Anesthesia and sedation outside the operating room: How to prevent risk and maintain good quality

Current Opinion in Anaesthesiology

Volumn 20, Issue 6, 2007, Pages 513-519

  Melloni, Claudio ^a,b  

^a Villa Torri Hospital   (Italy)

^b NONE   (Italy)

Author keywords

Complications; Liability; Morbidity; Mortality; Nonoperating room anesthesia; Office based anesthesia; Risk management

Indexed keywords

CHLORAL HYDRATE; NITROUS OXIDE; PROPOFOL;

ANESTHESIA COMPLICATION; COMPUTER ASSISTED TOMOGRAPHY; END TIDAL CARBON DIOXIDE TENSION; ENDOSCOPY; HEALTH CARE QUALITY; HUMAN; MEDICAL SOCIETY; NUCLEAR MAGNETIC RESONANCE IMAGING; OPERATING ROOM; OUTCOME ASSESSMENT; OXYGENATION; PLASTIC SURGERY; PRIORITY JOURNAL; REVIEW; RISK FACTOR; SEDATION; SURGICAL TECHNIQUE;

AMBULATORY SURGICAL PROCEDURES; ANESTHESIA; CONSCIOUS SEDATION; DENTISTRY, OPERATIVE; ENDOSCOPY, GASTROINTESTINAL; HUMANS; INTRAOPERATIVE COMPLICATIONS; LIABILITY, LEGAL; MAGNETIC RESONANCE IMAGING; MONITORING, INTRAOPERATIVE; PEDIATRICS; QUALITY OF HEALTH CARE; TOMOGRAPHY, X-RAY COMPUTED;

EID: 35948998869     PISSN: 09527907     EISSN: None     Source Type: Journal    
DOI: 10.1097/ACO.0b013e3282f06ba6     Document Type: Review

References (91)

