Safe sedation in a private clinic

Jong Wha Lee; Ki-Young Lee

doi:10.5124/jkma.2011.54.11.1179

J Korean Med Assoc > Volume 54(11); 2011 > Article

Lee and Lee: Safe sedation in a private clinic

Continuing Education Column

Journal of the Korean Medical Association

Journal of the Korean Medical Association 2011; 54(11): 1179-1188.

Published online: November 15, 2011

DOI: http://dx.doi.org/10.5124/jkma.2011.54.11.1179

Safe sedation in a private clinic

Jong Wha Lee, MD^1,², Ki-Young Lee, MD^1,²

¹Department of Anesthesiology and Pain Medicine, Yonsei University College of Medicine, Seoul, Korea.

²Anesthesia and Pain Research Institute, Yonsei University College of Medicine, Seoul, Korea.

Corresponding author: Ki-Young Lee, kylee504@yuhs.ac

Received October 10, 2011 Accepted October 23, 2011

This is an Open-Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract

Procedural sedation and analgesia are now becoming more frequently required and procedural safety is one of the main interests of private clinic physicians. Efforts to establish safe sedation and analgesia include patient assessment to avoid sedating patients with risk factors, training for drug administration, airway management, and treatment of adverse effects, proper preparation of monitoring and resuscitation equipments and recovery facility, thorough recording of the sedation process as well as the procedure itself, analysis of results and quality assessment. Complications during procedural sedation and analgesia, including nausea and vomiting, respiratory depression, hypoxia and even cardiac arrest, should be prevented and properly treated. In this review, basic requirements for procedural sedation and analgesia are to be described, such as sedatives/analgesics including propofol, midazolam, ketamine, etomidate and dexmedetomidine, and airway management with ventilatory support for respiratory depression. Most of all, proper education and repeated training for airway management with ventilatory support and cardiopulmonary resuscitation are critically important for all the personnel involving the procedural sedation and analgesia.

Moderate sedation; Sedatives; Adverse effects

References

1. Knape JT, Adriaensen H, vanAken H, Blunnie WP, Carlsson C, Dupont M, Pasch T. Board of Anaesthesiology of the European Union of Medical Specialists. Guidelines for sedation and/or analgesia by non-anaesthesiology doctors. Eur J Anaesthesiol 2007;24:563-567.

2. Brown TB, Lovato LM, Parker D. Procedural sedation in the acute care setting. Am Fam Physician 2005;71:85-90.

3. American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology 2002;96:1004-1017.

4. ASA physical status classification system [Internet] cited 2011 Sep 24. Park Ridge (IL): American Society of Anesthesiologists. Available from: http://www.asahq.org/clinical/physicalstatus.htm

5. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: a report by the American Society of Anesthesiologist Task Force on Preoperative Fasting. Anesthesiology 1999;90:896-905.

6. The 2011 guidelines of Korean Association of Cardiopulmonary Resuscitation for CPR [Internet] 2011;cited 2011 Sep 28. Seoul: Korean Association of Cardiopulmonary Resuscitation. Available from: http://www.kacpr.org/popup/file/2011_guidelines.pdf

7. Adam HK, Kay B, Douglas EJ. Blood disoprofol levels in anesthetised patients. Correlation of concentrations after single or repeated doses with hypnotic activity. Anaesthesia 1982;37:536-540.

8. Smith C, McEwan AI, Jhaveri R, Wilkinson M, Goodman D, Smith LR, Canada AT, Glass PS. The interaction of fentanyl on the Cp50 of propofol for loss of consciousness and skin incision. Anesthesiology 1994;81:820-828.

9. Mackenzie N, Grant IS. Propofol for intravenous sedation. Anaesthesia 1987;42:3-6.

10. Wilson E, Mackenzie N, Grant IS. A comparison of propofol and midazolam by infusion to provide sedation in patients who receive spinal anaesthesia. Anaesthesia 1988;43:Suppl. 91-94.

11. Beller JP, Pottecher T, Lugnier A, Mangin P, Otteni JC. Prolonged sedation with propofol in ICU patients: recovery and blood concentration changes during periodic interruptions in infusion. Br J Anaesth 1988;61:583-588.

12. Taylor MB, Grounds RM, Mulrooney PD, Morgan M. Ventilatory effects of propofol during induction of anaesthesia. Comparison with thiopentone. Anaesthesia 1986;41:816-820.

13. Goodman NW, Black AM, Carter JA. Some ventilatory effects of propofol as sole anaesthetic agent. Br J Anaesth 1987;59:1497-1503.

14. Jonsson MM, Lindahl SG, Eriksson LI. Effect of propofol on carotid body chemosensitivity and cholinergic chemotransduction. Anesthesiology 2005;102:110-116.

15. Larsen R, Rathgeber J, Bagdahn A, Lange H, Rieke H. Effects of propofol on cardiovascular dynamics and coronary blood flow in geriatric patients. A comparison with etomidate. Anaesthesia 1988;43:Suppl. 25-31.

16. Guidelines for safe use of propofol [Internet] cited 2011 Sep 28. Cheongwon: Korea Food & Drug Administration, National Institute of Food and Drug Safety Evaluation. Available from: http://www.kfda.go.kr/antidrug/ebook/propofol.html

17. Walder B, Elia N, Henzi I, Romand JR, Tramèr MR. A lack of evidence of superiority of propofol versus midazolam for sedation in mechanically ventilated critically ill patients: a qualitative and quantitative systematic review. Anesth Analg 2001;92:975-983.

