Non-Operating Room Anesthesia Flashcards
What are types of satellite locations (5)?
Radiology Cardiac Catheterization Lab Psychiatric Unit Endoscopy Office Based Practice
What are equipment requirements per ASA at satellite locations?
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
How should monitoring be completed in satellite locations?
standard/routines utilized in the OR must be maintained
What are the ASA/AANA guidelines require evaluation of patient’s
oxygenation
ventilation
circulation
temperature
What are some general comments about remote locations and anesthesia?
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
What are anesthesia implications for endoscopy (EGD)/ esophagogastroduodenoscopy?
local oropharygneal anesthesia with opioid + benzo VS general anesthesia with propofol (+/- ETT)
What are high risk groups for EGDs?
obese, OSA, GERD, asthma, obstruction/full stomach, hepatic disease
What is an esophagogastrodudenscopy?
endoscopic evaluation of the esophagus, pylorus, and stomach
may involve biopsy, mucosal/submucosal dissection, dilation and stenting
What is involved in a sigmoidoscopy & colonscopy?
biopsy, polypectomy/muscosal resection, stenting, dilation, etc.
What normally occurs in a sigmoidoscopy & colonscopy?
benzos + opioids VS propofol (GA)
generally involves insufflation of air, may involve the application of external pressure
What anesthesia can be performed in a sigmoidoscopy & colonscopy
benzos + opioids VS propofol (GA)
What are common complications of a sigmoidoscopy & colonscopy ?
laryngospasm, aspiration, and losing the airway
What is an endoscopic retrograde cholangiopancreatgraphy? (ERCP)
fluoroscopic exam of biliary and pancreatic duct that may involve stenting/removal of stones/laser lithotripsy
commonly in prone position
Who commonly receives ERCP?
pateints with cholangitis, pancreatitis, bile duct obstruciton, pancreatic cancer
What is required of the ERCP patient?
to be immobile
How is an ERCP performed?
GA with ETT
What are common bronchoscopic procedures?
endobronchial stenting, biopsy, laser therapy, dilation, cryotherapy, fiducial marker implant
What is common of patients receiving bronchoscopic procedures?
patients with signficant CV and pulmonary disease
What is the preferred method of bronchs?
TIVA
propofol, remifentanil, dexmedetomidine + muscle relaxants
what are associated complications of bronchs?
airway fire, bronchospams, bleeding and hypoxia
What makes up a radiology suite?
US
CT
MRI
Interventional (cardiac catheterization, neuroradiology)
non-invasive and don’t normally require anesthesia but may need anesthesia to lay still
What are general considerations in the radiology suite?
patient remains immobile for long periods
equipment is bulky
Why may general anesthesia be necessary in radiology suites?
lack of scavenging may limit the options
What are problems associated with bulky equipment in radiology suites?
impede access to patient
move and collide with anesthesia equipment
lines, pumps, ventilation tubing
will need extensions
What should be limited in the radiology suite?
radiation exposure
dose related cell death, tissue damage and malignancy (DNA ionization & free radical generation)
What is ALARA?
as low as reasonable possible
How can you decrease radiation exposure?
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)
How does contrast media come?
variable osmolarity, ionic or non-ionic
When is contrast media used?
used in diagnostic and therapeutic radiologic procedures (general radiology and MRI)
What are adverse reactions for contrast media?
range from mild to life threatening
hypersensitivity
renal toxicity
Describe non-ionic contrast media?
decrease pain on injection and decrease complications
How do you treat a hypersensitivity reaction to contrast media?
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
What is contrast induced nephropathy?
direct tubular toxicity due to release of free oxygen radicals and microvascular obstruction
What diseases have an increased risk in CIN?
diabetic renal insufficiency hypovolemia congestive heart failure HTN baseline proteinuria/Renal disease gout co-adminstration of other drugs that can cause renal tx
When does azotemia start?
24-48 hours
When does azotemia peak?
3-5 days
What do you monitor in CIN?
creatinine levels (0.5mg/dL within 24 hr is diagnostic)
What should you avoid with azotemia and CIN?
avoid surgical procedures during this period
How do you minimize the effects of contrast media?