1. Caplan RA, Posner KL, Ward RJ, Cheney FW. Adverse respiratory events in anesthesia: a closed claims analysis. Anesthesiology 1990; 72:828-833.
2. Cheney FW. The American Society of Anesthesiologists Closed Claims Project: what have we learned, how has it affected practice, and how will it affect practice in the future? Anesthesiology 1999; 91:552-556.
3. Aitkenhead AR. Injuries associated with anaesthesia: a global perspective. Br J Anaesth 2005; 95:95-109.
4. Campling EA, Devlin HB, Hoile RW, Lunn JN. The report of the national confidential enquiry into perioperative deaths 1990. London: Her Majesty's Stationery Office; 1992.
5. Domino KB. Office-based anesthesia: lessons learned from the closed claims project. ASA Newsletter 2001; 65:9-11; 15.
6. Schiebler M, Kaut-Watson C, Williams DL. Both sedated and critically ill require monitoring during MRI. In Vivo Research 1992-2000.
7. McBrien ME, Winder J, Smyth L. Anaesthesia for magnetic resonance imaging: a survey of current practice in the UK and Ireland. Anaesthesia 2000; 55:737-743.
8. Bluemke DA, Breiter SN. Sedation procedures in MR imaging: safety, effectiveness, and nursing effect on examinations. Radiology 2000; 216:645-652.
9. Malviya S, Voepel-Lewis T, Tait AR. Adverse events and risk factors associated with the sedation of children by nonanesthesiologists. Anaesth Analg 1997; 85:1207-1213.
10. Vade A, Sukhani R, Dolenga M, Habisohn-Schuck C. Chloral hydrate sedation of children undergoing CT and MR imaging: safety as judged by American Academy of Pediatrics guidelines. Am J Roentgenol 1995; 165:905-909.
11. McManus B. Trained nurses can provide safe and effective sedation of MRI in pediatric patients. Can J Anesth 2000; 47:197-200.
12. Martí-Bonmatí L, Ronchera-Oms CL, Casillas C, et al. Randomised double-blind clinical trial of intermediate vs high-dose chloral hydrate for neuroimaging of children. Neuroradiology 1995; 37:687-691.
13. Kao SC, Adamson SD, Tatman LH, Berbaum KS. A survey of postdischarge side effects of conscious sedation using chloral hydrate in pediatric CT and MR imaging. Pediatr Radiol 1999; 29:287-290.
14. Sury MRJ, Hatch DJ, Dicks Mireaux C, Chong WK. Development of a nurse led sedation service for paediatric magnetic resonance imaging. Lancet 1999; 353:1667-1671.
15. Malviya S, Voepel-Lewis T, Prochaska G, Tait AR. Prolonged recovery and delayed side effects of sedation for diagnostic imaging in children. Pediatrics 2000; 105:1-5.
16. Glasier CM, Stark JE, Brown R, et al. Rectal thiopental sodium for sedation of pediatric patients undergoing MR and other imaging studies. Am J Neuroradiol 1995; 16:111-114.
17. Greenberg SB, Adams RC, Aspinall CL. Initial experience with intravenous pentobarbital sedation for children undergoing MRI at a tertiary care pediatric hospital: the learning curve. Pediatr Radiol 2000; 30:689-691.
18. Pomeranz ES, Chudnofsky CR, Deegan TJ, et al. Rectal methohexital sedation for computer tomography imaging of stable pediatric emergency department patients. Pediatrics 2000; 105:1110-1114.
19. MacIntyre PA, Sury MRI. Is propofol infusion better than inhalational anesthesia for paediatric MRI? Anaesthesia 1996; 51:517.
20. Levati A, Colombo N, Arosio EM, et al. Propofol anesthesia in spontaneously breathing paediatric patients during magnetic resonance imaging. Acta Anaesthesiol Scand 1996; 40:561-565.
21. Vangerven M, Van Hemelriick J, Wouters P, et al. Light anesthesia with propofol for paediatric MRI. Anaesthesia 1992; 47:706-707.
22. Frankville DD, Spear RM, Dyck JB. The dose of propofol required to prevent children from moving during magnetic resonance imaging. Anesthesiology 1993; 79:953-956.
23. Frankville D, Spear R, Fisher B, Sheehan P. Is routine endotracheal intubation necessary when using intravenous anesthesia for MRI? [abstract]. Anesthesiology 1992; 77:A1165.
24. Reber A, Wetzel SG, Schnabel K, et al. Effect of combined mouth closure and chin lift on upper airway dimensions during routine magnetic resonance imaging in pediatric patients sedated with propofol. Anesthesiology 1999; 90:1617-1623.
25. Kain ZN, Gaal DJ, Kain TS, et al. A first pass cost analysis of propofol versus barbiturates for children undergoing magnetic resonance imaging. Anesth Analg 1994; 79:1102-1107.
26. Setlock MA, Palmisano BW, Martin LD, et al. Propofol for radiation therapy in small children. Anesth Analg 1992; 75:860-861.
27. Sargent MA, McEachern AM, Jamieson DH, Kahwaji R. Atelectasis on pediatric chest CT: comparison of sedation techniques. Pediatr Radiol 1999; 29:509-513.
28. Serafini G, Cornara G, Cavaloro F. Pulmonary atelectasis during paediatric anesthesia: CT scan evaluation and effect of positive end expiratory pressure (PEEP). Pediatr Anesth 1999; 9:225-228.
29. Zorab JSM. A general anesthesia service for magnetic resonance imaging. Eur J Anaesthesiol 1995; 12:387-395.
30. Cote C, Charles J, Helen W, Notterman DA, et al. Adverse sedation events in pediatrics: analysis of medication used for sedation. Pediatrics 2000; 106:633-644.
