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7835 Exam IV > Mod11: IR suite - TIPS - ECT - Transport of Patients > Flashcards

Mod11: IR suite - TIPS - ECT - Transport of Patients Flashcards

1
Q

IR Suite - Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Where are TIPS procedures typically performed?

A

In the IR suite

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2
Q

IR Suite - Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Where is the catheter inserted? where is it directed?

A

Catheter inserted in IJ → Liver

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3
Q

IR Suite - Transjugular Intrahepatic Portosystemic Shunt (TIPS)

What’s the goal of a TIPS procedure

A

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

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4
Q

IR Suite - Transjugular Intrahepatic Portosystemic Shunt (TIPS)

True or False: TIPS procedure improves mortality in liver failure patients

A

False

TIPS does not improve mortality!!

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5
Q

IR Suite - Transjugular Intrahepatic Portosystemic Shunt (TIPS)

What is a major risk of TIPS procedures?

A

Increase risk of developing encephalopathy

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6
Q

IR Suite - Transjugular Intrahepatic Portosystemic Shunt (TIPS)

How long do TIPS procedures last?

A

2-3hrs

Produces minimal stimulation

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7
Q

IR Suite - Transjugular Intrahepatic Portosystemic Shunt (TIPS)

What’s an appropriate anesthetic technique for TIPS?

A

General anesthesia

(These patients are very sick)

or Sedation

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8
Q

IR Suite - Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Which sytemic impairments should you be aware of on a pt scheduled for TIPS?

A

“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

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9
Q

IR Suite - Transjugular Intrahepatic Portosystemic Shunt (TIPS)

What factors place a pt scheduled for TIPS at increased risk of aspiration?

A

Recent GI bleed

↑ intragastric pressure (ascites)

↓ LOC (encephalopathy)

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10
Q

IR Suite - Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Why would a pt scheduled for TIPS not tolerate apneic period well?

A

Ascites => ↓ FRC

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11
Q

IR Suite - Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Which respiratoy alterations would you anticipate in a pt scheduled for TIPS?

A

↓ FRC

Pleural effusions

Intrapulmonary shunts

Pneumonia

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12
Q

IR Suite - Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Which CV alterations would you anticipate in a pt scheduled for TIPS?

A

ETOH cardiomyopathy

Altered volume status

Acute hemorrhage (bleeding varices/intraperitoneal)

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13
Q

IR Suite - Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Which Hematologic alterations would you anticipate in a pt scheduled for TIPS?

A

Coagulopathy

Thrombocytopenia

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14
Q

IR Suite - Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Which Neurologic alterations would you anticipate in a pt scheduled for TIPS?

A

Encephalopathy

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15
Q

IR Suite - Transjugular Intrahepatic Portosystemic Shunt (TIPS)

From a Pharmacokinetics stand point, why would you anticipate ↑ Vd in a pt scheduled for TIPS

A

Fluid accumulation in the abdominal cavity

(Ascites)

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16
Q

IR Suite - Transjugular Intrahepatic Portosystemic Shunt (TIPS)

From a Pharmacokinetics stand point, why would you anticipate ↓ protein binding in a pt scheduled for TIPS

A

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)

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17
Q

IR Suite - Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Why would you anticipate Hypoglycemia in a pt scheduled for TIPS

A

Depletion glycogen stores

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18
Q

IR Suite - Transjugular Intrahepatic Portosystemic Shunt (TIPS)

Why should UOP be closely monitored in a pt scheduled for TIPS

A

Worsening of renal function => hepatorenal syndrome

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19
Q

Electroconvulsive Therapy (ECT)

Which psychiatric disorders could be manged by Electroconvulsive Therapy (ECT)

A

Depression - Mania - Affective disorders in schizophrenics

Use of ECT is increasing in the U.S.

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20
Q

Electroconvulsive Therapy (ECT)

During an ECT, why is electrical current applied to brain?

A

To cause a Grand mal seizure

(Grand mal seizure has antidepressant effects)

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21
Q

Electroconvulsive Therapy (ECT)

What’s the duration of the tonic phase of the Grand mal seizure generated via ECT?

A

Short 10-15secs

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22
Q

Electroconvulsive Therapy (ECT)

What’s the duration of the clonic phase of the Grand mal seizure generated via ECT?

A

Prolonged: 30-60secs

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23
Q

Electroconvulsive Therapy (ECT)

What the Minimum seizure duration to ensure adequate antidepressant efficacy?

A

25secs

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24
Q

Electroconvulsive Therapy (ECT)

How is the EEG monitored during seizure?

A

Scalp electrodes

25
Q

Electroconvulsive Therapy (ECT)

Why is a BP cuff applied to a limb and inflated prior to administration of muscle relaxant?

A

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

26
Q

Electroconvulsive Therapy (ECT)

Where are ECT typically carried out?

A

PACU

near OR

Psychiatric institutions

27
Q

Electroconvulsive Therapy (ECT)

Why is a good bite block so important?

A

Prevents tongue bitting, and

Airway bleed

28
Q

Electroconvulsive Therapy (ECT)

Which autonomic nervous system responses would you see first?

Followed by:

A

PNS: Bradycardia => asystole

followed by:

SNS: Tachycardia => HTN

Others: Cardiac dsyrhythmia - Myocardial ishemia - MI

29
Q

Electroconvulsive Therapy (ECT)

Which Neurologic responses would you see?

