There is a significant increase in the volume and type of procedures performed outside of the operation room. The demand for sedation has outgrown the workforce of anesthesia providers, necessitating administration of sedation by various nonanesthesia providers . Compared with practice in the operating room, sedation administered by nonanesthesiologists outside the operating room may increase the risk of adverse events. Some of these include less standardized work environments, more healthcare staff unfamiliar with sedation and resuscitation, and a preponderance of higher risk patients (e.g., children) . As such, education and training of sedation is an essential part of clinical practice and patient safety for both anesthesiologists and nonanesthesiologists. Several professional societies have issued guidelines, curriculums, and practice advisories on this topic (Table 1). Although these guidelines differ in specific content, they emphasize that the training process should include sedative and analgesic pharmacology, levels of sedation, recognition of deeper than intended levels of sedation, basic airway management skills, implementation of a quality improvement process, and mentored practice in a patient care setting.
A wide variety of course types have been developed for sedation training. These include conventional didactic training, screen-based simulation training, and high-fidelity manikin-based training. Although courses vary in duration and scope, it is not well established what type of training is superior to others and what minimal clinical skills should be demonstrated before a clinician is deemed qualified to administer sedatives. Preliminary work suggests that simulation-based sedation training leads to improved outcomes such as increasing utility of capnography monitoring, better nontechnical behavior skill, and an improved perception of knowledge and confidence [6–8].
The article reviews recent innovations in sedation training and also describes examples of sedation training in Taiwan that utilize a multimodal education program composed of didactic, simulation training, and hands-on practice.
INNOVATIONS IN SEDATION TRAINING
Several innovations in sedation training have emerged as the scope of sedation practice has expanded across many specialties. Perhaps the most significant innovation is that several professional societies have issued guidelines, curriculums, and practice advisories on this topic. Some of these include a sedation curriculum developed in the United States in 2012 by gastroenterologists for endsocopy procedures (Multisociety Sedation Curriculum for Gastrointestinal Endoscopy) and a similar curriculum in Europe in 2013 [3,4]. The American Society of Anesthesiologists (ASA) released updated practical guideline for moderate procedural sedation and analgesia in 2018 [5▪▪]. These practice guidelines are an important step in establishing training expectations for hospital credentialing bodies.
Didactic training and supervised on the job training have been the traditional methods of training for nonanesthesiologist. To a lesser extent, where available, screen-based and high-fidelity simulation training have been used. A consistent theme among these and other professional medical organizations is the recommendation that simulation be used in sedation training for nonanesthesiologists. A limitation to traditional clinical training is that it does not reliably offer an opportunity for training in crisis management, to address deficiencies in human performance under stress, or addressing deficiencies in effective teamwork.
By way of innovation, an example of screen-based simulation is the ASA's moderate sedation training course directed at nonanesthesiologists who provide procedural sedation. This training address the sedation continuum, preprocedure evaluation and preparation, rescue, how rescue differs from resuscitation, respiratory complications, patient safety monitoring, airway assessment and management, sedation pharmacology, and recovery. It includes instruction and formative assessments of learning.
High-fidelity simulation training
Another innovation is the use of high-fidelity simulation to provide educational offerings for these items in the context of procedural sedation. Simulation-based training also has positive impacts on teamwork. Sauter et al. demonstrated a study that 26 nurses and 24 physicians in the emergency room were enrolled and completed 1-day simulation-based interprofessional and interdisciplinary training. The results showed better performance in confidence, awareness of an emergency, medical knowledge, and crisis resource management. Meanwhile, the time to give sedation for the procedure (luxated shoulder) was significantly decreased after simulation training (111 versus 187 min, P = 0.002) . Therefore, the simulation training enhanced the emergency room team cooperation and workflow.
