1. Anesthesia Outside the Anesthesia Outside the OR
Operating Room History:
• Pre-1990 few anesthetics were given by
Anesthesiologists outside the OR
• Several factors changed in the late 80's:
Jerrold Lerman BASc, MD, FRCPC, FANZCA • Awareness of deaths from sedation
Clinical Professor of Anesthesiology
Women’s & Children’s Hospital of Buffalo, SUNY, & • Increase demand for more compassionate
Strong Memorial Hospital, University of Rochester,
New York
care
• Adoption of practise guidelines
• Increase demand for outpatient procedures
• Popularity of propofol
Pediatric Oncology Centres
% of centres responding
Hain RDW, Campbell C
Procedure Arch Dis Child 2001:85;12
Adverse Drug Events Sedation by Nonanesthesiologists
Sedation in children: How effective is the sedation?
• Systematic review of reported events
• Observational study (1h) of 86 children
• 60/95 events resulted in death/neurologic injury
<12 years of age
• Factors:
• often due to medication overdose • Cath Lab, Endoscopy, CAT and dental
• associated with meds given by non-medicals or at home • Using BIS and UMSS
• 3 medications compared to 1 - 2 medications • Blinded to BIS reading
• all classes of sedation/routes of administration
• usually outside of medical supervision/monitoring • To achieve: conscious or deep sedation
Cote et al
Pediatrics 2000:106;633 Cont'd
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2. Sedation by Nonanesthesiologists Prolonged recovery
How effective were they?
• 53% (BIS) and 72% (UMSS) reached goal
• 35% (BIS) and 0% (UMSS) reached GA!
• 12% (BIS) and 28% (UMSS) were awake!
• 8% developed airway difficulties and
desaturation at deeper levels of sedation
Motas D, et al Malviya S, et al
Ped Anesth 2004:14;256 Pediatrics 2000:105;42
Anesthesia Outside the OR Anesthesia outside the OR
Considerations:
• Personnel
• Physical Plant
• Sites
• Techniques
To go where no other anesthesiologist • Tailored to the procedure
has dared go before... • Recovery
For a good reason!
Sedation by non-anesth Anesthesia Outside the OR
A Pediatric sedation/anesthesia program with For sedation:
dedicated care by Anesthesiologists and • Hem/Onc procedures: P ± morphine vs. M/K
Nurses for procedures outside the operating • 50 children undergoing minor procedures
room • Cardiorespiratory complications noted
Gozal D, et al
• 100% P and 92% M/K completed procedure
J Pediatr 2004:145;47 • 56% P and 16% M/K had side effects, most
common: desaturation
Sedation by non-anesthesiologists • Induction/recovery faster with P
• Recommend: sedation by airway/CPR experts
Litman RS
Curr Opin Anaesth 2005:18;263
Gottschling S, et al
Pediatr Hematol Oncol 2005:27;471
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3. Anesthesia Outside the OR Who should give anesthesia?
Pedi Outside the OR:
g a tr ic
n ia n • Nursing
si s
Conscious sedation Deep sedation
• Non-Anesthesiology MDs
ur • Anesthesiologists
a
N
si
Considerations:
he
• Types of patients
st • Personnel availability: monitor, sedation, procedure
ne
• Turf protection: iv vs. inhalational
General anaesthesia • Financial: pro-con
A
Sedation by Nurses/MD Anesthesia Outside the OR
Who should NOT be sedated by nursing:
Pharmacology: Complications: • Airway problems: congenital/acquired, snoring, craniofacial,
• young age apneas
• Pentobarbital
• Neonates and infants with complex diseases
• Chloral hydrate (infants) • dosing
• Neurological problems: raised ICP, handicapped, seizures
• 1% overall. not controlled
• Diazepam/midazolam • Cardiovascular disease: ie., cyanotic CHD
• Opioids • Oncology: mediastinal masses, chest mets and abscesses
• Emergency cases
• CM3 (IM).
• Multi-system organ dysfunction/failure.
Anesthesia Outside the OR Anesthesia Outside the OR
Reasons to involve anesthesia: Sites: • Recovery/near OR areas
• Increase efficiency/throughput in the unit. • Radiology: CT scan, MRI, IGT
• Conscious sedation/local anesthetic poorly • Cardiac catheterization laboratory
tolerated by children • Emergency department: ie., orthopedics
• Unco-operative, handicapped children • Medical procedures:
• Avoid unfriendliness/cost of Operating Room and • GI: endoscopy
PACU • Plastics: burns every am
• Oncololgy: bone marrow, LP, chemotherapy
• Transfer responsibility for sedation • Cardiology: echocardiograph
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4. Anesthesia Outside the OR Monitoring for Apnea
Anesthetic Equipment:
• Machine/gas tanks/suction
• Walled gas outlets, scavenging
• Room air exchanges?
