Office based anesthesia complications

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Office based anesthesia complications,2001-2

Office based anesthesia complications,2001-2

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  • 1. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Office based anesthesia :complications Claudio Melloni Direttore UO Anestesia e Rianimazione Ospedale di Faenza(RA)
  • 2. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Courtiss EH, Goldwyn RM, Joffe JM, Hannenberg AA. Anesthetic practices in ambulatory aesthetic surgery. Plast Reconst Surg 1994;93:792-801. Inchiesta tra i chirurghi plastici USA 13% respiratory arrest, 8% unplanned intubations, 3% intravascular injection of local anesthetic and 1% mortality However, closer examination of the anesthetic techniques performed and the personnel in the office, the most frequent anesthetic technique performed was monitored anesthesia care (MAC) (92%) with a nurse or anesthesiologist being present only 70% of the time. General anesthesia was administered by 54% of the practitioners and either the nurse or the anesthesiologist were always present. Interestingly, central neuroaxis blockade was performed by 10% of practitioners and the anesthesiologist was never present; instead 12% of the time the surgeon was in charge of the patient and 5% of the time a nurse. This might be the cause of the problems [8]
  • 3. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Courtiss EH, Goldwyn RM, Joffe JM, Hannenberg AA. Anesthetic practices in ambulatory aesthetic surgery. Plast Reconst Surg 1994;93:792-801. 0 20 40 60 80 100 % MAC Anest o CRNA SPI 0 2 4 6 8 10 12 14 % arresto resp intubaz non elettiva iniez intravasc mortalità Anestesista assente; spi effettuata dai chir Complicanze nell’ufficio Responsabilità………… Ma…
  • 4. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Complicazioni delle endoscopia digestiva 0.13-0.08% Mortalità 0.7-1/10.000 50% delle KO e 65% dei decessi dovuti a probl cardioresp
  • 5. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) 1989 ASGE Survey of Endoscopic sedation and monitoring practice(Gastrointest Endoscopy 1990;36:s13-18) 0 20 40 60 80 100 >75% 50-75% up to 33% none % dei paz sedati durante endoscopia UK ASGE
  • 6. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Attitudini degli endoscopisti nei confronti della sedazione(e anticolinergici.. 0 10 20 30 40 50 60 70 80 Midazolam Diazemuls Diazepam Petidine scopolamine atropine topical anesth topical anesth occas UK USA
  • 7. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Volume 97(9);September 2004:pp 800- 805 Who Is Willing to Undergo Endoscopy Without Sedation: Patients, Nurses, or the Physicians? Madan, Anand MD; Minocha, Anil MD, FACG.
  • 8. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Chi preferisce subire l’endoscopia senza sedazione? Madan A,Minocha A Who Is Willing to Undergo Endoscopy Without Sedation: Patients, Nurses, or the Physicians? 2004; 97:800-805 0 10 20 30 40 50 60 70 80 90 100 % pazienti:desiderio di sedazione medici IP della Gastro IP altri reparti prima della procedura dopo la procedura 127 patients, 117 nurses, and 51 physicians Patients with a high school or associates degree were less likely to forego sedation.
  • 9. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) problemi durante e dopo la procedura LUGAY M,OTTO G,KONG M,MASON DJ, WILETS I. Recovery Time and Safe Discharge of Endoscopy Patients After Conscious Sedation .Gastroenterology Nursing 19;1996:194-200 0 5 10 15 20 25 30 35 40 45 % pain hypertensione Hypotension bradycardia O2 desaturation weakness abdom.pain dizziness intraprocedure adverse occurrences postprocedure adv.occurr. Relaz significativa fra eventi avversi intra e post 69%(228)
  • 10. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Ko of endoscopic procedures. Freeman ML, Timothy Hennessy J, Cass OW, Phelley AM. Carbon dioxide retention and oxygen desaturation during gastrointestinal endoscopy. Gastroenterology 1993; 93: 331-339. Freeman ML. Sedation and monitoring for gastrointestinal endoscopy. Gastrointest Endosc Clin N Am 1994; 94: 475-499. 0 10 20 30 40 50 60 70 80 90 100 % fentanyl midaz desaturaz need o2 ipetens tachic egd colonscopy ercp
  • 11. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Fattori di rischio;eventi sentinella nella endoscopia digestiva? Desaturaz arteriose Wengrower 7% Rosenberg 2(con O2)-35%( senza O2) Freeman 40-70% Bouchut :0.4 con O2, 68% senza Tachicardia: Freeman 30-40% Rosenberg 30%
  • 12. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Rischio di aritmie cardiache 36% paz con mal cardiache 25% paz.con mal.resp. 16% paz apparentemente sani (Gupta Milit.Med 1990)
  • 13. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Fattori di rischio per eventi avversi nella endoscopia in sedazione cosciente Iber et al. (1993) » Mal maggiori » > 70 anni » ERCP. Nagengast (1993) Ischemia card mal cerebrovascolare Disfunz polm Obesità patol. severa anemia sanguinamento gastrointest. Insuff renale o epatica
  • 14. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Anormalità resp.e anestesia topica Mc Nicholas WS, Coffey M, Mc Donnel T, O'Regan R, Fitzgerald MX. Upper airway obstruction during sleep in normal subjects after selective topical oropharyngeal anesthesia. Am Rev Respir Dis 1987;135:1316-9 0 2 4 6 8 10 12 14 16 18 20 controlli anest orofaringea anest.nasale Apnea ostruttiva+ ipopnea apnea centrale+ipopnea apnee e ipopnee tot 9 normal subjects 20-28 y. Pressure sensitive receptor mechanism, afferent limb originating in the upper airway
  • 15. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) O2 per l’endoscopia digestiva tratto sup (Block R, Jankovski J, Johnston D, Wormsley K. The administration of supplementary oxygen to prevent hypoxia during upper alimentary endoscopy. Endoscopy 1993;25:269-73 O2 NO O2 SI Senza O2 Con O2
  • 16. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Saturazione O2 e premed con BDZ SaO2 89-92%; » Bell Scand J Gastroenterol 1990 Ulteriore riduz durante introduz dello strumento specie nei primi 3-4 min dopo premed. (Lieberman Gastroenterology 1985) BDZ+oppioide O2 desat ancora + spiccata (40%) +fattori di rischio (age>65,Cold…); » Hart & Classen Endoscopy 1990) » Cousins Scand J gastroenterol 1990)
  • 17. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Fattori contributori alla desaturazione in O2 durante endoscopia digestiva Ostruzione del faringe Compressione tracheale Distensione gastrica farmaci Anest loc.
  • 18. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Complicazioni che avvengono dopo chir amb. Le Ko postop dopo chir amb possono avere inizio durante la procedura,nella RR o dopo la dimissione. In una RASSEGNA DI 40 CENTRI,86% DELLE Ko avvenivano dopo il termine della chir! Dunque è necessario stretta vigilanza e elevato livello di assistenza durante il periodo postop (Natof, 1985a)
  • 19. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Mortalità e morbilità della oba /obs Office based anesthesia /office based surgery
  • 20. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) PERUGIA: CONDANNATI MEDICI PER PAZIENTE MORTA DURANTE LIPOSUZIONE PERUGIA, 11 MARZO - Si è concluso con la condanna di tutti gli imputati il processo davanti alla Corte d' Appello di Perugia a 3 medici per la morte di una paziente dopo un intervento di liposuzione. In serata i giudici di secondo grado hanno infatti condannato ADG a 2 anni di reclusione, S A a 1 anno e 4 mesi ed AP a 1 anno di reclusione. Tutti sono stati ritenuti colpevoli di omicidio colposo. Francesca De Tommaso morì nel 1993 dopo essersi sottoposta ad un intervento di liposcultura per eliminare 3 chilogrammi di grasso. I 3 medici erano stati processati in primo grado dal pretore di Ancona che aveva inflitto 2 anni di reclusione a DG ed A ed 1 anno e 4 mesi a P. La sentenza era poi stata parzialmente riformata dalla Corte d' Appello del capoluogo marchigiano e quindi annulla dalla Cassazione che aveva rinviato il processo alla Corte d'Appello di Perugia.
