Risks of anesthesia or sedation outside the operating room: the role of the anesthesia care provider

Anaesthesia considerations for assisted reproductive technology: a focused review

The global burden of infertility is significant and the evidence suggests it is increasing in prevalence worldwide. Assisted reproductive technologies (ARTs) are fertility related treatments used to achieve pregnancy which involve the manipulation of both oocytes and sperm. The specialty is rapidly growing and anaesthesia may be required for several stages in the ART cycle. Anaesthesiologists should appreciate the processes involved and how anaesthesia care can influence safe and effective treatment outcomes. In this review article we explain the key steps of the ART cycle and the role of anaesthesiologists in this process. We also highlight key patient considerations, the implications of remote site anaesthesia and the safety concerns with provision of sedation by non-anaesthesiologists. Finally we outline a typical anaesthetic technique used in our institution for transvaginal oocyte retrieval.

Place of high-flow nasal oxygen in nonoperating room anesthesia

PURPOSE OF REVIEW

This article aims to assess the utility of high-flow nasal oxygen (HFNO) therapy in nonoperating room anesthesia (NORA) settings.

RECENT FINDINGS

The number of procedural interventions under deep sedation in NORA is still increasing. Administration of oxygen is recommended to prevent hypoxemia and is usually delivered with standard oxygen through nasal cannula or a face mask. HFNO is a simple alternative with a high warmed humidified flow (ranging from 30 to 70 l/min) with a precise fraction inspired of oxygen (ranging from 21 to 100%). Compared to standard oxygen, HFNO has demonstrated efficacy in reducing the incidence of hypoxemia and the need for airway maneuvers. Research on HFNO has primarily focused on its application in gastrointestinal endoscopy procedures. Yet, it has also shown promising results in various other procedural interventions including bronchoscopy, cardiology, and endovascular procedures. However, the adoption of HFNO prompted considerations regarding cost-effectiveness and environmental impact.

SUMMARY

HFNO emerges as a compelling alternative to conventional oxygen delivery methods for preventing hypoxemia during procedural interventions in NORA. However, its utilization should be reserved for patients at moderate-to-high risk to mitigate the impact of cost and environmental factors.

Patient selection for nonoperating room anesthesia

PURPOSE OF REVIEW

Given the rapid growth of nonoperating room anesthesia (NORA) in recent years, it is essential to review its unique challenges as well as strategies for patient selection and care optimization.

RECENT FINDINGS

Recent investigations have uncovered an increasing prevalence of older and higher ASA physical status patients in NORA settings. Although closed claim data regarding patient injury demonstrate a lower proportion of NORA cases resulting in a claim than traditional operating room cases, NORA cases have an increased risk of claim for death. Challenges within NORA include site-specific differences, limitations in ergonomic design, and increased stress among anesthesia providers. Several authors have thus proposed strategies focusing on standardizing processes, site-specific protocols, and ergonomic improvements to mitigate risks.

SUMMARY

Considering the unique challenges of NORA settings, meticulous patient selection, risk stratification, and preoperative optimization are crucial. Embracing data-driven strategies and leveraging technological innovations (such as artificial intelligence) is imperative to refine quality control methods in targeted areas. Collaborative efforts led by anesthesia providers will ensure personalized, well tolerated, and improved patient outcomes across all phases of NORA care.

Non-operating Room Anesthesia (NORA): A Comprehensive Review of Monitored Anesthesia Care

Monitored anesthesia care (MAC) is being increasingly employed in non-operative environments, particularly in the realms of endoscopy and magnetic resonance imaging (MRI) procedures. This in-depth analysis delves into the essential components of MAC within these specific contexts, with a primary focus on ensuring patient safety, evaluating efficacy, and assessing procedural outcomes. It is a common practice in endoscopic procedures to necessitate sedation for the purpose of alleviating discomfort and anxiety, ultimately ensuring patient cooperation and the successful completion of the procedure. MAC, which entails the administration of sedatives and analgesics under the close supervision of an anesthesia professional, offers a personalized approach that carefully balances the depth of sedation with maintaining optimal patient safety standards. Within the domain of MRI procedures, where challenges such as claustrophobia and motion artifacts can significantly impact the process, MAC plays a crucial role in providing a controlled setting that not only enhances image quality but also improves patient compliance throughout the procedure. The review extensively investigates the various pharmacological agents commonly utilized in these scenarios, including but not limited to midazolam and fentanyl, shedding light on their pharmacokinetic and pharmacodynamic properties specific to these contexts. Furthermore, the critical role of the anesthesia provider in effectively managing potential complications, such as respiratory depression, hemodynamic instability, and allergic reactions, is thoroughly examined and discussed. The analysis extends to the implementation of MAC protocols, encompassing pre-procedural assessments, continuous intra-procedural monitoring, and comprehensive post-procedural care, all aimed at ensuring the best possible outcomes for patients. Additionally, the review delves into the economic considerations associated with MAC, taking into account its impact on procedural efficiency, healthcare costs, and patient throughput within these settings. By exploring current guidelines and recommendations established by professional societies such as the American Society of Anesthesiologists (ASA), this review aims to provide a holistic understanding of the best practices in MAC for both endoscopy and MRI procedures. Through the synthesis of available evidence, the primary objective of this review is to contribute to informing clinical practices, enhancing patient safety measures, improving procedural success rates, and ultimately advocating for the broader adoption of monitored anesthesia care in diverse non-operative medical settings.

Efficacy of intranasal administration of dexmedetomidine in combination with midazolam for sedation in infant with cleft lip and palate undergoing CT scan: a randomized controlled trial

BACKGROUND

There is a great challenge to sedation for infants with cleft lip and palate undergoing CT scan, because there is the younger age and no consensus on the type, dosage, and route of drug administration.

OBJECTIVE

This study aimed to evaluate the efficacy of intranasal administration of dexmedetomidine combined with midazolam as a sedative option for infants with cleft lip and palate under imaging procedures.

METHODS

Infants scheduled for cleft lip and palate repair surgery were randomly assigned to the IND group (intranasal dexmedetomidine 2 µg/kg alone) and the INDM group (intranasal dexmedetomidine 2 µg/kg combined with midazolam 0.05 mg/kg). The primary outcome was the proportion of infants underwent successful computed tomography (CT) scans under intranasal sedation. The secondary outcomes included onset time and duration of sedation, recovery time, Ramsay sedation scale, hemodynamic parameters during sedation, and adverse events. Data analyses involved the unpaired t-test, the repeated-measures analysis of variance test, and the continuity correction χ2 test.

RESULTS

One hundred five infants were included in the analysis. The proportion of infants underwent successful CT scans under sedation was significantly greater in the INDM group than in the IND group (47 [95.9%] vs. 45 [80.4%], p = 0.016). Additionally, the INDM group had a shorter onset time and a longer duration of sedation statistically (12 [8.5, 17] min vs. 16 [12, 20] min, p = 0.001; 80 [63.6, 92.5] min vs. 68.5 [38, 89] min, p = 0.014, respectively), and their recovery time was significantly longer (43 [30, 59.5] min vs. 31.5 [20.5, 53.5] min, p = 0.006). The difference in Ramsay sedation scale values 20 min after administration was statistically significant between the groups. No statistically significant difference was found between the groups in changes in heart rate and respiratory rate.

CONCLUSION

Intranasal administration of dexmedetomidine in combination with midazolam resulted in higher sedation success in comparison with sole dexmedetomidine. However, it has a relatively prolonged duration of sedation and recovery time.

