Week 7 - Non Operating Room Anesthesia Flashcards
What are the 10 standards for the delivery of anesthesia in a remote location?
- Preform a complete preanesthetic assessment
- Obtain informed consent
- Formulate patient specific anesthetic plan
- Implement and adjust anesthesia based on patients physiologic response
- Properly prepare, dispense, and label all medications
- Adhere to appropriate safety precautions
- Monitor and document patients condition and response to anesthesia
- Precautions to minimize risk of infection
- Complete, accurate, and time oriented documentation
- Transfer responsibility of care to qualified personnel
What anesthesia equipment should be dedicated strictly for use in remote locations in regard to office based anesthesia?
An anesthesia machine and portable anesthesia cart with the listed equipment, supplies, and medications
What are some requirements for administration of anesthesia in remote locations?
Minimum of 2 oxygen sources, positive pressure ventilation sources, defibrillator, suction, battery powered flashlight (with spare batteries), warm blankets…
What type of anesthesia ensures amnesia as a standard of care?
ONLY general anesthesia
Although minimal, moderate, and deep sedation may offer amnesia, they also may not.
Before inducing your patient, what should you do?
REASSESS the patient (vitals, airway status, response to pre procedure medications)
All medications drawn up prior to the case must ______
Be labeled with drug name, strength (concentration), amount, expiration date (if not used within 24 hours), time, and initials of the individual drawing up the medication.
What is the universal protocol?
Protocols for preventing wrong site, wrong procedure, and wrong person surgery.
Anesthesia provider is an integral part of the team involved in this.
What 6 things must be monitored during anesthesia?
Monitor ventilation continuously, oxygenation continuously, cardiovascular status continuously, body temperature continuously, neuromuscular function, and patient positioning.
Heart rate and blood pressure should be measured and documented _______
Q1 min during induction, Q5 min during maintenance
How can anesthesia providers reduce the risk of infection?
Clean equipment regularly, maintain sterility of supplies, assure medications aren’t expired, tampered with, or open prior to use.
Protective eye ware and sterile/non sterile gloves should be available.
Baseline patient vitals should be assessed and documented ___________
Prior to the start of anesthesia (HR, BP, SpO2, Temp, and EtCO2)
How does anesthesia care end?
Transfer of care to a qualified health care professional by giving a comprehensive report. Document this including the receiving staff member
The ________ of any monitoring standard should be documented and the reason for such __________ stated in the patients anesthesia record.
omission, omission
Depth of sedation is a continuum of what three progressive alterations?
Alterations in cognition, respirations, and protective reflexes.
What are the 4 levels of sedations?
Minimal sedation, moderate sedation/conscious sedation, deep sedation/analgesia, and general anesthesia
At what level of sedation may airway intervention be required?
Deep sedation
At what level of sedation is the patient able to give purposeful responses with verbal or tactile intervention?
Moderate/conscious sedation
Children under the age of ______ seem to be at the greatest risk for adverse events even with no underlying disease when going under anesthesia
5 years old
What adverse event is most common in children under the age of 5 undergoing anesthesia?
Respiratory events –> Respiratory depression, respiratory obstruction, and apnea
Adverse events are reduced in surgeries less than ___________
1 hour long (pediatric patients)
Children of all ages should be NPO of clear liquids for _______ hours before undergoing sedation
2
What are the recommendations for the duration of NPO status for solid food and non clear liquids (infant formula, milk) in children?
Less than 6 months = 4-6 hours
6-36 months = 6 hours
More than 36 months = 6-8 hours
What are some of the most common causes of pediatric anesthesia adverse events?
Drug errors, laryngospasm/stridor, hypotension, prolonged sedation after the procedure
Aging is associated with a progressive loss of functional reserve in what organ systems?
All!
Why do elderly patients show a greater storage of lipid soluble anesthetic agents?
Aging process includes an increase in the ratio of adipose tissue to aqueous body tissue.
Dosage requirements are usually __________ in elderly patients
decreased –> liver and kidney function decreases with age
Why must the anesthetist be extra cognizant of ventilation in the elderly population?
Lung compliance decrease, the ability to respond to hypoxia and hypercarbia also decreases in this population.
How does cardioversion work?
A synchronized shock to the R wave of the QRS complex closes an excitable gap in the myocardium, which causes currents to reenter and excite the electrical system.
