Office based-Anesthesia
Download as PPTX, PDF14 likes1,939 views
This document discusses office-based anesthesia. It notes that over 25% of surgeries are now performed in offices rather than hospitals. Office-based anesthesia, also called non-operating room anesthesia or ambulatory anesthesia, involves anesthesia performed in an outpatient setting like a doctor's office rather than an accredited surgery center or hospital. While standards of care are the same, office settings present unique challenges regarding safety, oversight, documentation, and experience level. The document outlines considerations for patient selection, appropriate procedures, personnel requirements, equipment needs, and pre-operative fasting guidelines for office-based anesthesia.
![Patient Selection
Country, year Fasting requirements at time of induction Comments
American Society of
Anesthesiologists, 2017[1]
2 hours clear liquids, not including alcohol
4 hours breast milk
6 hours nonhuman milk, infant formula, light meal
8 hours or more fried or fatty food or meat
Healthy patients, elective surgery, pregnant
patients not in labor
Light meal defined as toast or cereal with clear
liquid
European Society of
Anesthesiology, 2011[2]
2 hours clear liquids
4 hours breast milk
6 hours milk, infant formula, solid food
Chewing gum and sucking hard candy allowed up until time of induction
Applies to patients with obesity, diabetes, GERD,
nonlaboring pregnant patients
Encourages oral fluid up to 2 hours prior to
induction
Canadian Anesthesiologists'
Society, 2014[3]
2 hours clear liquids
4 hours breast milk
6 hours light meal, infant formula, and nonhuman milk
8 hours meat, fried, or fatty food
Association of Anaesthetists in
Great Britain and Ireland, 2010[4]
2 hours clear liquids
4 hours breast milk
6 hours solid food, infant formula, and cow's milk
Gum chewing should be treated as clear
Scandinavian Society of
Anaesthesiology and Intensive
Care Medicine, 2005[5]
2 hours clear liquids
4 hours breast milk and infant formula
6 hours solid food and cow's milk
2 hours chewing gum and any form of tobacco
Up to 1 hour prior to induction, 150 mL water
2 hours for preoperative carbohydrate drinks
intended for preoperative nutrition
German Society of
Anesthesiology and Intensive
Care, 2004[6]
2 hours clear liquids
4 hours breast milk and infant formula
6 hours meal
Australian and New Zealand
College of Anaesthetists, 2016[7]
2 hours clear liquids, all ages
3 hours breast milk for infants <6 months of age
4 hours formula for infants <6 months of age
6 hours breast milk, formula, limited solid food for children >6 months of
age and adults
Encourages oral fluid up to 2 hours prior to
induction
Up to 200 mL clear liquids per hour up until two
hours prior to induction for adults
Fasting guidelines of international anesthesia societies](https://image.slidesharecdn.com/office-basedanesthesia-180731153823/85/Office-based-Anesthesia-15-320.jpg)
![Requirements
Monitors
Noninvasive blood pressure with an assortment of cuff sizes
Heart rate/ECG
Pulse oximeter
Temperature
Capnography
Airway supplies
Nasal cannulae
Oral airways
Facemasks
Self-inflating bag-mask ventilation device
Laryngoscopes with blades in multiple sizes and styles (eg, Macintosh and Miller)
Endotracheal tubes in multiple sizes
Stylettes
Supraglottic airway devices (eg, LMA) in multiple sizes
Emergency airway equipment (supraglottic airway devices [eg, LMAs] in multiple sizes, videolaryngoscope [eg, Glidescope or CMAC], cricothyrotomy kit)
Suction catheters and suction equipment
Cardiac defibrillator
Emergency drugs
ACLS drugs (refer to UpToDate topics on ACLS)
Dantrolene and malignant hyperthermia supplies (refer to UpToDate topics on malignant hyperthermia)
20% lipid emulsion for local anesthetic systemic toxicity
Anesthetic drugs
Vascular cannulation equipment](https://image.slidesharecdn.com/office-basedanesthesia-180731153823/85/Office-based-Anesthesia-18-320.jpg)
![Anesthesia type (Selection of anesthetic agents)
Goals —short duration of action, absence of postoperative nausea and vomiting (PONV), and cost-
effectiveness.
Short duration — To facilitate rapid discharge after the procedure (ideally, one hour or less), only short-
acting agents are used to produce either sedation (eg, midazolam, propofol, ketamine,
or dexmedetomidine) or general anesthesia (eg, propofol, ketamine, or
dexmedetomidine and/or inhalational agents [eg, sevoflurane or desflurane]). Similarly, short-acting
opioids are used to provide analgesia (eg, fentanyl or remifentanil).
Nitrous oxide increases the risk of PONV, which has limited its use in patients susceptible to this
complication. However, in patients without risk factors for PONV, many anesthesiologists use nitrous
oxide in combination with intravenous agents or with a volatile anesthetic agent. Nitrous oxide reduces
the doses of other agents and may reduce costs and expedite emergence from anesthesia because of
its rapid offset.
