The anesthesia directed sedation service: Models, protocols, and challenges

Children undergo painful or distressing procedures in remote locations where anesthesia providers (anesthesiologists, certified registered nurse anesthetists, anesthesia assistants) are not always readily available. In these situations, sedation models with nonanesthesia care providers are necessary to fill the void that anesthesia services cannot provide. Many procedures do not require general anesthesia (even for the pediatric population), and may be accomplished with varying depths of sedation. Anesthesia, as a specialty, offers a special expertise which can be applied to the development, oversight, and implementation of a sedation service. Anesthesiologists already have knowledge of sedatives, analgesics, and anesthetics and possess the advanced intervention skills necessary to rescue from respiratory and hemodynamic compromise. This specialty has taken an active role in establishing guidelines and standards for the sedation of both adults and children over several decades. In addition, the Institute of Medicine recognizes the field of anesthesia as a model of patient safety: anesthesia associated mortality is currently considered to be as low as 1/200,000 or 300,000 anesthetics administered [1]. Sedation can be considered to be an extension of the specialty: knowledge of the cardiovascular and respiratory physiology, as well as the pharmacology of sedative agents are inherent to this discipline.