2. Who is a traveling
anesthesiologist(MAAS provider...)
• Anesthesiologist(consultant,fully trained,retired from
NHS(its me!|!|!),private practitioner
• Sedation for many dental facilities,ophtalmology
,plastic surgery & others
• Carries his own kit:drugs,equipment……..
• Responsible for :
– preop assessment,
– intraop care,
– postop care(discharge and prescriptions)
• Analgesia,antibiotics,special
requirements,recommendations………
• Cannot rely on anyone for anything,unless....
3. NORA classification
• In hospital,but outside
OR:radiology,cardiology,endoscopy
etc.:NORA,but in hospital.
• Out of hospital
– day surgery center;OR! NO NORA
–office:NORA
4. Definizioni
• In Italia ambulatorio=office
– Day surgery=chirurgia di giorno=struttura
attrezzata e riconosciuta:equipped and recognized
• USA: office=ufficio (del chirurgo)(of the
surgeon)
– Ambulatory:equipped and recognized -struttura attrezzata e
riconosciuta
–Ufficio:non attrezzato,non riconosciuto a
meno che non si abiliti per chirurgia…
5. Legal constraints
• USA vs Italy vs UK
• Sedazione cosciente
,sedo/analgesia cosciente..
12. Home
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We provide all your anesthesia
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our many years of experience
give us a unique understanding
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help us
to deliver only the best to your
patients
no matter what the setting or
situation
13. Film:
• Milky Way Anesthesia - Mobile Anesthesia
Services - Phoenix, Arizona, USA
• Milky Way Anesthesia
• http://youtu.be/Ckp24aNVowo
14. Expanding the role of the
anesthesiologist
ORA
• Operating room anesthesia:
NORA
• Non Operating room anesthesia
MAASS
•Mobile Anaesthesia and Sedation
Service
17. SIAARTI
• Recommendations for anesthesia and
sedation in nonoperating room locations
• Raccomandazioni per l’esecuzione
dell’anestesia e della sedazione al di fuori dei
blocchi operatori .
• SIAARTI Study Group for Safety in Anesthesia
and Intensive Care .
• Coordinator. E. Calderini
• Minerva Anestesiologica 2005;71:17-21.
18. General organization of the guideline:
• Definitions and aims
• Organization :model
• it is suggested that every Dept of Anesth. draft a organization model for
treatments outside OR’s….…
• Indications
• Patient selection:I & II: ASA III with limitations
• Supply and communications
19. USA
• Only 2% of residency training programs have
formal training in OBA
• There is a void in properly educating
anesthesiologists on how to prepare
themselves for offices.
• Hausman LM, Levine AI, Rosenblatt MA: A survey evaluating the training
of anesthesiology residents in officebased anesthesia. J Clin Anesth 2006;
18 (7): 499-503.
20. ASA Office Based Anesthesia
• Office Based Anesthesia.
• Considerations for anesthesiologists in setting up and
maintaining a safe office anesthesia environment.
•
• An information manual completed by the ASA committee
in Ambulatory Surgical care and the ASA task force on
Office based anesthesia
•
• Chair…
• Project Leader…
•
• Contribuing authors and task force members…..
21. ASA
• GUIDELINES FOR OFFICE-BASED ANESTHESIA
• Committee of Origin: Ambulatory Surgical Care
• (Approved by the ASA House of Delegates on
October 13, 1999, and last affirmed on
• October 21, 2009)
• These guidelines are intended to assist ASA
members who are considering the practice of
ambulatory anesthesia in the office setting:
office-based anesthesia (OBA).
22. ASA recognition...
• ….ASA recognizes the unique needs of this
growing practice and the increased
requests for ASA members to provide
OBA for health care practitioners* who
have developed their own office
operatories…..
23. ASA awareness...
• ..special problems that ASA members must
recognize when administering anesthesia in the office
setting. Compared with acute care hospitals and
licensed ambulatory surgical facilities, office
operatories currently have little or no
regulation, oversight or control by federal,
state or local laws.
24. ASA ….
• …..Therefore, ASA members must satisfactorily
investigate areas taken for granted in the
hospital or ambulatory surgical facility such as
governance, organization, construction
and equipment, as well as policies and
procedures, including fire, safety, drugs,
emergencies, staffing, training and
unanticipated patient transfers
25. Nora focal points :quality and safety
Patient
selection
Surgical
choices
Complication
rate
Equipment
and support
of the facility
Training
27. Problem dimension
• Membership Audit, American Society for Aesthetic Plastic Surgery,
Inc., Spring 1993.
• survey of members of the American Society for Aesthetic Plastic
Surgery (ASAPS)
• 48.7 % of members perform their aesthetic surgery in an
office surgical facility.
• Office-based surgery (OBS) accounts for 10 million of all elective
procedures performed in the United States double from a decade
ago. Although there are no good national registries to accurately
determine the amount of surgery done in office, the projections have
ranged from 17-24% of all elective ambulatory surgery
• AHA.Trends affecting hospitals and health systems May 2005. AHA TrendWatch ChartBook 2009.
