Sedation Safety and Comfort
In the realm of Pain Management, many new and cooperative efforts have been formed to increase both the modalities of pain therapies and patient care. These include increasing concerns over the area of patient safety and comfort for the interventional procedures associated with pain therapies, as well as the physiotherapies, chiropractic, and other modalities used to address both acute and chronic pain syndromes.
The pre-procedural and continued therapies of these modalities might invite the use of supplemental medication and care. It is for these reasons that the Health Care provider might—with the intake and evaluation of the patient—decide on the use of supplemental medication or ancillary support with the use of other licensed health care professionals.
Anesthetics, analgesics, and anxiolytics are the main medications of a pharmaceutical nature that change the level of consciousness and comfort during some of the interventional procedures for pain therapies. In this regard, all of the administrators of these agents should, and must, feel comfortable with regard to the specific medication’s pharmacological effects and the possibility of adverse events.
The site of therapeutic procedures, as well as the pharmacological means for change of consciousness, must meet all of the requirements necessary to insure the safety of the patient and all regulatory guidelines. In adhering to Quality of Care issues, one must review of the latest JCAHO (Joint Commission on Accreditation of Healthcare Organizations), American Society of Anesthesiologists (ASA), Federal Agency Guidelines, as well as the guidelines at the hospital, accredited surgery center, or office. Policy and procedural manuals should always be followed. This might change the character and nature of the location for the procedure, the equipment necessary for the alteration of consciousness, and the personnel necessary.
Proper pre-procedure evaluation is paramount in successfully completing the therapy when a change of consciousness is necessary. This means understanding the levels of consciousness which must be undertaken to complete the therapy.
Levels of Sedation
For the purpose of evaluation, it is important to rate the patient’s sedation need and assign it to one of the following categories:
Anxiolysis— can be considered as minimal sedation and will allow the patient to normally respond to verbal commands, and maintain both cardiovascular and respiratory stability and independence.
Moderate or Conscious Sedation— a designated individual is present to administer medication, to maintain sedation, and monitor the patient throughout the procedure—other than the person performing the procedure. The nature of the sedation should be to induce a depressed level of consciousness but allow the patient to respond to verbal commands, either alone or with light tactile stimulation. No interventions for ventilation support or change in cardiovascular function is affected.
Deep Sedation— would be considered if the pharmacologic interventions require the patient to be rendered with a significant loss of consciousness. The patient typically will not respond to verbal commands, and airway and/or ventilatory support may be needed. However, cardiovascular functions are usually maintained.
Anesthesia— which might be considered in certain circumstances, whereby deep analgesia is necessary to establish a state of complete loss of consciousness in order for the procedure to be done. This would include sedation at a level in which the loss of protective reflexes is impaired—including, but not limited to, airway reflexes (the potential for aspiration), or the loss of respiratory drive.
Personnel for the various levels of sedation may vary, but all who provide levels of sedation should have the accompanying credentialing and competency. Following the clinical policies and procedure manuals of the institutions and facilities where the procedures are done is particularly important to assure and maintain the highest standard for patient safety and quality of care.
Equipment necessary for monitoring and helping to evaluate the patient during sedation should be available and properly maintained. In addition, proper documentation of all medications used, as well as their timing, is essential for assurance of maximum safety and discharge planning. If supplemental post-procedure medication is necessary to alleviate pain, one will need the patient’s medication history to make sure there is no medication interaction which can render the patient in a prolonged sedative state. Patient education and compliance in this area is important.
The updating of information and procedures in the use of Conscious Sedation and Monitored Anesthesia Care are continuing, as personnel needs, credentialing, education, and patient’s care needs change. There are also economic factors which have been added to this mix—with insurers and other organizations either changing fees for reimbursement or denying them altogether. While it is evident that the health care environment is changing, all who work in the field of pain management recognize that patient care should never be compromised. In all cases, the choice of patient candidates, location, personnel, patient education, and therapeutic modalities should act as the major determinants for the appropriate level of sedation.