11 peersmanActa Orthopdica Belgica, Vol.74 - 3 - 2008No benefits or funds were received in support of this studyActa Orthop.Belg.,2008,,360-364Acta Orthopdica Belgica, Vol.74 - 3 - Site Infection (SSI) and risk stratifica-The ASA score ranges from 1 to 5 and isfelt to be predictive of potential surgical complica-tions (table I lists the 5 ASA scores and theirrespective criteria).of knee replacement surgery,it would appear intu-itive that the ASA score could be used to predictinfection.To our knowledge,the association of thereplacement surgery has not been assessed before.Here,we assess the association between the ASAscore and the risk of post-operative infection in aretrospective analysis of patients who underwentPatient selectionAll patients whohad TKA surgery performed duringfied.An infected TKA subset list within this same time-frame was also determined and reviewed.Three patientsidentified had records that were unavailable.Thesepatientsdata was not retrieved,so they were excluded.For each infected case,two controls were selected.Thecontrols were non-infected TKA patients,with surgeryperformed in the same year and month,matched for gen-der and age.As described before (3),eighty data itemsincluding diagnosis,co-morbid conditions,other riskfactors,ASA scores,surgical time,antibiotic coverage,and other general demographics were collected fromsonal data assistant (PDA) to a Microsoft Excel databaseA total of 6489 TKA procedures were identified withcases,20 surgeries were done prior to 1993 and diag-Preoperative evaluation and perioperative manage-Each patient scheduled for surgery was seen preoper-atively for medical clearance by an anesthesiologist whoassessed the ASA score.In addition to optimizing thepatients general medical status,particular attention wasination (skin,oral,and urinary etc.).The patients wereadmitted to the hospital on the day of surgery.The surgi-cal site was washed by the patient with anti-microbialsoap (povidone-iodine solution) the night prior to admis-sion and then shaved and washed again immediatelyprior to surgery.
Intravenous antibiotics were adminis-tered within 30 minutes of the surgical incision.Until1995,patients were routinely maintained on antibioticsfor 48 hours.After 1995,the protocol was changed tocoverage for only 24hours.
A first generationcephalosporin (cefazolin 1gm every 8hours) was theroutine prophylaxis.In cases of known penicillin orcephalosporin allergy,Vancomycin 500mg every12hours was administered.Closed suction wounddrainage was used for the first 24hours after surgery.For database management and statistical analysis,weused SAS software,version 9.1.3 and JMP,version 6(SAS Institute,Cary,NC,U.S.A.).To help the statisticalanalysis,a total co-morbidity score (TCOMORBID) wascreated.Each co-morbidity factor added 1 point to thetotal score.
The co-morbid conditions identified andrecorded are listed in table III.Patient TCOMORBIDscores ranged from 0 to 10.The non-infected cases neverscored higher than 4.All possible predictors of infectionwere tested against infection in bivariate analysis.Theassociation of the ASA score with infection was exam-ined in detail.Logistic regression with infection as thedependent variable was subsequently performed.RESULTSTable II lists the demographic information ofthepatients.There were no significant differencesin age,height or body weight between infectedTable I.
The ASA scoring systemCodePatient Pre-operative Physical Status1Normally healthy patient2Patient with mild systemic disease3Patient with severe systemic disease that is not4Patient with an incapacitating systemic disease that5Moribund patient who is not expected to survive for24 hours with or without operationActa Orthopdica Belgica, Vol.74 - 3 - with wound infection and that woundcontamination was the single most important fac-.Further,Wolters looked at all complica-tions after general surgeries in a multivariate analy-sis and again found an ASA score 3 was a signif-icant factorThree categories of variables have proven to bereliable predictors of SSI risk:(1) those that esti-mate the intrinsic degree of microbial contamina-tion of the surgical site,(2) those that measure theduration of an operation and (3) those that serve asmarkers of host susceptibility.
The degree ofmicrobial contamination of the surgical site was rel-atively constant in the studied population becauseall patients were treated according to the standard-We assessed the association of the duration of kneereplacement surgery and the risk of infection.We demonstrated that prolonged opera-tion time significantly correlated with infectionrisk,as well as with BMI and the total number ofcomorbidities.As for host susceptibility factors,wefound the ASA score not to be a good predictorHowever,the prevalence of infections doesincrease with higher ASA scores,but since most ofour patientsscores were below 3,we were unlike-ly to replicate Grosflams findings that an ASAscore 3 was a good predictive factorsmall number of patients with an ASA score 3 inthis usually non-emergency surgical population,that lowers this variables possible power as a pre-dictor.An ASA score beyond 2 showed anthe average ASA score for the infected TKA groupTable III.
Comorbidities of infected/control patientsComorbiditiesInfected (n=113)Non-infected (n=236)pInfections ( ulcers,diverticulitis)Prior surgeryOpen surgery28260.0014*Arthroscopic surgery2041NSRevision surgery 5130.0042*Duration of surgeryMalignant disease16240.29Vascular disease32650.90Chronic renal therapy20140.0009*Comorbidities used to calculate the TCOMORBID-score.p-values are for differences between infected/non-infected groups,using Mann-Whitney testThe presence of one of the comorbidities added 1 to the total TCOMORBID score.Table IV.