Available at:http://www.aha.org/aha/trendwatch/chartbook/2009/chart2-9.pdf. (Accessed May 12,
2009)
28. OBA point of view
• Succinctly stated, the 1999 HOD-approved
guidelines for OBA state, with respect to
perioperative care, “The anesthesiologist
should adhere to the ‘Basic Standards for
Preanesthesia Care,’ ‘Standards for Basic
Anesthetic Monitoring,’ ‘Standards for
Postanesthesia Care,’ and ‘Guidelines for
Ambulatory Anesthesia and Surgery’ as
promulgated by ASA.”
29. Patient(s)
• The patients undergoing procedures outside
the operating room are often older, medically
higher-risk patients
• most NORA claims involve higher-risk, elderly patients
undergoing nonemergency surgery
• Metzner J., Posner K.L., and Domino K.B.: The risk and safety of anesthesia at
remote locations: the US closed claims analysis. Current Opinion
Anaesthesiology 2009; 22: pp. 502-508
30. Diagnosis not made
• You see patients during the workup…………
• Unknown diseases
• Unknown patients….
• Incomplete sense of what we may encounter
during the procedure…
31. Preanesthetic preparation
• Preparation for NORA should be no different from
the preparation in the operating room.
– Preanesth.visit
– Fasting
– Premed.
– consent
• Preanesthetic preparation is very often done by
others, who may not consider the interactions
between a patient’s physical condition,
medications taken and the effects of anesthesia
32. Specific conditions that warrant special care when
providing anesthesia or sedation outside the operating room
• Patient unable to cooperate, e.g. severe intellectually disability
• Severe gastroesophageal reflux
• Medical conditions predisposing patients to reflux, e.g. gastroparesis secondary to diabetes mellitus
• Orthopnea
• Severe increased intracranial pressure
• Decreased level of consciousness/depression of protective airway reflexes
• Known difficult intubation
• Dental, oral, craniofacial, neck or thoracic abnormalities that could compromise the airway
• Presence of respiratory tract infection or unexplained fever
• Obstructive sleep apnea
• Morbid obesity
• Procedures limiting access to the airway
• Lengthy, complex or painful procedures
• Uncomfortable position
• Prone position
• Acute trauma
• Extremes of age
33. Patient, procedure and location
selection
• Several factors prohibit procedures to be safely undertaken outside
the operating room:
• (1) significant risk of major blood loss;(esophageal
varicosities???…….)
• (2) extended duration of surgery (>6 h);
• (3) critically ill patients;
• (4) the need for sophisticated, and at times subspecialized
anesthetic or surgical expertise or equipment(cardio-pulmonary
bypass, thoracic or intracranial surgery);
• (5) supply and support functions or resources are in limited supply
or not immediately available;
• (6) limited provision for postprocedural care;
• (7) the physical plant is inappropriate or fails to meet regulatory
standards.
34. inappropriate OBA patients
• unstable ASA 3 or greater
• recent MI in past 6 months
• severe cardiomyopathy
• uncontrolled HTN
• brittle or poorly controlled diabetes
• active multiple sclerosis
• acute substance abuse (drugs and alcohol)
• MH history
• severe morbid obesity (BMI >35, if equipment and stretcher size is limited), or morbid obesity (BMI >30
with poorly controlled comorbidities)
• severe COPD/ obstructive sleep apnea,
• pacemaker or AICD
• end-stage renal disease
• sickle cell disease
• patient on transplant list
• dementia (not oriented)
• psychologically unstable (rage/anger problems),
• Recent stroke within 3 months
• myasthenia gravis
• lack of adult escort
35. Location/space requirements for nonoperating room
anesthesia
• Adequate size with good access to the patient
• Uncluttered floor space
• An operating table, trolley or chair which can be readily
tilted into Trendelenburg position
• Adequate lighting including emergency lighting
• Sufficient electrical outlets including clearly marked
electrical outlets connected to an emergency back-up
power source
• Suitable clinical area for recovery of the patient which
must include oxygen, suction, resuscitation drugs and
equipment
• Emergency back-up call system to summon assistance
from the main operating room
36.
37.
38.
39.
40.
41.
42.
43.
44.
45.
46.
47.
48.
49. Staff
• A strict adherence to
minimum;scrubbed+circulating nurses?2?
• staff with appropriate training
• Interdepartmental/interpersonal cooperation
and understanding
– All very important when working outside the
familiar environment of the operating room
50.
51. Location and equipment
• Wherever the sedation or anesthetic is
performed, appropriate resuscitative equipment
and medications for cardiopulmonary
resuscitation must be immediately available
• ASA.Guidelines for non operating room anesthetizing
locations.Http:/www.asahq.org/publicationsAnd
Services/sgstoc.htm
• Capnography and pulse oximetry are invaluable
in a setting where patient observation is limited
(e.g. darkened room) or with limited access to
the patient (e.g. radiation oncology).
52. Procedure
• The anesthesiologist needs to understand the
requirements of the procedure, its potential
complications, its anticipated duration and the
specific needs of the proceduralists.
