Therapeutic and Diagnostic Procedures Flashcards
T/F Standards of anesthesia care and patient monitoring are the same regardless of location
TRUE
Procedures that might be anticipated to last several hours may best be performed with ______ at the onset rather than late conversioin after failure of _________
GA / sedation
Consider performing anticipated difficult intubation in the _______. Then what?
OR / then transfer to the site of the planned procedure
JCAHO defines anesthesia care as the administration of IV, IM or inhalation agents that may result in the loss of _____ _____________
protective reflexes
JCAHO introduced standards requiring anesthesia services participate with non-anesthesiology departments in setting up a ________ quality of care for patients undergoing _________ in all parts of the hospital.
uniform / sedation
During the case qualified anesthesia personnel must be present for the entire case. Nurses and rad techs are often less familiar with the management of anesthesia, therefore they are often unable to provide skilled assitance in an ___________ unless they receive specific training.
emergency
Office-based anesthesia is often used for _____ and _______ procedures. Patient requires a full ___________ workup.
ENT and dental / preoperative
Office based anesthesia usually uses a combination of ______ plus _______ or light GA with a mask or LMA
local / sedation
What are the agents of choice for office-based
Propofol, des, sevo, N20
Office-based anesthesia follows ____ and _______ guidelines
ASA and JCAHO
Office based anesthesia standards
Employment of appropriately trained and credentialed anesthesia personnel. Availability of properly maintained anesthesia equipment. Complete documentation of the care provided as required by other surgical sites. Use of standard ASA monitoring and availability of emergency equipment. Provision of a PACU that is staffed by trained nursing personnel. Establishment of a written plan for emergency transport of the patient to a comprehensive care center if a complication occurs.
Unique hazard to the radiology suite is __________ exposure. Imagine that now.
radiation
Radiation exposure can result in somatic effects of _______ and in terms of genetic injury resulting in __________ abnormalities caused by damage to the _________ cells or developing fetus
leukemia / fetal / gonadal
Max exposure annually
50 mSv
Lifetime cumulative dose
10 mSv x age
Monthly max exposure for pregos
0.5 mSV
T/F Fluroscopy is significantly _______ exposure to everyone than taking a single shot x-ray
less
Older contrast media was IONIZED, _____-osmolar and _____
hyper / toxic
New contrast media is NON-IONIZED (NEW NON IONIZED), has a _____ osmolality and improved side-effects
lower
Predisposing factors to adverse reactions from contrast media include history of what?
bronchospasm, allergy, cardiac disease, hypovolemia, hematologic disease, renal dysfunction, extremes of age, and medications like beta-blockers, asa, and NSAIDS.
What is a good plan for pre-treatment for iodinated contrast media
prednisone 50mg 12 hrs before and benadryl 50 mg immediately before the procedure
Mild reaction to contrast media
nausea, perception of warmth, headache, itchy rash and mild hives
Severe reaction to contrast media
vomiting, rigors, feeling faint, chest pain, severe hives, bronchospasm, dyspnea, arrythmias, and renal failure
Life-threatning reaction to contrast media
glottic edema/bronchospasm, pulmonary edema, arrythmias, cardiac arrest, and seizures/unconsciousness
Treatment for contrast media reaction
oxygen, bronchodilators, epi, corticosteroids, and antihistamines
Reactions to contrast media is well documented with those with renal dysfunction and preexisting renal dysfuntion related to ________
diabetes
Most cases of new or worsened renal funtion related to contrast media are _________ and resolve within ______. However, some cases progress to the point they need dialysis.
self-limited / 2weeks
What medication can be given to reduce nephrotoxicity due to contrast media
acetylcysteine
What is the problem with contrast media and metformin?
high risk of lactic acidosis
The number one problem with CT is _________________ to the patient
inaccessibility
What is mandatory protection required in the MRI?
hearing protection > 90 dB
_______ injury has been reported at site of EKG electrodes and areas where skin contacts the machine.
thermal
Most significant risk in the MRI suite is the effect of the magnet on _______ objects
ferrous
Contraindications for MRI include
shrapnel, vascular clips and shunts, wire spiral ETTs, PM, ICDs, mechanical heart valves, recently placed sternal wire, implanted biological pumps, tattoo ink with high concentrations of iron-oxide (permanent eyeliner) and intraocular ferromagnetic foreign bodies
Tattoo ink may contain high concentrations of iron oxide. Burns at tattoo sites have been reported after exposure to MRI magnetic fields but this is rare and the presence of permanenet eyeliner should not _______ the patient from an MRI
exclude
Examples of ferromagnetic items that should never be allowed in the vicinity of the MRI magnet
scissors, pens, keys, gas cylinders, anesthesia machine propak monitor, syringe pump, beeper (that’s funny), phone, steel chairs
MRI anesthesia: A common approach is to induce anesthesia in an area ________ to the MRI suite. What should be done for airway management?