Another advantage to high-fidelity simulation provides an environment for trainees to experience the impact of appropriate selection of sedative drugs, proper monitoring techniques, including the level of consciousness, pulse oximetry, the frequency of observations, awareness of hypoventilation, and management of complications of intravenous sedation, including basic to advanced life support and recovery care [9,10].
A nuanced improvement to high-fidelity training for sedation is in-situ training. In-situ sedation simulation training is simulation conducted in the actual clinical environment and may improve performance under the real scenario. Ben-Ari et al. presented a study evaluating the performance of sedation training before and after the in-situ simulation. Sixteen pediatricians were enrolled and completed the in-situ simulation. Participants then were re-evaluated using a validated score during subsequent sedation administrations in the emergency room. The results showed improved scores from a median of 4–6 (P < 0.0009), especially in the task of presedation preparation and equipment checks [12▪]. In summary, high-fidelity simulation (in-situ or in simulation center) provides a realistic environment to learn how to perform safe procedural sedation.
The ASA has a high-fidelity simulation offering that is part of a comprehensive sedation training program. This entire program includes a moderate and a deep sedation screen-based training program described above, a high-fidelity simulation course that reviews important elements of patient evaluation, periprocedural monitoring, and sedation pharmacology, and a mentored practice program.
Virtual reality simulation
An emerging innovation in simulation is virtual reality. It is an artificial three-dimensional immersive simulated environment that uses visual and auditory stimuli. Although only a few virtual reality sedation training programs have been developed, this technology may serve as an innovative platform for training and assessing skills relevant to sedation practice as has been reported for skills training in surgical fields [14,15▪]. Recent work by Zaveri et al. explored the utility of virtual reality sedation training for pediatric sedation. Their study was a randomized controlled trial comparing virtual reality pediatric sedation training with traditional screen-based training [16▪]. Educational outcome measures included high-fidelity simulation assessment of core skills needed for pediatric sedation practice. The result showed high participant satisfaction with the virtual reality module but no difference between groups. Future work is warranted to establish if this technology applied in sedation training merits further investment to improve patient outcomes. This may require specialized design of virtual reality modules that provide training and assessment tools of how well clinicians can manage rare but harmful adverse events associated with sedation practice.
Sedation safety checklists
Another innovation is the use of checklists. By way of background, the WHO Surgical Safety Checklist was developed to decrease errors and adverse events and increase teamwork and communication in surgery . Investigators have explored using a checklist approach to improving patient safety in pediatric sedation practice. For example, Kahlenberg et al.[18▪▪] studied the impact of a modified WHO pediatric procedural sedation safety checklist on risk reduction. They found that the adverse event rate in the 5 months immediately before implementing the checklist was 5.2% (54/1033). This rate changed to 3.6% (28/773) at 5 months after implementation but the difference was NS (P = 0.10). This finding may be misleading given that the incidence of severe adverse events in sedation is very rare and a large sample size is needed to properly detect a significant difference. Another limitation was that the data collection period after the checklist had been implemented was short. A longer period of checklist use (e.g., 12–18 months) may have demonstrated a further reduction in adverse events as more staff became facile and rigorous at using the checklist. Future work is warranted exploring the use of checklists in sedation for pre procedure patient assessment and verification of critical equipment and medications in the procedure suite, and equipment.
Sedative drug effect-site concentration
Another possible innovation for use in sedation practice is the use of drug displays that provide predicted drug effect site concentrations of sedatives and analgesics and their associated drug effects. Practitioners titrate sedatives and analgesics to maintain a patient in the desired level of sedation. This is an intuitive process that includes making frequent and accurate assessments of physiologic parameters (e.g., vital signs), responsiveness (e.g., response to a verbal and tactile stimuli), airway patency, and ventilation, often with the aid of capnography. Providing real time point of care predictions of drug effect-site concentrations and drug effects of interest (e.g., probability of loss of responsiveness, probability of ventilatory depression, probability of analgesia, etc.) may be a useful adjunct to the assessments described above. Several investigators have created models that estimate drug concentrations and effects in sedated volunteers and patients. Others have explored the use of predicted drug effect site concentrations and drug effects in sedation practice using propofol, midazolam, and selected opioids [19–21].