• Specific requirements differ with each type of
procedure and are discussed below
• New technologies…
• New technics…
53. Requisiti specifici per l’accreditamento
delle Strutture di ...RER
• Formato file: PDF
• RER
• REQUISITI SPECIFICI
• REQUISITI MINIMI IMPIANTISTICI E
TECNOLOGICI
• REQUISITI MINIMI STRUTTURALI
• REQUISITI MINIMI ORGANIZZATIVI
54. UK?
• SURGERY AND GENERAL ANAESTHESIA IN
GENERAL PRACTICE PREMISES
• Published by The Association of Anaesthetists
of Great Britain and Ireland
• 9 Bedford Square, London WC1B 3RA
• Tel: 0171 631 1650 Fax: 0171 631 4352
•1995
55. AAGBI: SURGERY AND GENERAL ANAESTHESIA
IN GENERAL PRACTICE PREMISE
• Section I Introduction 1
• Section II Necessary Facilities 3
• (i) Personnel
• (ii) Support Staff
• (iii) Organisational arrangements
• Section III Specialist Services 5
• (i) Anaesthetic services
• (ii) Surgical services
• Section IV Sterilisation Services 6
• Section V Technical Services 8
• (i) Anaesthetic, resuscitation and
• monitoring equipment
• (ii) Medical gases
• (iii) Volatile anaesthetic agents
• (iv) Waste anaesthetic agents
• Section VI Quality, Financial and Contractual 10
• Arrangements
• References 11
56.
57. NORA special skills
• NORA requires special skills and attitudes
– among 25 neuroanesthesiologists, only 3 were found to administer anesthesia with
the magnet inside the operating room intrinsically recognizing the need for a higher
level of technical skills.
– Archer DP, McTaggart Cowan RA, Falkenstein RJ, et al. Intraoperative mobile magnetic
resonance imaging for craniotomy lengthens the procedure but does not increase
morbidity. Can J Anesth 2002; 49:420426
• Nontechnical skills are also important since NORA also stresses other qualities,
like task management, team-working capability and coordination,
situation awareness, and decision-making.
• Since NORA involves special risks and difficulties, anaesthetists that are unsafe
due either to a lack of knowledge and skills or old age need to be identified
– Atkinson RS. The problem of the unsafe anaesthetist. Br J Anaesth 1994;
– 73:29–30.
– Katz JD. Issues of concern for the aging anesthesiologist. Anesth Analg 2001;
– 92:1487–1492.
58.
59. Sedationist ……….
• Nurses
– Bluemke DA, Breiter SN. Sedation procedures in MR imaging: safety, effectiveness,
– and nursing effect on examinations. Radiology 2000; 216:645–652.
– Sury MRJ, Hatch DJ, Dicks Mireaux C, Chong WK. Development of a nurse led sedation service for paediatric magnetic resonance imaging.
Lancet 1999; 353:1667–1671
• Physician
– Endoscopists……….
• quality of care and outcome ???Costs??
• Abenstein JP, Warner MA. Anesthesia providers, patient outcomes, and costs. Anesth Analg
1996; 82:1273–1283.
• Silber JH, Kennedy SK, Even-ShoshanO, et al. Anesthesiologist direction and
• patient outcomes. Anesthesiology 2000; 93:152–163.
• Cromwell J, Snyder K. Alternative cost-effective anesthesia care t eams.
• Nurs Econ 2000; 18:185–193.[13], and the cost implications of anesthesia
services .
60. • Anesthesia is a discipline that requires the constant
vigilance of well trained and experienced providers;
safety derives from high-level dedicated care,
teamwork,and rapid availability of physicians,
especially during medical crises.
• Clinical evidence supports the anesthesiologist-led
anesthesia care team as the safest and most cost-effective
method of delivering anesthesia.
– Death and failure to rescue were more frequent when care
was not directed by anesthesiologists
• However…….Sedation cannot be restricted to
anesthesiologists.
61. Guidelines for sedation by non anesthesiologists
• ASA practice guidelines for sedation and
analgesia by non-anesthesiologists.American
Society of Anesthesiologists Task Force on
Sedation and Analgesia by Non-
Anesthesiologists. Anesthesiology 2002;
96:1004–1017.
62.
63. main questions
• What would happen when a patient’s condition abruptly
changes
» or
• the patient moves to another stage of sedation?
• Who would be responsible for complications?
• every patient may become unstable, every single sedation
analgesic given outside the operating room should be done by
• one anesthesiologist/patient/unit of time
• the anaesthesiologist should be an experienced intensivist
should a crisis occur.
64. How to proceed
• anesthetic and monitoring equipment check
• Make a plan :sedation only.sedation+analgesia ,light,deep,GA
• be prepared for a change in procedure.
– It is my personal opinion that sedation and analgesia with spontaneous
respiration requires greater skills and experience than GA with airway control.
– Monitored anesthesia care for disabled children is much less expensive in the
dental rehabilitation office than GA in the operating room, but more sentinel
events have been reported
• All data should be obtained during the procedure, especially when
the anesthesiologist is away from the patient;
• this may require remote monitoring, special extension tubing, among
other means.
• be prepared for bad surprises, including sudden movement of the
patient, allergies, anaphylactic shock, need for vasopressors.
65. Special problems of NORA
• remote locations
• limited working space
• electrical interference with monitors and phones
• lighting and temperature inadequacies
• lack of skilled personnel, drugs, and supplies.
• Noises …..are unsettling for the patient and disturb the anesthesiologist. As alarm
recognition occurs 34% of the time under ideal conditions [76], noisy areas like MRI centers make
sound recognition and alarm perception very difficult. A presumed reason is that many alarms
• have similar sounds [77]..
66. Postoperative surveillance/transportation
• Almost all the potentially preventable office-based
injuries result from adverse respiratory events in the
recovery or postoperative periods; therefore, strict
surveillance should be exercised until full recovery.
