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Corresponding author at: Avda. E-mail address: halogenado gmail. Analysis of the death resulting from a deep sedation administered by a non-anesthetist physician who was convicted after a trial for manslaughter. A discussion is made of the potential impact of the adoption of the recently published recommendations for sedation by non-anesthetists, developed by the Sociedad Colombiana de Anestesiologia SCARE along with other scientific societies. Published by Elsevier. Publicado por Elsevier. The development of recommendations for sedation by non-anesthesiologists is subject to serious discussions among the interested parties all over the world. Likewise, in Colombia, this has hampered the possibility of creating standards; however their need is obvious, as cases of lethal outcomes that could be prevented with adherence to explicit safety strategies, occasionally happen. Preventable lethal outcomes do not occur exclusively in developing countries. The recent death of a celebrity, Michael Jackson, in the United States has put the problem of not complying with appropriate safety standards during sedation under the spotlight. This review analyzes the case of the deceased artist from the perspective of the recently developed recommendations for sedation by non-anesthesiologists in Colombia. According to the transcriptions available from the interview of his physician, the cardiologist Conrad Murray, with the police, 1 Michael Jackson had major sleeping problems. To address this situation, Jackson hired Murray two months before his death to provide combinations of medications, benzodiazepines and propofol, in order to sleep. According to his own testimony, on June 25, the physician was managing Jackson's chronic insomnia. After prescribing 10 mg of oral diazepam without any sleep induction, he inserted an intravenous catheter in the leg, gave 2 mg of lorazepam, and after observing minimal effects he gave another 2 mg of midazolam, again without major effect. In this situation the patient indicated he wanted 'milk' the denomination Jackson gave to propofol to which Murray complied, administering 25 mg of propofol with lidocaine, to minimize injection pain. The physician said he left the patient alone for a few minutes, and when he returned he found him in apnea with a femoral heart rate of bpm. He described no further details on the pulse oximetry or on the electrocardiographic monitoring or capnography. He began cardiac compressions. Afterwards, he provided mouth-to-mouth resuscitation, administered flumazenil, and then called help on Paramedics arrived and after 20 min. However, because of Murray's insistence he was transferred to a medical center where after all types of maneuvers, including insertion of an aortic counter pulsation balloon, he was declared dead 40 min. The patient's autopsy revealed high blood levels 2. Lidocaine 0. It should be noted that there was absence of any level of alcohol, barbiturates, cocaine, marijuana, amphetamines or any opioid. The autopsy also revealed excellent physical conditions of the patient and the absence of atherosclerosis. Several physicians participated in the trial, including a cardiologist, an internist expert in sleep disorders and two anesthesiologists, one as a witness of the prosecution and the other of the defense. On November 7, the jury gave a guilty verdict to Conrad Murray. On November 27, the judge sentenced him to four years in jail stating that Murray had committed criminal negligence in medical care and on his insistence of not admitting these errors, he represented a danger to society. In Colombia, after a fatal outcome related to sedation in , the health authorities of Bogota identified a total lack of recommendations or guidelines for sedation by non-anesthesiologists. The work of this ad hoc sedation committee included an extensive review of many sedation recommendations previously published elsewhere; after which a document was written, 3 to be used as the basis for public discussion in forums with authorized delegates from most of the scientific societies interested in the topic. Simultaneously, the development of recommendations for sedation of patients under 12 years old by non-anesthesiologists was directed by the Pediatric Anesthesia committee of SCARE with support of the Safety committee. The main concepts of the adult sedation document are:. The compliance to this recommendation is easier with the recommendation of using only one medication for sedation. Otherwise this level of sedation can only be performed by an anesthesiologist. Training is explicit and requires the passing of a theoretical-practical course specifically designed for the administration of sedation level I and II. The final goal of this document is to regulate the chaotic practice of sedation in Colombia, where it is common that non-anesthesiologists provide deep sedations level III , in which general anesthesia level IV can intermittently happen, exposing the patients to very high risks, as well as breaking the law, as general anesthesia is only allowed to be provided by graduated anesthesiologists in Colombia. The recommendations published in this issue of the Colombian Journal of Anesthesia 4 draw a middle line between the expectations of non-anesthesiologists who mistakenly extrapolate the international experience in sedation and consider that they should not be restricted in performing deep sedation, 5 and the expectations of some anesthesiologists who consider that all sedation or the use of some medications, like propofol, be restricted to exclusive anesthesiologist practice. Even though there is abundant literature suggesting the safety of sedation even deep sedation by non-anesthesiologists, this same literature consistently addresses safety strategies that are not easily implemented in the country's practice like expertise in advanced airway management, that requires periodical re-training; for example, how many gastroenterologists in Colombia, refresh their competencies briefly obtained during an ICU rotation? Or refresh formal training in sedation, monitoring expertise, including capnography, and biannual ACLS certification, among other competencies? These, unfortunately, are not universal in the country. On the other hand, the anesthesiologist is, by definition, an expert in sedation, as general anesthesia is the end of the continuum of sedation. However, in no country in the world is sedation level I or II considered to be an exclusive activity of anesthesiologists. The argument that a single dose of any sedative can lead to deep sedation or even general anesthesia is possible, but the training proposed, intends to minimize this risk as much as possible. Regarding propofol, the situation is different, as there are strong debates between those who