**5. Principles of safe procedural sedation and analgesia**

Most procedural sedation occur outside and far from operating theaters; others might occur in standalone clinics outside hospitals. This constitutes a risk, as should an airway emergency happen, anesthetists and other experts in airway management are usually not available to hand. Other emergencies such as cardiac arrests have been extensively reported in the medical literature. Based on above, it is paramount that patients selected for these procedures are carefully evaluated and stratified. A lot of emphasis should be put on airway assessment of these patients and if there is any doubt, they must be referred to a qualified anesthetist for further evaluation and classification.

#### **5.1 Pre-procedure patient assessment**

The first stage of secure sedation practice is the proper selection of patients for sedation. To assess his or her suitability for sedation outside the operating room, each patient must be explicitly evaluated.

Patient selection requires collecting patient information as well as supplying the patient with information. The retrieval and review of previous documents, i.e. medical, sedation, anesthesia and surgical history, should be included in preassessment wherever possible. Pre-procedural assessment should include history, examinations and laboratory investigations.

#### *5.1.1 Preoperative history*

The Preoperative history should include the patient's medical problems and the intended investigative or therapeutic procedure. History of chronic disease, severity and chronic medications should be investigated. Because of the possibility of drug interactions with anesthesia full medication history include using alcohol, tobacco, marijuana, cocaine, herbal medications, and psychotropic drugs sedatives, anxiolytics, antidepressants, antipsychotics, antiepileptics, and drugs used in the treatment of mania) should obtained from every patient. Previous allergic history should be elicited.

Furthermore, detailed history of previous sedation and anesthesia may disclose the previous perioperative challenges such as difficulty in airway management, aspiration, post-operative intensive care admission which may suggest unsuitability of such patients for out of hospital procedures. In addition, general review of organ system may be useful to identify undiagnosed problems.

#### *5.1.2 Physical examination*

Although, proper history direct the treating physician to perform focus examination, the physical examination is extremely important to detect abnormalities not obvious in the history. Both history and physical examination complement one another.

General examination should include minimally measurements of vital signs (Blood pressure, heart rate, respiratory rate and temperature), airway evaluation, cardiovascular and respiratory system examination.

#### *5.1.2.1 Airway examination*

Sedation practitioner should inspect patient's dentition for denture, bridges or loose teeth. Difficulty in mask ventilation and airway should be anticipated in edentulous as well as those with significant facial abnormalities such as micrognathia, prominent upper incisors, macroglossia, limited mouth opening, short neck, and limited neck mobilities. There are variety of airway reliable assessment scales such as upper lip bite test (ULBT) (**Table 1**) and Mallampati scale (**Table 2**) have been proposed to assist anesthesiologist and sedation practitioner to assist the airway. **Figures 1** and **2** [5].


**Table 1.** *Upper lip bite test (ULBT).* *Anaesthetic Considerations in Gastrointestinal Endoscopies DOI: http://dx.doi.org/10.5772/intechopen.96687*


**Table 2.** *Mallampati score.*