TRIAL REGISTRATION

ChiCTR2100049122, Clinical trial first registration date: 21/07/2021.

Procedural sedation and analgesia with propofol (PSA) for gynecologic surgery: A systematic review of the literature

OBJECTIVE

To identify which gynecologic procedures are eligible to be performed under PSA with propofol and to describe safety and effectiveness of these procedures in this setting.

METHODS

A systematic review of the literature was conducted in Pubmed (MEDLINE), Embase and The Cochrane Library from inception until September 21st 2022. Cohort studies and randomized controlled trials were included when they reported on clinical outcomes of gynecologic procedures under procedural sedation and analgesia in which propofol was used as an anesthetic. Studies were excluded when sedation without propofol was used, when they only mentioned the use of procedural sedation and analgesia but did not describe any clinical outcome parameters or when < 10 patients were included. The primary outcome parameter was completeness of procedure. Secondary outcome parameters were type of gynecologic procedure, intraoperative complication rate, patient satisfaction, postoperative pain, duration of hospital admission, patient's discomfort and ease of procedure as judged by the surgeon. The Cochrane risk of bias tool and the ROBINS-I tool were used for bias assessment. A narrative synthesis of the findings from the included studies was provided. Numbers and percentages were presented, as well as means with standard deviations and medians with interquartile range where applicable.

RESULTS

Eight studies were included. A total of 914 patients underwent gynecologic surgical procedures with procedural sedation and analgesia with propofol. Gynecological procedures varied from hysteroscopic procedures, vaginal prolapse surgery and laparoscopic procedures. The percentage of complete procedures was 89.8%-100%. Complications occurred in 0-6.5% of patients. Other outcomes were measured in various ways, but overall patient satisfaction was high and postoperative pain was low.

CONCLUSION

The use of PSA with propofol is promising for a wide range of gynecologic procedures, including hysteroscopic procedures, vaginal prolapse surgery and laparoscopic procedures. The use of PSA with propofol seems to be effective and safe and leads to high degree of patient satisfaction. More research is needed in order to determine for which types of procedures PSA can be used.

A Consensus-Driven Revision of the Accreditation Council for Graduate Medical Education Case Log System: Pediatric Anesthesiology Fellowship Education

BACKGROUND

Clinical experiences, quantified by case logs, are an integral part of pediatric anesthesiology fellowship programs. Accreditation of pediatric anesthesiology fellowships by the Accreditation Council of Graduate Medical Education (ACGME) and establishment of case log reporting occurred in 1997 and 2009, respectively. The specialty has evolved since then, but the case log system remains largely unchanged. The Pediatric Anesthesiology Program Directors Association (PAPDA) embarked on the development of an evidence-based case log proposal through the efforts of a case log task force (CLTF). This proposal was part of a larger consensus-building process of the Society for Pediatric Anesthesia (SPA) Task Force for Pediatric Anesthesiology Graduate Medical Education. The primary aim of case log revision was to propose an evidence-based, consensus-driven update to the pediatric anesthesiology case log system.

METHODS

This study was executed in 2 phases. The CLTF, composed of 10 program directors representing diverse pediatric anesthesiology fellowship programs across the country, utilized evidence-based literature to develop proposed new categories. After an approval vote by PAPDA membership, this proposal was included in the nationally representative, stakeholder-based Delphi process executed by the SPA Task Force on Graduate Medical Education. Thirty-seven participants engaged in this Delphi process, during which iterative rounds of surveys were used to select elements of the old and newly proposed case logs to create a final revision of categories and minimums for updated case logs. The Delphi methodology was used, with a two-thirds agreement as the threshold for inclusion.

RESULTS

Participation in the Delphi process was robust, and consensus was almost completely achieved by round 2 of 3 survey rounds. Participants suggested that total case minimums should increase from 240 to 300 (300-370). Participants agreed (75.86%) that the current case logs targeted the right types of cases, but requirements were too low (82.75%). They also agreed (85.19%) that the case log system and minimums deserved an update, and that this should be used as part of a competency-based assessment in pediatric anesthesia fellowships (96%). Participants supported new categories and provided recommended minimum numbers.

CONCLUSIONS

The pediatric anesthesiology case log system continues to have a place in the assessment of fellowship programs, but it requires an update. This Delphi process established broad support for new categories and benchmarked minimums to ensure the robustness of fellowship programs and to better prepare the pediatric anesthesiology workforce of the future for independent clinical practice.

Relapse after non-metastatic rhabdomyosarcoma: The impact of routine surveillance imaging on early detection and post-relapse survival

BACKGROUND

Patients with rhabdomyosarcoma (RMS) whose disease relapses have little chance of being cured, so front-line treatments are usually followed up with surveillance imaging in an effort to detect any recurrences as early as possible, and thereby improve post-relapse outcomes. The real benefit of such routine surveillance imaging in RMS remains to be demonstrated, however. This retrospective, single-center study examines how well surveillance imaging identifies recurrent tumors and its impact on post-relapse survival.

METHODS

The analysis concerned 79 patients <21 years old treated between 1985 and 2020 whose initially localized RMS relapsed. Clinical findings, treatment modalities, and survival were analyzed, comparing patients whose relapse was first suspected from symptoms they developed (clinical symptoms group) with those whose relapse was identified by radiological surveillance (routine imaging group).

RESULTS

Tumor relapses came to light because of clinical symptoms in 42 cases, and on routine imaging in 37. The time to relapse was much the same in the two groups. The median overall survival (OS) and 5-year OS rate were, respectively, 10 months and 12.6% in the clinical symptoms group, and 11 months and 27.5% in the routine imaging group (p-value .327). Among patients with favorable prognostic scores, survival was better for those in the routine imaging group (5-year OS 75.0% vs. 33.0%, p-value .047).

CONCLUSION

It remains doubtful whether surveillance imaging has any real impact on RMS relapse detection and patients' post-relapse survival. Further studies are needed to establish the most appropriate follow-up recommendations, taking the potentially negative effects of regular radiological exams into account.

Relapsing pediatric non-rhabdomyosarcoma soft tissue sarcomas: The impact of routine imaging surveillance on early detection and post-relapse survival

PURPOSE

The chances of patients with relapsing pediatric non-rhabdomyosarcoma soft tissue sarcomas (NRSTS) being cured are limited. This retrospective single-institutional study examines the potential role of routine surveillance imaging for detecting recurrent tumor, and its impact on post-relapse survival.

METHODS

The analysis concerned 86 patients < 21 years old with relapsing NRSTS treated from 1985 to 2020. Clinical findings, treatment modalities and survival were analyzed, comparing patients whose relapse was first suspected from symptoms (symptomatic group) with those whose relapse was detected by radiological surveillance (imaging group).

RESULTS

Tumor relapses were identified from clinical symptoms in 49 cases and on routine imaging in 37. Time to relapse was similar in the two groups. Routine imaging detected 6/32 local relapses and 31/48 distant relapses (and 79% of the cases of lung metastases). Overall survival (OS) at 5 years was 34.3% for the symptomatic group, and 24.0% for the imaging group (p-value 0.270). In patients with lung metastases at relapse, the 5-year OS was statistically better for the imaging group, that is, 25.8% versus 0% for the symptomatic group (p-value 0.044).

CONCLUSION

This is the first study to explore the role of surveillance imaging in pediatric NRSTS. Judging from our findings, the value of routine scanning of primary sites seems limited, while radiological surveillance may help to detect lung metastases, improving survival for this patient category. The potentially negative effects of periodic radiological exams should be considered in deciding the optimal follow-up for patients off therapy.

