Brainscape's Knowledge GenomeTM


Top Flashcards (Certified)
All Flashcards

Adv Principle Oral > Anesthesia in Remote Locations > Flashcards

Anesthesia in Remote Locations Flashcards

1
Q

Satellite location equipment checklist per ASA standards?

A
  • Reliable oxygen source with back-up- e-cylinders available for back up
  • Suction source- make sure it’s strong enough!
  • Waste gas scavenging- if you don’t have scavenging, have to do TIVA
  • Adequate monitoring equipment
    • Must meet ASA and AANA basic standards- must have all monitors, including ETCO2
    • During case & during post- anesthesia transport
  • Self inflating hand resuscitator bag
    • >90% FiO2 delivery
  • Sufficient safe electrical outlets- must be able to handle all anesthesia equipment
    • ​if working in wet environment- make sure electrical outlets are isolated or have a ground fault
  • Adequate patient and anesthesia equipment illumination with battery power back-up
  • Adequate space to freely access patient and anesthesia equipment
  • Emergency cart with defibrillator , emergency drugs and other emergency equipment
    • needs to be checked often
  • Reliable two way communication to request for help
    • Adequately trained support staff in procedure room & in post-anesthesia care location
    • staff need to be trained to appropriately assist CRNA/MDA in event o femergency
  • Anesthesia professional available throughout recovery period
  • Compliance with facility with all applicable safety and building codes
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

Monitoring required in remote environments

A
  • Standards/routines utilized in the OR must be maintained - same time out and checklists used in OR
    • Pre- and post-procedure checklists
    • Emergency protocols with contact numbers should be posted
      • if only anesthesia provider, do drills so staff can help in event of emergency (ie MH)
    • ASA/AANA guidelines require evaluation of patient’s
      • Oxygenation
      • Ventilation
      • Circulation
      • Temperature
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What is an EGD?

A

esophagogastroduodenoscopy

  • Fiberoptic endoscopic evaluation of the esophagus, pylorus, & stomach
  • May involve biopsy, mucosal/submucosal dissection, dilation, stenting, etc.
  • Local oropharyngeal anesthesia w /opioid + benzo VS general anesthesia with propofol
  • Aspiration and laryngospasm common
    • ​need to keep patient extremely deep
      • ​sometimes hard to do- may need dexmedetomidine or remifent and adjunct
    • topicalizing airway also helps
      • ​gargle lidocaine
      • spray lido in back of pharynx.
    • look for full stomach on scope
  • High risk groups: obese, OSA, GERD, asthma, obstruction/full stomach, hepatic disease
    • hepatic dx- full stomach, coag issues, ascites
    • asthmatics- do prophylactic alburterol
  • Consider ETT or Proseal LMA can be used (pediatric endoscope can fit through gastric drainage port)
    • LMA not ideal, gets in way
    • proseal better and can fit ped scope down gastric drainage port
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

Lower endoscopy: sigmoidoscopy and colonoscopy

A
  • Often a screening procedure with visualization of the lower GI tract to sigmoid colon or distal ileum but it may involve biopsy, polypectomy/mucosal resection, stenting, dilation,etc.
  • Involves air insufflation, may involve the application of external pressure (increase aspiration risk)
  • Benzos + opioids VS propofol (GA)
    • some GI docs say propofol gives better scope
  • typically less stimulating compared to upper endoscopy
  • could consider glyco to decrease airway secretion and decrease r/f laryngospasm
    • ​may cause urinary retention
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

ERCP considerations?

A
  • Fluoroscopic exam of biliary and pancreatic duct that may involve stenting/removal of stones/laser lithotripsy
    • 20-80 minutes, can be uncomfortable
    • scope used to inject contrast through duodenal papilla
  • Commonly performed in patients with cholangitis, pancreatitis, bile duct obstruction, pancreatic cancer, etc.
    • concern for sepsis, can be medically fragile
  • Requires immobile patient
    • typically always intubate
  • Often done in prone position- not in prone at GUH
  • May involve CO2 insufflation (hypercarbia)
    • same concerns with lap sx
  • GA w/ETT is preferred
    • procedural failure are twice as high when pt under sedation vs GA
    • complication rate for GA may be lower
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

Rigid bronchoscopic procedure concerns

A
  • Endobronchial stenting, biopsy, laser therapy, dilation, cryotherapy, fiducial marker implant, etc.
    • fiducial markers placed to assist with steriotactic radiosurgery
  • Patients often have significant CV and pulmonary disease.
    • COPD, lung CA, chronic aspiration, ETOH, etc
  • TIVA preferred method
    • can’t use VA- not consistent and polluting environment
    • Propofol, remifentanil, dexmedetomidine + muscle relaxants
      • MR nice to prevent coughing, also placing fiducial markers which need to be precise
      • HFJV (high frequency jet ventilation) can be used to provide ventilation
    • Associated complications = airway fire, bronchospasm, bleeding and hypoxia
      • limit O2 if you can
  • Use of steroids can decrease post-porceudre edema
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

