Reader Questions Conclusions on Remote Locations

Kenneth Green, MB, BS, FFARCS; Julia Metzner, MD 

To the Editor

I am writing in response to the recent article “Risks of Anesthesia Care in Remote Locations” in the spring-summer 2011 issue. I feel the authors draw the wrong conclusions from the described tragedy. The patient was given 3 drugs that are respiratory depressants. The dose was adjusted until the patient was asleep, felt no discomfort, and tolerated a foreign body in his throat. That state was formerly described as anesthetized, but the term MAC now seems to have replaced it. It now seems that general anesthesia is a term only used if a volatile agent is also used.

One could argue that the semantics are not important, but the whole issue of sedation versus anesthesia needs to be further examined.

With a general anesthetic it is customary to guarantee an airway, not to assume that it is probably OK. It is customary to use a capnogram, not just when it is probably needed, but in all cases. It is also customary not to take chances and hope that the outcome will be good. Putting an unconscious patient face down in the dark would be a triumph of optimism over prudence. To do it without a Plan B for instant access to the airway is hard to understand.

All of this has nothing to do with “Remote Locations.” What is remote is the observance of traditional anesthesia practices.

The authors describe the difficulties of providing safe care and describe dark rooms, inadequate anesthesia support, variability of monitoring, and so forth. To quote Nancy Reagan, “Just say no.” If one feels that the environment is not safe, then one must refuse to participate.

I think many anesthetists worry that they will be regarded as troublesome and uncooperative if they hold out for safety issues, but in fact, the opposite is true. Most surgeons, endoscopists, and the like have little training or knowledge of airway management. They want us to take charge of the safety issues, set the guidelines, organize the equipment, and make it safe. I believe they respect our expertise; the last thing they want is an anesthetic crisis, especially when preventable.

Kenneth Green, MB, BS, FFARCS
Waterville, ME

In Reply:

We thank Dr. Green for his interest in our newsletter article and we agree that anesthesia leadership in patient safety for out-of-operating room sedation is important. The intent of the anesthesia provider in the case presented was to administer moderate sedation. This case illustrates that with the continuum of sedation, moderate sedation may quickly progress to general anesthesia and be unrecognized, particularly when multiple drugs are administered during a short period and respiratory monitoring is inadequate. The transition from moderate sedation to general anesthesia also varies from patient-patient, as well as with changing degrees of procedural stimulation and pain.

Based upon the cases we analyzed, we hoped to deliver a clear message: vigilance and respiratory monitoring should be similar for sedation as for general anesthesia, independent of the place where anesthesia care is provided. As pointed out in your letter, continuous monitoring of exhaled CO2 constitutes the key preventative measure to respiratory mishaps in patients undergoing procedural sedation. The American Society of Anesthesiologists (ASA) Standards of Monitoring now requires capnography for monitoring ventilation during monitored anesthesia care, unless precluded or invalidated by the nature of the patient, procedure, or equipment (effective July 1, 2011).

Sincerely,
Julia Metzner, MD
Karen B. Domino, MD, MPH