Sedation Practices Research Articles

Cannulation: an update for dentists

Peripheral venous cannulation is a skill dentists may require in hospital jobs and sedation practice. This article provides a comprehensive overview of the technique, equipment, relative contraindications and potential complications. CPD/Clinical Relevance: To act as an update and refresher for the dental team on peripheral venous cannulation.

Descriptive analysis of palliative sedation in a pediatric palliative care unit

IntroductionData surrounding palliative sedation in pediatric patients is scarce. Our objective is to assess the utility of creating a quality standard for pediatric palliative sedation. Material and methodsA non-systematic review of the literature was used to find recommendations for pediatric palliative sedation, after which a definition was established based on three items: (1) indication, (2) consent, and (3) application. Afterwards, a retrospective analysis of palliative sedations applied by our unit over 5 years was performed. ResultsOut of 163 patients, palliative sedation was applied in 20, in 17 of them by our unit (14/20 males; median: 11.9 years). Twelve patients had oncological diseases, seven had neurological conditions, and one had a polymalformative syndrome. Nine patients had more than one symptom at the time of PS initiation with pain (11/17) and dyspnoea (10/17) being the most frequent. As for the definition, only three patients achieved a global completion, with the registration of the consent, specification of refractoriness and the establishment of an adequate initial sedative dose being the areas with more possible improvement. ConclusionsThe application of the definition allowed us to analyze and find areas of improvement for our clinical practice of palliative sedation in pediatric patients.

Low-Dose Esketamine as an Adjuvant to Propofol Sedation for Same-Visit Bidirectional Endoscopy: Protocol for a Multicenter Randomized Controlled Trial.

BackgroundSame-visit bidirectional endoscopy (esophagogastroduodenoscopy and colonoscopy) is widely performed under sedation. At present, the optimal sedation regimen remains unclear. This study aims to test the hypothesis that a low-dose esketamine added to propofol sedation reduces hemodynamic and respiratory adverse events in these procedures.MethodsIn this multicenter, randomized, double-blind, placebo-controlled trial, 660 adult patients scheduled for same-visit bidirectional endoscopy under sedation from 3 teaching hospitals in China will be recruited. Patients will be randomly allocated, in a 1:1 ratio, to an esketamine group or a normal saline group (n = 330 in each group), stratified by study center. All patients will receive intravenous propofol 0.5 mg/kg and sufentanil 0.1 μg/mL for induction of sedation, followed by intravenous esketamine 0.15 mg/kg or the same volume of normal saline. Propofol will be titrated to the target sedation levels during the procedures. The primary endpoint is a composite of desaturation (peripheral oxygen saturation < 90%) and hypotension (systolic blood pressure <80 mmHg or decrease >30% of baseline). Secondary endpoints include desaturation, hypotension, total dose of propofol, pain scores and fatigue scores on the 0–10 numerical rating scale, dizziness or headache, hallucination or nightmare, nausea or vomiting, endoscopist satisfaction, and patient satisfaction. All analyses will be intention-to-treat.DiscussionWe expect that a low-dose esketamine adjunct to propofol-based sedation will improve cardiorespiratory stability in patients undergoing same-visit bidirectional endoscopy, providing reference for clinical sedation practice during these procedures.Trial RegistrationChinese Clinical Trial Registry (Identifier: ChiCTR-ChiCTR2200055938).

Physicians' Experiences and Perceptions of Environmental Factors Affecting Their Practices of Continuous Deep Sedation until Death: A Secondary Qualitative Analysis of an Interview Study.

As previous research has paid little attention to environmental factors affecting the practice of continuous deep sedation until death (CDS), we aimed to explore these using physicians’ experiences and perceptions. We performed an interpretative thematic analysis of primary data from a qualitative interview study conducted from February to May 2019 in Belgium with 47 physicians. Structural factors were identified: the lack of professional and/or technical support in monitoring sedated patients; the use of guidelines in team contexts; the time constraints for treating individual patients and work pressure; the structural knowledge gap in medical education; the legal context for assisted dying; and the lack of a clear legal context for CDS. Cultural factors were identified: the moral reservations of care teams and/or institutions towards CDS; the presence of a palliative care culture within care teams and institutions; the culture of fear of making clinical errors regarding CDS among a group of physicians; the professional stigma of performing assisted dying among some of the physician population; the different understandings of CDS in medical and policy fields; and the societal taboo around suffering at the end of life and natural death. To conclude, improving CDS practice requires a whole-system approach considering environmental factors.

