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Ambulatory Surgery Centers
Some PSA agents are inhaled rather
than administered intravenously. For example,
nitrous oxide (N2O) is an analgesic/anxiolytic
gas with rapid onset and
fast recovery. The drug is delivered with
oxygen and has a wide margin of safety.
It has little effect on respiratory function,
nausea and vomiting are uncommon,
and reflex integrity is maintained.
Nitrous oxide is contraindicated in:
* chronic obstructive pulmonary disorder
*
severe emotional disturbances or
drug-related dependencies
* the first trimester of pregnancy
* treatment with bleomycin sulfate
* recent tympanic membrane graft
* methylenetetrahydrofolate reductase
deficiency.
Desflurane is an inhalational anesthetic
used to induce and maintain anesthesia
in adults. It may also be used
for the maintenance of anesthesia in
pediatric patients following induction
with other drugs. Unlike other anesthetics,
desflurane is not associated
with nephrotoxicity. Although expensive,
desflurane has become more popular
over the years due to its rapid onset
compared to other inhalational anesthetics.
However,
every anesthetic has side
effects. A potent vasodilator, desflurane
has been associated with increased
intracranial pressure and, in pediatric
populations, the emergence of delirium.
The most critical impact of desflurane is
its carbon monoxide production. In fact,
data from the UK's National Health Service
(NHS) suggest the gas produced
by desflurane has a global warming potential
2,500 times greater than carbon
dioxide. Scotland became the first
country to ban the use of desflurane
in 2023, according to Euronews, and
NHS England (which leads the NHS in
England specifically) appears likely to
prohibit it for anything but exceptional
circumstances. The European Union
plans to ban desflurane use beginning
January 1, 2026.
www.ormanager.com
PSA becomes a balancing act
It is tempting to draw a conclusion
about which is the " best " PS or PSA.
Various practices have yielded effective
therapeutic results. Benzoni and
Cascella highlight that the combination
of fentanyl and midazolam is widely adopted,
but other combinations (eg, propofol
and fentanyl or propofol and a
mixture of propofol and ketamine) are
also used with frequency. Combining
a short-acting benzodiazepine such as
midazolam (sedative, amnestic, and
anxiolytic properties but not analgesic
effects) with an opioid (eg, fentanyl) is
also an option. As described previously,
the remimazolam-oliceridine combination
has gained attention recently and
could grow in moderate and deep sedation
practice.
The level of sedation needed depends
on the type and duration of the
procedure, the patient's condition, their
vital signs, their ability to tolerate the
procedure, the expected pain amount,
and the need for pain control. Each
sedation and analgesic drug has advantages
and disadvantages. The selected
agent must meet the patient's needs
and profile. Administration of therapeutic
agents and patient monitoring
must be conducted according to practice
standards and the facility's policies
and procedures. Benzoni and Cascella
stress that " the ideal agent for PSA purposes
should possess sedative, analgesic,
and amnestic properties as well as
a rapid onset and short duration of action
to allow a safe and quick recovery
and discharge. "
Craddock says ACSs and practitioners
must consider what is best for
the patients, balancing between the
required therapeutic effects, patient
safety, practitioners' skills and credentials,
and cost-effectiveness. When it
comes to PSA, this translates to choosing
an appropriate level of sedation for
the desired outcomes with limited risks
and assigning qualified personnel to
administer the PSA. For example, moderate
sedation could be administered by
skilled nonanesthesiologists (subject to
state laws). ORM
-Uyen Vo, BSN, MBA, is a freelance
writer with more than 20 years of
experience in healthcare.
References
American College of Emergency Physicians.
Procedural Sedation in the
Emergency Department. February
2023.
Benzoni T, Cascella M. Procedural Sedation.
StatPearls. July 3, 2023.
Folino T B, Muco E, Safadi A O, et al.
Propofol. StatPearls. July 24, 2023.
Goudra B, Mason K P. Emerging Approaches
in Intravenous Moderate
and Deep Sedation. Journal of Clinical
Medicine. April 16, 2021.
Khan J, Liu M. Desflurane. StatPearls.
June 11, 2022.
Lingamchetty T N, Hosseini S A, Saadabadi
A. Midazolam. StatPearls.
June 5, 2023.
NYSORA. Intravenous Anesthetics. Accessed
February 2024.
Ramos-Matos C F, Bistas K G, LopezOjeda
W. Fentanyl. StatPearls. May
29, 2023.
Singh A, Anjankar A P. Propofol-Related
Infusion Syndrome: A Clinical
Review. Cureus. October 17, 2022.
Sedation and Anesthesia: Understanding
the Assessment Requirements.
The Joint Commission. February
2024.
Symons A. Scotland Becomes the First
Country To Ban The High-Emissions
Anaesthetic Desflurane. Euronews.
March 3, 2023.
Vellinga R, Valk B I, Absalom A R,
et al. What's new in intravenous
anaesthesia? New Hypnotics, new
models, and new Applications. Journal
of Clinical Medicine. June 17,
2022.
OR Manager | April 2024
29
https://www.acep.org/patient-care/policy-statements/procedural-sedation-in-the-emergency-department https://www.ncbi.nlm.nih.gov/books/NBK551685/ https://www.ncbi.nlm.nih.gov/books/NBK430884/ https://www.mdpi.com/2077-0383/10/8/1735 https://www.ncbi.nlm.nih.gov/books/NBK537106/ https://www.ncbi.nlm.nih.gov/books/NBK537321/ https://www.nysora.com/intravenous-anesthetics/ https://www.ncbi.nlm.nih.gov/books/NBK459275/ https://www.cureus.com/articles/117253-propofol-related-infusion-syndrome-a-clinical-review#!/ https://www.jointcommission.org/standards/standard-faqs/ambulatory/provision-of-care-treatment-and-services-pc/000001645/ https://www.euronews.com/green/2023/03/03/scotland-becomes-the-first-country-to-ban-the-high-emissions-anaesthetic-desflurane https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9224877/ http://www.ormanager.com

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