Il punto di vista dedll'anestesista

Servizio di Anestesia e Rianimazione Ospedale di Faenza(RA)

Office based

anesthesia

Office based

anesthesia

Claudio MelloniClaudio Melloni

Direttore Anestesia e RianimazioneDirettore Anestesia e Rianimazione

Ospedale di Faenza(RA)Ospedale di Faenza(RA)


Office based anesthesia:il punto di vista dell’anestesista

Claudio Melloni

DIRETTORE Anestesia E Rianimazione

Ospedale di Faenza


Lo stato dell’arte dell’OBA

ASA e Samba survey: American Society of Anesthesiologists/Society for Ambulatory

Anesthesia: Office Anesthesia Survey. Spring 1997. Park Ridge, IL, American Society of Anesthesiologists/Society for Ambulatory Anesthesia.

almeno 25% degli intervistati pratica OBA


Mercato Office Based Surgery

L’OBA non ha sempre accompagnato l’OBS

Molte branche chir fanno tutto da soli:oftalmologia,flebectomia,osteotomia pedidia,isteroscopia,laparoscopia,odontostomatologia…eseguite in locale

Colonscopia,esofagogastro..ecc locale + sedazione


OBA

Si sa,tra le righe,che molti sono stati i fornitori di anestesia improvvisati in ambiente chirurgico;ragionieri,segretarie,estetiste,Ota,IP,medici generici….…

In +,i chirurghi praticano AL da soli…. E non manca una ricca biblio sull’argomento.


AL da parte dei chirurghi ….

Cohn MS, Seiger E, Goldman S: Ambulatory phlebectomy using the tumescent technique for local anesthesia. Dermatol Surg 1995; 21:315‑8.

Cartwright PC, Snow BW, McNees DC: Urethral meatotomy in the office using topical EMLA cream for anesthesia. J Urol 1996; 156:857‑8.

Green SN, Yarian DL, Masciulli LM, Leff SR: Office repair of retinal detachment using a lincoff temporary balloon buckle. Ophthalmology 1996; 103:1804‑10.

Wood WA, Waynej: Office‑based surgery in podiatry. J Am Podiatr Assoc 1981; 71:591‑4.

McDonald HPjr: Office ambulatory surgery in urology. Urol Clin North Am 1987; 14:27‑30.

Gimpelson Rj, Courtiss EH, Goldwyn RM, Joffe JM, Hannenberg AA: Office hysteroscopy anesthetic practices in ambulatory aesthetic surgery. Clin Obstet Gynecol 1992; 35:270‑81.

Leach GE: Local anesthesia for laser prostatectomy. J Endourol 1995; 9:159‑61. Guardate quest’ultimo: Lewis LA: Methoxyflurane analgesia for office surgery. journal of Dermatologic

Surgical Oncology 1984; 10:85‑6.


Definizione di OBADefinizione di OBAsedesede

Poiché l’anestesia costituisce un continuum diprofondità,dalla anest locale alla sedazione

cosciente alla sedazione profonda e infine all’AG

Poiché l’anestesia costituisce un continuum diprofondità,dalla anest locale alla sedazione

cosciente alla sedazione profonda e infine all’AG

OBA indica solo la sede in cui si effettual’anestesia,non quale anestesia si impiega……..

OBA indica solo la sede in cui si effettual’anestesia,non quale anestesia si impiega……..


Obblighi dell'anestesistaObblighi dell'anestesistaaderenza a:aderenza a:

Guidelinesfor

AmbulatoryAnesthesia and

Surgery

Guidelinesfor

AmbulatoryAnesthesia and

Surgery

Standards forPostanesthesia Care'

Standards forPostanesthesia Care'

Basic Standards forPreanesthesia CareBasic Standards forPreanesthesia Care


AnestesiaAnestesia

IncoscienzaIncoscienza

AnalgesiaAnalgesia Rilassamentomuscolare

Rilassamentomuscolare


AnestesiaAnestesiacomponenticomponenti

IncoscienzaIncoscienza

analgesiaanalgesiaprotezione Stressprotezione Stress


Componenti A.G:Componenti A.G:questione di punti di vista....questione di punti di vista....

rilassam.musc7%

protezione stress21%

Analgesia29%

incoscienza43%

rilassam.musc7%

protezione stress21%

Analgesia29%

incoscienza43%


Anestesia come continuumAnestesia come continuumtransizione talora inevitabile....transizione talora inevitabile....

anestesiaanestesia

sedazionepesante

sedazionepesante

sedazioneleggera- cosciente

sedazioneleggera- cosciente


MuscleMusclerelaxationrelaxation

Control ofControl ofstress stress

responseresponse

UnconsciousnessUnconsciousness

Hypnotics + inhalation agentsHypnotics + inhalation agents

Muscle relaxantsMuscle relaxantsAnalgesicAnalgesic

drugsdrugs

Modern balanced anesthesiaModern balanced anesthesia


MuscleMusclerelaxationrelaxation

Control ofControl ofstress stress

responseresponse

UnconsciousnessUnconsciousness

Inhalation agents

Muscle relaxantsMuscle relaxants Analgesic drugsAnalgesic drugs

NeurolepticsNeuroleptics

Hypnotics and BDZs

Drugs for general anesthesiaDrugs for general anesthesia


Moderna anestesia bilanciataModerna anestesia bilanciataStanno insieme?Stanno insieme?

IpnosiIpnosi AmnesiaAmnesiaAnalgesiaAnalgesiaRilassamento

muscolareRilassamento

muscolare

protezionestress

protezionestress

protezioneriflessi

protezioneriflessi

Assenza dimovimentoAssenza dimovimento ????


Il bilanciamentodell'anestesia

Il bilanciamentodell'anestesia

AnestesiaAnestesia

depressionerespiratoria

depressionerespiratoria

depressionecardiovascolare

depressionecardiovascolare


Linee guida ASA per office anesthesia

Guidelines for Office-Based Anesthesiahttp://www.asahq.org/publicationsandServices/standards/12.pdf

Guidelines for Qualifications of Anesthesia Providers in the Office-Based Settinghttp://www.asahq.org/NEWSLETTERS/2000/01_00/statement0100.html

Guidelines for Ambulatory Anesthesia and Surgeryhttp://www.asahq.org/publicationsAndServices/standards/04.pdf

Guidelines for Nonoperating Room Anesthetizing Locationshttp://www.asahq.org/publicationsAndServices/standards/14.pdf

Position on Monitored Anesthesia Carehttp://www.asahq.org/publicationsAndServices/standards/23.pdf

Statement on Regional Anesthesiahttp://www.asahq.org/publicationsAndServices/standards/26.pdf

Statement on the Anesthesia Care Teamhttp://www.asahq.org/publicationsAndServices/standards/16.html

Basic Standards for Preanesthesia Care, Standards for Basic Anesthesia Monitoring, and Standards for Postanesthesia Carehttp://www.asahq.org/publicationsAndServices/standards/02.pd

fContinuum of Depth of Sedation Definition of General Anesthesia and Levels of sedation/Analgesiahttp://www.asahq.org/publicationsAndServices/standards/20.pdf


Linee guida SIAARTI utili per office anesthesia

LINEE GUIDA PER LA SICUREZZA IN ANESTESIA LOCO-REGIONALELINEE GUIDA PER LA SICUREZZA IN ANESTESIA LOCO-REGIONALE Commissione SIAARTI/AAROI,sull’anestesia in day surgery.

