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Anesthesia and sedation outside the operating room:
how to prevent risk and maintain good quality.

ARTICLE in CURRENT OPINION IN ANAESTHESIOLOGY · JANUARY 2008
Impact Factor: 2.53 · DOI: 10.1097/ACO.0b013e3282f06ba6 · Source: PubMed

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who would need to undergo repeat imaging under general anesthesia (GA). Melloni.1 per 1 000 000. risk discussion will encompass a few topics and be limited to management major morbidity and mortality. Italy tomography scanning Correspondence to C. Curr Opin Anaesthesiol 20:000–000. Since MRI is a highly expensive technique. except information derived from the events actually represent the majority of complications. 20:000–000 a complication rate of 16. Even are not well studied. Quality can only be assured by ensuring all alternative locations adhere to operating room As NORA may not follow the same patterns of compli- standards.ACO/200228. Villa Torri Private Hospital. experience and organization. It Keywords is therefore of paramount importance to define the risks complications. statistics validated in the operating room do not necessarily apply outside. the cost/efficacy of the anesthetic technique. however. Aborted procedures are costly. Italy Thirty-three cardiorespiratory arrests with 11 deaths were Tel: +39 0513 90048. 40138 Bologna. fax: +39 0513 05034. Anesthesia or sedation is ß 2007 Lippincott Williams & Wilkins needed because patients should not move during exam- 0952-7907 ination. as well as inconvenient for the patient. which indicates there is a higher risk for office-based While risks and complications of operating room anesthe- anesthesia. although a few closed claims are a monumental task such as the National Confidential appearing in the literature suggesting there is a higher risk. and to suggest adverse outcomes and minimizing their impact when how to prevent these risks and maintain quality of care. Nonoperating room anesthesia requires skills. and gastrointestinal endoscopy.it reported in 2 045 954 patients undergoing MRI [6]. ACO 200228 Anesthesia and sedation outside the operating room: how to prevent risk and maintain good quality Claudio Melloni Purpose of review Introduction The purpose of this review is to define risks for anesthesia Identifying the risks in anesthesia means preventing and sedation outside the operating room. and the 1 . A There are no recent data on risk for anesthesia outside the recent report [2]. via Fossolo 28. sia have been defined leading to measures able to Summary minimize them [3]. Three hundred patients undergoing MRI per year received sedation. The most common events in anesthesia Recent findings leading to injury were found to be respiratory [1]. Enquiry into perioperative deaths (UK) [4] did not Topics discussed focus on MRI and surgical procedures. giving Current Opinion in Anaesthesiology 2007. with began to examine the litigation from office-based anesthe- emphasis on full oxygenation and end-tidal carbon dioxide sia. other ambulatory anesthesia claims. e-mail: melloniclaudio@libero. Total nos of Pages: 7. The American Society of Anesthesia Risk factors for these procedures are identified and (ASA)-sponsored Closed Claims analysis [5] only recently quantified and measures to reduce them discussed. office-based anesthesia. mortality. distinguish between accidents occurring within or outside principally dental. plastic. but dis- GA general anesthesia NORA nonoperating room anesthesia tinguishing between deaths in sedated and nonsedated patients was not possible. ß 2007 Lippincott Williams & Wilkins. cations as operating room anesthesia. All uncooperative patients should be anesthe- tized. Consequently. morbidity.3 deaths Abbreviations per 1 000 000 MRI procedures. suggests that cardiovascular operating room. American Society of Anesthesia Closed Claims project. nonoperating of performing anesthesia outside the operating room. they occur. that is 5. Radiology: MRI and computerized axial Consultant Anesthesist. Bologna. procedure prolongation through poor quality imaging due to movement artifacts should be avoided. liability. the operating room. data on complications induced by Complications of anaesthesia outside the operating room nonoperating room anesthesia (NORA) are scarce. Our room anesthesia. concluding that the injury severity was greater than for monitoring. but anesthesia services and equipment are scarce in MRI centers [7].

