympathetic activity more thanpropofol, and the patients’ reported stress levels werelower (level II).62 When invasive and noninvasive
stimulation under intravenous sedation with midazolam
and propofol were applied, midazolam produced astronger amnesic effect than propofol (level II).63,64
When mental stress was applied under intravenous
sedation with propofol or dexmedetomidine, patients
who received propofol reported less stress and theirsatisfaction levels were higher compared with those who
received dexmedetomidine (level II).65 However, physiological and psychomotor functions recovered faster
after sedation with propofol than midazolam (level II).66
During conscious sedation used for tooth extraction,
patients were more satisfied with propofol sedation than

9

midazolam because of the rapid recovery and lack ofemotional discomfort (level II).67 Furthermore, patientstreated with midazolam or propofol showed comparable
ability to hold water in their mouth, suggesting that therisk of aspiration is low with either drug (level II).68
In patients with severe anxiety and fear of dental
treatment, intravenous sedation with benzodiazepine
has been conventionally performed with the expectationof good sedative and strong amnesic effect (level V)69,70;
however, in recent years, intravenous sedation using
propofol alone or a combination of propofol and a low
dose of benzodiazepine has been widely performed forregulating the depth of sedation and achieving prompt
recovery after sedation (level V).70 In patients with gag
reflex, reflex control may be difficult with benzodiazepine alone; when propofol monotherapy or benzodiazepine in combination with propofol was used, the reflex
was favorably controlled in a moderate or less sedative
state (level V).56,69–73 In patients with comorbid
disorders, such as hypertension or heart disease, it isuseful to use benzodiazepine alone or in combination
with propofol (level V).5,61,69,70 It has been reported thatin patients with physical disabilities without intellectual
disabilities, treatment could be safely performed using
benzodiazepine alone or in combination with propofol(level V).69,74,75 In patients with intellectual disabilities,
controlling the depth of sedation may be difficult withbenzodiazepine alone, and it is useful to use propofol
alone or in combination with benzodiazepine (level
V).69,76 However, if behavior management is difficult byintravenous conscious sedation alone, general anesthesia
may be considered (level V, VI).61,76 For patients
undergoing minor oral surgery, it has been reported
that treatment can be safely performed using benzodiazepine or propofol monotherapy or combination
therapy (level V).69
Bite force of sedated patients increases during
conscious sedation (Ramsay sedation score of 2–3)
using propofol and/or midazolam.77–79 The rate ofincrease was approximately 50% during conscious
sedation77 (level II). Bite force also increased withmidazolam alone or in combination with propofol, andthe rate of increase was approximately 50% formidazolam alone78 and approximately 80%79 for midazolam and propofol used in combination (level II).

Estimated dosage for healthy adults under conscious sedation, modified from Shibutani et al5
Benzodiazepine
Midazolam

DiazepamFlunitrazepam

Approximate dose

0.050–0.075 mg/kg

0.2–0.3 mg/kg

0.010–0.015 mg/kg

Administration rate
Estimated maximum dose

0.5–1.0 mg/30 s
5–7 mg

1–2 mg/30 s
20 mg

0.1–0.2 mg/30 s
1 mg

Intravenous Anesthetic
PropofolInduction dose 6–8 mg/kg/h
Maintenance dose 2–3 mg/kg/h
Adjustable
Depends on sedation time10

Practice Guidelines for Intravenous Conscious Sedation in Dentistry

Explanation. Benzodiazepines are characterized byanxiety amelioration and amnestic effects, and midazolam is the most frequently used benzodiazepine.
Propofol is characterized by inhibition of gag reflex andfavorable control of the sedation state. Dexmedetomidine is characterized by low respiratory depression andeasy arousal during sedation. If it is difficult to modify
the behavior of a patient with intellectual disabilities via
intravenous sedation alone, general anesthesia should beconsidered for safety.

