Cardioversionsi f C /Insertion of ICDs/PPM

RFA and EP studies

DrudDrud--induced Absence induced Absence of response to any of response to any

stim l sstim l s

DrugDrug--induced induced permissiveness of permissiveness of uncomfortable or uncomfortable or stimulusstimulus

Loss of protective airway Loss of protective airway reflexesreflexes

uncomfortable or uncomfortable or painful diagnostic or painful diagnostic or

interventional medical interventional medical or surgical proceduresor surgical procedures

Depression of respiration Depression of respiration Disturbance of Disturbance of

circulatory reflexescirculatory reflexes

Lack of memory of Lack of memory of distressing eventsdistressing events

analgesiaanalgesiayy analgesiaanalgesia

Purposeful response to verbal or tactile Purposeful response to verbal or tactile stimulationstimulationstimulationstimulationNo airway intervention requiredNo airway intervention requiredAdequate spontaneous ventilationAdequate spontaneous ventilationCardiovascular function usually Cardiovascular function usually Cardiovascular function usually Cardiovascular function usually maintainedmaintained

Minimal sedation Minimal sedation (Anxiolysis)1.1.ResponsivenessResponsiveness

Moderate sedation/Analgesia

2.2.AirwayAirway

Deep Sedation/Analgesia

3.3. Spontaneous Spontaneous ventilationventilation Sedation/Analgesia

General Anaesthesia

ventilationventilation

4.4.Cardiovascular Cardiovascular General Anaesthesia4.4.Cardiovascular Cardiovascular functionfunction

PatientPatientcomfortcomfortcomfortcomfort

Ideal Ideal operating operating conditioncondition

Patient Patient conditioncondition

safetysafety

Patient discomfortPatient discomforti i ji i jPatient injuryPatient injury

Adverse Adverse physiological and physiological and physiological and physiological and psychological psychological responsesresponses

Unintentional loss of Unintentional loss of Unintentional loss of Unintentional loss of consciousnessconsciousnessLoss of protective reflexesLoss of protective reflexesRespiratory depressionRespiratory depressionCardiovascular depressionCardiovascular depression

Diagnostic +/Diagnostic +/--therapeutictherapeutic

Allows patients to Allows patients to tolerate unpleasant tolerate unpleasant

d b d b Invasive, complexInvasive, complexMore sophisticatedMore sophisticated

procedures by procedures by relieving anxiety, relieving anxiety, discomfort paindiscomfort pain

Longer durationLonger durationMore frequent More frequent

th t i tith t i ti

discomfort, paindiscomfort, painMinimize patient Minimize patient movementmovement

catheterizationscatheterizationsHigh operator High operator concentrationconcentrationconcentrationconcentrationSpecial cardiac Special cardiac cathcathlablablablab

To be Practical = to understand what we are doing and the potential risks involvedare doing and the potential risks involved

1.Do no harm1.Do no harm2 Get it done2 Get it done2. Get it done2. Get it done3. Have contingencies3. Have contingencies

ASA Closed Claims Project - What have we ASA Closed Claims Project What have we learned, How has it affected practice, and How will it affect practice in the future?

….respiratory system eventsrespiratory system events accounted for a large share of all claims, and an especially large % of claims for death and brain large % of claims for death and brain damage

…..The most common events leading to (such) …..The most common events leading to (such) injury were inadequate ventilation, inadequate ventilation, esophageal intubation, and difficult esophageal intubation, and difficult tracheal intubationtracheal intubationtracheal intubationtracheal intubation

Anaesthesiology 1999; 91:552-6

Respiratory depression, after absolute or absolute or relative overdose relative overdose of sedative or opioidrelative overdose relative overdose of sedative or opioiddrugs, was the most common (25%) specific damaging mechanism in MAC specific damaging mechanism in MAC claims75% received a combination of 2 or combination of 2 or 75% received a combination of 2 or combination of 2 or more drugsmore drugsNearly half of the injuries were judged as Nearly half of the injuries were judged as preventablepreventable by additional or better monitoringmonitoring

Non-operating room anaesthesia claims had a higher severity of injury higher severity of injury and more had a higher severity of injury higher severity of injury and more substandard caresubstandard care than operating room claimsclaims.Inadequate oxygenation/ventilationInadequate oxygenation/ventilation was the most common mechanism of injurythe most common mechanism of injury.Maintenance of minimum monitoring monitoring standards and airway managementstandards and airway managementstandards and airway managementstandards and airway managementtraining is required for staff involved in patient sedationpatient sedation

