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![Sedationist ……….
• Nurses
– Bluemke DA, Breiter SN. Sedation procedures in MR imaging: safety, effectiveness,
– and nursing effect on examinations. Radiology 2000; 216:645–652.
– Sury MRJ, Hatch DJ, Dicks Mireaux C, Chong WK. Development of a nurse led sedation service for paediatric magnetic resonance imaging.
Lancet 1999; 353:1667–1671
• Physician
– Endoscopists……….
• quality of care and outcome ???Costs??
• Abenstein JP, Warner MA. Anesthesia providers, patient outcomes, and costs. Anesth Analg
1996; 82:1273–1283.
• Silber JH, Kennedy SK, Even-ShoshanO, et al. Anesthesiologist direction and
• patient outcomes. Anesthesiology 2000; 93:152–163.
• Cromwell J, Snyder K. Alternative cost-effective anesthesia care t eams.
• Nurs Econ 2000; 18:185–193.[13], and the cost implications of anesthesia
services .](https://image.slidesharecdn.com/thetravelinganesthesiologist-141207111415-conversion-gate01/85/The-traveling-anesthesiologist-59-320.jpg)
![Special problems of NORA
• remote locations
• limited working space
• electrical interference with monitors and phones
• lighting and temperature inadequacies
• lack of skilled personnel, drugs, and supplies.
• Noises …..are unsettling for the patient and disturb the anesthesiologist. As alarm
recognition occurs 34% of the time under ideal conditions [76], noisy areas like MRI centers make
sound recognition and alarm perception very difficult. A presumed reason is that many alarms
• have similar sounds [77]..](https://image.slidesharecdn.com/thetravelinganesthesiologist-141207111415-conversion-gate01/85/The-traveling-anesthesiologist-65-320.jpg)
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The traveling anesthesiologist
- 1. The traveling anesthesiologist,ossia l’anestesista viaggiante Claudio Melloni Libero professionista melloniclaudio@libero.it Napoli, SIA,2014
- 2. Who is atraveling anesthesiologist(MAAS provider...) • Anesthesiologist(consultant,fully trained,retired from NHS(its me!|!|!),private practitioner • Sedation for many dental facilities,ophtalmology ,plastic surgery & others • Carries his own kit:drugs,equipment…….. • Responsible for : – preop assessment, – intraop care, – postop care(discharge and prescriptions) • Analgesia,antibiotics,special requirements,recommendations……… • Cannot rely on anyone for anything,unless....
- 3. NORA classification •In hospital,but outside OR:radiology,cardiology,endoscopy etc.:NORA,but in hospital. • Out of hospital – day surgery center;OR! NO NORA –office:NORA
- 4. Definizioni • InItalia ambulatorio=office – Day surgery=chirurgia di giorno=struttura attrezzata e riconosciuta:equipped and recognized • USA: office=ufficio (del chirurgo)(of the surgeon) – Ambulatory:equipped and recognized -struttura attrezzata e riconosciuta –Ufficio:non attrezzato,non riconosciuto a meno che non si abiliti per chirurgia…
- 5. Legal constraints •USA vs Italy vs UK • Sedazione cosciente ,sedo/analgesia cosciente..
- 6. MAASS Mobile Anesthesiaand sedation Service
- 7. MAS :memento auderesemper Motoscafo armato silurante
- 8.
- 10. Milwaukee anesthesiologist launchmobile service
- 12. Home About »» Services » » Patient Information » » News & Events » » Resources » » Contact » » 503.594.1774 We provide all your Anesthesia Needs Our many years of experience have given us a unique understanding of your anesthesia needs and help us deliver only the best to your patients, no matter what the setting or situation. 1 2 3 4 5 6 Hospital Anesthesia Services Surgery Centers Mobile/Office Based Anesthesia Services We provide all your anesthesia needs.... our many years of experience give us a unique understanding of your anesthesia needs and help us to deliver only the best to your patients no matter what the setting or situation
- 13. Film: • MilkyWay Anesthesia - Mobile Anesthesia Services - Phoenix, Arizona, USA • Milky Way Anesthesia • http://youtu.be/Ckp24aNVowo
- 14. Expanding the roleof the anesthesiologist ORA • Operating room anesthesia: NORA • Non Operating room anesthesia MAASS •Mobile Anaesthesia and Sedation Service
- 15. Procedures outside op.room(POOR):with/withoutanesth? NORA • “Imaging” – CAT – MRI – Functional cerebral imaging – Interventional neuroadiol – US/CAT guided procedures:biopsies,therapies… – Radiother. – Telether:children! – Brachiter – Radiother intraop – radiochir • Psichiatry – ECT • Cardiology: – Catheter. – CS – Radiofreq.ablation • Gastroenterology – Sup;esofago,gastro…varici esof…. – Colon – Liver biopsies • ,orthop manipul,wounds. Removal of...…. • Surg.offices:everything: – oftalmology:retinoscopy,tonometry,elettr oretinography,,ant chmaber surg(cataract,iridectomy ,angiofluoro… – Plastic surgery :liposuctions,blepharoplasty otoplasty,facial miniliftings – Dental chair assist:implants,max sinus ..odontostomatologia • UrologY – ECSWLT – cistoscopy Laserther
- 16. NORA: organization (suggestions…)and guidelines
- 17. SIAARTI • Recommendationsfor anesthesia and sedation in nonoperating room locations • Raccomandazioni per l’esecuzione dell’anestesia e della sedazione al di fuori dei blocchi operatori . • SIAARTI Study Group for Safety in Anesthesia and Intensive Care . • Coordinator. E. Calderini • Minerva Anestesiologica 2005;71:17-21.
