The traveling anesthesiologist,ossial’anestesista viaggiante

Claudio MelloniLibero professionista

melloniclaudio@libero.itNapoli, SIA,2014

Who is a travelinganesthesiologist(MAAS provider...)

• Anesthesiologist(consultant,fully trained,retired fromNHS(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,specialrequirements,recommendations………

• Cannot rely on anyone for anything,unless....

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

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…

Legal constraints

• USA vs Italy vs UK

• Sedazione cosciente ,sedo/analgesia cosciente..

MAASSMobile Anesthesia and sedation

Service

MAS :memento audere semperMotoscafo armato silurante

SPECIES EVOLUTION

Milwaukee anesthesiologist launch mobile service

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We provide all your anesthesianeeds....our many years of experiencegive us a unique understandingof your anesthesia needs and help usto deliver only the best to yourpatientsno matter what the setting or situation

Film:

• Milky Way Anesthesia - Mobile AnesthesiaServices - Phoenix, Arizona, USA

• Milky Way Anesthesia

• http://youtu.be/Ckp24aNVowo

Expanding the role of the anesthesiologist

ORA• Operating room anesthesia:

NORA• Non Operating room anesthesia

MAASS

• Mobile Anaesthesia and SedationService

Procedures outside op.room(POOR):with/without anesth? NORA

• “Imaging”– CAT– MRI– Functional cerebral imaging– Interventional neuroadiol– US/CAT guided

procedures:biopsies,therapies…

– Radiother.– Telether:children!– Brachiter– Radiother intraop– radiochir

• Psichiatry– ECT

• Cardiology:– Catheter.– CS– Radiofreq.ablation

• Gastroenterology– Sup;esofago,gastro…varici esof….– Colon– Liver biopsies

• ,orthop manipul,wounds. Removalof...….

• Surg.offices:everything:– oftalmology:retinoscopy,tonometry,elettr

oretinography,,ant chmabersurg(cataract,iridectomy ,angiofluoro…

– Plastic surgery:liposuctions,blepharoplastyotoplasty,facial miniliftings

– Dental chair assist:implants,max sinus..odontostomatologia

• UrologY– ECSWLT– cistoscopy

Laserther

NORA:organization (suggestions…) and

guidelines

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.

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

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.

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 committeein Ambulatory Surgical care and the ASA task force on Office based anesthesia

•

• Chair…• Project Leader…•

• Contribuing authors and task force members…..

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).

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…..

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.

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

Nora focal points :quality and safety

Patientselection

Surgicalchoices

Complication rate

Training

Equipmentand supportof the facility

Office based surgery

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)

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.”

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 atremote locations: the US closed claims analysis. Current Opinion Anaesthesiology 2009; 22: pp. 502-508

Diagnosis not made

• You see patients during the workup…………

• Unknown diseases

• Unknown patients….

• Incomplete sense of what we may encounter during the procedure…

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

Specific conditions that warrant special care whenproviding 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

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.

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

Location/space requirements for nonoperating roomanesthesia

• 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

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

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 anesthetizinglocations.Http:/www.asahq.org/publicationsAndServices/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).

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…

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

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

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

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.

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 .

• 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.

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.

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.

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.

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]..

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.

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

Riduzione dello stress

ansia

dolore

Ambiente

Durata

attesa

STRESS

Sedazione:la notte prima,il giorno stesso,approcciopsicologico,ecc,ecc

Analgesia;oppioidi,N2O,A.L.

Musica,relax,TV,distrazione,

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

PRE AND POSTOP INSTRUCTIONS

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

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), ……………………….

Raccolta dati

c.M. 11/95

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:

fleboclisi: 1 2 3 4 MAC opp

AG

Min PAS PAD Fc SaO2 EtCO2 Osservazioni: bas

5

10

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25

30

35

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45

50

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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………………………………………………………………………

ConsensoPoliambulatorio 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…...……………………….……...

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…

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 localanaesthesia.

• 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 mustbe maintained.

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

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 loudlyrepeatedly

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

UMSS University of Michigan sedation scale

Sedation score

Awake and alert 0

Minimum sedation

Tired/sleepy,appropriate response to verbal conversationor sound

1

Moderate sedation

somnolent/sleeping,easily arousable with light tactilestimulation or a simple verbal command

2

Deep sedation Deep sleep,arousable only with significant physicalstimulation

3

unarousable 4

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

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?

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 whatyou have and where it is to be found

• Assume the practice has nothing except suctionand light(but you may inquire beforehand…)

Items for comfort

• Your own surgical clothes

• Patient blanket????

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 solutionLOndon

me

Drugs organized by actionhypnotics,sedative analgesics emergency

Diazepam fentanyl ondansetron

triazolam paracetamol dexamethasone

Midazolam codeine adrenaline

propofol tramadol atropine

ketamine Ketorolacl

amiodarone

dexmedetomidine celecoxib lidocaine

clonidine

naloxone

flumazenil

ephedrine

chlorpheniramine

salbutamol

Drugs organized by timingpremed intraop postop

Codeine+paracetamol midazolam Antidotes;flumazenil,naloxon

triazolam fentanyl VsPONV:ondansetron,dexamethasone

midazolam Propofol Analgesics;celecoxib,codeine+paracetamol,paracetamol,ketorolac,tramadol(???)

diazepam Dex???