7) CQ: Is it possible to increase the safety of intravenous
sedation if titration is performed?
Recommendation. When performing intravenous sedation, it is recommended that every drug be administered in small increments while observing the patient inorder to maintain an appropriate level of sedation(degree of recommendation: A evaluated by theWorking Group on Guidelines Development). In thiscase, the use of a BIS monitor (degree of recommendation: A) or infusion pump (degree of recommendation:C) is useful for preventing excessive sedation.
Scientific Basis. The ‘‘Practice Guidelines for Sedation
and Analgesia by Non-anesthesiologists’’ of the ASA(level VI in I),8 ‘‘Safety Guidelines for Intravenous
Sedation’’ of the Committee of the Japanese Dental
Association (level VI),5 and a multicenter survey on
intravenous sedation using midazolam (Ramsay score
2–3; level VI)61 reported that it was necessary toadminister sedatives in small increments while observing
the status of the patient in order to maintain appropriate
sedation.
By monitoring consciousness with a BIS monitor
during intravenous sedation, an appropriate sedation
depth could be maintained with a lower drug dose (level
II).53 In addition, the use of an infusion pump prevented
overdose of the drug (level III, V).80,81
Explanation. Since there are individual variations in
the drug dose required to induce an appropriate sedative
state, it is important to administer sedatives in small
increments while observing the status of the patient andtitrate the appropriate dose.

8) CQ: Is it useful to use an antagonist for intravenous
sedation?
Recommendation. Use of the specific antagonist
flumazenil when awakening is insufficient or slow afterusing a benzodiazepine or if respiratory depression is
prolonged (degree of recommendation: A). Intravenous-

Anesth Prog 65:e1–e18 2018

ly inject 0.2 mg; in cases where eye opening, physicalmovement, and so on are not observed, add 0.1 mg after
1 to 4 minutes and increase by 0.1-mg increments at 1minute intervals up to a total dose of 0.5 mg (degree ofrecommendation: B).
Scientific Basis. Intravenously inject an initial dose of
0.2 mg of flumazenil, with additional 0.1-mg doses up toa total dose of 0.5 mg. In case of benzodiazepine
overdose, if necessary, administer an intravenous
injection up to a total dose of 1.0 to 2.0 mg (level
III).8,82,83 It is recommended to administer additionaldoses as needed unless the patient awakens from the 0.2mg initial dose 4 minutes after administration (level
III).83
The antagonistic effect of flumazenil on sedation is
rapid, and its efficacy is good (level II).82,84 The
elimination half-life after intravenous injection is as
short as 50 minutes, and the effect duration is short.
Resedation (residual sedation) after awakening is notclinically problematic in the case of midazolam (levelII).84 It has been reported that when flumazenil wasadministered 18 minutes after administration of midazolam, awakening was observed in all patients after 2
minutes (ie, 20 minutes after administration of midazolam); mild resedation was observed at 40 minutes,
although the awakening process was faster than when
flumazenil was not administered (level III).85 Although
there are various opinions on the effects on respiratory
depression, it has been reported that antagonism against
respiratory depression is favorable in Japanese patients(level III).86 It has been reported that, in the case offlumazenil, a higher dose than that needed for overcoming sedation was necessary for recovering a sense ofbalance (level III).87 Sedation regimens that are intended
to induce routine reversal of sedatives are not recommended.
Seizure may occur in epileptic patients taking
benzodiazepine medications (level IV),88 or withdrawal
symptoms (e.. agitation) may rarely develop in patients
who regularly receive oral benzodiazepine (level IV).82,84
However, it has been reported that patients with severe
mental and physical disabilities who received up to 0.5
mg of flumazenil did not experience convulsions oragitation (level III).89

9) CQ: Is preparation for oxygen administrationnecessary during intraoperative management of
intravenous sedation?
Recommendation. Intravenous sedation has a risk of
respiratory depression, and preparation for the use of

