To the Editor
I address the controversy surrounding the use of conscious IV sedation. The discussions continue to examine the qualifications of those prescribing and administering the agents and of those who monitor the patient’s response. The question most frequently asked is, “Is this safe for the patient?”
The use of intravenous sedation was originally intended to do just that: sedate the patient. The actual relief of the surgical pain was provided by injection of local anesthetics into the surgical site to block painful sensations. The sedation served as a bridge to get the patient from being completely wide awake to being ready for surgery without there being undue psychic distress during injection of the local anesthetic agent into the surgical site. Small doses of narcotics were often also added to increase the patient’s threshold for pain but no expectation existed that this analgesia would replace a satisfactory local anesthetic. Sedation was continued during the procedure to increase patient comfort with the overall scenario. Enter midazolam and its amnesia-producing properties. Since that drug’s introduction, the concept of genuine patient comfort as a criterion for satisfactory care has undergone steady erosion to be replaced by the axiom, “if the patient doesn’t remember the pain, no harm has been done him.” Practitioners without anesthesia training, using intravenous midazolam augmented by a narcotic or ketamine, are often heard to remark to their patients that the procedure will be done under anesthesia. Nothing could be further from the truth. For surely if amnesia is the sole criterion for a complete and successful anesthetic, then 150 years of anesthesia research since the first clinical use of ether has been for nothing. And, the years of rigorous didactic and clinical training that physicians and nurse anesthetists have undergone must be viewed as unnecessary.
We must continue to emphasize to our “anesthesiologically challenged” colleagues that midazolam is neither an analgesic nor a hypnotic, nor is it an anesthetic. Doses of 10 milligrams or more are commonly administered for procedures of less than fifteen minutes duration. Such excessive doses are unnecessary, and in some instances unwise. The indication for midazolam is not sleep, nor immobilization, nor analgesia. It is conscious sedation and amnesia. I believe anesthesia providers must insist on being present if the patient’s pain is so great that immobilization becomes necessary. Patient movement is the hallmark of inadequate pain control; even sedated and sleeping patients respond to pain with movement. Analgesia is indicated under these circumstances – not more sedation.
I do not think we should accept the premise that amnesia alone represents quality care for a patient in pain. If we do, then we have subscribed ourselves, as anesthesia providers, to the untenable position that pain is acceptable if it is unremembered pain. Pain, whether remembered or not, must be treated. The conditions of hypertension and tachycardia which so often accompany painful procedures done with conscious IV sedation are indications for genuine interventions, not more midazolam. Either control of these parameters are important or they are not. Either patients are safe with uncontrolled hemodynamic values or they are in danger. There is no middle ground on which we can stand and assert that a blood pressure of 190/110 and a pulse of 125 is quality care for an amnestic patient and then turn around and assert it is failed care for a patient under general anesthesia.
It does us no good to say patients given IV conscious sedation seem not to be harmed even if inadequately cared for. Survival is not the criteria by which an intervention is measured. I suspect many patients would survive abdominal surgery even if given only midazolam and a narcotic. The truth is that the pharmacology of current anesthetic agents and adjuncts, combined with the art of administration, allows for a much safer and comfortable environment for abdominal surgery. Why then can not these same standards be applied to all pain inducing interventions? Why are patients undergoing endoscopic procedures, bone marrow aspirations, chest tube insertions, and other innumerable procedures without adequate pain control?
I find it inexcusable that patients are in pain in the surgical suites of this country. It is even less excusable since the introduction of easily titratable and short acting general anesthetic agents, improved airway management techniques such as the LMA, and the immediate presence of personnel trained in the management of acute pain. To use the excuse that patients require a longer recovery following adequate pain relief versus inadequate pain relief seems a hollow argument and a surrender to mediocrity in patient care. In our institution, many patients given general anesthesia for short surgical procedures, are discharged directly to the ambulatory care unit. After meeting written criteria such patients bypass first stage recovery. I know from conversations with other anesthesia providers that this is a growing practice, I think we must refocus the debate surrounding conscious IV sedation to include not only patient safety but quality of care. We cannot be satisfied until patients in pain receive appropriate care. We have the tools and experience to assist such patients. Let us use them.
Mike Stewart, MS, PNP, CRNA
Chief Nurse Anesthetist
Bloomington Anesthesiology Services