MINERVA ANESTESIOL 2005;71:325-34

A
IC
Morbidity and mortality related
to anesthesia outside the operating room

D
C. MELLONI

GH E

M
Morbidity and mortality related to sedation or Anestesia and Resuscitation Service
anesthesia outside the operating room has not Civil Hospital Faenza, Ravenna, Italy
been investigated so far, but it is assumed to

T
be a relevant problem because the increasing
needs for sedation/analgesia in remote loca-
tions for a wide range of diagnostic and oper- around the country that locations outside the
A

ative procedures (endoscopy, radiology, mag- OR and where anesthesia is occasionally pro-
netic resonance...) and the lack of monitoring,
inadequate training of personnel,insufficient
vided tend to be without any special equip-
ment for anesthesia and resuscitation or tend
PY V

staffing. Many complications could occur to

patients, like anaphylactic shock,accidental to be equipped with old machines,sometimes
hypothermia,difficult airway maintenance, obsolete and become unfamiliar even to the
aspiration,nausea and vomiting, and anesthe- anesthesiologists practicing in the very same
R

siologists, like exposure to pollution, radia- facility;

RI

tion, electromagnetic fields, falls and trauma.

Recent guidelines and personal experience are 2) personnel in the radiology dept or
presented and discussed. endoscopy are not familiar with anesthesia
CO NE

Key words: Treatment, outcome - Mortality -
Morbidity - Anesthesia outside operating room.
F or the purpose of the present lecture,I
could not find any relevant article dealing
exactly with this topic and therefore there is
I
and its complications and are less able to help
in case of emergencies, so that, in general,
there is less skilled people helping the anes-
thesiologist,who is, therefore,more or less
working alone. Since the greater impact on
morbidity and mortality seem to derive more
from proper monitoring,experience and train-

certainly a great need of this kind of infor- ing of staff and modifications in the perioper-
ative management than from choice of anes-
M

mation;however I suspect that morbidity and

mortality outside the operating room (OR)
(non operating room anesthesia, including
sedation and anesthesia) could be greater
than morbidity and mortality in the OR for the
following reasons:
1) it has been my experience travelling
Address reprint requests to: C. Melloni, Servizio di Anestesia
e Rianimazione, Ospedale di Faenza, viale Stradone, 48018
Faenza, Ravenna.
thesia techniques, these are the elements that
support the clinical impression outlined above.
However selected surgical procedures or
patient groups may benefit from specific anes-
thesiological approaches, like epidural anes-
thesia for peripheral vascular surgery;1 region-
al anesthesia for operative obstetrics,2 region-
al anesthesia for carotid endarterectomy;3
3) for the anesthesiologist the place can
be hazardous,in the sense that he/she is at