consider it as an exclusive medication to be used by anesthesiologists and those who consider that it can be used by non-anesthesiologists with restrictions. There are literature reports describing hundreds of thousands of cases using propofol for sedation during endoscopy with minimal morbidity. This has supported the development of guidelines for the use of propofol by non-anesthesiologists both in the United States 13 and in Europe. In the United States, the use propofol by non-anesthesiologists is almost universal during endoscopy. However Medicare, the health care insurance for individuals above 65 years old, did not allow the use of propofol by non-anesthesiologists, related to the fact that the FDA Food and Drug Administration, United States government agency regulating medications has established that the drug insert explicitly indicates that whoever administers the medication should have anesthesia expertise. The heated debate on regulating sedation is longstanding. In the United States sedation guidelines for non-anesthesiologists 14 have been subject of great criticism, and achieving the balance between positions is complex. Several distinguished anesthesia professors questioned this prohibition of propofol use by non-anesthesiologists as a fundamentalist and populist measure, because even though it seems reasonable, it has no literature support. When these recommendations for Colombia were developed, there was a consideration that propofol use among endoscopists is popular, so instead of prohibiting its use, it was regulated, specifying that it should be used only to achieve sedation level I and II, and that it should not be used with other medications commonly used, like opioids and benzodiazepines, because the combination of medications increases exponentially the risk of complications, and whoever administers sedation in Colombia rarely has the competencies to avoid clearly preventable complications, which can lead to fatal or serious adverse outcomes, as has effectively happened in the country with rates higher than those reported in the literature. This is a reality that developed countries had 20 years ago, when almost a hundred of deaths with sedation were reported, almost all by non-anesthesiologists, and clearly related to poor safety standards. The case described above is appropriate to discuss the relevance of adherence to safety recommendations in sedation. Steven Shafer, an anesthesiologist expert witness for the prosecution, Professor of Anesthesia at Columbia University, and a renowned authority in the pharmacology of intravenous agents, as well as author of the insert of the propofol ampoules available in the United States, made an excellent analysis of the safety standards Conrad Murray breached. This author describes 17 flagrant violations from his point of view, of which 16 are relevant for the issue of sedation table 1. When this case is analyzed considering the recommendations approved in Colombia, it is clear that almost all the safety issues identified by Shafer, which according to his testimony could all independently be lethal, could be preventable with adherence to these published recommendations. It is important to pin point that anesthesiologists who provide sedation are subject to the SCARE Minimal Standards for anesthesia practice in Colombia, 21 which are more strict, as the sedation by anesthesiologists can be as deep as level IV general anesthesia , and therefore the safety standards are higher. For example they require permanent monitoring of capnography and the electrocardiograph, among others. Several recent studies show the adherence to these standards in anesthesiologist administered sedations in Colombia. Safe sedation is a goal that should be actively pursued, as most of the morbidity is related to poor adherence to established recommendations. The efforts of the Safety Committee of SCARE, jointly with the other seven societies interested in the topic has made the published consensus possible with the intention of regulating the practice of sedation by non-anesthetists in Colombia. The concerns of health authorities are such that in the process of updating resolution of institutional certification, these recommendations will be included as mandatory to obtain permission to offer these services. It is expected that as result of this initiative, the patient's safety during sedation will improve significantly in Colombia. Pedro Ibarra is coauthor of the National Consensus: Recommendations for the sedation and analgesia by non-anesthesiologist physicians and dentists in patients older than Los Angeles Police Department. Transcript of recorded interview of: Conrad Murray, Forensic Science Laboratories. Laboratory analysis summary report. Ruiz I. Rev Col Gastroenterol. Rev Colomb Anestesiol. Forero PEA. Rev Colomb Gastroenterol. Endoscopist-directed administration of propofol: a worldwide safety experience. Nurse-administered propofol sedation for gastrointestinal endoscopic procedures: first Nordic results from implementation of a structured training program. Scand J Gastroenterol. Position statement: non-anesthesiologist administration of propofol for GI endoscopy. Gastrointest Endosc. Practice guidelines for sedation and analgesia by non-anesthesiologists. Epstein BS. The American Society of Anesthesiologist's efforts in developing guidelines for sedation and analgesia for non-anesthesiologists: the 40 th Rovenstine Lecture. Eur J Anaesthesiol. Perel A. Non-anaesthesiologists should not be allowed to administer propofol for procedural sedation: a Consensus Statement of 21 EuropeaNational Societies of Anaesthesia. Guidelines on non-anaesthesiologist administration of propofol for gastrointestinal endoscopy: a double-edged sword. Frequent hypoxemia and apnea after sedation with midazolam and fentanyl. Ariza F. Services on Demand Journal. All rights reserved. Todos los derechos resevados. Case record According to the transcriptions available from the interview of his physician, the cardiologist Conrad Murray, with the police, 1 Michael Jackson had major sleeping problems. Development of sedation recommendations in Colombia In Colombia, after a fatal outcome related to sedation in , the health authorities of Bogota identified a total lack of recommendations or guidelines for sedation by non-anesthesiologists. The main concepts of the adult sedation document are: a Considerationthatwiththeadoptionofsafetyrecommendations most complications are preventable during sedation by non-anesthesiologists. Competing Interests Pedro Ibarra is coauthor of the National Consensus: Recommendations for the sedation and analgesia by non-anesthesiologist physicians and dentists in patients older than Funding sources: The author's own resources. How to cite this article.

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