Seguridad en anestesia en procedimientos fuera de quirófano

Seguridad en anestesia en procedimientos fuera de quirófano

M.I. Fernández Jurado

HOSPITAL REGIONAL UNIVERSITARIO MÁLAGA

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SEGURIDAD EN ANESTESIA Dentro y fuera de quirófano igual y más aún fuera: •  Preanestesia y consentimiento “explicado” •  Verificar la instalación previamente:

–  Accesibilidad –  Gases anestésicos: Oxígeno y Aire? –  Aspiración con vacío central o aspirador individual? –  Ventilación de la sala y aspiración de gases? –  Conexiones eléctricas –  Teléfono, Internet?

•  Estación de anestesia y monitorización adecuada •  Espacio de Recuperación o forma de traslado

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…Y POR ESO,

PORQUE ES UN CONTÍNUO,

HABLAREMOS DE ANESTESIA

SIEMPRE, Y SOBRE TODO EN PEDIATRÍA,

AUNQUE EN MUCHOS CASOS

NO PASEMOS DEL NIVEL DE SEDACIÓN


Si hablamos de Anestesia, está claro que la debe realizar o dirigir un especialista Anestesiólogo y supervisar- guiar la actuación de quién la haga, individualizando cada caso

PREGUNTASACREDITACIÓN


1- En Sedación de adultos con Propofol para endoscopias digestivas continúa la polémica sobre su utilización por no anestesiólogos y actualmente:

a)-Falta evidencia y consenso con las sociedades de Anestesiología de que no debe ser usado por no anestesiólogos en todos los pacientes

b)-En pacientes ASA II y III lo están usando con resultados similares a los anestesiólogos a nivel de seguridad

c)-La SEDAR es contraria a esta utilización por considerar que es una anestesia

d)-Las sociedades de Digestivo y Enfermería están publicando de forma contradictoria

Verdadera la c

2-La monitorización segura para nivel de sedación moderada incluye

a)-Capnografía para la ASA (American Society of Anesthesiologists) según la revisión del 2014

b)- Las sociedades de Digestivo también la recomiendan

c)-Los niveles de recomendación de la ASA son menos exigentes que los de otras sociedades que realizan sedación

d)-En pediatría está bien establecido el uso de capnografía para todos los procedimientos de sedación

Verdadera la a

Divergencias a nivel de Recomendaciones de Seguridad

-La monitorización segura para nivel de sedación moderada incluye -Capnografía para la ASA (American Society of Anesthesiologists) según la revisión del 2014

- Las sociedades de Digestivo ASGE no la recomiendan -Los niveles de recomendación de la ASA son mucho más exigentes que los de otras sociedades que realizan sedación -En pediatría aún no está bien establecido el uso de capnografía para todos los procedimientos de sedación


Situación Actual Adultos En Sedación de adultos con Propofol para endoscopias digestivas continúa la polémica sobre su utilización por no anestesiólogos y actualmente:

-Falta evidencia y consenso con las sociedades de Anestesiología de que pueda ser usado por no anestesiólogos

-En pacientes ASA I y II lo están usando con resultados similares a los anestesiólogos a nivel de seguridad

-Las sociedades de Digestivo y Enfermería están publicando al unísono para defender su actuación

-La SEDAR es contraria a esta utilización por considerar que es una anestesia


…En Pediatría

•  Hay menos publicaciones, menos evidencia científica en general y los que más publican suelen ser Pediatras especialistas en Digestivo o Pediatras Intensivistas que en muchos países son los Anestesiólogos

•  Hay más estudios bien estructurados de sedación en pacientes críticos pediátricos



1.  LUGARES 2.  EQUIPO

• LÍDER -FORMACIÓN 3.  MONITORIZACIÓN 4.  DROGAS 5.  PACIENTE-S

Seguridad en anestesia en procedimientos fuera de quirófano


1. LUGARES


PROCEDIMIENTOS,LUGARESYPACIENTESDIFERENTES

HEMODINÁMICA SALADEPROCEDIMIENTOS-REHABILITACIÓN

v RESONANCIA v TAC/RADIOLOGÍA v LITOTRICIA v MEDICINA NUCLEAR v RADIOTERAPIA v OTROS

RADIOTERAPIA -monitorización


CONMÁSCARAPARALESIONESTRONCOENCEFALO


RADIOTERAPIA ABDOMINAL EN LECHO

Estándares y Guías en Sedación No hay Guías aceptadas entre diferentes sociedades científicas y existen

