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Commentary |
1Department of Radiology, Royal Free Hospital, Pond Street NW3 2QG, London and 2Department of Radiology, Royal Berkshire Hospital, Reading, UK
"When you've got a hammer everything looks like a nail"... Interventional radiology came of age with the medical profession's desire to develop minimally invasive therapies. One of the great appeals of interventional radiology was that most procedures were carried out under local anaesthesia, occasionally supplemented by iv sedation. This was embraced by all, as it allowed procedures to be undertaken on a day-case or short stay basis thus reducing the nurse and ward burden, it negated the need for the presence of an anaesthetist and Operating Department Assistant (ODA), and it did not use valuable theatre time. However, is this all-pervading minimalistic culture in the best interest of either the patient or the radiologist?
Historically, neuroradiologists have maintained close links with anaesthetists through their need for total patient compliance in carrying out both diagnostic and therapeutic neuroradiological procedures. General anaesthesia ensures patient immobility and allows controlled apnoea, permitting optimal image acquisition and treatment delivery. More importantly, experience has shown that should a complication occur during a procedure, such as aneurysm rupture, it is impossible to control the situation by coil delivery and detachment unless the patient remains absolutely immobile. These gold standards of anaesthesia are becoming increasingly necessary in general interventional work. It is no longer appropriate for the operator/anaesthetist role to be borne by the interventional radiologist alone. Reports for training of non-anaesthetic staff in the provision of sedation, monitoring and recovery of patients have been published [1]. The advice includes the need to be well versed in the pharmacology of opioids, benzodiazepines and their respective reversal agents; that staff need to be trained in the recovery and monitoring of patients and need 5 yearly updates in resuscitation techniques such as advance cardiac life support. In spite of these reports, recent media reports have again highlighted the increase in mortality rates in hospital patients undergoing procedures using sedation techniques when they are carried out by non-anaesthetic personnel.
Assessment of patients prior to sedation is at best cursory, usually taking the form of a simplified patient checklist. Most radiological units do not routinely use the categories described by the American Society of Anaesthesiologists. Although sedation techniques are safe and without mishap in the majority of individuals, there are certain patient groups in whom caution should be exercised, for example extremes of age [2], morbid obesity or wasting, active bleeding and concurrent systemic illness (cerebrovascular, cardiovascular, respiratory, liver or renal disease, infection and blood dyscrasias). Radiological investigation of children is a case in point. MRI is becoming increasingly used in the paediatric population as it produces excellent cross-sectional images without a radiation burden. MRI requires the patient to be completely immobile for a relatively long period of time in a rather noisy and enclosed space. To achieve this, dedicated paediatric centres have established nurse-led sedation services, with a high published success rate and no adverse respiratory events [3], a practice from which many lessons can be learnt.
It is in high risk groups that more and more "minimally invasive" interventional techniques are being undertaken. As a result, we are making ourselves more vulnerable to the possibility of suboptimal practice in the use of sedation because of an increase in the unpredictable and unreliable response in these patients to the administered agents. Frequently, analgesia in the form of opioids is given as an adjunct to iv sedation, so adding to the difficulties in management of the patient's airway and respiratory depression. Together, these agents are synergistic in their unwanted side effects such as decreasing patient cooperation and increasing irritability. Conversely, the increasing complexity of interventional procedures necessitates greater control over the degree of patient compliance if treatments are going to be both successful and without unnecessary morbidity or mortality.
Out of hours, with a very sick patient and no anaesthetic cover, the radiology department can feel like being isolated in a far flung corner of the British Empire—with a level of airway and pain control that would not be out of keeping with the time of Queen Victoria. When attempting technically challenging procedures, it would seem only common sense to allow the anaesthesia and pain control to be undertaken by a separate professional who has been trained in these areas and who can make appropriate decisions, regardless of the stage of the ongoing procedure. In the critically ill, in whom interventional radiology is used increasingly (vascular trauma, acutely ischaemic limbs, gastrointestinal, variceal or gynaecological haemorrhage, biliary and renal drainage in septicaemic patients), this would appear mandatory, as one cannot possibly be in complete control of the continuing resuscitation of an individual as well as concentrating on the technically demanding procedure in hand. This is a situation in which our surgical colleagues would never place themselves.
Trotteur et al [4] have undertaken a survey in the form of a mailed questionnaire to Belgian interventional radiologists; 54% of individuals had an anaesthetist present when administrating iv sedation. General anaesthesia was reserved for neuroradiological intervention (82%), triangular intrahepatic portosystemic shunt (TIPSS) (56%) and aortic stent grafting (70%). The conclusions from this study were that generally there was a high standard of practice in sedation and analgesia, but anaesthetists were underutilized. To a greater or less extent, this is reflected in current UK practice. As a professional group, radiologists should realize that their future is only partly determined by the development of new treatment modalities—it is also vital to look at current services and to identify areas that can be improved. This, together with increasing public expectation, necessitates improved treatment delivery at ever higher standards. Patient morbidity and mortality associated with interventional procedures performed under sedation is an area that can be improved, but it is in the provision and availability of general anaesthesia that real steps must be taken. This involves the development of treatment strategies alongside anaesthetic departments to markedly increase availability of anaesthetic cover for both general and sedation-based anaesthesia within the radiology department. Pain control is an area in which there is general ignorance and perhaps even disregard post-procedurally by radiologists, but it is an issue that would be greatly enhanced by anaesthetic input. This obviously encompasses equipment and manpower issues, both in finding sufficient anaesthetists to cover cases and also the need to furnish them with personnel in the form of ODAs and nursing staff (sometimes the greatest stumbling block within our own unit!).
We believe that, as a professional group, radiologists should be looking to the Royal College of Anaesthetists and the Royal College of Radiologists to update their joint guidance on sedation and anaesthesia in radiology in light of the marked recent developments in interventional radiology. There should be a concerted effort to obtain routine anaesthetic cover for a number of fixed sessions in general interventional practice in all busy units. For out of hours work, anaesthetic presence should be seen as standard practice for all procedures involving critically ill patients. It is not beyond the limits of any department to address these issues and, ultimately, all will reap the benefits.
Received for publication July 3, 2001. Revision received October 24, 2001. Accepted for publication November 6, 2001.
References
This article has been cited by other articles:
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  W C Culp, M N Payne, and M L Montgomery Thoracic paravertebral block for analgesia following liver mass radiofrequency ablation Br. J. Radiol., January 1, 2008; 81(961): e23 - e25. [Abstract] [Full Text] [PDF]
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