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In Response

Thomas, Joss MD; Dexter, Franklin MD, PhD; Todd, Michael M. MD

doi: 10.1213/XAA.0000000000000501
Case Reports: Letters to the Editor
Free

Department of Anesthesiology, University of Minnesota School of Medicine, Minneapolis, Minnesota

Department of Anesthesia, Carver College of Medicine, University of Iowa, Iowa City, Iowa

Department of Anesthesiology, University of Minnesota School of Medicine, Minneapolis, Minnesota

Department of Anesthesia, Carver College of Medicine, University of Iowa, Iowa City, Iowa, mmtodd@umn.edu, michael-todd@uiowa.edu

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Safety and an Anesthesiologist-Managed Nurse Sedation Program: A Response to Cravero et al

We thank Cravero et al1 for their interest in our work. They write that the “concern to the Society is the conclusion that the nurse sedation model is safe based on their observations. This conclusion is clearly not warranted given the very low expected incidence of major complications associated with anesthesia or sedation.” We agree with the authors; we did not conclude that “the nurse sedation model is safe.” In our article, “we reported the results of establishing and managing an anesthesiologist-supervised nurse sedation program for diagnostic imaging, endoscopy, bronchoscopy, and minor procedures, predominantly using propofol or dexmedetomidine. We showed a large, progressive increase in caseload, performed by a growing number of nurses but without increasing the number of supervising anesthesiologists or nurse anesthetists (1 per day).” We concluded that: “trained, supervised nurses can safely administer propofol or dexmedetomidine to selected patients for a wide variety of procedures.”

There is an important distinction between our conclusions and the concerns expressed by Cravero et al. We showed that the nurses can and did provide safe care. There were 22 postprocedural admissions (out of 11,038 cases). Sedation was thought to be contributory in 16—but most admissions were for observation only; 11 of 16 were discharged later the same day or the next morning. Only 1 patient required prolonged admission, and that case was quickly converted to direct anesthesiologist/certified registered nurse anesthetist, managed MAC. There were no cardiorespiratory arrests or deaths and no long-term morbidity in any patient cared for by the sedation team. The belief that different results would have been obtained with these patients undergoing these procedures with a different care team model is speculative.

Our findings do not mean that the nurse sedation model per se “is safe.” We have no way to know the generalizability of our findings to other settings or hospitals. Our case series was published in A&A Case Reports, not in Anesthesia & Analgesia, because we do not know the reproducibility of our findings at other hospitals. It is possible that implementation of nurse-managed sedation under different circumstances with different (or differently trained and supervised) personnel in a different health care system might yield different results.

It is also important to understand the context of the situation described in the article. At the time the sedation team was instituted, the option of providing direct anesthesiologist or certified registered nurse anesthetist managed care was not available. The alternative to the described system was to allow sedation to continue being managed by physicians and nurses with minimal training (eg, radiologists writing sedation orders for radiology nurses), a situation that was widely perceived to be less safe. The subsequent growth of the program was driven by increasing numbers of requests from the treating physicians (gastroenterologists, pulmonologists, hematologists, etc).

Although this approach may be viewed by many as a departure from traditional care models, we clearly demonstrated that it can work successfully, safely, and economically. Whether other institutions can or choose to mimic this success remains to be seen.

Joss Thomas, MD
Department of Anesthesiology
University of Minnesota School of Medicine
Minneapolis, Minnesota

Franklin Dexter, MD, PhD
Department of Anesthesia
Carver College of Medicine
University of Iowa
Iowa City, Iowa

Michael M. Todd, MD
Department of Anesthesiology
University of Minnesota School of Medicine
Minneapolis, Minnesota
Department of Anesthesia
Carver College of Medicine
University of Iowa
Iowa City, Iowa
mmtodd@umn.edu, michael-todd@uiowa.edu

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REFERENCE

1. Cravero JP, Flick RP, Malviya SV. Comment on growth in an anesthesiologist and nurse anesthetist-supervised sedation nurse program using propofol and dexmedetomidine. A A Case Rep. 2017;8:337.
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