Journal of Vascular and Interventional Radiology
Sedation and Analgesia in the Interventional Radiology Department
Section snippets
DEFINITIONS
Sedation refers to the use of pharmacologic and nonpharmacologic means to depress the central nervous system (CNS) and reduce patient anxiety and irritability. Proper sedation achieves anxiolysis (a state of diminished apprehension) and, in some circumstances, amnesia (a loss of memory of events during the procedure) (12). The stages of sedation have been categorized in an attempt to define targeted endpoints for drug administration (Table 1). Although these categories are useful to guide
GOALS OF SEDATION AND ANALGESIA
Surveys of practice patterns of sedation and analgesic use in IR departments in Europe and North America reveal that procedural medication delivery patterns are highly variable, with different levels and methods of sedation being used for similar procedures in different institutions (21, 22, 23). The use of sedation and systemic analgesia during routine diagnostic angiography was common in these surveys, despite the fact that most patients undergoing angiography experience only mild discomfort (
MEDICATIONS
The most commonly used medications for the administration of sedation and analgesia are summarized in Table 3.
NONPHARMACOLOGIC ADJUNCTS FOR SEDATION
Nonpharmacologic methods of analgesia and sedation such as hypnosis and anodyne imagery have been successfully used in the IR department (35, 36, 37, 38). They have been shown to significantly reduce drug requirements, and hypnosis has been shown to be a cost-effective method of delivering care to IR patients (39). Although the training of staff in techniques of hypnosis is reported to be relatively simple, the practice of nonpharmacologic methods of sedation and analgesia has yet to become
SUGGESTIONS FOR ADMINISTRATION OF SEDATION AND ANALGESIA
Many different medications are available for the induction of moderate sedation during IR procedures, and the drug or drug combination used in an institution will often vary depending on operator preference and experience. Some principles of drug administration may help to ensure safe and effective use of these agents:
- 1.
Sedative drugs should be easily titrated to the desired clinical effect and should have a predictable onset and duration of effect with a rapid recovery profile.
- 2.
Intravenous
SKILLS AND TRAINING OF PERSONNEL
All personnel responsible for the administration of sedation and analgesia and the monitoring of sedated patients both during and after the procedure must be capable of recognizing and acting on complications of oversedation. They must have knowledge of the pharmacology of the drugs that they are administering and be familiar with available antagonists (12). Personnel should be capable of maintaining airway patency and assisting ventilation. It is recommended that an individual with advanced
EQUIPMENT AND SETTING
Appropriate sedative and analgesic agents and their relevant reversal agents should be immediately available in the IR area. An oxygen source, suction equipment, nasal cannulae, appropriately sized oral airways, and a bag-valve mask should be in the procedure room. IR suites should be equipped with a cardiac monitor, an automatic blood pressure cuff, and a pulse oximeter. Appropriate emergency equipment must be immediately available. All IR departments should be equipped with a cardiac
PREPROCEDURE PATIENT PREPARATION
Patients should be evaluated with a medical history and physical examination to determine the degree of physiologic reserve of the CNS and cardiovascular and respiratory systems and to assess for the likelihood of the patient experiencing an adverse reaction to sedation. Details of medication use, drug allergies, time of last oral intake, abnormalities of major organ systems, and alcohol or substance abuse should be elicited. The physical examination should include assessment of vital signs,
PATIENT CONSENT
A discussion of the risks and benefits of receiving sedation and analgesia should be included during acquisition of informed consent. Estimates of the incidence of adverse events and fatalities related to sedation and analgesia are highly variable. However, the overall risk of significant adverse effects is thought to be low. A review of patients who underwent endoscopy after sedation with BZDs and supplemental narcotics reported the incidence of serious cardiopulmonary complications and death
PROCEDURE MONITORING AND PATIENT CARE
All patients receiving moderate sedation should receive supplemental oxygen, either through nasal prongs or a mask, and should have adequate intravenous access throughout the procedure and until the patient is no longer at risk of cardiopulmonary depression (12). All results of patient monitoring, including vital signs, depth of sedation, dose, route, and response to medications, must be documented in the patients' chart. Patients must be continuously monitored to assess the depth of sedation
POST-SEDATION CARE
Patients continue to be at significant risk of developing complications related to sedation and analgesia after their procedure. Continued observation, monitoring, and predetermined discharge criteria are therefore thought to decrease the likelihood of adverse outcomes after moderate and deep sedation (12). Postprocedure monitoring should be done in an appropriately staffed and equipped area until the patients are at their baseline level of consciousness.
