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The Perils and Pitfalls of Anesthesia Outside the Operating Room
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What is PSA?
Relationship between pain and opioid analgesics on the development of delirium following hip fracture. Fascia iliaca block vs intravenous fentanyl as an analgesic technique before positioning for spinal anesthesia in patients undergoing surgery for femur fractures—a randomized trial. J Clin Anesth. Femoral nerve blocks in fractures of femur: variation in the current UK practice and a review of the literature.
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Comparative effectiveness of pain management interventions for hip fracture: a systematic review. Ann Intern Med. Management of hip fractures in the elderly: evidence-based clinical practice guideline. Accessed August 6, National Clinical Guideline Center. The management of hip fracture in adults. Accessed August 10, Health Quality Ontario. Anesthesia machines and intravenous medication pumps have to be located far away from the patient, requiring a confusing mass of tubing and lines to maintain adequate monitoring and sedation — not to mention posing an occupational hazard to the anesthesia providers themselves.
Procedural team unfamiliar with anesthesia. Cardiology, radiology, and gastroenterology procedures are becoming less invasive but achieving much more — for example, we can now replace an aortic valve from a sheath in the groin. Traditionally, non-anesthesiologists have managed "conscious sedation" on their own with combinations of fentanyl and midazolam, and thus may be unfamiliar with the particular perils of combining propofol with opioids in an unprotected airway. In many cases, MAC may not be the safest approach — especially in the obese patient with a difficult airway.
Anesthesia team unfamiliar with the procedure. Likewise, as new technologies and procedures are being developed every day, it is difficult for the anesthesia team to keep up with what these specialists are doing to their patients.
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Moreover, given the minimally invasive approach of many of these procedures, it is difficult to gauge exactly what is going on. In an open laparotomy or laparoscopic procedure, the anesthesia provider can see exactly what the surgeon is incising, whether a vessel is bleeding, etc.
Anesthesia outside the operating room (EN)
This is not possible with a minimally invasive procedure done with fluoroscopy. Remote area. Many of these procedure suites are located far away from the operating rooms, or even on different floors. As such, help in the form of other anesthesiologists or anesthesia techs may be difficult to access. Transportation of these patients to the recovery area may take a long period of time, requiring high vigilance for patients newly emerging from anesthesia. All of these factors together probably contribute to the difficulties of administering anesthesia outside of the OR.
It is too much to expect hospitals to change the layout and locations of their procedural suites — although many hospitals are now considering installing hybrid operating rooms. Rather, anesthesiologists can focus on three main areas to improve safety in these locations: communication, medication administration, and monitoring.
Early identification of high-risk patients is imperative, and both procedural and anesthetic plans must be discussed amongst all teams. Medication administration. Medication administration must be judicious; as these cases are often minimally invasive with reduced analgesic requirements, single anesthetics such as propofol are often sufficient. Oversedation and hypoventilation are more likely when multiple medications anesthetic, opioid, benzodiazepine are given together.
Monitoring of a hypercapneic patient in the dark cardiac catheterization laboratory or CT scanner can be challenging.
Thus, accessory monitors, such as capnography, are necessary to monitor for adequate ventilation. Pulse oximetry is not sufficient as hypoxemia may be a late sign of hypoventilation. Unfortunately, complications are still going to occur in NORA locations, and subspecialists are going to continue to push the limit of what's possible. Anesthesiologists will be expected to take care of older and sicker patients in these areas. High standards for patient safety must be maintained wherever anesthesia is administered.