Discharge Criteria After Sedation

Practice guidelines serve as invaluable tools in healthcare, providing systematically developed recommendations to guide practitioners and patients in making informed decisions about medical care. These may take the form of primary care evaluations, key markers in blood tests, checklists before surgery, and more. Given how anesthetic agents affect the body and brain, anesthesia providers must balance the benefits of patients being able to recover at home with the risks of lingering effects from medications. As a result, professional societies within anesthesia as well as healthcare practices have developed specific criteria to allow patient discharge after sedation.

First, it is crucial to recognize that these guidelines, known as practice guidelines, are not intended to replace local institutional policies, act as absolute requirements, or guarantee specific outcomes. Given the ever-evolving landscape of medical knowledge, technology, and practice, practice guidelines undergo periodic revisions to reflect the latest advancements and best practices.

Before delving into the criteria for patient discharge after procedural sedation and analgesia, it is essential to comprehend the various levels of sedation. Minimal sedation refers to a drug-induced state in which patients exhibit normal responsiveness to verbal commands. While cognitive function and coordination may experience some impairment, there is no impact on ventilatory and cardiovascular functions. In the case of moderate/procedural sedation, a drug-induced depression of consciousness occurs, wherein patients purposefully respond to verbal commands, either unaccompanied or with light tactile stimulation. Importantly, maintaining a patent airway does not necessitate interventions, and spontaneous ventilation remains adequate, with cardiovascular function typically unaffected. Deep sedation involves a drug-induced depression of consciousness where patients are not easily aroused but respond purposefully to repeated or painful stimulation. While the ability to independently maintain ventilatory function may be compromised, cardiovascular function is generally sustained. In contrast, general anesthesia induces a drug-induced loss of consciousness, rendering patients unarousable. This state may lead to impaired cardiorespiratory function, necessitating various degrees of support.

Ensuring patient safety after procedural sedation involves meeting specific criteria before considering discharge. These criteria include: 1) Patient can manage symptoms such as pain, lightheadedness, and nausea to a satisfactory level. 2) Confirm stable vital signs, including respiratory and cardiac functions. 3) Verify that the patient’s mental status and physical function have returned to a level allowing for self-care with minimal to no assistance. 4) Ensure the availability of a reliable person at the patient’s home for at least a few hours to provide necessary support and supervision. 5) Determine that complications from the procedure itself do not necessitate ongoing monitoring.

Effective communication is paramount in ensuring patient understanding and compliance. Clinicians should provide clear, written discharge instructions to both the patient and the individual assisting with post-sedation care. These instructions should encompass details about the procedure, the expected course of recovery, potential problems, steps to take if issues arise, follow-up information, and guidelines for resuming normal activities. Patients should be informed about the possibility of experiencing mild symptoms for up to 24 hours and advised against engaging in activities like driving or operating machinery until the next day.

Several medical societies have published guidelines on discharge criteria after sedation. The European Society of Anaesthesiology and European Board of Anaesthesiology guidelines emphasize the importance of patients returning to their neuromuscular and cognitive baseline to minimize the risk of cardiorespiratory depression post-discharge. The guidelines outline four key criteria for determining patient suitability for discharge: 1) the procedure’s low-risk nature, 2) the patient’s restoration of mental and physiological baseline, 3) the tolerance of postoperative symptoms, and 4) the presence of a reliable person with the patient during the initial post-discharge hours. Similarly, the American Society of Anesthesiologists Committee on Standards and Practice Parameters guidelines underscore the need to minimize cardiorespiratory and central nervous system depression risks after discharge. They advocate for discharge criteria that include patient alertness and orientation, stable vital signs within acceptable limits, and the presence of a reliable adult accompanying outpatients upon discharge.

Adherence to established guidelines for procedural sedation and analgesia, particularly regarding discharge criteria, is paramount in ensuring patient safety and minimizing potential complications. Practitioners must remain vigilant in assessing individual patient factors and stay abreast of evolving best practices in the field to provide optimal care. The comprehensive integration of these guidelines fosters a patient-centric approach and enhances the overall quality of healthcare delivery.

References

1. Hinkelbein J, Lamperti M, Akeson J, et al. European Society of Anaesthesiology and European Board of Anaesthesiology guidelines for procedural sedation and analgesia in adults. Eur J Anaesthesiol. 2018 01;35(1):6-24.

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