Oxygenation should be monitored until
Obese Patients
Sedated obese patients are at increased risk of gastroesophageal reflux, upper airway obstruction, and oversedation (51, 52). The risk of reflux may be reduced by strict adherence to fasting requirements and preprocedure treatment with an oral H2 antagonist and metoclopramide. Upper airway obstruction can occur in obese patients at lighter levels of sedation, and therefore patients should be carefully monitored for this complication. Obese patients are more susceptible to the respiratory
Patients with Coronary Artery Disease
Coexistent coronary artery disease is frequently present in patients undergoing IR procedures, particularly for peripheral vascular or renovascular disease. Inadequate sedation can increase the risk of an acute cardiac event in these patients as a result of increased cardiac demand. Similarly, excessive sedation or respiratory suppression can also precipitate cardiac complications by inducing hypotension or hypoxemia.
Ideally, proper sedation and analgesia in the patient with coronary artery
WHEN TO ASK AN ANESTHETIST TO ATTEND
ASA guidelines recommend that an anesthesiologist be in attendance for all cases in which deep sedation or general anesthesia is the intended level of sedation. It is also recommended that for procedures on patients of ASA level 3, 4, or 5 during which any more than minimal sedation is to be administered, consideration should be given to seeking the consultation of an anesthesiologist regarding patient care (12).
The frequency with which an anesthesiologist attends IR procedures for other cases
Excessive Sedation
For most procedures performed without anesthesiology assistance, moderate sedation is the target level of sedation (Table 1), and if a deeper level of sedation is encountered, this should be considered an adverse event. Oversedation is not in and of itself dangerous to the patient. However, risks of airway compromise, hypoventilation, and hemodynamic instability increase significantly with the induction of deep sedation, and a properly trained individual with no other responsibilities must be
CONCLUSION
The provision of adequate sedation and analgesia to patients undergoing invasive diagnostic or therapeutic procedures in the IR department improves patient satisfaction and facilitates optimal patient care by reducing unwanted movement and stabilizing hemodynamic status. The administration of sedation and analgesia is associated with a significant risk of adverse effects, particularly respiratory compromise. However, knowledge of sedative and analgesic agents and their proper use, careful
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2023, Journal of Vascular and Interventional RadiologyModerate Sedation Education for Nurses in Interventional Radiology to Promote Patient Safety: Results of a National Survey
2021, Journal of Radiology NursingCitation Excerpt :While there is limited literature that describes the influencing variables or patient outcomes for patients receiving moderate sedation in IR, sedation is a part of many invasive procedures and plays an important role in the management of pain and anxiety for patients. Patients who suffer complications like oxygen desaturation, hypoventilation, hypotension, unresponsiveness, or cardiac arrest as a result of moderate sedation may require the use of narcotic reversal medications, oral airway placement, intubation, or even cardiopulmonary resuscitation (CPR), each of which can result in increased monitoring and recovery times, longer hospital stays, and unplanned admissions (Arepally, Oechsle, Kirkwood, & Savader, 2001; Martin & Lennox, 2003). The direct cost to the patient is clear, but it additionally places pressure on hospitals already trying to maximize quality and efficiency amidst increasingly strained resources.
Financial Effect of Unbundling Moderate Sedation from Procedural Codes in Radiology
2020, Journal of Vascular and Interventional RadiologySedation and analgesia in interventional radiology: Where do we stand, where are we heading and why does it matter?
2019, Diagnostic and Interventional ImagingModifying Institutional Guidelines Reduces the Likelihood of Oversedation During Interventional Procedures
2018, Journal of the American College of RadiologyCitation Excerpt :Naloxone is usually administered in 0.4-mg intravenous increments until the desired effects are met, up to a total dose of 10 mg. The duration of effect is 90 min, and repeated dosing may be required [3]. The adverse drug events with BZDs (eg, midazolam and diazepam) range from nausea and vomiting and hypotension to respiratory depression and cardiac arrhythmias [7].
Neither of the authors have identified a potential conflict of interest.