Overview of Open Airway Procedural Sedation
Several professional groups have tried different times to clearly explain what open airway procedural sedation (OAPS) is. While their definitions can slightly differ, there are some key elements they all agree on. We can use these shared aspects to create a simpler explanation of OAPS. Basically, OAPS is a process used during testing or treatment that helps to lessen anxiety, reduce pain, limit movement, or cause forgetfulness. This is done by using one or more types of drugs, with the goal to keep the airway open, maintain normal protective responses of the body, support natural breathing, and ensure heart and blood vessels function properly.
The way OAPS is carried out can vary widely. It is done by different healthcare professionals with a range of skills and backgrounds, in many different healthcare settings. Despite this variability, there are fundamental principles that stay the same no matter who is doing it, where it’s being done or how it’s being done.
Anatomy and Physiology of Open Airway Procedural Sedation
Doctors performing procedures with Oral Awake Procedures and Sedation (OAPS) need to have a deep understanding of the body’s structure and how it functions. This is especially true when it comes to the airway (the part of our body that lets us breathe) because the biggest risks from OAPS can happen there, even though they are rare. Studies show that problems like aspiration (breathing in something like food or liquid into the airways) and laryngospasm (a sudden spasm that blocks air from going into your lungs) are the most common serious issues that need emergency medical help during OAPS.
Therefore, doctors need to be skilled in assessing a patient’s airway before sedating them. This help figure out if a patient might be hard to ventilate (help breathe) or intubate (put a tube down the throat to help breathe). Part of this includes checking for things that make ventilation and intubation tricky. For instance, if the patient has a beard, is over 55, snores, is obese, or doesn’t have teeth, it might be harder for the doctor to help them breathe if they need it.
Notably, patients whose mouths open less than around 1 inch may not be suitable for OAPS. With a small opening, the doctor might not be able to see clearly and suction the mouth and the part of the throat that is visible through the mouth, or be able to use certain breathing aids, or put in a tube for breathing. It’s also important to know if the patient has had any past procedures or was born with any problems that might affect their airway. One of the tools doctors use to evaluate the airway before anesthesia is the Mallampati score. This is a scoring system based on how much room there is between the base of the tongue and the soft palate, with high scores indicating a potentially difficult airway and intubation process.
If the doctor is worried about any challenges related to the patient’s airway, they will think about whether OAPS should be done in a hospital setting. This can provide a safer environment for these patients if something goes wrong.
Why do People Need Open Airway Procedural Sedation
OAPS, or Office-Based Anesthesia and Procedural Sedation, is a medical approach that might be considered for certain medical procedures that could cause a lot of physical pain or emotional stress. This technique helps to keep you relaxed and comfortable during these procedures.
However, there’s no one-size-fits-all rule on when to use OAPS. The American Society of Anesthesiologists has provided guidelines, suggesting different levels of sedation for this technique. These levels can range from minimal sedation, which just helps you relax (also known as “anxiolysis”), to deep sedation, where you’re significantly relaxed but not unconscious.
The right level of sedation for each patient depends on some factors. These include how much pain is expected during the procedure, and how important it is for the patient to stay still (akinesia). So, the medical team will carefully consider your specific situation to determine the best sedation level for you.
When a Person Should Avoid Open Airway Procedural Sedation
There are no set rules that clearly state when a person can’t have OAPS, which is a type of surgery. This procedure is often crucial and is carried out despite the patient having other existing health problems. However, a detailed check of the person’s health and complete physical examination are extremely important. They help assess how healthy a person is before surgery and if they can handle anesthesia – the medication used for making you sleep during surgery.
There is a grade system called the ASA Physical Status Classification System, made in 1941, to understand and discuss a person’s health before surgery and providing anesthesia:
- ASA class I – This is given when a person is healthy.
- ASA Class II – Stands for individuals who have minor health problems.
- ASA Class III – Individuals with serious health problems.
- ASA Class IV – Represents patients with serious health problems which are life-threatening.
- ASA Class V – Individuals who are extremely unwell and aren’t expected to survive without the surgery.
- ASA Class VI – This is designated for individuals who are declared brain dead and whose organs are being donated.