muchas diferencias en las exigencias de cuidados y monitorización Ø  Standards of care for procedural sedation: Focus on differing perceptions among societies Indian J Anaesth. 2018 Jul;62(7):493-496. doi: 10.4103/ija.IJA_201_18. Ø  Sedation Practice Outside the Operating Room for Pediatric Gastrointestinal Endoscopy Indian Pediatr. 2015 Nov;52(11):989-90. Ø  Practice Guidelines for Moderate Procedural Sedation and Analgesia 2018 A Report by the American Society of Anesthesiologists Task Force on Moderate Procedural Sedation

and Analgesia, the American Association of Oral and Maxillofacial Surgeons, American College of Radiology, American Dental Association, American Society of Dentist Anesthesiologists, and Society of Interventional Radiology

Anesthesiology. 2018 Mar;128(3):437-479. doi: 10.1097/ALN.0000000000002043. Ø  Procedural sedation and analgesia for adults in Europe: Safety first. Regulada y con recertificación para no anestesiólogos Eur J Anaesthesiol. 2018 Jan;35(1):4-5.



2. EQUIPO • LÍDER • FORMACIÓN


Importancia del equipo formado, integrado y preparado • Interprofessional Team's Perception of Care Delivery After Implementation of a Pediatric Pain and Sedation Protocol. Crit Care Nurse. 2017 Jun;37(3):66-76.(USA) En Adultos, En algunos centros hospitalarios hay protocolos conjuntos que funcionan muy bien durante años con el liderazgo de Anestesiólogos, v.g La Coruña 2009, Elche 2013, Holanda 2014, • Safety and quality of procedural sedation and analgesia practice for adult patientsThroughout Europe: A step forward. Eur J Anaesthesiol. 2018 Jan;35(1):1-3. • Procedural sedation and analgesia for adults in Europe. Safety first. Eur J Anaesthesiol 2018;35:4–5 • Si no los hay, los no anestesiólogos toman la iniciativa y se autoforman

Seguridadyespecialistasquerealizanlasedaciónpediátrica(2010)


Impact of provider specialty on pediatric procedural sedation complication rates Between July 1, 2004, and December 31, 2008, 131 751 pediatric procedural sedation Pediatrics. 2011 May;127(5):e1154-60. Department of Anesthesiology and Critical Care Medicine, Alfred I. du Pont Hospital for Children, 1600 Rockland Road, Wilmington, DE 19803, USA No encuentran diferencias en complicaciones entre Anestesiólogos, Intensivistas, médicos de Urgencia, Pediatras y otros

SeguridadyespecialistasquerealizanlaAnestesia/sedaciónpediátrica(2018)


Incidence of peri-operative paediatric cardiac arrest: Influence of a specialised paediatric anaesthesia team. Eur J Anaesthesiol. 2018 Jul 25. doi: 10.1097/EJA.0000000000000863. [Epub ahead of print] A total of 36 243 paediatric anaesthetics (0 to 18 years) were administered between 2008 and 2016. Twelve of 25 paediatric cardiac arrests were classified as anaesthesia-attributable. The incidence of overall peri-operativepaediatric cardiac arrest was 8.1/10 000 (95% CI 5.2 to 12.7) in the period 2008 to 2013 and decreased to 4.6/10 000 (95% CI 2.1 to 10.2) in 2014 to 2016. For anaesthesia-attributable cardiac arrest, young age was the most contributory risk factor, whereas in overall paediatric cardiac arrest, ASA physical statuses 3 to 5 played a more important role From the Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne, Institute of Medical Statistics and Computational Biology… CONCLUSION: In this study on incidences of peri-operative paediatric cardiac arrest from a European tertiary care university hospital, implementation of a specialised paediatric anaesthesia team and training programme was associated with lower incidences of peri-operative paediatric cardiac arrest and a reduced probability of anaesthesia-attributable cardiac arrest.


