Getting it right: Is your sedation safe sedation?

1
Getting it right Is your sedation safe sedation?

• Duncan Bell
• Sunderland Royal Hospital

2

• Report of an Intercollegiate Working Party
  chaired by the Royal College of Anaesthetists
• Published November 2001

3
AOMRC

• Implementing and ensuring Safe Sedation Practice
  For Healthcare procedures in adults
• Available as a pdf file from www.aomrc.org.uk

4
Safe Sedation Practice

• What questions were asked?
• What conclusions were drawn?
• What recommendations were made?
• What are the implications for the BSG and its
  members?

5
Existing Guidelines on Sedation Practice

• Poswillo Report 1990
• BSG Recommendations 1991
• RCA and RCR 1992
• RCS Report 1993

6
What conclusions were drawn?

• Existing guidelines on safety, sedation and
  monitoring were generally sound.
• but

7

• There was evidence to suggest that sedative
  drugs are, in some circumstances, being used
  unnecessarily, inappropriately, or without
  adherence to some of the key components of
  published recommendations.

8
Evidence examined

• Included audits of -
• OGD 1995
• Colonoscopy Intercollegiate BSG 2001
• Bronchoscopy (Thorax)1997
• TOEC (Heart) 2000
• As well as -
• Admissions to ITU
• Medico-legal claims

9
Why are the guidelines not always being followed?

• Postgraduate training programmes for specialties
  that use sedation techniques frequently do not
  include any requirement for specific instruction.
• Resulting in many practitioners never receive
  formal training in sedation methods.

10
Are the methods used correct?

• .An associated cause for concern is the use,
  for sedation and by untrained staff, of drugs
  introduced primarily as IV anaesthetics (e.g.
  propofol and ketamine) .

11
Are the methods used correct? Propofol and
ketamine

• .Although these drugs have some excellent
  properties for use in sedation, very specialised
  knowledge, skills and equipment are needed.
  Certainly, these drugs cannot, at the present
  level of knowledge, be considered as safe for use
  by the operator-sedationist .

12
Are the methods used correct?

• .this is not to suggest that the techniques
  currently available are perfect because there is
  considerable room for development of many
  aspects.

13
Are the methods used correct?

• . such development must be carried out in
  formal, collaborative research projects, not by
  uncontrolled variations in day to day practice.

14
Are the methods used correct?

• .The key point is that safety will be optimised
  only if practitioners use defined methods of
  sedation for which they have received formal
  training .

15
Recommendations

• A) General Principles
• B) New Measures

16
Recommendations

• A) General Principles
• B) New Measures

17
Recommendations

• A) General Principles
• B) New Measures

18
New Measures The Working Party recommends that
- 1

• Royal Colleges, in association with the relevant
  sub-specialty organisations, should develop
  guidelines on sedation methods appropriate to
  clinical practice in their sphere of influence.

19
New Measures The Working Party recommends that
- 2

• Royal Colleges, and their Faculties should
  incorporate the necessary instruction and
  assessment into training and revalidation
  programmes of those specialties that use sedation
  techniques.

20
3 Clinical
governance framework at hospital level set up to
ensure a patient centred culture in which -

• Multidisciplinary team training
• Sedationist fully aware of possible
  adverse consequences and able to deal with them
• Audit of adverse incidents, complications
  and adherence to national and local protocols

21
4 NHS Trusts should
apply to sedation techniques the standard of the
Clinical Negligence Scheme which requires that -

• All medical and dental staff in training
  be competent in the technical skills and
  specified tasks expected of them.

22
5 Each hospital
should -

• nominate two consultants, one an
  anaesthetist and the other a user of sedation, to
  collaborate in the local implementation of
  guidelines and the provision of a specialist
  service for patients with particular problems.

23
6 Those responsible
for commissioning and providing healthcare in the
primary and private sectors should -

• ensure that similar processes are in
  place to ensure a high standard of sedation
  practice.

24
The implementation of recommendations 1-6 will
be aided by -

• Greater focus on clinical governance and
  revalidation
• As well as
• The current climate requiring greater individual
  responsibility for practice
• but

25
The implementation of recommendations 1-6 will
also require -

• Adequate resourcing
• Involve people with appropriate knowledge and
  skills
• Include monitoring and evaluation processes
• Have local as well as national elements

26
For the BSG Endoscopy Committee implementing
1-6 will require -

• Updating of the guidelines on both sedation and
  informed consent
• Liaison with the Royal Colleges and JAG
• Supporting individual members in their dealings
  with their local trusts, anaesthetists, PCGs and
  private hospitals
• ? Designing and running suitable courses on
  Conscious Sedation

27
Are the methods used correct?

• .benzodiazepines have no analgesic properties
  when conventional doses are given systemically,
  and attempts to use them to control pain will
  result in significant overdose.

28
Are the methods used correct?

• .If systemic analgesia is required the opioids
  produce a degree of sedation as well, and are
  widely used, but they have respiratory depressant
  and other adverse effects.

29
Are the methods used correct?

• .Inhalational sedation has an established role
  in dental practice and could be used more
  frequently in other settings.