Cover

The cover image is based on the Research Report Trends and patterns in the practice of pediatric sedation for magnetic resonance imaging in Japan: A longitudinal descriptive study from 2012 to 2019 by Tatsuya Tsuji et al., https://doi.org/10.1111/pan.14396.

Survey of Anesthesia, Sedation, and Non-sedation Practices for Children Undergoing Repetitive Cranial or Craniospinal Radiotherapy.

BackgroundChildren undergoing cranial or craniospinal radiotherapy may require over 30 treatments within a six-week period. Facilitating these many treatments with the patient under anesthesia presents a significant challenge, and the most preferred anesthetic methods remain unknown. The primary goal of this study was to determine the most preferred anesthetic methods and agents for children undergoing daily cranial or craniospinal radiotherapy.MethodsAn 83-item web-based survey was developed. An introductory email was sent to 505 physicians and child-life specialists with expertise in pediatric anesthesia and/or affiliated with pediatric radiation oncology departments.ResultsThe response rate was 128/505 (25%) and included specialists from Africa (5, 4%), Asia (18, 14%), Australia/Oceania (5, 4%), Europe (45, 35%), North America (50, 39%), and South America (5, 4%). The 128 respondents included 91 anesthesiologists (71%), 20 physicians who were not anesthesiologists (16%), 14 child life/social education specialists (11%), one radiotherapist, one pediatric radiation nurse, and one non-specified medical professional (all = 2%). Of the 128 respondents, 95 (74%) used anesthesia or sedation to facilitate repetitive cranial or craniospinal radiotherapy. Overall, total intravenous anesthesia without intubation was preferred by 67 of 95 (71%) specialists during one or more forms of radiotherapy. During photon-based radiotherapy, total intravenous anesthesia without intubation was the preferred anesthetic method with the patient in the supine (57/84, 68%) and prone positions (25/40, 63%). Propofol was the most used anesthetic agent for both supine (73/84, 87%) and prone positions (38/40, 95%). For proton radiotherapy, total intravenous anesthesia without intubation was the most preferred anesthetic method for the supine (32/42, 76%) and prone treatment positions (11/18, 61%), and propofol was the most used anesthetic (supine: 40/43, 93%; prone: 16/18, 89%).ConclusionsIn this survey of 95 specialists responsible for anesthesia or sedation of children undergoing repetitive cranial or craniospinal radiotherapy, propofol-based total intravenous anesthesia without intubation was the preferred anesthetic technique.

The Feasibility of Implementing Targeted SEDation in Mechanically Ventilated Emergency Department Patients: The ED-SED Pilot Trial.

Deep sedation in the emergency department (ED) is common, increases deep sedation in the ICU, and is negatively associated with outcome. Limiting ED deep sedation may, therefore, be a high-yield intervention to improve outcome. However, the feasibility of conducting an adequately powered ED-based clinical sedation trial is unknown. Our objectives were to assess trial feasibility in terms of: 1) recruitment, 2) protocol implementation and practice change, and 3) safety. Patient-centered clinical outcomes were assessed to better plan for a future large-scale clinical trial. Pragmatic, multicenter ( n = 3), prospective before-after pilot and feasibility trial. The ED and ICUs at three medical centers. Consecutive, adult mechanically ventilation ED patients. An educational initiative aimed at reliable ED sedation depth documentation and reducing the proportion of deeply sedated patients (primary outcome). Sedation-related data in the ED and the first 48 ICU hours were recorded. Deep sedation was defined as a Richmond Agitation-Sedation Scale of -3 to -5 or a Sedation-Agitation Scale of 1-3. One thousand three hundred fifty-six patients were screened; 415 comprised the final population. Lighter ED sedation was achieved in the intervention group, and the proportion of deeply sedated patients was reduced from 60.2% to 38.8% ( p < 0.01). There were no concerning trends in adverse events (i.e., inadvertent extubation, device removal, and awareness with paralysis). Mortality was 10.0% in the intervention group and 20.4% in the preintervention group ( p < 0.01). Compared with preintervention, the intervention group experienced more ventilator-free days [22.0 (9.0) vs 19.9 (10.6)] and ICU-free days [20.8 (8.7) vs 18.1 (10.4)], p < 0.05 for both. This pilot trial confirmed the feasibility of targeting the ED in order to improve sedation practices and reduce deep sedation. These findings justify an appropriately powered clinical trial regarding ED-based sedation to improve clinical outcomes.

