Diss. (sammanfattning) Stockholm : Karolinska institutet, 2009.

Introduction: A protocol for management of sedation and pain for mechanically ventilated patients at Flagstaff Medical Center (FMC) was implemented in August 2013. It was unknown whether the protocol is being adhered to or whether it has had an impact on patient outcomes. Objectives: To develop an audit and feedback mechanism to monitor adherence to sedation protocol at FMC and determine whether the protocol has impacted patient outcomes. Methods: A retrospective manual chart review was conducted including all mechanically ventilated adult patients for four, one-month periods: 1) pre-protocol; and 2) one month, 3) six months, and 4) 12 months post-protocol implementation. Results: 132 total patients were included (32 pre; 100 post-protocol). Mean weighted adherence score for post-protocol study groups were 5.0±0.6, 5.0±0.7, and 5.2±0.7 (p=0.926) out of ten. Time of mechanical ventilation (p=0.003) and hospital length of stay (LOS) (p=0.023) were reduced post (56±58h; 9.8±7.9days) vs. pre-protocol (90±67h; 13±7days). The adherence score was weakly correlated with hospital LOS but not time of mechanical ventilation. Conclusion: This project demonstrates improvements in patient outcomes from utilization of a sedation protocol. However, this project also highlights several challenges associated with the monitoring of protocol adherence. A lack of audit and feedback may be a factor in the observed unchanged adherence over time. Both research and monitoring activities are impaired by EHR systems that do not allow for the easy extraction of data. Ensuring that adequate audit and feedback strategies are designed and available prior to implementation of new protocols is an essential step in planning the implementation of a new protocol.

Background: Traumatic brain injury (TBI) patients are often sedated, yet sedation assessment scales have not been thoroughly studied in this population. This project inquiry describes the use of the Richmond Agitation Sedation Scale (RASS) in assessing sedation in TBI patients. Methods: A retrospective, descriptive analysis of 38 ventilated, sedated TBI patients was performed to describe 1) the characteristics of the study TBI population, 2) the use of the RASS to guide titration of sedation medication, and 3) the nursing perspective of a sedation titration protocol that includes the use of the RASS. Results: Prescribed RASS score for the study population was -2; the actual RASS score was -2.04 +/-1.05. The days spent on mechanical ventilation were 3.46 +/- 1.95. The Injury Severity Score (ISS) correlated with sedation titration (r = -0.373; p<.05). The ICD-9 code also correlated with the RASS (r = -0.400; p<0.05). There was no correlation between RASS and sedation titration (r = -0.061; p = 0.717). The majority of nurses perceived that when using the RASS, sedation level did not affect their feeling of accuracy of neurological assessment (56%), and the patient's agitation level did not affect their feeling of accurate neurological assessment (58%). Conclusion: While the degree of injury was associated with the ability of the TBI patient to maintain the prescribed RASS level, there was no association between the RASS score and sedation titration, indicating that in this small study, the RASS did not guide sedation titration in the TBI population. However, the time spent at the prescribed RASS level and days of mechanical ventilation, which was similar to reported norms, suggest that the RASS is an adequate tool for assessing sedation in the TBI population. From the nursing perspective, the use of the RASS was not a barrier in assessing sedation titration. To our knowledge, this is the first study to describe the use of RASS for assessment of sedation in TBI patients. Additional prospective studies are necessary to fully understand the ability of the RASS to guide sedation titration.