Radiology suite general considerations

A
  • Patient remains immobile for prolonged periods
    • may need GA just because it’s rather uncomfrotable
  • Bulky equipment (C-arms, X-ray tubes, screens, etc.):
    • impede access to patient
    • Move and collide with anesthesia equipment
      • Lines, pumps, ventilation tubing
      • Will need EXTENSIONS
  • Lack of scavenging may limit inhalation anesthetic agent techniques
  • patients can be sicker than those undergoing conventional surgery
  • lack of proper preop workup
  • diversity of procedures. 3 features in common
    • ​1) no surgical incision
    • 2) imagery involved fluoro, US, CT, PET, MRI
    • 3) Access to the target site (tumor, vasculature, organ) is via a small insertion site and catheters/wires
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

Contrast media condierations

A
  • Used in diagnostic and therapeutic radiologic procedures (general radiology and MRI)
  • Variable osmolarity; ionic or nonionic
    • higher the osmolarity, and ionic contrast agents are associated with dose and concentration-dependent adverse reactions in 5-8% of pt
    • low osmolarity has less risk for adverse reactions
  • Adverse reactions range from mild to life threatening
    • Hypersensitivity
      • CO2 can be used if contrast absolutely contraindicated
    • Renal toxicity
  • Idiosyncratic reactions unrelated to dose or concentration administered. Can be severe and include:
    • ​laryngeal edema
    • bronchospasm
    • pulmonary edema
    • hypotension
    • respiratory arrest or seizures
    • TXMT- O2, epi, bronchodilators
  • Pretreatment if hx of contrast reactions:
    • ​contrast reaction, steroids, diphenhydramine
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Contrast hypersensitivity treatment?

A
  • prompt recognition
  • oxygen
  • bronchodilators
  • epinephrine
  • fluid resuscitation
  • corticosteroids
  • Consider pretreatment with IV corticosteroids a few hours pre-procedure as well as H1 and H2 blockers
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

Contrast induced nephropathy considerations

A
  • Direct tubular toxicity due to release of free oxygen radicals and microvascular obstruction
    • incidence 7-15%
  • Increased risk in
    • Diabetic renal insufficiency
    • Hypovolemia
    • Congestive heart failure
    • HTN
    • Baseline proteinuria/renal disease
    • Gout
    • Co-administration of other drugs that cause renal tx
  • Azotemia starts at
    • 24-48 hours
    • peaks at 3-5 days monitor creatinine levels (increase of 0.5mg/dL within 24 hrs is diagnostic)
    • Avoid surgical procedures during this period
  • 3rd leading cause of hospital acquired renal failure
  • intra-arterial injection higher risk than IV admin
  • d/c metformin before contrast given- if this develops, increased r/f lactic acidosis
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

How to minimize the effects of contrast

A
  • Effects of Contrast can be minimized
    • Careful administration and limitation of total dose
    • Hydration 1st line protection administer 1ml/kg of normal saline 4 hours pre-procedure and continue for 12 hours post-procedure (Avoid volume overload in susceptible patients)
    • Administer sodium bicarbonate to promote renal elimination
    • Monitor serum creatinine for 72 hours
  • hydration only real protection against CIN
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

Coagulation status optimization before radiology procedures?

A
  • During percutaneous interventions bleeding can be occult
  • Patients often receive anticoagulants (to prevent clotting in response to foreign bodies in vessels)
  • INR <1.5, plt count >50,000
  • Hold medications
    • warfarin 5-7 days
    • ASA and clopidogrel 5 days
    • Fractionated heparin 12-24 hours
    • Heparin infusion 4-6 hours
    • NSAIDS held 1-2 days
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

Anesthesia consideration for interventional neuro-radiology

A
  • These procedures may require:
    • Deliberate hypotension or hypertension
    • Deliberate hypocapnia or hypercapnia
    • Rapid transition between deep sedation/analgesia and the awake responsive state
  • IR Access: 6-7 French grade sheath in femoral artery or in some instances carotid, axillary or brachial artery
    • concern for distal circulation
    • pulse ox on both toes
  • Contrast media is used
  • Anesthesia considerations include:
    • Hemorrhage: Potential cerebral aneurysm rupture, intracranial vessel rupture/damage. Hematoma at sheath insertion site
      • need BP down, admin protamine, convert to OR
        • ​protmaine reversal 1mg/100 IU heparin
      • extra IV setup needed
    • Occlusive complications: migration of embolic materials, vasospasm
    • Cerebral edema- NS/normosol
    • Patient’s existing co-morbidites -high risk for MI, stroke, laryngospasm?
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

