Out of Operating Room Anesthesia: A Comprehensive Review
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Situations like those that contributed to the death of Joan Rivers are addressed with particular emphasis on their recognition, prevention and management. The importance of safety as the key element in providing anesthesia in remote or unfamiliar areas is highlighted and discussed. A lack of accurate documentation is a major drawback in out of OR anesthesia practice and the reader is drawn to the importance of documentation, both from a practical and medico legal standpoint.
A separate chapter deals with research and future directions in out of OR anesthesia. Out of Operating Room Anesthesia: A Comprehensive Review , is primarily aimed at all anesthesia providers: anesthesiologists, nurse anesthetists and residents. Specific chapters such as dental anesthesia, anesthesia for ER procedures and sedation for cosmetic procedures will be useful as a reference guide to physicians exposed to brief training in anesthesia during their non-anesthesia residency program.
His main area of focus is out of operating room anesthesia with an emphasis on anesthesia for endoscopic procedures and total intravenous anesthesia. He has conducted clinical research and published extensively in this area. Dr Singh is a renowned consultant anesthesiologist working at one of the topmost hospitals in India All India institute of Medical Sciences- New Delhi. After obtaining a postgraduate degree in anesthesia in , Dr Singh has been actively contributing and publishing in the field of clinical anesthesia. He has published more than scholarly articles in various well known international scientific journals.
In addition, he has authored multiple chapters on various aspects of anesthesia in many well-known anesthesiology books. His research work in the out of operating room anesthesia field is well recognized and has received numerous citations across the globe. He notes that, previously, the use of diazepam along with local analgesia was relatively uncomplicated.
However, soon meperidine, atropine, fentanyl, methohexital, and a host of other drugs were also added. Polypharmacy posed a potential problem. A host of experts, including anesthesiologists, agreed on developing answers to frequently asked questions. Although the principles and definitions described in the document are not necessarily original but undoubtedly originated in the dental literature , they do represent important features, which continue to be emphasized, and must not be ignored.
Several of these are as follows:. From time to time, other Dental groups, such as The American Dental Association Chicago, Illinois and American Association of Oral and Maxillofacial Surgeons Rosemont, Illinois , have issued comprehensive guidelines for sedation and anesthesia; however their design and content are beyond the scope of this discussion.
Sedation guidelines were developed by the AAP primarily because of the reporting of a number of deaths in dental offices. Although a number of anesthesiologists, including myself, were members of one of the committees drafting the Guidelines, the ASA was not officially involved.
At the time of the referral, I was the Chair of this Committee. An official reply was drafted and specifically addressed items of concern, such as the requirement for the use of intravenous IV injections in patients undergoing Deep Sedation and General Anesthesia. In , the AAP published a revision of the Guidelines.
Use of pulse oximetry was required for both conscious and deep sedation. Note: I have not attempted to describe this important document in its entirety. Their contributions were acknowledged by the AAP. Several articles have been written that describe the evolution of the development of the AAP's Guidelines. Nothing could be further from the truth. To the contrary, ASA had taken a different path in generating guidelines for sedation and, as early as through our liaison activities with JCAHO, we were able to convince them to incorporate the concept of sedation into their accreditation standards.
In , the Food and Drug Administration approved the use of midazolam, and in , it was marketed in the United States. Midazolam was reported to be twice as potent as diazepam. As a result, its use was embraced by a variety of types of practitioners who administered sedation. Bailey et al. Further, most of these midazolam-associated adverse drug reaction reports involved care outside the operating room, where standards for the assessment of ventilation and oxygenation had not been defined and therefore were variable. In the Standards, the use of pulse oximetry was encouraged.
Largely due to their influential efforts, in the JCAH drafted proposed Standards for Surgery and Anesthesia services that addressed the surgical and anesthesia care of patients wherever they receive care in a hospital and to reflect current practices in the delivery of surgery and anesthesia care. Invasive procedures include, but are not necessarily limited to, percutaneous aspirations and biopsies, cardiac and vascular catheterizations, and endoscopies.
Requirements for assuring the availability of continuing medical education programs, monitoring the quality and appropriateness of anesthesia services, and other key items were included. The endoscopists, in particular, were very alarmed by this development and considered the whole issue to be a turf battle between them and the anesthesiologists.