- 18. General organization ofthe guideline: • Definitions and aims • Organization :model • it is suggested that every Dept of Anesth. draft a organization model for treatments outside OR’s….… • Indications • Patient selection:I & II: ASA III with limitations • Supply and communications
- 19. USA • Only2% of residency training programs have formal training in OBA • There is a void in properly educating anesthesiologists on how to prepare themselves for offices. • Hausman LM, Levine AI, Rosenblatt MA: A survey evaluating the training of anesthesiology residents in officebased anesthesia. J Clin Anesth 2006; 18 (7): 499-503.
- 20. ASA Office BasedAnesthesia • Office Based Anesthesia. • Considerations for anesthesiologists in setting up and maintaining a safe office anesthesia environment. • • An information manual completed by the ASA committee in Ambulatory Surgical care and the ASA task force on Office based anesthesia • • Chair… • Project Leader… • • Contribuing authors and task force members…..
- 21. ASA • GUIDELINESFOR OFFICE-BASED ANESTHESIA • Committee of Origin: Ambulatory Surgical Care • (Approved by the ASA House of Delegates on October 13, 1999, and last affirmed on • October 21, 2009) • These guidelines are intended to assist ASA members who are considering the practice of ambulatory anesthesia in the office setting: office-based anesthesia (OBA).
- 22. ASA recognition... •….ASA recognizes the unique needs of this growing practice and the increased requests for ASA members to provide OBA for health care practitioners* who have developed their own office operatories…..
- 23. ASA awareness... •..special problems that ASA members must recognize when administering anesthesia in the office setting. Compared with acute care hospitals and licensed ambulatory surgical facilities, office operatories currently have little or no regulation, oversight or control by federal, state or local laws.
- 24. ASA …. •…..Therefore, ASA members must satisfactorily investigate areas taken for granted in the hospital or ambulatory surgical facility such as governance, organization, construction and equipment, as well as policies and procedures, including fire, safety, drugs, emergencies, staffing, training and unanticipated patient transfers
- 25. Nora focal points:quality and safety Patient selection Surgical choices Complication rate Equipment and support of the facility Training
- 26.
- 27. Problem dimension •Membership Audit, American Society for Aesthetic Plastic Surgery, Inc., Spring 1993. • survey of members of the American Society for Aesthetic Plastic Surgery (ASAPS) • 48.7 % of members perform their aesthetic surgery in an office surgical facility. • Office-based surgery (OBS) accounts for 10 million of all elective procedures performed in the United States double from a decade ago. Although there are no good national registries to accurately determine the amount of surgery done in office, the projections have ranged from 17-24% of all elective ambulatory surgery • AHA.Trends affecting hospitals and health systems May 2005. AHA TrendWatch ChartBook 2009. Available at:http://www.aha.org/aha/trendwatch/chartbook/2009/chart2-9.pdf. (Accessed May 12, 2009)
- 28. OBA point ofview • Succinctly stated, the 1999 HOD-approved guidelines for OBA state, with respect to perioperative care, “The anesthesiologist should adhere to the ‘Basic Standards for Preanesthesia Care,’ ‘Standards for Basic Anesthetic Monitoring,’ ‘Standards for Postanesthesia Care,’ and ‘Guidelines for Ambulatory Anesthesia and Surgery’ as promulgated by ASA.”
- 29. Patient(s) • Thepatients undergoing procedures outside the operating room are often older, medically higher-risk patients • most NORA claims involve higher-risk, elderly patients undergoing nonemergency surgery • Metzner J., Posner K.L., and Domino K.B.: The risk and safety of anesthesia at remote locations: the US closed claims analysis. Current Opinion Anaesthesiology 2009; 22: pp. 502-508
- 30. Diagnosis not made • You see patients during the workup………… • Unknown diseases • Unknown patients…. • Incomplete sense of what we may encounter during the procedure…
- 31. Preanesthetic preparation •Preparation for NORA should be no different from the preparation in the operating room. – Preanesth.visit – Fasting – Premed. – consent • Preanesthetic preparation is very often done by others, who may not consider the interactions between a patient’s physical condition, medications taken and the effects of anesthesia
- 32. Specific conditions thatwarrant special care when providing anesthesia or sedation outside the operating room • Patient unable to cooperate, e.g. severe intellectually disability • Severe gastroesophageal reflux • Medical conditions predisposing patients to reflux, e.g. gastroparesis secondary to diabetes mellitus • Orthopnea • Severe increased intracranial pressure • Decreased level of consciousness/depression of protective airway reflexes • Known difficult intubation • Dental, oral, craniofacial, neck or thoracic abnormalities that could compromise the airway • Presence of respiratory tract infection or unexplained fever • Obstructive sleep apnea • Morbid obesity • Procedures limiting access to the airway • Lengthy, complex or painful procedures • Uncomfortable position • Prone position • Acute trauma • Extremes of age
- 33. Patient, procedure andlocation selection • Several factors prohibit procedures to be safely undertaken outside the operating room: • (1) significant risk of major blood loss;(esophageal varicosities???…….) • (2) extended duration of surgery (>6 h); • (3) critically ill patients; • (4) the need for sophisticated, and at times subspecialized anesthetic or surgical expertise or equipment(cardio-pulmonary bypass, thoracic or intracranial surgery); • (5) supply and support functions or resources are in limited supply or not immediately available; • (6) limited provision for postprocedural care; • (7) the physical plant is inappropriate or fails to meet regulatory standards.
