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Flashcards in Remote locations 2 Deck (28)
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What is the trend in office based procedures?

  • 17% of procedures occur in offices now- becoming more popular
  • Standards and QI are not as well defined as they are in hospitals
    • credentially procedures vary
  • no prospective randomized studies exist
    • some evidence suggests morbidity and mortality higher in office based procedures compared to ambulatory care


What was the difference between ambulatory and office based insurance claims?

  • Office based claims were more severe (leading to death) and more were avoidable


What are major causes of morbidity and mortality in offices?

  • overdose of LA
  • overdose of sedatives
    • use reversals with short half-lives
  • "occult" blood loss
  • PE
    • standards of prophylaxis met?
  • MH- no dantrolene or not enough in the office
  • hypovolemia
  • hypoxemia
    • airway obstruction, bronchospasm
    • inadequate monitoring, unrecognized esophageal intubation


What are 3 major causes of mortality in the office?

  • Over-sedation
  • inadequate monitoring
  • thromboembolic events


How do you determine if pt is appropriate for an office case?

  • ASA I and II
  • ASA III anesthesia pre-procedure consult and only for local and NO sedation
  • +/- OSA in office
    • avoid GA and opioids


What are other important considerations with office based care?

  • surgeon has ownership of practice
    • who makes decision and provides the supplies, equipment, and medications?
  • Surgeon- must have license, DEA #, insurance, and privileges at local hospital or comparable proof of adequate training
  • QI program- should include surgeon, anesthesia, nurses, support staff
  • medical records- 5-7 years of secure storage for pre op assessment, anesthetic record, consent, post-op


More considerations for office based care

  • controlled substances in double locked storage cabinet
    • must meet DEA, local, and state regulations
  • ACLS/PALS certified professional must be available until pt discharge
  • 1 hour firewall
  • need emergency generator battery back up for all electronic equipment
    • 1.5 hours back up minimum


What kinds of situations do you need an emergency plan for?


If you provide anesthesia in an office based setting, make sure you have medications and equipment for:

  • MH
  • LA toxicity
  • difficult airway
  • fire
  • regular schedule to replace expired agents and service equipment


What is the deal with Tumescent lidocaine?

  • Much larger volume of LA is injected into the cutaneous tissue where there is less vasculature
    • 1-4 cc per 1 cc fat
    • LA is much more diluted (0.025%-0.1% with NS/LR and 1:1,000,000 epi
    • peak serum LA is 12-14 hours later
    • max Lidocaine dose with this technique is 35-55 mg/kg
  • EBL is 1% of total volume of fat suctioned
  • limit liposuction to 5000 ml apirate of fat/fluid


What kinds of procedures are done in interventional cardiology?

  • Coronary angiography
  • cardiac catheterization
  • PCTA/Stenting
  • closure of cardiac defects (pediatrics)
  • percutaneous valve replacements
  • electrophysiologic studies
  • ablations
  • cardioversions


What is coronary angiography?  

How is it done?

  • Performed by passing a catheter retrograde through the aortic root and injection of contrast media into the ostia of the coronary arteries
  • Catheter is inserted via the femoral, brachial, or radial artery
  • Used to detect CAD, measure stenosis, and coronary spasm


What are the risks of interventional cardiology?

  • Hemorrhage
  • infection
  • ischemia
  • cardiac ischemia
  • coronary dissection
  • thrombembolic events
  • contrast related reactions
  • Anesthesia must be ready for an emergency!


How is the anesthesia managed for IR cardiology?

  • GA or sedation/analgesia
  • supplemental O2
  • ASA monitors
  • arterial BP vs non invasive
  •  IVs with extensions
  •  foley
  • monitor temp


What are common meds used in IR cardiology?

  • For anesthesia:
    • midaz
    • fentanyl
    • propofol
  • sublingual or IV nitroglycerin- for ischemic changes
  • heparin/protamine
  • provocative agents- to promote spasm
    • Ergonovine maleate or methylergonovine maleate
  • Diltiazem
  • Emergency resuscitation drugs and equipment


Considerations for IR Cardiology in pediatrics?

  • Usually require GA 
  • Midaz 0.5 mg/kg or inhalation induction
  • maintain oxygen saturation at baseline levels
    • may have shunting and live at lower level
  • blood loss is less tolerated
  • hematocrit monitored frequently and anemia treated
  • monitor for hypoglycemia and hypocalcemia
  • warm the room
  • sinus bradycardia (due to parasympathetic dominated responses)- use atropine
  • air bubbles very dangerous with intracardiac shunting


Electrophysiology studies:

When are they done?