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)
What do you administer to promote renal elimination with CIN?
sodium bicarb
What should be administered for CIN and for how long?
serum creatinine for 72 hours
Anesthesia Technique in radiology suites ranges from
local only with anesthesia stand-by
sedation/analgesic
general anesthesia
What does the anesthesia technique for radiology suite depend on?
procedure
desired level of anesthesia
underlying medical condition
open communication with radiologist
What is angiography?
examination by xray of blood or lymph vessels after injection of radiopaque substance
What should be kept out of the field during angiography?
ECG lead
ETT with metallic coids
Describe anesthesia implications with angiography
minimal discomfort potential long duration
local anesthesia at puncture site (usually femoral artery) +/- light sedation VS GA
What patients require anesthesia for CT
very young, patients with neurological diseases, trauma patients, may require sedation or general anesthesia
elderly or chronic pain
What is computed tomography?
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
How are body scan images viewed with CT?
rapidly acquiring views from numerous different projections, by rotating tube and detectors around the body
What is CT used for?
diagnostic and therapeutic purposes
biopsy, ablation of neoplastic process in thorax, abdomen, brain; diagnosis of trauma patients
chronic pain
What risk should be considered if PO contrast is utilized for a CT?
aspiration risk
What are two risks for CT that need to be additionally considered?
radiation risks
inaccessibility of patient during procedure
What is an MRI?
imaging depends on immersing the body in a steady, strong magnetic field, commonly up to 1.5 tesla
Is the magnet in the MRI always on?
Yes
What is absolute contraindicated in MRI?
ferromagnetic objects
Absolute and relative contraindications to MRI (8)
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
What are limitations to MRI?
limited patient access and visibilty
limited access for emergency personnel during scan
When does anesthesia get involved with MRI procedures?
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
What are disadvantages to MRI?
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
Describe anesthetic management for MRI
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
What is required for monitoring in MRI?
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
How is anesthesia managed in MRI?
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
What is external beam radiation therapy?
highly tissue targeted VS total body irradiation for malignancy
What is mostly completed in pediatric external beam radiation therapy?
usually propofol deep sedation
have long term indwelling catheter in place
What are considerations for external beam radiation therapy?
if CNS involvement- evaluate ICP
concurrent immunosuppressive/cytotoxic therapies
anesthesia must leave room during radiation
immobilization devices can restrict airway access
What is interventional neuro-radiology?
radiology guided endovascular approach to CNS leisons or related circulatory structures
gold standard
cerebral angiography
What are types of neuro-radiologic procedures?
embolization of AVM coiling of cerebral aneurysm angioplasty of atheroscolerotic leisons thrombolysis of acute thromboembolic stroke carotid stent
What may neuro-radiologic procedures possibly require?
deliberate hypotension or hypertensive
deliberate hypocapnia or hypercapnia
rapid transition between deep sedation/ anagelsia and the awake responsive state
What access do you need for interventional neuro-radiology?
6-7 french grade sheath in femoral artery or in some instances the carotid, axillary or brachial artery
What is used in neuro-radiologic procedures?
contrast used
What is essential for neuro-radiologic proceduers?
radiation safety policies
What are anesthesia considerations for neuro-radiology procedures
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
What is pre-op management for IR NR?
airway exam
history of contrast media reaction
evaluation of blood pressure
What is induction management for IR NR?
standard ASA monitors 2 IV sites radial arterial line foley catheter pad all pressure points
What is intraoperative IR NR anesthesia management?
heparin (70U/kg) 3000-5000u
deliberate hypotension
deliberate hypertension
EKG (manage for myocardial ischemia)
What are goal ACTs for IR NR management?
ACTs 2-2.5 times normal
How can you achieve deliberate hypotension in IR NR?
esmolol, labetolol, hydralazine or sodium nitroprusside
How can you achieve deliberate hypertension in IR NR?
phenylpherine
increase SBP 30-40% above baseline
What are anesthesia considerations for IR NR emergence?
administer anti-emetic
tight post-procedural BP control
smooth emergence to avoid coughing or bucking device migration, intracranial hemorrhage
What are interventional cardiac procedures?
coronary angiography cardiac catheterization PCTA/Stenting closure of cardiac defects percutaneous valve replacements electrophysiologic studies ablations cardioversions
Overall what is cath lab not optimized for?
anesthesia
What is coronary angiography?
performed by passing a catheter retrograde through the aortic root and injection of contrast media into the ostia of the coronary arteries
Where is catheter insertion is accomplished via
femoral, brachial or radial artery
What does interventional cardiology detect?