Incidence of perioperative paediatric cardiac arrest: Influence of a specialised paediatricanaesthesia team Eur J Anaesthesiol. 2018 Jul 25. doi: 10.1097/EJA.0000000000000863. [Epub ahead of print] A total of 36 243 paediatric anaesthetics (0 to 18 years) were administered between 2008 and 2016. From the Department of Anaesthesiology and Intensive Care Medicine, University Hospital of Cologne (AH, UT, HH, JH, TA, BWB, SAP), Institute of Medical Statistics and Computational Biology (IMSB), University of Cologne, Cologne (JF), Department of Anaesthesiology and Intensive Care Medicine, Marienhospital Brühl GmbH, Brühl (J-NM), Department of Paediatric Anaesthesia, Children's Hospital Cologne, Cologne (JK) and Faculty for Health, University of Witten/Herdecke, Witten, Germany (JK).


CONCLUSION: In this study on incidences of peri-operative paediatric cardiac arrest from a European tertiary care university hospital, implementation of a specialised paediatric anaesthesia team and training programme was associated with lower incidences of peri-operative paediatric cardiac arrest and a reduced probability of anaesthesia-attributable cardiac arrest Eur J Anaesthesiol. 2018 Jul 25. doi: 10.1097/EJA.0000000000000863. [Epub ahead of print]


2d. Minimal skills for training for non-anaesthesia providers dedicated to procedural sedation and analgesia Minimal requirements for provision of PSA include the ability to appropriately perform pre-procedural clinical assessments (including upper airway and co-morbidities assessment); competence at intravenous cannulation; appropriate skills for rapid assessment (by direct clinical observation and monitoring) and management of different levels of sedation; advanced airway management; diagnosis and management of respiratory and haemodynamic depression; detailed knowledge of the pharmacology of drugs used for PSA and for emergency management; certified competence in advanced life support and monitoring of the patient (very good consensus: level of evidence B: GoR strong).

Guidelines for procedural sedation and analgesia in adults. Eur J Anaesthesiol 2018; 35:6–24

Analgesia and sedation for painful interventions in

children and adolescents: KEY MESSAGES Dtsch Arztebl Int. 2010;107(14):241-7

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1.  ● During painful procedures and interventions,Children •  need adequate sedation/analgesia to prevent psychological and physical injury.

2.  ● Following the guidelines on sedation and analgesia in • children and adolescents published by the professional societies for anesthesiology and pediatrics increases patient safety.

3.  ● Creating a “sedation team” consisting of a physician • and a nurse, both specially trained for the task, reduces complication rates, increases patient safety, and contributes to the success of the interventions.

4. Non-anesthesiologists specially trained for the task

•  (the sedation team) can provide patient safety during sedation/analgesia of ASA class I and II patients that is comparable to that provided by anesthesiologists (including when propofol is used).

5. ● In terms of the safety and comfort of the patient, and

• the success rate of the interventions, deep sedation correctly carried out is preferable to inadequate, overshallow sedation.

6. ● In terms of the success of sedation/analgesia, no drug

• combination (e.g., propofol+ketamine, midazolam+ketamine, propofol+fentanyl, midazolam+fent …sedation is required that is adapted both to the needs of children and adolescents and to the

intervention to be performed; it must be carried out correctly, professionally, and in a routine manner by a team consisting of a physician and a nurse who have received structured training and are experienced in working with this age group


3. MONITORIZACIÓN

CAPNOGRAFÍA si


Established standards for using capnography within the operating theatre have significantly improved patient safety and it is hoped that the recent publication of new but similar capnography standards for application outside the operating theatre will do the same there. The reasons for the current low levels of implementation of some of these standards outside the operating room are worthy of further research. Curr Opin Anesthesiol 2016, 29:000–000

Las razones de los bajos niveles actuales de aplicación de algunas de estas normas fuera de quirófano son dignas de más investigación. **Recomendada por la ASA y Academy Medical Royal College para Sedación moderada-profunda en adultos

A Randomized Controlled Trial of Capnography During Sedation in a Pediatric Emergency

• DepartmentsofPediatrics,YaleUniversitySchoolofMedicine…

Am J Emerg Med. 2015 January;33(1):25–30(154niños)-Pediatrasdeurgencia)…capnographymayimprovethequalityofcareamongchildrenduringsedation

CAPNOGRAFÍA INDIFERENTE /CARA


Capnographic Monitoring in Routine EGD and Colonoscopy With Moderate Sedation: A Prospective, Randomized, Controlled Trial. Am J Gastroenterol. 2016;111(3):395-404. CONCLUSIONS(452 PACIENTES ADULTOS) ESPECIALISTAS DIGESTIVOS ..Capnographic monitoring in routine EGD or colonoscopy for ASAPS I and II patients does not reduce the incidence of hypoxemia

Capnographic Monitoring of Moderate Sedation During Low-Risk Screening Colonoscopy Does Not Improve Safety or Patient Satisfaction: A Prospective Cohort Study. Am J Gastroenterol. 2016 ;111(3):388-94.

