Regional Anaesthesia with Sedation Protocol to Safely Debride Sacral

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ORIGINAL ARTICLE Regional anaesthesia with sedation protocol to safely debride sacral pressure ulcers Daniel K O’Neill, Bryan Robins, Elizabeth A Ayello, Germaine Cuff, Patrick Linton, Harold Brem

O’Neill DK, Robins B, Ayello EA, Cuff G, Linton P, Brem H. Regional anaesthesia with sedation protocol to safely debride sacral pressure ulcers. Int Wound J 2012; 9:525–543

ABSTRACT A treatment challenge for patients with sacral pressure ulcers is balancing the need for adequate surgical debridement with appropriate anaesthesia management. We are functioning under the hypothesis that regional anaesthesia has advantages over general anaesthesia. We describe our regional anaesthesia protocol for perioperative and postoperative management. Key words: Anaesthesia • Pressure ulcer • Regional • Sacral • Wound

INTRODUCTION bone (2). These wounds may go unnoticed for Key Points A pressure ulcer can be deﬁned as a ’localised extended periods of time because they are more injury to the skin or underlying tissue, usu- prevalent in bed bound, paralysed patients as • more than 90% of the pressure ally over a bony prominence that results well as patients older than 65 years (2). The ulcer diagnoses were a sec- ondary diagnosis relating from from pressure, including pressure associated annual occurrence of these pressure ulcers is · another principal problem with shear’ (1). These ulcers can be exten- approximately 1 3–3 million (3), including over • it is vital that these ulcers are sive with damage to the skin and under- 500 000 hospitalisations where pressure ulcers properly diagnosed and treated lying soft tissue, muscle and even exposing were diagnosed (4). Nearly three out of four extended stays were in people over 65 years of age (4), and this age group also accounted for Authors: DK O’Neill, MD, Department of Anesthesiology, New 56·5% of principal diagnoses as well. More than York University School of Medicine, New York, NY 10016, USA; 90% of the pressure ulcer diagnoses were a sec- B Robins, BS, NYU-NIH Summer Program, New York University ondary diagnosis relating from another princi- Langone Medical Center, New York, NY 10016, USA; EA Ayello, · PhD, RN, ACNS-BC, CWON, MAPWCA, FAAN, Faculty, Excelsior pal problem (4), costing hospitals $10 2 billion College School of Nursing, The John A. Hartford Institute of in addition to the $752 million caused by pri- Geriatric Nursing, New York University College of Nursing, mary pressure ulcers (4). Pressure ulcers cause New York, NY, USA; G Cuff, BSN, MPH, CCRP, Department of longer hospital stays (4) and increase the risk Anesthesiology, New York University Langone Medical Center, of infection on top of the treatment costs out- New York, NY 10016, USA; P Linton, MD, Department of Anesthesiology, New York University School of Medicine, New lined above (5). There is substantial evidence York, NY 10016, USA; H Brem, MD, Division of Wound Healing that supports the fact that pressure ulcers are and Regenerative Medicine, Department of Surgery, Winthrop also associated with increased mortality and University Hospital, Mineola, NY, USA morbidity rates (6) and are the cause of death Address for correspondence: DK O’Neill, MD, Department of Anesthesiology, New York University School of Medicine, New in more than 104 000 persons per year in the York, NY 10016, USA USA alone (7). Therefore, it is vital that these E-mail: [email protected] ulcers are properly diagnosed and treated.

Key Point Challenges in healing sacral pressure the surgical debridement then finding the most ulcers effective mixture of topical, subcutaneous and • the vital aspect in the pain Pressure ulcers in adults usually occur over systemic anaesthesia (22). management and treatment of bony prominences such as the sacrum or the chronic wounds is first making heel (8,9). The sacrum located in the lower the decision to perform the sur- The role of surgery in treating sacral gical debridement then finding dorsum is the most common site for pressure pressure ulcers the most effective mixture of ulcers, where approximately 32% of pressure Surgery has inherent risks. Many patients, fam- topical, subcutaneous and sys- ulcers occur according to one study (10). Of ily members and attending physicians believe temic anaesthesia the newest category of pressure ulcers as that taking patients to the operating room for defined by the National Pressure Ulcer Advi- surgery and anaesthesia is excessively risky sory Panel (NPUAP) (1), suspected deep tissue compared with medical therapy. The wound injury is surprisingly more commonly found patient has more comorbidities and is at greater on the heels (41%) rather than on the sacrum risk than a normal average patient as evident (19%) (11). Once these ulcers are formed, they by the fact that wound patients have an aver- may become chronic wounds with physiologi- age score of 3·09 on the American Society of cal impairments that prevent the stimulation of Anaesthesiologists (ASA) physical status clas- wound healing even further (12-14). The blood sification scale (Table 1) compared with the supply to the sacral region defines an angio- overall average of 2·03 value for anaesthesia some. Compromised blood supply from pres- patients at a major university hospital (23). The sure, hypothermia and vasopressors can both ASA score does increase with severity of dis- contribute to the development of sacral pres- ease and the impact on function. The ordinal sure ulcers, as well as impair the angiogenic scale is based on an assessment of the entire response during wound healing. Sharp surgical present health condition of the patient dur- debridement promotes wound bed preparation ing the preoperative evaluation. The number for closure. The angiogenic response is depen- of comorbidities does combine to increase the dent upon where the region is anatomically and score, but it is not linear. For example, a single that the response is significantly skewed away disease with end-organ damage (like end-stage from the lower dorsum (15,16). This decreased renal disease requiring dialysis), which impairs angiogenic response contributes to the slower function places a patient at higher periopera- healing in the lumbosacral area (17), which tive risk than six relatively benign problems increases the likelihood of the need for sur- such as a lipoma or pin worms. gical intervention in a sacral pressure ulcer. The incidence of complications and mor- A sacral pressure ulcer is in close proxim- tality for patients who undergo anaesthe- ity to the rectum, which increases the likeli- sia is greater among patients with a higher hood of fecal contamination from incontinence ASA score (24). However, sharp surgical and can hinder healing in addition to making the wound larger (18,19). According to a Table 1 American Society of Anaesthesiologists physical protocol for the comprehensive treatment of status classification pressure ulcers (2), these aspects make sacral pressure ulcers a prime candidate for operative Class Patient Status debridement to allow tissue regeneration to I Healthy patient with no comorbidities start (20,21). Sharp debridement using a scalpel II A patient with mild systemic disease that should not is the preferred method used to eliminate the affect anaesthesia and surgery necrotic tissue, which hinders the healing pro- III A patient with a severe systemic disease that requires cess and possibly masks other factors such special care during surgery as infection that impede wound closure as IV A patient with a severe systemic disease or end-organ well (2). The National Pressure Ulcer Advi- damage that is life threatening and which must be sory Panel (NPUAP)/ European Pressure Ulcer addressed preoperatively, intraoperatively and Advisory Panel (EPUAP) Clinical Guidelines postoperatively by the anaesthesia team V A moribund patient whose life expectancy does not recommends that the vascular status and sta- exceed 24 hours irrespective of surgery bility of eschar heel ulcers be determined prior to sharp debridement (1). The vital aspect in Adapted from American Society of Anaesthesiologists. ASA the pain management and treatment of chronic physical status classification system. Available at: http://www.asahq. wounds is first making the decision to perform org/clinical/physicalstatus.htm

