Sedation Service Research Articles

Developing a nurse-led child sedation service

This article explores nurse-led sedation of children in preparation for investigations such as magnetic resonance imaging or minor surgical procedures. The importance of the multidisciplinary team in setting up, implementing and evaluating this new nurse-led initiative is described. Effective planning, involvement, agreement and training are key to a successful change in practice, with responsibility being delegated to competent nursing staff. Evaluation has shown all-round benefits. Trained nurse-led sedation is safe, effective and efficient and nurses are motivated to undertake this extended role.

Use of Intravenous Sedation in Periodontal Practice: A National Survey

In the early 1990s, much of the periodontal profession perceived an upcoming shift in services performed by periodontists as many patients began to expect sedation for periodontal surgery. As a result, in 1993 the American Academy of Periodontology began encouraging postgraduate periodontal programs to train residents in the use of conscious sedation. The purpose of this study is to investigate trends in the training of intravenous (i.v.) sedation in residency and its use in periodontal practice. An 18-question survey was mailed to a sample of 1596 active periodontists throughout the United States and Canada. Thirty-seven percent (596) of the surveys were returned. Twenty-two retired periodontists responded and were excluded from the analysis. The data from the remaining 574 surveys were analyzed with a statistical software package. Approximately half (49.8%) of the survey respondents offer i.v. sedation in their practices. Among respondents who completed residency prior to 1996, 42.6% offer i.v. sedation compared with 64.2% of respondents who completed residency in 1996 or later. The number of i.v. sedations performed in residency was moderately correlated with the number of i.v. sedations personally performed in periodontal practice (Spearman r = 0.5169, P <0.0001). The largest percentage of periodontists using i.v. sedation (74.0%) was reported from American Academy of Periodontology District 5 (south central United States), whereas District 7 (New Jersey and New York) reported the lowest usage (15.6%). Approximately half of all periodontists provide i.v. sedation, with more recent periodontal graduates more likely to personally offer and administer i.v. sedation services for their patients. Regional differences exist in the use and training of i.v. sedation.

Age-dependent safety analysis of propofol-based deep sedation for ERCP and EUS procedures at an endoscopy training center in a developing country

IntroductionEndoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasonography (EUS) procedures in elderly patients are on the rise, and they play an important role in the diagnosis and management of various gastrointestinal diseases. The use of deep sedation in these patients has been established as a safe and effective technique in Western countries; however, it is uncertain if the situation holds true among Asians. The present study aimed to evaluate the age-dependent safety analysis and clinical efficacy of propofol-based deep sedation (PBDS) for ERCP and EUS procedures in adult patients at a World Gastroenterology Organization (WGO) Endoscopy Training Center in Thailand.MethodsWe undertook a retrospective review of anesthesia or sedation service records of patients who underwent ERCP and EUS procedures. All procedures were performed by staff endoscopists, and all sedations were administered by anesthesia personnel in the endoscopy room.ResultsPBDS was provided for 491 ERCP and EUS procedures. Of these, 252 patients (mean age, 45.1 + 11.1 years, range 17–65 years) were in the <65 age group, 209 patients (mean age, 71.7 + 4.3 years, range 65–80 years) were in the 65–80 year-old group, and 30 patients (mean age, 84.6 + 4.2 years, range 81–97 years) were in the >80 age group. Common indications for the procedures were pancreatic tumor, cholelithiasis, and gastric tumor. Fentanyl, propofol, and midazolam were the most common sedative drugs used in all three groups. The mean doses of propofol and midazolam in the very old patients were relatively lower than in the other groups. The combination of propofol, midazolam, and fentanyl, as well as propofol and fentanyl, were frequently used in all patients. Sedation-related adverse events and procedure-related complications were not statistically significantly different among the three groups. Hypotension was the most common complication.ConclusionIn the setting of the WGO Endoscopy Training Center in a developing country, PBDS for ERCP and EUS procedures in elderly patients by trained anesthesia personnel with appropriate monitoring is relatively safe and effective. Although adverse cardiovascular events, including hypotension, in this aged group is common, all adverse events were usually transient, mild, and easily treated, with no sequelae.