Avoidance of postoperative nausea and vomiting (PONV) — Major consideration in any ambulatory
surgery setting. Incidence of PONV after outpatient surgery may be as high as 50 %, use a multimodal
approach to both prophylaxis and treatment. In patients at risk for PONV, employ a variety of antiemetic
drugs targeting different receptors, as well as anesthetic and analgesic techniques that do not cause
PONV. (see next page)
Cost-effectiveness — Cost is a valid but lesser concern in selection of anesthetics. Side effects such as
PONV and delayed recovery might negate cost advantages for certain agents and techniques
(eg, nitrous oxide)](https://image.slidesharecdn.com/office-basedanesthesia-180731153823/85/Office-based-Anesthesia-33-320.jpg)
Office based-Anesthesia
- 2. Definitions More than 25% of all surgical procedures today are being performed in offices rather than hospitals and other surgery centers Subset of both Non-Operating Room Anesthesia (NORA) and Ambulatory anesthesia An anesthetic that is performed in an outpatient venue such as an ofice or procedure room that is not accredited as either an Ambulatory Surgery Center (ASC) or as a hospital Understanding that the standards of anesthesia care and patient monitoring are the same regardless of location Terms • Non-Operating Room Anesthesia (NORA) • Ambulatory anesthesia • Anesthesia at remote location • Outpatient anesthesia • Office-based anesthesia (OBA)
- 3. Pros and Cons Pros Cons patient and surgeon convenience safety concerns cost containment little to no oversight regarding the certification/qualification greater personal attention and privacy to Patients Lack of documentation, general policies and procedures, and the reporting of adverse outcomes greater ease of scheduling for Surgeons Inadequate preoperative or postoperative nursing personnel consistency Lack of experience Lower rates nosocomial infection Today an estimated 1 in every 4 elective surgical procedures is performed in the officebased setting, accounting for over 10 million cases annually
- 4. Characteristic 1. Location: procedure never takes place in a typical operating suite 2. Operator: for the most part (although not always) the operator performing the procedure is not a surgeon but rather a medical interventionalist or proceduralist 3. Relative novelty: procedures and technologies used may be novel in one way or another All of above => • Scheduling inconsistencies • Ad hoc requests • Inadequate physical plant • Poor communication • Resource limitations can obstruct • Expeditious resolution Anesthesia is a discipline that requires the constant vigilance of well trained and experienced providers; safety derives from high-level dedicated care, teamwork,and rapid availability of physicians, especially during medical crises
- 5. Conceptual Model Development of OBA
- 6. Procedures Levels I-III refer to the complexity of surgeries Level III: Surgical procedures that require deep sedation/analgesia, general anesthesia or major conduction blocks and support of vital bodily functions Level II: Minor or major surgical procedures performed in conjunction with oral, parenteral or intravenous sedation or under analgesic or dissociative drugs Level I: Minor surgical procedures performed under topical, local or infiltration block anesthesia not involving drug-induced alteration of consciousness, other than minimal sedation utilizing preoperative oral anxiolytic medications
- 7. Procedures Services Personnel Required Equipment Required Level I 2 personnel including: a physician certified in AHA- approved BCLS. Bag mask valve Oxygen AED Pre-measured doses of certain drugs Level II 2 personnel including: a physician certified in AHA- approved ACLS or PALS and another person certified in AHA-approved BCLS. One of the above persons must attend the patient until discharge. Crash cart equipped to carry out ACLS protocols Level 1 equipment IV equipment Pulse oximeter EKG monitor Level III 2 personnel including: a physician certified in AHA- approved ACLS or PALS and another person certified in AHA-approved BCLS. One of the above persons must monitor the during the procedure. One of the above persons must attend the patient until discharge. Crash cart equipped to carry out ACLS protocols Level 1 equipment IV equipment Pulse oximeter EKG monitor
- 8. Procedures PROCEDURE SELECTION -Can patient safely undergo surgery in a given office-based setting? -Will the patient be able to recover from the procedure and be discharged within a reasonable timeframe? Inappropriate surgical procedures: -Blood loss that may require transfusion -Major fluid shifts -Moderate to severe postoperative pain requiring opioids Examples: • gastrointestinal endoscopy • Liposuction • aesthetic facial and breast surgery • oral and maxillofacial surgery • orthopedic surgery (including podiatry procedures) • gynecologic and genitourinary surgery • Ophthalmologic surgery • otolaryngology procedures
- 9. Procedures
- 10. Patient Selection Preoperative History and Physical Examination within 30 days prior to the procedure laboratory as indicated any medically indicated specialist consultation(s) Ideal patient for an office-based procedure has an ASA physical status of 1 or 2 ASA physical status 3 patients undergo an office-based procedure only after an anesthesia consultation and only have an office-based procedure performed under local anesthesia without sedation Features for evaluation: • Abnormalities of major organ systems, and stability and optimization of any medical illness. • Difficult airway, morbid obesity and/or obstructive sleep apnea. • Previous adverse experience with anesthesia and surgery, including malignant hyperthermia. • Current medications and drug allergies, including latex allergy. • Time and nature of the last oral intake. • History of alcohol or substance use or abuse. • Presence of a vested adult who assumes responsibility specifically for accompanying the patient from the office.
