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To describe the 5-year practice on palliative sedation in a specialized palliative care unit in a deprived region in Brazil, and to compare survival of patients with advanced cancer who were and were not sedated during their end-of-life care.
Retrospective cohort study in a tertiary teaching hospital. We described the practice of palliative sedation and compared the survival time between patients who were and were not sedated in their last days of life.
We included 906 patients who were admitted to the palliative care unit during the study period, of whom, 92 (10.2%) received palliative sedation. Patients who were sedated were younger, presented with higher rates of delirium, and reported more pain, suffering, and dyspnea than those who were not sedated. Median hospital survival of patients who received palliative sedation was 9.30 (CI 95%, 7.51–11.81) days and of patients who were not sedated was 8.2 (CI 95%, 7.3–9.0) days (P = 0.31). Adjusted for age and sex, palliative sedation was not significantly associated with hospital survival (hazard ratio = 0.93; CI 95%, 0.74–1.15).
Significance of results
Palliative sedation can be accomplished even in a deprived area. Delirium, dyspnea, and pain were more common in patients who were sedated. Median survival was not reduced in patients who were sedated.
Our aim was to describe the process of palliative sedation from the point of view of physicians and nurses working in palliative care in Brazil.
Ours was a descriptive study conducted between May and December of 2011, with purposeful snowball sampling of 32 physicians and 29 nurses working in facilities in Brazil that have adopted the practice of palliative care.
The symptoms prioritized for an indication of palliative sedation were dyspnea, delirium, and pain. Some 65.6% of respondents believed that the survival time of a patient in the final phase was not a determining factor for the indication of this measure, and that the patient, family, and healthcare team should participate in the decision-making process. For 42.6% of these professionals, the opinion of the family was the main barrier to an indication of this therapy.
Significance of results:
The opinion of the physicians and nurses who participated in this study converged with the principal national and international guidelines on palliative sedation. However, even though it is a therapy that has been adopted in palliative care, it remains a controversial practice.
This chapter focuses on the pharmacology of the drugs commonly used to provide moderate and deep sedation and their available reversal agents. Intravenous sedative and analgesic drugs should be given in small, incremental doses titrated to desired end points of sedation and analgesia, with adequate time allowed between doses to achieve those effects. Preemptive analgesia is a treatment that is initiated before surgical procedure to reduce sensitization of pain pathways. Potential drug interactions require the clinician providing sedation to be cognizant of potential drug-drug effects, which can lead to morbidity and mortality. Opioids in combination with benzodiazepines provide adequate moderate and/or deep sedation and analgesia for many potentially painful procedures. Other drugs used for deep sedation include propofol, ketamine, dexmedetomidine, and etomidate. Local anesthetics (LA) have the potential to produce deleterious side effects. The choice of a local anesthetic and care in its use are the primary determinants of toxicity.
This chapter covers pre-screening, history and physical for evaluation of patients who are potential candidates for procedures under sedation, as well as instructions for patients. Patients for elective procedures may be referred by their primary care physician or may be self-referred. Screening, evaluation, and instruction of patients requires clinical experience, and clerical staff members should not be performing any more than simple initial screening or instructing patients as to time, location, and routine standard instructions. The scope of practice of the surgeon/practitioner/physician(s) involved and the individual facility determine the range of procedures possible. The setting may be quite flexible and general (an operating room) or very specifically designed and equipped. Procedures should be scheduled in locations equipped both for the procedure and for sedation and any contingencies that can be routinely expected as a result of either the procedure or the patient.
The modern practice of sedation is the end result of a process of evolution in alteration of consciousness, likely starting with the discovery of the analgesic properties of ether. Recent technological advances have drastically changed the practice of sedation. One of the most significant was certainly the development of pulse oximetry during World War II by Glen Millikan. In 2002, the American Society of Anesthesiologists (ASA) appointed a task force to update practice guidelines for non-anesthesiologists administering sedation and analgesia. The Association of periOperative Registered Nurses (AORN) has produced guidelines for what every registered nurse should know about "conscious sedation". According to the AORN, moderate sedation/analgesia is produced by the administration of amnesic, analgesic, and sedative pharmacologic agents. With continued attention to a high standard of safety, many different professionals are able to provide sedation services to those patients who need them.
The nurse plays a very important role in administering procedural sedation and monitoring the patient receiving it. Receiving specialized training and adhering to strict institutional standards helps to keep patients safe. The nurse's primary responsibility during procedural sedation is exclusively to that patient. The American Association of Nurse Anesthetists (AANA) suggests that the registered nurse managing and monitoring the patient receiving sedation and analgesia should have no other responsibilities during the procedure. One of the most important things the nurse can do to prevent complications is to avoid overmedication. Intravenous sedative and analgesic drugs should be given in small, incremental doses that are titrated to the desired end point of sedation and analgesia. The American Society of Anesthesiologists (ASA) agrees that continued observation, monitoring, and predetermined discharge criteria decrease the likelihood of adverse outcomes for both moderate and deep sedation.
The demands made on a modern emergency department (ED) are such that having an internal capacity to provide a range of procedural sedation is essential to its functioning. Emergency physicians (EPs) have advanced airway management and resuscitation training to manage complications arising from sedation. A good working relationship between the department of anesthesia and the ED is thus of great importance in creating and maintaining a procedural sedation program. Both moderate and deep sedation have been shown to be safe tools in the hands of EP. Striking a balance between safety and prompt treatment is a prime consideration for the EP. The drug and dose should be primarily chosen as a function of the sedation assessment. For many ED sedations, propofol is chosen for its effects and short duration of action. The chapter also presents a few representative cases describing procedural sedation management of patients in the ED setting.
Sedation is described as a continuum, and it is often categorized according to the patient's level of consciousness as minimal, moderate, and deep sedation. Intravenous sedation can potentially cause numerous complications. The clinicians should therefore have a thorough knowledge of these possible complications and understand their management strategies. There are several scoring systems used to document the patient's mental status and depth of sedation, such as the Richmond Agitation-Sedation Scale (RASS) and the Inova Health System Sedation Scale (ISS). Prevention of complications starts with a thorough pre-procedural patient assessment. This chapter discusses, among other things, some of the patient-related risk factors and procedure-related risk factors. Among all the complications induced by intravenous sedation, respiratory complications are the most common. Moderate and deep sedation may have varying degrees of depressive effects on cardiovascular function, depending on the patient's physiological status and the dosage of sedatives administered.
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