BJA
Correspondence
funding is not available for anaesthesia. Finally, it so happens that the lead author for reference 6 quoted by Dr Conway is now a valued colleague in my own institution with whom we collaborate regularly.
Declaration of interest None declared. D. N. Hunter* S. Webb London, UK * E-mail: [email protected] 1 Webb S, Hunter D. Is sedation by non-anaesthetists really safe? Br J Anaesth 2013; 111: 136–8
Sedation by non-anaesthetists Editor—I read the article in the BJA 1 with interest and would like to make a few comments. Not all non-anaesthetists are the same. It is simplistic to compare a dentist with an emergency physician who has successfully completed 12 months of anaesthesia and intensive care medicine, regularly performs rapid sequence induction, either inside a hospital or by the roadside, and works every day in a resuscitation room. I suggest that this individual is not simply ‘picking up’ sedation skills and has more than ‘limited interest per se’ in safe sedation. There is a considerable literature on the safety of sedation in children and adults, which is certainly greater than ‘underpowered case series’ of a few hundred people.2 The authors suggest that extra costs will be incurred, the evidence suggests that sedating people out of theatre can produce significant cost savings.3
Declaration of interest A.A.B. chairs the Clinical Effectiveness Committee of the College of Emergency Medicine. A. A. Boyle Cambridge, UK E-mail: [email protected] 1 Webb S, Hunter D. Is sedation by non-anaesthetists really safe? Br J Anaesth 2013; 111: 136–8 2 Mallory M, Baxter A, Yanosky S. Emergency physician-administered propofol sedation: a report on 25,433 sedations from the Pediatric Sedation Research Consortium. Ann Emerg Med 2011; 57: 462–8 3 Boyle AA, Dixon V, Fenu E, Heinz P. Sedation of children in the emergency department for short painful procedures compared with theatre, how much does it save? Economic evaluation. Emerg Med J 2011; 28: 383–6
doi:10.1093/bja/aeu035
Editor—We thank Dr Boyle for his interest in our editorial.1 We wholeheartedly agree that not all non-anaesthetists are the same; indeed, emergency physicians and dentists have sedation and anaesthesia as part of their core curriculum of training, and are therefore much more knowledgeable and skilled in this area than those who have no prescribed training—cardiologists, for example. There is indeed considerable literature on propofol sedation in children especially, much published by the quoted Paediatric Sedation Research Consortium. This group consists of a large number of hospitals which provide specialist paediatric sedation teams. They have published a much larger series than that quoted by Dr Boyle, 49 836 sedations in 37 centres across the globe of which only 10.2% were administered by anaesthetists, 48.76% by paediatric intensivists, and 36.19% by emergency medicine physicians.2 One of the significant results was that the proportion of adverse events encountered was significantly lower among those children sedated by anaesthetists than other specialities (P,0.001). However, they point out in their article that: a careful analysis of our results does not simply reassure providers that propofol sedation/anaesthesia of children is safe, but it helps define the competencies required to deliver this care. Specifically, the incidence of apnoea and airway obstruction found in this study adds weight to the argument that credentialed providers of deep sedation/anaesthesia must also demonstrate proficiency in airway obstruction and respiratory depression management, or have immediate and completely reliable access to such assistance. We believe our findings call for some form of training and testing that is more realistic than that provided by a Pediatric Advanced Life Support class that is given, and tested, on mannikins.
But once again, this is not a ‘them and us’, we wish only to point out that evidence of safe practice of short procedures using intermittent propofol by trained healthcare workers in one speciality cannot be translated to safe use of infusions targeted at deeper sedation for prolonged procedures in another, and that appropriate training and skills have to be acquired for each circumstance.
Declaration of interest None declared. D. N. Hunter* S. Webb London, UK * E-mail: [email protected] 1 Webb S, Hunter D. Is sedation by non-anaesthetists really safe? Br J Anaesth 2013; 111: 136–8 2 Cravero JP, Beach M, Blike GT, et al. The incidence and nature of adverse events during pediatric sedation/anesthesia with propofol for procedures outside the operating room: a report from the Pediatric Sedation Research Consortium. Anesth Analg 2009; 108: 795– 804
doi:10.1093/bja/aeu036
585
Downloaded from http://bja.oxfordjournals.org/ at Univ of Iowa-Law Library on April 19, 2015
doi:10.1093/bja/aeu034
Reply from the authors
Correspondence
funding is not available for anaesthesia. Finally, it so happens that the lead author for reference 6 quoted by Dr Conway is now a valued colleague in my own institution with whom we collaborate regularly.