Reversal Agents in Sedation and Anesthesia Practice for Dentistry.

Reversal agents are defined as any drug used to counteract the pharmacologic effects of another drug. Several pharmacologic antagonists serve as essential drugs in the contemporary practices of sedation providers and anesthesiologists. Reversal or "antidote" drugs, such as flumazenil and naloxone, are often used in unintentional overdose situations involving significant benzodiazepine- and/or opioid-induced respiratory depression. Within the context of skeletal muscle relaxation, neostigmine and sugammadex are routinely used to reverse the effects of nondepolarizing neuromuscular blocking agents. In addition, the alpha-adrenergic antagonist phentolamine is used in dentistry as a local anesthetic reversal agent, decreasing its duration of action by inducing vasodilation. This review article discusses the pharmacology, uses, practical implications, adverse effects, and precautions needed for flumazenil, naloxone, neostigmine, sugammadex, and phentolamine within the context of sedation and anesthesia practice for dentistry.

Evaluation of Sedation and Monitoring for Gastrointestinal Endoscopy among Gastrointestinal Endoscopy Practitioners in Nigeria

Background: Several guidelines have been developed for the practice of gastrointestinal endoscopy. The rationale for sedation in gastrointestinal endoscopy is the alleviation of pain/discomfort and anxiety experienced by patients during the procedure. The aim of this study was to evaluate the use of sedation for gastrointestinal endoscopy among practitioners of gastrointestinal endoscopy at a conference in Nigeria.&#x0D; Materials and Methods: A cross-sectional descriptive study was carried out among gastrointestinal endoscopy practitioners. The study setting was the 13th annual general meeting and scientific conference of the Society for Gastroenterology and Hepatology in Nigeria (SOGHIN) that held in Port Harcourt Nigeria from 26th to 30th of July 2021.&#x0D; Results: A total of one hundred and four (104) respondents participated in the study. Fifty-two (50.0%) respondents carried out ≥15 upper gastrointestinal endoscopies per month in their centre. It was the opinion of 36 (34.6%) respondents that ≥15 lower gastrointestinal endoscopies per month were being done in their centre. Twenty-six (25%) respondents used the drug midazolam for sedating patients for upper gastrointestinal endoscopy, and another 26 (25%) use diazepam and pentazocine. Under-sedation was a problem for 44 (42.3%) respondents occasionally led to aborting the procedure. There was significant relationship between achievement of ≥ 90% sedation&#x0D; adequacy and the type of personnel administering the drug (P=0.000).&#x0D; Conclusion: Although better sedation has been reported to be achieved with the use of midazolam, there was no uniformity in the practice of sedation for gastrointestinal endoscopy among the respondents.

Postintubation Sedation After a Formulary Change From Succinylcholine to Rocuronium in a Critical Care Transport Organization

ObjectiveRocuronium is increasingly used as a first-line neuromuscular blocker (NMB) in rapid sequence intubation by transport teams. Prior work has shown that rocuronium is associated with a delay in postintubation sedation compared with intubation with succinylcholine. MethodsBoston MedFlight is a consortium-based transport organization. In 2017, the intubation protocol and formulary for Boston MedFlight was changed to replace succinylcholine with rocuronium. We performed a retrospective review of patients intubated by the critical care transport teams from January 2017 through December 2019. ResultsWe analyzed data for 264 intubations, 92 with succinylcholine and 172 with rocuronium. Ketamine and etomidate were the most common induction agents. The mean time from NMB administration to the first dose of sedation was 9.2 minutes (95% confidence interval, 5.4-23.7) for the succinylcholine cohort and 14.8 minutes (95% confidence interval, 8.4-38.0; P < .001) for the rocuronium cohort. After neuromuscular blockade, the total hourly weight-adjusted fentanyl dose was significantly lower for patients intubated with rocuronium compared with succinylcholine. ConclusionsIntubation with rocuronium was associated with a longer time until the administration of sedation and decreased postneuromuscular blockade fentanyl administration compared with intubation with succinylcholine. These findings suggest opportunities for improvement in sedation and analgesia practices after rocuronium rapid sequence intubation.

