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|Conscious Sedation FactFinder|
Committed to providing helpful information to International Spine Intervention Society members about key patient safety issues, the Patient Safety Committee has developed a FactFinder series. FactFinders will explore and debunk myths surrounding patient safety issues. The intent of this FactFinder is to address safety issues surrounding the use of conscious sedation.
Myth: Conscious sedation is typically needed when performing most interventional pain procedures (e.g. epidural steroid injections, sacroiliac injections, medial branch blocks, and radiofrequency denervation).
Fact: Routine use of sedation is not indicated for interventional spine procedures.
Sedation and analgesia include a continuum of states of consciousness ranging from minimal sedation (anxiolysis) to general anesthesia. This FactFinder will not address minimal sedation or anxiolysis; but will focus on moderate (conscious) sedation. “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.”1
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.2
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.3
If sedation increases the risks associated with interventional pain procedures, does sedation benefit patients? To determine patient perception of the need for sedation before epidural steroid injections and zygapophyseal joint injections, Cucuzzella TR, et al., surveyed 500 consecutive patients receiving lumbar, thoracic, and cervical epidural or facet injections. They found that only 17% of patients requested sedation before an initial injection, and concluded that routine sedation before diagnostic and therapeutic injections is not necessary. Thus the majority of patients would not request sedation before a procedure when given the option.4 In fact, the 17% cited in this study may be even higher than average. Diehn et al. demonstrated only a 3% dissatisfaction rate in nearly 6900 patients when transforaminal injections were performed without sedation.5 The findings from the two aforementioned retrospective trials were bolstered by a randomized controlled trial by Cohen who found that sedation did not predict satisfaction with care. Patients who received fentanyl as part of the sedation were not more likely to report pain relief.6 Collectively, these studies show high patient satisfaction without the routine use of sedation.
The findings that patients do not routinely need sedation are supported by the American Society of Anesthesiologists, which produced a 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 20, 2010). In that statement, it was the opinion of the Committee that the majority of minor pain procedures, under most routine circumstances, do not require anesthesia care other than local anesthesia (including epidural steroid injections, epidural blood patch, trigger point injections, sacroiliac joint injections, bursal injections, occipital nerve block, and facet injections). They further went on to state “the use of general anesthesia for routine pain procedures is warranted only in unusual circumstances”. However they also noted “procedures that are prolonged and/or painful often require intravenous sedation and may warrant use of monitored anesthesia care”.7
The following summarizes the International Spine Intervention Society Guidelines (2nd edition) regarding the use of sedation for pain procedures:8
For the frequently performed spinal procedures mentioned, conscious sedation has no clear added health/outcome benefit, could cause increased risk for certain complications, and adds to health care costs. Therefore, for these types of procedures, physicians should be judicious in the safe use of sedation for special circumstances, and patients should be advised during informed consent that sedation is not necessary. When longer procedures, such as discography or radiofrequency ablation are performed, the physician and patient need to weigh the risks and benefits of increased procedural harm with the minimal advantage associated with intravenous sedation. Providing patient educational material regarding sedation can assist patients in making informed decisions. If the physician performing the procedure decides to administer and supervise the sedation, they should be trained and qualified to do so. In these situations, a separate healthcare provider is required to assist with the administration of the medications and monitoring of the patient.
1. American Medical Association. (2013). CPT® 2014 Professional Edition. (4th ed., text rev.). Chicago, IL.
2. Hodges SD, Castleberg RL, Miller T, Ward R, Thornburg C. (1998). Cervical epidural steroid injection with intrinsic spinal cord damage. Two case reports. Spine, 23 (19), 2137–2140.
3. Rathmell JP, Michna E, Fitzgibbon DR, Stephens LS, Posner KL, Domino KB. (2011). Injury and liability associated with cervical procedures for chronic pain. Anesthesiology, 114, 918-926.
4. Cucuzzella, T.R., Delport, E.G., Kim, N., Marley, J., Pruitt, C., & Delport, A.G. (2006). A survey: Conscious sedation with epidural and zygapophyseal injections: is it necessary? Spine J, 6, 364-9.
5. Diehn FE, Geske JR, Amrami KK, Kaufmann TJ, Morris JM, Murthy NS, Thielen KR, Wald JT, Shelerud RA, Carter RE, Maus TP. (2013). An audit of transforaminal epidural steroid injections without sedation: low patient dissatisfaction and low vasovagal rates. Pain Med, 14, 994-998.
6. Cohen SP, Hameed H, Kurihara C, Pasquina PF, Patel AM, Babade M, Griffith SR, Erdek ME, Jamison DE, Hurley RW. (2014). The effect of sedation on the accuracy and treatment outcomes for diagnostic injections: a randomized, controlled, crossover study. Pain Med, 15,588-602.
7. American Society of Anesthesiologists. (2013). Standards, Guidelines, Statements, and Other Documents. Retrieved from https://www.asahq.org/For-Members/Standards-Guidelines and-Statements.aspx.
8. Bogduk, N (ed). Practice Guidelines for Spinal Diagnostic and Treatment Procedures, 2nd edn. San Francisco, 2013. 3-4.
11/15/2016Third Quarter 2016 Online Journal Club
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Radiofrequency Bio-Skills Lab - Long Beach, CA
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Evidence-Based Spine Interventions Seminar - Palm Springs, CA
Inaugural SIS Golf Tournament
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Lumbar Bio-Skills Lab - Phoenix, AZ
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Advanced Lumbar Bio-Skills Lab - Tampa, FL
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