Declaration of interest None declared. D. N. Hunter* S. Webb London, UK * E-mail: [email protected] 1 Webb S, Hunter D. Is sedation by non-anaesthetists really safe? Br J Anaesth 2013; 111: 136–8
Sedation by non-anaesthetists Editor—I read the article in the BJA 1 with interest and would like to make a few comments. Not all non-anaesthetists are the same. It is simplistic to compare a dentist with an emergency physician who has successfully completed 12 months of anaesthesia and intensive care medicine, regularly performs rapid sequence induction, either inside a hospital or by the roadside, and works every day in a resuscitation room. I suggest that this individual is not simply ‘picking up’ sedation skills and has more than ‘limited interest per se’ in safe sedation. There is a considerable literature on the safety of sedation in children and adults, which is certainly greater than ‘underpowered case series’ of a few hundred people.2 The authors suggest that extra costs will be incurred, the evidence suggests that sedating people out of theatre can produce significant cost savings.3
Declaration of interest A.A.B. chairs the Clinical Effectiveness Committee of the College of Emergency Medicine. A. A. Boyle Cambridge, UK E-mail: [email protected] 1 Webb S, Hunter D. Is sedation by non-anaesthetists really safe? Br J Anaesth 2013; 111: 136–8 2 Mallory M, Baxter A, Yanosky S. Emergency physician-administered propofol sedation: a report on 25,433 sedations from the Pediatric Sedation Research Consortium. Ann Emerg Med 2011; 57: 462–8 3 Boyle AA, Dixon V, Fenu E, Heinz P. Sedation of children in the emergency department for short painful procedures compared with theatre, how much does it save? Economic evaluation. Emerg Med J 2011; 28: 383–6
doi:10.1093/bja/aeu035
Editor—We thank Dr Boyle for his interest in our editorial.1 We wholeheartedly agree that not all non-anaesthetists are the same; indeed, emergency physicians and dentists have sedation and anaesthesia as part of their core curriculum of training, and are therefore much more knowledgeable and skilled in this area than those who have no prescribed training—cardiologists, for example. There is indeed considerable literature on propofol sedation in children especially, much published by the quoted Paediatric Sedation Research Consortium. This group consists of a large number of hospitals which provide specialist paediatric sedation teams. They have published a much larger series than that quoted by Dr Boyle, 49 836 sedations in 37 centres across the globe of which only 10.2% were administered by anaesthetists, 48.76% by paediatric intensivists, and 36.19% by emergency medicine physicians.2 One of the significant results was that the proportion of adverse events encountered was significantly lower among those children sedated by anaesthetists than other specialities (P,0.001). However, they point out in their article that: a careful analysis of our results does not simply reassure providers that propofol sedation/anaesthesia of children is safe, but it helps define the competencies required to deliver this care. Specifically, the incidence of apnoea and airway obstruction found in this study adds weight to the argument that credentialed providers of deep sedation/anaesthesia must also demonstrate proficiency in airway obstruction and respiratory depression management, or have immediate and completely reliable access to such assistance. We believe our findings call for some form of training and testing that is more realistic than that provided by a Pediatric Advanced Life Support class that is given, and tested, on mannikins.
But once again, this is not a ‘them and us’, we wish only to point out that evidence of safe practice of short procedures using intermittent propofol by trained healthcare workers in one speciality cannot be translated to safe use of infusions targeted at deeper sedation for prolonged procedures in another, and that appropriate training and skills have to be acquired for each circumstance.
Declaration of interest None declared. D. N. Hunter* S. Webb London, UK * E-mail: [email protected] 1 Webb S, Hunter D. Is sedation by non-anaesthetists really safe? Br J Anaesth 2013; 111: 136–8 2 Cravero JP, Beach M, Blike GT, et al. The incidence and nature of adverse events during pediatric sedation/anesthesia with propofol for procedures outside the operating room: a report from the Pediatric Sedation Research Consortium. Anesth Analg 2009; 108: 795– 804
doi:10.1093/bja/aeu036
585
Downloaded from http://bja.oxfordjournals.org/ at Univ of Iowa-Law Library on April 19, 2015
doi:10.1093/bja/aeu034
Reply from the authors