- 11. Patient Selection Function Examples 1. Identify absolute contraindications to ambulatory surgery Inability to identify a responsible caregiver other than for minor surgery with full and rapid recovery anticipated; severe uncorrectable cardiovascular disease 2. Identify need for optimization Patient requires further investigation, therapeutic modification, or intervention to improve functional status; identify a friend, relative or neighbor to act as caregiver 3. Highlight issues for anesthesiologist or other staff (which may alter management but do not preclude ambulatory surgery) Potentially difficult intubation necessitating advanced airway management skills; malignant hyperpyrexia– susceptible patient requiring trigger-free anesthetic; latex allergy; obese patient requiring operating table/trolley with high weight limit and extra width 4. Provide patient information Written information on preoperative preparation, medication management, preoperative fasting, etc. THE FOUR KEY FUNCTIONS OF A PREOPERATIVE ASSESSMENT AND PREPARATION SERVICE FOR AMBULATORY SURGERY
- 12. Patient Selection ASA Physical status Functional status Examples Risk status 1 Healthy, no disease outside surgical process Can walk up one flight of stairs or two level city blocks without distress Little or no anxiety Little or no risk Green flag for treatment 2 Mild to moderate systemic disease, medically well controlled, with no functional limitation Can walk up one flight of stairs or two level city blocks but will have to stop after completion of the exercise because of distress ASA I with extreme anxiety and fear, a respiratory condition, pregnancy or active allergies Well controlled disease states including diabetes, hypertension, obesity, epilepsy, asthma or thyroid conditions Minimal risk Yellow flag for treatment 3 Severe systemic disease that results in functional limitation Can walk up one flight of stairs or two level city blocks but will have to stop enroute because of distress History of angina pectoris, MI, CVA; HF >6 months ago, COPD, diabetes with vascular complications, poorly controlled HTN, morbid obesity Yellow flag for treatment 4 Severe incapacitating disease process that is a constant threat to life Unable to walk up one flight of stairs or two level city blocks Distress is present even at rest History of unstable angina, MI or CVA within last six months; severe HF, severe COPD; uncontrolled diabetes, HTN, epilepsy or thyroid condition Advanced pulmonary, renal or hepatic dysfunction The risk may be too great for elective surgical procedure Medical consultation needed for emergency treatment Red flag for treatment 5 Moribund patient not expected to survive 24 hours without an operation Ruptured abdominal aneurysm, pulmonary embolus, head injury with increased intracranial pressure Elective treatment is contraindicated; however, emergency surgery may be necessary Red flag for treatment 6 A declared brain-dead patient being maintained for harvesting of organs E Suffix to indicate emergency surgery for any class Any patient in whom an emergency operation is required Otherwise healthy young woman requiring D&C for persistent vaginal bleeding
- 13. Patient Selection Poor Candidates • Severe obesity • Severe obstructive sleep apnea (OSA) syndrome • Potentially difficult airway • Aspiration risk • Possible anaphylaxis risk (eg, significant drug or latex allergies, mast cell activation syndrome) • Possible malignant hyperthermia risk • Previous adverse outcomes after anesthesia • Severe chronic obstructive pulmonary disease • Seizure disorder • Myocardial infarction within the last six months • Stroke within the last three months • Abnormal bleeding or clotting tendency, including risk for deep vein thrombosis • Sickle cell disease • Poorly controlled diabetes • Poorly controlled hypertension • Poorly controlled psychiatric problems • History of substance abuse
- 15. Patient Selection Country, year Fasting requirements at time of induction Comments American Society of Anesthesiologists, 2017[1] 2 hours clear liquids, not including alcohol 4 hours breast milk 6 hours nonhuman milk, infant formula, light meal 8 hours or more fried or fatty food or meat Healthy patients, elective surgery, pregnant patients not in labor Light meal defined as toast or cereal with clear liquid European Society of Anesthesiology, 2011[2] 2 hours clear liquids 4 hours breast milk 6 hours milk, infant formula, solid food Chewing gum and sucking hard candy allowed up until time of induction Applies to patients with obesity, diabetes, GERD, nonlaboring pregnant patients Encourages oral fluid up to 2 hours prior to induction Canadian Anesthesiologists' Society, 2014[3] 2 hours clear liquids 4 hours breast milk 6 hours light meal, infant formula, and nonhuman milk 8 hours meat, fried, or fatty food Association of Anaesthetists in Great Britain and Ireland, 2010[4] 2 hours clear liquids 4 hours breast milk 6 hours solid food, infant formula, and cow's milk Gum chewing should be treated as clear Scandinavian Society of Anaesthesiology and Intensive Care Medicine, 2005[5] 2 hours clear liquids 4 hours breast milk and infant formula 6 hours solid food and cow's milk 2 hours chewing gum and any form of tobacco Up to 1 hour prior to induction, 150 mL water 2 hours for preoperative carbohydrate drinks intended for preoperative nutrition German Society of Anesthesiology and Intensive Care, 2004[6] 2 hours clear liquids 4 hours breast milk and infant formula 6 hours meal Australian and New Zealand College of Anaesthetists, 2016[7] 2 hours clear liquids, all ages 3 hours breast milk for infants <6 months of age 4 hours formula for infants <6 months of age 6 hours breast milk, formula, limited solid food for children >6 months of age and adults Encourages oral fluid up to 2 hours prior to induction Up to 200 mL clear liquids per hour up until two hours prior to induction for adults Fasting guidelines of international anesthesia societies