  • 21. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) PRATO Liposuzione, Nas sequestrano studio non autorizzato  PRATO, 18 OTTOBRE 2002 - Un locale utilizzato per interventi chirurgici di liposuzione è stato sequestrato dai carabinieri del Nas di Firenze in uno studio medico di Prato. Il locale - che era stato affittato da un chirurgo di Pisa - non avrebbe avuto alcuna autorizzazione per gli interventi di quel tipo. I carabinieri hanno sequestrato anche tutte le apparecchiature e le attrezzature e hanno denunciato il medico e il rappresentante legale dello studio per esercizio medico in locali non autorizzati.
  • 22. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Il chirurgo: «Una disgrazia» Morte dopo la liposuzione. Il dottor P:in tv: «L’intervento era perfettamente riuscito». L’autopsia conferma: la giovane commerciante è stata uccisa da un’embolia. Francavilla, tanti mazzi di fiori davanti al negozio di Mariana . Articolo di: Il Messaggero, Cronaca, Provincia Chieti, 19-02-2002 FRANCAVILLA — E’ stata una tromboembolia polmonare ad uccidere Mariana Bellomo, la giovane mamma deceduta a Francavilla sabato mattina. A confermarlo è stato l’esame autoptico effettuato dal dottor Armando Colagreco dell’istituto legale di Chieti. Quattro, forse addirittura cinque, gli emboli killer che hanno stroncato la vita di Mariana, 24 anni, madre di una bimba di appena 2 anni. E R P il medico che l’ha operata, va in tv e dice di non sentirsi responsabile: «L’intervento era perfettamente riuscito, ed è stato fatto rispettando tutte le procedure dal punto di vista sanitario».
  • 23. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • 24. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Chiesto il rinvio a giudizio per C G, il medico fiorentino che operò Bernadette Fontana, uccisa da un'infezione.Morta per liposuzione "Omicidio volontario" FIRENZE - Sapeva che avrebbe potuto uccidere. Sapeva che qualcuno, prima o poi, sarebbe morto a causa sua. Ma il sapere tutto questo non l'ha messa in guardia contro il pericolo che correva, e che avrebbe fatto correre agli altri. Per questo CG, il medico di Firenze che lo scorso anno fece un intervento di liposuzione su una donna che poì morì per un'infezione post- operatoria, è colpevole. Colpevole a tutti gli effetti. Per il pubblico ministero Paolo Canessa che ha condotto l'inchiesta sul caso, si tratta senza ombra di dubbio di omicidio volontario e per questo ne chiede il rinvio a giudizio: se il giudice accoglierà la richiesta del pm, Costanza Greco dovrà rispondere dell'omicidio di Bernadette Fontana, la donna di 48 anni morta per una grave infezione dopo essere passata sotto i ferri del medico fiorentino.
  • 25. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Ma non è finita qui. La dottoressa G.è anche accusata di lesioni colpose e lesioni volontarie gravi per aver provocato in quello stesso periodo di tempo, fra il 18 e il 20 marzo 1999, analoghe infezioni post-operatorie ad altre due pazienti, L. B., 39 anni, e P. F., 44 anni. Anche loro andarono dalla G.nella speranza di togliersi quei chili di troppo. Ma, dopo essersi sottoposte all'intervento di liposuzione al "Centro servizi Edonè" di Firenze che, tra l'altro, secondo l'accusa, non aveva neanche l'autorizzazione della Regione, se ne sono tornate a casa con un'infezione in eredità. ILpm Canessa è arrivato a contestare il reato di omicidio e di lesioni volontarie al medico dopo aver valutato anche altre ipotesi: la G.infatti inizialmente sembrava avere avuto un comportamento colposo. Ma dopo l'infezione provocata alla prima donna, L.B., la .G non prese precauzioni per evitare anche alle altre pazienti conseguenze disastrose. E continuò a operare senza mascherina chirurgica, a non sterilizzare la sala operatoria, a non prevedere nessuna profilassi antibiotica, utilizzando infine cannule per aspirazione e medicinali non adeguatamente sterilizzati. Per questo alla colpa si è aggiunta nella convinzione degli inquirenti una responsabilità volontaria della G.
  • 26. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Mortalità nella office surgery Morello DC,Colon GA, Fredricks S,Iverson RE,Singer R Patient Safety in Accredited Office Surgical Facilities. Plast Reconstr Surg, Volume 99(6).May 1997.1496-1500 7 casi ( 0.0017 %, 1 / 57,000) 1 decesso 3 gg dopo lifting facciale e frontale 2 decessi da occlusione della LAD ,1 durante mastoplast addit.e 1 4 h dopo rinoplastica. 3 decessi da complicanze intraop:1 /133,558 » ipossia cerebrale durante addominoplastica ,con decesso dopo 11 gg: – Un pnx iperteso durante mastoplastica con decesso 4 h più tardi – Un arresto cardioresp (con decesso più tardi) durante decompressione tunnel carpale
  • 27. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Incidenza di complicanze a confronto:office based vs day surg.centers Warner, M. A., Shields, S. E., and Chute, C. G. Major morbidity and mortality within 1 month of ambulatory surgery and anesthesia.J.A.M.A. 270: 1437, 1993 Natof, H. E. Complications associated with ambulatory surgery. J.A.M.A. 244: 1116, 1980 emorragia infezione Trasf in ospedale mortalità Morello 0,24% 0.09% 0.03% 0,0017% 1/57000 Natof 0.55% 0.74% 0.12% 0 Warner 0,0087 1/11273 14 MI 7 SNC 5 emb polm 5 insuff resp
  • 28. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Morello DC,Colon GA, Fredricks S,Iverson RE,Singer R Patient Safety in Accredited Office Surgical Facilities. Plast Reconstr Surg, Volume 99(6).May 1997.1496-1500 Questionario inviato ai 418 AAAASF,uffici chir accreditati Ripetizione del questionario alcune settimane a dopo a chi non aveva risposto 241 risposte :57.7 % (organizzazione curata da una ditta esterna , Chalana, Inc).
  • 29. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Casistica Morello DC,Colon GA, Fredricks S,Iverson RE,Singer R Patient Safety in Accredited Office Surgical Facilities. Plast Reconstr Surg, Volume 99(6).May 1997.1496-1500 400,675 interventi in 5 anni (Jan1, 1989 - Dec 31, 1993) » 253,355 estetici (63.2 %) ,147,320 ricostruttive (36.8 %). Complicazioni : 1877 (1/ 213 ), 0.47 % » Emorragie(ematomi intra-postop):965 ,1 /415 (0.24 %). » Episodi ipertensivi :414 ,1 /968 0.1 %). » Infezione (infezione maggiore o sepsi ) 350 , 1/1145 (0.09 %). » Ipotensione intra e postop :148 ,1 / 2707 (0.04 %). » Ritorno in sala op entro 24 h: 530 casi, 1/ 756 , (0.13 %, ) » Ospedalizzazione precauzionale 126 casi, 1/ 3180 (0.03 %)
  • 30. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Complicanze della office chirurgia plastica From:   Keyes: Plast Reconstr Surg, Volume 113(6).May 2004.1760-1770
  • 31. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Aritmie cardiache
  • 32. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Alterazioni della PA Intraop.
  • 33. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Trombosi venosa profonda/embolia polmonare
  • 34. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Pneumotorace
  • 35. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Worthington LM, Flynn PJ, Strunin L. Death in the dental chair — an avoidable catastrophe? British Journal of Anaesthesia 1998; 80:131-132. Attualmente circa 300 000 paz con GA per proc dentarie MINORI in UK. 2 decedono . » Anaesthesia most commonly consists of a mixture of oxygen, nitrous oxide and halothane and is administered in general dental practices, community dental surgeries and hospitals. dei 26 paz deceduti durante anest per dent. 1984–1993 (informaz da British Dental Association) > 50% bambini <16 anni L’eziol era equamente distribuita fra difficoltà resp e collasso cc improvviso Il decorso tipico era arresto card improvviso senza segni premonitori con resuscitazione impossibile ;all’autopsia nulla !
