Comfort for diagnostic and therapeutic procedures under sedation

The evolution of medicine during the past century has shown important scientific, technological, surgical, pharmacological and anesthetic breakthroughs that have enabled various types of procedures for our patients, consistently aiming at providing the best comfort and the highest safety standards.

In our daily practice, in addition to the procedures performed under general and regional anesthesia (regional blocks and peripheral nerve blocks) we do some procedures under Sedation (with or without local anesthesia), both in the operating theater or outside, and even in environments outside hospitals. This fact has resulted in an exponential increase in the number of therapeutic and diagnostic procedures in various healthcare areas, including dentistry, maxillofacial surgery, pediatric dentistry, peripheral vascular surgery, gastroenterology, fertility, and diagnostic imaging, inter alia.

At our institutions we perform anesthetic techniques that ensure the right conditions for various surgical procedures such as regional blocks (subarachnoid and epidural) and peripheral nerve blocks that are useful and safe for various types of surgeries; unfortunately, there are some drawbacks in the use of regional anesthesia: puncture site pain, fear of needles, and procedure memories. These factors emphasize the importance of sedation obtained from analgesia, anxiolysis, and amnesia that enable a seamless development of the technique.¹

This RCA issue includes an article on sedation and regional anesthesia written by Bermúdez et al.² The authors evaluated three sedation guidelines using a randomized clinical trial in a group of 75 patients undergoing regional anesthesia procedures. The patients were divided into three groups, using various drug combinations for sedation (midazolam, midazolam + fentanyl, midazolam + ketamine) and the results are consistent with the literature, indicating that patients undergoing procedures under sedation expressed a feeling of comfort and 100% of them agreed on accepting the same conditions for any future procedures. One aspect to be highlighted is that there were no complications during the trial.²

According to the definition of the “Real Academia de la Lengua” (Royal Academy of the Spanish Language) (RAE), to sedate means to pacify, to appease, to calm down³; therefore, sedation refers to the action of sedating, i.e., giving the patient the ability to tolerate uncomfortable or painful procedures, whether diagnostic, interventionist, dental or surgical, through the use of drugs.

The American Society of Anesthesiologists (ASA) offers a classification of the levels of sedation, ranging from anxiolysis, conscious sedation, profound sedation and general anesthesia, in the understanding that such classification is a continuum and that the patient may go through the former to the latter and hence be exposed to the potential risks of sedation.^4,5 The ASA also provides guidelines with the minimum safety standards for the patient undergoing any of these procedures, particularly outside the OR. We are then required to ensure the patient's safety, whether in the OR or at any other environment where sedation may be provided.

Pursuant to the Declaration of Helsinki of the World Medical Association (WMA), article 3 states that: “Every institution that administers sedation to patients shall comply with the standards acknowledged for a safe practice of anesthesia”,⁶ keeping in mind that the anesthesiologist if one of the key actors in ensuring the patient's safety whenever anesthesia is used; hence, it is our responsibility to provide the patient undergoing any procedure with all the conditions to make the patient feel safe and comfortable.

Despite being a very safe technique, we should not forget that we are also exposed to potential risks, regardless of the level of sedation of the patient. Such risks include: depression of the reflexes that protect the airway and subsequent obstruction, respiratory depression, depression of the cardiovascular system, adverse reactions to drugs – including anaphylaxis, variations in the response to the use of medicines, particularly in young infants and elderly patients, and any pre-existing conditions, in addition to the procedure-related risks. These risks have all been reported in the literature and we have sometimes faced them as well, so patient comfort means not just preventing any discomfort, but also generating confidence in the patient so that if any potential risks arise he/she may be confident that the situation will be properly and professionally managed. It is important to recall that simultaneous procedures should not be undertaken and this recommendation is also applicable to sedations; the level of complexity with an aware patient is as severe as when the patient is under general anesthesia.

As specialists we shall continue to perfect sedation techniques and offer our patients the best options based on the particular situation. I would like to stress the interest of the authors in promoting further research on the topic, considering the modest statistical information available in the country on this most important subject.

Papers like the one herein discussed should be a benchmark for further research focusing on the safe practice of anesthesia, and always keeping in mind the wellbeing of our patients.

Funding

None.

Conflicts of interest

The author has no conflicts of interest to declare.