Monitored anesthesia care (MAC) has been increasingly utilized in anesthesia services for diagnostic or therapeutic procedures for various non-surgical and surgical procedures in the last several decades [1]. It is also steadily increasing in demand by many different medical specialties: cardiology for cardioversion, defibrillation, transesophageal echocardiography, pacemaker/defibrillator implantation or removal, cardiac catheterization, and other cardiac monitoring devices; gastroenterology for endoscopic examinations, potential biopsies, and other therapeutic interventions; urology for cystoscopy, etc. [1, 2]. MAC has also been gradually applied for more complex procedures in patients receiving endovascular aortic stent placements, transcatheter aortic valve replacements, and even sophisticated procedures like Mitroclip. The aims of MAC for procedures are to enhance patient comfort and cooperation, maintain airway patency and hemodynamic stability, thus facilitating efficient and safe completion of the scheduled procedures.

Simulation has been extensively used in military and aviation training. In 2003, the Louisiana State University Health Sciences Center developed and successfully implemented a required simulation curriculum, one of the first of its kind in the United States. Since then, this practice has been widely accepted by many other medical schools, both in the United States and abroad. Simulation has been used for teaching medical students and residents, nursing students and practicing nurses, as well as clinical physicians in many fields of patient care. Simulation is one of the tools that can be effectively used to teach sedation to both anesthesiologists and non-anesthesiologists.

Today, there are an increasing number of procedures requiring moderate and deep sedation being performed outside the surgical suite. As a result, qualified non-anesthesia providers are administering varying levels of sedation to patients for a variety of diagnostic, therapeutic, and/or surgical procedures. Practitioners should provide patients with the benefits of sedation and/or analgesia while minimizing the associated risks. To do so, providers should understand the pharmacology of the agents being administered as well as the role of pharmacologic antagonists for opioids and benzodiazepines. Today’s practitioners are equipped with an abundance of versatile sedative agents that can be used alone and in combination. Furthermore, combinations of sedative and analgesics should be administered as appropriate for the procedure being performed and the condition of the patient. Policies and standards regarding administration of sedation and analgesia by non-anesthesia providers are addressed elsewhere in the book. This chapter focuses on the pharmacology of the drugs most used to provide moderate and deep sedation and their available reversal agents.

Modern dentistry has made much progress in pain control and in providing a patient-friendly service, which has expanded the dentist’s ability to perform a wide range of treatments in a pain-free environment. Nevertheless, despite revolutionary new dental techniques, it is well recognized in the dental literature that substantial fear exists concerning seeking dental care. This fear can be so extensive that people from all races and socioeconomic categories can be affected by it in some form.

The administration of anesthetics for sedation during pain management procedures is a challenge to any provider. While minor and interventional procedures are routinely performed in operating theaters, it is increasingly common for these same procedures to be performed in a variety of other settings and even without sedation at all. These sites include remote locations within the hospital, outpatient pain management centers, diagnostic centers, and physician offices.

Intravenous pharmacologic sedation is often chosen for surgical and nonsurgical procedures and is administered by an anesthesiologist, nurse anesthetist, or other trained professional. Sedation is described as a continuum, encompassing minimal, moderate, and deep sedation that can be categorized according to the patient’s level of consciousness (Figure 12.1). This categorization is subjective and the different levels of sedation can be achieved through changes in medication choice and dosage. There exist overlapping zones between levels of sedation. In clinical practice, deep sedation and general anesthesia share many of the same features in terms of patient awareness, lack of responsiveness, and risk of airway compromise.

Certain patient populations requiring sedation for procedures present the clinician with challenging decisions regarding their care and management. Some underlying medical disease states, airway abnormalities, or extremes of age require cautious pre-procedural assessment and planning when sedation is required to minimize the incidence of morbidity or mortality. It should be noted that some of these higher-risk patients should only be sedated by trained anesthesia providers. The following commonly encountered conditions are considered high risk and are associated with a higher rate of complications: old age, obesity, chronic obstructive pulmonary disease, coronary artery disease, and chronic renal failure. This chapter discusses important features of these higher-risk patients and practice management when sedation is required. In all cases, appropriate monitoring, prudent selection and dosing of sedative agents, and careful assessment are important to ensure the best outcome for these higher-risk patients.

