PS09 2014: Sedation for diagnostic and interventional procedures

 

This statement is endorsed by all the relevant groups (e.g. radiology, gastro)

 

List:

·         Premise

·         Definitions

·         Facilities

·         Staffing

·         Staffing scenarios

·         Anaesthetist required if…

·         Responsibilities of the sedationist

·         Non-anaesthetist sedationists

 

Premise:

·         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

 

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

·      Basically a lousy GA and requires equivalent care

General anaesthesia

·      LOC and reflex suppression

 

Facilities:

*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

 

Staffing: general rules

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

 

Staffing 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)

·      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

 

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, 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)

 

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

·      Regular certification in CPR

·      CPD

·      Audit / quality assurance / peer review

·      Must report sedation-related M&M

 

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