Vol. 71, N. 6 MINERVA ANESTESIOLOGICA 325

MELLONI MORBIDITY AND MORTALITY RELATED TO ANESTHESIA OUTSIDE THE OPERATING ROOM
best unfamiliar with the surroundings; drug
and instruments supplies are located in dif-
ferent places and very often the environ-
ments are scarcely lit and may be full of
equipment with difficult access to the patient
in case of need, the typical example being
magnetic resonance imaging (MRI) or sound-
proof places for hearing physiology exami-
nation, where the attending anesthesiologist
has to remain outside a closed door without
physical contact with the patient. It happens
D
all the time that the anesthesiologist himself
is more accident prone, especially for falls
due to cables or head trauma because of
GH E
unexpected obstacles during movements
around an unknown dimly lit place. Alternate
anesthesia locations might represent the ide-
M
al area for studies focusing on human errors
and performances according to the pio-
T
nieering work done by Cooper et al.;4
4) the emphasis on minimal monitoring is
very rarely met in remote locations, even
A
where sedation is routinely applied (endo-
scopy); because appropriate monitoring has
been identified as an important factor in the
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prevention of critical incidents and capable to
reduce the rate and gravity of complications
5 the implementation of monitoring in remote
locations is mandatory, with or without seda-
R
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tion/anesthesia.
A recent enquiry in the field of MRI has
collected data from 182 units in the USA:6
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patients treated were 2 045 954; cardiorespi-
ratory arrest occurred in 33, with 11 deaths,
giving a frequency of 16.1/1 000 000 MRI,
i.e. 5.3 deaths /1 000 000 MRI.
On the other hand there are no reasons to
believe that the patients case mix will be dif-
ferent between ordinary OR and remore loca-
I
tions, because patients presenting for diag-
M
nostic or other procedures are the same who
will be later operated upon in the OR; in
extreme cases, like politrauma patients in
shock, they could be treated and anesthetized
first in the radiology department and then
brought to the OR. In these cases it would be
difficult to separate morbidity and mortality
between remote locations and theaters,
because it is the continuum of care that influ-
ences the outcome and locations are therefore
difficult to evaluate in term of the more recent
326 MINERVA ANESTESIOLOGICA
reports on morbidity and mortality in anes-
thesia. The more comprehensive work ever
A
published (NCEPOD).7
5) There is controversy about who should
or could provide sedation/anesthesia cov-
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erage in remote locations; nurses have been
more and more enrolled for this purpose
with excellent results and an enviable record
of safety: 8 MRI examinations were com-
pleted in 93.5% of cases and time spent to
sedate patients was within acceptable ranges
(23.615.2 min for specialized MR nurses,
26.8 20.1 min for general radiology nurses
while inpatients nurses: took 47.3 + 36 min).
These good results (and other)determined a
new figure: the sedationist nurse! Many oth-
er factors have contributed to the successess
quoted, like,9 improvements in the ergonomy
of the area, with the sedation area near the
scanner, the presence of a designated seda-
tionist (nurse). Nurse were also involved in
the screening of patients as candidates for
sedation; and sedation was refused according
to protocol.
The brilliant results outlined prompted an
Editorial,10 but this organization raises the
issue of quality of care and outcome. In anes-
thesia a very provocative series of articles 11
originated a hot debate: this report has pre-
sented a review of anesthesia services and
the patient care and cost implications of these
services; starting from the declaration that
the scope of anesthesia care extends far
beyond the common misperception of
putting the patient to sleep, as a conse-
quence Anesthesiology is a complex med-
ical discipline that requires the constant vig-
ilance of well-trained and experienced
providers; this is probably the more important
reason why complications from anesthesia
have declined dramatically over the last 50
years, so that it is now as safe to be anes-
thetized as to be a passenger in an automo-
bile (Based on 1993 Minnesota Department of
Transportation data; personal communica-
tion, 1994). Many factors have contributed
to improvements in outcomes, but the pres-
ence of board-certified anesthesiologists has
been associated with the decline in death
and disability commonly attributed to adverse
perioperative events. The anesthesia care
Giugno 2005
MORBIDITY AND MORTALITY RELATED TO ANESTHESIA OUTSIDE THE OPERATING ROOM
team and hybrid practices appear to be the
safest methods of delivering anesthesia care.
This safety may be due, in part, to the rapid
availability of physicians, especially during
medical crises. When the data are critically
examined, the evidence is very supportive
that the anesthesiologist-led anesthesia care
team is the safest and most cost-effective
method of delivering anesthesia care. At this
