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Dr John M LOW MA. (Oxford University) BM.BCh. (Oxford University) FRCA., FHKCA., FANZCA., FHKAM.(Anaesthesiology) Partner, Dr. Roger Hung and Partners.

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Presentation on theme: "Dr John M LOW MA. (Oxford University) BM.BCh. (Oxford University) FRCA., FHKCA., FANZCA., FHKAM.(Anaesthesiology) Partner, Dr. Roger Hung and Partners."— Presentation transcript:

1 Dr John M LOW MA. (Oxford University) BM.BCh. (Oxford University) FRCA., FHKCA., FANZCA., FHKAM.(Anaesthesiology) Partner, Dr. Roger Hung and Partners

2 Sedation vs General Anaesthesia Achieving sympatholysis Pharmacology Practical aspects of M A C - equipment Regulatory aspects Managing patient work flow

3 Psychological and emotional Physical Instrumentation / Surgical Incision Pharyngeal/ Laryngeal stimulation Tomori Z, & Widdicombe J G (1969) J Physiol (London) 200:25 Exogenous catecholamines (LA) Cold Full bladder

4 JM Low et al (1986) B J Anaesth 58: Adrenergic Responses to Laryngoscopy

5 AnxietySedation SympatholysisAnalgesiaAnxiolytics Cold, Pain, Noxious Stimulus Fear Factor Sympathetic activation

6 Anxiolytics (benzodiazepines / propofol) Local analgesia - pain stimulus Fentanyl - pain stimulus; sympatholysis non-pharmacological factors (eg. cold) β - adrenergic blockade α - adrenergic blockade

7 MinimalModerateDeepG A Responsiveness Verbal commandsPurposeful response Response to deep pain Unrouseable Airway NormalNo need for intervention May need chin liftAirway / chin lift needed Spontaneous ventilation NormalAdequateMay not be adequate Often inadequate CVS function NormalUsually maintained May be impaired

8 IV Sedation: Pethidine / Morphine Midazolam / Diazepam/Diazemuls Monitored Anaesthetic Care Propofol / Dexmetatomidine (Precedex) Fentanyl / Alfentanil / Remifentanil Dynastat / Pethidine

9 Assessment and Informed consent Preparation of equipment Inhalational induction (paediatric case) IV access – Bolus and Maintenance Maintenance of patients airway Monitoring Recovery and Discharge

10 Excellent for induction (paediatrics) Short exposure to allow for i.v. access Unsuitable for long term use

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12 AMBU Bag readily accessible + / - Oxygen supplement Chin lift (teach D S A) Practical tricks of the trade

13 Posture – (take advantage of pharyngeal curvature) Horizontal position Neck extension Shoulder support Nasopharyngeal airway Loose gauze swab in pharynx Oral Dam Double suction (DSA) No irrigation – soft debris

14 Suction…..Suction……Suction……. Neck extension – double articulation headrest Cough / swallowing reflex present Oral Dam – if possible Loosely packed gauze swab Chin Lift -Train D S A Minimise irrigation

15 Soft elastic belt (for children) Safety belt (adults) Blanket (sympatholysis) Minor movement tolerable

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18 Inhalational techniques Excellent for paediatric induction No scavenging – closed ventilation Limited supply of gas / agent Complex equipment needed for maintenance Intravenous Techniques Propofol……propofol……propofol + / - Adjunct agents

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20 Non-barbituarate hypnotic anaesthetic Lipid soluble – preparation as emulsion Rapid hepatic & extra-hepatic metabolism Very rapid onset and recovery Half Life: T½= 2; 30; 180 mins Metabolites not active Hypnosis at μ g/ml Maintenance with infusion pump No atmospheric pollution

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22 Guaranteed sedation…..

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28 Loading dose – mg (1 mg/kg) Maintenance dose – mls/hr (80 μ g/kg/min) 20mg bolus prn. Titrating to patients threshold

29 At steady state Reduce rate by 10% every few minutes Slight non-purposeful movement (threshold) Add 10% and maintain Switch off when no more stimulation Every anaesthetic is a pharmacological experiment

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31 Midazolam (1-2 mg) Fentanyl (25 mcg / 0.5 mls) Pethidine mg/kg Remifentanil (20 μ g μ g/min) Dynastat (40 mg iv Q12H) Arcoxia (90 – 120 mg po.) Dexmetatomidine (Precedex) Labetalol (!) (5 – 15 mg)

32 IV equipment Monitoring Oxygen / AMBU bag Simple airway management Treatment of major side effects Anaphylaxis Extremes of HR Extremes of BP Bronchospasm Angina P O N V

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42 ASA I or II Age less than 70 years BMI less than 30 Satisfactory pre-op assessment questionnaire Easy access to hospital if necessary Escort available following procedure

43 Patient factors – ASA I / II Assessment of surgical risk Exclude risk of major bleeding Minimal risk of P O N V Satisfactory post-op pain control Patients domestic circumstances Why does this surgery justify hospitalisation ?

