anaesthesia out side operation theatre

1. Anesthesia Outside the Operating Room Dr. partab chand Sp:anaesthetist Khoula hospital

2. Introduction • Modern hospital practice has seen the role of the anaesthesiogist expand beyond the operating theatre complex. While the operating theatres have experienced staff, adequate equipment and monitors, providing anaesthesia outside this complex is challenging and requires expertise and skill.

3. CHALLENGES OF ANAESTHESIA IN REMOTE LOCATIONS • These can be classified as challenges related to: • • Equipment • • Staff • • The procedure • • The patient. Poor illumination Unplanned procedures Patient position Duration of the procedure bedside procedure Deep sedation

4. PATIENT POPULATION • Children • Uncooperative or anxious patients • Claustrophobic patients • Elderly or confused patients • Patients undergoing painful procedures • Movement disorders • Severe pain • Acute trauma with unstable cardiovascular, respiratory, or neurologic function • Significant co-morbidity

5. CHOICE OF ANESTHETIC TECHNIQUE • Monitoring only • Sedation • Regional anaesthesia • Total intravenous anaesthesia • General anaesthesia.

6. Post-procedure care • Patients who have had a procedure under general anaesthesia require: • Expert recovery - this may be either in the procedure room or • Patient may be transferred to the recovery room.

7. Anesthesia Outside the OR • Radiology- CT, MRI, Interventional • Radiation Therapy • Cardiology- Cardio version, PPM insertion, catheterization • Psychiatry- Electroconvulsive therapy • Gastroenterology- EGD, colonoscopy • Urology- ESWL

8. Anesthesia Outside the OR • Standards introduced by the Joint Commission on Accreditation of Healthcare Organizations • The American Society of Anesthesiologists (ASA) has developed practice guidelines for sedation and analgesia, • The ASA has developed standards to apply to anesthesia in remote locations

9. Uniform Quality of Care Outside the OR? • Joint Commission on Accreditation of Healthcare Organizations (JCAHO) enacted several standards in 2001. These requirements include: -Pre sedation assessment -Continuous physiologic monitoring -Credentialing of individuals providing different levels of sedation -Post sedation recovery and discharge -Maintenance of institution wide standards of care and quality.

10. ASA Guidelines for Non-operating Room Anesthetizing Locations [4] • Approved by House of Delegates on October 19, 1994, and last amended on October 15, 2003. • “Minimal guidelines which may be exceeded at any time based on the judgment of the involved anesthesia personnel”. • “ASA Standards, Guidelines and Policies should be adhered to in all non-operating room settings except where they are not applicable to the individual patient or care setting”.

11. ASA Guidelines • A reliable oxygen source with backup • A suction source • Waste gas scavenging • Adequate monitoring equipment to meet the standards for basic anesthetic monitoring • A self-inflating hand resuscitator bag • Sufficient safe electrical outlets • Adequate patient and anesthesia machine illumination with battery-powered backup • Sufficient space for the anesthesia care team • Emergency cart with a defibrillator • Emergency drugs, and other emergency equipment • A means of reliable two-way communication to request assistance • Compliance of the facility with all applicable safety and building codes • Adequately trained staff to support anesthesia team

12. JCAHO and ASA • Prospective study in a tertiary care center to determine the effects of the new guidelines on adverse events during sedation • 14,386 patients received PSA between July 1, 2001, and June 30, 2004 • 7.6% of patients had an adverse event, with the most common being hypoxemia (39.7% of all adverse events). A significant trend toward a decrease in the incidence of adverse events was found during the study. • Decrease in the incidence of adverse events during the study, implying that uniform standards of monitoring and care may lead to safer conditions for patients. Effect on Hospital-Wide Sedation Practices After Implementation of the 2001 JCAHO Procedural Sedation and Analgesia Guidelines. Raymond Pitetti, MD, MPH; Peter J. Davis, MD; Robert Redlinger, RN, MSN; Jean White, RN; Eugene Wiener, MD; Karen H. Calhoun, BSN, MBA. Arch Pediatr Adolesc Med. 2006;160:211-216.