CONCLUSIONS (966 PACIENTES ADULTOS) ESPECIALISTAS DIGESTIVOS

..Colonoscopy with moderate sedation is a low-risk procedure, and the addition of EtCO2 did not improve safety or patient satisfaction but did increase cost. These data suggest that routine capnography in this setting may not be cost effective and that EtCO2 might be reserved for patients at higher risk of adverse events.

MONITORDEOXIGENACIÓNCEREBRAL


This multicenter study enrolled 453 infants aged less than 6 months having general anesthesia for 30 min or more. Regional cerebral oxygenation was measured by near-infrared spectroscopy. Postoperatively, parents were contacted 7 days after the operation and asked whether their child had any seizures or other significant medical problems related to surgery CONCLUSIONS: Mild and moderate low cerebral saturation occurred frequently, whereas severe low cerebral saturation was uncommon. Low mean arterial pressure was common and not well associated with low cerebral saturation. Unrecognized severe desaturation lasting 3 min or longer in infants seems unlikely to explain the subsequent development of neurocognitive abnormalities.(¿?) Anesthesiology. 2018 Jan;128(1):85-96. doi: 10.1097/ALN.0000000000001920. An International, Multicenter, Observational Study of Cerebral Oxygenation during Infant and Neonatal Anesthesia. Olbrecht VA, et al

Anestesia Neurotoxicidad y Oxigenación Cerebral


4. DROGAS


•  In conclusion, nonanaesthetists have practiced PSA for many years. With the advent of newer drugs and better monitors there is an opportunity to make PSA safer. However, this would require collaboration among all specialties, including nursing, to promote education and understanding. Modules and courses tailored toward educating sediationists and opportunities for regular CPD to maintain skills would go a long way to promote safety in this field. Processed electroencephalography to better understand consciousness and to accurately identify and track sedation levels is an exciting area of research. Procedural sedation and analgesia for adults in Europe: Safety first. Eur J Anaesthesiol. 2018 Jan;35(1):4-5.

--- limiting sedation plans to single-agent pharmacy appears to be safer than using multi-agent plans. Pharmacologic Considerations for Pediatric Sedation and Anesthesia Outside the Operating Room: A Review for Anesthesia and Non-Anesthesia Providers. Paediatr Drugs. 2017 Oct;19(5):435-446


FÁRMACOS ANESTÉSICOS Y NEUROTOXICIDAD

OXIGENACIÓNCEREBRAL


This multicenter study enrolled 453 infants aged less than 6 months having general anesthesia for 30 min or more. Regional cerebral oxygenation was measured by near-infrared spectroscopy. Receiving general anesthesia for noncardiac surgery in centers located in Australia, the United States, China, and Italy.Postoperatively, parents were contacted 7 days after the operation and asked whether their child had any seizures or other significant medical problems related to surgery. CONCLUSIONS: Mild and moderate low cerebral saturation occurred frequently, whereas severe low cerebral saturation was uncommon. Low mean arterial pressure was common and not well associated with low cerebral saturation. Unrecognized severe desaturation lasting 3 min or longer in infants seems unlikely to explain the subsequent development of neurocognitive abnormalities. Anesthesiology. 2018 Jan;128(1):85-96. doi: 10.1097/ALN.0000000000001920. An International, Multicenter, Observational Study of Cerebral Oxygenation during Infant and Neonatal Anesthesia. Olbrecht VA, et al

Anestesia Neurotoxicidad y Oxigenación Cerebral

La desaturación cerebral severa de 3 minutos o más durante la anestesia en menores de 6 meses parece insuficiente para explicar el desarrollo de alteraciones neurocognitivas posteriores

Evitar errores de Medicación es crucial fuera de quirófano

Incidence, characteristics, and predictive factors for medication errors in paediatric anaesthesia: a prospective incident monitoring study •  Medication errors are not uncommon in paediatric

anaesthesia. Identification of the mechanisms related to medication errors might allow preventive measures that can be assessed in further studies.

