Chapter 58 NORA

Question 1

challenges with NORA

Answer 1

• unique locations
• support staff who are unfamiliar with anesthesia
• variation of the physical set up of the procedure room
• equipment may be poorly maintained
• remote positioning of a patient during a lengthy procedure

Question 2

an anesthesia machine and portable anesthesia cart with the listed equipment, supplies, and medications should be

Answer 2

dedicated strictly for use in remote locations

Question 3

therapeutic and diagnostic procedures require what kind of anesthesia?

Answer 3

minimal, moderate, or deep

Question 4

what type of anesthesia ensures amnesia as a standard of care?

Answer 4

general anesthesia

Question 5

standards for the delivery of anesthesia in a remote location

Answer 5

A. Perform a complete pre-anesthesia assessment
B. Obtained informed consent for the planned anesthetic intervention from the patient or legal guardian
C. Formulate a patient-specific plan for anesthesia care
D. Implement and adjunct the anesthesia care plan based on the patient’s physiologic response
E. Properly prepare, dispense, and label all medications to be used for the patient
F. Adhere to appropriate safety precautions and protocols, as established by the institution, to minimize risks to the patient and ancillary staff
G. Monitor and document the patient’s physiologic condition as appropriate for the type of anesthesia and specific patient needs
H. Precautions shall be taken to minimize the risk of infection to the patient, the operator, and ancillary personnel
I. There must be complete, accurate, and time-oriented documentation of pertinent information on the patient’s anesthesia record
J. After the anesthetic treatment for therapeutic or diagnostic procedures, transfer the responsibility for care of the patient to other qualified personnel in a manner that ensures continuity of care and patient safety

Question 6

what 4 things make NORA unique?

Answer 6

1. location (not what were used to)
2. personnel (operator is not a surgeon, staff may not understand anesthesia)
3. procedures (huge variety)
4. equipment and set up (you have to bring your own

Question 7

Standard V: mornitoring for NORA

Answer 7

• same as for all other cases
• still need to monitor ventilation, oxygenation, cadisovascular status, body temp and neuromuscular function

Question 8

responsiveness for: minimal, moderate (conscious), deep sedation, and general anesthesia

Answer 8

minimal = normal response to verbal stimuli

moderate/conscious = purposeful response to verbal or tatile stimulation

deep = purposeful response to repeated painful stimuli

general anesthesia = unarousable even with painful stimuli

Question 9

airway for: minimal, moderate (conscious), deep sedation, and general anesthesia

Answer 9

minimal = unaffected

moderate/conscious = no intervention required

deep = intervention may be required

general anesthesia = intervention often required

Question 10

respiratory function for: minimal, moderate (conscious), deep sedation, and general anesthesia

Answer 10

minimal = unaffected

moderate/conscious = adequate

deep = may be inadequate

general anesthesia = frequently inadequate

Question 11

cardiovascular function for: minimal, moderate (conscious), deep sedation, and general anesthesia

Answer 11

minimal = unaffected

moderate/conscious = usually maintained

deep = usually maintained

general anesthesia = may be impaired

Question 12

most common adverse events happen in NORA cases (in peds)

Answer 12

RESPIRATORY

• apnea
• respiratory depression
• respiratory obstruction

Question 13

most adverse events happen with procedures lasting longer than __ hour

Answer 13

1

Question 14

children of what age are at greater risk for adverse events?

Answer 14

less than 5

Question 15

2 populations that are commonly seen in NORA?

Answer 15

elderly and children

Question 16

most adverse anesthesia events are caused when __ anesthetic agents are used

Answer 16

mulitple

Question 17

peds NPO status for NORA procedures

Answer 17

• < 6 month: 4-6 hrs
• 6-36 months: 6 hr
• > 36 months: 8 hrs

Question 18

important things to keep in mind for safety purposes during peds assessment

Answer 18

• recent URIs
• fever
• cough
• snoring
• sputum production

could result in an airway compromise during sedation

Question 19

BOX 58.5
most common causes of peds A adverse events for therapeutic or diagnostic procedures

Answer 19

• drug errors
• NO₂ in combo with any other sedative medication
• inability to rescue the patient from an adverse anesthetic event
• unmet monitoring standards - especially respiration and oxygenation
• resp depression/ hypoventilation/ apnea
• airway obstruction
• bradycardia secondary to hypoxia
• laryngospasm/ stridor
• vomiting/aspiration/diarrhea
• hypotension
• inadequate sedation/paradoxical excitation (sustained irritability or combativeness)
• prolonged sedation after the procedure