In deaths increase the success rate but led to an incidence of occurring on the dental chair (26 between 1984 and adverse reactions of 21%. 69% of patients experience occur- of cranial disasters to monitored anesthesia care. which may lead to atelectasis obscuring small pulmonary metastasis [27]. The efficiency of the procedure depends on the interval from drug administration to scanning and emergence A mortality rate of nine in 1 000 000 was reported following quality: chloral hydrate needs time to act. An airway is needed in 20% of cases because of Pediatric sedation respiratory depression. recently. complexity and demands also stem from inter. main problems arise from irradiation and contrast media The most common intraoperative complaints were pain.03 to 0. with a mortality of 0.ACO/200228. propofol. Among 118 serious adverse events ial desaturation. dren sedated for MRI and computed tomography (CT) [10. but even in the during transit [30].8–9% of chil- [25. reactions. patients have also been described [37]. These events include hypoxemia. poor appetite patient selection (ASA 3) may have contributed to anes- and vomiting. Cardiac arrhythmias . complications and 65% of deaths [48]. corresponding cases per million [38]. care was judged to be poor. Hypoxemia was reported in 0. and post. when not serious The number of deaths in the UK. 2 Ambulatory anaesthesia failure rate. hypertension. and unplanned hospital recovery and nursing times.9].5 should be in the range of 100 mg/kg/min. anxyolitics and sedatives may be given before transferring the patient to Sentinel events in gastrointestinal endoscopy were arter- the procedural area.15.08%.15] and barbiturates thetic complications [36]. absence of failures [10]. Dental office atory events have been noted [11]. airway compromise. trans- (PEEP) completely prevents GA-induced atelectasis in ferring them from consciousness to deep sedation [47]. Benzodiazepines [14. The higher cost of the drug prevention. Inappropriate almost 70% unsteadiness. the postmor- tems did not clarify the cause of cardiac arrest [32].39–42].4% with oxygen to 70% following premedication in children.21] and good mental The incidence of mortality in GA perfomed for dentistry discharge. Increasing chloral Approximately 300 000 patients per year undergo GA for hydrate syrup dosage to 100 mg/kg [12] was found to minor dental procedures in the UK [31]. abdominal discom- and cardiologists.13–0. ranging from 0. Propofol requires a learning curve [19] and experience. discharge side effects can be disturbing.3–6% [43–45]. with the proper equipment. Therapeutic endoscopy The literature [29] and our experience have led to the The overall complication rate for upper gastrointestinal conclusion that. has decreased [13].7–1 per safer and time-effective way to provide conditions for 10 000. should be considered.35]. while hypotension. from 100 (1970–79) to 20 (1990–99) [34. with a high percentage of prolonged sleepiness.07% [46]. and airway compromise was reported in Imaging quality is better with spontaneous breathing 1. hyperactivity.26]. Cardiorespiratory problems account for half of high-quality scans. with faster turnover rates admission. however. Total nos of Pages: 7. weakness. The rences both during the procedure and the in-hospital stay. 12 occurred at home or chloral hydrate is less than 5% [8. GA offers a endoscopy is 0. accompanied by quick recovery. administration of oxygen/nitrous oxide/halothane [33]. simple manoeuvres like chin lift help to untreated. diazepam and. bradycardia and oxygen desa- actions with other specialists. prolonged sedation and emesis take their toll and severe desaturation or adverse respir. Nitrous oxide added to chloral hydrate increases hypo- Five centimeters of positive end-expiratory pressure ventilation from 70% to almost 100% of patients. fort and dizziness followed the procedure in over 25% of cases. Intra and postprocedure occurrences ing area for anesthesia. The failure rate for permanent neurological injury. more The radiology department is probably the most demand. and tachycardia (30–40%). Most patients receive sedation [49] with midazolam. Since sedation needs time to take effect. such as gastroenterologists turation. tracheal intubation being rarely Exploring ‘sentinel events’ – that is events that. To avoid involuntary movements dosage procedures has decreased in the latest reviews to 1–1. children [28]. but offers short recovery times [20. including death and without. their needs vary from resuscitation are strictly linked [50]. overall. if left required [23]. Unscheduled hospital admission ranged under pentobarbital sedation than with intermittent from 0. positive-pressure ventilation/GA. hypotension. to a target controlled infusion level of around 2 mg/ml [22]. may progress to major accidents – is crucial for maintain the airway [24]. 1993) following cardiorespiratory failure. hypoven- is largely compensated by savings in postanesthesia tilation. but deaths in young healthy [16–18] do not rate any better.