Evaluating the impact of the National Patient Safety Agency Guidelines on Midazolam injection on the Ambulatory, Hospital-based Conscious Sedation Services for minor oral and maxillofacial surgery

Evaluating the impact of the National Patient Safety Agency Guidelines on Midazolam injection on the Ambulatory, Hospital-based Conscious Sedation Services for minor oral and maxillofacial surgery

PTU-257 “Trials and tribulations of setting up an anaesthetist led day-case endoscopy list”

IntroductionEndoscopy in UK is performed under conscious sedation in daycase (DC) endoscopy units. Patients intolerant of the procedure subsequently undergo the procedure under a general anaesthetic in operating theatres. However...

PWE-205 Propofol-balanced anaesthesia for single balloon enteroscopy: a comparison between antegrade and retrograde intubation

IntroductionSingle balloon enteroscopy (SBE) procedure is a procedure for diagnosis and treatment in patients with abnormality of gastrointestinal tract especially for small bowel. It commonly performed either anterograde or retrograde...

PWE-206 Propofol deep sedation for elderly patients: a comparison between EUS with or without fine needle aspiration procedure

IntroductionThe aim of this study was to evaluate and compare the clinical efficacy of propofol deep sedation (PDS) for elderly patients underwent EUS with or without fine needle aspiration (FNA)...

Pediatric Sedation Outside of the Operating Room: A Multispecialty International Collaboration

Pediatric Sedation Outside of the Operating Room: A Multispecialty International Collaboration K. P. Mason ( ed.) Springer, September 2011, ISBN 978-0387097138, 518pp., Price £67.99 Sedation is a subject that most anaesthetists feel they should know about but few are practised in. It is an art form no better exemplified than in the challenges of the paediatric population. This book is therefore a welcome addition to the literature as it provides a thorough summary, in a little over 500 pages, of the challenges and solutions available to us. We start with a well-illustrated history chapter that describes the surprisingly (to me!) deep and long history of sedation practices going back more than 4500 years. This is followed by a physician’s perspective of procedural sedation that is a little brief. A very much US-based summary of safe sedation policies is rounded off by only a brief paragraph alluding to international standards. Scales and discharge criteria are dealt with thoroughly. The ensuing chapters on anatomy, physiology and pharmacology will be second nature to most anaesthetists but are worthy of recall. In particular, there are a couple of worked examples on children with OSA and a mediastinal mass that are very useful. This is followed by a highly detailed and challenging pharmacology section. The chapter on billing and reimbursement is very much relevant to the US market but not as pertinent to other health care systems. However, as the public purse is squeezed tighter, these may gain more relevance to the UK. Running a sedation service in a paediatric hospital, based on the editor’s own experiences in Boston, is interesting and well written but again relies heavily on an American model of nurse anaesthetists. Different areas of the hospital (intensive care, gastroenterology, emergency department) are dealt with in separate chapters with that on intensive care being particularly well and comprehensively described and referenced. Again, worked examples are the jewel in the crown in the emergency department section. There is some repetition in these chapters, particularly in the descriptions of pharmacological agents. The claim in the title of the book to be international is largely justified by chapters 17 and 18 that tell of the European and developing world experiences. We end with chapters on such wide-ranging subjects as drug development and acupuncture and an infusions chapter that I can’t help but feel would have sat better with the earlier pharmacology section. Of great interest is the chapter on benchmarking of adverse events that is the future of excellent service development. In summary, this is a thorough and well informed text, largely from a US perspective, that allows novice and experienced anaesthetists alike to develop and help form a safe and effective paediatric sedation service.

Pediatric Sedation Outside of the Operating Room: A Multispecialty International Collaboration

