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93 Cards in this Set
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- Back
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Standards for delivery of anesthesia in remote locations
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Perform a complete preanesthesia assmt
Obtain informed consent forthe planned anesthetic intervention from the patient or legal guardian. Formulate a patient specific plan for anesthesia care. Implement and adjust plan of care based on patient's physiologic response. Properly prepare, dispense andl abel all medicatins to be used for the patient....label with name strength, amt, and expiration date. Adhere to safety precautions, as est by the institution, to mimize the risks of fire, explosion, electrical shock, and equipment malfunction. Montior and document the patient;s physiologic condition as appropriate for thetype of anethesia and specific patient needs. Precaution shall be taken to mimize the risk of infection to the patient, operator and ancillary personnel. Complete and accurate and time-oriented documentation of pertinent information on the patient's anesthesia record. After the anesthetic tx, transfer the responsibility for care of patient to a qualified personnel in a manner that ensure continuity of care. |
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T/F: sedation has strict boundaries
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False - sedation can quickly progress from one level to another.
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What are some specific procedures in remote locations for which anesthesia may need to be given?
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Cardio:
- AID and pacer implantation: requires specific triggering of VF to test the limits of the device. Iso or halo + fentayl can increase threshold of stimulation needed. lidocaine and propofol does not. ETT may be required. Observe for ECG/hemodynamic changes after procedure. -Cardioversion: usually nonemergent, pt NPO, std ECG, monitor depth of sedation via eeg, give versed for sedation and amnesia beforehand, assist ventilatin via face mask and ambubag with high flow O2; ultra-short acting GA like propofol/thiopental/methihexital is given; once eyelid reflex gone all clear signal given and cardioversion done while pos-pr vent suspended. Muscle relaxatino not neccessary. If done on a non-NPO patient, ETT is necc to prevent aspiration. -RF catheter ablation: Moderate sedation for adults or GA for kids during pre-proc electrophysiological studies. Usually IJ or femoral artery is path used. Produces brief, retrosternal mild-mod anginalike pain. Short procedure. PATIENTS MUST REMAIN PERFECTLY STILL EXCEPT FOR RESPIRATORY MOVEMENT. Adults: moderate sedation/analgesia. Kids: general endotrach anesthesia with LMA or ETT. Full monitors and IV catheter a must. TIVA with propofol good choice; with ondanestron has much less risk of PONV. Pt must stop taking antiarrhymics preop. Percutaneous Coronary Intervention GI: -Colonoscopy, EGD, ERCP GYN: -Assisted Reproductive Technologies Office Based Surgery: -General Dental Procedures Pediatric Dentistry Oral and Maxillofacial Surgery Periodontics Endodontics General Denstistry and Prosthodontics Dental Hygiene Psych: -ECT -rTMS -Vagal Nerve Stimulatin |
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What are the considerations and treatment protocols for preventing IV contrast medium extravasation
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Considerations
Use IV catheters (not metal needles or butterflies) Avoid use of same vein if the first attempt at IV catheterization was missed. Ensure the IV catheter is patent and is free-flowing. Treatments: -Attempt to aspirate as much ICM as possible. -Elevate the affected limb -Apply ice packs for 20-60 minutes until swelling resolves. -may need heating pad vs. ice packs. -Observe patient for possible tissue damage r/t continual contact with icepack or heating pad. -Observe patient 2-4 hours before discharge - refer for med/surg tx prn. -F/U with patient assessing for residual pain, increased or dereased temptature, hardness, change in sesation, redness or blistering. |
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How long can a reaction to IV contrast medium take?
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Half hour to several days.
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How can the anesthesia provider minimize risk of allergic reaction to ICM?
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Assess for hx of allergies to contrast media in preanesthetic hx or increased risk (multiple medical problems, cardiac disease, preexisting azotemia, advanced age, pts being treated with nephrotoxic agents such as the aminoglucosides antimicrobials (-mycins) or NSAIDS. NEVER USE IN PREGNANT WOMEN!
Use smallest amount of contrast necc. Adequately hydrate patient 1 hr pre-procedure and for 24 hours post procedure. Pretreat those at risk with corticosteroids. If had moderate - severe rxn by hx, give H-1 histamine blocker (benadryl) and an H2 blocker together PO or IV. |
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T/F ICM is the most frequently used agent that causes anaphylactoid reactions.
