Download Remote Anesthesia

Anesthesia at Remote
Locations
Dr Abdollahi
5/5/2017
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Remote anesthesia
Anesthesiologists are increasingly being asked to provide
anesthetic care in locations outside of the OR.
It is the responsibility of the anesthesiologist to ensure that the
location meets the ASA guidelines for safety.
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Locations
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Radiology suites (MRI, CTSCAN)
Cardiac catheterization laboratories
Psychiatric units
Radiation therapy
Gastroentrology
Pulmonary medicine
Urology (ESWL)
General dentistry
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Anesthesiologists must maintain the same high standard of
anesthetic care provided in the operating suite.
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Large, mobile pieces of radiologic equipment, radiation hazards,
intense magnetic fields, paramedical personnel not familiar
with the anesthesia team, and other factors may make the
delivery of quality anesthetic care problematic.
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Remember that the key to efficient and safe remote anesthetic
relies on open communication between the anesthesiologist
and non-operating room personnel
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1994 Guidelines for non-operating room
anesthetizing locations
Reliable oxygen source with backup.
Suction source.
Waste gas scavenging.
Adequate monitoring equipment.
Self-inflating resuscitator bag.
Sufficient safe electrical outlets.
Adequate light and battery-powered backup.
Sufficient space.
Emergency cart with defibrillator, emergency drugs, and
emergency equipment.
Means of reliable two-way communication.
Compliance with safety and building codes.
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Remote monitoring
Qualified anesthesia personnel must be present for the
entire case.
Continuous monitoring of patient’s oxygenation,
ventilation, circulation, and temperature.
Oxygen concentrations of inspired gas: low
concentration alarm.
Blood oxygenation: pulse oximetry.
Ventilation: end-tidal carbon dioxide detection and
disconnect alarm.
Circulation: EKG, ABP (q 5min), invasive BP, and
oximetry.
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Anesthesia techniques used in non-operating room anesthetizing
locations range from no anesthesia, to sedation/ analgesia, to
general anesthesia.
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RADIOLOGY SUITE
Radiologic procedures that may require sedation/analgesia
include a number of imaging modalities such as radiology,
ultrasonography, CT, and MRI, as well as various interventions
that may be directed by the imaging modalities.
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Advances in imaging capability, as well as the availability of
advanced endovascular devices and RF probes, has
increased the use of radiology suites and increased the
demand for anesthesia services in these areas
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Intervention
Percutaneous drain placement,
Nephrostomy tube placement,
Percutaneous placement of feeding tubes,
Placement of intravascular access catheters,
Thrombolysis,
Dilation of stenotic vessels,
Embolization of tumors or arteriovenous malformations
(AVMs),
Tissue biopsy specimens may be obtained under radiologic
guidance
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Conditions may be treatable in the radiology
suite
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Some solid tumors may be treated by guided tissue ablation.
Painful metastases may be treated by guided radiofrequency
(RF) ablation.
Cerebrovascular lesions may be treated endovascularly with
guidance by digital subtraction angiography.
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General consideration
Medical history
Immobile
Claustrophobia
Environment (Crowded, Bulky radiology equipment ,high
voltage,change of position )
Lack of gas scavenging
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Radiation Safety
Radiation exposure is potentially harmful both in terms of its
somatic effects during an exposed individual's lifetime (e.g.,
production of leukemia) and in terms of genetic injury resulting
in fetal abnormalities caused by damage to the gonadal cells
or developing fetus.
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The maximal permissible radiation dose for occupationally
exposed persons is 5O millisieverts (mSv) annually, a lifetime
cumulative dose of 10 mSv x age, and monthly exposure of
0.5 mSv for pregnant women.
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Radiation exposure can be limited by wearing appropriate lead
aprons and thyroid shields, using movable leaded glass screens,
and using innovative techniques such as video monitoring and
remote mirroring of monitor data to allow remote conduct of
anesthesia when appropriate and required for the safety of
anesthesia personnel. Clearly, open communication between the
radiology and anesthesia teams is essential to minimize radiation
exposure. Adequate warning of initiation of imaging by the
radiology team allows the anesthesia personnel to take
appropriate precautions in a timely fashion
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Iodinated Contrast Media
Iodinated contrast agents are often used in diagnostic and therapeutic
radiologic procedures to assist imaging.
Adverse reactions to contrast media range from mild to immediately lifethreatening, and etiologies include direct toxicity,idiosyncratic reactions,
and allergic reactions, either anaphylactic or anaphylactoid Crable
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Predisposing factors include a history of bronchospasm,
history of allergy, underlying cardiac disease, hypovolemia,
hematologic disease, renal dysfunction, extremes of age,
anxiety, and medications such as B-blockers, aspirin, and
nonsteroidal anti-inflammatory drugs.