- 16. ASA Guidelines for Non-O.R. Anesthetizing Locations Sufficient space for equipment/personnel to allow expeditious access to pt, machine, monitoring equipment Reliable O2 source and back-up supply Adequate/reliable suction Adequate/reliable scavenging system for inhalation Anesthesia Self-inflating resuscitator bag for PPV Monitoring equipment to adhere to ASA standards Adequate anesthesia drugs, supplies, equipment for intended anesthesia care Sufficient electrical outlets, including clearly labeled outlets to backup emergency power, isolated with ground fault circuit interrupters if in a “wet location” Adequate lighting and backup illumination available Adequate trained staff to support the anesthesiologist Immediately available and reliable means of 2-way communication to request assistance. Emergency drugs, cart with defibrillator and other equipment for CPR Appropriate post-anesthesia management Statement on Nonoperating Room Anesthetizing Locations (2013)
- 17. RCoA recommendations(2011) • Familiarity with all remote areas • Standardized anesthetic equipments • Mandatory monitoring should be as for any location. • Availabilty of fully trained assistant • Ensuring patients safety • Expert recovery care • Accurate documentation of anesthetic procedure • Wherever poosible anesthesia provided by expert consultants
- 18. Requirements Monitors Noninvasive blood pressure with an assortment of cuff sizes Heart rate/ECG Pulse oximeter Temperature Capnography Airway supplies Nasal cannulae Oral airways Facemasks Self-inflating bag-mask ventilation device Laryngoscopes with blades in multiple sizes and styles (eg, Macintosh and Miller) Endotracheal tubes in multiple sizes Stylettes Supraglottic airway devices (eg, LMA) in multiple sizes Emergency airway equipment (supraglottic airway devices [eg, LMAs] in multiple sizes, videolaryngoscope [eg, Glidescope or CMAC], cricothyrotomy kit) Suction catheters and suction equipment Cardiac defibrillator Emergency drugs ACLS drugs (refer to UpToDate topics on ACLS) Dantrolene and malignant hyperthermia supplies (refer to UpToDate topics on malignant hyperthermia) 20% lipid emulsion for local anesthetic systemic toxicity Anesthetic drugs Vascular cannulation equipment
- 19. Requirements (ASA recommendation) At a minimum, all facilities should have a reliable source of oxygen, suction, resuscitation equipment and emergency drugs. Specific reference is made to the ASA “Statement on Nonoperating Room Anesthetizing Locations.” There should be sufficient space to accommodate all necessary equipment and personnel and to allow for expeditious access to the patient, anesthesia machine (when present) and all monitoring equipment. All equipment should be maintained, tested and inspected according to the manufacturer’s specifications. Back-up power sufficient to ensure patient protection in the event of an emergency should be available. In any location in which anesthesia is administered, there should be appropriate anesthesia apparatus and equipment which allow monitoring consistent with ASA “Standards for Basic Anesthetic Monitoring” and documentation of regular preventive maintenance as recommended by the manufacturer. In an office where anesthesia services are to be provided to infants and children, the required equipment, medication and resuscitative capabilities should be appropriately sized for a pediatric population.
- 20. Requirements (Basic Monitoring) Primary physiologic process/parameter targeted Monitoring equipment Principle Derived information Additional function Oxygenation Inspired gas O2content O2 analyzer (with a low-limit alarm in use) Paramagnetic sensor, fuel (galvanic) cell, polarographic (Clark) electrode, mass spectroscopy, or Raman scattering Inspired/expired O2 concentration when placed downstream from fresh flow control valves A low-level alarm is automatically activated by turning on the anesthesia machine Blood oxygenation Pulse oximeter The Beer-Lambert law applied to tissues and pulsatile blood flow. The relative absorbency at wavelengths of 660 and 940 nm is used to estimate saturation, which is derived from the ratio of oxyhemoglobin to the sum of oxyhemoglobin plus deoxyhemoglobin. Hemoglobin saturation, pulse rate, relative pulse amplitude displayed on plethysmography waveform Continuous evaluation of circulation, variable pitch pulse tone, and audible low-threshold alarm Ventilation Exhaled CO2 Capnograph CO2 molecules absorb infrared radiation at 4.26 micrometers, proportionate to the CO2 concentration present in the breath sample ETCO2, inspired CO2, diagnostic waveforms, respiratory rate, apnea detection Instantaneous information about: -Perfusion (how effectively CO2 is being transported through the vascular system) -Metabolism (how effectively CO2is being produced by cellular metabolism) -Confirmation of tracheal tube placement after intubation Integrity of ventilation system during mechanical ventilation Disconnection alarm Detects the cyclical changes in airway pressure in the normal range Alarms if a significant decrease in rate or pressure occurs Alarms if high pressures are sensed Pulmonary mechanics (volume, flow, pressure) Pulmonary flow and pressure sensors Volume of gas proportional to a drum movement, changes in differential pressure (near the Y-connector) or in electrical resistance (hot wire housed in a