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  1. Procedural sedation. Sedation and analgesia comprise a continuum of states ranging from minimal sedation (anxiolysis) through GA. Specially trained nurses provide sedation for the majority of procedures outside of the operating room for patients deemed ASA I and ASA II. Procedural sedation encompasses moderate sedation/analgesia, also known as conscious sedation (CS), and deep sedation. CS is defined as “a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained” (American Society of Anesthesiologists. Continuum of depth of sedation definition of GA and levels of sedation/analgesia. October 23, 2019). Common medications include midazolam and fentanyl. Deep sedation occurs when a deeper level of consciousness is reached. Patients can be aroused with repeated painful stimuli. Airway manipulation may be needed, and unintended GA may occur. Deep sedation requires special privileges and providers in airway management. The American Society of Anesthesiologists (ASA) and Joint Commission on Accreditation of Healthcare Organizations and state agencies (licensing boards) have a set of guidelines for provisions of nonphysicians to deliver conscious and deep sedation.
  2. MAC is physician-directed anesthesia service performed by a qualified anesthesia provider, for a diagnostic or therapeutic procedure. It does not describe the continuum of depth of sedation. It provides deeper levels of analgesia and sedation than moderate sedation and is beneficial for certain patients and procedures. Advantages include preservation of hemodynamics over GA. Ventilation may be affected, and rescue airway maneuvers may need to be performed. Inadvertent conversion to GA may occur, and equipment should be available. Although a “deep MAC” is appropriate for some patients, the risks/benefits have to be carefully weighed. Various elements factor into this decision including procedure, patient comorbidities, and clinical experience. MAC is associated with fewer hemodynamic perturbations and may be a better choice for a subset of patients with severely compromised cardiovascular function. For high-risk aspiration patients and/or procedures MAC can be performed after careful consideration. Anxiolytic and analgesic techniques if employed should focus on preserving airway reflexes.
  3. GA is used when a secured airway is necessary, when there is a need for a patient to be still (eg, long complex procedures), and when the procedures involve painful portions. The cardiopulmonary risk/benefits of GA in high-risk patients undergoing minimally invasive procedures have to be carefully considered on a case-by-case basis.
  4. Ultrasound-guided peripheral nerve blocks (PNBs) may be used as the primary anesthetic or as an adjunct for procedural and/or postprocedural analgesia.
    1. Brachial plexus nerve blocks are options for specific dysfunctional arteriovenous access procedures in patients with ESRD.
    2. Paravertebral nerve block (PVB) may be beneficial for procedures of the liver and kidney, specifically transhepatic biliary drains, liver ablations and embolizations, and renal ablations. Bilateral T7 to T10 PVB can be beneficial for liver lesions (as the liver is innervated bilaterally), whereas a single PVB suffices for renal procedures.
  5. High-frequency jet ventilation (HFJV) may be utilized to achieve a quiescent field superior to GA for intrathoracic or peridiaphragmatic percutaneous procedures such a pulmonary vein isolation, basilar pulmonary ablations and embolizations, or ablations of liver dome lesions.
  6. Selective lung isolation utilizing a double lumen tube or bronchial blockers has been used to achieve a static lung. In addition, these techniques are useful for lung protection of the nonaffected lung from hemorrhage for procedures such as bronchial artery embolizations of patients with hemoptysis and lung ablation of large tumors. A bronchoscope should be available to verify positioning.
  7. Enhanced recovery after procedure (ERAP) is an extension of ERAS and applied in NORA for painful procedures. Application of evidence-based opioid-sparing techniques can decrease post-procedural pain and opioid requirements. Preprocedural analgesics such as acetaminophen, celecoxib, and gabapentin can be beneficial. Administration of high-dose dexamethasone and antiemetics to avoid post-procedure ablation/embolization phenomena. This is most beneficial in the interventional oncology patient population undergoing embolizations and ablations and endoscopic retrograde cholangiopancreatography (ERCP).