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October 24, 2005
9:00:00 AM - 10:30:00 AM
Room C306
Procedural Sedation in a Large Teaching Hospital
Richard M. Pino, M.D., Ph.D., Ruth J. Bryan, R.N., M.S.N., C.A.P.A., Paul H. Alfille, M.D.
Anesthesia and Critical Care, Massachusetts General Hospital, Boston, Massachusetts, United States
Anesthesiologists are usually responsible for the administration of procedural sedation (PS) programs for non-anesthesiologists. As advocates for patient safety and the anticipation of increasing JCAHO requirements and surveillance, in 1999 we aggressively strengthened the PS program in our large teaching institution. Age-appropriate advanced life support certification was mandated for all physicians to provide some skills of airway and cardiopulmonary management. Physicians and RNs were formally re-credentialed bi-yearly after education via lecture, video or computer presentation. A database, accessible from all hospital computers, was created to list all providers credentialed sedation, expiration dates of their credentials, and the sedation policy. The added benefit of this database allows 24/7 knowledge of who is credentialed to do PS procedures off shift and on weekends. Over 800 personnel are now privileged to provide both conscious and deep sedation. Drugs have been limited to opiates and benzodiazepines with established safety thresholds that can be reversed if overdosed with the exception of ketamine that is permitted in the pediatric emergency room. Propofol and etomidate are strictly prohibited for sedation of non-intubated patients. The availability of an anesthesiologist for consultation via a dedicated hospital pager and routine communication with the nursing staff and physicians has enabled the timely evaluation of patients with questionable suitability for sedation and facilitated scheduling of more difficult patients for care by an anesthesia team. An essential requirement has been the submission of a quality assurance form (QA) that lists thirty-three reportable events for each PS patient. The table below presents the most common findings. There was a trend of decreased deep sedation cases and a decline decreased SpO2. In contrast, inadequate pain control and treatment of anxiety increased. These may be related to more extensive and lengthy procedures being performed under PS. There were no drug reactions, arrests, or deaths secondary to sedation.[table1]

Anesthesiology 2005; 103: A615
Quality Assurance Data for Procedural Sedation
Total Procedures24,90825,99922,23518,168
Conscious PS24,07724,84521,26516,733
Deep PS708 (2.8)*1031(4)817 (3.6)1,249 (7)
Unplanned Deep PS123 (0.5)123 (0.4)153 (0.7)146 (1)
Total Events162 (0.65)177 (0.68)213 (0.96)197 (1)
SpO2 < 90%34 (0.14)29 (0.11)87 (039)70 (0.39)
SBP < 20% baseline37 (0.15)28 (0.1)49 (0.22)65 (0.36)
Apnea or reversal23 (0.09)17 (0.07)21(0.09)20 (0.11)
Nausea/vomiting10 (0.04)11 (0.04)7 (0.03)9 (0.05)
Arrest13 (0.05)5 (0.02)3 (0.01)7 (0.04)
Death5 (0.02)5 (0.02)3 (0.01)7 (0.04)
Pain/anxiety16 (0.06)13 (0.05)9 (0.04)5 (0.03)
Anesth assist8 (0.03)7 (0.03)3 (0.01)4 (0.02)
*percent of total