• During transportation all the equipment necessary for
a safe journey should be at hand.
• The ideal recovery area should be ‘near’ the location
where the patient was treated. The safe solution is to
place patients in the postanesthesia care unit (PACU) or
recovery room, as for surgical patients.
67.
68. Safe Discharge
• To be discharged, the patient must have
– stable vital signs:BP,HR,SaO2,resp.
– be fully oriented
– ambulate without dizziness
– with minimal pain
– Minimal/no nausea or vomiting
– Minimal or no bleeding
– Able to dress himself .
Scores?
The patient should receive specific written instructions,
including management of pain, relevant postoperative
complications, and routine and emergency possibilities
69. Riduzione dello stress
ansia
dolore
Ambiente
attesa
Durata
STRESS
Sedazione:la notte
prima,il giorno
stesso,approccio
psicologico,ecc,ecc
Analgesia;oppioidi,
N2O,A.L.
Musica,relax,TV,distrazione,
70. Conclusion
• challenges : providing care for more medically complex
patients while adapting to fewer resources, with lack of
support system commonly available in the operating
room
• No anesthesia or sedation performed outside the
operating room should be considered minor; it requires
skill, experience, and organization.
• Anesthetic needs should be evaluated from a safety
point of view.
• Patient preparation, consent, sedation, analgesia or GA
should be performed utilizing the same standards as
adopted for the operating room
72. Recommendations
Poliambulatorio …………………………..
Modulo di consenso informato per procedure chirurgiche ambulatoriali o day surgery
Da consegnare al momento della prenotazione e riportare .
Si prega di leggere attentamente e riempire con i dati richiesti sopra le parti
indicate dai puntini(data,città,cognome,nome,intervento,firma).
Data:………………….
Città:………………….
Io sottoscritto……………………………………………………….
Dichiaro di attenermi alle seguenti disposizioni:
I)non assumere alcun cibo nelle 6 ore precedenti l'intervento,ne' liquidi nelle due ore
precedenti;
raccomandazioni per il digiuno preoperatorio*
MATERIALE INGERITO TEMPO MINIMO DI DIGIUNO
Liquidi chiari (acqua,caffè,the, succo senza polpa, bibite
gasate)
2 ore
Pasto leggero (toast e bibita) 6 ore
2)di non guidare alcuna automobile o motocicletta o bicicletta, od utilizzare qualsiasi
macchinario nelle 24 ore seguenti I'anestesia o sedazione ,
3)di non assumere alcoolici nelle 24 ore seguenti l'anestesia o sedazione;
4)di farmi riaccompagnare alla mia residenza da un adulto responsabile;
5)di rimanere in compagnia di un adulto responsabile una volta tornato al domicilio;
6) di non assumere alcuna decisione importante ne' firmare documenti
importanti(testamento,assicurazioni ecc.)nelle 24 ore seguenti;
7)di vestirmi in modo pratico,cosicchè il vestiario possa essere facilmente rimosso e
indossato e riposto in un armadietto;per es.tute da ginnastica con maniche larghe e
apertura frontale.
8)di non portare gioielli o altri oggetti di valore in ambulatorio;
9)di mettermi in contatto con l'unità chirurgica ambulatoriale nel caso insorga una
qualsiasi complicanza postoperatoria.
10) di assumere o avere già assunto la mia terapia agli intervalli soliti,con un poco
di acqua se necessario.
FIRMA .........................................................................................
ID:quest day surg e consenso.doc
73. Screening of patients 2
C.M 13/1/2009
Dott.Claudio Melloni
Specialista in Anestesia e Rianimazione
Via Fossolo 28
40138 Bologna
tel.:051390048
Questionario preoperatorio di autocompilazione
Si prega di barrare la risposta esatta con un segnetto o un cerchietto e/o riempire gli spazi sopra i
puntini con le informazioni richieste.Tutte le risposte sono confidenziali e coperte dal segreto
professionale.Grazie.
Cognome e nome:………………………………………………………….
indirizzo:via…………………….città:……………………………..Cap…..
tel:…………
età…. peso in kg…. altezza in cm…
Si sente ammalato? SI NO
Se Si,perché?………………………………………………
Ha o ha avuto una malattia seria ? SI NO
Se Si,perché?………………………………………………
Ha affanno dopo sforzo? SI NO
Ha tosse? SI NO
Ha sibili respiratori? SI NO
Ha dolore al petto da sforzo? SI NO
Ha gonfiore alle caviglie? SI NO
Ha o ha avuto malattie di cuore? SI NO
Ha o ha avuto malattie dei polmoni? SI NO
Ha o ha avuto malattie di fegato? SI NO
Ha o ha avuto malattie dello stomaco? reflusso?ulcera? SI NO
Ha o ha avuto malattie dei reni? SI NO
Ha o ha avuto malattie muscolari? SI NO
Ha o ha avuto malattie cerebrali? SI NO
Ha assunto farmaci negli ultimi tre mesi SI NO
Se Si,quali?………………………………………………
Prende gocce nasali o oculari? SI NO
È allergico a qualche medicinale? SI NO
E’ allergico a qualche cibo? SI NO
Ha subito interventi o anestesie negli ultimi 3 mesi?