13. Pre-anaesthetic assessment • History, • Any implant in body • Allergy to contrast, • H/o pregnancy, • Co-morbid conditions, sleep apnoea • General physical/systemic and Airway Examinations • Review PAC chart • Relevant investigations • NPO status.

14. Anesthetic Considerations • It is vital to confirm the presence and proper functioning of all equipment in the operating room. • The location of immediately available resuscitation equipment should be noted and protocols developed with the local staff for dealing with emergencies, including cardiopulmonary resuscitation and the management of anaphylaxis.

15. Anesthetic Considerations for MRI -No ferromagnetic components -Interference of monitors -Immobilization of monitors to prevent degradations of magnetic field homogeneity -Pt positioning -Narrow aperture (Obese pt’s may not fit) -Remote viewing necessary -limited access to pt/airway -Physical harm to those in the room? (hearing protection)

16. Monitoring • ECG -Rapidly changing magnetic fields produce artifact, and may mimic arrhythmias. -If ECG wires are in a loop, the magnetic field may heat the wires and leads, thus leading to thermal injury . • Pulse oximetry -like ECG wires, (may also produce thermal injury) • Capnography -Increased length of sampling line may have prolonged time delay • Blood pressure -Need for plastic components -Remote viewing monitor

17. Remote Viewing Is this a violation of the ASA Monitoring Standards? • ASA Monitoring Standard Qualified anesthesia personnel shall be present in the room throughout the conduct of all general anesthetics, regional anesthetics and monitored anesthesia care. “With the advent of MRI compatible instruments…anesthesia personnel should now remain in the room, as no biological hazard exists to normal human beings in the scanner room, especially at 10 feet from the magnet coil. However, individuals continue, by choice, to monitor from the SCR.”

18. Patient Positioning • Pt with spine disease had to undergo MRI with GA as they could not tolerate the supine position due to pain. • Anesthetic course was unremarkable over the 2 hour study. • Pt awakened with new-onset paraplegia, with an acute myelopathy at T12-L1. • Pt underwent emergency decompressive laminectomy. Case Reports Neurologic Deficits After General Anesthesia for MRI Margare Weglinski, MD; Keith H. Berge, MD; Dudley H. Davis, MD. New-Onset. Mayo Clin Proc. 2002;77:101-103.

19. Safety Considerations “Health Department Fines Westchester Medical Center $22,000 for its Failure to Ensure Patient Safety During MRI Procedures” - • AND… • A pt forgot about a hairpin in her hair, ended up travelling up her nose and lodging into her pharynx. • In Rochester, the magnetic force pulled a gun out of a police officer’s holster and fired a round that lodged in the wall. • Recently a problem with laryngoscope in the MRI at Khoula Hospital.

20. Zones in MRI • Zone One consists of all areas freely accessible to the general public • Zone Two acts as a buffer between Zone One and the more restrictive Zone Three. Here, patients are under the general supervision of MR personnel • Zone Three should be restricted by a physical barrier. Only approved MR personnel and patients that have undergone a medical questionnaire and interview are allowed inside Zone Three. The MR control room and/or computer room are located within Zone Three • Zone Four is strictly the area within the walls of the MR scanner room, sometimes called the magnet room. Access into the MR scanner room should only be available by passing through Zone Three.

21. Types of Anesthesia • General anaesthesia (ETT/LMA) • Conscious/deep sedation ± analgesia • TIVA • Other solution

22. General anesthesia • No specific anaesthetic technique • Adequate length of tubes, lines and wires • Induced after standard monitoring are placed • Airway can be secured with ETT/LMA • Maintain with inhaletional anaesthetics • Patients who have had a procedure under general anaesthesia require: • Expert recovery - this may be either in the procedure room or in the recovery room. • Observation in recovery room by qualified person and discharge after criteria are fulfilled.

23. sedation • Adequate sedation may result in apnea, hypoxia, hypercarbia. • Inadequate sedation may result in patient movement and a failed imaging study. • Efficacy of oral/rectally administered sedatives may not be predictable. • Patients with mental/emotional disorders may require deeper sedation/GA.