The objectives of this study were to determine the cardiopulmonary effects and pharmacokinetics of fentanyl in dogs during isoflurane anesthesia and during anesthetic recovery with or without dexmedetomidine or acepromazine sedation. This was investigated in 7 healthy dogs using a randomized cross over study design. Dogs were given fentanyl as an initial IV loading dose (5 μg/kg) followed by an infusion (5 μg/kg/hr) for 120 minutes during isoflurane anesthesia and for 60 minutes following isoflurane discontinuation. Dogs received IV dexmedetomidine (2.5 μg/kg), acepromazine (0.05 mg/kg) or saline at the time of isoflurane discontinuation. Cardiopulmonary variables were measured and blood samples were obtained at multiple time points during the anesthetic maintenance and recovery phases. Plasma concentrations of fentanyl were measured using HPLC-MS, and subsequent population pharmacokinetic analysis was performed. During isoflurane anesthesia, fentanyl bolus administration resulted in significant changes in measured cardiopulmonary variables, however, many returned to baseline values during the maintenance of anesthesia. During anesthetic recovery, dexmedetomidine administration resulted in significant increases in PaCO2, and decreases in PvO2 and CI. Systemic arterial blood pressures were significantly lower in dogs receiving acepromazine, however CI and PvO2 were significantly higher compared to the other treatments. Analysis of fentanyl plasma concentrations showed that fentanyl pharmacokinetics best fit a 2-compartmental model, with average concentrations in the treatment groups ranging from 1.6 to 4.5 ng/mL during isoflurane anesthesia, and from 1.6 to 2.0 ng/mL during anesthetic recovery. Plasma concentrations of fentanyl were significantly higher with dexmedetomidine administration compared to the other treatments during the recovery period. Compared to the maintenance phase of anesthesia, anesthetic recovery with dexmedetomidine administration did not significantly change fentanyl pharmacokinetics, while acepromazine administration increased systemic and intercompartmental clearance, and recovery without sedation increased the central volume of distribution and systemic clearance. In conclusion, recovery from anesthesia with concurrent fentanyl administration, with or without sedation, caused clinically significant alterations in cardiopulmonary function that influenced fentanyl disposition in healthy dogs. / Ontario Veterinary College Pet Trust Fund

Abstract Background: Patients in the terminal phase in the end-of-life often suffer of infractable symtoms such as pain, delirium and dyspnéa. In cases where no other symtomatic revelaing therapy is aduqate for revealing the suffering of the patient palliative sedation can be administrated. Palliative sedation means is to relieve unbearable symptoms by lowering the patient's level of consciousness by adminstration of sedatives. Objective: The aim of the study was to describe nurses experiences of paliative sedation and review the selected articles data collection method. Method: The Descriptive literature review based on 10 articles. Results: Based on nurses experiences, palliative sedation therapy is an aduqate method in revealing suffering caused by refractory symptoms in the terminal stage of life. The treatment can contribiute to a good quality of death. Palliative sedation implyes adverse effects on the patients social life as well as nutrition and hydration status. There is disagreement about whether physical or mental suffering is the correct indication for palliative sedation. The patient aswell as relatives i plays a major role in decision-making regarding palliative sedation. The nurse carries responsabilitys of grand massure and has a widespread role in decision-making and administration of palliative sedation. The treatment raises ethical issues and contribute to emotional stress for nurses, this is linked to the possibly life-shortening properties of the treatment. Questionaires, personal interviews and focus group interwievs where used as data collection methods in the included articles. Conclusion: Nurses carries a extensive role in decision-making and administration of palliative sedation. Palliativ sedering contributes to emotional stress as well as ethical issues. / Sammanfattning Bakgrund: Det är inte ovanligt att patienter i det terminala skedet upplever outhärdligt lidande relaterat till symptom som smärta, deleirium och dyspné. När ingen annan lindrande behandling ger adekvat symptomlindring kan palliativ sedering administreras.  Palliativ sedering innebär är genom administrering av sedativa läkemedel sänka patientens medvetandegrad i syftet att lindra outhärdliga symptom. Syfte: Studiens syfte var att beskriva sjuksköterskors erfarenheter av palliativ sedering samt granska de valda artiklarnas datainsamlingmetod. Metod: Beskrivande litteraturstudie baserad på 10 vetenskapliga artiklar. Resultat: Palliativ sedering ger adekvat lindring av outhärdliga symtom i det terminala skedet och kan bidra till en ökad livskvalité i livets slutskede. Behandlingen har negativa konsekvenser för nutrition- och vätsketillförsel samt patientens sociala liv. Det råder meningsskiljaktigheter om huruvida fysiskt eller psykiskt lidande är den korrekta indikationen för palliativ sedering. Patienten och anhöriga spelar en betydande roll för beslutsfatande och administrering. Sjuksköterskor är i hög grad delaktiga i behandlingen och bär ett stort ansvar över faktorer som beslutsfattande och administrering. Behandlingen väcker etiska frågeställningar och bidrar till emotionell belastning för sjuksköterskor, detta kopplat till behandlingens eventuellt livsförkortande egenskaper. De inkluderade artiklarna har använt sig av enkät, personliga intervjuer samt fokusgruppsintervjuer som datainsamlingsmetod. Slutsats: Sjuksköterskan har en utbredd roll i beslutsfattande och administrering av palliativ sedering. Palliativ sedering bidrar till emotionell belastning samt etiska frågeställningar.

