Procedural sedation and analgesia outside the operating room: Drug selection, safety, and emerging trends

ABSTRACT

Procedures performed outside the operating room now account for a substantial proportion of all anesthetic activity, with nonoperating room anesthesia projected to represent up to 50% of anesthetic interventions within the next decade. Workforce constraints in anesthesiology have accelerated the need for structured frameworks enabling nonanesthesiologists to provide procedural sedation and analgesia (PSA) safely. This narrative review evaluates drug selection, safety principles, and emerging pharmacological trends in PSA outside the operating room, with particular attention to the nonanesthesiologist provider model. Midazolam combined with fentanyl or ketamine remains the evidence-based foundation for nonanesthesiologist PSA. Ketamine’s dissociative profile preserves airway reflexes, spontaneous ventilation, and hemodynamic stability while providing reliable analgesia. Propofol and dexmedetomidine are unsuitable for nonanesthesiologist use: propofol carries the risk of irreversible transition to general anesthesia without a reversal agent, and dexmedetomidine is associated with significant bradycardia (odds ratio [OR]: 3.60; 95% confidence interval [CI]: 2.29–5.67) and hypotension (OR: 1.95; 95% CI: 1.25–3.05) without pharmacological reversal. Remimazolam, an ultra-short-acting reversible benzodiazepine with organ-independent metabolism, is the most promising emerging agent. Structured credentialing, capnography monitoring, and defined rescue competencies are essential institutional requirements for safe nonanesthesiologist practice.

Introduction

Minimally invasive and endoscopic techniques have transformed procedural medicine, shifting a growing proportion of diagnostic and therapeutic work outside the operating room.[1,2] Within the Ministry of National Guard Health Affairs in Saudi Arabia, nonoperating room anesthesia (NORA) now exceeds 5200 cases annually at a single center.[3] At King Salman Specialized Hospital (KSSH), a structured Moderate Sedation Course credentials nonanesthesiologist physicians and senior nursing staff to provide moderate sedation for defined procedures. This review examines drug selection, monitoring requirements, and the evidence base for the institutional restriction of propofol and dexmedetomidine at KSSH.

Methods

A structured narrative review was conducted. PubMed, MEDLINE, EMBASE, Cochrane Library, and Google Scholar were searched for the period January 2010 to January 2026. Search terms included: “procedural sedation,” “conscious sedation,” “moderate sedation’,” “non-operating room anaesthesia,” “NORA,” “ketamine PSA,” “remimazolam,” “esketamine sedation,” “propofol non-anaesthesiologist,” and “dexmedetomidine procedural sedation.” Guideline documents from the American Society of Anesthesiologists (ASA),[4,5] the European Society of Anaesthesiology,[6] and the American College of Emergency Physicians[7] were reviewed. Priority was given to systematic reviews, meta-analyses, and randomized controlled trials (RCTs); pharmacological studies and guideline documents were included where higher-level evidence was unavailable.

The sedation continuum and target depth

The ASA defines four levels of sedation depth: minimal sedation, moderate sedation, deep sedation, and general anesthesia [Table 1].[8] Moderate sedation is the exclusive target of nonanesthesiologist procedural sedation and analgesia (PSA), defined by purposeful response to verbal or tactile stimulation, maintained airway reflexes, adequate spontaneous ventilation, and hemodynamic stability. Transition to deeper levels can occur rapidly, particularly with agents lacking a dose-response ceiling or a reversal agent.[2,9]

Table 1.

The American Society of Anesthesiologists sedation continuum and relevance for nonanesthesiologist practice

Parameter	Minimal sedation	Moderate sedation	Deep sedation	General anesthesia	Nonanesthesiologist target
Responsiveness	Normal to verbal	Purposeful to verbal or tactile stimulation	Purposeful only to repeated or painful stimulation	Unarousable	Moderate sedation only
Airway	Unaffected	No intervention required	Intervention may be required	Intervention often required	Must be maintained independently
Ventilation	Unaffected	Adequate	May be inadequate	Frequently inadequate	Must remain adequate spontaneously
Cardiovascular function	Unaffected	Usually maintained	Usually maintained	May be impaired	Hemodynamic stability required
Cognitive function	Minimal impairment	Cooperative; responds to commands	Cannot reliably follow commands	Absent	Patient must respond to verbal commands

Source: ASA Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018. NORA=nonoperating room anesthesia; OR=odds ratio