• Pre-procedure evaluation Patient Counseling

1.How to Do No 1.How to Do No HarmHarm • Patient Counseling

• Preoperative preparationHarmHarm

• Monitoring• Choice of agents / Dose Titration2.How to get it 2.How to get it

donedone g• Personnel / Trainingdonedone

• Reversal agents• Emergency Equipment

S i l Sit ti

3.How to 3.How to prepare for prepare for

contingenciescontingencies • Special Situationscontingenciescontingencies

Practice Guidelines forPractice Guidelines forPractice Guidelines for Practice Guidelines for Sedation and Analgesia bySedation and Analgesia byg yg y

NonNon--AnesthesiologistsAnesthesiologistsAn Updated Report by the American An Updated Report by the American Society of Anesthesiologists TaskSociety of Anesthesiologists TaskSociety of Anesthesiologists Task Society of Anesthesiologists Task Force onForce on

S d i d A l i b NS d i d A l i b NSedation and Analgesia by NonSedation and Analgesia by Non--AnesthesiologistsAnesthesiologists

• SupportiveSuggestive

Strength of Strength of scientific scientific • Suggestive

• equivocalscientific scientific evidenceevidence

• Inconclusive• InsufficientLack of scientific Lack of scientific

evidenceevidence • silentevidenceevidence

• Strongly agree (5) to • Strongly disagree (1)

Survey responses Survey responses from consultants from consultants

for specified issuesfor specified issues g y g ( )for specified issuesfor specified issues

Professional Document Professional Document -- Review PS9 (2008)Review PS9 (2008)ddwww.anzca.edu.auwww.anzca.edu.au

Guidelines on Sedation and/or Analgesia Guidelines on Sedation and/or Analgesia for Diagnostic and Interventional for Diagnostic and Interventional for Diagnostic and Interventional for Diagnostic and Interventional Medical and Surgical ProceduresMedical and Surgical Procedures

Guidelines Guidelines –– defined as a ‘document offering advice’defined as a ‘document offering advice’

Relevant history Relevant history ––j t d tij t d ti th ith i›› major organ systems, sedationmajor organ systems, sedation--anaesthesiaanaesthesia

history, medications, allergies, last oral intakehistory, medications, allergies, last oral intakePhysical exam Physical exam ––›› Heart, lung, Heart, lung, airwayairwayLab testsLab testsDiscuss with patient risks benefits Discuss with patient risks benefits Discuss with patient risks, benefits, Discuss with patient risks, benefits, limitations, and alternativeslimitations, and alternatives

Previous problems, Previous problems, stridorstridor, snoring, sleep , snoring, sleep apneaapneappAdvanced rheumatoid arthritis, Advanced rheumatoid arthritis, chromosomal abnormality, significant chromosomal abnormality, significant

b itb itobesityobesityShort neck, limited neck extension, Short neck, limited neck extension, decreased (< 3 cm) hyoiddecreased (< 3 cm) hyoid mental distance mental distance decreased (< 3 cm) hyoiddecreased (< 3 cm) hyoid--mental distance, mental distance, neck mass, cervical spine problems, neck mass, cervical spine problems, dysmorphicdysmorphic facial featuresfacial featuresy py pSmall mouth opening (< 3 cm), dentition , Small mouth opening (< 3 cm), dentition , receding chinreceding chin

C lCase example

Elective procedures Elective procedures –– sufficient time for sufficient time for gastric emptyinggastric emptyinggastric emptyinggastric emptyingUrgent or emergent situations Urgent or emergent situations –– potential potential for pulmonary aspiration considered in for pulmonary aspiration considered in for pulmonary aspiration considered in for pulmonary aspiration considered in determining target level of sedation, determining target level of sedation, delay of procedure protection of delay of procedure protection of delay of procedure, protection of delay of procedure, protection of trachea by intubationtrachea by intubationFasting guidelines Fasting guidelines clear liquids 2h clear liquids 2h Fasting guidelines Fasting guidelines –– clear liquids 2h, clear liquids 2h, nonhuman milk and light meal 6h, fatty nonhuman milk and light meal 6h, fatty foods or meat may need longerfoods or meat may need longerfoods or meat may need longerfoods or meat may need longer