Chapitre 5. Évaluer le confort du patient en contexte de pratiques sédatives : enjeux éthiques des innovations en médecine palliative

In the context of end of life, palliative care offers support for the patient and his family, from a global perspective. This means paying attention to pain and difficult symptoms, but also to psychological, social and spiritual issues. Some situations confront healthcare teams with the difficulty of providing support to the end of life, not only in terms of relieving pain and suffering, but also when communication is impaired or even impossible. This is particularly the case with sedative practices. These situations involve providing comprehensive support by different evaluations of the patient&#8217;s pain and discomfort. This is therefore carried out by hetero-evaluation, by following observational pain assessment scales. Monitoring devices, such as ANI, usually used in anesthesia services, are experimented, for clinical purposes but also for research. In this article, we propose to analyze a clinical situation in which the use of ANI raised a whole series of questions about the use of the technical approach in palliative medicine and its integration into a care team. We will question some issues, in context, on the use of techniques and technologies in palliative medicine.

Current status of nitrous oxide use in pediatric patients.

Nitrous oxide is one of the most commonly used inhalational anesthetic agents used in practice. It is a cost-effective, pleasant, safe, and versatile anesthetic agent with many desirable properties like good quality analgesia, decreased awareness, accelerated induction and recovery from anesthesia, and reduced utilization of other expensive inhalational agents with potential cost savings. The use of nitrous oxide has been questioned by a lot of studies and case reports perceiving its adverse systemic, hematological, immune, and neurologic adverse effects. However, the literature in the recent past has tried to resolve the controversies related to its use. The concerns over an increase in cardiovascular complications and mortality following nitrous oxide use have been negated by recent data. However, its use in certain vulnerable populations like children with cobalamin and folate deficiency or defects in their metabolic pathways remains a cause of concern for its toxic effects. In this narrative review, we aim to discuss the pharmacological properties of nitrous oxide, the potential advantages and drawbacks of the use of nitrous oxide in children, address the neurodevelopmental and other systemic effects, and throw light on the evidence regarding the safety of nitrous oxide use and its current role in pediatric procedural sedation and anesthesia practice. The literature related to its use in the pediatric population for painful procedures and surgeries has been summarized.

Trends and patterns in the practice of pediatric sedation for magnetic resonance imaging in Japan: A longitudinal descriptive study from 2012 to 2019.

Worldwide, pediatric sedation for magnetic resonance imaging is a standard practice; however, there are few studies on its trends and patterns. This study aimed to investigate the trends and patterns of pediatric sedation for magnetic resonance imaging in Japan and determine the incidence of and risk factors for adverse events/interventions. This longitudinal descriptive study assessed children (age<15years) who underwent sedation for magnetic resonance imaging between April 2012 and December 2019 in Japan using a nationwide claims database. We assessed the patients' demographic characteristics, time trends in sedatives, sedative patterns by age, and adverse events/interventions within two post-sedation days. Further, we used multivariable logistic regression models to explore factors related to the incidence of adverse events/interventions. We identified 29 187 cases (median age, 2.0years; 55.2% males). The most common sedative was triclofos sodium (n=18 812, 51.7%). There was an increasing trend in barbiturate use (17.0% [2012] to 25.0% [2019]) and decreasing trends in the use of triclofos sodium (56.4% [2012] to 47.7% [2019]) and chloral hydrate (15.6% [2012] to 10.8% [2019]). We identified 534 adverse events/interventions in 460 cases (1.5%). Multivariable logistic regression analyses revealed that the incidence of adverse events/interventions mainly increased with the number of sedatives (≥3; adjusted odds ratio, 5.10; 95% confidence interval, 3.67-7.10) and unscheduled setting (adjusted odds ratio, 6.28; 95% confidence interval, 4.85-8.61); further, it decreased with high hospital procedure volume (adjusted odds ratio, 0.62; 95% confidence interval, 0.49-0.78). Based on a Japanese real-world setting, there is an increasing trend in barbiturate use and decreasing trends in the use of triclofos sodium and chloral hydrate in pediatric sedation for magnetic resonance imaging. Low hospital procedure volumes were associated with an increased risk of adverse events/interventions.

