I am attaching 3 articles here for anesthesiologist and non-anesthesiologists here to read and understand, so that you don't simply quote a study/guideline without understanding the content.
#1. CONTINUUM OF DEPTH OF SEDATION: DEFINITION OF GENERAL ANESTHESIA AND LEVELS OF SEDATION/ANALGESIA (Approved by the ASA House of Delegates on October 13, 1999, and last amended on October 15, 2014)
#2. Statement on Anesthetic Care During Interventional Pain Procedures for Adults, (Approved by the ASA House of Delegates on October 22, 2005 and last amended on October 26, 2016)
#3. Conscious Sedation FactFinder (Published December 2014)
I.
For non-anesthesiologists, please read #1 carefully and understand the different level of sedation and the continnum of depth of sedation, as well as the definition of MAC.
"Moderate (conscious) sedation is a drug-induced depression of consciousness during which patients respond purposefully to verbal command, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.”
Key words here are: patients respond purposefully to VERBAL command.
When "sedation" is provided in ASA setting with anesthesia service is involved, it is by definition MAC (monitored anesthesia care) for it to be payable. Therefore the sedation provided in ASA setting, either with propofol, or combination of propofol and versed/fentanyl would in general renders a patient between DEEP sedation at the minimum and general anesthesia where the patient is NOT responsive to VERBAL command.
Minimal sedation/anxiolysis and moderate sedation/analgesia/conscious sedation are what I am adovcating for patients undergoing spinal injection procedures.
As an anesethesiologist, I can tell you 2-4 mg of versed plus/minus 25mcg of fentanyl will not render a patient beyond conscious sedation. Patients are responsive to verbal stimuli with this level of "conscious sedation", yet comfortable, relaxed and follow commends to remain still and often have sufficent anterograde amnesia to not remember an unpleasant anxiety-provoking experience.
II.
Quoting from position statement from ASA (article #2),
"Many patients can undergo interventional pain procedures without the need for supplemental sedation in addition to local anesthesia. For most patients who require supplemental sedation, the physician performing the interventional pain procedure(s) can provide moderate (conscious) sedation as part of the procedure. For a limited number of patients a second provider may be required to manage moderate or deep sedation or, in selected cases other anesthesia services.”
So ASA position statement is this: many patients can have interventional procedures without supplemental sedation. For MOST patients who require sedation, conscious sedation should be offered. For some selected patients, additional provider or even anesthesiologists are required.
“Examples of procedures that typically do not require sedation include but are not limited to epidural steroid injections, epidural blood patch, trigger point injections, injections into the shoulder, hip, knee, facet, and sacroiliac joints, and occipital nerve blocks”. I don’t think anyone have issues with trigger points, joint injections, or SIJ injections, etc. IESI and blood patch, typically do not require sedation, but in some patients might.
“Significant anxiety may be an indication for moderate (conscious) sedation or anesthesia services. In addition, procedures that require the patient to remain motionless for a prolonged period of time and/or remain in a painful position may require sedation or anesthesia services”.
“Major nerve/plexus blocks are performed less often in the chronic pain clinic, but the Committee believes that these blocks may more commonly require moderate (conscious) sedation or anesthesia services (e.g., brachial plexus block, sciatic nerve block, and continuous catheter techniques)”.
So ASA position is pretty clear, moderate/conscious sedation should be readily available to patients and provided to them for some common spinal pain procedures, except trigger points, joint injections, or SIJ injections or IESI, etc.
III.
Conscious Sedation FactFinder authorized by 10 physicians, including David O’Brien, Jr., MD; Michael Bunch, MD; Clark C. Smith, MD; Alison Stout, DO; Wade King, MMed; Jeffrey Laseter, MD; Benoy Benny, MD; David J. Kennedy, MD; Nikolai Bogduk, MD; and Andrew Engel, MD.
All but 1 is actually anesthesia-trained, Laseter. Everyone else is PMR-trained. King, Bogduk and Engel are non-anesthesia trained.
So we have 9 non-anesthesia trained, and predominantly PMR-trained pain management physician making recommendation on something they have no experience or training in.
Is it ironic?
PMR physicians without appropriate training in anesthesiology should NOT be offering any type of sedation other than oral benzo. It’s beyond the scope of PMR training and practice.