time, public policy decisions should encour-
age the development of anesthesia care teams
D
where none exist, particularly in the rural
areas, and assure the continued utilization
of this patient care model. Within the same
GH E
line of reasoning the paper by Silber et al.11
demonstrated that adjusted odds ratios for
death and failure-to-rescue were greater when
M
care was not directed by anesthesiologists
whereas complications were not increased.
T
The authors concluded that both 30-day mor-
tality rate and mortality rate after complica-
tions (failure-to-rescue) were lower when
A
anesthesiologists directed anesthesia care.
The reasons behind nurses organization
instead of physicians are most probably eco-
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nomic, since nurses tend to cost less.12, 13
Moreover nurses are more attentive to
schemes and protocols and might be more
manipulated toward economy. The articles
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quoted have been heavily criticized 14 and I
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am sure that the debate will go on for a while,
at least in countries where CRNA are abun-
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dant and well trained.
It is true that the administration of sedation
could not be restricted to anesthesiologists;
every practicioner should be able to admin-
ister sedative and hypnotics titrated to effect;
however the problem has become so seri-
ous that the ASA has been obliged to publish
I
a report on Practice Guidelines for Sedation
M
and Analgesia by Non-Anesthesiologists.15
These guidelines have been endorsed by
The American College of Radiology, The
American Association of Oral and Maxillo-
facial Surgeons, and The American Society
for Gastrointestinal Endoscopy.
6) A point can be raised about produc-
tion pressure 16 and anesthesia in remote
locations could pass often underestimated
by the anesthesiologists themselves, being
rated as minor and therefore considered a
Vol. 71, N. 6 MINERVA ANESTESIOLOGICA
MELLONI
minor task, a nuisance, that is not so is
demonstrated by the frequent incidents
A
reported in the newpapers and the discon-
certing numbers quoted in;17 the authors
found 118 cases of death or severe damage
in sedated children, not associated with any
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general category of drug nor with route of
administration. The complication rate was
higher with 3 or > sedation medications and
12 pts suffered at home or in auto;chloral
hydrate being the drug most frequently
involved. Between type of procedures the
dental specialists were overrepresented: 39%!
A closed-claim analysis of anesthetic-related
deaths and permanent injuries in the dental
office setting conducted in cooperation with
a leading insurer of oral and maxillofacial
surgeons and dental anesthesiologists 18 found
a total of 13 cases occurring between 1974
and 1989. In each case, all available records,
reports, depositions, and proceedings were
reviewed. For each case were determined :
preoperative physical status of the patient,
anesthetic technique used (classified as either
general anesthesia or conscious sedation),
probable cause of the morbid event, avoid-
ability of the occurrence, and contributing
factors important to the outcome. The major-
ity of patients were classified as American
Society of Anesthesiologists (ASA) status II
or III. Most patients had preexisting condi-
tions, such as gross obesity, cardiac disease,
epilepsy, and chronic obstructive pulmonary
disease; hypoxia arising from airway obstruc-
tion and/or respiratory depression was the
most common cause of untoward events, and
most of the adverse events were determined
to be avoidable. The disproportionate num-
ber of patients in this sample who were at the
extremes of age and with ASA classifications
below 1 suggests that anesthesia risk may be
significantly increased in patients who fall
outside the healthy, young adult category
typically treated in the oral surgical/dental
outpatient setting. From the other part this
is the typical occurrence of patients present-
ing for many other procedures outside the
OR, underlining again the difficulty of screen-
ing patients in the current care setting.
In conclusion, I am expecting human errors
to occur more frequently in anesthesia done
327
MELLONI MORBIDITY AND MORTALITY RELATED TO ANESTHESIA OUTSIDE THE OPERATING ROOM
in remote locations , considering all the con-
founding factors mentioned above and the
existence of many other factors frequently
associated with incidents like inadequate
communication among personnel, haste or
lack of precaution, and distraction.
Expected complications
D
Anesthesiologists harm
Again I was unable to find any relevant
article dealing with accidents or incidents
GH E
occurring to anesthesiologists while work-
ing in remote locations in comparison with
the Ors; exposure of anesthesiologists to envi-
M
ronmental dangers has been studied appar-
ently only for OR.
I am expecting an increase in the expo-
T
sure to electromagnetic fields since many of
the anesthesia outside the operating room
(OORA) are in fact producers of EMF and
A
normal OR are already often in excess over
2-3 mg, a value accepted as safe.19
