Mod11: Cardioversion - Gastroenterology Suite Flashcards
Cardioversion
What is Cardioversion?
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
Cardioversion
What is the main concern with cardioversion?
Thromboembolism
Cardioversion
•A-fib/flutter > 48hrs ???
Slider 56 needs - 3rd bullet point
email sent to Dr. Haltermann
Cardioversion
When is anticoagulation therapy initiated before cardioversion? How long is it continued?
Initiated (Coumadin) 3wks prior
Continued for 4wks after
Cardioversion
Why is TEE often ordered prior to cardioversion? Is anesthesia involved in the TEE?
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
Cardioversion
How are anticoagulation and cardioversion handled if TEE shows low risk (i.e. No clot in the LAA) ?
Lower dose anticoagulation &
Immediate cardioversion
Cardioversion
How are anticoagulation and cardioversion handled if TEE shows High risk (Clot present in the LAA)?
Cardioversion postponed to allow for
adequate anticoagulation
Cardioversion
True or False: Cardioversion is brief and not distressing
False
Cardioversion is brief but distressing
Cardioversion
Why should cadioversion be carried out using sedation?
Because it is distressing
Patient should be asleep for the procedure
(<strong>Propopol</strong> or <strong>Ketamine</strong> in small doses)
Cardioversion
What is the appropriate Anesthetic Technique for cardioversion?
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!!!!”
Cardioversion
Intubation not required during cardioversion unless there is a risk for:
Aspiration
Cardioversion
What’s the effect of combining Cardioversion and TEE on the length of procedure?
Increases length of the procedure
Cardioversion
Due to increased length of the procedure when cardioversion and TEE are combined, what’s a beneficial anesthesia technique?
Propofol infusion
Cardioversion
How should the airway be protected during combined TEE cardioversion procedure?
Treatment similar to EGD
Posterior pharynx localized
Bite block placed
Deepen level of sedation with initial insertion of TEE probe
Gastroenterology Suite
True or False: many gastroenterologists provide their own sedation for GI endoscopy
True
They administer or have a nurse administer
<strong>Benzodiazepine</strong> (midazolam, diazepam)
with or without an <strong>opioid</strong> (fentanyl, alfentanil, meperidine)
Gastroenterology Suite
Why is there an increase in the incidence cardiorespiratory events during GI endoscopy
Combined administration of
Benzodiazepine (midazolam, diazepam)
with Opioid (fentanyl, alfentanil, meperidine)
Gastroenterology Suite
Which drug provides the best conditions for GI endoscopy?
Propofol
Provides excellent conditions
Gastroenterology Suite
Who can administer Propofol?
Many believe it should be administered by trained anesthesia providers only
Gastroenterology Suite
What insurance issues push GI MD into administering sedation themselves
Lumped billing
Insurance will pay one nominal amount for entire procedure
GI doc must decide if he/she wants to spilt that $$ with anesthesia
Gastroenterology Suite - Upper GI Endoscopy
Why would an Upper GI Endoscopy be performed?
Diagnostic
Biopsy
Therapeutic
Removal foreign body - Esophageal dilation
Treatment esophageal varices (banding, sclerotherapy)
Placement percutaneous gastrostomy
Gastroenterology Suite - Upper GI Endoscopy
How long do Upper GI Endoscopy procedures last? Are they painful?
Procedure typically brief (10-30”)
Generally painless but very stimulation*
(*passage of probe behind the tongue)
Gastroenterology Suite - Upper GI Endoscopy
True or False: Many (66-81%) tolerate Upper GI Endoscopy w/o sedation
True
According to presentation… But hard to beleive!!!
Gastroenterology Suite - Upper GI Endoscopy
What anesthetic techniques are typically used for Upper GI Endoscopy?
Deep conscious sedation sufficient
or
General Anesthesia
Gastroenterology Suite - Upper GI Endoscopy
When GA is used during Upper GI Endoscopy, which airway devices could be deployed?
ETT to protect airway and facilitate passage of endoscope
LMA’s have been used successfully
Gastroenterology Suite - Upper GI Endoscopy
Why would a Topical LA (Hurricaine or Citacaine) applied into oropharynx during an Upper GI Endoscopy?
To facilitate passage scope
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?
Topical LA abolishes gag reflex
Gastroenterology Suite - Upper GI Endoscopy
When placing a Bite block for an Upper GI Endoscopy, what are you concerned about?