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True.
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As little as how much ICM can initiate an anyphylactic reaction?
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1 cc
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What is the tx for anaphylaxtic reactions?
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MILD:
D/C causative agent immediately. Assess andaggressively manage the airway if necc. Diphenhydramine 50-100 mg IV Consider inhaled nebulized epi. (Primatene Mist) Continuously monitor and document VS, consider IVF. MOD - SEVERE -Terminate admin of causative agent. -100% O2 with ventilatory support -D/C all anesthetic meds immediately -Administer a wide open fluid bolus. -Give alpha-adrenergic agents as necessary to reverse severe hypotension. Epi in 5-10 mcg boluses or as IV gtt (.05-.1 mcg/kg.min titrated to effect for acceptable BP Norepi gtt of 0.5-30 mcg/min IV for SBP < 70 torr Dopamine 5-15 mcg/kg/min IV for BP 70-100 torr with signs and sx of shock Dobutamine 2-20 mcg/kg/min IV for SBP 70-100 torr with NO s/sx of shock. -Bronchodilators prn -Aminophyllilne 5-6 mg/kg -Corticosteroids may help some with BRONCHOspasm but not know to be hel pin acute anaphylactoid or anaphylactic reaction -Continuously monitor and document patient VS. |
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What are the s/sx of anaphylaxis?
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CV - dizziness, malaise, confusion, retrosternal pressure, diaphoresis, hypotension, tachcycardia, dysrhythmias, reduced SVR, pulmonary hypertension.
Cutaneous - pruritis, burning, tinglin, urticaria (hives), angioedema, erythema (redness, flushing), periorbital and/or facial edema. Respiratory - nasal stuffiness, dyspnea/tachypnea/acutre resp distress, chest tightness, intercostal and/or substernal retractions, coughing/sneezing/wheezing, perioral and /or intraoral edema, laryngeal edema or stridor, cyanosis, reduced pulmonary compliance, pulmonary edema Other - aura (feeling of doom), nausea, abdominal pain, vomiting, diarrhea, acute intravascular coagulation. |
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Do uncooperative children undergoing MRI do better with sedation or GA?
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GA with ett despite longer recover times...better stillness for image.
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Are opioids use with MRI?
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Not usually. Not painful.
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T/F: minimal sedation does not require full monitoring.
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FALSE: minimal sedation requires full monitoring.
**Deep sedation requires IV access and full monitoring. |
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T/F: AS newer more powerful MRIs come out, more everyday objects are safer to take into the MRI room.
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FALSE: With more powerful magnets, previously safe items can become missiles.
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What metals are safe within the MRI bore?
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Stainless steel, nonferrous alloys, nickel, titanium
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What are the s/sx (lecture) of anaphylaxis?
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Mild: nausea, pruritis, diaphoresis
Moderate: faintness, emesis, urticaria, laryngeal edema, bronchospasm Severe - seizures, hypotensive shock, respiratory arrest, cardiac arrest. |
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What compounds are most commonly assocaited with anaphylaxis?
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Iodine containing compounds.
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What type of ICM is associated with less anyphylactic risk?
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Gadolinum
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Prohylaxis for anyphylaxis?
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Steroids and antihistamines
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What is the number one reason anesthesia is needed during noninvasive procedures?
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Provide immobility
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T/F: Pregnant women are contraindicated in MRI suites?
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False
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Why should IV lines and leads be kept in straight alignment in MRI?
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Because a magnetic field can cause coiled lines to heat up...burn risk
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T/F: flexible LMAs and ett with wire windings are MRI safe?
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False - they can heat up and become a source of heat injury.
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What is a common SE of gadolinium chelates?
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Nausea
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Why is anesthesia useful in PET scan?
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Patient has to lie still for an hour. Glucose can alter results...avoid dextrose based/sugar containing meds.
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What are some anesthetic considerations and concerns for reducing morbidity and mortality during anesthesia in remote locations?
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-Small and unfamiliar surroundings for the anesthetist.