31. Worthington LM, Flynn PJ, Strunin L. Death in the dental chair: an avoidable catastrophe? Br J Anaesth 1998; 80:131-132.
32. Seel D. Mortality on the dental chair (UK): 1984-1993. Dental general anaesthesia. Report of a Clinical Standards Advisory Group Committee on General Anaesthesia for Dentistry. London: Department of Health; 1995.
33. Poswillo D. General anaesthesia, sedation and resuscitation in dentistry. Report of an Expert Working Party for the Standing Dental Advisory Committee. London: Department of Health; 1990.
34. Coplans MP, Curson I. Deaths associated with dentistry. Br Dent J 1982; 153:357-363.
35. Coplans MP, Curson I. Deaths associated with dentistry and dental disease. Anaesthesia 1993; 48:435-438.
36. Jastak JT, Peskin RM. Major morbidity or mortality from office anesthetic procedures: a closed-claim analysis of 13 cases. Anesth Prog 1991; 38:39-44.
37. Krippaehne JA, Montgomery MT. Morbidity and mortality from pharmacosedation and general anesthesia in the dental office. J Oral Maxillofac Surg 1992; 50:691-698.
38. Nkansah PJ, Haas DA, Sato MA. Mortality incidence in outpatient anesthesia for dentistry in Ontario. Oral Surg Oral Med Oral Pathol 1997; 83:646-651.
39. Malviya S, Voepel-Lewis T, Eldevick OP, et al. Sedation and general anesthesia in children undergoing MRI and CT: adverse events and outcomes. Br J Anaesth 2000; 84:743-748.
40. Egelhoff JC, Ball WS Jr, Koch BL, Parks TD. Safety and efficacy of sedation in children using a stuctured sedation program. Am J Roentgenol 1997; 168:1259-1262.
41. Lowrie L, Weiss AH, Lacombe C. The pediatric sedation unit: a mechanism for pediatric sedation. Pediatrics 1998; 102:E30.
42. Pohlgeers AP, Friedland LR, Keegan-Jones L. Combination fentanyl and diazepam for pediatric conscious sedation. Acad Emerg Med 1995; 2:879-883.
43. Schwanda AE, Frever DR, Sanfilippo DJ, et al. Brief unconscious sedation for painful pediatric oncology procedures: intravenous metohexital with appropriate monitoring is safe and effective. Am J Pediatr Hematol Oncol 1993; 15:370-376.
44. Green SM, Rothrock SG, Harris T, et al. Intramuscular ketamine for pediatric sedation in the emergency department: safety profile in 1022 cases. Ann Emerg Med 1998; 31:688-697.
45. Freyer DR, Schwanda AE, Sanfilippo DJ, et al. Intravenous metohexital for brief sedation of pediatric oncology outpatients: physiologic and behavioral responses. Pediatrics 1997; 99:E8.
46. Gozal D, Drengrer B, Levin PD, et al. A pediatric sedation anesthesia program with dedicated care by anesthesiologists and nurses for procedures outside the operating room. J Pediatr 2004; 145:47-52.
47. Litman RS, Kottra JA, Verga KA, et al. Chloral hydrate sedation: the additive sedative and respiratory depressant effects of nitrous oxide. Anesth Analg 1998; 86:724-728.
48. Thompson AM, Wright DJ, Murray W, et al. Analysis of 153 deaths after upper gastrointestinal endoscopy: room for improvement? Surg Endosc 2004; 18:22-25.
49. Cohen LB, Wecsler JS, Gaetano JN, et al. Endoscopic sedation in the United States: results from a nationwide survey. Am J Gastroenterol 2006; 101:967-974.
50. Lugay M, Otto G, Kong M, et al. Recovery time and safe discharge of endoscopy patients after conscious sedation. Gastroenterol Nurs 1996; 19:194-200.
51. Lazzaroni M, Bianchi Porro G. Preparation, premedication, and surveillance. Endoscopy 2001; 33:103-108.
52. Iber FL, Sutberry M, Gupta R, Kruss D. Evaluation of complications during and after conscious sedation for endoscopy using pulse oximetry. Gastrointest Endosc 1993; 39:620-625.
53. Nagengast FM. Sedation and monitoring in gastrointestinal endoscopy. Scand J Gastroenterol Suppl 1993; 200:28-32.
54. Byrne MF, Mitchell RM, Gerke H, et al. The need for caution with topical anesthesia during endoscopic procedures, as liberal use may result in methemoglobinemia. J Clin Gastroenterol 2004; 38:225-229.
55. McNicholas WS, Coffey M, Mc Donnel T, et al. Upper airway obstruction during sleep in normal subjects after selective topical oropharyngeal anesthesia. Am Rev Respir Dis 1987; 135:1316-1319.
56. Block R, Jankovski J, Johnston D, Wormsley K. The administration of supplementary oxygen to prevent hypoxia during upper alimentary endoscopy. Endoscopy 1993; 25:269-273.
57. Lamireau T, Dubreuil M, Daconciecao M. Oxygen saturation during esophagogastroduodenoscopy in children: general anesthesia versus intravenous sedation. J Pediatr Gastroenterol Nutr 1998; 27:172-175.
58. Oei-Lim VLB, Kalkman CJ, Bartelsman JFWM, et al. Cardiovascular responses, arterial oxygen saturation and plasma catecholamine concentration during upper gastrointestinal endoscopy using conscious sedation with midazolam or propofol. Eur J Anaesthesiol 1998; 15:535-543.
59. Wolfsen HC, Hemminger LL, Achem SR, et al. Complications of endoscopy of the upper gastrointestinal tract: a single-center experience. Mayo Clin Proc 2004; 79:1264-1267.
60. Clarke GA, Jacobson BC, Hammett RJ, Carr-Locke DL. The indications, utilization and safety of gastrointestinal endoscopy in an extremely elderly patient cohort. Endoscopy 2001; 33:580-584.
