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1、Off-site Anesthesia: New Challenges,Pattricia S Klarr, M.D. University of Michigan,What is the largest thing an endoscopist can remove from an anesthetized patient?,A Surgeon!,Goals and Objectives,-compare providing anesthesia in the endoscopy suite vs the operating room -review procedure types and
2、anesthetic considerations -discuss evolution of anesthetic presence and effect of cost and efficiency -discuss impact of technology on the future,Introduction,NORA: Non Operating Room Anesthesia Also known as “Remote, offsite”,Challenges,Not working with surgeons and operating room personnel Lack of
3、 understanding of respective processes Team building Equipment needs/space requirements,If the relationship of surgeons with anesthesia is a marriage without love,Then working with gastroenterologists is kind of like this,.but it doesnt have to be.,How did we get here?,Vast majority of endoscopic pr
4、ocedures can be done with (nurse) sedation What has evolved is improvement of technology and acuity of patients,NORA Rotation,“doing 5 straight days of the MPU is a bit much. Its not that the hours are bad, its just that the pace and workflow down here can be pretty frustrating, and after a couple o
5、f days of it, I feel like I need to go back to an OR or I may lose my mind.”,NORA GI anesthesia is like regular anesthesia because:,Standardized monitoring Preprocedure evaluation and preparation,Its different because,Access to specialized equipment is limited Less support from nearby anesthetic col
6、leagues,Other challenges,-inefficient scheduling -lack of access to medical records-open access patients -equipment upkeep/stocking of supplies -poor physical lay out -tech and nursing unfamiliar with anesthesia procedures -unfamiliarity with procedures/proceduralists,Conditions where anesthesia sup
7、port is indicated,Uncooperative/combative patient Severe GERD ASA3 OSA, morbid obesity Known/suspected difficult intubation Known difficult to sedate Chronic pain patients,Anesthesia support for:,Prolonged, difficult or painful procedures Abnormal body habitus making positioning difficult Extremes o
8、f ages,Common Endoscopic Procedures,-Colonoscopy -Esophagogastroduodenoscopy (EGD) -Endoscopic Ultrasonography (EUS) -Endoscopic Retrograde Cholangiopancreatography (ERCP) -Double balloon enteroscopy (DBE) -Endoscopic Mucosal Resection (EMR),Mostly done with light to moderate sedation Deep sedation
9、indicated with Uncooperative patient Tolerant to pain/antianxiety medication ASA3 Anesthetic choices include midazolam/fentanyl and or propofol,EGD,Moderate to deep sedation Consider intubation with severe reflux, aspiration risk,EUS,Ultrasound probe larger May require deep sedation to general anest
10、hesia -better yield with FNA with deeper anesthetic,ERCP,Weigh risk versus benefits of deep sedation and intubating patient. Patients are prone GERD is common comorbidity,Double Balloon Endoscopy,General anesthesia for oral entry Improves visualization of entire GI tract.,Endoscopic Mucosal Resectio
11、n,Removes mucosal lesions while preserving the submucosa and deeper layers. -diagnosis and treatment of superficial lesions, precancerous such as Barretts -can be curative early superficial cancers of GI tract Deep vs. General Anesthesia,Risks Associated with GI Endoscopy,-Hemodynamic instability -e
12、lderly with limited cardiac reserve -dehydrated after prep -vagal response to GI distention -Aspiration risk -Airway access -shared airway,Closed Claims NORA Findings,24 NORA Claims from 1990-2001 -half were from GI Suite -most were MAC -7of the 9 respiratory NORA events were GI 4 of the 7 were duri
13、ng ERCP,Respiratory Events,-half respiratory events deemed preventable with better monitoring -respiratory complications associated with -nonvigilance -inappropriate anesthetic choice -untrained staff -poor documentation,Further Findings,Inadequate oxygenation/ventilation was most common damaging ev
14、ent -oversedation -lack of monitoring specifically 02 sat monitor and capnography -Reviewers judged care as substandard in 54% of cases and preventable with better monitoring in 32% of cases,Lessons Learned/Recommendations,Standard monitors for all anesthesia locations Capnography and pulse oximitry
15、 can prevent respiratory complications Supplemental oxygen may disguise hypoventilation if capnogram not used.,Safety Rules in Anesthesia!,-Reliable -standardization of care -minimum monitoring standards capnography/pulse oximitry,Reliability,-continuous learning -just and fair culture individuals a
16、re appreciated and accountable -enthusiasm for teamwork -debriefing -support of leadership -effective flow of information,Have anesthesia machine,Will Travel OK, were needed. We are safe and reliable. They are going to love us in the endoscopy suite now, right?,Propofol,Increase in colonoscopy for cancer screening Propofol sedation in many ways superior to fentanyl / midazolam rapid turn over = more volume Very safe for use in moderate sedation,Pesky FDA Warning Label,“For general