-Inadequate access to patient -Lack of adequately trained ancillary personnel -Insufficient staffing -Insufficient lighting -Ltd. electrical supply -Hypothermia -Hypovolemia -Allegies and/or anaphylaxis -Aspiration -Airway mgmt difficulties. -Pain -Post-procedure N/V -Awareness -Lack of scavenging of waste anesthetic gases. |
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t/f: Interventional Radiology procedures are painful, invasive to the patient and may need to be done over several sessions.
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True - except angiography and radiotherapy
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Why is the trend moving towards a GA in IR procedures?
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B/C of superior image quality with motionless patient.
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How is patient monitored during intraoperative radiation therapy?
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Via closed circuit video with hands off anesthesia during the tx.
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What are the s/sx of hemorrhage in a sedated patietn?
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Sudden HA, N/V and vascular pain.
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What are the s/sx of hemorrhage in a patient under GA?
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Sudden bradycardia.
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What do you do if your patient experiences hemorrhage during intraop radiation tx?
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Secure the airway
Support CV system D/C heparin and give protamine (1 mg/100 units adminstered) |
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What is the top intraoperative risk during interventional radiology?
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Hemorrhage
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Who gets IR?
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Infants to geriatrics in a range of health.
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When you are doing aneesthesia in remote locations....what should you always know the location of?
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Crash Cart
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What does anesthesia involve for ECT?
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Administration of an ultra brief GA for lack of consciousness.
Sux, Cisatracurium, Atracurium, Rocuronium |
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T/F: ECT lowers the seizure threshold.
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False: ECT produces anticonvulsant effects that raise the seizure threshold and decrease seizure duration, exerting a positive effect on the brain.
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Absolute contraindications to ECT
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Pheochromocytoma
MI w/in past 4-6 weeks Cerebrovascular accident (<3 months) Recent intracranial surgery (<3 months). Intracranial mass lesion Unstable cervical spine |
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Relative contraindications to ECT
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Angina
CHF Cardiac rhythm mgmt device Severe pulmonary disease Major bone fracture Glaucoma Retinal detachment Thrombophlebitis Pregnancy |
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What are some reasons anesthesia in remote locations is on the rise?
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-Dev. of large complex equipment that cannot be moved to OR.
-More surgeries being done in clinics and off-hospital sites to contain costs. |
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What are the three components of the 3step paradigm to anesthesia at an alternate site?
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the Patient, Procedure and Environment
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Three-step approach
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1 Environment - Anesthesia Equipment, Anesthesia monitors, Suction, Resuscitation Equipment, Personnel, Technical equipment, Radiation hazard, Magnetic Fields, Ambient Temp, Warming blankets
2. Procedure - Diagnostic vs Therapeutic, Duration, Level of discomfort or pain, Position of patient, Special requirements, Potential complications, Surgical support 3. Patient - Ability to tolerate sedation vs. GA, ASA grade and morbidity, Airway assmt, Allergies - esp to IV contrast, Monitoring requirements - simple vs. advanced. |
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Why does the anesthetist need to be familiar with the procedure?
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So the anesthesia plan can be developed with patient need, duration of anesthetic, level of pain anticipated and special requirements of the anesthetist in mind.
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Describe the tonic and clonic phases of ECT:
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Tonic phase generally lasts 10-15 secs and involves a parasympathetic bradycardia and hypotension.
Then the clonic phase (sympathetic) lasts 30-60s and involves tachycardia and HTN. Min duration of seizure for effectiveness = 20-25 seconds. |
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The ASA closed claims study involving remote anesthesia revealed that:
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The #1 claim was inadequate ventilation/oxygenation (difficult airway, inadequate airway equipment, unrecognized hypoventilation)and could have been prevented with pulse-oximtery monitoring.
Other factors were: Most cases were MAC cases Extremes of Age Substandard Care |
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How can distance from the patient be a factor?
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May not be able to do an ongoing physical assessment.
Difficulty monitoring adequacy of ventilation. Low pt. satisfaction b/c anesthetist not close enough to recognize need for pain control. Neonates: extubation vs R mainstem is a matter of mm. Peripheral nerve injury is possible s/t unrecognized malpositioning. |
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Are sedation levels static?
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No - they fluctuate and the provider needs to be proficient in rescue if patient becomes too deep.
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After an anesthetic in a remote location, where should the patient go?
