This Invited Commentary accompanies the following original article:
Hinkelbein J, Lamperti M, Akeson J, et al. European Society of Anaesthesiology and European Board of Anaesthesiology guidelines for procedural sedation and analgesia in adults. Eur J Anaesthesiol 2018; 35:6–24
Over the last decade there has been a remarkable increase in procedures undertaken under sedation. This is because of better drugs and better monitoring systems. We welcome the introduction of formalised guidelines for well tolerated practice of procedural sedation from a respected international author group.1 It is noteworthy that despite multiple references to Associations and Royal Colleges from the United Kingdom, there was no UK representation on this group.
The guidelines correctly identified that the term ‘conscious sedation’ is ambiguous and procedural sedation and analgesia (PSA) is a much better concept. Although the guidelines recommend that anaesthesiologists should be supportive and facilitate well tolerated sedation practice, they should not be too restrictive of the practice of PSA by nonanaesthetists and the guidelines provide a good framework for well tolerated PSA.
For international guidelines such as these the terminology should be valid across countries. For instance, in the European context the term ‘sedationist’ may be more appropriate because nonclinicians undertake PSA. The term ‘code blue’ would be better understood as ‘emergency alarm’. The term ‘anaesthesia professional’ is used interchangeably with ‘anaesthesiologist’, which is confusing.
For well tolerated PSA, staffing specifications are crucial. The interventionist should not be the sedationist. The sedationist should be trained and must have adequate continuing professional development (CPD) and have sole responsibility to administer and monitor the patient during PSA.2 There should be at least one spare healthcare assistant apart from an assistant or staff nurse. The idea is to provide a framework for safe numbers of staffing wherever PSA is undertaken.
An important lesson is that most fatal incidents result from inadequate oxygenation and/or ventilation in nonoperating room areas. The emphasis should be on maintenance of oxygenation rather than instrumentation of the airway. In line with this recommendation, the UK Resuscitation Council no longer mandates endotracheal intubation and the laryngeal mask airway (a supraglottic device) is an integral part of emergency equipment in Europe.3
It would be prudent to specify ‘cardiopulmonary resuscitation (CPR) competency’. Perhaps we need to qualify the statement ‘all personnel in charge of the PSA should be certified for CPR’. First, there should be a designated person in charge of sedation. ‘CPR competency’ should specify either intermediate life support as in the UK, or advanced life support/advanced cardiac life support. As a minimum, at least two people in the room should be ‘CPR competent’. They could both be intermediate life support trained, although advanced life support training would be preferable.
The emphasis has been rightly placed on prevention via focused preprocedural assessment to identify risk factors, which would require the need for anaesthetic support. Thorough assessment should be undertaken by the responsible sedationist prior to procedure. Anaesthetic guidelines on assessment and preoperative preparation can be used. For instance, perioperative guidelines for fasting are translatable for PSA. There are many facilities where sedation is performed without an anaesthetist ‘immediately available’ and the emphasis should in our view be on ensuring adequate personnel, training, equipment, recovery and discharge wherever PSA is undertaken.
The task force's recommendation suggesting that patients aged over 70 years should be managed by anaesthesiologists is contentious. Patients in this age group are routinely managed successfully by various specialties. There is no doubt that robust assessment should be undertaken prior to PSA in this population, but the focus should be on training sedationists to do this better through education and training. This also holds true in our view for use of drugs especially those with a narrow margin of safety such as propofol and opioids. In nonanaesthetic hands these drugs can be fatal and require good knowledge, adequate monitoring at all times and lots of experience along with the ability to competently manage complications, especially airway management.
The usefulness of examinations and minimum passing scores is debatable. In the United Kingdom, most medical specialties practising PSA have incorporated a module on sedation. This is part of competency-based training for radiology, gastroenterology, nephrology and so on. We feel it would be more important to stipulate regular sedation practice CPD (2- to 3-yearly) for sedationists along with attendance at advanced airway management workshops/simulator sessions. There is overwhelming evidence that awareness of human factors in critical events promotes safety and exposure to ‘what if’ scenarios can be best undertaken via simulator-based training. Attending half a day theatre list every 2 to 3 years with an anaesthetic colleague could help maintain airway skills.
It is uncommon in the European setting for propofol to be used as a primary agent for sedation by nonanaesthetists. Midazolam, fentanyl and morphine remain the most commonly used drugs for PSA. A detailed knowledge of individual drugs and their interactions is mandatory for the sedationist.
Introduction of minimal monitoring standards for PSA as in anaesthesia is a welcome move to improve safety. Along with noninvasive blood pressure, ECG monitoring is recommended as mandatory for PSA.
Perhaps the most important monitoring modality for PSA as recognised by the Association of Anaesthetists of Great Britain and Ireland,4 Resuscitation Council UK and the European Journal of Anaesthesiology guideline is capnography. Nonanaesthetists may be less familiar with capnography techniques and their limitations and with the newer capnography machines employing microstream technology. The American Society of Anesthesiologists’ closed claims analysis for remote locations placed major emphasis on the use of capnography and suggested that 62% of claims were preventable by better monitoring.5 There are multiple online free training resources available for capnography and with the possibility of incentive payments for this monitoring in some health systems, the technology may not be too expensive. Ideally, PSA would be safer with capnography for all interventions. In the interim, risk stratification of procedures that require deeper sedation would help identify PSA interventions where capnography should be used.
Recovery from PSA and discharge require fulfilment of two separate score thresholds. The post-anaesthesia care unit score or other recovery scoring system is suitable for establishing adequate recovery. The level of monitoring in recovery should be of the same standard as during PSA. Patients should be monitored for at least 30 min in recovery and fulfil the recovery criteria before stepping down care. As recommended in the guidelines, the Aldrete score should be used for discharging patients home.
In conclusion, nonanaesthetists have practiced PSA for many years. With the advent of newer drugs and better monitors there is an opportunity to make PSA safer. However, this would require collaboration among all specialties, including nursing, to promote education and understanding. Modules and courses tailored toward educating sediationists and opportunities for regular CPD to maintain skills would go a long way to promote safety in this field. Processed electroencephalography to better understand consciousness and to accurately identify and track sedation levels is an exciting area of research.
Acknowledgements relating to this article
Assistance with the invited commentary: none.
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Conflicts of interest: none.
Comment from the editor: this invited commentary was checked and accepted by the editors but was not sent for external peer review.
This article was checked and accepted by the Editors, but was not sent for external peer-review.