Table Of ContentS A F E S E D A T I O N
FOR ALL PRACTITIONERS
S
Sedation is a vital tool for allowing investigations and procedures to be
A
performed without full anaesthesia, but demand for sedation greatly F
E
outstrips the supply of trained anaesthetists. Sedation requires care
S
if it is to be used correctly and modern sedationists, including junior E
D
doctors in all specialties, medical students, anaesthetists, dentists, and
A
theatre, dental and paediatric nurses, must be able to demonstrate T
I
they can practise safely. They need a sound understanding of the basic O
sciences involved, and an intimate knowledge of the required standards N
of practice. This book is a fi rst-line educational resource for all those
F
training in the techniques of sedation, and for those already practising O
R
who wish to consolidate their knowledge in a structured way.
A
L
This highly practical handbook is therefore ideal for experienced and novice L
practitioners alike. It covers basic principles including patient selection P
R
and assessment, pharmacology, resuscitation competencies, monitoring
A S A F E S E D A T I O N
equipment and legal issues, and the numerous clinical scenarios bring C
T
pertinent issues to life, emphasising the importance of safe practice. It is a
I
T
unique universal introduction for practitioners from any clinical background.
I FOR ALL PRACTITIONERS
O
N
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Edited by Daryl Dob, Griselda Cooper and Anita Holdcroft
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E
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S
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Safe Sedation for All Practitioners
A Practical Guide
TThhiiss ppaaggee iinntteennttiioonnaallllyy lleefftt bbllaannkk
Safe Sedation for All Practitioners
A Practical Guide
JAMES WATTS BSc MB ChB FRCA
Consultant in Anaesthesia and Intensive Care Medicine
East Lancashire Hospitals Trust
Radcliffe Publishing
Oxford (cid:129) New York
CRC Press
Taylor & Francis Group
6000 Broken Sound Parkway NW, Suite 300
Boca Raton, FL 33487-2742
© 2008 by James Watts
CRC Press is an imprint of Taylor & Francis Group, an Informa business
No claim to original U.S. Government works
Version Date: 20160525
International Standard Book Number-13: 978-1-138-03147-0 (eBook - PDF)
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sarily reflect the views/opinions of the publishers. The information or guidance contained in this book is intended for
use by medical, scientific or health-care professionals and is provided strictly as a supplement to the medical or other
professional’s own judgement, their knowledge of the patient’s medical history, relevant manufacturer’s instructions and
the appropriate best practice guidelines. Because of the rapid advances in medical science, any information or advice on
dosages, procedures or diagnoses should be independently verified. The reader is strongly urged to consult the relevant
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Contents
Preface vii
About the author x
1 Sedation for procedures, treatments and investigations:
a general introduction 1
2 Training in sedation 13
3 Patient assessment and selection 25
4 Principles of safety in sedation 39
5 Drugs in sedation practice 69
6 Medico-legal aspects of sedation 87
7 Sedation in paediatric practice 103
8 Sedation and the elderly 123
9 Sedation in community dental practice 131
10 Sedation for radiological procedures 141
11 Sedation in critical care 149
12 Sedation in palliative care 159
13 Sedation for miscellaneous procedures 165
Index 177
TThhiiss ppaaggee iinntteennttiioonnaallllyy lleefftt bbllaannkk
Preface
Sedative adj. having a calming effect. n. a sedative drug.
The Oxford Popular English Dictionary (2001)
Anaesthesia is one of the Victorians’ most important legacies for the modern
world. Prior to its introduction, surgery was by necessity brutal and fast,
as methods of pain relief were only partially effective at best. The ability to
perform painless surgery has been regarded as one of the greatest human
achievements, and the development of anaesthesia has been recognised by
both the public and the medical profession as one of the top three medical
milestones of the last 170 years.1 However, there are a great many procedures
and treatments for which full general anaesthesia is regarded as too great
an intervention, but for which a state of reduced anxiety and consciousness
is still necessary. This state is referred to as ‘sedation.’ The term is used
ubiquitously in many contexts in the healthcare setting, but this text will
be confi ned to a discussion of sedation as a means of allowing patients to
comfortably undergo some form of medical intervention, or of circumstances
in which sedation is used as a defi ned part of a medical treatment.