monitor or ventilator) Inspired and expired volume, flow, and airway pressure Pressure volume and flow volume loops Circulation Cardiac activity ECG The ECG monitor detects, amplifies, displays, and records the ECG signal. Heart rate and rhythm ST segment depression/elevation and trend over time, with an audible alarm warning of significant arrhythmias or asystole Arterial BP Noninvasive BP monitor Oscillometric devices automatically inflate and deflate the cuff, and have electronic pressure sensors that record the pressure oscillations of the arteries. The pressure at which maximal oscillations occur as the cuff is deflated corresponds with MAP. Proprietary algorithms are used to calculate systolic and diastolic BP. Arterial BP Indicator of organ perfusion Temperature Temperature Devices with a semiconductor, electrical resistance decreases as Core or peripheral A greater than 2°C core-to-periphery
- 21. Requirements Drugs 1. Epinephrine 2. Atropine, glycopyrrolate 3. Antihistamines 4. Hydrocortisone 5. Ephedrine 6. Vasopressors (norepinephrine, phenylephrine, vasopressin, dopamine) 7. Calcium chloride or gluconate 8. Glucose 9. Naloxone 10. Flumazenil (Romazicon) 11. Antiemetics 12. Sodium bicarbonate 13. Lidocaine 14. Adenosine 15. Magnesium sulfate 16. Digoxin 17. Furosemide 18. Potassium chloride 19. Heparin sodium 20. Aspirin 21. Amiodarone 22. Verapamil 23. Procainamide 24. Nitroglycerin 25. Esmolol 26. Labetolol 27. A minimum of 20 ampules of dantrolene sodium readily available
- 22. Safety Two literature reviews : Adverse incidents occurred in 0.05 percent and deaths in 0.0017 percent of office-based surgeries Office facility resources: >> Facilities should comply with all applicable federal, state and local laws, codes and regulations pertaining to fire prevention, building construction and occupancy, accommodations for the disabled, occupational safety and health, and disposal of medical waste and hazardous waste >> Should have a Medical Director or Governing Body for stablishing policy and being responsible >> Ideally, these procedures should be performed in an accredited facility >> Anesthesiologist should participate in ongoing continuous quality improvement and risk management activities Anesthetic techniques: >> Conscious sedation, deep sedation, general anesthesia, or local anesthesia were all safe options for oral and maxillofacial surgery in an office setting Regulation: >> Paucity of guidance and regulation implies additional responsibility for anesthesiologists practicing in office-based settings
- 23. Safety Major factors that contribute to OBA safety include those related to: 1. Procedure and/or surgery selection 2. Patient Selection 3. Facility Preparedness 4. Use of Checklists 5. Provider Education 6. Accreditation
- 24. Safety (Accreditation) 1. Physical layout of the office 2. Environmental safety/infection control 3. Patient and personnel records 4. Surgeon qualification a. Training b. Local hospital privileges (surgical and admission) 5. Office administration 6. Anesthesiologist requirements 7. Staffing intraoperatively and postoperatively 8. Monitoring capabilities both intraoperatively and postoperatively 9. Ancillary care 10. Equipment 11. Drugs (emergency, controlled substances, routine medications) 12. BLS, ACLS/PALS certification 13. Temperature 14. Neuromuscular functioning 15. Patient positioning 16. Pre- and postanesthesia care/documentation 17. Quality assurance/peer review 18. Liability insurance 19. PACU evaluation 20. Discharge evaluation 21. Emergency preparedness (fire/admission/transfer, etc.) Factors considered in accrediting an office for surgical procedures
- 25. Safety (WHO surgical safety checklist) Sign in Before induction of anesthesia Patient has confirmed: --Identity --Site --Procedure --Consent --Site marked/not applicable --Anesthesia safety check completed --Pulse oximeter on patient and functioning Does patient have a: Known allergy? --No --Yes Difficult airway/aspiration risk? --No --Yes, and equipment/assistance available Risk of >500 mL blood loss (7 mL/kg in children)? --No --Yes, and adequate intravenous access and fluids planned Time out Before skin incision --Confirm all team members have introduced themselves by name and role --Surgeon, anesthesia professional, and nurse verbally confirm -Patient -Site -Procedure Anticipated critical events --Surgeon reviews: What are the critical or unexpected steps, operative duration, anticipated blood loss? --Anesthesia team reviews: Are there any patient-specific concerns? --Nursing team reviews: Has sterility (including indicator results) been confirmed? Are there equipment issues or any concerns? Has antibiotic prophylaxis been given within the last 60 minutes? --Yes --Not applicable Is essential imaging displayed? --Yes --Not applicable Sign out Before patient leaves operating room Nurse verbally confirms with the team: --The name of the procedure recorded --That instrument, sponge, and needle counts are correct (or not applicable) --How the specimen is labeled (including patient name) --Whether there are any equipment problems to be addressed --Surgeon, anesthesia professional, and nurse review the key concerns for recovery and management of this patient
- 26. Safety (WHO surgical safety checklist)
- 27. Safety
- 28. Anesthesia type The choice of technique depends on the procedure and the preferences of the surgeon, patient and anesthesiologist Analgesia: Decreased perception of painful Stimuli. Anxiolysis: Decreased anxiety. Sedation: Decreased awareness of environment. Conscious sedation: Decreased level of awareness that allows toleration of an unpleasant procedure while maintaining the ability to spontaneously breathe and protect the airway. Deep sedation: Unconscious state during which patients do not respond to voice or light touch; minimal spontaneous movement; may be accompanied by partial or complete loss of protective reflexes. General anesthesia: Loss of response to painful stimuli and loss of protective reflexes. Regional Anesthesia
