September 2001
Volume 65 |
Number 9
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| Letters
To The Editor |
Procedural Sedation, not ‘Conscious Sedation’
I read with interest Dr. Lema’s thoughtful discussion (April
2001 “Ventilations”) of one of the challenging issues
in credentialing nonanesthesiologists to administer sedatives
and analgesics for procedures. While I agree with Dr. Lema’s
main point, I must state that using the generic term “conscious
sedation,” rather than the broader term “procedural
sedation,” may be misleading. It may also contribute to poor
understanding and skills on the part of nonanesthesiologists who
may administer sedatives and analgesics. As the Joint Commission
on Accreditation of Healthcare Organizations (JCAHO) now emphasizes
(Standard TX.2, January 2001) and as we anesthesiologists well
know, there is tremendous individual variability in response to
these pharmacologic interventions, such that there is a continuous
spectrum of levels of sedation. Below is a succinct summary of
the levels of sedation as defined by JCAHO:
Level 1: minimal sedation/anxiolysis — no significant
effect on respiratory or cardiovascular function; these interventions
do not fall under the JCAHO procedural sedation guidelines
Level 2: moderate sedation (this one subcategory of procedural
sedation is closest to what might appropriately be described as
“conscious sedation”) — respiratory and cardiovascular
reflexes are usually maintained
Level 3: deep sedation — respiratory reflexes are
often impaired; cardiovascular reflexes may be impaired
Level 4: “anesthesia” — general anesthesia
and major regional anesthesia with attendant significant depressive
effects on cardiovascular and/or respiratory function
Of particular importance is that the 2001 standards require that
practitioners who administer sedatives and analgesics with an
intended level of sedation must possess the skills to “rescue”
patients who unintentionally slip into the next level of sedation.
This “levels of sedation” approach, while not perfect,
is long overdue and, in my experience overseeing this area in
our medical center, has enhanced understanding, vigilance and
skills on the part of nonanesthesiologists involved in procedural
sedation.
In summary, I believe it is best to avoid the misleading and
perhaps now obsolete generic term “conscious sedation”
and instead use the term “procedural sedation ” to refer
to this important area of nonanesthesiologist practice where anesthesiology
consultation and clinical/administrative oversight are critical.
John M. Freedman, M.D.
Santa Rosa, California
Editor’s Note: A rose by any other name
would still smell as sweet. Regardless of how we partition sedation,
the risk of poorly prepared practitioners delivering more than
meets the definition is real. Patient protection is our primary
concern. Sedation by nonanesthesiologists is at best a compromise
that prioritizes practitioners’ convenience, patients’
convenience and profitability before safety. We, as hospital chairs,
are the only safeguard for patients undergoing procedures in the
absence of an anesthesiologist’s presence.
— M.J.L.
To Do or Not to Do
I liked your May “Ventilations,” especially the suggested
dress code. It reminded me that I once proposed that our Surgical
Evaluation Committee improve the process of granting privileges.
Instead of a lot of phony paperwork evaluations of new surgeons,
they would ask the evaluator to check “yes” or “no”:
I would allow this surgeon to perform this procedure on me. Naturally,
they paid no attention.
LeRoy Misuraca, M.D.
Long Beach, California
Show Me the Money
Eddy Fraifeld, M.D., (May 2001 “Letters to the Editor”)
is right on the money, so to speak, when he encourages us to train
residents in coding and billing rather than wasting time on matters
of professionalism. After all, anesthesiology is a business, is
it not? Let us strip away the veneer and get right to the bottom
line: How do we make the most money the fastest? Oh, and we should
be grateful that Dr. Fraifeld did not waste time pulling a pair
of pants (or even scrubs) over his bathing suit prior to showing
up in the emergency room. At least he wasn’t sunbathing in
the nude!
Keep up the good work, Dr. Lema.
Steven A. Deem, M.D.
Seattle, Washington
San Francisco ‘Niners’ Question
Residency Match Numbers
I have always enjoyed reading the wonderful summary that Alan
W. Grogano, M.D., has provided year after year about the anesthesia
medical student-resident match. Well done, as usual (May 2001
Newsletter). However, I did have one issue.
Although likely technically accurate, we felt the University
of California-San Francisco (UCSF) was misrepresented by stating
that the top three schools, as far as the number of resident applicants
match is concerned, contributed only 12 of the medical students
who went into anesthesiology. We think the inference was incorrect
as it relates to UCSF. That year, nine resident applicants were
from UCSF. We have consistently and always recruited eight to
10 medical students into anesthesia, except for 1996. We also
congratulate those departments who have recruited more than nine
medical students per year into anesthesia.
In any event, there you are.
Ronald D. Miller, M.D.
San Francisco, California
Nix Executions From Medicine
Thank you for the July installment of “Ventilations.”
Quite apart from one’s views on abortion, euthanasia or even
capital punishment, one would think that all anesthesiologists
could agree that the execution of criminals for the State is not
an act of medical care. Physicians, by the nature of the profession,
can and should help remedy some of the results of the failings
of individuals, politicians and society as a whole. This is not
one of them. Thanks again. Keep stirring the pot.
Terrence Webber, M.D., J.D.
Denver, Colorado
Locked Carts Open Pandora’s Box
Recent institutional policies devised to address (perceived)
accreditation standards may actually lead to disaster. For example,
many hospitals have removed patients’ names from operating
room scheduling boards in the name of patient confidentiality,
[using] first name only, initials, Social Security number or another
scheme. This is both unnecessary and potentially catastrophic.
Of greater concern are policies that demand anesthesia carts
and supplies be locked in areas such as obstetrics, where immediate
access to equipment and agents is unquestionable. Within the secure
confines of the operating room, noncontrolled agents must be secured
and out-of-view because of the concern that unlicensed personnel
such as scrub technicians, anesthesia-workroom and custodial staff
represent a tampering risk. Securing agents at the end of each
case distracts attention from the patient and hinders immediate
access. Most importantly, anesthesiologists should take the lead
in speaking out against the profiling of these dedicated employees
as untrustworthy.
The Joint Commission on Accreditation of Healthcare Organizations
states that its standards do not require these draconian policies.
Its consultants and surveyors demand otherwise. I have asked the
Anesthesia Patient Safety Foundation to take the lead in determining
whether such policies are indeed dangerous.
Martin S. Bogetz, M.D.
Kentfield, California
The views and opinions expressed in the “Letters to the
Editor” are those of the authors and do not necessarily reflect
the views of ASA or the NEWSLETTER Editorial Board. Letters submitted
for consideration should not exceed 300 words in length. The Editor
has the authority to accept or reject any letter submitted for
publication. Personal correspondence to the Editor by letter or
e-mail must be clearly indicated as “Not for Publication”
by the sender. Letters must be signed (although name may be withheld
on request) and are subject to editing and abridgment.
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