Careful transferCareful transfer i f i fEnsure patient comfortEnsure patient comfort

Proper positioning especially head and Proper positioning especially head and p p g p yp p g p yneck for the long procedure neck for the long procedure Protection of limbs and pressure pointsProtection of limbs and pressure pointsProtection of limbs and pressure pointsProtection of limbs and pressure pointsPatient kept warmPatient kept warmLet patient know what is going on Let patient know what is going on ––simple words/ simple actions can do simple words/ simple actions can do p pp p

ECG, Blood pressure and heart rateECG, Blood pressure and heart rate b l d b l d Response to verbal commands Response to verbal commands

Pulse Pulse oximetryoximetry**yyPulmonary ventilation*Pulmonary ventilation*›› Observation auscultationObservation auscultation›› Observation, auscultationObservation, auscultation›› Exhaled COExhaled CO2 2 monitoringmonitoringData record at appropriate intervals Data record at appropriate intervals before, during, after procedurebefore, during, after procedure

Ventilation and oxygenation are Ventilation and oxygenation are separate (though related) physiological separate (though related) physiological separate (though related) physiological separate (though related) physiological processesprocesses

Detection of apnea or hypoventilation Detection of apnea or hypoventilation Detection of apnea or hypoventilation Detection of apnea or hypoventilation may be delayed in patients receiving may be delayed in patients receiving supplemental O2 during MACsupplemental O2 during MACsupplemental O2 during MACsupplemental O2 during MAC

Downs JB Downs JB RespirRespir Care 2003; 48(6):611Care 2003; 48(6):611--2020

ET CO2 it i d i d tiET CO2 monitoring during sedation

Apnea lasting 20 s or more is common in Apnea lasting 20 s or more is common in patients undergoing MAC and is not patients undergoing MAC and is not

grap

hy

pa e s u de go g C a d s o pa e s u de go g C a d s o easily noticed by sedation providers but easily noticed by sedation providers but can be detected by nasal endcan be detected by nasal end--tidal CO2 tidal CO2 monitoringmonitoring

Cap

nog monitoringmonitoring

Higher O2 flow rates decreased Higher O2 flow rates decreased amplitude of amplitude of capnographcapnograph but do not but do not interfere apnea detectioninterfere apnea detectioninterfere apnea detectioninterfere apnea detection

AnesthAnesth AnalgAnalg 2004; 99:3792004; 99:379--8282

y

detects peripheral tissue oxygen detects peripheral tissue oxygen saturation and saturation and hypoxaemiahypoxaemia

e ox

imet

ry Variable pitch ‘beep’ gives continuous Variable pitch ‘beep’ gives continuous audible indication of oxygen saturationaudible indication of oxygen saturation

pulse Supplemental O2 Supplemental O2 –– increased margin of increased margin of

safety, but delayed diagnosis of safety, but delayed diagnosis of hypoventilationhypoventilationhypoventilationhypoventilation

Designated Designated individual, other than individual, other than

Pharmacology of Pharmacology of sedative and sedative and

the practitioner the practitioner performing the performing the

analgesic agentsanalgesic agentsPharmacology of Pharmacology of

procedureprocedureTo monitor the To monitor the

available available antagonists antagonists

patient throughout patient throughout the procedurethe procedure

BLSBLSACLS ACLS

May/may not assist May/may not assist with other taskswith other tasks

Prepare for Prepare for emergenciesemergencies

Oxygen delivery Oxygen delivery equipmentequipment

›› SuctionSuction›› Airway equipmentsAirway equipments

Oxygen supplementOxygen supplementRoutine/If hypoxemicRoutine/If hypoxemicy q py q p

›› Means of positiveMeans of positive--pressure ventilationpressure ventilation

/ yp/ yp› As routine

›› Basic resuscitative Basic resuscitative medicationsmedications

›› defibrillatordefibrillator

sedatives /analgesics, bolus / infusionsedatives /analgesics, bolus / infusion( id l di i )( id l di i )(can consider oral premedication)(can consider oral premedication)Medications given incrementally with Medications given incrementally with g yg ysufficient time between doses to assess sufficient time between doses to assess effectseffectseffectseffectsAppropriate dose reduction if both Appropriate dose reduction if both sedatives and analgesics used sedatives and analgesics used sedatives and analgesics used sedatives and analgesics used (especially in elderly & patients with (especially in elderly & patients with

th di )th di )other organ disease)other organ disease)