SI NO
Se Si,perché?………………………………………………
È mai stato operato prima d’ora? SI NO
Se Si,perché?………………………………………………
Ci sono state strane storie in famiglia di incidenti insorti durante o subito dopo anestesia?
SI NO
Porta occhiali o lenti a contatto? SI NO
Porta protesi dentarie o ponti mobili? SI NO
Beve più di in bicchiere di vino o di un superalcoolico al giorno?
SI NO
Fuma? SI NO
Se Si,quanto ?...................................................................
Ci sono stati altri problemi di salute fisica o mentale non compresi in questa lista?
SI NO
Se Si,quali?………………………………………………
Fa movimento o sport? SI NO
Se sì,che cosa(per es bicicletta,lavori di casa,orto,raccolta frutta,ecc), ……………………….
74. Raccolta dati
data: ...../....../.... sede……………………………...
COGNOME E NOME.....................................................................................
INDIRIZZO: TEL:………….
ETÀ: ........ PESO(KG) ......... ALTEZZA(CM)......... ASA: ........
INTERVENTO:................................................................................................
ANESTESISTA:..................................CHIRURGO:..........................................
anestetico locale: Si No farmaco...............................mg............................................
adrenalina: Si No dose:
via aerea: spont guedel maschera IOT IRT COPA LMA
respirazione:spont. ass man. IPPV O2 si no maschera occhialini
Premedicazione:...................................................ora:.......
induzione(farmaci,dosi):..................................................................................................... ........
mantenimento:............................................................................................................................
inizio anestesia:ora................ inizio chirurgia:ora..................................................
Via
venosa:
c.M. 11/95
fleboclisi: 1 2 3 4 MAC opp
AG
Min PAS PAD Fc SaO2 EtCO2 Osservazioni:
bas
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
80
85
90
95
100
105
110
115
120
125
130
135
140
145
150
155
160
165
170
175
180
totali:farmaci:ipnotici/sedativi:............................an algesici:........................mi orilassanti:............... ......
altri: stop.analgesia:
fine anestesia:ora fine chirurgia:ora.................................................. .......
apertura occhi:ora................ orientamento:ora:..….. RS ora………….estub ora:……… seduto:h..............................in piedi
h……………. vestirsi h:……. .. camminare h:…………… mingere h:……….. bere,h………………………effetti
collaterali:……………………………PONV: se si,terapia………………..no. dolore: se si,terapia…………………..oppNO
Dimissione:ora………………………………………………………………………
75. Consenso Poliambulatorio S.Lucia
Via Murri 164
Bologna
DICHIARAZIONE DI AVVENUTA INFORMAZIONE E CONSENSO ALL’ANESTESIA
Io Sottoscritto/a……………………………………........………. nato/a a …………….................
..............................................................................................il...........................................................
Dichiaro di essere stato informato/a dal Medico Anestesista dr…………………………………...
che le mie condizioni di salute mi collocano nella classe ASA*……. ed il rischio relativo all’intervento
chirurgico al quale io verro’ sottoposto/a è ………………………………………**
Ho compreso le informazioni circa il tipo di anestesia più appropriato nella mia situazione e, dopo avere
preso in considerazione anche le eventuali alternative, dò il mio consenso al trattamento anestesiologico
concordato che sarà il seguente:………. ……………………........….
Sono stato informato che tale trattamento, qualora si verificassero condizioni particolari che mi verranno
spiegate, potrebbe essere modificato.
Mi è stato spiegato che l’anestesia, pur essendo fra le metodiche più sicure della medicina moderna, può
comportare ancora oggi in rarissimi casi complicanze mortali o gravi danni permanenti, in particolare di
tipo neurologico. Mi ritengo adeguatamente informato e non desidero ricevere ulteriori informazioni.
In seguito alla mia richiesta di ulteriori informazioni, ho ricevuto e compreso ogni spiegazione sui
trattamenti anestesiologici che verranno adottati prima, durante e dopo l’intervento. In particolare, ho
compreso le informazioni circa le complicanze più comuni e prevedibili nel mio caso specifico, che
consistono in:…………………………………………………………..............
Autorizzo inoltre il Medico Anestesista a comunicare notizie relative al mio stato di salute
a…………………………………………………………………………………………………......
...........................................................................................................................................................
Dichiarazioni particolari:…………………………………………………………….......................
........................................................................................................................................................................
..............................................................................................................................................
DATA.....................................
Firma del Paziente Firma del Medico Anestesista
……………………………………. .............................................…….
Firma del Tutore/……………………………..……di…...……………………….……...
76. Is not only the patient,but the
combination of
patient,surgeon,procedure
• Long procedure on good compliant patients..
• Short procedure on difficult patients
• Surgeon attitude
• Patient psycology
• Money…
77.
78. From the General Dental Council UK:
• CONSCIOUS SEDATION
• 4.11 Conscious sedation can be an effective method of facilitating dental
treatment and is normally used in conjunction with appropriate local
anaesthesia.
• Conscious sedation is defined as:
• A technique in which the use of a drug or drugs produces a state of
depression of the central nervous system enabling treatment to be carried
out, but during which verbal contact with the patient is maintained
throughout the period of sedation. The drugs and techniques used to
provide conscious sedation for dental treatment should carry a margin of
safety wide enough to render loss of consciousness unlikely.
