Special article
Sedations in diagnostic and/or therapeutic procedures: Quality and safety recommendations
Sedaciones en procedimientos diagnósticos y/o terapéuticos: recomendaciones de calidad y seguridad
R. Cabadas Aviona,
, J.M. Rabanal Llevotb, M.À. Gil de Bernabéc, E. Guasch Arévalod, C. Aldecoa Álvarez-Santullanoe, M. Echevarría Morenof
Corresponding author
a Servicio Anestesiología, Hospital Povisa, Vigo, Spain
b Servicio de Anestesiología, Hospital Universitario Marqués de Valdecilla, Santander, Spain
c Servicio de Anestesiología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
d Servicio de Anestesiología, Hospital Universitario La Paz, Madrid, Spain
e Servicio de Anestesiología, Hospital Universitario Rio Hortega, Valladolid, Spain
f Servicio de Anestesiología, Hospital de Valme, Sevilla, Spain
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Cabadas Avion, J.M. Rabanal Llevot, M.À. Gil de Bernabé, E. Guasch Arévalo, C. Aldecoa Álvarez-Santullano, M. Echevarría Moreno" "autores" => array:6 [ 0 => array:4 [ "nombre" => "R." "apellidos" => "Cabadas Avion" "email" => array:1 [ 0 => "rcabadas@povisa.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "J.M." "apellidos" => "Rabanal Llevot" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "M.À." "apellidos" => "Gil de Bernabé" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "E." "apellidos" => "Guasch Arévalo" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">d</span>" "identificador" => "aff0020" ] ] ] 4 => array:3 [ "nombre" => "C." "apellidos" => "Aldecoa Álvarez-Santullano" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">e</span>" "identificador" => "aff0025" ] ] ] 5 => array:3 [ "nombre" => "M." "apellidos" => "Echevarría Moreno" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">f</span>" "identificador" => "aff0030" ] ] ] ] "afiliaciones" => array:6 [ 0 => array:3 [ "entidad" => "Servicio Anestesiología, Hospital Povisa, Vigo, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Anestesiología, Hospital Universitario Marqués de Valdecilla, Santander, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Anestesiología, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Anestesiología, Hospital Universitario La Paz, Madrid, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Servicio de Anestesiología, Hospital Universitario Rio Hortega, Valladolid, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Servicio de Anestesiología, Hospital de Valme, Sevilla, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Sedaciones en procedimientos diagnósticos y/o terapéuticos: recomendaciones de calidad y seguridad" ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">The increased demand for sedation or anaesthesia techniques by various specialties (gastroenterology, pulmonology, cardiology, radiology, etc.) for different procedures performed outside the operating room now accounts for 20%–30% of the activity of anaesthesiology departments. The development of different advanced diagnostic techniques, such as mass colorectal cancer screening programmes, has increased the need for sedation and anaesthesia techniques to the extent that anaesthesiology departments are sometimes overwhelmed and unable to provide adequate care. Estimates suggest that over 1,000,000 such procedures (digestive, cardiological, respiratory endoscopy, etc.) are performed each year.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">1</span></a> However, it is important to remember that the presence of an anaesthesiologist to oversee these techniques is a means of guaranteeing patient safety and improving the conditions in which the procedures are carried out by the different specialists involved.</p><p id="par0010" class="elsevierStylePara elsevierViewall">Recently, Arnal et al.,<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">2</span></a> prompted by the different sedation techniques is used in Spain, gathered data from the Spanish Anaesthesia and Critical Care Incident Reporting System to create a patient-safety centred consensus document that was published in the <span class="elsevierStyleSmallCaps">Spanish Journal of Anesthesiology</span>. The recommendations were reviewed by a large expert working group, and has formed the basis for this study in which the Spanish Society of Anaesthesiology and Critical Care (SEDAR) outlines the fundamental aspects to be considered when administering sedation outside the operating room.</p><p id="par0015" class="elsevierStylePara elsevierViewall">We at SEDAR consider is essential to protocolise the administration of sedation in Spanish hospitals to ensure that it is performed in accordance with scientific evidence and international recommendations<a class="elsevierStyleCrossRefs" href="#bib0100"><span class="elsevierStyleSup">3,4</span></a> (Declaration of Helsinki,<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a> Joint Commission,<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">6</span></a> Food and Drug Administration<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">7</span></a>). For this purpose, we created a working group to review the available scientific literature and international recommendations and draft a protocol defining the most relevant aspects of this technique in order to maximise the effectiveness, efficiency, quality and safety sedation procedures. This consensus document has been approved by the Spanish Society of Anesthesiology, Critical Care and Pain Management.