and supplies. Risk factors for adverse outcomes in endoscopy with Mortality following liposuction averaged 19. these data induced the Florida Board The above considerations imply that patients. extremely old patients [60]. responsible that office-based liposuction is less risky than hospital- for hypertension and arrhythmias [58]. since sedation standing centers and hospitals [72]. working space. Topical (one in 5000) [67]. tracheal compression.2% in the cedures. statements (founded on settled insurance liability claims) cedure-induced rise in cathecolamines. the quality of Special problems of NORA care in these very often elderly and fragile patients needs NORA problems derive from remote locations. with better results in the office than the time under ideal conditions [76]. NORA claims have 30 days from gastrointestinal therapeutic endoscopy pro. especially of Medicine to declare on 10 August 2000 a 90-day if premedicated. and further declines during endoscopy and benzo.2% in the period 1990–2001). which documents that the door should tention. limited to be improved. revealed 46 cases in more than 600 000 procedures per- diazepine plus opioid administration. electrical interference with monitors and phones. and may be prevented by better monitoring. as a 0. As alarm recognition occurs 34% of institutions [63]. specialists in other fields. emphasis on plastic surgery Office-based anesthesia appears to be safe. Since alarm volume and recog- however. have similar sounds [77]. should receive supplementary oxygen moratorium on office-based surgery because ‘there is [56]. local anesthetic pneumopathy and 16% for apparently healthy individuals intravascular injection in 3% and there was 1% mortality. like operating desaturation during esophagoduodenoscopy. we suggest that alarms be set at tionnaire [66] that respiratory arrest occurred in 13% of maximum levels in NORA environments. GA formed in the office. nition rate are correlated. as it may identify Liability risks hypoventilation and apnea that may not emerge during NORA claims were found to more frequently involve supplemental oxygenation [61]. monitoring was poor in may be more exposed [75]. and care was suboptimal in 27% of patients with upper gastrointestinal bleeding. with special skilled personnel.1 per 100 000 conscious sedation have been identified [52. lack of Office-based anesthesia. besides methemoglobinemia [54]. gastric dis.ACO/200228. This contradicts and analgesia at least partially counteract the pro. were similar in NORA and deaths (UK) [62] examined 1818 inpatient deaths within operating room claims [74]. raising the issue of the creden- tion after topical anesthesia [57].53]. . Capnography is most useful during and even after endoscopy. lighting and temperature inadequacies. 25% with cases. In children. unplanned intubations in 8%. because plastic surgeons declared in a ques. physicians or other licensed physicians. Fourteen percent of patients were judged to 1970s to 1. substandard care (63%) than operating room claims (29%). Total nos of Pages: 7. however. An analysis of deaths 6 years later [70] alone. Thus. The National Confidential Enquiry into perioperative Payments made. since arterial oxygen saturation in ambient air very an immediate danger to the health welfare and safety often ranges from around 89% to 92% after premedication of patients’. as the latter accounted for 71% of following endoscopy relate to team experience. 23% of cases. Anesthesia outside the operating room Melloni 3 occurred in 36% of patients with cardiopathy. drugs. The guidelines for qualifica- tions of anesthesia providers have been discussed by Pharynx obstruction. absolutely safe but. MRI centers make sound recognition and alarm percep- tion very difficult. noisy areas like in ambulatory centers [64. and local anesthesia contribute to oxygen be left open to other anesthesia providers. with malpractice claims compared with 21% in the office some centers presenting excellent results [59] even in setting [73]. the ASA [71]. Other specialists have received excessive sedation. Sedation for diagnostic endoscopy is recommended The mortality rate in the office is greater than in free- for ethical and physiological reasons.0017% Noises are unsettling for the patient and disturb the mortality rate (1/57 000) was reported in accredited anesthesiologist. Anesthesiologist attendance was rare. tials of anesthesia providers. pulmonary embolism being the most oropharingeal or nasal anesthesia is considered to be frequent killer [68]. Complications based procedures. Since 320 000–354 000 liposuctions are performed yearly in the USA [69]. drugs. A presumed reason is that many alarms Greater figures may emerge from nonaccredited centers.65]. increased sixfold over the decades (from 0. The great majority of these cases with oxygen/nitrous oxide/halothane plus intubation were related to nonboard-certified plastic surgeons and ensures higher oxygen saturation than midazolam seda. significantly increases obstructive and central apnea [55]. [51].

