Author: Leopoldo Rodriguez, M.D., FAAP, FASA
ASA Monitor 02 2018, Vol.82, 8-9.
Fresh off a restful beach vacation, you arrive at Advanced Surgery and Endoscopy Center, a freestanding multispecialty site newly staffed by your group. While enjoying your breakfast, you are emergently called to the GI suite to attend to George, an elderly gentleman having a difficult resection of a proximal colon mass under sedation provided by the GI physician and a nurse. George is moderately obese (BMI 33) with hypertension, COPD on inhaled bronchodilator therapy and obstructive sleep apnea treated with nighttime CPAP. As you are quickly assessing him, the frantic nurse tells you that George was really anxious and wanted to “be completely knocked out.” Midway through the procedure, the GI physician was struggling, and George was moving despite loud snoring. The nurse had given a total of midazolam 8 mg I.V. and fentanyl 100 mcg I.V. in divided doses, at which point George began to retch and his breathing became “rocky.” The nurse is trying to ventilate via an Ambu-bag, the SpO2 is now in the mid 70s, EtCO2 is absent and his HR is falling …
Welcome to the world of non-operating room anesthesia (NORA), a place filled with unique challenges and dangers in locations outside of the anesthesiologists’ traditional comfort zones. Recent years have seen the accelerated development of more sophisticated “non- or minimally invasive” medical procedures that don’t need an O.R. but still require some sort of sedation or anesthesia for patient cooperation and comfort. A 2010 article in Gastrointestinal Endoscopy estimated that for EGD and colonoscopy procedures alone, the rate of anesthesia professional participation was projected to grow from approximately 24 percent in 2009 to 53 percent by 2015. Expensive and limited hospital O.R. time is being reserved for higherrisk procedures. Insurers are also driving the shift as a cost-saving maneuver. Those financial pressures and incentives, combined with a lower nosocomial infection rate for ASC procedures (4.84/1,000 versus as high as 8.95/1,000 in a hospital setting), help explain why NORA cases in ambulatory settings have grown significantly.
Many NORA procedures are painful, uncomfortable or lengthy, and may require MAC or GA. Other NORA procedures, especially in the ambulatory setting, utilize the model where the attending physician and a nurse provide the sedation somewhere on the continuum from mild to moderate to deep. These may include procedures in diagnostic or interventional radiology, cardiac catheterization or electrophysiologic studies, TEE and cardioversion, gastroenterology, bronchoscopy and thoracentesis, officebased surgery, pediatric procedures, and dental or oral surgery. Many anesthesia departments or groups will simply not have the staffing capacity or budgets to provide service to multiple NORA sites.
NORA procedures of all types have been associated with anesthesia-related complications and deaths as described in the ASA Closed Claims Project and Pediatric Sedation Research Consortium databases. In 2011, the Anesthesia Patient Safety Foundation published an analysis by Metzer and Domino comparing claims for injuries since 1990 associated with anesthesia in remote locations (n=87) versus anesthesia in traditional O.R. settings (n=3,286). Patients in remote settings were more likely to be older, sicker and having an emergency procedure than those in the O.R. The incidence of death was almost double for remote location claims, most commonly due to an adverse respiratory event, and most frequently due to inadequate oxygenation or ventilation. Injuries in remote locations were also more likely to be deemed preventable by better monitoring.
Poor patient selection process, oversedation, an unexpected difficult airway, inadequate oxygenation, ventilation or laryngospasm can all contribute to untoward events and patient injury in NORA locations. The quality and availability of appropriate monitoring equipment, particularly capnography, will also impact patient safety. We’d all agree that the best defender against patient injury is a vigilant anesthesia provider, but for multiple reasons, that isn’t always possible. As a resource to physicians and nurses who provide moderate and deep sedation to patients (many in a freestanding or office-based ambulatory setting), ASA has developed two sets of educational modules, “Safe Sedation Training – Moderate” and “Safe Sedation Training – Deep.” These courses are available online through the ASA Education Center and provide both didactic coverage of patient evaluation and appropriateness, pharmacology of sedatives, sedation plans, monitoring considerations and a discussion of potential complications as well as interactive sessions that provide feedback to the learner. Checklists, examples of pertinent sedation policies and a discussion of the role of succinylcholine as an emergency agent for laryngospasm are included.
And as for George, he was successfully rescued from his episode of oversedation, airway obstruction, hypoventilation and laryngospasm by your skilled anesthesia hands and knowledge of pharmacology. You later speak to an incredibly thankful administrator about ways your group can help them improve patient safety and outcomes at their center.
In summary, NORA, especially in the ambulatory setting, is here to stay. Those procedures have inherent risks and complications that are often worsened by logistical issues and poor patient selection. Utilization of a well-organized and thoughtfully prepared program like the ASA Safe Sedation Training modules may also improve patient safety in the ambulatory NORA environment.
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Safe Sedation Training – Moderate. American Society of Anesthesiologists website. https://www.asahq.org/education/online-learning/safe-sedation-training-moderate. Last accessed December 11, 2017.
Safe Sedation Training – Deep. American Society of Anesthesiologists website. https://www.asahq.org/education/online-learning/safe-sedation-training-deep. Last accessed December 11, 2017.