Letters to the Editor:
To the Editor:
These comments address the Letter to the Editor by Dr. Kyle M. Jones, Summer
1999 APSF Newsletter concerning deep sedation. I agree with Dr. Jones'
discussion in his letter. It is time for anesthesia organizations to step forward
and create sensible guidelines for all anesthesia and non-anesthesia personnel
administering hypnotic or anesthetic agents for sedation. The multiple guidelines
created by several professional societies only result in confusion among anesthesia
providers, emergency room physicians, nurses, and administrators over the control
and responsibility of conscious sedation.
Deep Sedation is an issue at the forefront of this debate. At times, as an anesthesia provider, I am called to assist in the care of patients where the administration of conscious sedation is already in progress. The physician usually requests additional medication to control pain. During these episodes, I am expected to administer enough medication to deeply sedate the patient. This results in a condition of profound analgesia, very similar to general anesthesia. I think this is the exact point where a line is crossed in this debate. The goal of medication administration is no longer sedation, but also control of moderate to severe pain. Pain control is the hinge in the decision regarding the appropriate use of conscious sedation techniques. A clear well-defined distinction in the goal of administering medication for only mild pain and sedation has to be universally accepted. Patients experiencing procedures which produce more than mild pain need the care of anesthesia personnel in the Operating Room. Pain control needs to be the focus in this debate. Pain control is only possible in a controlled environment by careful titration of potent analgesics or anesthetic agents. In the use of very potent drugs, there are personnel and training issues involved. At times, non-anesthesia personnel are inadequately trained and uncomfortable participating in the dosing, monitoring, airway control and provision of the proper environment for deeply sedated children and adults. Proper conditions are readily available in the Operating Room with anesthesia personnel in attendance.
The use of the anesthetic agent ketamine has emerged as the Emergency Room's silver bullet in pediatric sedation. Unpleasant recall, flashbacks, oral secretions, and inadequate sedation with pain are all known side effects of ketamine, especially in sub-anesthetic doses. It is my impression in actual anesthesia practice that the use of ketamine in the Operating Room has nearly been abandoned in favor of a controlled intravenous or inhalation induction and then maintenance of sedation or anesthesia. Also involved in the Emergency Room use of ketamine issue is the necessity of starting an intravenous line or, contrarily, just administering the ketamine intramuscularly, which means there is no immediate intravenous access for emergency medications or medications to facilitate airway control. In the Operating Room, an intravenous line is humanely started just as the child loses consciousness.
Kevin Perlinger, CRNA
Duluth, MN
To The Editor:
I was so pleased to see the excellent article on latex allergy by Dr. Arnold
Berry in the Fall 1999 Newsletter.1
I only wish to expand upon the paragraph concerning alternatives to high protein, powdered latex gloves. The paragraph discusses the advantages and disadvantages of chlorinated NRL gloves. It then goes on to mention "Other alternatives to NRL..." but only mentions vinyl. Vinyl indeed has many drawbacks as an alternative to latex. Fortunately, there are many gloves made of other non-latex materials available today. These include nitrile, styrene butadiene, and neoprene, to name just a few. Most glove manufacturers now produce at least one line of non-latex gloves. I urge everyone to try these gloves. Many have excellent tactile and physical properties. Yes, most of these gloves are more expensive than latex. But as the excellent article by Phillips, et al.2 points out, this cost is more than counterbalanced by the cost of continuing to disable healthcare personnel by ongoing exposure to latex allergens. In addition, if we are truly concerned about patient safety, we must stop exposing our patients to this potentially deadly allergen.
Barbara Zucker-Pinchoff, MD (BZPMD@aol.com)
Director, Physicians Against Latex Sensitization
New York, NY
References
1. Berry AJ. Latex Allergy: A Problem for Patients and Personnel. APSF Newsletter
1999;14:33.
2. Phillips VL, Goodrich MA, Sullivan TJ. Am J of Public Health 1999;89:1024-1028.
To the Editor:
I found Dr. Zvara's article in the Fall 1999 APSF Newsletter advocating
regional anesthesia for carotid surgery to be of great interest. My own experience
with cervical plexus blocks for carotid surgery was stimulated by a vascular
surgeon who had trained with regional techniques for carotid surgery leading
me to research the topic and learn the technique.
When we first started using regional anesthesia with patients awake for carotid surgery in our OR, intra-operative EEG monitoring was felt to be a "community standard" and so a number of patients were initially done awake with EEG monitoring. One of our early experiences involved a patient sustaining severe bradycardia and brief asystole upon manipulation of the carotid body leading to loss of cerebral profusion. The patient became unconscious literally in midsentence. Atropine and ephedrine were administered, pulse and blood pressure promptly returned and the patient resumed the conversation totally unaware that anything had transpired. Only after the whole episode was complete and we were again conversing with the patient did the EEG show any change at all. After a repeat of similar occurrence shortly thereafter, we adopted having an awake patient conversing with the anesthesiologist as the gold standard in neurological monitoring, and I have been sold on the value of the technique since. The only caveat is that success depends upon a committed, skilled and well-prepared anesthesiologist, and an adept, gentle, and invested surgeon, and a suitable patient.
That said, I have great difficulty with concluding that regional anesthesia is the technique of choice for carotid surgery in absence of better, more methodologically consistent, and powerful data to support that conclusion. Dr. Zvara is correct to observe that there is tremendous variation in techniques and outcomes. The statement that many teams have excellent outcomes with general anesthesia is an important one, and in the absence of further data, suggest caution - in touting the superiority of one technique over another. Regional anesthesia is indeed an important option in our armamentarium, and should be considered for carotid procedures, but it is not yet proven to be a superior technique with regard to patient outcome.
R. Screven Farmer, M.D.
Tucson, AZ