In addition to this grading system, there are other tools that help assess the risk before surgery and anesthesia. For example, ACS NSQIP calculator and the Revised Cardiac Risk Index are especially useful.
For patients with major health conditions, the use of different anesthesia techniques might be beneficial. Where the anesthesia is given is also an important factor. For patients who are at high risk (like those in ASA III and beyond), it might be better to administer anesthesia in a hospital rather than an outpatient clinic. Lastly, only qualified and certified professionals should perform OAPS.
Equipment used for Open Airway Procedural Sedation
Before carrying out OAPS, a type of medical procedure, health care providers should have certain tools and supplies ready or nearby. Here’s a rundown of what’s needed for this procedure:
Firstly, there are devices that help to keep an eye on the patient’s vital signs, such as blood pressure, heart rhythm, breath carbon dioxide levels, oxygen levels in the blood, and body temperature. This includes a stethoscope and other monitoring equipment.
Then there are materials needed to start an IV, or a small, thin tube that gives medicine or fluids directly into a vein. There’s also a suction tool, called a Yankauer suction tip, used to remove fluids from the patient’s mouth or throat during the procedure.
The next group of supplies are related to maintaining the patient’s airway – in other words, making sure that air can smoothly go in and out of the lungs. These include a bag-valve-mask (a device that helps provide breaths to a patient who is not breathing), a supraglottic airway (a tube used if conventional methods fail), a bougie (a thin flexible instrument used to guide the endotracheal tube), a laryngoscope with blades (allows the practitioner to view the larynx), oropharyngeal and nasopharyngeal airway adjuncts (plastic devices that keep the airway open), and endotracheal tubes of suitable sizes (tube inserted into the windpipe through the mouth or nose).
Equipment for giving extra oxygen are also needed. This includes a nasal cannula, a simple face mask, and a high-flow oxygen mask.
Lastly, there are the necessary rescue medications and reversal agents, these are drugs used to reverse the effect of other drugs or to treat potential complications that may arise during the procedure.
It’s important to routinely check all equipment and supplies to ensure effective operation and to make sure they haven’t expired. Additionally, everyone involved in OAPS should regularly revise how to properly use each of these tools and supplies.
Who is needed to perform Open Airway Procedural Sedation?
In an outpatient surgery – which is a type of surgery that doesn’t require you to stay overnight at the hospital – there are several medical professionals involved. This team typically includes the surgeon who does the operation, an anesthesiologist or anesthetist (who are responsible for administering the anesthesia to make you sleep during the surgery), a nurse, a technician, and other support staff.
Additionally, there are always at least 2 members of the team who have specific lifesaving certification: Basic Life Support (BLS), Advanced Cardiac Life Support (ACLS), and, depending on the age of the patients they are working with, Pediatric Advanced Life Support (PALS). These are important hospital procedures to help keep you safe in case of an emergency.
It’s also important to note that there might be certain rules or laws that the hospital has to follow depending on where it’s located. These are set by regulatory agencies, and the hospital makes sure to review these in detail to ensure everything is being done correctly and safely.
Preparing for Open Airway Procedural Sedation
Doctors and medical staff follow a detailed and systematic approach to prepare for surgery, such as an open appendectomy (OAPS). They follow a set of rules known as the Universal Protocol, and a procedure called a surgical “time-out.” These ensure the patient’s safety and successful surgery. The steps typically include the following:
1. Making sure of the patient’s identity, the planned surgery, and that the patient has given their consent. Consent means the patient understands and agrees to have the surgery.
2. Checking the patient’s past medical history and any recent changes. This also includes checking for any known allergies the patient may have.
3. Making sure the patient hasn’t eaten (nil per os or NPO status). This is important in reducing the risk of vomiting and choking during anesthesia.
4. Marking the exact spot and side of the body where the surgery will be done to avoid any confusion.
5. Checking to see that the right medicines and equipment related to anesthesia are available and have not expired. This includes backup medicines, tools to undo the effects of anesthesia, and equipment for helping a patient breathe.
6. Making sure all the necessary monitoring equipment are correctly connected to the patient. This equipment helps doctors keep an eye on the patient’s vital signs like heart rate, blood pressure, etc. during the surgery.
