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N931 Advanced Principles > Non-Operating Room Anesthesia > Flashcards

Non-Operating Room Anesthesia Flashcards

1
Q

What are types of satellite locations (5)?

A 
Radiology
Cardiac Catheterization Lab
Psychiatric Unit
Endoscopy
Office Based Practice
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2
Q

What are equipment requirements per ASA at satellite locations?

A

Reliable O2 source with back-up
Suction source
Waste gas scavenging
Adequate monitoring equipment
Self- inflating hand resuscitator bag
Sufficient safe electrical outlets
adequate patient and anesthesia equipment illumination with battery power back-up
adequate space to freely access patient and anesthesia equipment
emergency cart with defibrillator, emergency drugs and other emergency equipment
reliable two way communication to request for help
adequately trained support staff in procedure room & in post-anesthesia care location
compliance with facility with all applicable safety and building codes

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3
Q

How should monitoring be completed in satellite locations?

A

standard/routines utilized in the OR must be maintained

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4
Q

What are the ASA/AANA guidelines require evaluation of patient’s

A

oxygenation
ventilation
circulation
temperature

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5
Q

What are some general comments about remote locations and anesthesia?

A

design of satellite location is for the procedure (anesthesia is an afterthought)
personnel may be less familiar with management of patient under anesthesia
procedure table limits
pre-procedures assessment/ optimization often not completed in advance= delays + cancelations

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6
Q

What are anesthesia implications for endoscopy (EGD)/ esophagogastroduodenoscopy?

A

local oropharygneal anesthesia with opioid + benzo VS general anesthesia with propofol (+/- ETT)

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7
Q

What are high risk groups for EGDs?

A

obese, OSA, GERD, asthma, obstruction/full stomach, hepatic disease

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8
Q

What is an esophagogastrodudenscopy?

A

endoscopic evaluation of the esophagus, pylorus, and stomach

may involve biopsy, mucosal/submucosal dissection, dilation and stenting

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9
Q

What is involved in a sigmoidoscopy & colonscopy?

A

biopsy, polypectomy/muscosal resection, stenting, dilation, etc.

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10
Q

What normally occurs in a sigmoidoscopy & colonscopy?

A

benzos + opioids VS propofol (GA)

generally involves insufflation of air, may involve the application of external pressure

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11
Q

What anesthesia can be performed in a sigmoidoscopy & colonscopy

A

benzos + opioids VS propofol (GA)

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12
Q

What are common complications of a sigmoidoscopy & colonscopy ?

A

laryngospasm, aspiration, and losing the airway

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13
Q

What is an endoscopic retrograde cholangiopancreatgraphy? (ERCP)

A

fluoroscopic exam of biliary and pancreatic duct that may involve stenting/removal of stones/laser lithotripsy
commonly in prone position

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14
Q

Who commonly receives ERCP?

A

pateints with cholangitis, pancreatitis, bile duct obstruciton, pancreatic cancer

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15
Q

What is required of the ERCP patient?

A

to be immobile

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16
Q

How is an ERCP performed?

A

GA with ETT

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17
Q

What are common bronchoscopic procedures?

A

endobronchial stenting, biopsy, laser therapy, dilation, cryotherapy, fiducial marker implant

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18
Q

What is common of patients receiving bronchoscopic procedures?

A

patients with signficant CV and pulmonary disease

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19
Q

What is the preferred method of bronchs?

A

TIVA

propofol, remifentanil, dexmedetomidine + muscle relaxants

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20
Q

what are associated complications of bronchs?

A

airway fire, bronchospams, bleeding and hypoxia

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21
Q

What makes up a radiology suite?

A

US
CT
MRI
Interventional (cardiac catheterization, neuroradiology)
non-invasive and don’t normally require anesthesia but may need anesthesia to lay still

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22
Q

What are general considerations in the radiology suite?

A

patient remains immobile for long periods

equipment is bulky

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23
Q

Why may general anesthesia be necessary in radiology suites?