18. Gross JB, Zebrowski ME, Carel WD, Gardner S, Smith TC. Time course of ventilatory depression after thiopental and midazolam in normal subjects and in patients with chronic obstructive pulmonary disease. Anesthesiology 1983;58:540-544.

19. Sunzel M, Paalzow L, Berggren L, Eriksson I. Respiratory and cardiovascular effects in relation to plasma levels of midazolam and diazepam. Br J Clin Pharmacol 1988;25:561-569.

20. Reves JG, Fragen RJ, Vinik HR, Greenblatt DJ. Midazolam: pharmacology and uses. Anesthesiology 1985;62:310-324.

21. White PF, Way WL, Trevor AJ. Ketamine--its pharmacology and therapeutic uses. Anesthesiology 1982;56:119-136.

22. Okamoto GU, Duperon DF, Jedrychowski JR. Clinical evaluation of the effects of ketamine sedation on pediatric dental patients. J Clin Pediatr Dent 1992;16:253-257.

23. Soliman MG, Brindle GF, Kuster G. Response to hypercapnia under ketamine anaesthesia. Can Anaesth Soc J 1975;22:486-494.

24. Corssen G, Gutierrez J, Reves JG, Huber FC Jr. Ketamine in the anesthetic management of asthmatic patients. Anesth Analg 1972;51:588-596.

25. Savege TM, Colvin MP, Weaver EJ, Bond C, Drake J, Inniss R. A comparison of some cardiorespiratory effects of althesin and ketamine when used for induction of anaesthesia in patients with cardiac disease. Br J Anaesth 1976;48:1071-1081.

26. Sussman DR. A comparative evaluation of ketamine anesthesia in children and adults. Anesthesiology 1974;40:459-464.

27. Fragen RJ, Caldwell N. Comparison of a new formulation of etomidate with thiopental: side effects and awakening times. Anesthesiology 1979;50:242-244.

28. Gooding JM, Weng JT, Smith RA, Berninger GT, Kirby RR. Cardiovascular and pulmonary responses following etomidate induction of anesthesia in patients with demonstrated cardiac disease. Anesth Analg 1979;58:40-41.

29. Criado A, Maseda J, Navarro E, Escarpa A, Avello F. Induction of anaesthesia with etomidate: haemodynamic study of 36 patients. Br J Anaesth 1980;52:803-806.

30. Wagner RL, White PF. Etomidate inhibits adrenocortical function in surgical patients. Anesthesiology 1984;61:647-651.

31. Bhana N, Goa KL, McClellan KJ. Dexmedetomidine. Drugs 2000;59:263-268.

32. Precedex (dexmedetomidine hydrochloride) injection: prescribing information [Internet] 2010;cited 2011 Sep 29. Lake Forest (IL): Hospira Inc. Available from: http://www.accessdata.fda.gov/drugsatfda_docs/label/2010/021038s017lbl.pdf

33. Ebert TJ, Hall JE, Barney JA, Uhrich TD, Colinco MD. The effects of increasing plasma concentrations of dexmedetomidine in humans. Anesthesiology 2000;93:382-394.

34. Hsu YW, Cortinez LI, Robertson KM, Keifer JC, Sum-Ping ST, Moretti EW, Young CC, Wright DR, Macleod DB, Somma J. Dexmedetomidine pharmacodynamics. Part I: crossover comparison of the respiratory effects of dexmedetomidine and remifentanil in healthy volunteers. Anesthesiology 2004;101:1066-1076.

35. Bloor BC, Ward DS, Belleville JP, Maze M. Effects of intravenous dexmedetomidine in humans II Hemodynamic changes. Anesthesiology 1992;77:1134-1142.

36. Apan A, Doganci N, Ergan A, Buyukkocak U. Bispectral index-guided intraoperative sedation with dexmedetomidine and midazolam infusion in outpatient cataract surgery. Minerva Anestesiol 2009;75:239-244.

37. Drummond JC, Dao AV, Roth DM, Cheng CR, Atwater BI, Minokadeh A, Pasco LC, Patel PM. Effect of dexmedetomidine on cerebral blood flow velocity, cerebral metabolic rate, and carbon dioxide response in normal humans. Anesthesiology 2008;108:225-232.

38. Venn RM, Bryant A, Hall GM, Grounds RM. Effects of dexmedetomidine on adrenocortical function, and the cardiovascular, endocrine and inflammatory responses in postoperative patients needing sedation in the intensive care unit. Br J Anaesth 2001;86:650-656.

39. Iirola T, Vilo S, Aantaa R, Wendelin-Saarenhovi M, Neuvonen PJ, Scheinin M, Olkkola KT. Dexmedetomidine inhibits gastric emptying and oro-caecal transit in healthy volunteers. Br J Anaesth 2011;106:522-527.

40. Abdalla MI, Al Mansouri F, Bener A. Dexmedetomidine during local anesthesia. J Anesth 2006;20:54-56.

41. Hoy SM, Keating GM. Dexmedetomidine: a review of its use for sedation in mechanically ventilated patients in an intensive care setting and for procedural sedation. Drugs 2011;71:1481-1501.