Titlu scurt
The Impact of the European Guidelines for Sedation by non-Anaesthesiologists for Gastroenterology Practice Johanns T. A. Knape Department of Anesthesia, University Medical Center, Utrecht, The Netherlands President European Society of Anaesthesiology 2008 – 2009
Introduction The increase in diagnostic and therapeutic endoscopic procedures, especially in gastroenterology but also in other medical specialties, has contributed dramatically to the quality of care in the last few decades. Usually, these procedures do not require general anaesthesia but many of these procedures are not comfortable to undergo and even may produce pain in patients. The anaesthesia workforce in most countries is insufficient to provide support by an anesthetic team to fulfill all demands for sedation in conjunction with these procedures for all patients.
The problem The introduction of modern pharmaceutical techniques using intravenous benzodiazepines, short-acting analgetics and some short-acting hypnotics has been welcomed both by practioners and patients. However, the widespread use of these drugs has resulted in a number of adverse effects, mainly airway obstruction, respiratory depression cardiovascular collaps and even in death. Moreover, inadequately performed sedation procedures (providing anxiolysis where pain is the main problem) leads to inadequate suffering by patients combined with unsafe sedation.
Consensus: half of a solution The European Board of Anaesthesiology (EBA) of the Europe of the European Union of Medical Specialists J Gastrointestin Liver Dis December 2007 Vol.16 No 4, 429-430 Address for correspondence: Prof. J.T.A. Knape Chair Department of Anaesthesiology University Medical Center Utrecht P.O. Box 85500 3508 GA Utrecht The Netherlands Email:
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(EUMS/UEMS) has issued guidelines on sedation by nonanaesthesiologists recently (1). This document describes in detail the conditions which permit sedation of selected patients safely by nonanaesthesiologists. Important conditions are: adequate selection of patients, the assignment of a qualified and competent person whose sole task is to monitor the patient, adequate monitoring of sedation level, respiration and circulation, adequate registration of relevant vital events, adequate recovery, complication registration and quality assessment. It is the conviction of the task force on sedation by the EBA, that in this way, safe sedation can be performed by non-anaesthesiologists, although it speaks for itself that active involvement of an anaesthesia department in this matter, in a specific hospital, is mandatory. Safety of patients is and should be the most important aim of anaesthesiology as a medical specialty.
Implementation efforts: the other half Although the publication of a guideline on sedation is an important step forward, it is wrong to believe that the publication of a guideline will solve the whole underlying problem immediately. As happens unfortunately with many guidelines, the implementation of it is another problem and another challenge, which requires other qualities and competencies. The guideline on sedation by non-anaesthesiologists in the Netherlands of 1998 (2), for example, was only implemented in 22 % of hospitals thereafter. Following a number of tragic fatal accidents which were caused by inadequate sedation practice, the Surgeon General in The Netherlands has ordered a revision of the guideline in 2005. He asked for specific emphasis on: - setting up a detailed training curriculum for sedation by non-anaesthesiologists leading to a certificate of “sedation practitioner”; - developing proposals for financing sedation by nonanaesthesiologists in medical practice on a national scale;
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- developing an realistic implemantation plan; - developing quality indicators for sedation by nonanaesthesiologists; - developing proposals for clinical investgations to evaluate the effects of implementation on quality and safety.
The near future: what is to be done Gastroenterology traditionally has been a medical specialty showing much interest and involvement in sedation for procedures such as colonoscopy, ERCP, esophageal dilatation and other. Gastroenterology therefore has a great interest in high quality and safety in sedating patients. As stated before: the publication of this guideline is a major step forward but the recent publication in the Romanian Anaesthesia Journal (3) of this guideline will not change the daily practice at all. Being such important specialties with respect to sedation and having such great interest in providing safe care, it is of importance that both the Anaesthesiology and Gastroenterology profession learn from the faults of others in the recent past. These two specialties therefore should take the lead also in this country in the important process of training and implementing sedation by non-anaesthesiologists. By
Knape
doing this the cooperation and mutual respect between these specialties, leading to a safer practice for the patients, may serve as an example for more medical specialties to realize that progress and improvements in medicine are achieved not by the efforts of solo players but by mulitidisciplinary efforts of experts in their respective fields of expertise. The ultimate goal is being prepared to share expertise and encourage one another for the improvement of care. These are the National and European challenges which will take health care forward.
References 1. Knape JT, Adriaensen H, van Aken H, et al. Board of Anaesthesiology of the European Union of Medical Specialists. Guidelines for sedation and/or analgesia by non-anaesthesiology doctors. Eur J Anaesthesiol 2007;24:563-567 2. Knape JT, van Everdingen JJ. [Guideline for administration of sedatives and analgesics by physicians who are not anesthesiologists. National Organization for Quality Assurance in Hospitals]. Ned Tijdschr Geneeskd [Dutch] 1999;143:10981102 3. Comisia de Anesteziologie: Ghiduri de sedare si/sau analgezie pentru medicii din alte specialitati decat anestezie-terapie intensiva. J Rom Anest Ter Intens [Romanian] 2007 ; 14 : 129 – 133.
