Copy of shashi Final Remote Location Anaesthesia - shashi

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Role of Anaesthesiologist in Remote Location:

Role of Anaesthesiologist in Remote Location Dr. Shashi Kant Specialist Dept. of Anaesthesia and Criticalcare Tata Main Hospital Jamshedpur

Expanding Horizon of Anaesthesia services:

Expanding Horizon of Anaesthesia services Palliative

Importance of Remote location Anaesthesia:

Importance of Remote location Anaesthesia Activities are increasing : Advanced Diagnostic & Therapeutic activities. Patient demands sedation without recall. More complex procedures, situation and patients. Balancing act : Procedure Vs Safety . Guidelines Vs Availability . Who does the sedation ?

Remote Location:

Remote Location

Remote Location -TMH:

Remote Location -TMH

Remote Location -TMH:

Remote Location -TMH

Remote Location -TMH:

Remote Location -TMH

Remote Location:

Remote Location Neurological intervention Cardiac intervention Angioplasty

Remote Location- Definition ( RCoA guidance 2011):

Remote Location- Definition ( RCoA guidance 2011 )

Concern at remote sites - ABC :

Concern at remote sites - ABC

Pediatric sedation :

Pediatric sedation Incidence: Hypoxemia : 0.8%- 0.9% in children during MRI and CT Airway compromise : 1.3% - 6% Hospital admission : 0.03%- 0.07% ( unscheduled ) Current Opinion Anaesthesiology 2007: 20: 513- 519

Review – ASA close claims*:

Severity of Injury : Remote location > OR claims. Death almost double in remote location claims ( p < 0.001 ) OR claims : more of temporary injuries ( Transient Nerve Injury ) Review – ASA close claims* * Metzner J, Posner KL, Domino KB: The risk and safety of anesthesia at remote locations: the US closed claims analysis. Curr Opin Anaesthesiol 2009; 22:502-8.

Remote Vs. OR claims – Respiratory event:

Mechanism of injury- adverse respiratory events in both claims Remote location 2 times > OR claims . (fig.2A) Inadequate oxygenation/ Ventilation: 7 times > OR claims ( fig. 2B) Remote Vs. OR claims – Respiratory event

The injuries in remote locations:

more often judged as being preventable by better monitoring The injuries in remote locations

ASA & JCAHO – guidelines safety first :

ASA & JCAHO – guidelines safety first

JCAHO - Uniform Quality of Care :

JCAHO - Uniform Quality of Care Recommendation : Pre sedation assessment. Continuous physiologic monitoring Credentialing of individuals providing different levels of sedation Post sedation recovery and discharge Maintenance of institution wide standards of care and quality assurance for all levels of care. Joint Commission on Accreditation of Healthcare Organizations (JCAHO) - recommendation 2001 .

Guidelines of the American Society of Anesthesiologists: Directory of Members, American Society of Anesthesiologists. Park Ridge, IL, AmericanSociety of Anesthesiologists, 1997, p 404.:

Guidelines of the American Society of Anesthesiologists: Directory of Members, American Society of Anesthesiologists. Park Ridge, IL, AmericanSociety of Anesthesiologists, 1997, p 404. ASA - Guideline Anaesthetist Responsibility

Who should provide office based anaesthesaia:

Experienced consultant Trainee under direct supervision of consultant Physician working at remote location- sedation ( ACLS provider ) Who should provide office based anaesthesaia

Aim of anaesthesia care in remote location :

Aim of anaesthesia care in remote location Safe Anaesthesia : Patient’s / Care giver safety Standards of anaesthesia & monitoring- does not differ Communication : closed loop communication Knowledge of working environment : CT/ MRI Follow guide lines : ASA / JCAHO Need based modification of technique Training of staff – procedure ; resuscitation ( contrast reaction) Rapid recovery & Safe discharge / ICU transfer

Challenges of anaesthesia:

Challenges of anaesthesia I. Unfamiliarity of Anaesthetist : with one or more isolated environment available equipment assistance being provided procedure being undertaken and patient II. Difficulties with communication and immediate availability of senior/expert assistance