debridement is necessary to remove sources 5-6% of total hospitalisation costs (28,29). These Key Points of infection and sepsis from the wound that costs result from expensive intraoperative pro- will increase mortality rates or prevent wound cedures, medications, staffing and physiologi- • sharp surgical debridement is closure (10). This procedure has been described cal monitors, which places them at the forefront necessary to remove sources of in detail and has been shown to be safe and of intense health care industry scrutiny (30). infection and sepsis from the wound that will increase mor- have low-mortality rates even in patients with One method to cut costs to both anaesthesia tality rates or prevent wound multiplecomorbidities (10). departments and hospitals would be to closure The formation of new pressure ulcers is also decrease Postanaesthesia Care Unit (PACU) • the operating room provides something to consider when evaluating the and postoperative admissions by investigating a safe environment for patient risks of surgery. Between 4·7% (25) and 45% the types of anaesthetic techniques (31). care • we describe general anaesthe- (26) of surgical patients are at risk of developing The post-anesthesia care unit (PACU) or sia in some detail because many pressure ulcers, where the only reliable indica- recovery room is essential for stabilisation surgeons erroneously believe tor was the length of surgery. This is because and management of most surgical patients. that all sedated patients are of the fact that patients are immobile and can- Decreased PACU stay and postoperative under general anaesthesia not feel pain caused by an extended period admissions have been shown to be benefits of pressure and shearing forces (27). In addi- of increased use of regional techniques ver- tion, an awake patient can position themselves sus general anaesthesia techniques (31). When comfortably on the operating room table, but spinal anaesthesia was used as an alternative anaesthetised patients lack the motor control to general anaesthesia in knee arthroscopies to adjust their position to relieve these forces (an outpatient procedure), there was no dif- and prevent pressure injuries (27). Therefore, a ference in the readiness for discharge (32). lengthy procedure makes the operating table The spinal anaesthesia group had lower pain an ideal place to develop new ulcers especially scores and no nausea and vomiting compared in the presence of elderly frail skin, hypother- with a 19% incidence of these symptoms in the mia and haemodynamic instability requir- patients who received general anaesthesia (32). ing vasopressors (27). Special techniques for Another study on anterior cruciate ligament patient positioning are used including padding repairs found an increase in PACU bypassing to decrease the risk of skin breakdown. Because after the use of peripheral nerve blocks for debridement procedures are usually brief, postoperative pain management as opposed anaesthesia protocols that minimise duration to general anaesthesia (33). Therefore PACU and depth of sedation are preferred. The oper- bypassing and shorter PACU duration can be ating room provides a safe environment for accomplished by reducing postoperative pain patient care. The surgeons have the benefit incidence, nausea, vomiting and other postop- of highly skilled nursing and technical staff, erative complications, especially with regional modern equipment, adequate lighting, sterile anaesthesia (32). We describe general anaes- surgical field and professional anaesthetic care. thesia in some detail because many surgeons Although many may claim that sacral ulcers erroneously believe that all sedated patients can be debrided ’at the bedside’ to minimise the are under general anaesthesia. In addition, use of operating room resources, patients may general anaesthesia is required when regional develop sepsis from inadequately treated infec- blocks fail to provide adequate antinocicep- tions including osteomyelitis and myositis. tion or are unable to provide the operating This surgical infection diagnostic challenge is conditions needed for surgical success. When a analogous to differentiating cellulitis which can local infiltration block is administered for sacral be treated medically and necrotising fasciitis debridement, the recovery would primarily which needs to be treated surgically. The ’con- be dependent upon the duration of action of servative’ strategy of ’benign neglect’ by avoid- the intravenous (IV) anaesthetics. When spinal ing surgical intervention may be ’cost effective’ anaesthesia is used, for example, in a spinal for policy makers who tolerate attrition like cord patient to decrease the risk of autonomic hospice rather than promoting wound healing. hyperreflexia, the sensory and motor function of the spinal cord should return to the baseline Financial concerns state. Knowledge of complete or incomplete The financial burden for both the patient and spinal cord function would be necessary to the hospital to bear for a surgical procedure attain preoperatively. The duration of action is significant. Perioperative costs account for of the intrathecal sodium channel blocker may

Key Points vary from 40 to 50 minutes for plain procaine from the preoperative evaluation through the from 180 to 240 minutes for dibucaine with postoperative care. This literature review also • on the basis of the litera- epinephrine. During the duration of resid- examined financial data that looked at the costs ture surrounding the benefits ual neuroaxial blockade, special additional of regional compared with general anaesthesia of regional anaesthesia, it is the conclusion of this wound heal- care needs to be maintained to protect injury techniques by looking at several cost drivers in ing and regenerative medicine especially to the skin and peripheral nerves the preoperative, intraoperative and postoper- team, that a protocol of a of the lower extremities. The Bromage scale is ative costs. regional block with sedation as used commonly to grade block recovery. needed is the most effective Protocol for the administration of an anaesthesia regimen for sharp anaesthesia regimen to a sharp surgical debridement Anaesthesia for pressure ulcer patients • this literature review also exam- The sparse literature about anaesthesia proto- debridement candidate ined financial data that looked cols for wound care, especially for pressure It must be emphasised that our protocol for at the costs of regional com- ulcers, provides limited guidance as to the preventing the appearance of new pressure pared with general anaesthesia best method given the wide variation in tech- ulcers and promoting healing of existing sacral techniques by looking at several pressure ulcers using sharp, surgical debride- cost drivers in the preoperative, niques available (34). Sacral pressure ulcers intra operative and postopera- can be debrided in the lateral or prone posi- ment and anaesthesia (Table 2) is designed to tive costs tion with local, regional or general anaesthesia maintain homeostasis during times that would with various degrees of sedation and air- otherwise be traumatic for both the patient as way management (34). Sacral pressure ulcers well as the patient’s family. The protocol is ini- demand significantly different anaesthesia reg- tiated when the surgeon decides to schedule a imens than other pressure ulcers, because they surgical procedure in the operating room. could be outside the scope of certain anaesthesia treatments that could be applied to other Acknowledge that every patient with pressure pressure ulcers (34). The anaesthesia technique ulcers has comorbidities, which increase the is usually determined and applied based on risk associated with anaesthesia the preference of the anaesthesiologist after Pressure ulcers are caused by unrelieved pres- completing the preoperative anaesthesia eval- sure, which obstructs blood flow creating a uation. This practice often leads to a common deficiency of oxygenation and nutrients creat- misconception that anaesthesia refers to only ing tissue destruction (2,3). Therefore, certain general anaesthesia even when regional blocks comorbidities are associated with the forma- can be and are used (35). On the basis of the tion of these pressure ulcers. These comor- literature surrounding the benefits of regional bidities must be accounted for, and they anaesthesia, it is the conclusion of this wound comprise risk factors for anaesthesia compli- healing and regenerative medicine team, that cations. A frequent risk factor associated with a protocol of a regional block with sedation the formation of a new pressure ulcer is lim- as needed is the most effective anaesthesia ited mobility, which results from amputations, regimen for sharp surgical debridement (35). paralysis, neurological disorders (multiple This is because it limits complications, reduces sclerosis, Alzheimer’s, dementia, etc.), coma postoperative pain and decreases the eco- or sedation, and so forth (36). These might not nomic burden placed on both the health care be direct risk factors for anaesthesia, but they stakeholders and the patient. This protocol do influence certain factors of the overall treat- acknowledges the limitations of regional anaes- ment and pain management with analgesia. thesia and realises that pre-existing conditions Pressure ulcers are also associated with or failed blocks require the anaesthesiologist to malnutrition, which could be caused by eat- re-evaluate the anaesthetic technique (35). ing disorders, dehydration or dietary restric- tions (36). Indices of nutritional status include albumin, prealbumin and cholesterol. Malnu- METHODS trition is important for the anaesthesiologist Literature review to take into account including drug dosing As a result of a comprehensive study of given the changes in volume of distribution, the literature pertaining to both regional and protein binding to α–1 glucoprotein and phar- general anaesthesia, we compiled this proto- macodynamic effects to decrease the risk of col, which functions to give guidelines on problems. One study found electrolyte imbal- proper application and management of the care ances and significantly slower heart rates

Table 2 Protocol for anaesthesia administration for surgical debridement of sacral pressure ulcer © O’Neill & Ayello 2012

1 Acknowledge that every patient with pressure ulcers has comorbidities which increase the risk associated with anaesthesia. 2 The preoperative assessment begins with the medical history, physical examination, laboratory analysis and consultation of medical specialists as indicated. 3 The expectation of the consultant is to characterise the disease, medically optimise and risk stratify the patient prior to surgery and anaesthesia. 4 All laboratory results and diagnostic studies are evaluated for abnormalities and are corrected as indicated. 5 All patients with cardiac rhythmic management devices (CRMD) are interrogated to ensure proper functioning. 6 To decrease the risk of aspiration pneumonia from gastric regurgitation, Nothing Per Os (or mouth) orders are enforced. 7 Intravenous (IV) fluids and medications are administered preoperatively for inpatients, diabetics and those who need medications. 8 All patients are monitored intraoperatively according to American Society of Anaesthesiology (ASA) standards. 9 Regional anaesthesia (local, peripheral and central) with sedation (none, light or deep) is administered as the default regimen with general IV or inhalational agents used when blocks are not carried out. 10 Goals of airway management are to maintain airway patency, oxygenation and ventilation using the minimum invasiveness of airway devices. 11 All patients are monitored postoperatively for duration appropriate to their acuity. during preoperative assessments compared maximum protection for both the patient and Key Point with healthy patients (37). the institution. The evaluation begins with Pressure ulcers are also linked with many the medical history then proceeds to physical • the preoperative assessment other conditions that can severely compli- examination, laboratory analysis and finally has become crucial, as the role cate an anaesthesia regimen. These include to consultation of medical specialists as indi- of the anaesthesiologist has expanded outside of the operat- diabetes mellitus, vasculitis and other vas- cated by the attending anaesthesiologist. The ingroomandanincreasednum- cular collagen disorders, immunodeficiency, physical examination takes vital signs and con- ber of ambulatory procedures, corticosteroid therapy, congestive heart fail- firms the presence of any conditions that could such as surgical debridement, ure, malignancies, end-stage renal disease and compromise the patient intraoperatively. Labo- are performed chronic obstructive pulmonary disease (36). ratory tests are ordered as necessary to discover All of these conditions have implications for any underlying conditions that could compli- surgery and wound healing. cate the procedure and explain any abnormalities observed during the physical examination. The preoperative assessment begins with the History of malignant hyperthermia (MH) by medical history, physical examination, questionnaire or interview requires avoidance laboratory analysis and consultation of of triggering agents such as succinylcholine medical specialists as indicated and potent inhalational anaesthetics such as isoflurane, sevoflurane or desflurane. Family The preoperative assessment has become history of MH should prompt a call to the crucial, as the role of the anaesthesiologist MH hotline and diagnosis by muscle biopsy. has expanded outside of the operating room A questionnaire or muscle biopsy about anaes- and an increased number of ambulatory thesia history in the patient and family is also procedures, such as surgical debridement, are useful for diagnosing the risk of MH. Further- performed (38). It is also vital in securing the more, a consultation is usually necessary and safety of the patient during the admission of beneficial to the operative care of a patient an anaesthesia regimen. The Australian Inci- and is usually ordered to clarify any existing dent Monitoring Society concluded that 3·1% medical issues. of complications were directly attributed to deficient, and 11% to inadequate preoperative assessments (38). Davis determined that The expectation of the consultant is to 53 of 135 patient deaths (39%) linked to anaes- characterise the disease, medically optimise thesia resulted from inadequate preoperative and risk stratify the patient prior to surgery assessments and suboptimal monitoring of and anaesthesia existing medical conditions (39). Preoperative consultations should be initiated The preoperative assessment needs to for the diagnosis, evaluation and treatment be thorough and complete to ensure the of a newly or poorly managed condition and

