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Steven c. Hall, MoD. Associate Professor of Cliniall AneSthesiology Northwestern University Mediall Cent~ Children's Memorial Hospital Chicago, Illinois 60614

The first pediatric anesthetic in the United States was administered by Crawford Long of Georgia in 1842.1 The ether anesthetic was given in a general practitioner's office, without the benefits of extensive monitoring, intravenous fluids, documentation of vital signs, or designated postanesthetic recovery facilities. Our practice has changed drnrnatically since Dr. CraWford's early experiences, with the overwhelming majority of pediatric anesthetics now administered in well-equipped and -staffed operating rooms under strictly controlled conditions. Today, anesthesiologists also are asked increasingly to provide sedation or general anesthesia outside the traditional operating room environment.

Because of our expertise in patient evaluation, adequate monitoring, and administration of drugs as well as our complete approach to the needs of sedated patients, anesthesiologists should be able to provide superior conditions for a variety of painful or uncomfortable procedures. Physicians responsible for cardiac catheterization, magnetic resonance imaging (MRI) examinations, invasive radiography, emergency room care, and many other procedures have found their anesthesia departments to be valuable resources for both clinical service and advice about reasonable methods of sedation and alternatives to general anesthesia (Table 1). These practitioners also have found that an efficient anesthesiologist actually can decrease the total time needed to perform some procedures by providing a cooperative or immobile patient.

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Perhaps the greatest strength we anesthesiologists bring to the care of patients outside the operating room is our appreciation of the need for a comprehensive approach to patient care. Preanesthetic evaluation, proper medication selection, fasting or "nothing-by-mouth" decisions, monitoring, postanesthetic care, and follow-up are inherent aspects of our routine approach to patients.

Unfortunately, this comprehensive approach is not necessarily routine practice outside our profession. Many nonanesthesia practitioners do not use a systemic approach to patients, which requires attention to patient selection, extensive monitoring and recording of vital signs during sedation, and evaluation before discharge. There are two definite advantages to anesthesiologists' becoming more involved in providing service outside the operating room. First, patients are assured a high level of care when sedated or anesthetized. Second, as nonanesthesiologists involved in care of

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Comprehensive Approach to Care

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Computer tomographic scanning

Magnetic resonance imaging scanning Invasive radiography Radiation therapy Ultrasonography Kidney biopsy

Cardiac catheterization

Cardiac echocardiography Neonatal Intensive Care Patent ductus ligation

Repair of congenital diaphragmatic hernia Closure of gastroschisis

Emergency room

Fracture reduction

Bone marrow aspiration

TABU;: 1

Potential Anesthetizing Sites Outside the Operating RO()ff'

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sedated patients become more aware of approaches we use for these situations, we can communicate principles and methods that can then be used successfully when the pres~nce of an anesthesiologist is not warranted.

&1ablishing Protocols ~enever administration of anesthesia is contemplated, in or outside the operating r()4)m, it is important for the anesthesia se1Vice to survey both the needs of the particular pn)Cedure and the facilities available. After the consulting se1Vice's needs have been identified, it is possible to discuss the ability of the anesthesia department to assist in providing coverage.

To define and guide the various aspects of patient care, it is useful to develop pnJtocols with the consulting se1Vice (Table 2). These protocols are developed by in"olving anesthesia, nursing, and other involved physicians and techni(:al staff to facilitate communication among personnel involved in patient care. Altho,ugh every institution is different, certain issues should be addressed. The most common protocols developed concern appropriate patient selection, time and method of scheduling, apIpropriate number of cases per day, required laboratory work, and required history-

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Fasting and NPO times

Scheduling and notification of family

Responsibility for preprocedure history and physical examination Responsibility for labol(l1ory work (if needed) "c Responsibility for informed consent (if needed) Minimum personnel requirements

Are nursing or auxiliary staff needed?

Does physician of consulting selVice need to be present? ~\f~) Postanesthesia recovery (where and by whom?)

"","cy Postprocedure pain relief. , "~ "

Qualityassurance c A'!.,frl~, ; ,", ,

Discharge criteria and instructions .);

Management of complications, including unexpected admission~i~ Responsibility for postprocedure follow-up i~!

TABLE 2.