A comparison of neuromuscular blockade and reversal using cisatricurium and neostigmine with rocuronium and sugamadex on the quality of recovery from general anaesthesia for percutaneous closure of left atria appendage

BACKGROUND

There is a growing interest in minimally invasive left atrial appendage closure therapies. However, for successful catheter surgery, it is necessary to achieve high-quality postoperative recovery. The aim of the study is to comparison of neuromuscular blockade and reversal using cisatricurium and neostigmine with rocuronium and sugamadex on the quality of recovery from general anaesthesia for percutaneous closure of left atria appendage.

METHODS

Eighty-four patients who received percutaneous LAAC were randomly placed into two groups, general anesthesia and endotracheal intubation with either propofol-remifentanil-cisatracurium-neostigmine (group C) or propofol-remifentanil-rocuronium-sugammadex (group S). The QoR-40 questionnaire was used to assess recovery quality 6 h after surgery, and the time of spontaneous respiration, the time of consciousness recovery, the time of extubation, the duration in the postanaesthesia care unit (PACU), and the adverse events after awakening were collected.

RESULTS

Compared with the group C, the group S demonstrated significantly higher individual QoR-40 dimension scores, a significantly shorter recovery time for spontaneous respiration and consciousness, time of extubation, and duration in the PACU, and a lower incidence of transient hypoxemia, agitation, nausea and vomiting and urinary retention. There was a non-significant trend for the length of stay in the hospital in both groups.

CONCLUSIONS

General anesthesia and endotracheal intubation with propofol-remifentanil-rocuronium-sugammadex provided better quality of recovery, shorter anaesthesia duration, and lower incidence of hypoxemia and agitation. Neuromuscular blockade and reversal using rocuronium and sugamadex is better than with cisatricurium and neostigmine on the quality of recovery from general anaesthesia for percutaneous closure of left atria appendage.

TRIAL REGISTRATION

chictr.org, ChiCTR2000031857. Registered on April 12, 2020.

Evaluation of highly accelerated wave controlled aliasing in parallel imaging (Wave-CAIPI) susceptibility-weighted imaging in the non-sedated pediatric setting: a pilot study

BACKGROUND

Susceptibility-weighted imaging (SWI) is highly sensitive for intracranial hemorrhagic and mineralized lesions but is associated with long scan times. Wave controlled aliasing in parallel imaging (Wave-CAIPI) enables greater acceleration factors and might facilitate broader application of SWI, especially in motion-prone populations.

OBJECTIVE

To compare highly accelerated Wave-CAIPI SWI to standard SWI in the non-sedated pediatric outpatient setting, with respect to the following variables: estimated scan time, image noise, artifacts, visualization of normal anatomy and visualization of pathology.

MATERIALS AND METHODS

Twenty-eight children (11 girls, 17 boys; mean age ± standard deviation [SD] = 128.3±62 months) underwent 3-tesla (T) brain MRI, including standard three-dimensional (3-D) SWI sequence followed by a highly accelerated Wave-CAIPI SWI sequence for each subject. We rated all studies using a predefined 5-point scale and used the Wilcoxon signed rank test to assess the difference for each variable between sequences.

RESULTS

Wave-CAIPI SWI provided a 78% and 67% reduction in estimated scan time using the 32- and 20-channel coils, respectively, corresponding to estimated scan time reductions of 3.5 min and 3 min, respectively. All 28 children were imaged without anesthesia. Inter-reader agreement ranged from fair to substantial (k=0.67 for evaluation of pathology, 0.55 for anatomical contrast, 0.3 for central noise, and 0.71 for artifacts). Image noise was rated higher in the central brain with wave SWI (P<0.01), but not in the peripheral brain. There was no significant difference in the visualization of normal anatomical structures and visualization of pathology between the standard and wave SWI sequences (P=0.77 and P=0.79, respectively).

CONCLUSION

Highly accelerated Wave-CAIPI SWI of the brain can provide similar image quality to standard SWI, with estimated scan time reduction of 3-3.5 min depending on the radiofrequency coil used, with fewer motion artifacts, at a cost of mild but perceptibly increased noise in the central brain.

Melatonin for non-operating room sedation in paediatric population: a systematic review and meta-analysis

CONTEXT

The literature on melatonin as a sedative agent in children is limited.

OBJECTIVE

To conduct a systematic review of studies assessing the efficacy and safety of melatonin for non-operating room sedation in children.

METHODS

Medline, Embase, Cochrane Library and Cumulative Index to Nursing and Allied Health were searched until 9 April 2020 for studies using melatonin and reporting one of the prespecified outcomes of this review. Two authors independently assessed the eligibility, risk of bias and extracted the data. Studies with a similar study design, comparator and procedure were pooled using the fixed-effect model.

RESULTS

25 studies (clinical trials=3, observational studies=9, descriptive studies=13) were included. Melatonin was used for electroencephalogram (EEG) (n=12), brainstem evoked response audiometry (n=8) and magnetic resonance imaging (MRI) (n=5). No significant differences were noted on meta-analysis of EEG studies comparing melatonin with sleep deprivation (SD) (relative risk (RR) 1.06 (95% CI 0.99 to 1.12)), melatonin with chloral hydrate (RR 0.97 (95% CI 0.89 to 1.05)) and melatonin alone with melatonin and SD combined (RR 1.03 (95% CI 0.97 to 1.10)) for successful procedure completion. However, significantly higher sedation failure was noted in melatonin alone compared with melatonin and SD combined (RR 1.55 (95% CI 1.02 to 2.33)) for EEG. Additionally, meta-analysis showed lower sleep latency for melatonin compared with SD (mean difference -10.21 (95% CI -11.53 to -8.89) for EEG. No major adverse events were reported with melatonin.

CONCLUSION

Although several studies were identified, and no serious safety concerns were noted, the evidence was not of high quality to establish melatonin's efficacy for non-operating room sedation in children.

Incidence of Adverse Effects of Propofol for Procedural Sedation/Anesthesia in the Pediatric Emergency Population: A Systematic Review and Meta-Analysis

BACKGROUND

To investigate the incidence of adverse effects of propofol among pediatric population for sedation or anesthesia.

METHODS

We performed Cochrane Library, PubMed, CNKI, VIP, and Wanfang databases to research relevant literature. We did sensitivity analysis to assess the incidence of adverse effects of propofol among pediatric population for sedation or anesthesia.

RESULTS

In 132 studies, eight RCTs were included in this analysis. The result showed that adverse events (bradypnea, hypotension, hypertension, and apnea) were significantly improved in the pediatric emergency population in the propofol group, but it had no effect on the incidence of cough attacks, desaturation, agitation, stridor, and laryngospasm. Furthermore, the subgroup analysis showed that those who received propofol for had decreased adverse effects compared with the patients who received ketamine treatment (SMD = 0.44, 95%CI = [0.28, 0.67], I 2 = 0%, and P = 0.0002), which demonstrated that propofol could decrease the incidence of adverse effects compared with ketamine and ketofol.

CONCLUSIONS

The study demonstrated that propofol may decrease the incidence of bradypnea, hypotension, hypertension, and apnea, but it had no effect on the incidence of cough attacks, desaturation, agitation, stridor, and laryngospasm. Furthermore, more large RCTs are needed to assess incidence of adverse effects of propofol among pediatric population.