- 34. inappropriate OBA patients • unstable ASA 3 or greater • recent MI in past 6 months • severe cardiomyopathy • uncontrolled HTN • brittle or poorly controlled diabetes • active multiple sclerosis • acute substance abuse (drugs and alcohol) • MH history • severe morbid obesity (BMI >35, if equipment and stretcher size is limited), or morbid obesity (BMI >30 with poorly controlled comorbidities) • severe COPD/ obstructive sleep apnea, • pacemaker or AICD • end-stage renal disease • sickle cell disease • patient on transplant list • dementia (not oriented) • psychologically unstable (rage/anger problems), • Recent stroke within 3 months • myasthenia gravis • lack of adult escort
- 35. Location/space requirements fornonoperating room anesthesia • Adequate size with good access to the patient • Uncluttered floor space • An operating table, trolley or chair which can be readily tilted into Trendelenburg position • Adequate lighting including emergency lighting • Sufficient electrical outlets including clearly marked electrical outlets connected to an emergency back-up power source • Suitable clinical area for recovery of the patient which must include oxygen, suction, resuscitation drugs and equipment • Emergency back-up call system to summon assistance from the main operating room
- 49. Staff • Astrict adherence to minimum;scrubbed+circulating nurses?2? • staff with appropriate training • Interdepartmental/interpersonal cooperation and understanding – All very important when working outside the familiar environment of the operating room
- 51. Location and equipment • Wherever the sedation or anesthetic is performed, appropriate resuscitative equipment and medications for cardiopulmonary resuscitation must be immediately available • ASA.Guidelines for non operating room anesthetizing locations.Http:/www.asahq.org/publicationsAnd Services/sgstoc.htm • Capnography and pulse oximetry are invaluable in a setting where patient observation is limited (e.g. darkened room) or with limited access to the patient (e.g. radiation oncology).
- 52. Procedure • Theanesthesiologist needs to understand the requirements of the procedure, its potential complications, its anticipated duration and the specific needs of the proceduralists. • Specific requirements differ with each type of procedure and are discussed below • New technologies… • New technics…
- 53. Requisiti specifici perl’accreditamento delle Strutture di ...RER • Formato file: PDF • RER • REQUISITI SPECIFICI • REQUISITI MINIMI IMPIANTISTICI E TECNOLOGICI • REQUISITI MINIMI STRUTTURALI • REQUISITI MINIMI ORGANIZZATIVI
- 54. UK? • SURGERYAND GENERAL ANAESTHESIA IN GENERAL PRACTICE PREMISES • Published by The Association of Anaesthetists of Great Britain and Ireland • 9 Bedford Square, London WC1B 3RA • Tel: 0171 631 1650 Fax: 0171 631 4352 •1995
- 55. AAGBI: SURGERY ANDGENERAL ANAESTHESIA IN GENERAL PRACTICE PREMISE • Section I Introduction 1 • Section II Necessary Facilities 3 • (i) Personnel • (ii) Support Staff • (iii) Organisational arrangements • Section III Specialist Services 5 • (i) Anaesthetic services • (ii) Surgical services • Section IV Sterilisation Services 6 • Section V Technical Services 8 • (i) Anaesthetic, resuscitation and • monitoring equipment • (ii) Medical gases • (iii) Volatile anaesthetic agents • (iv) Waste anaesthetic agents • Section VI Quality, Financial and Contractual 10 • Arrangements • References 11
- 57. NORA special skills • NORA requires special skills and attitudes – among 25 neuroanesthesiologists, only 3 were found to administer anesthesia with the magnet inside the operating room intrinsically recognizing the need for a higher level of technical skills. – Archer DP, McTaggart Cowan RA, Falkenstein RJ, et al. Intraoperative mobile magnetic resonance imaging for craniotomy lengthens the procedure but does not increase morbidity. Can J Anesth 2002; 49:420426 • Nontechnical skills are also important since NORA also stresses other qualities, like task management, team-working capability and coordination, situation awareness, and decision-making. • Since NORA involves special risks and difficulties, anaesthetists that are unsafe due either to a lack of knowledge and skills or old age need to be identified – Atkinson RS. The problem of the unsafe anaesthetist. Br J Anaesth 1994; – 73:29–30. – Katz JD. Issues of concern for the aging anesthesiologist. Anesth Analg 2001; – 92:1487–1492.
- 59. Sedationist ………. •Nurses – Bluemke DA, Breiter SN. Sedation procedures in MR imaging: safety, effectiveness, – and nursing effect on examinations. Radiology 2000; 216:645–652. – Sury MRJ, Hatch DJ, Dicks Mireaux C, Chong WK. Development of a nurse led sedation service for paediatric magnetic resonance imaging. Lancet 1999; 353:1667–1671 • Physician – Endoscopists………. • quality of care and outcome ???Costs?? • Abenstein JP, Warner MA. Anesthesia providers, patient outcomes, and costs. Anesth Analg 1996; 82:1273–1283. • Silber JH, Kennedy SK, Even-ShoshanO, et al. Anesthesiologist direction and • patient outcomes. Anesthesiology 2000; 93:152–163. • Cromwell J, Snyder K. Alternative cost-effective anesthesia care t eams. • Nurs Econ 2000; 18:185–193.[13], and the cost implications of anesthesia services .
- 60. • Anesthesia isa discipline that requires the constant vigilance of well trained and experienced providers; safety derives from high-level dedicated care, teamwork,and rapid availability of physicians, especially during medical crises. • Clinical evidence supports the anesthesiologist-led anesthesia care team as the safest and most cost-effective method of delivering anesthesia. – Death and failure to rescue were more frequent when care was not directed by anesthesiologists • However…….Sedation cannot be restricted to anesthesiologists.
- 61. Guidelines for sedationby non anesthesiologists • ASA practice guidelines for sedation and analgesia by non-anesthesiologists.American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non- Anesthesiologists. Anesthesiology 2002; 96:1004–1017.