Table of Contents Preface Acknowledgments Part I: Pediatric Sedation outside the Operating Room 1. The History of Sedation 2. Procedural Sedation - Let's Review the Basics: The Pediatrician's Perspective 3. Sedation Policies, Recommendations and Guidelines Across the Specialties and Continents 4. Sedation Scales and Discharge Criteria: How Do They Differ? Which One to Choose? Do They Really Apply to Sedation? 5. Physiological Monitoring for Procedural Sedation: The Routine and Beyond 6. The Pediatric Airway: Anatomy, Challenges, and Solutions 7. Pediatric Physiology: How Does it Differ from Adults? 8. Pharmacology and Clinical Application of Sedatives, Analgesics and Adjuncts 9. Pharmacokinetics and Pharmacodynamics in the Pediatric Population 10. Billing and Reimbursement for Sedation Services Part II: Sedation Models Delivered by Different Specialties: A Global Voyage 11. The Pediatric Hospital Medicine Service: Models, Protocols, and Challenges 12. The Anesthesia Directed Sedation Service: Models, Protocols, and Challenges 13. Sedation in the Intensive Care Unit: Challenges, Outcomes and Future Strategies 14. Sedation for Pediatric Gastrointestinal Procedures 15. Sedation in the Emergency Department: A Complex and Multifactorial Challenge 16. Sedation of Pediatric Patients for Dental Procedures 17. Pediatric Sedation: The European Experience and Approach 18. Pediatric Sedation in the Underdeveloped Third World - An African Perspective: Models, Protocols, and Challenges Part III: Safety in Sedation 19. Pediatric Sedatives and the Food and Drug Administration (FDA): Challenges, Limitations, and Drugs in Development 20. Incidence and Stratification of Adverse Events Associated with Sedation: Is there a Benchmark? 21. Medicolegal Risks and Outcomes of Sedation 22. Designing a Safe Pediatric Sedation Service: Adopting a New Culture Part IV: Sedation into the 22nd Century 23. Intravenous Infusions for Sedation: Rationale, State of the Art and Future Trends 24. Usage of Complementary and Alternative Medicine in Pediatric Sedation 25. Future of Pediatric Sedation Index

Office-Based Deep Sedation for Pediatric Ophthalmologic Procedures Using a Sedation Service Model

Aims. (1) To assess the efficacy and safety of pediatric office-based sedation for ophthalmologic procedures using a pediatric sedation service model. (2) To assess the reduction in hospital charges of this model of care delivery compared to the operating room (OR) setting for similar procedures. Background. Sedation is used to facilitate pediatric procedures and to immobilize patients for imaging and examination. We believe that the pediatric sedation service model can be used to facilitate office-based deep sedation for brief ophthalmologic procedures and examinations. Methods. After IRB approval, all children who underwent office-based ophthalmologic procedures at our institution between January 1, 2000 and July 31, 2008 were identified using the sedation service database and the electronic health record. A comparison of hospital charges between similar procedures in the operating room was performed. Results. A total of 855 procedures were reviewed. Procedure completion rate was 100% (C.I. 99.62–100). There were no serious complications or unanticipated admissions. Our analysis showed a significant reduction in hospital charges (average of $1287 per patient) as a result of absent OR and recovery unit charges. Conclusions. Pediatric ophthalmologic minor procedures can be performed using a sedation service model with significant reductions in hospital charges.

Estimating the need for dental sedation. 3. Analysis of factors contributing to non-attendance for dental treatment in the general population, across 12 English primary care trusts

This is the third paper in a series of four examining a tool which could be used to determine sedation need among patients. The aim of this paper was to assess the reasons why people do not attend the dentist regularly, in order to understand the potential need for sedation services among both attending and non-attending patients. A large telephone survey conducted across 12 primary care trusts (PCTs) found that 17% of participants did not attend the dentist regularly. One of the top reasons given for non-attendance that could be considered a barrier was fear/anxiety. The figure reached in paper 2 ( 2011; 211: E11) stated that approximately 5% of attending patients will, at some time, need sedation services. However, the data from this survey have suggested that anxiety accounts for 16% of people who do not attend the dentist regularly. It could be assumed that if non-attending patients were included, with high levels of anxiety, the sedation need would rise to 6.9% throughout the entire population.

Development of a pediatric hospitalist sedation service: Training and implementation

There is growing demand for safe and effective procedural sedation in pediatric facilities nationally. Currently, these needs are being met by a variety of providers and sedation techniques, including anesthesiologists, pediatric intensivists, emergency medicine physicians, and pediatric hospitalists. There is currently no consensus regarding the training required by non-anesthesiologists to provide safe sedation. We will outline the training method developed at St. Louis Children's Hospital. In 2003, the Division of Pediatric Anesthesia at St. Louis Children's Hospital approached the Division of Pediatric Hospitalist Medicine as a resource to provide pediatric sedation outside of the operating room. Over the last seven years, Pediatric Hospitalist Sedation services have evolved into a three-tiered system of sedation providers. The first tier provides sedation services in the emergency unit (EU) and the Center for After Hours Referral for Emergency Services (CARES). The second tier provides sedation throughout the hospital including the EU, CARES, inpatient units, Ambulatory Procedure Center (APC), and Pediatric Acute Wound Service (PAWS); it also provides night/weekend sedation call for urgent needs. The third tier provides sedation in all of the second-tier locations, as well as utilizing propofol in the APC. This training program has resulted in a successful pediatric hospitalist sedation service. Based on fiscal year 2009 billing data, the division performed 2,471 sedations. We currently have 43 hospitalists providing Tier-One sedation, 18 Tier-Two providers, and six Tier-Three providers. A pediatric hospitalist sedation service with proper training and oversight can successfully augment sedation provided by anesthesiologists.