Anesth Prog 65:e1–e18 2018

intraoperative oxygen administration is necessary (degree of recommendation: A evaluated by the Working
Group on Guidelines Development).
Scientific Basis. During surgical treatment of 20
patients, intravenous sedation with 0.5 mg/kg of pentazocine and 0.2 mg/kg of diazepam was performed, and therespiratory state was observed from arterial blood gas
analysis. These results indicated that the mean arterial
oxygen partial pressure (PaO2) was 88.1 6 14.3 mm Hg
after pentazocine and rapidly decreased to 64.2 6 10.2mm Hg after administration of diazepam (level IV).90
Propofol (6 mg/kg/h) was administered over 10
minutes to 8 adult male volunteers. It was subsequently
maintained at 4 mg/kg/h, and a significant decrease intidal volume was observed from 10 minutes after thestart of administration to 5 minutes after discontinuation (level IV).91
When a sedating dose of diazepam or flunitrazepam
was administered to 335 patients between the ages of 20
and 80 years, the rate at which the transcutaneous
oxygen saturation level was 93% or less increased withage (an increase was especially noted in patients 60 years
or older; level IV).92
In a study investigating amnestic effects and intraoperative respiratory depression in 313 patients who
underwent intraoral surgery using midazolam, it wasreported that 127 patients (40.6%) had decreasedtranscutaneous oxygen saturation (93% or less; levelIV).93
Guidelines for sedation of the ASA8 for nonanesthesiologists (level VI in I) and guidelines for sedation of
the ADA7 (level VI) state the necessity of preparing foroxygen administration.
The results of an investigation of the presence ofcomplications during endoscopic treatment under sedation in 200 patients with obstructive sleep apnea and 200
controls revealed that oxygen administration was
required for obstructive sleep apnea, suggesting that
preparation for oxygen administration is indispensable.94
Explanation. Since the risk of developing hypoxia inelderly patients, persons with an underlying disease, or
persons with individual susceptibility to drugs is possible
during intravenous sedation using midazolam or propofol, preparation for oxygen administration using anasal mask, nasal cannula, and so forth is indispensable.

10) CQ: Does intraoperative sedation management
require preparation of emergency equipment?
Recommendation. Drugs used in intravenous sedation
have a risk of causing respiratory arrest and cardiac

Fujisawa

11arrest depending on the patient’s susceptibility, dosage,administration rate, and underlying diseases of thepatient, and preparation of emergency equipment
necessary for basic life support is essential (degree ofrecommendation: A evaluated by the Working Groupon Guidelines Development).
Scientific Basis. A questionnaire survey of intravenous sedation regimens conducted at 77 institutions (eg,a dental university, dental school in a university, oral
surgery department in a medical school) revealed that
respiratory depression and glossoptosis occurred in 37
facilities, respiratory arrest in 8, and cardiac arrest in 4.
Thus, the need for emergency equipment is valid (levelIV).5 In a questionnaire survey administered to 29
dental universities and dental school anesthesiology
departments across Japan, an intubation instrument was
required in 5 facilities (level IV).29 An investigation of
intravenous sedation methods using propofol andfentanyl in 785 patients revealed that emergency
responses were necessary in some cases (respiratory
depression in 22 patients, hypotension in 3, bradycardia
in 1, and postoperative angina pectoris in 1; level IV).95
There was 1 patient who underwent intravenous
sedation and developed neurologic shock; artificial
respiration with atropine and 100% oxygen and administration of dopamine were necessary (level V).37 There
was also a case in which cardiac arrest occurred when thepatient’s vein was accessed during intravenous sedation,and it was necessary to perform precordial thump andadminister atropine and ephedrine (level V).96
In the ‘‘Practice Guidelines for Sedation and Analgesia by Non-anesthesiologists’’ of the ASA5 (level VI in I)
and ‘‘Guidelines for the Use of Sedation and General
Anesthesia by Dentists’’ of the ADA7 (level VI), thenecessity for acquiring basic life support skills is noted.
Explanation. When performing intravenous sedation,
there is a risk that symptoms of respiratory andcardiovascular suppression will arise, and it is indispensable to acquire the knowledge and skill for using
emergency instruments, such as auxiliary instruments
for airway management.

11) CQ: Does intraoperative management of intravenous
sedation require acquisition of airway management andresuscitation skills?
Recommendation. When using intravenous sedation,
there is a risk of glossoptosis and respiratory depression,and acquisition of airway management and resuscitation
techniques is essential (degree of recommendation: A
evaluated by the Working Group on Guidelines
Development).