ASA score and infection percentageASA ScoreInfected (%)Non-infected (%)14 (3.54)15 (6.36)246 (40.71)151 (63.98)356 (49.56)67 (28.39)47 (6.19)3 (1.27)500Values are absolute number
1100 15NS 1100.15 Medications RD 03/08 Parkland Health & Hospital System Women & Infant Specialty Health
Nursery Services Procedure Manual
Moderate Sedation/Analgesia for Nursery Services
Any sedation administered by a practitioner/provider other than an Anesthesiologist or Certified Registered Nurse Anesthetist (CRNA).
Sedation administered NS 1100.15 Medications RD 03/08 Page 2 of 10
Be immediately available throughoutentire procedure
Assign an ASA score.
Refer to Figure 1.
Assign a Mallampati Class Scadministration of sedation the assigned RN shall perform a patient assessment including assignment of the Aldrete Score and document on the Moderate the immediate area in which unless the patient is being transported to the ea/unit where staff is qualified to definitions) nesthesiologists and CRNAs.
Contraindications for mknown hyper-sensitivity, untreated acute narrow-angle glaucoma, hemodynamic instability, trained in professional standards and techniques to administer pharmacologic agents to predictably achieve desired levels criteria set by the cause moderate (conscious) sedation.They may do so to only patients with III.Patients with an ASA score of IV or greater require an anesthesia consultation.The provider shall select and order the medication and will determine the maximum dosageand route of administration.
The provider shall be dosages shall be recorded on the appropriate form with the patients An RN shall monitor the patient for potential adverse reactions to the medication(s) being administered.
Adverse reactions shall be reported immediately to the provider.There shall be a registered nurse or other qualified individual dedicated to on responsible for monitoring the patient may not perform the procedure or have any other NS 1100.15 Medications RD 03/08 Page 3 of 10 Each patient requiring moderate (cAmerican Society of Anesthesiologists (ASA) score performed and invasive procedure.
ASA Physical Status Classification System
I A normal healthy patient II A patient with mild systemic disease III A patient with severe systemic disease IV A patient with severe systemic disease that is constant threat to life V A moribund patient who is not expected to survive without an operation.
These definitions appear in each annual edition of the ASA Relative Value Guide.
American Society of Anesthesiologists, January 14, 2003
To provide safe and effective patient care management when for diagnostic and therapeutic procedures.
To minimize physical discomfort and pain.
To minimize negative psychological responses to treatment by providing analgesia.
To control behavior.Guidelines for Sedation
Sedatives are generally administethe sedation of a patient ss of the patients protective reflexes; l of sedation to obtundation
Conscious Sedation Monitoring - Parkland Health & Hospital …
the assignment of the ASA patient classification score and a focused airway examination. The history should focus on identifying risk factors that increase the (actaorthopaedica.be)
Care Of Patients Undergoing Moderate And Deep Procedural Sedation
ASA Classification One tool used to determine a patient’s risk for anesthesia is the ASA ... ** ASA score of IV or V ** Uncontrolled COPD, Asthma, CHF, HTN (parklandhospital.com)
sedatives in any child, the credentialed provider must have the skills and equipment necessary to safety manage patients who
The patient must undergo a documented presedation medical evaluatA patient classification score and a focused airway examination.
The history should focus on identifying risk factors that increase the sensitivity to sedatives or analgesic medicomplication or difficulties in managing complications if they were to arise.
The NS 1100.15 Medications RD 03/08 Page 4 of 10
There should be an appropr Children should not receive sedative or anxiolytic medicationsby skilled medical personnel.
Sedative and anxiolytic presence of individuals skilled in ai Age and size appropriate should be checked before sedation and be immediately available.
All patients sedated for a procedure must tored with a cardiac
An individual must be specifically assigned to monitor the patients cardiorespiratory
Specific discharge criteria must be used when discharging a patient home after the than 50 weeks postconceptual age shall remain hospitalized on pulse oximetry with heart rate for 24 hours post Definitions
ysis) A drug induced state during which patients respond normally to verbal commands.
Although cognitive function and coordinatcardiovascular functions are unaffected.ed to maintain a patent airway, and spontaneous A drug-induced depression of consciousness during which patients cannot be easily epeated or painful stimuled.
Patients may require assistance in maintaining a patent airwventilation may be This is restricted to use byNS 1100.15 Medications RD 03/08 Page 5 of 10 A medically controlled drug induced depression of consciousness that:
Allows protective reflexes to be maintained;
Retains the patients ability to macontinuously;
Maintains regular, continuous and adequate spontaneous ventilation and cardiovascular function;
Permits the patient to have appropriate responses to light physical stimulation or
Any administration by any route of sedatives, hypnotics ornd/or opiate agents that is intended to
The administration of a medication to
Small dosages of a single oral anti-anxiety agent given toprocedure are NOT conscious sedation.
