NORA

Question 1

What are the first two AANA Standards of Care?

Answer 1

I. Patient rights: autonomy, privacy, safety
II. Pre-anesthesia assessment/evaluation
-Cardiopulmonary function test: METs

Question 2

Functional capacity is measured in METs (metabolic equivalent of task). What is 1 MET equivalent to?

Answer 2

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

Question 3

What are the MET scores and their equivalent level of exercise?

Answer 3

Question 4

What are the AANA Standards of care III, IV, and V

Answer 4

III. Patient specific plan
IV. Informed Consent
-must be before case started
V. Documentation: accurate, timely, legible

Question 5

What are the AANA Standards of care VI, VII, VIII?

Answer 5

VI. Equipment; verify functioning
VII. Plan/modification of plan
-CRNA provides anesthesia care until responsiblilty passed to another anesthesia provider
VIII. Patient positioning

Question 6

Which aortic stenosis patients are considered for transcatheter Aortic Valve replacement?

Answer 6

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

Question 7

What are the AANA Standards of care IX?

Answer 7

IX: Monitoring/Alarms
Oxygenation, ventilation, cardiovascular status, thermoregulation, neuromuscular response
Patient’s physiologic condition
Audible alarms (can mute but can’t turn off)
Variable pitch
Threshold alarms
Max is 2 minutes
Malignant Hyperthermia (if giving agents that cause MH, need alarms to ID MH early)

Question 8

What are the AANA Standards of care X

Answer 8

X: Infection control policies
One syringe, one needle, one patient, one time.

Question 9

What are the AANA Standards of care XI?

Answer 9

XI: Transfer of care
GA needs appropriate recovery

Question 10

What are the post anesthesia recovery scoring systems used to assess patient readiness for discharge?

Answer 10

Modified Aldrete Scoring System and Postanesthesia Discharge Scoring System

Question 11

Describe the Standard Aldrete Score.

Answer 11

Question 12

Describe the Modified Aldrete Score.

Answer 12

Modified Aldrete Score

Question 13

Describe the Postanesthesia Discharge Score.

Answer 13

Question 14

What are the ASA Standards for NORA?

Answer 14

Question 15

Describe the differences between Conscious Sedation and General Anesthesia.

Answer 15

Question 16

Describe the various levels of sedation to include minimal, moderate and deep sedation.

Answer 16

Minimal
Responds to verbal commands
Anxiolysis
Moderate
Responds to verbal/tactile stimulation
Depressed LOC
Deep
Responds to painful stimulation
Independent ventilation may be impaired

Question 17

If a patient loses consciousness and ability to respond purposefully, while breathing spontaneously without airway in place the anesthesia is considered to be ____________ anesthesia?

Answer 17

General anesthesia
LOC w/o ability to purposefully respond is always GA.

Question 18

What are some patient factors that require anesthesia in NORA setting

Answer 18

Anxiety/panic disorders
Cerebral palsy
Seizure disorders
Pain
Acute trauma
Increased intracranial pressure
Significant comorbidities
Extreme ages
Drug/alcohol additions
Emergent or Routine procedures outside the OR

Question 19

What NORA procedure is performed for cerebral aneurysms?

Answer 19

Cerebral coiling: a minimally invasive procedure where catheter passed through vessel and platinum coil is detached to fill the aneurysm.

Provides: clotting/scarring/occlusion of vessel

Question 20

What type of anesthetic is recommended for cerebral coiling?

Answer 20

GETA (to prevent movement/accidental rupture)
CO2 levels can be manipulated via respiratory rate, hence ETT often required
large bore IV
VAA/propofol drip/precedex
arterial line; may need to manipulate BP

Question 21

Why might ETCO2 be manipulated in a cerebral aneurysm coiling procedure?

Answer 21

Elevated CO2 can lead to:
-cerebral vasodilation
-can increase ICP
-Respiratory acidosis
-disruption of enzyme and neurotransmitter activity (causing cognitive dysfunction)

Question 22

What is the minimally invasive procedure for abdominal aneurysm?

Answer 22

Catheter placed through vessel to insert synthetic graft.
Graft provides non-aneurysmal lumen to prevent aneurysm rupture

Question 23

What is the recommended anesthesia for abdominal aneurysm graft placement?

Answer 23

GETA usually recommended:
-large bore IV/A-line
-Heparin, frequent ACTs, protamine
-Foley catheter
-controlled, mild HoTN

Question 24

What is a Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure? Is this procedure curative?

Answer 24

*Decompression of portal circulation in patients with portal hypertension and recurrent GI bleeds who have failed medical therapy.
*Catheter and stent through internal Jugular Vein
*Cannot correct existing liver damage

Question 25

What are the anesthesia implications for TIPS procedure?

