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May 2002
Volume 66 |
Number 5
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| House of Delegates
Adopts Updated 'Guidelines for Sedation and Analgesia by Nonanesthesiologists' |
Jeffrey B. Gross, M.D., Chair
Task Force on Sedation and Analgesia by Nonanesthesiologists
On October 17, 2001, the ASA House of Delegates approved an
update to the ASA "Guidelines for Sedation and Analgesia
by Nonanesthesiologists." This document, which was published
in April in Anesthesiology, represents the culmination of two
years of work by members of the ASA Task Force on Sedation and
Analgesia by Nonanesthesiologists.1 The task force includes anesthesiologists
(Peter L. Bailey, M.D., Charles J. Coté, M.D., Fred G. Davis,
M.D., Burton S. Epstein, M.D., Lesley I. Gilbertson, M.D., and
John M. Zerwas, M.D.), a gastroenterologist (Gregory Zuccaro,
Jr., M.D.) and two methodologists (Richard Connis, Ph.D., and
David Nickinovich, Ph.D.)
The impetus for updating the guidelines in 2001 was fourfold:
1) in 1999, the ASA House of Delegates adopted formal definitions
of levels of sedation and analgesia, including levels of sedation
ranging from minimal sedation (anxiolysis) through general anesthesia
[Table
1]; 2) the Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) has incorporated these definitions into
its 2001 standards for sedation and anesthesia care; 3) there
have been a large number of questions regarding the use of rapidly
acting anesthetic induction agents (especially propofol and ketamine)
for moderate ("conscious") and deep sedation by nonanesthesiologists;
and 4) ASA practice guidelines require re-evaluation at five-year
intervals.
Primary data for the guidelines were gathered from a systematic
review of more than 1,800 articles published between 1966 and
2001; of these, 357 articles contained data relevant to the practice
of sedation and analgesia by nonanesthesiologists. Further input
was provided by a panel of more than 50 consultants, including
anesthesiologists and nonanesthesiologist practitioners of specialties
where sedation is commonly administered for diagnostic or therapeutic
procedures. Prior to adoption, the guidelines also were presented
in two open forums. Official representatives of specialty societies
representing practitioners who frequently perform sedation and
analgesia were invited to participate.
In addition to validating and updating the recommendations presented
in the original version of the guidelines as adopted by the House
of Delegates in 1995, the updated version extends the scope of
the guidelines to include deep sedation as well as moderate or
conscious sedation. It is the hope of the task force that the
changes incorporated in the updated guidelines, as enumerated
below, will make this document more useful both to members of
the Society and to those nonanesthesiologists who administer sedation
and analgesia.
The updated guidelines specifically incorporate ASA definitions
of levels of sedation [Table
1] rather than defining "conscious sedation"
in a vacuum. Since ASA definitions have been adopted by accrediting
organizations such as JCAHO, this makes the guidelines more useful
in addressing accreditation issues. By addressing both moderate
and deep sedation, the guidelines may now be applied by a greater
number of practitioners performing a wider variety of procedures;
patients requiring "deep sedation" are no longer beyond
the scope of the guidelines.
In accordance with this, the guidelines now include the concept
of rescue – practitioners administering moderate sedation
should have the skills and equipment necessary to "rescue"
a patient from inadvertent deep sedation, while those administering
deep sedation should be able to rescue a patient from inadvertent
general anesthesia. Additionally, the exclusion for minimal sedation,
or anxiolysis, has been expanded and clarified. Thus the guideline
recommendations do not apply to patients who receive either nitrous
oxide alone or a single oral sedative or analgesic in doses appropriate
for unsupervised management of anxiety, insomnia and pain. (Note
that chloral hydrate is specifically not excluded.) In accordance
with JCAHO standards, the updated guidelines recommend that the
results of preprocedure evaluation be reconfirmed just before
the procedure begins to ensure that the patient remains a suitable
candidate for the selected level of sedation. The preprocedure
fasting recommendations have been adjusted to conform to recently
published ASA guidelines for preprocedure fasting.2 To address
concerns raised by members of the American College of Emergency
Physicians at our open forums, recommendations have been modified
to suggest that in urgent, emergent or other situations where
gastric emptying is impaired, the potential for pulmonary aspiration
of gastric contents must be considered in determining 1) the target
level of sedation, 2) whether the procedure should be delayed
or 3) whether the trachea should be protected by intubation.