Preop and induction concerns for neuro-radiology

A
  • Pre-op
    • Airway exam
    • History of contrast media reaction
    • Evaluation of blood pressure
  • Induction (GA VS conscious sedation)- depends on 1) complexity of procedure 2) need for BP/CO2 manipulation 3) need for pt neuro assessment during case
    • Standard ASA monitors
    • 2 IV sites
    • Radial arterial line
    • Foley catheter
    • Pad all pressure points
    • Will procedure physician perform the WADA or SAFE tests?
      • WADA- test used to determine dominant side for spech/memory. inject barb and perform neuro assessment
      • SAFE test is extension of WADA test. Test performed before embolization of vessel.
        • inject barbituate into vessel they’re going to embolize. if patient ok, can go ahead and embolize
  • Sedation- propofol +/- midzaolam and fent. precedex can also be used (less Resp depression and maintains neuro assessment)
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

Intraop management interventional neuro-radiology

A

Intra-op

  • Heparin
    • 70 U/kg (3000-5000 U)
    • Goal: ACT 2-2.5 times normal
      • need plan to reverse, need protamine (1mg/ 100 IU heparin)
  • Deliberate Hypotension
    • Esmolol, labetolol, hydralazine or sodium nitroprusside
  • Deliberate hypertension
    • Phenylephrine
    • Increase SBP 30-40% above baseline
  • ECG
    • Monitor for myocardial ischemia
How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

Emergence tips for interventional neuro-radiology anesthesia mgmt

A
  • Administer antiemetic
  • Tight post-procedural BP control- no hypo/hypertension
  • Smooth emergence to avoid coughing or bucking, device migration, intracranial hemorrhage
    • precedex
    • LTA
17
Q

Considerations of coronary angiography?

A
  • Coronary angiography:
    • performed by passing a catheter retrograde through the aortic root and injection of contrast media into the ostia of the coronary arteries
  • Catheter insertion is accomplished via:
    • femoral, brachial or radial artery
  • CAD , % stenosis & coronary spasm detected
  • Risks include:
    • Hemorrhage, infection, ischemia, cardiac ischemia, coronary dissection, thrombembolic events, contrast related reactions
  • Anesthesia should be prepared to handle unstable patient should emergency occur
18
Q

Anesthesia management of coronary angiography?

A
  • Anesthesia management
  • Sedation/Analgesia
  • General anesthesia
  • Supplemental oxygen
  • ASA monitors
    • Arterial BP and non-invasive BP
    • IV’s with extensions
    • Foley catheter
    • Monitor temp
  • Common Pharmacologic Agents
    • Midazolam
    • Fentanyl
    • Propofol
  • Sublingual or IV nitroglycerin
  • Heparin/Protamine
  • Provocative agents
    • Ergonovine maleate or methylergonovine maleate
  • Diltiazem
  • Emergency Resuscitation drugs and equipment must be readily available
19
Q

EP studies and ablation considerations?

A
  • Patients stop antiarrhythmic drugs before the study
    • Cardiologist will provoke the dysrhythmia they want to ablate
      • stop all antidysrhythmics prior to surgery so it can be provoked
    • Cardioversion via cardiac catheters or external defibrillation pads
  • Long procedures (4-8 hours)
    • patient needs to be immobile for long time!
  • Sedation is used with brief periods of general anesthesia for the shorter procedures such as atrial flutter ablations (Barash)
  • let cardiologsit know when you’re giving SNS drugs

GA preferred for the longer cases (a fib)/patient must be immobile during mapping

  • Volatile anesthetics and/or propofol, remifentanil appropriate
  • No muscle relaxant (phrenic nerve monitoring)
  • High frequency jet ventilation sometimes used to reduce chest movement with ventilation (need frequent ABGs and TIVA)
  • Need esophageal temperature monitoring with placement verified by fluoro (conductive heat transfer to the esophagus can cause burns/injury)
  • Watch fluid status with radiofrequency ablation (can have high fluid volumes used for irrigation absorbed).
  • Cardiac tamponade can occur (wire perforation)
    • recognize quickly
    • cardiac tamponade (decrease PP. tachycardia)
      • ​reverse protamine
      • call cardiac surgeon
      • cardiologst–> pericardiocentesis
20
Q

Cardioversion overview?

A
  • General Anesthesia is required
    • Usually propofol with nasal cannula/natural airway and ambu bag back up
  • May require pre-procedure TEE to assess for clot formation in atria
    • Increase procedure/sedation time
  • Standard ASA monitors
  • Assess cardiovascular status & medical therapy
  • NPO status
  • Emergency if arrhythmia causes patient to be hemodynamically unstable
21
Q

What do you need for cardioversion? Steps?

