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Advanced Principles- Fall 2018 > Remote locations > Flashcards

Flashcards in Remote locations Deck (39)
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1

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

2

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

(12)

  • 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

3

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

4

What are the different depths of anesthesia?

 

5

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.

6

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.

7

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

8

What groups are high risk during an EGD?

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

9

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

10

How can the anesthesia be done for lower endoscopy?

  • benzos and opioids or propofol (GA)

11

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

12

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

13

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

14

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

15

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

16

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

17

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

18

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

19

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)

20

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.

21

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%

22

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

23

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

24

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

25

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

26

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

27

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!

28

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

29

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

30

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