Olivier%20Langeron,%20MD,%20PhD

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Updates on the sedation outside the Operating
Room

• Olivier Langeron, MD, PhD
• Department of Anesthesiology and Intensive Care
• Pitié-Salpêtrière Hospital
• Paris, France

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Disclosures

• BAXTER
• COOK medical
• COVIDIEN

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Anesthesia where do we come from ?
Preop assessment Monitoring PACU

• Safety era
• Quality era
• 
  Consumption/fulfilmen
  t
• era

On/Off Anesthetic agents PONV
New techniques / new needs Anesthesia  in the
package 
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ASA CLOSED CLAIMS ANALYSIS
Cheney FW Anesthesiology 1999
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T 1/145 500
P 1/21 200
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Sedation outside the OR what are the issues ?
Organisational
Medical
Sedation outside the OR
Technical environment
Economic pressure
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Our expansion
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Their expansion and increased needs
RadiologyGastroenterology Cardiology ...
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Anaesthetists and Sedation in the Radiology
Department Involved or left behind? Carol
J. Peden Anaesthesia, 2005, 60, pages 423425
National Confidential Enquiry into Perioperative
Deaths 2000 for Radiology and Interventional
Neuroradiology 303 deaths, among them 19 not
monitored at all 60 did not have pulse oximetry
monitoring 40 did not have their blood pressure
taken 16 died who were monitored by a
radiographer - the gold standard for patient
monitoring during interventional vascular
procedures should be pulse oximetry, blood
pressure and ECG. - someone other than the
radiologist should be responsible for the
patient.
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Swiss cheese model
No staff No equipement
No predefined strategy No equipement
NO assessment
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Definition
Continuum
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Pre-procedure assessment

• Evaluate patient
• Previous anesthesia or sedation history
• Adverse responses and allergies
• Evaluate co-morbidities and decide on
  appropriateness of the procedure
• Airway History and Examination
• Previous problems
• Difficulty anticipated?

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DMV risk factors
http//www.sfar.org/cexpintubdifficile.html

• Increasing risk if at least 2 of these factors
• Age gt55 yr
• BMI gt26kg/m2
• Jaw protrusion severely limited
• Lack of teeth
• Snoring
• Beard
• X 4 risk of difficult intubation with a DMV

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DI risk factors
http//www.sfar.org/cexpintubdifficile.html

• History of a DI
• Recommended criteria (mandatory )
• Mallampati class gtII
• TMD lt65mm
• MO lt35mm
• Supplementary criteria
• Limited jaw protrusion
• Limited cervical spine mobility
• Criteria dependent on context
• BMI gt 35kg/m2
• OSA with neck circumference gt 45.6cm
• Neck and/or facial pathology
• Pre-eclampsia

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0 facteur 1 facteur 2 facteurs 3 ou plus
Lee Circulation 1999
0-1 factor low risk (lt 1,3) 2 factors medium
risk (3,6) 3 facteurs or more high risk
(9,1)
AUC de LEE score and outcome Cohorte de
validation 0,81
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Morbid obesity Sleep apnea Symptomatic
gastro-esophageal reflux disease Pregnancy
Neonates and infants Advanced lung / cardiac
diseases
Patients who may not be good candidate for
sedation risk stratification
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Basic equipments and monitoring

• ECG
• Noninvasive BP
• SpO2
• Oxygen
• Tracheal intubation trolley
• Suction
• Defibrillator
• IV equipment and solutions
• Emergency drugs

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Basic Airway Equipment

• O2, suction, nasal cannula, face masks (different
  sizes) , self-inflating bagmask
• Oral and nasal airways
• LMAs
• Laryngoscopes (metal blades)
• Endotracheal tubes and gum elastic bougie

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Increasing failure in plastic blade group 17
vs. 3 P lt 0.01
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Protocols are required

• Fasting and NPO times
• Patient / Family information
• Preop evaluation
• Staff and equipments requirements
• Per-procedure vital signs and drugs
  administration recording
• PACU facilities
• Discharge criteria
• Follow up procedure (On call anesthesiologist)

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Fasting Guidelines (from ASA)

• Ingested material Minimum Fasting Period
• Clear liquids 2 hrs
• Breast milk 4 hrs
• Infant formula 6 hrs
• Nonhuman milk 6 hrs
• Light meal 6 hrs

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Goals of sedation

• Anxiolysis Analgesia
• Safety / reversibility - short acting agents
  (propofol)
• Optimal conditions for the operator

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Documentation During Procedure

• Vital signs
• Drug administration
• Monitors used (SpO2, ECG)
• Patient responsiveness (Ramsay Score sometimes
  used)

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Recovery Phase

• PACU unit
• Dedicated area with dedicated personnel
• Standard discharge criteria (awake, stable, etc.)
  
• Ambulatory procedure as required (needs an
  escort home and cannot drive)

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Unsolved questions

• Will we be able to provide enough
  anesthesiologists and/or CRNA for this purpose ?
• Creation of a Sedation department (trained
  nurses, CRNA, anesthesiologists) ?
• Delegate the sedation but delegate also the
  responsability ?
• Anesthesiologists employed as  fireman  in case
  of incident/accident ? Who is responsible ?

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Anaesthetists and Sedation in the Radiology
Department Involved or left behind? Carol
J. Peden Anaesthesia, 2005, 60, pages 423425
RCR guidelines make a number of suggestions
Radiologists should invite anaesthetists to their
department to show them the current scope of work
Anaesthetic departments should be involved in
the training of junior radiologists to perform
sedation and resuscitation There should be
liaison over the production of local protocols
Fixed anaesthetic sessions in radiology may
be necessary in some departments Paediatric
and neuroradiology requirements for sedation,
analgesia and anaesthesia must be considered when
developing services The quality of
cooperation between the departments should be
assessed in training and accreditation visits
by the respective Royal Colleges. .
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To summarize sedation outside the OR 

• Organisation is mandatory
• Involvment since the beginning of the procedure
  is capital
• Cooperation between specialists is essential
• Periodic evaluation is required (quality
  insurance)

Sedation is already Anesthesia
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Be carreful Sedation requires expertise