• Airway equipment (baffled nasal prongs (Salter))
• Monitors (including slave)
• Drugs:
• IV access (port or N2O or EMLA®)
• Propofol and N2 O (no ketamine)
• Midazolam and fentanyl
• Inhaled agents Keidan I, et al.
Pediatrics 2008:122;293
Emergency Equipment Anesthesia Outside the OR
Anesthesia:
• all procedures are vetted by anesthesia: minor
medical procedures
• no airway, sick or complex children or < 1 year
• General anesthesia: short-acting meds
• avoid ALL long-acting meds, opioids
• Recovery: patient room, clinic bed or elsewhere.
ASA Task Force on Sedation and Analgesia by non-Anesthesiologists
Anesthesiology 2002:96;1004
Anesthesia Outside the OR Anesthesia Outside the OR
Recovery:
Anesthetic Plan: In the procedure room:
• Booking schedule (start and finish times)
• Airway reflexes
• Fasting guidelines (2, 4, 6, 8 hours) • Purposeful movement
• Preoperative investigations • Responds to commands
• Preoperative anesthetic questionnaire
• Vital signs including weight! Kg or lbs?
In the short-stay unit or patient’s room:
• Information pamphlet/consent
• Oxygen by mask
• Avoid premed; parents may accompany child • 30 minutes minimum of nursing supervision:
stable VS, minimal N &V, hydrated,
discharge instructions.
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5. Depth of Sedation
s
tric
dia
pe
e in
rol
No
ASA Task Force on Sedation and Analgesia by non-Anesthesiologists
Anesthesiology 2002:96;1004
Anesthesia by GI MDs Anesthesia by GI MDs
Survey of 51 endoscopy centres: Results:
• How do they conduct upper endoscopy in • <6 mo: 35% conscious, 22% GA, 43% nada
children • >6 mo: 45% conscious, 47% GA, 8% nada
• 33 University, 8 community, 10 private • 1-3 yr: 12% N2O for conscious, 24%
• Response rate of 84% lidocaine
• 14% routinely use GA, 40% offer choice • >5 yr: 19% N2O for conscious, 42%
• Choices: conscious sedation or GA lidocaine
Michaud L, et al
Cont'd Endoscopy 2005:37;167
Anesthesia by GI MDs Adverse Events from PSRC
Which strategy? Between 2004 & 2007:
• Retrospective review 402 sedations • >49,000 propofol sedations/anesthesia
• EGDs and colonoscopies • CPR x 2, aspirn x 4, no deaths
• Sedation and complications (airway, agitation, N/V, • Satn <90% x 30 s 154
muscle twitch) • Airway obstrn apnea 575
Per 10,000 children
• Midaz/Dem (192), Midaz/Dem/Ket (82), • Laryngospasm 96
Midaz/Ket (128)
• Unexpected admissions 7.1
• Complications: M/D > M/D/K > M/K (P<0.001)
• M/K most sedation, P<0.07 • No differences between anesthesiologists
and non-anesthesiologists
Gilger MA, et al Cravero JP, et al.
Gastrointest Endosc 2004:59;659 Anesth Analg 2009:108;795
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6. Anesthesia Outside the OR
Regimen for upper endoscopy:
• Fasted, unpremedicated
• Parents, monitors, semi-decubitus, no
airway
• Limitation for size:
• < 1 yr or < 10 kg, trachea must be intubated
• > 1 yr or > 10 kg, no airway
• No opioids, long-acting sedatives!
Anesthesia Outside the OR Anesthesia Outside the OR
Indications for EGD: Regimen for upper endoscopy:
• Abdominal pain • Should their tracheas be intubated?
• Fasted
• Esophageal pain/heartburn
• Positioned in lateral decubitus
• Vomiting/regurgitation/diarrhea • Scope in the stomach
• Gastric or rectal bleeding • Suction in the stomach
• Suspected IBD • Anesthesia at the head
• After 25 years…no regurgitations
Anesthesia Outside the OR
Regimen for endoscopy:
• For upper endoscopy -- iv with mask/N2 O then d/c N2O
• Apply baffled NP, 2 lpm O2, iv propofol (2 mg/kg).