Summary of: Estimating the need for dental sedation. 1. The Indicator of Sedation Need (IOSN) – a novel assessment tool

While the control of pain and anxiety is fundamental to the practice of dentistry, the use of conscious sedation in dentistry is very variable among dentists. The need for conscious sedation could be considered by assessing and ranking a combination of information on patient anxiety, medical history and the complexity of the anticipated clinical treatment. By undertaking this systemtic assessment an indication of sedation need may be developed which would act as an aide to decision making and, potentially, referral management. Such a tool could also be used by commissioners who need to identify patients who need conscious sedation for dental treatment in order to plan, commission and deliver appropriate sedation services.

Estimating the need for dental sedation. 1. The Indicator of Sedation Need (IOSN) – a novel assessment tool

While the control of pain and anxiety is fundamental to the practice of dentistry, the use of conscious sedation in dentistry is very variable among dentists. The need for conscious sedation could be considered by assessing and ranking a combination of information on patient anxiety, medical history and the complexity of the anticipated clinical treatment. By undertaking this systemtic assessment an indication of sedation need may be developed which would act as an aide to decision making and, potentially, referral management. Such a tool could also be used by commissioners who need to identify patients who need conscious sedation for dental treatment in order to plan, commission and deliver appropriate sedation services.

Original article. Intravenous sedation for gastrointestinal endoscopy in very elderly patients of Thailand

Abstract Background: The use of sedation for gastrointestinal endoscopy (GIE) procedures in elderly patients has been established as a safe and effective technique. However, it is still uncertain whether the situation is valid for Asians. Objective: Evaluate the outcome of intravenous sedation (IVS) for GIE procedures in very elderly patients (&gt;86 years old) in Thailand and compare the clinical efficacy of IVS between very elderly and those younger (&lt;86 years old) Methods: We undertook a retrospective review of the sedation service records of patients who underwent GIE procedures between 2007 and 2008 at Siriraj Hospital, Thailand. All sedations were administered by anesthetic personnel in the endoscopy room. The cohort was divided into three groups, &lt;65 years old (group 1), 65-85 years old (group 2), and &gt;86 years old (group 3). Results: Sedation was provided for 1,779 patients (965, 687, and 127 patients in group 1, 2, and 3, respectively) in 2,061 GIE procedures. Fentanyl, midazolam and propofol were the most common IVS drugs used in all three groups. Patients in group 3 required lower mean doses of these intravenous sedatives than those in group 1 or 2 (p &lt;0.001). Mean procedure time in group 3 was longer than in group 1 or 2 (p=0.010). Adverse events in group 3 occurred more frequently when compared to group 1 or 2 (p &lt;0.001). Transient hypotension was the main complication across all aged groups. Conclusion: IVS for GIE procedure in very elderly patients was associated with higher minor advance events but relatively safe and effective when carried out by trained anesthetic personnel with appropriate monitoring and dose adjustment.

Impact of Provider Specialty on Pediatric Procedural Sedation Complication Rates

To determine if pediatric procedural sedation-provider medical specialty affects major complication rates when sedation-providers are part of an organized sedation service. The 38 self-selected members of the Pediatric Sedation Research Consortium prospectively collected data under institutional review board approval. Demographic data, primary and coexisting illness, procedure, medications used, outcomes, airway interventions, provider specialty, and adverse events were reported on a self-audited, Web-based data collection tool. Major complications were defined as aspiration, death, cardiac arrest, unplanned hospital admission or level-of-care increase, or emergency anesthesia consultation. Event rates per 10 000 sedations, 95% confidence intervals, and odds ratios were calculated using anesthesiologists as the reference group and were then adjusted for age, emergency status, American Society of Anesthesiologists physical status > 2, nil per os for solids, propofol use, and clustering by site. Between July 1, 2004, and December 31, 2008, 131 751 pediatric procedural sedation cases were recorded; there were 122 major complications and no deaths. Major complication rates and 95% confidence intervals per 10 000 sedations were as follows: anesthesiologists, 7.6 (4.6-12.8); emergency medicine, 7.8 (5.5-11.2); intensivist, 9.6 (7.3-12.6); pediatrician, 12.4 (6.9-20.4); and other, 10.2 (5.1-18.3). There was no statistical difference (P > .05) among provider's complication rates before or after adjustment for potential confounding variables. In our sedation services consortium, pediatric procedural sedation performed outside the operating room is unlikely to yield serious adverse outcomes. Within this framework, no differences were evident in either the adjusted or unadjusted rates of major complications among different pediatric specialists.