Prompt recognition plus treatment of contrast media reactions is
important to prevent progression of less severe reactions and
lessen the impact of severe reactions
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Treatment
Treatment is symptomatic, for example, oxygen and
bronchodilators to treat bronchospasm. Severe or resistant
bronchospasm may require treatment with epinephrine.
Typically, corticosteroids and antihistamines are given to
symptomatic patients under the assumption that the etiology
is immunologic.
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Prophylaxis
pretreatment with prednisolone, 5O mg 12 hours before a
procedure requiring contrast media, and diphenhydramine,
5O mg immediately before the procedure.
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Renal dysfunction is well documented in association with
radiologic contrast media, particularly in patients with
preexisting renal dysfunction and most especially in patients
with preexisting renal dysfunction related to diabetes.
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Most cases of new or worsened renal function related to contrast
media are self-limited and resolve within 2 weeks.
However, some patients may progress to the point of requiring
dialysis.
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Recent studies have demonstrated a reduction in contrast media
nephrotoxicity by the administration of acetylcysteine.Lifethreatening lactic acidosis may develop in non-insulindependent diabetic patients who are receiving metformin and
have preexisting renal dysfunction if their renal function
declines further. Extra care is needed when patients taking
metformin receive radiologic contrast media.
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Anesthesia in the Radiology Suite
Minimal to moderate sedation/analgesia is the technique used
for most patients undergoing these procedures.
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For most adults, combinations of intravenous benzodiazepines
and opioids (i.e., titration of midazolam and fentanyl) are
sufficient to ensure comfort during the procedure. The use of
more potent anesthetic agents such as propofol,
methohexital, and ketamine is best reserved for specialists in
anesthesia.However, understanding the procedure in question
is important in selection of the appropriate anesthetic
technique.
The patient's condition, the anticipated level of stimulation, and
patient position during the procedure are all important
considerations.
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A patient undergoing ultrasound-guided hepatic biopsy might
have ascites, which would render that patient prone to
aspiration if sedated, and penetration of the hepatic capsule
by the biopsy needle would be anticipated to be quite painful.
Such a patient might benefit from general anesthesia rather
than sedation/analgesia.
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Procedures that might be anticipated to last several hours may
best be performed with general anesthesia at the outset
rather than late conversion after failure of sedation/ analgesia,
when patient access might be limited by catheter placement
and radiologic equipment.
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Pediatric patients merit special consideration. Some radiologic
procedures require patients to remain still for prolonged
periods, which may not be possible for infants and children,
even with sedation/analgesia. (chloral hydrate orally for
radiologic procedures 25 to 5O mg/kg for infants younger than
4 months, 5O mg/kg for older children)
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Patients with difficult airways, whether anticipated or not, can be
problematic in settings outside the operating suite . I prefer to
perform anticipated difficult endotracheal intubations in the
operating suite with its improved availability of skilled assistants
and specialized equipment. Once the airway is controlled, the
patient can be transported to the site of the planned procedure
should it be necessary to perform the procedure outside the
operating suite.
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MAGNETIC RESONANCE IMAGING
The most significant risk posed in the MRI suite is the effect of
the magnet on ferrous objects.
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MRI
MRI scanning has a number of limitations. Imaging is time
consuming, and individual scans may take up to 20 minutes,
with an entire examination lasting more than 1 hour.
Switching on and off of the RF generators produces loud noises
(>90 dB).
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MRI
Hearing protection is mandatory for both the patient and health
care personnel who must be present in the scanning room.
Heating resulting from the RF energy of nonferromagnetic
prosthetic devices has not proved to be a problem. Body
surfaces do absorb this RF energy, but it is unlikely that the
patient's temperature will increase by more than 1°C.
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MRI
The most significant risk posed in the MRI suite is the effect of
the magnet on ferrous objects.
Dislodgement and malfunction of implanted biologic devices or
other objects containing ferromagnetic material are also real
possibilities. Such items include shrapnel, vascular clips and
shunts, wire spiral endotracheal tubes, pacemakers,automatic
implantable cardioverter-defibrillators (ICDs), mechanical
heart valves, and implanted biologic pumps.
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MRI
Tattoo ink may contain high concentrations of iron oxide. Burns
at tattoo sites have been reported after exposure to MRI
magnetic fields, but such incidents are very rare and the
presence of, for example, permanent eyeliner should not
exclude the patient from MRI examination.
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Anesthetic Management for MRI
Anesthesia in the MRI suite poses several unique problems, including the
following:
1. Limited patient access and visibility, especially when the patient must be
placed head first into the magnet
2. Absolute need to exclude ferromagnetic components
3. Interference/malfunction of monitoring equipment produced by the
changing magnetic field and RF Currents
4. Potential degradation of the imaging caused by the stray RF currents
produced by the monitoring equipment and leads
5. The necessity to not move the anesthetic and monitoring equipment
once the examination has started to prevent degradation of magnetic
field homogeneity
6. Limited access to the MRI suite for emergency personnel in accordance
with the recommended policies noted earlier
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A common approach now is to induce anesthesia in an induction
area adjacent to the MRI suite outside the magnetic field by
using conventional equipment with the patient on a dedicated
MRI transport table that is not ferromagnetic.