Protocols for Anesthesia Outside the Operating Room

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and-physical examination. nle anesthesia service must decide if American Society of Anesthesiologists classification 3 or 4 patients can be anesthetizeQ and, if so, what special consultations or laboratory work are required. An example is the child with asthma. A5thma is a common problem in young children, and policies should be developed and understood about preanesthetic bronchodilator therapy, drug concentrations, and steroid preparation. Another example is the preterm infant Although preterm infants less than 46-60 weeks postconceptual age will not commonly be anesthetized outside the operating room, policies about overnight admission of these patients should be clearly established.

Polides about fasting have' changed dramatically in the last few years. Clear liquid administration up unti12-3 h l)efore anesthesia often is acceptable now.2.3 It is reasonable to do the same outside the 'operating room, though capricious scheduling can make this difficult One specific problem with fasting and sedation is the fact that ornl contrast material is necessary for rnaJly abdominal radiologic examinations. Administration of significant volumes of fluid in a child deprived of protective reflexes can put the patient at risk for aspiration. If only "light" or "conscious" sedation is used, there is still a risk that this Will progress to ,deeper sedation with obtundation of reflexes. As sedation progresses toward anesthesia, the physician in charge of sedation must be aware of the patient's potential full stornach and its risks.

Two areas often overlookecl when anesthesia is given outside the traditional operating room environment are postaJlesthetic follow-up and quality assur.mce. Not only must parents have detailed instructions at discharge, as in the operating room, but there should be the same follow-up as after a standard surgical procedure. In many institutions, outpatient surgery patients are evaluated with follow-up calls the day after surgery. Patients given anesthesia outside th,e operating room should receive the same attention. Anesthetics given outside the operating room should be subjected to the same quality assur.mce investigation and rrumagement as are those in the operating room environment

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As anesthesiologists increasingly move to sites outside the operating room, it has become obvious that several areas pose recurrent difficulties. These problems can be divided into four general categories:

1. ,Equipment-related problems;

2. Patient-related medical problems;

3. Challenges related to anc~etic or sedation technique; 4. Administrative and politi,ca! problems.

Examples of each of these aJ"eas will be discussed, along with some potential solu,tions.

Challenges in Ane'sthetic Care outside the Operating Room

Equipment and Space Umitations The first area usually addressed is the physiCll facility to be used. Although it is possible to use completely l=K>1table equipment, it is helpful to have piped oxygen, suction, and nitrous oxide a~ailable. Two often overlooked features are adequate and appropriate electriCll outlets and a method for scavenging waste anesthetic gases. Adequate space for preanestl1letic evaluations, parent waiting, postanesthetic recovery, and storage must be identifieCL

If equipment such as a standard anesthesia machine and monitors are to be used, consideration is given to traJ1sport of that equipment to the anesthetizing location.

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For instance, if a standard anesthesia machine is top heavy and tips easily, the installation of larger-than-normal, hard-rubber wheels on a broadened base will increase its stability.

An example of the need for special monitoring and anesthetic equipment is sedation or general anesthesia administered in an MRI scanner.

Magnetic Resonance Imaging. Magnetic resonance imaging has become increasingly popular for evaluation of lesions in childhood, but MRI examinations present several unusual problems to the radiologist and anesthesiologist. First, MRI studies are longer than standard radiologic techniques. Because of longer periods of examination and the need for minimal patient movement, deep sedation or general anesttlesia is more commonly used. Second, the patient in the imaging coil is physically re'moved from obselVers, making direct monitoring difficult. The obselVer must rely on electronic or physical monitors to assess adequate cardiopulmonary stability. Commonly used monitors include electrocardiograph, indirect blood pressure, pulse oximetry, and chest plethysmography. Third, in children, a large number of such examinations are done because of central nelVous system abnormalities, such as tumors, intraventricular or extracerebral hemorrhage, Arnold-Chiari malformations, and periventricular leukomalacia. 4 These underlying abnormalities can make sedation more difficult and risky because of dangers of upper airway obstruction or increased intramt1ial pressure. Examinations now are being done on the youngest of children, including newborns.5 It is crucial to monitor cardiac and, most important, ventilatory status :in newborns because of their increased risk of upper airway obstruction, hypoventilation, and apnea.

