Therapeutic & Diagnostic Procedures Flashcards
Understanding that the standards of anesthesia care and patient monitoring are the same regardless of _____
location***
Realize that remote locations have different safety concerns, such as radiation and powerful magnetic fields.
Sedation practices may result in ____ or _____ which must be rapidly recognized and managed to avoid risk of aspiration, hypoxic brain damage, cardiac arrest, or death.
cardiac or respiratory depression***
It is the responsibility of the anesthesia provider to ensure that the location meets the
ASA guidelines for safety
The ASA published guidelines, standards, & definitions of general anesthesia & levels of sedation.
Understanding the procedure, ______ , the anticipated level of stimulation, and patient position during the procedure are all important considerations.
the patient’s condition***
Procedures that might be anticipated to last _____ may best be performed with GA at the onset rather than _____ after failure of sedation.
Several hours
late conversion***
- Consider performing anticipated difficult intubations in the operating room.
- Once the airway is controlled, the patient can be transported 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 ______ for patients undergoing sedation in all parts of the hospital
uniform quality of care***
JCAHO - Patients that receive anesthesia or sedation at alternative sites should expect the same ____ that they would receive in the OR.
standard of care***
Anesthesia providers undertake most of their training in the OR surrounded by familiar ______ experienced in the care of anesthetized patients.
equipment & staff***
At the conclusion of the procedure, patients should ______ supervised by personnel who are trained to take care of unconscious patients & with appropriate monitoring & resuscitation equipment immediately at hand.
recover from anesthesia or sedation in a PACU or similar setting***
Who must be present the entire case?
Qualified anesthesia personnel must be present for the entire case.
Nurses and radiology techs are often less familiar with the management of anesthesia, therefore they are often unable to provide skilled assistance in an emergency unless they receive specific training.
What monitoring is required in out of OR anesthesia
Supplemental Oxygen Pulse oximetry End-tidal carbon dioxide detection and disconnect alarm. EKG & NIBP Temperature Patient positioning
After the case, patients must be ____
medically stable before transport***
Patient must be accompanied to the recovery area with what?
Provisions for O2 delivery and monitoring on the transport cart are required.
Emergency medications***
Office based anesthesia is usually used for what type of procedures?
ENT and dental
Office based anesthesia require what?
A full pre-op workup**
Who are not good candidates for office based anesthesia?
potentially difficult airways
What type of anesthesia is used in office based settings and what agents?
Procedures often involve local anesthesia plus IV sedation or light general anesthesia with a mask or LMA.
Agents of choice include: Propofol Sevo Des N2O
Office based anesthesia ASA and JCAHO guidelines
Employment of appropriately _____
Availability of properly maintained ____
Complete documentation of the ___ as required at other surgical sites.
Use of standard ___ & availability of ___
Provision of a ____ that is staffed by trained nursing personnel.
Establishment of a written plan for ____ of the patient to a comprehensive care center if a complication occurs.
trained and credentialed anesthesia personnel.
anesthesia equipment.
care provided
ASA monitoring; emergency equipment.
PACU
emergency transport
*** this whole slide
In US, CT, MRI, RFA, and neuro-coiling, there is a unique risk for
radiation exposure***
What are the risks of radiation exposure?
Leukemia and fetal abnormalities (abnormalities caused by damage to the gonadal cells or developing fetus).
Dosimeters are required for radiation exposure, what is the annual maximum exposure? Lifetime? Monthly for pregnant women?
Annual: maximum exposure 50 mSv
Lifetime: 10 mSv x age
Pregnant: 0.5 mSv
T/F: Fluoroscopy is significantly less exposure to everyone than taking single shot x-rays.
True
What can be done to limit radiation exposure
by wearing appropriate lead aprons and thyroid shields, using movable leaded glass screens, and using innovative techniques such as video monitoring and remote mirroring
Iodinated Contrast Media
Older ionized contrast media were hyper-osmolar and toxic.
Newer non-ionized contrast media have ___
lower osmolality and improved side-effects***
Predisposing factors to adverse reactions from contrast media include a history of: ___9___
bronchospasm allergy cardiac disease hypovolemia hematologic disease renal dysfunction extremes of age anxiety medications (beta-blockers, aspirin, and NSAIDs). ***
What is the pre-treatment for contrast media?
prednisone, 5O mg 12 hours before
diphenhydramine, 5O mg immediately before the procedure
What are the mild, severe and lifethreatening reactions to contrast media?
MILD: nausea, perception of warmth, headache, itchy rash, and mild hives.
