Procedural Sedation- CAS Position Paper

A position paper from the Canadian Anesthesiologists’ Society on procedural sedation, incorporating patient selection and pre-procedural assessment and monitoring. A dedicated provider for deeper sedation is advised along with developing institutional guidelines and policies. Monitoring of oxygen saturation and capnography are vital. Fasting guideline as per ASA are recommended in all but the lightest sedation scenarios. Rescue equipment and medications should be available. Proper recovery and discharge assessment is required, such as the use of modified Aldrete scoring.



Propofol Sedation in Elderly

An analysis of 740 patients over 75 years of age undergoing sedation in the ER revealed it is by and large a safe practice. Propofol was used in the majority, followed by Morphine and Midazolam, then many others.

The authors found – “A sentinel adverse event rate of 2.6% including a hypoxaemia rate of 0.5%, with no adverse outcomes sets a benchmark for elderly sedation”. Apnea(without hypoxia), hypotension and hypoxia ranked in order as the most common sentinel events. Recommendations include quality pre-oxygenation, an initial propofol bolus of no more than 0.5 mg kg−1, and perhaps most importantly, a robust training and governance framework.



Patient-Controlled Vs. Clinician-Controlled Sedation With Propofol

A systematic review and meta-analysis of randomized controlled trials compared patient-controlled Propofol (including target-controlled) sedation with clinician-controlled sedation for diagnostic or therapeutic procedures.

There was no difference in oxygen desaturation but patient control significantly decreased the risk of rescue interventions for sedation-related adverse events like chin lift, bag/mask ventilation, vasopressors or bradycardia treatment. Attempts were made to control for the use of other medications. Operator and patient satisfaction were similar. The overall quality of the evidence was low, so clinician involvement still seems mandatory for now.



Radiation Safety in Anesthesiology

Whereas most pediatric anesthesiologists had concerns about radiation safety, the findings in this study were quite concerning. “Dosimeters were rarely (13%) or never used (52%) and were mandated in only 28.5% of institutions. Virtually none of the respondents had ever taken a radiation safety course, received a personal radiation dose report, notification of their radiation exposure, or knew how many millirem/y was considered safe”.

It is reminiscent of non-scavenged ORs in the past where exposure to gases was common. The authors highlight the need for a safety culture in institutions and the need for more rigorous use of lead and thyroid shields, eye protection and dosimeter use.


Agitation in adults in the post-anaesthesia care unit

This analysis studied factors associated with agitation after general anesthesia in adults:

Substance use disorder, cognitive impairment, psychiatric conditions, obesity, fall risk, presence of indwelling tracheal tubes/NG tubes/chest tubes/urinary catheters.

Such factors could help plan and allocate staff and resources to the post-anesthesia care unit to optimize patient safety.


Discharge Home from ICU

An interesting study finds no increased risks with discharge directly home from ICU rather than the usual step down to a ward. The study was retrospective and such patients were younger, more likely to be admitted with a diagnosis of overdose, substance withdrawal, seizures, or metabolic coma, to have a lower severity of acute illness on ICU admission, and receive less than 48 hours of invasive mechanical ventilation.

There were no significant increases in readmissions, ER visits in 30 days or 1 year mortality. While not a general recommendation, selected patients may be candidates for discharge directly home.