CAD
% stenosis
coronary spasm detected
What are the risks of interventional cardiology?
hemorrhage, infection, ischemia, cardiac ischemia, coronary dissection, thromboemobolic events, contrast related reactions
What should anesthesia prepare for in IR CARDs?
unstable patient should an emergency occur
What are considerations for interventional cardiology?
anesthesia management (sedation/analgesia) vs general anesthesia supplemental oxygen asa monitors arterial BP and non-invasive BP IVs with extensions foley catheter monitor temp
What are common pharmacologic agents?
midazolam fentanyl propofol sublingual or IV nitroglycerin heparin/ protamine provactive agents (erognovine maleate or methylergonovine malerate) diltiazem
What are EP studies?
patients stop anti-arrhythmics drugs prior to study
cardiologist provokes the dysrhythmias they want to ablate
cardioversion via cardiac catheters or external defibrillation pads
How long are EP studies?
4-8 hours
Describe anesthesia in EP studies
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)
What is needed for pacemaker insertion?
sedation/anagelsia VS internal defibrillator may need brief period of general
hemodynamic unstable
When is an arterial line needed for a pacemarker insertion?
EF <20%
What is elective cardioversion?
used to convert supraventricular and ventricular arrhythmias to sinus rhythm by the delivery of synchronized direct current electric shock
Describe the requirements for cardioversion
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
What may be required prior to cardioversion and why?
pre-procedure TEE to assess for clot formation in atria
increase procedure/sedation time
What do you need for cardioversion?
full general anesthesia set-up intubating equipment medications supplemental oxygen and method of positive pressure vent suction resuscitation equipment
What are the steps to cardioversion?
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
What are indications for ECT?
major depression PTSD mania schizophrenia parkinson's syndrome
Describe ECT
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
How many treatments are needed for ECT?
2-3 per week until improvements
What does ECT cause?
seizure activity causes initial parasympathetic discharge followed by intense sympathetic discharge
What needs to be reviewed prior to ECT?
H&P
review prior treatments
review current drug therapy
(TCAs, SSRIs, MAO inhibitors, lithium carbonate)
What are contraindications to ECT?
phenochromocytoma increased ICP recent CVA high risk pregnancy aortic and cerebral aneurysms
What is required from anesthesia for ECT?
ASA monitors (including standard NIBP)
pre-treatment 0.2mg glycopyrrolate
pre-oxygenate
Describe ECT process
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
What are medications and doses for ECT?
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
What are emergency drugs for ECT?
esmolol, labetolol, calcium channel blockers
What is essential for ECT?
good record keeping essential for subsequent treatments
Describe recovery after ECT?
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
What does not apply to office base anesthesia?
strict standards and regulation of hospitals and surgery centers
What is seen (and supported by evidence) in office based procedures?
higher morbidity and mortality
What are causes of morbidity and mortality of office based anesthesia?
over dose local anesthesia over dose sedatives occult blood loss pulmonary embolism hypovolemia hypoxemia
Who are appropriate patients for office based anesthesia?
ASA 1/2
ASA 3 anesthesia pre-procedure + consult and only local no sedation
OSA avoided sedation and especially GA in office based
What are other considerations in office based anesthesia?
surgeon often has ownership of practice
state regulations
following lawful and ethnical billing
quality assurance program
What needs to be confirmed with surgeon for office base surgery?
license, DEA #, adequate liability insurance should have priviledges to perform procedure local hospital (or comparable proof of adequate training)
Who comprises a quality assurance program?
surgeon, anesthesia team members, nurses, support staff
Where are controlled substances stored in office based anesthesia?
double locked storage cabinet
procedures must be consistent wtih DEA, local, and state regulation
What MUST BE AVAILABLE in an office based setting if anesthesia is administered?
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
What is the peak serum of local tumescent?
12-14 hours later
What is the max dose of tumescent?
35-55mg/kg
What is the limit of tumescent?
5000ml of total aspirate (fat/fluid)
