Residual curarization

Nora e reversal della miorisoluzione.C.MelloniLibero professionista Napoli SIA 2016

Assenza di conflitto di interessiNon ho alcun interesse commerciale o finanziario nei farmaci citati nella presente letttura n ho ricevuto fondi per questa lettura .Napoli SIA 2013

Complicanze gravi durante MRITotale pazienti trattati con MRI:2.045.95433 arresti cardioresp.11 decessi16.1/1.000.000 di MRI,con 5,3 decessi/1.000.000 di MRI

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Dati su 182 MRI USA (Schiebler M,Kaut-Watson C,Williams DL Both sedated and critically ill require monitoring during MRI(In Vivo Research,1992-2000)Napoli SIA 2013

3010+/-188 pazient/anno

Anaesthesia for magnetic resonance imaging: a survey of current practice in the UK and Ireland.Napoli SIA 2013 McBrien M. E. et al. Anaesthesia 55:737-743, 2000Postal questionnaire was sent to 120 MRI units in UK and 6 in Republic of Ireland100 (79%) responses:46 units had an anaesthetic service (36 units on a regular basis, 10 on demand)

AnaesthetistGAA: General Adult AnaesthetistGPA: General Paediatric NAP: Neuroanaesthetist with regular Paediatric practiceNA: Neuroanaesthetist with no regular paediatric practiceSedation provided by nonanesth personnelSedation provided by anesth,personnel

Cote,C,Charles,J,Helen,W,Notterman,DA,Daniel A.,Weinberg JA,Mc CLoskey C. Adverse sedation events in pediatrics ;analysis of medication used for sedation. Pediatrics 106:633-64.:2000.Napoli SIA 2013

118 cases from the adverse drug reporting System of the FDA,US Pharmacopeia and a results of a survey of pediatric specialists

Allocation of medication related adverse eventsNapoli SIA 2013

Single drug administration associated with death or permanent neurologic injuryNapoli SIA 2013

Relationship of interest of negative outcomeNapoli SIA 2013 No with general category of drugNo with route of administrationYes with 3 or > sedation medications12 pts suffered at home or in auto;chloral hydrate most frequently involvedDental specialists overrepresented:39%!

Complicazioni delle endoscopia digestiva0.13-0.08% Mortalit 0.7-1/10.00050% delle KO e 65% dei decessi dovuti a probl cardioresp

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1989 ASGE Survey of Endoscopic sedation and monitoring practice(Gastrointest Endoscopy 1990;36:s13-18)Napoli SIA 2013

problemi durante e dopo la procedura LUGAY M,OTTO G,KONG M,MASON DJ, WILETS I. Recovery Time and Safe Discharge of Endoscopy Patients After Conscious Sedation .Gastroenterology Nursing 19;1996:194-200 Napoli SIA 2013

Ko of endoscopic procedures.Freeman ML, Timothy Hennessy J, Cass OW, Phelley AM. Carbon dioxide retention and oxygen desaturation during gastrointestinal endoscopy. Gastroenterology 1993; 93: 331-339.Freeman ML. Sedation and monitoring for gastrointestinal endoscopy. Gastrointest Endosc Clin N Am 1994; 94: 475-499.Napoli SIA 2013

Anormalit resp.e anestesia topicaMc Nicholas WS, Coffey M, Mc Donnel T, O'Regan R, Fitzgerald MX. Upper airway obstruction during sleep in normal subjects after selective topical oropharyngeal anesthesia. Am Rev Respir Dis 1987;135:1316-9 Napoli SIA 2013

9 normal subjects20-28 y.

Saturazione O2 e premed con BDZSaO2 89-92%;Bell Scand J Gastroenterol 1990

Ulteriore riduz durante introduz dello strumento specie nei primi 3-4 min dopo premed. (Lieberman Gastroenterology 1985)BDZ+oppioide O2 desat ancora + spiccata (40%)+fattori di rischio (age>65,Cold); Hart & Classen Endoscopy 1990)Cousins Scand J gastroenterol 1990)Napoli SIA 2013

Fattori contributori alla desaturazione in O2 durante endoscopia digestiva Ostruzione del faringeCompressione tracheale Distensione gastricafarmaciAnest locNapoli SIA 2013

Deaths in the dentists office References:(1) Lee HH et al, Trends in death associated with pediatric dental sedation and general anesthesia. Paediatr Anaesth. 2013 Aug;23(8):741-6.(2) Chicka MC et al, Adverse events during pediatric dental anesthesia and sedation: a review of closed malpractice insurance claims. Pediatr Dent.2012 May-Jun;34(3):231-8.Napoli SIA 2013

