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7835 Exam IV > Mod11: Cardioversion - Gastroenterology Suite > Flashcards

Mod11: Cardioversion - Gastroenterology Suite Flashcards

1
Q

Cardioversion

What is Cardioversion?

A

Delivery of high electrical shock to the heart in an attempt to convert from a dysrhythmia back into a NSR

Used in the treatment of A-fib & A-flutter

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2
Q

Cardioversion

What is the main concern with cardioversion?

A

Thromboembolism

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3
Q

Cardioversion

•A-fib/flutter > 48hrs ???

Slider 56 needs - 3rd bullet point

A

email sent to Dr. Haltermann

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4
Q

Cardioversion

When is anticoagulation therapy initiated before cardioversion? How long is it continued?

A

Initiated (Coumadin) 3wks prior

Continued for 4wks after

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5
Q

Cardioversion

Why is TEE often ordered prior to cardioversion? Is anesthesia involved in the TEE?

A

TEE is ordered to determine risk

(TEE looks for the presence of a <u>clot in the LAA</u>)

Anesthesia may or may not be involved with TEE

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6
Q

Cardioversion

How are anticoagulation and cardioversion handled if TEE shows low risk (i.e. No clot in the LAA) ?

A

Lower dose anticoagulation &

Immediate cardioversion

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7
Q

Cardioversion

How are anticoagulation and cardioversion handled if TEE shows High risk (Clot present in the LAA)?

A

Cardioversion postponed to allow for

adequate anticoagulation

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8
Q

Cardioversion

True or False: Cardioversion is brief and not distressing

A

False

Cardioversion is brief but distressing

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9
Q

Cardioversion

Why should cadioversion be carried out using sedation?

A

Because it is distressing

Patient should be asleep for the procedure

(<strong>Propopol</strong> or <strong>Ketamine</strong> in small doses)

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10
Q

Cardioversion

What is the appropriate Anesthetic Technique for cardioversion?

A

Small bolus IV induction agent most common

Etomidate: most cardiac stable - could see myoclonus - could make EKG interpretation more difficult - could also take more time for effects

Versed: larger dose necessary => prolonged recovery - Must consider half-life if reversed with Flumazenil, since the Flumazenil may ware off before the versed, which may lead to resedation

Propofol: Hypotension is the main concern - Have a pressor (Neo) available

If very depressed/low EF => consider 20mg Propofol and 20mg of Ketamine

“May need to break this!!!!”

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11
Q

Cardioversion

Intubation not required during cardioversion unless there is a risk for:

A

Aspiration

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12
Q

Cardioversion

What’s the effect of combining Cardioversion and TEE on the length of procedure?

A

Increases length of the procedure

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13
Q

Cardioversion

Due to increased length of the procedure when cardioversion and TEE are combined, what’s a beneficial anesthesia technique?

A

Propofol infusion

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14
Q

Cardioversion

How should the airway be protected during combined TEE cardioversion procedure?

A

Treatment similar to EGD

Posterior pharynx localized

Bite block placed

Deepen level of sedation with initial insertion of TEE probe

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15
Q

Gastroenterology Suite

True or False: many gastroenterologists provide their own sedation for GI endoscopy

A

True

They administer or have a nurse administer

<strong>Benzodiazepine</strong> (midazolam, diazepam)

with or without an <strong>opioid</strong> (fentanyl, alfentanil, meperidine)

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16
Q

Gastroenterology Suite

Why is there an increase in the incidence cardiorespiratory events during GI endoscopy

A

Combined administration of

Benzodiazepine (midazolam, diazepam)

with Opioid (fentanyl, alfentanil, meperidine)

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17
Q

Gastroenterology Suite

Which drug provides the best conditions for GI endoscopy?

A

Propofol

Provides excellent conditions

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18
Q

Gastroenterology Suite

Who can administer Propofol?

A

Many believe it should be administered by trained anesthesia providers only

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19
Q

Gastroenterology Suite

What insurance issues push GI MD into administering sedation themselves

A

Lumped billing

Insurance will pay one nominal amount for entire procedure

GI doc must decide if he/she wants to spilt that $$ with anesthesia

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20
Q

Gastroenterology Suite - Upper GI Endoscopy

Why would an Upper GI Endoscopy be performed?

A

Diagnostic

Biopsy

Therapeutic

Removal foreign body - Esophageal dilation

Treatment esophageal varices (banding, sclerotherapy)

Placement percutaneous gastrostomy

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21
Q

Gastroenterology Suite - Upper GI Endoscopy

How long do Upper GI Endoscopy procedures last? Are they painful?

A

Procedure typically brief (10-30”)

Generally painless but very stimulation*

(*passage of probe behind the tongue)

22
Q

Gastroenterology Suite - Upper GI Endoscopy

True or False: Many (66-81%) tolerate Upper GI Endoscopy w/o sedation

A

True

According to presentation… But hard to beleive!!!

23
Q

Gastroenterology Suite - Upper GI Endoscopy

What anesthetic techniques are typically used for Upper GI Endoscopy?

A

Deep conscious sedation sufficient

or

General Anesthesia

24
Q

Gastroenterology Suite - Upper GI Endoscopy

When GA is used during Upper GI Endoscopy, which airway devices could be deployed?

A

ETT to protect airway and facilitate passage of endoscope

LMA’s have been used successfully

25
Q

Gastroenterology Suite - Upper GI Endoscopy

Why would a Topical LA (Hurricaine or Citacaine) applied into oropharynx during an Upper GI Endoscopy?

A

To facilitate passage scope

26
Q

Gastroenterology Suite - Upper GI Endoscopy

Why is the risk of aspiration increased when a Topical LA is applied into oropharynx during an Upper GI Endoscopy?

