Olivier Langeron, MD, PhD Department of Anesthesiology and Intensive Care

1. Updates on the sedation outside the Operating Room Olivier Langeron, MD, PhD Department of Anesthesiology and Intensive Care Pitié-Salpêtrière Hospital Paris, France

2. Disclosures • BAXTER • COOK medical • COVIDIEN

3. Anesthesia : where do we come from ? Preop assessment Monitoring PACU Safetyera Qualityera Consumption/fulfilment era On/Off Anesthetic agents PONV New techniques / new needs Anesthesia « in the package »

4. ASA CLOSED CLAIMS ANALYSIS Cheney FW Anesthesiology 1999

5. T : 1/145 500 P : 1/21 200

6. Sedation outside the OR : what are the issues ? Organisational Medical Sedationoutside the OR Technicalenvironment Economic pressure

7. Our expansion…

8. Their expansion and increasedneeds : RadiologyGastroenterology Cardiology ...

9. Anaesthetists and Sedation in the Radiology Department: Involved or left behind? Carol J. Peden Anaesthesia, 2005, 60, pages 423–425 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.

10. Swisscheese model NO assessment No staff No equipement No predefinedstrategy No equipement

11. Definition Continuum

12. 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?

13. DMV risk factors http://www.sfar.org/cexpintubdifficile.html • Increasing risk if at least 2 of these factors: • Age >55 yr • BMI >26kg/m2 • Jaw protrusion severely limited • Lack of teeth • Snoring • Beard • X 4 risk of difficult intubation with a DMV

14. DI risk factors http://www.sfar.org/cexpintubdifficile.html • History of a DI ++++ • Recommended criteria (mandatory +++) : Mallampati class >II TMD <65mm MO <35mm • Supplementary criteria Limited jaw protrusion Limited cervical spine mobility • Criteria dependent on context BMI > 35kg/m2 OSA with neck circumference > 45.6cm Neck and/or facial pathology Pre-eclampsia

15. % 0 facteur 1 facteur 2 facteurs 3 ou plus Lee Circulation 1999 0-1 factor : low risk (< 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

16. 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

17. Basic equipments and monitoring • ECG • Noninvasive BP • SpO2 • Oxygen • Tracheal intubation trolley • Suction • Defibrillator • IV equipment and solutions • Emergency drugs

18. Basic Airway Equipment • O2, suction, nasal cannula, face masks (different sizes) , self-inflatingbagmask • Oral and nasal airways • LMAs • Laryngoscopes (metalblades) • Endotracheal tubes and gumelastic bougie

19. Increasingfailure in plastic blade group : 17 vs. 3%; P < 0.01

20. 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)

21. Fasting Guidelines (from ASA) IngestedmaterialMinimum FastingPeriod • Clearliquids 2 hrs • Breastmilk 4 hrs • Infant formula 6 hrs • Nonhumanmilk 6 hrs • Light meal 6 hrs

22. Goals of sedation • Anxiolysis – Analgesia • Safety / reversibility - short acting agents (propofol) • Optimal conditions for the operator

23. Documentation During Procedure • Vital signs • Drug administration • Monitors used(SpO2, ECG) • Patient responsiveness (Ramsay Score sometimesused)

24. Recovery Phase • PACU unit • Dedicatedarea withdedicated personnel • Standard dischargecriteria (awake, stable, etc.) • Ambulatoryprocedure as required (needsan escort home and cannotdrive)

27. 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 ?

28. Anaesthetists and Sedation in the Radiology Department: Involved or left behind? Carol J. Peden Anaesthesia, 2005, 60, pages 423–425 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. .

29. To summarize : sedation outside the OR  • Organisation ismandatory • Involvmentsince the beginning of the procedureis capital • Cooperationbetweenspecialistsis essential • Periodicevaluationisrequired (qualityinsurance) Sedation is already Anesthesia ++++

30. Be carreful Sedationrequires expertise