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AMBULATORY SURGERY CENTERS
BY UYEN VO
Procedural sedation analgesia considerations for ASC leaders
he promise of quicker recovery
and fewer complications from
sedation, anesthesia, and pain
management have drawn clinicians and
patients alike to procedures performed
in ambulatory surgery centers (ASCs)
and other outpatient settings. However,
sedation, anesthesia, and analgesia
add their own risks to those of the procedure
itself. Understanding the latest
methods and medications in procedural
sedation analgesia (PSA) is critical to
providing safe and effective care before,
during, and after surgical procedures.
The right PSA varies from patient
to patient. Factors to consider include
the type and duration of the procedure,
the expected level of pain, the need for
pain control, the patient's condition,
and the patient's ability to tolerate the
procedure. Caretakers also must stay
abreast of the latest developments as
new drugs evolve and others fall out
of favor. Benzoni and Cascella say the
most effective PSA regimen should have
sedative, analgesic, and amnestic properties
with a rapid onset and short duration
to enable a safe and quick recovery
and discharge.
T
PSA is patient-specific
Sometimes incorrectly referred to as
" conscious sedation, " procedural sedation
(PS) is " a technique of administering
sedatives or dissociative agents
with or without analgesics to induce a
state that allows the patient to tolerate
unpleasant procedures, " according
to the American College of Emergency
Physicians. PS involves " a continuum of
altered levels of consciousness (including
minimal, moderate, and deep), and
dissociative sedation. "
Further, there is a distinction between
sedation, dissociation, and analgesia.
Sedation enables the patient to
relax and lie still; analgesia is pain management;
and dissociation is a state of
mind-body separation. PS is not general
anesthesia or pain control alone but
is an individualized approach for each
26
OR Manager | April 2024
patient. Because PS is commonly administered
by combining sedatives with
analgesics to reduce the perception of
pain, PS also can serve as PSA.
The Joint Commission outlines three
levels of sedation:
* Moderate sedation: Patients can respond
purposefully to verbal commands,
which may be accompanied
by light tactile stimulation. Cardiovascular
function and spontaneous
ventilation are maintained, and no
interventions are needed to maintain
a patent airway.
* Deep sedation/analgesia: Patients
can respond purposefully to
repeated or painful stimulation but
cannot be easily aroused. Their ventilatory
function may be impaired,
and maintaining a patent airway may
require intervention. Cardiovascular
function is usually not impaired.
* Anesthesia: This includes general
anesthesia and spinal anesthesia
(spinal, epidural, or a major area of
the body), but not local anesthesia.
Patients are unable to independently
maintain ventilatory function and require
interventions such as positive
pressure ventilation. Cardiovascular
functions may be impacted, and patients
cannot be aroused even by
painful stimulation.
Propofol proliferates
The market for sedation agents and
analgesics continues to evolve. More effective,
safer drugs with quicker onset,
shorter recovery, and fewer complications
have replaced those older ones.
According to NYSORA, an international
educational organization focusing
on anesthesiology, ultrasound, regional
anesthesia, and pain medicine, propofol
is the most frequently administered anesthetic
drug for induction and maintenance
of anesthesia. With a rapid onset
of 15 to 30 seconds and a duration of 1
to 3 minutes, it is widely used for moderate
sedation and short-term general
anesthesia beyond the OR, whether in
Propofol-related
Infusion Syndrome
(PRIS)
PRIS is a rare but serious adverse effect of
prolonged propofol infusion in mechanically
intubated patients (usually > 4mg/
kg/hour for more than 24 hours), as highlighted
by Folino et al. Children younger
than 3 years old are especially vulnerable.
PRIS is also prevalent in patients younger
than 18 years old as they are more sensitive
to intravenous anesthetics than adult
patients. PRIS features include metabolic
acidosis, hyperkalemia, hyperlipidemia,
and rhabdomyolysis, progressing to renal
and cardiac failure and mortality.
Upon noticing the appearance of PRIS
features, practitioners must stop propofol
infusion immediately. Mortality associated
with PRIS has been estimated to be
around 33% and becomes even higher if
the diagnosis is delayed.
the intensive care unit (ICU), the interventional
radiology suite, or in an ambulatory
setting.
Propofol is an intravenous anesthetic
administered as a bolus, an infusion, or
some combination of the two. Due to
its milky white appearance after dissolving
in a lipid emulsion, propofol is also
known as " milk of anesthesia. " The
drug of choice for general anesthesia in
stable obstetric patients, it is also common
for sedation in intubated, mechanically
ventilated ICU patients. It is safe
during pregnancy (although there is a
risk of neonatal central nervous system
and respiratory depression), as well as
in children (maintenance anesthesia for
those 2 months and older and general
anesthesia for those 3 years and older
or with IV access). Off-label uses include
treatment of refractory status epilepticus
in children and adults and refractory
postoperative nausea and vomiting,
both common side effects of procedural
sedation.
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