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Safe Sedation for patients with special needs

Safe Sedation for patients with special needs. Dr John M LOW MA. (Oxford University) BM.BCh . (Oxford University) FRCA. , FHKCA. , FANZCA., FHKAM .( Anaesthesiology ) Partner, Dr. Roger Hung and Partners. Overview. Achieving sympatholysis Sedation vs General Anaesthesia

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Safe Sedation for patients with special needs

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  1. Safe Sedation for patients with special needs Dr John M LOW MA. (Oxford University) BM.BCh. (Oxford University) FRCA., FHKCA., FANZCA.,FHKAM.(Anaesthesiology) Partner, Dr. Roger Hung and Partners

  2. Overview • Achieving sympatholysis • Sedation vs General Anaesthesia • Minimal Pharmacology • Practical aspects of M A C - equipment • Regulatory aspects • Managing patient work flow

  3. ↑sympathetic activity • Psychological and emotional • Physical • Instrumentation / Surgical Incision • Pharyngeal/ Laryngeal stimulation Tomori Z, & Widdicombe J G (1969) J Physiol (London) 200:25 • Exogenous catecholamines (LA) • Cold • Full bladder

  4. Noxious stimulation JM Low et al (1986) B J Anaesth 58:471-477 Adrenergic Responses to Laryngoscopy

  5. Reducing sympathetic activity

  6. Reducing sympathetic activity • Anxiolytics(benzodiazepines / propofol) • Local analgesia - ↓ pain stimulus • Fentanyl - ↓ pain stimulus; sympatholysis • ↓ non-pharmacological factors (eg. cold) • β - adrenergic blockade • α - adrenergic blockade

  7. Sedation vs G A

  8. Typical Workflow- M A C • Assessment and Informed consent • Preparation of equipment • Inhalational induction (paediatric case) • IV access – Bolus and Maintenance • Maintenance of patient’s airway • Monitoring • Recovery and Discharge

  9. M A C – a pragmatic approach • Inhalational techniques • Excellent for paediatric induction • No scavenging – closed ventilation • Limited supply of gas / agent • Complex equipment needed for maintenance • Intravenous Techniques • Propofol……propofol……propofol • + / - Adjunct agents

  10. M A C – typical sequence

  11. O2 / N2O /Sevoflurane • Excellent for induction (paediatrics) • Short exposure to allow for i.v. access • Unsuitable for prolonged use

  12. Common drugs for sedation • IV Sedation: • Pethidine / Morphine • Midazolam / Diazepam/Diazemuls • Monitored AnaesthesiaCare • Propofol / Dexmetatomidine (Precedex) • Fentanyl / Alfentanil / Remifentanil • Dynastat / Pethidine

  13. Propofoldi-isopropyl phenol

  14. Propofol Pharmacology • Non-barbituarate hypnotic anaesthetic • Lipid soluble – preparation as emulsion • Rapid hepatic & extra-hepatic metabolism • Very rapid onset and recovery • Half Life: T½= 2; 30; 180 mins • Metabolites not active • Hypnosis at 1.5-6 μg/ml • Maintenance with infusion pump • No atmospheric pollution

  15. Propofol – Pharmacokinetics

  16. Propofol – Pharmacokinetics Guaranteed sedation…..

  17. Propofol Pharmacokinetics

  18. Propofol Pharmacokinetics for the rest of us

  19. Propofol Pharmacokinetics for the rest of us

  20. Propofol Pharmacokinetics for the rest of us

  21. Bathtub Pharmacokinetics

  22. In practice • Loading dose – 40-80 mg (1 mg/kg) • Maintenance dose – 25-60 mls/hr (80 μg/kg/min) • 20mg bolus prn. • Titrating to patient’s threshold

  23. Titrating to patient’s threshold • At steady state • Reduce rate by 10% every few minutes • Slight non-purposeful movement (threshold) • Add 10% and maintain • Switch off when no more stimulation “Every anaesthetic is a pharmacological experiment”

