OVERVIEW:
VOCAB:
OFFSITE ANESTHESIA
anesthesia delivered by an anesthesia provider in a location other than the operation room
OVERVIEW:
WHY ARE MORE PROCEDURE PERFORMED MORE FREQUENTLY OUTSIDE THE OR (2 REASONS)
- rapid technological development
- increasing financial constraints
OVERVIEW
WHY IS AN ANESTHESIA PROVIDER NECESSARY FOR OFFSITE PROCEDURES (2 REASONS)
- more comples procedures
- higher acuity patients
CHALLENGES
(7 without details)
- Procedure suite layouts not conducive to anesthesia delivery
- Lac of equipment routinely used in OR
- Lack of immediately accessible emergency equipment
- Remote location to experienced anesthesia help
- Lack of standardization of equipment/monitors/ pt preop prep
- Personnel lack understanding of anesthesia & not trained to help
- Unfamiliarity of the procedure & physical surroundings to anesthesia provider
CHALLENGES
- PROCEDURE SUITE LAYOUT (4)
- no room for anesthesia machine, monitors
- limited access to patient
- unable to adjust thermostat
- heavily shielded radation-proof room, only remote monitoring is possible
CHALLENGES
LACK OF EQUIPMENT ROUTINELY USED IN OR (3)
- Scavenging system
- pipelined O2, air, nitrous oxide
- suction
CHALLENGES
LACK OF IMMDIATELY ACCESSIBLE EMERGENCY EQUIPMENT (3)
- defibrillator
- difficult airway cart
- malignant hyperthermia cart
SAFE ANESTHESIA
ASA RECOMMENDATIONS (15)
- O2 - reliable source
- Suction - adequate functioning / reliable
- Scavening system - adequate & reliable
- Resuscitator bag - self-inflating - deliver 90% O2 as means to deliver positive pressure ventilation
- Anesthesia Monitors
- Anesthesia Medications
- Anesthesia Equipment
- Anesthesia machine - maintained to current OR standards
- Electrical outlets
- Illumination - of pt, monitors, & machine
- Space - for equipment, personal, for rapid access to pt, machine, monitors
- Emergency cart w/ defibrillator, drugs, equipment for CPR
- Staff - trained to support anesthesia provider
- Codes - building & safety codes observed
- Post anesthesia management
SAFE ANESTHESIA
AIRWAY CONSIDERATIONS
EQUIPMENT (2 airways, adjunct, 2 tubes)
oral or nasal airways
laryngoscopes / other intubation adjuncts
ETT / LMAs
SAFE ANESTHESIA
ASA “STANDARDS FOR BASIC MONITORING (4)
SPECIFICS (7)
- Circulation
- Oxygenation
- Ventilation
- Temperature
- EKG
- BP (q5min)
- Pulse oxymetry
- Capnography or capnmetry
- Oxygen analyzer (general anesthesia)
- Low oxygen alarm
- Temperature
SAFE ANESTHESIA
ASA PRE-OP GUIDELINES
same as OR
- gather pertinant medical, anesthetic history
- review relevant diagnostic test, labs
- focused physical exam
- dicussion of anesthetic plan with pt and CONSENT
DETERMINANTS OF ANESTHESIA TECHNIQUE (6)
- age
- position
- level of immobility
- patient condition
- patient/surgeon request
- airway risk
MONITORED ANESTHESIA CARE (MAC)
VOCAB:
CONSCIOUS SEDATION / MODERATE SEDATION
DEEP SEDATION
- sedated / relaxed / able to purposefully respond to verbal or physical stimulation / self maintained patent airway / spontaneous ventiation / protective airway reflexes
- controlled, depressed LOC / purposeful response w/ repeated or painful stimulatoin / adequate spontaneous ventilation / may need help with patency / protective airway reflexes lost
OFFSITE LOCATIONS (5)
- Gastrointestinal endoscopy suite
- cardiac cath & electrophysiology lab
- radiology suite
a. inerventional radiology (neuroradiology/angiography)
b. MRI / CT scan - elecgtroconvulsive therapy unit
- physicians’ procedure rooms (dentist / podiatrist / dermatologist)
OFFSITE LOCATIONS
GASTROINTESTINAL ENDOSCOPY PROCEDURES
- TYPES OF PROCDURES
- NEED TO CONFIRM…
- WHAT DO FIRST
- MAC vs. GA CONSIDERATIONS (5)
- POSITIONING
