Remote locations

Question 1

What are some satellite locations?

Answer 1

• 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

Question 2

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

(12)

Answer 2

• 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

Question 3

What are the monitoring standards of care?

Answer 3

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

Question 4

What are the different depths of anesthesia?

Answer 4

Question 5

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

Answer 5

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

Question 6

What is MAC?

Answer 6

• 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.

Question 7

What is an upper endoscopy?

Why might it be done?

What kind of anesthesia is used?

What does EGD stand for?

Answer 7

• 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

Question 8

What groups are high risk during an EGD?

Answer 8

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

Question 9

What is a lower endoscopy?

Answer 9

• 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

Question 10

How can the anesthesia be done for lower endoscopy?

Answer 10

• benzos and opioids or propofol (GA)

Question 11

What is ERCP?

Answer 11

• 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

Question 12

What is done during a rigid bronchoscopic procedure?

Answer 12

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

Question 13

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

What are some complications?

Answer 13

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

Question 14

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

Answer 14

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

Question 15

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

Answer 15

• 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

Question 16

What does ALARA mean?

How is it achieved?

Answer 16

• 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

Question 17

What do you need to know about contrast media?

Answer 17

• 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

Question 18

How can you treat a contrast media hypersensitivity reaction?

Answer 18

• 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

Question 19

How does contrast media affect the kidney?

Who is at increased risk?

Answer 19

• 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)

Question 20

What is Azotemia and when does it occur?

Answer 20

• 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.

Question 21

How can we minimize complications with contrast?

Answer 21

• 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%

Question 22

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

What does it depend on?

Answer 22

• 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

Question 23

General information about Angiography

Answer 23

• 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

Question 24

How does Computed Tomography work?

Answer 24

• 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

Question 25

What is CT used for?

Answer 25

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

Question 26

General considerations for CT.

Answer 26

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

Question 27

How does MRI work?

Answer 27

* 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!

Question 28

What are some contraindications in MRI?

Answer 28

* 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

Question 29

What are limitations of MRI?

Answer 29

* 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

Question 30

What are some considerations for anesthesia in MRI?

Answer 30

* 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

Question 31

How is anesthetic management done for an MRI?

Answer 31

* induction occurs in an adjacent area * atient is transferred via an MRI transport table * MRI-compatible anesthesia machine/monitoring are connected * MRI transport table available for emergency should rapid exit be necessary * Must meet all ASA standards for monitoring * ECG/pulse ox risk for thermal injury, make sure to check it! * extension tubing may make capnography read difficult * ETT or LMA * TIVA (with long tubing) if no compatible anesthesia machine * must be in room with patient if you can see them or monitors from outside

Question 32

What is External beam radiation therapy?

Answer 32

* Highly tissue targeted vs total body irradiation for malignancy * Anesthesia required for pediatric cases * usually propofol deep sedation or GA * usually have long term indwelling access * Considerations: * If CNS involvement, evaluate ICP * concurrent immunosuppressive/cytotoxic therapies * anesthesia must leave room during radiation * immobilization devices can restrict airway access

Question 33

What is interventional neuro-Radiology?

Answer 33

* Radiologically guided endovascular approach to CNS lesions or related circulatory structures * cerebral angiography * better outcomes with IR for grade 1 and 2 aneurisms * Neuroradiologic procedures include: * embolization of AVMs * coiling of cerebral aneurysms * angioplasty of atherosclerotic lesions * thrombolysis of acute thromboembolic stroke * can give TPA to the site, avoiding systemic effects * carotic stent

Question 34

What may be required during interventional Neuro-Radiology?

Answer 34

* deliberate hypotension or hypertension * deliberate hypocapnia or hypercapnia * rapid transition between deep sedation/analgesia dn the awake responsive state * Access: 6-7 fr grade sheath in femoral artery or sometimes in carotid, axillary or brachial artery * contrast media is used

Question 35

What are some anesthesia considerations during interventional neuro-Radiology?

Answer 35

* Hemorrhage * potential for cerebral aneurysm rupture * intracranial vessel damage * hematoma at sheath insertion site * Occlusive complications * migration of embolic materials * vasospasm * Cerebral edema * patient's co-morbidities

Question 36

What should you do for pre-op and induction for IR neuro?

Answer 36

* Pre-op * airway exam * history of contrast reaction * evaluation of BP * induction (GA vs conscious sedation) * standard ASA monitors * 2 IV sited * radial arterial line * foley * pad all pressure points * will the procedure physician perform the WADA or SAFE tests?

Question 37

What is WADA? SAFE?

Answer 37

* WADA- inject barbituate into carotid to see which side is dominate for speech and memory * SAFE- not carotid, but smaller tributary vessel, same test * \*\*Goal to avoid causing loss of function

Question 38

Intra-op managment: How to avoid clot? deliberate hypotension? deliberate hypertension? ecg?

Answer 38

* Heparin * 70 U/kg (3000-5000) * Goal: ACT 2-2.5 x normal * deliberate hypotension * esmolol * labetolol * hydralazine * SNP * deliberate hypertension * phenylephrine * increase SBP 30-40% above baseline * ECG * monitor for myocardial ischemia

Question 39

How do you emerge a pt in neuro IR?

Answer 39

* administer antiemetic * tight post-procedural BP control * smooth emergence to avoid coughing or bucking * do not want to cause high pressures