- 29. • Class A-C refer to the level of anesthesia provided as described by the American College of Surgeons Class C: Provides for major surgical procedures that require general or regional block anesthesia and support of vital bodily function. AAASF standards use a similar A, B, C, C-M classification, and specifically restrict the use of propofol to Class C facilities. Class B: Provides for minor or major surgical procedures performed in conjunction with oral, parenteral or intravenous sedation or under analgesic or dissociative drugs. Class A: Provides for minor surgical procedures performed under topical and local infiltration blocks with or without oral or intramuscular preoperative sedation. Excluded are spinal, epidural, axillary, stellate ganglion block, regional blocks (such as interscalene), supraclavicular, infraclavicular, and intravenous regional anesthesia. Anesthesia type
- 30. Anesthesia type 1. Minimal sedation (anxiolysis) a. Drug-induced sedation b. Patient responds normally to verbal commands c. Cognitive and motor function may be impaired d. Ventilatory and cardiovascular functions maintained normally 2. Moderate sedation/analgesia (conscious sedation) a. Drug-induced sedation b. Patient responds purposefully to verbal commands either alone or with light tactile stimulation c. Patient maintains a patent airway and spontaneous ventilation d. Cardiovascular function maintained 3. Deep sedation/analgesia a. Drug-induced sedation b. Patient cannot be easily aroused but can respond purposefully to repeated or painful stimulation c. Ventilatory function may be impaired, requiring assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate d. Cardiovascular function is usually maintained 4. General anesthesia a. Drug-induced loss of consciousness b. Patients are not aroused by painful stimulation c. Ventilatory function is often impaired; patient may require assistance in maintaining a patent airway d. Spontaneous ventilation may be impaired, as well as neuromuscular functioning e. Positive pressure ventilation is often required f. Cardiovascular function may be impaired American Society of Anesthesiologists (ASA) definitions of levels of sedation/anesthesi a
- 31. Anesthesia type (Regional and Neuroaxial) 1. rapid onset and offset 2. easy administration 3. minimal expense 4. minimal side effects or complications Ultrasound-guided interscalene and supraclavicular blocks spinal anaesthetic techniques for common ambulatory procedures highlight the success of combining subclinical doses of local anaesthetics and intrathecal opioid adjuncts The neuraxial block with shorter acting local anaesthetic agents, specific to the expected duration of surgery, may provide superior recovery profiles small-gauge, pencil-point needles are responsible for the success of outpatient spinal anaesthesia with acceptable rates (0–2%) of (PDPH)
- 32. Anesthesia type (SPINAL ANAESTHESIA) Use of small 25- or 27-gauze pencil point needle Fine-gauge, pencil-point spinal needles has reduced the incidence of significant postdural puncture headache to 0.5% to 1% Prevent prolonged motor block or impairment of joint position sense Lidocaine has an appropriate duration but ceased as a result of a high incidence of TNS Bupivacaine may cause unacceptable delays in home discharge if used in standard doses Reduce the dose of bupivacaine by using of patient positioning or the addition of adjuvants, such as fentanyl Clonidine can be used to supplement low-dose spinal anesthesia, but it may prolong motor block, exacerbate hypotension, and delay voiding
- 33. Anesthesia type (Selection of anesthetic agents) Goals —short duration of action, absence of postoperative nausea and vomiting (PONV), and cost- effectiveness. Short duration — To facilitate rapid discharge after the procedure (ideally, one hour or less), only short- acting agents are used to produce either sedation (eg, midazolam, propofol, ketamine, or dexmedetomidine) or general anesthesia (eg, propofol, ketamine, or dexmedetomidine and/or inhalational agents [eg, sevoflurane or desflurane]). Similarly, short-acting opioids are used to provide analgesia (eg, fentanyl or remifentanil). Nitrous oxide increases the risk of PONV, which has limited its use in patients susceptible to this complication. However, in patients without risk factors for PONV, many anesthesiologists use nitrous oxide in combination with intravenous agents or with a volatile anesthetic agent. Nitrous oxide reduces the doses of other agents and may reduce costs and expedite emergence from anesthesia because of its rapid offset. Avoidance of postoperative nausea and vomiting (PONV) — Major consideration in any ambulatory surgery setting. Incidence of PONV after outpatient surgery may be as high as 50 %, use a multimodal approach to both prophylaxis and treatment. In patients at risk for PONV, employ a variety of antiemetic drugs targeting different receptors, as well as anesthetic and analgesic techniques that do not cause PONV. (see next page) Cost-effectiveness — Cost is a valid but lesser concern in selection of anesthetics. Side effects such as PONV and delayed recovery might negate cost advantages for certain agents and techniques (eg, nitrous oxide)
