Governance

Governance issues include:

Training

Sadly, research and audit have continually identified avoidable morbidity and mortality from sedation [16]. The most common recurring theme is the lack of formal training for the appropriate administration of sedative drugs and prompt recognition and treatment of sedation-related complications.

Given that deeper levels of sedation are indistinguishable from general anaesthesia, you should have the knowledge and skills to manage and rescue a patient from general anaesthesia. The College requires you to have successfully completed the Initial Assessment of Competence of the Royal College of Anaesthetists and have been accredited through a local training programme [6].

The latter includes training in:

  • ASA grading
  • Pre-procedural assessment including prediction of difficulty in airway management
  • Pre-procedural fasting and risk benefit assessment
  • Consent and documentation
  • Drug selection and preparation: benzodiazepine/opioid combinations, intervals between increments and reversal drugs
  • Monitoring, complications (e.g. hypoxia and hypotension) and rescue strategies
  • Governance and audit
  • Drug selection with emphasis on potential alternative strategies and/or lighter sedation
  • Safe use of propofol

For those of you (like myself) who trained before the IAoC was introduced, I suggest that you discuss your competence with your lead clinician and sedation committee (more of this in a minute).

Learning Bite

If you are using propofol for sedation, you should be comfortable that your skills include managing general anaesthesia.

Documentation

You should document patient evaluation, consent, data from monitoring during and after sedation and readiness for discharge. A dedicated, electronic, password-protected database is helpful [13]. In addition, consider prospective use of an audit tool produced by an international consensus [17], noting in particular the sentinel risk descriptors and interventions in the table.

Table 1: Sentinel risk descriptors and interventions

Sentinel risk descriptors Sentinel interventions
Oxygen desaturation, severe (< 75% at any time) or prolonged (< 90% for > 60s) Chest compressions
Apnoea, prolonged (>60s) Tracheal intubation
Cardiovascular collapse/shock (clinical evidence of inadequate perfusion) Administration of:

  • Neuromuscular block
  • Pressor/epinephrine
  • Atropine to treat bradycardia
Cardiac arrest/absent pulse

Risk management

Ensure that the environment in which you use propofol includes the following facilities:

  • Full resuscitation equipment for the administration of basic and advanced life support. Equipment and drugs should be checked daily, and after each use. That such checks have occurred should be routinely recorded
  • Difficult airway equipment
  • Continuous high flow oxygen with appropriate devices for administration
  • High pressure suction with appropriate suction catheters
  • A trolley capable of being tipped head down
  • Monitoring: Pulse oximeter, ECG, NIBP and continuous quantitative capnography
  • Appropriate range of intravenous cannulae
  • An appropriate range of intravenous fluids and infusion devices
  • Manual handling devices

Audit process

To ensure appropriate governance of sedation within an institution, the Academy of Royal Medical Colleges recommend a sedation committee and a nominated lead clinician for sedation [15].

Their audit process considers:

  • Was the ‘sedator’ signed off for the use of propofol?
  • Was a specific sedation monitoring chart used?
  • Were the indications for propofol appropriate?
  • Were any contra-indications acknowledged?
  • What complications arose and how were they managed?
  • Was any clinical incident reported through your trust’s clinical incident reporting mechanism; and in a timely fashion?

Learning Bite

There should be routine and transparent audit of your departmental sedation practice.

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