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Advanced Principles- Fall 2018 > Remote locations > Flashcards

Flashcards in Remote locations Deck (39)
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What are some satellite locations?

  • radiology
  • cardiac cath lab
  • psych units- for ECTs
  • endoscopy
  • office based practice
  • **patients are becoming sicker in these remote units
    • not as much personnel or the equipment of the OR


What equipment do you need to in Satellite locations per the ASA standards?


  • Reliable oxygen source with back-up
    • some office settings wont have pipeline
  • suction- make sure it is adequate!
  • waste gas scavenging
  • Monitoring equipment
    • must meet basic standards during case and post-anesthesia transport
  • self inflating ambu bag (>90% FiO2 delivery)
  • adequate patient and anesthesia equipment illumination with battery power back-up
  • adequate space to freely access patient and anesthesia equipment.
  • emergency cart with defibrillator and drugs
  • reliable two-way communication to request help
  • adequately trained support staff 
    • including anesthesia professional available during recovery period
  • compliance with safety and building codes
  • sufficient safe electrical outlets


What are the monitoring standards of care?

  • Pre and post procedure checklists
  • emergency protocols with contact numbers
  • ASA/AANA monitoring:
    • oxygenation
      • spo2
    • ventilation
      • capnography
    • circulation
      • ekg, BP
    • temperature


What are the different depths of anesthesia?



What are the four major issues that determine appropriate classification of anesthetic depth?

  • responsiveness
  • airway
  • spontaneous ventilation
  • CV function
  • **must always be ready to support pt for one stage beyond what is planned for.


What is MAC?

  • When an anesthesia provider is involved in the care of a pt while they are having a procedure
  • May just be there just in case support is needed
    • Do everything the same as normal and always be on the ready to do more.


What is an upper endoscopy?

Why might it be done?

What kind of anesthesia is used?

What does EGD stand for?

  • Endoscopic evaluation of the esophagus, pylorus, and stomach
    • sometimes d/t nausea, abdominal pain, foreign body, monitor vericies
  • May involve biopys, mucosal/submucosal dissection, dilation, stenting, etc.
  • Local oropharyngeal anesthesia with opioid and benzo vs general anesthesi with propofol
    • GA with propofol is anywhere from 100-300 mcg/kg/min
    • Carrie does:
      • gargle 4% lidocaine
      • 2 mg/kg propofol to start
    • aspiration and laryngospasm common
  • EGD = esophagogastroduodenoscopy


What groups are high risk during an EGD?

  • Obese
  • OSA
  • GERD
  • asthma
  • obstruction/full stomach
  • hepatic disease


What is a lower endoscopy?

  • Sigmoidoscopy and colonoscopy
  • Generally involves insufflation of air, may involve the application of external pressure 
    • increased aspiration risk
    • may cause vagal response
  • May involve biopsy, polypectomy/mucosal resection, stenting, dilation, etc


How can the anesthesia be done for lower endoscopy?

  • benzos and opioids or propofol (GA)


What is ERCP?

  • Fluoroscopic exam of biliary and pancreatic duct that may involve stenting/removal of stones/laser lithotripsy
  • Commonly performed in patients with cholangitis, pancreatitis, bile duct obstruction, pancreatic cancer, etc
    • may not be as responsive to pressors, keep ahead
  • requires pt to be immobile
  • often done in prone position
  • GA w/ETT is preferred


What is done during a rigid bronchoscopic procedure?

  • Endobronchial stenting
  • biopsy
  • laser therapy
  • dilation
  • cryotherapy
  • fiducial marker implant
  • **these patients often have significant CV and pulmonary disease


What is the preferred method of anesthetic for a rigid bronch?

What are some complications?

  • TIVA
    • propofol, remifentanil, dexmedetomidine, and muscle relaxant
  • Complications:
    • airway fire
    • bronchospasm
    • bleeding
    • hypoxia


What are three features that make providing anesthesia in radiology suites different?

  • There is no incision
  • Access through vasculature (femoral artery)
  • Must deal with lots of radiation


What are some general considerations/challenges in the radiology suite?

  • Patient remains immpbile for prolonged periods
  • lots of bulky equipment 
    • limits our ability to access the patient
    • can colide with our equipment
    • requires us to need extensions
    • can press against and possibly harm the patient
  • Some rooms dont have scavenging system which will limit GA
  • Must try to limit radiation exposure
    • radiation causes dose-related cell death, tissue damage and malignancy (DNA ionization and free radical generation)
    • direct exposure to pt
    • scatter exposure to providers


What does ALARA mean?

How is it achieved?