Retrospective audit of midazolam dose and intravenous sedation record keeping in a primary care oral surgery service

Regular and robust audit of conscious sedation practice is key to the delivery of safe and effective patient care in all clinical settings. Analysis of outcomes will help to highlight any necessary modifications to procedures and techniques. The Intercollegiate Advisory Committee for Sedation in Dentistry (IACSD) states that conscious sedation procedures must be the subject of robust and regular audit in which every member within the team takes part.1 This completed audit cycle highlighted the efficacy of intravenous (IV) midazolam in anxious patients undergoing oral surgical procedures and the suitability for its use in the primary care setting. No patient safety concerns or complications were recorded in this audit and midazolam was administered within the recommended dose range. By the conclusion of two audit cycles, all clinicians providing intravenous sedation within the service were aware of the missing elements in sedation record-keeping and were able to complete accurate contemporaneous records before, during and after conscious sedation, ensuring the continuous delivery of high-quality, safe, and patient-centred care.

Retrospective review for procedural sedation and analgesia in paediatric patients in urgent care centre in a local private hospital in Hong Kong

Introduction: Procedural sedation and analgesia in children refer to the use of pharmacological measures to facilitate the management of painful procedures or emergency imaging, usually in emergency setting by non-anaesthetists. Emergency clinicians, nurses, patients and caregivers all have their roles to play in providing a safe sedation practice in the busy emergency department. Method: We did a retrospective review of all procedural sedation and analgesia done in patients below the age of 12 in our urgent care centre from October 2018 to August 2019. Results: There were 144 patients being identified in our review. Majority of them received intramuscular ketamine ranging from 2 to 4 mg/kg. There was no documented severe adverse effect in our review. Conclusion: Paediatric procedural sedation and analgesia is generally safe, efficient, adequate and facilitate early patient discharge.

Multicenter Retrospective Review of Ketamine Use in the ICU.

IMPORTANCE:The response of ICU patients to continuously infused ketamine when it is used for analgesia and/or sedation remains poorly established.OBJECTIVES:To describe continuous infusion (CI) ketamine use in critically ill patients, including indications, dose and duration, adverse effects, patient outcomes, time in goal pain/sedation score range, exposure to analgesics/sedatives, and delirium.DESIGN, SETTING, AND PARTICIPANTS:Multicenter, retrospective, observational study from twenty-five diverse institutions in the United States. Patients receiving CI ketamine between January 2014 and December 2017.MAIN OUTCOMES AND MEASURES:Chart review evaluating institutional and patient demographics, ketamine indication, dose, administration, and adverse effects. Pain/sedation scores, cumulative doses of sedatives and analgesics, and delirium screenings in the 24 hours prior to ketamine were compared with those at 0–24 hours and 25–48 hours after.RESULTS:A total of 390 patients were included (median age, 54.5 yr; interquartile range, 39–65 yr; 61% males). Primary ICU types were medical (35.3%), surgical (23.3%), and trauma (17.7%). Most common indications were analgesia/sedation (n = 357, 91.5%). Starting doses were 0.2 mg/kg/hr (0.1–0.5 mg/kg/hr) and continued for 1.6 days (0.6–2.9 d). Hemodynamics in the first 4 hours after ketamine were variable (hypertension 24.0%, hypotension 23.5%, tachycardia 19.5%, bradycardia 2.3%); other adverse effects were minimal. Compared with 24 hours prior, there was a significant increase in proportion of time spent within goal pain score after ketamine initiation (24 hr prior: 68.9% [66.7–72.6%], 0–24 hr: 78.6% [74.3–82.5%], 25–48 hr: 80.3% [74.6–84.3%]; p < 0.001) and time spent within goal sedation score (24 hr prior: 57.1% [52.5–60.0%], 0–24 hr: 64.1% [60.7–67.2%], 25–48 hr: 68.9% [65.5–79.5%]; p < 0.001). There was also a significant reduction in IV morphine (mg) equivalents (24 hr prior: 120 [25–400], 0–24 hr: 118 [10–363], 25–48 hr: 80 [5–328]; p < 0.005), midazolam (mg) equivalents (24 hr prior: 11 [4–67], 0–24 hr: 6 [0–68], 25–48 hr: 3 [0–57]; p < 0.001), propofol (mg) (24 hr prior: 942 [223–4,018], 0–24 hr: 160 [0–2,776], 25–48 hr: 0 [0–1,859]; p < 0.001), and dexmedetomidine (µg) (24 hr prior: 1,025 [276–1,925], 0–24 hr: 285 [0–1,283], 25–48 hr: 0 [0–826]; p < 0.001). There was no difference in proportion of time spent positive for delirium (24 hr prior: 43.0% [17.0–47.0%], 0–24 hr: 39.5% [27.0–43.8%], 25–48 hr: 0% [0–43.7%]; p = 0.233). Limitations to these data include lack of a comparator group, potential for confounders and selection bias, and varying pain and sedation practices that may have changed since completion of the study.CONCLUSIONS AND RELEVANCE:There is variability in the use of CI ketamine. Hemodynamic instability was the most common adverse effect. In the 48 hours after ketamine initiation compared with the 24 hours prior, proportion of time spent in goal pain/sedation score range increased and exposure to other analgesics/sedatives decreased.