Several nuances to this line of investigation merit discussion. First, sedation practitioners may choose to use more than one drug when providing care to patients undergoing painful but brief procedures. The combination of drugs is typically an opioid and a sedative. Given that their interactions are synergistic for nearly all drug effects, the models must account for this interaction. Second, the time course of most drugs is difficult to predict without a computer. Model predictions require complex math that is difficult for a clinician to use real time without the aid of a computer. The ability to visualize the time course of a sedative bolus or infusion may be useful in guiding titration to minimize unwanted deeper than intended sedation or clinically worrisome ventilatory depression.
The recent rise in utilization of artificial intelligence may prove useful in building more accurate models that better predict drug concentrations and effects.
Another possible innovation for use in sedation practice is capnography. Continuous capnography monitoring has been encouraged during sedation for procedures such as bronchoscopy , esophagogastroduodenoscopy (EGD) [23,24], and pediatric procedures. Capnography is displayed in both graphical (waveform) and numerical form and is currently the most widely recommended method for monitoring carbon dioxide. Of note, it is important to recognize that when using capnography in sedation practice, it does not measure end tidal carbon dioxide as is frequently presented on physiologic monitors. Most monitors that have the capability of monitoring carbon dioxide assume that gas measurements are taken from patients with an instrumented airway.
Capnography when the sample line is attached to a nasal cannula or a face mask used for delivery of supplemental oxygen can provide a substantially different waveform from what is typically encountered when sampled from an intubated mechanically ventilated patient. Fresh gas flow, whether the patient is a nasal or oral breather, and partial or complete airway obstruction can substantially influence the waveform presented to a sedation practitioner. For the trained anesthesiologist, interpretation of the capnography waveform may be straightforward, but for the nonanesthesiologists, the addition of capnography may not prevent hypoxemia . Capnography training is needed to ensure that sedation practitioners are familiar with possible artifacts and how to interpret the waveform signal.
The primary advantage of capnography is that it can quickly detect apnea from either central ventilatory depression or partial or complete airway obstruction. Monitors typically alarm when no carbon dioxide is detected within 20–30 s. This is much faster than the development of hypoxia following apena which may take several minutes, especially in the presence of supplemental oxygen.
As capnography monitoring is implemented in sedation suites, there are a few nuances that merit discussion. For example, oral capnography may better represent breathing pattern during EGD procedures [26▪]. Novel bite blocks which monitor both nasal and oral capnography may help better interpret breathing . With the increasing popularity of high-flow nasal cannulas, detection of capnography may be more difficult to use. Novel noninvasive devices such as transcutaneous capnography monitoring may be useful for detection of hypercapnia but does not show respiratory pattern .
IN-OFFICE DENTAL SEDATION EDUCATION PROGRAM: TAIWAN EXPERIENCE
The prevalence of dental carries in preschool children is very high in Taiwan. Children that require complex dental restorations often need sedation to complete these procedures. For safety concerns, these children are often transferred to the hospital for sedation. To improve consistency in the administration of sedation for this patient population, a group of anesthesiologists in Taiwan formed Stardust Sedation and Anesthesia. This group focuses on improving practice in ambulatory anesthesia and providing safe pediatric in-office sedation services. To that end, Stardust Sedation and Anesthesia group held a 3-day educational program for Taiwanese anesthesiologists that reviewed the American Academy of Pediatrics Guidelines for monitoring and management of pediatric patients before, during, and after sedation for diagnostic and therapeutic procedures .