A significância clínica dos achados eletrocardiográficos para pacientes sem histórico de doença cardiovascular é pequeno ou inexistente, porém em pacientes com doenças cardiovasculares poderia justificar o uso de monitoração contínua, incluindo o uso de eletrocardiograma além de terapêutica comportamental ou medicamentosa para certos procedimentos odontológicos com níveis de estresse moderado a elevado. Este estudo teve como objetivo a avaliação das alterações eletrocardiográficas em cirurgias para a colocação de implantes dentários sob anestesia local com cloridrato de lidocaína 2% associado a epinefrina, com uso de pré-medicação ansiolítica com 15mg de midazolam. O estudo foi realizado em 15 pacientes ASA I, com necessidade de implantes dentários, bilaterais em mandíbula. O estudo foi comparativo com placebo administrado aleatoriamente, duplo cego 1 hora antes ao procedimento. O eletrocardiograma registrou 12 derivações estáticas a cada 2 minutos e o registro da derivação D2 de maneira contínua, avaliando o comportamento morfológico da onda eletrocardiográfica e a presença de arritmias durante o experimento. Não foram encontradas diferenças significantes entre os grupos estudados. Quando comparamos o comportamento dos parâmetros eletrocardiográficos durante as fases do procedimento, observamos diferenças estatística (p<0,01) para a freqüência cardíaca, amplitude da onda P e duração dos intervalos RR e QTc para o grupo com sedação. Foram observadas arritmias em 53,3% dos pacientes. As arritmias encontradas foram a taquicardia e a bradicardia sinusal, as extrasístoles supraventriculares, ventriculares e extrasístole atrial bloqueada, em ambos os grupos de maneira semelhante, com maior incidência nas fases inicio e perfuração. As arritmias encontradas foram consideradas de baixo risco para pacientes sem compromeitmento sistêmico. Concluiu-se que o uso de 15mg de midazolam não apresentou diferença quando comparado ao placebo. A fase incisão apresentou maiores valores de freqüência cardíaca e amplitude da onda P e menores para duração dos intervalos RR e QTc. As arritmias mais frequentes foram as extra-sístoles e a taquicardias sinusais. / The clinical significance of eletrocardiographic evalution in patients without cardiovascular disease is very small. However, continuous monitoring using electrocardiogram and anxiety control methods, such as behaviour manegement technique and premedication, may be justified in patients with cardiovascular disease undergoing dental procedures that cause stress. The aim of this study was to evaluate the electrocardiographic alterations that occur during oral implant surgeries under local anesthesia with a 2% lidocaine hydrochloride,1: 100,000 epinephrine and midazolam sedation. One hour prior to surgery, patients were given premedication (15 mg midazolam or placebo). The subjects of this study were 15 ASA I patients, who needed bilateral implant surgery on the lower jaw. A total of 30 implant surgeries were evaluated in a double blind study. Electrocardiographic tracing the 12 static leads every two minutes and Lead II was registered in a continuous manner during sugery. Automatic measurement of the following electrocardiographic parameters were also performed: heart rate (HR), duration and amplitude of P wave, ST segment depression, duration of PR segment, QRS complex, and duration of RR, QT and QTc intervals. No statistically significant differences were found between the groups, midazolam and placebo. Howerver, analysis of the data at different stages of implant surgery showed significant difference at 1% level in relation to heart rate and, amplitude of P wave, duration of RR and QTc intervals in the midazolam group. Cardiac arrhythmias were found in 53,3% of the patients. The following cardiac arrhythmias were detected: sinusal tachycardia and bradycardia, sinusal arrhythmia, supraventricular extrasystole, ventricular extrasystole, and blocked atrial extrasystole. Arrhythmias occurred, most frequently, at the begining of implant surgery and during drilling, in a similar pattern in both groups. The arrhythmias detected in these patients were considered low risk factors in patients with no systemic alterations. In conclusion, the use of 15 mg of midazolam seemed to be no different from placebo in this study. During incision, we observed the highest heart rate values and amplitude of P wave and the lowest RR and QTc intervals. Extrasystole and sinusal tachycardia were the most frequent arrhythmias detected in these patients.

