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1、Off-site Anesthesia: New ChallengesPattricia S Klarr, M.D.University of MichiganWhat 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 anesthe
2、tic considerations-discuss evolution of anesthetic presence and effect of cost and efficiency-discuss impact of technology on the future IntroductionNORA: Non Operating Room AnesthesiaAlso known as “Remote, offsite”Challenges1. Not working with surgeons and operating room personnel2. Lack of underst
3、anding of respective processes3. Team building4. Equipment needs/space requirementsIf the relationship of surgeons with anesthesia is a marriage without loveThen working with gastroenterologists is kind of like this.but it doesnt have to be.How did we get here?Vast majority of endoscopic procedures
4、can be done with (nurse) sedationWhat has evolved is improvement of technology and acuity of patientsNORA 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 of days of it
5、, 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 monitoringPreprocedure evaluation and preparationIts different becauseAccess to specialized equipment is limitedLess support from nearby anesthetic colleaguesOther chall
6、enges-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/proceduralistsConditions where anesthesia support is indicatedUncoopera
7、tive/combative patientSevere GERDASA3OSA, morbid obesityKnown/suspected difficult intubationKnown difficult to sedateChronic pain patientsAnesthesia support for:Prolonged, difficult or painful proceduresAbnormal body habitus making positioning difficultExtremes of agesCommon Endoscopic Procedures-Co
8、lonoscopy-Esophagogastroduodenoscopy (EGD)-Endoscopic Ultrasonography (EUS)-Endoscopic Retrograde Cholangiopancreatography (ERCP)-Double balloon enteroscopy (DBE)-Endoscopic Mucosal Resection (EMR) 1. Mostly done with light to moderate sedation2. Deep sedation indicated with 1.Uncooperative patient2
9、.Tolerant to pain/antianxiety medication3.ASA33. Anesthetic choices include midazolam/fentanyl and or propofolEGD1. Moderate to deep sedation2. Consider intubation with severe reflux, aspiration riskEUS1. Ultrasound probe larger2. May require deep sedation to general anesthesia -better yield with FN
10、A with deeper anesthetic ERCP1. Weigh risk versus benefits of deep sedation and intubating patient.2. Patients are prone3. GERD is common comorbidityDouble Balloon Endoscopy1. General anesthesia for oral entry2. Improves visualization of entire GI tract.Endoscopic Mucosal ResectionRemoves mucosal le
11、sions 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 tractDeep vs. General AnesthesiaRisks Associated with GI Endoscopy-Hemodynamic instability-elderly with limited cardia
12、c reserve-dehydrated after prep-vagal response to GI distention-Aspiration risk-Airway access-shared airwayClosed Claims NORA Findings 24 NORA Claims from 1990-2001-half were from GI Suite-most were MAC-7of the 9 respiratory NORA events were GI4 of the 7 were during ERCPRespiratory Events-half respi
13、ratory events deemed preventable with better monitoring-respiratory complications associated with-nonvigilance-inappropriate anesthetic choice-untrained staff-poor documentationFurther FindingsInadequate oxygenation/ventilation was most common damaging event-oversedation-lack of monitoring specifica
14、lly 02 sat monitor and capnography-Reviewers judged care as substandard in 54% of cases and preventable with better monitoring in 32% of casesLessons Learned/RecommendationsStandard monitors for all anesthesia locationsCapnography and pulse oximitry can prevent respiratory complicationsSupplemental
15、oxygen may disguise hypoventilation if capnogram not used. Safety Rules in Anesthesia!-Reliable-standardization of care-minimum monitoring standardscapnography/pulse oximitryReliability-continuous learning-just and fair cultureindividuals are appreciated and accountable-enthusiasm for teamwork-debri
16、efing-support of leadership-effective flow of informationHave anesthesia machineWill TravelOK, were needed. We are safe and reliable.They are going to love us in the endoscopy suite now, right?PropofolIncrease in colonoscopy for cancer screeningPropofol sedation in many ways superior to fentanyl / m
17、idazolamrapid turn over = more volumeVery safe for use in moderate sedationPesky FDA Warning Label“For general anesthesia or MAC sedation, (propofol) should be administered only by persons trained in the administration of general anesthesia and not involved in the conduct of the surgical/diagnostic
18、procedure. “GASTROENTEROLOGY VIEW“Much of this debate, during a time of increasing health care costs and decreasing physician reimbursements, seems to reflect economic rather than clinical concerns” Douglas K Rex in The science and politics of propofol, Am J. Gastroenterology 2004ANESTHESIA RESPONSE
19、“(T)his is purely a move by gastroenterologists related to reimbursement. Its not for improved patient safety; its not for improved patient outcomes”. Gervirtz, MD, MPH, Gastroendonews, May 2005Revenue from EndoscopyGastroenterologistDouglas Rex, M.D“Trained Registered Nurses/endoscopy teams can adm
20、inister propofol safely for endoscopy”Gastroenterology 2005Oral Surgeon Weighs In-passing an ACLS course every 2 years doesnt make you skilled to handle BMV an unconscious patient in laryngospasm-Joel Weaver, DDS, PhDAnesthesia Progress, Summer 2006Endoscopist-directed Administration of Propofol: A
21、Worldwide Safety Experience Douglas K Rex, et al*Findings:In almost 650,000 cases of endoscopist directed propofol sedation cases world-wide, there were only 15 major complications:11 need for intubation 4 deaths 0 permanent neurological injuriesConclusionParaphrasing:1. Endoscopist directed propofo