Changes in the guidelines related to patient monitoring during
sedation include recommendations that monitoring of exhaled carbon
dioxide should be considered for all patients receiving deep sedation
and for patients whose ventilation cannot be directly observed
during moderate sedation. Also, electrocardiographic monitoring
is recommended for all patients undergoing deep sedation in addition
to patients with significant cardiovascular disease undergoing
moderate sedation. The revised guidelines are consistent with
the previous version in allowing the individual monitoring the
patient to perform minor, interruptible tasks once a stable level
of moderate sedation has been established; however, for deep sedation,
the revised guidelines require that the individual monitoring
the patient have no other responsibilities. For patients undergoing
deep sedation, the guidelines require that an individual with
advanced life support skills (e.g., airway management, cardiovascular
pharmacology, defibrillation) be in the procedure room and that
a defibrillator be immediately available. The guidelines recommend
that supplemental oxygen be administered to all patients undergoing
deep sedation unless specifically contraindicated. Of course the
recommendation that all patients receiving moderate sedation be
monitored by pulse oximetry has been extended to include patients
undergoing deep sedation as well.
One of the more controversial issues addressed by the new guidelines
is the use of anesthetic induction agents like methohexital, thiopental
and propofol during moderate or deep sedation. Based on the available
evidence, the updated guidelines recommend that patients receiving
propofol, thiopental or methohexital receive care consistent with
the recommendations for deep sedation regardless of the level
of sedation actually intended. Thus, if a nonanesthesiologist
wishes to use propofol to provide moderate sedation, he or she
must ensure that there is an individual in the procedure room
with advanced life support skills, that advanced life support
equipment is immediately available, that the individual monitoring
the patient has no other responsibilities and that supplemental
oxygen is administered unless specifically contraindicated. The
recommendations are not as strict for ketamine, although the guidelines
warn practitioners that patients may be more deeply sedated than
they appear after receiving this drug.
Is there any evidence that the practice guidelines have improved
patient safety or altered the practice of nonanesthesiologists
who administer sedation/analgesia? In a recently published cohort
study, Hoffman et al. demonstrated that for procedural sedation
in pediatric patients, performing (and presumably acting upon)
a structured risk assessment like that recommended in both the
original and updated ASA guidelines as well as long-standing American
Academy of Pediatrics guidelines significantly reduced the risk
of hemodynamic or cardiovascular complications (odds ratio =0.1,
P<0.02). This improvement was especially pronounced in patients
receiving deep sedation.3 In addition, a recent survey revealed
that nonanesthesiologists who perform moderate sedation complied
with significantly more of the practices recommended by the guidelines
in the year 2001 than they did in 1995.4
It is the hope of the task force that the updated guidelines
will be useful both to anesthesiologists and to nonanesthesiologists
who administer sedation and analgesia. By following the recommendations
incorporated in the guidelines, practitioners should be able to
improve the quality of nonanesthesiologist-provided sedation while
reducing associated risks.
References:
1. Practice guidelines for sedation and analgesia by nonanesthesiologists.
An updated report by the American Society of Anesthesiologists
Task Force on Sedation and Analgesia by Nonanesthesiologists.
Anesthesiology. 2002; 96:1004-1017.
2. Practice guidelines for preoperative fasting and the use of
pharmacologic agents to reduce the risk of pulmonary aspiration:
Application to healthy patients undergoing electric procedures:
A report by the American Society of Anesthesiologists Task Force
on Preoperative Fasting. Anesthesiology. 1999; 90:896-905.
3. Hoffman GM, Nowakowski R, Troshynski TJ, et al. Risk reduction
in pediatric procedural sedation by application of an American
Academy of Pediatrics/American Society of Anesthesiologists Process
Model. Pediatrics. 2002; 109:236-243.
4. Gross JB, Astle MJ. Have the ASA guidelines for sedation and
analgesia influenced the clinical practice of non-anesthesiologists?
Anesth Analg. 2002; 94 (suppl):S134.
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Jeffrey
B. Gross, M.D., is Professor of Anesthesiology and Pharmacology,
University of Connecticut School of Medicine, Farmington,
Connecticut. |
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