NORA - Exam 6 Flashcards
Which kind of anesthesia ensures amnesia?
general
How must your meds be labeled?
- Drug name
- Strength
- Amount (if you can’t tell from the container)
- expiration date (if not using within 24 hours)
- time
- initials
Does mild sedation need etCO2 per AANA?
no
When do you have to monitor temperature? When is it optional?
Standard: GA
Optional: mild, moderate, deep sedation
What age of child is at greatest risk for adverse events of sedation? What are these events?
Less than 5 years of age; respiratory depression, apnea etc
What is the relationship between length of surgery and adverse reactions?
Less than 1 hour, reduced amount of adverse reactions
What is the cause of most adverse anesthetic events?
Multiple anesthetic agents being used
NPO for food/non-clear liquids for:
<6 months
6-36 months
>36 months
< 6 months: 4-6 hours
6-36 months: 6 hours
36< months: 6-8 hours
What is cardioversion?
Synchronized countershock to the R wave of the QRS to convert unstable afib/flutter, stable VT
How does cardioversion work?
Closes an excitable gap in the myocardium, causing currents to re-enter and excite the electrical system of the heart
Do patients need to be NPO for cardioversion?
No if emergent
Yes if non-emergent
Optimal shock conversion for afib/flutter
50-100 J
up to 360 J
Paddle placement for cardioversion
- Parasternally over 2nd to 3rd intercostal space
- Other paddle over apex of the heart
Anesthetic technique for cardioversion
- TIVA
-Versed beforehand
-Propofol/etomidate as anesthetic (IV) - Muscle relaxant NOT necessary
- MUST intubate if patient has not fasted (anesthetic plan is changed to general ETT)
What is radiofrequency catheter ablation?
Catheter with an electrode on the tip guided on fluoroscopy to an area of the heart muscle that demonstrated accessory electrical conductivity
-Usually for SVT, but can treat other arrhythmias
-Catheter guided via femoral artery and vein to the area of accessory electrical pathway or internal jugular
What is cryoablation?
liquid nitrous oxide cause -22 to -75 C
-Safer in AV node region compared to RFCA
What is ice mapping?
Temporary freezing to see if it will fix the arrhythmia, if it does, cool further to permanently destroy tissue
Retrosternal angina pain of mild/moderate intensity for 1-2 minutes. Is this normal during RFCA?
yes
Anesthetic choice for RFCA
-Moderate sedation + local +analgesia
-Kids: use LMA/GETT
Why is TIVA ideal for RFCA?
Because the pulmonary artery is occluded, resulting in a loss of 25% of CO
-Interferes with inhalation of volatile anesthetics
What is important to monitor during RFCA?
ECG
-Patient stops taking all antiarrhythmics before this procedure
Possible injury as a result of RFCA?
1.Thermal injury to esophagus during RFCA of left atrium
-Arterioesophageal fistual can occur!
2. CVA
3. Cardiac tamponade
4. Aortic valve damage
Is it okay if there is space between the esophageal probe and the esophagus? What is the purpose of using an esophageal probe?
No; to monitor the temperature of the left atria – don’t want thermal injury
Most electrophysiology procedures require MAC. Which electrophysiology procedures require GETT
RFCA Atrial fibrillation
V-Tach/V-Fib RFCA WITH epicardial approach
Lead extraction
Is endoscopy okay for pregnant women?
Yes; but should be delayed until after delivery if possible
Which drugs are okay to give in pregnancy?
Most IV drugs, except versed
-Can give versed, but it crosses placental barrier and creates CNS depression
Volatile anesthetics (unsure)
No N2O
What does endoscopy do to aspiration risk?
increases
What is the position/anesthetic technique for endoscopy?
moderate/deep sedation MAC
supine or LLD
What additional medication should be considered with upper endoscopy?
antisialogogues
Colonoscopy position and anesthetic technique
Deep sedation, sometimes GA
Left lateral decubitus
Adverse event that can occur due to colonscopy procedure?
Vagal response
-Distention of the colon
ERCP preoperative assessment includes what labs?
CBC
liver chemistry
amylase/lipase levels
clotting function
ERCP preoperative assessment includes what particular patient issues?
-Use of anticoagulants
-Bleeding history
-Prothestic heart valves
Risk of bleeding in general
-Allergies to IV contrast
What is the position/technique for ERCP?
Deep sedation or general ETT
Prone, semi-prone or LLD
What are emergent concerns with endoscopy, colonoscopy and ERCP?
Vomiting, aspiration, laryngospasm, bleeding, severe bradycardia, hypotension, bowel rupture, or duct rupture
How does CT work?
Dense structures reduces energy of x-ray beam
How does MRI function?
