Mod11: Anesthesia Provided at Alternate Sites - The Patient

Question 1

_{Anesthesia Provided OOR - The Patient}

Why is anesthesia usally called OOR?

Answer 1

When the pt is unable to tolerate procedure w/o sedation, or

When the procedure has failed with simple sedation administered by a non-anesthesia provider

Question 2

_{Anesthesia Provided OOR - The Patient}

When called OOR, what do you need to figure out first?

Answer 2

Perform a normal pre-op evaluation

Airway assessment

Comorbidities and ASA class

Determine if sedation will be enough based on the type of procedure and the pt’s condition

Answer the question what do they need from anesthesia?

Determine Sedation vs. General

Question 3

_{Anesthesia Provided OOR - The Patient}

When calling anesthesia OOR, what is the physician concerned about the most?

Answer 3

Allergies

_{Many will be allergic to IV contrast}

_{Physician concerned about sedating them + giving them contrast that they are allegic to}

_{Of note: Some pts may be allergic to both contrast and benadryl - What do you do? - Could be that they are allergic to older contrast vs newer contrats that almost no one is allergic to - change contrats!!!}

Question 4

_{Anesthesia Provided OOR - The Patient}

In an OOR procedure, which monitoring could you do without? which ones are required? How can you tell?

Answer 4

Is pt is healthy enough and procedure is benign enough then a NIBP cuff, a pulse ox, EtCo2 should do

For a big procedure with a potential fluid shift, then an arterial line & a CVP monitoring are needed

Ultimately you must decide between Simple vs Invasive monitoring???

Question 5

_{Anesthesia Provided OOR - The Patient}

Which Patient Factors Require Sedation or
General Anesthesia at Alternate Sites?

Answer 5

Anxiety panic disorders - Claustrophobia

Developmental delay - Mentally challenged

Cerebral palsy - Seizure disorder

Movement disorders - Severe pain

Acute trauma with hemodynamic instability

Significant comorbidity - Child

Morbidly obese pt that cannot fit comfortably in MRI scanner without sedation

Question 6

_{Anesthesia Provided OOR - The Patient}

What can you do to make a morbidly obese pt fit comfortably in MRI scanner?

Answer 6

Sedation

Question 7

_{Anesthesia Provided OOR - Procedures}

What is the best thing you can do when you are having a procedure for the first time, or with a new surgeon, or at an unfamiliar location, or any combination of the prviously mentioned?

Answer 7

Vital the anesthesia provider understands nature of procedure, including

^{Positioning - Length - Pain level}

Collaborate with physicians, dentists, and others performing interventional procedures

^{Needs/special requests - Discuss contingencies for adverse outcomes}

Question 8

_{Anesthesia Provided OOR - Procedures}

Why is it so important to ask lots of questions when you are having a procedure for the first time, or with a new surgeon, or at an unfamiliar location, or any combination of the above mentioned situations?

Answer 8

Allows for development of an anesthetic plan that provides safe patient care and facilitates the procedure

Question 9

_{Anesthesia Provided OOR - Procedures}

What are common radiology procedures at alternate sites?

Answer 9

CT - MRI - Interventional Radiology

Interventional Neuroradiology

GAMMA knife

Question 10

_{Anesthesia Provided OOR - Procedures}

What are common Radiotherapy procedures at alternate sites?

Answer 10

Radiation therapy

Intraoperative radiotherapy

Radiosurgery

Question 11

_{Anesthesia Provided OOR - Procedures}

Besides Radiology and Radiotherapy procedures, procedures from which other specialties are common at alternate sites?