adjacent / intubate with ETT or LMA to admin GA
MRI at UPMC HAMOT
MRI compatible laryngoscope, travel drug box, suction control is outside the MRI suite and induction happens in the MRI suite, use propofol, LMA with sevo @ 1 mac or less
T/F resuscitiation efforts should take place outside the scanner b/c laryngoscopes, 02 cylinders and defibrilators cannot be taken close to the magnet
TRUE
What do these procedures often require? Embolization of cerebral and dural AVM’s, coiling of cerebral aneurysms, angioplasty of sclerotic lesions, and thrombolysis of acute thromboembolic stroke.
deliberate hypotension and deliberate hypocapnia
________ ______________ is called for during cerebral ischemia in attempt to maximize collateral flow
deliberate hypertension
In interventional radiology, the radiologist may requrest rapid transition between deep sedation and _________ responsive state
awake
Cerebral coiling tips
could be from deep IV sedation to GETA, 2 large bore Ivs, PRE-induction Art line, fluid warmer and upper bair hugger, ACTS checked frequently with goal of 2-2.5 times normal,
What kind of emergence with cerebral coiling
smooth emergence, prevent coughing and prevent device migration. Admin antiemetics prior to emergence.
Cardiac cath lab anesthesia is usually _________ and GETA is reserved for ________ failure or airway control to manage respiratory failure
sedation / sedation
With RFA, what should medications should you consider during the RFA portion of the procedure
versed and fentanyl
Stenosis of greater than ____ to ____% is considered to be significant. CAD is classified as one, two or three-vessel disease or Left ______ coronary disease
50-70% / main
What is common after stenotic coronary artery is dilated from stenting or ballooning.
ventricular arrhythmias
Target ACT for most cath lab procedures
> 300
What can happen with protamine administration?
predictable peripheral vasodilation, and less common anaphylaxis and anaphylactoid reactions or the rare catastrophic pulmonary vasoconstriction crisis associated with protamine administration
Platelet aggregation inhibitors
abciximab, ticlodipine, clopidogrel
A notable side effect of abciximab is elevation of the _____ independent of heparin
ACT
T/F with an ERCP patients usually experience discomfort with instrumentation and stenting of the biliary and pancreatic ducts
TRUE
Antispasmodics like glucagon decrease the incidence of spasm but may result in _____ _______
sinus tachy
If sphincter of Oddi manometry is being performed what should be avoided?
opiods, glycopyrrolate, atropine and glucagon (due to alteration of the sphincter tone)
Patients presenting for ERCP may have significant comorbidities such as
acute cholangitis with septicemia, jaundice with liver dysfunction, coagulopathy, bleeding from esophageal varices resulting in hypovolemia, biliary stricture after major hepato-biliary surgery including liver transplantation
Transjugular Intrahepatic Portosystemic Shunt (TIPS) procedure connects the right or left portal vein to one of the three _______ veins to ______ the portal circulation in patients with portal HTN. Obviously, these patients have poor hepatic function. The procedure it self causes minimal stimulatioin as performed under sedation or GA.
hepatic / decompress
AIRWAY preop considerations for TIPS procedure
Aspiration r/t recent GI bleed, increased intragastric pressure decreased LOC d/t hepatic encephalopathy
RESPIRATORY preop consideratiosn for TIPS procedure
decreased FRC d/t ascites, pleural effusions, intrapulmonary shunts, pneumonia
CARDIO preop considerations for TIPS procedure
associated alcoholic cardiomyopathy, altered volume status, acute hemorrhage d/t esophageal varices, intraperitoneal hemorrhage
HEMATOLOGIC preop considerations for TIPS procedure
coagulopathy and thrombocytopenia
NEUROLOGIC considerations for TIPS procedure
hepatic encephalopathy
ECT therapeutic effects are thought to result from the release of ___________ during the electrically induced grand mal ________
neurotransmitters / seizure
Nueroendocrine responses to ECT included increased levels of ______ ________. What are they?
stress hormones / ACTH, cortisol, arginine, vasopressin, prolactin, GH
With ECT you can see _______ with NIIDDM, wheras ______________ may be seen when the diabetes is insulin dependent
improvement / hyperglycemia
Physiologic response to ECT results in a grand mal seizure where the TONIC phase lasts _____ and the clonic phase lasts _______
10-15 sec / 30-60 sec
ECT can cause ______ CBF and ICP
increased
Cardiovascular response to ECT
initial bradycardia followed by HTN and tachycardia, dysrhythmias, myocardial ischemia
ECT can also result in what other things?