  24. Individual Titration

  25. Maintenance of the airway • AMBU Bag readily accessible • + / - Oxygen supplement • Chin lift (teach D S A) • Practical “tricks of the trade”

  26. Practical “tricks” • Posture – (take advantage of pharyngeal curvature) • Horizontal position • Neck extension • Shoulder support • Nasopharyngeal airway • Loose gauze swab in pharynx • Oral Dam • Double suction (DSA) • No irrigation – soft debris

  27. Irrigation without aspiration • Suction…..Suction……Suction……. • Neck extension – double articulation headrest • Cough / swallowing reflex present • Oral Dam – if possible • Loosely packed gauze swab • Chin Lift -Train D S A • Minimise irrigation

  28. Patient Positioning • Soft elastic belt (for children) • Safety belt (adults) • Blanket (sympatholysis) • Minor movement tolerable

  29. Patient Positioning

  30. Supplementary Agents • Midazolam (1-2 mg) • Fentanyl (25 mcg / 0.5 mls) • Pethidine 0.5-1 mg/kg • Remifentanil (20μg + 2.5 μg/min) • Dynastat (40 mg iv Q12H) • Arcoxia (90 – 120 mg po.) • Dexmetatomidine (Precedex) • Labetalol (!) (5 – 15 mg)

  31. Sedation - equipment • IV equipment • Monitoring • Oxygen / AMBU bag • Simple airway management • Treatment of major side effects • Anaphylaxis • Extremes of HR • Extremes of BP • Bronchospasm • Angina • P O N V

  32. Monitoring and iv infusion

  33. Oxygen supply

  34. Contingency Equipment: Vital SignsTM Airway Pack

  35. Contingency Equipment

  36. Contingency Equipment

  37. Emergency Drugs • P O N V – metoclopramide / odansetron / dexamethasone • Hypotension – phenylephrine / ephedrine • Hypertension – nifedepine / labetalol / hydrallazine • Bradycardia – atropine / isoprenaline / dobutamine • Tachycardia – esmolol / fentanyl • Bronchospasm – ventolin inhaler / aminophylline • Acute Angina – nitroglycerine patch / sl. • Anaphylaxis – adrenaline / Ca++ / hydrocortisone / dexamethasone • Allergy – chlorpheniramine • Antagonists – naloxone / flumazenil

  38. Contingency Equipment

  39. Contingency Equipment

  40. Utility Trolley

  41. Utility Trolley

  42. Intra nasal spray

  43. Patient selection • ASA I or II • Age less than 70 years • BMI less than 30 • Satisfactory pre-op assessment questionnaire • Easy access to hospital if necessary • Escort available following procedure

  44. Patient Work Flow • Presentation and decision to operate • Screening Questionnaire • Concurrent medications / Allergies / Cardio- respiratory status • Fasting instructions • Day of procedure – Consent; Contact; Re-assessment; Payment • Recovery Stage I Stage II • Escort to and from clinic • Written Instructions – Medication; Analgesia; • driving, machinery, signing of legal documents, cooking, etc.,

  45. Fasting Instructions • 6 hours - solids • Food and snacks • Milk • Milky drinks • Fresh orange juice • 2 Hours – clear fluids • Water • Ribena • Apple juice • Orange squash

  46. Range of Dental Procedures • Paediatric – M O S • Paediatric –dental restoration • Often minimal stimulation • Pulpectomy will need LA • Combative / mentally handicapped

  47. Practical Aspects • Equipment – Mandatory ←→ Best Practice • Protocols / Check List – for nursing staff • Documentation Pre-operative diagnosis – justify procedure Pre-operative assessment – questionnaire Written pre-operative instructions / fasting time Consent for surgery – informed / explicit Consent for sedation – informed / explicit Sedation - vital signs record / positioning / drugs / timetable of events Operation Record – diagnosis / findings/ procedure / closure Written Post-Operative instructions – escort present

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