Propofol-based deep sedation for endoscopic retrograde cholangiopancreatography procedure in sick elderly patients in a developing country

Introduction:The aim of this study was to evaluate and compare the clinical efficacy of propofol-based deep sedation (PBDS) for endoscopic retrograde cholangiopancreatography (ERCP) procedure in sick (American Society of Anesthesiologists [ASA] physical status III–IV) and nonsick (ASA physical status I–II) elderly patients in a teaching hospital in Thailand.Methods:We undertook a retrospective review of the anesthesia or sedation service records of elderly patients who underwent ERCP procedures from October 2007 to September 2008. All patients were classified into two groups according to the ASA physical status. In group A, the patients had ASA physical status I–II, while in group B, the patients had ASA physical status III–IV. The primary outcome variable of the study was the successful completion of the procedure. The secondary outcome variables were sedation-related adverse events during and immediately after the procedure.Results:There were 158 elderly patients who underwent ERCP procedure by using PBDS during the study period. Of these, 109 patients were in group A and 49 patients were in group B. There were no significant differences in age, gender, weight, duration of ERCP, indication of procedure, and the mean dose of fentanyl, propofol, and midazolam between the two groups. All patients in both groups successfully completed the procedure except eight patients in group A and three patients in group B (P = 0.781). Overall, respiratory and cardiovascular adverse events in both groups were not significantly different. All adverse events were easily treated, with no adverse sequelae.Conclusion:In the setting of a developing country, PBDS for ERCP procedure in sick elderly patients by trained anesthetic personnel with appropriate monitoring was safe and effective. The clinical efficacy of this technique in sick elderly patients was not different or worse than in nonsick elderly patients. Serious adverse events were rare in our population.

Pediatric Sedation and Analgesia in a Developing Country

The management of acute pain and anxiety in children undergoing diagnostic and therapeutic procedures has developed substantially in the past two decades. An increase in the numbers of investigations and non-surgical interventions in children has created an enormous demand for sedation services. Procedural sedation and analgesia for children is now widely practiced by a various group of the specialists. The goal of procedural sedation is the safe and effective control of pain, anxiety and motion as well as to provide an appropriate degree of memory loss or decreased awareness. Short acting, rapid onset drugs with little adverse effects and improved safety profiles are replacing outdated regimens. This article is to discuss the decision making process used to determine appropriate drug selection, dosing and sedation endpoint. It also reviews the current status of sedation and analgesia for pediatric procedures in a developing country.

The Sedation Service Reimbursement Dilemma

There are many misconceptions with billing for sedation services. It is not the setting or the type of provider or medication used, but the depth of sedation provided, that determines the type of sedation service that should be reported. Any qualified physician or nonphysician provider may report anesthesia services for deep sedation. Advanced negotiation with the hospital and third-party payers is the key to successful reimbursement for a sedation service.

Sedation for dental treatment of children in the primary care sector (UK)

To audit the clinical practice of a dental sedation service in the primary care sector and determine which services dentists use to manage unco-operative children. Retrospective analysis and prospective audit. Sedation clinic in primary care, 2007, England. Children attending for dental treatment under sedation. General dental practitioners (GDPs) in the Brighton and West Sussex regions. Questionnaire. Clinical service audit, patient satisfaction, referrer satisfaction. Four hundred children (age range 5-12 years) had been referred for caries (78%), with the remainder for orthodontic extractions. The most common treatment carried out on primary and permanent teeth was extractions followed by restorations. A combination of intravenous (IV) midazolam/ketamine/fentanyl was used in 40% of cases, and IV midazolam/ketamine was used in 34% of cases. Seventy-four percent of parents responded to the satisfaction questionnaire; of these 97% rated sedation as excellent/good and 80% would choose sedation or recommend sedation for others. Only 45% of questionnaires to referrers were returned. Fifty-six percent of dentists preferred general anaesthesia (GA) and 66% preferred IV sedation. Dental treatment for children was provided under IV sedation with most parents satisfied with the procedure. Little difference was seen between referring dentists' perceptions of IV sedation or GA.