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Safe Sedation for patients with special needs. Dr John M LOW MA. (Oxford University) BM.BCh . (Oxford University) FRCA. , FHKCA. , FANZCA., FHKAM .( Anaesthesiology ) Partner, Dr. Roger Hung and Partners. Overview. Sedation vs General Anaesthesia Achieving sympatholysis

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safe sedation for patients with special needs

Safe Sedation for patients with special needs

Dr John M LOW

MA. (Oxford University) BM.BCh. (Oxford University)

FRCA., FHKCA., FANZCA.,FHKAM.(Anaesthesiology)

Partner, Dr. Roger Hung and Partners

overview
Overview
  • Sedation vs General Anaesthesia
  • Achieving sympatholysis
  • Pharmacology
  • Practical aspects of M A C - equipment
  • Regulatory aspects
  • Managing patient work flow
sympathetic activity
↑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
noxious stimulation
Noxious stimulation

JM Low et al (1986) B J Anaesth 58:471-477

Adrenergic Responses to Laryngoscopy

reducing sympathetic activity1
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
common drugs for sedation
Common drugs for sedation
  • IV Sedation:
    • Pethidine / Morphine
    • Midazolam / Diazepam/Diazemuls
  • Monitored Anaesthetic Care
    • Propofol / Dexmetatomidine (Precedex)
    • Fentanyl / Alfentanil / Remifentanil
    • Dynastat / Pethidine
typical sequence m a c
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
o 2 n 2 o sevoflurane
O2 / N2O /Sevoflurane
  • Excellent for induction (paediatrics)
  • Short exposure to allow for i.v. access
  • Unsuitable for long term use
maintenance of the airway
Maintenance of the airway
  • AMBU Bag readily accessible
  • + / - Oxygen supplement
  • Chin lift (teach D S A)
  • Practical “tricks of the trade”
practical tricks
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
irrigatio n without aspiration
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
patient positioning
Patient Positioning
  • Soft elastic belt (for children)
  • Safety belt (adults)
  • Blanket (sympatholysis)
  • Minor movement tolerable
m a c a pragmatic approach
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
propofol pharmacology
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
propofol pharmacokinetics1
Propofol – Pharmacokinetics

Guaranteed sedation…..

in practice
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
titrating to patient s threshold
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”

supplementary agents
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)
sedation equipment
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
patient selection
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
what procedures are appropriate
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 ?
patient work flow
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.,
fasting instructions
Fasting Instructions
  • 6 hours - solids
  • Food and snacks
  • Milk
  • Milky drinks
  • Fresh orange juice
  • 2 Hours – clear fluids
  • Water
  • Ribena
  • Apple juice
  • Orange squash
range of procedures
Range of procedures
  • Examination -/+ x-ray
  • Dental Hygiene
  • Restoration
  • S S crown
  • R C T
  • Extraction
  • Orthodontics -/+ impression
range of dental procedures
Range of Dental Procedures
  • Paediatric – M O S
  • Paediatric –dental restoration
    • Often minimal stimulation
    • Pulpectomy will need LA
  • Combative / mentally handicapped
range of dental procedures1
Range of Dental Procedures
  • Adult – M O S
  • Dental Implants
  • Aesthetic dentistry
  • Mentally handicapped
clinic selection
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
practical aspects
Practical Aspects
  • Equipment – Mandatory ←→ Best Practice
  • Protocols / Check List – for nursing staff
  • Documentation

Pre-operative diagnosis – justify procedure

Pre-operative assessment – questionnaire

Written pre-operative instructions / fasting time

Consent for surgery – informed / explicit

Consent for sedation – informed / explicit

Sedation - vital signs record / positioning / drugs / timetable of events

Operation Record – diagnosis / findings/ procedure / closure

Written Post-Operative instructions – escort present

regulatory aspects
Regulatory aspects
  • American Society of Anesthesiologists
  • American Dental Association
    • Task Force of Sedation & Analgesia
    • Practice Guidelines for Sedation
      • Anesthesiology 2002 96:1004-1017
regulatory aspects1
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

useful reference texts
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)
are there additional risks
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
contingency planning
Contingency Planning
  • Oxygen (Cylinder /Oxygen Concentrator)
  • Sedation Drugs
  • Resuscitation Drugs
  • Prolonged Recovery
  • P O N V
  • Vaso-vagalsycope
  • Protocol for hospitalisation
  • Local Analgesia Toxicity
  • (Malignant Hyperpyrexia)
emergency drugs
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
fitness for discharge
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
discharge work flow
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)
benefits of o b a
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
summary
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
summary1
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
cd rom contents
CD-ROM Contents
  • EQUIPMENT Specifications
  • GUIDELINES for clinical practice
  • TEMPLATES for documentation
  • POWERPOINT
thank you very much
Thank you very much

Mount Yotei, 羊蹄山, ShikotsuToya National Park, Hokkaido, Japan