Answer 25

GETA recommended RSI Large bore IV/Arterial line Volume replacement??? Albumin, PRBC’s (type and cross) Preop/Intraop meds: consider drug metabolism (liver vs renal)

Question 26

Describe the interventional cardiology procedures EPS/EPA

Answer 26

EPS: electrophysiology study -identify aberrant conduction pathway location EPA: electrophysiology ablation -ablation to correct conduction

Question 27

Electrophysiology Ablation is often done if patient is unresponsive to _____________?

Answer 27

Cardioversion

Question 28

Electrophysiology Ablation pros and cons?

Answer 28

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)

Question 29

What are the current guidelines for TEE/cardioversion?

Answer 29

Most successful with A fib <7 days duration TEE to r/o mural thrombus or atrial vegetation Cardioversion: NO LOCAL ANESTHETIC/Na Ch blockade (will l/t systole)

Question 30

What drug(s) is/are direct thrombin inhibitors?

Answer 30

Dabigatran (Pradaxa)

Question 31

How do direct thrombin inhibitors work?

Answer 31

Antagonizes thrombin to prevent fibrinogen → fibrin

Question 32

What drug(s) is/are Factor Xa inhibitors?

Answer 32

- Rivaroxaban (Xarelto) - Apixaban (Eliquis) - Edoxaban (Savaysa)

Question 33

What laboratory test will measure Pradaxa's (Dabigatran) effects?

Answer 33

dTT (direct thrombin time) Prolonged time is sign that Pradaxa is working

Question 34

What drugs can reverse the effects of coumadin?

Answer 34

Vitamin K FFP

Question 35

What drugs reverse the effects of direct thrombin inhibitors and factor Xa inhibitors?

Answer 35

- Factor concentrates - PCC (prothrombin complex concentrates)

Question 36

What is the MOA of Factor Xa inhibitors?

Answer 36

Factor Xa converts factor II (prothrombin) to factor IIa (thrombin) Xa inhibitors block this conversion Prevents cleavage of prothrombin → thrombin **thrombin activates fibrinogen → to fibrin. Fibrin stabilizes clot**

Question 37

What is most important in prevention of radiation damage, shielding or distance?

Answer 37

Distance

Question 38

What are the anesthesia considerations for TAVR?

Answer 38

GA vs conscious sedation: discuss with surgeon -GA ideal if needing ventilation control, muscle relaxation or if TEE used Conscious sedation: improved hemodynamic stability

Question 39

What are the two approaches for TAVR and which is most commonly used?

Answer 39

Transfemoral (most common) Transapical

Question 40

What are some anesthesia considerations for EGD/Colonscopy?

Answer 40

Lateral position Biflow nasal cannula usually sufficient Typically conscious sedation utilized -exceptions: esophageal obstruction/foreign object, active bleed/vomiting

Question 41

What are ERCPs used to diagnose and treat?

Answer 41

ERCP used to diagnose and treat biliary and pancreatic disorders Commonly done for: biliary stenosis jaundice common duct stones

Question 42

Anesthesia considerations for patient undergoing ERCP?

Answer 42

Extreme comorbidites with this patient population Prone with head turned to side GETA recommended; patient moves a lot with sedation

Question 43

What are the medication consideration for ERCP?

Answer 43

antispasmodic: Glucagon helps identify and enter spinchter of Oddi w/o causing spasm -limit opioids: prevent Spinchter of Oddi spasm -Anti-emetics: rationale: Glucagon will trigger CTZ. GI surgery may stimulate GI tract (emesis)

Question 44

Indications for electroconvulsive therapy?

Answer 44

Bipolar/schizophrenia Extreme depression SI

Question 45

What is the mechanism behind use of electroconvulsive therapy?

Answer 45

Induces tonic/clonic seizure -this causes release of neurotransmitters

Question 46

What is the treatment regime for electroconvulsive therapy?

Answer 46

Treatment is 3x/week for 12 treatments then therapy is weaned.

Question 47

What are the physiologic responses to electroconvulsive therapy?

Answer 47

Initial parasympathetic activity (incontinence/decreased HR) Followed by 10-20 min sympathetic stimulation Myalgias (may last 2-7 days) Headache Emergence agitation/confusion

Question 48

Anesthesia for Electroconvulsive therapy?

Answer 48

General anesthesia -Ambu bag with bite block -atropine/glycopyrrolate (to reduce parasympathetic outflow) -Propofol/succinylcholine

Question 49

What are some additional interventions for electroconvulsive therapy?

Answer 49

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 in patient d/t return to psychiatric unit)