To the Editor

The “six sigma level” term has been mentioned in several recent publications and is a great testimony to our profession. The safety level has been from years of hard work and investigations of many physicians and of course vigilance. Now our hard work is being ripped from us through fuzzy logic and laziness in our ranks. Conscious sedation has become a hot topic in our town since JCAHO mandated a unified conscious sedation policy to be formed in the hospital. Every physician who has ever used sedation now wants their methods to be incorporated in this policy. The rub is over deep sedation, a nice gray zone into which every professional group and society has muddled their definition through some publication that is now the doctrine for their particular members. Unfortunately there have been anesthesiologists who have helped with these guidelines and definitions primarily because the ASA doesn’t want to comment. Sure, they give us guidelines for conscious sedation with the mention that “patients whose only response is reflex withdrawal from a painful stimulus are sedated to a greater degree than encompassed by ‘sedation/analgesia.’” The problem is that ER physicians are using ketamine, Brevital, and other hypnotics saying they are physicians, they understand the drugs, and their complications are minimal.

Muddled Zone

It would be easy to continue with the earlier sedation policies we had and let each department come up with their own and then track the morbidity and mortality. JCAHO wants it different, and I believe ethically we are the ones to help since we are the experts. In real life out here, the zone between deeply sedated and general anesthesia is muddled with different definitions from several professional societies, with past usage and protocols, with hospital administration wanting procedures done everywhere and anytime (promptly), and other factors that I believe compromise our six sigma level.

Silence Decried

When is the APSF Newsletter going to comment? The ASA Newsletter has recently commented on outpatient/office-based procedures with anesthesia involvement. I personally believe this isn’t as much of a problem as non-anesthesia personnel giving hypnotic agents for sedation. I can only sum up with this quote from the Academy of ER Physicians: “the AAP and ASA guidelines differ from ACEP in that they specify a surrogate marker for intact airway reflexes and respiratory drive (i.e., the requirement of an ‘appropriate’ or ‘purposeful’ response to external stimuli). Whether this surrogate marker reflects a reliable approximation of the limits of the intact airway-sedation continuum is uncertain. There is no research to verify whether clinicians can indeed push sedation beyond these surrogate markers while ensuring consistent retention of protective airway reflexes and respiratory drive.” Also, the last but not least quote is: “We believe that the level of sedation required for most painful procedures in children is deep sedation.” Comments and suggestions are welcome.

Kyle M. Jones, MD
Huntsville, AL