Multidisciplinary management to optimize outcome of ultrasound-guided high-intensity focused ultrasound (HIFU) in patients with uterine fibroids

Little is known about the specific anaesthesiological and multidisciplinary management of high-intensity focused ultrasound (HIFU) in uterine fibroids. This observational single-center study is the first reporting on an interdisciplinary approach to optimize outcome following ultrasound (US)-guided HIFU in German-speaking countries. A sample of forty patients with symptomatic uterine fibroids was treated by HIFU. Relevant treatment parameters such as total treatment time for intervention, anaesthesia, and sonication time as well as total energy, body temperature, peri-interventional medication and complications were analyzed. Interventional variables did not correlate significantly either with opioid dose or with body temperature. The average fibroid volume reduction rate was 37.8% ± 23.5%, 48.5% ± 22.0% and 70.2% ± 25.5% after 3, 6 and 12 months, respectively. No major anaesthesiological complications occurred apart from an epileptic seizure prior to HIFU treatment in one patient. Peri-procedural hyperthermia (> 37.5 °C) occurred in two patients. Post-procedural two patients experienced a sciatic nerve irritation up to one year; one patient with very large treated fibroid experienced strong short-lasting post-procedural pain. There were two complication-free pregnancies of HIFU-treated patients. Multidisciplinary management is crucial to optimize safety and outcome of US-guided HIFU for uterine fibroids. Peri-procedural pain and temperature management are critical points where an adequate collaboration between anesthesiologist and interventionalist is mandatory.

Morbidity, mortality, and systems safety in non-operating room anaesthesia: a narrative review

Non-operating room anaesthesia (NORA) describes anaesthesia delivered outside a traditional operating room (OR) setting. Non-operating room anaesthesia cases have increased significantly in the last 20 yr and are projected to account for half of all anaesthetics delivered in the next decade. In contrast to most other medication administration contexts, NORA is performed in high-volume fast-paced environments not optimised for anaesthesia care. These predisposing factors combined with increasing case volume, less provider experience, and higher-acuity patients increase the potential for preventable adverse events. Our narrative review examines morbidity and mortality in NORA settings compared with the OR and the systems factors impacting safety in NORA. A review of the literature from January 1, 1994 to March 5, 2021 was conducted using PubMed, CINAHL, Scopus, and ProQuest. After completing abstract screening and full-text review, 30 articles were selected for inclusion. These articles suggested higher rates of morbidity and mortality in NORA cases compared with OR cases. This included a higher proportion of death claims and complications attributable to inadequate oxygenation, and a higher likelihood that adverse events are preventable. Despite relatively few attempts to quantify safety concerns, it was possible to find a range of systems safety concerns repeated across multiple studies, including insufficient lighting, noise, cramped workspace, and restricted access to patients. Old and unfamiliar equipment, lack of team familiarity, and limited preoperative evaluation are also commonly noted challenges. Applying a systems view of safety, it is possible to suggest a range of methods to improve NORA safety and performance.

Fifteen Years' Experience With Safe and Effective Procedural Sedation in Infants and Children in a General Emergency Department

OBJECTIVE

To evaluate procedural sedation (PS) in infants/children, performed by emergency physicians in a general (nonpediatric) emergency department (ED).

METHODS

Procedural sedation prospectively recorded on a standardized form over 15 years. Demographics, sedatives, and analgesia associations with adverse events were explored with logistic regressions.

RESULTS

Of 3274 consecutive PS, 1177 were pediatric: 2 months to 21 years, mean age (±SD) 8.7 ± 5.2 years, 63% boys, 717 White, 435 Black, 25 other. Eight hundred and seventy were American Society of Anesthesiology (ASA) 1, 256 ASA 2, 39 ASA 3, 11 ASA 4, 1 ASA 5. Procedural sedation indications are as follows: fracture reduction (n = 649), dislocation reduction (n = 114), suturing/wound care (n = 244), lumbar puncture (n = 49), incision and drainage (n = 37), foreign body removal (n = 28), other (n = 56). Sedatives were ketamine (n = 762), propofol ( = 354), benzodiazepines (n = 157), etomidate (n = 39), barbiturates (n = 39). There were 47.4% that received an intravenous opioid. Success rate was 100%. Side effects included nausea/vomiting, itching/rash, emergence reaction, myoclonus, paradoxical reaction, cough, hiccups. Complications were oxygen desaturation less than 90%, bradypnea respiratory rate less than 8, apnea, tachypnea, hypotension, hypertension, bradycardia, tachycardia. Normal range of vital signs was age-dependent. Seventy-four PS (6.3%) resulted in a side effect and 8 PS (3.2%) a complication. No one died, required hospital admission, intubation, or any invasive procedure.

CONCLUSIONS

Adverse events in infants/children undergoing PS in a general ED are low and comparable to a pediatric ED at a children's hospital. Pediatric PS can be done safely and effectively in a general ED by nonpediatric EM physicians for a wide array of procedures.

Patient monitoring in the nonoperating room anesthesia (NORA) setting: current advances in technology

PURPOSE OF REVIEW

Nonoperating room anesthesia (NORA) procedures continue to increase in type and complexity as procedural medicine makes technical advances. Patients presenting for NORA procedures are also older and sicker than ever. Commensurate with the requirements of procedural medicine, anesthetic monitoring must meet the American Society of Anesthesiologists standards for basic monitoring.

RECENT FINDINGS

There have been improvements in the required monitors that are used for intraoperative patient care. Some of these changes have been with new technologies and others have occurred with software refinements. In addition, specialized monitoring devises have also been introduced into NORA locations (depth of hypnosis, respiratory monitoring, point-of care ultrasound). These additions to the monitoring tools available to the anesthesiologist working in the NORA-environment push the boundaries of procedures which may be accomplished in this setting.

SUMMARY

NORA procedures constitute a growing percentage of total administered anesthetics. There is no difference in the monitoring standard between that of an anesthetic administered in an operating room and a NORA location. Anesthesiologists in the NORA setting must have the same compendium of monitors available as do their colleagues working in the operating suite.

Frameworks for trainee education in the nonoperating room setting

PURPOSE OF REVIEW

As the volume and types of procedures requiring anesthesiologist involvement in the nonoperating room anesthesia (NORA) setting continue to grow, it is important to create a formal curriculum and clearly define educational goals.

RECENT FINDINGS

A NORA rotation should be accompanied by a dedicated curriculum that should include topics such as education objectives, information about different interventional procedures, anesthesia techniques and equipment, and safety principles. NORA environment may be unfamiliar to anesthesia residents. The trainees must also learn the principles of efficiency, rapid recovery from anesthesia, and timely room turnover. Resident education in NORA should be an essential component of their training. The goals and objectives of the NORA educational experience should include not only developing the clinical knowledge necessary to implement the specific type of anesthetic desired for each procedure, but also the practical knowledge of care coordination needed to safely and efficiently work in the NORA setting.

SUMMARY

As educators, we must foster and grow a resident's resilience by continually challenging them with new clinical scenarios and giving them appropriate autonomy to take risks and move outside of their comfort zone. Residents should understand that exposure to such unique and demanding environment can be transformative.

Safety and Complications of Sedation Anesthesia during Pediatric Auditory Brainstem Response Testing

OBJECTIVE

The auditory brainstem response (ABR) test has been widely used in childhood. Although it is a painless procedure, sedation can be needed in pediatric patients. Thus, this study aimed to evaluate safety and complications of sedation anesthesia applied in pediatric patients during ABR testing.

METHODS

Medical records of 75 children who underwent ABR testing between 2018 and 2020 were evaluated retrospectively in terms of applicability, safety, and complications of sedation anesthesia.