• The level of sedation must be such that the patient remains
conscious,retains protective reflexes, and is able to understand and to
respond to verbal commands. ‘Deep sedation’ in which these criteria are not
fulfilled must be regarded as general anaesthesia.
• In the case of patients who are unable to respond to verbal contact even
when fully conscious the normal method of communicating with them must
be maintained.
79. Ramsey Sedation Scale
• Response to command score
• Patient awake,anxious ,agitated,restless 1
• Pt. Awake,cooperative,orientated,tranquil 2
• Pt drowsy with response to command 3
• Pt asleep with brisk response to glabella tap or
loud auditory stimulus 4
• Pt asleep,sluggish response to stimulus 5
• No response to firm nail bed pressure or other
noxious stimuli 6
80. OAA/S Observer’s assessment of
awareness/ sedation scale
•
•
Responsiveness speech score
Respons rapidly to name in normal tone normal 5
Lethargic response to name spoken loudly
repeatedly
Mild slowing 4
Responds only after name spoken loudly or
repeatedly
Slurring or slowing 3
Responds after mild prodding or shaking Few recognized words 3
Does not respond after mild prodding or shaking 1
81. UMSS University of Michigan sedation
scale
Sedation score
Awake and alert 0
Minimum
sedation
Tired/sleepy,appropriate response to verbal conversation
or sound
1
Moderate
sedation
somnolent/sleeping,easily arousable with light tactile
stimulation or a simple verbal command
2
Deep sedation Deep sleep,arousable only with significant physical
stimulation
3
unarousable 4
82. Vital signs monitor(s)
• General principles:
– Robust,but protect during transport ,good packaging
– Lightweight;???< 1kg…..
– Battery operated ;look for replacement
– Easy to operate
– Good visibility
– Good price
– Maintenance free,parts easy to find(cables,sensors)
• ECG,NIBP,SaO2,EtCO2,resp.
• EEG?????CSM…..
• Spare monitoring in case of failure;at least SaO2…
• Thermometer
• Phonendoscope
83. Emergency material
• Laryngoscope;2 at least,check batterie frequently
• Full assortment of blades,right and curves
• LMA size 2,3,4,5
• Bougie
• Magill forceps,
• Frova introducer
• O2 and CO2 catheters
• IV lines(latex free)+ three way extension
• Defibrillator,portable,battery operated,semiautomatic
• tracheostomy kit????
• Hand or foot operated suction
• Self inflating bag+reservoir(O2 100% capable)
• Face masks
• Guedel airway,any size(COPA)
• Oxygen tank;5 lt??3 lt?2 lt? 1 lt?
84. Practice Guiding priciples
• Never trust anyone
• Never run out on anything;replace immediately
• Always have more you think you might need
• Pack everything by yourself so you know what
you have and where it is to be found
• Assume the practice has nothing except suction
and light(but you may inquire beforehand…)
86. Mobile kit
• How to organize???
• 1)frequency of use:items always
,rarely,hopefully never
»Or
• 2)drugs,iv,patient comfort
• 3)airway equipment
• 4) monitoring
Sedation solution
LOndon
me
94. Be prepared…………
• Pre-filled syringes;most common
sedatives/analgesics/vasopressors/atropine
– My choice:
midazolam/fentanest/ephedrine/atropine
• Airway rescue;
– LMA,Laryngoscope,ETT,self inflating bag,Oxygen
• Adrenaline bag
• Patient pre discharge evaluation:Aldrede??
• Street fitness;accompanying person
95. Pre prepared…..be prepared
• Pre prepared syringes:
– Atropine
– Effortil/ephedrine
– Midazolam
– Fentanyl
– Propofol??
– Clonidine(catapresan)
– Electrolytes
– ???specific for the procedure???
106. Farmaci essenziali
• Ossigeno;bombola da 5 lt,come minimo,200 atm,con va e
vieni ,mascherina facciale ,occhialini nasali
– 3 maschere facciali adulti,piccola,media ,grande
Adrenalina,fiale da 1 mg :FASTJECT 2 ml,siringa
preriempita,iniett(77 £):330 microgr o 165 microgr
Video prodotto dall'Allergopharma che illustra come usare
l'adrenalina auto iniettabile (Fastjekt) in caso di shock anafilattico.
• Nitroglicerina:cp sublinguali 0.3-0.4 mg,Carvasin 5 mg ,Natispray
• Antistaminico:clorfeniramina(trimeton) fiale 10
mg,Prometazina(farganesse 50 mg)
• Albuterolo,salbutamolo(Ventolin)
• Aspirina;cp 160-325 mg
107. Farmaci essenziali
farmaco indicazioni Dose iniziale(adulti)
ossigeno sempre Inalazione 100% Bombol
,masch
ere,am
bu
adrenalina anafilassi 0,1 mg ev;0.5 mg i.m. Fiale,pe
nna
Asma che non
risponde al
salbutamolo
0,1 mg ev;0.2—0.5 mg i.m.
Arresto cardiaco 1 mg ev
Fastjekt anafilassi Siringa preriempita 330 0pp 165
microgr ,im.
