NORA Flashcards
ASA NORA guidelines
- Oxygen and backup
- Suction
- Scavenging System
- Resus Bag (90% fio2)
- Drugs, Supplies for Proc
- Monitoring
- Electrical Outlets
- Space
- Crash Cart
- Communication, 2 way
- Observation of Codes
- PACU
When to consider GA…
longer procedures
JCAHO anesthesia definition
admin of IV, IM or inhalation agents that may result in loss of protective reflexes
Should pts expect same standard of care outside of OR when receiving sedation/anesthesia?
yea, duh
Needed for transport to recovery area…
oxygen and monitoring
emergency meds
Office based anesthesia: general
- pt needs full preop workup
- difficult airway not ideal
- prop, des, nitrous, sevo
Office based anesthesia: JCAHO and ASA guidelines
- trained, credentialed personnel
- maintained anes equip
- documentation tool
- monitors and emerg equip
- PACU and trained nursing
- protocols
Radiation exposure can cause
- leukemia & fetal abnormalities
- dosimeters required (max 50 mSv annually
- lead
Iodinated contrast media
old= hyperosmolar and toxic new = lower osmolality & improved s/e
Predisposing factors for rxn to contrast media…
hx of bronschospasm, allergy, cardiac disease, hypovolemia, hematologic disease, renal dysfunction, extremes of age, enxiety, meds (betablockers, aspirin, NSAIDs)
Pre-treatment for contrast media…
- prednisone 50 mg, 12 hrs before
- benedryl 50 mg immediately before
Mild rxn to contrast media
nausea, perception of warmth, headache, itchy, rash, hives
severe rxn to contrast media
vomiting, rigors, feel faint, chest pain, severe hives, bronchospasm, dyspnea, arrythmias, renal failure
life-threatening rxn to contrast media
glottic edema/bronchospasm, pulmonary edema, arrythmias, cardiac arrest, seizures
Treatment of contrast reaction
oxygen bronchodilators epi corticosteroids antihistamines
Metformin & contrast media
-pts can develop life-threatening lactic acidosis (NIDDM)
Which med has been shown to decrease nephrotoxicity with admin of contrast media?
acetylcysteine
CT
- need immobility
- inaccessibility to pt
MRI
- good soft tissue contrast
- no ionizing radiation
- movement = artifact
- thermal injury potential
- magnet is always on
Is hearing protection mandatory for MRI?
yes, > 90 dB
MRI contraindications
schrapnel, vascular clips, shunts, spiral ETT, pacemaker, some tattoo ink
Is deep sedation advisable for MRI?
No, you don’t have good access to the pt
Which procedures often require deliberate hypotension and deliberate hypocapnia?
cerebral and dural AVM’s, coiling, etv.
When may deliberate HTN be called for?
cerebral ischemia - want to maximize collateral blood flow
Cerebral coiling
- deep sedation –> GA spectrum
- always 2 IV, art-line
- fluid warmer, upper bair
- ACT’s - goal 2-2.5x normal
Why is smooth emergence so important in IR?
-prone to device migration or intracranial hemorrhage
Stenosis of coronary artery >50-70% the normal diameter indicates…
- pt considered hemodynamically significant
- after dilation of stenotic coronary artery, ventricular arrhythmias may develop
Glucagon
-decreases spasm at sphincter of oddi, but can cause sinus tachycardia
If sphincter of oddi manometry is being performed, which meds should be avoided?
glucagon, opioids, glycopyrrolate & atropine
TIPS procedure
- transjugular intrahepatic prtosystemic shunt
- decompresses portal circulation
- minimal stim, 2-3 hrs
TIPS considerations
- airway - aspiration
- decreased FRC d/t ascites
- esophageal varices
- coagulopathy
- hepatic encephalopathy
ECT therapy response
- grand mal (10-15 second tonic phase, 30-60 second clonic phase)
- increased CBF & ICP
- bradycardia –> HTN and tachy
- muscle aches, fractures
- sudden death
Contraindications to ECT
absolute: pheochromocytoma
relative: increased ICP
recent CVA, CV conduction defects, high risk pregnancy, aneurysms
ECT anesthesia considerations
-bite block
-maybe paralytic to prevent injury
-toradol 15-30 mg
-hyperventilate w/ 100%
goal = seizure lasting 30-60 seconds
Preferred NMB for ECT
anectine (0.75-1.5 mg/kg)
ECT: robinul & atropine
can prevent parasympathetic effects of ECT (salivation, bradycardia, asystole)
ECT: labetolol & esmolol
labetolol 0.3 mg/kg
esmolol 1 mg/kg
aid in hemodynamic response, esmolol has lesser effect on seizure duration
ECT: clonidine & precedex
control BP without effecting seizure duration
Seizure activity causes…
initial parasympathetic discharge –> bradycardia.
Are arrythmias a contraindication to ECT therapy?
not in themselves…need other reasons
Most common cause of death with ECT
MI & arrythmias
Dental surgery: ketamine
IV = 1-2 mg/kg IM= 2-4 mg/kg oral = 5-10 mg/kg
Minimal sedation (anxiolysis)
-respond normally, just chill
Moderate sedation/analgesia
“conscious sedation”
-still follow commands either alone or with light tactile stim
Deep sedation/analgesia
- not easily aroused, but respond to noxious stim
- may need some airway support
General anesthesia
- not arousable
- cannot protect airway
Ramsay scale
1-6
1- anxious
2- normal
6- no response
Modified Aldrete
adds up
used in PACU
need 9 or better to get out of pacu
NPO guidelines
meal - 8 hrs
clears 2-4 hrs
PACU guidelines
VS q10 mins x 3
then q1hr x2, or until fully recovered using aldrete score
if pt was resus, then need an hour