RESULTS

The ages ranged from 3 to 9 (mean 6.2) years. Comorbidity was detected in 20% (n = 15); 3 had multiple comorbidities, and the most common comorbidity was Down syndrome (4%). The drugs used in sedation anesthesia were midazolam in 81.3% (n = 61), a combination of propofol and ketamine in 14.7% (n = 11), and only propofol in 4% (n = 3) of the patients. An additional drug use was needed in 44% (n = 33). The mean procedure time was 40 (range 30-55) min. The mean anesthesia duration was 45 (range 35-60) min. The mean recovery time was 10 (range 5-15) min. Complications related to anesthesia developed in 4 (5.33%) of the patients; respiratory distress, agitation, cough, and nausea-vomiting were seen in one of the patients, respectively. Complications like bradycardia and respiratory or cardiac arrest were not seen at all.

CONCLUSIONS

The complication rate of sedation anesthesia performed during ABR testing of pediatric patients is quite low. It may be more beneficial to use combinations of sedation drugs instead of using a single sedation drug. Although sedation anesthesia appears to be safe in general, the potentially life-threatening complications of sedative agents should be remembered, especially in children who have comorbidities.

Anaesthesia for minimally invasive cardiac procedures in the catheterization lab

PURPOSE OF REVIEW

The share of cardiac procedures performed in settings involving nonoperating room anaesthesia (NORA) continues to grow rapidly, and the number of publications related to anaesthetic techniques in cardiac catheterization laboratories is substantial. We aim to summarize the most recent evidence about outcomes related to type of anaesthetic in minimally invasive cardiac procedures.

RECENT FINDINGS

The latest studies, primarily focused on transcatheter aortic valve replacement (TAVR) and transcatheter mitral valve repair (TMVr), demonstrate the need for reliable monitoring and appropriate training of the interdisciplinary teams involved in this high-risk NORA setting.

SUMMARY

Inappropriate sedation and concurrent inadequate oxygenation are main risk factors for claims involving NORA care. Current evidence deriving from TAVR shows that monitored anaesthesia care (MAC) is associated with shorter length of stay and lower mortality.

Food allergy history and reaction to propofol administration in a large pediatric population

BACKGROUND

Anaphylaxis to propofol is rare; however, providers face a clinical quandary as medication warnings still exist regarding propofol administration to egg-, soy-, and peanut-allergic patients.

AIMS

The primary aim evaluated the rate of allergic reactions during propofol-containing anesthesia in patients listed allergic to egg, soy, or peanut compared with nonallergic patients who received propofol. The secondary aim evaluated the relationship between food allergy history and allergy testing data.

METHODS

A retrospective chart review conducted between May 2012 and October 2018 identified pediatric patients listed allergic to egg, soy, and/or peanut, who received propofol. Allergy testing and results are presented. Evidence of allergic reaction to propofol during anesthesia was evaluated, and compared with a large nonallergic cohort who received propofol.

RESULTS

Of the 232 392 anesthetics administered, 177 360 (76%) included propofol and 11308 (6%) involved a patient listed allergic to at least 1 index food. A large number of patients had no food allergy testing (n = 6153) or negative testing (n = 2198). Of the 3435 patients listed egg-allergic, 976 tested positive; 750 tested negative; and 1709 had no testing. Of the 2011 patients listed soy-allergic, 322 tested positive; 585 tested negative; and 1104 had no testing. Additionally, 5862 patients were listed peanut-allergic; 1659 tested positive; 863 tested negative and 3340 had no testing. One record of proven propofol anaphylaxis occurred; it was in a patient without a history of food allergies. There were 6 other cases of suspected allergy to propofol. One had a peanut and tree nut allergy and was lost to follow-up; one had no testing available, while 4 patients had positive propofol allergy testing and positive allergy tests to other medications. The rate of proven propofol anaphylaxis during anesthesia in the nonallergic cohort was 0.06/10 000, and the rate in egg- and soy-allergic patients was 0/5446. One patient with a listed peanut allergy had a possible reaction to propofol.

CONCLUSIONS

In the listed food-allergic cohort, the majority had no allergy testing or negative testing. We found no evidence of a relationship between food allergy history and perioperative propofol reaction. We suggest multiply allergic and atopic patients may have a similar likelihood of propofol reaction as with other medications.

Effectiveness and safety of same day discharge after left atrial appendage closure under moderate conscious sedation

BACKGROUND

Left atrial appendage occlusion (LAAO) using Watchman device has become a world-wide, well-established therapeutic alternative to chronic systemic oral anticoagulation in patient who are at high-risk of bleeding with paroxysmal (PAF) or chronic atrial fibrillation (Afib). Currently, LAAO procedures are performed under general anesthesia (GA) and patients stay overnight post procedure in the United States. We aimed to present the effectiveness and safety of same day discharge following LAAO under moderate conscious sedation (MCS) in patients without procedural complications.

METHODS

A total of 112 patients between August 2019 and May 2020 with elevated CHA₂ DS₂ VASc (median score of 3) underwent transesophageal echocardiography (TEE)-guided LAAO with FDA approved Watchman (Boston Scientific, MN) under MCS and discharged home on the same day 6 hr following their post procedural transthoracic echocardiogram (TTE) evaluations. All patients had next day TTE and follow up at the cardiology clinic. We prospectively evaluated clinical and procedural outcomes using medical records of these patients.

RESULTS

Among all the patients, the mean age was 83.5 ± 8.5 years, 45 (40%) were women. Procedural duration, device implant time and fluoroscopic times were 45 ± 8.6, 14.5 ± 7.8 and 10.2 ± 1.2 min, respectively. The median required dosage of propofol was 105 ± 2.8 mg. No complications arose from MCS. There was no need for conversion to GA in any of the patients during the procedure. All patients were able to be discharged 6 hr following their TTE evaluation post procedure. There were no procedural complications.

CONCLUSIONS

Same day discharge following LAAO closure seems to be safe and effective in patients without procedural complications. LAAO can also be performed safely and effectively under moderate conscious sedation. Applying moderate conscious sedation may simplify the LAAO procedure, reduce procedural time, procedural costs and hospital stay while increasing overall patient satisfaction.

Efficacy and Safety of Pediatric Procedural Sedation Outside the Operating Room

Background

The volume of pediatric Procedural Sedation and Analgesia (PSA) outside the operating room has been increasing. This high clinical demand leads non-anesthesiologists, especially pediatric intensivists, pediatricians, and emergency physicians, to take a role in performing procedural sedation. Our department has established the PSA service by pediatric intensivists since 2015.

Objectives

We aimed to assess the efficacy and safety of PSA outside the operating room conducted by pediatric intensivists and identify risk factors for severe adverse events.

Methods

This was a retrospective descriptive study conducted from January 2015 to July 2019. Children aged less than 20 years who underwent procedural sedation were included. We collected demographic data, sedative and analgesic medications, American Society of Anesthesiologists (ASA) Physical Status Classification, indications for sedation, the success of procedural sedation, and any adverse events.

Results

Altogether, 395 patients with 561 procedural sedation cases were included. The median age was 55 months (range: 15 to 119 months), and 58.5% (231/395) were male. The rate of successful procedures under PSA was 99.3%. Serious Adverse Events (SAE) occurred in 2.7%. Patients who received more than three sedative medications had higher SAE than patients who received fewer medications (adjusted for age, location of sedation, type of procedure, and ASA classification) (odds ratio: 8.043; 95% CI: 2.472 - 26.173, P = 0.001).