- 63. main questions •What would happen when a patient’s condition abruptly changes » or • the patient moves to another stage of sedation? • Who would be responsible for complications? • every patient may become unstable, every single sedation analgesic given outside the operating room should be done by • one anesthesiologist/patient/unit of time • the anaesthesiologist should be an experienced intensivist should a crisis occur.
- 64. How to proceed • anesthetic and monitoring equipment check • Make a plan :sedation only.sedation+analgesia ,light,deep,GA • be prepared for a change in procedure. – It is my personal opinion that sedation and analgesia with spontaneous respiration requires greater skills and experience than GA with airway control. – Monitored anesthesia care for disabled children is much less expensive in the dental rehabilitation office than GA in the operating room, but more sentinel events have been reported • All data should be obtained during the procedure, especially when the anesthesiologist is away from the patient; • this may require remote monitoring, special extension tubing, among other means. • be prepared for bad surprises, including sudden movement of the patient, allergies, anaphylactic shock, need for vasopressors.
- 65. Special problems ofNORA • remote locations • limited working space • electrical interference with monitors and phones • lighting and temperature inadequacies • lack of skilled personnel, drugs, and supplies. • Noises …..are unsettling for the patient and disturb the anesthesiologist. As alarm recognition occurs 34% of the time under ideal conditions [76], noisy areas like MRI centers make sound recognition and alarm perception very difficult. A presumed reason is that many alarms • have similar sounds [77]..
- 66. Postoperative surveillance/transportation •Almost all the potentially preventable office-based injuries result from adverse respiratory events in the recovery or postoperative periods; therefore, strict surveillance should be exercised until full recovery. • During transportation all the equipment necessary for a safe journey should be at hand. • The ideal recovery area should be ‘near’ the location where the patient was treated. The safe solution is to place patients in the postanesthesia care unit (PACU) or recovery room, as for surgical patients.
- 68. Safe Discharge •To be discharged, the patient must have – stable vital signs:BP,HR,SaO2,resp. – be fully oriented – ambulate without dizziness – with minimal pain – Minimal/no nausea or vomiting – Minimal or no bleeding – Able to dress himself . Scores? The patient should receive specific written instructions, including management of pain, relevant postoperative complications, and routine and emergency possibilities
- 69. Riduzione dello stress ansia dolore Ambiente attesa Durata STRESS Sedazione:la notte prima,il giorno stesso,approccio psicologico,ecc,ecc Analgesia;oppioidi, N2O,A.L. Musica,relax,TV,distrazione,
- 70. Conclusion • challenges: providing care for more medically complex patients while adapting to fewer resources, with lack of support system commonly available in the operating room • No anesthesia or sedation performed outside the operating room should be considered minor; it requires skill, experience, and organization. • Anesthetic needs should be evaluated from a safety point of view. • Patient preparation, consent, sedation, analgesia or GA should be performed utilizing the same standards as adopted for the operating room
- 71. PRE AND POSTOPINSTRUCTIONS
- 72. Recommendations Poliambulatorio ………………………….. Modulo di consenso informato per procedure chirurgiche ambulatoriali o day surgery Da consegnare al momento della prenotazione e riportare . Si prega di leggere attentamente e riempire con i dati richiesti sopra le parti indicate dai puntini(data,città,cognome,nome,intervento,firma). Data:…………………. Città:…………………. Io sottoscritto………………………………………………………. Dichiaro di attenermi alle seguenti disposizioni: I)non assumere alcun cibo nelle 6 ore precedenti l'intervento,ne' liquidi nelle due ore precedenti; raccomandazioni per il digiuno preoperatorio* MATERIALE INGERITO TEMPO MINIMO DI DIGIUNO Liquidi chiari (acqua,caffè,the, succo senza polpa, bibite gasate) 2 ore Pasto leggero (toast e bibita) 6 ore 2)di non guidare alcuna automobile o motocicletta o bicicletta, od utilizzare qualsiasi macchinario nelle 24 ore seguenti I'anestesia o sedazione , 3)di non assumere alcoolici nelle 24 ore seguenti l'anestesia o sedazione; 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,cosicchè il vestiario possa essere facilmente rimosso e indossato e riposto in un armadietto;per es.tute da ginnastica con maniche larghe e apertura frontale. 8)di non portare gioielli o altri oggetti di valore in ambulatorio; 9)di mettermi in contatto con l'unità chirurgica ambulatoriale nel caso insorga una qualsiasi complicanza postoperatoria. 10) di assumere o avere già assunto la mia terapia agli intervalli soliti,con un poco di acqua se necessario. FIRMA ......................................................................................... ID:quest day surg e consenso.doc
- 73. Screening of patients2 C.M 13/1/2009 Dott.Claudio Melloni Specialista in Anestesia e Rianimazione Via Fossolo 28 40138 Bologna tel.:051390048 Questionario preoperatorio di autocompilazione Si prega di barrare la risposta esatta con un segnetto o un cerchietto e/o riempire gli spazi sopra i puntini con le informazioni richieste.Tutte le risposte sono confidenziali e coperte dal segreto professionale.Grazie. Cognome e nome:…………………………………………………………. indirizzo:via…………………….città:……………………………..Cap….. tel:………… età…. peso in kg…. altezza in cm… Si sente ammalato? SI NO Se Si,perché?……………………………………………… Ha o ha avuto una malattia seria ? SI NO Se Si,perché?……………………………………………… Ha affanno dopo sforzo? SI NO Ha tosse? SI NO Ha sibili respiratori? SI NO Ha dolore al petto da sforzo? SI NO Ha gonfiore alle caviglie? SI NO Ha o ha avuto malattie di cuore? SI NO Ha o ha avuto malattie dei polmoni? SI NO Ha o ha avuto malattie di fegato? SI NO Ha o ha avuto malattie dello stomaco? reflusso?ulcera? SI NO Ha o ha avuto malattie dei reni? SI NO Ha o ha avuto malattie muscolari? SI NO Ha o ha avuto malattie cerebrali? SI NO Ha assunto farmaci negli ultimi tre mesi SI NO Se Si,quali?……………………………………………… Prende gocce nasali o oculari? SI NO È allergico a qualche medicinale? SI NO E’ allergico a qualche cibo? SI NO Ha subito interventi o anestesie negli ultimi 3 mesi? SI NO Se Si,perché?……………………………………………… È mai stato operato prima d’ora? SI NO Se Si,perché?……………………………………………… Ci sono state strane storie in famiglia di incidenti insorti durante o subito dopo anestesia? SI NO Porta occhiali o lenti a contatto? SI NO Porta protesi dentarie o ponti mobili? SI NO Beve più di in bicchiere di vino o di un superalcoolico al giorno? SI NO Fuma? SI NO Se Si,quanto ?................................................................... Ci sono stati altri problemi di salute fisica o mentale non compresi in questa lista? SI NO Se Si,quali?……………………………………………… Fa movimento o sport? SI NO Se sì,che cosa(per es bicicletta,lavori di casa,orto,raccolta frutta,ecc), ……………………….