- 34. Anesthesia type (Selection of anesthetic agents) General Anesthesia MAC Anesthesia Premedication Midazolam 2 mg IV (in holding area) andMidazolam 2 mg IV (in holding area) Induction 0.25-1 mg IV during procedure titrated to effectPropofol 2.0-2.5 mg/kg IV or Thiopental 3-5 mg/kg IV or O2 3-4 L/min by nasal cannula or 6-8 L/min by face mask with capnograph ± Fentanyl 1 μg/kg IV Muscle Relaxation Succinylcholine 1 mg/kg IV (for intubation) Propofol 1-1.5 mg/kg IV then 50- 100 μg/kg/min or Vecuronium 0.1 mg/kg IV or Dexmedetomidine 1 μg/kg for 15- 20 min then 0.2-0.7 μg/kg/h orCisatracurium 0.2 mg/kg IV or Rocuronium 0.6-1.2 mg/kg IV or Remifentanil 0.25-0.75 μg/kg/min Maintenance of Anesthesia Fentanyl 12.5-25 μg IV can be titrated to effect and monitor for respiratory depression O230%-100% ± N2O 0%-70% plus Desflurane or sevoflurane Reversal of muscle relaxation Neostigmine 0.07 mg/kg IV plus Glycopyrrolate 0.01 mg/kg IV Analgesia Fentanyl 25 μg IV titrated to effect up to 100 μg total Morphine 1-4 mg IV titrated to effect up to 8 mg total (Monitor for respiratory depression) Nausea prophylaxis Dolasetron 12.5 mg IV ± Metoclopramide 10 mg IV Consider OG tube placement and suction for patients at risk for postoperative nausea and vomiting (PONV). O2100% Suction oropharynx Extubate (based on standard extubation criteria) • The use of muscle relaxants in office-based surgery is the same as in any ambulatory surgical setting. A rapid-onset short-duration non-depolarizing neuromuscular junction blocking drug, Rapacuronium, is being developed and might prove ideal for office- based anesthesia which was withdrawn from clinical use because of a frequent incidence of severe bronchospasm, although other factors such as inconvenient administration, declining use of endotracheal intubation, and large costs also contributed to its lack of commercial success • An alternative to short-acting NMBDs is terminating the neuromuscular blockade with sugammadex, which can rapidly and completely reverse rocuronium (or vecuronium) independent of the degree of residual neuromuscular block
- 35. Monitored Anesthesia Care According to the ASA position statement, MAC is a specific anesthesia service for a diagnostic or therapeutic procedure and does not describe the continuum of depth of sedation Indications for MAC include the type of procedure, the patient’s clinical condition, and the potential need to convert to a general or regional anesthetic. Furthermore, it includes all aspects of anesthetic care, including a preprocedure visit, intraprocedure care, and postprocedure recovery management The anesthesia provider must be prepared and qualified to convert to general anesthesia if necessary. If the patient loses consciousness and the ability to respond purposefully, the anesthesia care is a general anesthetic, irrespective of whether airway instrumentation is required ASA standard monitoring, which includes electrocardiography (ECG), pulse oximetry, noninvasive blood pressure, and more recently end-tidal carbon dioxide (ETCO2) monitoring, must be used for every anesthetic including MAC. Patients scheduled for MAC should receive a preoperative assessment similar to any other preoperative patient MAC is unique in that it also requires an element of cooperation on the part of the patient. It is important for the patient to accept the possibility to some degree of awareness during the procedure, to tolerate positioning required for surgery, and in some instances, to be able to communicate with the surgeon or proceduralist Successful MAC involves the use of combinations of anesthetic agents. Typically, a combination of a sedative hypnotic and an analgesic agent is used in dosages that vary depending on the goals of the anesthetic and the requirements of the procedure. Medications with minimal side effects and short duration of action are preferable in ambulatory anesthesia, where efficiency and rapid recovery are highly desirable.
- 36. Monitored Anesthesia Care Profile of Drugs Frequently Used in Monitored Anesthesia Care
- 37. Anesthesia type (Avoidance of PONV) Prophylactic drugs: may include: scopolamine, and/or intravenous administration of one or more of the following intravenous agents: dexamethasone, ondansetron, famotidine, and/or metoclopramide. Anesthetic techniques: to minimize PONV include use of TIVA, usually with propofol alone or in combination with an opioid. Also, dexmedetomidine may be used as an adjunct anesthetic agent. Other techniques include use of Neuraxial Anesthesia (spinal or epidural) or Peripheral Nerve Blocks, with or without catheters. Opioid-sparing analgesics: are used when feasible (eg, acetaminophen and/or NSAIDs). Nitrous oxide: is avoided in patients at high risk for PONV. Adequate Hydration: may be useful in prevention of PONV (avoiding orthostatic hypotension and consequent decreased blood flow to the midbrain emetic centers). For most healthy adult patients undergoing minimally-invasive relatively short outpatient surgical procedures that are not associated with significant fluid shifts or blood loss, 1 to 2 L of a balanced electrolyte solution (eg, Ringer’s lactate solution) is administered during surgery. Such empiric fluid administration addresses the mild dehydration caused by preoperative fasting, and is associated with less postoperative nausea and vomiting as well as less postoperative pain. Postoperative period: patients who develop PONV receive additional multimodal therapy including the same agents used for prophylaxis. Promethazine, Haloperidol, and/or Diphenhydramine are given, if needed. Aprepitant (neurokinin- 1 receptor antagonist)is another option. Persistent severe PONV may be necessary to admit a to an inpatient facility.