SEVERE: vomiting, rigors, feeling faint, chest pain, severe hives, bronchospasm, dyspnea, arrythmias, and renal failure.
LIFE-THREATENING: glottic edema/bronchospasm, pulmonary edema, arrythmias, cardiac arrest, and seizures/unconsciousness.
***
What is the treatment for reactions to contrast media?
O2, bronchodilators, epi, corticosteroids, and antihistamines***
Renal dysfunction is well documented in association with contrast media, particularly in patients with preexisting renal dysfunction and most especially in patients with preexisting renal dysfunction related to ___
Most cases of new or worsened renal function related to contrast media are ___ and resolve within 2 weeks.
diabetes***
self-limited***
Recent studies have demonstrated a reduction in contrast media nephrotoxicity by the administration of ____
acetylcysteine***
Life-threatening _____ may develop in non-insulin-dependent diabetic patients who are receiving ____ and have preexisting renal dysfunction if their renal function declines further.
lactic acidosis***
metformin***
CT:
Two-dimensional, cross-sectional image.
Each cross-section requires a few seconds of ___
Pt immobility is required.
It is often noisy, warm, and claustrophobic.
CT can be used for diagnostic and therapeutic purposes.
Number one problem: ____
radiation exposure
inaccessibility to the patient***
MRI:
Able to obtain images in any plane & excellent soft tissue contrast.
Does not produce ___ is non-invasive, and does not produce biologically ____
Hearing protection is ____
Thermal injury has been reported at site of ___ and areas where skin ___
Most significant risk in the MRI suite is the effect of the magnet on ____.
ionizing radiation; deleterious effects
Hearing protection is mandatory (>90 dB)***
EKG electrodes; contacts the machine.
ferrous objects
Contraindications for MRI
Shrapnel, vascular clips and shunts, wire spiral ETT’s, pacemakers, 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 ***
Why is tattoo ink a possible contraindication?
may contain high concentrations of iron oxide***
Burns at tattoo sites have been reported after exposure to MRI magnetic fields, but such incidents are very rare and the presence of, for example, permanent eyeliner
_____ should never be allowed in the vicinity of the MRI magnet
Ferromagnetic items ***
scissors, pens, keys, gas cylinders, anesthesia machine, pro-pak monitor, syringe pump, beeper, phone, and steel chairs.
Cards with magnetic strips will be de-magnetized, including ____
credit cards and ID badges.
A common approach now is to induce anesthesia in an ____ by using conventional equipment with the patient on a dedicated MRI transport table that is not ferromagnetic.
induction area adjacent to the MRI suite outside the magnetic field***
Because the patient’s airway is not easily accessed during the MRI scan & because patient assessment / communication are limited by both the magnet bore & the loud noise associated with MRI scanning, what type of anesthesia is not advisable?
deep sedation/analgesia is not advisable***
Patients requiring more than _____ are probably most safely administered a general anesthetic with airway control by either ETT or an LMA.
moderate sedation/analgesia***
What do we used for our induction?
Generally Propofol only for induction
- Little need for versed or fentanyl
LMA w/ Sevo @ less then or equal to 1.0 MAC
T/F: Resuscitation attempts should take place outside the scanner b/c laryngoscopes, O2 cylinders, and defibrillators cannot be taken close to the magnet.
TRUE
Radiology RFA:
Often done in CT but occasionally MRI.
Kidney, lung, and liver.
It is our job to check ____. Radiology techs are not trained to be concerned.
Extremely poor access to ____
pressure points and padding***
the patient***
IR:
Embolization of cerebral and dural AVM’s, coiling of cerebral aneurysms, angioplasty of sclerotic lesions, and thrombolysis of acute thromboembolic stroke.
These procedures often require deliberate ____ and deliberate ____
hypotension & hypocapnia***
_____ is called for during cerebral ischemia in an attempt to maximize collateral flow.
Deliberate hypertension***
Cerebral Coiling:
Radiologist may request anything from deep IV sedation to GA with ETT.
Always have __ large-bore IV’s in place. One for drug infusion and one for rapid fluid administration.
____ A-line.
Fluid warmer & upper bair hugger.
ACT’s will be checked frequently. Target ___ normal)
2
Pre-induction
2-2.5x’s
IR
_____ from anesthesia is important in these patients, who may be prone to device migration or intracranial hemorrhage.
Administration of ___ before emergence is certainly reasonable, and precautions to avoid ____
Smooth emergence***
antiemetics***
coughing and/or “bucking”***
Elective Cardioversion:
Generally follows shortly after completion of ___
Cart with emergency drugs
Propofol or Etomidate
Standard monitoring with EtCO2
Preoxygenate (nasal cannula)
Give small incremental doses of sedation until the eyelash reflex is abolished. This is a ____
Consider RSI with ETT if high risk for aspiration.
