Mod11: Cardioversion - Gastroenterology Suite Flashcards by Olivier Mba

_{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

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_{Cardioversion}

What is the main concern with cardioversion?

Thromboembolism

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_{Cardioversion}

•A-fib/flutter > 48hrs ???

Slider 56 needs - 3rd bullet point

email sent to Dr. Haltermann

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_{Cardioversion}

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

Initiated (Coumadin) 3wks prior

Continued for 4wks after

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_{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 clot in the LAA)}

Anesthesia may or may not be involved with TEE

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_{Cardioversion}

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

Lower dose anticoagulation &

Immediate cardioversion

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_{Cardioversion}

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

Cardioversion postponed to allow for

adequate anticoagulation

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_{Cardioversion}

True or False: Cardioversion is brief and not distressing

False

Cardioversion is brief but distressing

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_{Cardioversion}

Why should cadioversion be carried out using sedation?

Because it is distressing

Patient should be asleep for the procedure

^{(Propopol or Ketamine in small doses)}

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_{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!!!!”}

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_{Cardioversion}

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

Aspiration

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Cardioversion

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

Increases length of the procedure

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_{Cardioversion}

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

Propofol infusion

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_{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

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_{Gastroenterology Suite}

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

True

_{They administer or have a nurse administer}

_{Benzodiazepine (midazolam, diazepam)}

_{with or without an opioid (fentanyl, alfentanil, meperidine)}

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_{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)

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_{Gastroenterology Suite}

Which drug provides the best conditions for GI endoscopy?

Propofol

Provides excellent conditions

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_{Gastroenterology Suite}

Who can administer Propofol?

Many believe it should be administered by trained anesthesia providers only

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_{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

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_{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}

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_{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

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

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Mod11: Cardioversion - Gastroenterology Suite Flashcards

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