  • 36. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Mortality on the dental chair (UK) :1984-1993 Seel D. Dental General Anaesthesia. Report of a Clinical Standards Advisory Group Committee on General Anaesthesia for Dentistry. London: Department of Health, 1995 Poswillo D. General anaesthesia, sedation and resuscitation in dentistry. Report of an Expert Working Party for the Standing Dental Advisory Committee. London: Department of Health, 1990. O2 /N2O/aloth Mortalità 9/ 1.000.000, i.e 1/111.0000 50 % <16 anni Cause;resp diff e improvviso collasso cc.
  • 37. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Decessi sulla sedia del dentista in UK Coplans MP, Curson I..eaths associated with dentistry.British Dental Journal 1982; 153:357-363. Coplans MP, Curson I.Deaths associated with dentistry.and dental disease. Anaesthesia1993; 48:435-438 Seel D. Dental General Anaesthesia. Report of a Clinical Standards Advisory Group Committee on General Anaesthesia for Dentistry. London: Department of Health, 1995 Poswillo D. General anaesthesia, sedation and resuscitation in dentistry. Report of an Expert Working Party for the Standing Dental Advisory Committee. London: Department of Health, 1990 0 10 20 30 40 50 60 70 80 90 100 tot numb. 1970-79 1980-89 1990-99 GA . 15 million GA
  • 38. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Decessi da chirurgia dentaria e maxillo-faciale 0/416. 561 paz (1989), 147 medici,AG,sedazione e/o locale :871 episodi sincopali (nessuno in AG...) » D'Eramo EM. Morbidity and mortality with outpatient anesthesia. The Massachusetts experience. J Oral Maxillofac Surg 1992;50:700-704. 1/274.000 » Tomlin PJ. Death in outpatient dental anesthetic practice. Anaesthesia 1974;29:551-570. 1 / 229 730 » Coplans MP, Curson I. Deaths associated with dentistry. Br Dent J 1982;153:357-369. » Variabilità delle cifre………….
  • 39. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Jastak JT, Peskin RM. Major morbidity or mortality from office anesthetic procedures: a closed-claim analysis of 13 cases. Anesth Prog. 1991 Mar-Apr;38(2):39-44. A closed-claim analysis(cartelle,deposizioni,informazioni,autopsie,pro c legali) dei decessi legati all’anestesia e danni permanenti nel contesto dell’ambulatorio dentistico In cooperaz con il principale assicuratore della categoria (dentisti, chir maxillo faciali, anestesisti del settore) Un totale di 13 casi fra 1974 e 1989
  • 40. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Risultati dell’analisi dei closed-claim delle morti anestetiche nell’ambulatorioi dentistico La maggioranza dei paz erano ASA status II o III. Molti con patologie preesistenti:obesità patologica,mal cardiache,epilessia,COPD……… Ipossia da ostruz delle vie aeree e/o depress resp la causa + frequente La maggior parte delle volte evitabili…… Estremi di età e ASA >1 indicano rischio aum nel contesto dell’anest. office dentistica!
  • 41. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Eventi dannosi in ufficio 0 10 20 30 40 50 % eventi resp probl cardiovasc probl.attrezz probl con farmaci traumi da aghi ?? Errori di dosaggio,allergia,IM Broncospasmo,depressione resp severa,ipossia,fallita o errata intubaz,ostruzione…
  • 42. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Mortalità in odonto
  • 43. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) General Anesthesia in Dentistry da Nkansah PJ, Haas DA, Sato MA. Mortality incidence in outpatient anesthesia for dentistry in Ontario. Oral Surg Oral Med Oral Pathol 1997;83:647. Poswillo report
  • 44. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Anesthesia providers and hospital-based surgical procedures,1970-1996. from Cromwell J. Barriers in achieving a cost-effective workforce mix: lessons from anesthesiology. J Health Policy Law 1999;24:1333.
  • 45. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Linee guida della American Academy of Oral and Maxillofacial Surgery (AAOMS) Parameters and pathways: clinical practice guidelines for oral and maxillofacial surgery, version 2.0. Philadelphia: W.B. Saunders, 1995 Parametri assistenziali che riflettono il consenso di gruppi di praticanti(società,associazioni…) :strategie di trattamento dei pazienti,con » Linee guida » Criteri clinici » Standard » American Academy of Oral and Maxillofacial Surgery (AAOMS) e ASA :documentazione delle sedazioni: » Registrazione di tutti I farmaci,dosaggi,segni vitali,monitoraggi e sedi di iniezione parenterali Parameters and pathways: Clinical practice guidelines for oral and maxillofacial surgery, version 3.0. Philadelphia: W.B. Saunders, 2000 Revisione e aggiornamento ; » Personale » Documentazione » Assistenza postop. Sedazione aggiornata come “time-oriented anesthesia record" cioè documenta farmaci,dosi;vie;monitoraggio (ECG,PA,SaO2)continuo con orari.
  • 46. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Linee guida della ASA per la sedazione 1996 Practice guidelines for sedation and analgesia by non- anesthesiologists.Anesthesiology 1996; 84:459-471 Registrazione simultanea dei: » livelli di coscienza » funzione resp » emodinamica » prima,durante la procedura ad intervalli regolari,;nella fase di ripresa e al momento della dimissione Anche la chir maxillo faciale ha poi definito più precisamente I ciriteri per il monitoraggio postop e la dimissione Invece di “ segni vitali stabili prima della dimissione” Ora specificamente raccomanda "determinazione e documentazione della ossigenazione,ventilazione,circolazione e temperatura stabili prima della dimissione” Nel 2000 è stato stabilito che il chirurgo determini che “il paziente è ritornato al suo stato basale fisico e mentale di prima dell’intervento e non è più a rischio di depressione cardiorespiratoria” In passato la formula era “il paziente risponde appropriatamente”
  • 47. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Personale aggiuntivo 1 persona preparata e competente per BLS (il chirurgo deve essere ALS se somministra sedazione…) 2 persone con BCLS o equivalente in caso di AG + recentemente ASA e American Association of Pediatrics (AAP) hanno definito le quqlifiche :AAPnelle linee guida ultime Definisce la presenza oltre al chirurgo di una altra persona in caso di sedazione profonda la cui unica responsabilità sia di osservare costantemente “i segni vitali del paziente,la pervietà delle vie aeree e la’deguatzza della ventilazione e per somministrare farmaci” Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures. Pediatrics 1992;89:1110-1115 Nell’ ASA "Statement of Qualifications of Anesthesia Providers in the Office-Based Setting," (1999),è scritto che"ASA believes that anesthesiologist participation in an office-based surgery is optimally desirable as an important anesthesia safety standard and will always support such a standard. It does not oppose however regulatory requirements that, where necessary, speak merely in terms of `physician supervision‘”
  • 48. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Collaborazione su indicazioni per pazienti in ambito OBS/OBA ASA Committee on Ambulatory Surgical Care Society for Ambulatory Anesthesia (SAMBA) stanno sviluppando policies to safeguard the increasing numbers Anesthesia Patient Safety Foundation Dipartimenti della salute e società di anestesia locali per creare dei legami con le società di accreditamento interazione con American College of Surgeons (ACS).
