Volume 4, Issue 10 S A M B A T A L K S - PAGE 1 March, 2005

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Do you have a problem case or situation in ambulatory anesthesia about which you would like some advice? Would you like to reply to questions others have raised about ambulatory anesthesia issues? Do you have any comments or opinions regarding any topic related to ambulatory anesthesia which you would like to share with other professionals? If you answered "yes" to any of the above, then "Join the Discussion" here.

To enter the Discussion with a question, reply, or other comment, please contact us. Your question/reply/comment will be published in this section of the next available issue of SAMBA TALKS. Include your name (or initials), city, and state, if you would like these published. Please note that because of the high volume of questions we receive, there is often a delay of 1 to 2 months before the questions can be published.

Questions and responses from previous months are now available at the eNewsletter Discussion Archive. If you have any comments regarding the previous questions, please submit them to SAMBA Discussion, and they will be published here next month.

Please note: The information presented in the below replies does not represent SAMBA policy. The replies are solely the opinions of the individuals who wrote them.

?? - LAST MONTH'S QUESTIONS WITH REPLIES - ?? - TOP

QUESTION 1:

I am a nurse working in GI Endoscopy. We are updating our protocols and procedures. I would like information regarding cardiac monitoring during GI Endoscopy in a patient receiving moderate sedation. What does the ASA recommend?

-- From Grace Smith, R.N. B.S.N., C.G.R.N., Rochester, NY

REPLY:

This is an excellent question, and an important practical issue. The ASA has developed a set of " Practice Guidelines For Sedation And Analgesia By Non-Anesthesiologists", which can be viewed at http://www.asahq.org/publicationsAndServices/sedation1017.pdf. It was most recently amended in October 2001.

These guidelines were specifically designed to be used for moderate and deep sedation, which were defined as:

Moderate Sedation/Analgesia ("Conscious Sedation") is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands, either alone or accompanied by light tactile stimulation. No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.

Deep Sedation/Analgesia is a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained.

The guidelines state that electrocardiographic monitoring should be used during moderate sedation in patients with significant cardiovascular disease or those undergoing procedures where dysrhythmias are anticipated. It is recommended for all patients undergoing deep sedation.

Other monitors recommended in the guidelines for both moderate and deep sedation are: continuous pulse oximetry, observation and/or auscultation of ventilation "at regular intervals", and blood pressure measurements every 5 minutes. The level of consciousness should also be assessed "at regular intervals" throughout the sedation process. Verbal stimuli should be used for moderate sedation, and more profound stimuli can be used for deep sedation.  

-- From D. Daley, M.D., Houston, TX

QUESTION 2:

Should pregnant patients receive anesthesia (general, Bier blocks, axillary blocks) for surgery in free-standing ASC's?  Would doing digital or wrist blocks place any risk on the ASC? 

-- Anonymous  

REPLY:

In general, pregnant patients in the third trimester should not receive general or regional anesthesia in ASCs, as the risks of preterm labor and/or fetal distress require the immediate availability of obstetrical and neonatal back-up which is not possible in the majority of ASCs. Only in the very unusual situation that an ASC is within the immediate vicinity of an obstetrical unit, and the appropriate personnel are immediately available, would I consider it appropriate to do these patients in an ASC.

In the first trimester, all non-emergency surgery should be avoided. There is an increased risk of teratogenicity during this trimester, and there may be an increased risk of spontaneous abortion. If an ASC commonly deals with emergency surgery, then pregnant patients in the first trimester may be acceptable candidates.... if the center is ready to also deal with the possibility of a spontaneous abortion.

The situation with anesthesia for surgery at an ASC during the second trimester is less clear-cut. Typically, surgery which cannot be postponed until after delivery is performed during this trimester, as it is considered to be the period during which the combined risks of teratogenicity, preterm labor and fetal distress are lowest. However, obstetrical consultation should be available to assess the need for tocolytic therapy if preterm labor develops, especially in the last part of this trimester. As well, fetal heart rate monitoring is generally recommended after ~16 weeks gestation, and obstetrical personnel should be available to help interpret the results and manage the patient(s) if abnormalities are detected.

Keeping the above in mind, for the majority of ASCs it is probably most practical to simply avoid providing anesthesia (general, Bier blocks, or axillary blocks) for all pregnant patients. However, if one chooses to provide anesthesia to these patients, preoperative consultation with an obstetrician is imperative.

Even digital or wrist blocks may put the ASC at an increased risk. If a toxic reaction (eg. seizure) from an inadvertent intravenous injection occurs, the "full stomach'' considerations and airway changes of the pregnant patient can make the management of such a reaction more difficult than usual. As well, two and not just one patient may be adversely effected by such an event. However, the possibility of an inadvertent intravenous injection from these blocks is very small, and an ASC may decide that the possibility is small enough that it is willing to allow these blocks in pregnant patients. If so, I would suggest that an anesthesiologist should be immediately available in case such a reaction occurs; policies be established which include the precautions which should be taken for pregnant patients, such as left uterine displacement after ~ 20 weeks gestation; and supplemental sedation be avoided, due to the unknown teratogenic effects of these drugs and their potential enhanced potency in the pregnant patient.

-- Anonymous

EDITOR'S COMMENT: Further information regarding the management of pregnant patients in the ambulatory surgery setting can be found in the Discussion Archive.

?? -- THIS MONTH'S QUESTION -- ?? - TOP

QUESTION:

I am a non-physician quality administrator working with a pediatric task force in a mid west hospital. Several questions have come up that I thought I would pose to your group: What does the SAMBA &/or ASA say about administration of chloral hydrate to pediatric patients for the purposes of sedation during or prior to OP procedures?  Are there guidelines which address specific agents like chloral hydrate for the purposes of sedation and what do their guidelines look like?

-- From Steven C. Thayer, Grand Rapids, MI

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