44 Presentation and decision to operate Screening Questionnaire Concurrent medications / Allergies / Cardio- respiratory status Fasting instructions Day of procedure – Consent; Contact; Re-assessment; Payment Recovery Stage I Stage II Escort to and from clinic Written Instructions – Medication; Analgesia; driving, machinery, signing of legal documents, cooking, etc.,

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46 6 hours - solids Food and snacks Milk Milky drinks Fresh orange juice 2 Hours – clear fluids Water Ribena Apple juice Orange squash

47 Examination -/+ x-ray Dental Hygiene Restoration S S crown R C T Extraction Orthodontics -/+ impression

48 Paediatric – M O S Paediatric –dental restoration Often minimal stimulation Pulpectomy will need LA Combative / mentally handicapped

49 Adult – M O S Dental Implants Aesthetic dentistry Mentally handicapped

50 Preliminary visit to clinic – assess environment Establish rapport with surgeon Check List of mandatory equipment Second visit – check all facilities Then – (third visit) - book patient

51 Equipment – Mandatory Best Practice Protocols / Check List – for nursing staff Documentation Pre-operative diagnosis – justify procedure Pre-operative assessment – questionnaire Written pre-operative instructions / fasting time Consent for surgery – informed / explicit Consent for sedation – informed / explicit Sedation - vital signs record / positioning / drugs / timetable of events Operation Record – diagnosis / findings/ procedure / closure Written Post-Operative instructions – escort present

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54 American Society of Anesthesiologists American Dental Association Task Force of Sedation & Analgesia Practice Guidelines for Sedation Anesthesiology :

55 International Guidelines ASA / ADA* AAGBI / NICE Guidelines NHS UK* ASA Day Case Surgery Guidelines* Hong Kong College of Anaesthesiologists* Hong Kong Academy of Medicine* HK Society of Paediatric Dentistry* Mid Lothian Day Case Surgery Process Chart* * Copies included in CD-ROM

56 Manual of Office-Based Anesthesia Procedures Fred E Shapiro Lippincott Williams & Wilkins Guidelines on Sedation for Dental Procedures HKSPD Task Force American Heart Association – Emergency Cardiac Care A H A / Worldpoint

57 No greater or less than hospital setting ASA Closed Claims analysis Greater need for contingency planning Emergency Protocols Staff training in BCLS ACLS Simulate Drills (e.g. hypoxia)

58 Oxygen (Cylinder /Oxygen Concentrator) Sedation Drugs Resuscitation Drugs Prolonged Recovery P O N V Vaso-vagal sycope Protocol for hospitalisation Local Analgesia Toxicity (Malignant Hyperpyrexia)

59 P O N V – metoclopramide / odansetron / dexamethasone Hypotension – phenylephrine / ephedrine Hypertension – nifedepine / labetalol / hydrallazine Bradycardia – atropine / isoprenaline / dobutamine Tachycardia – esmolol / fentanyl Bronchospasm – ventolin inhaler / aminophylline Acute Angina – nitroglycerine patch / sl. Anaphylaxis – adrenaline / Ca++ / hydrocortisone / dexamethasone Allergy – chlorpheniramine Antagonists – naloxone / flumazenil

60 Stable vital signs Orientation – time, place, person Satisfactory pain control Able to dress; walk; pass urine No bleeding ; No P O N V ; Escort present

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63 Discharge Criteria- Modified Aldrete Score / PADSS (Korttila) Post-operative Instructions – written Escort is mandatory Supply of post-op drugs – analgesic; antibiotics Emergency contact number - nurse / surgeon Initiate telephone follow up on the next day Post operative follow up in clinic Alert system for pathology result (malignancy)

64 One Stop for the patient / client Control over scheduling No waiting for hospital beds Less competition for OT schedule No delay because of emergency OT Minimal risk of hospital acquired infection Reduced cost for patient and insurance

65 M A C is safe Separate Operator and Sedationist M A C is a growing market Trends in USA: OBA - >50% services Recent adverse publicity locally (gynaecology; liposuction; mammoplasty) Follow guidelines

66 M A C is safe ( Big MAC may not be) Separate Operator and Sedationist M A C is a growing market Trends in USA: OBA - >50% services Recent adverse publicity locally (gynaecology; liposuction; mammoplasty) Follow guidelines

67 EQUIPMENT Specifications GUIDELINES for clinical practice TEMPLATES for documentation POWERPOINT

68 Mount Yotei,, Shikotsu Toya National Park, Hokkaido, Japan


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