Mod11: IR suite - TIPS - ECT - Transport of Patients Flashcards
IR Suite - Transjugular Intrahepatic Portosystemic Shunt (TIPS)
Where are TIPS procedures typically performed?
In the IR suite
IR Suite - Transjugular Intrahepatic Portosystemic Shunt (TIPS)
Where is the catheter inserted? where is it directed?
Catheter inserted in IJ → Liver
IR Suite - Transjugular Intrahepatic Portosystemic Shunt (TIPS)
What’s the goal of a TIPS procedure
Connects R or L portal vein to one of three hepatic veins
Decompresses portal circulation in patients with portal hypertension
Prophylaxis of bleeding varices
Control refractory cirrhotic ascites
Temporary relief while awaiting liver transplantation
IR Suite - Transjugular Intrahepatic Portosystemic Shunt (TIPS)
True or False: TIPS procedure improves mortality in liver failure patients
False
TIPS does not improve mortality!!
IR Suite - Transjugular Intrahepatic Portosystemic Shunt (TIPS)
What is a major risk of TIPS procedures?
Increase risk of developing encephalopathy
IR Suite - Transjugular Intrahepatic Portosystemic Shunt (TIPS)
How long do TIPS procedures last?
2-3hrs
Produces minimal stimulation
IR Suite - Transjugular Intrahepatic Portosystemic Shunt (TIPS)
What’s an appropriate anesthetic technique for TIPS?
General anesthesia
(These patients are very sick)
or Sedation
IR Suite - Transjugular Intrahepatic Portosystemic Shunt (TIPS)
Which sytemic impairments should you be aware of on a pt scheduled for TIPS?
“Significant” hepatic dysfunction
↑ Risk for aspiration
Recent GI bleed, ↑ intragastric pressure (ascites), ↓ LOC (encephalopathy)
Respiratory
↓ FRC, Pleural effusions, intrapulmonary shunts, pneumonia
CV
ETOH cardiomyopathy, altered volume status, acute hemorrhage (bleeding varices/intraperitoneal)
Hematologic
Coagulopathy, thrombocytopenia
Neurologic
Encephalopathy
IR Suite - Transjugular Intrahepatic Portosystemic Shunt (TIPS)
What factors place a pt scheduled for TIPS at increased risk of aspiration?
Recent GI bleed
↑ intragastric pressure (ascites)
↓ LOC (encephalopathy)
IR Suite - Transjugular Intrahepatic Portosystemic Shunt (TIPS)
Why would a pt scheduled for TIPS not tolerate apneic period well?
Ascites => ↓ FRC
IR Suite - Transjugular Intrahepatic Portosystemic Shunt (TIPS)
Which respiratoy alterations would you anticipate in a pt scheduled for TIPS?
↓ FRC
Pleural effusions
Intrapulmonary shunts
Pneumonia
IR Suite - Transjugular Intrahepatic Portosystemic Shunt (TIPS)
Which CV alterations would you anticipate in a pt scheduled for TIPS?
ETOH cardiomyopathy
Altered volume status
Acute hemorrhage (bleeding varices/intraperitoneal)
IR Suite - Transjugular Intrahepatic Portosystemic Shunt (TIPS)
Which Hematologic alterations would you anticipate in a pt scheduled for TIPS?
Coagulopathy
Thrombocytopenia
IR Suite - Transjugular Intrahepatic Portosystemic Shunt (TIPS)
Which Neurologic alterations would you anticipate in a pt scheduled for TIPS?
Encephalopathy
IR Suite - Transjugular Intrahepatic Portosystemic Shunt (TIPS)
From a Pharmacokinetics stand point, why would you anticipate ↑ Vd in a pt scheduled for TIPS
Fluid accumulation in the abdominal cavity
(Ascites)
IR Suite - Transjugular Intrahepatic Portosystemic Shunt (TIPS)
From a Pharmacokinetics stand point, why would you anticipate ↓ protein binding in a pt scheduled for TIPS
More albumin shifted into the abdominal compartment
and Less in the intravascular fluid, leading to:
Altered drug metabolism/excretion
CNS sensitivity variable
Unpredictable response to anesthesia
Careful monitoring required
Arterial line commonly required
Continuous BP monitoring & labs
Frequent labs
ABG - Electrolytes Abnormalities common (diuretics/fluid shifts)
IR Suite - Transjugular Intrahepatic Portosystemic Shunt (TIPS)
Why would you anticipate Hypoglycemia in a pt scheduled for TIPS
Depletion glycogen stores
IR Suite - Transjugular Intrahepatic Portosystemic Shunt (TIPS)
Why should UOP be closely monitored in a pt scheduled for TIPS
Worsening of renal function => hepatorenal syndrome
Electroconvulsive Therapy (ECT)
Which psychiatric disorders could be manged by Electroconvulsive Therapy (ECT)
Depression - Mania - Affective disorders in schizophrenics
Use of ECT is increasing in the U.S.
