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

2.  Achieving sympatholysis  Sedation vs General Anaesthesia  Minimal 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 58:471-477 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.  Assessment and Informed consent  Preparation of equipment  Inhalational induction (paediatric case)  IV access – Bolus and Maintenance  Maintenance of patient’s airway  Monitoring  Recovery and Discharge

9.  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

11.  Excellent for induction (paediatrics)  Short exposure to allow for i.v. access  Unsuitable for prolonged use

12.  IV Sedation:  Pethidine / Morphine  Midazolam / Diazepam/Diazemuls  Monitored Anaesthesia Care  Propofol / Dexmetatomidine (Precedex)  Fentanyl / Alfentanil / Remifentanil  Dynastat / Pethidine

14.  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 1.5-6 μ g/ml  Maintenance with infusion pump  No atmospheric pollution

16. Guaranteed sedation…..

22.  Loading dose – 40-80 mg (1 mg/kg)  Maintenance dose – 25-60 mls/hr (80 μ g/kg/min)  20mg bolus prn.  Titrating to patient’s threshold

23.  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”

25.  AMBU Bag readily accessible  + / - Oxygen supplement  Chin lift (teach D S A)  Practical “tricks of the trade”

26.  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

27.  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

28.  Soft elastic belt (for children)  Safety belt (adults)  Blanket (sympatholysis)  Minor movement tolerable

30.  Midazolam (1-2 mg)  Fentanyl (25 mcg / 0.5 mls)  Pethidine 0.5-1 mg/kg  Remifentanil (20 μ g + 2.5 μ g/min)  Dynastat (40 mg iv Q12H)  Arcoxia (90 – 120 mg po.)  Dexmetatomidine (Precedex)  Labetalol (!) (5 – 15 mg)

31.  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

37.  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

43.  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

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.,

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

47.  Paediatric – M O S  Paediatric –dental restoration  Often minimal stimulation  Pulpectomy will need LA  Combative / mentally handicapped

48.  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

51.  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

52.  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)

53.  American Society of Anesthesiologists  American Dental Association  Task Force of Sedation & Analgesia  Practice Guidelines for Sedation  Anesthesiology 2002 96:1004-1017

54.  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* * To be posted on WebSite

55.  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

56.  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

57.  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

58.  Manual of Office-Based Anesthesia Procedures  Fred E Shapiro Lippincott Williams & Wilkins www.amazon.com  Guidelines on Sedation for Dental Procedures  HKSPD Task Force www.hkspd.org  American Heart Association – Emergency Cardiac Care  A H A / Worldpoint www.eworldpoint.com)

59. Mount Yotei, 羊蹄山, Shikotsu Toya National Park, Hokkaido, Japan

61.  EQUIPMENT Specifications  GUIDELINES for clinical practice  TEMPLATES for documentation  POWERPOINT

62.  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)  http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2044.2011.06651.x/pdf

63.  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)

64.  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

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

66.  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

67.  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

68.  Adult – M O S  Dental Implants  Aesthetic dentistry  Mentally handicapped

69.  American Society of Anesthesiologists  American Dental Association  Task Force of Sedation & Analgesia  Practice Guidelines for Sedation  Anesthesiology 2002 96:1004-1017

70.  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

71.  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)  http://onlinelibrary.wiley.com/doi/10.1111/j.1365-2044.2011.06651.x/pdf

72.  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)

75.  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  Patient’s domestic circumstances  Why does this surgery justify hospitalisation ?

76.  American Society of Anesthesiologists  American Dental Association  Task Force of Sedation & Analgesia  Practice Guidelines for Sedation  Anesthesiology 2002 96:1004-1017

77.  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* * To be posted on WebSite

78.  Manual of Office-Based Anesthesia Procedures  Fred E Shapiro Lippincott Williams & Wilkins www.amazon.com  Guidelines on Sedation for Dental Procedures  HKSPD Task Force www.hkspd.org  American Heart Association – Emergency Cardiac Care  A H A / Worldpoint www.eworldpoint.com)

79.  Adult – M O S  Dental Implants  Aesthetic dentistry  Mentally handicapped

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

81.  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