Transcript anesthesia in remote locations

GOALS FOR THIS LECTURE
• EXPLORE REASONS WHY WE ARE PROVIDING SO
MUCH MORE OF THESE SERVICES
• DISCUSS THE UNIQUE DEMANDS AND RISKS OF
ANESTHETIZING IN REMOTE LOCATIONS AND
DEVELOP STRATEGIES TO IMPROVE PATIENT SAFETY
AND MINIMIZE LIABILITY
• COMPARE OURSELVES TO NON-ANESTHESIA
PROVIDERS IN THE SEDATION ARENA
GOALS
• UNDERSTAND THE PURPOSE OF ASA CLOSED
CLAIMS PROJECT
• REVIEW FINDINGS OF ASA CLOSED CLAIMS DATA
PERTINENT TO ANESTHESIA IN REMOTE
LOCATIONS
• PRACTICE STANDARDS AND GUIDELINES IN
REMOTE LOCATIONS
• DISCUSS STRATEGIES FOR SPECIFIC LOCATIONS
WHAT DO WE NEED TO DO
DIFFERENTLY?
WHERE WILL I BE TODAY?
• Growing demand for anesthesia services outside of
the operating room over the past few decades due to:
• Advances in diagnostic and interventional procedures
in fixed locations such as special radiology units (MRI,
CT), cardiac cath and EP labs, radiation oncology,
endoscopy suites, dental clinics, burn units, psychiatric
units for ECT, renal units for lithotripsy (trailer trash),
bedside tracheostomy in ICU, and gynecologic units for
IVF.
WHERE WILL I BE TODAY?
• Constraints on time for OR availability for non-surgical
anesthesia
• Legitimate need of certain patient groups (pediatric,
mentally challenged, high risk co-morbidities such as
severe OSA/BiPAP, super morbid obesity, severe end
organ dysfunction)
• Demands of patients for sedation and lack of recall
(pediatric dental, GI endoscopy, claustrophobic
patients for imaging studies.)
INHERENT PROBLEMS AND CHALLENGES
The delivery of safe anesthesia in
remote locations is made difficult
for a variety of confounding
circumstances
.
INHERENT PROBLEMS
 As non-surgical patients, often fall through
the cracks as far as pre-testing.
 Not properly evaluated preoperatively
 Results in rushing the day of the procedure
 Results in delays in remote location and
delays in the OR later in the day due to the
domino effect of tardiness anywhere in the
process
INHERENT PROBLEMS
 Cramped rooms
 Poor lighting
 Staff unfamiliar with anesthetized patients
and our equipment
 Potential lack of rigorous pre-procedural
check-in processes
 Far from colleagues and back up help in a
crisis situation
INHERENT PROBLEMS
 Inadequate anesthesia support
 Staff unfamiliar with anesthetized
patients and our equipment
 Lack of rigorous pre-procedural check-in
processes
 Far from colleagues and back up help in
a crisis
INHERENT PROBLEMS
 Unfamiliar environment
 Anesthesia equipment often different than OR
equipment
 Physical set up different
 Inadequate monitoring equipment
 Inadequate stocking of supplies and drugs
 Equipment may not be well maintained or checked
routinely.
US
VERSUS
THEM
DO WE MATTER?
How good a job has our nonanesthesia colleagues done in
providing procedural sedation?
DO WE MATTER?
 Not so good, apparently, or our services would not be
so much more frequently requested or demanded.
 Many reasons: US patients DEMAND sedation, and
not just mild to moderate sedation (benzodiazepine
based with or without opioids)
 Demanding deep sedation with a shift towards
Propofol as the agent of choice
Propofol
•
•
•
•
•
Sedative, hypnotic
Respiratory depression
Hypotension
Anti-emetic
How did we practice
before this agent?
RISKS OF SEDATION BY NON-ANESTHESIA
PROVIDERS
What have we learned from our
gastroenterology colleagues regarding
safety of sedating this patient
population? What types of patients
have they harmed?
.
WHAT HAPPENED?