Sicurezza della NORA:odontoiatriaNapoli SIA 2016Lee HH et al, Trends in death associated with pediatric dental sedation and general anesthesia. Paediatr Anaesth. 2013 Aug;23(8):741-6. analisi di 25 morti di bambini per anestesia , effettuata nello studio dentistico ,di cui 17 in sedazioneChicka MC et al, Adverse events during pediatric dental anesthesia and sedation: a review of closed malpractice insurance claims. Pediatr Dent.2012 May-Jun;34(3):231-8. 17 disastri :13 sedation, 3 AL da sola ,1 GA53% morte o danno cerebrale permanente

Lee HH et al, Trends in death associated with pediatric dental sedation and general anesthesia. Paediatr Anaesth. 2013 Aug;23(8):741-6 analisi di 25 morti di bambini per anestesia , effettuata nello studio dentistico ,di cui 17 in sedazione. Napoli SIA 2013

Pediatric dental deaths by anesthesia provider and age categories Napoli SIA 2013

Lee HH et al, Trends in death associated with pediatric dental sedation and general anesthesia. Paediatr Anaesth. 2013 Aug;23(8):741-6

Pediatric dental deaths by anesthesia provider and facility type Napoli SIA 2013

Lee HH et al, Trends in death associated with pediatric dental sedation and general anesthesia. Paediatr Anaesth. 2013 Aug;23(8):741-6

Pediatr Dent. 2012 May-Jun;34(3):231-8.Adverse events during pediatric dental anesthesia and sedation: a review of closed malpractice insurance claims.Chicka MC1, Dembo JB, Mathu-Muju KR, Nash DA, Bush HMCollege of Dentistry, University of Kentucky, Lexington, KY, USA..malpractice claims di 2 assicurazioni professionali USA 1993-2007.17 disastri :13 isedation2, 3 AL da sola 1 iGA53% morte o danno cerebrale permanente Et media was 3.6anni;6 , 6 casi presente solo il dentista 2 2 AL solaoverdoses Di LA in 41% Sede:ufficio del dentista 71% dei casiDelle 13 sedazioni,solo 1 monitorato.CONCLUSIONS:Very young patients ( 3-years-old) are at greatest risk during administration of sedative and/or local anesthetic agents. Some practitioners are inadequately monitoring patients during sedation procedures. Adverse events have a high chance of occurring at the dental office where care is being providedNapoli SIA 2013

Fox 40 Sacramento:Dentist Charged in Death of Patient After Trying to Extract 20 TeethA Connecticut dentist turned himself into Enfield police on Tuesday in connection with the death of one of his patients.Dr. Rashmi Chhotabhai Patel, 45, of Suffield, was charged with criminally negligent homicide and tampering with evidence on Tuesday. Judy Gan, 64, and her husband Michael arrived at Enfield Family Dental, which is located at 71 Hazard, for 20 teeth extractions, implants and grafts in Februrary 2014.Napoli SIA 2013

Children periodically die in dental offices due to complications of general anesthesia or intravenous sedation. Links to recent reports include the followingA3-year-old girl dies in San Ramon, CAafter a dental procedure in July 2016.A 14-month-old child, scheduled to have 2 cavities filled, dies in an Austin, TX dental office. The dentist and an anesthesiologist were both present.A 6-year-old boy, scheduled to have teeth capped at a dental clinic, has anesthesia and dies after the breathing tube is removed.Another 6-year-old boy, scheduled to have a tooth extracted by an oral surgeon, dies after the oral surgeon administers general anesthesia.Napoli SIA 2013

ColonscopiaAdverse events during colonoscopy:2-3/1000 colonPerforazioni,sanguinamento,infezioni,probl cardiovasc....Sethi A, Song LM.Adverse events related to colonic endoscopic mucosal resection and polypectomy. Gastrointest Endosc Clin N Am. 2015 Jan;25(1):55-69.)Particolarmente a rischio per tutte le elencate complicanze sono gli anziani,> 80 anni(Day LW1, Kwon A, Inadomi JM, Walter LC, Somsouk MAdverse events in older patients undergoing colonoscopy: a systematic review and meta-analysis. Gastrointest Endosc. 2011 Oct;74(4):885-96. Warren JL1, Klabunde CN, Mariotto AB, Meekins A, Topor M, Brown ML, Ransohoff DF.Adverse events after outpatient colonoscopy in the Medicare populationAnn Intern Med. 2009 Jun 16;150(12):849-57, W152..

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Bhananker SM, Posner KL, Cheney FW, et al. Injury and liability associatedwith monitored anesthesia care: a closed claim analysis. Anesthesiology2006; 104:228234 Napoli SIA 2016

Closed claims NORA vs Sala opNORA Sala opTipo di anestesia MAC 58%MAC 6%Age >7050%19%Eventi resp++++Inadeguata ossigenaz/ventilaz33%2%

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Chang B1, Kaye AD, Diaz JH, Westlake B, Dutton RP, Urman RD.

