Anaesthetists: A Literature Review

There has been a growing request to the anaesthetists in the last decade to provide sedation outside the operating room for invasive and non-invasive procedures (1). If we consider this activity as a separate specialty and that it should be managed only by specialists in anesthesia for the potential life-threatening complications related to some adverse events reported in the literature (2), this could increase our workload by 70% (3,4). This conflicts with the upcoming shortage of anaesthetists around the world (5). As a result, different specialties apart anaesthesiology developed sedation training programs focused on adverse events and the interventions necessary to correct the situation (6), in an attempt to improve the safety of the procedure

This allows avoiding potential adverse effects of sedatives and analgesic drugs on airway patency, respiratory function, and hemodynamic balance as the cornerstone for a safe sedation. Complications during procedural sedation may be prevented by the appropriate pre-evaluation of the patient, intraprocedural monitoring of physiologic functions, and early intervention when adverse effects are recognized.
This review will present the most recent review of the literature on drugs used for procedural sedation, new methods for delivering sedation and an overview on the training required for managing complications related to procedural sedation.
UPDATE ON OLD AND NEW SEDATIVE

Respiratory depression has been reported to occur after single-use of remifentanil in a dose-related fashion above 0.2 µg/kg/min or with 0.1 µg /kg/min in combination with propofol (27). The use of remifentanil as a solo sedative agent has been investigated in an observational study by a team of French investigators (28) that has concluded that target-controlled infusion (TCI) with remifentanil is appropriate for conscious sedation, even in fragile patients or for long-duration procedures. They noted, however, that a risk for respiratory depression suggests that the approach be used only in a controlled environment with continuous monitoring. The trial included 91 patients, all of whom required conscious sedation with spontaneous ventilation. Each patient received a target-controlled infusion of remifentanil, with an initial target of 2 ng/mL and the target was increased if the patient complained of pain or was agitated. 37% of patients had at least one episode of respiratory rate below 8 breaths per minute. But most of the time it was of very brief duration, and could be reversed by verbal command, light stimulation or by decreasing the target. As the authors identified, failure of sedation was a real possibility, for this reason a controlled environment is critical and skilled