24. What Constitutes Sedation? Levels defined by the ASA on October 13, 1999. Minimal sedation (anxiolysis) • Pt responds to commands, no change in ventilation/cardiovascular status, cognitive/motor function impaired. Moderate Sedation/Analgesia - Pt responds purposely to commands alone or with light stimulation, maintains spontaneous ventilation and cardiovascular status. Deep Sedation/Analgesia • Pt not easily arousable, responds to pain, may need assistance with airway and ventilation, cardiovascular status maintained. General Anesthesia Unarousable even with painful stimulus, Intervention required for airway, spontaneous ventilation frequently inadequate, cardiovascular status may be impaired.

25. Contraindications to sedation -Risk of aspiration -Possible airway obstruction -Raised ICP, etc.

26. TIVA • Utilization of protocol provided adequate levels of sedation at appropriate low doses • 93% of children had no signs of airway obstruction with a shoulder roll. • Mean infusion rate was 193 mcg/kg/min with patient movement at a mean of 175 mcg/kg/min. • Mean time from end of MRI to discharge was 44 minutes Propofol total intravenous anesthesia for MRI in children. Andrew G. Usher MB ChB FANZCA, Ramona A. Kearney MD FRCPC and Ban C.H. Tsui MD FRCPC. Pediatric Anesthesia. Volume 15 Issue 1, Pages 23 – 28. Published Online: 20 Oct 2004.

27. MRI- to summarise Anesthesia • Most childrenrequire sedation or general anesthesia to tolerate MRI • Oral sedation techniques, if appropriately administered, have a success rate of 93% • Oral chloral hydrate is a popular agent ( 25-50 mg/kg for infants younger than 4 months and 50-75 mg/kg for older children) • Benzodiazepines such as midazolam administered either orally (0.25 to 0.75 mg/kg) or intravenously (0.05 to 0.15 mg/kg) are also commonly used for sedation • Deep sedation with propofol infusion, oxygen administration via nasal cannula/ mask and end-tidal carbon dioxide monitoring is a successful technique • Children are initially sedated with incremental propofol boluses up to 3 mg/kg with or without midazolam, & then maintained with an infusion of 1-3mg/kg/hr, with supplemental boluses of 1 mg/kg for movement

28. In the case of an emergency • The MRI technicians should be notified, • To stop the scan sequence, • Patient rapidly to be removed. • Resuscitation attempts should take place outside the scanner because equipment such as laryngoscopes, oxygen cylinders, and cardiac defibrillators cannot be taken close to the MRI machine.

29. Risk and Quality Anesthesia and sedation outside the operating room: how to prevent risk and maintain good quality. Melloni, Claudio. Ambulatoryanaesthesia: Current Opinion in Anaesthesiology. 20(6):513-519, December 2007. • Complications of anesthesia outside the operating room are not well studied. • A few closed claims are appearing in the literature suggesting there is a higher risk. • Risk factors for these procedures are identified with emphasis on full oxygenation & Etco2 monitoring. • Non-operating room anesthesia requires skills, experience and organization. • Quality can only be assured by ensuring all alternative locations adhere to operating room standards.

30. Failures of Anesthesia For MRI • Airway obstruction • Desaturation • Allergic reactions • Aspiration • Cardiac arrest

31. Reasons for Failure? Sedation and general anaesthesia in children undergoing MRI and CT: adverse events and outcomes. S. Malviya, T. Voepel-Lewis, O. P. Eldevik, D. T. Rockwell, J. H. Wong and A. R. Tait. British Journal of Anaesthesia, 2000, Vol. 84, No. 6 743-748 • Adverse events of hypoxemia and/or failed sedation occurred more often in older children, those with benzodiazepines as the sole medication, and those with ASA Class IV or higher.

32. Prevention of Anesthetic/MRI Failure • Organized sedation/anesthetic protocols outside of the OR • Adherence to ASA monitoring standards • Adequate training, • Utilization of proper monitors and MRI compatible equipment • Adhere to recommendations.

