Remote locations 2 Flashcards
What is the trend in office based procedures?
- 17% of procedures occur in offices now- becoming more popular
- Standards and QI are not as well defined as they are in hospitals
- credentially procedures vary
- no prospective randomized studies exist
- some evidence suggests morbidity and mortality higher in office based procedures compared to ambulatory care
What was the difference between ambulatory and office based insurance claims?
- Office based claims were more severe (leading to death) and more were avoidable
What are major causes of morbidity and mortality in offices?
- overdose of LA
- overdose of sedatives
- use reversals with short half-lives
- “occult” blood loss
- PE
- standards of prophylaxis met?
- MH- no dantrolene or not enough in the office
- hypovolemia
- hypoxemia
- airway obstruction, bronchospasm
- inadequate monitoring, unrecognized esophageal intubation
What are 3 major causes of mortality in the office?
- Over-sedation
- inadequate monitoring
- thromboembolic events
How do you determine if pt is appropriate for an office case?
- ASA I and II
- ASA III anesthesia pre-procedure consult and only for local and NO sedation
- +/- OSA in office
- avoid GA and opioids
What are other important considerations with office based care?
- surgeon has ownership of practice
- who makes decision and provides the supplies, equipment, and medications?
- Surgeon- must have license, DEA #, insurance, and privileges at local hospital or comparable proof of adequate training
- QI program- should include surgeon, anesthesia, nurses, support staff
- medical records- 5-7 years of secure storage for pre op assessment, anesthetic record, consent, post-op
More considerations for office based care
- controlled substances in double locked storage cabinet
- must meet DEA, local, and state regulations
- ACLS/PALS certified professional must be available until pt discharge
- 1 hour firewall
- need emergency generator battery back up for all electronic equipment
- 1.5 hours back up minimum
What kinds of situations do you need an emergency plan for?
If you provide anesthesia in an office based setting, make sure you have medications and equipment for:
- MH
- LA toxicity
- difficult airway
- fire
- ACLS/PALS
- regular schedule to replace expired agents and service equipment
What is the deal with Tumescent lidocaine?
- Much larger volume of LA is injected into the cutaneous tissue where there is less vasculature
- 1-4 cc per 1 cc fat
- LA is much more diluted (0.025%-0.1% with NS/LR and 1:1,000,000 epi
- peak serum LA is 12-14 hours later
- max Lidocaine dose with this technique is 35-55 mg/kg
- EBL is 1% of total volume of fat suctioned
- limit liposuction to 5000 ml apirate of fat/fluid
What kinds of procedures are done in interventional cardiology?
- Coronary angiography
- cardiac catheterization
- PCTA/Stenting
- closure of cardiac defects (pediatrics)
- percutaneous valve replacements
- electrophysiologic studies
- ablations
- cardioversions
What is coronary angiography?
How is it done?
- Performed by passing a catheter retrograde through the aortic root and injection of contrast media into the ostia of the coronary arteries
- Catheter is inserted via the femoral, brachial, or radial artery
- Used to detect CAD, measure stenosis, and coronary spasm
What are the risks of interventional cardiology?
- Hemorrhage
- infection
- ischemia
- cardiac ischemia
- coronary dissection
- thrombembolic events
- contrast related reactions
- Anesthesia must be ready for an emergency!
How is the anesthesia managed for IR cardiology?
- GA or sedation/analgesia
- supplemental O2
- ASA monitors
- arterial BP vs non invasive
- IVs with extensions
- foley
- monitor temp
What are common meds used in IR cardiology?
- For anesthesia:
- midaz
- fentanyl
- propofol
- sublingual or IV nitroglycerin- for ischemic changes
- heparin/protamine
- provocative agents- to promote spasm
- Ergonovine maleate or methylergonovine maleate
- Diltiazem
- Emergency resuscitation drugs and equipment
