Intraveneus sedation by non-anaesthetists: Implementation of Dutch guidelines
Willem Beekhuizen, MD, CASA clinics The Netherlands
In this communication the implementation of the Dutch guidelines for deep intravenous
sedation in four abortionclinics is reported. Our experiences may be helpful to other
professionals who are considering to offer intravenous sedation to women who prefer to
have a painless procedure.
Safe and effective intravenous sedation requires strict adherence to guidelines when
administered by physicians who are not anesthesiologists. For that reason national
guidelines were developed in several countries, including The Netherlands, with
cooperation of the Dutch association of anesthetists.
The recommendations in the published guidelines should be used for the formulation of
local protocols in hospitals and clinics and adjusted to the specified speciality and
procedure. However, several years after publication of the guidelines, a number of
countries report a serious lack of implementation of existing guidelines. At present (2006)
the 1998 Dutch guidelines are evaluated and it seems that Dutch abortion doctors are one
of the few subspeciality organizations that formulated interdisciplinairy sedation protocols
appropriate to clinical practice in abortion clinics.
In July 2001 the management of the Dutch CASA-clinics contracted an advisory
anaesthetist and nominated a abortion doctor and a dedicated professional for quality
development to collaborate in the local implementation of guidelines, starting in a single
clinic. Protocols for formal multidisciplinary team training in sedation and resuscitation and
for the availability of appropriate equipment and drugs were formulated. The clarification of
the different responabilties of the teammembers in the process required special attention.
We will present examples of Procedure descriptions and Work Instructions in the Free
Communication. The anaesthetist advised to change to a single drug system: only propofol
iv is administered as a sedative drug. Possible adverse consequences of intravenous
sedation were identified and protocols formulated how to deal with these.
Requirements for both theoretical and practical training were formalised. For each
candidate a personal plan for training was drawn up, depending on his previous
experience. Trainingplans include:
Clinical lessons by the anaesthetist, a pharmacologist and an abortiondoctor
Guideline-texts, Documents of the existing quality system such as Process Descriptions
and Working Instructions for both doctors and nursing staff
Legal and formal aspects of anaesthesia and sedation, responsabilities
Training in skills such as life support, defibrillation and treatment of advesre incidents such
as anaphylactic reactions
A final practical and theoretical exam by the anesthetist completes the training, and a
certificate is granted.
On-going audit of complications was organised within the existing clinical quality
framework of blamefree reporting of accidents or near accidents.
In 2003-2005 this program for safe sedation practice was extended to three more CASA-
Plans for the near future include:
An audit in all clinics to check compliance with protocols.
Construction of a skillslab (inspired by the well known ATLS-training)
Construction of a module in the CASA-EPR for specific recording of sedation related
Incorporation of safe sedation practice into training and revalidation programmes of the
national NGvA (Dutch association of abortion doctors)