Electroconvulsive Therapy (ECT)
During an ECT, why is electrical current applied to brain?
To cause a Grand mal seizure
(Grand mal seizure has antidepressant effects)
Electroconvulsive Therapy (ECT)
What’s the duration of the tonic phase of the Grand mal seizure generated via ECT?
Short 10-15secs
Electroconvulsive Therapy (ECT)
What’s the duration of the clonic phase of the Grand mal seizure generated via ECT?
Prolonged: 30-60secs
Electroconvulsive Therapy (ECT)
What the Minimum seizure duration to ensure adequate antidepressant efficacy?
25secs
Electroconvulsive Therapy (ECT)
How is the EEG monitored during seizure?
Scalp electrodes
Electroconvulsive Therapy (ECT)
Why is a BP cuff applied to a limb and inflated prior to administration of muscle relaxant?
To monitor seizure in that distal area
Cuff is inflated just prior to giving the Sux* or the Roc
(Typically Sux, unless contraindicated)
The muscle relaxant does not go distal to the cuff
Seizure could then be monitored in that distal area
Once the Psychiatrist administer the ECT only that limb distal to the cuff will seize - The rest of the body will not
Electroconvulsive Therapy (ECT)
Where are ECT typically carried out?
PACU
near OR
Psychiatric institutions
Electroconvulsive Therapy (ECT)
Why is a good bite block so important?
Prevents tongue bitting, and
Airway bleed
Electroconvulsive Therapy (ECT)
Which autonomic nervous system responses would you see first?
Followed by:
PNS: Bradycardia => asystole
followed by:
SNS: Tachycardia => HTN
Others: Cardiac dsyrhythmia - Myocardial ishemia - MI
Electroconvulsive Therapy (ECT)
Which Neurologic responses would you see?
Short term memory loss
High risk for headaches
Increased risk of seizure if preexisting neuro dz
(e.g., Status epilepticus)
Muscle aches
Fracture dislocations
Electroconvulsive Therapy (ECT)
What are goals of anesthesia during ECT?
Acheive amnesia
Airway management
Prevention from bodily harm
Control of hemodynamic changes
Smooth, rapid emergence
Electroconvulsive Therapy (ECT)
What’s the “Gold Standard” induction agent for ECT?
Methohexital (1-1.5mg/kg)
Electroconvulsive Therapy (ECT)
What’s the benefit of Methohexital over another induction agent such as Etomidate?
Methohexital will ↓ seizure duration
(in a dose dependent manner)
Etomidate will prolong seizure duration
Electroconvulsive Therapy (ECT)
Besides “prolongation of seizure duration”, what are other negative effects of Etomidate (0.15 – 0.3mg/kg) that makes it not suitable for ECT?
Myoclonus
Delayed recovery
Doesn’t depress SNS response
Accentuates HTN/tachycardia
Electroconvulsive Therapy (ECT)
How does Propofol affect seizure threshold?
Propofol Raises the seizure threshold
(making it more difficult to have a seizure)
Typically a good thing, but in ECT, we are trying to cause a seizure
This is the reason why we use Methahexatal because we want to ensure that they have a seizure for at least 25 sec
Electroconvulsive Therapy (ECT)
Which induction agent is most effective at attenuating hemodynamic responses during ECT?
Propofol
Electroconvulsive Therapy (ECT)
What are other benefits of Propofol?
Recovery rapid
Anticonvulsant effects
Reduces seizure duration - Small doses (0.75mg/kg) - Duration acceptable
Electroconvulsive Therapy (ECT)
True or False: Propofol may have an adverse effect on the outcome of ECT
False
Propofol Not proven to adversely affect outcome of ECT
Electroconvulsive Therapy (ECT)
What are the benefits of alfentanil/remifentanil addition during ECT?
Decreased induction dose
Prolonged seizure duration
<strong>(</strong>without decreasing depth of anesthesia)
Electroconvulsive Therapy (ECT)
What’s the purpose of using muscle relaxants during ECT?
