Twilight Sleep: Symptoms, Causes, Treatment

Analgesia (synonyms: analgosedation, sedoanalgesia) is the drug-induced elimination of pain (analgesia) with simultaneous sedation or dulling of consciousness. The procedure is also commonly referred to as “painless twilight sleep“. In contrast to classical anesthesia, the patient breathes by himself (spontaneous breathing) and responds to external stimuli.

Indications (areas of application)

Contraindications

  • Aspiration hazard (ingestion of material (e.g., saliva, fluid) into the respiratory tract).
  • Critical airway
  • Respiratory insufficiency (inadequate respiratory mechanics resulting in disruption of gas exchange in the lungs).
  • Severely impaired cardiovascular function (cardiovascular function).
  • Increased intracranial (“inside the skull”) pressure with nausea and/or clouding of consciousness
  • Contraindications to analgesics (pain medications), narcotics (medications used for anesthesia), and sedatives (tranquilizers) being used

Before analgesia

Before analgesia, food abstinence must be observed. A grace period (abstinence) of six hours after solid food and two hours after clear liquids is sufficient for this purpose. Prior to the procedure/examination, the physician must conduct an educational interview with the patient to clarify questions, obtain medical history, and inform the patient of risks and complications.The patient is given venous access, i.e., a catheter through which medication and – if necessary – infusions can be administered into the vein (and thus into the blood). The medication, e.g. the hypnotic (sleeping pill) propofol, is also injected via this access.Immediately before analgosedation, the physician asks about the last food intake and checks the oral and dental status (also for forensic traceability in the event of damage in the event of an intubation/insertion of a tube (ventilation tube) into the trachea required in an emergency).At the start of analgosedation, medical monitoring (supervision) begins, This consists of: Electrocardiogram (ECG), pulse oximetry (measurement of pulse and oxygen content of the blood) and blood pressure measurement (if necessary invasive arterial blood pressure measurement in high-risk patients).Requirements for workplace equipment and monitoring:

In addition to the endoscopist or surgeon, qualified personnel must be present. In the German guideline on sedation and analgesia (analgesia) of patients by non-anesthesiologists is the following wording on staffing: a second, in the monitoring of patients who have received sedatives and / or analgesics specially trained, qualified person has to reliably perform the task of patient monitoring. Up to moderate levels of analgesia, this monitoring may be performed by non-physician staff qualified to do so as part of the delegation process. The person monitoring sedation may not perform any other duties during this time.

The procedure

Analgesia is usually performed with the aid of parenteral (“bypassing the intestine”) anesthetics (drugs that cause a reversible reduction or elimination of pain sensation) in combination with oral or parenteral sedatives (tranquilizers). Benzodiazepines (midazolam and diazepam) with or without opiates (fentanyl and morphine) have long been used for this purpose. However, the short-acting hypnotic propofol (“propofol short-acting anesthesia“) is increasingly being used worldwide for endoscopies (“mirror procedures”). It has a rapid onset of action and a short duration of action without a clinically relevant analgesic effect (“analgesic effect”).It is particularly suitable for deep sedation and leads to a pleasant falling asleep and waking up. For painful procedures, it is combined with either a local anesthetic (local anesthetic) or a systemically active analgesic (painkiller, e.g., an opioid). Ketamine can also be used as an analgesic. This can be combined with propofol or midazolam.

After analgesia

After the procedure, the phase of postoperative observation of the patient begins, if necessary in a separate recovery room.Before discharging the patient, the attending physician will satisfy himself that the patient is again awake and oriented before handing him over to an escort.The patient should arrange to go home before the procedure by arranging for an escort to pick him up and take him home.Caution. After analgosedation, for legal reasons, active participation in road traffic (car, motorcycle, bicycle) is strictly prohibited on the day of the examination.

Possible complications

  • Benzodiazepines: hypersalivation (synonyms: sialorrhea, sialorrhea; ptyalism; increased salivation) (sometimes); ataxia (movement disorder) and agitation (rarely)
  • Ketamine: apnea, airway obstruction (common with repetitive doses/repeat doses and overdose), hypersalivation (common), restless awakening, nightmares, hallucinations (common), nystagmus/uncontrollable rhythmic movements of the eyes (common), laryngospasm (vocal spasm) (rare), nausea (nausea), and vomiting
  • Propofol: Hypotension (low blood pressure), respiratory depression to apnea.
  • Opioids: respiratory depression
  • Propofol infusion syndrome (PRIS); symptoms:

    In most reported PRIS cases, propofol was used at a dose > 5 mg/kg/h and for a period of more than 48 hours; in isolated cases, PRIS has been described even after a short infusion period with moderate doses (> 4 mg/kg/h); lethality (mortality) averaged 51% (few cases)

  • Minorkomplications (0.3%).
    • Paradoxical reaction
    • Respiratory depression (sO2 < 90% over 10 sec; in case of overdose).
    • Hypotension (> 25 %)
    • Drop in heart rate (< 20%)
    • Other (laryngospasm, allergic reaction, aspiration, vomiting, seizure, extravasation (injection or infusion fluid enters tissue adjacent to punctured vessel), cardiac arrhythmias, patient fall, dissociative stupor/complete loss of activity with otherwise awake consciousness)
  • Major complications (0.01%; case rate: 350,000 sedations): admission to ICU, need for intubation, resuscitation; death (0.004%)

Further notes

  • Pain sensation during venous cannulation (placement of a cannula/hollow needle) and propofol application (administration of propofol) provides an indication of the expected postoperative pain intensity.