All practitioners providing PSA must be able to rescue patients from inadvertent deeper sedation, managing airway obstruction, hypoventilation, hypoxia, and hypotension. The ASA granting-privileges statement requires formal training in this rescue competency before credentialing.[5]

Pharmacological review of PSA agents

The ideal PSA agent for nonanesthesiologist use should provide rapid, titratable sedation; analgesia and amnesia; preserved airway reflexes and spontaneous ventilation; hemodynamic stability; short duration; and, above all, a specific reversal agent.[2,9,10] No single agent fulfils all criteria. Clinical practice relies on drug combinations that exploit the complementary strengths of each agent while minimizing cumulative adverse effects. Table 2 provides a comparative summary of agents used in procedural sedation outside the operating room, drawing on published pharmacological reviews, randomised controlled trials, and guideline documents.[2,4,8,9,10,11,12,13,14,15,16,17,18]

Table 2.

Comprehensive drug comparison for procedural sedation and analgesia outside the operating room

Agent	Class	Onset IV	Duration	Analgesic	Amnestic	Reversal agent	Key adverse effects	Status for nonanesthesiologist PSA
Midazolam	Benzodiazepine	2–3 min	30–60 min	No	Yes	Flumazenil	Respiratory depression; ↑ effect in elderly; paradoxical agitation	Approved—Cornerstone agent; reversible; titratable
Fentanyl	Opioid	1–2 min	30–60 min	Yes (potent)	Minimal	Naloxone	Respiratory depression; rigid chest syndrome at high doses	Approved—Combined with midazolam for painful procedures
Ketamine	Dissociative/NMDA antagonist	<1 min IV	5–15 min IV	Yes (excellent)	Yes	None (monitor)	Emergence agitation; ↑ secretions; ↑ HR/BP	Approved — First choice for painful procedures; co-administer midazolam to reduce emergence
Nitrous oxide	Inhaled analgesic/anxiolytic	<1 min (inhaled)	<5 min	Mild	Partial	None	Nausea; diffusion hypoxia; teratogenic with prolonged use; requires scavenging	Approved with training—Brief painful procedures; scavenging equipment required
Propofol	GABA-A agonist	<1 min	5–10 min	No	Yes	None	Rapid deep sedation/apnea; hypotension in up to 30%; no reversal	Restricted — Anesthesia personnel required per ASA 2024. No reversal agent; inadvertent general anesthesia risk
Dexmedetomidine	α₂-adrenergic agonist	5–10 min (loading dose required)	60–120 min	Mild	Minimal	None	Bradycardia (OR: 3.60); hypotension (OR: 1.95); prolonged recovery; infusion pump required	Restricted—Hemodynamic risk without reversal incompatible with ward-based moderate sedation
Remimazolam†	Ultra-short- acting benzodiazepine	1–3 min	10–20 min	No	Yes	Flumazenil	Mild hypotension; no pain on injection; organ-independent metabolism	Emerging—FDA-approved; reversible; median 6-min recovery; promising formulary candidate
Esketamine†	S(+)-ketamine enantiomer	<1 min	5–15 min	Yes	Yes	None	Psychomimetic effects (less than racemic ketamine); ↑ secretions	Emerging—Half dose of racemic ketamine; reduces hemodynamic depression as propofol adjunct in anesthesiologist-led NORA

^†Emerging agents not yet in standard nonanesthesiologist formularies. BP=blood pressure; IV=intravenous; FDA=Food and Drug Administration; GABA=gamma-aminobutyric acid; HR=heart rate; ; NMDA=N-methyl-D-aspartate; NORA=nonoperating room anesthesia; OR=odds ratio; PSA=procedural sedation and analgesia.

Benzodiazepines – Midazolam

Midazolam is the cornerstone of nonanesthesiologist PSA.[2,9] As a water-soluble imidazobenzodiazepine acting via positive allosteric modulation of gamma-aminobutyric acid (GABA)-A receptors, it produces dose-dependent sedation, anxiolysis, anterograde amnesia, and skeletal muscle relaxation, but has no analgesic activity. It must be combined with an opioid or ketamine for painful procedures.[8,9]

Onset follows intravenous (IV) administration within 2–3 min, with peak effect at 5–7 min and clinical duration of 30–60 min. Flumazenil (0.2 mg IV, repeatable to 1 mg total) is the specific reversal agent, the most important safety feature for nonanesthesiologist use.[5,9] Dose reductions of 25%–50% are mandatory in patients older than 65 years, those with hepatic impairment, and those receiving other central nervous system depressants.[19]

