• anaesthesia

Imagine breaking your ankle. Worse still having a fracture/dislocation of your ankle that you recognise needs manipulation. What are your thoughts preprocedure? How confident are you of a painless (and hopefully successful) reduction? Might we assume that deep down, you dread an uncomfortable experience and its recall? In similar circumstances what are patients’ genuine experiences?

Analysis of the emergency medicine literature reveals widely varying recall rates: 7%,1 12%–13%,2 12%–16%,3 65%4 and 90%.5 More importantly, patients reporting painful recall of the procedure on return to baseline mental status has been recorded as 2%–6%,2 10%–14%3 and 30%.4 In a randomised controlled trial comparing sedation with ketamine versus propofol by Miner et al, patients recall of any pain during the procedure was 2% of those randomised to ketamine and 6% of those given propofol; all reported 100% satisfaction with the treatment they received during the procedure.1 In an earlier randomised controlled trial targeting deep sedation, Miner et al recorded painful recall more often: in 9.9% of those patients given 1 mg/kg propofol and 10 μg/kg alfentanil, and in 13.5% in those given propofol alone.3 All patients had been given titrated intravenous morphine up to 20 min prior to the procedure. Patient satisfaction was 94% in both groups. Six of 20 patients in a study by Freeston et al4 were able to recall pain postprocedure. Two of these rated their pain as 9/10 and 10/10 and their satisfaction as 4/10 and 5/10, respectively. Both received midazolam/morphine combinations, the former widely regarded as reliably providing amnesia. In summary, painful recall does occur after procedural sedation, even when deeper levels of sedation are targeted. Painful recall unsurprisingly correlates indirectly with patient satisfaction: lower levels of recall are associated with higher satisfaction rates.

Better communication with patients requiring procedural sedation is a key message from a recent report from the Royal College of Anaesthetists and Association of Anaesthetists of Great Britain and Ireland6 (their fifth National Audit Project: NAP5). The study recommends avoiding terms such as ‘we’ll give you something to make you sleep’, or ‘you won’t be aware of anything’, since these terms describe the state of anaesthesia or total amnesia. It argues that we should stress that procedural sedation is not general anaesthesia; amnesia is a side effect of sedation and not a guarantee. The report offers a useful table defining levels of sedation and analgesia with respect to patient response and intervention. It does not mention the unique effect of ketamine—we have added ‘dissociative sedation’ to the otherwise original table (table 1). In addition, we would advocate seeking informed consent and feedback when the patient regains full consciousness. We note patient dissatisfaction following sedation does not feature as an adverse event in an internationally accepted audit tool7 we have previously endorsed on behalf of the Royal College of Emergency Medicine (RCEM).8 Importantly, patient satisfaction will feature in the RCEM 2015 audit on procedural sedation and analgesia.