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ORIGINAL ARTICLE
Year : 2000  |  Volume : 17  |  Issue : 1  |  Page : 41-43
 

Sedoanalgesia in endourology


Department of Urology, Seth G.S. Medical College and King Edward VII Memorial Hospital, Mumbai, India

Correspondence Address:
Sulabha Punekar
302, Manish Apartments, Nehru Road, Vile Parle (East), Mumbai - 400 057
India
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Source of Support: None, Conflict of Interest: None


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   Abstract 

Sedoanalgesia is a combination of sedation and local anesthesia. It provides safe operating conditions for a wide variety of patients. We studied this technique in 68 pa­tients undergoing various endourological procedures. We present our findings along with the advantages of this pro­cedure.


Keywords: Sedation; Analgesia.


How to cite this article:
Rao S, Punekar S, Swami G, Kinne J S, Karhadkar S. Sedoanalgesia in endourology. Indian J Urol 2000;17:41-3

How to cite this URL:
Rao S, Punekar S, Swami G, Kinne J S, Karhadkar S. Sedoanalgesia in endourology. Indian J Urol [serial online] 2000 [cited 2019 May 20];17:41-3. Available from: http://www.indianjurol.com/text.asp?2000/17/1/41/41012



   Introduction Top


Sedation and analgesia or sedoanalgesia describes a state which allows patients to tolerate painful procedures while maintaining adequate cardiorespiratory function and the ability to respond purposefully to verbal commands and/ or tactile stimulation. [1] It is eminently suitable for day-care procedures in urology. [2] We studied the efficacy of this tech­nique in 68 patients undergoing endourological proce­dures. The technique, advantages and applications are described.


   Materials and Methods Top


Between September 1998 and February 1999 a prospec­tive study was performed in 68 patients who underwent various endoscopic procedures of the upper and lower urinary tract. All patients underwent a thorough evalua­tion which included detailed medical history, systemic evaluation and laboratory and radiological investigations. Based on the above, these patients were assigned an ap­propriate grade of ASA risk.

Patients were given adequate counselling regarding sedoanesthesia as well as the surgical procedure. They were advised to fast the night before the procedure.

15 mg of intravenous pentazocine was given to all pa­tients followed by intravenous midazolam 10 minutes be­fore the procedure. The usual dose of intravenous midazolam for sedation is 0.03 mg/kg body weight. Midazolam was given in small, incremental doses titrated to the desired endpoint of analgesia and sedation. We started with a minimum dose of I mg. The maximum re­quirement was up to 1.5 mg in this study.

The patient was given position, painted and draped. Five to ten minutes following sedation, local anesthesia was administered. 2% lignocaine gel was used for urethral pro­cedures. Lignocaine gel (2%) diluted with equal amount of saline was instilled into the bladder for bladder proce­dures. For ureteric procedures, retrograde ureteric cathe­terization was performed and 10 ml of 1 % lignocaine was instilled in the renal pelvis and ureters. For PCNLs, 1% lignocaine was infiltrated along the tract for puncture and dilatation. Once entry was gained into the PCS, 10 ml lignocaine gel diluted with equal amount of saline was instilled through Amplatz sheath.

Failure of the procedure was defined as severe or intol­erable pain necessitating abandonment of the procedure or conversion to conventional anesthesia.


   Patient Monitoring Top


The vital parameters were monitored intraoperatively and pen-operatively by a member of the surgical team. Pulse, blood pressure and respiration were recorded

  1. before the procedure
  2. after administration of each drug intravenously
  3. at regular intervals during the procedure
  4. on completion of the procedure
  5. before discharge.


The level of consciousness was monitored by talking to the patients during the procedure. The response of the patients to the verbal commands served as a guide to their level of consciousness.

At the time of discharge the degree of pain was assessed using a simple pain scale. [3] Criteria for discharge included an alert oriented patient with stable vital parameters.


   Results Top


Between September 1998 and February 1999, 68 pa­tients underwent endourological procedures under sedo­analgesia. These patients ranged in age from 18 yrs to 68 yrs (mean age 43) and included 42 males and 26 females. The details of the surgical procedure are in [Table 1], [Table 2].

Eight (11.76%) of our patients experienced intolerable pain during the procedure which was subsequently aban­doned [Table 1]. These cases were classified as failures. Seven of our patients had vomiting postprocedure. This was not severe and was treated with metoclopromide. There were no major cardiovascular or respiratory prob­lems during this time related to our use of sedative agents. None of our patients were over sedated and all were able to respond to verbal stimulus throughout the procedure.

The results of a simple pain scale [3] scoring is in [Table 1].


   Discussion Top


Sedoanalgesia is a technique developed to provide safe and satisfactory operating conditions in a wide range of patients independent of age and overall level of fitness. While new technology and minimally invasive procedures have led to a significant decrease in the morbidity of urologic surgery, the risk of conventional anesthesia re­mains the same. Sedoanalgeisa aims to address this defi­ciency. It is eminently suitable for the elderly and medically unfit if there is adequate intra-operative and postoperative monitoring. [2]

Pentazocine is an opioid with potent analgesic activity. It may produce nausea and respiratory depression but these are less pronounced as compared to other opioids.

Midazolam, a benzodiazepine, has become popular be­cause of its combination of water-solubility, rapid onset and short duration of action. It produces reliable amnesia with few side-effects. Moreover it causes significant an­xiolysis. Mental function returns to not i nal in 4 hours, thus making it a popular choice for ambulatory surgery and regional anesthesia. Moreover the development of a safe and effective benzodiazepine antagonist, flumazenil, has made drugs like midazolam even more useful should ex­cess sedation occur. [4] Midazolam decreases anxiety with­out causing excessive sedation, provides amnesia for the peri-operative period while maintaining co-operation prior to loss of consciousness. However it has no analgesic prop­erties and cannot alone be used for pain control.

Both pentazocine and midazolam can cause respiratory depression in higher doses. Therefore they should be given slowly and monitored carefully. In our group of patients there was no respiratory complication related to either of these two drugs nor did we require to use the midazolam antagonist, flumazenil.

The use of sedoanalgesia is especially pertinent to in­stitutions like ours, i.e., large teaching hospitals with a heavy work load, shortage of skilled manpower and long theatre-waiting lists. There is an improvement in theatre dynamics with little time wasted between cases. [5] This re­sults in greater time efficiency and greater work output per day leading to a reduction in the waiting list.

Secondly most of these patients can be treated on a day­care basis. Most of our patients were alert and well ori­ented in a few hours and were discharged the same day if their vital parameters were normal. This has helped ease the burden on our already overcrowded wards.

Thirdly sedoanalgesia can be used in patients with con­siderable risk from conventional anesthesia. This must especially be a consideration in urology which has a high percentage of patients who are elderly and medically un­fit.

Thus in conclusion, sedonalgesia is a safe and effective procedure in the vast majority of patients especially in the elderly with associated co-morbid conditions. Appropri­ate patient selection, proper counselling and close moni­toring is the key to success.

 
   References Top

1.Practice guidelines for sedation and analgesia by non-anesthesio­logists. A report by the American Society of Anesthesiologists, Task Force on Sedation and Analgesia by Non-Anesthesiologists. Anesthesiology 1996; 84: 459-471.  Back to cited text no. 1    
2.Briggs TP, Anson KM, Jones A, Coker BJ, Miller RA. Urological day case surgery in elderly and medically unfit patients using sedoanalgesia: what are the limits? Br J Urol 1995; 75: 708-711.  Back to cited text no. 2  [PUBMED]  
3.Habibi S, Coursin DB. Assessment of sedation, analgesia, and neu­romuscular blockade in the perioperative period. Int Anesthesiol Clin 1996; 34: 215-241.  Back to cited text no. 3  [PUBMED]  
4.Goodman and Gilman's The Pharmacological Basis of Therapeutics (9th ed.), McGraw Hill. 303pp.  Back to cited text no. 4    
5.Birch BRP, Anson KM, Miller RA. Sedoanalgesia in urology: a safe, cost-effective alternative to general anesthesia: A review of 1020 cases. Br J Urol 1990; 66: 342-350.  Back to cited text no. 5    



 
 
    Tables

  [Table 1], [Table 2]



 

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    Abstract
    Introduction
    Materials and Me...
    Patient Monitoring
    Results
    Discussion
    References
    Article Tables

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