The Academy of Medical Royal Colleges has introduced sedation guidelines in 2013, highlighting areas that needed focus, setting fundamental standards of practice and guides for action. However the uptake of these guidelines has been slow. In February 2021, a new guideline was published, reinforcing certain aspects of the previous guideline and issuing new perspectives in other areas. In this blog, we discuss common areas of concern and address 5 aspects of implementing safe sedation practice.
Common areas of concern
The guidelines highlight several areas of concern in sedation practice that need focus:
- inadequate pre-sedation assessment
- inadequate monitoring of patients undergoing sedation
- excessive doses in the elderly/frail patient
- failure to titrate drugs to effect
- lack of appreciation of the risks implicit in the use of drug combinations, e.g. synergism
- association of the use of flumazenil, a benzodiazepine antagonist, with the use of excessive doses of benzodiazepine and the lack of, or poor, recovery facilities
- minimal training of those administering sedation and the lack of supervision of inexperienced trainees
1. Implementing pre-assessment for safe sedation
Inadequate pre-assessment is a recurring factor in sedation-related adverse events and poor outcomes, for all specialties. Sick or elderly patients may have significant comorbidity. In younger patients, the presence of heart disease, cerebrovascular disease, lung disease, liver failure, anaemia, shock and morbid obesity may indicate dangerous risk factors.
Pre-operative assessment and preparation of patients, focusing on medical, social and psychological assessment and evaluation of risk is essential.
Sedating practitioners should always ask themselves beforehand ‘Will I be able to ventilate this patient, if necessary?’
2. Information and consent
Consent is essential to sedation. Information should be provided at an appropriate time (not at the last moment) when there is a chance to have a discussion and for the patient to be able to ask questions, understand the choices and risks before making a decision to sedate.
Risks and benefits must be clearly explained and proper distinction should be made between average risk and personalised risk. Alternatives to sedation (typically general anaesthesia or local anaesthesia with behavioural techniques) should be clearly explained. Psychological preparation of patients is an important part of preparation for sedation.
3. Titration to effect
Titration to effect is one of the most important aspects in safe sedation. The initial dose is determined by careful pre-assessment of the patient and any relevant history, and this dose must have taken full effect before any additional dose is given. Subsequent doses, if necessary, should be carefully titrated to achieve the desired effect.
In principle, titrating a drug/ drugs to optimal effect is critical to safely achieving a recognised sedation endpoint, thereby avoiding inadvertent over-sedation or general anaesthesia.
Clinical and instrumental monitoring to a degree relevant to the patient’s medical status and the sedation method, must be used.
- Level of Sedation: regular communication with the patient is crucial to make sure patients maintain a purposeful response and are not overstated.
- Respiratory function:
- Continuous waveform capnography should be used to monitor adequacy of ventilation for all patients undergoing moderate or deep sedation
- Cardiovascular function:
- Blood pressure monitoring every 3-5 min.
- Where conscious sedation is used and continuous verbal contact with the patient maintained, ECG monitoring is not essential.
One of the key recommendations of guidelines is that all professionals involved in sedation receive formal training. The following learning outcomes have been identified:
- To gain a fundamental understanding of what is meant by conscious sedation and the risks associated with deeper levels of sedation.
- To be able to describe the differences between conscious sedation and deeper levels of sedation, with its attendant potential risks to patient safety.
- To gain a fundamental understanding that loss of verbal responsiveness/deep sedation requires the same level of skills and care as for general anaesthesia.
- To recognise the important principle of minimum intervention, where the simplest and safest technique which is likely to be effective is used to achieve the clinical goal.
- To gain a fundamental understanding of the particular dangers associated with the use of multiple sedative drugs, especially in the elderly and young children.
- To be able to safely deliver pharmacological sedation to appropriate patients and recognise the limits of their competency and experience.
- To be able to discuss where and when deeper levels of sedation or anaesthesia may be indicated.
- To be able to manage sedation-related side effects in a timely manner, ensuring patient safety is of paramount consideration at all times.
If you need formal sedation training, check SedateUK courses here.
If you want to learn more about implementing safe sedation standards, watch the free webinar here.