Remote locations Flashcards
1
Q
What are some satellite locations?
A
- radiology
- cardiac cath lab
- psych units- for ECTs
- endoscopy
- office based practice
- **patients are becoming sicker in these remote units
- not as much personnel or the equipment of the OR
2
Q
What equipment do you need to in Satellite locations per the ASA standards?
(12)
A
- Reliable oxygen source with back-up
- some office settings wont have pipeline
- suction- make sure it is adequate!
- waste gas scavenging
- Monitoring equipment
- must meet basic standards during case and post-anesthesia transport
- self inflating ambu bag (>90% FiO2 delivery)
- adequate patient and anesthesia equipment illumination with battery power back-up
- adequate space to freely access patient and anesthesia equipment.
- emergency cart with defibrillator and drugs
- reliable two-way communication to request help
- adequately trained support staff
- including anesthesia professional available during recovery period
- compliance with safety and building codes
- sufficient safe electrical outlets
3
Q
What are the monitoring standards of care?
A
- Pre and post procedure checklists
- emergency protocols with contact numbers
- ASA/AANA monitoring:
- oxygenation
- spo2
- ventilation
- capnography
- circulation
- ekg, BP
- temperature
- oxygenation
4
Q
What are the different depths of anesthesia?
A
5
Q
What are the four major issues that determine appropriate classification of anesthetic depth?
A
- responsiveness
- airway
- spontaneous ventilation
- CV function
- **must always be ready to support pt for one stage beyond what is planned for.
6
Q
What is MAC?
A
- When an anesthesia provider is involved in the care of a pt while they are having a procedure
- May just be there just in case support is needed
- Do everything the same as normal and always be on the ready to do more.
7
Q
What is an upper endoscopy?
Why might it be done?
What kind of anesthesia is used?
What does EGD stand for?
A
- Endoscopic evaluation of the esophagus, pylorus, and stomach
- sometimes d/t nausea, abdominal pain, foreign body, monitor vericies
- May involve biopys, mucosal/submucosal dissection, dilation, stenting, etc.
- Local oropharyngeal anesthesia with opioid and benzo vs general anesthesi with propofol
- GA with propofol is anywhere from 100-300 mcg/kg/min
- Carrie does:
- gargle 4% lidocaine
- 2 mg/kg propofol to start
- aspiration and laryngospasm common
- EGD = esophagogastroduodenoscopy
8
Q
What groups are high risk during an EGD?
A
- Obese
- OSA
- GERD
- asthma
- obstruction/full stomach
- hepatic disease
9
Q
What is a lower endoscopy?
A
- Sigmoidoscopy and colonoscopy
- Generally involves insufflation of air, may involve the application of external pressure
- increased aspiration risk
- may cause vagal response
- May involve biopsy, polypectomy/mucosal resection, stenting, dilation, etc
10
Q
How can the anesthesia be done for lower endoscopy?
A
- benzos and opioids or propofol (GA)
11
Q
What is ERCP?
A
- Fluoroscopic exam of biliary and pancreatic duct that may involve stenting/removal of stones/laser lithotripsy
- Commonly performed in patients with cholangitis, pancreatitis, bile duct obstruction, pancreatic cancer, etc
- may not be as responsive to pressors, keep ahead
- requires pt to be immobile
- often done in prone position
- GA w/ETT is preferred
12
Q
What is done during a rigid bronchoscopic procedure?
A
- Endobronchial stenting
- biopsy
- laser therapy
- dilation
- cryotherapy
- fiducial marker implant
- **these patients often have significant CV and pulmonary disease
13
Q
What is the preferred method of anesthetic for a rigid bronch?
What are some complications?
A
- TIVA
- propofol, remifentanil, dexmedetomidine, and muscle relaxant
- Complications:
- airway fire
- bronchospasm
- bleeding
- hypoxia
14
Q
What are three features that make providing anesthesia in radiology suites different?
A
- There is no incision
- Access through vasculature (femoral artery)
- Must deal with lots of radiation
15
Q
What are some general considerations/challenges in the radiology suite?