for the creation of a risk evaluation that the function tests, complete blood count, type patient, anaesthesiologist and surgeon can use and screen (T&S), coagulation studies [pro- to make patient care decisions (38). The person thrombin time (PT), international normalized requesting the consultation should ask spe- ratio (INR), activated partial thromboplastin cific questions about the patient health status time (APTT)], serum chemistries, urinalysis and the tasks that need to be performed prior and pregnancy tests (41). Surgical patients can to the procedure. The result of the consulta- bleed to a point of requiring blood products. tion should be a descriptive letter or progress Therefore, a T&S would be indicated to exclude note summarising the patient’s medical condi- the risk of antibodies and antigen–antibody tions, along with the results of the diagnostic incompatibility which may delay blood prod- tests (38). Omitted data about the patient’s con- uct volume resuscitation during haemorrhage. dition could delay surgery and increase costs. Electronic cross matching has recently been Occasionally, an anaesthesiologist will receive introduced to improve the efficiency and effec- a handwritten note from a medical consultant tiveness of the process. During surgery, the which reads ’Patient is cleared for surgery’. haemostatic balance between bleeding and This substitute for a proper evaluation and clotting needs to be addressed to minimise the assessment is not only useless, but is insulting risk of haemorrhage, stroke, deep vein throm- to the anaesthesiologist who is responsible for bosis (DVT) and pulmonary embolism. The clearing the patient for the operating room. For coagulation cascade and platelet function are a pressure ulcer, one consultant must be the both important to evaluate in the preoperative wound care specialist or operating surgeon. assessment of risk. Most surgeons are fine with Other specialists could include internist, cardi- INR below 2·2, but platelets may need to be ologist, pulmonologist, nephrologist, haema- ordered. All substances that increase bleeding tologist, neurologist and/or rheumatologist. risk that a patient is taking including antico- The diagnostic results that accompany the let- agulants, antiplatelets and some herbals need ter are vital for the anaesthesiologist’s ability to be considered. For example, some patients to make an independent, unbiased decision may not report that they are taking herbals about patient risk and to plan the anaesthesia that have haemostatic impact like garlic. Clin- regimen accordingly. ical decision support should be available for staff because the list of agents influencing the haemostatic system continues to grow. All laboratory results and diagnostic studies are evaluated for abnormalities and are corrected as indicated All patients with CRMD are interrogated to Laboratory examinations should only be pre- ensure proper functioning scribed to patients who present an increased A cardiac rhythm management device (CRMD) risk of complications based on medical history is an implanted pacemaker (PM) or an or the physical examination. This will help implanted cardioverter-defibrillator (ICD) (42). to keep costs down and preserve valuable Patients with these devices are at risk of devel- materials (28–31,40). Each institution should oping complications during surgery because develop standards which are in alignment of the malfunction of the device (42–45). For with national guidelines and individual patient example, the electrocautery can be sensed by an needs. When preoperative test results are ICD which would trigger inappropriate elec- abnormal, correcting the abnormality reduces trical therapy (defibrillation) which would not the risk of developing perioperative compli- only be painful or hazardous for the patient, cations. Testing is most efficient when the but could prematurely deplete the generator most sensitive and specific tests are used power supply (45). to confirm an existing abnormality that was Successful perioperative procedures with uncovered during the initial medical history CRMD patients depend on the preoperative and physical examination (40). The following evaluation (45). After acknowledging that the tests should be ordered for the preanaes- patient has a CRMD, device testing consists thesia evaluation when appropriate: electro- of determining the type and manufacturer cardiogram (ECG), echocardiography, stress of the device, determining if the patient is tests, angiography, chest X-rays, pulmonary PM dependent for antibradycardia function

and understanding the function of the device tubes (50,51). However, the risk of pulmonary Key Point in the perioperative patient (42–47). Direct aspiration needs to be balanced with the risks interrogation of the CRMD by a device expert of excessive NPO status leading to dehydration • wound patients typically have like a cardiac electrophysiologist or corporate and starvation. comorbidities which need to representative remains the ’gold standard’ for Recent studies have linked prolonged be addressed prior to the start of the debridement, many determining the battery status, quality of the preoperative fasting periods to problems such requiring hospital admission for leads and appropriateness of the settings at the as irritability, headache, emesis, hypotension, medical optimization time of interrogation (48). It is imperative that hypovolaemia and hypoglycaemia (52–55). this device interrogation data be acquired and Therefore, NPO orders should be according a therapeutic plan is established in a timely to the ASA guidelines which serve as recom- manner for optimal perioperative care (45). mendations that can be adopted to fit clinical The preoperative evaluation should be needs and constraints (56). What one eats or based on the ASA guidelines. This includes drinks makes a difference in regards to NPO (1) determining the extent of electromagnetic orders and anaesthesia. Therefore, ASA guide- interference (EMI) during the debridement, lines call for a fasting period for clear liquids (2) determining any adjustments to the CRMD (water, fruit juices without pulp, carbonated programming that are needed, (3) suspending beverage, clear tea, black coffee, etc.) of at antitachyarrhythmia functions if present, least 2 hours and non human milk and or (4) advising the surgeon of the use of a bipolar a light meal (toast and clear liquids) of at electrocautery system or ultrasonic scalpel to least 6 hours prior to anaesthesia (56). The con- limit EMI on generators and leads, (5) assuring tent and make-up of a heavier meal needs the operating room has temporary pacing to be accounted for because it increases the and defibrillation machines available and gastric emptying time (56). Emergency cases (6) evaluating the possible impact of anaesthe- with full stomachs or patients with abnor- sia on CRMD function in the patient (44,46). In mal gastric emptying or lower oesophageal general, PM function should be maintained but sphincter function require special approaches sensing function can be temporarily disabled. to airway management which include rapid During the postoperative care the device sequence induction with intubation, awake should be reset to the preoperative settings, intubation or regional anaesthesia without re-enabled if necessary and re-interrogated sedation. to ensure proper function for discharge (48). Failure to re-establish tachyarrhymia therapy after the procedure defeats the purpose of IV fluids and medications are administered protecting the patient from lethal ventricular preoperatively for inpatients, diabetics and tachycardias (48). those who need medications Wound patients typically have comorbidities which need to be addressed prior to the To decrease the risk of aspiration pneumonia start of the debridement, many requiring from gastric regurgitation, NPO (or by hospital admission for medical optimisation. mouth orders) are enforced Oral medications should be converted to the Nothing Per Os (NPO) is a precaution that IV equivalent unless an ’NPO except Meds’ anaesthesiologists use to decrease the risks of guideline is appropriate for the patient and is morbidity or mortality. NPO is prescribed to consistent with institutional policies. lower stomach acidity and gastric fluid vol- These medications can include orally admin- ume before the operation in order to decrease istered antibiotics, antihypertensives, antico- the risks of aspiration pneumonia, which is agulants, antiplatelets, oral hypoglycaemics a cause of morbidity from Acute Respira- analgesics, antidepressants, antivirals and oth- tory Distress Syndrome and mortality from ers that may change the risk of developing multiple organ failure (49). Poor oral hygiene perioperative complications. Patients with dif- especially in debilitated patients who can not ficult vascular access can undergo special pro- care for their own mouths has also been cedures preoperatively like ultrasound guided associated with aspiration pneumonia (50,51). peripherally inserted central catheter (PICC) Patients with dysphagia should have swallow- line insertion which can save operating room ing studies to evaluate the need for feeding time.