Opioid analgesics – fentanyl and morphine

Opioids are the essential analgesic partner in PSA for painful procedures. Fentanyl is preferred: highly lipophilic, IV onset within 1–2 min, analgesia lasting 30–60 min, and minimal cardiovascular depression.[9,20] Unlike morphine, fentanyl does not trigger histamine release, reducing the risk of bronchoconstriction and hypotension. Naloxone (0.1–0.4 mg IV) reverses opioid effects. Rapid injection of fentanyl above 5 µg/kg carries a risk of rigid chest syndrome,[21] negligible at standard PSA doses of 1–2 µg/kg. Morphine’s slower onset, longer duration, histamine release, and accumulation of active metabolites in renal failure make it less suitable for short procedures.

Ketamine – the dissociative agent

Ketamine, an N-methyl-D-aspartate (NMDA) receptor antagonist, produces a dissociative state with profound sedation, analgesia, and amnesia while preserving airway protective reflexes, spontaneous ventilation, and hemodynamic stability through sympathomimetic stimulation.[9,10] These properties make it the most suitable single agent for nonanesthesiologist PSA of painful procedures. IV doses of 1–2 mg/kg give onset within 30–60 s with dissociation lasting 5–15 min; incremental redosing of 0.5–1 mg/kg can extend sedation safely.[9]

The traditional contraindication in patients with raised intracranial pressure is not supported by contemporary evidence. A 2020 systematic review by Gregers et al. and a 2014 meta-analysis by Wang et al. both found that ketamine does not increase intracranial pressure compared with opioids at standard sedative doses.[22,23] Emergence reactions, vivid dreams, hallucinations, and agitation occur in approximately 5%–20% of adults. Low-dose midazolam (1–2 mg IV at the end of the procedure) substantially reduces their incidence.[9,24] Controlled trials comparing midazolam/ketamine with midazolam/fentanyl consistently show less respiratory desaturation in the ketamine group, a clinically important difference in nonanesthesiologist settings.[24]

Nitrous oxide

Nitrous oxide (50% N₂O/50% O₂ as Entonox), delivered by demand-valve mask, provides analgesia, anxiolysis, and mild sedation within 2–3 min with full recovery within 5 min.[25] It is suited to brief painful procedures where inhalational delivery is feasible. Supplemental oxygen for 5 min after stopping prevents diffusion hypoxia. Scavenging equipment is required to limit occupational exposure. Prolonged or repeated use is teratogenic and is contraindicated in the first trimester of pregnancy.

Propofol – clinical profile and evidence for restriction

Propofol, a lipophilic GABA-A modulator, produces sedation within 30–60 s with clearance in 5–10 min.[9] Its speed and short duration dominate anesthesiologist-led PSA, particularly in gastrointestinal endoscopy. However, it is disqualified from nonanesthesiologist moderate sedation on three grounds. First, there is no reversal agent. Second, the dose-response curve is steep and unpredictable: the margin between moderate and deep sedation is narrow and varies considerably between patients.[4] Third, it has no analgesic properties, requiring concurrent opioids that compound the risk of respiratory depression. Additionally, vasodilation and negative inotropy cause clinically significant hypotension in up to 30% of cases, posing particular risk in elderly, hypovolemic, or cardiac patients.[7,9]

The ASA 2024 statement on propofol is unambiguous: “Due to the potential for rapid, profound changes in sedative/anaesthetic depth and the lack of antagonist medications, agents such as propofol require special attention. Even if moderate sedation is intended, patients receiving propofol should receive care consistent with that required for deep sedation. Non-anaesthesia personnel who administer propofol should be qualified to rescue patients whose level of sedation becomes deeper than initially intended and who enter, if briefly, a state of general anaesthesia.”[4] This language requires propofol administrators to hold deep-sedation credentialing, substantially beyond a moderate sedation course. The restriction at KSSH is therefore well-founded.

Dexmedetomidine – clinical profile and evidence for restriction

Dexmedetomidine, a highly selective α₂-adrenergic agonist, provides sedation, anxiolysis, and mild analgesia without significant respiratory depression at therapeutic doses.[17,18] In NORA settings, it appears attractive precisely because it spares ventilation. However, a 2021 systematic review and meta-analysis by Fonseca et al. quantified its hemodynamic risks: dexmedetomidine was associated with a significantly higher rate of hypotension (odds ratio [OR]: 1.95; 95% confidence interval [CI]: 1.25–3.05) and a markedly higher rate of bradycardia (OR: 3.60; 95% CI: 2.29–5.67) than comparator agents, regardless of the bradycardia definition used.[16]

Further limitations include a 10-min IV loading infusion requirement, the absence of a specific reversal agent (hemodynamic adverse effects are managed only supportively with atropine or ephedrine), recovery times of 60–120 min, and mandatory infusion pump delivery, infrastructure incompatible with ward-based moderate sedation.[17,18,26] These characteristics make dexmedetomidine unsuitable as a routine PSA agent in nonanesthesiologist settings at KSSH. The restriction is evidence-based.