</p><p id="par0020" class="elsevierStylePara elsevierViewall">The Joint Commission<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">6</span></a> is an independent, non-profit organisation that accredits health care organisations and programmes. Its mission is to continuously improve health care by evaluating health care organisations and inspiring them to excel in providing safe and effective care. The Joint Commission assigns anaesthesia departments the role of organising the administration of moderate and deep sedation through the ASC.2 standard, which states that “Anaesthesia services (including moderate and deep sedation) are under the direction of one or more qualified individuals”. In the Joint Commission's standards, sedation is described in a separate subsection of the “anaesthesia and surgical care” set of standards, given the risks to patient safety. In section 54.A of its ASC.3 standard, the Joint Commission requires that “Policies and procedures guide the care of patients undergoing moderate and deep sedation”. According to this standard, “sedation, particularly moderate and deep sedation, represents risks for patients and therefore must be administered using clear definitions, policies and procedures. A patient will progress from one level of sedation to another depending to the drugs administered, the route of administration and the dose. Important elements to consider include the patient's ability to maintain protective reflexes, an independent and continuous airway, and the response to physical stimuli or verbal commands.”</p><p id="par0025" class="elsevierStylePara elsevierViewall">According to Monedero et al.,<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">8</span></a> the Declaration of Helsinki,<a class="elsevierStyleCrossRef" href="#bib0110"><span class="elsevierStyleSup">5</span></a> a consensus document jointly drawn up by the European Society of Anaesthesiology and the European Board of Anaesthesiology and presented at the Helsinki European Congress in 2010, “represents the opinion shared in Europe on the feasible and valuable measures that can improve the safety of the surgical patient, and recommends the practical steps that every anaesthesiologist and anaesthesiology service should include in their medical practice, if they have not already done so”. The Declaration makes specific reference to the field of sedation: “All institutions providing sedation to patients must comply with anaesthesiology recognised sedation standards for safe practice”.</p><p id="par0030" class="elsevierStylePara elsevierViewall">In this document, SEDAR has established the basic sedation-related activities in anaesthesiology departments, and calls on healthcare institutions to use it as a basis from drawing up sedation protocols.</p><p id="par0035" class="elsevierStylePara elsevierViewall">We define the different phases of the sedation process in order to establish the basic parameters that must be met when protocolising sedation in each hospital.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Definition of sedation</span><p id="par0040" class="elsevierStylePara elsevierViewall">Sedation consists of administering a drug that will allow the patient to tolerate a diagnostic/therapeutic procedure while maintaining cardiorespiratory function. The impairment/alteration of the level of consciousness (to varying degrees) is a characteristic of this technique.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Pre-sedation evaluation</span><p id="par0045" class="elsevierStylePara elsevierViewall">There is broad consensus among experts on the need to evaluate the patient prior to administering sedation, to obtain specific informed consent, and on the need for prior preparation, including fasting and the management of chronic medication. This pre-sedation evaluation must be performed by the team that is responsible for sedation.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">2</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">The patient's physiological status must be evaluated before administering sedation, since the presence of concomitant diseases can increase the risk of complications during sedation.<a class="elsevierStyleCrossRefs" href="#bib0130"><span class="elsevierStyleSup">9,10</span></a> Therefore, an adequate pre-procedure evaluation will reduce the likelihood of adverse events and the risks inherent to these outcomes. If necessary, additional tests should be requested, depending on the patient's concomitant disease or the results of the endoscopic examination. For this purpose, the guidelines for requesting complementary tests in major ambulatory surgery (MAS) recently approved by the Spanish Society of Anaesthesiology can be used.<a class="elsevierStyleCrossRef" href="#bib0140"><span class="elsevierStyleSup">11</span></a></p><p id="par0055" class="elsevierStylePara elsevierViewall">The pre-anaesthesia evaluation for simple procedures (gastroscopy, colonoscopy – including colorectal cancer screening colonoscopy) can consist of a general health status test, such as the one attached here as Appendix A. If the patient is classified ASA III or IV, or will undergo a lengthy, complex procedures (for example, endoscopic retrograde cholangiopancreatography), the standard anaesthesia workup used in any surgical procedure should be performed.