A
  • Full general anesthesia set-up (just in case)
  • Intubating equipment
  • Medications
  • Supplemental oxygen and method of positive pressure vent
  • Suction
  • Resuscitation equipment

Steps:

  1. Pre-oxygenate with 100% oxygen
  2. Small incremental doses of IV anesthetic until loss of lid reflex
  3. Assess for unconsciousness, mask is removed. ALL CLEAR
  4. Synchronized countershock administered
  5. Monitor rhythm closely
  6. Manually ventilate/support airway until return of spontaneous ventilation
  7. Remain with patient until awake and alert. Sign off patient to ICU nurse ACLS trained
22
Q

ECT?

A
  • Introduced in 1930’s
  • Indications include
    • Major depression
    • PTSD
    • Mania
    • Schizophrenia
    • Parkinson’s Syndrome
  • Currently an accepted practice
    • Usually 3 times per week for 6-12 treatments– weekly or monthly therapy to prevent relapse
23
Q

ECT Process?

A
  • Programmed electrical stimulation of the CNS to initiate seizure activity
    • typically don’t use propofol because it would interfere with therapy
    • typically use methohexital, etomidate
    • need seizure of 25 seconds for benefit
  • 2 electrodes applied to patient’s scalp
  • Series of electrical pulses at precise energy levels are delivered to induce a seizure
  • Treatments 2-3 per week until improvement
  • Seizure activity causes initial parasympathetic discharge followed by intense sympathetic discharge
    • Can see bradycardia and even asystole followed by tachycardia and HTN
    • Increased CBF ICP, dysrhythmia, myocardial ischemia and NV events possible
    • short term memory loss, myalgies, fracture, HA, emergence agitation, S/E, sudden death
24
Q

What to review preop for ECT? Contraindications

A
  • H&P
  • Review Prior Treatments
  • Review current drug therapy
    • Tricyclic Antidepressants
    • SSRIs
    • MAO inhibitors- JIC- iproniazid, phenelzine, isocarboxazid, tranylcypromine, selegiline, moclobemide, befloxatone, brofaromine
    • Lithium Carbonate
  • Contraindications:
    • Pheochromocytoma
    • Increased ICP
    • Recent CVA
    • High Risk Pregnancy
    • Aortic and Cerebral Aneurysms
25
Q

Anesthesia for ECT?

A
  • ASA monitors (including standard NIBP)
  • Pretreatment 0.2mg Glycopyrrolate IV- compensate for PSNS outflow
  • Pre-oxygenate
  • General Anesthesia is induced
    • Induction drug
    • Loss of lid reflex
    • Ensure adequate mask ventilation*
    • Insert bite block
    • 2nd BP cuff applied to extremity and inflated BEFORE muscle relaxant (acts as tourniquet)
      • will allow to visualize the seizure
    • Neuromuscular blocker
    • Stimulus is delivered to induce a seizure
  • Peripheral/Central Seizure observation is made
  • Ventilation (mask VS LMA) continues until patient awakens and delivered to care of RR staff
  • Anesthetic goals-
    • amnesia
    • airway mgmt
    • prevention of sz related injury
    • control of HD response
    • smooth rapid emergency
26
Q

Medications for ECT?

A
  • Methohexital 0.75-1.5mg/kg- GOLD STANDARD
    • ​Less anti-seizure activity compared with others
  • Etomidate 0.15-0.3 mg/kg
    • associated with greater seizure duration
    • slightly longer recovery and more myoclonus
  • Propofol 0.75mg/kg
    • reduces hemodynamic response but is anti-sireuzre— have to use lower dose to avoid interfering with sz activity
  • Succinylcholine 0.75-1.5mg/kg- prevent injury
  • Ketamine???- controversial
  • Emergency Drugs
    • Esmolol, Labetolol, Calcium channel blockers
  • Dexmedetomidine1 ug/kg 10 minutes pre-induction
    • controls SNS response without impacting sz duration
  • Consider 15-30 mg ketorolac for post-procedure myalgia
  • Good record keeping essential for
  • subsequent treatments
27
Q

Recovery ECT

A
  • Medically stable to transport
  • Received by appropriately trained staff
  • Accompanied by provider of anesthesia
  • Transport with oxygen and monitoring
  • Discharge only after they have met specific criteria
28
Q

What is tumescent?

A
  • Tumescent: large volume of local anesthetic injected
  • 1-4cc per 1cc fat
  • EBL is 1% total volume suctioned
  • NS/LR with lidocaine 0.025%-0.1% & 1:1,000,000 epi
  • Peak serum local [] 12-14 hours later
  • Max lidocaine dose with this route is much higher 35-55mg/kg
  • Limit 5000ml of total aspirate (fat/fluid)

Adv Principle Oral (9 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions