NonOR Anesthesia Flashcards
Which nonOR procedural area has more malpractice claims for death compared with OR settings?
GI Suite
Approximately what % of all anesthetics occur outside the OR?
~55%
NonOR anesthesia offers what kind of services?
Full range of anesthesia to all age groups
What NonOR adverse event had more closed claims than OR?
Death lol
How do standards of care in NonOR anesthesia compare to OR?
They don’t! They have the exact same standards.
What are the A-J (or 10) standards of NonOR anesthesia care
A. Preanesthesia Assessment
B. Obtain Informed Consent
C. Form a Patient-Specific Anesthesia Plan
D. Implement/Adjust the Plan based on pt response
E. Prepare, Dispense, and Label all Medications to be used
F. Adhere to safety precautions
G. Monitor and Document pt condition
H. Infection Control
I. Complete, Accurate, Timely Documentation
J. Transfer, continuity of care
Only what kind of anesthesia ensures amnesia?
General Anesthesia. So, discuss expectations with the patient.
When is temperature monitoring required vs optional in NonOR?
Required with general anesthesia. Optional during mild, moderate, or deep.
In cases of moderate or deep sedation, AANA and ASA mandate the measurement of?
etCO2
What must the anesthesia provider do before leaving the patient in the recovery area?
Thoroughly assess the stability of the patient and airway maintenance
Minimal Sedation was formerly known as?
Anxiolysis
During minimal sedation, what are the effects on:
Responsiveness,
Airway,
Spontaneous Ventilation, and
Cardiovascular Function
Responsiveness: Normal response to verbal stimuli. Some cognitive function and coordination may be impaired.
Airway: Unaffected
Spontaneous Ventilation: Unaffected
Cardiovascular Function: Unaffected
Moderate Sedation/Analgesia was formerly known as?
Conscious sedation
During moderate sedation, what are the effects on:
Responsiveness,
Airway,
Spontaneous Ventilation, and
Cardiovascular Function
Responsiveness: Purposeful response to verbile OR tactile stimulation.
Airway: No intervention required
Spontaneous Ventilation: Adequate
Cardiovascular Function: Usually maintained
Is reflexive withdrawal from a painful stimulus considered a purposeful response?
No, not considered purposeful
During Deep Sedation/Analgesia, what are the effects on:
Responsiveness,
Airway,
Spontaneous Ventilation, and
Cardiovascular Function
Responsiveness: Purposeful response following repeated or painful stimulation
Airway: Intervention may be required
Spontaneous Ventilation: May be inadequate
Cardiovascular: Usually maintained
What is deep sedation/analgesia?
Drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully after repeated or painful stimulation.
During General Anesthesia, what are the effects on:
Responsiveness,
Airway,
Spontaneous Ventilation, and
Cardiovascular Function
Responsiveness: Unarousable even with painful stimulation
Airway: Intervention often required
Spontaneous Ventilation: Frequently Inadequate
Cardiovascular: May be impaired
During anesthesia, what causes patients to need airway or ventilatory support?
Assistance maintaining a patent airway and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function.
In NonOR anesthesia cases, what is one of the most common minor adverse events?
Inadequate pain control
Children under ____ years old seem to be at the greatest risk for adverse events even with no underlying disease
Under the age of 5!
The goals of nonoperating room anesthesia, no matter the environment, are:
- Get familiar with the environment
- As safe as the operating room
What is one of the most common reasons for adverse events in pediatrics?
use of multiple drugs, especially sedative medication
What problems are most often encountered with adverse events in pediatrics?
Respiratory events: depression, obstruction, apnea
Pediatric adverse reactions are reduced with procedures that last?
Less than 1 hour
It is essential to preoperatively assess for ____ in pediatric patients to reduce the risk of airway compromise
Respiratory Infection
-fever, snoring, sputum production, cough
Initial cardioversion shock dose?
Start 50-100J, can go all the way to 360 J
What is the initial bolus dose of propofol?
0.5-1 mg/kg
What age group is at the highest risk of pediatric adverse events?
Less than 5 years old
Do geriatrics have an increased or decreased affinity for lipid soluble agents?
Increased and have a decreased metabolic rate
Geriatrics are more or less likely to experience delirium and post-operative cognitive deficits.
More!
How does thermoregulation change in geriatrics?
decreased thermoregulation
What two medications are preferred for cardioversion
propofol or etomidate for low EF
What are some anesthetic requirements for cardioversion?
NPO
Oxygen, Monitors, Resuscitation equipment
What kind of sedation is preferred for cardioversion?
Moderate to Deep Sedation or a Room Air General
Muscle Relaxant NOT needed.
What medications need to be avoided during RadioFrequency (RFA) Cryoablation
Avoid Lidocaine (can mask arrhythmias)
Inhaled Volatile Gases (PA occluded during ablation)
What anesthetic considerations are needed for RadioFrequency (RFA) Cryoablation
-Esophageal temp probe: risk for thermal injury with LA ablation
-Artline, vasoconstrictor, Inotropes
-Need patient to remain very still
What can go wrong with a transeptal ablation technique?
