Procedural Sedation and Analgesia

CHAPTER 2 Procedural Sedation and Analgesia



Sylvana Guidotti


Procedural sedation and analgesia (PSA) is the clinical practice of using pharmacologic agents to achieve a measurable level of sedation, while performing typically painful or anxiety-provoking procedures. The term conscious sedation is no longer used because it describes neither the intent nor the outcome of the process. PSA allows the nonanesthesiologist to perform selected procedures in a safe and controlled setting.


The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) has produced sedation guidelines to describe and define the spectrum of PSA. More important, the American Society of Anesthesiologists (ASA) and the American College of Emergency Physicians (ACEP) have published guidelines for PSA by nonanesthesiologists and emergency physicians, respectively. As defined by the ASA, PSA is a continuum from minimal sedation/analgesia to general anesthesia.


Minimal sedation occurs when the patient continues to respond normally to verbal commands without cardiopulmonary functions being affected. Moderate sedation is a state of depressed consciousness where the patient responds appropriately to verbal command with or without light tactile stimuli. Dissociative sedation should be considered a form of moderate sedation that occurs when a dissociative pharmacologic agent produces a trancelike state. The result is analgesia and amnesia while protective airway reflexes and cardiovascular stability are maintained. Deep sedation causes a depression of consciousness in which the patient is not easily arousable but responds purposefully with repeated or painful stimuli. At this level, the patient may require assistance in maintaining airway and ventilation. General anesthesia is at the end of the spectrum; consciousness is lost and the patient is unarousable to any stimuli. The patient requires ventilatory assistance, and cardiovascular function may be affected or impaired.


For coding purposes, the American Medical Association CPT coding manual describes “moderate (conscious) sedation” as a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is maintained. It does not include minimal sedation (anxiolysis), deep sedation, or monitored anesthesia care (Table 2-1).



TABLE 2-1 Operational Definitions and Characterizations of Levels of Sedation–Analgesia

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PSA comprises three components. First there is the process of sedation, which requires a thorough knowledge of the agents being administered. Next is the intended procedure to be performed. Finally, there are the unpredictable side effects and untoward reactions to the sedating medications, which can occur during or in the recovery phase of the procedure.


The physician should be familiar with all of the appropriate monitoring and rescue equipment. A suitably trained provider should assist with the sedation. All individuals who participate in the care of the patient undergoing PSA must demonstrate ongoing clinical competency and be privileged for the procedure if they will be performing it in a hospital setting.



Indications


As nonanesthesiologist physicians become more comfortable with PSA, the roster of appropriate procedures where these agents are beneficial continues to expand. The list includes, but is not limited to, the following:


• Anal procedures

• Biopsy procedures

• Bone marrow aspiration or biopsy

• Bronchoscopy

• Cardioversion (electrical or chemical)

• Dental/oral surgical procedures

• Endometrial biopsy

• Essure contraceptive placement

• Fracture reductions/care

• Gastrointestinal endoscopy

• Hysterosalpingography

• Lumbar puncture

• Magnetic resonance imaging/computed tomography scans/invasive radiographic procedures

• Office dilation and curettage/vacuum aspiration

• Orthopedic procedures

• Phlebectomy

• Plastic/cosmetic/laser procedures

• Wound repair/care, including burns; large excisions

PSA can be used in conjunction with and as a supplement to digital blocks, hematoma blocks, or regional nerve blocks as well as topical anesthetic agents. These modalities may obviate the need for deeper levels of sedation. Other distractions for the patient such as music or videos are useful adjuncts.



Contraindications


Elective procedures on pregnant patients should be deferred until after delivery. Patients with severe unstable systemic disease and patients with potentially unstable airways should be directed to a higher level of care. The ASA classification of systemic disease is designed to guide the physician as to which patients are appropriate candidates for PSA (Table 2-2).


TABLE 2-2 American Society of Anesthesiologists (ASA) Physical Status Classification





















ASA Classification Sedation Risk
Class I: Normal healthy patient Minimal
Class II: Mild systemic disease without physical limitation Low
Class III: Severe systemic disease with functional limitations Intermediate
Class IV: Severe systemic disease that is a constant threat to life High
Class V: Moribund patient who may not survive without procedure Extremely high

Class II patients include those with well-controlled hypertension, controlled non–insulin-dependent diabetes, and minimal cardiac or respiratory disease. Class III patients include those with insulin-dependent diabetes mellitus, poorly controlled hypertension, significant cardiac or respiratory disease, and significant renal or hepatic disease. Based on individual experience and skill in providing sedation, practitioners may decide to limit the amount of patient risk they are willing to accept, using the ASA guidelines.


In general, the nonanesthesiologist physician who provides PSA in the private office setting should do so on patients with class II status or less. For hospital-based procedures outside of the operating room, PSA may be performed on patients up to and including class III status.


The ASA has set forth preprocedure fasting guidelines for scheduled elective cases. However, in separate recommendations for PSA, the ASA states, “The literature does not provide sufficient evidence to test the hypothesis that preprocedure fasting results in a decreased incidence of adverse outcomes in patients undergoing either moderate or deep sedation.” The current guidelines are the result of consensus, rather than being evidence based, with respect to the risk of aspiration. The recommendations are 6 hours for solids, cow’s milk, and infant formula; 4 hours for breast milk; and 2 hours for clear liquids. ACEP recognizes that there are certain emergent situations in which the benefits of PSA at any sedation depth outweigh the potential risks. In all other circumstances, it would be best to strictly adhere to the fasting guidelines. Thus, if a patient has not followed the aforementioned fasting guidelines, it would be best to postpone the procedure or just not use significant PSA.



Equipment



• A single unit with blood pressure and electrocardiographic measurements, variable-pitch beep pulse oximeter, and recording device is the ideal monitor for PSA. Individual units are acceptable but require repeated manual recordings of the readings on the patient’s chart.

• Angiocatheter for intravenous (IV) access (at least 20 gauge), IV solution, and stand.

• Oxygen source.

• Medications for sedation and analgesia.

• Reversal medications.

• Diphenhydramine and epinephrine to be used in the event of severe allergic reactions.

• Crash cart or Banyan kit with equipment and medications for basic and advanced cardiac life support (ACLS; see Chapter 220, Anaphylaxis).

• Suction device.

• Defibrillator (Fig. 2-1).

image

Figure 2-1 Defibrillator.


(Courtesy of Zoll Medical Corp., Chelmsford, Mass.)

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May 14, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Procedural Sedation and Analgesia

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