Circulation 60,475 • Volume 14, No. 4 • Winter 1999

CRNA Notes Danger in Confusion of Sedation, Analgesia; Calls for Guidelines

Kevin Perlinger, CRNA

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