  • 49. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Cause di morte durante liposuzione. Grazer F, deJong RH. Fatal outcomes from liposuction: census survey of cosmetic surgeons. Plast Reconstr Surg 2000;105:436-46. Embolia polmonare 23% Perforazione visceri addominali 14,6% Anestesiologiche 10% Embolia grassosa 8,5% Insuff cardioresp 5,4% Infez massiva 5,4% Emorragia 4,6% Sconosciuta o confidenziale 28,5% Mortalità globale 19,1 per 100.000,ossia 1/5000
  • 50. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Complicazioni delle liposuzioni per area trattata Grazer F, deJong RH. Fatal outcomes from liposuction: census survey of cosmetic surgeons. Plast Reconstr Surg 2000;105:436-46. 72 39 3 14 8 6 addome natiche,estr.i nf estr sup dorso sup dorso inf testa,collo
  • 51. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Mortalità da liposuzione .Grazer F, deJong RH. Fatal outcomes from liposuction: census survey of cosmetic surgeons. Plast Reconstr Surg 2000;105:436-46. sede Morti tot Morti % Sede chir % office 62 47,7% 45% Day surg 39 30% 29% Sala op ospedale 22 17% 26% sconosciuta 7 5,4%
  • 52. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) 21 luglio 2000,UK.,eadings21 luglio 2000,UK.,eadings Vietata AG nello studio dentisticoVietata AG nello studio dentistico 18 mesi di tempo per la transizione in ambiente ospedaliero. 18 mesi di tempo per la transizione in ambiente ospedaliero.
  • 53. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) August 10, 2000, Florida Board of Medicine August 10, 2000, Florida Board of Medicine 90 days moratorium on Office surgery 90 days moratorium on Office surgery ..."there is an immediate danger to the health,safety and welfare of patients".... ..."there is an immediate danger to the health,safety and welfare of patients"....
  • 54. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Conclusioni In ambulatorio non si puo fare di tutto Selezione dei pazienti Selezione delle procedure chir; – Selezione degli operatori……… –Il rischio clinico e le possibili sequele medico legali sono maggiori!
  • 55. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Numeratore/denominatore:Casistica/co mplicanze……..
  • 56. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Problemi dell'officeProblemi dell'office L’anestesia è divenuta + sicura…L’anestesia è divenuta + sicura… Migliorato monitoraggio(linee guida)Migliorato monitoraggio(linee guida) Farmaci più sicuriFarmaci più sicuri Conoscenza migliore dei rischiConoscenza migliore dei rischi Aumentata disponibilità degli anestesisti(numerica….)Aumentata disponibilità degli anestesisti(numerica….) Ma.....Ma..... nell'office le risorse ospedaliere non ci sono!nell'office le risorse ospedaliere non ci sono! Ed è la capacità ed esperienza del personale che garantisce la sicurezza!Ed è la capacità ed esperienza del personale che garantisce la sicurezza!
  • 57. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Cause di danno MAC?? Errori da farmaci,in partic.oppioidi nei paz ambulatoriali….. Queste tendenze avvertono chir ed anest dei rischi e chiedono che entrambi definiscano bene quali pazienti e quali procedure siano approriate per la struttura office….. Si deve assolutamente evitare di soggiacere alle pressioni economiche di risparmio/guadagno ricorrendo alla office chir !
  • 58. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Attività ASA e SAMBA:Task Force on OBA Attività ASA e SAMBA:Task Force on OBA Committee on ambulatory surgical careCommittee on ambulatory surgical care ASA OBA guidelines 1999ASA OBA guidelines 1999 OBA Practice manual ottobre 2000OBA Practice manual ottobre 2000 ASA workshops su OBA:nov 1999,Luglio 2002ASA workshops su OBA:nov 1999,Luglio 2002 ASA OBA training workshops genn 2000,aprASA OBA training workshops genn 2000,apr Legame con le principali associaz di certificazione e scientifiche:JCAHO,AAHC,AAASF,ACS,ASPS,NPSF,MHAUS,FSMB,OIG…. Legame con le principali associaz di certificazione e scientifiche:JCAHO,AAHC,AAASF,ACS,ASPS,NPSF,MHAUS,FSMB,OIG….
  • 59. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Office based anesthesiaOffice based anesthesia sfida del nuovo millenniosfida del nuovo millennio Gli standard assistenziali non devono essere inferiori a quelli ambulatoriali o ospedalieri Gli standard assistenziali non devono essere inferiori a quelli ambulatoriali o ospedalieri La sfida per gli anestesisti è quella di trasportare l’esperienza e i modelli di pratica acquisiti nelle sale op ospedaliere agli ambienti office… La sfida per gli anestesisti è quella di trasportare l’esperienza e i modelli di pratica acquisiti nelle sale op ospedaliere agli ambienti office…
  • 60. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Criteri di selezione dei pazienti Figure
  • 61. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Home -> Professional Resources Since Sept. 1, 2000, physician's offices that do more than local anesthesia or sedation procedures have been required to register with the Board of Medical Examiners (BME), pay a registration fee and comply with certain rules. Offices that are already accredited by the joint Commission on Accreditation of Healthcare Organizations, the American Association for the Accreditation of Ambulatory Surgery Facilities, or the Accreditation for Ambulatory Health Care are exempted. The BME has adopted the ASA standards and guidelines (see http://www.asahq.org). Therefore, the same safety measures used in hospitals are incorporated into the office setting. The following are highlights of the rules: preoperative evaluation, informed consent (including informing the patient if care is shared with other non-physician providers), intraoperative monitoring, secondary power source in the OR, properly serviced and maintained equipment with service logs for 7 years, emergency drugs and equipment for CPR and malignant hyperthermia, transfer agreements in case of emergency. In addition, the operating surgeon or anesthesiologist shall maintain current competency in ACLS or PALS. At a minimum, at least two persons, including the surgeon or anesthesiologist, shall maintain current competency in basic life support. Physicians must notify the board within 15 days if a procedure performed results in an unanticipated and unplanned transport of the patient to a hospital for observation or treatment for a period in excess of 24 hours, or a patient's death intraoperatively or within the immediate postoperative period. Immediate postoperative period is defined as 72 hours. The Board of Medical Examiners voted to adopt the proposed rules at its meeting on March 31, 2000. Download the BME rules:
  • 62. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Sistema raccomandato per valutazione preop. (ASA task force on preanesthesia evaluation) CATEGORIA CHIRURGICA υ 1 2 3 4 5 CLASSE ANESTETICA: π 1 giorno intervento giorno intervento giorno intervento Medico curante prima del giorno dell’intervento Anestesista prima del giorno dell’intervento 2 giorno intervento giorno intervento Medico curante prima del giorno dell’intervento Anestesista prima del giorno dell’intervento Anestesista prima del giorno dell’intervento 3 Medico curante prima del giorno dell’intervento Anestesista prima del giorno dell’intervento Anestesista prima del giorno dell’intervento Anestesista prima del giorno dell’intervento Anestesista prima del giorno dell’intervento 4 Medico curante prima del giorno dell’intervento Anestesista prima del giorno dell’intervento Anestesista prima del giorno dell’intervento Anestesista prima del giorno dell’intervento Anestesista prima del giorno dell’intervento
  • 63. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Valutazione preoperatoria: flow chart p a z s a n o s p e c i a l i s t i c a g e n e r a l e c o n s u l e n z a m e d i c a p a z a m m a l a t o e s a m i d i l a b e c g R X S c r e e n i n g p r e o p e r a t o r i o c o m p u t e r i z z a t o C h i r u r g o : p a t o l o g i a c h i r u r g i c a t i p o d i i n t e r v e n t o Valutaz.anestesiologica
  • 64. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Utilizzo di un questionario come screening tool 1 Have you ever had a heart attack? 2 Have you ever had heart trouble? 3 Have you ever had heart failure? 4 Have you ever had fluid in your lungs? 5 Do you have a heart murmur? 6 Did you have rheumatic fever as a child? 7 Do you ever have chest pain, angina, or chest tightness? 8 Have you ever been treated for an irregular heart beat? 9 Do you have high blood pressure? 10 Do you ever have difficulty with your breathing? 11 Do you have asthma, bronchitis, or emphysema? 12 Do you cough frequently? 13 Does climbing one flight of stairs make you short of breath? 14 Does walking one city block make you short of breath?