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Informed consent</span><p id="par0060" class="elsevierStylePara elsevierViewall">All patients must sign 2 informed consent forms:<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">•</span><p id="par0065" class="elsevierStylePara elsevierViewall">A form describing the type of diagnostic-therapeutic procedure and the risks involved.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">•</span><p id="par0070" class="elsevierStylePara elsevierViewall">A form describing the type of sedation/general anaesthesia to be administered and the risks involved. The form must clearly state who administers the sedation (clearly specifying whether it is an anaesthesiologist).</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">•</span><p id="par0075" class="elsevierStylePara elsevierViewall">Each hospital must draw up informed consent forms that comply with regional and national regulations.</p></li></ul></p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0020">Levels of sedation</span><p id="par0080" class="elsevierStylePara elsevierViewall">Before starting sedation, the target level for the particular endoscopic procedure must be established.</p><p id="par0085" class="elsevierStylePara elsevierViewall">The depth of sedation will vary, and in this respect SEDAR recommends using the European Society of Anaesthesiology classification.<a class="elsevierStyleCrossRef" href="#bib0145"><span class="elsevierStyleSup">12</span></a><ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">•</span><p id="par0090" class="elsevierStylePara elsevierViewall">Sedation level 1: Fully awake.</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">•</span><p id="par0095" class="elsevierStylePara elsevierViewall">Sedation level 2: Drowsy.</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">•</span><p id="par0100" class="elsevierStylePara elsevierViewall">Sedation level 3: Apparently asleep but rousable by normal speech.</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">•</span><p id="par0105" class="elsevierStylePara elsevierViewall">Sedation level 4: Apparently asleep but responding to a standardised physical stimulus.</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">•</span><p id="par0110" class="elsevierStylePara elsevierViewall">Sedation level 5: Asleep, but not responding to physical stimuli (comatose). Increased risk of respiratory and cardiovascular depression.</p></li></ul></p><p id="par0115" class="elsevierStylePara elsevierViewall">This scale is used in some studies because it is a quick and easy guide to monitoring sedation levels.<a class="elsevierStyleCrossRefs" href="#bib0150"><span class="elsevierStyleSup">13,14</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">We consider it essential to evaluate and continuously monitor the patient's level of clinical sedation, either as a therapeutic objective or as an undesirable effect of the drugs administered. The level of sedation should be monitored continuously and recorded.</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Drugs</span><p id="par0125" class="elsevierStylePara elsevierViewall">A discussion of the wide range of sedative or aesthetic drugs available is beyond the scope of this document. Good understanding of the management and side effects associated with each drug is essential, and the clinician must have the skills needed to resolve any complications that may arise.</p><p id="par0130" class="elsevierStylePara elsevierViewall">However, it is important to mention that only anaesthesiologists may administer propofol, and it must be used as indicated in the package insert<a class="elsevierStyleCrossRef" href="#bib0160"><span class="elsevierStyleSup">15</span></a>: “Propofol (10<span class="elsevierStyleHsp" style=""></span>mg/ml) should be administered only in hospitals or adequately equipped day therapy units by physicians trained in the administration of general anaesthesia or management in an intensive care unit”. This is also endorsed by the Food and Drug Administration,<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">7</span></a> which has issued 2 alerts banning the use of propofol by non-anaesthesiologists. Therefore, use of propofol requires the presence of an anaesthesiologist in the diagnostic and/or therapeutic procedures room.</p><p id="par0135" class="elsevierStylePara elsevierViewall">We also recommend that the use of other analgesics and/or sedatives by other physicians in any context must be comply with professional rules of conduct, and the clinician involved must be prepared to substantiate his or her competence during any civil or criminal proceedings brought for sedation-related injury.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Patient selection</span><p id="par0140" class="elsevierStylePara elsevierViewall">Each hospital should define its patient selection circuit, ensuring that each patient receives an adequate pre-procedure assessment based on their concomitant diseases and the scheduled procedure.</p><p id="par0145" class="elsevierStylePara elsevierViewall">The doctor ordering the procedure is responsible for indicating the potential need for sedation.</p><p id="par0150" class="elsevierStylePara elsevierViewall">We recommend that each hospital draw up a specific sedation care protocol that is managed by the anaesthesia service, but that includes all the departments involved (multidisciplinary) and is approved by the hospital management.