PS09 2014: Sedation for diagnostic and interventional procedures

 

List:

·        Premise

·        Definitions

·        Facilities

·        Staffing: general rules

·        Staffing: specific scenarios

·        Anaesthetist required if…

·        Responsibilities of the seditionist

·        Non-anaesthetist sedationists

 

Premise:

·        Aims of sedation are to facilitation ± comfort ± analgesia ± amnesia (NOT unconsciousness)

·        Therapeutic index varies between drugs (high for benzos, low for propofol)

·        Pharmacodynamic sensitivity varies between patient (high if well, low if unwell)

·        Accidental transition from sedation to anaesthesia is common

 

Definitions:

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

·      Virtually the same as GA and so requires equivalent care

General anaesthesia

·      LOC and reflex suppression

 

Facilities:

Environment

·      Easy access in and out

·      Space for resuscitation

·      Lighting

Equipment

·      Airway: standard devices + suction

·      Breathing: bag-mask, oxygen source

·      Circulation: vascular access

Drugs

·      Sedation

·      Reversal (flumazenil, naloxone)

·      Emergency (adrenaline, atropine, crystalloid, glucose)

Monitoring

·      Always: SpO2/HR + NIBP + conscious state (AVPU)

·      Optional: ECG

·      Available: etCO2

Emergency

·      Buzzer

·      Response plan (e.g. code blue team)

·      Defibrillator

 

Staffing: general rules

Sedationist

·      Conscious sedation: any suitably trained doctor

·      Deep sedation: anaesthetist or equivalent

Assistant

·      Present for induction and emergence

·      Available during maintenance

·      Recommend exclusive assistant if complex

 

Staffing: specific scenarios

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

 

Anaesthetist required if:

Patient factors

·      Very young (<2y) or very old

·      Major comorbidities (e.g. sleep apnoea)

·      Severe active illness (e.g. upper GI bleed)

Anaesthetic factors

·      Known anaesthetic difficulty

·      Risk of aspiration

·      Previous adverse event

 

Responsibilities of the sedationist:

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, synergy

·      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)

 

Non-anaesthetist sedationists:

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

·      ALS

·      CPD

·      QI/QA

·      M&M

 

 

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