  • 65. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Utilizzo di un questionario come screening tool 15 Do you now or have you recently smoked cigarettes? If yes, how many packs per day? For how many years? 16 Do you have liver disease, or a history of jaundice or hepatitis? 17 Do you drink more than three drinks of alcohol per day? If yes, how many per week? 18 Do you have indigestion, heartburn, or a hiatus hernia? 19 Do you have a history of thyroid problems? 20 Do you have diabetes? 21 Do you have a kidney problem? 22 Do you have numbness or weakness of your arms or legs? 23 Do you have epilepsy, blackouts, or seizures? 24 Have you had problems with blood clots, or excessive bleeding? 25 Do you have any other important medical problems? Please list. 26 Have you ever had an anaesthetic? If yes, when was your last one? 27 Have you or any member of your family had a reaction to an anaesthetic? 28 Do you have arthritis or pain in your neck or jaw? 29 Do you have dentures, capped or loose teeth? 30 Do you think you may be pregnant? 31 Have you taken prednisone, steroid medication, or cortisone-like drugs in the past year? 32 Please list any food or medication allergies that you have: 33 Please list any medications you are currently taking: 34 Please list any operations you have had in the past: 35 If this is the day of surgery, when did you last eat or drink?
  • 66. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Preop process modelPreop process model from the Cleveland Clinic Foundationfrom the Cleveland Clinic Foundation Demographics and type of surgery Demographics and type of surgery Computer assisted Health screening Computer assisted Health screening Lab,EKG,RXLab,EKG,RX surgery team H&P+lab follow upew Sub-Point surgery team H&P+lab follow upew Sub-Point NewGen.Int Med concult NewGen.Int Med concult medic.spec.consultation medic.spec.consultation Surg.office health y unhealthy Express criteria satisfied Day of surgery yes no Preop anesth cleara nce
  • 67. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Consenso e disposizioni pre e postop. Gentilissimo sig……………….. come il collega chirurgo dott…………………..Le avrà già spiegato,per la riuscita ottimale dell’intervento è importante attenersi scrupolosamente alle raccomandazioni elencate che la preghiamo di leggere,firmare,e conservare per il giorno dell’intervento,quando la riconsegnerà compilata all’anestesista.RingraziandoLa anticipatamente della collaborazione, ----------------------------- Si prega di leggere attentamente e riempire con i dati richiesti lo spazio sopra i puntini(data,città, nome, cognome,intervento,firma). Data:…………………. Città:…………………. Io sottoscritto………………………………………………………. acconsento che l'intervento di ………………………………………………………………….. venga eseguito in anestesia generate e /o locale come spiegato dall’anestesista dott……………………... Dichiaro di attenermi alle seguenti disposizioni: I)non ho assunto alcun cibo nelle 6 ore precedenti l'intervento,ne' liquidi nelle due ore precedenti;(quindi liquidi quali bevande non alcooliche,the zuccherato,coca cola,ecc sono consentiti) 2)di non guidare alcuna automobile o motocicletta o bicicletta, od utilizzare qualsiasi macchinario nelle 24 ore seguenti I'anestesia, 3)di non assumere alcoolici nelle 24 ore seguenti l'anestesia; 4)di farmi riaccompagnare alla mia residenza da un adulto responsabile; 5)di rimanere in compagnia di un adulto responsabile una volta tornato al domicilio; 6) di non assumere alcuna decisione importante ne' firmare documenti importanti(testamento,assicurazioni ecc.)nelle 24 ore seguenti; 7)di vestirmi in modo pratico il giorno dell’intervento ,cosicchè il vestiario possa essere facilmente rimosso e indossato e riposto in un armadietto;
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  • 70. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Questionario postoperatorio I e II giornata
  • 71. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) THANK YOU FOR YOURTHANK YOU FOR YOUR ATTENTIONATTENTION
  • 72. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) FINE II
  • 73. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Rao, R. B., Ely, S. F., Hoffman, R. S. Deaths related to liposuction. N. Engl. J. Med. 340: 1471, 1999
  • 74. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) There are three basic types of outpatient surgical facilities: (1) the hospital controlled ambulatory facility; (2) the free-standing ambulatory surgical facility; and (3) the surgical suite in the physician's office. Selection criteria in the office setting Can we perform any kind of surgical procedure in the office? The answer is no. The selection criteria in this setting are similar to standard ambulatory surgery. However, liability and risk office-based practice are greater, compared to the other types of outpatient surgical facilities (hospital controlled ambulatory facility and free-standing ambulatory surgical facility).
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  • 80. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Domino, KB: Office-Based Anesthesia: Lessons Learned from the Closed Claims Project. ASA Newsletter 65(6): 9-11, 15, 2001. Budget-driven decision-making threatens the safety of office-based surgery. Anaesthesia has become remarkably safe because of several factors, including improved monit-oring, safer drugs, heightened awareness of anaesthetic risks, and perhaps most importantly, the increased availability of anaesthesiologists [31••]. In an office, where the hospital resources of emergency personnel and equipment are unavailable, it is the training of the personnel providing the anaesthesia which ensures patient safety. Whereas most office anaesthesia is MAC and therefore might appear to be less dangerous than general anaesthesia, data from the USA closed claims project indicate a rising percentage of claims after MAC in the 1990s [29••]. A sobering statistic is the increase in medication error deaths in the USA caused by anaesthetic and analgesic (primarily opioids) drugs in outpatients over the decade between 1983 and 1993 [32•]. These trends warn the anaesthesiologist and surgeon of the increased risk of office-based anaesthesia, and demand that both the surgeon and anaesthesiologist agree on which patients and which procedures are appropriate for their facility. Compromising patient safety because of pressures to perform relatively inexpensive office surgery must be scrupulously avoided.
  • 81. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Procedures performed under MAC in the informal setting of the physician's office require heightened vigilance by the anaesthesiologist. A review of the ASA closed claims project database revealed that claims involving MAC have increased from 1.6% of the total claims in the 1970s to 6% in the 1990s [29••]. The severity of these claims is similar to those occurring under general anaesthesia, including death (34%) and permanent brain damage (19%). Overall, the data from this project suggest that improved monitoring, notably pulse oximetry and end-tidal CO2 detection, has decreased patient morbidity, as reflected by a decrease in ventilatory complications relative to cardiac complications [30•].
  • 82. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Patients filing claims for adverse anesthesia events in the office-based setting exhibited similar demographic characteristics to patients filing claims in other ambulatory settings [Table 1]. Most were middle-aged, ASA Physical Status 1 or ASA Physical Status 2 women undergoing elective surgery under general anesthesia. Dental and plastic surgery were the most common procedures performed in the office-based group. Both ambulatory groups were generally younger and healthier than inpatients in the Closed Claims database.2
  • 83. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Severity of Injury The severity of injury for office-based claims was greater than for other ambulatory anesthesia claims [Figure 1]. Most (62 percent) ambulatory anesthesia claims were for a temporary and nondisabling injury, compared to 21 percent of office-based claims (P <0.01). In contrast, 64 percent of office-based claims were for death, compared to 21 percent of ambulatory anesthesia claims (P <0.01). Although these data may reflect decreased patient safety in the office-based setting , the lack of denominator data (e.g., the number of cases performed in each setting) prevents the estimation of risk or safety. In addition, the data may reflect a difference in patient liability profile and propensity to sue in the office- based versus ambulatory care settings.
