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Correspondence

The sedation dispute: what is next?

Petrou, Anastasios; Arnaoutoglou, Heleni; Papadopoulos, Georgios

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European Journal of Anaesthesiology: January 2013 - Volume 30 - Issue 1 - p 39-40
doi: 10.1097/EJA.0b013e328356ba6b

Editor,

In regard to the extensive discussion on the administration of sedation by non-anaesthetists,1–4 we would like to comment on a few issues.

The ‘ownership’ of medical procedures (in this case, procedural sedation) by certain specialities was not, and presumably will never be, granted. It is a well known fact that procedural sedation has, to a large extent, slipped out of the hands of anaesthesiologists. There are many reasons for this, and they vary among countries and continents; this is not the issue here. A lot of procedures are already shared by many medical specialities (for instance, revascularisation of an obstructed coronary artery by cardiothoracic surgeons or cardiologists; securing an airway through endotracheal intubation by anaesthetists, emergency physicians, neonatologists or intensive care physicians). Extensive, authoritative ruling is not a means of improving efficacy or safety. Although guidelines offer a road map of safe and highly effective practice, there is no disagreement that they should not be regarded as compulsory rules.

Taking into account all of the above, we propose that the issue of who is administering procedural sedation should be addressed as follows. First, we need to consider safety and expertise. The important outcome is whether the procedure is performed in safe conditions and with high professional expertise. If this is the case, let it be so, irrespective of who is administering the sedation, anaesthesiologist or not. The aim is reached and the public enjoys high-quality services. If the procedure is not performed in safe conditions and with high professional expertise, then let us work on it. Let us sit down together and work on safety procedures, adequate training, unequivocal certification, scrupulous monitoring of the procedural sedation and immediate intervention, when needed. There are many effective ways of doing so.

Second, we need to consider the specialities concerned. Everyone should work together on resolving these issues. We should never forget that dividing medicine into specialities was done in order to improve performance, not in order to produce distinct disciplines/sciences.

Third, we need to consider the personnel. There is no doubt that anaesthetists administer sedation with the utmost efficacy and safety. We are ‘de jure’ the ‘senior’ advisors on this topic, as sedation is a constituent of our primary occupation, that is, administering anaesthesia to the extent needed by the patient. By doing so, we can certainly argue on the ‘science’ of sedation, how to teach and monitor procedural sedation and how to measure outcome. Other specialities administer sedation too, but as a ‘side-job’, in order to enable their own, unique task, such as gastrointestinal endoscopy, or the reduction of a dislocated joint, or for prolonged mechanical ventilation. The contribution of the involved specialists to the discussion is vital and a ‘sine qua non’, as they too are effectors of sedation to ever increasing percentages.

Fourth, we need to consider the instructors. Who should provide teaching, training and certification? Certainly, the most experienced ‘sedation providers’, irrespective of their primary speciality. How can we evaluate their experience and expertise? By monitoring, through national registries and standard settings, their case load, the quality of service and outcome.

Fifth, we need to consider the practitioners. Who is qualified to administer procedural sedation? If sedation is part of primary training (which is the case for anaesthetists, intensive care physicians, paediatric intensivists and emergency physicians), then these specialities are ‘de jure’ qualified. If sedation is to be added as a supplementary training, then the curriculum of the particular medical speciality should be structured by the respective medical colleges, approved by the corresponding medical councils and professional societies and put into effect in the training hospitals of the corresponding specialities. Consultation on procedural sedation issues and possible referrals to anaesthetists for advanced management should be an acceptable and effective way of treating more difficult cases, either because of the patient's physical status and co-morbidities or because of the complexity of the procedure.

Sixth, we need to consider medication. Propofol is an intravenous anaesthetic drug and its administration should probably remain ‘restricted’, allowing administration by anaesthetists, intensive care physicians, paediatric intensivists and emergency physicians only, until extended data on its safe use for procedural sedation are available.

Seventh, we need to consider rules and guidelines. Extended rules will downgrade the whole discussion and procedure to an endless bureaucracy. One thing is for sure: the person who administers procedural sedation should do so as his/her exclusive task during the procedure. Let us not ignore the fact that this exclusive focusing has made anaesthesia a safe medical procedure since its invention 160 years ago. On a personal note, we do not consider a nurse-administered procedural sedation as a good idea. This intensely debated procedure should not be provided by anyone other than medical doctors.

Eighth, we need to consider cost and reimbursement. There may be financial reasoning in this debate. Whoever meets the procedural sedation demands should perform it and get reimbursed for the service. If another speciality, other than anaesthetists, intensive care or emergency physicians or paediatric intensivists can effectively perform it, these specialists should be paid. As all sedation services would have the same standards, they should be reimbursed equally.

Finally, we need to consider patients’ rights. The freedom of choosing service providers should not be compromised once these rules apply. If the patient acknowledges that an anaesthetist instead of, for instance, a gastroenterologist would better meet their expectations and needs for procedural sedation, and they or their health insurance provider agrees to pay for the service, there should be no conflict as to who should administer the procedural sedation.

We understand that sound theory does not always translate to the delivery of high-quality and safe medical care. However, if we agree on the procedures needed in order to resolve the controversy, we might have already travelled half the distance. There is a long-standing experience of implementing standards of care. Let us prove that we can deliver the goods!

Acknowledgements

Assistance with the letter: none declared.

Financial support and sponsorship: none declared.

Conflicts of interest: none declared.

References

1. Pelosi P. on behalf of the Board of the European Society of AnaesthesiologyRetraction of endorsement: European Society of Gastrointestinal Endoscopy, European Society of Gastroenterology and Endoscopy Nurses and Associates and the European Society of Anaesthesiology Guideline – nonanaesthesiologist administration of propofol for gastrointestinal endoscopy. Eur J Anaesthesiol 2012; 29:208–212.
2. Perel A. Nonanaesthesiologists should not be allowed to administer propofol for procedural sedation: a consensus statement of 21 European national societies of anaesthesia. Eur J Anaesthesiol 2011; 28:580–584.
3. Dumonceau JM, Riphaus A, Aparicio JR, et al. NAAP Task Force MembersEuropean Society of Gastrointestinal Endoscopy, European Society of Gastroenterology and Endoscopy Nurses and Associates, and the European Society of Anaesthesiology Guideline: nonanaesthesiologist administration of propofol for GI endoscopy. Eur J Anaesthesiol 2010; 27:1016–1030.
4. Delaunay L, Gentili M, Cittanova ML, et al. Anaesthesia by nonanaesthesiologists: the Pandora box is open!. Eur J Anaesthesiol 2012; 29:50–51.
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