How is it done?

Anesthesia requirements?

  • Done for somebody with arrhythmias that arent being treated effectively pharmacologically
  • Patients stop antiarrhythmic drugs before the study
    • cardiologist will provoke the dysrhythmia they want to ablate
    • cardioversion via cardiac catheters or external defibrillation pads
  • Sedation is used with brief periods of general anesthesia
  • GA is preferred to keep pt still during mapping
    • long procedures (4-8 hours)
    • VA and/or propofol 
    • no muscle relaxant because phrenic nerve monitoring is required.


Pacemaker insertion:



  • Anesthetic:
    • sedation/analgesia
    • may need period of GA for insertion of internal defibrillator
  • These patients can be hemodynamically unstable
    • A-line if EF < 20%


What is elective cardioversion used for?

  • Used to convert supraventricular and ventricular arrhythmias to sinus rhythm by the delivery of synchronized direct current electric shock
    • used when medications are not successful
    • Can be done emergently (when pt is unstable)or electively
  • This is very uncomfortable. almost always use GA


How is Cardioversion done?


  • GA is required- it is very uncomfortable
    • usually propofol with NC/natural airway and ambu bag back up
  • May require pre-procedure TEE to assess for clot formation in atria
    • increases procedure/sedation time
  • Standard ASA monitors
  • assess cardiovascular status and medical therapy
  • NPO status


What equipment do you need for cardioversion?

  • full GA set up
  • intubating equipment
  • medications
  • supplemental O2 and method of positive pressure ventilation
  • suction
  • resuscitation equipment


What are the steps to cardioversion?

  1. pre-oxygenate with 100% O2
  2. small incremental doses of IV anesthetic until osss of lid reflex
  3. assess for unconsciousness, mask is removed. ALL CLEAR
  4. Synchronized countershock administered
  5. monitor rhythm closely
  6. manually ventilate/support airway until return of spontaneous ventilation
  7. remain with the patient until awake and alert
  8. sign off patient to ICU nurse ACLS trained


Electroconvulsive therapy:

What is it used for?

  • Major depression
  • PTSD
  • mania
  • schizophrenia
  • parkinson's syndrome
  • usually used when pt has failed all other therapies
    • side effects and risks


How is ECT done?

  • Programmed electrical stimulation of the CNS to initiate seizure activity
  • 2 electrodes applied to patient's scalp
  • series of electrical pulses at precise energy levels are delivered to induce a seizure
  • treatments 2-3 per week until improvement (usually 10-12)
  • seizure activity causes initial parasympathetic discharge followed by intense sympathetic discharge
    • seizure needs to be at least 25 seconds, usually last a couple of minutes


What are some problems associated with ECT?

  • Increased ICP
  • dysrhythmia
    • ischemia
    • stroke
  • severe muscle movement (give succs to prevent injury)
  • memory loss around the event


What are some contraindications for ECT?

  • Pheochromocytoma
  • increased ICP
  • recent CVA
  • high risk pregnancy
  • aortic and cerebral aneurysms


How is anesthesia done for ECT?

  • ASA monitors
  • pretreat with 0.2 mg Glyco
  • pre oxygenate
  • GA is induced
    • induction drug (methohexital)
    • loss of lid reflex
    • ensure adequate mask ventilation
    • insert bite block
    • 2nd BP cuff applied to extremity and inflated BEFORE muscle relaxant to act as tourniquet
      • use this extremity to evaluate the peripheral effects of the sz
    • neuromuscular blocker (succ)
  • stimulus is delivered to induce a sz
  • peripheral/central sz observation is made
  • mask ventilation continues until patient awakens and transported to recovery


What medications can be used for ECT?


  • Gold Standard: Methohexital 0.75-1.5 mg/kg
  • Etomidate 0.15-0.3 mg/kg
    • associated with a slightly longer seizure
  • propofol 0.75 mg/kg
    • anti seizure qualities, use lower dose and in conjunction with remifentanyl
  • succ 0.75-1.5 mg/kg
  • Ketamine ??
    • SNS discharge from procedure + SNS discharge from ketamine might not be ideal for some patients
  • Emergency drugs: esmolol, labetolol, CCB
  • Dexmedetomidine 1 mcg/kg 10 minutes pre-induction
    • controls the SNS response without affecting the seizure
  • consider 15-30 mg ketorolac for post-procedure myalgia
  • **check previous records to see what works for patient and fine tune the anesthetic over time