Monitoring requirements

Safe PSA depends equally on drug choice and the monitoring infrastructure surrounding it. The ASA 2018 Practice Guidelines mandate continuous pulse oximetry, blood pressure measurement every 3–5 min, continuous electrocardiography for elderly and cardiac patients, and a dedicated observer whose sole role is patient monitoring.[8] Preprocedure assessment must include ASA Physical Status classification, Mallampati airway scoring, identification of contraindications, and confirmation of fasting status (2 h for clear liquids; 6 h for solids in elective procedures).[5,8]

Capnography, continuous end-tidal CO₂ monitoring, deserves particular emphasis. Pulse oximetry is a lagging indicator of hypoventilation, especially when supplemental oxygen is running. Capnography detects aponia and hypoventilation 60–90 s before oxygen desaturation, giving a critical window for intervention. A Cochrane review by Wall et al. confirmed that capnography reduces the incidence of oxygen desaturation during emergency department PSA.[27] The ASA 2018 guidelines strongly recommend it for moderate sedation.[8] A discrepancy exists: the multisociety gastrointestinal endoscopy sedation curriculum does not mandate capnography for endoscopic procedures.[25] Given the established benefit, capnography should be adopted as the standard for all nonanesthesiologist PSA at KSSH.

Before initiating any sedation, rescue equipment must be immediately to hand: supplemental oxygen, suction, a correctly sized bag-valve-mask, flumazenil (0.2 mg/mL drawn up), naloxone (0.4 mg/mL drawn up), and a resuscitation cart within reach.[4,5] A 2025 review by Fernandez Robles and Oprea specifically addressed the growing challenge of sedating high-risk patients, ASA III–IV, severe cardiorespiratory comorbidity, frailty, or extreme age, increasingly referred for NORA as minimally invasive techniques expand.[28] In such patients, drug selection must be tailored to individual comorbidities and sedation goals defined explicitly before starting. Discharge criteria should include SpO₂ above 95% on room air for at least 15 min, hemodynamic stability within 20% of baseline, orientation to person and place, acceptable pain score, and a responsible adult escort for outpatients.[5,8]

Clinical scenarios and drug selection pathway

Table 3 presents seven representative clinical scenarios with evidence-based recommendations for drug selection, monitoring, and provider level.[2,7,8,9,10,20] Drug selection follows a three-branch pathway: procedural pain intensity, patient risk profile, and setting-specific constraints.

Table 3.

Clinical scenarios with evidence-based procedural sedation and analgesia recommendations for nonanesthesiologist providers

Clinical scenario	Setting	Recommended regimen	Key safety considerations	Reversal	Provider level
GI endoscopy/colonoscopy	Endoscopy unit	Midazolam+fentanyl; OR remimazolam+fentanyl (where available)	Aspiration risk; reduce all doses in elderly	Yes (both)	Nonanesthesiologist (credentialled)
Bone marrow biopsy/oncology procedure	Oncology ward	Midazolam+ketamine (MidaKet protocol)	Emergence agitation: premedicate with midazolam	Partial (midazolam)	Nonanesthesiologist (credentialled)
Fracture reduction/joint dislocation	Emergency department	Ketamine±midazolam	Airway reflexes preserved; avoid in active psychosis	Partial (midazolam)	Emergency physician (credentialled)
Bronchoscopy/BAL	Pulmonology/ICU	Midazolam+fentanyl+topical lignocaine	Preserve airway responsiveness; avoid deep sedation	Yes (both)	Pulmonologist with sedation privileges
MRI/CT (claustrophobic adult)	Radiology	Oral or intranasal midazolam±fentanyl (IV access preferred)	MRI-compatible monitoring mandatory; no direct provider access during scan	Yes (flumazenil)	Credentialled nurse/physician with remote monitoring
Wound care/abscess I&D	ED/Outpatient	Fentanyl±midazolam; nitrous oxide for very brief procedures	Combine with local anesthesia to minimize systemic doses	Yes (both)	Nurse-led with physician oversight
Interventional radiology/ERCP	IR suite	Anesthesiologist-led NORA preferred; if nonanesthesiologist: midazolam+fentanyl for ASA I–II only	Prolonged; prone position restricts airway access	Partial	Anesthesiologist preferred for ASA III–IV; credentialled nonanesthesiologist for simple ASA I–II cases