Qualifications: qualifications her Procedure form PS 3776 Consent for Anesthesia Provider Procedure Monitoring form PS 2380
Moderate Sedation Monitoring form PS 5001 form PS 7922 Cardiac/Respiratory Monitor
Immediately Available: Crash Cart with drugs and intubation equipment
Reversal Agents (Naloxone, for Transport: NS 1100.15 Medications RD 03/08 Page 6 of 10 All of the above requirements CMC Sedation Assessment and Flowsheet Form Refer to Nursery procedure 600.25 Preparing and Transporting Neonates A medical history shall be on the medical record indicating any significant medical
Pre-procedural assessment including an airway exam and the assignment of an ASA sc
ProceduralsedationCare of Patients Undergoing Moderate and Deep Procedural provide clinicians with guidelines for procedural sedation use that will promote the benefits of sedation while minimizing the associated risks.
All moderate and deep procedural sedation performed at HCMC shall be done in accordance with the American Society of Anesthesiology guidelines and the Joint Commission on the Accreditation of Health Care Organizations standards.
Sedation used within the scope of this policy addresses the need to decrease anxiety, assist in the management of pain, moderate physiologic responses to stress during a diagnostic procedure or patient treatment, and expedite procedures in uncooperative adults and children that require the patient remain still.
This policy applies to all patient care areas where moderate and/or deep procedural sedation is used.
Since sedation is a continuum, this policy is designed to provide for a safe level of patient care at any level of sedation, including those patients who achieve a deeper level of sedation then originally intended and who may lose their ability to maintain independent ventilatory function.
This policy is not intended to cover sedation which results from the use of drugs that are primarily intended to alleviate severe pain over time, provide minimal sedation (anxiolysis), sedate for ventilator management, provide analgesia via intrathecal or epidural routes, address post-operative pain, manage continuous seizures or alcohol withdrawal, treat psychiatric illness, or manage behavior in cognitively impaired patients.
With the new procedural sedation there are 4 levels of sedation.
LEVEL 1 MINIMAL SEDATION:
A drug-induced state during which patients respond swiftly to verbal commands.The patients airway, spontaneous ventilation and cardiovascular function are unaffected.Minimal sedation corresponds to a Ramsey Sedation score of 1, 2 or 3.
LEVEL 2 MODERATE SEDATION formerly known as conscious sedation
A drug-induced depression of consciousness during which patients have a delayed or sluggish response (appropriate for their developmental age) to verbal commands, either alone or accompanied by light tactile stimulation.No interventions are required to maintain a patent airway, and spontaneous ventilation is adequate.
LEVEL 3 DEEP SEDATION
A drug-induced depression of consciousness during which patients cannot be easily aroused, but respond appropriately for their developmental age following repeated or painful stimulation.
The ability to independently maintain ventilatory function may be impaired.
LEVEL 4 ANESTHESIA
A drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation.
The ability to independently maintain ventilatory function is often impaired.
One tool used to determine a patients risk for anesthesia is the ASA Classification tool listed below.
ASA Class Definition
A normal, healthy patient
A patient with mild systemic disease and no functional limitations (e.g., tobacco use, controlled hypertension, controlled diabetes)
A patient with moderate to severe systemic disease that results in some functional limitations (e.g., COPD, asthma, CHF, CRF, uncontrolled diabetes).
IV A patient with severe systemic disease that is a constant threat to live and is functionally incapacitating (metastatic CA, cardiomyopathy)
ASA Class V is assigned only in those patients who are not likely to survive with or without the planned : Physicians or Licensed Independent Practitioners (LIPs) who oversee care of patients.
Sufficient numbers of qualified personnel are present during a procedure.
Minimum requirement is one person to complete procedure, and one person to monitor patient
Provide the medication used to produce sedation.Continuously monitor the patient.
May assist with minor, interruptible tasks, but shall not leave patients side.
Educational Requirements: BLS.
Completion of the sedation self-learning packet (new version available 2003).
Demonstration of competency in the following:
o Proper oxygen administration.o Use of bag/valve/mask apparatus for ventilation.o Use of suction equipment on the crash cart.
o Use of pulse oximetry.o Ability to obtain IV access.For moderate sedation with high risk patients (ASA score of IV or V) or deep sedation, all of the above plus:
o ECG monitoring.
o Advance life support for appropriate for patient age.
Planning begins when the procedure is first scheduled.
High Risk Patients High-risk patients are considered any patients receiving deep sedation and those whose pre-assessment reveals any of the following: *Documented history of difficult intubation and /or reaction ** Presence of a difficult airway ** ASA score of IV or V ** Uncontrolled COPD, Asthma, CHF, HTN ** Current arrhythmia
*Must notify Anesthesia prior to moderate-deep sedation **May need to notify Anesthesia prior to sedation
Age Specific Considerations: Why are age specific considerations important?
To provide for Individual Patient Assessment To provide for patient safety
What are the high-risk age groups for procedural sedation? Infants/toddlers Older adults
What is a key item for the following developmental stages? Pediatric Fear, difficulty with comprehending necessity of procedure Adult loss of independence or control Geriatric Fear, may have cognitive or physiologic deficits
Pediatrics: Physiologic Differences: Dosing per kilogram only size is important Airway small size large head large tongue Circulatory difficulty with peripheral access