Conclusions

Our data suggest that children who undergo procedural sedation outside the operating room conducted by pediatric intensivists are safe and effectively treated. Receiving more than three sedative medications is the independent risk factor associated with serious adverse events.

High Incidence of Burst Suppression during Propofol Sedation for Outpatient Colonoscopy: Lessons Learned from Neuromonitoring

Background

Although anesthesia providers may plan for moderate sedation, the depth of sedation is rarely quantified. Using processed electroencephalography (EEG) to assess the depth of sedation, this study investigates the incidence of general anesthesia with variable burst suppression in patients receiving propofol for outpatient colonoscopy. The lessons learned from neuromonitoring can then be used to guide institutional best sedation practice.

Methods

This was a prospective observational study of 119 outpatients undergoing colonoscopy at Thomas Jefferson University Hospital (TJUH). Propofol was administered by CRNAs under anesthesiologists' supervision. The Patient State Index (PSi™) generated by the Masimo SedLine® Brain Root Function monitor (Masimo Corp., Irvine, CA) was used to assess the depth of sedation. PSi data correlating to general anesthesia with variable burst suppression were confirmed by neuroelectrophysiologists' interpretation of unprocessed EEG.

Results

PSi values of <50 consistent with general anesthesia were attained in 118/119 (99.1%) patients. Of these patients, 33 (27.7%) attained PSi values <25 consistent with variable burst suppression. The 118 patients that reached PSi <50 spent a significantly greater percentage (53.1% vs. 42%) of their case at PSi levels <50 compared to PSi levels >50 (p=0.001). Mean total propofol dose was significantly correlated to patient PSi during periods of PSi <25 (R=0.406, p=0.021).

Conclusion

Although providers planned for moderate to deep sedation, processed EEG showed patients were under general anesthesia, often with burst suppression. Anesthesiologists and endoscopists may utilize processed EEG to recognize their institutional practice patterns of procedural sedation with propofol and improve upon it.

Impact of Anesthetic and Ventilation Strategies on Invasive Hemodynamic Measurements in Pediatric Heart Transplant Recipients

BACKGROUND

Care of pediatric heart transplant recipients relies upon serial invasive hemodynamic evaluation, generally performed under the artificial conditions created by anesthesia and supportive ventilation.

OBJECTIVES

This study aimed to evaluate the hemodynamic impacts of different anesthetic and ventilatory strategies.

METHODS

We compared retrospectively the cardiac index, right- and left-sided filling pressures, and pulmonary and systemic vascular resistances of all clinically well and rejection-free heart transplant recipients catheterized from 2005 through 2017. Effects of spontaneous versus positive pressure ventilation and of sedation versus general anesthesia were tested with generalized linear mixed models for repeated measures using robust sandwich estimators of the covariance matrices. Least squared means showed adjusted mean outcome values, controlled for appropriate confounders.

RESULTS

720 catheterizations from 101 recipients met inclusion criteria. Adjusted cardiac index was 3.14 L/min/m² (95% CI 3.01-3.67) among spontaneously breathing and 2.71 L/min/m² (95% CI 2.56-2.86) among ventilated recipients (p < 0.0001). With spontaneous breathing, left filling pressures were lower (9.9 vs 11.0 mmHg, p = 0.030) and systemic vascular resistances were higher (24.0 vs 20.5 Woods units, p < 0.0001). After isolating sedated from anesthetized spontaneously breathing patients, the observed differences in filling pressures and resistances emerged as a function of sedation versus general anesthesia rather than of spontaneous versus positive pressure ventilation.

CONCLUSION

In pediatric heart transplant recipients, positive pressure ventilation reduces cardiac output but does not alter filling pressures or vascular resistances. Moderate sedation yields lower left filling pressures and higher systemic vascular resistances than does general anesthesia. Differences are quantitatively small.

Predicting unconsciousness after propofol administration: qCON, BIS, and ALPHA band frequency power

During anesthesia induction with propofol the level of arousal progressively decreases until reaching loss of consciousness (LOC). In addition, there is a shift of alpha activity from parieto-occipital to frontal zones, defined as anteriorization. Whilst monitoring LOC and anteriorization would be useful to improve propofol dosage and patient safety, the current devices for anesthetic depth monitoring are unable to detect these events. The aim of this study was to observe LOC and anteriorization during anesthesia induction with propofol by applying electrodes placed in the frontal and parietal areas. Bispectral index (BIS) and quantium consciousness index (qCON) monitors were simultaneously employed. BIS™ and qCON sensors were placed in the frontal and parieto-occipital regions of 10 alopecic patients who underwent anesthesia with propofol, alfentanil, and remifentanil. The initial biophase target of propofol was 2.5 mcg/mL which was gradually increased until reaching LOC. Wilcoxon signed-rank test was used to study differences in alpha power and qCON/BIS indices along the study; and Pk value to evaluate predictive capability of anteriorization of BIS, qCON, and alpha waves. Parietal BIS and qCON values became significantly higher than frontal values 15 min after loss of eye reflex. Anteriorization was observed with both monitors. Pk values for BIS and qCON were strongly predictive of frontal alpha absolute power. During anesthesia induction with propofol it is possible to identify anteriorization with BIS and qCON in the frontal and parieto-occipital regions. Both indices showed different patterns which need to be further studied.

The Use of Intranasal Dexmedetomidine and Midazolam for Sedated Magnetic Resonance Imaging in Children: A Report From the Pediatric Sedation Research Consortium

OBJECTIVE

The objective of this study was to describe the use of intranasal dexmedetomidine (IN DEX) for sedated magnetic resonance imaging (MRI) examinations in children. The use of IN DEX for MRI in children has not been well described in the literature.

MATERIALS AND METHODS

The Pediatric Sedation Research Consortium (PSRC) is a collaborative and multidisciplinary group of sedation practitioners dedicated to understanding and improving the process of pediatric sedation. We searched the 2007 version of the PSRC database solely for instances in which IN DEX was used for MRI diagnostic studies. Patients receiving intravenous medications were excluded. Patient demographics, IN DEX dose, adjunct medications and dose, as well as procedure completion, complications, interventions, and monitoring providers were analyzed.

RESULTS

A total of 224 sedation encounters were included in our primary analysis. There were no major adverse events. Most sedations (88%) required no intervention. Registered nurses were the monitoring provider in over 99% of cases. The median (interquartile range) dose of dexmedetomidine was 3 (2.5-3) mcg/kg. Adjunctive midazolam was used in 219/224 (98%) of the cases. All procedures were completed.

CONCLUSIONS

This report from the PSRC shows that IN DEX in combination with midazolam is an effective medication regimen for children who require an MRI with sedation.

Safety in the nonoperating room anesthesia suite is not an accident: lessons from the National Transportation Safety Board

PURPOSE OF REVIEW

To review the findings of National Transportation Safety Board-related aviation near misses and catastrophes and apply these principles to the nonoperating room anesthesia (NORA) suite.

RECENT FINDINGS

NORA is a specialty that has seen tremendous growth. In 2019, NORA contributes to a larger proportion of anesthesia practice than ever before. With this growth, the NORA anesthesiologist and team are challenged to provide safe, high-quality care for more patients, often with complex comorbidities, and are forced to utilize deeper levels of sedation and anesthesia than ever before. These added pressures create new avenues for human error and adverse outcomes.