  • As low as reasonably achievable
    • lead aprons
    • thyroid shields
    • moveable leaded glass screens
    • leaded eyeglasses
    • remote or video monitoring when appropriate
    • dosimeters should be worn
      • one under lead apron
      • one on collar above lead apron


What do you need to know about contrast media?

  • Used in diagnostic and therapeutic radiologic procedures
    • general radiology and MRI
  • Variable osmolarity; ionic or non-ionic
    • non-ionic causes less pain and fewer complications
  • Adverse reactions range from mild to life threatening
    • hypersensitivity
    • renal toxicity


How can you treat a contrast media hypersensitivity reaction?

  • Prompt recognition!
  • oxygen
  • bronchodilators
  • epinephrine
  • fluid resuscitation
  • corticosteroids
  • consider pre-treatment with IV corticosteroids a few hours pre-procedure as well as H1 and H2 blockers
    • not great evidence to support this


How does contrast media affect the kidney?

Who is at increased risk?

  • Causes direct tubular toxicity due to release of free oxygen radicals and microvascular obstruction
  • Increased risk in:
    • diabetic renal insufficiency
    • hypovolemia
    • CHF
    • HTN
    • baseline proteinuria/renal disease
    • Gout
    • co-administration of other drugs that cause reanal problems (Ketorolac)


What is Azotemia and when does it occur?

  • Azotemia- abnormally high levels of nitrogen containing compounds in the blood (urea, cr, etc.)
  • occurs 24-48 hours after contrast media is given
  • peaks at 3-5 days 
  • monitor creatinine levels
    • increase of 0.5 mg/dL within 24 hours is diagnostic
    • Avoid surgical procedures during this period.


How can we minimize complications with contrast?

  • administer slowly
  • limit dose to least amount required
  • administer with hydration 1 ml/kg of NS 4 hours pre-procedure and continue for 12 hours post-procedure
  • administer sodium bicarbonate to promote renal elimination
    • increases pH of urine and the ionized fraction of contrast so it can be eliminated
  • monitor serum creatinine for 72 hours
  • N-Acetylcysteine (yes according to Miller, unproven according to Barash)
    • 600 mg PO twice daily will blunt renal injury 2% vs 21%


What kinds of anesthesia techniques are used in the Radiology suite?

What does it depend on?

  • Techniques:
    • local only with anesthesia on stand-by
    • sedation/analgesia
    • general
  • depends on:
    • procedure
    • desired level of anesthesia
    • underlying medical conditions (parkinson's)
    • open communication with radiologists


General information about Angiography

  • Minimal discomfort but potential for long duration and pt must remain motionless
  • local anesthesia at puncture site (usually femoral artery)
    • +/- light sedation vs GA
  • during contrast injection be prepared for decrease in HR and BP
  • Extension tubing
  • keep ECG leads out of imaging field
  • Avoid ETT with metallic coils if ETT in imaging field


How does Computed Tomography work?

  • Uses X-ray beam to image slices of the body (each takes <1 sec)
  • Amount of radiation transmitted is collected by photo-multiplier tubes and is counted digitally
  • Body scan image can be viewed by rapidly acquiring views from numerous different projections by rotating tubes and detectors around body


What is CT used for?


  • diagnostic and therapeutic purposes
    • biopsy/ablation of neoplastic process in thorax, abdomen, brain
    • diagnosis of trauma patients
    • chronic pain treatement


General considerations for CT.

  • Procedure will dictate the anesthetic
  • consider risk of aspiration if PO contrast is used
  • patient is inaccessible during procedure
  • lots of radiation exposure


How does MRI work?

  • Body is immersed in a steady, strong magnetic field
    • 1.5 Tesla, which is 15,000 Gauss
    • the Earths magnetic field is 0.5 Gauss
  • The magnet is ALWAYS on!


What are some contraindications in MRI?

  • Pacemakers/defibrillators
  • cochlear implants
  • pumps or nerve stimulators
  • aneurysm clips
  • intravascular wires
  • former trauma victims with bullets or metal shrapnel
  • first trimester pregnancy (minimal data to support this)
  • metal implants need to be monitored for increased temp


What are limitations of MRI?

  • time consuming exam
    • anxiety and claustrophobie
  • any movement and it wont work
  • obese pts may not fit in scanner
    • 50-65 cm in diameter
  • loud noises (>90 dB)
  • heat generation/risk of thermal injury
    • do not wind up cables or wires
  • any ferrous object can become a missile


What are some considerations for anesthesia in MRI?

  • anesthesia is involved when:
    • sedation fails or is risky (OSA)
    • it is impossible to control movement without GA (pediatrics, parkinsons,etc)
    • need to protect the pts airway or control ventilation
  • you have limited access and visibility of patient
  • limited access for emergency personnel during scan