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Sedation for Your Procedure - Anesthesiologist or Not?

INTRODUCTION
A question that is frequently asked arises when a patient is faced with the prospect of having some type of procedure (either not surgery or "minor" surgery) done with sedation. How does sedation compare with anesthesia and should an anesthesiologist be providing sedation? What exactly is conscious sedation? Is it enough? Is it safe? An anxious patient is often concerned that they won't get "enough" sedation. On the other hand, a patient may also be worried that they will get deep sedation, perhaps more than is safe, but not have the expertise of an anesthesiologist.

Certainly the issue of what is comonly known as "procedural sedation" or "conscious sedation" is a complex and sometimes controversial one. A single article such as this one cannot hope to address all of the nuances involved. However, some general principles can guide the decision making process of whether a patient should have sedation by a non-anesthesiologist or a higher level of care by an anesthesiologist.

Disclaimer: As an anesthesiologist, I am obviously giving my own perspective about this situation. Anesthesiologists receive extensive training and are confident that the level of care they deliver is excellent. While I try to give a balanced discussion of the issue here, my personal and professional bias may show through in some instances. Again, I hope to provide some basic facts here but the patient is responsible in the end for asking the right questions and for making the decision about what type of care to receive.

DEFINITION OF SEDATION
Anesthesiologists are well trained to provide all levels of anesthetic care, including sedation. Other healthcare providers and personnel are also trained to provide sedation. Is there a difference? How about the difference between sedation and "conscious sedation" or other forms of sedation? As you can see, it is important to clearly define what sedation is before a discussion of what is appropriate can occur. What should be clear is that there are different levels of sedation. Let's look at a few here:

Minimal or light sedation involves the administration of small amounts of medication in order to deal with anxiety or agitation. This amount of sedation might make a procedure that is otherwise difficult a little bit easier. This type of sedation is usually not sufficient for a significant procedure or painful intervention to occur. The defining characteristic of this type of sedation is that the patient still appears relatively awake and is able to communicate clearly at all times.

A higher level of sedation is often known as conscious sedation or procedural sedation. This is what is usually provided for office procedures, dental procedures, radiologic procedures such as CT scans and MRI, etc. The hallmark of this type of sedation is that patients are obviously sedated when you look at them, but they are able to respond to stimuli (such as verbal questioning). Hence, the term "conscious sedation" - the patient is obviously sedated but is still "conscious" and responsive.

An even higher level of sedation is what is known as deep sedation. In this form of sedation, the patient is clearly sedated and may only respond minimally to very significant stimuli (high levels of pain, etc.) or may not respond at all in some cases.

Once we move past the level of deep sedation, we come to what is known as general anesthesia - where a patient is unconscious and unresponsive, even in the face of significant stimuli. This is what might be provided for surgery and remains the practice domain of nurse anesthetists and anesthesiologists.

One additional term that deserves a definition is that of Monitored Anesthesia Care or MAC, which is a specific description of care given by an anesthesiologist. MAC refers to a continuum of sedation ranging from light to deep. Indeed, as anesthesiologists provide MAC, they are prepared to lighten or deepen the level of sedation and even provide general anesthesia as needed.

No matter what type of sedation you receive or what type of healthcare provider gives you that sedation, there are some common requirements that should be followed:

TRAINING
Administering sedation is not something that every healthcare provider should be doing. It is a learned skill, and like other skills that are practiced in the delivery of healthcare, individuals participating in sedation of a patient need to be trained. This training teaches skills that are necessary and credentials the healthcare provider to make sure that they are qualified to provide sedation in a safe manner.

An important point is that the person administering sedation should be trained to deal with the next deeper level of sedation for the sedation to be safe. This is because it is not always easy to keep a patient at a stable level of sedation as their needs change during a procedure. So, for example, someone who is intending to deliver conscious sedation (where the intent is to keep the patient conscious and responsive at all times) may find that the patient occasionally crosses over to deep sedation (where the patient is not responsive). Until this can be corrected (ususally by giving less medication to the patient), the healthcare provider must be able to manage deep sedation.

This is the reason that you won't find non-anesthesiologists that are credentialed to do deep sedation. You see, the next deeper level is general anesthesia and only trained anesthesia providers are trained to give general anesthesia. It is also why there is a specific term (MAC, as defined above) for sedation given by anesthesia providers - only they can provide the widest range of anesthesia from light sedation all the way to general anesthesia if needed.

It is also important that others involved in the process of sedation be trained, even if they are not the ones directing or administering the medication. Sedation requires monitoring and other skills that every person involved in the process should be familiar with. Most hospitals will require that the staff in the room at least be trained in basic life support (CPR) and that someone also be trained in advanced cardiac life support (ACLS).

COMMON REQUIREMENTS
No matter who is providing sedation (or anesthesia for that matter), where it is being provided (whether the hospital or the office) and what it is being provided for, there are some common requirements that should be present. Already mentioned is the need for close monitoring. Things like blood pressure, heart rate, etc. should be monitored during sedation. In addition, there should be a person that is only there to monitor and care for the patient, i.e. that person should not be participating in the medical procedure and should only be participating in the sedation process. Lastly, even when not in a hospital, locations providing sedation should have the ability to handle emergencies, which means that they must have emergency equipment readily available.

WHY NOT ANESTHESIOLOGISTS FOR EVERYONE?
So if anesthesiologists have the most training and are able to provide deeper levels of sedation, why are they not involved in every case? Simply put, anesthesiologists are not always available, they aren't always the most affordable option, and the level of care that they provide is not always needed. While it would be nice to have an anesthesiologist every time sedation was needed, this is simply not a viable option for every patient in every case in every location.

Also, it should be made very clear that non-anesthesiologists can be trained to give sedation safely. I am not suggesting in this article that anesthesiologists should be the only people allowed to provide sedation. Sedation is not "magic," it is a learned medical skill. The key to doing things right is proper training and a properly prepared environment.

An anesthesia provider may still be needed if the procedure likely cannot be done without deep sedation. It should also be considered if the patient has a number of medical problems. In that situation, anesthesia providers have more training and experience in how sedation interacts with other medications and how these medical problems might affect the sedation. Clearly, a patient that has had previous difficulty with sedation or anesthesia should probably seek the expertise an anesthesiologist can provide.

In the end the decision whether to have conscious sedation or to have a deeper level of sedation is a choice that must be tailored to each individual situation. What is needed depends on the procedure planned, the patient's expectations and desires, the patient's medical condition, etc. Just as there is not a single anesthetic that works for every surgery and every patient, there is not one method of sedation that works every time. As always, patients should be encouraged to ask questions, explore options and, together with their physician, make a choice that is both safe and effective.

 

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