33. Other Solutions? • Open MRI for obese patients & those with claustrophobia • Music/images within MRI • Low intensity MR machines

35. References 1- Stoelting, Robert K. and Miller, Ronald, et al. Basics of Anesthesia. 5th ed. Churchill, Livingstone, Elsevier. Philadelphia. 2007. pp. 551 2- Barash, Paul G., Cullen, Bruce F., Stoelting, Robert K. Handbook of Clinical Anesthesia. 5th ed. Lippincott Williams & Wilkens. Philadelphia. 2006. pp. 828-852. 3- Leak, Jessie A. Hospital-Based Anesthesia Outside of the Operating Room. ASA Newsletter October 2003, Volume 67, Number 10. 4- Guidelines for Nonoperating Room Anesthetizing Locations. American Society of Anesthesiologists. http://www.asahq.org/Washington/oba.htm 5- Miller, Ronald D. Miller’s Anesthesia. 6th ed. Churchhill Livingstone. Philadelphia. 2004. 6- American Society of Anesthesiologists, Inc. Practice Guidelines for Sedation and Analgesia by Non-Anesthesiologists An Updated Report by the American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Anesthesiology 2002; 96:1004 7- Effect on Hospital-Wide Sedation Practices After Implementation of the 2001 JCAHO Procedural Sedation and Analgesia Guidelines. Raymond Pitetti, MD, MPH; Peter J. Davis, MD; Robert Redlinger, RN, MSN; Jean White, RN; Eugene Wiener, MD; Karen H. Calhoun, BSN, MBA. Arch Pediatr Adolesc Med. 2006;160:211-216. 8- Anesthesia and sedation outside the operating room: how to prevent risk and maintain good quality. Melloni, Claudio. Ambulatory anaesthesia: Current Opinion in Anaesthesiology. 20(6):513-519, December 2007. 9- Adult claustrophobia, anxiety and sedation in MRI. Murphy KJ, Brunberg JA. Magnetic Resonance Imaging. 1997;15(1):51-4. 10- http://health.ucsd.edu/specialties/mri/ptinfo/how.htm. UCSD Radiology Department 11- http://spnl.stanford.edu/participating/mriwork_detailed.htm. http://spnl.stanford.edu/images/top_bar.jpg 12- Margare Weglinski, MD; Keith H. Berge, MD; Dudley H. Davis, MD. New-Onset Neurologic Deficits After General Anesthesia for MRI. Mayo Clin Proc. 2002;77:101-103. Case Report..

36. References 13- “Health Department Fines Westchester Medical Center $22,000 for its Failure to Ensure Patient Safety During MRI Procedures”. http://www.health.state.ny.us/press/releases/2001/wmcmri.htm 14- “Boy, 6, Dies of Skull Injury During MRI,” David W. Chen. New York Times. July 31, 2001 15- Paul M Kempen, MD, PhD. Editorial- http://www.apsf.org/resource_center/newsletter/2005/summer/05mri.htm 16- Sedation versus general anesthesia in MRI. M.P. Boidin MD, PhD, G.R. Wolff MD, C. Doelman MD Afdeling Anesthesiologie Amphia Ziekenhuis Breda. Breda, The Netherlands. ClinicalWindow.net, Issue 10 August 2002. 18- Propofol total intravenous anesthesia for MRI in children. Andrew G. Usher MB ChB FANZCA, Ramona A. Kearney MD FRCPC and Ban C.H. Tsui MD FRCPC. Pediatric Anesthesia. Volume 15 Issue 1, Pages 23 – 28. Published Online: 20 Oct 2004. 19- Anaesthesia with midazolam and S-(+)-ketamine in spontaneously breathing paediatric patients during magnetic resonance imaging. G. Haeseler, O. Zuzan, G. Köhn, S. Piepenbrock & M. Leuwer. Pediatric Anesthesia. Volume 10 Issue 5, Pages 513 – 519. Published Online: 25 Dec 2001.