It is relevant to ask why a book on the basics of sedation practice is
required if sedation is already widely used throughout the healthcare sector.
However, it should be appreciated that sedating a patient is not a risk-free
enterprise. There is an assumption that the act of sedation is inherently safer
than inducing general anaesthesia, although there is no real evidence base
to support this belief. Some authorities have suggested that there is a 1 in
2000 risk of 30-day mortality associated with the use of sedation (usually
due to cardiovascular or respiratory problems), compared with an estimated
mortality of around 1 in 100 000 for general anaesthesia. Other analyses
vii
viii PREFACE
have shown that 14% of patients undergoing endoscopy received a sedative
overdose. In addition, medical procedures themselves can be associated
with physiological problems such as hypoxia or cardiac abnormalities –
phenomena which sedation itself might exacerbate.2–4
If there are serious problems with regard to the way that sedation is
performed, one could ask why guidelines have not been formulated to
standardise practice. In fact many guidelines exist, but there is evidence that
they are not universally adhered to. The reasons for this are legion. Some
groups of practitioners may consider that certain guidelines do not apply
to their fi eld of practice, while others may feel that, due to a lack of proper
randomised controlled trials, the guidelines are not evidence based and are
therefore open to challenge. Furthermore, there is a lack of formal training
in sedative techniques in non-anaesthetic medical specialties, and so there
is good reason to believe that knowledge with regard to basic safe practices,
as well as ignorance of existing guidelines, may be a problem. Finally, many
non-medically and non-dentally trained healthcare practitioners, who
may not necessarily have access to the guidelines produced by a specialist
association, are providing sedation for an increasing variety of interventions.
It is clearly essential for everyone in the team that is caring for the patient
to have the same understanding of the principles and issues involved.
Therefore the question inevitably arises as to why, if the situation is so
fraught with hazards, the administration of sedation is not restricted solely
to those with anaesthetic training. The answer, of course, is that demand for
sedation greatly outstrips the supply of anaesthetists. However, there is a
good argument for believing that anaesthetists should be heavily involved
in the quality control of non-anaesthetic sedation services, even if they
themselves cannot actively participate.
Sedation is a tool that requires care if it is to be used correctly. The
modern sedationist must therefore be able to demonstrate that they can
practise safely. This means that they should be able to produce evidence
that they have undergone adequate training in relevant skills, and that
they have maintained and developed those skills. This requires a sound
understanding of the basic sciences involved, and an intimate knowledge
of the standards of practice that should be adhered to. The aim of this book
is to be useful in this regard to any sedationist from any background. It is
intended to be a fi rst-line educational resource for those who are training in
the techniques of sedation, and also for those who already practise, but who
wish to consolidate their knowledge in a structured way. It is hoped that
it will provide a rational syllabus that is easy to use, and that will provide
sedationists at any level of experience with a fi rm basis on which to develop
PREFACE ix
their practice, grounded upon a sound understanding of basic principles,
including patient selection and assessment, pharmacology, monitoring
equip ment and legal issues. These precepts are illustrated throughout
by relevant clinical scenarios derived from real-life situations. Where
appropriate, these have been attributed to the relevant sources. Where the
scenarios are unattributed, they are derived from personal communications
with fellow clinicians who wish to remain anonymous.
What this book does not aim to do is to provide a ‘one method fi ts every
situation’ recipe for sedation. The experienced and safe sedationist should,
of course, be able to adapt their practice appropriately depending upon cir-
cum stances and, most importantly, to recognise when they have reached the
limits of their competency and more expert assistance is required.
James Watts
January 2008
References
1 Medical milestones. Celebrating key advances since 1840. BMJ. 2007; 334
(Supplement).
2 Quine MA, Bell GD, McCloy RF et al. A prospective audit of upper
gastrointestinal endoscopy in two regions of England: safety, staffi ng and
sedation methods. Gut. 1995; 36: 462–7.
3 Jenkins K, Baker AB. Consent and anaesthetic risk. Anaesthesia. 2003; 58: 962–84.
4 National Confi dential Enquiry into Patient Outcome and Death. Scoping Our
Practice; www.ncepod.org.uk/pdf/2004/04sum.pdf (accessed 27 June 2007).