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To a post anesthesia care unit or similar setting.
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The use of what type of contrast media reduces risk of allergic rx?
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Low-osmolar, nonionic contrast media.
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What is CN/
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Contrast-induced Neuropathy - 3rd leading cause of hospital acquired renal failure.
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How can CN risk be minimized?
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Adequate hydration and bicarb infusions 1 hr before procedure.
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What patients are more prone to contrast reactions?
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Those with atopy (production of IgE in response to common allergens) and shellfish allergies.
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How can ionizing radiation exposure occur?
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Direct source
Leakage from equipment Scatter from equipment |
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What are the most intense sources of ionizing radiation?
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Most - fluoroscopy (>75,000 mrem)
Middle - CT (170 mrem head, 680 mrem abdominal) Lowest - CXR (8 millirem) |
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What is the maximum annual occupational exposure limit?
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5000 mrem
50 msv |
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How many msv are in 1 mrem?
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1 millirem = .01 milliseiverts
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What anesthetic considerations must occur during an angiogram?
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Secure extensions on circuits and lines and monitors so they won't get dislodged as radiologist swings xray back and forth.
Little metallic coils in ett and radiopaque EKC pads can produce annoying artifact. Hypotension and bradycardia can occur during injection of the contrast media. |
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What are some anesthesia considerations for interventinoal neuroradiology?
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Anticoagulation required during and up to 24 hours post procedure (3000-5000 initial bolus, followed by infusion) for clotting time 1.5-2..5 patient baseline.
Concern over air embolism from femoral sheath. Hematoma or hemorrhage from femoral artery puncture. Be prepared to treat severe bradycardia or transient asystole 2 catastrophic complications are intracranial hemmorhage and thromboembolic stroke. |
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What anesthesia techniques are suitable for interventional radiology?
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GA - w/ett or LMA
Conscious sedation (Dex may be a good choice here b/c of its lack of resp depression) May have to manipulate blood pressure and control ETCO2. Controlled hypotension used to facilitate emobolization of AVMs. Phenylephedrine good choice to maintain moderate hypertension for maintain CPP Sleep-awake-sleep: uses propofol infusion so patient can waken for neuro assmt mid procedure before being sedated again. |
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What is an absolute contraindication to RF ablation?
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Presence of a cardiac pacemaker.
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What is the strength of MRIs measured in?
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Tesla; clinical MRIs generate a field of .15-2.0 tesla
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What is the meaning of gauss line?
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The field around an MRI in which electrical equipment will malfx is measured in concentric rings known as GAUSS lines.
5 gauss line = point of cardiac pacemaker failure 30 gauss line=point of safety for most infusion pumpts. 50 gauss line = point where ferromagnetic gas cylinders become lethal missiles. - |
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Aside from removing all ferrous metals from the room and your own person, what precations should be taken when performing anesthesia for a patient getting an MRI?
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-Realize that EKG is sensitive to magnetic fields and changes will appear on monitor.
-Keep lines and cables straight. Insulate lead from patient's skin. These all can heat up and cause thermal injury during MRI. -Long sampling tubes for capnographs and anesthetic agent monitoring if no MRI compatible ones are avail. -Hearing protection for patient and anesthetist (noises are as high as 90dB) - |
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Where should resuscitation attempts take place in MRI?
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Away from scanner - b/c many rescue devices/equipments are ferrous alloys
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T/F: Children who have GA for MRI have fewer complications.
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True
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Is PO oral chloral hydrate effective for children getting MRI?
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Yes
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T/F: sedation withi IV propofol infusion, O2 via NC + ETCO2 monitoring is effective for children getting MRI.
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True - initial sedation with 3mg/kg propofol with or without midazolam 0.2-0.5mg/kg then maintained at propofol 1-3mg/kg/hr. Boluses of 1mg/kg prn.
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What are some attendant issues among patients who are undergoing intraoperative radiation therapy for cancerous tumors?
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nutritional deficiency, dehydration, lyte imbalances and coagulopathies complicate the anesthesia.
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What is a challenge to the anesthetist in interventional intraoperative radiation therapy.
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Have to leave the room....have to do remote anesthesia...have to monitor remotely
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What is the (per lecture) average annual dose of radiation exposure?