12

Practice Guidelines for Intravenous Conscious Sedation in Dentistry

Scientific Basis. When midazolam (0.068 6 0.004 mg/kg) was administered to 14 male volunteers, occlusionpressure of "8.2 6 1.4 cmH2O, upper airway resistanceof 21.0 6 2.0 cmH2O/L/s, and suppression of respiration were observed (level IV).97
In a study investigating oral cavity water retention
ability in the sedated state, propofol (target bloodconcentration of 2.2 lg/mL) or midazolam (0.07 mg/kg)
was administered to 14 male volunteers; 1 patient withmidazolam could not hold water in the oral cavity andswallowed, and 1 patient choked and spit the liquid out.
Thus, while the risk of aspiration was low, it was notcompletely absent (level III).68
Among the 804 patients who received intravenous
sedation with midazolam, 22 had an increase in bloodpressure of 30% or higher, 19 had a decrease, 26 had anincrease in pulse rate, 5 had a decrease, 8 hadarrhythmia, 23 had respiratory depression, 30 had a
SpO2 decrease of 7% or more, and 4 had an allergic
reaction.38 Among the 1134 patients who received
intravenous sedation with propofol, 18 had an increasein blood pressure of more than 30%, 115 had a decrease,75 had an increase in pulse rate, 16 had a decrease, 2 hadarrhythmia, 49 had respiratory depression, 32 had an
SpO2 decrease of 7% or more, and 2 had an allergic-likereaction (level IV).38
When intravenous sedation using diazepam (2.5–7.5mg) was performed in four men (aged 65 to 87 years)
with complicated cardiac disease, glossoptosis wascaused by administration of 7.5 mg of diazepam inone 65-year-old man, and airway management was
required (level V).98
When 1 to 2 mg of midazolam was administered topatients with Sheehan syndrome, unresponsiveness
continued for 2 to 3 hours (level V).99 An investigationof intraoperative and postoperative complications of
304 patients aged 65 years and older in whom
intravenous sedation was performed revealed decreased
SpO2 intraoperatively in 43 patients, aspiration in 11,
glossoptosis in 4, and hypotension in 1; postoperatively,
snoring due to upper airway obstruction and decreased
SpO2 were observed in 74 patients (level IV).100
The necessity to acquire basic life support techniques
is mentioned in both the ‘‘Practice Guidelines for
Sedation and Analgesia by Non-Anesthesiologists’’ ofthe ASA8 and the sedation guidelines of the ADA.7
Intraoperative accidents occurred in 18.4% of 1309
cases of intravenous sedation performed at a university
hospital, and respiratory depression was the mostfrequent type.3
Explanation. Intravenous sedation using midazolam
and propofol may result in upper airway obstruction
and aspiration. Therefore, it is essential for the person
performing sedation to prepare various airway-securing

Anesth Prog 65:e1–e18 2018devices and study practical techniques and cardiopulmonary resuscitation.

POSTOPERATIVE MANAGEMENT
1) CQ: How can recovery from intravenous sedation be
evaluated?
Recommendation. Consideration for psychomotor andbalance functioning, which are indicated to have themost delayed recovery, is necessary (degree of recommendation: A evaluated by the Working Group on
Guidelines Development). When determining the success of recovery, appropriate recovery evaluation
criteria and evaluation methods should be selectedaccording to the purpose of the determination (degreeof recommendation: A). In daily clinical practice, a
simple method of determination should be used (degreeof recommendation: B).
Scientific Basis. It has been reported that recovery
after intravenous sedation for cognitive and psychomotor
functions is most delayed (level II and level III),101,102
balance (level II and level III),103,104 or both equivalently(level II and level III).66,105 It has also been reported that,in the case of propofol, recovery of the sensory feeling oflightheadedness while walking is more delayed thanpsychomotor and balance functions (level II).105
Evaluation of psychomotor function was originally
thought to be the most important metric in evaluating
recovery from general anesthesia and intravenous
sedation; although psychomotor function tests thathave been reported in the past are highly useful for
research, they are difficult to use in clinical practicebecause of the complexity of implementation (level VI inI).106 Equilibrium testing using specialized equipment issimilarly difficult to use in clinical practice (level III).66
Explanation. Metrics to be evaluated immediately after
intravenous sedation, which are also intraoperative
monitoring metrics, are consciousness, oxygenation, airway/ventilation, and circulation. An evidence-based gold
standard has not been established for simple determinationof the recovery process in daily clinical practice.