Answer 11

Gastroenterology

^{Upper and Lower endoscopies - ERCPs - Liver biopsies - TEEPs}

Cardiology

^{Cardiac catherization - Ablations - Cardioversions - TEE - AICDs and PPMs placement}

Psychiatry

^ECTs

Question 12

_{Anesthesia Provided OOR - Procedures}

Which level of Anesthesia is characterized by:

• Normal response to verbal stimulation*
• Unaffected airway*
• Unaffected spontatneous ventilation*
• Unaffected CV function?*

Answer 12

Minimal Sedation

(Anxiolysis)

Question 13

_{Anesthesia Provided OOR - Procedures}

Which level of Anesthesia is characterized by:

• Purposeful response to verbal or tactile stimulation*
• No airway intervention required*
• Adequate spontaneous ventilation*
• CV funtion maintained?*

Answer 13

Moderate Sedation/ Analgesia

(“Conscious Sedation”)

Question 14

_{Anesthesia Provided OOR - Procedures}

Which level of Anesthesia is characterized by:

• Purposeful response after repeated or painful stimulation*
• Airway intervention may be required*
• Spontaneous ventilation may be inadequate*
• Usually maintained CV funtion?*

Answer 14

Deep Sedation/ Analgesia

Question 15

_{Anesthesia Provided OOR - Procedures}

Which level of Anesthesia is characterized by:

• Unarousable even with painful stimulation*
• Airway intervention often required*
• Spontaneous ventilation ferquently inadequate*
• CV funtion may be impaired?*

Answer 15

General Anesthesia

Question 16

_{Anesthesia Provided OOR - Procedures}

What’s the issue with reporting “MAC” or “General” while conveying the type of anesthesia being delivered at an alternate site?

Answer 16

Because other words such as

• Minimal Sedation​,*
• Moderate Sedation/ Analgesia* or
• Deep Sedation/ Analgesia*

are more precise in conveying what you are doing vs MAC or General

Question 17

_{Anesthesia Provided OOR - Procedures}

True or False

The level of sedation should never be changed in the midle of a procedure

Answer 17

False

Level of sedation/analgesia/anesthesia frequently varies during course of the procedure

Question 18

_{Anesthesia Provided OOR - Procedures}

What’s the concern with having an RN administer sedation?

Answer 18

Individuals administering a given level of sedation must be able to rescue the patient should the level of sedation become deeper

Question 19

_{Anesthesia Provided OOR - Procedures}

Guidelines for Non anesthesia Providers administering sedation & analgesia:

Answer 19

Guidelines cover what to expect, what’s appropriate, what’s inappropriate

_{•..\AANA - Policy Guidelines in the Administration of Sedation and Analgesia.htm}

_{•..\ASA Postition Statement on nonanesthesilogy providers administering moderate sedation.pdf}

_{•..\ASA Postition Statement on nonanesthesiology providers administering deep sedation.pdf}

Question 20

_{Anesthesia Provided OOR - Procedures}

How does JACHO defines Anesthesia Care? What should anyone conducting anesthesia be comfortable doing if don’t do as planned?

Answer 20

Administration of IV, IM, or inhalation agents that may result in the loss of the patient’s protective reflexes

Anyone conducting anesthesia care needs to be comfortable rescuing the pt if they loose those protective reflexes

Question 21

_{Anesthesia Provided OOR - Procedures}

True or False: all Pts should receive the same standard of care at an alternate site as they would in the OR

Answer 21

True

Question 22

_{Anesthesia Provided OOR - Procedures}

According to ASA Guidelines for Nonoperating Anesthetizing Locations, who must be present in room throughout conduction of “anesthesia”

Answer 22

A Qualified anesthesia provider

Question 23

_{Anesthesia Provided OOR - Procedures}

According to ASA Guidelines for Nonoperating Anesthetizing Locations, which pt’s variables must be continually evaluated during anesthesia?

Answer 23

Oxygenation, ventilation, circulation, and temperature

Question 24

_{Anesthesia Provided OOR - Procedures}

According to ASA Guidelines for Nonoperating Anesthetizing Locations, where should pts recover after anesthesia? Who should care for them? and what equipment should be available to them?

Answer 24

Patients should recover in a PACU or similar setting

Trained personnel able to care for unconscious pts

Appropriate monitoring & resuscitative equipment immediately available

Question 25

_{Anesthesia Provided OOR - Procedures}

Links to important Guidelines documentation

Answer 25

• ASA Guidelines for Nonoperating Anesthetizing Locations.pdf
• AANA Scopes & Standards of Practice.pdf