All patients are monitored intraoperatively or electrical mechanical dissociation. Causes according to ASA standards of PEA include hypovolaemia, hypoxaemia, All cases of sharp, surgical debridement in the hyperkalaemia, acidosis, myocardial infarc- operating room use anaesthesia services which tion, pneumothorax, pericardial tamponade apply the ASA standards for monitoring. In and pulmonary embolism. Therefore, pulse contrast to a ’local case’ where ’local anaes- should be routinely measured by plethesmog- thesia’ is administered by the surgeon and raphy with pulse oximetry. The pleth signal is monitoring is by non anaesthesia personnel reassuring when present, but may be absent who may or may not have other procedural for a variety of reasons ranging from artefact to responsibilities. The ASA has two standards for cardiac arrest. In general, adequate perfusion to basic anaesthesia monitoring. One standard is the finger tips or ear lobes suggests adequate based mainly on physical examination by a cer- perfusion to the vessel rich group including tified anaesthesia provider. That individual’s brain, heart and liver. sole responsibility is observing the mucosal ASA standards recommend temperature to colour, movement of the chest wall, rate and be monitored (57). Although MH is rare, it depth of respirations, presence of shivering or is potentially fatal. Fever associated with sys- diaphoresis and response to painful stimuli of temic inflammatory response syndrome (SIRS) the patient for the duration of the procedure or sepsis can be seen in the occasional infected and anaesthesia care (57). The other standard patient. Hypothermia is a daily risk in the is the continuous monitoring of oxygenation, operating room because the cold physical ventilation, circulation and temperature (57). environment and heat loss factors including When the ASA standards are not followed, conduction, convection, radiation and evapo- there is a 17·7% rate of complications (58). ration. Neuroaxial blocks and general anaes- Quantitative oxygenation assessment and thesia impair the patient’s ability to maintain continuous monitoring with pulse oximetry is central autonomic thermoregulatory control based on the strong conviction that oxygen and peripheral thermogenesis (65). Sedatives delivery and aerobic metabolism is most administered such as propofol (66,67), mida- beneficial to the patient (59). Because of its zolam (68,69) and opioids (70,71) reduce vaso- ease of interpretation and continuous nature, constriction and decrease shivering thresholds, pulse oximetry is used almost universally (57). furthering hampering thermogenesis. Pulse oximetry does not replace monitoring This protocol also recommends glucose man- spontaneous ventilation using observation of agement to prevent and treat hypoglycaemia chest movement, auscultation of breath sounds or hyperglycaemia which has negative conse- and/or capnography (60). Capnography is quences for wound infections (72) and a linear effective in assessing airway patency and correlation with death rates (73). Even though respiratory rate. The change of an end tidal BIS (bispectral EEG) and EMG monitoring are carbon dioxide concentration waveform can not required, the use of brain monitors can help indicate an abnormality such as an airway optimise hypnotic drug titration for deep seda- obstruction and/or apnoea (61). tion and general anaesthesia. Given the risk Proper intraoperative monitoring standards of awareness during surgery when using neu- of circulation require a continuous electrocar- romuscular blockade, BIS monitoring is highly diogram (ECG) display, heart rate, pulse and recommended for general anaesthetics. BIS val- arterial blood pressure measurements recorded ues less than 70 are associated with a chance of at least every 5 minutes. The ECG Lead II can recall less than 1 in 1 million. Extremely low BIS best detect atrial dysrhythmias (62) and in com- values with high suppression ratios are unde- bination with V5 provide the best sensitivity sirable and can increase risk of mortality (74). for ischaemia recognition short of transoe- The question has been raised as to whether we sophageal echocardiography (63,64). use regional anaesthesia with sedation? If not, Pulse can be assessed by physical examina- how do patients tolerate hearing the events tion (palpitation, auscultation) or by technolog- in the OR? Patient-centred care challenges us ical monitoring (oximetry or invasive pressure to be concerned about patient satisfaction and measurement) (59). Heart rate measured by emotional needs in the operating room. Seda- the ECG (voltage) can display a normal num- tion should be titrated to the patient’s needs. ber during pulseless electrical activity (PEA) Some patients prefer to be ’wide awake’ as

long as they do not feel pain. The sense of con- including spasticity, may determine the strat- trol gives them comfort. Other patients have egy chosen to maintain comfort and home- fears of mutilation and aversion to the smell ostatsis. In our practice, neuropathic patients of burning flesh from the cautery so they pre- especially paraplegics and quadriplegics as fer to be ’asleep’. Other patients simply want well as those with regional blocks such as local to enjoy the good feeling of IV anaesthetics or spinal require little or no sedation and can administered in a safe environment. The pre- breathe spontaneously. Chest rolls are used operative assessment provides the strategy for to allow diaphragmatic offloading to prevent sedation when using regional anaesthesia. The restricted ventilation. Deep sedation or gen- ’events’ in the OR can be more pleasant for eral anaesthesia prompts most practitioners the awake patient with a warm, nurturing to intubate patients for the prone position. environment cultivated by empathetic staff. In In contrast, the lateral position provides bet- most operating rooms, the ’events’ are routine ter access to the airway and more favourable for staff, but unusual for most patients except mechanics for spontaneous ventilation com- those who have frequent surgical procedures. pared with the prone position. Sedating a Catastrophic events are uncommon so ’drama’ patient for sacral debridement in the lateral is usually unnecessary. position is similar to colonoscopy assuming there is antinociception. Regional anaesthesia (local, peripheral or In the absence of complete central neu- central) with sedation (none, light or deep) is ropathy like paraplegia, antinociception would administered as the default regimen with be needed pharmacologically using sodium general IV and/or inhalational agents used channel blockade. Regional blocks can be cat- when blocks are not carried out egorised as local infiltration blocks, peripheral The approach to the anaesthesia technique blocks or central blocks (Figure 1). One regional is influenced by the patient position during anaesthesia regimen uses a local infiltration surgery. For example, sacral ulcers can be block with sedation as needed for amnesia debrided in the lateral position or the prone and hypnosis. If no open wound is present, position. The prone position requires an extra a transcutaneous injection of sodium channel level of assessment and concern about airway blocker like 1% lidocaine is performed prior management and ventilation. What about the to the incision. In the presence of an open issues of airway management of the prone wound, local anaesthesia can be administered patient needing debridement of a sacral pres- topically or subcutaneously. The subcutaneous sure ulcer? The priorities for airway manage- technique for local anaesthesia injection into ment include maintenance of airway patency, the wound edge is less painful compared with oxygenation and ventilation. The more seda- transcutaneous injection (75). When injecting tion required for the case, the greater the local anaesthesia to the skin, it is important likelihood of apnoea and/or airway obstruction. Paraplegics or patients with spinal anaesthesia can be positioned prone while awake to ensure comfort and adequate ventilation because positioning can be problematic. When antinociception is adequate, minimal sedation is required. Many anaesthesiologist will use endotracheal intubation for all prone cases to avoid the challenges of airway management without an endotracheal tube (ET). We hypoth- esise that neuromuscular blockade commonly used for intubation presents unnecessary problems with muscular weakness in debilitated patients which could lead to respiratory failure. This is a topic for a separate paper. Patients with spinal cord injury always need individualised assessment of their anaes- Figure 1. Regional anaesthesia hierarchy for sacral pressure thetic need. The unique pattern of impairment ulcers. © O’Neill & Ayello 2012

to deposit the anaesthetic in or barely under (phenylephrine, ephedrine or norepinephrine) the dermis layer, otherwise the small, unmyeli- as needed. The location of drug delivery influ- nated nociceptive fibres that populate the epi- ences the efficacy and complication rate (81,82). dermis will not be anaesthetised (76). It is Regional anaesthesia with sedation as difficult to fully anaesthetise infected tissue needed is the default regimen of this protocol with Lidocaine. Topical agents do not penetrate with general anaesthesia as a second choice. devitalised tissues. Locally infiltrated sodium Sedation should be used for amnesia or hyp- channel blockers require adequate distribution nosis if the patient has anxiety that would of the drug to the afferent nerves. Infected and prevent a safe procedure. Light sedation using devitalised tissues may be difficult to ’numb’ midazolam (0·01 mg kg IV PRN) and fentanyl using local techniques. Regional techniques (0·5 μg/kg IV PRN) for analgesia is the sug- including peripheral and central block or gen- gested combination. For a patient with sleep eral anaesthesia are alternatives to local infiltra- apnoea or a difficult airway, a dexmedeto- tion when drug tissue distribution factors exist. midine (0·2–0·6 μg/kg/minute) (83) infusion The total dose of local anaesthetic adjusted could be used because it produces less res- for body weight should be below the limit for piratory depression (84). When deep sedation toxicity. Local anaesthetic toxicity needs to be and hypnosis become necessary, the light seda- accounted for as high plasma concentrations tive drugs should be used in combination of these drugs can cause seizures, respiratory with propofol (25–200 μg/kg/minute) plus or failure and cardiovascular collapse (77). The minus ketamine (20–50 μg/kg IV PRN). systemic effects are noted because sodium The Pro-Etom InfusionTM (30 ml total at channels exist in both nerves and muscles 0·6–1·2 ml/kg/hour) is used by some anaes- including the heart. The total dose of sodium thesia providers to blend the benefits of channel blocker combined with the rate of propofol (200 mg in 20 ml) and etomidate administration, absorption and elimination (20 mg in 10 ml). Methohexothal infusion could influence the risk of complications (24). (25–200 μg/kg/minutes) can be used when Peripheral blocks or central blocks can propofol is not desirable for deep seda- also be used for pressure ulcers. Paraver- tion (85). Opioid and non opioid (ketorolac tebral blocks are more commonly used for or acetaminophen) analgesic agents have been trochanteric or ischial pressure ulcers com- used to supplement sedative anaesthetics to pared with sacral pressure ulcers. Central increase patient comfort during surgery (86). blocks for sacral procedures include spinal When antinociception fails to be achieved or epidural blocks for antinociception with with underlying neuropathy or a sodium chan- sedation as needed. Lidocaine, bupivacaine nel blockade, the anaesthesiologist should use and tetracaine are the three most common general anaesthetics. Total intravenous anaes- spinal blockade drugs. Bupivacaine has almost thesia (TIVA) with propofol (25–200 μg/kg/ replaced the use of lidocaine because less inci- minutes), fentanyl (0·5 μg/kg IV PRN) or dence of transient neurological symptoms post- remifentanil (25–200 ng/kg/minutes) plus or operatively (78–80). Intrathecal opioids have minus ketamine (20–50 μg/kg IV PRN) is one little effect on haemodynamics, but can cause option. Another option is to balance general IV respiratory depression. Epidural blocks require agents with the inhalational agents (isoflurane, higher drug dosages and volumes compared sevoflurane or desflurane). This technique may with spinal blocks because the dura mater be preferred when the patient presents to the limits the drug distribution to the cerebral operating room with an ET or tracheostomy. spinal fluid. Lidocaine is the most com- Inhalational agents could be used with or with- mon epidural anaesthetic but bupivacaine out blocks or IV administration. However, this and ropivacaine can also be used as longer technique using sevoflurane and nitrous oxide lasting local anaesthetics. However, central has a slower induction time compared with blocks with sodium channel blockade can lead TIVA (87). In a pure inhalational anaesthesia to sympathectomy, bradycardia, decreased technique, there is no background IV anal- preload, decreased afterload, decreased car- gesia for postoperative pain control (88). As diac output and hypotensison (24). Therefore, commonly performed with paediatric patients, central blockades require adequate vascular inhalational induction with sevoflurane with access, fluid administration and vasopressors nitrous oxide can be used to obtain vascular

