NORA Flashcards
What are the first two AANA Standards of Care?
I. Patient rights: autonomy, privacy, safety
II. Pre-anesthesia assessment/evaluation
-Cardiopulmonary function test: METs
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 are the AANA Standards of care III, IV, and V
III. Patient specific plan
IV. Informed Consent
-must be before case started
V. Documentation: accurate, timely, legible
What are the AANA Standards of care VI, VII, VIII?
VI. Equipment; verify functioning
VII. Plan/modification of plan
-CRNA provides anesthesia care until responsiblilty passed to another anesthesia provider
VIII. Patient positioning
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 AANA Standards of care IX?
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)
What are the AANA Standards of care X
X: Infection control policies
One syringe, one needle, one patient, one time.
What are the AANA Standards of care XI?
XI: Transfer of care
GA needs appropriate recovery
What are the post anesthesia recovery scoring systems used to assess patient readiness for discharge?
Modified Aldrete Scoring System and Postanesthesia Discharge Scoring System
Describe the Standard Aldrete Score.
Describe the Modified Aldrete Score.
Modified Aldrete Score
Describe the Postanesthesia Discharge Score.
What are the ASA Standards for NORA?
Describe the differences between Conscious Sedation and General Anesthesia.
Describe the various levels of sedation to include minimal, moderate and deep sedation.
Minimal
Responds to verbal commands
Anxiolysis
Moderate
Responds to verbal/tactile stimulation
Depressed LOC
Deep
Responds to painful stimulation
Independent ventilation may be impaired
If a patient loses consciousness and ability to respond purposefully, while breathing spontaneously without airway in place the anesthesia is considered to be ____________ anesthesia?
General anesthesia
LOC w/o ability to purposefully respond is always GA.
What are some patient factors that require anesthesia in NORA setting
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
What NORA procedure is performed for cerebral aneurysms?
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
What type of anesthetic is recommended for cerebral coiling?
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
Why might ETCO2 be manipulated in a cerebral aneurysm coiling procedure?
Elevated CO2 can lead to:
-cerebral vasodilation
-can increase ICP
-Respiratory acidosis
-disruption of enzyme and neurotransmitter activity (causing cognitive dysfunction)
What is the minimally invasive procedure for abdominal aneurysm?
Catheter placed through vessel to insert synthetic graft.
Graft provides non-aneurysmal lumen to prevent aneurysm rupture
What is the recommended anesthesia for abdominal aneurysm graft placement?
GETA usually recommended:
-large bore IV/A-line
-Heparin, frequent ACTs, protamine
-Foley catheter
-controlled, mild HoTN
What is a Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure? Is this procedure curative?
*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
What are the anesthesia implications for TIPS procedure?
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)
Describe the interventional cardiology procedures EPS/EPA
EPS: electrophysiology study
-identify aberrant conduction pathway location
EPA: electrophysiology ablation
-ablation to correct conduction
Electrophysiology Ablation is often done if patient is unresponsive to _____________?
Cardioversion
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 are the current guidelines for TEE/cardioversion?
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)
What drug(s) is/are direct thrombin inhibitors?
Dabigatran (Pradaxa)
How do direct thrombin inhibitors work?
Antagonizes thrombin to prevent fibrinogen → fibrin
What drug(s) is/are Factor Xa inhibitors?
- Rivaroxaban (Xarelto)
- Apixaban (Eliquis)
- Edoxaban (Savaysa)
What laboratory test will measure Pradaxa’s (Dabigatran) effects?
dTT
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
- PCC
What is the MOA of Factor Xa inhibitors?
Prevents cleavage of prothrombin → thrombin
What is most important in prevention of radiation damage, shielding or distance?
Distance
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 bleed/vomiting
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
Anesthesia considerations for patient undergoing ERCP?
Extreme comorbidites with this patient population
Prone with head turned to side
GETA recommended; patient moves a lot with sedation
What are the medication consideration for ERCP?
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)
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 interventions 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 in patient d/t return to psychiatric unit)
