This statement is endorsed by all the relevant groups (e.g. radiology, gastro)
· Premise
· Definitions
· Facilities
· Staffing
· Staffing scenarios
· Anaesthetist required if…
· Responsibilities of the sedationist
· Non-anaesthetist sedationists
· Aims of sedation: facilitate procedure ± comfort ± analgesia ± amnesia (not LOC)
· Therapeutic index varies between drugs (high for benzos, low for propofol)
· Pharmacodynamic sensitivity varies between patient
· Accidental transition from sedation to anaesthesia is common
Sedation |
· Drug-induced tolerance of uncomfortable procedure · Continuum between awake and anaesthetized |
Conscious sedation |
· Respond to command · No LOC so minimal risk |
Deeper sedation |
· Respond to painful stimulation · Risk of LOC apnoea, airway obstruction, hypotension · Basically a lousy GA and requires equivalent care |
General anaesthesia |
· LOC and reflex suppression |
*N.B. each facility is responsible for ensuring sedation is done safely*
Environment |
· Easy access in and out · Space for resuscitation · Lighting |
Airway and breathing |
· Oxygen source + delivery (strongly consider for all patients) · Suction + Yankeur + catheters · Bag-mask device · OPA, LMA, ETT |
Venous access |
· For all patients except Scenario 0 |
Drugs |
· Sedation · Reversal (flumazenil, naloxone) · Emergency (adrenaline, atropine, crystalloid, glucose) |
Monitoring |
· Always: conscious state (AVPU), continuous SpO2, HR, NIBP · Maybe: ECG · Available: etCO2 |
Emergency |
· Buzzer · Response plan (e.g. code blue) · Defibrillator |
Conscious sedation |
· Suitably trained doctor |
Deep sedation or GA |
· Anaesthetist or equivalent |
During induction and emergence |
· Assistant right there |
During maintenance |
· Assistant available |
If complex case |
· Recommend two assistants |
|
Methoxyflurane Low dose oral |
1.Proceduralist-sedationist 2.Nurse |
|
Conscious sedation ASA 1-2 |
1.Proceduralist-sedationist 2.Scrub nurse 3.Anaesthetic nurse |
|
Conscious sedation ASA 1-3. PPF/Thio only if trained. |
1.Proceduralist 2.Sedationist 3.Shared nurse |
|
Conscious sedation in ASA1-3. PPF/Thio only if trained |
1.Proceduralist 2.Sedationist 3.Scrub nurse 4.Anaesthetic nurse |
|
Anything |
1.Proceduralist 2.Anaesthetist or equivalent 3.Shared nurse |
|
Anything |
1.Proceduralist 2.Anaesthetist or equivalent 3.Scrub nurse 4.Anaesthetic nurse |
Patient factors |
· Very young (<2y) · Very old · Major comorbidities (e.g. sleep apnoea) · Severe active illness (e.g. upper GI bleed) |
Anaesthetic factors |
· Known anaesthetic difficulty (e.g. difficult intubation) · Risk of aspiration (e.g. recent meal) · Previous adverse event during sedation |
Pre-op |
· Assessment: Hx/Ex/Ix · Plan/information/discussion/consent · Identify patients needing an anaesthetist |
Intra-op |
· Understands the drugs: route, dose, time course, effects, synergism · Monitoring: conscious state, cardioresp status · Manage side effects: airway obstruction, apnoea, hypotension |
Post-op |
· Handover · Authorise discharge · Medical transfer if required |
(plus documentation of all the above)
Training |
· At least 3 months FTE · Crisis simulation course (old hands exempt from training requirement) |
Assessment |
· Assessment of competency · Anaesthetists involved in training and credentialing |
Upkeep |
· Regular certification in CPR · CPD · Audit / quality assurance / peer review · Must report sedation-related M&M |
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