  • 84. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Mechanism of Injury The "damaging event" is the particular aspect of anesthesia management that led to patient injury. The most common damaging events in the Closed Claims database overall (including inpatient and pain claims) are respiratory system (22 percent), cardiovascular system (11 percent) and equipment-related (10 percent) events. The damaging events in office-based claims involved mostly respiratory system events (50 percent) and drug-related events (25 percent) [Table 2]. The respiratory system damaging events in office-based claims included airway obstruction, bronchospasm, inadequate oxygenation-ventilation and esophageal intubation. The drug-related damaging events included wrong dose or drug, malignant hyperthermia and allergic drug reaction. Although there was a trend for an increase in respiratory system events in the office-based claims compared to other ambulatory anesthesia claims, this difference was not statistically significant [Table 2]. The injury in office-based claims against anesthesiologists occurred through intra-anesthesia in most claims (64 percent), in the recovery phase in 14 percent and after discharge in 21 percent of claims. The location of the damaging event was similar in other ambulatory anesthesia claims, although there was a trend for fewer injuries occurring after discharge (7 percent of ambulatory claims).
  • 85. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Preventability of Injury In contrast to injuries in ambulatory anesthesia claims, a higher proportion of injuries in office-based claims were judged by the Closed Claims reviewers as being potentially preventable by better monitoring [Figure 2]. More than 46 percent of office-based injuries were judged to be preventable by better monitoring, in contrast to only 13 percent of ambulatory anesthesia claims (P<0.01). All the potentially preventable office-based injuries resulted from adverse respiratory events in the recovery or postoperative periods, which were judged to be preventable by use of pulse oximetry. This profile is quite different from injuries occurring during other ambulatory anesthesia claims.
  • 86. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Liability and Payment There was a trend to judge the anesthesia care as sub-standard more frequently in the office-based claims than in other ambulatory claims. Fifty percent of office- based claims had received care that was clearly substandard compared to 34 percent of ambulatory anesthesia claims (difference not statistically significant). Although anesthesia care met standards in 36 percent of office-based claims, postoperative care after discharge was substandard in several of these claims. Payment was made in a greater proportion of office-based claims than ambulatory claims (92 percent versus 59 percent, respectively [Table 3]). In addition, the payment amounts were greater for office-based claims (median payment of $200,000) than for other ambulatory anesthesia claims (median payment of $85,000). This is not surprising since the payment amount correlates with severity of injury, and office-based claims involved more severe injuries. 3 There was, however, a broad range of payment in both groups reflecting patient demographics, severity of injury, standard of care and regional differences (Table 3). In summary, office-based claims (although few in number due to the delay in entering the database) had a greater severity of injury and higher proportion and amount of payment than claims from other ambulatory anesthesia settings. In addition, a greater proportion of injuries in office-based claims were judged to be preventable by monitoring, especially in the postoperative period. These preliminary data suggest that safety efforts involving office-based anesthesia should focus on improving care in the recovery and postoperative phases.
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  • 88. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Caratteristiche generali degli standard e linee guida utili per anestesia
  • 89. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Harvard University Hospitals in Boston [3]. These patient care practice guidelines were followed by the development of Standards for Basic Intraoperative Monitoring by the American Society of Anesthesiologists [4]. The standards were promoted as uniform practice guidelines for anesthesia care. In an effort to standardize clinical monitoring during anesthesia care across the country, these guidelines were applied to the operating room and any other alternative sites where anesthesia care would be delivered. As well as the standard monitoring of electrocardiography, pulse rate and blood pressure, capnography, pulse oximetry and temperature monitoring also became national standards. Individual practice site requirements were also defined (Table 2). It is vital that each anesthesia care site meet established standards. General ethical and responsible practice metho-dologies were presented in the American Society of Anesthesiologist's Guidelines for the Ethical Practice of Anesthesiology [5]. The guidelines are also independent of site.
  • 90. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) The Joint Commission on Accreditation of Healthcare Organizations mandates one uniform standard for anesthesia care in all locations within a healthcare facility, including operating rooms and alternative sites. ‘The standards ... apply when any patients, in any setting, receive, for any purpose, by any route, general, spinal, or other major regional anesthesia; or sedation (with or without analgesia) for which there is reasonable expectation that in the manner used the sedation/analgesia will result in the loss of protective reflexes for a significant percentage of a group of patients.’ [5]. The Director of Anesthesiology has complete facility-wide responsibility for the quality of anesthesia care provided whether delivered by an anesthesiologist or other provider. The American Society of Anesthesiologists has also developed guidelines for non-anesthesiologists providing sedation and analgesia both inside and outside the operating room (Table 3) [6]. Guidelines have been developed by other medical and dental organizations for the care of patients undergoing procedures requiring sedation or anesthesia [7-11]. These include endoscopic procedures by gastroenterologists, electroconvulsive therapy by psychiatrists, and invasive procedures performed on pediatric patients. The Academy of Pediatrics was one of the first professional organizations to develop guidelines for the administration of sedation by its members
  • 91. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Although there have often not been specific, new policies developed for anesthesia care in alternative sites, the World Wide Web has provided widespread availability and easy dispersion of patient care policies and guidelines already in place. Both the Canadian Anaesthetists' Society (Guidelines for the Practice of Anaesthesia Outside a Hospital [12•]) and the Australian and New Zealand College of Anaesthetists have developed policies for alternative site anesthesia care [13] for patient monitoring, anesthetic equipment, sedation for specific procedures and patient recovery. It is clear that guidelines for anesthetic practice must provide the same quality of patient care for patients being cared for outside the operating room as for those undergoing operating room care. This includes all aspects of patient care, including pre-procedural evaluation and post-anesthesia care and recovery. The care standards must be uniform even if alternative sites do not have dedicated recovery facilities and personnel. The American Society of Post-Anesthesia Nurses has guidelines requiring one-to-one nursing for patients requiring life support (mechanical ventilation, vasopressors) with a second nurse available, and one-to-two nursing for stable cases after major procedures and for pediatric patients [14]. One-to-three nursing is appropriate for uncomplicated adults. In most countries, the Department of Anesthesia has overall administrative responsibility for recovery facilities. Not only must recommended national physician organizational guidelines be met, but all facilities must also conform to hospital standards developed and published by national standards organizations.
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  • 105. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Etichettatura delle siringhe!!!
  • 106. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Principi fondamentaliThe fundamental principle that must govern OBA is that patient safety cannot be sacrificed for any of the aforementioned four major considerations—i.e., the standard of anesthetic care does not decrease because of venue change (11). Indeed, because OBA is a subset of ambulatory anesthesia, the ASA guidelines for ambulatory anesthesia and surgery as well as the more recently adopted guidelines for office-based anesthesia must be followed. The two sets of guidelines emphasize the need for 1.Adequate professional and administrative staff, as well as housekeeping and maintenance personnel. 2.Preoperative evaluation with necessary tests and consultations as medically indicated. 3.The development of an anesthesia plan acceptable to the patient, the administration or medical direction of same, as well as the discharge of the patient remain physician responsibilities. 4.Patients who receive other than unsupplemented local anesthesia must be discharged with a responsible adult and provided written postoperative and follow-up instructions. Because the office facilities vary considerably, anesthesiologists must ensure that the facility is adequately equipped, with the following as a minimum: 5.Sufficient space and electrical outlets plus adequate illumination must be provided, including backup power (this is listed first because space is something for which anesthesiologists frequently must fight in the office as well as the hospital or ASF). 6.A reliable source of oxygen adequate for the length of the procedure plus a backup supply, the latter to be at least equivalent to an E cylinder, and the ability to administer positive pressure ventilation. 7.Emergency cart with defibrillator and appropriate drugs. 8.A reliable source of motor-driven suction. 9.If inhaled anesthetics are to be used, an anesthesia machine equivalent to that of the hospital operating room and a system for scavenging waste anesthetic gas must be available. 10.Basic monitoring of oxygenation (pulse oximetry), ventilation (minute ventilation for general anesthesia and capnography for intubation), circulation (blood pressure every 5 min and continuous electrocardiogram display), and temperature (when clinically significant changes in temperature are intended, anticipated, or suggested) is essential. 11.All applicable building and safety codes and facility standards must be observed and federal, state, and local laws obeyed.