For the same reason, PMR physicians are not qualified to make medical necessity determination of sedation provided in interventional spinal procedures.
For the same analogy, an anesthesia-trained pain management physician without appropriate training in EMG/NCS should not be making recommendation on medical necessity of EMG/NCS.
Now let’s look at the content of “Factfinder”.
“Cases of neurologic injury have been reported in patients undergoing interventional pain procedures; some were believed to be due to heavy or over-sedation. In these cases, sedation resulted in the inability of the patients to respond to any potential discomfort or paresthesias to warn practitioners”.
“For cervical procedures, an analysis of closed claims involving cervical interlaminar or transforaminal injections revealed that when the patient is heavily sedated during the procedure or unresponsive at the time of injection, there is an increased risk of spinal cord injury.”
So it is talking about of HEAVY/OVER-SEDATION. It is actually defined by ASA in the continuum article #1 as “deep sedation and general anesthesia”.
Yes, ASA does NOT recommend deep sedation/general anesthesia in most if not all spinal pain procedures.
But please do NOT equate deep sedation to moderate/conscious sedation. Studies might have shown risks of complication with deep sedation, but I challenge ANY of you to find any studies to show conscious/moderate sedation lead to significant complications of a spinal procedure due to moderate sedation being offered.
However, it is what exactly the “Factfinder” tried to do in the next paragraph by making this quantum leap,
“If sedation increases the risks associated with interventional pain procedures, does sedation benefit patients?”
Now the so-called “Factfinder” lumped moderate sedation with deep sedation/heavy-sedation/over-sedation into ONE inclusive term, “sedation” and tried to jump to the conclusion that “sedation” is not necessary in general.
To remind you, ASA guideline on sedation and spinal procedures are clear and specific, again quoted below,
“Significant anxiety may be an indication for moderate (conscious) sedation or anesthesia services. In addition, procedures that require the patient to remain motionless for a prolonged period of time and/or remain in a painful position may require sedation or anesthesia services”.
To summarize,
- Risks: while I completely agree deep sedation/over-sedation increases risks of complication in spinal procedures, there are no evidences to suggest conscious sedation increases risks of complications. “Factfinder” tried to make this jump, but instead only weakened its argument. It also tried to discourage using sedation for diagnostic procedures, such as MNBB. In my opinion, one should not be making reliable diagnostic evaluation immediately after the MNBB anyway, whether a patient receives sedation or not, IV or PO. Topical injection of local anesthetics can cause false positive and needle insertion sites can cause enough “injection pain” and lead to false negative. One should make reliable determination of diagnostic value in the 1 day following MNBB if only local anesthetics are used or 3 to 10 days if local plus steroids are used.
- Benefit: “Factfinder” tried to refute the benefit of “sedation” by citing studies showing no change in patient satisfaction. Well, if benefit is only defined by patient satisfaction, then just offer the conscious sedation as an option to patients and let them decide. Furthermore, benefit is defined not only by patient satisfaction, but also medically by reducing vasovagal events, avoiding hypertensive crisis, improving procedure accuracy and safety by keeping patient remain calm and still, etc.
- Alternative: sure, we can offer PO benzo for anxiolytics. It may be enough for some patients, but for some patients in certain procedures may not be enough in terms of level of anxiolysis and unpleasant lingering sedative effect for hours. On the other hand, 2mg of IV versed wears off in 2 hours. At any rate, IV conscious sedation should be offered along with oral anxiolytics as an alternative. Speaking on a personal level, If you, like me have received both of them in the past as a patient, you would not hesitate to choose IV versed over Xanax anytime of day.
In conclusion, I recommend any of you to refer to ASA positional statement instead of this so-called “Factfinder” or even SIS guideline by the same group of PMR physicians.
Remember this, ASA might not have complete authority on the guidelines of interventional spine procedures. However, when it comes to guideline on sedation and anesthesia, no one can argue with ASA on its authoritative power, not me or you as interventional pain physician, not anyone in PMR specialty with no training or experience in anesthesiology, not any surgeon screaming and yelling in operating room, trying to dictate what anesthesiologist sees as the best method to keep patient sedated or anesthetized.
This issue has been fought in court and been determined long ago who has final saying in terms of what anesthetics is most appropriate for a patient undergoing a procedure or surgery.