Antibiotics ; a couple:amox,genta,cilinda,ciproflox…..

Ket????

Halop or drop Cristalloids;NACl,PET

Colloids:HES

Iv cath:22,20g

transport

• From big suitcases to trolleys…a personal history

Airplane case:25 kg....

Carrellino portavaligie

Bougie,Forceps,Introducer+O2,LMA,spare batteries,lubricant,O2 and CO2

prongs

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

Pre prepared…..be prepared

• Pre prepared syringes:

– Atropine

– Effortil/ephedrine

– Midazolam

– Fentanyl

– Propofol??

– Clonidine(catapresan)

– Electrolytes

– ???specific for the procedure???

Plenty of space

O2 desat;why?

They are pulling the chin!!

IVO 7712

IVO 7712

Patient fully covered:access?

Avere le cose giuste

Attrezzature e farmaci

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,siringapreriempita,iniett(77 £):330 microgr o 165 microgrVideo 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

Farmaci essenziali farmaco indicazioni Dose iniziale(adulti)

ossigeno sempre Inalazione 100% Bombol,maschere,ambu

adrenalina anafilassi 0,1 mg ev;0.5 mg i.m. Fiale,penna

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(Trinitrina 0.3,carvasin 5 mg)

Dolore anginoso 0.3-0.4 mg,sublinguale Cp,fiale

Natispray,sublinguale)

Clorfeniramina/Trimeton)

Reaz.allergica 10 mg ev,i.m. fiale

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 oprotossido d’azoto(N2O)

Buprenorfina

Dolore anginoso che non risponde all NTG

2 mg ev,3-5 mg imInalazione al 30-35% con O20.15-0.3 mg subling o im o ev

Lorazepam(Tavor) Crisi epilettica ,attacchi di panico

4 mg i.m o ev lentaCp 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

Mobiletto con farmaci e materiale di emergenza

However……

• After the first visit,having ascertained the presence and function of some equipment,hemay rely upon some items of the

facility,especially if heavy:

• O2 tank

• Multiparameter monitor

Vena sicura

• Cateterino

• Fissaggio “ certosino”

• Prolunga con rubinetto a tre vie

• Fleboclisi a bassa velocità di infusione

IL CARRELLO DELLE EMERGENZE(CRASH CART)

Il

Minimum Crash Cart Supplies and Drugs

• (Based on 2010 ACLS Protocols) • This list is based on the 2011 American Heart

Association Advanced Cardiovascular Life SupportProvider Manual and does not include AdultImmediate 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 arriveand must be reviewed by the anesthesia and medical staff at your facility and approved by the Medical Executive Committee and Governing Board.

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

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.

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.

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)

Approximate FiO2 delivered by nasalcannula

• Flow rate lt/min approx FiO2

• 1 0.24

• 2 0.28

• 3 0.32

• 4 0.36

• 5 0.40

Sidestream-...

COPA

Dimenticavo:il telefonino!!!!

Appsmediche!!

TRANSPORTATION

requirements

• Good running condition

• Fast enough,powerful,

• Always ready to go

• Good cargo capacity

• (parking space…..)

• Going everywhere,always,all wheather…» Therefore

» 4 motion:low gears?

Motto:Vivere pericolosamente .....

THE END

First and second Jeep

The last one

The future

Maschera con reservoir

• http://youtu.be/nEbsKfLl1n4

• Acquisti materiale consumabile;doctorshop,doctorpoint

autorizzazione acquisto FU-3.doc

SIAD Ozzano Emilia via Libertà 17 www.siad.com

• 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.•

•

•

•

•In fede

•

•………………………………………………..

•

• Luogo, Data ………………….,……………….•

• 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

NORA

• Governance• organization• construction and equipment• policies and procedures, including :

– Fire– safety– drugs– emergencies– staffing– training – unanticipated patient transfers

503.207.4992

We Specialize in Dental Anesthesia for Children and Adults.

Limelight GroupMOBILE ANESTHESIA SERVICES

Home Services Scheduling Forms About Contact

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

Very old obese patient……

The environment

• Ideal vs real ;seen !!!

• Skilled help?

• Vigilance!!!!motto ASA o occhio di falco……

tipologia

• A)segue diversi studi e/ o poliambulatori,nonattrezzati: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...

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...;prescrivere!!!

– all’appuntamento ,almeno mezz’ora prima( 1 h...)

Sedazione durante intervento;iatrosedazione,farmacosedazionecontrollo del doloreDurata del trattamentoControllo del dolore ;intraop postop:prescrizione:analgesici,antibiotici,ansiolitici se necessari,

Intraoperative and postoperative monitoring

• Recommendations:

• Minimum standards during anesthesia

• Check of the anesthesia mchine

• Postanesthetic care

• Cinical and organizational day sugery ”

patient

surgeonprocedure

• 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.