» Coordinatore: M. SOLCA– G.BETTELLI, M.LEUCCI, C.MATTIA, V.A.PEDUTO, E.RECCHIA, P.RUJU, I.SALVO,

A.TERREVOLI

RACCOMANDAZIONI CLINICO-ORGANIZZATIVE PER L’ANESTESIA IN DAY-SURGERY

Raccomandazioni per l’anestesia nel Day Hospital Raccomandazioni per il monitoraggio di minima del paziente durante

anestesia.I Edizione febbraio 1990,II Edizione giugno 1996. RACCOMANDAZIONI PER LA VALUTAZIONE ANESTESIOLOGICA IN PREVISIONE DI PROCEDURE DIAGNOSTICHE - TERAPEUTICHE IN ELEZIONE

Ecc,ecc


Courtiss EH, Goldwyn RM, Joffe JM, Hannenberg AA. Anesthetic practices in ambulatory aesthetic surgery. Plast Reconst Surg 1994;93:792-801.

Inchiesta tra i chirurghi plastici USA 13% respiratory arrest, 8% unplanned

intubations, 3% intravascular injection of local anesthetic and 1% mortality

However, closer examination of the anesthetic techniques performed and the personnel in the office, the most frequent anesthetic technique performed was monitored anesthesia care (MAC) (92%) with a nurse or anesthesiologist being present only 70% of the time. General anesthesia was administered by 54% of the practitioners and either the nurse or the anesthesiologist were always present. Interestingly, central neuroaxis blockade was performed by 10% of practitioners and the anesthesiologist was never present; instead 12% of the time the surgeon was in charge of the patient and 5% of the time a nurse. This might be the cause of the problems [8]


Courtiss EH, Goldwyn RM, Joffe JM, Hannenberg AA. Anesthetic practices in ambulatory aesthetic surgery. Plast Reconst Surg 1994;93:792-801.

0 20 40 60 80 100

%

MAC

Anest o CRNA

SPI

0 2 4 6 8 10 12 14

%

arresto resp

intubaz non elettiva

iniez intravasc

mortalità Anestesista assente;spi effettuata dai chir

Complicanze nell’ufficio Responsabilità…………

Ma…


Complicazioni delle endoscopia digestiva

0.13-0.08% Mortalità 0.7-1/10.000

50% delle KO e 65% dei decessi dovuti a probl cardioresp


I closed claims USA

ASA


ASA closed claims database

Ci sono 2 fonti di dati : La % di claims da MAC è cresciuta dall

1.4% % del 1970 al 6.4% del 1990 I danni derivati dalla MAC sono simili a

quelli della AG:morte 34%,danno cerebrale permanente 19%


Caratteristiche dei pazienti nella pratica office

Domino, KB: Office-Based Anesthesia: Lessons Learned from the Closed Claims Project. ASA Newsletter 65(6): 9-11, 15, 2001.

ient Characteristics

Ambulatory Anesthesia(n=753)

Office-Based(n=14)

Age (mean in years) 41 45

Female (%) 58 64

ASA 1-2 (%) 82 89

Elective surgery (%) 97 100

Anesthesia Type

General (%) 66 71

MAC (%) 10 14

Surgical procedure

Dental (%) 3 21

Plastic surgery (%) 32* 21*

Other (%) 64† 14†

* P <0.05 Ambulatory vs. Office-Based† P <0.01 Ambulatory vs. Office-BasedPercentages do not equal 100% due to rounding


Gravità delle lesioni nella pratica in ufficio vs quella ambulatoriale

Domino, KB: Office-Based Anesthesia: Lessons Learned from the Closed Claims Project. ASA Newsletter 65(6): 9-11, 15, 2001.

0

10

20

30

40

50

60

70

%

noninvalidante/temporanea

invalidante/permanente morte

ambulatoriale

office

Ambulat: 753Office :14

Casistica tot.ASA closed claims:5490**


Meccanismo del dannoDomino, KB: Office-Based Anesthesia: Lessons Learned from the Closed Claims

Project. ASA Newsletter 65(6): 9-11, 15, 2001. Ambulatory Anesthesia

(n=666)* Office-Based

(n=12)

Type of Event n (%) n (%)

Respiratory 150 (22) 6 (50)

Cardiovascular 67 (10) 1 (8)

Equipment 74 (11) 1 (8)

Drug-related 58 (9) 3 (25)

Block-needle trauma 41 (6) 1 (8)


Prevedibilità con monitoraggio migliore

Domino, KB: Office-Based Anesthesia: Lessons Learned from the Closed Claims

Project. ASA Newsletter 65(6): 9-11, 15, 2001.

0

10

20

30

40

50

60

70

80

90

si no

ambulatoriale

office

Casistica tot.ASA closed claims:5490

Ambulat: 753 Office :14

*


Responsabilità e indennizzo

Context of CarePayment

ProportionMedian

PaymentRange (Min-

Max)

Ambulatory Anesthesia (n=695)*

59%† $85,000‡$34-

$14,700,000

Office-Based (n=13)* 92%† $200,000‡$10,000-$2,000,000

* Includes only claims where payment data are known† P < 0.01 Ambulatory vs. Office-Based by the Chi Square test with z-test‡ < 0.05 Ambulatory vs. Office-Based by the Mann-Whitney U. rank of payments


Problemi dell'officeProblemi dell'officeL’anestesia è divenuta + sicura…L’anestesia è divenuta + sicura…

Migliorato monitoraggio(linee guida)Migliorato monitoraggio(linee guida)

Farmaci più sicuriFarmaci più sicuri

Conoscenza migliore dei rischiConoscenza migliore dei rischi

Aumentata disponibilità degli anestesisti(numerica….)Aumentata disponibilità degli anestesisti(numerica….)

Ma.....Ma.....

nell'office le risorse ospedaliere non ci sono!nell'office le risorse ospedaliere non ci sono!

Ed è la capacità ed esperienza del personale che garantisce la sicurezza!Ed è la capacità ed esperienza del personale che garantisce la sicurezza!


Cause di danno

MAC?? Errori da farmaci,in partic.oppioidi nei paz

ambulatoriali….. Queste tendenze avvertono chir ed anest dei

rischi e chiedono che entrambi definiscano bene quali pazienti e quali procedure siano approriate per la struttura office…..