short-term memory loss, muschle aches, fractures, dislocations, status epilepticus, and sudden death
Absolute contraindication to ECT
pheocromocytoma
Relative contraindications to ECT
increased ICP, recent CVA, cardio conduction defects, high-risk pregnancy, aortic and cerebral aneurysms
ECT anesthetic considerations
Propofol (attenuates hemodynamic response to ECT), short acting opiods (remi, alfenta), muscle relaxants like succs to prevent fractures and dislocations, toradol in younger patients
With ECT, robinul and atropine can prevent the ___________ effects of ECT (salivation, bradycardia, asystole)
parasympathetic
With ECT, labetolol (0.3 mg/kg) and esmolol (1 mg/kg) both ameliorate the hemodynamic responses, although ____________ has a lesser effect on seizure DURATION
esmolol
__________ and ___________ administered before induction for ECT are effective in controlling BP w/o affecting seizure duration
clonidine and dexmedetomidine
Most common cause of death with ECT
MI and arrhythmia
With ECT, seizure activity causes an initial ___________ discharge manifested by bradycardia, occasional asystole, PAC, PVC. Hypotension and salivation may be noted and then sympatetic activity
parasympathetic
ECG changes with ECT include
ST-segment depression, T-wave inversion and without myocardial enzyme changes
arrhythmias associated with ECT even when pre-existing are usually ____ _______
self-limited
Anesthetic considerations for those with Down Syndrome
cardiac conduction defects, macroglossia, hypoplastic maxilla, palatal abnormalities, mandibular protrusion
Anesthetic management for Down’s Dental surgery: Ketamine IV, IM or Oral. Oral midazolam. EMLA cream to place IV. Tracheal intubation (often nasal) is required to protect the airway. LMA has been used as well. Immediate post-op complications include bleeding, airway obstruction and laryngeal spasm. What are the ketamine doses?
IV=1-2 mg/kg ORAL=5-10mg/kg IM=2-4mg/kg
Sedation comprises a continuum of states from minimal _______ to ______
sedation / GA
_________ is a drug-induced state during which patients respond normally to verbal commands. Although congnitive functioin and physical coordination may be impaired, airway reflexes, and ventilatory and cardiovascular functions are unaffected
Minimal sedation (anxiolysis)
________________ is a drug-induced depression of consciousness during which patients respond purposefully to verbal commands either alone or accompanied by light tactile stimulation. No interventions are required to maintain patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained.
moderate sedation/analgesia (Conscious Sedation)
___________ is a drug-induced depression of consciousness during which patients cannot be easilly aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assitance in maintaining a patent airway, and spontaneous ventilation may be INADEQUATE. Cardiovascular function is usually maintained
Deep Sedation / Analgesia
__________ is a drug-induced loss of consciousness during which patients are not arousable, even by painful stimulation. The ability to independently maintain ventilatory function is often impaired. Patients often require assitance in maintaining a patent airway, and positive pressure ventilation may be required because of depressed spontaneous ventilation or drug-induced depression of neuromuscular function. Cardiovascular function may be impaired.
General Anesthesia
Because sedation is a continuum, it is not always possible to predict how an individual patient will __________
respond
Review the table on slide 69
continuum of depth of sedation
Patient anxious and agitatated or restless or both
Ramsay 1
Patient cooperative, oriented, tranquil
Ramsay 2
Patient responds to commands only
Ramsay 3
Brisk response to light glabellar tap or audiotory stimulus
Ramsay 4
Sluggish response to a light glabellar tap or auditory stimulus
Ramsay 5
No response to the stimuli mentioned in items 1-4
Ramsay 6
Review modified aldrete score on slide 71. What areas does this look at?
Motor activity, Breathing, BP, Consciousness, Oxygen saturation (score range 0-10)
Examples of difficult to sedate patients
high level of anxiety, psychiatric disorders, chronic opioid use, mental status changes, dementia
For sedation procedures, ages 6 months to adult can have clear liquids up to ___ to ___ hours prior to surgery
2 to 4 hours
Children younger than 6 months can have clear liquids up to ____ hours prior to sedation
2 hours
Review table for solids and nonclear liquids
slide 77
Application of sedation: Choice of agent and technique is dependent on __________________, requirements of contstraints imposed by the patient or procedure, and likelihood of producing a deeper level of sedation than anticipated. Because patiets are unpredictable, practitioners need to be able to rescue patient whose level of sedation becomes deeper than intended.
experience and preference of the practitioner
Recovery and disposition after sedation: _________ score must be used. Vitals must be taken every _____ min X ___, then every _____ x _____ or until full recovery of Aldrete score of ___ or better
Aldrete / 10 min x 3 / 1 hr x 2 / 9 or better
Patient must be observed a minimum of _____ min post procedure
30 min
If resuscitative measures were required the patient needs to be observed for ______
1 hour
Discharge from hospital criteria: Fully awake with an Aldrete of ___ or better. Hydration is adequate. Able to walk _____, where appropriate. Accompanied by a reasonable adult. Advised regarding aftercare with written and verbal discharge instructions. Responsible attending physician must write discharge order and note including patient status. A _______ may discharge the patient utilizing all the above criteria
9 / unassisted / registered nurse
