Sedation

A patient with lung cancer has recurrent pleural effusions. He has had two chest tubes placed at outside hospitals to drain the fluid around his lung, but each time the chest tube is removed, the fluid reaccumulates and his symptoms of shortness of breath return. Ultimately, he is scheduled for a placement of a permanent chest tube called a Pleurex catheter which will allow him to drain the pleural effusions at home. While the initial chest tubes are placed with local anesthesia and surgeon-determined sedation, the Pleurex catheter is scheduled for anesthesiologist-delivered sedation which we call monitored anesthesia care even though the surgical procedure is not so different.

Many procedures are done with sedation ordered by a non-anesthesiologist. Nurses can administer medications for colonoscopy ordered by a gastroenterologist, reduction of a disclocation ordered by an emergency physician, or a chest tube placement ordered by a surgeon. And even though the medications they use are identical to the medications I use, sedation by an anesthesiologist is different. My sole concern is the patient's comfort and safety. The proceduralist doesn't have to worry about the vital signs, the patient's level of sleepiness, and the actual procedure simultaneously; I simplify his responsibilities so he doesn't have to multitask. I'm also extremely familiar with common sedation medications like fentanyl, midazolam, and propofol, and I have tricks up my sleeve like ketamine, alfentanil, and dexmedetomidine if the clinical situation requires something more complex. But of course, scheduling an operating room and an anesthesiologist for a case with sedation uses a lot more resources.

In comparing his prior chest tube experiences with the pleurex catheter experience, the patient thought there was a complete black-and-white difference. At the outside hospital, he was uncomfortable, did not feel that the proceduralist was listening, and did not get adequate sedation. When we did his pleurex catheter in the operating room, he was snoozing lightly, woke up immediately, and completely satisfied. He shook my hand in the recovery room and assured me that if he had to get something with sedation in the future, he hoped he would have an anesthesiologist.