2) CQ: What are the indications for allowing the patient
to be discharged home after intravenous sedation?
(1) What are the indications for allowing the patient totravel by car or taxi with an attendant after being
discharged?
Recommendation. The following must be confirmed:(a) vital signs are stable; (b) the basic psychomotor

Anesth Prog 65:e1–e18 2018

ability to recognize people, places, time, and so forth
has recovered; and (c) independent and stable walking
at normal speed is possible, or basic equilibrium
function is restored, such as being able to remain
standing for 30 seconds during the bipedal stance testwith eyes closed (degree of recommendation: A
evaluated by the Working Group on Guidelines
Development). Furthermore, it is also necessary toconfirm that there is no need for treatment of (d)postoperative hemorrhage, (e) pain, or (f) nausea orvomiting (degree of recommendation: A evaluated by
the Working Group on Guidelines Development). (g)Postoperative instructions and printout with contact
information must be given when returning home(degree of recommendation: A evaluated by theWorking Group on Guidelines Development).
It is desirable to confirm that there are nocomplaints or abnormalities by telephone call after
return home (degree of recommendation: C). The
ability to drink water is not a necessary condition of
the criteria for permission to return home, and thiscondition should be left up to the patient (degree ofrecommendation: A).
Scientific Basis. The success of outpatient surgery
depends on whether the patient who undergoes generalanesthesia or sedation can return home at the appropriate time based on correct evaluation, and criteria forsafe home return have been indicated (level VI).107 In asystematic review, a clinical scoring system useful for
determining when to give a patient permission to returnhome was presented (level VI in I).106 The ASA also
proposed guidelines for postoperative management,
which can be applied to general anesthesia, local
anesthesia, and moderate or deep sedation, and thecriteria permitting return home are indicated in theguidelines (level VI in I).108 There is also a summary of
the conditions permitting return home after intravenous
sedation written in Japanese (level VI).5
Postoperative instructions and a printout with contact
information must be distributed to patients returninghome (level VI, level VI in I, level VI in I).106–108
In recent years, confirmation of an ability to drink
water and urinate has been excluded from the essential
items allowing permission to return home (level VI in I,
level VI in I, level II [concerning drinking of water]).106,108,109
Explanation. There are no reports of randomized
controlled trials that have used the criteria for returninghome after administering general anesthesia or sedationand the presence of adverse events as endpoints. The
guidelines to date have been summarized with reference
to opinions from expert committees and guidelines
frequently used in daily clinical practice. The criteria
used for giving permission to be discharged home in thisFujisawa

13

article were also created based on the above 4
guidelines.5,109–111(2) What are the indications for allowing patients to bedischarged home by walking?
Recommendation. To evaluate a patient’s ability towalk home, it is desirable to perform a dynamic
equilibrium function evaluation. For example, anevaluator has the patient quickly perform an Up &Go test (ie, stand up from a chair, walk forward 3–5
m, and sit back in the chair again), confirm subjective
and objective dizziness (degree of recommendation:C), or measure the required time for completion of
the test (Timed Up and Go test; degree of recommendation: B).
Scientific Basis. Posturography (a term describing
techniques used to quantify postural control in uprightstance in either static or dynamic conditions) testingshould be performed. The Timed Up and Go test is areliable and simple dynamic balance test, well correlatedwith precise computerized dynamic posturography (level
III).66 A significant difference in Timed Up and Go test
values between community-dwelling old persons with ahistory of fall or no fall has been demonstrated (level
III).110
Explanation. If recovery of equilibrium function andmuscular strength is insufficient after sedation, there is apossibility of a fall; caution is needed, especially inelderly patients, because a decline in equilibrium
function is observed at baseline, before undergoing
sedation.
(3) Concerning the necessity of an attendant
Recommendation. After undergoing sedation, thepatient should always be accompanied by an attendant
when being discharged home (degree of recommendation: A evaluated by the Working Group on Guidelines
Development). If it is unavoidable for the patient toreturn home alone, measures, such as delaying thepatient’s return home, should be taken (degree ofrecommendation: A evaluated by the Working Groupon Guidelines Development). In such a case, the use of
propofol is preferable (degree of recommendation: A). It
is essential for the patient to return home with anattendant when using diazepam or flunitrazepam(degree of recommendation: A).
Scientific Basis. According to the ADA Sedation
Guidelines (level VI),7 the ASA Guidelines on Postanesthesia Care (level VI in I),108 and the ASA ‘‘Practice
Guidelines for Sedation and Analgesia by Non-anesthesiologists’’ (level VI in I),8 the presence of an attendant isalways required for the patient to return home after
undergoing intravenous sedation.