TEE***
Short procedure.***
During a cardiac RFA, ___ & ___ are used to titrate in during the more painful parts of the procedure. (esp. the ablation)
Midazolam and fentanyl
Pacer and ICD checks:
These ICD checks are not with out risk. Check pulses and watch the EKG, pulse ox and arterial wave-forms closely. People have been known to code and require CPR.
just a statement..
Coronary artery disease assessment:
Stenosis greater than ____ the normal arterial diameter are considered hemodynamically significant, although lesser stenosis may be clinically important.
50% to 70%**
Coronary artery disease is classified as one-, two-, or three-vessel disease or left main coronary disease.
CAD:
After dilation of the stenotic coronary artery, ____ may develop and require treatment.
ventricular arrhythmias***
Heparin commonly being administered during interventional cardiac catheterization and have resulted in improved outcomes despite the reduction in heparin dose.
Typical Heparin dose:
Heparin dose for IR:
ACT goal for IR:
Reversed with:
Typical Heparin dose: 2500-5000
Heparin dose for IR: 10,000
ACT goal for IR: >300
Reversed with: protamine
Watch for peripheral vasodilation, as well as less predictable anaphylactic and anaphylactoid reactions or the rare catastrophic pulmonary vasoconstrictive crisis associated with protamine administration
____ used have included abciximab, ticlopidine, and clopidogrel.
Platelet aggregation inhibitors***
A notable side effect of abciximab is elevation of the ACT independent of heparin
GI:
The American Gastroenterological Association recommends appropriate training for endoscopists in sedation techniques & involvement of an ____
Patient positioning (left lateral vs prone) = Poor ___
anesthesiologist in selected cases.
airway access***
ERCP:
Important in the diagnosis & treatment of biliary & pancreatic diseases.
Antispamodics (____) decrease the incidence of spasm but may result in ____
If ____ manometry is being performed, ___4___ should be avoided d/t alteration of sphincter tone.
glucagon*
sinus tachycardia*
sphincter of Oddi***
opiods, glycopyrrolate, atropine, & glucagon***
Patients presenting for emergency ERCP may have significant _____
comorbidities***
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)
Connects the right or left portal vein to one of the three hepatic veins to ____ in patients with portal HTN.
Patients usually have ____ requiring careful preoperative assessment.
The procedure;
- Causes minimal stimulation
- Lasts between ___ hrs
- Performed under sedation or GA
decompress the portal circulation***
significant hepatic dysfunction***
2-3hrs***
Pre-op Consideration for TIPS Airway: Resp: CV: Hematologic: Neurologic:
Airway (aspiration)
- Recent GI bleed
- Increased intragastric pressure
- Decreased LOC d/t hepatic encephalopathy
Respiratory system
- Decreased FRC d/t ascites
- Pleural effusion
- Intrapulmonary shunts
- Pneumonia
Cardiovascular system
- Associated alcoholic cardiomyopathy
- Altered volume status
- Acute hemorrhage d/t esophageal varices
- Intraperitoneal hemorrhage
Hematologic system
- Coagulopathy
- Thrombocytopenia
Neurologic System
- Hepatic encephalopaty
What is electroconvulsive therapy used for?
Used to treat depression, mania, & affective disorders in patients with schizophrenia as well as a number of other psychiatric disorders.
How often is ETC performed?
Typically, ECT is performed 3 times a week for 6-12 treatments followed by weekly or monthly maintenance therapy to prevent relapses.
ECT therapeutic effects are thought to result from…
release of neurotransmitters during the electrically induce grandmal seizure***
Neuroendocrine responses to ECT include increased levels of ____
stress hormones***
Including adrenocorticotropic hormone, cortisol, and arginine vasopressin, as well as prolactin and growth hormone
____ & _____ increase immediately after ETC.
Norepinephrine & epinephrine***
Epinephrine levels decrease more rapidly thereafter.
Glucose homeostasis is variably affected by ECT.
Improvement in control of non-insulin-dependent diabetes is generally noted, whereas _____ may be seen when the diabetes is insulin dependent.
hyperglycemia***
Physiologic Response to ECT:
Grand mal seizure - 10-15 second tonic phase - 30-60 second clonic phase Increased CBF & ICP Cardiovascular response; - Initial bradycardia followed by HTN & tachycardia - Dysrhythmias - Myocardial ischemia Short-term memory loss Muscle aches / fractures / dislocations Status epilepticus Sudden death
What is the absolute contraindication to ECT?