A
- Patient remains immpbile for prolonged periods
- lots of bulky equipment
- limits our ability to access the patient
- can colide with our equipment
- requires us to need extensions
- can press against and possibly harm the patient
- Some rooms dont have scavenging system which will limit GA
- Must try to limit radiation exposure
- radiation causes dose-related cell death, tissue damage and malignancy (DNA ionization and free radical generation)
- direct exposure to pt
- scatter exposure to providers
16
Q
What does ALARA mean?
How is it achieved?
A
- As low as reasonably achievable
- lead aprons
- thyroid shields
- moveable leaded glass screens
- leaded eyeglasses
- remote or video monitoring when appropriate
- dosimeters should be worn
- one under lead apron
- one on collar above lead apron
17
Q
What do you need to know about contrast media?
A
- Used in diagnostic and therapeutic radiologic procedures
- general radiology and MRI
- Variable osmolarity; ionic or non-ionic
- non-ionic causes less pain and fewer complications
- Adverse reactions range from mild to life threatening
- hypersensitivity
- renal toxicity
18
Q
How can you treat a contrast media hypersensitivity reaction?
A
- Prompt recognition!
- oxygen
- bronchodilators
- epinephrine
- fluid resuscitation
- corticosteroids
- consider pre-treatment with IV corticosteroids a few hours pre-procedure as well as H1 and H2 blockers
- not great evidence to support this
19
Q
How does contrast media affect the kidney?
Who is at increased risk?
A
- Causes direct tubular toxicity due to release of free oxygen radicals and microvascular obstruction
- Increased risk in:
- diabetic renal insufficiency
- hypovolemia
- CHF
- HTN
- baseline proteinuria/renal disease
- Gout
- co-administration of other drugs that cause reanal problems (Ketorolac)
20
Q
What is Azotemia and when does it occur?
A
- Azotemia- abnormally high levels of nitrogen containing compounds in the blood (urea, cr, etc.)
- occurs 24-48 hours after contrast media is given
- peaks at 3-5 days
- monitor creatinine levels
- increase of 0.5 mg/dL within 24 hours is diagnostic
- Avoid surgical procedures during this period.
21
Q
How can we minimize complications with contrast?
A
- administer slowly
- limit dose to least amount required
- administer with hydration 1 ml/kg of NS 4 hours pre-procedure and continue for 12 hours post-procedure
- administer sodium bicarbonate to promote renal elimination
- increases pH of urine and the ionized fraction of contrast so it can be eliminated
- monitor serum creatinine for 72 hours
- N-Acetylcysteine (yes according to Miller, unproven according to Barash)
- 600 mg PO twice daily will blunt renal injury 2% vs 21%
22
Q
What kinds of anesthesia techniques are used in the Radiology suite?
What does it depend on?
A
- Techniques:
- local only with anesthesia on stand-by
- sedation/analgesia
- general
- depends on:
- procedure
- desired level of anesthesia
- underlying medical conditions (parkinson’s)
- open communication with radiologists
23
Q
General information about Angiography
A
- Minimal discomfort but potential for long duration and pt must remain motionless
- local anesthesia at puncture site (usually femoral artery)
- +/- light sedation vs GA
- during contrast injection be prepared for decrease in HR and BP
- Extension tubing
- keep ECG leads out of imaging field
- Avoid ETT with metallic coils if ETT in imaging field
24
Q
How does Computed Tomography work?
A
- Uses X-ray beam to image slices of the body (each takes <1 sec)
- Amount of radiation transmitted is collected by photo-multiplier tubes and is counted digitally
- Body scan image can be viewed by rapidly acquiring views from numerous different projections by rotating tubes and detectors around body
25
Q
What is CT used for?
A
- diagnostic and therapeutic purposes
- biopsy/ablation of neoplastic process in thorax, abdomen, brain
- diagnosis of trauma patients
- chronic pain treatement
26
Q
General considerations for CT.
A
- Procedure will dictate the anesthetic
- consider risk of aspiration if PO contrast is used
- patient is inaccessible during procedure
- lots of radiation exposure
27
Q
How does MRI work?
A
- Body is immersed in a steady, strong magnetic field
- 1.5 Tesla, which is 15,000 Gauss
- the Earths magnetic field is 0.5 Gauss
- The magnet is ALWAYS on!
28
Q
What are some contraindications in MRI?
