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What must i consider to safely anesthetize someone

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    What must i consider to safely anesthetize someone What must i consider to safely anesthetize someone Presentation Transcript

    •   What Must I Consider to Safely Anesthetize Someone in the Office Setting? Chapter 47: Evidence based practice of anaesthesiology Dr.ANVAR SADATH.A.E.
    • INTRODUCTION
      • Anaesthetic care in office setting –Often a significant component of the responsibilities of an anesthesiologist.
      • Advantages – cost containment, patient privacy, ease of scheduling, and decreased risk of nosocomial infection.
      • Safety concerns
      • Hoefflin and colleagues found no complications after 23,000 procedures. Plast Reconstr Surg   2001; 107:243-251
      • Sullivan and Tattini: over 5000 surgical procedures by five independent surgeons, no deaths occurred over the 5-year period. Med Health RI   2001; 84:392-394 .
      • Retrospective study of adverse outcomes in 3615 patients undergoing 4778 procedures from1995-2000---No deaths were reported
    • COMPONENTS OF OFFICE SAFETY
      • Physical Considerations
      • Physician Qualifications
      • Patient and Procedure Selection
    • Physical Considerations
      • Physical design of the office –
        • Adequate space for all operating room functions
        • Anesthesia equipments
          • availability and placement of oxygen lines ,
          • venting,
          • emergency egress of patient
        • Periop monitoring facilities
        • Office staffing
        • Emergency admission planning ,fire safety, infection control
        • Accreditation status.
        • accredited by any nationally recognized agencies, such as JCI, American Association for Accreditation of Ambulatory Surgery Facilities, and the Accreditation Association for Ambulatory Health Care. .
      • Practitioners should be constantly vigilant in maintaining a safe anesthetizing location.
    • Physician Qualifications
      • The qualifications of the surgeon, as well as the anesthesia provider, must be considered.
      • Surgeon should be certified by one of the boards recognised by American Board of medical specialities
      • Surgeon has privileges to perform the proposed procedure at a local hospital.
      • Surgeon should also have admitting privileges in a nearby hospital for an unplanned emergency admission.
      • Active license, registration, and Drug Enforcement Administration (DEA) certificate, as well as adequate malpractice coverage, must be maintained and continued medical education (CME) credit earnedfor both anaesthetist and surgeon
    • Patient and Procedure Selection
      • Type of procedure and appropriateness in office setting -must be clearly defined
      • Patients with significant comorbidities are not ideal candidates and should be excluded
      • Only ASA 1 and 2 patients should undergo general anesthesia, although occasionally an ASA 3 patient may be acceptable.
      • Difficult airway raises a potential problem
    • EVIDENCE
      • The ASA is a strong proponent of patient safety
      • that all anesthetizing locations should meet the same safety standards and has published recommendations specifically for the office-based anesthesiologist.
      • The ASPS has also published guidelines for its members
      • Joint responsibility of the individual surgeon and anesthesiologist to ensure that patient safety is a priority in each office and to follow all local, state, and society-mandated regulations.
    • Evidences
      • Scientific data in the field of office-based anesthesia and surgery in the literature are sparse.
      • J ClinAnesth   2006; 18:499-503
      • Data from the specialty of ambulatory anesthesia is applied to the office-based setting.
      • Most data are from retrospective analysis of the experience in Florida. Dermatol Surg   2004 Plast Reconstr Surg   2006 .
      • Vila et al-
      9.2 /100000 66 /100000 Office surgery 0.78/ 100000 5.3 /100000 Ambulatory surgery Death rate Adverse events
    • Evidences, DVT, PE
      • Perioperative DVT and Pulmonary embolism are found as significant cause of death in office setting
      • Reinish and colleagues - 0.39% (37 of 9493) incidences of DVT following face-lift surgery.
      • 40.5% (15 of 37) progressed to pulmonary embolism.
      • Plast Surg Forum   1998; 21:159 .