22、l administration is safe.2. Anesthesia providers have higher costs relative to potential benefitsOh, by the way-one of the limitations of the paper was “the reliability of the data depended on the self-reporting by the individual participating centers”-and about the co-author, John A. Walker, his co
23、nflict disclosure includes this:CEO of Dr. NAPSFrom the InternetDr. NAPS Inc. is a company that educates and trains RNs and physicians in the safe use of Propofol for procedural sedation. We will assist you in integrating the use of NAPS (nurse administered Propofol sedation) into your practice sett
24、ing efficiently and effectively. John Walker, CEO*Gastroenterology Wants InPosition statement: nonanesthesiologist administratration of propofol for GI endoscopy: “with adequate training, physician-supervised nurse administration of propofol can be done safely and effectively” joint statement of AAS
25、LD, ACG, AGA, and ASGE 2009The fight over propofol:Michael Jackson death June 2009CMS guidelines 2010.propofol is only indicated for general anesthesia, MAC and for the sedations of the mechanically-ventilated patients.-Anesthesia Department is responsible for oversiteFDA deny ACG request 8/10-argum
26、ents not compelling-supports CMS requirement for anesthesia training if use propofolFDA-restrictionOff label use of propfol opened up liability issues for gastroenterologistsbye-bye Dr NAPSEuropean instruction still availableDr. Cohen responds:“I believe the vast majority of endoscopists target mode
27、rate sedation, not deep. Therefore, FDAs concerns about the risk of deep sedation and general anesthesia are unwarranted.”Cote studyPredictors of complications during endoscopy:-male gender-high BMI-ASA score of 3 or higher-overall, deep sedation with propofol is safe for advanced endoscopic casesCo
28、teThe vast majority of MAC cases (87.3%) could be considered slipping into a state of general anesthesia.Metzner and Domino 2010Many studies arent blinded are biased and have conflict of interest-reliable studies are hampered by low incidence of severe adverse events, are expensive and difficult to
29、performNORA Near Miss CausesAnesthesiology News, March, 2013Ootaki Paper 2012-retrospective analysis of 371 patients-compared yield of EUS-FNA of solid pancreatic masses73% vs. 83% diagnostic with GA-believe better patient cooperation attributed to improvement-cost impact?Ootaki, et al, Anesthesiolo
30、gy 2012: 117:1044-50Technology to the Rescue?From GI private practitioners“FDA approval of (Sedasys) does not make patient care “dummy-proof” or safest for a given patient, because in the event of a misadventure, a “rescue expert is not immediately available to assist. It is ludicrous to assume that
31、 (training or new technology) will render community gastroenterologist as competent as anesthesia professionals”From the Oct. 9, 2013Wall Street Journal: “Robots vs. Anesthesiologists”J&Js New Sedation Machine Promises Cheaper Colonoscopies; Doctors Fight Back By Jonathan D. Rockoff Anesthesiologist
32、s, who are among the highest-paid physicians, have long fought people in health care who target their specialty to curb costs. Now the doctors are confronting a different kind of foe: machines.A new system called Sedasys, made by Johnson & Johnson, would automate the sedation of many patients underg
33、oing colon-cancer screenings. Sedation Machine Promises Cheaper Colonoscopies would automate (the) sedation That could take anesthesiologists out of the room, eliminating a big source of income for the doctors. More than $1 billion is spent each year sedating. Sedasys and ASASlide presentation and P
34、anel discussionAt 2013 Annual Meeting in San FranciscoLog into ASA member website for access-video “Is Sedasys a Disruptive Device”Ad hoc committee finalized recommendations for Sedasys on 1/22/14If all else failsVideo produced by Dr. Douglas Rex-endoscopy is a very low risk-Propopfol has high patie
35、nt satisfaction-general anesthesia can improve diagnostic outcomes-the literature is full of biased studiesWhat We KnowWhat We Dont know-Safety outcomes NAPs vs Anesthesia-Replacing providers with machines is cost-effectiveBut as long as these stories exist:Propofol kills Michael Jackson3 year old d
36、ies in dental officeOur jobs are safe!Summary-compared providing anesthesia in the endoscopy suite vs the operating room-reviewed procedure types and anesthetic considerations-discussed evolution of anesthetic presence and effect of cost and efficiency-discussed impact of technology on the future Re
37、ferences1.Rex DK, Heuss LT, Walker JA, Qi R. Trained registered nurses/endoscopy teams can administer propofol safely for endoscopy. Gastroenterology 2005; 129(5):1384-1391.2.Weaver JM. The great debate on nurse-administered propofol sedation (NAPS) Where should we stand?Anesthesia Progress, Summer
38、2006; 53(2):31-33.3.Rex DK, et al. Endoscopist-directed administration of propofol: A worldwide safety experience. Gastroenterology, 2009; 137(4):1229-1237.4.Cote GA, et al. Incidence of sedation-related complications with propofol use during advanced endoscopic procedures. Clinical Gastroenterology
39、 and Hepatology, 2010; 8(2):137-142.5.Metzner J, Domino KB. Risks of anesthesia or sedation outside the operating room: the role of the anesthesia care provider. Curr Opin Anaesthesiol. 2010; 23(4):523-31.6.Ootaki C et al. Does general anesthesia increase the diagnostic yield of endoscopic ultrasound-guided fine needle aspiration of pancreatic masses? Anesthesiology. 201; 117(5):1044-50.7.Rex DK. The Science and politics of propofol. Am J Gastroenterol, 2004; 99(11):2080-3.8.Gervirtz. Nurse-administered propofol regularly puts patients at risk. Gastroendonews, 2005, May.Questions?
