TIVA outside operating room

Information about TIVA outside operating room

Published on June 13, 2016

Author: souvikmaitra1

Source: slideshare.net

Content

1. TIVA outside the OR Souvik Maitra MD, DNB Assistant Professor, Department of Anaesthesia& Intensive Care, PGIMER, Chandigarh 6/11/16

2. More than 25% procedure necessitate anesthesiologists' presence are done outside operating room 6/11/16

3. Hypoxia occurred in 40.2 cases per 1000 in adult patients 6/11/16 Acad Emerg Med. 2016;23(2):119-34.

4. Hypoxia occurred in 157 times in 10000 cases in children 6/11/16 Pediatrics. 2006;118(3):1087-96.

5. Areas need anaesthesiologits’ presence • Radiology (CT, MRI, interventional radiology) • Cardiac catheterization lab • Endoscopy suite • Ovum pick up for IVF • Modified- ECT 6/11/16

6. TIVA out side OR • TIVA can be used for any procedures/ surgeries if not contraindicated • Particularly suitable for MRI, image guided neuro-interventional procedures, ERCP, cardiac catheterization etc. 6/11/16

7. TIVA: Is it really beneficial? • Less PONV- both in patients who are at high or low risk of PONV • Reduction in extubation time & PACU stay when compared to Desflurane based anaesthesia • Hemodynamic stability during emergence • More costly than inhalation technique 6/11/16

8. • A small RCT compared TCI, manual TIVA and sevoflurane based anaesthesia for brain biopsy- no difference in emergence and hemodynamics 6/11/16

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11. At the cost of…. 6/11/16

12. But….. • All these evidences are obtained when TIVA was used in OR • No randomized trial has compared TIVA with other anaesthetic technique outside OR 6/11/16

13. TIVA: Manual vs TCI 6/11/16 TCI required higher propofol dose, less intervention Quality of sedation was similar Adverse effects were similar

14. TIVA: Continuous infusion vs repeated boluses? 6/11/16 Pediatr Crit Care Med. 2011;12(6):e262-5.

15. 6/11/16 A single dose of propofol without a continuous infusion can provide appropriate sedation in children undergoing MRI for <30 min. Significantly shorter recover time with single bolus regimen

16. Drugs used for TIVA outside OR/ procedural sedation • Propofol • Midazolam • Fentanyl/ alfentanil/ remifentanil • Dexmedetomidine • Thiopentone/ Methohexital/ pentobarbital • Ketamine 6/11/16

17. 6/11/16 “patients have a better recovery profile after propofol sedation for ERCP procedures than after midazolam and meperidine Sedation”

18. Propofol for GI endoscopy: Red alerts? • Use of propofol- more life threatening events 6/11/16

19. Dexmedetomidine: As a sole agent • Used in pediatric MRI as sole agent • Relatively high dose was used (2-3 mcg/kg boluses followed by 1-2 mcg/kg/hr) • Around 20% patients required additional boluses of rescue drug • Hypotension & bradycardia are common concern • Respiratory compromise uncommon 6/11/16 Int J Pediatr 2015;2015:397372. Paediatr Anaesth. 2008;18(5):403-11

20. Paediatric sedation: Propofol or Dexmedetomidine? 6/11/16 Int J Clin Exp Med. 2015 Aug 15;8(8):11881-9.

21. 6/11/16

22. Similar results from RCTs 6/11/16

23. 6/11/16 Less patients’ satisfaction More hemodynamic changes

24. Dexmedetomidine- opioid combination • Dexmed-Remifentanil combination was equivalent to propofol- remifentanil combination for GI endoscopy • Side effect profile was similar • Endoscopists were more satisfied with dexmed probably less GI motility 6/11/16 World J Gastroenterol. 2015;21(12):3671-8.

25. Ketamine: Dose it have a role in modern anaesthesia practice? • Evidences are available from mostly cardiac catheterization laboratory • Low dose ketamine does not affect recovery profile when used along with propofol • No advantages when used along with dexmedetomidine 6/11/16 Pediatr Cardiol. 200526(5):553-7. Clin Ther. 2010;32(4):701-9.

26. Ketofol (Propofol- ketamine combination) • Propofol- Ketamine combination has been used both for induction of anaesthesia and sedation • Primary aim is hemodynamic stability • Reduction in adverse effects of either drug is the aim of this technique 6/11/16

27. 6/11/16

28. A significant reduction in respiratory complications 6/11/16

29. A similar incidence of psychomimetic events 6/11/16

30. Less hemodynamic changes 6/11/16 Hypotension Bradycardia

31. A similar incidence of nausea-vomiting 6/11/16

32. Optimum propofol: Ketamine ratio? 6/11/16 10:1 propofol-ketamine ratio provided greatest hemodynamic stability and least recovery time

33. Ketamine or Opioid? 6/11/16

34. 6/11/16 A significant reduction in recovery time with remifentanil (median 10.3 minutes versus 22.5 minutes)

35. 6/11/16 More propofol required in fentanyl group, quality of recovery was similar

36. 6/11/16 Similar incidence of adverse effects and quality of sedation

37. Propofol: Safety concerns 6/11/16

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39. Propofol versus Pentobarbital 6/11/16

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42. • Dexmedetomidine may be an alternative for image guided procedure • Less airway maneuver required • Discharge time similar 6/11/16 J Res Med Sci. 2014;19(6):549-54.

43. • Etomidate is also a reasonable alternative • Better quality sedation • Less airway intervention required 6/11/16 Pediatr Emerg Care. 2007;23(10):690-5

44. Midazolam premedication? 6/11/16

45. 6/11/16 • Increased incidence of desaturation (1.6% versus 7.3%) • Similar emergence reaction (7.1% versus 6.2%) • Less vomiting with midazolam

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48. Oocyte retrieval: Does anaesthetic technique matters? • All anaesthetic techniques are equally effective • Propofol- whether it affects pregnancy outcome or not is controversial • GA may be associated with worse outcome when compared to SAB- 6/11/16 Cochrane Database Syst Rev. 2013 Jan 31;(1):CD004829. Anesth Pain Med. 2013;3(2):239-42.

49. • Remifentanil may be a better choice than fentanyl • Propofol accumulates in follicular fluid- dose & duration related, effects unknown 6/11/16 Int J Fertil Steril. 2011;5(2):86-9.

50. Most of these remote locations do not have a scavenging system, so….. 6/11/16

51. What these studies did not say…. • N2O is potential green house gas and responsible for 6% of heating and causes ozone depletion • All halogenated inhalation anaesthetics are also green house gases 6/11/16 Science. 2009;326:123–125. Nature. 1989;341:635–637

52. Arctic ices are melting fast….. 6/11/16

53. Thank you! 6/11/16

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