Practices in sedation, analgesia, mobilization, delirium, and sleep deprivation in adult intensive care units (SAMDS-ICU): an international survey before and during the COVID-19 pandemic

BackgroundSince the publication of the 2018 Clinical Guidelines about sedation, analgesia, delirium, mobilization, and sleep deprivation in critically ill patients, no evaluation and adequacy assessment of these recommendations were studied in an international context. This survey aimed to investigate these current practices and if the COVID-19 pandemic has changed them.MethodsThis study was an open multinational electronic survey directed to physicians working in adult intensive care units (ICUs), which was performed in two steps: before and during the COVID-19 pandemic.ResultsWe analyzed 1768 questionnaires and 1539 (87%) were complete. Before the COVID-19 pandemic, we received 1476 questionnaires and 292 were submitted later. The following practices were observed before the pandemic: the Visual Analog Scale (VAS) (61.5%), the Behavioral Pain Scale (BPS) (48.2%), the Richmond Agitation Sedation Scale (RASS) (76.6%), and the Confusion Assessment Method for the Intensive Care Unit (CAM-ICU) (66.6%) were the most frequently tools used to assess pain, sedation level, and delirium, respectively; midazolam and fentanyl were the most frequently used drugs for inducing sedation and analgesia (84.8% and 78.3%, respectively), whereas haloperidol (68.8%) and atypical antipsychotics (69.4%) were the most prescribed drugs for delirium treatment; some physicians regularly prescribed drugs to induce sleep (19.1%) or ordered mechanical restraints as part of their routine (6.2%) for patients on mechanical ventilation; non-pharmacological strategies were frequently applied for pain, delirium, and sleep deprivation management. During the COVID-19 pandemic, the intensive care specialty was independently associated with best practices. Moreover, the mechanical ventilation rate was higher, patients received sedation more often (94% versus 86.1%, p < 0.001) and sedation goals were discussed more frequently in daily rounds. Morphine was the main drug used for analgesia (77.2%), and some sedative drugs, such as midazolam, propofol, ketamine and quetiapine, were used more frequently.ConclusionsMost sedation, analgesia and delirium practices were comparable before and during the COVID-19 pandemic. During the pandemic, the intensive care specialty was a variable that was independently associated with the best practices. Although many findings are in accordance with evidence-based recommendations, some practices still need improvement.

Using inhalation sedation in practice

This article outlines considerations for use of inhalation sedation (IS) in a primary care setting. It looks at indications, contra-indications and case selection for use of IS in practice. The article also considers relevant rules, regulations and guidelines a practitioner should be aware of if practicing inhalation sedation. Some useful practical tips are included on setting up an inhalation sedation practice and being compliant with the Care Quality Commission (CQC) regulations. Standard requirements for staff and patient safety in practice setting are discussed, as are training, governance and CPD requirements for the dental team providing sedation in accordance with latest guidelines on conscious sedation.CPD/Clinical Relevance: This article will be useful for clinicians looking to update their knowledge on the use of inhalation sedation in the primary care setting.

Nursing Guidelines for Sedation Titration or Pausing to Facilitate Neurological Assessment.

