PG09(G) released for six-month pilot
16 November 2022
ANZCA has released for pilot the professional document PG09(G) Guideline on procedural sedation and its accompanying background paper (PG09(G)BP).
The review of PG09 began in 2021 and included 29 colleges and key stakeholders (listed in the document), the largest collaborative professional document review ever undertaken by the college.
It involved multiple email exchanges, two rounds of consultation and four Document Development Group (DDG) meetings (three via Zoom due to COVID-19, and one face-to-face meeting).
Collaboration was an important component of this review to ensure procedural sedation in all settings was addressed. Broad representation and co-badging were deliberate outcomes aimed at promoting penetration through stakeholder colleges and societies and compliance by sedationists.
ANZCA’s mission “to serve the community by fostering safety and high-quality patient care in anaesthesia, perioperative medicine and pain medicine" was a driving factor of the PG09 review beyond the specialty of anaesthesia and into the broader span of medical disciplines.
PG09 (formerly titled PS09 Guidelines on Sedation and/or Analgesia for Diagnostic and Interventional Medical, Dental or Surgical Procedures) and its accompanying background paper (PS09BP) were last reviewed in 2014.
In October 2021, the draft revised versions of PG09(G) Guideline on procedural sedation and PG09(G)BP, which were a major re-write of the 2014 version, were circulated for the first round of stakeholder consultation. Significant feedback was received, and the subsequent revised version recirculated for a broad second round of stakeholder consultation in April 2022.
Changes resulting from the current review include:
1. Levels of sedation
In the 2014 version of PS09 the medications used to manage sedation formed the focus of the recommendations. However, any given medication can lead to different depths of sedation depending on the dose administered and patient factors. For example, use of minimal doses of propofol in any given cohort of patients will have a different risk profile from that when given in large doses.
Consequently, in the current draft there has been a shift in focus from the drugs administered to depths of sedation, recognising that risks are more closely linked to sedation depth. This necessitated clarification and redefining levels of sedation, which have been modified in this version.
2. Exclusion of deep sedation
The ANZCA fellowship view and that of the college has long been that anaesthesia extends from sedation through to general anaesthesia and includes major regional anaesthesia.
This perception is incompatible with the fact that sedation services are provided by a range of clinicians, who by this definition could be perceived as anaesthetists.
To avoid this misconception, sedation needed to be separated from anaesthesia even though it constitutes part of the spectrum of anaesthesia practice.
The risks of deep sedation rapidly and inadvertently progressing to general anaesthesia are well recognised and may be viewed as part of the general anaesthesia spectrum.
As stated in PG09 and PG09(G)BP, managing patients under general anaesthesia is complex, high-risk and requires extensive training and it is unreasonable to expect any practitioner who has not completed such training to manage general anaesthesia.
Consequently, the scope of PG09 was amended to omit deep sedation to avoid any possible perception that PG09 supports sedationists administering deep sedation.
PS09 2014 did not adequately address paediatric sedation, which from ANZCA’s perspective was within the realm of anaesthesia as defined at that time and was guided by PG29(A) Guideline for the provision of anaesthesia care to children.
Paediatric content was added as a result of strong canvassing by stakeholders including DDG members with experience in paediatric anaesthesia and paediatric dental procedures.
Despite this experience, it was agreed that additional expertise in paediatric sedation was advisable. As a result, the DDG appointed an expert group comprising representatives from diverse areas of paediatric sedation practice to contribute to the process.
4. Safe sedation competencies
A major deficiency identified was the significant disparity in competencies across sedationists.
Risks associated with sedation are related to the targeted/achieved depth of sedation.
Consequently, it is expected that sedationists should achieve and demonstrate competencies commensurate with their targeted depths plus one level deeper, in case of unintentionally exceeding the targeted depth.
Stakeholders enthusiastically campaigned for the inclusion of the competencies. The integration into PG09 of the Safe Sedation Competencies (originally developed for adult patients and excluding paediatric patients) required the development of additional paediatric-specific competencies developed with advice from the paediatric expert group.
The competencies are presented as appendix IV to facilitate access to the information as well as to facilitate review and updating the competencies.
PG09(G) Guideline on procedural sedation and its background paper PG09(G)BP have been released for a six-month pilot period. Feedback is encouraged during the pilot. If you have any comments or queries please email us.
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