The first day focused on understanding the nature of pediatric dental treatment, drug choice, and basic concepts of pediatric dental sedation. The second day focused on different experiences among hospitals and clinics, and the use of capnography and pretracheal stethoscope in dental sedation. The third day focused on organizing an effective dental sedation team and crisis management. There were also hands-on and simulation classes throughout the 3-day course. Therefore 2012, More than 6000 children had been treated under sedation in these dental clinics. The age of the kids receiving pediatric treatment is on average 3 years old. The treatment time ranges from 1 to 5.5 h, with the average time of 2.5 h. The incidence of intubation is 0.17%.
Three major modifications greatly improved the quality of dental sedation. First, a sedation dosing strategy was implemented that maintained a low basal rate of propofol with the use of an intermittent bolus regimen after local anesthetics was given. Second, proper placement of oral gauze and the choice of different suction devices among dental procedures that ensured airway patency. Third, a multimodal sedation regimen was used to minimize adverse side effects of each sedative and analgesic. Several innovation techniques were also applied. To minimize stress when establishing intravenous access, premedication with oral benzodiazepine–antihistamine–ketamine cocktail was used. In our experience, when targeting deep sedation, maintaining airway patency is often needed (e.g., chin-lift). However, it is impractical to perform a persistent chin-lift throughout an entire dental procedure as it would likely interfere with the dental treatment. To that end, we modified a paint roller handle and added a cushion pad over the head to provide an easy and convenient method of maintaining airway patency during pediatric dental procedures that require moderate to deep sedation (Fig. 1). Capnography and pretracheal stethoscope were also used to consistently monitoring airway patency.
MODERATE SEDATION COURSE FOR COSMETIC SURGERY: TAIWAN EXPERIENCE
Sedation and analgesia for plastic surgery procedures is often performed by a surgeon or operating room nurse. Their skills and experience in sedation practice, airway management, patient selection, and detected deeper than intended sedation levels are uncertain and likely inadequate. In 2018, a federal law was passed in Taiwan that required an anesthesiologist be present for procedures that require more than moderate sedation. For moderate sedation, an independent nonanesthesiologist doctor other than the surgeon may provide sedation and analgesia after they have completed proper professional training provided by the Taiwan Society of Anesthesiologists (TSA).
To that end, the practice guidelines for moderate procedural sedation and analgesia developed by the ASA and adopted and modified by the TSA were used to develop a sedation training course for nonanesthesiologists interested in providing minimal or moderate sedation. The course is offered in an observed structure clinical examination (OSCE) center of a medical center. The 1-day course consists of a 2-h lecture covering topics germane to moderate procedural sedation to include the sedation continuum, rescue and monitoring equipment, sedation pharmacology, rescue techniques, postsedation care. This is followed by a set of OSCEs that are used to train participants in patient evaluation, airway evaluation, and sedation documentation. Participants then complete three screen-based simulation courses that address under and oversedation and patient rescue. Each participant then completes a written examination and OSCE-based assessments of course material. Upon successful completion, participants receive a certificate of completion and their exam scores. Clinicians desiring to provide moderate sedation are also required to have an active advanced cardiac life support certification.
Procedural sedation training is essential to maintain patient safety, especially for nonanesthesiologists. Many educational offerings have been developed for sedation training and vary in their scope and breadth. Standards and performance expectations for this type of training have been established by several professional societies but are not consistently adhered to. With the expansion of sedation practices where anesthesia care providers are not available, several innovations have been introduced or considered to improve patient safety. Some of these include development of sedation practice guidelines by professional organizations, improvements in screen-based simulation and high-fidelity simulation, early development of virtual reality sedation training, implementation of checklists and capnography monitoring, and utilization of a drug display that presents the time course of predicted drug concentrations and effects.
Despite a wide range of course offerings and potential innovations to improve patient safety, there is a paucity of work exploring the effectiveness of sedation training for nonanesthesiologist sedation practitioners. Studies that characterize adverse outcomes (incidence and severity) and how sedation training may decrease the incidence of these outcomes is warranted. Available publications are primarily descriptive of course offerings in simulation laboratories and patient care practices, but lack sample sizes and experimental designs capable of exploring the potential impact of training on patient outcomes.