ASA=American Society of Anesthesiologists Physical Status classification; BAL=bronchoalveolar lavage; CT=computed tomography; ED=Emergency department; ERCP=endoscopic retrograde cholangiopancreatography; GI=gastrointestinal; I&D=Incision and drainage; IR=interventional radiology; MRI=magnetic resonance imaging; NORA=nonoperating room anesthesia

For anxious but nonpainful procedures such as claustrophobia during imaging, midazolam 1–3 mg IV titrated to effect is the agent of choice; intranasal midazolam is an alternative before IV access is established.[9] For mildly painful procedures, wound care, venipuncture, midazolam 1–2 mg IV with fentanyl 25–50 µg IV is appropriate.[9,20] Nitrous oxide 50% provides an alternative for very brief painful procedures where inhalational delivery is available.[25]

For moderately to severely painful procedures, fracture reduction, bone marrow biopsy, and abscess drainage, the MidaKet protocol (midazolam 1–2 mg IV followed by ketamine 0.5–1.5 mg/kg IV) is the most evidence-supported regimen, combining midazolam’s amnestic and emergence-reducing properties with ketamine’s analgesia and hemodynamic preservation.[24] Glycopyrrolate 0.2 mg IV may be given to reduce ketamine-associated secretions where relevant, such as during bronchoscopy-adjacent procedures.

For endoscopic procedures, colonoscopy, upper gastrointestinal endoscopy, and bronchoscopy, midazolam 2–4 mg IV with fentanyl 50–100 µg IV is the standard nonanesthesiologist regimen.[2,8] ASA IV patients must always be referred for anesthesiologist-led care. Interventional radiology and endoscopic retrograde cholangiopancreatography, prolonged procedures with prone positioning restricting airway access, are best managed under anesthesiologist-led NORA, with nonanesthesiologist involvement confined to simple, short ASA I–II cases.

Special populations

Elderly patients (older than 65 years) are the highest-risk group for adverse events during PSA.[19] Reduced hepatic and renal clearance prolongs drug half-lives; decreased protein binding raises free drug concentrations; and diminished baroreceptor sensitivity and respiratory reserve compound the risk. The same absolute dose of midazolam or fentanyl produces considerably deeper sedation in an 80-year-old than in a 40-year-old. Doses should be reduced by 25–50% from standard adult recommendations, titrated slowly with intervals of at least 3–5 min between increments, and vigilance for delayed respiratory depression maintained after the procedure ends.[19]

Pediatric PSA outside the operating room requires pharmacokinetic and pharmacodynamic expertise that exceeds standard moderate sedation credentialing.[29] The Paediatric Sedation Research Consortium confirmed the safety of ketamine in 22,645 pediatric sedations, but specifically in the hands of trained pediatric providers with established rescue protocols.[30] At KSSH, pediatric PSA should be managed by anesthesiology or pediatric specialists with dedicated pediatric sedation credentialing, unless the procedure is routine and low-risk.

Emerging pharmacological trends

Remimazolam

Remimazolam (ByFavo® USA, Anerem® Japan, and Aptimyda™ EU) is an ultra-short-acting benzodiazepine designed to overcome the limitations of midazolam.[12,13] A metabolically labile ester linkage allows rapid hydrolysis by tissue carboxylesterases to an inactive metabolite, giving a terminal half-life of 7–11 min, independent of hepatic or renal function, compared with 1.5–3 h for midazolam.[11,12]

A post-hoc analysis of three phase 3 trials by Dao et al. confirmed that remimazolam achieved a median 3 min from the first dose to procedure start (versus 8 min for midazolam), a median 6-minute recovery to full alertness (versus 14 min), and lower fentanyl co-requirement.[11] Phase 3 bronchoscopy and colonoscopy trials demonstrate successful sedation in over 90% of patients, with lower respiratory depression rates than propofol and modest hemodynamic changes.[15,31] Flumazenil reversibility is preserved, the key safety feature for non-anesthesiologist settings.