Pheochromocytoma***
What is the relative contraindication to ECT?
Increased intracranial pressure, Recent cerebrovascular accident, Cardiovascular conduction defects, High-risk pregnancy, Aortic and cerebral aneurysms.
Anesthetic requirements for ETC
Amnesia Airway management Prevention of bodily injury from seizure Control of hemodynamic changes Smooth, rapid emergence
Anesthetic considerations;
Patients with depression are often elderly with a number of coexisting conditions
What anesthetic meds are used for ETC
Propofol is effective at attenuating the acute hemodynamic response to ECT with rapid recovery as well as having anticonvulsant effects.
Short-acting opiods (alfentanil, remifentanil) can be used to decrease the dose of induction drug.
What must be placed prior to inducing the seizure
a bite guard***
Muscle relaxants are used to prevent ____ during the seizure
musculoskeletal complications (fractures, dislocations)
Anectine (0.75 - 1.5mg/kg) is preferable to the longer acting nondepolarizing agents.
Additions meds for ETC Toradol: Robinul & atropine: Labetalol & Esmolol: Clonidine & dexmetomidine:
Toradol (15-30mg) helps reduce ECT-induced myalgia in younger patients.
Robinul & atropine can prevent the parasympathetic effects of ECT (salivation, bradycardia, asystole).
Labetalol (0.3mg/kg) & Esmolol (1mg/kg) both ameliorate the hemodynamic responses, although, esmolol has a lesser effect on seizure duration.
Clonidine & dexmetomidine (1mcg/kg over 10min) administered before induction of anesthesia are effective in controlling BP w/o affecting seizure duration.
Complications of ETC
Seizure activity causes an initial parasympathetic discharge manifested by bradycardia, occasional asystole, premature atrial and ventricular contractions, or a combination of these abnormalities. Hypotension and salivation may be noted and then sympatric activity.
ECG changes, including ST-segment depression and T-wave inversion
Most common cause of death from ETC
MI & arrhythmia
Patients with Down Syndrome are commonly encountered, & possible abnormalities should be assessed
Cardiac abnormalities
- Conduction abnormalities & structural defects
Risk of atlanto-occipital dislocation
Airway difficulties
- Macroglossia
- Hypoplasitic maxilla
- Palatal abnormalities
- Mandibular protrusion
Anesthetic management
Ketamine
Ketamine
- 1-2mg/kg IV
- 5-10mg/kg orally
- 2-4mg/kg IM
Oral midazolam
EMLA cream to facilitate IV placement
Tracheal intubation (often nasal) is required to protect the airway.
Define Minimal Sedation (Anxiolysis)
a drug-induced state during which patients respond normally to verbal commands. Although cognitive function and physical coordination may be impaired, airway reflexes, and ventilatory and cardiovascular functions are unaffected***
Define Moderate Sedation/Analgesia (“Conscious Sedation”)
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 a patent airway, and spontaneous ventilation is adequate. Cardiovascular function is usually maintained***
Define Deep Sedation/Analgesia
a drug-induced depression of consciousness during which patients cannot be easily aroused but respond purposefully following repeated or painful stimulation. The ability to independently maintain ventilatory function may be impaired. Patients may require assistance in maintaining a patent airway, and spontaneous ventilation may be inadequate. Cardiovascular function is usually maintained***
Define General Anesthesia
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 assistance 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***
T/F: Because sedation is a continuum, it is not always possible to predict how an individual patient will respond.
True***
Practitioners intending to produce a given level of sedation should be able to rescue patients whose level of sedation becomes deeper than initially intended.
Ramsey Sedation scoring system
1 - pt anxious and agitated or restless; or both
2 - Pt co-operative, oriented and tranquil
3 - Pt responds to commands only
4 - Brisk response to light glabellar tap or auditory stimulus
5 - Sluggish response to light glabellar tap or auditory stimulus
6 - No response to the stimuli mentioned in items 4 & 5
Modified Aldrete Score
Look at slide 71
T/F: anywhere that you give anesthesia should have etco2
TRUE***
Recovery from sedation:
____scoring must be used
A score of ___ or better for D/C
VS how often
Aldrete
9
every 10 minutes x 3 then every hour x2 (or until fully recovered to an Aldrete score of 9 or better
Patient must be observed for a minimum of ____ post procedure.
If resuscitative measures were required the patient needs to be observed for _____.
30 minutes
an hour