Nitroglicerina(Trinitrin
a 0.3,carvasin 5 mg)
Dolore anginoso 0.3-0.4 mg,sublinguale Cp,fiale
Natispray,sublinguale)
Clorfeniramina/Trimet
Reaz.allergica 10 mg ev,i.m. fiale
108. Altri farmaci per emergenza
farmaco indicazione Dose iniziale adulto
atropina Bradicardia
significativa,attacco vaso
vagale
0.5 mg ev,im
efedrina Ipotensione significativa 5-10 mg iv,10-25 mg im
idrocortisone Insuff.surrenalica 100-200 mg iv o im
anafilassi 100-200 mg iv o im
Morfina o
protossido d’azoto(N2O)
Buprenorfina
Dolore anginoso che non
risponde all NTG
2 mg ev,3-5 mg im
Inalazione al 30-35% con O2
0.15-0.3 mg subling o im o ev
Lorazepam(Tavor) Crisi epilettica
,attacchi di panico
4 mg i.m o ev lenta
Cp per os 1 mg
Midazolam Crisi epilettica 5 mg i.m. o ev
ranitidina Anafilassi,allergia 50 mg ev o 150 mg p.os
Ondansetron(zofran) Nausea,vomito 4 mg,iv o im
111. However……
• After the first visit,having ascertained the
presence and function of some equipment,he
may rely upon some items of the
facility,especially if heavy:
• O2 tank
• Multiparameter monitor
112. Vena sicura
• Cateterino
• Fissaggio “ certosino”
• Prolunga con rubinetto a tre vie
• Fleboclisi a bassa velocità di infusione
115. Minimum Crash Cart Supplies and
Drugs
• (Based on 2010 ACLS Protocols)
• This list is based on the 2011 American Heart
Association Advanced Cardiovascular Life Support
Provider Manual and does not include Adult
Immediate Post-Cardiac Arrest Care.
– Disclaimer:This list was created to show the basic supplies
and equipment required for emergency treatment in an
ambulatory surgery center while waiting for EMS to arrive
and must be reviewed by the anesthesia and medical staff
at your facility and approved by the Medical Executive
Committee and Governing Board.
116. Minimum Crash Cart Supplies and Drugs
(Based on 2010 ACLS Protocols
• Defibrillator/EKG monitor with external pacing capabilities
• or
• AED (automated external defibrillator)
• Adult Electrode defibrillator pads
• Portable suction machine
• suction canister
• suction tubing
• Suction Catheters
• Yankauer Suction Tip
• Clipboard, code worksheets, ACLS algorithms
• Electrode pads/ Defibrillator Pads
• Trach Tray; Cuffed Tracheostomy Tubes: Shiley
• Adult Cricothyrotomy Kit
• Cardiac backboard
• Ambu bag with adult mask
• Portable 02 tanks
• Adult Face Mask non-rebreather
• Nasal Cannula
• Nebulizer Kit
• Airway Patency:
• Nasopharyngeal Airways, assorted sizes
• or
• Oropharyngeal Airways: assorted sizes
• Airway Management:
• Advanced:
• Laryngoscope handle and assorted blades
• C-Batteries for laryngoscope
• Endotracheal Tubes:Assorted sizes, Cuffed and uncuffed
• Stylet
• LMA (laryngeal mask airway) - assorted sizes
• or
• Esophageal-tracheal tube
• or
• laryngeal tube
• MEDICATIONS
• NAME DOSE ROUTE
• Adenosine 6 mg/2ml IV
• Albuterol Inhaler 3ml INH
• Aspirin 325mg PO
• Atropine syringe 1mg/10ml IV
• Atropine 0.4mg/ml IV
• Amiodarone 150mg/3ml IV
• Calcium Chloride 10% syringe IV
• Diphenhydramine 50mg/ml IV
• Dextrose 50%W 25gm/50 ml IV
• Dopamine 400 mg/5ml IV
• Epinephrine 1:1,000 amp/ autoinjector IV
• Epinephrine 1:10,000 syringe IV
• Furosemide 40mg/4ml IV
• Hydrocortisone 100mg/ 2ml IV
• Lidocaine 2%syringe 100 mg IV
• Mag Sulfate 50% syringe IV or IM
• Methylprednisolone 125 mg IV
• Morphine sulfate Narcotic Cabinet IV
• Narcan 0.4mg/ml IV
• Nitroglycerine 0.4mg SL
• Procainamide 100mg/ml IV
• Sodium Bicarb 8.4% 50mEq IV
• Sotalol 100mg IV Sterile Water 10ml IV
• 0.9% Na chloride 10ml IV
• Vasopressin 10units/ml IV
• Lidocaine 4% 2gm 500ml IV
• IV catheters, tape, alcohol wipes, tourniquets, tongue blades
• IO Needles
• IV Tubing- primary and piggyback
• IV solutions: Lactated Ringers, Normal Saline
• Needles, syring
117. La valigetta degli orrori
set di rianimazione
completo di:
bombola
ricaricabile di
ossigeno da 0,5 LT
in acciaio, riduttore
con manometro ed
erogatore, pallone
rianimatore,
maschera
rianimazione, 2
cannule di Guedel,
pinza tiralingua,
apribocca
elicoidale, tubo
atossico, in
contenitore plastico
antiurto.
118. Bombola di ossigeno
• 5 litri,200 atm=1000 litri
• Se usate 6 lt/min ce n’è per 166 min......
• Guardate la pressione;quando è ,per es, a 80
atm,significa che ci sono ancora 400 lt...
• A 20-30 atm è meglio sostituire con una altra
piena.
119.
120.
121.
122.
123.
