63: Sedation and Anesthesia Outside the Operating Room

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CHAPTER 63 Sedation and Anesthesia Outside the Operating Room

Mark H. Chandler, MD

1 What procedures outside the operating room require sedation or general anesthesia?

image Radiologic procedures, including computed tomography, magnetic resonance imaging (MRI), and interventional radiology; often a lack of patient cooperation necessitates the need for anesthesia assistance
image Cardiac catheterizations, insertion of implantable cardiac defibrillators, coronary arteriography, radiofrequency ablation, and cardioversions
image Surgical procedures in office settings
image Extracorporeal shock-wave lithotripsy and cystoscopy
image Upper and lower gastrointestinal endoscopy, liver biopsy, and endoscopic retrograde cholangiopancreatography
image Therapeutic radiation
image Electroconvulsive therapy
image Any number of pediatric procedures
image Invasive procedures outside the operating room, including central venous line insertion, percutaneous tracheostomy, diagnostic peritoneal lavage, thoracocentesis, pericardiocentesis, tube thoracotomy, vascular cut down, and bronchoscopy
image Emergency airway management anywhere in the hospital
image Anesthesia in military settings, including on the battlefield

2 What equipment and standards are necessary for safely conducting an anesthetic outside the operating room?

image A reliable source of oxygen with a backup supply (e.g., green oxygen E-cylinder)
image Suction
image If inhalation anesthetics are to be used, an anesthesia machine complete with scavenging capabilities
image A self-inflating hand resuscitator (Ambu) bag capable of delivering at least 90% oxygen
image Standard anesthetic drugs, airway equipment, and monitoring necessary for the intended anesthetic and the subsequent transport
image Sufficient electrical outlets, including clearly labeled emergency electrical outlets
image Illumination, including battery-powered backup illumination (not simply a laryngoscope)
image An emergency cart with a defibrillator, emergency drugs, and other equipment adequate to provide cardiopulmonary resuscitation
image Staff trained to support the anesthesiologist and transport the patient and a reliable means of two-way communication to request assistance
image Appropriate postanesthesic management

This can be remembered with the mnemonic MAO IS SAME PEST:

M = Machine (with scavenger)
A = Ambu bag
O = Oxygen (with backup supply)
I = Illumination
S = Suction
S = Space
A = Anesthetic drugs and equipment
M = Monitors
E = Electricity
P = Postanesthesia care unit
E = Emergency cart
S = Staff
T = Telephone

3 What monitoring is necessary for administration of any anesthetic, regardless of whether it is in the operating room or elsewhere?

The American Society of Anesthesiologists (ASA) has established two basic monitoring standards for all anesthesia care, regardless of where it is administered:

1 Qualified anesthesia personnel must be present during the administration of any general anesthetics, regional anesthetics, and monitored anesthesia care.
2 Oxygenation, ventilation, circulation, and temperature shall be continually evaluated in any patient undergoing an anesthetic. Specifically the ASA requires the following:

image Oxygenation: During all anesthetics a quantitative method of assessing oxygenation such as pulse oximetry shall be used. When using an anesthesia machine, an oxygen analyzer with a low oxygen concentration limit alarm shall be used.
image Ventilation: At the very least, all patients undergoing an anesthetic will be assessed for qualitative clinical signs of ventilation such as observed chest excursion, movement of the reservoir breathing bag, or auscultation of breath sounds. When an endotracheal tube or laryngeal mask airway is inserted, its correct positioning must be verified by identification of carbon dioxide in the expired gas, and carbon dioxide must be monitored with capnography or capnometry.
image Circulation: Every patient receiving anesthesia shall have an electrocardiogram (ECG) continuously displayed throughout the anesthetic and shall have blood pressure and heart rate evaluated at least every 5 minutes. In addition, every patient receiving general anesthesia will have circulatory function continually evaluated by one of the following methods: palpation of a pulse, auscultation of heart sounds, monitoring of a tracing of intra-arterial pressure, or pulse oximetry.
image Body temperature: Whenever clinically significant changes in body temperature are expected, anticipated, or suspected, a patient receiving anesthesia shall have temperature monitored.

4 How might anesthesiologists be involved in establishing standards for sedation and analgesia conducted by nonanesthesiologists?

Given the rising cost of health care and the expense of operating room time, more and more procedures are now being performed in other areas of the hospital with nonanesthesiologists administering sedation and analgesia. Although this trend may help contain costs, it poses safety concerns. Anesthesiologists possess unique knowledge and expertise regarding the use of various pharmacologic agents and in the management of patients undergoing sedation and analgesia. For these reasons anesthesiologists are frequently called on (and indeed, necessary) to help establish hospital policies and procedures regarding sedation and analgesia by nonanesthesiologists.

5 Explain conscious sedation and the continuum of depth of anesthesia

The ASA Task Force on Sedation and Analgesia by Nonanesthesiologists states that sedation and analgesia comprise a continuum of states ranging from minimal sedation to general anesthesia. Understanding the concept of the continuum of anesthesia is a critical first step for nonanesthesiologists to administer sedation and analgesia. The term conscious sedation, which is often used by nonanesthesiologists to refer to sedation administered in settings other than the operating room, is considered moderate sedation/analgesia and is defined in Table 63-1.

TABLE 63-1 Definition of General Anesthesia and Levels of Sedation/Analgesia*

image

6 What are some of the requirements for the administration of moderate sedation by nonanesthesiologists?

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