Remote Locations Flashcards
What must you make sure to turn off before leaving a room?
- The O2 source.
- No pipeline available, only large cylinders.
- Limited O2 supply.
Equipment needed for satellite
- O2 source with backup
- Suction
- Scavenging
- Monitoring equipment
- Ambu bag with PEEP
- Enough electrical outlets
- Adequate lighting, with battery power back-up - Emergency cart with defibrillator, drugs, and other emergency stuff - Reliable communication for help - Compliance with all safety and building codes
ASA requires monitoring of
- Oxygenation (O2 sat)
- Ventilation (EtCO2)
- Circulation (BP). EKG is NOT circulation
- Temperature
Considerations for radiology suites
- Patients often immobile for long periods of time
- Bulky equipment may get in the way of easily accessing the patient
- Lack of scavenging can limit GA options if you end up needing them
- You need lead aprons with thyroid shields
- Dosemeters should be worn
Adverse reactions to contrast media require these interventions
- O2
- Bronchodilators (B2 agonists)
- Antihistamines
- Corticosteroids (blocking the immune response, and supporting the SNS)
- If patient is at risk, you may want to consider giving prophylactic corticosteroids and H1 & H2 antagonists
Contrast reactions are more likely in patients with
- Bronchospasm history
- History of other allergies
- Renal or cardiac disease
- Extremes of age
What should you be aware of if your patient says they were itchy the last time they received contrast medium?
They may have a similar reaction, or it could be worse the next time they receive it
Why is contrast medium nephrotoxic?
- Free oxygen radicals are release that damage renal tubules and the microvascular circulation
- It can also cause microvascular obstruction.
- Contrast media is HYPERtonic, so if your patient is dehydrated, it could be extremely concentrated within the nephron and cause damage.
- NPO deficits should be replaced prior to receiving contrast.
- Hydration is also key to contrast clearance.
If a patient has a bad response to contrast media, azotemia starts at __ - __ hours, and peaks at ___ - ___ days. It’s important to avoid surgical procedures during this period.
24-48 hours
3-5 days
How can the effects of contrast be minimized?
- Hydration is the first line of protection
- Give 1 mL/kg/hr of NS 4 hours before the procedure, and continue for 12 hours after the procedure.
- Careful administration and limitation of total dose - Monitor serum Cr levels for 72 hours
- Give bicarb to promote renal excreation
N-acetylcysteine
PO drug that can be given to blunt the renal effects of contrast for the with CRI (name and dose)
N-Acetylcysteine
600 mg BID
Minimimal Sedation
Moderate Sedation/Analgesia
Deep Sedation/Analgesia
General Anesthesia
-
Minimal Sedation = Anxiolysis, Pt responds normally to verbal commands
- Normal cardiac and pulmonary function
-
Moderate Sedation = Responds to commands alone or with light tactile stimulation
- Normal cardiac and pulmonary function
-
Deep Sedation = Not easily aroused, but responds purposefully to repeated or painful stimuli
- Normal cardiac function
- ventilation may be impaired, and may need help maintaining an airway (oral/nasal airway)
-
General Anesthesia = Loss of consciousness
- Not aroused by painful stimuli
- Often needs help ventilating and maintaining an airway
- Cardiovascular function may be impaired
During MAC, is coughing good or bad?
- Good, because it means the patient is able to manage and protect their own airway.
- It’s only bad when they start having stridor.
In MRI, the strong magnetic field exerts a strength of ___ Tesla, or ___ Gauss
- 1.5 Tesla 15,000 Gauss
- (The earth’s magnetic field is only about 0.5 Gauss)
MRI and EKG leads
- Either use ones that are MRI compatible, or frequently switch the positions of normal ones during the scan. Failure to do so could cause burns.
Where does anesthesia induction occur when providing anesthesia for MRI
- In an adjacent area.
- Can’t be within the room, because airway equipment such as laryngoscopes can’t be used within the MRI’s magnetic field.
- Patient is then transported on MRI safe stretcher, and connected to the anesthesia machine.
- Patient is emerged in the same area where the induction took place (where emergency equipment is available)
Contraindications to MRI scans
- Pacemakers
- Aneurysm clips
- Intravascular wires
- First trimester of pregnancy (although little data exists to support this)
- Metal implants (need to be monitored for increase in temperature)
Procedures that occur in interventional neuro-radiology
- Endovascular approach to CNS lesions or related circulatory structures
- Embolization of AVMs
- Aneurysm coilings
- Angioplasty of atherosclerotic lesions
- Thrombolysis of acute embolic strokes
- Carotid stent placement
Anesthetic considerations for neuro-radiologiy
- May need deliberate hypotension or tight BP control
- (obtain an a-line)
- Also have all ASA monitors
- Foley catheter
- 2 IVs
Meds used for deliberate hypotension
- Esmolol
- labetolol
- SNP
Meds for deliberate HTN
Phenylephrine to increase BP by 30-40%
What is important for emergence in neuro-radiology?
Antiemetics***
- We don’t want coughing, bucking, or retching following the procedure that could lead to device migration or intracranial hemorrhage
Risks involved in interventional cardiology
- Hemorrhage of coronaries, infection, ischemia of coronaries or distal limb from access point, thromboembolic events, contrast reactions.
- Bottom line is, there area lot of risks, so make sure you are prepared to handle an emergency situation.
These are provocative agents used to induce coronary spasm
Ergonovine maleate or Methylergonovine maleate
Interventional cardiology for pediatrics
- Warm the room
- Use atropine to treat sinus bradycardia
- Usually require general anesthesia
- Give midazolam 0.5 mg/kg or inhalational induction
-
Blood loss is less tolerated than in adults
- Hematocrit is monitored frequently
- Also monitor for hypoglycemia and hypocalcemia
EP Studies
Electrophysiology Studies - minimally invasive procedure that tests the electrical conduction system of the heart to assess the electrical activity and conduction pathways of the heart - often long procedures that can be done with an LMA - heart rhythms are often very unstable because they are told to stop their heart meds prior to the procedure
Pacemaker insertion
- Can be done under sedation
- Internal defibrillators may need brief period of GA -
- Case is usually hemodynamically unstable
- Get an a-line if EF low
What type of anesthesia is needed for cardioversion?
(LA, sedation, or GA?)
GA
Anesthetic procedure for cardioversion
- Pre-oxygenate
- Incremental doses of induction med until LOC and loss of lash reflex occurs
- Remove facemask
- Deliver synchronized shock
- Closely monitor heart rhythm
- Manually ventilate until spontaneous respirations return
- Remain with patient until they are alert and awake.
- Hand off to ACLS trained ICU nurse
Contraindications to ECT
- Pheo (don’t want more SNS output)
- Increased ICP
- Recent CVA
- High risk pregnancy
- Aortic and cerebral aneurysms
To prevent profound bradycardia from initial PSNS discharge that occurs with ECT, what can be given?
0.2 mg Glycopyrrolate
Anesthesia for ECT
- Pre-oxygenate
- Induce anesthesia, and ensure that you can mask the person adequately
- Insert bite block
- Inflate the BP cuff
- Paralyze the patient with 0.5mg/kg Sux
- Induce the seizure
- Ventilate the patient until they awaken
What is the gold standard induction agent for ECT?
-
Methohexital!! 0.75-1 mg/kg
- decreases the seizure threshold.
- Beware, because it can cause extreme pain on induction.
- Propofol can be used as well, but reduces seizure duration, so it’s not very common.
Treatment for PSNS and SNS discharge with ECT
- PSNS discharge = 0.2 mg Glycopyrrolate
- SNS = Esmolol and labetolol