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Staff requirements and functions</span><p id="par0155" class="elsevierStylePara elsevierViewall">Patients receiving sedation should be under the care and supervision of trained health professionals. An anaesthesiologist is trained in the administration of sedation, and the hospital's management board should ensure that the anaesthesia service is equipped with the trained clinicians, nurses, and material resources needed to fulfil these responsibilities.</p><p id="par0160" class="elsevierStylePara elsevierViewall">Nurse anaesthesiologists can and should play an important role in providing care and monitoring patients receiving sedation, always under the direct supervision of the attending anaesthesiologist.</p><p id="par0165" class="elsevierStylePara elsevierViewall">SEDAR recommendations for any type of sedation are:<ul class="elsevierStyleList" id="lis0015"><li class="elsevierStyleListItem" id="lsti0045"><span class="elsevierStyleLabel">•</span><p id="par0170" class="elsevierStylePara elsevierViewall">Follow the standards for safe sedation established in the Declaration of Helsinki. This means that anaesthesia departments must supervise all sedation procedures (also established by the Joint Commission).</p></li><li class="elsevierStyleListItem" id="lsti0050"><span class="elsevierStyleLabel">•</span><p id="par0175" class="elsevierStylePara elsevierViewall">Non-anaesthesiologists should only administer sedation up to level 3, since higher levels are associated with an increased risk of complications.<a class="elsevierStyleCrossRef" href="#bib0165"><span class="elsevierStyleSup">16</span></a></p></li><li class="elsevierStyleListItem" id="lsti0055"><span class="elsevierStyleLabel">•</span><p id="par0180" class="elsevierStylePara elsevierViewall">An anaesthesiologist must be available to immediately treat any complications that may arise.</p></li><li class="elsevierStyleListItem" id="lsti0060"><span class="elsevierStyleLabel">•</span><p id="par0185" class="elsevierStylePara elsevierViewall">We strongly recommended that the anaesthesiology service and the service responsible for the procedure should jointly protocolise the drugs and maximum doses to be used (always avoiding propofol).</p></li></ul></p><p id="par0190" class="elsevierStylePara elsevierViewall">As anaesthesiology departments are responsible for organising sedation in all invasive surgical procedures, each hospital must provide sufficient human resources to guarantee patient safety and quality of care by drawing up the protocols required for each case.</p><p id="par0195" class="elsevierStylePara elsevierViewall">Clinicians involved in sedation procedures should avoid all risk practices that compromise patient safety. The most common such practice involves the same clinician performing both the procedure and the sedation.</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Facilities and equipment</span><p id="par0200" class="elsevierStylePara elsevierViewall">Diagnostic and/or therapeutic procedures are usually performed in endoscopy and/or radiology rooms (endoscopic retrograde cholangiopancreatography), although they are occasionally performed in other areas (emergency room, intensive care unit). The rooms where these procedures are performed must have the resources needed to guarantee patient safety:<ul class="elsevierStyleList" id="lis0020"><li class="elsevierStyleListItem" id="lsti0065"><span class="elsevierStyleLabel">-</span><p id="par0205" class="elsevierStylePara elsevierViewall">They must be large enough to accommodate all the necessary human and material resources.</p></li><li class="elsevierStyleListItem" id="lsti0070"><span class="elsevierStyleLabel">-</span><p id="par0210" class="elsevierStylePara elsevierViewall">We recommend providing a table that allows the patient to be placed in a Trendelenburg position.</p></li><li class="elsevierStyleListItem" id="lsti0075"><span class="elsevierStyleLabel">-</span><p id="par0215" class="elsevierStylePara elsevierViewall">It is advisable to have an anaesthetic machine with its corresponding monitoring equipment in each endoscopy room.</p></li><li class="elsevierStyleListItem" id="lsti0080"><span class="elsevierStyleLabel">-</span><p id="par0220" class="elsevierStylePara elsevierViewall">Monitoring should include non-invasive blood pressure, ECG, and blood oxygen, as a minimum.</p></li><li class="elsevierStyleListItem" id="lsti0085"><span class="elsevierStyleLabel">-</span><p id="par0225" class="elsevierStylePara elsevierViewall">It is advisable to provide a capnograph. This is particularly important in high-risk patients undergoing very lengthy procedures.</p></li><li class="elsevierStyleListItem" id="lsti0090"><span class="elsevierStyleLabel">-</span><p id="par0230" class="elsevierStylePara elsevierViewall">It is essential to provide airway management devices (laryngoscope, tracheal tubes, masks, etc.), aspiration systems, intravenous catheters, drips, and a “crash trolley” equipped with the drugs necessary for any type of sedation, and the drugs and equipment necessary for cardiopulmonary resuscitation.