 Switch from benzodiazepine/opioid based
sedation protocol to Propofol
 Highly controversial issue (credentialing,
literature, media)
 Only advantage conferred by Propofol is a shorter
recovery time
 Catastrophic disadvantages of Propofol
administered by non-anesthesia providers,
INADEQUATE STUDIES
 Studies lack adequate numbers and statistical power.
 They did not monitor ETCO2, so apneic episodes were
often missed.
 Few of the patients in published studies were sick
(ASA III,IV, V), obese, or had sleep apnea.
 Most studies poorly controlled and fail to meet
inclusion criteria for the primary objectives of the
proposed study design.
SEEMS LIKE WE ARE ALL HAVING THE SAME
PROBLEM WITH OLDER, SICKER, HEAVIER
PATIENTS. NO WONDER THEY’RE HAVING
TROUBLE AND NEED US!
CAPNOGRAPHY
 Apnea lasting longer than 30 seconds is missed in 63% of
patients by endoscopists,
 In ER’s where MD’s are administering Propofol for sedation,
capnography identified all cases of hypoxemia BEFORE the onset
of O2 saturations plummeting. Median time from capnographic
evidence of respiratory depression to hypoxemia was 60
seconds.
 ASA recommends the use of ETCO2 monitoring to assess
adequacy of ventilation during MAC with Propofol (ASAHQ
Statement on Safe Use of Propofol, 17 March, 2010)
THEIR LITERATURE
Rex looked at 646,000 endoscopist
directed Propofol sedations for EGD and
colonoscopies and documented 4 deaths.
All were ASA 3 or 4.
Estimated cost per life-year saved was
$5.3Million, if anesthesiologists were
substituted and had prevented all the
deaths.
THEIR LITERATURE
 Problem: While their literature fails to show huge
differences in morbidity and mortality between nonanesthesia provided sedation, insurance companies
reimburse our services – they recognize the safety
value of our care or they wouldn’t pay.
 Reality: Code blues/Rapid response calls in these
remote locations were a common occurrence in the
past and continue to be a reality even today.
 Again, our patient population is their, too.
ASA CLOSED CLAIMS PROJECT
1980’s – crisis of affordability in professional
liability insurance
Anesthesiologists – bad risk
3% of insured physicians, but 11% of total dollars
paid for patient injury
Risk reflected in soaring malpractice premiums
Ellison Pierce, Jr. MD
1984 President of ASA
Programs to improve patient safety and
prevent anesthetic injury
Closed Claims Project, assigned to ASA
Committee on Professional Liability
PROBLEM WITH DATA ACQUISITION
1
2
3
• 1984 – little comprehensive information on the
scope and cause of anesthetic injury in US
• Significant anesthesia injury is a relatively rare
occurrence.
• Therefore, difficult to study prospectively or by
retrospective medical record review, even from
multiple institutions.
SOLUTION
1
• Study of insurance company closed claims
2
• Cost-effective approach to data collection, extensive
data on injuries from many different institutions.
3
• All this data could be gathered in one centralized
location, the ASA Closed Claims Data Base.
DATA OBTAINED FROM INSURANCE COMPANIES
1
2
3
•Hospital Record
•Anesthesia Record
•Narrative statements of involved personnel
•Expert and peer reviews
•Deposition summaries, outcome reports
•Cost of settlement or jury awards
TASK OF CLOSED CLAIMS PROJECT
1
• Provide a concentrated collection of information
on relatively rare events leading to anesthesiarelated injury.
2
• Gain access to and collect information from
professional liability organizations throughout the
USA.
3
• Identify the major areas of anesthesia-related
patient injury and design strategies to improve
patient safety.
INHERENT LIMITATIONS OF CLOSED CLAIMS
1
•Not all malpractice insurance companies
have cooperated and provided closed claims
data.
2
• By 1999 insurance companies covering only 14,500 of
the total 23,000 practicing anesthesiologists
cooperated with the Closed Claims Database.