A

lack of scavenging may limit the options

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24
Q

What are problems associated with bulky equipment in radiology suites?

A

impede access to patient
move and collide with anesthesia equipment
lines, pumps, ventilation tubing
will need extensions

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25
Q

What should be limited in the radiology suite?

A

radiation exposure

dose related cell death, tissue damage and malignancy (DNA ionization & free radical generation)

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26
Q

What is ALARA?

A

as low as reasonable possible

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27
Q

How can you decrease radiation exposure?

A 
lead aprons
thyroid shields
moveable leaded glass screens
leaded eyeglasses
remote or video monitoring when appropriate (very briefly stepping out of the room during image)
dosimeters should be worn
(one under lead apron)
(one on collar above lead apron)
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28
Q

How does contrast media come?

A

variable osmolarity, ionic or non-ionic

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29
Q

When is contrast media used?

A

used in diagnostic and therapeutic radiologic procedures (general radiology and MRI)

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30
Q

What are adverse reactions for contrast media?

A

range from mild to life threatening
hypersensitivity
renal toxicity

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31
Q

Describe non-ionic contrast media?

A

decrease pain on injection and decrease complications

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32
Q

How do you treat a hypersensitivity reaction to contrast media?

A 
prompt recongition
oxygen
bronchodilators
epinephrine
fluid resusitation
corticosteroids
consider pre-treatment with IV corticosteroids a few hours pre-procedure as well as H1 and H2 blockers
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33
Q

What is contrast induced nephropathy?

A

direct tubular toxicity due to release of free oxygen radicals and microvascular obstruction

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34
Q

What diseases have an increased risk in CIN?

A 
diabetic renal insufficiency
hypovolemia
congestive heart failure
HTN
baseline proteinuria/Renal disease
gout
co-adminstration of other drugs that can cause renal tx
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35
Q

When does azotemia start?

A

24-48 hours

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36
Q

When does azotemia peak?

A

3-5 days

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37
Q

What do you monitor in CIN?

A

creatinine levels (0.5mg/dL within 24 hr is diagnostic)

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38
Q

What should you avoid with azotemia and CIN?

A

avoid surgical procedures during this period

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39
Q

How do you minimize the effects of contrast media?

A

careful administration and limitation of total dose
hydration 1st line protection administer 1ml/kg of normal saline 4 hours pre-procedure and continue for 12 hours post-procedure (avoid volume overload in susceptible patients)

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40
Q

What do you administer to promote renal elimination with CIN?

A

sodium bicarb

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41
Q

What should be administered for CIN and for how long?

A

serum creatinine for 72 hours

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42
Q

Anesthesia Technique in radiology suites ranges from

A

local only with anesthesia stand-by
sedation/analgesic
general anesthesia

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43
Q

What does the anesthesia technique for radiology suite depend on?

A

procedure
desired level of anesthesia
underlying medical condition
open communication with radiologist

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44
Q

What is angiography?

A

examination by xray of blood or lymph vessels after injection of radiopaque substance

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45
Q

What should be kept out of the field during angiography?

A

ECG lead

ETT with metallic coids

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46
Q

Describe anesthesia implications with angiography

A

minimal discomfort potential long duration

local anesthesia at puncture site (usually femoral artery) +/- light sedation VS GA

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47
Q

What patients require anesthesia for CT

A

very young, patients with neurological diseases, trauma patients, may require sedation or general anesthesia
elderly or chronic pain

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48
Q

What is computed tomography?

A

technique that uses x-ray beam to image slices of the body <1sec
amount of radiation transmitted is collected by photo multipler tubes and counted digitally

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49
Q

How are body scan images viewed with CT?

A

rapidly acquiring views from numerous different projections, by rotating tube and detectors around the body

50
Q

What is CT used for?

A

diagnostic and therapeutic purposes
biopsy, ablation of neoplastic process in thorax, abdomen, brain; diagnosis of trauma patients
chronic pain

51
Q

What risk should be considered if PO contrast is utilized for a CT?