At the request of Jim Roberts, M. After a lengthy discussion, Dr. One of the results of this meeting was the establishment of a dialogue between the endoscopists and anesthesiologists at a national level. Anesthesiologists and endoscopists began a dialogue but disagreed on several key issues: 1 the level of sedation for which the JCAH Standards applied, and 2 the use of the pulse oximeter.
ASA documents that could be used as the basis for designing policies and procedures such as Standards for Basic Intraoperative Monitoring were noted. Although many other significant events occurred in the redrafting of the language of the JCAHO Standards between and , suffice it to say that confusion and conflict reigned within ASA and between our organization and other specialties.
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The ASGE Governing Board concluded that during conventional IV conscious sedation employed by most endoscopists, protective reflexes are not lost in a significant percentage of patients. I am ashamed and embarrassed to be a member of a professional society, which did not assume the role of patient's advocate… etc. The ASA was silent. This illustrates that, even if there had been objections from our representatives at the PTAC level, their recommendations might have been accepted, rejected, or modified by the two levels above them; e.
Between and , we learned many lessons from Guidelines and Standards generated by other organizations and received valuable input from our members about what they needed to fulfill their departmental and institutional commitments related to the development of policies and procedures for the practice of nonanesthesiologists who provided sedation outside the operating room.
Thus began ASA's efforts to establish its own Guidelines for this purpose. In , Richard Stein, M. The products guidelines were expected to be derived from science-based analysis of the literature, expert opinion, and perspective of health care providers. Although the process that ASA adopted for guideline development is highly relevant, the details are beyond the scope of this lecture.
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If they refused, ASA would proceed. AHCPR was not interested. Gross, M.
Anesthesia for outpatient dental procedures — Penn State
Prior to its final publication, the task force solicited opinions on the guidelines from selected experts consultants in the field of anesthesiology and from other specialties in which sedation and analgesia is commonly administered. Keefe, M. The Guidelines were welcomed by the ASA membership. On the surface, it appeared that ASA had produced an evidence-based guideline, which would be embraced by all nonanesthesiologist practitioners. Unfortunately this was not the case. Can painful procedures or nonpainful procedures requiring complete immobility e.
We believe the answer is no. The myth of the achievability of a state of conscious sedation in which pediatric patients are simultaneously responsive to voice stimulus while immobile in the face of pain is just that—a myth. Meanwhile, JCAHO was still collecting examples of adverse events associated with the use of sedation by nonanesthesiologists outside the operating room environment. Presumably, much of the recurring problems related to practitioners underestimating the degree of sedation provided and not instituting the monitoring and resuscitative efforts required. Zerwas formed a working group.
Neeld was asked, and he agreed, to allow the Committee to expand its charge in order to define other states in addition to that of general anesthesia. She was thoroughly impressed. A dialogue ensued and alterations were recommended. It incorporated recommendations for management of a patient in whom deep sedation is produced.
Gross has provided a summary of the review process. Some of this criticism could have been anticipated. A perception remains that ASA's Guidelines are self-serving. Some believe that the recommendations for safe practice imply that anesthesia personnel should be involved when moderate or deep sedation is administered. In order to conform to the latter, some hospital officials have demanded the presence of a member of the anesthesiology department when sedation is administered in the magnetic resonance imaging or endoscopy suite.
In general, this is not true. For example, consider pulse oximetry.
Connis, Ph. As is the case in many areas of medicine in which guidelines are intended to direct decisions, what is intended to be an evidence-based document ultimately ends up as one which is based largely on the consensus of experts. Two of these are 1 lack of agreement with specific guidelines—interpretation of evidence, and 2 lack of agreement with guidelines in general—biased synthesis.
The doubters have even extended their skepticism to the issue of whether or not administration of sedation even requires the presence of a physician. Perhaps the EEG technicians Note: described in accompanying article could be trained to respond to the monitor's beep. One would feel more comfortable if the current costly recommendations JCAHO Standards were developed by a group with less potential conflict of interest than anesthesiologists, and validated with empirical data. There's a cost for maintaining safe practice.
It's called knowledge and experience. Even those who agree with the concept are uncertain about the extent to which we should direct the educational endeavor. A continuing medical education course, for example, cannot simulate a formal residency in anesthesia. To me, the pivotal issue, which remains, is how to convince a variety of practitioners about the actual hazards of administering sedation.