Pela sua alta incidência, morbidade, mortalidade e custos ao sistema de saúde, a sepse se destaca entre as diversas indicações de internação em unidade de terapia intensiva (UTI). A disfunção da microcirculação tem papel central na gênese e manutenção da síndrome séptica, sendo um marco fisiopatológico desta síndrome. Pacientes críticos invariavelmente estão ansiosos, agitados, confusos, desconfortáveis e/ou com dor. Neste contexto, drogas sedativas são amplamente utilizadas na medicina intensiva. A dexmedetomidina, um agonista potente e altamente seletivo dos receptores alfa-2 adrenérgicos, vem conquistando espaço como o sedativo de escolha nas UTIs por seus efeitos de sedação consciente, redução da duração e incidência de delirium e preservação da ventilação espontânea. Apesar destas possíveis vantagens, a indicação de uso da dexmedetomidina na síndrome séptica ainda carece de conhecimentos sobre seus efeitos na microcirculação e perfusão orgânica. Com o intuito de caracterizar os efeitos microcirculatórios da dexmedetomidina em um modelo murino de endotoxemia que permite estudos in vivo da inflamação e disfunção da perfusão microvascular, hamsters Sírios dourados submetidos à endotoxemia induzida por administração intravenosa de lipopolissacarídeo de Escherichia coli (LPS, 1,0 mg.kg-1) foram sedados com dexmedetomidina (5,0 &#956;g.kg.h-1). A microscopia intravital da preparação experimental (câmara dorsal) permitiu a realização de uma análise quantitativa das variáveis microvasculares e do rolamento e adesão de leucócitos à parede venular. Também foram analisados os parâmetros macro-hemodinâmicos e gasométricos (arterial e venoso portal), as concentrações de lactato arterial e venoso portal, a água pulmonar total e a sobrevivência do animal. Animais não-endotoxêmicos e/ou tratados com solução salina a 0,9% serviram como controles neste experimento. O LPS aumentou o rolamento e a adesão de leucócitos à parede venular, diminuiu a densidade capilar funcional e a velocidade das hemácias nos capilares e induziu acidose metabólica. O tratamento com dexmedetomidina atenuou significativamente estas respostas patológicas (p < 0,05). A frequência de pulso dos animais foi significativamente reduzida pela droga (p < 0,05). Outros resultados não foram tão expressivos (estatisticamente ou clinicamente). Estes resultados indicam que a utilização de dexmedetomidina produz um efeito protetor sobre a microcirculação da câmara dorsal de hamsters endotoxêmicos. Efeitos anti-inflamatórios da dexmedetomidina sobre os leucócitos e o endotélio poderiam melhorar a perfusão capilar e representar o mecanismo in vivo de ação da droga na microcirculação. / Due to its high incidence, morbidity, mortality and costs to the healthcare system, sepsis stands out among the many indications for intensive care unit (ICU) admission. The microcirculatory dysfunction plays a central role in the genesis and maintenance of the septic syndrome, being a pathophysiologic milestone in this syndrome. Critically ill patients are invariably anxious, agitated, confused, uncomfortable and/or with pain. In this context, sedative drugs are widely used in intensive care medicine. Dexmedetomidine, a potent and highly selective agonist of alpha-2 adrenergic receptors, is gaining ground as the sedative of choice in ICUs due to its effects of "conscious sedation", reducing the duration and incidence of delirium and preservation of spontaneous ventilation. Despite these potential advantages, the indication of dexmedetomidine in sepsis syndrome still lacks knowledge about its effects on microcirculation and perfusion. To characterize microcirculatory actions of dexmedetomidine in an endotoxemia rodent model that allows in vivo studies of microvascular inflammation and perfusion dysfunction, endotoxemia-submitted Syrian golden hamsters, induced by intravenous Escherichia coli lipopolysaccharide (LPS, 1,0 mg.kg-1) administration, were sedated with dexmedetomidine (5,0 &#956;g.kg.h-1). Intravital microscopy of skinfold chamber preparations allowed quantitative analysis of microvascular variables and venular leukocyte rolling and adhesion. Macro-hemodynamic parameters, arterial and portal venous blood gases and lactate concentrations, pulmonary total water, and animal survival were also analyzed. Non-endotoxemic and/or normal saline treated animals served as controls in this experiment. LPS increased leukocyte rolling and adhesion, decreased functional capillary density and red blood cell velocity, and induced metabolic acidosis. Dexmedetomidine treatment significantly attenuated these pathologic responses (p < 0.05). The pulse rate was significantly reduced by the drug (p < 0.05). Other results were not as expressive (statistically or clinically). These results indicate that the use of dexmedetomidine yields a protective effect on the microcirculation of the dorsal skinfold in endotoxemic hamsters. Anti-inflammatory dexmedetomidine effects on leukocytes and the endothelium, subsequently improving capillary perfusion, could represent the in vivo mechanism of the microcirculatory action of the drug.