A

aspiration risk

52
Q

What are two risks for CT that need to be additionally considered?

A

radiation risks

inaccessibility of patient during procedure

53
Q

What is an MRI?

A

imaging depends on immersing the body in a steady, strong magnetic field, commonly up to 1.5 tesla

54
Q

Is the magnet in the MRI always on?

A

Yes

55
Q

What is absolute contraindicated in MRI?

A

ferromagnetic objects

56
Q

Absolute and relative contraindications to MRI (8)

A

pacemakers/defibrillators
cochlear implants
pumps or nerve stimulators
aneurysms clips
intravascular wires
former trauma victims with bullets or metal shrapnel
first trimester of pregnancy (minimal support data)
metal implants need to be monitored for temperature

57
Q

What are limitations to MRI?

A

limited patient access and visibilty

limited access for emergency personnel during scan

58
Q

When does anesthesia get involved with MRI procedures?

A

sedation fails or is too risky
it is impossible to control movement with a general anesthesia
need to protect the patient’s airway/control ventilation

59
Q

What are disadvantages to MRI?

A

time consuming exam which leads to anxiety and claustrophobia
any movement produces artifact
obese patients can not fit
loud noises (>90dB)
heat generation/ risk of thermal injury (do not wind up cables/wires)
effect of magnet on ferrous objects

60
Q

Describe anesthetic management for MRI

A

induction occurs in adjacent area
patient is transferred via MRI transport table
MRI compatible anesthesia machine/monitoring are connected
MRI transport table available for emergency and should rapid exit be necessary

61
Q

What is required for monitoring in MRI?

A 
Must meet ASA requirements for monitoring, yet must be MRI compatible
ECG/ pulse ox risk for thermal injury
ECG artifact issues
capnography
non-invasive BP
62
Q

How is anesthesia managed in MRI?

A

secure the airway with ett or lma
anesthesia maintained with VA or TIVA
provider may or may not be present in room
awakened/resuscitated in the induction area

63
Q

What is external beam radiation therapy?

A

highly tissue targeted VS total body irradiation for malignancy

64
Q

What is mostly completed in pediatric external beam radiation therapy?

A

usually propofol deep sedation

have long term indwelling catheter in place

65
Q

What are considerations for external beam radiation therapy?

A

if CNS involvement- evaluate ICP
concurrent immunosuppressive/cytotoxic therapies
anesthesia must leave room during radiation
immobilization devices can restrict airway access

66
Q

What is interventional neuro-radiology?

A

radiology guided endovascular approach to CNS leisons or related circulatory structures
gold standard
cerebral angiography

67
Q

What are types of neuro-radiologic procedures?

A 
embolization of AVM
coiling of cerebral aneurysm 
angioplasty of atheroscolerotic leisons
thrombolysis of acute thromboembolic stroke
carotid stent
68
Q

What may neuro-radiologic procedures possibly require?

A

deliberate hypotension or hypertensive
deliberate hypocapnia or hypercapnia
rapid transition between deep sedation/ anagelsia and the awake responsive state

69
Q

What access do you need for interventional neuro-radiology?

A

6-7 french grade sheath in femoral artery or in some instances the carotid, axillary or brachial artery

70
Q

What is used in neuro-radiologic procedures?

A

contrast used

71
Q

What is essential for neuro-radiologic proceduers?

A

radiation safety policies

72
Q

What are anesthesia considerations for neuro-radiology procedures

A

hemorrhage: potential cerebral aneurysm rupture, intra-cranial vessel rupture/damage
hematoma at sheath insertion site
occlusive complications: migration of embolic materials, vasospasm
cerebral edema
patient’s existing co-morbidities

73
Q

What is pre-op management for IR NR?

A

airway exam
history of contrast media reaction
evaluation of blood pressure

74
Q

What is induction management for IR NR?

A 
standard ASA monitors
2 IV sites
radial arterial line
foley catheter 
pad all  pressure points
75
Q

What is intraoperative IR NR anesthesia management?

