CHAPTER 63 Sedation and Anesthesia Outside the Operating Room
1 What procedures outside the operating room require sedation or general anesthesia?
Radiologic procedures, including computed tomography, magnetic resonance imaging (MRI), and interventional radiology; often a lack of patient cooperation necessitates the need for anesthesia assistance
Cardiac catheterizations, insertion of implantable cardiac defibrillators, coronary arteriography, radiofrequency ablation, and cardioversions
Upper and lower gastrointestinal endoscopy, liver biopsy, and endoscopic retrograde cholangiopancreatography
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
2 What equipment and standards are necessary for safely conducting an anesthetic outside the operating room?
If inhalation anesthetics are to be used, an anesthesia machine complete with scavenging capabilities
Standard anesthetic drugs, airway equipment, and monitoring necessary for the intended anesthetic and the subsequent transport
An emergency cart with a defibrillator, emergency drugs, and other equipment adequate to provide cardiopulmonary resuscitation
Staff trained to support the anesthesiologist and transport the patient and a reliable means of two-way communication to request assistance
This can be remembered with the mnemonic MAO IS SAME PEST:
3 What monitoring is necessary for administration of any anesthetic, regardless of whether it is in the operating room or elsewhere?
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:
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.
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.
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.
4 How might anesthesiologists be involved in establishing standards for sedation and analgesia conducted 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.