Anesthesia In remote locations Flashcards
What would be considered”Remote” locations
for anesthesia providers?
Availability of large complex equipment for diagnosis and treatment.
JCACHO requires anesthesia to deliver same uniform quality of care
anywhere in the hospital.
Anesthesia plan should be designed around patient-environmentprocedure.
ASA GUIDELINES FOR NON-OPERATING ROOM ANESTHETIZING LOCATIONS (NORA)
Oxygen
Suction
Scavenging system for inhaled agents
Anesthetic equipment
Electrical outlets
Adequate illumination (not always possible)
Sufficient space
Resuscitation equipment immediately available
Adequately trained staff to assist anesthesia
Observe building and safety standards
Postanesthesia care facilities
ASA basic standards of monitoring
Standard I-
a qualified anesthesia provider should
be present in the room throughout the conduct of
anesthesia
ASA basic standards of monitoring
Standard II-
Continual evaluation of oxygenation,
ventilation, circulation, and temperature (why?).
How many times do you bag with RSI
Zero
PATIENT (HEALTH STATUS)
Ability to tolerate sedation vs. general anesthesia
ASA grade and co-morbidity
Airway assessment (morbid obese)
Allergies-IV contrast
Monitoring requirements-simple vs. advanced
Minimal sedation anxiolytic responsiveness
Responsiveness Normal response
to verbal stimulation
Moderate sedation/ analgesia
“conscious sedation” responsiveness
Purposeful response to verbal or tactile stimulation
Deep sedation analgesia responsiveness
Purposeful response following repeated or painful
stimulation
Unarousable even with painful stimulus
General anesthesia
Airway Unaffected
Minimal sedation
NO intervention required airway
Moderate sedation
Intervention may be required for airway
Deep sedation
Intervention required airway
General anesthesia
Spontaneous ventilation Unaffected
Minimal sedation
Never give
Midazolam on ECT
Midazolam
Increase the seizure threshold
Spontaneous ventilation adequate
Moderate
Spontaneous ventilation May be inadequate
Deep sedation and analgesia
Spontaneous ventilation Frequently
inadequate
General anesthesia
Cardiovascular function Unaffected
Minimal sedation
Usually maintained : CV function
Moderate and Deep sedation
May be impaired: CV function
General sedation
GI endoscopy drug of Choice
Propofol
In all other NORA site make sure GI Suite:
RN in suite available for help
Check IV
Check Suction
Emergency drugs ready
Have 2U of blood ready for active GI bleed(some of these
cases are done in the ICU at the bedside)
Atropine might be needed for Vagal response
What does the 3 step approach involve in NORA (PPE)
Patient
Procedure
Environment
Three step approach: The patient
the patient: may require sedation or anesthesia to tolerate NORA procedures
Anxiety, panic disorder, claustrophobia, Cerebral Palsy and movement disorders, pain, trauma, child, seizures, raised ICP
Three step approach: The procedure
NPPL Nature of the procedure Position Pain associated with procedure Length of procedure
MRI NORA limits Magnetic field Keep your Make sure you have Keep your patient warm Keep an eye on possible Be ready for transport (what would you need for it?)
- limits accessibility of anesthesia equipment
- cell phone, pager, and wallet out of the room
- drugs and airway ready in locked anesthesia cart (orient RN about their location)
- airway complications and IV disconnection
Pediatric patients Airway\_\_\_\_\_\_\_\_ General anesthesia with\_\_\_\_\_\_\_\_\_ Drugs \_\_\_\_\_\_\_\_\_\_\_\_\_ Drugs ready for\_\_\_\_\_\_\_\_ Observe for drug allergic reaction after\_\_\_\_\_\_
LMA vs. ETT small requirements Propofol and Sux, or just inhaled agents bradycardia and airway complications IV contrast administration
Pediatric patients in NORA 2 biggest concerns
IV access and airway management
Pediatric patients : Try to “judge” the length of the procedure to make a plan for
keeping your patient warm
For NICU Evaluate patient’s status Dilute your Albumin\_\_\_\_\_ Normal saline syringes for IV flush Check IV access Have RT in room during surgical procedure for ventilatory settings (jet ventilators) Have NICU RN available for extra help
wt, respiratory status, hemodynamic status, drips, sepsis)
emergency drugs
(Epi at 1mcg/cc)
5% 5cc/kg over 10-15 min
Pediatric Cancer Center
Emergency drugs (atropine and Sux for airway)
RN in suite
Drug of choice- Propofol
Oxygen , AMBU bag