A

heparin (70U/kg) 3000-5000u
deliberate hypotension
deliberate hypertension
EKG (manage for myocardial ischemia)

76
Q

What are goal ACTs for IR NR management?

A

ACTs 2-2.5 times normal

77
Q

How can you achieve deliberate hypotension in IR NR?

A

esmolol, labetolol, hydralazine or sodium nitroprusside

78
Q

How can you achieve deliberate hypertension in IR NR?

A

phenylpherine

increase SBP 30-40% above baseline

79
Q

What are anesthesia considerations for IR NR emergence?

A

administer anti-emetic
tight post-procedural BP control
smooth emergence to avoid coughing or bucking device migration, intracranial hemorrhage

80
Q

What are interventional cardiac procedures?

A 
coronary angiography
cardiac catheterization
PCTA/Stenting
closure of cardiac defects
percutaneous valve replacements
electrophysiologic studies
ablations
cardioversions
81
Q

Overall what is cath lab not optimized for?

A

anesthesia

82
Q

What is coronary angiography?

A

performed by passing a catheter retrograde through the aortic root and injection of contrast media into the ostia of the coronary arteries

83
Q

Where is catheter insertion is accomplished via

A

femoral, brachial or radial artery

84
Q

What does interventional cardiology detect?

A

CAD
% stenosis
coronary spasm detected

85
Q

What are the risks of interventional cardiology?

A

hemorrhage, infection, ischemia, cardiac ischemia, coronary dissection, thromboemobolic events, contrast related reactions

86
Q

What should anesthesia prepare for in IR CARDs?

A

unstable patient should an emergency occur

87
Q

What are considerations for interventional cardiology?

A 
anesthesia management (sedation/analgesia) vs general anesthesia
supplemental oxygen
asa monitors
arterial BP and non-invasive BP
IVs with extensions
foley catheter
monitor temp
88
Q

What are common pharmacologic agents?

A 
midazolam
fentanyl
propofol
sublingual or IV nitroglycerin
heparin/ protamine
provactive agents (erognovine maleate or methylergonovine malerate)
diltiazem
89
Q

What are EP studies?

A

patients stop anti-arrhythmics drugs prior to study
cardiologist provokes the dysrhythmias they want to ablate
cardioversion via cardiac catheters or external defibrillation pads

90
Q

How long are EP studies?

A

4-8 hours

91
Q

Describe anesthesia in EP studies

A

sedation is used with brief periods of general anesthesia
general anesthesia is preferred because the patient must be completely still during mapping
(VA agents or propofol)
No muscle relaxant (phrenic nerve monitoring)

92
Q

What is needed for pacemaker insertion?

A

sedation/anagelsia VS internal defibrillator may need brief period of general
hemodynamic unstable

93
Q

When is an arterial line needed for a pacemarker insertion?

A

EF <20%

94
Q

What is elective cardioversion?

A

used to convert supraventricular and ventricular arrhythmias to sinus rhythm by the delivery of synchronized direct current electric shock

95
Q

Describe the requirements for cardioversion

A

GA (propofol with nasal cannula/ natural airway and ambu bag for backup)
Standard ASA monitors
assess cardiovascular status and medical therapy
NPO status
emergency if arrhythmia causes patient to be hemodynamically unstable

96
Q

What may be required prior to cardioversion and why?

A

pre-procedure TEE to assess for clot formation in atria

increase procedure/sedation time

97
Q

What do you need for cardioversion?

A 
full general anesthesia set-up 
intubating equipment
medications
supplemental oxygen and method of positive pressure vent
suction
resuscitation equipment
98
Q

What are the steps to cardioversion?

A

pre-oxygenate with 100% oxygen
small incremental doses of IV anesthetic until loss of lid reflex
assess for unconsciousness, mask is removed ALL clear
synchronized countershock administered
monitored rhythm closely
manually ventilate/support airway until return of spontaneous ventilation
remain with patient until awake and alert
sign off patient to ICU nurse ACLS trained

99
Q

What are indications for ECT?