access if the adult patient presents with exces- measured by infrared spectroscopy and other sive anxiety or needle phobia (89). techniques at the airway as an index of air- Neuromuscular blockade should only be way patency and quality of ventilation without used as a last resort as a part of general measurement of an arterial blood gas. anaesthesia. Succinycholine is extremely useful Continuous assessment of oxygenation and for rapid sequence induction and treatment of ventilation is extremely important when laryngospasm. Short acting succcinylcholine, a sedation is given. Vigilance is essential to depolarising muscle relaxant, can have severe allow early detection, early intervention and side effects like hyperkalaemia, especially avoiding catastrophes such as hypoxic brain in patients with extrajunctional nicotinic injury from airway obstruction, apnoea and/or receptors from disability. Although uncom- cardiac arrest. mon, succinylcholine can trigger MH leading Ventilation methods are classiﬁed into three to hypercarbia, hypoxia, hyperthermia, hyper- categories (Figure 3). Unsupported negative kalaemia and death even if treated with dantro- pressure spontaneous ventilation is most nat- lene upon recognition of the symptoms (90). In ural which can be maintained with any airway addition, non depolarising blockers such as device or circuit. Positive pressure ventilation rocuronium, vecuronium and cis-atracurium requires a breathing system that generates a can be associated with residual neuromus- pressure above atmospheric pressure to over- cular weakness which can increase risks of come resistance and compliance factors. Man- respiratory failure in debilitated patients with ual ventilation using the circle system with sarcopenia. anaesthesia bag, the ambu bag (manual resus- citator), or Jackson Rees circuit bag provides Goals of airway management are to maintain positive pressure by the hand of the anaes- airway patency, oxygenation and ventilation thesia provider. Controlled mechanical venti- using the minimum invasiveness of airway lation provides positive pressure ventilation devices using either volume control or pressure con- This protocol recommends that airway man- trol using either an ICU ventilator or standard agement without tracheal intubation be con- anaesthesia machine. The breaths can be either sidered whenever possible on the premise that mandatory (set number machine triggered) or complications associated with intubation are spontaneous (patient triggered). Synchronisa- worth minimising. These airway management tion modes are designed to prevent patient- techniques include simple face mask ventila- ventilator asynchrony which can present as the tion, oral and nasal airways and supraglottic patient ’ﬁghting the ventilator’ and/or as ven- devices like laryngeal mask airways (LMA). tilator associated lung injury like barotrauma. However, this protocol acknowledges that ETs Newer anaesthesia machines have sensors and or surgical airways (existing tracheostomies or other features which allow them to function rarely, emergency cricothyroidotomy) may be like sophisticated ICU ventilators. necessary occasionally. Room air light sedation techniques allow Lets review respiratory physiology and the pulse oximetry to be an index of hypoven- difference between oxygenation and ventila- tilation as well as hypoxaemia based on the tion (Figure 2). Catabolism, which is half of oxygen-haemoglobin saturation curve. Hyper- metabolism, involves oxidation of fuels such carbia will cause desaturation when the alveoli as glucose, amino acids and fatty acids to pro- contain 78% nitrogen (room air), but may not duce chemical energy in the form of adenosine when alveolar oxygen is higher (91). When tri-phosphate (ATP). The metabolic rate can supplemental oxygen is used, capnography be estimated by oxygen consumption (VO2) should be monitored to ensure airway patency and/or carbon dioxide production (VCO2). and respiration rate (Figure 4 – capnography). Oxygen delivery represents the transport of An abnormality in the CO2 wave can be arte- inhaled oxygen to the cellular mitochondria for fact, central apnoea or airway obstruction (61) oxidative phosphorylation. The carbon dioxide (Figure 4B – capnography). The disruption of from the decarboxylation steps in the Kreb’s the waveform should prompt immediate action tricarboxylic acid cycle gets transported to the for assessment and intervention. alveoli via the venous blood for diffusion, dilu- Simple face masks and nasal cannula tion and exhalation. This ’fuel exhaust’ can be can promote small increases in the fraction

Figure 2. Review of respiratory physiology. © O’Neill & Ayello 2012

of inspired oxygen (FiO2) which helps provide an easy seal while simultaneously to alleviate hypoxaemia (92,93). Simple face allowing for easy observation of condensation masks provide supplemental oxygen to both and evaporation from ventilation or the unex- the nose and mouth while providing the pected vomited stomach contents. A mask with opportunity for superior gas analysis com- a strap can be used to achieve a tighter seal to pared with nasal cannula (Figure 5 – simple prevent room air dilutions of 100% O2 and per- face mask with gas sampling). Mouth breathers mitting positive pressure ventilation to treat perform better with simple face masks. Exhaled airway obstructions, apnoea and/or hypoven- water vapour accumulated on the face mask tilation. Using the circle system and anaesthesia during ventilation can be detected, but this bag, one can measure the expired tidal volumes protocol still suggests digital and graphical and airway pressure associated with manual or display of ventilation via capnography. This controlled ventilation. An ambu bag is required protocol recommends clear-plastic masks with to be present in all procedure rooms for all cases large volume, low-pressure cushions which as a low-tech resuscitation device.

responsibilities including contemporaneous documentation (95). Why use an LMA over an ET? Supra- glottic airway can be inserted without using neuromuscular blockade which is an advan- tage compared with tracheal intubation (96). In addition, non anaesthesiologists are typically more successful at placing LMAs compared with performing tracheal intubations (97). The absence of neuromuscular blockade can allow spontaneous ventilation which is desirable, especially in an outpatient surgical setting for optimal drug titration and faster emer- gence (95). Patients receiving general anaesthesia in the outpatient setting for LMAs compared with ETs have been shown to have shorter PACU stays because the drug concentrations are more favourable with fewer side effects (96). ETs with general anaesthetics using either spontaneous or positive pressure ventilation add a level of safety because respiratory depression and loss of reflexes are expected. Figure 3. Classification of ventilation techniques. © O’Neill & Ayello 2012 In typical patients, usually the anaesthesiologist will induce anaesthesia prior to intubation which leads to amnesia, apnoea and areflexia. If a seal between the mask and the face can- In high risk airway patients, where intubation not be properly achieved alternative methods may be challenging or difficult, spontaneous must be implemented. Failed seals can occur as ventilation is maintained until ET placement a result of patient intolerance (cannot stand the is confirmed to decrease risk of hypoxaemia. mask on their face) which can lead to extended Therefore in high risk airway patients, the intu- periods of time with the mask removed or bation plan is opposite that the usual plan poorly positioned to increase comfort (94). (Table 3). ETs are commonly inserted using Nasopharyngeal oxygen via nasal cannula direct laryngoscopy for placement below the positioned at the exterior nostrils is a safe vocal cords and above the tracheal carina. and comfortable alternative to face masks (94). Video scopes such as the glide scope or fibreop- Newer nasal cannula models have gas tic bronchoscopes may be necessary for some exchange analysis ports in their design which challenging intubations. Like the LMA, ETs makes them more desirable than older models maintain airway patency while freeing the which had limitations like monitoring CO2. hands of the anaesthesiologist to attend to other The evolution of supraglottic airway devices responsibilities. In addition to reliably prevent- including the LMA and I-Gel have been an ing pharyngeal collapse and laryngospasm, the advancement in anaesthesia (Figure 6 – airway ET with the inflatable cuff decreases the risk devices). Supraglottic airway devices keep the of pulmonary aspiration of the gastric contents tongue and pharyngeal soft tissue away from and saliva (Figure 6 – LMA versus ET). the lumen of the trachea to maintain air- Surgical airways remain the last resort. way patency. This is important as the role of Elective patients with respiratory failure or the anaesthesiologist is dynamic management severe dysphagia may require tracheostomy. and multitasking. As the anaesthesiologist no Emergency cricothyroidotomy is the treatment longer has to manually maintain the adequate of choice for the ’unable to intubate–unable seal and mask fit with chin lift, this frees to ventilate’ scenario which the ASA difficult up the anaesthesiologist’s hands which can airway algorithm was designed to avoid. then be used to maintain IVs, preparation and Induction of general anaesthesia for intuba- administration of drugs and even fulfil other tion results in amnesia, apnoea and areflexia.