There are unique difficulties with monitoring in the MRI scanner.6-8 .The monitor can interfere with imaging signals. Because MRI depends on maintenance of a static magnetic field and pulsed radiofrequency energy, there can be distortion clfMRI results by unshielded ferromagnetic materials in the monitors or their ~Ies. Also, MRI radiofrequency signals can induce currents in ferromagnetic elements of Ithe monitors themselves. These induced currents can distort monitoring signals, even to the point of maldng the monitor unusable. There are now several monitoring system~ specifically designed to be used in the MRI scanner without distortion of signal.9 Th4~ monitors depend on shielding, nonferromagnetic components, and mters to produce satisfactory performance. Pulse oximeters, electrocardiographs, and noninwsive blc>Od pressure monitors that work well with 1.5 Tesla scanners, the m~ POWert:u1 rommerciiallyavailable

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MRI units, now are available. Radiofrequency energy also "{20. produ:e increased

temperature in ferromagnetic monitor elements to a degree that burns can be induced. Pulse oximeter, temperature, and electrocardiographic implicated in these thermal injuries. Increased total body tllOUgh this is not believed to be a problem.

It is possible to modify- equipment to ,

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of a burn. It is prudent to use only

by its manufacturer for use in the MRI equipment, fl-aying or separation of shielding use, providing potential sites for overheating radiofrequenensation, and embolism. Umbrellas have become dislodged into the right ventricle and aorta. As with balloon dilations, the anesthesiologiSt must consider underlying cardiac anomaly and intended procedure in ch~ing an anesthetic Rarely, it is necessary to proceed rapidly to a conventional operating room for further intervention.

CUITent experience witJil anesthesia for the child with congenital heart disease has demonstrated that it is pclSSible to anesthetize virtually all of these patients safely.20.21 A wide variety of agents cm be used, including ketamine, volatile agents, and opioids. It is important for the anc~esiologist to be aware of the physiologic alterations that each drug produces and to titrate these drugs against monitored changes in the patient. There are two important CIVeats:

1. A~ should nclt be induced in children with congenital heat1 disease u~ there is reasonable and rapid access to resuscitative drugs, such as inotropes. If the practitioner normally preJ)afes an inotropic infusion before inducing a child with a specific lesion in the OPOth receiving sedation and in the immediate postsedation period Each child receiving ~oedation should have some evaluation of general health performed before the sedation regimen is chosen and administered. This should include a history of previous sedative ~lI1d anesthetic drug exposures and possible allergies. Need for informed consent is a controversial topic and should be determined at an institutional level in conjunction ~vith hospital administration. A record of the patient's reaction to sedation, including \rital signs, is a useful monitoring tool. Specific discharge criteria that clearly establish who can discharge the patient and what criteria must be met before discharge should l>e employed. If the child is leaving the institution, the adult responsible for the child ~,hould have clear instructions about aJre in the postsedation period, complication rnanagement, and the need for the adult call the institution if there is any question ~Lbout the child's status or aJre.

All of the sedation given to children can be ordered, administered, and monitored by nonanesthesiologists. Rc;tablishment and adherence to reasonable but comprehensive bruidelines are important components of ensuring pediatric patient safety. Also important is the ability of the anesthesia department to provide timely aJre for patients that have ~pecial needs. At Northwestern Univ.ersity Medical Center, a regularly scheduled day t~ch week has been appropriated for anesthesiology personnel to be available to service ~!pecific areas, such as MRI and aJrdiac catheterization.

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J.~drninistrative and Politica1 Concerns

There are several administrative issues that need to be addressed when anesthesiology

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personnel are working in a new environment. Adequate personnel for any anesthetizing location is an early and important consideration. Anesthes!ologists routinely depend on other physicians, nurses, and auxiliary personnel during their normal routines to speed patient preparation, transport, and recovery. These personnel may not readily be available in areas outside the operating room. Before embarking on coverage in a new area, the anesthesiologist but be informed of who will be responsible for patient scheduling, preprocedure history and physicals (if required), laboratory work (if required), and informed consent. Institutions that already have busy and efficient outpatient surgery units may find use of these facilities and personnel effective for preparing and directing patient flow. Other areas of the institution, such as the outpatient clinic, often have expertise in handling these activities. As personnel needs are discussed, remember that there may be an occasional situation where someone is needed to go the pharmacy, laboratory, or blood bank expeditiously and that personnel and procedures should be available for this.

One particularly troublesome area can be postanesthetic recovery. Although postanesthesia care units adjacent to operating rooms provide the highest level of care, transport from distant areas to postanesthesia care units can be difficult or cumbersome. Recovery can be accomplished in areas closer to the anesthetizing site only if there are appropriately trained and equipped staff available who do not have other concurrent responsibilities. Training nursing staff who normally work in areas outside the operating room to perform as postanesthetic recovery personnel is useful in the recovery of patients who have received general anesthesia as well as children who have received sedation from nonanesthesiologists.

