ACCS Learning outcome: Provide safe basic anaesthetic care including sedation

Mastering Safe Basic Anaesthetic Care and Procedural Sedation

Executive Summary

This briefing document provides a comprehensive guide for Acute Care Common Stem (ACCS) trainees in Emergency Medicine to achieve excellence in the learning outcome of providing safe basic anaesthetic care and procedural sedation. Mastery extends beyond pharmacology to encompass meticulous preparation, environmental optimization, airway stewardship, and human factors. Excellence is defined by proactive preparation, creating a safe environment before the patient is present.

Key principles for safe practice include a profound understanding of sedative agents (Propofol, Ketamine, Midazolam, Fentanyl), their physiological profiles, and potential complications. Adherence to national guidelines, such as those from the Royal College of Emergency Medicine (RCEM) and the Academy of Medical Royal Colleges (AoMRC), is fundamental, treating procedural sedation with the same vigilance as general anaesthesia. The procedural framework is structured into five phases: Knowledge Foundation, Preparation, Execution, RSI Assistance, and Recovery.

Essential steps for every procedure involve a formal airway assessment using the LEMON mnemonic, a thorough equipment check using the SOAP-ME checklist, and a structured team brief. Capnography is mandatory for breath-by-breath ventilation analysis, as pulse oximetry has a significant lag time. Pre-oxygenation via high-flow nasal cannulae (apnoeic oxygenation) is the most critical step to prevent desaturation. Post-procedure, vigilant 1:1 monitoring must continue until the patient returns to their baseline, as a significant number of airway complications occur during recovery. Evidence for this competency is gathered through Direct Observation of Procedural Skills (DOPS), Case-Based Discussions (CbD), simulation, and a comprehensive logbook.

ACCS Learning Outcome: Provide Safe Basic Anaesthetic Care Including Sedation

The objective is to progress from a 'competent' to an 'excellent' practitioner in procedural sedation and basic airway management within the emergency department setting. This outcome requires a deep understanding of risks, pre-operative patient assessment, safe induction and maintenance of anaesthesia or sedation for ASA 1/1E and 2/2E patients, and effective management of recovery and complications [1, 2]. The entrustment decisions by the end of ACCS training include the ability to pre-operatively assess patients, provide urgent anaesthesia and perioperative care, and deliver safe procedural sedation.

Clinically Relevant Anatomy: The Pre-Sedation Airway Assessment

A formal, documented airway assessment is mandatory before every sedation procedure to anticipate and plan for potential difficulty. The assessment focuses on anatomical features that predict challenges with bag-valve-mask ventilation, supraglottic airway insertion, or laryngoscopy.

LEMON Law Mnemonic: A structured approach to assess the airway [5]:

L - Look Externally: Identify any external features associated with a difficult airway (e.g., small mandible, large tongue, facial trauma).
E - Evaluate (3-3-2 Rule):

3 fingers: Inter-incisor distance should be at least 3 fingers wide.
3 fingers: The distance from the hyoid bone to the chin should be at least 3 fingers wide.
2 fingers: The distance from the thyroid notch to the floor of the mouth should be at least 2 fingers wide.

M - Mallampati Score: Assess the visibility of pharyngeal structures.
O - Obstruction: Identify any signs of airway obstruction (e.g., stridor, muffled voice, swelling).
N - Neck Mobility: Assess the range of motion of the cervical spine.

Dentition: A thorough check for any loose teeth, caps, or crowns is essential to prevent dislodgement and potential aspiration during airway manipulation.

Clinical Assessment: Pre-Procedural Evaluation

The pre-sedation assessment evaluates the patient's suitability for the procedure and identifies physiological risks. This is structured using the A, B, C, D, E framework.

Airway:

History: Ask about previous difficulties with anaesthesia, snoring, or obstructive sleep apnoea.
Examination: Perform and document the LEMON assessment and check dentition as detailed above.

Breathing:

History: Inquire about respiratory conditions (e.g., asthma, COPD) and smoking history.
Examination: Assess respiratory rate, oxygen saturation (SpO2), and auscultate for any abnormalities. Note baseline work of breathing.

Circulation:

History: Identify any cardiovascular comorbidities, including ischaemic heart disease, heart failure, or arrhythmias. Note any history of hypo- or hypertension.
Examination: Measure heart rate and blood pressure. Assess peripheral perfusion. Consider the patient's fluid status, particularly in cases of sepsis where haemodynamic instability is a risk.

Disability:

History: Note any neurological conditions, previous stroke, or substance use.
Examination: Assess baseline neurological status, including GCS or AVPU score.