(A)

(B)

are NPO and are likely to be easy to mask ventilate and intubate easily using direct laryngoscopy. Plan B is used for the challenging or difficult intubation because spontaneous ventilation with maintenance of airway reflexes minimises the risk of hypoxaemia. The spontaneous breathing or so-called ’awake’ technique usually involves airway topicalisation with sodium channel blockers such as lidocaine and sedation (midazolam, fentanyl, droperidol, dexmedetomine, ketamine and/or propofol) for comfort and cooperation. Once the ET Figure 5. Face mask gas sampling and oxygen delivery. placement is confirmed by the usual methods, © O’Neill & Ayello 2012 induction of anaesthesia can proceed without the risk of airway obstruction. Consequently, there is a risk of airway obstruction, hypoxaemia and hypercarbia (respira- All patients are monitored postoperatively for tory acidosis) if mask ventilation with oxygen the duration appropriate to their acuity and/or intubation are not successful. There are Generally, patients are transferred to the two major approaches to endotracheal intuba- PACU postoperatively. The PACU should tion (Table 3): plan A is induction of anaesthe- be staffed with the attending anaesthesiolo- sia followed by intubation; Plan B is intubation gist, trained recovery room nurses and other followed by induction of anaesthesia. Plan A support personnel, who have a comprehen- is most commonly used because most patients sive understanding of possible complications

(A) (B)

Figure 6. Airway devices: Head to head comparison. (A) Supraglotic laryngeal mask. (B) Endotracheal tube.

Table 3 Airway management strategies for intubation Table 4 Basis of assessment for discharge from anaesthesia © O’Neill & Ayello 2012 (Aldrete) © O’Neill & Ayello 2012

Plan A Induce anaesthesia, then intubate 1 Haemodynamic stability achieved Plan B Intubate, then induce anaesthesia 2 Low risk of blood loss from surgical site 3 Baseline neurological status satisfactory 4 Low risk of respiratory depression and treatment protocols (89,90). Patients are 5 Comfortable monitored until they meet the discharge criteria (Table 4). The ASA guidelines as sum- anaesthesiologist feels that the patient is at marised by the Aldrete score state that prior Key Point minimal risk for developing any postoperative to PACU discharge, patients should be at complications. • patients with pressure ulcers baseline neurological status (awake and alert, are typically quite ill and have if so preop) with vital signs within acceptable multiple comorbidities making limits (98). Patients need to meet an acceptable DISCUSSION wound management and healing a challenge hospital specific score of a set of criteria defined Patients with pressure ulcers are typically by where the procedure was performed. For quite ill and have multiple comorbidities mak- outpatients, a responsible adult should be ing wound management and healing a chal- present to take the patient home if accept- lenge. Debridement is an important component able and a written set of instructions should be of wound bed preparation. As debridement provided with the patient (98). Although the removes non functioning keratinocytes and anaesthesiologist may occasionally choose to bioburden, it must be extensive enough to bypass the PACU, patients from the operating provide the scaffold for tissue repair and stimu- room usually go to the PACU prior to transfer lation of wound healing. Adequacy of debride- to the floor, ICU or discharged home. ment to the ’margin of response’ is based on the When the anaesthesiologist decides, it may biological understanding of the impairments be possible to ’fast track’ the recovery patients to healing of a chronic wound (103). Assur- by bypassing the PACU (Table 4) (99). This ing adequacy of debridement requires probing approach is usually used for patients who and manipulation of the wound that is painful. had ambulatory surgery or inpatients with Pressure ulcer pain may preclude using some local anaesthesia with minimal sedation or methods of debridement. Management of pain prolonged PACU hold times. PACU bypass so that enough debridement of the wound can is a cost effective, safe and efficient alterna- be undertaken is essential. tive to the PACU for these patients (99–102). Advances in anaesthesiology over the This technique should only be used when the last two decades including pulse oximetry,

Key Points capnography, advanced airway management, 5 Allman RM, Goode PS, Burst N, Bartolucci AA, as well as, ultrasound guided vascular access Thomas DR. Pressure ulcers, hospital complications, and disease severity: impact on hospital • management of pain so that and regional block techniques have improved costs and length of stay. Adv Wound Care enough debridement of the patient safety in the operating room. Although wound can be undertaken is 1999;12:22–30. there are inherent risks with anaesthesia, fear of essential 6 Landi F, Onder G, Russo A, Bernabei R. Pressure • significantly lower mortality the operating room, especially receiving anaes- ulcer and mortality in frail elderly people living rates for wound patients who thesia, should not prevent a wound patient in community. Arch Gerontol Geriatr 2007;44 Suppl 1:217–23. had debridements compared from obtaining the surgical debridement they 7 Redelings MD, Lee NE, Sorvillo F. Pressure ulcers: with those who did not suggest desperately need to stimulate wound closure. more lethal than we thought? Adv Skin Wound this surgery to be life saving Significantly lower mortality rates for wound Care 2005;18:367–72. • as no literature exists on using 8 Black JM, Cuddigan JE, Walko MA, Didier LA, a protocol emphasising regional patients who had debridements compared Lander MJ, Kelpe MR. Medical device related anaesthesia with sedation as with those who did not (2,10,104) suggest this pressure ulcers in hospitalized patients. Int needed for operative debride- surgery to be life saving. The use of this Wound J 2010 [Epub]. ment, it is the recommenda- anaesthesia protocol will undoubtedly assist 9 VanGilder C, Amlung S, Harrision S, Meyer S. tion that through this proto- the attending physicians of wound patients Results of the 2008–2009 international pressure col a retrospective chart review ulcer prevalence survey and a 3 year, acute care, on outcomes of sacral pres- in securing consent from the patient and per- unit-specific analysis. Ostomy Wound Manage sure ulcer debridements with forming a safe, successful debridement with 2009;55:39–45. regional anaesthesia be per- minimal complications. 10 Schiffman J, Golinko MS, Yan A, Flattau A, Tomic- formed This anaesthesia protocol promotes the Canic M, Brem H. Operative debridement of • a randomised, stratified premise that subspeciality training in wound pressure ulcers. World J Surg 2009;33:1396–402. prospective clinical trial with 11 VanGilder C, MacFarlane GD, Harrison P, Lachen- the use of this protocol is also anaesthesia is advantageous for patients with bruch C, Meyer S. The demographics of sus- suggested for the future non healing wounds like sacral pressure ulcers. pected deep tissue injury in the United States: As no literature exists on using a protocol an analysis of the International Pressure Ulcer emphasising regional anaesthesia with seda- Prevalence Survey 2006–2009. Adv Skin Wound tion as needed for operative debridement, Care 2010;3:254–61. it is the recommendation that through this 12 Lazarus GS, Cooper DM, Knighton DR, Margolis protocol a retrospective chart review on out- DJ, Pecoraro RE, Rodeheaver G, Robson MC. Definitions and guidelines for assessment of comes of sacral pressure ulcer debridements wounds and evaluation of healing. Arch with regional anaesthesia be performed. A Dermatol 1994;130:489–93. randomised, stratified prospective clinical trial 13 Mostow EN. Diagnosis and classification of with the use of this protocol is also suggested chronic wounds. Clin Dermatol 1994;12:3–9. for the future. 14 Stojadinovic O, Brem H, Vouthounis C, Lee B, Fellon J, Stallcup M, Merchant A, Galiano RD, Tomic-Canic M. Molecular pathogenesis ACKNOWLEDGEMENT of chronic wounds: the role of beta-catenin and This work was supported by NIH Grant RO1 c-myc in the inhibition of epithelialization and LM008443-04. wound healing. Am J Pathol 2005;167:59–69. 15 Auerbach R, Auerbach W. Regional differences in the growth of normal and neoplastic cells. REFERENCES Science 1982;215:127–34. 1 National Pressure Ulcer Advisory Panel (NPUAP) 16 Auerbach R, Morrissey LW, Kubai L, Sidky YA. and European Pressure Ulcer Advisory Panel Regional differences in tumor growth: studies of (EPUAP). Prevention and treatment of pressure the vascualr system. Int J Cancer 1978;22:40–6. ulcers: clinical practice guideline. Washington, 17 Kubai L, Auerbach R. Regional differences in the DC: National Pressure Ulcer Advisory Panel, growth of skin transplants. Transplantation 2009. 1980;30:128–31. 2 Brem H, Lyder CH. Protocol for the successful 18 Ger R. Fecal diversion in management of large treatment of pressure ulcers. Am Surg 2004;188 infected perianal lesions. Dis Colon Rectum Suppl:9S–17S 1996;39:1327–9. 3 Lyder CH. Pressure ulcer prevention and manage- 19 Beldon P. Problems encountered managing pres- ment. JAMA 2003;289:223–6. sure ulceration of the sacrum. Br J Community 4 Russo CA, Steiner C, Spector W. Hospitalizations Nurs 2008;13;S6, S8, 10passim. related to pressure ulcers among adults 18 20 Longe RL. Current concepts in clinical therapeu- years and older 2006. Healthcare Cost and tics: pressure sores. Clin Pharm 1986;5:669–81. Utilization Project (HCUP) Statistical Brief 64. 21 Brem H, Nierman DM, Nelson JE. Pressure ulcers Rockville, MD: Agency for Healthcare Research in the chronically critically ill patient. Crit Care and Quality, 2008. URL http://www.hcup- Clin 2002;18:683–94. us.ahrq.gov/reports/statbriefs/sb64.pdf [acce- 22 Freedman G, Entero H, Brem H. Practical treat- ssed on 21 June 2010] ment of pain in patients with chronic wounds:

pathogenesis-guided management. Am J Surg 38 Kluger MT, Tham EJ, Coleman NA, Runciman 2004;188 Suppl:31S–5S. WB, Bullock MF. Inadequate pre-operative 23 O’Neill DK. Operative anesthesia for stage 3 and evaluation and preparation: a review of 197 4 pressure ulcers, July 2010, Lecture, NYU reports from the Australian incident monitoring Kimmel Wound Center Pressure Ulcer Course study. Anaesthesia 2000;55:1173–8. Lecture. New York University Langone Medical 39 Davis NJ, ed. Anaesthesia-related mortality in Center. Australia 1994–1996. Melbourne, Australia: 24 Faccenda KA, Finucane BT. Complications of Capital Press, 1999. regional anesthesia: incidence and prevention. 40 Morgan GE Jr, Mikhail MS, Murray MJ. The prac- Drug Saf 2001;24:413–42. tice of anesthesiology. Chapter 1. In: Morgan GE 25 Lewicki LJ, Mion L, Splane KG, Samstag D, Secic Jr, Mikhail MS, Murray MJ, editors. Clinical M. Patient risk factors for pressure ulcers during anesthesiology, 4rd edition. McGraw-Hill Com- cardiac surgery. AORN J 1997;65:933–42. panies Inc, 2006. 26 Grous CA, Reilly NJ, Gift AG. Skin integrity in 41 Pasternak LR, Arens JF, Caplan RA, Connis RT. patients undergoing prolonged operations. Practice advisory for preanesthesia evaluation. J Wound Ostomy Continence Nurs 1997;24: J Anesth 2002;96:485–96. 86–91. 42 Zaidan JR, Atlee JL, Belott P, Briesacher KS. Prac- 27 Schoonhoven L, Defloor T, van der Tweel I, tice advisory for the perioperative management Buskens E, Grypdonck MH. Risk indicators for of patients with cardiac rhythm management pressure ulcers during surgery. Appl Nurs Res devices: pacemakers and implantable cardiover 2002;15:163–73. ter-defibrillators. J Anesth 2005;103:186–98. 28 Orkin FK. Meaningful cost reduction. Penny wise, 43 Atlee JL, Bernstein AD. Cardiac rhythm manage- pound foolish. Anesthesiology 1995;83:1135–7. ment devices (Part I): indications, device, selec- 29 White PF, White LD. Cost containment in the tion and function. J Anesth 2001;95:1265–80. 44 Atlee JL, Bernstein AD. Cardiac rhythm manage- operating room: who is responsible? J Clin ment devices (Part II): perioperative manage- Anesth 1994;6:351–6. ment. J Anesth 2001;95:1492–506. 30 Vogel WA, Manecke GR Jr, Poppers PJ. The ethics 45 Buchanan K, Bernstein N, Ayello EA, O’Neill DK. of cost containment from the anesthesiologist’s Cardiac device interrogation for safer care of perspective. J Clin Anesth 1999;11:73–7. surgical wound patients. Adv Skin Wound Care 31 Schuster M, Standl T. Cost drivers in anesthesia: 2011; 24:507–14. manpower, technique and other factors. J Curr 46 Crossley GH, Poole JE, Rozner MA. The Heart Opin Anaesthesiol 2006;19:177–84. Rhythm Society Expert Consensus Statement 32 Korhonen AM, Valanne JV, Jokela RM, Ravaska P, on the perioperative management of patients Kortitila KT. A comparison of selective spinal with implantable defibrillators, pacemakers anesthesia with hyperbaric bupivacaine and and arrhythmia monitors: facilities and patient general anesthesia with desflurane for outpa- management, Heart Rhythm Society, May 2011. tient knee arthroscopy. Anesth Analg 2004; 99: 47 Jacob S, Shahzad MA, Maheshwari R, Panaich 1668–73. SS, Aravindhakshan R. Cardiac rhythm device 33 Williams BA, Kentor ML, Vogt MT, Vogt WB, identification algorithm using X-Rays: CaRDIA- Coley KC, Wiliams JP, Roberts MS, Chelly JE, X. Heart Rhythm 2011; 8:915–22. Harner CD, Fu FH. Economics of nerve block 48 Rozner MA. The patient with a cardiac pacemaker pain management after anterior cruciate lig- or implanted defibrillator and management ament reconstruction: potential hospital cost during anaesthesia. Curr Opin Anaesthesiol savings via associated postanesthesia care unit 2007;20:261–8. bypass and same-day discharge. Anesthesiol- 49 Anderson M, Comrie R. Adopting preoperative ogy 2004; 100:697–706. fasting guidelines. AORN 2009;90:73–80. 34 O’Neill DK, Maggi J. Anesthetic care for patients 50 Yoneyama T, Yoshida M, Ohrui T, Mukaiyama H, with skin breakdown. J Clin Anesth 2009;27: Hoshiba K, Ihara S. Oral care reduces pneumo- 599–603. nia in older patients in nursing homes. JAGS 35 O’Neill DK, Tsui S, Ayello EA, Cuff G, Brem H. 2002; 50:430–3. Anesthesia protocol for heel pressure ulcer 51 Scannapieco FA. Pneumonia in nonambulatory debridement. Adv Skin Wound Care 2012;25: patients: the role of oral bacteria and oral 209–19. hygiene JADA 2006; 137:21S–5S. 36 Sweitzer Bobbie J. Overview of preoperative 52 Crenshaw JT, Winslow EH. Preoperative fasting: assessment and management. Chapter 4. old habits die hard. Am J Nurs 2002;102:36–44; In: Longnecker DE, Brown DL, Newman MF, quiz 45. Zapol WM, editors. Anesthesiology. New York: 53 Green CR, Pandit SK, Schork MA. Preoperative McGraw Hill Medical, 2008. fasting time: is the traditional policy changing? 37 Hanci V, Ayoglu H, Yurtlu S, Yildirim N, Results of a national survey. Anesth Analg 1996; Okyay RD, Erdogan G, Sayin E, Turan IO. An 83:123–8. evaluation of P wave dispersion, QT, corrected 54 Shime N, Ono A, Chihara E, Tanaka Y. Current QT and corrected QT dispersion intervals on practice of preoperative fasting: a nationwide the electrocardiograms of malnourished adults. survey in Japanese anesthesia-teaching hospi- Anaesth Intensive Care 2010;38:122–7. tals. J Anesth 2005;19:187–92.