- 74. Raccolta dati data:...../....../.... sede……………………………... COGNOME E NOME..................................................................................... INDIRIZZO: TEL:…………. ETÀ: ........ PESO(KG) ......... ALTEZZA(CM)......... ASA: ........ INTERVENTO:................................................................................................ ANESTESISTA:..................................CHIRURGO:.......................................... anestetico locale: Si No farmaco...............................mg............................................ adrenalina: Si No dose: via aerea: spont guedel maschera IOT IRT COPA LMA respirazione:spont. ass man. IPPV O2 si no maschera occhialini Premedicazione:...................................................ora:....... induzione(farmaci,dosi):..................................................................................................... ........ mantenimento:............................................................................................................................ inizio anestesia:ora................ inizio chirurgia:ora.................................................. Via venosa: c.M. 11/95 fleboclisi: 1 2 3 4 MAC opp AG Min PAS PAD Fc SaO2 EtCO2 Osservazioni: bas 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95 100 105 110 115 120 125 130 135 140 145 150 155 160 165 170 175 180 totali:farmaci:ipnotici/sedativi:............................an algesici:........................mi orilassanti:............... ...... altri: stop.analgesia: fine anestesia:ora fine chirurgia:ora.................................................. ....... apertura occhi:ora................ orientamento:ora:..….. RS ora………….estub ora:……… seduto:h..............................in piedi h……………. vestirsi h:……. .. camminare h:…………… mingere h:……….. bere,h………………………effetti collaterali:……………………………PONV: se si,terapia………………..no. dolore: se si,terapia…………………..oppNO Dimissione:ora………………………………………………………………………
- 75. Consenso Poliambulatorio S.Lucia Via Murri 164 Bologna DICHIARAZIONE DI AVVENUTA INFORMAZIONE E CONSENSO ALL’ANESTESIA Io Sottoscritto/a……………………………………........………. nato/a a ……………................. ..............................................................................................il........................................................... Dichiaro di essere stato informato/a dal Medico Anestesista dr…………………………………... che le mie condizioni di salute mi collocano nella classe ASA*……. ed il rischio relativo all’intervento chirurgico al quale io verro’ sottoposto/a è ………………………………………** Ho compreso le informazioni circa il tipo di anestesia più appropriato nella mia situazione e, dopo avere preso in considerazione anche le eventuali alternative, dò il mio consenso al trattamento anestesiologico concordato che sarà il seguente:………. ……………………........…. Sono stato informato che tale trattamento, qualora si verificassero condizioni particolari che mi verranno spiegate, potrebbe essere modificato. Mi è stato spiegato che l’anestesia, pur essendo fra le metodiche più sicure della medicina moderna, può comportare ancora oggi in rarissimi casi complicanze mortali o gravi danni permanenti, in particolare di tipo neurologico. Mi ritengo adeguatamente informato e non desidero ricevere ulteriori informazioni. In seguito alla mia richiesta di ulteriori informazioni, ho ricevuto e compreso ogni spiegazione sui trattamenti anestesiologici che verranno adottati prima, durante e dopo l’intervento. In particolare, ho compreso le informazioni circa le complicanze più comuni e prevedibili nel mio caso specifico, che consistono in:………………………………………………………….............. Autorizzo inoltre il Medico Anestesista a comunicare notizie relative al mio stato di salute a…………………………………………………………………………………………………...... ........................................................................................................................................................... Dichiarazioni particolari:……………………………………………………………....................... ........................................................................................................................................................................ .............................................................................................................................................. DATA..................................... Firma del Paziente Firma del Medico Anestesista ……………………………………. .............................................……. Firma del Tutore/……………………………..……di…...……………………….……...
- 76. Is not onlythe patient,but the combination of patient,surgeon,procedure • Long procedure on good compliant patients.. • Short procedure on difficult patients • Surgeon attitude • Patient psycology • Money…
- 78. From the GeneralDental Council UK: • CONSCIOUS SEDATION • 4.11 Conscious sedation can be an effective method of facilitating dental treatment and is normally used in conjunction with appropriate local anaesthesia. • Conscious sedation is defined as: • A technique in which the use of a drug or drugs produces a state of depression of the central nervous system enabling treatment to be carried out, but during which verbal contact with the patient is maintained throughout the period of sedation. The drugs and techniques used to provide conscious sedation for dental treatment should carry a margin of safety wide enough to render loss of consciousness unlikely. • The level of sedation must be such that the patient remains conscious,retains protective reflexes, and is able to understand and to respond to verbal commands. ‘Deep sedation’ in which these criteria are not fulfilled must be regarded as general anaesthesia. • In the case of patients who are unable to respond to verbal contact even when fully conscious the normal method of communicating with them must be maintained.