Complications of Non-Operating Room Procedures: Outcomes From the National Anesthesia Clinical Outcomes Registry.J Patient Saf. 2015 Apr 7. [Epub ahead of print]

National Anesthesia Clinical Outcomes Registry database was examined to compare OR to NORA anesthetic complications and patient demographics.12,252,846 cases were analyzed, with 205 practices contributing information, representing 1494 facilities and 7767 physician providers. Year 2010-2013OP room vs NORA Nora ptaients plder> 50 (61.92% versus 55.56%, P < 0.0001).MAC ad (20.15%) and sedation (2.05%) more common in NORA locations. The most common minor complications were postoperative nausea and vomiting (1.06%), inadequate pain control (1.01%), and hemodynamic instability (0.62%). The most common major complications were serious hemodynamic instability (0.10%) and upgrade of care (0.10%). There was a greater incidence of complications in cardiology and radiology locations. Overall mortality was higher in OR versus NORA (0.04% versus 0.02%, P < 0.0001). Subcategory analysis showed increased incidence of death in cardiology and radiology locations (0.05%).CONCLUSIONS:Non-OR anesthesia procedures have lower morbidity and mortality rates than OR procedures, contrary to some previously published studies. However, the increased complication rates in both the cardiology and radiology locations may need to be the target of future safety investigations. Providers must ensure proper monitoring of patients, and NORA locations need to be held to the same standard of care as the main operating room. Further studies need to identify at-risk patients and procedures that may predispose patients to complications

Obbiettivi anestesiologici della NORAInduzione rapidaRisveglio rapidoAssenza di sequele;dolore,PONV..Rapidit di ripresa:street fitness???

Requisiti di un anestetico/analgesico/ipnotico/ miorilassante per la NORAInizio di azione rapidoScomparsa rapida; Assenza di effetti prolungatiAssenza di effetti cardiovascolari(liberazione di istamina...);PA,FC,ECG...Assenza ( o quasi) di reazioni allergiche/anafilattiche Antagonismo rapido????o sua inutilit???Assenza di PORC per i miorilassanti.... Napoli SIA 2016

Quando sono necessari/utili i miorilassanti???Primo punto:

Gli scopi della intubazione trachealeGaranzia del mantenimento della perviet delle vie aeree superiori;Protezione delle vie aeree da parte del contenuto gastrico;Permettere la ventilazione artificiale meccanica a pressione positiva;Permettere la aspirazione dellalbero tracheobronchiale

Indicazioni allintubazione endotrachealeSupporto alla ventilazione durante AG:Tipo di chirurgia...Sito operativo vicino/conflitto con vie aeree..Chir addominale,toracica,cardio..,neuro..Posizioni difficili:prona/lat...Chirurgia prolungataPaziente a rischio di aspirazione polmonare;coma,trauma....Ventilazione in maschera difficileNecessit(anche presunta) di ventilaz postop.

Quali necessit e per quali procedure ??Procedure nelle quali necessaria/preferibile la AG,specie per assicurare immobilit(RMN;neurrad interv,biopsie tac guidate)Bambini...ampio spettro di interventi.....Pazienti non cooperanti,claustrofobici,traumatizzati....Quando si deve stare distanti dal paziente?Radiazioni Posizione pronaOscuritCompetizione per le vie aeree

Durata difficile da predireLa fine pu essere per improvvisa,specie se non conosciamo lintervento......mantenere la comunicazione con lo specialista,anzi,chiedere in anticipo............

gastrointest

NEURORADIOLOGIA:

Embolizzazione di aneurismi/malformazioni vascolariInterventi stereotattici sotto monitoraggio EEG/RMN/TAC.... Diagnostic imaging proceduresMRI,Ciclotron :AV malformaz,pituitary tumors,retinoblastomas.radiation painless,but positioning may take hours.....head fixation painfulTerapia radiante Brachiterapia Trauma cranico....

Sala di emodinamica/cardiologia interventisticaRivascolarizzazione percutanea.,angiografia,stent....(pazienti con distress acuto,emodinamicamente instabili,Difetti interatriali e/o ventricolari(TEE)Defibrillatore impiantabile

gastroenterologiaDiagnosticaTerapeuticaErcpVarici.....

Trasporti;ambulanza,elicottero,aereo..Pazienti criticiInterventistica stradale/terremoti,ecc.

Varie OdontostomatologiaCentro ustioniTerapia elettroconvulsivaLitotrissia Ginecologia,fertilizzazione,isteroscopia,miomectomiaBeware of situation whwere the anesthesioloogist is callled after the intervention has starterd and the patient found uncooperative.oculistica

Apriamo una discussione su come intubare,cio con quali farmaci? Quando? Adiuvanti.....?