      • 83.7% of the embolic events were associated with the patient having undergone a general anesthesia
      • Most unfavorable outcomes are often secondary to inadequate monitoring, oversedation, and thromboembolitic events.
    • Risk Factors for the Development of Deep Vein Thrombosis (DVT
      •     Age >40. 
      •   Antithrombin III deficiency. 
      •    Central nervous system disease
      •    Family history of DVT 
      •    Heart failure
      • Hypercoagulable states, Lupus anticoagulant, Malignancy 
      •   Polycythemia 
      • Obesity 
      •    Oral contraceptive use , Previous miscarriage 
      •    Radiation therapy for pelvic neoplasm
      •   Severe infection, Trauma , Venous insufficiency
      • The ASPS recommends that patients be stratified according to risk and the prophylactic treatment be directed by risk.
    • Preoperative hematology consultation with consideration of perioperative antithrombotic therapy Procedure >30 min Treatment as per patients with moderate risk Age >40 with concomitant risk factors High risk Frequent alterations of the operating room table Oral contraceptive use Intermittent pneumatic compression of calf or ankle (before sedation and continued until patient is awake and moving) Procedure >30 min Proper positioning Age >40 with no other risks Moderate risk Avoid constriction and external pressure Short duration Knees flexed at 5 degrees Uncomplicated surgery Comfortable position No risk factors Low risk Treatment Cohort
    • GUIDELINES
      • The ASPS published a practice advisory dealing with procedure and patient selection for the office-based practitioner. Few data to support exclusion of specific procedures and patient population
      • Anticipated blood loss exceeding 500 mL-Exclude
      • Active patient warming devices needed
      • Procedures should be less than 2 hours in duration and be limited to 20% of body surface area.
      • Large-volume liposuction (> 5 L of lipoaspirant) is associated with significant derangements of normal physiology.
      • Caution against large-volume liposuction combined with another procedure.
    • OSA
      • ASA published “Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea”
      • Scientific data for the ASA recommendations regarding patient selection are insufficient
      • Most agree that superficial surgery or minor orthopedic procedures under local or regional anesthesia and lithotripsy are acceptable ambulatory procedures
      • Airway surgery such as uvulopalatopharyringoplasty, tonsillectomy in patients younger than 3 years, and upper abdominal laparoscopy should not be performed.
    • Duration of procedure
      • Procedures lasting > 1 hour were associated with a higher incidence of unplanned hospital admission. Can J Anaesth   1997; 45:612-619.
      • Recent data suggest that duration alone is not predictive of an unplanned admission. preexisting comorbidities and type of procedure itself are more predictive . Br J Plast Surg   1999; 52:33-36.
      • Longer procedures are often associated with postoperative nausea and vomiting, postoperative pain, and bleeding . Can J Anaesth   1997 JAMA   1989.
      • ASPS has recommended that procedures be limited to 6 hours and be completed by 3 pm.
    • AREAS OF UNCERTAINTY
      • Few scientific data to exclude any particular patient.
      • No hard and fast standards for patient selection.
      • Consider coexisting diseases, previous adverse reaction to anesthesia,current medications and allergies,nothing-by-mouth status,potential difficult airway,substance abuse, and the presence of an escort when considering any patient for office procedure
    • AUTHORS' RECOMMENDATIONS
      • Safety “Checklist” for OBA Providers
      • OFFICE
      • Accreditation status
      • Design and layout- space, recovery, emergency egress
      • Policies and procedures manual- infection control, narcotic, gas transport, fire safety, emergency preparedness.
      • Perioperative monitoring capabilities and defibrillator.
      • Crash cart
      • Oxygen, anesthesia machine,suction, scavenging system
      • SURGEON/ANESTHESIA PROVIDER- license, qualification, CME, BLS/ACLS knowledge, admitting privilege
      • Patient selection- ASA status, co-existing disease, difficult airway, DVT prophylaxis.
      • PROCEDURE SELECTION- Duration, anticipated blood loss or fluid shift, hypothermia, postop pain, PONV.
    • thank you