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around 3 milliseverts
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How many millisieverts does a CXR provide? A CT scan? (from PP)
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0.04 mSv per CXR
2.0 mSv per CT scan |
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Per lecture, what is the annual occupational radiation exposure limit?
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50mSv
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T/F: Ketamine is useful for children who have myocardial depression for sedation?
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True - useful when used with propofol in an infusion
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What anesthetic drugs do not interfere with cardiac conduction during electrophysiological procedures?
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Inhalational agents & propofol.
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Why is propofol good in kids undergoing RF ablation?
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B/C these kids are prone to vomiting...propofol decreases that and keeps them still.
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Should the anesthetist be prepared to assist in cardiac pacing or cardioversion during RA procedures?
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Yes - pt's likely to experience dysrythmias
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What type of anesthesia is required for cardioversion generally?
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A small bolus of any currently available IV induction agent generally suffices.
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If patient is undergoing a TEE, will a NC suffice for O2 delivery?
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Yes - generally the patient can maintain his/her own airway during the procedure.
If patient needs deeper sedation for TEE, LMA + LTA to oropharynx with propofol sedation works well. |
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Do you need a biteblock with TEE?
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Good idea - pt can bite and injure self/probe.
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What increases aspiration risk with TEE and Upper GI endoscopy?
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Local anesthetic sprayed onto orppharynx to facilitiate passage of instruments.
Upper GI done prone or semiprone. |
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If a patient is having an ERCP with manometry, what meds should you avoid?
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glycopyrolate, atropine and glucagon...they effect sphincter of Oddi pressure.
If S. of Oddi spasms, relief is good with naloxone. |
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Methohexital, etomidate and propofol are considered good induction agents for ECT. What are the pros and cons of each
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Methohexital 1-1.5 mg/kg is good, but produces does dependent siezures.
Etomidate 0.15-0.3mg/kg is associated with a longer seizure, but also myoclonus and delayed recovery. HTN and tachycardia can be accentuated b/c it doesn't depress the CV system. Over repeated ECT tx, adrenal suppression can occur. Propofol attenuates the body's acute hemodynamic response to ECT, but tends to shorten siezure duration. Keep doses small and this is not generally a problem Remifentanil + induction agent can reduce dose of agent needed and produce good seizure results. |
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Why are NMB agents used during ECT?
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To prevent MS complicatons like fractures or dislocations.
Sux is most common. |
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What drugs increase the seizure threshold in ECT (undesirable)?
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Benzos, barbituates
Propofol can, but when combined with brevital works well.. |
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What is a problem using etomidate for ECT?
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Adrenal suppression over repeated sessions.
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Esmolol and labetalol both attenuate the hemodynamic response during ECT - which one has a distinct advantage?
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Esmolol - it has a lesser effect on seizure threshold.
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Are alpha-2 receptor agonists helpful in ECT?
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Yes, when given over 10 min just prior to ECT both clonidine and dexmedetemodine effectively control BP without affecting seizure threshold.
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What is important to remember about transport ventilators when doing anesthesia in a mobile location?
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They are O2 driven...know how much you have in your cylinder.
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What is the half-life of heparin?
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90 minutes
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How do you give IV heparin?
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As close to the IV as possible, aspirate first to ensure patency of IV. Always double check heparin with another provider.
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What part of anticoagulation is the anesthesia provider responsible for?
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Administering heparin and checking coags.
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What med is critical to give if you have a severe anyphylactic reaction?
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Epinephrine
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What are some H1 blockers?
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H1 receptors tend to produce the symptoms already listed and activate allergic reactions.
H2 receptors tend to act as negative feedback receptors and turn the allergic reaction off. They also activate the acid-producing, parietal cells of the stomach lining H1 Blockers: Dimenhydrinate (Gravol) 50-100 mg qid Diphenhydramine (Benadryl) 25-50 mg qid Alkylamines Chlorpheniramine (chlortipalon) 4 mg tid Dexchlorpheniramine 2-4 mg tid Phenothiazines Promethazine (Phenergan) 10-25 mg bid Piperazines Hydroxyzine (Atarax) 10-25 mg tid Piperidines Cyproheptadine (Periactin) 4 mg tid Azatadine (Zadine) 1-2 mg tid |