A
- Pacemakers/defibrillators
- cochlear implants
- pumps or nerve stimulators
- aneurysm clips
- intravascular wires
- former trauma victims with bullets or metal shrapnel
- first trimester pregnancy (minimal data to support this)
- metal implants need to be monitored for increased temp
29
Q
What are limitations of MRI?
A
- time consuming exam
- anxiety and claustrophobie
- any movement and it wont work
- obese pts may not fit in scanner
- 50-65 cm in diameter
- loud noises (>90 dB)
- heat generation/risk of thermal injury
- do not wind up cables or wires
- any ferrous object can become a missile
30
Q
What are some considerations for anesthesia in MRI?
A
- anesthesia is involved when:
- sedation fails or is risky (OSA)
- it is impossible to control movement without GA (pediatrics, parkinsons,etc)
- need to protect the pts airway or control ventilation
- you have limited access and visibility of patient
- limited access for emergency personnel during scan
31
Q
How is anesthetic management done for an MRI?
A
- induction occurs in an adjacent area
- atient is transferred via an MRI transport table
- MRI-compatible anesthesia machine/monitoring are connected
- MRI transport table available for emergency should rapid exit be necessary
- Must meet all ASA standards for monitoring
- ECG/pulse ox risk for thermal injury, make sure to check it!
- extension tubing may make capnography read difficult
- ETT or LMA
- TIVA (with long tubing) if no compatible anesthesia machine
- must be in room with patient if you can see them or monitors from outside
32
Q
What is External beam radiation therapy?
A
- Highly tissue targeted vs total body irradiation for malignancy
- Anesthesia required for pediatric cases
- usually propofol deep sedation or GA
- usually have long term indwelling access
- Considerations:
- If CNS involvement, evaluate ICP
- concurrent immunosuppressive/cytotoxic therapies
- anesthesia must leave room during radiation
- immobilization devices can restrict airway access
33
Q
What is interventional neuro-Radiology?
A
- Radiologically guided endovascular approach to CNS lesions or related circulatory structures
- cerebral angiography
- better outcomes with IR for grade 1 and 2 aneurisms
- Neuroradiologic procedures include:
- embolization of AVMs
- coiling of cerebral aneurysms
- angioplasty of atherosclerotic lesions
- thrombolysis of acute thromboembolic stroke
- can give TPA to the site, avoiding systemic effects
- carotic stent
34
Q
What may be required during interventional Neuro-Radiology?
A
- deliberate hypotension or hypertension
- deliberate hypocapnia or hypercapnia
- rapid transition between deep sedation/analgesia dn the awake responsive state
- Access: 6-7 fr grade sheath in femoral artery or sometimes in carotid, axillary or brachial artery
- contrast media is used
35
Q
What are some anesthesia considerations during interventional neuro-Radiology?
A
- Hemorrhage
- potential for cerebral aneurysm rupture
- intracranial vessel damage
- hematoma at sheath insertion site
- Occlusive complications
- migration of embolic materials
- vasospasm
- Cerebral edema
- patient’s co-morbidities
36
Q
What should you do for pre-op and induction for IR neuro?
A
- Pre-op
- airway exam
- history of contrast reaction
- evaluation of BP
- induction (GA vs conscious sedation)
- standard ASA monitors
- 2 IV sited
- radial arterial line
- foley
- pad all pressure points
- will the procedure physician perform the WADA or SAFE tests?
37
Q
What is WADA?
SAFE?
A
- WADA- inject barbituate into carotid to see which side is dominate for speech and memory
- SAFE- not carotid, but smaller tributary vessel, same test
- **Goal to avoid causing loss of function
38
Q
Intra-op managment:
How to avoid clot?
deliberate hypotension?
deliberate hypertension?
ecg?
A
- Heparin
- 70 U/kg (3000-5000)
- Goal: ACT 2-2.5 x normal
- deliberate hypotension
- esmolol
- labetolol
- hydralazine
- SNP
- deliberate hypertension
- phenylephrine
- increase SBP 30-40% above baseline
- ECG
- monitor for myocardial ischemia
39
Q
How do you emerge a pt in neuro IR?
A
- administer antiemetic
- tight post-procedural BP control
- smooth emergence to avoid coughing or bucking
- do not want to cause high pressures