only three were found to involve higher-risk. . with access to emergency power behind nurse rather than physician organizations are supply. at least in countries where certified registered defibrillator.14]. isolated electric power cost-effective method of delivering anesthesia. like task management. and that competency in endoscopy should be assured by the anaesthesiologist should be an experienced intensi- national guidelines. when this is not possible. lated by economy. especially during (f) Adequate monitoring equipment to adhere to stan- medical crises. Patients Patients undergoing NORA may be more ill than those NORA requires special skills and attitudes. elderly patients undergoing nonemer- administer anesthesia with the magnet inside the operat. special case. are probably (h) Sufficient space for equipment and personnel and more attentive to protocols. for anesthesiologists. since nurses cost less [84]. and not only.81].90. The debate [85] will continue for a (i) Immediate suitability of an emergency cart with while. Bulky equip. dards for basic anesthetic monitoring. this task is very often assumed by and implemented. gency surgery [72]. AQ1 Anesthesiologist(s) . sedation and analgesia by non-anesthesiologists’ [86]. with excellent results and (a) Reliable oxygen source including a backup supply. Death or electric circuits with ground fault interruption and failure to rescue were more frequent when care in ‘wet areas’ like cystoscopy. situation awareness. for instance. Even though practitioners should be able to administer (l) Appropriate postanesthesia management. would happen when a patient’s condition abruptly changes or the patient moves to another stage of seda- The National Confidential Enquiry into perioperative tion? Who would be responsible for complications? Since deaths (UK) [62] found that the number of yearly pro. who may not consider the interactions higher level of technical skills. It recommended done by one anesthesiologist/patient/unit of time. teamwork. Nontechnical skills are also between a patient’s physical condition. team-working capability and coordination. and decision-making. Clinical evidence supports the anesthe. the physician performing the procedure. 4 Ambulatory anaesthesia Inside the operating room every effort is made to access sedative and hypnotics titrated to effect. other consultants I believe that the main questions are as follows: what as well. since NORA also stresses other qualities. No such recommendations exist vist should a crisis occur. (k) Observation of all applicable building and safety Sedation cannot be restricted to anesthesiologists. and associations. and the effects of anesthesia. transportation. enviable safety records [8. so the ASA published its ‘Practice guidelines for equipment and precautions are needed. every patient may become unstable. medications taken important [79]. (e) Adequate drugs. labor was not directed by anesthesiologists [83]. planned activity. (j) Reliable two-way communication. etc. ment may impede access to the patient and warrant which have been endorsed by several scientific colleges airways to be secured even for minor procedures. intrinsically recognizing the need for a done by others. Total nos of Pages: 7. arthroscopy. (b) Adequate and reliable suction. but nurses have been more and more involved. likely economic. [13]. the following recommendations taken from the ASA Many centers and countries have adopted the post of guidelines for NORA locations [87] should be followed ‘sedationist’. and may be more manipu. and rapid availability of physicians. . codes and facility standards. whose competency is simply assumed by the specialist diploma. vigilance of well trained and experienced providers. and the cost implications of anesthesia services [82]. this is not the the patient easily. (d) Self-inflating resuscitation bag capable of delivering Anesthesia is a discipline that requires the constant an inspired oxygen fraction (FiO2) of 0. In Italy. (c) Adequate and reliable scavenging system if anes- The issue of quality of care and outcome has been raised thetic gases are to be used. supplies and equipment for the safety derives from high-level dedicated care. however. every single seda- cedures performed by some consultant endoscopists was tion analgesic given outside the operating room should be too low to ensure proficiency and skill. attending an operating room. . siologist-led anesthesia care team as the safest and most (g) Sufficient electrical outlets. possible to operating room standards. Quality improvement should rely on raising the standards thetists that are unsafe due either to a lack of knowledge of every location where sedation and anesthesia are and skills or old age need to be identified [80. anaes. Quality issues Since NORA involves special risks and difficulties. as most NORA claims among 25 neuroanesthesiologists. In the meantime. emergency drugs. The reasons and delivery suites.ACO/200228. Preanesthetic preparation is very often ing room [78]. nurse anesthetists are numerous and well trained.