- 79. Ramsey Sedation Scale • Response to command score • Patient awake,anxious ,agitated,restless 1 • Pt. Awake,cooperative,orientated,tranquil 2 • Pt drowsy with response to command 3 • Pt asleep with brisk response to glabella tap or loud auditory stimulus 4 • Pt asleep,sluggish response to stimulus 5 • No response to firm nail bed pressure or other noxious stimuli 6
- 80. OAA/S Observer’s assessmentof awareness/ sedation scale • • Responsiveness speech score Respons rapidly to name in normal tone normal 5 Lethargic response to name spoken loudly repeatedly Mild slowing 4 Responds only after name spoken loudly or repeatedly Slurring or slowing 3 Responds after mild prodding or shaking Few recognized words 3 Does not respond after mild prodding or shaking 1
- 81. UMSS University ofMichigan sedation scale Sedation score Awake and alert 0 Minimum sedation Tired/sleepy,appropriate response to verbal conversation or sound 1 Moderate sedation somnolent/sleeping,easily arousable with light tactile stimulation or a simple verbal command 2 Deep sedation Deep sleep,arousable only with significant physical stimulation 3 unarousable 4
- 82. Vital signs monitor(s) • General principles: – Robust,but protect during transport ,good packaging – Lightweight;???< 1kg….. – Battery operated ;look for replacement – Easy to operate – Good visibility – Good price – Maintenance free,parts easy to find(cables,sensors) • ECG,NIBP,SaO2,EtCO2,resp. • EEG?????CSM….. • Spare monitoring in case of failure;at least SaO2… • Thermometer • Phonendoscope
- 83. Emergency material •Laryngoscope;2 at least,check batterie frequently • Full assortment of blades,right and curves • LMA size 2,3,4,5 • Bougie • Magill forceps, • Frova introducer • O2 and CO2 catheters • IV lines(latex free)+ three way extension • Defibrillator,portable,battery operated,semiautomatic • tracheostomy kit???? • Hand or foot operated suction • Self inflating bag+reservoir(O2 100% capable) • Face masks • Guedel airway,any size(COPA) • Oxygen tank;5 lt??3 lt?2 lt? 1 lt?
- 84. Practice Guiding priciples • Never trust anyone • Never run out on anything;replace immediately • Always have more you think you might need • Pack everything by yourself so you know what you have and where it is to be found • Assume the practice has nothing except suction and light(but you may inquire beforehand…)
- 85. Items for comfort • Your own surgical clothes • Patient blanket????
- 86. Mobile kit •How to organize??? • 1)frequency of use:items always ,rarely,hopefully never »Or • 2)drugs,iv,patient comfort • 3)airway equipment • 4) monitoring Sedation solution LOndon me
- 87. Drugs organized byaction hypnotics,sedative analgesics emergency Diazepam fentanyl ondansetron triazolam paracetamol dexamethasone Midazolam codeine adrenaline propofol tramadol atropine ketamine Ketorolac l amiodarone dexmedetomidine celecoxib lidocaine clonidine naloxone flumazenil ephedrine chlorpheniramine salbutamol
- 88. Drugs organized bytiming premed intraop postop Codeine+paracetamol midazolam Antidotes;flumazenil,naloxon triazolam fentanyl Vs PONV:ondansetron,dexamet hasone midazolam Propofol Analgesics;celecoxib,codeine +paracetamol,paracetamol,k etorolac,tramadol(???) diazepam Dex??? Antibiotics ; a couple:amox,genta,cilinda,ci proflox….. Ket???? Halop or drop Cristalloids;NACl,PET Colloids:HES Iv cath:22,20g
- 89. transport • Frombig suitcases to trolleys…a personal history
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- 93.
- 94. Be prepared………… •Pre-filled syringes;most common sedatives/analgesics/vasopressors/atropine – My choice: midazolam/fentanest/ephedrine/atropine • Airway rescue; – LMA,Laryngoscope,ETT,self inflating bag,Oxygen • Adrenaline bag • Patient pre discharge evaluation:Aldrede?? • Street fitness;accompanying person
- 95. Pre prepared…..be prepared • Pre prepared syringes: – Atropine – Effortil/ephedrine – Midazolam – Fentanyl – Propofol?? – Clonidine(catapresan) – Electrolytes – ???specific for the procedure???
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- 101. They are pullingthe chin!!