Incredibile ,ma vero,sullargomento con quali farmaci intubare e quando non c molto.....Forse non ci siamo posti il problema come una priorit...ma non intubiamo solo noi anestesisti..........E le condizioni/necessit sono molto varie:elezione in sala op(anestesista),emergenza in PS(Psoccorsista),strada...(IP?Rian??)NORA(anestesista?)Arresto cardiaco:cardiologo?IP?medico???

Capacit di intubare

Esperienza prima di tutto.........OPERATORE Strumenti......lame,video....

Intubation with or without muscle relaxants???

[Comparison of the effects of remifentanil and remifentanil plus lidocaine on intubation conditions in intellectually disabled patients].Eyigor C, Cagiran E, Balcioglu T, Uyar M.Braz J Anesthesiol. 2014 Jul-Aug;64(4):263-8Background and objectives: This is a prospective, randomized, single-blind study. We aimed to compare the tracheal intubation conditions and hemodynamic responses either remifentanil or a combination of remifentanil and lidocaine with sevoflurane induction in the absence of neuromuscular blocking agents. Methods: Fifty intellectually disabled, American Society of Anesthesiologists I-II patients who underwent tooth extraction under outpatient general anesthesia were included in this study. Patients were randomized to receive either 2 g kg1 remifentanil (Group 1, n = 25) or a combi- nation of 2 g kg1 remifentanil and 1 mg kg1 lidocaine (Group 2, n = 25). To evaluate intubation conditions, Helbo-Hansen scoring system was used. In patients who scored 2 points or less in all scorings, intubation conditions were considered acceptable, however if any of the scores was greater than 2, intubation conditions were regarded unacceptable. Mean arterial pressure, heart rate and peripheral oxygen saturation (SpO2) were recorded at baseline, after opioid administration, before intubation, and at 1, 3, and 5 min after intubation. Results: Acceptable intubation parameters were achieved in 24 patients in Group 1 (96%) and in 23 patients in Group 2 (92%). In intra-group comparisons, the heart rate and mean arterial pressure values at all-time points in both groups showed a significant decrease compared to baseline values (p = 0.000) Conclusion: By the addition of 2 g/kg remifentanil during sevoflurane induction, successful tracheal intubation can be accomplished without using muscle relaxants in intellectually dis- abled patients who undergo outpatient dental extraction. Also worth noting, the addition of 1 mg/kg lidocaine to 2 g/kg remifentanil does not provide any additional improvement in the intubation parameters.

meglio intubare con i miorilassanti o no?Siiiii...Per attenti al timing.......:possibilmente alla massima profondit di blocco(monitoraggio!!!!) orbicularis oculi> pollice???Ma non diminuisce la frequenza di lesioni Mencke, T1, Echternach M, Plinkert PK, Johann U, Afan N, Rensing H, Noeldge-Schomburg G, Knoll H, Larsen R. Does the timing of tracheal intubation based on neuromuscular monitoring decrease laryngeal injury? A randomized, prospective, controlled trial. Anesth Analg. 2006

Miorilassanti si/NO

Lutilizzo dei miorilassanti migliora le condizioni per intubazione e diminuisce le sequele locali traumatiche Anesthesiology. 2003 May;98(5):1049-56.Laryngeal morbidity and quality of tracheal intubation: a randomized controlled trial.Mencke T, Echternach M, Kleinschmidt S, Lux P, Barth V, Plinkert PK, Fuchs-Buder T.

Can J Anaesth. 2003 Feb;50(2):121-6. Muscle relaxation and increasing doses of propofol improve intubating conditions. Lieutaud T1, Billard V, Khalaf H, Debaene B.Atrac + dosi crescenti di propof.

Mencke T, Echternach M, Kleinschmidt S, Lux P, Barth V, Plinkert PK, Fuchs-Buder T. Laryngeal morbidity and quality of tracheal intubation: a randomized controlled trial. Anesthesiology. 2003 May;98(5):1049-56. .

Mencke T, Echternach M, Kleinschmidt S, Lux P, Barth V, Plinkert PK, Fuchs-Buder T. Laryngeal morbidity and quality of tracheal intubation: a randomized controlled trial. Anesthesiology. 2003 May;98(5):1049-56.

Intubation damage....

Wilcox SR, Bittner EA, Elmer J, Seigel TA, Nguyen NT, Dhillon A, et al. Neuromuscular blocking agent administration for emergent tracheal intubation is associated with decreased prevalence of procedure-related complications. Crit Care Med 2012;40:1808-13NMB siNMB noNum of attempts:185%78% :3 +1%4%Cormack Lehane 176%62% 216%24% 38%11% 41%3%Hypoxemia