Recent meta-analytic evidence further supports remimazolam’s formulary case. AbuJwaid et al. (2025), pooling four RCTs (630 patients), found that remimazolam reduced induction time by 3.2 min (95% CI: −5.51 to −0.91), shortened recovery time (standardized mean difference −0.976; 95% CI −1.48 to −0.47), and halved rescue sedation requirements (OR: 0.22; 95% CI: 0.11–0.47) compared with midazolam, without increasing hypoxia or hypotension rates.[32] A 2026 Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-compliant meta-analysis by Yuan et al. of 13 RCTs (2002 patients) confirmed remimazolam superiority for bronchoscopic sedation across all comparators, with a favorable safety profile.[33] Wang et al., in a meta-analysis of 11 RCTs (1808 elderly patients), found that remimazolam significantly reduced postoperative delirium and better preserved cognitive function compared with other sedatives, important evidence given the elderly populations prevalent in NORA.[34]

Esketamine

Esketamine is the S(+)-enantiomer of racemic ketamine. Its approximately twofold higher NMDA receptor affinity means equivalent analgesia and sedation can be achieved at half the racemic dose, potentially reducing psychomimetic and cardiovascular adverse effects.[14,35] A 2024 systematic review and meta-analysis by Kan et al. (25 studies and 3455 participants) found that esketamine combinations significantly reduced hypotension, bradycardia, and oxygen desaturation compared with propofol alone, though the benefit was predominantly seen in esketamine–propofol combinations in anesthesiologist-led NORA settings.[14] Its most immediate nonanesthesiologist application is as an alternative to racemic ketamine, offering equivalent analgesia with a cleaner pharmacological profile and reduced secretion burden.

Nonpharmacological adjuncts

Topical and local anesthesia, applied systematically before and during procedures, materially reduces systemic sedative and analgesic requirements, an underused strategy in nonanesthesiologist practice.[2,20] Structured preprocedure anxiety counselling, music therapy, and, where available, virtual reality distraction have each shown measurable reductions in procedural anxiety and opioid consumption.[30] These measures are not peripheral to a sedation program; they reduce drug doses and lower the probability of inadvertent deep sedation.

Institutional frameworks and credentialing

The ASA Granting Privileges Statement (2022) specifies that credentialled nonanesthesia practitioners must complete formal training in: sedative and analgesic pharmacology; risk stratification and airway assessment; monitoring standards; recognition and management of adverse events (airway obstruction, hypoventilation, aspiration, hypotension, and arrhythmias); airway rescue skills; reversal agent administration; simulation; documentation; and recertification, typically every 2 years.[5]

The KSSH Moderate Sedation Course is a sound institutional response to growing demand for nonanesthesiologist PSA. A mature program should incorporate prospective adverse event documentation, including near-misses, with structured feedback.[36] Tracking sedation-related adverse event rates (respiratory, hemodynamic, and procedural) across providers and units is a primary quality indicator. KSSH is positioned to develop a PSA registry covering complications, reversal agent use, unplanned escalation to anesthesiology, and patient satisfaction, alongside the pain assessment audit frameworks already running under CBAHI and JCI standards.

Conclusion

PSA outside the operating room has moved from an occasional anesthetic adjunct to a central pillar of modern procedural medicine.[1,2] Midazolam combined with fentanyl or ketamine remains the most evidence-supported regimen for nonanesthesiologist moderate sedation.[2,9,10,24] Ketamine’s preservation of airway reflexes, spontaneous ventilation, and hemodynamic stability while providing reliable analgesia makes it the preferred agent for painful procedures.

The restriction of propofol and dexmedetomidine to anesthesiologist-led administration at KSSH is evidence-based, not overcautious. Propofol’s narrow therapeutic window and lack of reversal, combined with dexmedetomidine’s meta-analytically confirmed bradycardia (OR: 3.60; 95% CI: 2.29–5.67) and hypotension (OR: 1.95; 95% CI: 1.25–3.05)[16] without reversal, place both agents beyond the safe scope of practitioners credentialled only for moderate sedation.[4]

Remimazolam has earned its position as the most clinically significant emerging sedative. FDA approval, flumazenil reversibility, organ-independent metabolism, and accumulating 2025–2026 meta-analytic data demonstrating superiority over midazolam for bronchoscopic sedation[32,33] and reduced postoperative delirium in elderly patients[34] support a formal formulary review for the KSSH nonanesthesiologist PSA program. Structured credentialing, capnography adoption,[27] clearly defined rescue competencies, and systematic quality monitoring are the institutional requirements within which any pharmacological choice must operate.

Conflicts of interest

There are no conflicts of interest.

Funding Statement

Nil.