3
•Do not have the denominator of total number of cases done by
those 14,500 anesthesiologists, therefore, closed claims data
do not generate calculated risk data of anesthetic injury.
ORIGINAL CLOSED CLAIMS RESULTS
1
2
3
•4000 claims from 1970-1994
•Reviewed by volunteer anesthesiologists
using standardized data collection.
•Assess of cause of injury and appropriateness
of care by several reviewers
ORIGINAL CLAIMS DATA
1
2
3
• Claims entered in data base on anonymous
basis.
• No identification of defendant, plaintiff,
location, institution, company so impossible to
match claims in data base to their source files.
• Funded entirely by the ASA
HOW IS DATA USED?
1
•Ongoing analysis of database. Any
emerging patterns of injury prompts
action.
2
•Triggers a manuscript for peer reviewed
journals for further analysis of emerging
patient safety and liability issues.
3
•All results are reported in meeting
abstracts and the ASA Newsletter.
Figure 1
The American Society of Anesthesiologists
Closed Claims Project: What Have We
Learned, How Has It Affected Practice, and
How Will It Affect Practice in the Future?
Cheney, Frederick W.
Anesthesiology. 91(2):552-556, August
1999.
doi:
Figure 1. The incidence of death, brain
damage, and nerve injury as a percentage
of total claims in a given time period. A
significant reduction in the proportion of
claims for death and brain damage
occurred between 1970–1979 and 1990–
1994 (*P <or= to 0.01, Z test).
Copyright © 2012 Anesthesiology. Published by Lippincott Williams & Wilkins.
34
CARDIAC ARREST WITH SAB
 6 deaths, 8 permanent brain damage.
 Hypothesis: Poor cerebral perfusion pressure during closed
cardiac massage in the presence of high sympathetic blockade.
 Advocated early administration of epinephrine in response to
severe bradycardia and hypotension with SAB
 Example of how the Closed Claims Database results in
modifications of practice patterns resulting in improved patient
safety.
MAJOR TRENDS FROM DATABASE
1
2
3
•Respiratory system events large share of
claims
•Large percentage of claims for death and
brain injury
•Most common events: inadequate
ventilation, esophageal intubation, difficult
tracheal intubation
ASA COMMITTEE OF STANDARDS
1
2
3
•Resulted in formulation of standards
requiring use of pulse oximetry
intraoperatively
•The use of ETCO2 for the verification of
endotracheal intubation
•The use of pulse oximetry in the PACU
FUTURE TRENDS AND IMPROVED SAFETY
Question?
Does SaO2
and ETCO2
monitoring
improve
patient
safety?
Severity of injury decreasing, fewer
claims for brain death and brain injury
from 1970’s to 1990’s
Increase in claims for minor injuries
Significant decrease in malpractice
premiums implies an overall reduction
in severe injuries
MORE TRENDS NOTED
Severe
injuries
(death
and brain
damage)
cause has
changed
over time.
Inadequate ventilation and esophageal
intubations 2-3 time more common preSaO2 and ETCO2 monitoring
Difficult intubation claims fairly static over
time frame (before algorithms and
advanced airway devices)
Nerve injuries have become leading cause
of anesthesia related injury – suggests the
mechanism of such injuries still not yet
known.
Figure 2
The American Society of Anesthesiologists
Closed Claims Project: What Have We
Learned, How Has It Affected Practice, and
How Will It Affect Practice in the Future?
Cheney, Frederick W.
Anesthesiology. 91(2):552-556, August
1999.
doi:
Figure 2. The incidence of respiratory,
cardiovascular, and equipment‐related
damaging events as a percentage of the
total claims for death and brain damage in
each time period (*P <or= to 0.05, Z test)
(compared with 1970–1979).
Copyright © 2012 Anesthesiology. Published by Lippincott Williams & Wilkins.
40
RISK OF ANESTEHSIA CARE IN REMOTE
LOCATIONS
COPYRIGHT © 2009 WOLTERS KLUWER. PUBLISHED BY
LIPPINCOTT WILLIAMS & WILKINS.