Although the health hazards related to EMF
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exposure are still equivocal, anesthesiolo-
gists should consider making an effort to
improve their environment and reduce their
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exposure to EMF.
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Contamination/pollution
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Since many emote locations have no pro-
vision for gas scavenging,the use of inhala-
tional anesthesia in these areas will certainly
cause higher levels of exposure to inhalation
agents for all personnel present, so that a clear
indication exists for total intravenous seda-
I
tion/anesthesia. Difficulties with IV access,
especially in the paediatric age group,could
M
however justify the presence of all the equip-
ment for inhalational anesthesia. As a matter
of fact,once that the place is equipped,it should
include the possibility to choose whatsoever
anesthesia/sedation available.
Hypothermia
Monitoring of temperature is rarely employ-
ed in OR, and it is not surprising that it would
be absolutely exceptional in NORA. I believe
328 MINERVA ANESTESIOLOGICA
that hypothermia would occur frequently
because very often the remote locations
A
(especially XR and MRI departments) are
heavily air conditioned due to the need to
avoid excess heat for the equipment and
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therefore it is reasonable to expect a vast
majority of patients to became hypothermic
if exposed long enough to the ambient air in
these areas,especially children. The only
exception could be MRI, where substantial
warming of the patient inside the magnet
could occur, especially children , because
the heat dissipated by the strong magnetic
field. Temperature monitoring in the MRI
environment is very difficult because the risk
of burns and equipment malfuntion so that
checks could be intermittent and miss the
diagnosis.
Accidental hypothermia has many unto-
ward side effects, some of which very dan-
gerous 20 as a consequence the patient should
be protected in any possible way,kept cov-
ered until the very last minute that the exam-
ination /procedure starts and every effort
should be directed toward the maintenance
of thermal homeostasis,including warming
blankets with surface air heating and heating
of fluids if administered in large quantities.
Special care should be provided for children
and neonates.If the warming equipment
could not be used for some reason (i.e.
incompatibility with the magnetic field) a
useful trick could be the preemptive warm-
ing of the patient in the holding area. One to
2 h of forced-air prewarming has been shown
to reduce redistribution hypothermia asso-
ciated with induction of general anesthesia in
volunteers 21 and patients.22 In general, pre-
warming reduces afterdrop by a factor of
two. As a result, most prewarmed patients
remain normothermic (core temperature >36
C), whereas those who were not warmed
become hypothermic after 1 h of anesthe-
sia.An additional advantage is that warming
induces vasodilation, which facilitates inser-
tion of intravenous and arterial catheters.
Aspiration of gastric content, regurgitation
Every patient where protective airway
reflexes are obtunded by sedative/hypnotics
Giugno 2005
MORBIDITY AND MORTALITY RELATED TO ANESTHESIA OUTSIDE THE OPERATING ROOM
or analgesics is at risk for aspiration and there-
fore in case of sedation /anesthesia the
patients should be prepared as is customary
for elective surgery, with the additional prob-
lem that many patients are outpatients and
there is no warranty that they followed the
instructions given (if any...). At the moment
the general consensus for preop fasting has
become that clear fluids are allowed until 2
hours before the induction of anesthesia/
sedation, while solids are withheld for at least
D
6 hours and 8 hours if the meal included
fried food or meat.23
An additional problem is represented by
GH E
patients prepared for colonoscopy , where up
to 3-5 l of fluids are given for bowel prep with
a serious potential for regurgitation;24 again
M
this risk has not been quantitated exactly.
Hypovolemia
T
Patients prepared for colonoscopy or X-ray
of the intestine (barium enema etc.) have
A
often been subjected to a strict diet and
purged repeatedly; in these cases the poten-
tiat risk of serious hypotension following
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induction with drugs possessing vasodilata-
tory or cardiac depressant actions has to be
anticipated and care taken toward preven-
R
tion. Slow injection of the drugs, plus a gen-
RI
erous prehydration before induction is gen-
erally sufficient and it is wise to maintain a
good hydration.
CO NE
Airway
Difficulties in airway management consti-
tute the first cause of malpractice against
anesthesiologists and death or severe brain
damage are the catastrophic consequences
I
of undiagnosed hypoventilation and/or
M
apnea. The closed claims report 25 empha-
sizes the need for a thorough evaluation of
the airways and suggests the need for a con-
tinuous monitoring of ventilation and oxy-
genation. It is therefore evident that anes-
thesia or sedation in remote locations should