  • 107. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Principi fondamentali 2 Less obvious, but equally important, is the need to review policies and procedures, including transfer protocols in the event that hospitalization is required. Similarly, the capabilities of both the facility and the surgeon must be equal to the task of handling the proposed procedure. Moss (12), who led the fight to regulate OBA and surgery in New Jersey, has addressed the issue of cost required to meet reasonable standards: “The $2500 pulse oximeter or the $15,000 refurbished anesthesia machine spread over years of use and thousands of patients makes the per-patient cost insignificant.” He also emphasized the need for complete evaluation of an office before agreeing to provide OBA. Although physical plant, anesthesia equipment, and monitors are obvious considerations, support staffing, capability of the surgeon, facility protocols, and policies must also be evaluated.
  • 108. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Raccomandazioni ASA,ASAPS e ASPS 1. Be accredited by a national or state recognized accrediting agency/organization such as the American Association for Accreditation for Ambulatory Surgery Facilities (AAAASF), Accreditation Association for Ambulatory Health Care (AAAHC), or the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO). 2. Be certified to participate in the Medicare program under Title XVIII. 3. Be licensed by the state in which the facility is located. regular inspections and report to their state agencies, provide ongoing staff training, credential their personnel, and have emergency equipment on hand such as crash carts.
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  • 110. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Porterfield and Franklin Porterfield HW, Franklin LT. The use of general anesthesia in the office surgery facility. Clin Plast Surg 1983;10:289- 294. reviewed their 16 years of experience in office-based plastic surgery procedures. They performed 13 080 cases under local anesthesia with or without sedation and 5038 under general anesthesia. They concluded that to maintain a low admission rate of 0.02% it is essential to have adequate and rational selection criteria, based on the patients' medical health and the surgical procedure. They included ASA I or II patients and procedures without extensive blood loss which were completed within a time frame that allowed the patient to awaken adequately and leave the facility by late in the afternoon [10].
  • 111. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Davis [11] Davis JE, Sugioka K. Selecting the patient for major ambulatory surgery. Surgical anesthesiology evaluations. Surgical Clinics of Northamerica 1987;67(4):721-732 selected surgical procedures based on the intensity of postoperative surgical care. He divided the surgical procedures into four levels (I-IV) (Figure 1) [11]. Those procedures appropiate for office-based surgery and anesthesia belong to level I, where no postoperative care is needed. However, the line of demarcation can shift to the right, and surgical procedures belonging to level Ia or II can be included in the office, depending on the surgical and anesthetic skills, on the office-resources, on the proximity to a hospital and, most importantly, on the patient's medical health. This means that surgical procedures performed in the office can belong either to level I, Ia or II. Tobin also considered that the extent of the surgery should be determined more by the nature of the recovery period than by the surgical procedure itself and patients should be in excellent health with no significant medical problems [2].
  • 112. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Limits of the office setting Why is it so critical to perform an adequate selection of the patient and the surgical procedure? Because there are of course some limits in the office setting. First, based on the limited scope of the office-unit (as well as in the free-standing facility), both the staff and medical capabilities are less extensive than those within a hospital. Second, the service is likely to be available on limited basis. Urgent care would be referred to an hospital emergency department. Finally, the office surgical suite is designed to treat patients whose stay is normally less than 4 h. It is not designed to ‘even occasionally’ hold a patient for a 24-h observation (such as in a free-standing unit or a hospital). In those exceptional cases, the patient would be referred to a hospital of reference (Figure 2) [9].
  • 113. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Figure
  • 114. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Diapo della aggressività interventi da anest ambulat e schemi per ospedale
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  • 116. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Mortalità durante OBA 1.A 3-yr-old boy developed a seizure followed by cyanosis during laser removal of port wine stains. No oxygen was available. 2.Malignant hyperthermia occurred in a 28-yr-old woman having breast augmentation. Temperature was 107°F (41.67 °C) on arrival in the emergency room. No dantrolene was available. 3.A 51-yr-old man underwent a 9.5-hr combined liposuction, penile enlargement, and face-lift. He was kept in the office overnight under the care of an agency nurse, who noted 2 h later that the patient was in respiratory distress and that the oxygen tank was empty. Paramedics were contacted 30 min later. Not surprisingly, the patient was dead on arrival at a local hospital 40 min later. Se queste procedure fossero state effettuate in un unità di day surg o ospedale……………………… IL probl ha preso tanta cosnsistenza che The risks associated with OBA were considered so great in the United Kingdom that, on July 21, 2000, the administration of general anesthesia in a dentist’s office was banned. Dentists and oral surgeons were given 18 mo to transition their practices to a hospital setting. Considering the emphasis on cost-containment by governmental agencies, the decision to move patients to the more expensive hospital setting must reflect great concern of the United Kingdom authorities concerning the OBA risk to patients.
  • 117. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Morti in ufficio…….. 10San Francisco Examiner 17 August 1993. [Context Link] 11The San Diego Tribune 13 January 1989. [Context Link]
  • 118. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Medicina preventiva vs trattamento delle complicanze Preventive medicine is always preferable to rescue from complications. In addition to adhering to the standards summarized above, careful patient selection is the best way to avoid complications. In particular, patients with comorbid disease, especially chronic obstructive pulmonary disease, epilepsy, heart disease, and obesity, must be evaluated carefully and completely, so specialty consultation can be included when indicated. When in doubt, referral of these patients to a more complete facility than a surgeon’s office is strongly advised, even though such a decision may produce friction—even an acrimonious confrontation—with the referring surgeon, the patient, or both.
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  • 120. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Many surgeons administer intravenous sedation, but for procedures requiring general or regional anaesthesia, they seek the assistance of an anaesthesiologist or certified registered nurse anaesthetist (CRNA) [12•]. The CRNA is often the surgeon's choice if, in the surgeon's opinion, the procedure requires only a slightly deeper level of sedation than the surgeon is accustomed to administering himself. For procedures requiring general anaesthesia in the USA (except New Hampshire), the anaesthesia is administered by an anaesthesiologist, a CRNA supervised by an anaesthesiologist, or a CRNA supervised by the surgeon. In most other developed countries such as Australia or the UK, a specialist anaesthetic medical practitioner must be present if general anaesthesia is administered. Anaesthetic techniques The range of anaesthetic techniques in office-based practice is the same as in hospital-based practice, especially ambulatory surgery. The overriding concern is rapid discharge. Recovery facilities and personnel in the office setting are usually incapable of monitoring patients who are heavily sedated, have a long-lasting spinal block, or are suffering from severe pain or nausea. The majority of office-based anaesthesia is monitored anaesthetic care (MAC). Improvements in monitoring capability, notably continuous pulse oximetry and expired CO2 display, provide the anaesthesiologist a better understanding of the patient's response to sedative and analgesic medications [13•]. Today's anaesthesiologist can more safely provide deep levels of sedation in appropriate patients, however, as in any anaesthetizing location, the critical threshold of patient unresponsiveness must not be crossed unwittingly. An anaesthesiologist can deliberately breach the boundary between MAC and general anaesthesia in appropriate patients if airway equipment is available and both the patient and the surgeon understand the risks. For procedures requiring general anaesthesia in the office, the laryngeal mask airway is a significant technological improvement, not only for routine use but also for the emergency ventilation of patients with an unanticipated difficult airway [14]. Anaesthetic drugs The close control offered by rapidly acting and rapidly eliminated drugs is especially useful in the office setting. Midazolam, propofol, ketamine, and methohexital are the sedative hypnotics we use. A propofol infusion combined with an opioid and sometimes midazolam or ketamine provides an easily adjusted depth of sedation or general anaesthesia [15,16]. A new short-acting benzodiazepine, Ro 48-6791, is being developed and might play a role in office-based anaesthesia [17]. Analgesics administered in office-based anaesthesia include non-steroidal anti-inflammatory drugs and opioids. A short period of relatively profound intraoperative analgesia can be produced using fentanyl, alfentanil, or remifentanil. In the US, remifentanil is infused for both MAC and general anaesthesia, but in Australia it is approved for use only in artificially ventilated patients. There is no major difference between these drugs in the speed of recovery after relatively short anaesthetics; however, recovery from longer anaesthetics should be significantly faster using remifentanil [16]. The haemodynamic response to surgical stimuli is suppressed better by remifentanil than by alfentanil, so remifentanil might be preferable in patients at risk of myocardial ischaemia [18]. When administering remifentanil, provision for postoperative analgesia must be made because pain is one of the chief reasons for delayed discharge from ambulatory surgical centres, and is the third most common reason for return hospital visits [19,20]. Although the respiratory depression and nausea associated with opioids can be particularly troublesome in the office setting (where postoperative care of a patient can delay the following cases), parenteral or oral opioids are the mainstay of postoperative analgesia. 