Therapeutic and Diagnostic Procedures Flashcards by Mark Next

T/F Standards of anesthesia care and patient monitoring are the same regardless of location

TRUE

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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

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Consider performing anticipated difficult intubation in the _______. Then what?

OR / then transfer to the site of the planned procedure

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JCAHO defines anesthesia care as the administration of IV, IM or inhalation agents that may result in the loss of _____ _____________

protective reflexes

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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

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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

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Office-based anesthesia is often used for _____ and _______ procedures. Patient requires a full ___________ workup.

ENT and dental / preoperative

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Office based anesthesia usually uses a combination of ______ plus _______ or light GA with a mask or LMA

local / sedation

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What are the agents of choice for office-based

Propofol, des, sevo, N20

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Office-based anesthesia follows ____ and _______ guidelines

ASA and JCAHO

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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.

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Unique hazard to the radiology suite is __________ exposure. Imagine that now.

radiation

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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

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Max exposure annually

50 mSv

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Lifetime cumulative dose

10 mSv x age

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Monthly max exposure for pregos

0.5 mSV

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T/F Fluroscopy is significantly _______ exposure to everyone than taking a single shot x-ray

less

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Older contrast media was IONIZED, _____-osmolar and _____

hyper / toxic

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New contrast media is NON-IONIZED (NEW NON IONIZED), has a _____ osmolality and improved side-effects

lower

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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.

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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

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Mild reaction to contrast media

nausea, perception of warmth, headache, itchy rash and mild hives

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Severe reaction to contrast media

vomiting, rigors, feeling faint, chest pain, severe hives, bronchospasm, dyspnea, arrythmias, and renal failure

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Life-threatning reaction to contrast media

glottic edema/bronchospasm, pulmonary edema, arrythmias, cardiac arrest, and seizures/unconsciousness

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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