O presente estudo objetiva mostrar ao Cirurgião Dentista, os quesitos necessários para se formar um Odontólogo apto a praticar a sedação inalatória, bem como os itens de segurança e de respaldo legal que deverão compor o seu ambiente de trabalho ao se utiliza desta técnica. O estudo foi fundamentado a partir de revisão de literatura sobre o tema, tendo como metodologia o estilo de Vancouver. A analgesia inalatória pela mistura gasosa de óxido nitroso e oxigênio constitui um excelente instrumento no controle da dor e da ansiedade dos pacientes durante o tratamento odontológico. É importante observar que a técnica de analgesia inalatória pela mistura gasosa de óxido nitroso e oxigênio deve ser realizada por meio de normatização técnica para garantir a eficiência da técnica e evitar transtornos. O roteiro proposto no trabalho visa apresentar as características de segurança e detalhamento das especificações técnicas dos estabelecimentos de assistência odontológica para o emprego da técnica de analgesia inalatória pela mistura gasosa de óxido nitroso e oxigênio. / This study has as objective to suggest a number of propositions in order to prepare and develop a dental office to perform conscious sedation by inhalatory analgesia using nitrous oxide/oxygen mixture. It was based on the revision of literature about the subject, having as methodology the Vancouver style. The conscientious sedation constitutes an excellent instrument in the control of the patient?s anxiety during dental treatment. It also will show to the Dentist the necessary requirements to the training of his personal and himself. It is important to observe that the technique itself must follow normative rules to guarantee its efficiency. The scope considered in the work aims present characteristics of security and detailed specifications to establish dental assistance for the use of conscious sedation by nitrous oxide/oxygen mixture.

Magister Scientiae Dentium - MSc(Dent) / The aim of the study was to compare two doses of intranasal midazolam (INM) 0.3 mg/kg and 0.5 mg/kg in terms of effectiveness and recovery time. Design:-This study was a Randomized Controlled Trial (RCT) and Triple blinded study. Sample and methods A sample of one hundred and eighteen children aged from 4-6 years old were randomly assigned for Intranasal sedation (INS) to either the 0.3 mg/kg group or the 0.5 mg/kg group. Children were taken in fasting and non-fasting conditions. The children were monitored using a pulse-oximeter, the sedation was assessed using Wilson sedation scale and the anxiety and behaviour scales were rated by Venham’s scale throughout the treatment. The facial image Scale (FIS) was also used to assess anxiety and mood of children before and after treatment. Results The mean BMI of children was found to be from 14-16. Intranasal sedation with both 0.3 mg/kg and 0.5 mg/kg midazolam was completed in 100% of the children. The pulse rates were within normal limit but statistically lower in the 0.5 mg/kg group. Oxygen saturation was above 98% in all except for one child who desaturated to 90%. Thirty five percent found this route acceptable in this study; Nine percent had burning sensation from midazolam. The state anxiety between the two groups of 0.3 mg/kg and 0.5 mg/kg were insignificant using Venham’s scale. However, behaviour scores showed statistical significant results of p value (0.03) and (0.04) in the behaviour during LA and behaviour during extractions respectively. The facial images scale (FIS) ratings chosen by the children before and after sedation was insignificant to the anxiety and behaviour ratings. The FIS revealed that 66% chose a happy face at the end of treatment. Fifty percent of the children in the study chose the same image before and after sedation. There were no adverse events encountered during the procedure. Conclusion INS with midazolam using the 0.3 mg/kg or 0.5 mg/kg doses resulted in safe and effective sedation. The 0.5 mg/kg proved to be more effective than the 0.3 mg/kg in providing better behaviour and decreasing anxiety when compared with the 0.3 mg/kg dose. The 0.5 mg/kg dose was found to be safe and the recovery time was slightly more than the 0.3 mg/kg but the difference was not clinically significant.