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, ORG 9487, is being developed and might prove ideal for office-based anaesthesia [21]. Inhalational agents are playing an increasing role in office anaesthesia as anaesthesiologists move into this practice. Offices must provide suction for scavenging volatile anaesthetics or the anaesthetic machine must have a charcoal filter. Sevoflurane and desflurane potentially offer a rapid emergence [22,23], an attractive feature in office-based anaesthesia, but these agents are associated with a higher incidence of emergence delirium [22,23]. This delirium can be disquieting for other patients and can tax the limited personnel available in the office setting. Sevoflurane has remarkable cardiovascular stability and is significantly less irritating to the airway than the other halogenated agents [24,25]. If choosing a single halogenated agent for office-based anaesthesia (a reasonable possibility in order to minimize equipment weight and bulk) sevoflurane is a logical choice. Equipment and facilities Anaesthesiologists must be circumspect when asked to provide anaesthesia in a new office location [26]. They assume responsibility for the equipment, facilities, and drugs required to provide safe anaesthesia, and must develop a contingency plan for equipment or power failure. A reliable means of transporting a patient to the nearest hospital in the event of a disaster should be outlined, and the hospital emergency room director should be made aware of the plans to provide anaesthesia in the office. Physiological monitoring of the patient must meet or exceed the relevant local standards for anaesthetic monitoring [27,28]. Procedures performed under MAC in the informal setting of the physician's office require heightened vigilance by the anaesthesiologist. A review of the ASA closed claims project database revealed that claims involving MAC have increased from 1.6% of the total claims in the 1970s to 6% in the 1990s [29••]. The severity of these claims is similar to those occurring under general anaesthesia, including death (34%) and permanent brain damage (19%). Overall, the data from this project suggest that improved monitoring, notably pulse oximetry and end-tidal CO2 detection, has decreased patient morbidity, as reflected by a decrease in ventilatory complications relative
  • 121. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • 122. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Cause della insufficienza rianimativa Attrezzature di rianimazioine inadeguate Monitoragio insufficientemspecie puilsossimetria Erore umano Lento riconoscimento dell’evento Mancanza di esperienza Sovradosaggio gfarmacologico Inadeguata valutazione preop. Inadeguiata valutaz postop
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  • 124. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • 125. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Qualificazioni mediche Specializzazione Partica ospedlaiera nella discipilina Possibilità di ricovero?
  • 126. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Surgical Facility Standards Plastic surgery performed under anesthesia, other than minor local anesthesia and/or minimal oral tranquilization, should be performed in a surgical facility that meets at least one of the following criteria: * accredited by a national or state-recognized accrediting agency/organization such as the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF), the Accreditation Association for Ambulatory Health Care (AAAHC), or the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) * certified to participate in the Medicare program under Title XVIII * licensed by the state in which the facility is located.
  • 127. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Patient Safety in Office-Based Surgery Facilities: II. Patient Selection [COSMETIC SECTION: COSMETIC SPECIAL TOPIC] Iverson, Ronald E. M.D.; Lynch, Dennis J. M.D.; ASPS Task Force on Patient Safety in Office-based Surgery Facilities
  • 128. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Selezione dei pazienti preoperative patient history should include personal health history, identification of comorbidities, social history, family history, medication regimen (prescription and nonprescription), allergies (drug, latex, tape) and reaction, review of the body systems, and availability of a responsible adult to assist with postoperative instructions and care. The physical examination is essential for assessing the patient’s clinical status preoperatively and should include an estimate of general health and appearance; measurement of height and weight; assessment of vital signs, including the heart and lung; and an examination of the anatomical area of the surgery. A sample preoperative history and physical form is shown in
  • 129. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • 130. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Questionario…
  • 131. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)
  • 132. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) identifying comorbidities that are relevant to the procedure or that may predispose the patient to intraoperative or postoperative complications. When evaluating the patient, particular attention should be given to factors such as age, weight, and history of other illnesses, including diabetes mellitus, cardiac diseases, and respiratory conditions. The physician should evaluate the patient for a history of (or potential for) venous thromboembolism, and when indicated, should consult the appropriate ASPS Practice Advisory and/or Clinical Practice Guideline for thrombosis risk ratings and thromboprophylaxis measures. 3,4 The surgeon should refer patients with significant comorbidities to medical specialists when indicated.
  • 133. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) On the basis of the patient’s preoperative history and physical examination results, pertinent tests should be ordered, including: electrocardiogram in patients over 45 years of age electrocardiogram at any age when known cardiac conditions are present complete blood count/blood chemistries, as needed, for detailed evaluation of specific diagnosis, such as anemia, diabetes mellitus, hypertension, diuretic therapy additional tests as appropriate, depending on the patient’s status as determined through the medical history and physical examination or because of the specific procedure being performed (see ASPS Clinical Practice Guideline for specific procedures; http://www.plasticsurgery.org/psf/ psfhome/clinprac/index.htm).
  • 134. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) The ASA House of Delegates approved “Guidelines for Office- Based Anesthesia” in October of 1999 (http://www.asahq.org/ProfInfo/offbasedguide.htm ). These comprehensive guidelines focus on the delivery of safe anesthesia care in doctor’s offices by anesthesiologists and certified registered nurse anesthetists. The ASA Task Force on Office-Based Anesthesia has recently created a manual that provides practical advice for surgeons and anesthesiologists interested in setting up and maintaining a safe office-based surgery environment. The ASPS and ASAPS have taken an unprecedented stance by mandating that all outpatient plastic and cosmetic surgery must be done in an accredited facility. Over a 3-year period that began in June of 1999 and will end in July of 2002, members must transition to perform outpatient surgeries in accredited and/or licensed facilities that meet at least one of the following criteria 2,3
  • 135. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Conclusioni La oba sta crescendo rapidamente ed è necessario regolamentarla come hanno fatto alcuni stati USA California, Florida,e New Jersey,Tezxas :I dugbbi sorti circa la qualità dell’assistenza devono essere dissolti da regolamentazioni appropriate e ragionevoli che coinvolgano i professionisti consnetano La scelta di eseguire interventi in ambulatorio piuttosto che in strutture più attrezzate deve basarsi su considerazioni tecniche legate alal propria professionalità ed allo stto fisico del paziente piuttosto che su consideraziomni economiche.La costo effiacci è soloiun fattore e devono prevalere considerazioni di qualità e scicurezza Negli USA è stata fondata ed è attiva una società (Society for Office-Based Anesthesia)che ha lo scopo di milgiorare continuamente la qualkità dell’assistenza e e la sicurezza dei pazienti e iniziative analoghe devono esser intraprese in Italia per la salvagiardia dei cittadini,mma anche dei professionisti E’ probabile che il sistema assicurativo debba farsi carico anche della OBS e OBA e non posa necesasriamente proporre tariffe basse Per il mioguioramento dellapartica cgirurgica ed anestesiologica ambulatoriale è necassrio seguire delel linee guida nazionali ed internazionali e formare dei professionisti esperti in questo settore ,cher non può che essere un continuum assistenziale che riguarda tutto il perioepratorio
  • 136. Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA) Diapo di esempi attrezz e monitor….