124. Cannula brevettata a 2 vie per somministrazione di
ossigeno e campionamento della CO2 espirata
setto che separa
le due vie
Curva della CO2 espirata(etCO2)
163. Maschera con reservoir
• http://youtu.be/nEbsKfLl1n4
• Acquisti materiale
consumabile;doctorshop,doctorpoint
164. SIAD Ozzano Emilia via Libertà 17
• ALLEGATO 3 – DICHIARAZIONE SOSTITUTIVA DI CERTIFICAZIONE (ai sensi dell’art. 46 del D.P.R. 28/12/2000, n. 445)
•
•
• Il/la sottoscritto/a……………………………………………………………………………..
•
•
• Responsabile dell’Ente di Soccorso/Studio Medico…………………………………………..
•
•
• con sede in……………………………………………………………………………………….
•
•
• Partita IVA/C.F…………………………………………………………………………………
•
•
•
• Consapevole delle sanzioni penali, nel caso di dichiarazioni non veritiere, di formazione o uso di atti falsi, richiamate dall’art. 76 del DPR n. 445/2000
•
•
• DICHIARA
•
• di essere soggetto autorizzato al rifornimento all’ingrosso di gas medicinali e di impiegare gli stessi sotto la propria sola responsabilità.
•
•
•
•
•
www.siad.com
autorizzazione acquisto FU-3.doc
In fede
•
•
………………………………………………..
•
• Luogo, Data ………………….,……………….
•
165. • buongiorno,
• non possiamo vendere medicinali a studi medici che non abbiano
sottoscritto l’allegato che Le inoltro...
•
• Riesce ad inoltrare ai due medici il modulo, facendomelo poi avere via e-mail
o via fax allo 051 796026?
• Grazie mille
•
• Massimiliano Lucchina
• Servizio Vendita
•
• SIAD S.p.A. | I-40064 Ozzano dell'Emilia (BO) - Via della Libertà, 17
• Tel. +39 051 799399 | Fax +39 051 796026
• massimiliano_lucchina@siad.eu | www.siad.com
166.
167.
168. NORA
• Governance
• organization
• construction and equipment
• policies and procedures, including :
– Fire
– safety
– drugs
– emergencies
– staffing
– training
– unanticipated patient transfers
169.
170.
171.
172.
173. 503.207.4992
Limelight Group
MOBILE ANESTHESIA SERVICES
Home Services Scheduling Forms About Contact
We Specialize in Dental Anesthesia for Children and Adults.
Limelight Sedation mobile
anesthesia services
Mobile Anesthesia Services
Sleep Dentistry - You don’t have to have
anxiety during a dental visit anymore.
Dr. Enrique Abreu
Limelight Group’s mission is to make dental procedures more comfortable
and approachable to those who need it most. We provide deep sedation,
and intravenous (IV) general anesthesia at your dental o ffice.
This provides a few things for the dentist and patient:
• Comfortable dental experience with little to no memory of the events
• Decreased discomfort afterwards since stronger medications can be
used
• Reduced procedure time since dentist can work more efficiently
FAQ:
• Is it safe?
Yes, millions of cases are performed every year using the medications we
employ.
We use all of the same safety precautions and monitoring equipment that
is used in a hospital operating room. Limelight group owns and travels
with all of their own equipment.
-Defibrillator w/ pacer
-Anesthesia monitor w/ end-tidal CO2
-5-lead EKG
-Oxygen
• Who is watching me while I'm asleep?
A board certified medical anesthesiologist will be with you during your
entire procedure, monitoring all of your vital signs constantly. This gives
your dentist the peace of mind to focus on your dental work. See mor e
180. The environment
• Ideal vs real ;seen !!!
• Skilled help?
• Vigilance!!!!motto ASA o occhio di falco……
181. tipologia
• A)segue diversi studi e/ o poliambulatori,non
attrezzati:OBA/NORA
• B) opera presso diverse strutture,
attrezzate,ma diverse ;case di
cura,poliambulatori,ecc,ecc.
• C) opera sia come A che come B
– Libero professionista o part time...
182. Prevenzione:Riduzione dello stress
• Richiesta di consultazione;Medico curante,cardiologo...
• Scelta dell’ora,meglio la mattina presto per i paz ansiosi ,dopo una notte di sonno....
• Minimizzare il tempo di attesa, a meno che non si sfrutti per la sedazione...
• Segni vitali preop e postop
• Premedicazione:
– la notte prima
dell’appuntamento;ipnotico/sedativo:diazepam,triazolam,flurazepam,zolpidem,zaleplon...;prescr
ivere!!!
– all’appuntamento ,almeno mezz’ora prima( 1 h...)
Sedazione durante intervento;iatrosedazione,farmacosedazione
controllo del dolore
Durata del trattamento
Controllo del dolore ;intraop postop
:prescrizione:analgesici,antibiotici,ansiolitici se necessari,
183. Intraoperative and postoperative monitoring
• Recommendations:
• Minimum standards during anesthesia
• Check of the anesthesia mchine
• Postanesthetic care
• Cinical and organizational day sugery ”
185. • Twersky R, Philip B, et al. 2008 Revision of
Office Based Guidelines.Considerations for
Setting Up and Maintaining a Safe
OfficeAnesthesia Environment. 2008 2nd
edition and revision, original 2000 ASA
Publication.