Philosophiae Doctor - PhD / Conscious sedation or moderate sedation and analgesia is an effective and popular alternative option for procedures outside the operating theater. If conscious sedation is a viable alternative to general anaesthesia then we as sedation practitioners must use safe sedation techniques in facilities that meet all the requirements for safe practice. Three studies were done to determine the safety and efficacy of conscious sedation outside the operating theatre. In the first study post sedation satisfaction in one hundred children aged 3-9 years was evaluated. It was extremely important to determine whether the combination of midazolam, ketamine and propofol, called an advanced sedation technique (SASA, 2015), can be safely used for paediatric sedation outside the operating theatre. The incidence of side-effects after conscious sedation using multiple drugs were documented. It is clear that intravenous sedation with midazolam, ketamine and propofol is safe and effective to use. There may be side effects but they are not long lasting and usually not life-threatening. In the second study intravenous sedation was administered to 447 adults (aged 18 years and older) using fentanyl (sublimazeR), ketamine (ketalar), midazolam (dormicum) and propofol (Diprivan) (FKMP) called an advanced sedation technique. Post sedation satisfaction, post sedation recovery on arrival home, and the relationship between side effects and different dental procedures were evaluated. The results of the study show that side effects are possible, and can be expected, when we use sedative and analgesic drugs for sedation. However, we report a low incidence of side effects when we compare it with other studies in literature as mentioned. It is known that the use of combinations of drugs may cause unforeseen synergistic pharmacological effects which can be lifethreatening. Our results show that the drugs used can be safely used for advanced sedation techniques. In trying to demonstrate the safety of sedative and analgesic agents used during sedation we looked at the haemodynamic parameters, duration of sedation, pulse rate and systolic blood pressure, in the third study. The sedation records of 335 patients for dental surgery were assessed for the period 2010 – 2011. Our results show the mean Duration of sedation is substantially and statistically significantly greater with combination FKMP than with the other combinations. The mean duration of sedation is not significantly different between ketamine and propofol (KP) and fentanyl, ketamine and propofol (FKP) (Figure 10). The use of polypharmacy regarding the combination of drugs, specifically FKMP, will cause a longer duration of sedation. This has implications for safety, as well as the side effect profile during and after sedation. When we use combinations of drugs patients were more comfortable which shows that we do not yet have a single drug that has all the characteristics of an ideal drug for sedation. Different combinations of drugs are used by other practitioners with a higher incidence of side effects. It is difficult to explain the higher values of blood pressures when all four drugs were used. It may have been a ketamine effect, although one would not expect this when using propofol with ketamine. In clinical terms the higher blood pressures are no reason for concern as all our patients were classified as ASA I and II. Our research study support the view that ketamine can be used safely outside the operating theatre with exciting possibilities for Third World countries for procedures outside the operating theatre. Sedation can be considered a reasonable alternative to general anaesthesia for certain surgical procedures in the Third World. Sedation will be an attractive option not only as far as costs are involved but also the availability of sedation providers. The important lesson from all the results is that sedation providers must be trained in procedural sedation as defined by all international sedation guidelines. We proved in this research study that sedation can be done safely, however we need to make a contribution to train sedation providers. Sedation will become an attractive alternative to general anaesthesia because of the low side-effect profile and high patient satisfaction. It is interesting that few studies are available that looked at this aspect of sedation. It is clear that a high side-effect profile can contribute to an unsafe sedation technique. Severe nausea and vomiting can cause numerous haemodynamic disturbances and dehydration. Our research study support the findings of the study by Lapere et al., (2015) that there is a high rate of patient satisfaction, and a low side-effect profile during and after sedation. This is an extremely important research study and the results are crucial as far as an option for healthcare in developing countries. Sub-Saharan Africa is a densely populated and resource poor subcontinent that provides unique challenges in patient care. These challenges include a lack of facilities and staff for the performance of operative as well as non-operative procedures. In conclusion, we feel that we are part of Sub-Saharan Africa with all the problems mentioned as far as provision of healthcare is concerned. This research study can make a crucial contribution to safe and cost-effective management of healthcare in Africa for procedures outside the operating theatre.