A

Short term memory loss

High risk for headaches

Increased risk of seizure if preexisting neuro dz

(e.g., Status epilepticus)

Muscle aches

Fracture dislocations

30
Q

Electroconvulsive Therapy (ECT)

What are goals of anesthesia during ECT?

A

Acheive amnesia

Airway management

Prevention from bodily harm

Control of hemodynamic changes

Smooth, rapid emergence

31
Q

Electroconvulsive Therapy (ECT)

What’s the “Gold Standard” induction agent for ECT?

A

Methohexital (1-1.5mg/kg)

32
Q

Electroconvulsive Therapy (ECT)

What’s the benefit of Methohexital over another induction agent such as Etomidate?

A

Methohexital will ↓ seizure duration

(in a dose dependent manner)

Etomidate will prolong seizure duration

33
Q

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?

A

Myoclonus

Delayed recovery

Doesn’t depress SNS response

Accentuates HTN/tachycardia

34
Q

Electroconvulsive Therapy (ECT)

How does Propofol affect seizure threshold?

A

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

35
Q

Electroconvulsive Therapy (ECT)

Which induction agent is most effective at attenuating hemodynamic responses during ECT?

A

Propofol

36
Q

Electroconvulsive Therapy (ECT)

What are other benefits of Propofol?

A

Recovery rapid

Anticonvulsant effects

Reduces seizure duration - Small doses (0.75mg/kg) - Duration acceptable

37
Q

Electroconvulsive Therapy (ECT)

True or False: Propofol may have an adverse effect on the outcome of ECT

A

False

Propofol Not proven to adversely affect outcome of ECT

38
Q

Electroconvulsive Therapy (ECT)

What are the benefits of alfentanil/remifentanil addition during ECT?

A

Decreased induction dose

Prolonged seizure duration

<strong>(</strong>without decreasing depth of anesthesia)

39
Q

Electroconvulsive Therapy (ECT)

What’s the purpose of using muscle relaxants during ECT?

A

Prevent musculoskeletal complications

40
Q

Electroconvulsive Therapy (ECT)

What’s the most commonly used muscle relaxant during ECT? How is it administered?

A

Succinylcholine (0.75 - 1.5mg/kg IV)

41
Q

Electroconvulsive Therapy (ECT)

What are the Steps of anesthesia during ECT?

A

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

42
Q

Electroconvulsive Therapy (ECT)

True or False: Moderate hyperventilation prior to ECT improves quality & duration of seizure.

A

True

43
Q

Electroconvulsive Therapy (ECT)

What can we give to prevent or minimize muscle pain (Myalgia) during ECT?

A

Ketorolac - ASA - Acetaminophen before treatment

44
Q

Electroconvulsive Therapy (ECT)

What’s the initial autonomic nervous system response you get from ECT?

A

PNS effects (salivation, bradycardia, asystole)

45
Q

Electroconvulsive Therapy (ECT)

How could you prevent excessive PNS response on a pt with a history of asystole on prior treament?

A

Premedicate with glycopyrrolate or atropine

46
Q

Electroconvulsive Therapy (ECT)

What’s the concern about premedication with Atropine?

A

The PNS response is followed by an intense SNS stimulation

Atropine could exascerbate the SNS stimulation

47
Q

Electroconvulsive Therapy (ECT)

Which drugs could be used to attenuate the SNS response

A

Labetalol (0.3mg/kg)

Esmolol (1mg/kg), less effect on seizure duration than labetalol

Ca++ Channel antagonists (Nifedipine, Nicardipine, Diltiazem)

Clonidine

48
Q

Transport of Patients

After anesthesia at alternate/remote sites, why must the Patient always be accompanied by a member of the anesthesia team?

A

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

49
Q

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?

A

“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)

50
Q

Transport of Patients

When Transporting a pt on ventilator, which is not typical, what other provider should accompany you?

A

A Respiratory Therapist

51
Q

Transport of Patients

Which supplies should you have on you when transporting or “Bag & Draging” an unstable pt?

A

Spare anesthetic & emergency drugs

Airway equipment for intubation or reintubation

(ET tubes, laryngoscope blades)

Portable defibrillator if patients condition warrants

52
Q

Transport of Patients

Why is it important to notify destination prior to initiating transportation?

A

Allows for appropriate preparations can be made in advance

Important to communicate pt’s condition

(stable, unstable, guarded)

53
Q

Transport of Patients

Which preparations would you expect have been made at destination prior to pt’s arrival?

A

Ventilator settings (by RT) for intubated or not pts

Infusions (pumps ready)

Blood products

54
Q

Transport of Patients

Why should you secure elevators ahead of transport?

A

To prevent delays during transfer

55
Q

Anesthesia at alternate sites

True or False: number & complexity of procedures done at alternate sites in on the rise

A

True

Expansion of anesthesia services in areas remote from OR that may not be familiar to the anesthesia provider is on the rise

56
Q

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?

A

Consider needs of the PATIENTS

Particular problems posed by the PROCEDURE

Hazards/limitations of the ENVIRONMENT

57
Q

Anesthesia at alternate sites

What’s the biggest take away about out of OR anesthesia regarding supplies availability?

A

If you don’t bring something with you,

YOU DO NOT HAVE IT!!!

If you will or might need it, bring it with you.

58
Q

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

A

TRUE

7835 Exam IV (21 decks)

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