Dipole movement of the hydrogen atom
What is the fringe field of the MRI?
Electromagnetic energy greatly drops off just outside the margins of the bore of the electromagnet
Zones of the MRI?
Zone 1: Freely accessible
Zone 2: MRI personnel determine who passes through here
Zone 3: Restricted area, can only enter after being screened for ferromagnetic material
Zone 4: MRI scanner room (is within zone 3)
Anesthesia considerations For CT?
-Patient must be supine
-Full spectrum of anesthesia may be delivered
-Anaphylaxis from ICM
-Diabetic patients cannot take metformin –> lactic acidosis
What increases risk for ICM anaphylaxis
- Asthma history**
- hx of allergy***
- multiple morbidities
- HOCM
How to treat anaphylactoid reaction of ICM?
-Corticosteroids (pretreatment)
-H1 and H2 blockers
Safe metals for MRI?
Stainless steel
nonferrous
nickel
titanium
What could happen to cardiac pacemakers in the MRI?
Literally anything
Potentially harmful items in MRI?
-Penile implants
-brain/dorsal column stimulators
-Heart valves
-AICD
-permanent eyeliners/tattoos
-prosthesis
-implanted pumps
-internal metal plates
-aneurysm clips
-metallic sutures
-shrapnel
-tissue expanders with metallic ports
How to prevent induced current and tissue loops?
Ensure leads and IV tubing are NOT touching the patient at all
Patient tissue should be touching itself
-e.g. hand cannot touch thigh, legs cannot touch each other
Does MRI affect pregnant women?
no
Technique of anesthetic for IR?
- Full spectrum, mostly GA
- Goal is to have rapid recovery so you can assess patient neuro status
What is the antidote to heparin?
Protamine 1 mg/100units of heparin
Why are pediatric patients (<5) at greatest risk for adverse effects?
Overmedication; apnea, respiratory depression, respiratory obstruction
AICD components
Pulse generator
Lead electrode
Cardiac pacemaker types
Unipolar - Generator is used at other pole
-More susceptible to interference
Bipolar
What is generally the underlying rhythm (2) in a patient with an AICD?
Pulseless Vtach or Vfib
After the leads are placed procedurally for AICD placement, is the next part of the procedure stimulating?
Yes; they may also induce vfib
AICD
-Vfib treatment
-V-tach treatment
Vfib - shock in 10-15 seconds
V-tach anti-tachycardic pacing
Which arrhythmia in pediatrics is most commonly treated with radiofrequency ablation?
SVT
Why is glycopyrrolate used during colonoscopy?
Bradycardia
Anti-peristalsis to pass into the cecum
At what point during an EGD/colonoscopy is the most stimulating part
Dilator insertion
-Give propofol before this portion
For NORA cardiac procedures, what should always be on the patient in case of emergency?
Transcutaneous pacing pads
Three rhythms requiring AICD placement; most common population characteristics?
SVT
-Young, healthy
-Symptomatic
Ventricular Dysrhythmias
-Elderly
-Low EF, CAD, CHF
-Low EF, BBB
-Paces both ventricles
Definition of contrast-induced renal impairment?
Cr increase by 0.5 mg/dL
When does contrast media renal impairment show up? For how long
24-48 hrs up to 5 days
How can you lessen contrast media renal impairment?
IV hydration (increase extracellular fluid)
Smaller doses of dye
DC nephrotoxic drugs
Acetylcesteine
What adverse system outcome can occur specifically because of the MRi procedure?
Nephrogenic systemic fibrosis
-Caused by gadolinium contrast agent
-Scleroderma internally and externally
-Occurs days/months after exposure
-Renal impairment puts you at risk
What kind of cylinder can enter the MRI?
Aluminium!
“Brushed metal”
Elective cardioversion
-indications
-Afib
-aflutter
-SVT
Elective cardioversion
-anesthesia mgmt
-equiptment
-review labs (cbc, coags, lytes), EKG, NPO status
-IV agents: benzos, thiopental, methohexital, etomidate (myoclonus may interfere with rhythm interpretation) propofol
-good depth of anesthesia, shock, monitor airway/recovery
-monitors, O2 source, NRB, suction, crash cart, airway equiptment
Cardioseal
-indications
-process
closure of septal defects (PDA, ASD) by deploying umbrella device
-fem access needed + use of contrast + introducer to place device (can have hoTN in this moment)
Cardioseal
-equipment
-anesthesia mgmt
-AGM, cart, monitor, airway equipment and drugs
-GA + ETT REQUIRED due to continuous TEE, possibly need pt immobile
-maybe art line, maybe fluoro
-1.5-2hr case
-pt monitored 24 hrpostop