They also ensure that all necessary equipment and imaging for the procedure is available and the patient is properly positioned for the surgery. This preparatory process significantly contributes to the success of the surgery and the safety of the patient.
How is Open Airway Procedural Sedation performed
The perfect drug for numbing pain, soothing the patient, and causing memory loss during minor surgical procedures (known as OAPS – office-based ambulatory procedures) would work quickly, have a short-lasting effect, allowing patients to recover and go home swiftly. But unfortunately, no single drug fits the bill perfectly. Therefore, doctors often mix multiple drugs to achieve the desired effects, with a common combination being a quick-acting anxiety-relief drug like midazolam and a strong pain relief drug like fentanyl.
These drugs are used to relieve anxiety and panic, create a temporary memory loss to help you forget about the procedure (midazolam), as well as manage pain (fentanyl). There are other combinations as well, such as ‘ketofol’ which is a mix of ketamine and propofol, which studies have shown to have fewer side effects such as difficulty in breathing compared to using single drugs.
You should recognize a few drugs typically used during OAPS:
Midazolam: This is a drug that eases anxiety and induces temporary memory loss. For healthy adults, a typical dose is 1 to 2 mg given intravenously (injected into a vein), and additional doses of the same size every 3 to 5 minutes until the drug does its job. It’s rare for anyone to need more than 5mg. The effects of midazolam can be reversed with a drug called flumazenil if necessary.
Fentanyl: This is a type of painkiller, especially used for its pain-relieving effects. It is synthetic and can be given in many different ways. It’s often preferred over other opiates like morphine as it causes less histamine release, and therefore theoretically less drops in blood pressure and side effects like itching. Any serious side effects of Fentanyl, such as slowed or stopped breathing, can be reversed with a drug called Narcan (naloxone).
Propofol: This is an anaesthetic that’s often used in both general anaesthesia and OAPS. It sends you to sleep, makes you forget, and also reduces the chance of feeling sick after surgery. Plus, it has quick effects and wears off quickly too, which makes it particularly useful for OAPS.
Ketamine: This is an anaesthetic that’s used for sedation, pain relief, and even slight memory loss. Unfortunately, its use is often limited by the potential for unpleasant reactions when you wake up and spasms in the voice box, along with other factors.
Knowing about these four drugs and how they’re used in OAPS can help you understand more about the process. There are many other drugs that can be used during OAPS for specific purposes, but details on those are beyond the scope of this discussion.
Possible Complications of Open Airway Procedural Sedation
Complications can sometimes occur when doctors need to keep a patient’s airway open or manage a situation where the airway isn’t working correctly. For example, complications could include problems such as low oxygen levels due to slow or shallow breathing, vomiting and breathing in of the vomit, tightening of the voice box or airways, and severe allergic reactions. Even though less common, other serious complications could include seizures, heart attacks, cardiac arrests, and strokes.
It’s vital for care providers to have the skills, tools, and knowledge to deal with these emergencies and send the patient to a more highly equipped facility when necessary. They should be well-versed in before-surgery evaluation and patient selection, airway management, and different emergency response protocols. They also need to be knowledgeable about anesthesia.
Regular monthly reviews of different emergency situations and how to manage them can help reduce negative outcomes due to complications involving the airway.
For instance, someone managing patient care should know how to tell if a patient has laryngospasm, or involuntary muscle spasms in the voice box. These signs might include a wheezing sound when inhaling, changes in the pattern of exhaled carbon dioxide, and lower oxygen levels. To make sure that the patient continues to get enough oxygen and can breathe effectively, healthcare providers should follow a specific procedure. This includes giving continuous positive airway pressure (a technique that delivers constant and steady air pressure) using a bag-valve mask, increasing the depth of anesthesia, and if needed, administering a muscle relaxant. The last resort would be to insert a breathing tube.
What Else Should I Know About Open Airway Procedural Sedation?
If done by a skilled and educated professional, regardless of their field of expertise, OAPS (Office-based Anesthesia and Procedure Sedation) can be a safe, fast, and gentle method for carrying out procedures that might otherwise be unbearable due to pain, discomfort, or emotional stress. OAPS provides anesthesia outside of an operating room, often in offices or clinics. This can help make medical procedures less stressful and more comfortable for patients, no matter their medical history or needs.