Financial support and sponsorship
Conflicts of interest
B.-C.S., MD was the ex-CEO and currently anesthesiologists of Stardust Sedation and Anesthesia Group. For the remaining authors none were declared.
REFERENCES AND RECOMMENDED READING
Papers of particular interest, published within the annual period of review, have been highlighted as:
- ▪ of special interest
- ▪▪ of outstanding interest
1. Pisansky AJ, Beutler SS, Urman RD. Education and training for nonanesthesia providers performing deep sedation. Curr Opin Anaesthesiol 2016; 29:499–505.
2. Webster CS, Mason KP, Shafer SL. Threats to safety during sedation outside of the operating room and the death of Michael Jackson. Curr Opin Anaesthesiol 2016; 29 (Suppl 1):S36–S47.
3. American Association for Study of Liver Diseases; American College of Gastroenterology; American Gastroenterological Association. Multisociety sedation curriculum for gastrointestinal endoscopy. Gastrointest Endosc 2012; 76:e1–e25.
4. Dumonceau JM, Riphaus A, Beilenhoff U, et al. European curriculum for sedation training in gastrointestinal endoscopy: position statement of the European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA). Endoscopy 2013; 45:496–504.
5▪▪. American Society of Anesthesiologists. Practice guidelines for moderate procedural sedation and analgesia 2018: a report by the American Society of Anesthesiologists Task Force on Moderate Procedural Sedation and Analgesia, the American Association of Oral and Maxillofacial Surgeons, American College of Radiology, American Dental Association, American Society of Dentist Anesthesiologists, and Society of Interventional Radiology. Anesthesiology 2018; 128:437–479.
The latest version of sedation guideline released by American Society of Anesthesiologists (ASA). The new recommendations include continual monitoring of ventilation with capnography, sedatives intended for general anesthesia (propofol, ketamine, and etomidate), and quality improvement processes.
6. Haba M, Komasawa N, Sanuki T, et al. Effect of simulation
-based sedation training course for dentists on emergency response monitoring. Am J Emerg Med 2018; 36:1115–1116.
7. Hadfield A, Thompson S, Hall J, et al. Perception of simulation
training in emergencies for dental sedation practitioners. Clin Teach 2018; 15:52–56.
8. Friedman N, Sagi D, Ziv A, et al. Pediatric residents’ simulation
-based training in patient safety
during sedation. Eur J Pediatr 2018; 177:1863–1867.
9. Da B, Buxbaum J. Training and competency in sedation practice in gastrointestinal endoscopy. Gastrointest Endosc Clin N Am 2016; 26:443–462.
10. Lee TH, Lee CK. Endoscopic sedation: from training to performance. Clin Endosc 2014; 47:141–150.
11. Sauter TC, Hautz WE, Hostettler S, et al. Interprofessional and interdisciplinary simulation
-based training leads to safe sedation procedures in the emergency department. Scand J Trauma Resusc Emerg Med 2016; 24:97.
12▪. Ben-Ari M, Chayen G, Steiner IP, et al. The effect of in situ simulation
training on the performance of tasks related to patient safety
during sedation. J Anesth 2018; 32:300–304.
A small sized, before-and-after study showed in-situ simulation training can improve the performance in real pediatric sedation.
13. Cook DA, Erwin PJ, Triola MM. Computerized virtual patients in health professions education: a systematic review and meta-analysis. Acad Med 2010; 85:1589–1602.
14. Badash I, Burtt K, Solorzano CA, et al. Innovations in surgery simulation
: a review of past, current and future techniques. Ann Transl Med 2016; 4:453.
15▪. Khan R, Plahouras J, Johnston BC, et al. Virtual reality simulation
training for health professions trainees in gastrointestinal endoscopy. Cochrane Database Syst Rev 2018; 8:CD008237.