Bite block could dislodge or obstruct ETT
Gastroenterology Suite - Upper GI Endoscopy
What’s the pt’s position during an Upper GI Endoscopy?
Semi seating
Gastroenterology Suite - Upper GI Endoscopy
What’s the pt’s position during an ERCP?
Prone or semi-prone position with head rotated to side
Gastroenterology Suite - Upper GI Endoscopy
What are position related concerns during an Upper GI Endoscopy?
Eye, lip, teeth trauma
Brachial plexus injury
Gastroenterology Suite - Upper GI Endoscopy
During an Upper GI Endoscopy Brachial plexus injury is most likely to occur in which position?
Prone or semi-prone position with the head turned
Long procedures
Gastroenterology Suite - Upper GI Endoscopy
What’s a potential complication of HurriCaine spray during Upper GI Endoscopy?
Methemoglobinemia (MetHb)
Gastroenterology Suite - Upper GI Endoscopy
What is Methemoglobinemia (MetHb)?
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
GI Suite - Endoscopic Retrograde Cholangiopancreatography (ERCP)
What are things you do not want to do to a sick person when performing anesthesia?
You don’t want to have to:
intubate them
Flip them prone
Be limited on what drug you can give them
GI Suite - Endoscopic Retrograde Cholangiopancreatography (ERCP)
Why are ERCP cases challenging to the anesthesia provider?
Because you may have to:
Intubate them
Flip them prone
Be limited on which drug you can administer
(No Anesthetic gas)
GI Suite - Endoscopic Retrograde Cholangiopancreatography (ERCP)
What are ERCP procedures used for?
Diagnosis/Treatment of both
pancreatic & biliary diseases
GI Suite - Endoscopic Retrograde Cholangiopancreatography (ERCP)
What’s the goal of ERCP?
Instrumentation biliary/pancreatic duct systems
(place stent/extract stones)
Stops blockages
GI Suite - Endoscopic Retrograde Cholangiopancreatography (ERCP)
During an ERCP, scope is advanced following which path?
Mouth → stomach → duodenum → ampulla of Vater
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?
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
GI Suite - Endoscopic Retrograde Cholangiopancreatography (ERCP)
According to the texbook, how long do ERCPs usually last?
20-80”
(Last much longer in practice)
GI Suite - Endoscopic Retrograde Cholangiopancreatography (ERCP)
Why is General Anesthesia the preferred technique for ERCPs?
Moderate to significant pain
(experienced with biliary and pancreatic duct manipulation)
Prone position
GI Suite - Endoscopic Retrograde Cholangiopancreatography (ERCP)
According to the texbook, what are other anesthetic options during ERCPs?
Conscious or deep sedation recommended
5-8% require general anesthesia
GI Suite - Endoscopic Retrograde Cholangiopancreatography (ERCP)
What’s the typial position for ERCP?
Prone - Semi prone - Head turned to the side
Airway/positioning similar to upper GI
GI Suite - Endoscopic Retrograde Cholangiopancreatography (ERCP)
Why should opioids be avoided during ERCP?
Opioids can cause spasm of the sphincter of Oddi
Fenatnyl>Morphine
Naloxone is the reversal!!!
GI Suite - Endoscopic Retrograde Cholangiopancreatography (ERCP)
Which analgesic drug is recommended for ERCP? and why?
Remifentanil
Short acting
GI Suite - Endoscopic Retrograde Cholangiopancreatography (ERCP)
Why would abx be given duringg ERCP
Transient bacteremia
GI Suite - Endoscopic Retrograde Cholangiopancreatography (ERCP)
What’s the cause of Transient bacteremia noted during ERCP?
After stenting, backed up fluid comes out and
accumulated bacteria are realeased
GI Suite - Endoscopic Retrograde Cholangiopancreatography (ERCP)
Which comorbidities accompany pts undergoing ERCPs?
High risk of sepsis
Liver dysfunction => jaundice
GI Suite - Endoscopic Retrograde Cholangiopancreatography (ERCP)
Which drugs are given to stop spasm within the GI system
Antispasmodics = Hyoscy-amine
Can reduce the length of the procedure
Can make the pt more comfortable
GI Suite - Endoscopic Retrograde Cholangiopancreatography (ERCP)
How about Emergency ERCP???
Ask Dr Halterman
Ref: slide 63
