orm_asc_october-2024 - 7

Ambulatory Surgery Centers
Sedation, Vo
Continued from page 1
PSA is patient-specific
Sometimes incorrectly referred to as
" conscious sedation, " procedural sedation
(PS) is " a technique of administering
sedatives or dissociative agents
with or without analgesics to induce a
state that allows the patient to tolerate
unpleasant procedures, " according
to the American College of Emergency
Physicians. PS involves " a continuum of
altered levels of consciousness (including
minimal, moderate, and deep), and
dissociative sedation. "
Further,
there is a distinction between
sedation, dissociation, and analgesia.
Sedation enables the patient to
relax and lie still; analgesia is pain management;
and dissociation is a state of
mind-body separation. PS is not general
anesthesia or pain control alone but
is an individualized approach for each
patient. Because PS is commonly administered
by combining sedatives with
analgesics to reduce the perception of
pain, PS also can serve as PSA.
The Joint Commission outlines three
levels of sedation:
* Moderate sedation: Patients can respond
purposefully to verbal commands,
which may be accompanied
by light tactile stimulation. Cardiovascular
function and spontaneous
ventilation are maintained, and no
interventions are needed to maintain
a patent airway.
* Deep sedation/analgesia: Patients
can respond purposefully to repeated
or painful stimulation but
cannot be easily aroused. Their ventilatory
function may be impaired,
and maintaining a patent airway may
require intervention. Cardiovascular
function is usually not impaired.
* Anesthesia: This includes general
anesthesia and spinal anesthesia
(spinal, epidural, or a major area of
the body), but not local anesthesia.
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Patients are unable to independently
maintain ventilatory function and require
interventions such as positive
pressure ventilation. Cardiovascular
functions may be impacted, and patients
cannot be aroused even by
painful stimulation.
Propofol proliferates
The market for sedation agents and
analgesics continues to evolve. More effective,
safer drugs with quicker onset,
shorter recovery, and fewer complications
have replaced those older ones.
According to NYSORA, an international
educational organization focusing
on anesthesiology, ultrasound, regional
anesthesia, and pain medicine, propofol
is the most frequently administered anesthetic
drug for induction and maintenance
of anesthesia. With a rapid onset
of 15 to 30 seconds and a duration
of 1 to 3 minutes, it is widely used for
moderate sedation and short-term general
anesthesia beyond the OR, whether
in the intensive care unit (ICU), the interventional
radiology suite, or in an
ambulatory setting.
Propofol is an intravenous anesthetic
administered as a bolus, an infusion, or
some combination of the two. Due to
its milky white appearance after dissolving
in a lipid emulsion, propofol is also
known as " milk of anesthesia. " The
drug of choice for general anesthesia in
stable obstetric patients, it is also common
for sedation in intubated, mechanically
ventilated ICU patients. It is safe
during pregnancy (although there is a
risk of neonatal central nervous system
and respiratory depression), as well as
in children (maintenance anesthesia
for those 2 months and older and general
anesthesia for those 3 years and
older or with IV access). Off-label uses
include treatment of refractory status
epilepticus in children and adults and
refractory postoperative nausea and
vomiting, both common side effects of
procedural sedation.
In fact, propofol's antiemetic properties-along
with its rapid onset, short
Propofol-related
Infusion Syndrome
(PRIS)
PRIS is a rare but serious adverse effect of
prolonged propofol infusion in mechanically
intubated patients (usually > 4mg/
kg/hour for more than 24 hours), as highlighted
by Folino et al. Children younger
than 3 years old are especially vulnerable.
PRIS is also prevalent in patients younger
than 18 years old as they are more sensitive
to intravenous anesthetics than adult
patients. PRIS features include metabolic
acidosis, hyperkalemia, hyperlipidemia,
and rhabdomyolysis, progressing to renal
and cardiac failure and mortality.
Upon noticing the appearance of PRIS
features, practitioners must stop propofol
infusion immediately. Mortality associated
with PRIS has been estimated to be
around 33% and becomes even higher if
the diagnosis is delayed.
duration, and relative
safety for a wide range
of patients-often leads
it to be preferred over
other drugs, says Biraj
Patel, MD, an anesthesiologist
practicing in New
York City and founder of
PreferredMD. According
to literature, although propofol does not
have much of an analgesic effect, analgesics
such as fentanyl or Toradol can
be added to the regimen. Propofol also
can be used to reverse some of the effects
of local anesthetics, such as seizures.
The drug's quick half-life reduces
the risk of overdose in ASC settings,
even with a bolus dose. Patients can
quickly emerge from procedural sedation
with no hallucinations. Propofol's costeffectiveness
also makes it a drug of
choice for many ASCs.
Transient local pain at the injection
site is the most common adverse reaction.
Dr Patel advises caretakers to
monitor patients for airway and hemoBiraj
Patel,
MD
ASC Leader | October 2024
7
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