A

Topical LA abolishes gag reflex

27
Q

Gastroenterology Suite - Upper GI Endoscopy

When placing a Bite block for an Upper GI Endoscopy, what are you concerned about?

A

Bite block could dislodge or obstruct ETT

28
Q

Gastroenterology Suite - Upper GI Endoscopy

What’s the pt’s position during an Upper GI Endoscopy?

A

Semi seating

29
Q

Gastroenterology Suite - Upper GI Endoscopy

What’s the pt’s position during an ERCP?

A

Prone or semi-prone position with head rotated to side

30
Q

Gastroenterology Suite - Upper GI Endoscopy

What are position related concerns during an Upper GI Endoscopy?

A

Eye, lip, teeth trauma

Brachial plexus injury

31
Q

Gastroenterology Suite - Upper GI Endoscopy

During an Upper GI Endoscopy Brachial plexus injury is most likely to occur in which position?

A

Prone or semi-prone position with the head turned

Long procedures

32
Q

Gastroenterology Suite - Upper GI Endoscopy

What’s a potential complication of HurriCaine spray during Upper GI Endoscopy?

A

Methemoglobinemia (MetHb)

33
Q

Gastroenterology Suite - Upper GI Endoscopy

What is Methemoglobinemia (MetHb)?

A

Blood disorder in which an abnormal amount of methemoglobin is produced.

Methemoglobin is a form of hemoglobin that cannot bind oxygen, which means it cannot carry oxygen to tissues.

In Methemoglobin the iron in the heme group is in the Fe3+ (ferric) state, not the Fe2+(ferrous) of normal hemoglobin

With the iron in the heme group is in the Fe3+ (ferric) state, hemoglobin cannot bind oxygen

34
Q

GI Suite - Endoscopic Retrograde Cholangiopancreatography (ERCP)

What are things you do not want to do to a sick person when performing anesthesia?

A

You don’t want to have to:

intubate them

Flip them prone

Be limited on what drug you can give them

35
Q

GI Suite - Endoscopic Retrograde Cholangiopancreatography (ERCP)

Why are ERCP cases challenging to the anesthesia provider?

A

Because you may have to:

Intubate them

Flip them prone

Be limited on which drug you can administer

(No Anesthetic gas)

36
Q

GI Suite - Endoscopic Retrograde Cholangiopancreatography (ERCP)

What are ERCP procedures used for?

A

Diagnosis/Treatment of both

pancreatic & biliary diseases

37
Q

GI Suite - Endoscopic Retrograde Cholangiopancreatography (ERCP)

What’s the goal of ERCP?

A

Instrumentation biliary/pancreatic duct systems

(place stent/extract stones)

Stops blockages

38
Q

GI Suite - Endoscopic Retrograde Cholangiopancreatography (ERCP)

During an ERCP, scope is advanced following which path?

A

Mouth → stomach → duodenum → ampulla of Vater

39
Q

GI Suite - Endoscopic Retrograde Cholangiopancreatography (ERCP)

Which drugs should Not be given during an ERCP, especially when a SOM (Sphincter of Oddi manometer) is anticipated?

A

Anticholinergics (Glyco, Atropine) & Glucagon

SOM (Sphincter of Oddi manometer) measures the pressures in the Sphincter of Oddi area

Anticholinergics will stop Sphincter of Oddi spasm and you don’t want that

40
Q

GI Suite - Endoscopic Retrograde Cholangiopancreatography (ERCP)

According to the texbook, how long do ERCPs usually last?

A

20-80”

(Last much longer in practice)

41
Q

GI Suite - Endoscopic Retrograde Cholangiopancreatography (ERCP)

Why is General Anesthesia the preferred technique for ERCPs?

A

​Moderate to significant pain

(experienced with biliary and pancreatic duct manipulation)

Prone position

42
Q

GI Suite - Endoscopic Retrograde Cholangiopancreatography (ERCP)

According to the texbook, what are other anesthetic options during ERCPs?

A

Conscious or deep sedation recommended

5-8% require general anesthesia

43
Q

GI Suite - Endoscopic Retrograde Cholangiopancreatography (ERCP)

What’s the typial position for ERCP?

A

Prone - Semi prone - Head turned to the side

Airway/positioning similar to upper GI

44
Q

GI Suite - Endoscopic Retrograde Cholangiopancreatography (ERCP)

Why should opioids be avoided during ERCP?

A

Opioids can cause spasm of the sphincter of Oddi

Fenatnyl>Morphine

Naloxone is the reversal!!!

45
Q

GI Suite - Endoscopic Retrograde Cholangiopancreatography (ERCP)

Which analgesic drug is recommended for ERCP? and why?

A

Remifentanil

Short acting

46
Q

GI Suite - Endoscopic Retrograde Cholangiopancreatography (ERCP)

Why would abx be given duringg ERCP

A

Transient bacteremia

47
Q

GI Suite - Endoscopic Retrograde Cholangiopancreatography (ERCP)

What’s the cause of Transient bacteremia noted during ERCP?

A

After stenting, backed up fluid comes out and

accumulated bacteria are realeased

48
Q

GI Suite - Endoscopic Retrograde Cholangiopancreatography (ERCP)

Which comorbidities accompany pts undergoing ERCPs?

A

High risk of sepsis

Liver dysfunction => jaundice

49
Q

GI Suite - Endoscopic Retrograde Cholangiopancreatography (ERCP)

Which drugs are given to stop spasm within the GI system

A

Antispasmodics = Hyoscy-amine

Can reduce the length of the procedure

Can make the pt more comfortable

50
Q

GI Suite - Endoscopic Retrograde Cholangiopancreatography (ERCP)

How about Emergency ERCP???

A

Ask Dr Halterman

Ref: slide 63

7835 Exam IV (21 decks)

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