Exposure:

History & Examination: Conduct a full secondary survey to ensure no other injuries or conditions are missed. Note patient weight for accurate drug dosing. Assign an ASA (American Society of Anesthesiologists) physical status classification. This LO focuses on ASA 1/1E and 2/2E patients.

Key Investigations and Monitoring

Continuous, vigilant monitoring is a cornerstone of safe sedation and is equivalent to the standard required for general anaesthesia [4].

Mandatory Monitoring Suite:

Capnography: Provides real-time, breath-by-breath analysis of ventilation and is the earliest indicator of apnoea or airway obstruction [6]. It is considered mandatory.
Pulse Oximetry (SpO2): Measures oxygen saturation but has a significant lag time compared to capnography.
Electrocardiogram (ECG): For continuous monitoring of heart rate and rhythm.
Non-Invasive Blood Pressure (NIBP): Must be cycled every 3-5 minutes to monitor for haemodynamic changes.

Capnography Interpretation [6]:

Normal Square Wave: Indicates effective ventilation.
Loss of Waveform: Signifies apnoea or complete airway obstruction.
Damped/Shark-Fin Waveform: Suggests partial airway obstruction (e.g., snoring, laryngospasm) or a poor monitoring seal.

Treatment: A Phased Approach to Safe Sedation

Excellence is achieved through a structured, multi-phase process that prioritises safety and preparation.

Phase 1: The Knowledge Foundation

A deep understanding of pharmacology and guidelines is a prerequisite for safe practice. The practitioner must understand the physiological profile of each drug beyond simple dose recall [3].

Drug	Primary Use	Pros	Cons/Risks
Propofol	Deep Sedation / RSI	Rapid onset/offset, anti-emetic properties.	Hypotension (>15% drop common), apnoea, pain on injection.
Ketamine	Dissociative Sedation	Preserves respiratory drive/airway reflexes, haemodynamically stable.	Laryngospasm (0.3% risk), emergence phenomenon, hypersalivation.
Midazolam	Anxiolysis / Amnesia	Reversible (Flumazenil), excellent amnesia.	Respiratory depression, variable duration, accumulation in renal failure.
Fentanyl	Analgesia	Rapid onset, cardio-stable.	Chest wall rigidity (rare/high dose), respiratory depression synergism with sedatives.

Furthermore, practitioners must be familiar with the RCEM & AoMRC Safe Sedation Guidelines, which state that the depth of sedation is a continuum, and one must always be prepared to rescue a patient who enters a deeper level of sedation than intended [4].

Phase 2: Preparation and Environment (The "Setup")

This phase defines the expert practitioner. The environment must be optimized for safety before the procedure begins.

Step 1: Equipment Check (SOAP-ME Mnemonic)

Suction: Turned on, working, with a rigid yankauer catheter placed under the patient's pillow.
Oxygen: High-flow source available, Bag-Valve-Mask (BVM) connected, and nasal cannulae ready for apnoeic oxygenation.
Airway: Oropharyngeal (OPA) and Nasopharyngeal (NPA) airways of appropriate sizes, a correctly sized supraglottic airway (e.g., i-gel/LMA), and a checked laryngoscope with blades.
Pharmacy: All sedation and analgesic drugs drawn up and clearly labelled. A flush must be available. Emergency drugs (e.g., Ephedrine/Metaraminol for hypotension, Atropine for bradycardia) must be immediately to hand.
Monitoring: All mandatory monitoring (Capnography, ECG, SpO2, NIBP) applied and functioning.
Equipment: A defibrillator with pads applied to the patient if they are at high risk.

Step 2: The Team Brief

Conduct a formal "Time Out" or use a local safety checklist (LocSSIPs).
Assign Roles: Clearly designate the airway doctor, the proceduralist, and the monitoring nurse.
Verbalize Plan B: Explicitly state the contingency plan. For example: "If the patient desaturates, we will stop the procedure, perform a jaw thrust, and use the BVM."

Phase 3: The Procedure (Execution)

1. Pre-oxygenation: This is the single most important step to increase the patient's reserve and delay desaturation.

Apply nasal cannulae at 15L/min before starting sedation and leave them on throughout. This provides apnoeic oxygenation (also known as NODESAT - Nasal Oxygenation During Efforts at Securing a Tube) [7].
Aim for denitrogenation, evidenced by an end-tidal O2 concentration >85% if available.

2. Drug Administration:

Start low, go slow. Titrate drugs to effect.
Be mindful that arm-to-brain circulation time can be prolonged in shocked or elderly patients.
Flush the IV line between boluses to ensure the full dose is delivered and to avoid "dead space" stacking.

3. Airway Maintenance:

Be proactive with simple manoeuvres. Snoring indicates obstruction and requires immediate intervention.
Chin Lift / Jaw Thrust: Apply aggressively at the first sign of obstruction.
Oropharyngeal Airway (OPA): Insert only if the patient tolerates it without gagging.
Nasopharyngeal Airway (NPA): Often better tolerated at lighter levels of sedation.

Phase 4: Assisting in Rapid Sequence Induction (RSI)

ACCS trainees must be competent assistants during an RSI.

Cricoid Pressure: Understand correct application (10N when awake, 30N when asleep) and when to release (during active vomiting or if it obstructs the intubator's view) [8].
Passing Equipment: Know the ergonomics of passing the endotracheal tube and other equipment to the intubator.
Failed Intubation Drills: Be intimately familiar with the Difficult Airway Society (DAS) guidelines [9]:

Plan A: Laryngoscopy and intubation.
Plan B: Insertion of a Supraglottic Airway Device (SAD).
Plan C: Facemask ventilation.
Plan D: CICO (Cannot Intubate, Cannot Oxygenate) - Front of Neck Access.

Excellence Tip: Enhance team situational awareness by vocalizing time and vital signs during the procedure (e.g., "Sats are 94% and dropping, BP is 100 systolic").

Phase 5: Post-Procedure and Recovery

Safe care does not end until the patient has fully returned to their baseline physiological and cognitive state. The Fourth National Audit Project (NAP4) highlighted that a significant number of airway disasters occur in the recovery phase [10].

Monitoring: Continue 1:1 dedicated monitoring until the patient is awake, responsive, and verbalizing.
Discharge Criteria: Use a formal scoring system (e.g., Aldrete Score) to ensure clear criteria are met before the patient is discharged from the recovery area to a ward or home.

Complications: Recognition and Management

Anticipating and managing complications is a critical component of safe sedation.

Complication	Timeframe	Key Signs	Management
Hypotension	Immediate	>15% drop in BP (common with Propofol).	Have vasopressors (Ephedrine/Metaraminol) ready. Consider fluid bolus.
Respiratory Depression/Apnoea	Immediate	Loss of capnography waveform, decreased respiratory rate, desaturation.	Stop sedation, provide jaw thrust/chin lift, assist ventilation with BVM. Consider reversal agents (Flumazenil for Midazolam).
Airway Obstruction	Immediate	Snoring, stridor, damped capnography waveform.	Aggressive jaw thrust/chin lift. Insert OPA or NPA. Stop procedure if unresolved.
Laryngospasm (0.3% with Ketamine)	Immediate	Stridor, tracheal tug, paradoxical chest movement, desaturation.	Deepen sedation, apply positive pressure with BVM.
Emergence Phenomenon (Ketamine)	Recovery	Agitation, hallucinations.	Provide reassurance in a quiet environment. Consider small doses of Midazolam if severe.
Chest Wall Rigidity (Fentanyl)	Immediate	Inability to ventilate patient with BVM despite patent airway.	Requires neuromuscular blockade for management. Rare, associated with high doses.
Recovery Phase Complications	Delayed	Airway obstruction, desaturation, aspiration.	Maintain 1:1 monitoring until patient meets formal discharge criteria. Never leave a recovering patient unattended [10].

Evidencing Competence for Portfolio

To demonstrate progression and achievement of this learning outcome, trainees should gather a variety of evidence.

Workplace-Based Assessments:

Direct Observation of Procedural Skills (DOPS): Aim for at least 3-5 logged cases of procedural sedation. Also, seek assessment in BVM ventilation and insertion of an LMA/i-gel.
Case Based Discussions (CbD): Discuss complex cases, such as the sedation of a physiologically compromised (e.g., septic) patient.
HALO (Hobbs, Holroyd, and Langford Observation) in Sedation
IAC (Initial Assessment of Competence)
MCR (Multi-Consultant Report)
MSF (Multi-Source Feedback)

Logbook: Maintain a detailed logbook of all sedation and airway management cases.
Simulation: Actively participate in simulation training. Attending a dedicated "Safe Sedation" course or running local scenarios on managing sedation complications like laryngospasm is highly valuable.
CPD and Reflection:

Utilize RCEM Learning modules, SBAs, and SAQs relevant to the LO. These automatically generate a certificate of completion in the CPD Diary.
Reflection on all learning activities is highly valued and demonstrates a commitment to professional development.

References

Intercollegiate Committee for Acute Care Common Stem Training. ACCS Curriculum 2021. London: ICACCST; 2021.
Royal College of Emergency Medicine. RCEM Curriculum 2021. London: RCEM; 2021.
Brown TB, Lovato LM, Parker D. Procedural sedation in the acute care setting. Am Fam Physician. 2005;71(1):85-90.
Academy of Medical Royal Colleges. Safe Sedation Practice for Healthcare Procedures: Standards and Guidance. London: AoMRC; 2013.
Reed MJ, Dunn MJ, McKeown DW. Can an airway assessment score predict difficulty at intubation in the emergency department? Emerg Med J. 2005;22(2):99-102.
Cook TM, Woodall N, Harper J, Benger J. Major complications of airway management in the UK: results of the Fourth National Audit Project of the Royal College of Anaesthetists and the Difficult Airway Society. Part 2: intensive care and emergency department. Br J Anaesth. 2011;106(5):632-642.
Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med. 2012;59(3):165-175.
Vanner RG. Cricoid pressure. Int J Obstet Anesth. 2009;18(4):103-105.
Frerk C, Mitchell VS, McNarry AF, et al. Difficult Airway Society 2015 guidelines for management of unanticipated difficult intubation in adults. Br J Anaesth. 2015;115(6):827-848.

Peterson GN, Domino KB, Caplan RA, Posner KL, Lee LA, Cheney FW. Management of the difficult airway: a closed claims analysis. Anesthesiology. 2005;103(1):33-39.

A structured script designed for an ACCS trainee leading an RSI. This script follows the DAS (Difficult Airway Society) logic and is designed to be read out loud during the "Time Out" phase, just before drugs are pushed.

It is divided into The Situation, The Strategy (Plans A-D), and Role Assignment.

The "Time Out" Script

Lead (Intubator): "Okay everyone, stop for a moment. Let's confirm the plan. My name is [Name] and I am leading the airway."

1. The Situation

Lead: "We are performing a Rapid Sequence Induction on this [Age] year old patient for [Indication: e.g., reduced GCS/respiratory failure]. We anticipate a [Standard / Difficult] airway."

2. The Strategy (The DAS Approach)

This is the most critical part. You must verbalize the failure plan so the team is mentally prepared.

Lead: "Here is the airway plan:"

"Plan A (Primary Plan): I will intubate using a Video Laryngoscope (Mac 4 blade) and a Bougie. I will use [Drug X] and [Drug Y]. We will use 30 degrees head-up positioning."
"Plan B (Rescue Oxygenation): If I fail to intubate after a maximum of 2 attempts—or if the saturations drop below 90%—I will stop. We will insert a size [4] i-gel to re-oxygenate."
"Plan C (Facemask): If the i-gel fails to ventilate, we will move to two-person Bag-Valve-Mask ventilation with an oral airway."
"Plan D (Emergency): If we cannot intubate and cannot oxygenate via i-gel or facemask, this is a CICO (Can't Intubate, Can't Oxygenate) scenario. I will declare 'CICO' and perform a Front of Neck Access (FONA) using the scalpel-bougie-tube technique."

3. Role Assignment

Point to specific people. Do not shout into the void.

Lead: "Let's confirm roles:"

"[Name], you are on Drugs. Please confirm you have [Drug doses] drawn up and flushed. Push only when I say."
"[Name], you are my Airway Assistant. You will provide Cricoid pressure (if used) and pass me the equipment."
"[Name], you are the Team Leader/Scribe. Please watch the monitor. Call out clearly if Sats drop below 93% or Hypotension occurs."

4. Final Check

Lead: "Does anyone have any questions or concerns before we start? ... Okay, let's pre-oxygenate."

Key Phrases for During the Procedure

Even with a perfect brief, communication can break down during the stress of the procedure. Use these standardized phrases to maintain control:

1. To Standardize the Handoff:

"I have a view. Grade 2. Passing the bougie... Bougie is in. Railroading the tube... Tube is in. Cuff up."

2. To Optimize a Failed First Attempt:

"Attempt one failed. Saturations are stable. I am going to optimize: Change my blade / Adjust head position / Apply external laryngeal manipulation. Going for attempt two."

3. To Declare Failure (Crucial for safety):

"Attempt two failed. I am moving to Plan B. Pass me the i-gel."

4. To Declare CICO:

"Failed oxygenation. This is a CICO situation. Open the FONA pack. I am proceeding to front of neck access."

Why this script works

Shared Mental Model: The nurse knows exactly when to hand you the i-gel without you having to scream for it.
Cognitive Offloading: By stating "Max 2 attempts" out loud, you prevent yourself from getting "task fixated" and trying a third or fourth time while the patient becomes hypoxic.
Empowerment: Explicitly telling the Scribe to "call out if sats drop" gives them permission to interrupt you, which is a vital safety barrier.

==============================