2.2 Anesthesia For Remote Locations

Front 1

List some standards for Remote Locations:

Back 1

Primary & backup O2
Suction device
Scavenging system
Ambu bag
Anesthesia drugs & supplies
Monitoring Eq.
Emergency power outlets & lighting (generator)
Access to pt, machine & support eq.
Crash cart(defibrilator)
Immediate access to anesthesia personnel

Front 2

Name areas you will be exposed to Radiology?

Back 2

MRI
CT
Interventional Radiology

Front 3

MRI: Special patient considerations with who you bring to MRI?

Back 3

ICU pts
pts w/ claustrophobia
confused pts
pediatric pts

Front 4

What concerns with acoustics should be considered in MRI?

Back 4

Very loud 95dB, may lead to tinnitus (ears ringing) or temporary hearing loss

Front 5

Why do NAs prefer to use general rather than sedation?

Back 5

Failure rate w/ sedation = 15%

Front 6

What are some anesthetic choices for MRI patients?

Back 6

Sedative:
Oral or rectal (highly unpredictable)
IV conscious sedation (demerol & versed admin per RN)

Front 7

What are some contraindications of anesthetic choice in MRI pts?

Back 7

Inc. risk of aspiration
Airway obstruction or resp irregularities, inc. ICP (PaCO2)
Renal or hepatic dysfunction
Unpredictable drug effect (adverse effects:restlessness)

Front 8

What are some other considerations with anesthetic choice when dealing with MRI pts?

Back 8

Inc. morbidity w/ sedation (age associated)
ASA class
Use of benzodiazepines as the sole agent
Risks associated w/ sedation despite clinician belief
General anesthesia results in stable, controlled situation when anesthesia team present

Front 9

What are some drug choices for MRI pts?

Back 9

Chloral Hydrate (oral or rectal)
Midazolam/Versed (careful when combining w/ opioids) Antidote=flumazenil (Anexate)
General anesthetic setup

Front 10

What is required for anesthesia/vent patients in MRI?

Back 10

Special equipment - huge cost $$ so not many institutions have this set up

Front 11

What options are available for anesthesia & MRI pts?

Back 11

Compatible machine w/ a pressure vent to drive the bellows (complete machine checks required)
Bird vent for driving pressure

Front 12

Who may need CT?

Back 12

Needle guided biopsy
Detection of aneurysm via CTA

Front 13

Consideration for CT?

Back 13

Regular anesthesia eq. is ok
You must leave the room during imaging secondary to radiation (bad: limits access to pts airways)

Front 14

Some concerns w/ Interventional Radiology?

Back 14

Ares of interest are:
Neuroradiography (Diagnosis & treatment of cerebral aneurysms
Peripheral Embolizations of Distal Vessels, tumors, epistaxis (nose bleed)

Front 15

Concerning Aneurysms & IR?
What are some %?
What are two types?

Back 15

80% anterior circulation
20% posterior circulation
1% risk of rupture depending on size & location

Saccular (berry) most common, bulge in the side wall of the aneurysm
Giant - may be saccular or fusiform, more than 2.5cm diameter

Front 16

What is an angiogram?

Back 16

Catheter is passed through as artery to the vessels of the brain
Contrast is injected & x-ray taken to determine the size & treatment options

Front 17

What is Endovascular Coiling & what type of aneurysm is it performed on?

Back 17

Pt usually under general anesthesia and closely monitored (arterial line some cases).
Minimally invasive where a catheter is passed from femoral artery to the aneurysm & Neuroradiologist packs it w/ platinum coils to prevent blood flow into it.
Saccular (Berry)

Front 18

Other procedures where CT & anesthesia may be associated?

Back 18

Pts w/ Epistaxis (nonresolved)
Tumors that have vascular component

Front 19

What are some cardiovascular procedures anesthesia may be required?

Back 19

AICD/Pacer insertions (treatment of dysrhythmias) transvenous approach -- AICD-GETA preferred d/t potential life threatening cardiac dysrythmia (arterial line required)
Cardioversion (brief GA or conscious sedation; etomidate or propofol) - Very little recall; used on new dysrhythmia (A-Fib; SVT)

Front 20

What is electroconvulsive therapy (ECT) purpose & its effects? WHy may anesthesia be needed?

Back 20

Produce gen. seizure for treatment of psychiatric Dx (Depression)
Inital: Central parasympathetic centers are activated leading to bradydysrythmais & poss sinus pause.
Later: sympathetically mediated inc. in BP & HR

Front 21

How are pts positioned for ECT?

What should the setup include?

Back 21

Supine

Standard monitors, inc. nerve stimulator & isolation of one extremity w/ a 2nd BP cuff or tourney
Standard intubation eq.

Front 22

How is the ECT procedure done?

Back 22

Glycopyrolate pretreatment
Induction w/ STP, etomidate, Brevital or propofol & succs
Mivacurium (if pseudocholinerterase deficiency possible)
Labetalol (prior for BP)
Rubber bite block & hypervenilate
Disorientation postictal

Front 23

What are absolute contraindications of ECT?

Back 23

Recent MI (cardiac events 67% related deaths)
Pheochromocytoma (adrenal tumor)

Front 24

What are relative contraindications of ECT?

Back 24

Aortic aneurysm
CHF
Angina
Thrombophlebitis
Inc. ICP (recent CVA or neuro procedure)
Retinal detachment

Front 25

ECT study by Wajima et al?

Back 25

Verapamil adm IV mg/kg reduced the inc. in peak HR & MAP postictal
Did NOT reduce the duration of the seizure

Front 26

What is ERCP?

Back 26

Endoscopic retrograde cholangiopancreatography

Front 27

What are the levels of sedation per ASA & JCAHO?

Back 27

1. Minimal sedation
2. Moderate sedation/analgesia
3. Deep sedation/analgesia
4. General anesthesia

Front 28

Considerations w/ monitoring anesthesia & ERCP?

Back 28

If Deep sedation required - physician must be able to rescue pt from unintended general anesthesia (tube/BVM).
Few gastroenterologists will take general anethetic responsibility.
CRNA may be supervised by operating practitoner.

Front 29

What are other considerations w/ ERCP?

Back 29

Pulse Ox - NOT substitute for monitoring ventilatory function
Standard induction (ETT secured d/t endoscope in throat)
Oral topical anesthetics (gag reflex & decr. aspiration risk
Crash cart in suite
Positioning is typically prone

Front 30

What pts might require anesthesia for Radiation therapy?

Back 30

Young children.
Claustrophobic adults.

Front 31

What is Radiation Therapy?

Back 31

Sharply defined beams used to irradiate tumor volume & spare normal tissue.
Movement must be minimized or other tissue may be at risk.
Simulation required to plan the direction of the beams, amount of radiation & # of treatments

Front 32

List 2 facts about XRT & children.

Back 32

Children <2.5 y/o require anesthesia.
Children >3 y/o can usually be coerced into lying still but the planning phase takes longer & may not be tolerated (esp if mask/cradle immobilization device formed)

Front 33

What are some of the tumors that many be address by XRT?

Back 33

1. Neuroblastoma.
2. Medulloblastoma.
3. Ependymoma.
4. Germ cell tumors
5. CNS leukemia.

Front 34

How is positioning handled w/ XRT?

Back 34

Must accommodate optimal position for XRT & anesthesia provider.
CSI: prone w/ head flexed to minimize cervical lordosis (special device to help)

TBI:
Adults - standing
Children - lit prone & supine & lung fields may be blocked w/ lead (avoid irradiating lungs w/ shield above the child)

Front 35

What shoud be addressed XRT Preprocedure?

Back 35

Establish good rapport (adult/child)
NPO importance (clear liquids: 2hr; breast milk: 4-6hr; Milk/Solids: 6-8hr)

Front 36

How should you evaluate XRT Preprocedure pts?

Back 36

Systematically
Acute ARI: risk vs. benefit basis
Delay Treatment: excessive runny nose, fever & cough

Front 37

Intraprocedure aspects of anesthesia w/ XRT?

Back 37

Anesthetic brief & permit immobility w/o resp or cardiac compromise.
IV, inhalation & IM successfull used.
PICC & mediport insertion d/t daily treatment ("Noodle" accessed Mon & removed Fri after treatment)

Front 38

Monitoring XRT involves what?

Back 38

Standard monitors & O2 insufflation via mask or NC (for Peds= "glow" or "princess finger" & "muscle tester")

Front 39

Standard medications for XRT involve?

Back 39

Propofol: 1.5-2 mg/kg slowly w/ maintan infusion (50-100 mcg/kg/min)
Mask inductions w/ Sevoflurane (requirements?)

PBT bias: Propofol1mg/kg w/ Ketamine 1 mg/kg & titrate; Pretreat glycopyrrolate 0.01 mg/kg

Front 40

XRT steps should flow how?

Back 40

Smoothly:
1. Let child get the noodle out, clean it w/ betadine (no needles: glycopyrrolate, then ketamine/propofol mix, then zofran 100 mcg/kg, attach to infusion & drip/titrate

Front 41

What is a possible infusion for children when XRT monitoring?

Back 41

Propofol diluted 2:1 (200mg in 100cc NS).

OR

Propofol (above mixture) + Ketamine 0.2mg/cc (20mg in 100cc NS)

Midazolam??????

Front 42

XRT recovery entails what?

Back 42

You must recover pt or take them to PACU.
Monitors & pts must sit & control head before dischargin home.
Tell parents to watch for S&S & seek immediate help is necessary.

Front 43

Emergency intubations can occur where?

What kind of pt may require this?

Back 43

Anywhere in hospital. (Floor, ICU, ER, Trauma bay, Pre-op, etc)

Respiratory Distress.
Cardiac Arrest.
Trauma
ETT change (leaking cuff)

Front 44

What eq. should you have for STAT intubations?

Back 44

Code box (bag) in department AKA Airway box
Code Kits (crash cart)
Drugs

Front 45

How should emergency intubations be done?

Back 45

As quickly & effiectly as possible (PMHx, Labs, Allergies, other)
Decide plan bases on situation (drugs/no drugs)
Difficult airway algorithm

Front 46

Considerations for Respiratory Distress?

Back 46

Gas exchange & will quickly desaturate
Secretions
BMT, platelet count (low?) which can lead to pliable tissues bleeding
Oxygenate as much as possible & intubate.

Front 47

Cardiac arrest considerations?

Back 47

Unusual places.
Drugs for sedation not necessary.
ETT placement (BSS vs EtCO2).
Know your role - Who is leading the code?

Front 48

What do you address w/ Trauma patients?

Back 48

Assess quickly & maintain C-spine.
Induction meds when appropriate
Intubate & confirm.
Chest x-ray
Document (brief events, blade type, visualization, EET size, Secure @ xxmm, CXR, Placement verified by Radiology, Care/report to _____

Front 49

What involves changing out an ETT?

Back 49

Usually in ICU
Assess situation, reason for exchange
Cook exchange cath or bougie
Be caurful removing & replacing ETT, once out, revisualization may be difficult
Document