Question 20

ACID & pacemakers

Answer 20

ACID = 2 parts (pulse generator and lead electrode)

pacemaker = (unipolar or bipolar)

most common underlying rhythm is pulseless VT or VF

Question 21

anesthesia for AICD and pacemakers

Answer 21

• usually local and some sedation
• at end… they will cause pt to go into VF to check if AICD is working… give propofol before this
• ALWAYS have transcutaneous packing pads available and on patient

Question 22

what types of patients commonly present for AICD placement?

Answer 22

• Supraventricular dysrhythmias (younger and healthier)
• Ventricular dysrhythmias (older, low EF, CAD)
• CHF (low EF, left BBB)

Question 23

what happens at the end of AICD placement that is very uncomfortable for patient and tricky for us

Answer 23

• putting patient into vfib
• have to give patient something (prop) so they can tolerate it
• might need to place patient into vfib several times of lead placement is sketchy

give 5 mins between vfib episodes

Question 24

how long do pacemakers last?

Answer 24

6-10 years

Question 25

joules that are used for synchronized cardioversion

Answer 25

50-100J

Question 26

what part of the pacemaker insertion can be uncomfortable for the patient?

Answer 26

tunneling of the leads

Question 27

sedation for synchronized cardioversion

Answer 27

- probably prop before shock - sometimes etomidate if they are unstable

Question 28

ablation and anesthesia

Answer 28

- radio frequency = short and usually with sedation - cryofrequency = used before or instead of RFCA - start by ice-mapping heart - cryo causes less discomfort and higher success rate

Question 29

with longer ablation cases, what are some anesthesia considerations

Answer 29

- patients can experience angina-like pain - may need deeper sedation or GA - use esophageal stethoscope to monitor left atrial temp

Question 30

PCI procedures use x-radiation/fluoroscopy doses as

Answer 30

keep radiation *As Low As Reasonably Achievable* known as the radiation principle: ALARA

Question 31

pediatrics and ablation

Answer 31

SVT is most common tachyarrhythmia treated in peds with radiofrequency ablation

Question 32

colonoscopy looks at colon from anus --> __

Answer 32

cecum

Question 33

sedation for colonoscopy

Answer 33

light to deep manipulation of colon is painful (splenic and hepatic flexures are rough)

Question 34

watch for what with colonoscopies

Answer 34

- bradycardia (caused by vagal reflex) - colon spasms can occur as well - have glycopyrrolate ready for both conditions - if its really bad tell doc to reduce amount of air in colon

Question 35

spray airway with what in EGD?

Answer 35

benzocaine (think metHb) or lidocaine

Question 36

if you are doing EGD for GI bleed, what should be your anesthetic technique

Answer 36

probably GA with ETT to protect airway and support hemodynamics better

Question 37

before ERCP: labs

Answer 37

liver enzymes

Question 38

what will be used in ERCP that we should ask about allergies to

Answer 38

contrast dye

Question 39

position for ERCP

Answer 39

prone or left lateral decubitus

Question 40

occupational hazards for CT

Answer 40

- if you're in the room you have to protect yourself from radiation - radiation exposure is cumulative over a lifetime !!

Question 41

anesthetic implications for CT

Answer 41

- patient needs to be motionless - contrast media concerns - ionizing radiation may be a *problem in kids* - airway management can be difficult

Question 42

2 types of contrast media reaction

Answer 42

anaphylactoid = histamine release from basophils or mast cells (NOT ANTIBODY/ANTIGEN MEDIATED) chemotoxic = directly due to inherent chemical action of specific agent on specific organ (contrast-induced renal failure)

Question 43

anesthetic agents that may cause problems with assisted reproductive technologies (ART)

Answer 43

morphine, sevo, desflurane, NSAID's, & metoclopramide

Question 44

T/F magnitude of chemotoxic reaction to contrast media depends on the amount or concentration of the offending agent

Answer 44

TRUE if you give more, the result will be worse

Question 45

T/F magnitude of anaphylactoid reaction to contrast media depends on the amount or concentration of the offending agent

Answer 45

FALSE can have reaction to 1mL or 100mL