41
ASA CLOSED CLAIMS PROJECT REVIEW
 Despite most procedures being relatively noninvasive, serious adverse outcomes occur.
 Analyzed claims for injuries from 1990 and later
in ASA Closed Claims Database to compare
injuries associated with claims for anesthesia
care in remote locations (87) and in the OR
setting (3286)
ANESTHESIA PATIENT SAFETY FOUNDATION NEWSLETTER,
SPRING/SUMMER 2011
REMOTE LOCATION PATIENT IDENTIFIERS
1
•Compared to patients in the OR they were
•OLDER (20% >70 years old)
2
•SICKER
•69% ASA 3-5
3
•More often underwent an EMERGENCY
procedure (36%)
MORE DIFFERENCES FROM THE OR
1
2
3
•MAC predominant anesthetic technique, 8
times more frequent than OR (50% vs.6%)
•GI Suite most commonly involved (32%
claims), followed by cath lab or EP lab (25%).
•MRI scanner most common radiology claim
location.
OR VS. REMOTE CLAIMS
1
2
3
•Severity of injury greater in remote
locations (death, permanent brain damage)
•Death rate double in remote locations
•Proportion of respiratory events double in
remote locations
MOST COMMON RESPIRATORY EVENT
1
2
3
•INADEQUATE OXYGENATION/VENTILATION
•7 TIMES MORE FREQUENT THAN OR
•MORE OFTEN JUDGED AS BEING
PREVENTABLE BY BETTER MONITORING
RESPIRATORY DEPRESSION
1
2
3
•Overdose of sedative-hypnotic-analgesic
responsible for 26/84 claims
•Overdose responsible for 50% GI claims
•Patient factors for over sedation were
obesity, OSA, ASA Class 305, age >70
OTHER CHARACTERISTICS
1
2
3
•Propofol most common drug implicated
in over dosage and injury or death
•Capnography only utilized in 15% of
•claims
•Absolutely no respiratory monitoring
documented in another 15% of cases
CONCLUSIONS
SUBSTANDARD CARE, PREVENTABLE BY BETTER
MONITORING, WAS IMPLICATED IN THE
MAJORITY OF CLAIMS ASSOCIATED WITH
DEATH.
REMEMBER, THESE WERE MAC AND GA
ADMINISTERED BY US, NOT THEM!
RECOMMENDATIONS
1
2
3
• MAC in remote locations poses significant risk for over
sedation and inadequate oxygenation/ventilation
•Capnography can minimize patient risk in
remote locations
•Finally, GA with secured airway may be safer than deep
sedation (MAC) in some patients (OSA) and certain
procedures (prone, MRI scanner or anything with limited
access to patient’s airway.
WHAT IS MAC?
1
2
3
•Monitored anesthesia Care?
•Minimal airway control?
•Mostly apneic and cyanotic?
MONITORED ANESTHESIA CARE INCLUDES
 Diagnosis and treatment of clinical problems that
occur during the procedure
 Support of vital functions
 Administration of sedatives, analgesics, hypnotics,
anesthetic agents or other medications as necessary
for patient safety
 Psychological support and physical comfort
DISTINGUISHING MAC FROM MODERATE
SEDATION/ANALGESIA
(CONSCIOUS SEDATION)
ECONOMICS COMMITTEE
AMENDED BY ASA HOUSE OF
DELEGATES ON
OCTOBER 21, 2009
“MAC”
Monitored anesthesia care may include varying
levels of sedation, analgesia and anxiolysis as
necessary
“ If the patient loses consciousness and the ability to
respond purposefully, the anesthesia care is a
general anesthetic, irrespective of whether airway
instrumentation is required”
ASA House of delegates- 2008
STANDARDS FOR BASIC MONITORING
Approved by ASA House of Delegate
Effective Date July 1, 2011
During moderate or deep sedation the adequacy of ventilation
shall be evaluated by continual observation of
QUALATATIVE CLINICAL SIGNS AND MONITORING FOR THE
PRESENCE OF EXHALED CARBON DIOXIDE unless
precluded or invalidated by the nature of the patient
(monitoring with CPAP/BiPAP causing a leak), procedure, or
equipment.