Si deve assolutamente evitare di soggiacere alle pressioni economiche di risparmio/guadagno ricorrendo alla office chir !


Attività ASA e SAMBA:Task Forceon OBA

Attività ASA e SAMBA:Task Forceon OBA

Committee on ambulatory surgical careCommittee on ambulatory surgical care

ASA OBA guidelines 1999ASA OBA guidelines 1999

OBA Practice manual ottobre 2000OBA Practice manual ottobre 2000

ASA workshops su OBA:nov 1999,Luglio 2002ASA workshops su OBA:nov 1999,Luglio 2002

ASA OBA training workshops genn 2000,aprASA OBA training workshops genn 2000,apr

Legame con le principali associaz di certificazione escientifiche:JCAHO,AAHC,AAASF,ACS,ASPS,NPSF,MHAUS,FSMB,OIG….

Legame con le principali associaz di certificazione escientifiche:JCAHO,AAHC,AAASF,ACS,ASPS,NPSF,MHAUS,FSMB,OIG….


Office based anesthesiaOffice based anesthesiasfida del nuovo millenniosfida del nuovo millennio

Gli standard assistenziali non devono essereinferiori a quelli ambulatoriali o ospedalieri

Gli standard assistenziali non devono essereinferiori a quelli ambulatoriali o ospedalieri

La sfida per gli anestesisti è quella ditrasportare l’esperienza e i modelli di pratica

acquisiti nelle sale op ospedaliere agliambienti office…

La sfida per gli anestesisti è quella ditrasportare l’esperienza e i modelli di pratica

acquisiti nelle sale op ospedaliere agliambienti office…


ASA Guidelines for Office basedanesthesia

Amministrazione e governo clinico

Qualità dell'assistenza

Struttura e sicurezza

Monitoraggio , attrezzatura

Emergenza e trasferimentiEmergenza e trasferimenti


Lista dei controlli da effettuare per sedazione/anestesia al di fuori

della sala op.

Comunicazioni;telefono,interfono… Illuminazione Prese elettriche;quantità e tipo…. Farmaci presenti in sede e quali invece da portare Ci sono monitoraggi e funzionano? Carrello di emergenza ;il personale lo usa? C’è spazio dove indurre AG?se l’AG è indotta in un luogo diverso da quello

dell’intervento,attrezzatura e farmaci devono essere mossi con il paziente? Il personale conosce le procedure di emergenza?anestetiche? Ci sono pericoli specifici per il personale anestesiologico e/ o il paziente?(radiazioni) Dove avviene la fase di risveglio/ripresa? Fonti di ossigeno Aspiratore(potente)

» Apparecchiature isolate o a muro» Arrivano al paziente?


Vena sicura


Flussometri(O2),Pompe siringa,capnometro…..


Pulsossimetria,capnometria


Ossigenazione,Defibrillatore,airways……….


Ossigenare a tutti i costi


Ossigenazione in tutti i modi


Apparecchio di anestesia,prese

filtrate,cavi..batterie


Un poco di monitor……..


Pubblicità sanitaria


Valigie e trasporto,prese filtrate


Pompa siringa,airways


Carrello farmaci e materiali,piano appoggio


Guidelines for non operating room anesthetizing locations (approved by House of Delegates Oct 19,1994) ,

Park Ridge,Il. American Society of Anesthesiologists 2001.


GUIDELINES FOR NONOPERATING ROOM ANESTHETIZING LOCATIONS(Approved by House of Delegates on October 19, 1994,and last amended on October 15, 2003)

O2 +riserva.centralizzato meglio Aspiratore Scarico dei gas se anest inalatoria Pallone autoespansibile con O2 90% Farmaci anest adeguati in tipo e quantità Monitoraggio adeg agli standard Se anest inalatoria,app.anest controllato Prese elettr. qb+gr.continuità.Se chir bagnata,sicurezza cavi,terra e interruttore isol.

Illuminaz adeg per anest e chir + riserva Spazio adeg Personale adeg Carrello emerg con def ,farmaci,cpr Personale di supporto Comunicaz bidirez Rispetto dei codici di sicurezza abitaz Assistenza postanest adeguata nel trasporto e personale


Criteri per la dimissione dei pazienti dopo

sedazione o AG:Texas Children hosp,1998. Osservazione per almeno 30 min.dopo la procedura Vie aeree pervie e respirazione adeguata Sveglio e reattivo… Polso e pressione stabili Assenza di sanguinamento Assenza o minima nausea ASSENZA DI VOMITO Assenza o minimo dolore o dolenzia vedi Tolia……………….


Principio fondamentale

Gli standard di assistenza anestesiologica non cambiano cambiando ambiente


Fondamentali 1 Staff professionale e amministrativo adeguato Staff di pulizia e mantenimento Valutazione preop

» test e consulti Pianificazione anestetica accettata dal paz e dalla direzione medica

della sede Responsabilizzazione medica della dimissione del paziente Pazienti che ricevono anche solo sedazione oltre alla anaestesia

locale devono essere accompagnati da un adulto responsabile per il domicilio

Istruzioni scritte per I pazienti


Fondamentali 2 Equipaggiamento adeguato: Spazio sufficiente Prese elettriche adeguate Illuminazione buona Fonte di alimentazione alternativa:gruppo di continuità,batterie….. Fonte di ossigeno sufficiente per la durata della procedura e oltre Possibilità di ventilazione positiva Carrello di emergenza con defibrillatore e farmaci appropriati Aspirazione(indipendente dalle fonti di energia) Se anestesia inalatoria :aparecchio di anestesia + SCARICO GAS Monitoraggio di base adeguato Controllo dei regolamenti di sicurezza locali;regionali,statali……


Fondamentali nascosti Rivedere protocolli e procedure Trasferimento in caso di ospedalizzazione Capacità dei chirurghi e del personale Commisurazione alle procedure proposte


Raccomandazioni ulteriori per i chirurghi:1 &….

Sicurezza innanzitutto piuttosto che risparmio o convenienza Storia clinica completa e test di laboratorio appropriati Se il paz non è a posto o presenta qualche problema medico particolare e rimangono

dubbi……….non operare L’anestesia deve essere somministrata da un anestesista esperto o da un IP

specializzato in anestesia Procedure come liposuzioni abbondanti o interventi combinati con tempi op prolungati

…………meglio ricovero e monitoraggio postop per almeno 24 h Stabilire un valido team fra chir e anest. Il chirurgo deve possedere I privilegi di staff per l’intervento ambulatoriale in un

ospedale ragionevolmente vicino L’intervento da effettuarsi deve rientrare nell’area specifica di competenza. Protocolli e procedure per tutti I tipi di emergenze chirurgiche


Raccomandazioni ulteriori per i chirurghi: & 2….