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- 105. Avere le cosegiuste Attrezzature e farmaci
- 106. Farmaci essenziali •Ossigeno;bombola da 5 lt,come minimo,200 atm,con va e vieni ,mascherina facciale ,occhialini nasali – 3 maschere facciali adulti,piccola,media ,grande Adrenalina,fiale da 1 mg :FASTJECT 2 ml,siringa preriempita,iniett(77 £):330 microgr o 165 microgr Video prodotto dall'Allergopharma che illustra come usare l'adrenalina auto iniettabile (Fastjekt) in caso di shock anafilattico. • Nitroglicerina:cp sublinguali 0.3-0.4 mg,Carvasin 5 mg ,Natispray • Antistaminico:clorfeniramina(trimeton) fiale 10 mg,Prometazina(farganesse 50 mg) • Albuterolo,salbutamolo(Ventolin) • Aspirina;cp 160-325 mg
- 107. Farmaci essenziali farmacoindicazioni Dose iniziale(adulti) ossigeno sempre Inalazione 100% Bombol ,masch ere,am bu adrenalina anafilassi 0,1 mg ev;0.5 mg i.m. Fiale,pe nna Asma che non risponde al salbutamolo 0,1 mg ev;0.2—0.5 mg i.m. Arresto cardiaco 1 mg ev Fastjekt anafilassi Siringa preriempita 330 0pp 165 microgr ,im. Nitroglicerina(Trinitrin a 0.3,carvasin 5 mg) Dolore anginoso 0.3-0.4 mg,sublinguale Cp,fiale Natispray,sublinguale) Clorfeniramina/Trimet Reaz.allergica 10 mg ev,i.m. fiale
- 108. Altri farmaci peremergenza farmaco indicazione Dose iniziale adulto atropina Bradicardia significativa,attacco vaso vagale 0.5 mg ev,im efedrina Ipotensione significativa 5-10 mg iv,10-25 mg im idrocortisone Insuff.surrenalica 100-200 mg iv o im anafilassi 100-200 mg iv o im Morfina o protossido d’azoto(N2O) Buprenorfina Dolore anginoso che non risponde all NTG 2 mg ev,3-5 mg im Inalazione al 30-35% con O2 0.15-0.3 mg subling o im o ev Lorazepam(Tavor) Crisi epilettica ,attacchi di panico 4 mg i.m o ev lenta Cp per os 1 mg Midazolam Crisi epilettica 5 mg i.m. o ev ranitidina Anafilassi,allergia 50 mg ev o 150 mg p.os Ondansetron(zofran) Nausea,vomito 4 mg,iv o im
- 109. Mobiletto con farmacie materiale di emergenza
- 111. However…… • Afterthe first visit,having ascertained the presence and function of some equipment,he may rely upon some items of the facility,especially if heavy: • O2 tank • Multiparameter monitor
- 112. Vena sicura •Cateterino • Fissaggio “ certosino” • Prolunga con rubinetto a tre vie • Fleboclisi a bassa velocità di infusione
- 113. IL CARRELLO DELLE EMERGENZE(CRASH CART)
- 114.
- 115. Minimum Crash CartSupplies and Drugs • (Based on 2010 ACLS Protocols) • This list is based on the 2011 American Heart Association Advanced Cardiovascular Life Support Provider Manual and does not include Adult Immediate Post-Cardiac Arrest Care. – Disclaimer:This list was created to show the basic supplies and equipment required for emergency treatment in an ambulatory surgery center while waiting for EMS to arrive and must be reviewed by the anesthesia and medical staff at your facility and approved by the Medical Executive Committee and Governing Board.
- 116. Minimum Crash CartSupplies and Drugs (Based on 2010 ACLS Protocols • Defibrillator/EKG monitor with external pacing capabilities • or • AED (automated external defibrillator) • Adult Electrode defibrillator pads • Portable suction machine • suction canister • suction tubing • Suction Catheters • Yankauer Suction Tip • Clipboard, code worksheets, ACLS algorithms • Electrode pads/ Defibrillator Pads • Trach Tray; Cuffed Tracheostomy Tubes: Shiley • Adult Cricothyrotomy Kit • Cardiac backboard • Ambu bag with adult mask • Portable 02 tanks • Adult Face Mask non-rebreather • Nasal Cannula • Nebulizer Kit • Airway Patency: • Nasopharyngeal Airways, assorted sizes • or • Oropharyngeal Airways: assorted sizes • Airway Management: • Advanced: • Laryngoscope handle and assorted blades • C-Batteries for laryngoscope • Endotracheal Tubes:Assorted sizes, Cuffed and uncuffed • Stylet • LMA (laryngeal mask airway) - assorted sizes • or • Esophageal-tracheal tube • or • laryngeal tube • MEDICATIONS • NAME DOSE ROUTE • Adenosine 6 mg/2ml IV • Albuterol Inhaler 3ml INH • Aspirin 325mg PO • Atropine syringe 1mg/10ml IV • Atropine 0.4mg/ml IV • Amiodarone 150mg/3ml IV • Calcium Chloride 10% syringe IV • Diphenhydramine 50mg/ml IV • Dextrose 50%W 25gm/50 ml IV • Dopamine 400 mg/5ml IV • Epinephrine 1:1,000 amp/ autoinjector IV • Epinephrine 1:10,000 syringe IV • Furosemide 40mg/4ml IV • Hydrocortisone 100mg/ 2ml IV • Lidocaine 2%syringe 100 mg IV • Mag Sulfate 50% syringe IV or IM • Methylprednisolone 125 mg IV • Morphine sulfate Narcotic Cabinet IV • Narcan 0.4mg/ml IV • Nitroglycerine 0.4mg SL • Procainamide 100mg/ml IV • Sodium Bicarb 8.4% 50mEq IV • Sotalol 100mg IV Sterile Water 10ml IV • 0.9% Na chloride 10ml IV • Vasopressin 10units/ml IV • Lidocaine 4% 2gm 500ml IV • IV catheters, tape, alcohol wipes, tourniquets, tongue blades • IO Needles • IV Tubing- primary and piggyback • IV solutions: Lactated Ringers, Normal Saline • Needles, syring
- 117. La valigetta degliorrori set di rianimazione completo di: bombola ricaricabile di ossigeno da 0,5 LT in acciaio, riduttore con manometro ed erogatore, pallone rianimatore, maschera rianimazione, 2 cannule di Guedel, pinza tiralingua, apribocca elicoidale, tubo atossico, in contenitore plastico antiurto.
- 118. Bombola di ossigeno • 5 litri,200 atm=1000 litri • Se usate 6 lt/min ce n’è per 166 min...... • Guardate la pressione;quando è ,per es, a 80 atm,significa che ci sono ancora 400 lt... • A 20-30 atm è meglio sostituire con una altra piena.
