Chapter 58 NORA Flashcards
challenges with NORA
- unique locations
- support staff who are unfamiliar with anesthesia
- variation of the physical set up of the procedure room
- equipment may be poorly maintained
- remote positioning of a patient during a lengthy procedure
an anesthesia machine and portable anesthesia cart with the listed equipment, supplies, and medications should be
dedicated strictly for use in remote locations
therapeutic and diagnostic procedures require what kind of anesthesia?
minimal, moderate, or deep
what type of anesthesia ensures amnesia as a standard of care?
general anesthesia
standards for the delivery of anesthesia in a remote location
A. Perform a complete pre-anesthesia assessment
B. Obtained informed consent for the planned anesthetic intervention from the patient or legal guardian
C. Formulate a patient-specific plan for anesthesia care
D. Implement and adjunct the anesthesia care plan based on the patient’s physiologic response
E. Properly prepare, dispense, and label all medications to be used for the patient
F. Adhere to appropriate safety precautions and protocols, as established by the institution, to minimize risks to the patient and ancillary staff
G. Monitor and document the patient’s physiologic condition as appropriate for the type of anesthesia and specific patient needs
H. Precautions shall be taken to minimize the risk of infection to the patient, the operator, and ancillary personnel
I. There must be complete, accurate, and time-oriented documentation of pertinent information on the patient’s anesthesia record
J. After the anesthetic treatment for therapeutic or diagnostic procedures, transfer the responsibility for care of the patient to other qualified personnel in a manner that ensures continuity of care and patient safety
what 4 things make NORA unique?
- location (not what were used to)
- personnel (operator is not a surgeon, staff may not understand anesthesia)
- procedures (huge variety)
- equipment and set up (you have to bring your own
Standard V: mornitoring for NORA
- same as for all other cases
- still need to monitor ventilation, oxygenation, cadisovascular status, body temp and neuromuscular function
responsiveness for: minimal, moderate (conscious), deep sedation, and general anesthesia
minimal = normal response to verbal stimuli
moderate/conscious = purposeful response to verbal or tatile stimulation
deep = purposeful response to repeated painful stimuli
general anesthesia = unarousable even with painful stimuli
airway for: minimal, moderate (conscious), deep sedation, and general anesthesia
minimal = unaffected
moderate/conscious = no intervention required
deep = intervention may be required
general anesthesia = intervention often required
respiratory function for: minimal, moderate (conscious), deep sedation, and general anesthesia
minimal = unaffected
moderate/conscious = adequate
deep = may be inadequate
general anesthesia = frequently inadequate
cardiovascular function for: minimal, moderate (conscious), deep sedation, and general anesthesia
minimal = unaffected
moderate/conscious = usually maintained
deep = usually maintained
general anesthesia = may be impaired
most common adverse events happen in NORA cases (in peds)
RESPIRATORY
- apnea
- respiratory depression
- respiratory obstruction
most adverse events happen with procedures lasting longer than __ hour
1
children of what age are at greater risk for adverse events?
less than 5
2 populations that are commonly seen in NORA?
elderly and children
most adverse anesthesia events are caused when __ anesthetic agents are used
mulitple
peds NPO status for NORA procedures
- < 6 month: 4-6 hrs
- 6-36 months: 6 hr
- > 36 months: 8 hrs
important things to keep in mind for safety purposes during peds assessment
- recent URIs
- fever
- cough
- snoring
- sputum production
could result in an airway compromise during sedation
BOX 58.5
most common causes of peds A adverse events for therapeutic or diagnostic procedures
- drug errors
- NO₂ in combo with any other sedative medication
- inability to rescue the patient from an adverse anesthetic event
- unmet monitoring standards - especially respiration and oxygenation
- resp depression/ hypoventilation/ apnea
- airway obstruction
- bradycardia secondary to hypoxia
- laryngospasm/ stridor
- vomiting/aspiration/diarrhea
- hypotension
- inadequate sedation/paradoxical excitation (sustained irritability or combativeness)
- prolonged sedation after the procedure
ACID & pacemakers
ACID = 2 parts (pulse generator and lead electrode)
pacemaker = (unipolar or bipolar)
most common underlying rhythm is pulseless VT or VF
anesthesia for AICD and pacemakers
- usually local and some sedation
- at end… they will cause pt to go into VF to check if AICD is working… give propofol before this
- ALWAYS have transcutaneous packing pads available and on patient
what types of patients commonly present for AICD placement?
- Supraventricular dysrhythmias (younger and healthier)
- Ventricular dysrhythmias (older, low EF, CAD)
- CHF (low EF, left BBB)
what happens at the end of AICD placement that is very uncomfortable for patient and tricky for us
- putting patient into vfib
- have to give patient something (prop) so they can tolerate it
- might need to place patient into vfib several times of lead placement is sketchy
give 5 mins between vfib episodes
how long do pacemakers last?
6-10 years
joules that are used for synchronized cardioversion
50-100J
what part of the pacemaker insertion can be uncomfortable for the patient?
tunneling of the leads
sedation for synchronized cardioversion
- probably prop before shock
- sometimes etomidate if they are unstable
ablation and anesthesia
- radio frequency = short and usually with sedation
- cryofrequency = used before or instead of RFCA
- start by ice-mapping heart
- cryo causes less discomfort and higher success rate
with longer ablation cases, what are some anesthesia considerations
- patients can experience angina-like pain
- may need deeper sedation or GA
- use esophageal stethoscope to monitor left atrial temp
PCI procedures use x-radiation/fluoroscopy doses as
keep radiation As Low As Reasonably Achievable
known as the radiation principle: ALARA
pediatrics and ablation
SVT is most common tachyarrhythmia treated in peds with radiofrequency ablation
colonoscopy looks at colon from anus –> __
cecum
sedation for colonoscopy
light to deep
manipulation of colon is painful (splenic and hepatic flexures are rough)
watch for what with colonoscopies
- bradycardia (caused by vagal reflex)
- colon spasms can occur as well
- have glycopyrrolate ready for both conditions
- if its really bad tell doc to reduce amount of air in colon
spray airway with what in EGD?
benzocaine (think metHb) or lidocaine
if you are doing EGD for GI bleed, what should be your anesthetic technique
probably GA with ETT to protect airway and support hemodynamics better
before ERCP: labs
liver enzymes
what will be used in ERCP that we should ask about allergies to
contrast dye
position for ERCP
prone or left lateral decubitus
occupational hazards for CT
- if you’re in the room you have to protect yourself from radiation
- radiation exposure is cumulative over a lifetime !!
anesthetic implications for CT
- patient needs to be motionless
- contrast media concerns
- ionizing radiation may be a problem in kids
- airway management can be difficult
2 types of contrast media reaction
anaphylactoid = histamine release from basophils or mast cells (NOT ANTIBODY/ANTIGEN MEDIATED)
chemotoxic = directly due to inherent chemical action of specific agent on specific organ (contrast-induced renal failure)
anesthetic agents that may cause problems with assisted reproductive technologies (ART)
morphine, sevo, desflurane, NSAID’s, & metoclopramide
T/F magnitude of chemotoxic reaction to contrast media depends on the amount or concentration of the offending agent
TRUE
if you give more, the result will be worse
T/F magnitude of anaphylactoid reaction to contrast media depends on the amount or concentration of the offending agent
FALSE
can have reaction to 1mL or 100mL