Tenere archivio ordinato per tutti I tipi di intervento ,dei consensi ;ecc Educazione dei pazienti pre e postop per ogni specifico intervento Assumi o collabora solo con pesonale infermieristico e anestesiologico qualificqto.in

base alla teroria del legame più debole;il chir è forte tanto quanto il suo impiegqto più debole

Aggiorna e controlla tutta l’attrezzatura a rotazione con sistemi di supporrto per le cose vitali come l’apparecchio di anestesia e l’O2

Dotarsi di tutti gli strumenti di sicurezza e degli standard assistenziali:ossimetri,capnografi,riscaldatori ,sistemi pneumatici anti dvt,ecc

Valuta periodicamente le prestazioni :chir,anest,IP;ecc conferenze mortalità/morbidità

* il personale operatorio chiave deve essere certificato in BLS e ALS

Educazione continua !!!!


Criteri di selezione dei pazienti

Figure


Home -> Professional Resources Since Sept. 1, 2000, physician's offices that do more than local anesthesia or sedation procedures have been

required to register with the Board of Medical Examiners (BME), pay a registration fee and comply with certain rules.

Offices that are already accredited by the joint Commission on Accreditation of Healthcare Organizations, the American Association for the Accreditation of Ambulatory Surgery Facilities, or the Accreditation for Ambulatory Health Care are exempted.

The BME has adopted the ASA standards and guidelines (see http://www.asahq.org). Therefore, the same safety measures used in hospitals are incorporated into the office setting. The following are highlights of the rules:

preoperative evaluation, informed consent (including informing the patient if care is shared with other non-physician providers), intraoperative monitoring, secondary power source in the OR, properly serviced and maintained equipment with service logs for 7 years, emergency drugs and equipment for CPR and malignant hyperthermia, transfer agreements in case of emergency. In addition, the operating surgeon or anesthesiologist shall maintain current competency in ACLS or PALS. At

a minimum, at least two persons, including the surgeon or anesthesiologist, shall maintain current competency in basic life support.

Physicians must notify the board within 15 days if a procedure performed results in an unanticipated and unplanned transport of the patient to a hospital for observation or treatment for a period in excess of 24 hours, or a patient's death intraoperatively or within the immediate postoperative period. Immediate postoperative period is defined as 72 hours.

The Board of Medical Examiners voted to adopt the proposed rules at its meeting on March 31, 2000. Download the BME rules:


Sistema raccomandato per valutazione preop.

(ASA task force on preanesthesia evaluation)CATEGORIA

CHIRURGICA 1 2 3 4 5

CLASSE

ANESTETICA:

1 giorno intervento giorno intervento giorno intervento Medico curanteprima del giornodell’intervento

Anestesista primadel giornodell’intervento

2 giorno intervento giorno intervento Medico curanteprima del giornodell’intervento



3 Medico curanteprima del giornodell’intervento





4 Medico curanteprima del giornodell’intervento






Valutazione preoperatoria:flow chart

p az san o

sp ec ia lis t ica g en era le

con su len za m ed ica

p az am m ala to

esam i d i labecgR X

S creening preopera tor iocom puter izza to

C hirurgo:pa tologia chirurgicat ip o d i in te rven to

Valutaz.anestesiologica


Utilizzo di un questionario come screening tool

1 Have you ever had a heart attack? 2 Have you ever had heart trouble? 3 Have you ever had heart failure? 4 Have you ever had fluid in your lungs? 5 Do you have a heart murmur? 6 Did you have rheumatic fever as a child? 7 Do you ever have chest pain, angina, or chest tightness? 8 Have you ever been treated for an irregular heart beat? 9 Do you have high blood pressure? 10 Do you ever have difficulty with your breathing? 11 Do you have asthma, bronchitis, or emphysema? 12 Do you cough frequently? 13 Does climbing one flight of stairs make you short of breath? 14 Does walking one city block make you short of breath?


Utilizzo di un questionario come screening tool

15 Do you now or have you recently smoked cigarettes? If yes, how many packs per day? For how many years? 16 Do you have liver disease, or a history of jaundice or hepatitis? 17 Do you drink more than three drinks of alcohol per day? If yes, how many per week? 18 Do you have indigestion, heartburn, or a hiatus hernia? 19 Do you have a history of thyroid problems? 20 Do you have diabetes? 21 Do you have a kidney problem? 22 Do you have numbness or weakness of your arms or legs? 23 Do you have epilepsy, blackouts, or seizures? 24 Have you had problems with blood clots, or excessive bleeding? 25 Do you have any other important medical problems? Please list. 26 Have you ever had an anaesthetic? If yes, when was your last one? 27 Have you or any member of your family had a reaction to an anaesthetic? 28 Do you have arthritis or pain in your neck or jaw? 29 Do you have dentures, capped or loose teeth? 30 Do you think you may be pregnant? 31 Have you taken prednisone, steroid medication, or cortisone-like drugs in the past year? 32 Please list any food or medication allergies that you have: 33 Please list any medications you are currently taking: 34 Please list any operations you have had in the past: 35 If this is the day of surgery, when did you last eat or drink? 36 Age: Weight: (lbs or kg) Height: (inches or cm)


Preop process modelPreop process modelfrom the Cleveland Clinic Foundationfrom the Cleveland Clinic Foundation

Demographicsand type of

surgery

Demographicsand type of

surgery

Computer assistedHealth screening

Computer assistedHealth screening

Lab,EKG,RXLab,EKG,RX

surgery teamH&P+lab followupew Sub-Point

surgery teamH&P+lab followupew Sub-Point

NewGen.IntMed concultNewGen.IntMed concult

medic.spec.consultationmedic.spec.consultation

Surg.office

healthy

unhealthy

Express criteria satisfied

Day of surgery

yes

no

Preop

anesthclearanc

e


Consenso e disposizioni pre e postop.

Gentilissimo sig……………….. come il collega chirurgo dott…………………..Le avrà già spiegato,per la riuscita ottimale dell’intervento

è importante attenersi scrupolosamente alle raccomandazioni elencate che la preghiamo di leggere,firmare,e conservare per il giorno dell’intervento,quando la riconsegnerà compilata all’anestesista.RingraziandoLa anticipatamente della collaborazione,

----------------------------- Si prega di leggere attentamente e riempire con i dati richiesti lo spazio sopra i puntini(data,città, nome, cognome,intervento,firma). Data:…………………. Città:…………………. Io sottoscritto………………………………………………………. acconsento che l'intervento di ………………………………………………………………….. venga eseguito in anestesia generate e /o locale come spiegato dall’anestesista dott……………………... Dichiaro di attenermi alle seguenti disposizioni: I)non ho assunto alcun cibo nelle 6 ore precedenti l'intervento,ne' liquidi nelle due ore precedenti;(quindi liquidi quali bevande non alcooliche,the zuccherato,coca cola,ecc sono consentiti) 2)di non guidare alcuna automobile o motocicletta o bicicletta, od utilizzare qualsiasi macchinario nelle 24 ore seguenti I'anestesia, 3)di non assumere alcoolici nelle 24 ore seguenti l'anestesia; 4)di farmi riaccompagnare alla mia residenza da un adulto responsabile; 5)di rimanere in compagnia di un adulto responsabile una volta tornato al domicilio; 6) di non assumere alcuna decisione importante ne' firmare documenti importanti(testamento,assicurazioni ecc.)nelle 24 ore seguenti; 7)di vestirmi in modo pratico il giorno dell’intervento ,cosicchè il vestiario possa essere facilmente rimosso e indossato e riposto in un

armadietto; 8)di non portare gioielli o altri oggetti di valore in ambulatorio; 9)di mettermi in contatto con l'unità chirurgica ambulatoriale nel caso insorga una qualsiasi complicanza postoperatoria. FIRMA .........................................................................................


Questionario postoperatorio I e II giornata


L'ufficio deve accreditarsi??L'ufficio deve accreditarsi??a chi si deve rivolgere ?a chi si deve rivolgere ?

richiestavolontariarichiesta

volontaria

deve rispondere atutti gli organismicertificanti?

deve rispondere atutti gli organismicertificanti?

obbligo di leggeobbligo di leggederegulation......deregulation......

anestesia itinerante??anestesia itinerante??


Accreditamento degli office chirurgici

Ente Num offices accredit

Costo($) Supervisione anest

JCAHOJoint Commission on Accreditation of Heakthcare organizations

40 3975 LIP

AAAASFAmerican Association for Accreditation of Ambulatory surgical facilities

>600 1000-3700 Anesthesiologist,MD supervis

AAAHCAccreditation Association for Ambulatory Health Care

160 3000-4000 MD,DDS,MD supervis


A quale ente certificatore rivolgersi?

JCAHO AAAHC AAAASF

Grande esperienza ospedaliera

Validi per le sedi ambulatoriali

Esperienza limitata a office per chir plastica

Nuovi standard richiedono molte sedi per feedback

Nuovi standard anestesiologici appena emessi

Nuovi standard anestesiologici appena emessi;altri standard richiedono aggiornamento


Osservazioni finali sulla collaborazione anestesiologico/chirurgica……….

Joas (1) emphasizes, “The comfort of both patient and surgeon is of significant concern to the anesthesiologist to maintain good will and continued case flow from the surgeon.” Similarly, Koch has pointed out, “Disputes regarding anesthesia care are on quite uneven playing fields. For instance, if a technique departs from what the surgeon prefers or if there is a difference in opinion about the prudence of proceeding with the particular case the surgeon can just as easily invite a colleague or an alternate provider


Critica alla collaborazione anestesista/chirurgo

Difficile da accettare?ma così funzionano I consulenti:se il curante non è d’accordo con il consiglio diagnostico-terapeutico del consulente,…….chiama un altro consulente !

Buone relazioni con il chirurgo essenziali,ma non dimenticate mai la sicurezza !

L’anestesista protegge il paz dallo stress chirurgico Osservare gli standard ! Anche se ciò può significare cancellare il caso e prendersi gli

insulti del chirurgo! In caso di dubbio pensate al paziente e alla vostra responsabilità

professionale e al rischio della vostra autonomia……..


OBA come miglioramento ?

L’anestesista diviene il medico del perioperatorio….non ci sono altri consulenti,……..

l’industria svilupperà apparecchi e monitor sempre + compatti l’ambiente office richiederà sempre + attenzione da parte

degli anestesisti:pazienti giovani e/o sani…. in ospedale o centro di day surg esiste un sistema di

protezione e consulenza;in office il sistema è l’anestesista Necessità di capacità organizzative e di comunicazione e non

solo per l’anestesista ….. innovazione spinta dall’esperienza


Consider outsourcing anesthesiology servicesSource: Cosmetic Surgery TimesBy: Steven Bloch, M.D.Originally published: January 1, 2006


THANK YOU FOR THANK YOU FOR YOUR ATTENTIONYOUR ATTENTION


FINE II


Etichettatura delle siringhe!!!


Principi fondamentali The fundamental principle that must govern OBA is that patient safety cannot be sacrificed for any of the aforementioned four major considerations—i.e., the standard of anesthetic care does not decrease because of venue change (11). Indeed, because OBA is a subset of ambulatory anesthesia, the ASA guidelines for ambulatory anesthesia and surgery as well as the more recently adopted guidelines for office-based anesthesia must be followed. The two sets of guidelines emphasize the need for

1.Adequate professional and administrative staff, as well as housekeeping and maintenance personnel. 2.Preoperative evaluation with necessary tests and consultations as medically indicated. 3.The development of an anesthesia plan acceptable to the patient, the administration or medical direction of same, as well

as the discharge of the patient remain physician responsibilities. 4.Patients who receive other than unsupplemented local anesthesia must be discharged with a responsible adult and

provided written postoperative and follow-up instructions. Because the office facilities vary considerably, anesthesiologists must ensure that the facility is adequately equipped, with

the following as a minimum: 5.Sufficient space and electrical outlets plus adequate illumination must be provided, including backup power (this is listed

first because space is something for which anesthesiologists frequently must fight in the office as well as the hospital or ASF).

6.A reliable source of oxygen adequate for the length of the procedure plus a backup supply, the latter to be at least equivalent to an E cylinder, and the ability to administer positive pressure ventilation.

7.Emergency cart with defibrillator and appropriate drugs. 8.A reliable source of motor-driven suction. 9.If inhaled anesthetics are to be used, an anesthesia machine equivalent to that of the hospital operating room and a

system for scavenging waste anesthetic gas must be available. 10.Basic monitoring of oxygenation (pulse oximetry), ventilation (minute ventilation for general anesthesia and capnography

for intubation), circulation (blood pressure every 5 min and continuous electrocardiogram display), and temperature (when clinically significant changes in temperature are intended, anticipated, or suggested) is essential.

11.All applicable building and safety codes and facility standards must be observed and federal, state, and local laws obeyed.


Because the office facilities vary considerably, anesthesiologists must ensure that the facility is adequately equipped, with the following as a minimum:

5.Sufficient space and electrical outlets plus adequate illumination must be provided, including backup power (this is listed first because space is something for which anesthesiologists frequently must fight in the office as well as the hospital or ASF).

6.A reliable source of oxygen adequate for the length of the procedure plus a backup supply, the latter to be at least equivalent to an E cylinder, and the ability to administer positive pressure ventilation.

7.Emergency cart with defibrillator and appropriate drugs. 8.A reliable source of motor-driven suction. 9.If inhaled anesthetics are to be used, an anesthesia machine equivalent to that of the

hospital operating room and a system for scavenging waste anesthetic gas must be available.

10.Basic monitoring of oxygenation (pulse oximetry), ventilation (minute ventilation for general anesthesia and capnography for intubation), circulation (blood pressure every 5 min and continuous electrocardiogram display), and temperature (when clinically significant changes in temperature are intended, anticipated, or suggested) is essential.

11.All applicable building and safety codes and facility standards must be observed and federal, state, and local laws obeyed.


Principi fondamentali 2

Less obvious, but equally important, is the need to review policies and procedures, including transfer protocols in the event that hospitalization is required. Similarly, the capabilities of both the facility and the surgeon must be equal to the task of handling the proposed procedure.

Moss (12), who led the fight to regulate OBA and surgery in New Jersey, has addressed the issue of cost required to meet reasonable standards: “The $2500 pulse oximeter or the $15,000 refurbished anesthesia machine spread over years of use and thousands of patients makes the per-patient cost insignificant.” He also emphasized the need for complete evaluation of an office before agreeing to provide OBA. Although physical plant, anesthesia equipment, and monitors are obvious considerations, support staffing, capability of the surgeon, facility protocols, and policies must also be evaluated.


Raccomandazioni ASA,ASAPS e ASPS

1. Be accredited by a national or state recognized accrediting agency/organization such as the American Association for Accreditation for Ambulatory Surgery Facilities (AAAASF), Accreditation Association for Ambulatory Health Care (AAAHC), or the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO).

2. Be certified to participate in the Medicare program under Title XVIII.

3. Be licensed by the state in which the facility is located. regular inspections and report to their state agencies,

provide ongoing staff training, credential their personnel, and have emergency equipment on hand such as crash carts.


Raccomandazioni ulteriori per i chirurghi

What can we do as individual plastic surgeons within our clinical practices in addition to our major organizations’ efforts to enhance patient safety in outpatient surgery settings? We are encouraged to consider the following:

* Patient safety comes first before cost and convenience. In the final analysis, this is more important than any mandate or moratorium.

* A complete medical history is taken, including any appropriate laboratory tests. If the patient is not healthy or has any extenuating medical problems, the patient needs a proper medical evaluation. If any doubt remains, do not operate.

* Anesthesia should be administered by a skilled licensed professional, either an anesthesiologist or a certified registered nurse anesthetist.

* Procedures such as large-volume liposuction and combination procedures with prolonged anesthesia and operative time should be considered for inpatient surgery or postoperative monitoring in an accredited facility for at least 24 hours. (Use common sense and good surgical judgment.)

* A total operating team effort emphasizing communication between the anesthesia personnel and surgeon should be established to promote safety.

* The surgeon should have staff privileges to perform the specific procedure being done in the outpatient setting at a hospital within reasonable proximity. Procedures should only be done if they are in the surgeon’s specific area of expertise.

* Have specific policies in place for all types of potential outpatient surgery emergencies. * Maintain appropriate documentation of medical history and informed consent. * Provide uniform preoperative and postoperative patient education for specific procedures. * Hire only qualified nursing and anesthesia personnel. Use the “weak link theory” in your practice. You are only as strong as your

weakest employee. * Update and test all operating room equipment on a rotating basis, with backup support available for vital equipment failures such

as anesthesia equipment and the oxygen delivery system. * Provide the elements of patient safety and current standard of care including humidifiers, oximeters, capnography, warming

blankets, and pneumatics/compression leg garments. * Periodically evaluate the surgical team’s performance, including surgeons, anesthesiologists, and nurses, in peer review

morbidity and mortality conferences. * Strongly suggest that key operative personnel are certified in advanced cardiac life support and maintain updated continuing

medical education in outpatient surgery advances.


Porterfield and Franklin Porterfield HW, Franklin LT. The use of general anesthesia in the office surgery facility. Clin Plast Surg 1983;10:289-294. reviewed their 16 years of experience in office-based plastic surgery procedures. They performed 13 080 cases under local anesthesia with or without sedation and 5038 under general anesthesia. They concluded that to maintain a low admission rate of 0.02% it is essential to have adequate and rational selection criteria, based on the patients' medical health and the surgical procedure. They included ASA I or II patients and procedures without extensive blood loss which were completed within a time frame that allowed the patient to awaken adequately and leave the facility by late in the afternoon [10].


Davis [11] Davis JE, Sugioka K. Selecting the patient for major ambulatory surgery. Surgical anesthesiology evaluations. Surgical Clinics of Northamerica 1987;67(4):721-732 selected surgical procedures based on the intensity of postoperative surgical care. He divided the surgical procedures into four levels (I-IV) (Figure 1) [11]. Those procedures appropiate for office-based surgery and anesthesia belong to level I, where no postoperative care is needed. However, the line of demarcation can shift to the right, and surgical procedures belonging to level Ia or II can be included in the office, depending on the surgical and anesthetic skills, on the office-resources, on the proximity to a hospital and, most importantly, on the patient's medical health. This means that surgical procedures performed in the office can belong either to level I, Ia or II. Tobin also considered that the extent of the surgery should be determined more by the nature of the recovery period than by the surgical procedure itself and patients should be in excellent health with no significant medical problems [2].


Limits of the office setting Why is it so critical to perform an adequate selection of the

patient and the surgical procedure? Because there are of course some limits in the office setting. First, based on the limited scope of the office-unit (as well as in the free-standing facility), both the staff and medical capabilities are less extensive than those within a hospital. Second, the service is likely to be available on limited basis. Urgent care would be referred to an hospital emergency department. Finally, the office surgical suite is designed to treat patients whose stay is normally less than 4 h. It is not designed to ‘even occasionally’ hold a patient for a 24-h observation (such as in a free-standing unit or a hospital). In those exceptional cases, the patient would be referred to a hospital of reference (Figure 2) [9].


Diapo della aggressività interventi da anest ambulat e schemi per ospedale


Mortalità durante OBA

1.A 3-yr-old boy developed a seizure followed by cyanosis during laser removal of port wine stains. No oxygen was available.

2.Malignant hyperthermia occurred in a 28-yr-old woman having breast augmentation. Temperature was 107°F (41.67 °C) on arrival in the emergency room. No dantrolene was available.

3.A 51-yr-old man underwent a 9.5-hr combined liposuction, penile enlargement, and face-lift. He was kept in the office overnight under the care of an agency nurse, who noted 2 h later that the patient was in respiratory distress and that the oxygen tank was empty. Paramedics were contacted 30 min later. Not surprisingly, the patient was dead on arrival at a local hospital 40 min later.

Se queste procedure fossero state effettuate in un unità di day surg o ospedale………………………

IL probl ha preso tanta cosnsistenza che The risks associated with OBA were considered so great in the United Kingdom that, on July 21, 2000, the administration of general anesthesia in a dentist’s office was banned. Dentists and oral surgeons were given 18 mo to transition their practices to a hospital setting. Considering the emphasis on cost-containment by governmental agencies, the decision to move patients to the more expensive hospital setting must reflect great concern of the United Kingdom authorities concerning the OBA risk to patients.


Morti in ufficio……..

10San Francisco Examiner 17 August 1993. [Context Link]

11The San Diego Tribune 13 January 1989. [Context Link]


Medicina preventiva vs trattamento delle

complicanze

Preventive medicine is always preferable to rescue from complications. In addition to adhering to the standards summarized above, careful patient selection is the best way to avoid complications. In particular, patients with comorbid disease, especially chronic obstructive pulmonary disease, epilepsy, heart disease, and obesity, must be evaluated carefully and completely, so specialty consultation can be included when indicated. When in doubt, referral of these patients to a more complete facility than a surgeon’s office is strongly advised, even though such a decision may produce friction—even an acrimonious confrontation—with the referring surgeon, the patient, or both.


Many surgeons administer intravenous sedation, but for procedures requiring general or regional anaesthesia, they seek the assistance of an anaesthesiologist or certified registered nurse anaesthetist (CRNA) [12•]. The CRNA is often the surgeon's choice if, in the surgeon's opinion, the procedure requires only a slightly deeper level of sedation than the surgeon is accustomed to administering himself. For procedures requiring general anaesthesia in the USA (except New Hampshire), the anaesthesia is administered by an anaesthesiologist, a CRNA supervised by an anaesthesiologist, or a CRNA supervised by the surgeon. In most other developed countries such as Australia or the UK, a specialist anaesthetic medical practitioner must be present if general anaesthesia is administered.

Anaesthetic techniques The range of anaesthetic techniques in office-based practice is the same as in hospital-based practice, especially ambulatory surgery. The overriding concern is rapid discharge. Recovery

facilities and personnel in the office setting are usually incapable of monitoring patients who are heavily sedated, have a long-lasting spinal block, or are suffering from severe pain or nausea. The majority of office-based anaesthesia is monitored anaesthetic care (MAC). Improvements in monitoring capability, notably continuous pulse oximetry and expired CO2 display, provide the anaesthesiologist a better understanding of the patient's response to sedative and analgesic medications [13•]. Today's anaesthesiologist can more safely provide deep levels of sedation in appropriate patients, however, as in any anaesthetizing location, the critical threshold of patient unresponsiveness must not be crossed unwittingly. An anaesthesiologist can deliberately breach the boundary between MAC and general anaesthesia in appropriate patients if airway equipment is available and both the patient and the surgeon understand the risks. For procedures requiring general anaesthesia in the office, the laryngeal mask airway is a significant technological improvement, not only for routine use but also for the emergency ventilation of patients with an unanticipated difficult airway [14].

Anaesthetic drugs The close control offered by rapidly acting and rapidly eliminated drugs is especially useful in the office setting. Midazolam, propofol, ketamine, and methohexital are the sedative hypnotics

we use. A propofol infusion combined with an opioid and sometimes midazolam or ketamine provides an easily adjusted depth of sedation or general anaesthesia [15,16]. A new short-acting benzodiazepine, Ro 48-6791, is being developed and might play a role in office-based anaesthesia [17].

Analgesics administered in office-based anaesthesia include non-steroidal anti-inflammatory drugs and opioids. A short period of relatively profound intraoperative analgesia can be produced using fentanyl, alfentanil, or remifentanil. In the US, remifentanil is infused for both MAC and general anaesthesia, but in Australia it is approved for use only in artificially ventilated patients. There is no major difference between these drugs in the speed of recovery after relatively short anaesthetics; however, recovery from longer anaesthetics should be significantly faster using remifentanil [16]. The haemodynamic response to surgical stimuli is suppressed better by remifentanil than by alfentanil, so remifentanil might be preferable in patients at risk of myocardial ischaemia [18]. When administering remifentanil, provision for postoperative analgesia must be made because pain is one of the chief reasons for delayed discharge from ambulatory surgical centres, and is the third most common reason for return hospital visits [19,20]. Although the respiratory depression and nausea associated with opioids can be particularly troublesome in the office setting (where postoperative care of a patient can delay the following cases), parenteral or oral opioids are the mainstay of postoperative analgesia.

The use of muscle relaxants in office-based surgery is the same as in any ambulatory surgical setting. A rapid-onset short-duration non-depolarizing neuromuscular junction blocking drug, ORG 9487, is being developed and might prove ideal for office-based anaesthesia [21].

Inhalational agents are playing an increasing role in office anaesthesia as anaesthesiologists move into this practice. Offices must provide suction for scavenging volatile anaesthetics or the anaesthetic machine must have a charcoal filter. Sevoflurane and desflurane potentially offer a rapid emergence [22,23], an attractive feature in office-based anaesthesia, but these agents are associated with a higher incidence of emergence delirium [22,23]. This delirium can be disquieting for other patients and can tax the limited personnel available in the office setting. Sevoflurane has remarkable cardiovascular stability and is significantly less irritating to the airway than the other halogenated agents [24,25]. If choosing a single halogenated agent for office-based anaesthesia (a reasonable possibility in order to minimize equipment weight and bulk) sevoflurane is a logical choice.

Equipment and facilities Anaesthesiologists must be circumspect when asked to provide anaesthesia in a new office location [26]. They assume responsibility for the equipment, facilities, and drugs required to

provide safe anaesthesia, and must develop a contingency plan for equipment or power failure. A reliable means of transporting a patient to the nearest hospital in the event of a disaster should be outlined, and the hospital emergency room director should be made aware of the plans to provide anaesthesia in the office.

Physiological monitoring of the patient must meet or exceed the relevant local standards for anaesthetic monitoring [27,28]. Procedures performed under MAC in the informal setting of the physician's office require heightened vigilance by the anaesthesiologist. A review of the ASA closed claims project database revealed that claims involving MAC have increased from 1.6% of the total claims in the 1970s to 6% in the 1990s [29••]. The severity of these claims is similar to those occurring under general anaesthesia, including death (34%) and permanent brain damage (19%). Overall, the data from this project suggest that improved monitoring, notably pulse oximetry and end-tidal CO2 detection, has decreased patient morbidity, as reflected by a decrease in ventilatory complications relative to cardiac complications [30•].

Whether using an intravenous or inhalational anaesthetic technique, a means of administering positive pressure ventilation with oxygen must be available, along with appropriately sized masks, endotracheal tubes, and laryngoscopes. A reliable and powerful suction apparatus is always required. A plan, trained personnel, and the necessary equipment for securing a difficult airway must be available. Resuscitation equipment, including a defibrillator and emergency medications, must be in the office. If administering agents which might trigger malignant hyperthermia, dantrolene must be available.


Cause della insufficienza rianimativa

Attrezzature di rianimazioine inadeguate Monitoragio insufficientemspecie puilsossimetria Erore umano Lento riconoscimento dell’evento Mancanza di esperienza Sovradosaggio gfarmacologico Inadeguata valutazione preop. Inadeguiata valutaz postop


Qualificazioni mediche

Specializzazione Partica ospedlaiera nella discipilina Possibilità di ricovero?


Surgical Facility Standards Plastic surgery performed under anesthesia, other than

minor local anesthesia and/or minimal oral tranquilization, should be performed in a surgical facility that meets at least one of the following criteria:

* accredited by a national or state-recognized accrediting agency/organization such as the American Association for Accreditation of Ambulatory Surgery Facilities (AAAASF), the Accreditation Association for Ambulatory Health Care (AAAHC), or the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)

* certified to participate in the Medicare program under Title XVIII

* licensed by the state in which the facility is located.


Patient Safety in Office-Based Surgery Facilities: II. Patient Selection

[COSMETIC SECTION: COSMETIC SPECIAL TOPIC]

Iverson, Ronald E. M.D.; Lynch, Dennis J. M.D.; ASPS Task Force on Patient Safety in Office-based Surgery Facilities


Selezione dei pazienti

preoperative patient history should include personal health history, identification of comorbidities, social history, family history, medication regimen (prescription and nonprescription), allergies (drug, latex, tape) and reaction, review of the body systems, and availability of a responsible adult to assist with postoperative instructions and care. The physical examination is essential for assessing the patient’s clinical status preoperatively and should include an estimate of general health and appearance; measurement of height and weight; assessment of vital signs, including the heart and lung; and an examination of the anatomical area of the surgery. A sample preoperative history and physical form is shown in


identifying comorbidities that are relevant to the procedure or that may predispose the patient to intraoperative or postoperative complications. When evaluating the patient, particular attention should be given to factors such as age, weight, and history of other illnesses, including diabetes mellitus, cardiac diseases, and respiratory conditions. The physician should evaluate the patient for a history of (or potential for) venous thromboembolism, and when indicated, should consult the appropriate ASPS Practice Advisory and/or Clinical Practice Guideline for thrombosis risk ratings and thromboprophylaxis measures. 3,4 The surgeon should refer patients with significant comorbidities to medical specialists when indicated.


On the basis of the patient’s preoperative history and physical examination results, pertinent tests should be ordered, including:

electrocardiogram in patients over 45 years of age electrocardiogram at any age when known cardiac conditions are present complete blood count/blood chemistries, as needed, for detailed evaluation of

specific diagnosis, such as anemia, diabetes mellitus, hypertension, diuretic therapy

additional tests as appropriate, depending on the patient’s status as determined through the medical history and physical examination or because of the specific procedure being performed (see ASPS Clinical Practice Guideline for specific procedures; http://www.plasticsurgery.org/psf/ psfhome/clinprac/index.htm).


The ASA House of Delegates approved “Guidelines for Office-Based Anesthesia” in October of 1999 (http://www.asahq.org/ProfInfo/offbasedguide.htm ). These comprehensive guidelines focus on the delivery of safe anesthesia care in doctor’s offices by anesthesiologists and certified registered nurse anesthetists. The ASA Task Force on Office-Based Anesthesia has recently created a manual that provides practical advice for surgeons and anesthesiologists interested in setting up and maintaining a safe office-based surgery environment. The ASPS and ASAPS have taken an unprecedented stance by mandating that all outpatient plastic and cosmetic surgery must be done in an accredited facility. Over a 3-year period that began in June of 1999 and will end in July of 2002, members must transition to perform outpatient surgeries in accredited and/or licensed facilities that meet at least one of the following criteria 2,3


Conclusioni

La oba sta crescendo rapidamente ed è necessario regolamentarla come hanno fatto alcuni stati USA California, Florida,e New Jersey,Tezxas :I dugbbi sorti circa la qualità dell’assistenza devono essere dissolti da regolamentazioni appropriate e ragionevoli che coinvolgano i professionisti consnetano La scelta di eseguire interventi in ambulatorio piuttosto che in strutture più attrezzate deve basarsi su considerazioni tecniche legate alal propria professionalità ed allo stto fisico del paziente piuttosto che su consideraziomni economiche.La costo effiacci è soloiun fattore e devono prevalere considerazioni di qualità e scicurezza Negli USA è stata fondata ed è attiva una società (Society for Office-Based Anesthesia)che ha lo scopo di milgiorare continuamente la qualkità dell’assistenza e e la sicurezza dei pazienti e iniziative analoghe devono esser intraprese in Italia per la salvagiardia dei cittadini,mma anche dei professionisti

E’ probabile che il sistema assicurativo debba farsi carico anche della OBS e OBA e non posa necesasriamente proporre tariffe basse

Per il mioguioramento dellapartica cgirurgica ed anestesiologica ambulatoriale è necassrio seguire delel linee guida nazionali ed internazionali e formare dei professionisti esperti in questo settore ,cher non può che essere un continuum assistenziale che riguarda tutto il perioepratorio


Diapo di esempi attrezz e monitor….


Classi di aggressività chirurgica…………


Questionario…


Schemi schede anest;quest preop;;;;;vedi milano ;;;;;;


Materiale occorrente nel carrello della rianimazione:Materiale numero

pallone di Ambu 1maschera di gomma nera: numero 5 1 numero 4 1 numero 3 1maschera monouso trasparente grande 1 media 1 cateter mount 1filtro antibatterico 1tubi endotracheali :numero 7.5 1 “ 7 1 “ 6.5 1tubi di Guedel calibro 3 1 “ “ “ “ “ 2 1

manici da laringoscopio con pile: 2

lame da laringoscopiomedia curva 1grande “ 1media retta 1grande “ 1siringhe da 20 ml 2siringhe da 10 ml 2siringhe da 5 ml 2siringhe da 2 o 2.5 ml 2rotoli di cerotto di seta;largo 1stretto 1


Farmaci per carrello della rianimazione:Materiale numero

ADRENAliNA 2Aleudrin o Alupent 2Aminofillina 2ATROPINA 2Bentelan 2Bicarbonato di sodio 8.4% 2Calciocatapresan 2Cordarone 2Dobutamina 2dopamina(revivan) 2Emagel 2Isoprenalina 2isoproterenolo 2Lanoxin 2Lasix 2Levicor 2Lidocaina 2Solumedrol 2Trimeton 2Uraprene 2Valium 2Venitrin 2Visken 2

CATETERI E.V VIALON:22G 220 G 418G 416 G 2DEFLUSSORI FLEBOCLISI 4

Il punto di vista dedll'anestesista

Health & Medicine

Transcript of Il punto di vista dedll'anestesista