Technique of Anaesthesia at remote location:

Technique of Anaesthesia at remote location Monitored Anaesthesia Care (MAC) Sedation : minimal, moderate & deep sedation Regional & General Anaesthesia

Slide 22:

Amnesia sedation Hypnosis Coma Death Awake Sedation

Sedation terminology - ASA:

Sedation terminology - ASA

Procedural sedation and analgesia - PSA:

Procedural sedation and analgesia - PSA PSA is a “ technique” of administering sedatives or dissociative agents with or without analgesics to induce a state that allows the patient ; to tolerate unpleasant procedures while maintaining cardio respiratory function. Aim : Depressed level of consciousness while the patient maintains oxygenation and airway control independently The American College of Emergency Physicians (ACEP )

PAC & preparation for remote location :

PAC & preparation for remote location Pre anaesthesia - ( procedure, consent, fasting status ) Anaesthesia monitor: NIBP, ECG, Sao2, Etco2. WHO checklist ?

Equipment check :

Guidelines for Monitoring and Management of Pediatric Patients During and After Sedation for Diagnostic and Therapeutic Procedures: An Update. American Academy of Pediatric dentistry, 2006. Available at: www.aapd.org/media/ policies.asp Equipment check

Know - Drugs & doses:

Know - Drugs & doses Drug Dose - adult ( I.V.) Duration Side effect Midaz. 0.02-0.1mg/Kg. ® 25% of initial. Max 2.5mg/dose. / elderly 1.5mg 30- 60min Resp. depression& hypotension Fenta. 1- 2mcg/ kg; ® after 30 mins 30-60min Chest wall rigidity, Apnoea ;hypotension Propof. Ketofol 0.5- 1mg/kg ; 0.5mg increment Q 3-5 min Prop: Ket. =1:1/ 2:1 3-10 min Rapid onset rapid recovery Hypotension , depression - CVS

Slide 28:

Drug Dose - Pediatric Comment Midaz. 0.05-0.1mg/Kg.( IV)= T- 6mgm I.M. = 0.1-0.2mg/kg; oral/intra nasal Resp.depression& hypotension Fenta . 1mcg/ kg; ® 1mcg/kg Total not exceed 4mcg/kg Chest wall rigidity, Apnoea ;hypotension Resp. depression Propof. Ketam. Dexmed. 1- 1.5mg/kg ; 0.21 - 0.5mg increment Q 3-5 min or infusion 50-150 mcg/ kg/ min 1-2mg/kg I.V. ; 2-5mg/kg I.M 0.5- 1.5mcg/Kg ® 1- 1.5mcg/kg/hr Rapid onset rapid recovery. Loss of Air way reflex.Hypotension , depression - CVS

Context – Sensitive Half –Time of I.V. Anaesthetics:

Context – Sensitive Half –Time of I.V. Anaesthetics Time for Plasma level to drop by 50% after cessation of infusion

Dexmedetomidine:

30 Sedation Analgesia Amnesia Anxiolysis Hypnosis α 2 Agonists Dexmedetomidine Concerns Hypotension & bradycardia Infusion device

Drugs & doses:

ICU book 3 rd edn. Drugs & doses

Documentation of Anaesthesia:

Documentation of Anaesthesia Interval at 15 min. for conscious sedation 5 min. for deep sedation & GA Ramsay sedation scale Score from 1 (agitated ) – 6 (no response light glabellar tap)

Discharge Criteria:

awake patient to pre sedation level Aldrete scale of 8 or more is a must. discharge instructions - patient and the care giver Discharge Criteria

Balancing act : Anaesth vs. Safety:

Balancing act : Anaesth vs. Safety MRI ERCP.

Take home message:

Take home message Remember the acronym “SOAPME”- check (i.e. Suction, Oxygen, Airway, Pharmacy Monitors & Equipment ) before providing Sedation ,MAC and GA in remote location . The success in anaesthesia for remote locations depends upon the balancing act of expert anaesthesiologist with leadership quality and availability of resources.

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