The systemic review showed virtual reality simulation-based training can be used to supplement early conventional endoscopy training for health professions trainees with limited or no prior endoscopic experience. However, there was insufficient evidence to use virtual reality simulation-based training as a replacement for early conventional endoscopy training.
16▪. Zaveri PP, Davis AB, O’Connell KJ, et al. Virtual reality for pediatric sedation: a randomized controlled trial using simulation
. Cureus 2016; 8:e486.
The study compared the effectiveness of virtual reality simulation and web-based education, and there was no difference between groups. But the sample size is small.
17. Haynes AB, Weiser TG, Berry WR, et al. A surgical safety checklist to reduce morbidity and mortality in a global population. N Engl J Med 2009; 360:491–499.
18▪▪. Kahlenberg L, Harsey L, Patterson M, et al. Implementation of a modified WHO pediatric procedural sedation safety checklist and its impact on risk reduction. Hosp Pediatr 2017; 7:225–231.
The study demonstrated an implementation of sedation safety checklist with a completion rate of 75%. The use of the checklist improved capture of critical safety elements but did not reduce the adverse events rate.
19. Johnson KB, Syroid ND, Gupta DK, et al. An evaluation of remifentanil propofol response surfaces for loss of responsiveness, loss of response to surrogates of painful stimuli and laryngoscopy in patients undergoing elective surgery. Anesth Analg 2008; 106:471–479.
20. Liou JY, Ting CK, Hou MC, et al. A response surface model exploration of dosing strategies in gastrointestinal endoscopies using midazolam and opioids. Medicine (Baltimore) 2016; 95:e3520.
21. Na SH, Song Y, Kim SY, et al. A simulation
study of propofol effect-site concentration for appropriate sedation in pediatric patients undergoing brain MRI: pharmacodynamic analysis. Yonsei Med J 2017; 58:1216–1221.
22. Ishiwata T, Tsushima K, Terada J, et al. Efficacy of end-tidal capnography monitoring during flexible bronchoscopy in nonintubated patients under sedation: a randomized controlled study. Respiration 2018; 96:355–362.
23. Jopling MW, Qiu J. Capnography sensor use is associated with reduction of adverse outcomes during gastrointestinal endoscopic procedures with sedation administration. BMC Anesthesiol 2017; 17:157.
24. Kim SH, Park M, Lee J, et al. The addition of capnography to standard monitoring reduces hypoxemic events during gastrointestinal endoscopic sedation: a systematic review and meta-analysis. Ther Clin Risk Manag 2018; 14:1605–1614.
25. van Loon K, van Rheineck Leyssius AT, van Zaane B, et al. Capnography during deep sedation with propofol by nonanesthesiologists: a randomized controlled trial. Anesth Analg 2014; 119:49–55.
26▪. Teng WN, Ting CK, Wang YT, et al. Oral capnography is more effective than nasal capnography during sedative upper gastrointestinal endoscopy. J Clin Monit Comput 2018; 32:321–326.
A novel-designed oral bite demonstrated more accurate end tidal carbon dioxide (EtCO2) detection than traditional nasal capnography during sedative esophagogastroduodenoscopy.
27. Teng WN, Ting CK, Wang YT, et al. Novel mandibular advancement bite block with supplemental oxygen to both nasal and oral cavity improves oxygenation during esophagogastroduodenoscopy: a bench comparison. J Clin Monit Comput 2019; 33:523–530.
28. Ebeling CG, Riccio CA. Apneic oxygenation with high-flow nasal cannula and transcutaneous carbon dioxide monitoring during airway surgery: a case series. A A Pract 2019; 12:366–368.
29. Cote CJ, Wilson S. American Academy of Pediatrics; American Academy of Pediatric Dentistry. Guidelines for monitoring and management of pediatric patients before, during, and after sedation for diagnostic and therapeutic procedures: update 2016. Pediatrics 2016; 138:e1–e31.