A reply

Abstract

Many thanks to Professor Wildsmith for his thought provoking letter. As author of many publications pertaining to safety in anaesthesia, I am particularly grateful for his comments. To address a few points arising from the letter, the first relates to the Academy’s Recommendations which refer only to ‘conscious sedation’ [1]. As we know sedation is not a single entity but rather a continuum. Conscious or moderate sedation refers to a drug-induced depression of consciousness during which a patient responds 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. Deep sedation refers to a state of drug-induced depression of consciousness during which patients cannot easily be aroused, but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be impaired [2]. As our study illustrates, of the 111 participants who completed the questionnaire, 14 participants had a patient who suffered a hypoxia event; six, a patient who experienced respiratory depression; two, a patient who lost consciousness; four, a patient with prolonged sedation and two, a patient who required anaesthesia assistance. These adverse events suggest a level of sedation greater than ‘conscious or moderate’ sedation closer to deep sedation or perhaps even general anaesthesia. Herein lies the dilemma, the guidelines laid down by the Academy for the administration of conscious sedation by non-anaesthetists are just that, guidelines for ‘conscious sedation’. This study suggests that approximately 20% of non-anaesthetic doctors have had occasion where the ‘conscious sedation state’ they hoped to achieve was in reality closer to deep sedation. Where does this leave us as anaesthetists logistically and ethically? As correctly identified by Professor Wildsmith, we simply do not have the manpower resources to staff all out of operating theatre locations, nor perhaps do we wish to. Current practices often lead to late rescue missions suboptimal for patient care, and indeed for inter-departmental morale. Guidelines created by intercollegiate bodies are a useful starting point for establishing best practice, but need to permeate to the local level to have their desired impact. Most fundamental to this process is training, and we as anaesthetists have an important role to play in the practical education of non-anaesthetists in both the administration, and recognition of safe sedation.