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SAFE SEDATION FOR PATIENTS WITH SPECIAL NEEDS
Dr John M LOWMA. (Oxford University) BM.BCh. (Oxford University)
FRCA., FHKCA., FANZCA., FHKAM.(Anaesthesiology)
Partner, Dr. Roger Hung and Partners
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Overview
Sedation vs General Anaesthesia Achieving sympatholysis Pharmacology Practical aspects of M A C - equipment Regulatory aspects Managing patient work flow
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↑sympathetic activity
Psychological and emotional Physical
Instrumentation / Surgical Incision Pharyngeal/ Laryngeal stimulation
Tomori Z, & Widdicombe J G (1969) J Physiol (London) 200:25
Exogenous catecholamines (LA) Cold Full bladder
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Noxious stimulation
JM Low et al (1986) B J Anaesth 58:471-477Adrenergic Responses to Laryngoscopy
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Reducing sympathetic activity
Anxiety Sedation
Sympatholysis
Analgesia
Anxiolytics
Cold, Pain, Noxious Stimulus
Fear Factor Sympathetic activation
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Reducing sympathetic activity
Anxiolytics (benzodiazepines / propofol)
Local analgesia - ↓ pain stimulus Fentanyl - ↓ pain stimulus; sympatholysis ↓ non-pharmacological factors (eg. cold) β - adrenergic blockade α - adrenergic blockade
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Sedation vs G A
Minimal Moderate Deep G A
Responsiveness Verbal commands
Purposeful response
Response to deep pain
Unrouseable
Airway Normal No need for intervention
May need chin lift
Airway / chin lift needed
Spontaneous ventilation
Normal Adequate May not be adequate
Often inadequate
CVS functionNormal Usually
maintainedUsually maintained
May be impaired
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Common drugs for sedation
IV Sedation: Pethidine / Morphine Midazolam / Diazepam/Diazemuls
Monitored Anaesthetic Care Propofol / Dexmetatomidine (Precedex) Fentanyl / Alfentanil / Remifentanil Dynastat / Pethidine
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Typical sequence - M A C
Assessment and Informed consent Preparation of equipment Inhalational induction (paediatric case) IV access – Bolus and Maintenance Maintenance of patient’s airway Monitoring Recovery and Discharge
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O2 / N2O /Sevoflurane
Excellent for induction (paediatrics) Short exposure to allow for i.v. access Unsuitable for long term use
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Intra nasal spray
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Maintenance of the airway
AMBU Bag readily accessible + / - Oxygen supplement Chin lift (teach D S A) Practical “tricks of the trade”
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Practical “tricks”
Posture – (take advantage of pharyngeal curvature)
Horizontal position Neck extension Shoulder support
Nasopharyngeal airway Loose gauze swab in pharynx Oral Dam Double suction (DSA) No irrigation – soft debris
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Irrigation without aspiration
Suction…..Suction……Suction……. Neck extension – double articulation
headrest Cough / swallowing reflex present Oral Dam – if possible Loosely packed gauze swab Chin Lift -Train D S A Minimise irrigation
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Patient Positioning
Soft elastic belt (for children)
Safety belt (adults) Blanket (sympatholysis) Minor movement tolerable
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Patient Positioning
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M A C – typical sequence
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M A C – a pragmatic approach
Inhalational techniques Excellent for paediatric induction No scavenging – closed ventilation Limited supply of gas / agent Complex equipment needed for maintenance
Intravenous Techniques Propofol……propofol……propofol + / - Adjunct agents
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Propofoldi-isopropyl phenol
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Propofol Pharmacology
Non-barbituarate hypnotic anaesthetic Lipid soluble – preparation as emulsion Rapid hepatic & extra-hepatic metabolism Very rapid onset and recovery Half Life: T½= 2; 30; 180 mins Metabolites not active Hypnosis at 1.5-6 μg/ml Maintenance with infusion pump No atmospheric pollution
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Propofol – Pharmacokinetics
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Propofol – Pharmacokinetics
Guaranteed sedation…..
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Propofol Pharmacokinetics
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Propofol Pharmacokinetics for the rest of us
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Propofol Pharmacokinetics for the rest of us
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Propofol Pharmacokinetics for the rest of us
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Bathtub Pharmacokinetics
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In practice
Loading dose – 40-80 mg (1 mg/kg)
Maintenance dose – 25-60 mls/hr (80 μg/kg/min)
20mg bolus prn. Titrating to patient’s threshold
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Titrating to patient’s threshold
At steady state Reduce rate by 10% every few minutes Slight non-purposeful movement (threshold) Add 10% and maintain Switch off when no more stimulation
“Every anaesthetic is a pharmacological experiment”
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Individual Titration
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Supplementary Agents
Midazolam (1-2 mg) Fentanyl (25 mcg / 0.5 mls) Pethidine 0.5-1 mg/kg Remifentanil (20μg + 2.5 μg/min) Dynastat (40 mg iv Q12H) Arcoxia (90 – 120 mg po.) Dexmetatomidine (Precedex) Labetalol (!) (5 – 15 mg)
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Sedation - equipment
IV equipment Monitoring Oxygen / AMBU bag Simple airway management Treatment of major side effects
Anaphylaxis Extremes of HR Extremes of BP Bronchospasm Angina P O N V
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Monitoring and iv infusion
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Oxygen supply
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Contingency Equipment: Vital SignsTM Airway Pack
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Contingency Equipment
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Contingency Equipment
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Contingency Equipment
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Contingency Equipment
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Utility Trolley
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Utility Trolley
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Patient selection
ASA I or II Age less than 70 years BMI less than 30 Satisfactory pre-op assessment
questionnaire Easy access to hospital if necessary Escort available following procedure
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What procedures are appropriate ?