An issue that is both administrative and political in nature is the willingness of a given area to have procedures done that require the presence of an anesthesiologist. An example of this is IX~rformance of surgical procedures in the neonatal intensive care unit

Neonatal Intensive Care: Ductus Ligation. There is a trend in some tertiary hospitals to perform some surgical procedures in the neonatal intensive care unit The advantage of this is the ability to perform relatively straightforward procedures without the need to transport the infant to the operating room. When the patient is C'P":ially small, there is concern that transport to the operating room puts the child at particular risk for hypothetmia, accidental extubation, inadequate ventilation or positive end-expiratory pressure, dislodgement of vascular lines, and inferior monitoring.

Procedures performed in the intensive care unit of Children's Memorial Hospital have included patent ductl.1S arteriosus ligation, repair of congenital diaphragmatic hernia, closure of gastt.mIJ8is, arId exploratory laparotomy for necrotizing enterocolitis. These procedures all have the pc(ential for sudden blood loss, hypotension, and cardiac arrest Anesthetic preparation and management are the same as those provided in the operating room:

.Blood must be on-sitt~ and checked; .Resuscitative drugs should be available immediately; .The same instruments as those used in the operating room must be available; .All personnel must understand their responsibilities for both routine and emergent

conditions. Anesthetic management in the intensive care unit, however, has several problems: .Space for equipment :md patient access is limited;

.There often are other patients and unrelated personnel sharing the room; .Room temperature cannot be manipulated as easily as it is in the operating room;

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.Infection control is a concern because of the nature of the area;

.The unit's nursing staff are not u-ained and do not practice in the same manner 3.5 do operating room nurses.

For these reasons, some intensive care nursing staff may not be enthusiastic about having surgical procedures done in what is viewed as "their area. " If the intensive care unit staff is not positive about the arrangement, the process will not go smoothly. Consequently, it is important to determine the willingness of the staff to participate before implementing new procedures. Questions about space, staffing, infection control, and responsibility for ordering blood and drugs should be resolved before proceeding. If the local staff are not agreeable and committed to having procedures done in their area, it may be wise to reevaluate the need.

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There has been increased interest in the use of nitrous oxide and deep sedation by emergency room physicians for suturing and setting simple fractures. Deep sedation is being used increasingly by pediatricians, radiologists, and surgeons for endoscopies, a:hocardiography, invasive angiography, bone marrow biopsies, and an ever-expanding li'it of procedures. As physicians become more aware of the need for humane treatment or children in pain or discomfort, there will be increasing reliance on sedation and analgesia. As anesthesiologists, we have the opportunity not only to provide care and a..~istance in non~ditional settings but also to help educate our colleagues about aJ;>propriate evaluation, monitoring, and treatment

The Emergency Room and Beyond

Because anesthesiol~ are increasingly asked to provide sedation and anesthetic se1Vices outside rl1e operating room, it is important to maintain rl1e priorities that have made us successful in our ttaditional environment. It is our responsibility to ensure that we prnctice in areas wirl1 adequate space and equipment loGI1 codes for electrical outlets, lighting, access, and ventilation must be observed. Protocols should be established arid understood by all partidpants for patient suitability, preanesthetic evaluations and preparation, scheduling, postanesthetic care, discharge, and postdischarge follow-up. All important new element in care is appropriate quality assurance or improvement activities. These quality-related efforts should match rl10Se in rl1e operating room setting. l3stly, it is important to ensure that rl1e physidans who aVJ.il rl1emselves of our services jJ(: comfortable in rl1eir internctions wirl1 us. This will help guarantee that rl1e patient receives rl1e best possible care.

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Summary

1. Faulconer A, Keys TE: Foundations of Anesthesiology. Springfield, Charles C Thomas, 1965, pp 314-315

2. Schreiner MS, Triebwasser A, Keon 11>: Ingestion of liquids compared with preoperative fasting in pediatric oulJYdtients. Anesthesiology 72:593-597 , 1990

3. Splinter WM, SdJaffer 3D, Zunder IH: dear fluids three hoU11) before surgery do not affect the gastric fluid contents of children. Can] Anaesth 37:498-501, 1990

References

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4. Byme P, Welch R, Johnson MA, Damlh J, Piper M: Serial magnetic resonance imaging in neonatal h}1JOxic.ischemic encephalopathy.] Pediatr 117:694-700, 1990

5. Keeney SE, Adcock EW, McArdle CB: Prospective observations of 100 high-risk neonates by high-field (1.5 Tesla) magnetic resonance imaging of the central nervous system: 1. Intraventricular and extracerebrallesions. Pediatrics 87:421--430, 1991