STATEMENT ON RESPIRATORY MONITORING DURING
ENDOSCOPIC PROCEDURES
Approved by the ASA House of Delegates Oct. 21, 2009
Monitoring of ETCO2 should be CONSIDERED for all endoscopies,
especially of the upper GI tract (shared airway) when Propofol
alone or in combo with benzodiazepines and/or opioids. ERCP,
requiring the prone position, poses extreme danger and requires
CAREFUL ATTENTION TO AIRWAY MANAGEMENT as ventilatory
monitoring, airway maintenance and resuscitation may be
especially difficult.
Metzner J, Posner KL, Domino KB. The risk and safety of
anesthesia at remote locations. The US closed claims
analysis. Curr Opinion Anaesthesiol. 2009;22:502-508
Metzner J, Posner KL, Domino KB. The risk and safety of
anesthesia at remote locations. The US closed claims
analysis. Curr Opinion Anaesthesiol. 2009;22:502-508
ASA Guidelines
• Reliable source of Oxygen…with back-up
– Piped O2 encouraged, 1 full bottle
– Checked before cases begin
• Reliable suction
• Anesthetic gas Scavenger
• Equipment:
– Self inflating bag capable of FiO2 90%
– Adequate Drugs, Monitoring Equipment
– Standard Anesthesia machine (if inhalational
used)
ANESTHESIA STANDARDS
OUTSIDE THE OR
 Anesthesia equipment should be of the same caliber
as that in the OR
 Pre-anesthetic evaluation process should be the same
as that for patients undergoing surgical procedures
RADIATION SAFETY
1
• A unique hazard in the radiology suite is radiation
• Exposure.
2
• Dosimeters should be worn, lead aprons and
thyroid shields.
3
• Maximum annual dose 50 mSv (millisieverts)
• Pregnant women less than 0.5 mSv monthly
RADIATION SAFETY
4
5
6
•Movable leaded glass screens
•Remote monitoring via video link
•Warning that radiation is initiated
REACTIONS TO IODINATED CONTRAST
MILD
SEVERE
LIFE THREATENING
Nausea, Retching
Vomiting
Glottic Edema
Perception of warmth
Rigors
Bronchospasm
Headache
Feeling Faint
Pulmonary Edema
Itchy Rash
Chest Pain
Life Threatening
Arrhythmias
Urticaria
Urticaria
Cardiac Arrest
Bronchospasm,
Dyspnea
Seizures/
Unconsciousness
Abdominal Pain,
Diarrhea
Arrhythmias
Renal Failure
67
Adults for MRI
68
Jaw elevation device (JED)
Do you stay in the scanner?
Why?
• If pt is unstable
• Study requires
suspended
respirations
• Sound is 90-100
decibels
• No one can hear
YOU scream
72
Advantages of TIVA
• Components can be regulated
independently
• Anesthetic area remains unpolluted by
trace concentrations of nitrous
oxide/volatile agents
• Vaporizers are not needed
• Prevents delivery of hypoxic mixtures
• Non-triggering of malignant hyperthermia
Ketamine
•
•
•
•
•
Analgesia
Sedation
Cardiovascular stability
Bronchodilation
Cheap!
• Tachycardia?
• Secretions
• Hallucinations
Sedation
Amnesia
Analgesia
Hypnosis
Anxiolysis
α2 Agonists
76
CT scan
77
Intubation for EGD?
• Patients with high risk for aspiration
– Severe Gastric reflux
– Achalasia
– Bowel obstruction
– Uncontrollable bleeding
– Otherwise patients receive MAC for upper
endoscopy
ERCP- Technique
• Unless morbid obesity, MAC with propofol
infusion and ketamine
• Midazolam- 1-2 mg
• Propofol induction- 1-2 mg/kg
• 25-50mg ketamine in 20cc propofol infusion at
30-40ug/kg/min
• Decrease/eliminate ketamine and continue
with propofol