Prevent musculoskeletal complications
Electroconvulsive Therapy (ECT)
What’s the most commonly used muscle relaxant during ECT? How is it administered?
Succinylcholine (0.75 - 1.5mg/kg IV)
Electroconvulsive Therapy (ECT)
What are the Steps of anesthesia during ECT?
Induction agent choice (Methohexital or Brevital)
Allow to pt to fall asleep
Ventilate with 100% O2 via self-inflating bag & mask
Put BP cuff up
Insert oral airway
Give Sux
Continue to Ventilate with 100% O2
LMA may also improve ventilation
Bite guard placed to Protect teeth/tongue
ECT applied
Electroconvulsive Therapy (ECT)
True or False: Moderate hyperventilation prior to ECT improves quality & duration of seizure.
True
Electroconvulsive Therapy (ECT)
What can we give to prevent or minimize muscle pain (Myalgia) during ECT?
Ketorolac - ASA - Acetaminophen before treatment
Electroconvulsive Therapy (ECT)
What’s the initial autonomic nervous system response you get from ECT?
PNS effects (salivation, bradycardia, asystole)
Electroconvulsive Therapy (ECT)
How could you prevent excessive PNS response on a pt with a history of asystole on prior treament?
Premedicate with glycopyrrolate or atropine
Electroconvulsive Therapy (ECT)
What’s the concern about premedication with Atropine?
The PNS response is followed by an intense SNS stimulation
Atropine could exascerbate the SNS stimulation
Electroconvulsive Therapy (ECT)
Which drugs could be used to attenuate the SNS response
Labetalol (0.3mg/kg)
Esmolol (1mg/kg), less effect on seizure duration than labetalol
Ca++ Channel antagonists (Nifedipine, Nicardipine, Diltiazem)
Clonidine
Transport of Patients
After anesthesia at alternate/remote sites, why must the Patient always be accompanied by a member of the anesthesia team?
Standards of care
Patient’s care must be handed over to a qualified provider tarined to take care of pt at the level of sedation used
Allows to continuously evaluate, monitor, and support the patient’s medical condition
Transport of Patients
Which method could be used to transport an ntubated/ventilated ICU patient on multiple gtts for sedation/hemodynamic support etc,, back to the ICU?
“Bag & Drag”
Continue to ventilate the pt through an ambu bag
Adequate supply O2 (always check your O2 tank)
Have a manual self-inflating bag for hand ventilation
Typically do not transport on ventilators
(RT must be present if transport on vent)
Ensure adequate battery power
(for monitors, vent, bed)
Transport of Patients
When Transporting a pt on ventilator, which is not typical, what other provider should accompany you?
A Respiratory Therapist
Transport of Patients
Which supplies should you have on you when transporting or “Bag & Draging” an unstable pt?
Spare anesthetic & emergency drugs
Airway equipment for intubation or reintubation
(ET tubes, laryngoscope blades)
Portable defibrillator if patients condition warrants
Transport of Patients
Why is it important to notify destination prior to initiating transportation?
Allows for appropriate preparations can be made in advance
Important to communicate pt’s condition
(stable, unstable, guarded)
Transport of Patients
Which preparations would you expect have been made at destination prior to pt’s arrival?
Ventilator settings (by RT) for intubated or not pts
Infusions (pumps ready)
Blood products
Transport of Patients
Why should you secure elevators ahead of transport?
To prevent delays during transfer
Anesthesia at alternate sites
True or False: number & complexity of procedures done at alternate sites in on the rise
True
Expansion of anesthesia services in areas remote from OR that may not be familiar to the anesthesia provider is on the rise
Anesthesia at alternate sites
In preparation to administer anesthesia or sedation at an alternate site, following a simple three-step approach can be helpful. What are the components of this approach?
Consider needs of the PATIENTS
Particular problems posed by the PROCEDURE
Hazards/limitations of the ENVIRONMENT
Anesthesia at alternate sites
What’s the biggest take away about out of OR anesthesia regarding supplies availability?
If you don’t bring something with you,
YOU DO NOT HAVE IT!!!
If you will or might need it, bring it with you.
Anesthesia at alternate sites
True or False: STANDARS OF ANESTHESIA CARE & MONITORING at alternate sites SHOULD BE NO DIFFERENT THAN THOSE PROVIDED IN THE CONVENTIONAL OPERATING ROOM
TRUE