As a rule of thumb. [88] found the same mortality and morbidity rates aration. facilities in which anesthesia is administered are equipped with a central gas supply system. Bhananker evaluated from a safety point of view. 5 Domino KB. for surgical patients. published within the annual period of review. allergies. The gas amount left in the cylinder must be continuously monitored and the cylinder replaced before it is com. ASA Newsletter 2001. The safe solution is to place patients in the supply. 55:737–743. and organization. 000–000). If oxygen is delivered be optimal. Lunn JN. 1992. overdose of sedative or opioid drugs. it has to be carefully checked covered every day. The few data available do not seem experience. 91:552–556. Devlin HB. but distant locations should have their emer- without flowmeters. and how will it affect practice in the future? Anesthesiology 1999. Winder J. ally when the anaesthesiologist is away from the patient.  of outstanding interest Additional references related to this topic can also be found in the Current ive in the dental rehabilitation office than GA in the World Literature section in this issue (pp. 660 l. strict surveillance duration and a backup supply are critical. 15. analgesia or GA should be during monitored anesthesia care with a greater pro. Project: what have we learned. this may require remote monitoring. change in procedure. Adverse respiratory events in reported [89]. if half empty. How to proceed After carrying out an anesthestic and monitoring equip. 65:9–11. Anesthetic needs should be to prefer monitored anesthesia care to GA. 72:828–833. project. Measures of outcome pletely empty. but more sentinel events have been 1 Caplan RA. Hoile RW. 95:95–109. operating room. London: Her Majesty’s Stationery Office. In Vivo Research 1992–2000. Monitored  of special interest anesthesia care for disabled children is much less expens. Since such equipment is staffing: consider how many NORA activities should be not used on a daily basis. Posner KL. Anaesthesia for magnetic resonance Almost all the potentially preventable office-based inju. An invitation is being made to sche- before each use and a program of maintenance should be dule fixed days for different tasks in order to organize the instituted. Total nos of Pages: 7. so new anesthesiologists may be unfamiliar with it and machines NORA activities require time. Both sedated and critically ill AQ2 require monitoring during MRI. Injuries associated with anaesthesia: a global perspective. sedation. at a pressure of 135 atm. It is my personal opinion that sedation and analgesia with spontaneous References and recommended reading respiration requires greater skills and experience than Papers of particular interest. movement of the patient. Virtually all should be exercised until full recovery. Kaut-Watson C. therefore. The same considerations apply for monitors. the anesthesiologist and local personnel must first postanesthesia care unit (PACU) or recovery room. as ensure that an adequate supply of oxygen is available. Anaesthesia ries result from adverse respiratory events in the recovery 2000. which means adequate may no longer meet standards. 5 l capacity at a pressure of 200 atm roughly contains emergency treatment of airways is paradigmatic [90]. tubing. Cylinders (E type) are safe journey should be at hand. Williams DL. Smyth L. at least in During transportation all the equipment necessary for a the more industrialized countries. anesthesia services. Anesthesia outside the operating room Melloni 5 A reliable source of oxygen adequate for the procedure or postoperative periods [5]. anesthesia: a closed claims analysis. an E cylinder of Critical incidents may be more frequent in NORA. Old equipment is often kept in NORA areas. including sudden confidential enquiry into perioperative deaths 1990. especi. 2 Cheney FW. The ideal recovery area rarely seen on anesthesia machines today. it requires skill. have been highlighted as: general anesthesia with airway control. and at The availability of a difficult intubation cart in the 100 atm. outcome is influenced by care quality [91]. 6 Schiebler M. performed utilizing the same standards as adopted for portion of respiratory depression after absolute or relative the operating room. among other means. The anaesthesiologist 4 Campling EA.ACO/200228. special extension Br J Anaesth 2005. anaphylactic shock. 1000 l of oxygen. 80 min. how has it affected practice. 500 l. consent. its consumption is unknown and gency trolley with a reasonable choice of airways. Anesthesiology 1990. The report of the national must be prepared for bad surprises. Patient prep- et al. . Cheney FW. Conclusion ment check. The American Society of Anesthesiologists Closed Claims All data should be obtained during the procedure. Office-based anesthesia: lessons learned from the closed claims and need for vasopressors. 3 Aitkenhead AR. specific pro- tocols should be adopted for NORA and personnel Equipment in nonoperating room anesthesia organized accordingly. imaging: a survey of current practice in the UK and Ireland. If 6 l/min are consumed. Since extra care is recommended. a full cylinder will ICU or PACU that can be called upon for rescue would last 160 min. if anesthesia is should be ‘near’ the location where the patient was to be delivered in a location without a central medical gas treated. the anesthetic plan should be followed but No anesthesia or sedation performed outside the operat- the anaesthesiologist should always be prepared for a ing room should be considered minor. Ward RJ. Postoperative surveillance/transportation 7 McBrien ME.

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