A simulator for safe procedural sedation.
Titrate your drugs, hold the right depth, and get the procedure finished. Too deep and too light are both dangerous.
55-year-old man — screening upper endoscopy
55-year-old man, 65 kg, ASA II. Diagnostic upper endoscopy for epigastric discomfort. No significant comorbidities, Mallampati II, no history of obstructive sleep apnea, NPO since midnight. He has a brisk gag reflex, so movement is expected as the scope passes the oropharynx. The scope occupies the mouth for the whole case: a mask cannot be sealed until the endoscopist withdraws it.
62-year-old woman — screening colonoscopy
62-year-old woman, 74 kg, ASA II (hypertension on a thiazide, BMI 27). Screening colonoscopy with possible polypectomy. Mallampati II, no OSA, bowel prep completed and clear liquids until 3 hours ago. Nothing occupies the airway during this case: a mask can be sealed and a nasal airway placed at any moment without interrupting the endoscopist. The case is long (20-30 minutes) and the stimulus is not where most trainees expect it — insertion is mild, and looping at the flexures is the real peak.
28-year-old man — sedation to hold still
28-year-old man, 70 kg, ASA II, autism spectrum disorder with intellectual disability; he cannot hold still for imaging. Contrast-enhanced CT under brief sedation, in the radiology suite — away from the OR, with your own equipment and no immediate help. There is essentially no painful stimulus in this case, and any movement ruins the acquisition (a repeat scan means another radiation dose).
82-year-old woman — frail, malnourished, post-stroke dysphagia
82-year-old woman, 42 kg, ASA III. Percutaneous endoscopic gastrostomy for dysphagia and malnutrition after a stroke. Frail, albumin 2.4 g/dL, edentulous with a collapsible upper airway. Age and low protein binding make her markedly more sensitive to sedatives and prolong their effect. A gastroscope occupies the mouth throughout, so mask ventilation requires the endoscopist to withdraw it.
34-year-old woman — MAC with tumescent local anesthesia
34-year-old woman, 55 kg, ASA I. Elective liposuction of the abdomen and thighs in an office-based surgical suite. No comorbidities. Tumescent local anesthesia is infiltrated over a wide field and you provide monitored anesthesia care alongside it. Cannula passes are moderately stimulating. Because a large total dose of lidocaine goes in, the cumulative mg/kg is the number that matters most in this case.
68-year-old man — local infiltration with monitored anesthesia care
68-year-old man, 72 kg, ASA II (hypertension, well controlled on an ACE inhibitor). Open mesh repair of a right inguinal hernia under local infiltration with monitored anesthesia care. The surgeon infiltrates the field; your sedation covers anxiety and movement. Traction on the hernia sac produces visceral pain that local infiltration of the skin does not reach. At 68 he is somewhat more sensitive to sedatives than a young adult and recovers more slowly.
24-year-old man — anterior dislocation after a fall
24-year-old man, 70 kg, ASA I. Anterior dislocation of the right shoulder after a fall while playing basketball. In severe pain, holding the arm and unable to move it; radiographs show no fracture. Closed reduction in the emergency department. He ate two hours ago — this is a non-fasted patient, and the aspiration risk is part of the decision.
68-year-old man — persistent atrial fibrillation, EF 45%
68-year-old man, 85 kg, ASA III. Persistent atrial fibrillation for six months, ejection fraction 45%, hypertension, therapeutic apixaban documented for more than three weeks. Elective synchronized cardioversion. The procedure itself lasts seconds, but it is unpleasant enough that he has to be properly asleep for it — and there is almost no stimulus before or after the shock to keep him breathing. With a reduced ejection fraction, he tolerates a drop in blood pressure poorly.
78-year-old man — pulmonary vein isolation
78-year-old man, 58 kg, ASA III (paroxysmal atrial fibrillation, hypertension, CKD stage 3). Pulmonary vein isolation in the electrophysiology lab. A long case requiring the patient to lie still — movement during catheter manipulation risks perforation and tamponade. At 78 with reduced renal function, drugs take longer to reach the effect site and longer to leave it: he feels unresponsive early and accumulates late.
Cardiac arrest, anaphylaxis and other critical events — the main simulator.
⚠ Educational simulator — not for patient care | Clinical supervision: Haruto Fujita, MD | Details & disclaimer