61. Lightdale JR, Goldmann DA, Feldman HA, et al. Microstream capnography improves patient monitoring during moderate sedation: a randomized, controlled trial. Pediatrics 2006; 117:1170-1178.
62. Scoping our practice. London: National Confidential Enquiry into Patient Outcome and Death (NCEPOD); 2004.
63. Morello DC, Colon GA, Fredricks S, et al. Patient safety in accredited office surgical facilities. Plast Reconstr Surg 1997; 99:1496-1500.
64. Warner MA, Shields SE, Chute CG. Major morbidity and mortality within 1 month of ambulatory surgery and anesthesia. JAMA 1993; 270:1437-1441.
65. Natof HE. Complications associated with ambulatory surgery. JAMA 1980; 244:1116-1118.
66. Courtiss EH, Goldwyn RM, Joffe JM, Hannenberg AA. Anesthetic practices in ambulatory aesthetic surgery. Plast Reconst Surg 1994; 93:792-801.
67. Keyes GR, Singer R, Iverson RE, et al. Analysis of outpatient surgery center safety using an internet-based quality improvement and peer review program. Plast Reconstr Surg 2004; 113:1760-1770.
68. Reinisch JF, Bresnick SD, Walker JWT, Rosso RF. Deep venous thrombosis and pulmonary embolus after face lift: a study of incidence and prophylaxis. Plastic Reconstr Surg 2001; 107:1570-1575.
69. National plastic surgery statistics. American Society of Plastic Surgeons; 2000-2004.
70. Clayman MA, Seagle BM. Office surgery safety: the myths and truths behind the Florida moratoria: six years of Florida data. Plast Reconstr Surg 2006; 118:777-785.
71. ASA statements on qualifications of anesthesia providers in the office based setting, approved by ASA House of Delegates 13 October 1999 and last affirmed 2004. http://www.asahq.org/publicationsAndServices/Standards/29.pdf. 2004.
72. Grazer F, deJong RH. Fatal outcomes from liposuction: census survey of cosmetic surgeons. Plast Reconstr Surg 2000; 105:436-446.
73. Coleman WP, Hanke CW, Lillis P, et al. Does the location of the surgery or the specialty of the physician affect malpractice claims in liposuction? Dermatol Surg 1999; 25:343-347.
74. Robbertze R, Posner KL, Domino KB. Closed claims review of anesthesia for procedures outside the operating room. Curr Opin Anaesthesiol 2006; 19:436-442. Excellent review of the topic, highlighting the risks coming from the gastrointestinal suite, MRI, computed tomography, angiography and cardiology.
75. Petrini DA, Petrini JL. Risk assessment and management for endoscopists in an ambulatory surgery center. Gastrointest Endosc Clin N Am 2006; 16:801-815.
76. Loeb RG, Jones BR, Leonard RA, Behrman K. Recognition accuracy of current operating room alarms. Anesth Analg 1992; 75:499-505.
77. Samuels SI. An alarming problem [letter]. Anesthesiology 1986; 64:128.
78. Archer DP, McTaggart Cowan RA, Falkenstein RJ, et al. Intraoperative mobile magnetic resonance imaging for craniotomy lengthens the procedure but does not increase morbidity. Can J Anesth 2002; 49:420-426.
79. Fletcher G, Flin R, McGeorge P, et al. Anaesthetists' Non-Technical Skills (ANTS): evaluation of a behavioural marker system. Br J Anaesth 2003; 90:580-588.
80. Atkinson RS. The problem of the unsafe anaesthetist. Br J Anaesth 1994; 73:29-30.
81. Katz JD. Issues of concern for the aging anesthesiologist. Anesth Analg 2001; 92:1487-1492.
82. Abenstein JP, Warner MA. Anesthesia providers, patient outcomes, and costs. Anesth Analg 1996; 82:1273-1283.
83. Silber JH, Kennedy SK, Even-Shoshan O, et al. Anesthesiologist direction and patient outcomes. Anesthesiology 2000; 93:152-163.
84. Cromwell J, Snyder K. Alternative cost-effective anesthesia care t eams. Nurs Econ 2000; 18:185-193.
85. Martin-Sheridan D, Wing P. Anesthesia providers, patient outcomes, and costs: a critique. AANA J 1996; 64:528-534.
86. ASA practice guidelines for sedation and analgesia by non-anesthesiologists. American Society of Anesthesiologists Task Force on Sedation and Analgesia by Non-Anesthesiologists. Anesthesiology 2002; 96:1004-1017.
87. ASA guidelines for non operating room anesthetizing locations (approved by House of Delegates 19 October1994). Park Ridge, Illinois. American Society of Anesthesiologists; 2001; last amended on 15 October 2003. http://www.asahq.org/ publicationsAndServices/standards/14.pdf.2003.
88. Bhananker SM, Posner KL, Cheney FW, et al. Injury and liability associated with monitored anesthesia care: a closed claims analysis. Anesthesiology 2006; 104:228-234.
89. Lalwani K, Kitchin J, Lax P. Office-based dental rehabilitation in children with special healthcare needs using a pediatric sedation service model. J Oral Maxillofac Surg 2007; 65:427-433. Office-based dental rehabilitation using a pediatric sedation service model in disabled children is reasonably safe and obtains average savings of US$4849 per patient, compared with the hospital operating room.
90. Bogdonoff DL, Stone DJ. Emergency management of the airway outside the operating room. Can J Anaesth 1992; 39:1069-1089.
91. Arbous MS, Meursing AEE, van Kleef JW, et al. Impact of anesthesia management characteristics on severe morbidity and mortality. Anesthesiology 2005; 102:257-268.