As otolaryngologists are performing more procedures on an in-office basis, more are also using conscious sedation in the clinic setting. They are not alone: nearly 70% of all surgical procedures are performed on an outpatient basis with conscious sedation, which avoids the costs of inpatient care. The demand for conscious sedation currently exceeds the availability of anesthesiologists and nurse anesthetists to administer the sedation, and therefore more physicians and nurses are being trained in the administration and monitoring of conscious sedation, at both moderate and deep levels.
Not surprisingly, the trend toward surgeons administering in-office conscious sedation themselves is occurring alongside concerns about safety. An article in the Wall Street Journal (August 9, 2006) pointed to the risks associated with conscious sedation, and particularly with nonanesthesiologist practitioners administering it. New guidelines have been developed by both the University HealthSystems Consortium (UHC) and the American Society of Anesthesiologists (ASA) to address these concerns and ensure the safe use of conscious sedation when the state of moderate sedation is induced. The ASA guidelines (www.asahq.org/publicationsAndServices/credentialing.pdf ) define levels of sedation and monitoring equipment, as well as the formal training, that a practitioner should have in order to safely administer moderate sedation. Both organizations are also developing guidelines for non-anesthesia professionals to administer deep sedation.
The guidelines define moderate sedation as a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation, and specify that intubation is not required and that spontaneous ventilation is adequate. Deep sedation is defined as a state in which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. Patients in deep sedation may also need intubation because spontaneous ventilation may be inadequate.
Proper Training Required
The key message is safety first, said Ira D. Papel, MD, in a phone interview. Physicians who use it need to be trained in appropriate dosing and have appropriate monitoring equipment, and they also need to know the signs that the patient may have an inappropriate dose, either too high or too low. Dr. Papel is a facial plastic and reconstructive surgeon in private practice in Baltimore, where he is an associate professor of otolaryngology/head and neck surgery at Johns Hopkins Medical Center. He is also an immediate past president of the American Academy of Facial Plastic and Reconstructive Surgery.
Physicians are using it more often for minor surgical procedures, and they can use it in-office for many procedures that don’t need to be performed in the hospital or surgery center, he said. There are many settings that offer courses in conscious sedation. Most hospitals offer one-day courses, as do many associations’ conferences and meetings. Most hospitals are willing to give physicians the privilege to do conscious sedation if they’ve undergone such training.
Although there are no special considerations for otolaryngologists to bear in mind for using conscious sedation, those who want to use it in their offices generally need more training, because it is not emphasized in residency, Dr. Papel said. He stressed that using it effectively requires different skills from those used to administer general anesthesia, which may be the frame of reference for most otolaryngologists.
When a patient is under conscious sedation, the physician should monitor blood pressure, pulse, and blood oxygen saturation. Therefore, they should use the following monitoring equipment: a continuous blood pressure cuff, an electrocardiograph machine, and a pulse oximeter.
Responsive but not Reactive
The patient should be responsive to questions and directions, but should not be reacting to the procedure. You don’t want them to be too depressed, but the patient should not be feeling the procedure and having a bad experience, Dr. Papel said. Although the patient is awake and can respond to questions, he or she may not remember the procedure.
When offering conscious sedation to patients, physicians need to tell them that they cannot drive home and also should not rely on a taxi, because they may not be able to communicate directions effectively. Therefore, they should have a responsible family member or friend drive them instead. They should also not make any important decisions for 48 hours after receiving sedation, and they may feel the after- effects of sedation for several hours. Physicians should watch patients for approximately one-half hour after the procedure to make sure it is safe for them to leave. They should be breathing well, alert, and mobile.
Using conscious sedation should be feasible for most otolaryngologists, said Dr. Papel. Thousands of physicians are using it all over the country. If you have the proper monitoring equipment and remember that safety comes first, it should go well.
Caution Is in Order
Like Dr. Papel, Alastair Carruthers, MD, stressed in a phone interview that caution should be the guidepost for conscious sedation for any procedure. He is a clinical professor of dermatology at the University of British Columbia in Vancouver, British Columbia, Canada, and he is the president-elect of the American Society for Dermatologic Surgeons.
I think conscious sedation is extremely valuable in the right set of circumstances, he said. You want to have a patient with a good anesthetic risk, and you want a facility that is properly equipped, with proper monitoring and drugs to induce sedation and correct sedation if any problems occur.
He added that some procedures may not be appropriate for conscious sedation, or that the typical approach needs to be modified for a sedated patient. I don’t think it’s appropriate for liposuction unless you use a lower safe level of lidocaine, he said, noting that lidocaine and sedating agents are metabolized by the same liver enzymes, and therefore, the risk of drug-drug interaction is increased.
In addition to monitoring equipment and reversing medication, the facility needs to have the equipment necessary to intubate, should the occasion arise, including a laryngoscope. The cart needs to be checked on a regular basis, and the staff needs to be trained in conscious sedation, Dr. Carruthers added. Ideally an anesthesiologist should be present. It’s an excellent technique, but it’s one level short of general anesthesia and you need to manage it properly, and the facilities should be accredited by a proper accrediting agency.
Although the thought of yet another accreditation process may be daunting, it should be a collaborative experience between the facility and the accreditation agency, he said. I find the accreditation process nothing but helpful, Dr. Carruthers said, adding that if the facility’s effort to strive for excellence is obvious, the accreditation staff will become more relaxed over time.
He agreed with Dr. Papel that patients should be advised not only not to drive, but to bring a driver rather than relying on a cab, and to delay important decisions for 48 hours after having been sedated.
Although his preference is for an anesthesiologist to monitor the conscious sedation, he added that there is a role for surgeons to administer it under certain circumstances. I think a physician licensed to practice should be able to do what he or she is trained to do, he said. If an individual goes through a prescribed course of training to safely administer and supervise conscious, that’s fine.
However, he stressed that the key is safety. The person administering the sedation-an anesthesiologist, surgeon, or nurse anesthetist-needs to be able to concentrate on an individual if things go wrong, he said.
©2006 The Triological Society