SUMMARY

Safety in modern anesthesia practice often draws comparison to the aviation industry. From distinct preoperational checklists, defined courses of action, safety monitoring and the process of guiding individuals through a journey, there are many similarities between the practice of anesthesia and flying an airplane. Consistent human performance is paramount to creating safe outcomes. Although human errors are inevitable in any complex process, the goal for both the pilot and physician is to ensure the safety of their passengers and patients, respectively. As the aviation industry has had proven success at managing human error with a dramatic improvement in safety, a deeper look at several key examples will allow for comparisons of how to implement these strategies to improve NORA safety.

Is surveillance imaging in pediatric patients treated for localized rhabdomyosarcoma useful? The European experience

Background

After the completion of therapy, patients with localized rhabdomyosarcoma (RMS) are subjected to intensive radiological tumor surveillance. However, the clinical benefit of this surveillance is unclear. This study retrospectively analyzed the value of off‐therapy surveillance by comparing the survival of patients in whom relapse was detected by routine imaging (the imaging group) and patients in whom relapse was first suspected by symptoms (the symptom group).

Methods

This study included patients with relapsed RMS after the completion of therapy for localized RMS who were treated in large pediatric oncology hospitals in France, the United Kingdom, Italy, and the Netherlands and who were enrolled in the International Society of Paediatric Oncology Malignant Mesenchymal Tumor 95 (1995‐2004) study, the Italian Paediatric Soft Tissue Sarcoma Committee Rhabdomyosarcoma 96 (1996‐2004) study, or the European Paediatric Soft Tissue Sarcoma Study Group Rhabdomyosarcoma 2005 (2005‐2013) study. The survival times after relapse were compared with a log‐rank test between patients in the imaging group and patients in the symptom group.

Results

In total, 199 patients with relapsed RMS were included: 78 patients (39.2%) in the imaging group and 121 patients (60.8%) in the symptom group. The median follow‐up time after relapse was 7.4 years (interquartile range, 3.9‐11.5 years) for survivors (n = 86); the 3‐year postrelapse survival rate was 50% (95% confidence interval [CI], 38%‐61%) for the imaging group and 46% (95% CI, 37%‐55%) for the symptom group (P = .7).

Conclusions

Although systematic routine imaging is the standard of care after RMS therapy, the majority of relapses were detected as a result of clinical symptoms. This study found no survival advantage for patients whose relapse was detected before the emergence of clinical symptoms. These results show that the value of off‐therapy surveillance is controversial, particularly because repeated imaging may also entail potential harm.

This study assesses the clinical value of radiological surveillance imaging in pediatric patients with rhabdomyosarcoma, which is routinely performed after the completion of therapy. In the majority of patients, relapse is detected because of symptoms, and there is no evidence that early detection by imaging results in improved survival.

Monitored Anesthesia Care for Cardiovascular Interventions

The interventional cardiology is growing and evolving. Many complex procedures are now performed outside the operating room to manage cardiovascular pathologies which had been traditionally treated with cardiac surgery. Appropriate sedation strategy is crucial for improved patient comfort and successful procedure while ensuring safety. Sedation for cardiovascular intervention is frequently challenging, especially in critically-ill, high-risk patients. This review addresses pre-procedure evaluation and preparation of patients, proper monitoring, commonly used sedatives and analgesics, and considerations for specific procedures. Appropriate depth of sedation and analgesia should be balanced with patient, procedural and institutional factors. Understanding of the pharmacology of sedatives/analgesics, vigilant monitoring, ability and proper preparation for management of potential complications may improve outcomes in patients undergoing sedation for cardiovascular procedures.

Evaluating Patient-Centered Outcomes in Clinical Trials of Procedural Sedation, Part 2 Safety: Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research Recommendations

The Sedation Consortium on Endpoints and Procedures for Treatment, Education, and Research, established by the Analgesic, Anesthetic, and Addiction Clinical Trial Translations, Innovations, Opportunities, and Networks, a public-private partnership with the US Food and Drug Administration, convened a second meeting of sedation experts from a variety of clinical specialties and research backgrounds to develop recommendations for procedural sedation research. The previous meeting addressed efficacy and patient- and/or family-centered outcomes. This meeting addressed issues of safety, which was defined as "the avoidance of physical or psychological harm." A literature review identified 133 articles addressing safety measures in procedural sedation clinical trials. After basic reporting of vital signs, the most commonly measured safety parameter was oxygen saturation. Adverse events were inconsistently defined throughout the studies. Only 6 of the 133 studies used a previously validated measure of safety. The meeting identified methodological problems associated with measuring infrequent adverse events. With a consensus discussion, a set of core and supplemental measures were recommended to code for safety in future procedural clinical trials. When adopted, these measures should improve the integration of safety data across studies and facilitate comparisons in systematic reviews and meta-analyses.

Guidelines for Monitoring and Management of Pediatric Patients Before, During, and After Sedation for Diagnostic and Therapeutic Procedures

The safe sedation of children for procedures requires a systematic approach that includes the following: no administration of sedating medication without the safety net of medical/dental supervision, careful presedation evaluation for underlying medical or surgical conditions that would place the child at increased risk from sedating medications, appropriate fasting for elective procedures and a balance between the depth of sedation and risk for those who are unable to fast because of the urgent nature of the procedure, a focused airway examination for large (kissing) tonsils or anatomic airway abnormalities that might increase the potential for airway obstruction, a clear understanding of the medication's pharmacokinetic and pharmacodynamic effects and drug interactions, appropriate training and skills in airway management to allow rescue of the patient, age- and size-appropriate equipment for airway management and venous access, appropriate medications and reversal agents, sufficient numbers of appropriately trained staff to both carry out the procedure and monitor the patient, appropriate physiologic monitoring during and after the procedure, a properly equipped and staffed recovery area, recovery to the presedation level of consciousness before discharge from medical/dental supervision, and appropriate discharge instructions. This report was developed through a collaborative effort of the American Academy of Pediatrics and the American Academy of Pediatric Dentistry to offer pediatric providers updated information and guidance in delivering safe sedation to children.

Sedation Strategies for Procedures Outside the Operating Room

With the rapid development of diagnostic and therapeutic procedures performed outside the operating room (OR), the need for appropriate sedation care has emerged in importance to ensure the safety and comfort of patients and clinicians. The preparation and administration of sedatives and sedation care outside the OR require careful attention, proper monitoring systems, and clinically useful sedation guidelines. This literature review addresses proper monitoring and selection of sedatives for diagnostic and interventional procedures outside the OR. As the depth of sedation increases, respiratory depression and cardiovascular suppression become serious, necessitating careful surveillance using appropriate monitoring equipment.

Capnography Monitoring During Procedural Sedation and Analgesia

Procedural sedation is used to alleviate pain and anxiety associated with diagnostic procedures in the acute care setting. Although commonly used, procedural sedation is not without risk. Key to reducing this risk is early identification of risk factors through presedation screening and monitoring during the procedure. Electrocardiogram, respiratory rate, blood pressure, and pulse oximetry commonly are monitored. These parameters do not reliably identify airway and ventilation compromise. Capnography measures exhaled carbon dioxide and provides early identification of airway obstruction and hypoventilation. Capnography is useful in patients receiving supplemental oxygen. In these patients, oxygen desaturation reported by pulse oximetry may lag during episodes of respiratory depression and apnea. Capnography indicates partial pressure of end-tidal carbon dioxide and provides information regarding airway integrity and patterns of ventilation compromise. Implementation of this technology may provide an additional layer of safety, reducing risk of respiratory compromise in patients receiving procedural sedation.

Safety of Pediatric Peripheral Blood Stem Cell Harvest in Daycare Setting: An Institutional Experience

Introduction

Children serving as a donor for their siblings will require anesthesia or sedation. In view of shortage of time and space in operating room setting, peripheral blood stem cell (PBSC) harvest is performed as a daycare procedure.