55 Diks J, van Hoorn DE, Nijveldt RJ, Boelens PG, twice as much as the vasoconstriction threshold. Hofman Z, Bouritius H, van Norren K, van Anesthesiology 1997;86:1046–54. Leeuwen PA. Preoperative fasting: an outdated 71 Kurz A, Go JC, Sessler DI, Kaer K, Larson concept? JPEN 2005;29:298–304. MD, Bjorksten AR. Alfentanil slightly increases 56 Warner MA, Caplan RA, Epstein BS, Gibbs CP, the sweating threshold and markedly reduces Keller CE, Leak JA, Maltby R, Nickinovich the vasoconstriction and shivering thresholds. DG, Schreiner MS, Weinlander CM. Practice Anesthesiology 1995;83:293–9. guidleines for preoperative fasting and the 72 Zerr KJ, Furnary AP, Grunkemeier GL, Bookin S, use of pharmacologic agents to reduce the Kanhere V, Starr A. Glucose control lowers the risk of pulmonary aspiration: application to risk of wound infection in diabetics after open healthy patients undergoing elective proce- heart operations. Ann Thorac Surg 1997;63: dures. J Anesth 1999;90:896–905. 356–61. 57 Anonymous. Standards for basic anesthetic 73 van den Berghe G, Wouters P, Weekers F, Verwaest monitoring. ASA Directory of Members, C, Bruyninckx F, Schetz M, Vlasselaers D, 2004. http://www.asahq.org/For-Members/ Ferdinande P, Lauwers P, Bouillon R. Intensive Standards-Guidelines-and-Statements.aspx insulin therapy in critically Ill patients. N Engl 58 Tinker JH, Dull DL, Caplan RA, Ward RJ, Cheney J Med 2001;345:1359–67. FW. Role of monitoring devices in prevention 74 Monk TG, Saini V, Weldon C, Sigl JC. Anesthetic of anesthetic mishaps: a closed claims analysis. management and one-year mortality after non- J Anesth 1989;71:541–6. cardiac surgery. Anesth Analg 2005;100:4–10. 59 Eichhorn JH. Pulse oximetry as a standard of 75 Bartfield JM, Sokaris SJ, Raccio-Robak N. Local practice in anesthesia. J Anesth 1993;78:423–6. anesthesia for lacerations: pain of infiltration 60 Harris RS, Sebel PS. Monitored anesthesia care and inside vs outside the wound. Acad Emerg Med conscious sedation. Chapter 68. In: Longnecker 1998;5:100–4. 76 Hilliges M, Wang L, Johansson O. Ultrastructural DE,BrownDL,NewmanMF,ZapolWM,edi- evidence for nerve fibers within all vital layers tors. Anesthesiology. New York: McGraw Hill of the human epidermis. J Invest Dermatol Medical, 2008. 1995;104:134–7. 61 Cheifetz IM, Myers TR. Should every mechanically 77 Lambert LA, Lambert DH, Strichartz GR. Irre- ventilated patient be monitored with capnogra- versible conduction block in isolated nerve phy from intubation to extubation? Respir Care by high concentrations of local anesthetics. 2007;52:423–42. J Anesth 1994;80:1082–93. 62 Kistner JR, Miller ED, Epstein RM. More than V 5 78 Hampl KL, Schneider MC, Ummenhofer W, Drewe needed (letter). Anesthesiology 1977;47:75–6. J. Transient neurologic symptoms after spinal 63 London MJ, Hollenberg M, Wong MG. Intraoper- anesthesia. Anesth Analg 1995;81:1148–53. ative myocardial ischemia: localization by con- 79 Hampl KR, Heinzmann-Wiedmer S, Luginbuehl I, tinuous 12-lead electrocardiography. J Anesth Harms C, Seeberger M, Schneider MC, Dras- 1988;69:232–41. ner K. Transient neurologic symptoms after 64 Blackburn H, Katigbak R. What electrocardio- spinal anesthesia: a lower incidence with prilo- graphic leads to take after exercise? Am Heart J caine and bupivacaine than with lidocaine. 1964;67:184–5. J Anesth 1998;88:629–33. 65 Sessler DI, Ponte J. Shivering during epidural 80 Keld DB, Hein L, Dalgaard M, Krogh L, Rodt SA. anesthesia. Anesthesiology 1990;72:816–21. The incidence of transient neurologic symptoms 66 Leslie K, Sessler DI, Bjorksten AR, Ozaki M, Mat- (TNS) after spinal anaesthesia in patients under- sukawa T, Schroeder M, Lin S. Propofol causes going surgery in the supine position. Hyper- a dose-dependent decrease in the thermoregu- baric lidocaine 5% versus hyperbaric bupiva- latory threshold for vasoconstriction but has lit- caine 0.5%. Acta Anaesthesiol Scand 2000;44: tle effect on sweating. Anesthesiology 1994;81: 285–90. 353–60. 81 Magnusdottir H, Kimo K, Ricksten S. High tho- 67 Matsukawa T, Kurz A, Sessler DI, Bjorksten AR, racic epidural analgesia does not inhibit sym- Merrifield B, Cheng C. Propofol linearly reduces pathetic nerve activity in the lower extremities. the vasoconstriction and shivering thresholds. Anesthesiology 1999;91:1299–304. Anesthesiology 1995;82:1169–80. 82 Basse L, Werner M, Kehlet H. Is urinary drainage 68 Kurz A, Sessler DI, Annadata R, Dechert M, necessary during continuous epidural anesthe- Christensen R, Bjorksten AR. Midazolam sia after colonic resection. Reg Anesthes Pain minimally impairs thermoregulatory control. Med 2000;25:498–501. Anesth Analg 1995;81:393–8. 83 Arain SR, Ebert TJ. The efficacy, side effects, and 69 Toyota K, Sakura S, Saito Y, Ozasa H, Uchida H. recovery characteristics of dexmedetomidine The effect of pre-operative administration of versus propofol when used for intraoperative midazolam on the development of intra- sedation. Anesth Analg 2002;95:461–6. operative hypothermia. Anaesthesia 2004;59: 84 Ramsay MA, Luterman DL. Dexmedetomidine as 116–21. a total intravenous anesthetic agent. J Anesth 70 Kurz A, Ikeda T, Sessler DI, Larson MD, 2004;101:787–90. Bjorksten AR, Dechert M, Christensen R. 85 Sa Rego MM, Inagaki Y, White PF. Cost- Meperidine decreases the shivering threshold effectiveness of methohexital versus propofol

for sedation during monitored anesthesia care. 96 Luba K, Cutter TW. Supraglottic airway devices Anesth Analg 1999;88:723–8. in the ambulatory setting. Anesthesiol Clin 86 Gesztesi Z, Sa Rego MM, White PF. The compar- 2010;28:295–314. ative effectiveness of fentanyl and its newer 97 Martin PD, Cyna AM, Hunter WA, Henry J, analogs during extracorporeal shock wave Ramayya GP. Training nursing staff in airway lithotripsy under monitored anesthesia care. management for resuscitation. A clinical com- Anesth Analg 2000;90:567–70. parison of the face mask and laryngeal mask. 87 Hong JY, Kang YS, Kil HK. Anaesthesia for Anaesthesia 1993;48:33–7. day case excisional breast biopsy: propofol- 98 American Society of Anesthesiologists Task Force remifentanil compared with sevoﬂurane- on Postanesthetic Care. Practice guidelines for nitrous oxide. Eur J Anaesthesiol 2008; 25:460–7. postanesthetic care: a report by the American 88 Moore JK, Elliott RA, Payne K, Moore EW, St Leger Society of Anesthesiologists Task Force on AS, Harper NJ, Pollard BJ, Kerr J. The effect of Postanesthetic Care. J Anesth 2002;96:742–52. anaesthetic agents on induction, recovery and 99 White PF, Rawal S, Nguyen J, Watkins A. PACU patient preferences in adult day case surgery: fast-tracking: an alternative to ‘‘bypassing’’ the a 7-day follow-up randomized controlled trial. PACU for facilitating the recovery process after Eur J Anaesthesiol 2008; 25:876–83. ambulatory surgery. J Perianesth Nurs 2003; 89 Joshi GP. Inhalational techniques in ambulatory 18:247–53. anesthesia. Anesthesiol Clin N Am 2003;21: 100 Kiekkas P, Poulopoulou M, Papahatzi A, Androut- 263–72. sopoulou C, Maliouki M, Prinou A. Workload of 90 Halliday NJ. Malignant hyperthermia. J Craniofac postanaesthesia care unit nurses and intensive Surg 2003;14:800–2. care overﬂow. Br J Nurs 2005;14:434–8. 91 Sivilotti ML, Messenger DW, van Vlymen J, 101 Kluger MT, Bullock MF. Recovery room incidents: Dungery PE, Murray HE. A comparative eval- a review of 419 reports from the Anaesthetic uation of capnometry versus pulse oximetry Incident Monitoring Study (AIMS). Anaesthesia during procedural sedation and analgesia on 2002;57:1060–6. room air. CJEM 2010; 12:397–404. 102 Marshall SI, Chung F. Discharge criteria and 92 Oh TE, Duncan AW. Oxygen therapy. Med J Aust complications after ambulatory surgery. Anesth 1988;149:141–6. Analg 1999;88:508–17. 93 Considine J. The reliability of clinical indicators 103 Tomic-Canic M, Ayello EA, Stojadinovic O, of oxygenation: a literature review. Contemp Golinko MS, Brem H. Using gene transcription Nurse 2005; 18:258–67. patterns (Bar coding scans) to guide wound 94 Eastwood GM, Dennis MJ. Nasopharyngeal (NPO) debridement and healing. Adv Skin Wound oxygen as a safe and comfortable alternative Care 2008;21:487–92. to face mask oxygen therapy. Aust Crit Care 104 Dellinger RP, Levy MM, Carlet JM, Bion J, 2006;19:22–4. Parker MM, Jaeschke R. Surviving sepsis cam- 95 Joshi GP, Inagaki Y, White PF, Taylor-Kennedy L, paign: international guidelines for management Wat LI, Gevirtz C, McCraney JM, McCulloch of severe sepsis and septic shock: 2008 Inten- DA. Use of the laryngeal mask airway as an sive Care Med 2008;34:17–60. alternative to tracheal tube during ambulatory anesthesia. Anesth Analg 1997;85:573–7.