- 124. Cannula brevettata a2 vie per somministrazione di ossigeno e campionamento della CO2 espirata setto che separa le due vie Curva della CO2 espirata(etCO2)
- 125. Approximate FiO2 deliveredby nasal cannula • Flow rate lt/min approx FiO2 • 1 0.24 • 2 0.28 • 3 0.32 • 4 0.36 • 5 0.40
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- 151. Dimenticavo:il telefonino!!!! Apps mediche!!
- 152.
- 153. requirements • Goodrunning condition • Fast enough,powerful, • Always ready to go • Good cargo capacity • (parking space…..) • Going everywhere,always,all wheather… » Therefore » 4 motion:low gears?
- 154.
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- 156. First and secondJeep
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- 163. Maschera con reservoir • http://youtu.be/nEbsKfLl1n4 • Acquisti materiale consumabile;doctorshop,doctorpoint
- 164. SIAD Ozzano Emiliavia Libertà 17 • ALLEGATO 3 – DICHIARAZIONE SOSTITUTIVA DI CERTIFICAZIONE (ai sensi dell’art. 46 del D.P.R. 28/12/2000, n. 445) • • • Il/la sottoscritto/a…………………………………………………………………………….. • • • Responsabile dell’Ente di Soccorso/Studio Medico………………………………………….. • • • con sede in………………………………………………………………………………………. • • • Partita IVA/C.F………………………………………………………………………………… • • • • Consapevole delle sanzioni penali, nel caso di dichiarazioni non veritiere, di formazione o uso di atti falsi, richiamate dall’art. 76 del DPR n. 445/2000 • • • DICHIARA • • di essere soggetto autorizzato al rifornimento all’ingrosso di gas medicinali e di impiegare gli stessi sotto la propria sola responsabilità. • • • • • www.siad.com autorizzazione acquisto FU-3.doc In fede • • ……………………………………………….. • • Luogo, Data ………………….,………………. •
- 165. • buongiorno, •non possiamo vendere medicinali a studi medici che non abbiano sottoscritto l’allegato che Le inoltro... • • Riesce ad inoltrare ai due medici il modulo, facendomelo poi avere via e-mail o via fax allo 051 796026? • Grazie mille • • Massimiliano Lucchina • Servizio Vendita • • SIAD S.p.A. | I-40064 Ozzano dell'Emilia (BO) - Via della Libertà, 17 • Tel. +39 051 799399 | Fax +39 051 796026 • massimiliano_lucchina@siad.eu | www.siad.com
- 168. NORA • Governance • organization • construction and equipment • policies and procedures, including : – Fire – safety – drugs – emergencies – staffing – training – unanticipated patient transfers
- 173. 503.207.4992 Limelight Group MOBILE ANESTHESIA SERVICES Home Services Scheduling Forms About Contact We Specialize in Dental Anesthesia for Children and Adults. Limelight Sedation mobile anesthesia services Mobile Anesthesia Services Sleep Dentistry - You don’t have to have anxiety during a dental visit anymore. Dr. Enrique Abreu Limelight Group’s mission is to make dental procedures more comfortable and approachable to those who need it most. We provide deep sedation, and intravenous (IV) general anesthesia at your dental o ffice. This provides a few things for the dentist and patient: • Comfortable dental experience with little to no memory of the events • Decreased discomfort afterwards since stronger medications can be used • Reduced procedure time since dentist can work more efficiently FAQ: • Is it safe? Yes, millions of cases are performed every year using the medications we employ. We use all of the same safety precautions and monitoring equipment that is used in a hospital operating room. Limelight group owns and travels with all of their own equipment. -Defibrillator w/ pacer -Anesthesia monitor w/ end-tidal CO2 -5-lead EKG -Oxygen • Who is watching me while I'm asleep? A board certified medical anesthesiologist will be with you during your entire procedure, monitoring all of your vital signs constantly. This gives your dentist the peace of mind to focus on your dental work. See mor e
- 175. Very old obesepatient……
- 180. The environment •Ideal vs real ;seen !!! • Skilled help? • Vigilance!!!!motto ASA o occhio di falco……
- 181. tipologia • A)seguediversi studi e/ o poliambulatori,non attrezzati:OBA/NORA • B) opera presso diverse strutture, attrezzate,ma diverse ;case di cura,poliambulatori,ecc,ecc. • C) opera sia come A che come B – Libero professionista o part time...
- 182. Prevenzione:Riduzione dello stress • Richiesta di consultazione;Medico curante,cardiologo... • Scelta dell’ora,meglio la mattina presto per i paz ansiosi ,dopo una notte di sonno.... • Minimizzare il tempo di attesa, a meno che non si sfrutti per la sedazione... • Segni vitali preop e postop • Premedicazione: – la notte prima dell’appuntamento;ipnotico/sedativo:diazepam,triazolam,flurazepam,zolpidem,zaleplon...;prescr ivere!!! – all’appuntamento ,almeno mezz’ora prima( 1 h...) Sedazione durante intervento;iatrosedazione,farmacosedazione controllo del dolore Durata del trattamento Controllo del dolore ;intraop postop :prescrizione:analgesici,antibiotici,ansiolitici se necessari,
- 183. Intraoperative and postoperativemonitoring • Recommendations: • Minimum standards during anesthesia • Check of the anesthesia mchine • Postanesthetic care • Cinical and organizational day sugery ”
- 184.
- 185. • Twersky R,Philip B, et al. 2008 Revision of Office Based Guidelines.Considerations for Setting Up and Maintaining a Safe OfficeAnesthesia Environment. 2008 2nd edition and revision, original 2000 ASA Publication.