Patient factors – ASA I / II Assessment of surgical risk Exclude risk of major bleeding Minimal risk of P O N V Satisfactory post-op pain control Patient’s domestic circumstances
Why does this surgery justify hospitalisation ?
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Patient Work Flow
Presentation and decision to operate Screening Questionnaire
Concurrent medications / Allergies / Cardio- respiratory status
Fasting instructions Day of procedure – Consent; Contact; Re-assessment; Payment
Recovery Stage I Stage II
Escort to and from clinic Written Instructions – Medication; Analgesia;
driving, machinery, signing of legal documents, cooking, etc.,
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Fasting Instructions
6 hours - solids
Food and snacks Milk Milky drinks Fresh orange juice
2 Hours – clear fluids
Water Ribena Apple juice Orange squash
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Range of procedures
Examination -/+ x-ray Dental Hygiene Restoration S S crown R C T Extraction Orthodontics -/+ impression
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Range of Dental Procedures
Paediatric – M O S Paediatric –dental restoration
Often minimal stimulation Pulpectomy will need LA
Combative / mentally handicapped
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Range of Dental Procedures
Adult – M O S Dental Implants Aesthetic dentistry Mentally handicapped
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Clinic Selection
Preliminary visit to clinic – assess environment
Establish rapport with surgeon “Check List” of mandatory equipment Second visit – check all facilities Then – (third visit) - book patient
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Practical Aspects
Equipment – Mandatory ←→ Best Practice Protocols / Check List – for nursing staff Documentation
Pre-operative diagnosis – justify procedurePre-operative assessment – questionnaireWritten pre-operative instructions / fasting timeConsent for surgery – informed / explicitConsent for sedation – informed / explicitSedation - vital signs record / positioning / drugs / timetable of
events
Operation Record – diagnosis / findings/ procedure / closure
Written Post-Operative instructions – escort present
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Regulatory aspects
American Society of Anesthesiologists American Dental Association
Task Force of Sedation & Analgesia Practice Guidelines for Sedation
Anesthesiology 2002 96:1004-1017
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Regulatory aspects
International Guidelines ASA / ADA* AAGBI / NICE Guidelines NHS UK* ASA Day Case Surgery Guidelines*
Hong Kong College of Anaesthesiologists* Hong Kong Academy of Medicine* HK Society of Paediatric Dentistry* Mid Lothian Day Case Surgery Process
Chart*
* Copies included in CD-ROM
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Useful Reference Texts
Manual of Office-Based Anesthesia Procedures Fred E Shapiro Lippincott Williams & Wilkins www.amazon.com
Guidelines on Sedation for Dental Procedures HKSPD Task Force www.hkspd.org
American Heart Association – Emergency Cardiac Care A H A / Worldpoint www.eworldpoint.com)
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Are there additional risks ? No greater or less than hospital setting ASA Closed Claims analysis Greater need for contingency planning Emergency Protocols Staff training in BCLS ACLS Simulate Drills (e.g. hypoxia)
http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2044.2011.06651.x/pdf
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Contingency Planning
Oxygen (Cylinder /Oxygen Concentrator) Sedation Drugs Resuscitation Drugs Prolonged Recovery P O N V Vaso-vagal sycope Protocol for hospitalisation Local Analgesia Toxicity (Malignant Hyperpyrexia)
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Emergency Drugs
P O N V – metoclopramide / odansetron / dexamethasone
Hypotension – phenylephrine / ephedrine
Hypertension – nifedepine / labetalol / hydrallazine
Bradycardia – atropine / isoprenaline / dobutamine
Tachycardia – esmolol / fentanyl
Bronchospasm – ventolin inhaler / aminophylline
Acute Angina – nitroglycerine patch / sl.
Anaphylaxis – adrenaline / Ca++ / hydrocortisone / dexamethasone
Allergy – chlorpheniramine
Antagonists – naloxone / flumazenil
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Fitness for discharge
Stable vital signs Orientation – time, place, person Satisfactory pain control Able to dress; walk; pass urine No bleeding ; No P O N V ; Escort present
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Modified Aldrete Score
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Post Anaesthesia Discharge Score(Korttila)
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Discharge Work Flow
Discharge Criteria- Modified Aldrete Score / PADSS (Korttila)
Post-operative Instructions – written
Escort is mandatory Supply of post-op drugs – analgesic; antibiotics
Emergency contact number - nurse / surgeon
Initiate telephone follow up on the next day Post operative follow up in clinic Alert system for pathology result
(malignancy)
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Benefits of O B A
One Stop for the patient / client Control over scheduling No waiting for hospital beds Less competition for OT schedule No delay because of emergency OT Minimal risk of hospital acquired infection Reduced cost for patient and insurance
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Summary
M A C is safe Separate Operator and Sedationist M A C is a growing market
Trends in USA: OBA - >50% services Recent adverse publicity locally
(gynaecology; liposuction; mammoplasty) Follow guidelines
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Summary
M A C is safe ( “Big MAC” may not be)
Separate Operator and Sedationist M A C is a growing market
Trends in USA: OBA - >50% services Recent adverse publicity locally
(gynaecology; liposuction; mammoplasty) Follow guidelines
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CD-ROM Contents
EQUIPMENT Specifications GUIDELINES for clinical practice TEMPLATES for documentation POWERPOINT
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Thank you very much
Mount Yotei, 羊蹄山 , Shikotsu Toya National Park, Hokkaido, Japan