• Insert bite block, scope, repeat doses of propofol (1-2
mg/kg) to prevent movement prn.
• Monitor respiration using visually and using
capnography.
• Alternatives include propofol & remifentanil or tracheal
intubation/GA
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7. Anesthesia Outside the OR Anesthesia Outside the OR
Regimen for isolated colonoscopy: Anesthesia for MRI:
• N2O by mask, iv then propofol (1-2 mg/kg) • Consent for GA
• Face mask or LMA with N2O • Physical plant:
• Maintenance: • MRI compatible machine
• Intermittent propofol--may be required at • Monitor in MRI and remote
splenic and hepatic flexures • MRI bed detachable or not?
• Wide awake after N2O discontinued • Anesthetic equipment…laryngoscope
• AVOID opioids • Preoperative preparation: admit, orders etc
Anesthesia Outside the OR Anesthesia Outside the OR
Anesthesia for MRI: Anesthesia for MRI:
• Airway algorithm:
• Nasal prongs; baffled, O2 and CO2 sampling
• Indications for airway support:
• Position head, neck, roll, taped forehead • Craniofacial or airway anomalies
• Oral airway • Chronic lung disease or myopathy
• Nasopharyngeal airway • Preterm/immature infant
• LMA • OSA, obese
• Tracheal tube
• Multisystem failure
Propofol for TIVA CSHT and Drugs
Manual parameters in children:
• Infusion rates:
• adults: 10-8-6 mg/kg/h 50% greater dose
• children 3-11 yr: 15-13-11-10-9 mg/kg/h in kids!
• ↑ dosing for Infants & cognitively impaired
• Larger doses in children, termination by Remi
redistribution ⇒ increased CSHT = slower
recovery
Hughes MA, et al McFarlan CS, et al.
McFarlan CS, et al. Anesthesiology 1992:76;336 Pediatr Anaesth 1999:9;209
Pediatr Anaesth 1999:9;209
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8. Sedation for Cog. Impaired
Kannikeswaran N, et al. Kamibayashi T, et al
Pedaitr Anesth 2009:19;250 Anesthesiology 2000:93;1345
Kinetics <2 and >2 yr High Dose Dex: CV effects
Retrospective analysis:
t1/2β = 1.6 h
• 747 children for radiologic studies
• Dex loading dose:
1 mcg/kg
• <2 yr need ↑ loading
• ↑ dose from 2 to 3 mcg/kg, and ↑ infusion
0
dose due to ↑ VD, from 1 to 1.5-2 mcg/kg/h
• similar clearance,
thus similar • ↑ sedation success from 92% to 98%
t1/2β = 2.3 h maintenance infusion
rates • Recovery ↓ from 35 min to 24 min✻
• However, bradycardia 16%!
Mason K, et al.
Vilo S, et al. ✻ Aldrete score ≥ 9
Pediatr Anesth 2008:18, 403
Br J Anaesth 2008: 100, 697
High Dose Dex: CV effects Dex vs Propofol for MRI
After sevoflurane induction:
• Dex 1 mcg/kg IV, midazolam 0.1 mg/kg then Dex 0.5
mcg/kg/h
• Propofol 2 mg/kg IV, then 300 mcg/kg/min x 10 min followed
by 250 mcg/kg/min
• Fully responsive: Dex 44 min vs. P 30 min✻
• PACU d/c: Dex 50 min vs. P 36 min❉
• End scan to hospital d/c: Dex 98 min vs. P 80 min✻
Mason K, et al. ✻ P<0.05 Heard C, et al.
Pediatr Anesth 2008:18, 403 Anesth Analg 2008;107, 1832
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9. Dex for MRI: CV effects Anesthesia outside the OR
Discharge criteria:
• Awake
• UMSS yielded better assessment of suitability
for discharge than observational scores
Malviya S, et al
Anesthesiology 2004:100, 218
• Maintains oxygenation
• Returned to pre-sedation activity level
• No vomiting, no pain
Heard C, et al.
Anesth Analg 2008;107, 1832
Anesthesia Outside the OR Anesthesia Outside the OR
After all is said and done… Popularity of the service:
• before anesthesia, there was inadequate • Profile of anaesthesia has been
sedation for these minor procedures heightened
• protocols, infrastructure and personnel must • Doctors, parents and children ask for the
anaesthetic service
be approved by all stakeholders
• Work efficiency has increased since the
• preoperative preparation and anticipation of introduction of this program
unexpected events must be thorough • But can we control/limit the rate of growth of
this service?
• there is no such thing as a “minor anesthetic”
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