British Journal of Anaesthesia, 120 (3): 563e570 (2018)



5. PACIENTE-S

Infecciones respiratorias y anestesia


Peri-operative respiratory adverse events in children with upper respiratory tract infections allowed to proceed with anaesthesia: The French national study. Peri-operative respiratory adverse events (PRAEs) in paediatric patients with upper respiratory tract infections (URTIs) remain inadequately explored in patients allowed to proceed to anaesthesia and surgery. 621 children were included and 489 (78.7%) anaesthetised CONCLUSION: The risk of PRAE in patients anaesthetised in the presence of URTI was similar to previous publications - close to 30%. In the light of our findings, first, current rescheduling indications should be questioned, and second, further medical and organisational strategies should be investigated to reduce PRAE in children with URTI. Eur J Anaesthesiol. 2018 Aug 16. doi: 10.1097/EJA.0000000000000875. [Epub ahead of print]

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INFOGRAPHICS IN ANESTHESIOLOGY--Ramgolam A, et al. Inhalational versus intravenous induction of anesthesia in children with a high risk of perioperative respiratory adverse events: A randomized controlled trial. Anesthesiology 2018; 128:1065–74.June 2018

Con factores de riesgo, una inducción intravenosa puede ser mejor (Australia 300 niños con 2 o + factores de riesgo)

OTRASSITUACIONESESPECIALES


Ø  SAOS y Masas cervicales o Mediastínicas GUIDELINES.European Society of Anaesthesiology and European Board of Anaesthesiology guidelines for procedural sedation and analgesia in adults …Management of OSAS patients undergoing PSA requires thorough and appropriate understanding of different pharmacological options available, where minimal doses of hypnotics should be used and opioids avoided. Dexmedetomidine has been used with a good safety profil and could be considered as an alternative choice for PSA if OSAS is documented. In patients with severe OSAS, the use of nasal continuous positive airway pressure (CPAP) might reduce risks of post-procedural respiratory Eur J Anaesthesiol 2018; 35:6–24 Ø CONMOCIÓN CEREBRAL Concussion in pediatric surgical patients scheduled for time-sensitive surgical procedures. Conclusions: The impact of surgery with general anesthesia in pediatric patients with a recent concussion is unknown. No changes in post-op disposition were noted in this patient population. However, our findings support the need to measure neurocognitive function before and after administration of operative procedures in a larger population with a recent concussion compared with controls. Journal of Concussion ,1: 1–8, 2017

•  Dos horas para líquidos claros siempre que el vaciado gástrico sea normal

•  Postponer la anestesia si el niño tiene sintomatología o infecciones respiratorias

–  Si es imprescindible, preferible i.v. •  Utilizar el menor número de

fármacos •  La canalización de vía venosa no es

obligatoria siempre •  Después de un traumatismo /conmoción

cerebral es recomendable explorar la función cognitiva antes y después de la anestesia

•  Aplicar las medidas de sujeción adecuadas individualmente


AYUNO-DROGAS-VÍA AÉREA-SUJECIÓN

•  Material para control de vía aérea normal y difícil

–  (de menos a más) Ø  In infants undergoing minor elective

procedures, LMAs were associated with clinically significantly fewer PRAE and lower occurrence of major PRAE (laryngospasm and bronchospasm) than endotracheal tubes. This difference should be a consideration in airway device selection

Perioperative respiratory adverse events (PRAE) Ø  The effect of endotracheal tubes

versus laryngeal mask airways on perioperative respiratory adverse events in infants: a randomised controlled trial

www.thelancet.com Vol 389, 18, 2017

Principios Básicos para seguridad en la anestesia fuera de quirófano

•  Equipo entrenado y con

patrones de actuación •  ***Siempre con Enfermería •  Teléfono fijo y móvil a mano •  Maleta preparada con todo lo

posible •  Estación de anestesia

compatible con el lugar de trabajo

•  Monitorización básica con capnografía

•  Etiquetar las jeringas de medicación ¡¡¡

•  Individualizar la preparación al – Lugar de trabajo

– Paciente – Procedimiento


Seguridad en anestesia en procedimientos fuera de quirófano

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