A 
major depression
PTSD
mania
schizophrenia
parkinson's syndrome
100
Q

Describe ECT

A

programmed electrical stimulation of the CNS to initiate seizure activity
2 electrode are applied to patient’s scalp
series of electrical pulses at precise energy levels are delivered to induce a seizure

101
Q

How many treatments are needed for ECT?

A

2-3 per week until improvements

102
Q

What does ECT cause?

A

seizure activity causes initial parasympathetic discharge followed by intense sympathetic discharge

103
Q

What needs to be reviewed prior to ECT?

A

H&P
review prior treatments
review current drug therapy
(TCAs, SSRIs, MAO inhibitors, lithium carbonate)

104
Q

What are contraindications to ECT?

A 
phenochromocytoma
increased ICP
recent CVA
high risk pregnancy
aortic and cerebral aneurysms
105
Q

What is required from anesthesia for ECT?

A

ASA monitors (including standard NIBP)
pre-treatment 0.2mg glycopyrrolate
pre-oxygenate

106
Q

Describe ECT process

A

GA is induced (induction drug, loss of lid reflex, ensure adequate mask ventilation, insert bite block, 2nd BP cuff applied to extremity and inflated BEFORE muscle relaxant
NMR
stimulus delivered to induce a seizure
peripheral/ central seizure observation is made
ventilation (mask or LMA) continues until patient is awake and delivered to care of RR staff

107
Q

What are medications and doses for ECT?

A

methohexital 0.75-1.5mg/kg
etomidate 0.15-0.3mg/kg
propofol 0.75mg
succinylcholine 0.75-1.5mg/kg
dexmedetomidine 1mcg/kg 10 minutes pre-induction
15-30mg of ketorlax for post-procedure myalgia

108
Q

What are emergency drugs for ECT?

A

esmolol, labetolol, calcium channel blockers

109
Q

What is essential for ECT?

A

good record keeping essential for subsequent treatments

110
Q

Describe recovery after ECT?

A 
medically stable to transport
received by appropriately trained staff
accompanied by provider of anesthesia
transport with oxygen and monitoring
discharge only after they have met specific criteria
111
Q

What does not apply to office base anesthesia?

A

strict standards and regulation of hospitals and surgery centers

112
Q

What is seen (and supported by evidence) in office based procedures?

A

higher morbidity and mortality

113
Q

What are causes of morbidity and mortality of office based anesthesia?

A 
over dose local anesthesia
over dose sedatives
occult blood loss
pulmonary embolism
hypovolemia
hypoxemia
114
Q

Who are appropriate patients for office based anesthesia?

A

ASA 1/2
ASA 3 anesthesia pre-procedure + consult and only local no sedation
OSA avoided sedation and especially GA in office based

115
Q

What are other considerations in office based anesthesia?

A

surgeon often has ownership of practice
state regulations
following lawful and ethnical billing
quality assurance program

116
Q

What needs to be confirmed with surgeon for office base surgery?

A

license, DEA #, adequate liability insurance should have priviledges to perform procedure local hospital (or comparable proof of adequate training)

117
Q

Who comprises a quality assurance program?

A

surgeon, anesthesia team members, nurses, support staff

118
Q

Where are controlled substances stored in office based anesthesia?

A

double locked storage cabinet

procedures must be consistent wtih DEA, local, and state regulation

119
Q

What MUST BE AVAILABLE in an office based setting if anesthesia is administered?

A

medications and equipment to follow all emergency protocols
MH, LA toxicity, ASA difficult airway, acls/pals protocols
regular schedule to replace expired agents and service equipment
regular drills: airway, fire, MH etc

120
Q

What is the peak serum of local tumescent?

A

12-14 hours later

121
Q

What is the max dose of tumescent?

A

35-55mg/kg

122
Q

What is the limit of tumescent?

A

5000ml of total aspirate (fat/fluid)

N931 Advanced Principles (14 decks)

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