be followed by more frequent occurrences of
respiratory depression tantamount more dan-
gerous because of the lack of recognition of
the problem, the lack of a proper training of
the staff and the absence of a structured plan
Vol. 71, N. 6 MINERVA ANESTESIOLOGICA
MELLONI
of treatment, including the use of an algory-
thm for the emergency treatment of the air-
A
way 26 to whom the use of LMA was more
recently added.27 In a recent report 10% of the
anesthesiologists of the Oxford region admit-
ted not having a personal plan for an alter-
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native emergency airway management;28
Brimacombe suggested guidelines for difficult
airway management in remote locations and
analyzed the reason for the preference for
LMA.29
It is my opinion that every place where
sedation is employed should be equipped
with at least two different options in case of
difficulties with airway management. In gen-
eral the LMA would offer superior safety
because it does not require special skills in
comparison with tracheal intubation;it is faster
and more effective even in the hands of inex-
perienced personnel.30
The LMA was inserted rapidly and effec-
tively by dentists inexperienced in airway
management after a short period of simple
training ;that may be critical when personnel
experienced in intubation are not readily
available.
Intubation skills require a long training 31
and a continuous rehearsal in order to be
reasonably successful in a limited amount of
time.
Unfortunately some of the diagnostic tech-
niques where anesthesia coverage is occa-
sionally requested, like esofagogastroscopy,
exclude the use of the LMA and therefore
there are not many other options,especially
so for non anestesiologists.
The provision of extra oxygen is always
wise and should never be negated to any-
body subjected to sedation /analgesia or anes-
thesia; oxygenation could be achieved even
in the absence of ventilation provided that the
airways are patent. A pre-oxygenation for 3
min in normal patients 32 reaches a 95% den-
itrogenation of the lungs, but this time inter-
val should be more prolonged in severe
emphysematous lungs.33 These techniques
prolong the time to dangerous desaturation
in cases of apnea and/or difficult airway
maintenance and are stronlgly recommeded
before administration of sedation/anesthe-
sia.34
329
MELLONI MORBIDITY AND MORTALITY RELATED TO ANESTHESIA OUTSIDE THE OPERATING ROOM
Allergies and anaphylactic shock
Reactions to radio contrast media (RCM)
are well documented.35 Most case reports
concern diagnostic radiological procedures
without general anesthesia. Mild adverse reac-
tions, mostly vasodilatation, occur in 3% of all
contrast radiological examinations, but it is the
idiosyncratic anaphylactoid reactions that
may be fatal and which cause the greatest
clinical concern. Few case reports describe
D
systemic anaphylactic reactions mediated via
antigen-specific IgE antibodies formed from
previous exposure to RCM, but the reactions
GH E
are thought to have mainly an anaphylactoid
character.36 There are 2 groups of RCM: ion-
ic, hyperosmolar (1500 mOsm kg-1) or first
M
generation solutions, and the newer, second
generation, non-ionic, hypo- and iso-osmo-
lar (350-700 mOsm kg-1) agents. It is widely
T
accepted that the first-generation RCMs are
more toxic and more immunogenic and
therefore responsible for a higher morbidity,
A
including allergic reactions.
There is emerging evidence, however,37
that some of the newer non-ionic hypo-osmo-
PY V
lar RCMs can trigger a true anaphylactic reac-
tion, directly activating IgE antibodies.
Iopamidol and ioversol, for example, have
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chemical structures that resemble the mirror
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molecules of succinylcholine and other neu-
romuscular blocking agents. They have two
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identical side-chains containing quaternary
ammonium groups which can cross-link to
IgE molecules. In theory, these new RCM
could be more immunogenic than the older
first generation ionic hyperosmolar solutions,
but there are insufficient data to confirm this.
However, new preparations have significantly
I
lower overall toxicity and fewer side-effects.
In 1970, Ansell 38 reported life-threatening
M
reactions to the first generation ionic con-
trast agents in 0.01-0.02% of all radiological
examinations but more recently the incidence
of a fatal outcome has been reported in only
1 in 40 000 administrations.39 In 1992,
Lieberman 40 reported an incidence of severe,
but not necessarily fatal, anaphylactoid reac-
tions in 1-2% of all contrast studies, perhaps
attributable to the growing number of radio-
logical investigations and previous under-
330 MINERVA ANESTESIOLOGICA
reporting of adverse reactions. With the intro-
duction of the new generation of non-ionic,
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low-osmolar RCM, this risk has been reduced
5-10 fold.41
Iohexol (Omnipaque) is another new, sec-
ond generation RCM. It is the most frequently
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used x-ray contrast medium for arteriogra-
phy, cardioangiography, urography, hys-
