Sedation and Analgesia in the Interventional Radiology Department

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Administration of sedation and analgesia in the interventional radiology suite is often necessary during painful diagnostic and therapeutic procedures. Although sedative and analgesic agents are generally safe, catastrophic complications related to their use can occur, often as a result of incorrect drug administration or inadequate patient monitoring. The incidence of adverse outcomes related to provision of sedation and analgesia can be reduced with improved understanding of the pharmacology of these medications, by providing adequate monitoring to sedated patients, by recognizing patients who are at increased risk of experiencing an adverse drug reaction, and by early and appropriate management of complications.

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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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    Neither of the authors have identified a potential conflict of interest.

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