Anaesthetist support during sedation for patients undergoing minimally invasive procedures outside the operating room

摘要

This Invited Commentary accompanies the following article: Trouve-Buisson T, Arvieux L, Bedague D, et al. Anaesthesiological support in a cardiac electrophysiology laboratory: a single-centre, prospective observational study. Eur J Anaesthesiol 2013; 30:658–663. In the past 20 years, technological progress has allowed for less invasive surgical interventions leading to a reduction in tissue lesions, bleeding and inflammation. Patient outcome has, therefore, improved related in part to the introduction of modern scopic and robotic techniques, but also to a better safety culture surrounding the surgical procedure, including the use of guidelines and checklists1 formulated by the surgical/anaesthesia team. In a similar manner, minimally invasive interventions by radiologists, cardiologists, gastroenterologists and respiratory physicians have been developed and introduced into clinical practice. Most of these disciplines initiated their minimally invasive intervention program without the mandatory presence of the anaesthetist because the procedures were considered safe with only minimal tissue injury and patient discomfort. With increased operator experience, however, more invasive interventions started to be carried out in patients who were also more fragile. Concerns about patient safety and comfort needed to be addressed and a variety of strategies were implemented in different centres. Some institutions opted for a close collaboration with the anaesthetic staff whereby non-operating room minimally invasive interventions were always undertaken in the presence of an anaesthetist. As the anaesthetic team has extensive experience in patient safety (and principally in respiratory and cardiovascular support) during surgical interventions, it seemed natural that this knowledge would also be beneficial for non-operating room interventions.2,3 Some other hospitals opted for standardised training modules4 offered by the anaesthetic team in order to educate interventionists on the pharmacology and titration of sedative drugs and in airway and cardiovascular protection. This allowed the interventionalist to 'go solo' after an appropriate period of experience and to titrate certain drugs. Other centres introduced a more fluid, hybrid model in which simpler interventions in the American Society of Anesthesiologists (ASA) 1/2 patients were performed by the team of interventionists alone but more complex interventions, or ASA 3/4 type patients, were undertaken with the support of anaesthetists using preinterventional triage criteria. Although hybrid models may offer the greatest value in terms of treatment costs, comfort and safety issues, the different strategies have never been compared in large trials. In this issue of the European Journal of Anaesthesiology, Trouve-Buisson et al.5 report on a high number of adverse events (29%) during the implantation of cardiovascular implantable electronic devices with an interventional duration of approximately 1 h in high-risk patients (85% ASA status 3/4). Around 50% of these adverse events were respiratory in origin, the remaining being cardiovascular. Cardiovascular complications were more severe than the respiratory complications. On the basis of the high incidence of these events, the authors concluded that the presence of an anaesthesia team member is mandatory to guarantee patient safety. Of note, the authors had not investigated postinterventional adverse events including in-hospital mortality which may be high and could involve an intermediate or intensive care admission. Although intuitive, counting adverse events during minimally invasive procedures may be flawed if used to justify the presence of an anaesthetist. For example, most interventions in this study (92%) were performed under deep sedation, itself a technique that is associated with a high number of respiratory 'events'. The anaesthetist – although very capable of treating respiratory complications – may unwittingly be the very re