terosalpingography, gastrointestinal tract and
CT investigations. It is a non-ionic, monomer-
ic, tri-iodinated, water-soluble, isotonic solu-
tion containing iohexol 140-350 mg ml-1. It is
almost 100% excreted unchanged through
the kidneys within 24 hour of administration.
It is less than 2% protein bound and has no
detectable metabolites.
Many cases of severe allergic/anaphylactic
reactions to contrast medium under general
anesthesia and during a major surgical inter-
vention have been described 42 often diffi-
cult to diagnose because the simultaneous
presence of many confounding factors,like
delay of occurrence, lack of some signs of an
acute allergic reaction (e.g. bronchospasm,
histamine release), which may make the
recognition of anaphylactic shock very diffi-
cult. Furthermore, the time of the reaction
coincided with surgical manipulation of the
aorta, when aortic rupture is particularly dif-
ficult to exclude.
Since GA might mahe diagnosis of ana-
phylactic shock more difficult,we agree that
any awake (central or peripheral nerve block-
ade) anaesthetic technique would contribute
to a quicker recognition of an adverse aller-
gic reaction and therefore prompt more
immediate resuscitation as underlined in a
recent case report.43, 44
Therefore every X-ray dept should have
all the drugs necessary for the treatment of
allergy and shock, including an O2 source,an
emergency tray for drugs and resuscitation
equipment and a plan of treatment .
Patients with an history of allergies or atopy
should receive a antihistamine prophylaxis
pluscortisone (H1+H2 blockers + prednisone
for instance), but there is no scientific proof
that this practice would really protect the
patient. The opinion of an eminent review
article 45 was that there is little benefit in pre-
medicating allergic patients with histamine I
Giugno 2005
MORBIDITY AND MORTALITY RELATED TO ANESTHESIA OUTSIDE THE OPERATING ROOM
and histamine II blockers or corticosteroids
before surgery or anesthesia . Although they
could minimize the severity of anaphylaxis,
these drugs may also blunt the early signs of
anaphylaxis, leaving a full-blown episode as
the presenting sign. These drugs should be
reserved for the early treatment of anaphy-
laxis.
Other accidents have been reported from
drugs or syringe swaps (personal communi-
cation): KCl instead of NaCl; this again con-
D
firms the need for proper training of techni-
cians and nurses.
PONV
GH E
The avoidance of PONV is of paramount
M
importance because it is the first or second
problem that all patients confess they would
do their best to avoid, very often more than
pain.46
T
PONV contributes to patient dissatisfac-
tion and prolongs the hospital stay and it is
A
one of the first causes for unplanned patient
admission to the hospital following day
sugery, thereby increasing hospitalization
PY V
costs and inconvenience for the patient.
Patients at risk of ponv can be identified
(female sex, young age, certain procedures,
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non smoking status, previous history of kine-
RI
tosis or ponv).47
A very simple score has been construct-
CO NE
ed:48 the final score consisted of 4 predic-
tors: female gender, history of motion sick-
ness (MS) or PONV, nonsmoking, and the
use of postoperative opioids. If none, one,
two, three, or four of these risk factors were
present, the incidences of PONV were 10%,
21%, 39%, 61% and 79%.
I
Every effort should be undertaken to treat
M
the symptoms as soon as they appear and
to apply a pharmacologic prophylactic reg-
imen in the patients at risk with a combi-
nation therapy,including desamethazone,
ondan-setron like agents and avoiding,if
possible, emetogenic drugs like opiates,eto-
midate.49, 50
Because pain does not accompany many of
the procedures in remote locations,at least
the use of opiates could be avoided and pref-
erence given to drugs possessing intrinsic
Vol. 71, N. 6 MINERVA ANESTESIOLOGICA
MELLONI
antiemetic properties,like propofol for seda-
tion/hypnosis or FANS for mild discomfort
A
or pain
Metoclopramide has not proven to be effi-
cacious 51 while H I blockers could contribute
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to the antiemetic effects decreasing the quan-
tity of the gastric juice and an the same time
offering extraprotection against aspiration
,providing that there should be enough time
for the peak action of the drug before the
procedure.
Because PONV could be elicited by
vestibular stimulation due to early ambula-
tion, patients should be invited to lay still
after the procedure until they feel fit to leave
and every movement should be accom-
plished with calm adopting the upright pos-
ture in steps; orthostatic hypotension can be
treated with vasopressors (ephedrine, Effortil)
at the same time avoiding disturbing visual or
olphactory stimuli .
Technique or procedure related complica-
tions
Perforation of the bowel during colonosco-
py may be increased due to the lack of the
subjective symptoms of impending perfora-
tion in an anestethized patients ;however
colonoscopy with a sedated or anesthetized
patient could contribute to a more relaxed
examination without haste from the part of
the surgeon and therefore contribute to bet-