Q Per The Joint Commission, we need clearer nursing titration/pausing guidelines to facilitate serial neurological assessments. How can we titrate or pause sedation/analgesia infusions to facilitate serial neurological assessments as well as “standard” wake-up assessments in a way that is compliant with regulatory agencies?A Richard Arbour, MSN, RN, CCRN, CNRN, CCNS, CCTC, replies:The Joint Commission (TJC) overview of sedation, analgesia, restraints, and other practices has added additional requirements to documentation, policies, and clinical review as a means to increase standardization of care and, most importantly, patient safety. In particular, TJC has closely evaluated sedation/analgesia dosing and titration.Optimal, goal-directed sedation practices are well established and include 4 components. First, validated clinical assessment tools such as the Sedation-Agitation Scale and the Richmond Agitation-Sedation Scale (RASS) are used to determine therapeutic end points for patients who are not pharmacologically paralyzed.1–3 Second, targeted clinical end points for sedative/hypnotic agents are optimally aimed at “lighter” levels of sedation (eg, a RASS score of 0 to −2 [light sedation]),1 unless higher levels are clinically necessary; patients with these “lighter” levels of sedation are best described as calm and interactive and are able to respond appropriately to stimulation.2,4 Third, sedatives/hypnotic agents should be periodically interrupted or titrated down. This component has become well established since a landmark study in which Kress et al5 identified a connection between daily interruption of sedation and a shorter duration of mechanical ventilation; in current practice, meticulous patient selection and close monitoring are paramount to protect vulnerable patients from harm. Fourth, attention must be given to sedation and analgesic needs and to clinically appropriate nonpharmacological comfort measures, and treatable causes of agitation, pain, and delirium must be addressed.2–4To achieve optimal, goal-directed therapy, all 4 of these points need to be included in a plan of care. Previously, a team may have ordered a “wake-up assessment” for a patient, and that patient’s sedation/analgesic agents may have been abruptly stopped. From a regulatory perspective that assessment order may not have constituted a complete medication order. A complete medication order for titration includes the following items: Note that TJC allows for range orders and multiple range orders, so a provider can order titration increments for a range of times and doses. A direct care nurse would then apply their knowledge and experience with the patient to select the most appropriate interval and dose from among the ordered range when necessary.Clearer titration guidelines to facilitate serial neurological evaluation would include the required order elements and specifically attend to the desired clinical goal for wakefulness or responsiveness (eg, a RASS score of 0 to −1). In addition, downward titration of central nervous system depressants should be specified in institutional policy addressing titration, which should also include a specific callout for daily spontaneous awakening trials (SATs). One such example addressing regulatory considerations is outlined below.To the specific practice question, when considering an awakening trial for neurological assessment followed by specified baseline assessment and goals of care, optimal patient selection from among the neuroscience population is necessary to establish optimal risk/benefit analysis. Documentation should include baseline dosing for any central nervous system depressant, sedation depth, and repeat assessment after each dose change. When a patient’s sedation assessment identifies elements that remain outside the provider-ordered parameters, appropriate communication with the provider and documentation are indicated. If the order does not fit the clinical situation, contact the provider, clarify the order, and document.The importance of interdisciplinary collaboration cannot be overstated: it is essential in optimal patient selection for downward titration of sedation/analgesia to allow neurological evaluation. Respiratory therapy is integral when ventilator support is being titrated as an intervention to manage agitation or ventilator dyssynchrony. In addition to assessing patients and documenting, nurses implement nonpharmacological interventions, calm the patient and family, and facilitate a healing, caring environment. Pharmacy team members offer expertise in optimizing pharmacological therapies for managing pain and agitation. Physicians and advanced care providers are accountable for the overall plan of care and multisystem support. Of particular note is how practices such as sedation/analgesia titration and interruption continue to evolve on the basis of best available evidence and in collaboration with health care regulatory bodies. This collaboration has been useful in practice and in improving patient safety.

Attitudes and Behaviors of Gastroenterology Specialists Toward Sedation Practices in Endoscopy Units in Turkey: Is Anesthesia Mandatory?

Attitudes and Behaviors of Gastroenterology Specialists Toward Sedation Practices in Endoscopy Units in Turkey: Is Anesthesia Mandatory?