14

Practice Guidelines for Intravenous Conscious Sedation in Dentistry

The recovery time of psychomotor function, memory
ability, and equilibrium function after intravenous
sedation with propofol in long cases is 60 minutes by
flicker fusion test (level II),111 30 minutes by a memory
test using several pictures and cards (level II),64 and 40
minutes by dynamic balance test (level III),66 respectively.
Even 7 hours after intravenous administration ofdiazepam (0.3 mg/kg), the fluctuation value in precise
computerized posturography was twice the preadministration value (level II).103 After intravenous administration of diazepam (0.3 mg/kg), psychomotor function
tests, such as a coordination test and critical flicker
fusion test, revealed that functioning did not recover by
6 hours but did after 8 hours (level II).101 Even 10 hours
after intravenous administration of flunitrazepam (0.02
mg/kg), psychomotor function tests, such as the handeye coordination test, revealed that functioning did notrecover. Therefore, if more than 0.02 mg/kg offlunitrazepam is used, the patient is not indicated toreturn home on the same day (level II).112(4) Permission for driving of an automobile or performing work requiring important judgment
Recommendation. After undergoing intravenous sedation, driving of an automobile or performing work that
requires important judgment on the same day must be
avoided (degree of recommendation: A).
Scientific Basis. Based on psychomotor function
testing, operation of an automobile or machinery must
be avoided for 6 hours after a 0.15-mg/kg dose and 10
hours after a 0.3-mg/kg dose of intravenous diazepam(level II).101
Results from multiple sleep latency tests suggested that
operation of an automobile or heavy machinery should
be avoided 8 hours after administration of midazolam
and fentanyl, and the main cause of the recovery delay
was midazolam rather than fentanyl (level II).113
Explanation. The time required for complete recovery
of psychomotor function is never brief. Furthermore, it
has been reported that recovery after intravenous
propofol was noted after 2 hours using a driving
simulator.114 However, it is debatable whether recovery
in a driving simulator test is an indicator of safe
implementation in practice, and considering the seriousness of an automobile accident, it seems reasonable
to allow a sufficient margin of safety.

3) CQ: How should postoperative complications bemonitored?
Recommendation. In the recovery room, SpO2 should
be monitored in order to prevent hypoxia (degree ofAnesth Prog 65:e1–e18 2018

recommendation: A). It is also desirable to monitor
blood pressure and pulse rate (degree of recommendation: B evaluated by the Working Group on Guidelines
Development).
Criteria for airway narrowing and respiratory depression are glossoptosis, paradoxical respiration, decreased
SpO2, and so forth, and the criterion for hypoxemia
requiring treatment is a SpO2 less than 93% in room air(degree of recommendation: A). The criterion for
determination of abnormal circulatory dynamics is apersistent increase or decrease of 30% or more inpreoperative blood pressure and pulse rate values(degree of recommendation: B evaluated by the Working Group on Guidelines Development).
Scientific Basis. Pulse oximetry detected postoperative
hypoxemia and associated unforeseeable events, but nodifference was found in the incidence of postoperativecomplications with or without pulse oximetry (level I).115
In the guidelines for sedation in dentistry (level VI,
level VI in I),7,116 the ‘‘Practice Guidelines for Sedation
and Analgesia by Non-anesthesiologists’’ created by the
ASA (level VI in I),8 and the guidelines for postanesthetic care by an anesthesiologist (level VI in I),108 it isstated that monitoring should be continued in therecovery room after performing intravenous sedation.
Patients who had an SpO2 reading less than 93%
when entering the recovery room following surgery
received further treatment for hypoxemia during theirstay in the recovery room regardless of the subsequent
presence or absence of oxygen administration or theadministration method (level II).117
Explanation. The consultants of the ASA’s task force
report stated, ‘‘There is no literature clearly indicatingthat postoperative monitoring effects have contributed
to patient outcomes, but postoperative monitoring isnecessary.’’8 Other key guidelines also lack consistency
with the evidence but advocate the need for postoperative monitoring.

REFERENCES
1. Kotani J. Sedation, 1 concept of psycho-sedation. In:
Fukushima K, Harada J, Shimada M, Ichinohe T, Niwa H,
eds. Dental Anesthesiology [in Japanese]. 7th ed. Tokyo, Japan:
Ishiyaku-syuppan; 2011:205–207.
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