Free of serious adverse effectsNot associated with significant drug Not associated with significant drug interactionsDose not accumulate with repeated dosing Dose not accumulate with repeated dosing even in presence of organ dysfunctionEasy to administeryQuick and predictable onset and dissipation of effectThe drug(s) YOU are familiar and The drug(s) YOU are familiar and experienced with experienced with pp

Intravenous Intravenous anastheticanasthetic agentsagents such as such as ggpropofolpropofol must only be used by a must only be used by a secondsecondmedical practitioner medical practitioner trainedtrained in their use in their use because of the risk of unintentional loss of because of the risk of unintentional loss of because of the risk of unintentional loss of because of the risk of unintentional loss of consciousness. These agents must consciousness. These agents must notnot be be administered by the administered by the proceduralistproceduralist..yy pp----------------------------------------------------------

Unconscious Sedation/analgesia with Unconscious Sedation/analgesia with propofolpropofol versus versus conscious sedation with conscious sedation with fentanylfentanyl//midazolammidazolam for for catheter ablation of AF: a prospective catheter ablation of AF: a prospective catheter ablation of AF: a prospective, catheter ablation of AF: a prospective, randomized studyrandomized study

Tang et al Chin Med J 2007;120(22):2036Tang et al Chin Med J 2007;120(22):2036--88

11 encouraged or stimulated to breathe encouraged or stimulated to breathe 1.1. encouraged or stimulated to breathe encouraged or stimulated to breathe deeplydeeply

ii2.2. Receive supplemental oxygenReceive supplemental oxygen3.3. Receive positive pressure ventilation if Receive positive pressure ventilation if p pp p

spontaneous ventilation is inadequatespontaneous ventilation is inadequate44 Pharmacological reversalPharmacological reversal4.4. Pharmacological reversalPharmacological reversal

NaloxoneNaloxone and and flumazenilflumazenil available available

Prolong observation Prolong observation after after

whenever whenever opiodsopiods or or benzodiazeoinesbenzodiazeoines

i ii i

pharmacologoicalpharmacologoicalreversal to ensure reversal to ensure

iiadministered administered ––especially helpful in especially helpful in

h i h i

respiratory respiratory depression does not depression does not

cases where airway cases where airway control and positive control and positive pressure ventilation pressure ventilation

recurrecurRoutine use of Routine use of

llpressure ventilation pressure ventilation are difficultare difficult

reversalreversal

Observation until patients no longer at Observation until patients no longer at risk for cardiorisk for cardio respiratory depressionrespiratory depressionrisk for cardiorisk for cardio--respiratory depressionrespiratory depressionAppropriate discharge criteriaAppropriate discharge criteria

Severe underlying medical problemsSevere underlying medical problemsA i t lt ti / difi ti f A i t lt ti / difi ti f ›› Appropriate consultations/ modification of Appropriate consultations/ modification of techniquestechniques

Risk of severe cardiovascular or Risk of severe cardiovascular or respiratory compromise or need for respiratory compromise or need for complete unresponsiveness to obtain complete unresponsiveness to obtain adequate operating conditionsadequate operating conditionsq p gq p g›› Consult Consult anaesthesiologistsanaesthesiologists

A minimum period of full time equivalent A minimum period of full time equivalent supervised training in procedural supervised training in procedural supervised training in procedural supervised training in procedural sedation/analgesia and sedation/analgesia and anaesthesiaanaesthesiaA longstanding clinical experience as A longstanding clinical experience as equivalentequivalentqqCredentiallingCredentialling, training and clinical , training and clinical support of such medical practitioners support of such medical practitioners ––support of such medical practitioners support of such medical practitioners close cooperation from close cooperation from anaesthetistsanaesthetists in in the hospitalthe hospitalthe hospitalthe hospital

Is your own setting optimum to provide Is your own setting optimum to provide safe sedation/safe sedation/anaesthesiaanaesthesia for the for the safe sedation/safe sedation/anaesthesiaanaesthesia for the for the relevant procedures?relevant procedures?

Wh t i th it bl t i i f Wh t i th it bl t i i f What is the suitable training for nonWhat is the suitable training for non--anaesthesiologistsanaesthesiologists to provide/assist safe to provide/assist safe sedation?sedation?