Optimal shock dose for cardioversion?
50-100 Joules. Can go all the way up to 360 if needed. Much less electrical energy is required to synchronously cardio-vert a patient when compared to asynchronous defibrillation.
Should patients be NPO prior to cardioversion?
YES, unless deemed an emergency
Where does the operator apply the cardioversion-defibrillator paddles?
Use conduction gel. One paddle or pad is placed parasternally (either side of the sternum) over the second or third intercostal space. The other paddle is placed over the apex of the heart.
What level of sedation is generally adequate for cardioversion?
Moderate/conscious sedation.
Deep or General RA PREFERRED
This can be achieved using ultra short acting general anesthetics such as propofol or etomidate (for low EF)
Midazolam NOT NECESSARY
Muscle relaxant is not necessary
What should be done if cardioversion is required in a patient who hasn’t fasted?
GETA to prevent aspiration of gastric contents
What is Radio Frequency Catheter Ablation? (RFCA)
Uses a catheter tip which is guided under fluoroscopy (continuous xray) to an area of heart muscle that has demonstrated accessory electrical conductive pathways, then destroying these pathways
This is the foremost therapy for treatment of many arrhythmias
How does Cryoablation work?
Can be used prior or in place of RFCA. Liquid nitrous oxide is circulated through the catheter tip to cause temps between -22 to -75 degrees C, permanently destroying arrhythmogenic tissue.
What is ice-mapping when using cryoablation?
Catheter probe is used to freeze tissue before it is permanently destroyed. This ensures area of tissue is responsible for the arrhythmia prior to destruction
In regard to cryoablation or RFCA, what type of anesthesia is generally used?
Moderate/conscious sedation with a local anesthetic applied by the operator.
Children may require general anesthesia with an LMA or ET tube.
Why is TIVA preferred during cryoablation?
Because the PA can become partially occluded during this procedure, this can decrease the uptake of volatile anesthetic.
Should the patient continue taking their antiarrhythmic medications prior to RFCA or cryoablation
No, also no lidocaine
What is an extremely rare, but life threatening complication that can occur during RFCA?
Thermal injury to the esophagus during RFCA of the LA. This can lead to ulcerations or an artrioesophogeal fistula.
Insertion of a esophageal temperature probe, and positioning of this probe is essential during RFCA.
How should the esophageal temperature probe be positioned?
The probe is alongside the esophageal tissues with NO space between them
What are some common RFCA procedural complications?
Bleeding, ECG changes, cerebrovascular accidents, cardiac tamponade, or damage to the aortic valve.
What are some common arteries and veins used for access in PCI?
Femoral/brachial/radial arteries, and the femoral vein
What type of anesthesia is generally used during PCI?
Patient dependent. Ranges from IV moderate/conscious sedation to general anesthesia, aided with local at the insertion site of the stent.
What is endoscopic retrograde cholangiopancreatography (ERCP)?
Used for the diagnosis of obstructive, neoplastic, and inflammatory pancretobiliary structures.
This method is decreasing however due to more less invasive and noninvasive techniques.
What type of procedure may be recommended for persistent and recurrent dyspepsia (heartburn)?
EGD
What is used in endoscope procedures to insufflate the gastrointestinal tract?
Air or CO2
Can pregnant patients undergo endoscopy procedures?
Yes, but elective procedures should be reconsidered and consulted with the patients obstetrician
What non sedative medication may be required for EGD’s?
Glycopyrrolate, anti-cholinergic that decreases production of saliva, also helps with vagal response
Lidocaine Bolus or gargle to ease pain down throat
How does vagal stimulation occur during endoscopy procedures and what would this lead to?
This can occur due to distention of the colon. Some findings include bradydysrhythmias, hypotension, and ECG changes.
What position do patients need to be in for a ERCP procedure?
Prone with head to the right –> Can also be semi-prone or slight left lateral decubitus position in some situations
EGD/Colonoscopy –> Left lateral decubitus
Patients undergoing ERCP are generally more ______ than patients undergoing EGD and Colonoscopy
ill
Propofol provides _________ amnesia, but little ___________ amnesia
anterograde, retrograde
After a colonoscopy, how is abdominal pain and distention relived?
Passing gas
What is ERCP morbidity most often correlated with?
Reactions to iodinated contrast media
What is the most common Artificial Reproductive Technology (ART) method?
IVF
What medications should be avoided in Artificial Reproductive Technology (ART)?
Morphine –> effects fertilization in sea urchins
Sevo and Des –> negative effects to ART outcomes
NSAIDS –> inhibits implantation
Metoclopramide/Droperidol –> induce rapid hyper prolactinemia
What type of sedation is generally adequate in ART?
Moderate/conscious sedation
Regional intrathecal, paracervical blocks, or GA can be administered.
What are some common risks associated with ART?
Increased risk of multiple gestations, atypical implantations, and smokers require twice as many attempts at successful IVF as non-smokers.
Smoking is DISCOURAGED!
IVF is generally preformed on what types of patients?
ASA class I-II in their 3rd-4th decade of life.
What is Essure?
Only method approved by FDA for hysteroscopic tubal sterilization. Occludes the fallopian tubes by stimulating tissue fibrosis and scarring.
Why are NSAIDS recommended in Essure procedures?
Decreases tubal spasms
What are some contraindications to Essure procedures?
Patient less than 6 weeks postpartum, contrast allergy, immunocompromised, PID, known anomaly…
What type of anesthesia is considered for Essure procedures?
Anxiolytics, oral narcotics, paracervical blocks
GA is considered to releive anxiety, control pain, and maintain immobility during the procedure.
What non-sedative medication should be given in dental procedures requiring anesthesia?
Glycopyrrolate. Excess salvation can lead to coughing, choking, laryngospasm, or aspiration in the sedated patient.
Intraoral local anesthesia is a __________ ___________
Cardiac depressant. This may cause either CNS depression or excitation
What is a papoose board?
An pediatric immobilization device that can be used to safely restrain the patient until anxiolytics can be given
Intranasal or rectal __________ can be used prior to GETA and has proven as effective as nitrous oxide.
midazolam
What nerve in dental procedures is most often responsible for pain?
Trigeminal
Nasal intubation is considered in dental surgeries due to _________
Sharing of the airway with the DDS
In dental anesthesia, local anesthesia in conjunction with higher concentrations than normal of epinephrine ensures __________
hemostasis
What is the purpose of a dental dam?
Prevent aspiration of dental burs and endodontic files
How does ECT work?
Causes changes in brain chemistry by causing enhancement of dopaminergic, serotonergic, adrenergic communication
Also causes an increase in seizure threshold and decreases seizure duration
What are some parasympathetic responses during a seizure?
Occur during tonic phase –> Bradycardia, hypotension, and bradydysryhthmias
What is an appropriate etomidate induction dose for ECT?
0.15-0.3 mg/kg IV
What is an appropriate propofol induction dose for ECT?
0.75-1.5 mg/kg IV
How is the tourniquet applied during ECT? Why is it applied this way?
Tourniquet is usually a manual blood pressure cuff applied around the lower extremity. It is applied slightly higher than systolic blood pressure. This causes the muscle relaxant to not reach this area below the tourniquet so you can observe the seizure.
What paralytic is generally given for ECT?
Succinylcholine –> this is used due to its rapid onset, short duration, and independent reversibility
What are some cerebral effects of ECT?
Increased CBF and ICP
What are some general effects of ECT?
Increased IOP, IGP, and hypoventilation
How much caffeine is given prior to ECT and what effect does this have?
500 mg IV, this PROLONGS seizure
What are some absolute contraindications to ECT?
Pheochromocytoma, recent MI (4-6 weeks), recent CVA (3 months ago or less), recent intracranial surgery (3 months or less), intracranial mass lesion, unstable cervical spine
How long do ECT seizures usually last?
30 - 90 seconds
A nerve stimulator must be used during ECT. What other medication is needed but may not always need to be used?
reversal agents (Sugammadex)
When should GETA be used in ECT?
Patients at risk for gastrointestinal reflux or hiatal hernias
What physiologic conditions can prolong seizures?
Hyperventilation and hypocapnia
3 types of impairments following ECT
Postictal confusion –> Restless, confused and agitated immediately after the seizure and 30 mins after. May be due to increased lactate level
Anterograde memory dysfunction –> rapidly forgets new information. Should subside in a few days - weeks
Retrograde memory dysfunction –> Loss of memories from several weeks to months prior of ECT
Difference between rTMS (repetitive transcranial magnetic stimulation) and MST (magnetic seizure therapy)
rTMS –> Produces bursts of pulses called “trains”. Current through electromagnetic coil on scalp to elicit convulsion. Evaluated by motor threshold of thumb or index finger
MST –> More intense than rTMS and longer in duration. Can be localized to the prefrontal cortex (works for MDD). Induces tonic clonic seizures that resembles ECT
Advantages of rTMS and MST over ECT
Faster recovery time than ECT
What is Vagal Nerve Stimulation?
A surgical implantation of a electrical stimulator that connects with the left vagus nerve in the patients chest. Originally approved for treatment of epilepsy, now can be used for major depressive episodes.
CT scans use _________ projected at different angles to give an overall picture
X-rays
CT are excellent for imaging _______. Quality can be enhanced with ____________
bone. Iodinated contrast
Good for visualizing vascular or GI studies
MRI is measured in _________
teslas
Can be anywhere from 0.15-4 teslas, but generally only 0.15-2 teslas
What contrast is used in MRI studies?
Gadopentetate dimeglumine –> Far fewer ADR’s to this contrast
What is Zone III of the MRI suite?
Restricted area. Movement in this area is controlled by MRI personnel. Access is only granted after screening for ferromagnetic objects.
Radiation surgery vs radiation therapy
Radiation surgery –> Delivery of a single massive dose of radiation
Radiation therapy –> Delivery of smaller doses of radiation over several sessions
1 tesla = _________ gauss
10,000
What is INR?
Diagnosis and treatment of CNS diseases.
Some procedures preformed with INR –> removal of emboli from stoke, occlusion of malformed vascular structures, embolization of cerebral vascular aneurysms
Adverse reactions are more likely to occur in what patients receiving iodinated contrast media?
Patients with asthma, history of allergies, or patients with multiple comorbidities
HOCM vs LOCM constrast
HOCM –> High osmolar, contains FEW dissolved particles and iodine particles causing a shift from the cells into the vein with the ICM. Cheaper and used more often
LOCM –> Low osmolar, closely iso-molar, less fluid shifts from the cell. FEWER REACTIONS WITH LOCM!
Can pregnant patients receive contrast for CT studies?
No
How to safeguard against renal failure when using contrast media?
Adequate hydration 1 hour prior to contrast and for 24 hours after.
Patients at risk for possible anaphylactoid reactions from contrast media should be pretreated with ________
Corticosteroids
Blood flow is __________ by strong magnetic fields produced during an MRI.
Decreased. BP compensates by rising so you may see HTN
During an MRI, large tissue loops (hand touching the hip or thigh) can cause what?
Can cause a current loop to from resulting in severe burns
What restrictions do pregnant anesthesia providers have in the MRI suite?
None
Preg/non preg should still practice remotely when scan is occurring
Any sedatives containing glucose should be avoided in what procedures?
PET scans. Isotope fluorodeoxyglucose is injected and absorbed into metabolically active cells. Must remain STILL one hour after injection.
Patient should be properly fasted to reduce blood sugar levels as well.
What are the goals of NORA no matter the environment?
Familiarity with the environment and to ensure this environment is as safe as the OR
NORA safety checklist before induction of anesthesia
When would you expect to see a purposeful response after repeated or painful stimuli?
Deep sedation
What drug can cause paradoxical excitation in pediatric patients
Benadryl
This has sedating effects in adult populations, but can actually cause the opposite effects in pediatric patients
What induction agent should be considered for cardioversion if the patient presents with a reduced EF (less than 49%)?
Etomidate
0.15-.03 mg/kg IV
What techniques may be utilized if IV insertion is not feasible for a pediatric dental case (name 4)?
- PO premedication (ketamine, midazolam, other narcotics)
- Inhalation induction
- Intranasal (midazolam)
- Rectal (midazolam)
these would likely be follow up by IV insertion and nasal intubation
Why are methohexital and etomidate not recommended when patients need to remain absolutely still?
- Methohexital, increases spontaneous muscle movement such as hiccups
- Etomidate, myoclonic movements
What are medications that shorten seizure duration? (Drugs to stay away from in ECT)
Diltiazem
Diazepam
Fentanyl
Lidocaine
Lorazepam
Midazolam
Propofol
Sevoflurane
What are medications that can prolong seizure duration? (Things to use when conducting ECT)
Alfentanil with propofol
Aminophylline
Caffeine
Clozapine
Etomidate
Ketamine
What is the MOST common side effect of contrast dye used within an MRI setting?
Nausea
For patients that received intrathecal anesthesia during assisted reproductive technology procedures, what 3 things are required before discharge?
- Recovery of sensation
- ability to ambulate
- ability to void
Why must protamine be delivered slow? When should it be avoided?
- Can result in hypotension.
- Avoid in patients with allergies to salmon sperm
Give 1 mg per 100 units of heparin
EP studies typically take how long?
Typically 6 - 10 hours
What anesthetic drug is primarily used during cardioversion? Which drug according to Dr. Elam has no use due to effectiveness of first drug/duration of procedure?
- Propofol
- Versed
What type of postoperative instructions should be given to elderly patients?
Verbal, written, AND to both the elderly patient and cargiver.
Aging increases the inability to respond to ___________ and ___________ especially when under anesthesia.
- Hypoxia
- Hypercapnia
When should temperature monitoring be used when? When is it a standard of care?
- When significant changes are intended and anticipated
- During general anesthesia
According to TJC, what defines “immediately” regarding your preanesthetic evaluation?
As in the moments “just” before sedation is administered
What is the mean age of patients undergoing non-OR procedures as compared to OR procedures?
3.5 years older
What are the postanesthetic considerations for patients following EGD or colonoscopy?
- Nausea/vomiting
- cramping/bloating/distention
- rectal bleeding
- dehydration (from bowel prep or NPO status)
In addition to the administration of moderate sedation, __________ may help to facilitate ease of upper endoscopy
Lidocaine bolus (per Dr. Elam) or gargled viscous lidocaine
Which GI procedure may be more likely to require general anesthesia due to patient positioning?
ERCP
* prone/semiprone/extreme left lateral compromises airway access and inhibits airway rescue if needed
What potentially life-threatening complication should you be on high alert for when a patient is undergoing RFCA with a transseptal approach?
- Cardiac tamponade
Triad –> Hypotension, tachycardia, narrowing pulse pressure
Symptoms associated with bowel prep for GI procedures may require the administration of _____________
IV fluids
* LR or NS
A patient is experiencing retrosternal, angina-like chest pain during RFCA - you know that this is _____________
A common side-effect, often lasting < 1-2 minutes
Patients must undergo ___________ before RFCA can be chosen as a therapy
Electrophysiological studies
Periodic patient assessment of what 4 things should occur at frequent intervals to ensure proper protective measures?
- eye protection
- skin integrity
- bony prominences
- extremity positioning
Name 4 reasons for decreased dosage requirements of anesthetic drugs in the geriatric population
- Greater storage of lipid-soluble anesthetics
- Decreased metabolism/excretion
- Cerebral atrophy suggests increased sensitivity to anesthetics
- Increased risk for perioperative delirium/postoperative cognitive dysfunction
What preprocedural assement findings might predict the result of airway compromise during sedation of the pediatric patient?
- recent URI
- fever
- cough
- snoring
- sputum production
In addition to the use of opioids in pain control, multimodal analgesia utilizes:
* ________
* ________
* ________
* ________
to augment analgesia
- acetaminophen
- gabapentinoids
- NSAIDs
- ketamine
Accepted standards for moderate and deep sedation state that equipment must be available to monitor:
1. ____
2. ____
3. ____
4. ____
5. ____
- heart rate via ECG
- respiratory rate
- adequacy of pulmonary ventilation (EtCO2)
- oxygenation via pulse oximetry
- blood pressure measurement
In cases of moderate or deep sedation, the AANA and ASA mandate the measurement of _____________
- End tidal carbon dioxide
All remote locations should have the ability to manage a variety of anesthetic procedures and should include what 6 things to provide safe patient care?
- equipment (e.g. monitors)
- emergency medications
- supplies (e.g. nasal cannula, mask, syringes)
- positive pressure ventilation
- resuscitation (e.g. defibrillator)
- suction
Avoiding GA if possible is appropriate in all populations, but especially in ____________ populations
geriatric