ter diagnosis and localization of lesions,
notwithstanding the gratitude of the patients.
MRI has a peculiar range of complications
linked to the existence of the strong mag-
netic field,with missile being attired into the
magnet ,like needles,pumps,chairs ,and cat-
astrophic incidents with oxygen tanks.
Transferring patients from stretchers or
chairs to X-ray tables represents often a prob-
lem and injuries have followed from falls,slip-
ping, improper positioning on non padded
surfaces etc. We recommend the use of slid-
ing mattresses, proper padding of all areas of
the body of the patient in contact with hard
surfaces and extreme attention to movements
of the X-ray table, because injuries may occur
in areas different from those in contact of
the table due to the translation required by
331
MELLONI MORBIDITY AND MORTALITY RELATED TO ANESTHESIA OUTSIDE THE OPERATING ROOM
the technique,the classical example being
elbow hitting the gentry inside the CT scan for
thoracic imaging. The closed claim analysis
reveals 52 a wide spectrum of lesions ,with
ulnar neuropathy representing 1/3of all nerve
injuries; less-frequent sites of nerve injury
were the brachial plexus (23%) and the lum-
bosacral nerve roots (16%). In a large pro-
portion of cases, the exact mechanism of
injury was unclear despite evidence of inten-
sive investigation in the claim files.
D
It is very interesting to note that the closed
claims reviewers judged that the standard of
care had been met significantly more often in
GH E
claims involving nerve damage than in claims
not involving nerve damage;knowing the
scarce attention paid to positioning oustide
the OR.
M appropriate use of the described monitoring
I would be very curious about nerve dam-
T
age in X-ray departments and alike,where
patients lay often on very hard surfaces for
prolonged periods.
A
The need for remote monitoring
The recognition of the problems of seda-
PY V
tion and anesthesia in remote location has
prompted many Scientific Societies 53 and
the SIAARTI between them 54 to emanate
R
guidelines. In general, the consensus has
RI
been that locations where sedation/anes-
thesia is administered should be equipped
CO NE
and provided with the same standards of
the regular Ors. It is also clear that special
locations like MRI need special equipment
either inside or outside the room ,defining
more precisely the opportunity for remote
monitoring.
Remote monitoring of the patient should be
I
as more complete as more distant should the
M
anesthesiologist remain during the procedure
and from this point of view CO2 and SAO2 are
probably more important than otner moni-
tors.55
Standards for monitoring are intended to
encourage quality patient care, which are
consistent with the ASA Standards for Basic
Anesthetic Monitoring.56 The ASA has pub-
lished guidelines for non-OR locations and
guidelines for office-based anesthesia.57, 58
These guidelines are minimal requirements,
332 MINERVA ANESTESIOLOGICA
and the anesthesiologist may exceed these
at any time based on the clinical judgment.
A
These ASA guidelines should be used in
conjunction with other ASA standards that
are applicable to anesthesia provided outside
IC
the OR, including the Guidelines for
Ambulatory Anesthesia and Surgery. 59
These standards apply to all anesthesia care
(MAC, regional and general anesthesia) and
in all environments. It should not come as a
surprise that anesthesia monitoring outside
the OR is no different than inside the OR.
The difficulty lies in adapting the environ-
ment and personnel to the single standard of
care. In certain rare or unusual circum-
stances, some of these methods of moni-
toring may be clinically impractical and
methods may fail to detect untoward clini-
cal developments.
Since the best monitor is the dedicated and
vigilant anesthesiologist (or nurse sedationist),
we as professional could not delegate the
responsability to foster safety for patients in
areas outside the operating room ,either for
sedation /anesthesia or without and armed
with our expertise should help develop
guidelines for the upgrading of education
and monitoring.
Riassunto
Morbidit e mortalit correlate allanestesia sommi-
nistrata in sedi diverse dalla sala operatoria
La morbidit e la mortalit correlate alla sedazio-
ne o allanestesia eseguite in sedi diverse dalla sala
operatoria non sono ancora state studiate, ma si pen-
sa che rappresentino un problema rilevante a causa
dellaumentata necessit di somministrare sedazio-
ne/anestesia in luoghi disagiati per un ampia gamma
di procedure diagnostiche ed operatorie (endoscopia,
radiologia, risonanza magnetica) e per la mancanza
di monitoraggio, linadeguato addestramento del per-
sonale, la carenza dello staff. Molte sono le compli-
canze possibili per i pazienti, quali lo shock anafilat-
tico, lipotermia accidentale, difficolt a mantenere
la perviet delle vie aeree, laspirazione, la nausea e
il vomito. Per gli anestesisti si pu avere esposizione
alla polluzione, alle radiazioni, ai campi elettroma-
gnetici, alle cadute e ai traumi.
Parole chiave: Trattamento, risultati - Morbidit -
Mortalit - Sala operatoria.
Giugno 2005
MORBIDITY AND MORTALITY RELATED TO ANESTHESIA OUTSIDE THE OPERATING ROOM
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