Task force issues report on safe sedation practices

September 18, 2006

Almost 70% of minor surgeries are now performed in surgical centers, physicians' offices, and hospital outpatient departments. Procedures including cardiac catheterizations and colonoscopies can be done using sedatives such as midazolam and fentanyl instead of general anesthesia.

This increased use of sedation for such procedures has led to a greater demand for anesthesiologists and nurse anesthetists. Unfortunately, busy hospitals and surgical centers cannot always meet this need. So more cardiologists, gastroenterologists, and other practitioners are petitioning their hospitals for the right to administer sedation without anesthesia personnel present.

Unfortunately, when medical professionals who are not adequately trained in anesthesia and safety practices administer powerful sedatives, the risks of cardiac complications, brain damage, respiratory problems, and even death can increase. Karen Domino, M.D., MPH., a professor of anesthesiology at the University of Washington in Seattle and chair of the American Society of Anesthesiologists' (ASA) Committee on Professional Liability, said that an analysis of the ASA's closed-claims database found that more than 40% of malpractice claims associated with sedative use monitored by an anesthesiologist involved death or brain damage. She reported that a similar proportion of general anesthesia claims resulted in the same outcomes. She said that the data were published earlier this year in the February 2006 issue of the journal Anesthesiology.

Domino went on to say that most of the claims involved either propofol alone or polypharmacy, i.e., some combination of propofol, a benzodiazepine, and an opioid. "One of the comments we had was that when you are mixing and matching drugs, as anesthesiologists do, you are more likely to get potentiation of the depression of spontaneous breathing and airway obstruction than you would with the use of a single agent," she said.

The University HealthSystem Consortium (UHC), an alliance of 95 academic medical centers located mainly in the United States, recently issued best practice recommendations for deep procedural sedation in patients without a controlled airway. The document was developed by a multidisciplinary task force.

According to the authors, deep procedural sedation should be performed only in areas approved by the institution. Each approved location should contain, among other things, an emergency cart with a defibrillator, emergency drugs, and other equipment necessary for cardiopulmonary resuscitation. The location should also be staffed with support personnel for the practitioner administering sedation and analgesia.

The task force recommended that all practitioners pass a written pharmacology exam. In addition, all nonexempt physicians should attend an institutionally approved pharmacology course. The course should cover: medications, appropriate drug selection, dosages, time to peak effect, dosing intervals, treatment of overdoses, and the use of reversal agents such a naloxone and flumazenil. Exempted physicians are those who are board certified in emergency medicine, critical care medicine, pulmonary medicine, neonatology, and oral maxillofacial surgery.

The authors also recommended that all practitioners pass an exam on the institution's deep sedation policy. "We tried to ensure safety when we developed our guidelines for the use of sedative drugs by setting dose limits for situations when they are used by nonanesthesia personnel," said Karen Petros, Pharm.D., a clinical pharmacy specialist for surgery and trauma at the West Virginia University Medical Center in Morgantown. "Guidelines for appropriate patient monitoring are also outlined within the document." She mentioned that the medical center's anesthesia department provided input and approved the guidelines.

Petros went on to say that, "Currently, we are not using propofol in a setting devoid of anesthesia personnel. For MAC, we use a very specific dose of a benzodiazepine, such as midazolam. We do not use propofol as a first-line agent, but if it does become necessary to use propofol, we get anesthesia personnel involved." She added that she believes that in certain circumstances, sedatives can be used safely without an anesthesiologist or nurse anesthetist present. "However, strict limits regarding these situations must be set."

THE AUTHOR is a writer based in New Jersey.