</p></li></ul></p></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Post-procedure monitoring</span><p id="par0235" class="elsevierStylePara elsevierViewall">After completion of the procedure, the patient should be transferred to a recovery room, where they can be monitored until transfer to the ward, or until discharge home in ambulatory procedures, according to hospital protocols.</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Documentation requirements</span><p id="par0240" class="elsevierStylePara elsevierViewall">The inter-procedure anaesthesia report, and the post-procedure clinical record should be completed according to the standard protocols in place in each hospital.</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Discharge criteria</span><p id="par0245" class="elsevierStylePara elsevierViewall">Diagnostic/therapeutic procedures involving sedation can be performed on an outpatient or in-patient basis. The criteria for hospital discharge must be correctly protocolised. It is advisable to use a scoring system to determine the appropriate time of hospital discharge (the scales usually used in outpatient surgery are valid<a class="elsevierStyleCrossRef" href="#bib0170"><span class="elsevierStyleSup">17</span></a>).</p></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Resources</span><p id="par0250" class="elsevierStylePara elsevierViewall">Anaesthesiology departments should organise their human and material resources in order to meet the objectives set out in this document. The different regional healthcare authorities and hospital management boards must, for their part, provide all the human or material resources needed to guarantee the efficacy, efficiency, quality and safety targets set out in this document.</p><p id="par0255" class="elsevierStylePara elsevierViewall">These recommendations are, of course, dynamic and may change to keep pace with scientific and technical advances and/or changes in the services provided by each healthcare provider.</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Zero risk sedation project</span><p id="par0260" class="elsevierStylePara elsevierViewall">SEDAR supports the creation of a national programme to reduce the risk of sedation outside the operating room. The second stage will involve developing the content of this programme and the corresponding monitoring indicators.</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Conflicts of interest</span><p id="par0265" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:15 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Definition of sedation" ] 1 => array:2 [ "identificador" => "sec0010" "titulo" => "Pre-sedation evaluation" ] 2 => array:2 [ "identificador" => "sec0015" "titulo" => "Informed consent" ] 3 => array:2 [ "identificador" => "sec0020" "titulo" => "Levels of sedation" ] 4 => array:2 [ "identificador" => "sec0025" "titulo" => "Drugs" ] 5 => array:2 [ "identificador" => "sec0030" "titulo" => "Patient selection" ] 6 => array:2 [ "identificador" => "sec0035" "titulo" => "Staff requirements and functions" ] 7 => array:2 [ "identificador" => "sec0040" "titulo" => "Facilities and equipment" ] 8 => array:2 [ "identificador" => "sec0045" "titulo" => "Post-procedure monitoring" ] 9 => array:2 [ "identificador" => "sec0050" "titulo" => "Documentation requirements" ] 10 => array:2 [ "identificador" => "sec0055" "titulo" => "Discharge criteria" ] 11 => array:2 [ "identificador" => "sec0060" "titulo" => "Resources" ] 12 => array:2 [ "identificador" => "sec0065" "titulo" => "Zero risk sedation project" ] 13 => array:2 [ "identificador" => "sec0070" "titulo" => "Conflicts of interest" ] 14 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2018-06-04" "fechaAceptado" => "2018-06-05" "NotaPie" => array:2 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Cabadas Avion R, Rabanal Llevot JM, Gil de Bernabé MÀ, Guasch Arévalo E, Aldecoa Álvarez-Santullano C, Echevarría Moreno M. Sedaciones en procedimientos diagnósticos y/o terapéuticos: recomendaciones de calidad y seguridad. Rev Esp Anestesiol Reanim. 2018;65:520–524.</p>" ] 1 => array:2 [ "etiqueta" => "☆☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0010">This article is part of the Anaesthesiology and Resuscitation Continuing Medical Education Program. An evaluation of the questions on this article can be made through the Internet by accessing the Education Section of the following web page: <a class="elsevierStyleInterRef" target="_blank" id="intr0005" href="https://www.elsevier.es/redar">https://www.elsevier.es/redar</a></p>" ] ] "apendice" => array:1 [ 0 => array:1 [ "seccion" => array:1 [ 0 => array:4 [ "apendice" => "<p id="par0275" class="elsevierStylePara elsevierViewall">The following is the supplementary data to this article:<elsevierMultimedia ident="upi0005"></elsevierMultimedia></p>" "etiqueta" => "Appendix A" "titulo" => "Supplementary data" "identificador" => "sec0080" ] ] ] ] "multimedia" => array:1 [ 0 => array:5 [ "identificador" => "upi0005" "tipo" => "MULTIMEDIAECOMPONENTE" "mostrarFloat" => false "mostrarDisplay" => true "Ecomponente" => array:2 [ "fichero" => "mmc1.pdf" "ficheroTamanyo" => 237347 ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:17 [ 0 => array:3 [ "identificador" => "bib0090" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Gastrointestinal endoscopy sedation and monitoring practices in Spain: a nationwide survey in the year 2014" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.J. 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