- EGD / colonoscopy / ERCP (endoscopic retrograd choleangio-pancreatography)
- NPO status. Pt at high risk for aspiration
- Preoxygenate
- emergent cases / full stomach / pathology / pt medical history / body habitus
- pt prone with heard turn to side and arms bent up at 90 degress
OFFSITE LOCATIONS
CARDIAC CATH / ELECTOPHYSIOLOGY LAB
-TYPE OF PROCEDURES (7)
- coronary stents
- percutaneous closure of septal defects
- percutaneous valve repair & replacemnt
a. pacemaker / defibrillator placements
b. percutaneous catheter-based therapy/ablation - biventricular pacemaker lead placement
- implantable cardiac defibrillators
- lead extraction
- battery changes
OFFSITE LOCATIONS
CARDIAC CATH / ELECTOPHYSIOLOGY LAB
TRANSESOPHAGEAL ECHOLCARDIOGRAM/ CARDIOVERSION
- purpose
- things to consider ___ vs ____
- things to consider ___ vs ____
- what do first / with what / for how long
- med swish & swallow
- drugs may use
- direct current electric shocks to convert abnormal cardiac rhythm
- elective vs. semi-emergent
- heavy sedation vs light GA
- preoxygenate with 100% O2 for 3-5 minutes
- lidocaine
- short acting agents
propofol, etomidate, methohexital, benzodiazepines
OFFSITE LOCATIONS
RADIOLOGY
INTERVENTIONAL NEURORADIOLOGY
- what type of patient seen here
- name 2 procedures
- patients with abnormal vascular pathology of brain and/or spinal cord
- arterial venous malformations emoblicationscerebral aneurysm coiling
OFFSITE LOCATIONS
RADIOLOGY
RADIATION THERAPY (MAC vs GA)
- what is it
- protect yourself (5)
- retinoblastoma pt population
- inpt or outpt
- repeated exposure to therapeutic radation
- radiation sheild apronsthroid shieldseyewearbadges - radiation exposuredistance
- 2months - 5 years old
- outpt
OFFSITE LOCATIONS
RADIOLOGY
MRI (MAC vs GA & LMA vs ETT)
- explain about the atoms
- why must anesthesia be used frequently during the procedure
- why must monitors be placed beyond MRI’s field of strength
- where place ECG leads
- what kind of cables should use if possible and why
- where place Sao2 detectors & where avoid placing wires and why
- the nucleus of certain atoms, when placed in a magnetic field, absorb or emit radiation. Nuclei with an odd number of protons respond to MRI
- b/c pt must lay completely still
–some monitors can act as an atntennae & distort images
- close to the magnetic center & in close proximity to one another
- fiberoptic cables & electrodes to avoid interference w/ tracings
- as far away from magnetic core.
skin
heat generated by electrical currents passing thru the electrical oximetry lead wires may cause burns
OFFSITE LOCATIONS
RADIOLOGY
CT SCAN (computerized tomography)
- who is at risk for aspiration (2)
- patient movement may cause (2)
OTHER STUFF TO KNOW
pediatric patients
stereotactic-guided surgery
MAC vs GA
-pts w/ oral contrast
with emergency procedure
- kinking of oxygen tubingdisconnection of breathing circuit
OFFSITE LOCATIONS
ELECTROCONVULSIVE THERAPY (ECT)
- pt population
- what place on pt
- goal of therapy
- goal of anesthetist
- what must anesthetist do first
- what must anesthetist do until pt resumes spontaneous respirations
- pts with severe acute depression / suicidal tendencies / no response to antidepressant pharmaceutical regimens
- unilateral or bilateral electrodes are placed over pt head
- produced generalized therapeutic seizures 30-60s induced seizures cause a tonic phase then clonic phase
- to maintain pt airway, cardiovascular monitoring & medications to ensure amnesia & muscle paralysis to prevent injuries
- preoxygenate
- controlled mask ventilation
OFFSITE LOCATIONS
DENTAL OFFICE
-why is communication with dentist essential
OTHER INFO TO KNOW
MAC vs GA
inpt vs outpt
pediactric & mentally challenged pt groups
-for airway safety
