NORA Flashcards
NORA unique challenges
- working with non-anesthesia personnel
- scheduling priorities = rushed prep
- equipment problems
- unfamiliar environment
- inadequate supplies, equipment, etc
- lax “check-in” policies
- stressful distance from the patien
- isolated from other anesthesia providers
ASA statement on NORA locations about what is needed
- O2 source and back up
- suction meeting OR standards
- scavenging for volatiles and N2O
- self-inflating ambu bag with greater than 90% O2 ability, monitoring that meets “basics”, anesthesia machine at OR standards if volatiles and/or N2O being used
- adequate electrical outlets + emergency back-up
- adequate lighting + battery back-up
- adequate space for equipment and patient access
- crash cart with defibrillator, drugs, and CPR supplies
- adequately trained staff for anesthesia support
- dependable communication devices
- all building and safety codes must be followed
- trained staff for post-procedure care including transport personnel
BIG deal communication requirement
dependable communication devices
what are we doing in these places?
EVERYTHING
- bronchoscopy
- GI endoscopy
- cardiac (cath lab)
- diagnostic radiology
- interventional radiology
- ICU (pts too unstable to move)
- dental
- plastics
- ophthalmology
higher frequency of _____ _____ and ______
severe injury and death
> 50% NORA-related claims involving deaths: patients received sub-standard anesthesia care _________ by improved _______ techniques
preventable
monitoring
sub-optimal ____ and failure to provide _____ _____ were the leading causes of poor outcomes
care
safe practice
most claims were related to:
inadequate oxygenation and/or ventilation (loss of airway)
______ most common cause - (___% of claims)
MAC (50% of claims)
1/3 are due to _____-_____ leading to respiratory depression
over-sedation
most claims are d/t over-sedation: limited _______ monitoring or no _______ monitoring at all
EtCO2
respiratory
Mean age of NORA patients is ____ ____ _____ than OR patients
3.5 years greater
this means more medically ______/more _______/less stable ______ ____
complex
comorbidities
surgical risk
NORA has higher percent of ASA
ASA III-V patients (37.6% compared to 33%)
because many NORA procedures are minimally invasive, patients are more likely to be _______ _____/____ _____
discharged early/same day
general considerations, patient factors:
- ASA
- comorbidities
- airway
- level of sedation
- analgesia needed
- basic vs. advanced monitoring
general considerations, environment:
- equipment (basic and ER), personnel, radiation/magnetic fields, temperature, portable monitoring, and O2
- more non-anesthesia trained personnel being licensed to administer sedation in NORA areas
general considerations, procedure:
- diagnostic v. therapeutic
- expected duration
- positioning
- surgical back-up
endoscopy
- airway compression/obstruction
- prone/semi prone positioning
- limited access to patient airway
- aspiration
pulmonary
- neck positioning
- pre-procedure ABG
- shared airway
- apneic oxygenation
- local anesthesia/blunted airway reflexes
cardiology
- high risk of dysrhythmias
- invasive monitoring (art line, CVP, PA)
- TTE/TEE
pediatrics
- general vs. deep sedation with local/regional
- neuroapoptosis - “feed and wrap”
- airway obstruction, hypoxia, bradycardia
fertility
- neuraxial
- regional
- sedation
- GA
- anesthetic agent accumulation in the follicular fluid
magnets force ______ to align with magnetic field
protons
radiofrequency current stimulates protons causing them to:
spin against the pull of the magnetic field
when this current is turned off, MRI sensors detect the ______ ______ as the ______ ______
energy released
protons realign
the time and amount of energy released varies with the _________ and ________ chemistry
environment and tissue chemistry
radiofrequency radiation emitted by MRI scanners is absorbed by the patient as ____ _____
heat energy
magnet strength is measured in _____
teslas (T)
most common magnet strength
1.5 T and 3T (the higher the number, the stronger the scale)
now approved in the US is ____ T
7 T
in the works:
10.5 T (weighs 3x more than a Boeing 737)
MRI has ____ zones
4
the zones are _____-_____ T
0.5-4 T
anesthesia machine, monitors, stretchers, IV poles must be ____ compatible, and all staff must be _________
MRI
de-magnetized
NORA has _____ mortality rate than the OR
lower (0.02% compared to 0.04%)
most common minor NORA adverse outcomes:
- PONV
- inadequate pain control
- hemodynamic instability
most major complications:
- serious hemodynamic instability
- upgrade of care
highest NORA mortality categories:
cardiology and radiology (0.05%)
significant NORA risk:
- over-sedation
- inadequate ventilation and oxygenation
all typically during MAC cases
when providing NORA, the same ASA safety requirements must be _____ as those in the _____
met
OR
NORA includes specific challenges related to _____, ______, ______, and ______
environment, equipment, personnel, and isolation
Many NORA adverse outcomes can be prevented with:
vigilant