Aim

This study aims to find out whether performing PBSC harvest in hematology blood collection area as a daycare procedure is safe or not.

Settings and Design

This secondary analysis included 164 pediatric PBSC harvest (154 pediatric donors, of which 10 had repeat harvesting done) donors, performed under anesthesia, in the Department of Hematology, between January 2009 and June 2017.

Materials and Methods

Donors were examined, informed consent was obtained, and adequate premedications were ensured. Induction was intravenous for cooperative donors or inhalational sevoflurane followed by intravenous maintenance infusion using either face mask or a laryngeal mask airway (LMA). During the procedure, vitals are monitored with a noninvasive monitor. Normal hemodynamics were ensured before transferring the children to the ward.

Statistical Analysis

Statistical analysis was performed using SPSS 16.0 statistical software. Descriptive statistics and frequencies were used for the data description.

Results

A total of 137 donors (median age of 5 years) were induced with sevoflurane and LMA was used in 84 children and face mask in 53. Twenty-seven children cooperated for intravenous induction. Various combinations of propofol, dexmedetomidine, and ketamine were used with respiratory and hemodynamic stability. The median duration of anesthesia was 250 (165-375) min. The recovery from anesthesia was smooth with a median wake-up time of 20 (5-60) min.

Conclusion

This retrospective analysis demonstrates that nonoperating room anesthesia for pediatric age group for PBSC harvest can be safely and successfully accomplished outside the operation room setting by a consultant anesthesiologist.

End-tidal carbon dioxide monitoring improves patient safety during propofol-based sedation for breast lumpectomy: A randomised controlled trial

BACKGROUND

The use of sedation is becoming more commonplace. Although pulse oximetry is a standard monitoring procedure during sedation, it cannot accurately detect early hypoventilation. End-tidal carbon dioxide (EtCO2) monitoring can be an earlier indicator of airway compromise; however, the existing literature is limited to a few studies with varying outcomes.

OBJECTIVES

To evaluate whether EtCO2 monitoring decreases the incidences of CO2 retention and apnoeic events in propofol-based sedation.

DESIGN

Randomised controlled study.

SETTING

A tertiary hospital.

PATIENTS

Two hundred women (aged 18 to 65 years, ASA physical status 1 or 2) who were scheduled for breast lumpectomy between June 2017 and August 2017.

INTERVENTIONS

Patients were allocated randomly to receive either standard monitoring or standard monitoring and EtCO2 monitoring.

MAIN OUTCOME MEASURES

The primary outcome was the incidence of CO2 retention. The secondary outcomes were the number of actions taken to restore ventilation, variations in PaCO2 and pH, the frequency of apnoea and the recovery time.

RESULTS

CO2 retention occurred significantly less often in the EtCO2 monitoring group (10 vs. 87%; P < 0.0001). In the standard monitoring group, the mean PaCO2 was more than 6 kPa (45 mmHg) and the pH was less than 7.35 at 5, 10, 20 and 30 min after induction of anaesthesia and at the end of the procedure. Both values were within the normal range in the EtCO2 monitoring group. The number of airway interventions performed was significantly higher in the EtCO2 monitoring group (9.8 ± 1.8 vs. 1.9 ± 1.0; P < 0.0001). Apnoea occurred significantly less often in the EtCO2 monitoring group (0 vs. 10%; P < 0.0001) and recovery time was shorter (9.9 ± 1.4 vs. 11.4 ± 2.1 min; P = 0.048).

CONCLUSION

The addition of EtCO2 monitoring to standard monitoring during propofol-based sedation can improve patient safety by decreasing the incidence of CO2 retention, and therefore the risk of hypoxaemia through early recognition of apnoea, and can also shorten recovery time.

TRIAL REGISTRATION

This trial is registered with http://www.chictr.org.cn (ChiCTR-INR-17011537).

Mental Nerve Blocks for Lip Brachytherapy: A Case Report

High dose rate interstitial brachytherapy is a commonly performed procedure for carcinoma of the lower lip. Placement of the brachytherapy catheters can be painful and may require monitored anesthesia care or general anesthesia. We present the use of bilateral mental nerve blocks with minimal sedation to facilitate placement of brachytherapy catheters.

Practical considerations in the development of a nonoperating room anesthesia practice

PURPOSE OF REVIEW

More than 25% of the procedures necessitating an anesthesia provider's involvement are performed outside the operating room. As a result, it is imperative that the expansion of anesthesia services to any new nonoperating room anesthesia (NORA) location takes into account the challenges and safety considerations associated with such a transformation.

RECENT FINDINGS

Although the adverse events encountered in the NORA suite are similar to those met in the operating room, the frequency and implications are different. In addition, many adverse events are site specific. Hypoxemia events, including cardiac arrest continue to dominate all areas of NORA practice. Challenges posed by new minimally invasive procedures continue to grow. Electronic documentation is rapidly expanding into the NORA suite, which brings both advantages and challenges.

SUMMARY

Involvement of anesthesia providers at the development stage and an understanding of the administrative and clinical challenges are essential elements in the building of a NORA practice.

Anesthesia Practice in Pediatric Radiation Oncology: Mayo Clinic Arizona's Experience 2014-2016

OBJECTIVE

Understanding the goals of targeted radiation therapy in pediatrics is critical to developing high quality and safe anesthetic plans in this patient population. An ideal anesthetic plan includes allaying anxiety and achieving optimal immobilization, while ensuring rapid and efficient recovery.

METHODS

We conducted a retrospective chart review of children receiving anesthesia for radiation oncology procedures from 1/1/2014 to 7/31/2016. No anesthetics were excluded from the analysis. The electronic anesthesia records were analyzed for perianesthetic complications along with efficiency data. To compare our results to past and current data, we identified relevant medical literature covering a period from 1984-2017.

RESULTS

A total of 997 anesthetic procedures were delivered in 58 unique patients. The vast majority of anesthetics were single-agent anesthesia with propofol. The average duration of radiation treatment was 13.24 min. The average duration of anesthesia was 37.81 min, and the average duration to meet discharge criteria in the recovery room was 29.50 min. There were seven instances of perianesthetic complications (0.7%) and no complications noted for the 80 CT simulations. Two of the seven complications occurred in patients receiving total body irradiation.

DISCUSSION

The 5-year survival rate for pediatric cancers has improved greatly in part due to more effective and targeted radiation therapy. Providing an anesthetic with minimal complications is critical for successful daily radiation treatment. The results of our data analysis corroborate other contemporary studies showing minimal risk to patients undergoing radiation therapy under general anesthesia with propofol.

CONCLUSION

Our data reveal that single-agent anesthesia with propofol administered by a dedicated anesthesia team is safe and efficient and should be considered for patients requiring multiple radiation treatments under anesthesia.

Safety of Non-Operating Room Anesthesia: A Closed Claims Update

Malpractice claims for non-operating room anesthesia care (NORA) had a higher proportion of claims for death than claims in operating rooms (ORs). NORA claims most frequently involved monitored anesthesia care. Inadequate oxygenation/ventilation was responsible for one-third of NORA claims, often judged probably preventable by better monitoring. Fewer malpractice claims for NORA occurred than for OR anesthesia as assessed by the relative numbers of in NORA versus OR procedures. The proportion of claims in cardiology and radiology NORA locations were increased compared with estimates of cases in these locations. Although NORA is safe, adherence to safe clinical practice is important.