Puncture LV and cause tamponade
In the geriatric population, a MET score greater than ____ is a good predictor they will be able to handle anesthetic from a cardiac standpoint
METs of 4 or more
RadioFrequency (RFA) or Cryoablation is usually accessed through?
the groin
What sort of anesthesia is usually performed for RadioFrequency (RFA) or Cryoablation
Local/MAC
you could do TIVA or General
During RadioFrequency (RFA) or Cryoablations, should the patient be anticoagulated?
Yes, often with heparin. Check frequent ACTs and then reverse with protamine (usually 10mg)
What can happen if you give protamine too quickly?
Can tank blood pressure
What must be covered for radiation safety during RadioFrequency (RFA) Cryoablation?
Thyroid, long bones, reproductive organs, and EYES if you are in frequently
Complications of PCI
arrhythmogenesis
hemorrhage, embolism
Contrast: anaphylaxis, nephropathy
Vasovagal response
Htn/HoTn
Respiratory collapse
Cardiac arrest
ALARA stands for?
As Low As Reasonably Possible
EGD evaluates what structures?
Mucosa of esophagus, stomach, or duodenum
Colonoscopy evaluates?
Cecum to anus
Why do we do ERCPs?
Biliary/Pancreatic Duct obstruction or drainage
Unexplained jaundice, abnormal CT
Biopsy
Mapping pancreatic duct
Sphincter of Oddi
What position are patients in for ERCPs
Endoscopically and in the prone position
Anesthetic considerations for GI procedures
Strict NPO guidelines: greater risk for aspiration
Moderate sedation: prop, midaz, fentanyl
Deep Sedation or GA for ERCPs
Bowel Prepped? consider volume
Prepare for vagal stimulation
Is a foreign body considered a full stomach?
Yes. Intubate and remove.
What is the primary concern for Post Op ERCP patients
contrast dye reaction
Mild: N/V, pruritus, sweating, flushing hives
Moderate: Syncope, hyperemesis, severe hives, hypotension, Tachy/brady, “mild” bronchospasm
Severe: shock, angioedema, seizures
Colonoscopy PACU considerations
N/V
cramping
dehydration
must pass fart check
Anesthetic Considerations for IVF
Moderate Sedation is usually sufficient.
Avoid Morphine, NSAIDS, and Reglan
Avoid Sevo and Des
ISO is A-OKAY
Anesthetic Considerations for Hysteroscopic Sterilization
Contraindications: <6 wks PP, PID, contrast allergy, immunocompromised, positive HCG
Pretreat with NSAIDS
Pediatric Dental Anesthesia Considerations
- Anxiolytics
-ketamine, precedex, and midaz
Nasal Intubation, if possible for more visualization
ECT procedure goal is to? What will you need?
Intentionally induced generalized seizure. Anticonvulsant Effects: Raises Threshold, Decreases duration
Meed conducting gel, electrodes, tourniquet (isolate one foot) , bite block, alternating electrical currents
Do we usually intubate patients under ECT?
No. Ultra-quick general anesthesia. Bite Block, Mask Ventilate. Low-dose paralytics.
Physiologic Effects of ECT
Massive Parasympathetic Outflow (tonic phase)
SLUDGE
S: Salivation
L: Lacrimation (excessive tearing)
U: Urination or urinary incontinence
D: Defecation or diarrhea
G: Gastrointestinal distress
E: Emesis
Bradycardia, Hypotension, Heart Blocks, Asystole
Massive Sympathetic Putflow (Clonic Phase)
Flushing, Tachycardia, HTN, Tachyarrythmias
Increased CBF
Increased ICP
Increased IOP
Increased IGP
Hypoventilation
HA, mixed amnesia
transiest but exaggerated
What pharmacologic agents prolong seizure
alfentanil + propofol
Aminophylline
Caffeine 500mg
Clozapine
Etomidate
Ketamine
Hyperventilation
What pharmacologic agents shorten seizure
dilitiazem
fentanyl
lidocaine
BZDs
propofol
sevo
IV Contrast Media: HOCM vs LOCM
HOCM: High Osmolar Contrast Media - few dissolved particles and iodine atoms. Higher reaction solution. Draws fluid out of cells into vessels.
LOCM: Low Osmolar Contract Media - greater number of dissolved particles with iodine. More isotonic. Most costly.
MRI ZONES
Zone I: Free Access to General Public
Zone II: Supervised, like a waiting room
Zone III: Restricted Ferromagnetic-Free Zone - where I bring the patient as an ICU nurse
Zone IV: Within zone 3, scanner room
Prohibited Items in MRI
AICD, PPM, Wires, LEads
Mechanical Valves, Cochlear Implants
Surgical Clips, Coils
MRI anesthesia considerations
MRI compatabile equipement
The table is hard; pad the pt
Blood flow decreases in strong magnetic fields: GA
Ear plugs
consider hands-off anesthesia
How does electromagnetic fields influence pacemakers
Can cause inhibition, asynchrony, heating of battery or leads, dislodgement
IR Anesthetic Considerations
Absolutely Immobile, controlled periods of apnea
Can be very painful
Full range of anesthesia
May need to do a wake-up neuro check
LEAVE THE ROOM
closed circuit monitoring - hands off anesthesia
Delayed Entry 30-60s heavy door