Perioperative anesthesia care for the patients undergoing ophthalmologic procedures is unique and sometimes challenging. Many of the ophthalmologic procedures can often be done with sedation/monitored anesthesia care (MAC) [1]. Intravenous sedatives combined with topical/local/regional anesthesia during eye surgery can alleviate patients’ pain, fear, anxiety, thus improving outcomes [2]. In this chapter we review the current practices and trends in anesthesia service with respect to MAC for ophthalmologic procedures with topical/local/regional anesthesia [1, 2, 3]. The nerve blocks performed for eye surgery determine, to some extent, the techniques and requirement of the sedation level by the anesthesia service. And the traditions of surgery teams and hospitals also affect the choice of sedation technique. The evolvement of surgical techniques seems to facilitate the trend that sedation is more and more used in the eye surgical procedures. Anesthesia care options are also based on surgeons’ skill and anesthesia providers’ comfort level, and the patients’ expectations and demands. Regardless, patients’ safety and perioperative care quality are the key determinants [1, 3, 4].

Neuropathic pain (NP) is a subtype of chronic pain syndrome defined by International Association of the Study of Pain (IASP) as a “pain caused by a lesion or disease of the somatosensory system.” Consequence of CNS or PNS lesions are activities generated in the somatosensory system without peripheral afferent stimulation. The pathophysiology of the somatosensory system is injury causing complex ectopic signaling between neuronal pathways. There are several types of antineuropathic medications that are currently utilized to treat this subtype of pain, including gabapentin, pregabalin, and duloxetine, amongst others.

Complex regional pain syndrome (CRPS) is a long-term pain condition that commonly affects the extremities and is associated with increased sensitivity to pain and touch. CRPS is classified into two types: CRPS-I and CRPS-II. The former occurs when there is no apparent nerve damage, whereas the latter is linked to known nerve damage. Psychological factors may play a role in the development of CRPS, with studies indicating that individuals with a history of depression and PTSD are at a higher risk of developing this condition. There are various treatment options available for CRPS, including physical therapy, medication, and interventional techniques such as nerve blocks and transcranial stimulation. However, larger and more comprehensive studies are needed to assess the effectiveness of these therapies. While NSAIDs have not been found to be effective in treating CRPS, sympathetic nerve blocks are commonly used but have mixed results. Finally, spinal cord stimulation (SCS) is a surgical treatment option that is recommended after conservative treatments have failed to produce significant symptom relief over several months.

Vertebral compression fractures are characterized by a break in the vertebrae comprising the spinal column, most likely on the anterior side and most commonly occurring when the osseous matrix has been weakened. The high morbidity and mortality associated with VCFs have given rise to an estimated annual medical cost of $13.8 billion in the United States alone. Prevention includes screening at-risk individuals’ bone marrow density and augmenting individuals with decreased bone density with bisphosphonates or RANK ligand inhibitors. The management of VCFs has been heavily debated with arguments for both conservative management and invasive augmentation through vertebroplasty and kyphoplasty. Invasive management should be considered in patients with uncontrolled pain, significant vertebral misalignment, and height deformities.

Over-the-counter analgesics, including NSAIDs and acetaminophen, are often the first-line medication for nonspecific low back pain (LBP). Current guidelines recommend their use as the initial treatment for LBP. In addition to these medications, antidepressants, muscle relaxants, and opioids can also be effective treatments for chronic LBP. Acetaminophen, which is also known as paracetamol internationally, is commonly used for its pain-relieving and fever-reducing properties. Although the mechanism of action is not fully elucidated, acetaminophen is known to inhibit cyclooxygenase (COX-1 and COX-2), resulting in inhibition of prostaglandin synthesis. It works by lowering body temperature during fever and inhibiting the activity of COX-3, resulting in analgesic and antipyretic effects. Para-acetyl-aminophenol (acetaminophen) acts as a reducing agent and inactivates the oxidized cyclooxygenase enzyme. Nonsteroidal anti-inflammatory drugs (NSAIDs), on the other hand, are more effective for LBP due to their superior anti-inflammatory effects. They are often compared to acetaminophen or used in combination for LBP treatment.