|Year : 2000 | Volume
| Issue : 1 | Page : 41-43
Sedoanalgesia in endourology
Sandhya Rao, Sulabha Punekar, Gajanan Swami, J Sathish Kinne, Sunil Karhadkar
Department of Urology, Seth G.S. Medical College and King Edward VII Memorial Hospital, Mumbai, India
302, Manish Apartments, Nehru Road, Vile Parle (East), Mumbai - 400 057
Source of Support: None, Conflict of Interest: None
| 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
| Introduction|| |
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.  It is eminently suitable for day-care procedures in urology.  We studied the efficacy of this technique in 68 patients undergoing endourological procedures. The technique, advantages and applications are described.
| Materials and Methods|| |
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|| |
The vital parameters were monitored intraoperatively and pen-operatively by a member of the surgical team. Pulse, blood pressure and respiration were recorded
- before the procedure
- after administration of each drug intravenously
- at regular intervals during the procedure
- on completion of the procedure
- 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.  Criteria for discharge included an alert oriented patient with stable vital parameters.
| Results|| |
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  scoring is in [Table 1].
| Discussion|| |
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. 
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.  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.  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|| |
|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. |
|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. [PUBMED] |
|3.||Habibi S, Coursin DB. Assessment of sedation, analgesia, and neuromuscular blockade in the perioperative period. Int Anesthesiol Clin 1996; 34: 215-241. [PUBMED] |
|4.||Goodman and Gilman's The Pharmacological Basis of Therapeutics (9th ed.), McGraw Hill. 303pp. |
|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. |
[Table 1], [Table 2]