- 38. RECOVERY Suitable clinical area for recovery of the patient which must include oxygen, suction, resuscitation drugs and equipment Almost all the potentially preventable office-based injuries result from adverse respiratory events in the recovery or postoperative periods; therefore, strict surveillance should be exercised until full recovery The ideal recovery area should be ‘near’ the location where the patient was treated • Standard Equipment Oxygen Suction Pulse oximeter Electrocardiogram Blood pressure monitor Temperature monitor • Emergency Equipment Airway = oral/nasal airways, oxygen cannulae Breathing = face masks, endotracheal tubes, laryngoscopes, and laryngeal mask airways (LMAs) Circulation = intravenous catheters and fluids Drugs = emergency cart containing all life support equipment • Design Close proximity to the operating room (OR) Open designated area Well lighted Easily accessible Allow room for equipment Electrical outlets
- 39. RECOVERY (non Opioid Pain medication) Drug Usual analgesic dose (intravenous) Maximum dose per day (mg) Para-aminophenol derivative Acetaminophen (paracetamol, APAP) Weight ≥50 kg: 650 mg IV every 4 hours or 1000 mg IV every 6 hours Weight <50 kg: 12.5 mg/kg IV every 4 hours or 15 mg/kg IV every 6 hours Weight ≥50 kg: 4000 mg IV Weight <50 kg: 75 mg/kg per day up to 3750 mg IV Nonselective NSAIDs* Ketorolac Age <65 years and weight ≥50 kg: 15 to 30 mg IV every 6 hours Age ≥65 years or weight <50 kg: 15 mg IV every 6 hours Age <65 years and weight ≥50 kg: 120 mg IV per day for up to five days Age ≥65 years or weight <50 kg: 60 mg per day IV for up to five days Ibuprofen 400 to 800 mg IV every 6 hours 3200 mg IV Diclofenac 37.5 mg IV every 6 hours 150 mg IV Selective COX-2 inhibitor Parecoxib (not available in United States) 20 to 40 mg IV every 6 to 12 hours Age <65 years: 80 mg IV Age ≥65 years and body weight <50 kg: 40 mg IV
- 40. DISCHARGE Postanesthesia Recovery Score (Modified Aldrete Score) (0-2 point scale) Activity 2=Moves all extremities voluntarily or on command 1=Moves two extremities 0=Unable to move extremities Respiration 2=Breathes deeply and coughs freely 1=Dyspneic, shallow or limited breathing 0=Apnea Circulation 2=BP ± 20mm of preanesthetic level 1=BP ± 20-50mm of preanesthetic level 0=BP ± 50mm of preanesthetic level Consciousness 2=Fully awake 1=Arousable on calling 0=Not responding Oxygen saturation 2=SpO2 >92% on room air 1=Supplemental O2 required to maintain SpO2 >90% 0=SpO2 <92% with O2 supplementation 10=Total score Score >9 required for PACU discharge
- 41. DISCHARGE Criteria for discharge from the Post Anesthesia Care Unit Extended Criteria Minimum Criteria Central nervous system Awake, alert, oriented, moves all extremities Hemodynamically stable Airway and breathing Can take deep breaths, color pink, and oxygen saturation >92% on room air Adequate pain control Circulatory Stable vital signs No nausea or vomiting Renal Ability to void urine Gastrointestinal Absence of severe nausea/vomiting, able to tolerate fluids Pain Control of significant pain Regional anesthesia Resolution of a spinal/epidural block Temperature Normothermia Major surgical complications Absent Home discharge Ride available
- 42. DISCHARGE following simple recovery criteria are beneficial in routine clinical practice: I. simple psychomotor tests like memory and sensory motor coordination II. recovery of motor and sensory functions: With spinal anaesthesia, it is generally accepted that motor and sensory functions return before recovery of sympathetic nerve system III. two successive orthostatic MAP decrease of 10% or less IV. prior to ambulation, patients should have normal perianal sensation (S4–5), ability to plantarflex the foot, and proprioception of the big toe
- 43. COMPLICATIONs The severity of injury for office-based claims was greater than for other ambulatory anesthesia claims Some of the early literature broaches concerns about the safety of office-based procedures and anesthesia. However, more recent data have shown that care in ambulatory settings is comparable to hospitals and ambulatory surgery centers, especially when offices are accredited and their proceduralists are board-certified Examples of adverse events to be reviewed in office-based anesthesia Death, cardiac or respiratory arrest Re-intubation (unplanned) Central or peripheral nervous system deficit Myocardial infarction Pulmonary edema or aspiration pneumonia Anaphylaxis or adverse drug reaction, including drug errors Postdural puncture headache Dental injury Eye injury Surgical infection or excessive blood loss Unplanned admission Wrong procedure, patient, surgical or regional block site
- 44. COMPLICATIONs More than 46 percent of office-based injuries are preventable by better monitoring All the potentially preventable office-based injuries resulted from adverse respiratory events in the recovery or postoperative periods • The most common damaging events in the Closed Claims database overall (including inpatient and pain claims): --Respiratory system (22 percent) --Cardiovascular system (11 percent) --Equipment-related (10 percent) events • The damaging events in office-based claims involved: --Respiratory system events (50 percent) (included airway obstruction, bronchospasm, inadequate oxygenation-ventilation and esophageal Intubation) --drug-related events (25 percent) (included wrong dose or drug, malignant hyperthermia and allergic drug reaction)