Non-Operating Room Anesthesia (NORA) Flashcards
What are AANA standards of care 1, 2, 3?
1: Patient rights: autonomy, privacy, safety
2: Pre-anesthesia assessment
3: Patient specific plan
What are AANA standards of care 4, 5, 6?
4: Informed consent
5: Documentation
6: Functioning equipment
What are AANA standards of care 7, 8 , 9?
7: Plan modification
8: Patient positioning
9: Monitoring/alarms
What are AANA standards of care 10 and 11?
10: Infection control
11: Transfer of care
Functional capacity is measured in METs (metabolic equivalent of task). What is 1 MET equivalent to?
MET is rate of energy consumption at rest
1 MET=3.5 mL/kg/min
<5 MET Poor
5-8 fair
9-11 Good
12 Excellent
What are the MET scores and their equivalent level of exercise?
What does the modified aldrete scoring system PARS?
- Respirations
- O2 saturation (color)
- Consciousness
- Circulation
- Activity (movement)
Review these ASA standards for NORA
Someone who responds to verbal commands, and is provided with anxiolysis would be considered what level of sedation?
Minimal sedation
Someone who responds to verbal/tactile stimulation but has a depressed LOC would be considered what level of sedation?
Moderate sedation
Someone who responds to painful stimulation but with impaired independent ventilation would be considered what level of sedation?
Deep sedation
If a patient loses consciousness and the ability to purposfully respond the anesthetic is considered?
general anesthetic
whether airway support is required or not
What type of anesthetic is recommended for cerebral coiling? Why might ETCO2 need manipulation during this procedure?
GETA w/ arterial line and large bore IV.
May manipulate CO2 for cerebral vasculature response:
- Hypercarbia => vasodilation
- Hypocarbia => vasoconstriction
What complications can accompany an aneurysm repair procedure?
- Rupture, dissection
- contrast sensitivity, anaphylaxis
- groin hematoma
What anesthetic choice would be appropriate for abdominal aneurysm repair?
GETA, a-line, large bore IV
- heparin, ACTs, protamine
- foley
- controlled mild hypotension
What anesthetic would be appropriate for a Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure?
- GETA, RSI
- Large bore IV
- A-line
- albumin, PRBCs
What anesthetic considerations should be made with EP ablation?
- sedation vs general
- must have external defibrillation pads
- hold anti-arrhythmic
- xray protection (shield, lead, distance)
Electrophysiology Ablation pros and cons?
Pros:
-minimally invasive
-60-85% curative on first attempt
Cons:
-Lengthy (2-6 hrs)
-uncomfortable
-may induce V tach/V fib (defib pads on @ all times)
What is most important in prevention of radiation damage, shielding or distance?
Distance
Describe the intrinsic pathway of the clotting cascade:
damaged endothelium or exposure to collagen ⇒ 12a ⇒ 11a ⇒ 9a + 8a ⇒ 10a + 5a ⇒ turns prothrombin (2) into thrombin (2a) ⇒ thrombin turns fibrinogen (1) into fibrin (1a) ⇒ fibrin + 13a needed for plt aggregation and clot formation
Describe the extrinsic pathway of the clotting cascade
tissue trauma releases tissue factor ⇒ TF + 7a ⇒ 10a + 5a ⇒ turns prothrombin (2) into thrombin (2a) ⇒ thrombin turns fibrinogen (1) into fibrin (1a) ⇒ fibrin + 13a needed for plt aggregation and clot formation
What drug(s) is/are direct thrombin inhibitors?
Dabigatran (Pradaxa)
How do direct thrombin inhibitors work?
Antagonizes thrombin to prevent fibrinogen → fibrin
What laboratory test will measure Pradaxa’s (Dabigatran) effects?
dTT
What drug(s) is/are Factor Xa inhibitors?
- Rivaroxaban (Xarelto)
- Apixaban (Eliquis)
- Edoxaban (Savaysa)
What is the MOA of Factor Xa inhibitors?
Prevents cleavage of prothrombin → thrombin
What drugs can reverse the effects of coumadin?
Vitamin K
FFP
What drugs reverse the effects of direct thrombin inhibitors and factor Xa inhibitors?
- Factor concentrates
- Prothromin Complex (PCC)
What is the effect of CO₂ levels on cerebral blood flow?
Hypercapnia = cerebral vasodilation = Increased CBF/ICP
Which aortic stenosis patients are considered for transcatheter Aortic Valve replacement?
Symptomatic pts with:
-high surgical risk (any age)
-predicted post-TAVR survival of >12 months
- >80 years old
Younger patients with life expectancy <10 years
What are the anesthesia considerations for TAVR?
GA vs conscious sedation: discuss with surgeon
-GA ideal if needing ventilation control, muscle relaxation or if TEE used
Conscious sedation: improved hemodynamic stability
What are the two approaches for TAVR and which is most commonly used?
Transfemoral (most common)
Transapical
What are some anesthesia considerations for EGD/Colonscopy?
- Lateral position
- Biflow nasal cannula usually sufficient
- Typically conscious sedation utilized-exceptions: esophageal obstruction/foreign object
- active bleeding/vomiting = automatic GETA
What are ERCPs used to diagnose and treat?
ERCP used to diagnose and treat biliary and pancreatic disorders
Commonly done for:
biliary stenosis
jaundice
common duct stones
MRCPs are only diagnostic
Anesthesia considerations for patient undergoing ERCP?
- Extreme comorbidites with this patient population
- Prone with head turned to side
- GETA
What are the medication consideration for ERCP?
- antispasmodic: Glucagon helps identify and enter spinchter of Oddi w/o causing spasm
- Avoid opioids: causes Spinchter of Oddi spasm
- Anti-emetics:
rationale: Glucagon will trigger CTZ. GI surgery may stimulate GI tract (emesis)
Indications for electroconvulsive therapy?
- Bipolar/schizophrenia
- Extreme depression
- SI
What is the mechanism behind use of electroconvulsive therapy?
Induces tonic/clonic seizure
-this causes release of neurotransmitters
What is the treatment regime for electroconvulsive therapy?
Treatment is 3x/week for 12 treatments then therapy is weaned.
What are the physiologic responses to electroconvulsive therapy?
- Initial parasympathetic activity (incontinence/decreased HR)
- Followed by 10-20 min sympathetic stimulation
- Myalgias (may last 2-7 days)
- Headache
- Emergence agitation/confusion
Anesthesia for Electroconvulsive therapy?
General anesthesia
-Ambu bag with bite block
-atropine/glycopyrrolate (to reduce parasympathetic outflow)
-Propofol/succinylcholine
What are some additional anesthetic considerations for electroconvulsive therapy?
- Hyperventilation
- Protection of extremities
- Ativan/Haldol on standby (may have manic episode after ECT)
- Treat HTN with short-acting beta blocker (Esmolol)
- IV d/c in PACU (even if inpatient d/t return to psychiatric unit)