6. Karlik SJ, Heatherley T, Pavan F, Stein J, l£bron F, Rutt B, Carey 1., Wexler R, Gelb A: Patient anesthesia and monitoring at a 1.5 T MR1 installation. Magn Reson Med 7:210-221, 1988

7. Nixon C, Hirsch NP, Orrnerod IEC,Johnson G: Nuclear magnetic resonance: Its implications for the anaesthetist. Anaesthesia 41:131-137, 1986

8. ROth JL, Nugent M, Gray Jl':, Julsrud PR, Berquist TH, Sill JC, Kispert DB: Patient monitoring during magnetic resonance imaging. Anesthesiology 62:80-83, 1985

9. Sellden H, DeChateau P, I~kman G, tinder B, Saaf J, Wahlund L-O: Circulatory monitoring of children during anaesthesia in low-field magnetic resonance imaging. Acta Anaesthesiol Scand 34:41-43, 1990

10. Ramsay JG, Gale 1., Sykes MK: A ventilator for use in nuclear magnetic resonance studies. BrJ Anaesth 58:1181-1184, 1986

11. Klein AS, Blanch PB: Evaluation of six ventilators within the MR1 environment (abstract). Anesthesiology 75:A403, 1991

12. Smith DS, Askey P, Young ML, Kressel HY: Anesthetic management of acutely ilI patients during magnetic resonance imaging. Anesthesiology 65:710-711, 1986

13. Rao PS: Balloon pulmonary valvuloplasty: A review. Clin CardioI12:55- 74, 1989

14. Choy M, Beekman RH, Crclw!ey DC, Snider AR, Dick M, Rosenthal A: Percutaneous balloon valvuloplasty for valvar aortic stenosis in inf.mts and children. Am J Cardiol 59: 1010-1013, 1987

15. Beekman RH, Rocchini AP, Dick M, Snider AR, Crowley DC, SelWer GA, Spicer RL, Rosenthal A: Percutaneous balloon angioplasty for native coorctation of the aorta. J Am ColI Cardiol 10:1078--1084, 1987

16. HelIenbrand WE, Fahey JT, McGoWdfi FX, Weltin GG, Kleinman cs: Trnnsesophageal echocardiographic guidance of transcatheter closure of atrial septal defect. Am J Cardiol 66:207-213, 1990

17. Rome.U, Keane]F, Perry SB, Spevak PJ, LocklE: Double-umbreIla closure of atrial defects. Circulation 82:751-758, 1990

18. Bridges NO, Perry SB, Keane ]F, Goldstein SAN, MandelI V, Mayer lE, Jonas RA, Casteneda AR, Lock lE: Preoperativ~. transcatheter closure of congenital muscular ventricular defects. N EnglJ Med 324:1312-1317, 1991

19. Latson IA, Hofschire PJ, Kugler ]D, Cheatham JP, Gumbiner CH, Danford DA: Transcatheter closure of patent ductus arteriosus in pediatric patients. J Pediatr 115:549-553, 1989

20. Salem MR, Hall SC, Motoyarna EK: Anesthesia for thoracic and cardiovascular surgery, Smith's Anesthesia for Infants alld Children. 5th edition. Edited by Motoyama EK, Davis PJ. St. Louis, CY Mosby, 1990, pp 518--545

21. Hickey PR, Wessel DL: Anesthesia for congenital heart disease, Pediatric Anesthesia. 2nd edition. Edited by Gregory GA. New York, ChurchilI-livingstone, 1989, pp 833-892

22. Fisher DM: Sedation of pediatric patients: An anesthesiologist's perspective. Radiology 175:613-615, 1990

23. Keeter S, Benator RM, Weinberg SM, Hartenberg MA: Sedation in pediatric CT: National survey of current practict~. Radiology 175:745-752, 1990

24. Marsh B, White M, Morton N, KennyGNC: Pharmacokinetic model driven infusion ofpropofol in children. Br J Anaesth 67:41-48, 1991

25. HannalIah RS, Baker SB, Casey W, McGilI WA, Broadrnan LM, NordenJM: Propofol: Effective dose and induction chaIacteristics in unpremedicated children. Anesthesiology 74:217- 219, 1991

26. Committee on Drugs, Section on Anesthesiology: Guidelines for the elective use of conscious sedation, deep sedation, and general anesthesia in pediatric patients. Pediatrics 76:317- 321, 1985

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