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MRI
Because the patient's airway is not easily accessed during the
MRI scan and because patient assessment and
communication are limited by both the magnet bore in which
the patient is placed and the loud noise associated with MRI
scanning, deep sedation/analgesia is not advisable. Patients
requiring more than moderate sedation/analgesia are
probably most safely administered a general anesthetic with
airway control by either endotracheal intubation or a laryngeal
mask airway (LMA).
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Contraindications for MRI include:
Shrapnel, vascular clips and shunts, wire spiral ETT’s,
pacemakers, ICDs, mechanical heart valves, recently
placed sternal wire, implanted biological pumps, tattoo
ink with high concentrations of iron-oxide (permanent
eyeliner), and intraocular ferromagnetic foreign bodies.
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Ferromagnetic items should never be allowed in the vicinity of
the MRI magnet, including: scissors, pens, keys, gas
cylinders, anesthesia machine, syringe pump, beeper,
phone, and steel chairs.
Cards with magnetic strips will be de-magnetized, including
credit cards and ID badges.
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ANESTHESIA FOR INTERVENTIONAl
NEURORADIOlOGY
Include embolization of cerebral and dural AVMs, coiling of
cerebral aneurysms, angioplasty of atherosclerotic lesions,
and thrombolysis of acute thromboembolic stroke.
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These procedures may involve deliberate hypotension,
deliberate hypercapnia, or deliberate cerebral ischemia as
part of the procedure; a requirement for rapid transition
between deep sedation/ analgesia and the awake, responsive
state; and severe potential procedural complications.
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Anesthetic Management
Preprocedural anesthetic evaluation is similar to that
before neurosurgical procedures. Airway examination
is important in as much as airway manipulation during
the procedure is not possible because of interference
with head positioning for imaging. Particularly
important is a history of previous experience with
radiologic procedures and any history of contrast
media reaction. Because blood pressure management
is important for these procedures, preoperative
evaluation for hypertension is important, as is good
preoperative control of existing hypertension.
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Heparin is commonly administered during these
procedures, with a target activated clotting time (ACT) of
2 to 2.5 times the baseline value. Deliberate hypotension
is frequently used during AVM embolization to decrease
flow to feeding vessels, as well as during some trial
balloon occlusions. Agents such as esmolol, labetalol,
or sodium nitroprusside are all useful in this situation.
Deliberate hypertension is called for during cerebral
ischemia in an attempt to maximize collateral flow.
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Phenylephrine is generally used, both as a bolus and as an
infusion titrated to increase systolic blood pressure 30%to
40% above baseline. Close monitoring of ECG parameters for
signs of myocardial ischemia is critical in this case. Smooth
emergence from anesthesia is important in these patients,
who may be prone to device migration or intracranial
hemorrhage. Administration of antiemetics before
emergence is certainly reasonable, and precautions to avoid
coughing andl/bucking" should be taken.
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INTERVENTIONAL CARDIOLOGY
lnterventional cardiology procedures include coronary
angiography and cardiac catheterization, coronary artery
angioplasty/stenting, valvotomy, closure of intracardiac
defects, electrophysiologic studies with pathway
ablation, and cardioversion.
Electrophysioiogic Studies and Catheter Ablation of
abnormal Conduction Pathways , Pacemaker and
Cardioverter- defibrillator implantation.
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The usual anesthesia management is by sedation/analgesia, with
general anesthesia reserved for sedation failure, uncooperative
patients, or those who require airway control to manage
respiratory failure.
Anesthetic agents used commonly include fentanyl and
midazolam, sometimes supplemented with propofol.
Sedation and analgesia are helpful in reducing the discomfort .
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Typical heparin doses range from 2500 to 5000 IV
intravenously. For interventional procedures, higher
heparin doses (i.e., 10,000 IV intravenously) are given,
with a target ACT of over 300 seconds. Patients must be
monitored carefully after protamine administration to
detect the predictable peripheral vasodilation, as well as
less predictable anaphylactic and anaphylactoid
reactions or the rare catastrophic pulmonary
vasoconstrictive crisis associated with protamine
administration.
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Heparin are increasingly commonly being administered during
interventional cardiac catheterization and have resulted in
improved outcomes despite the reduction in heparin dose.
Platelet aggregation inhibitors used have included abciximab,
ticlopidine, and clopidogrel. Numerous studies have shown the
benefits of anti platelet therapy in both acute and chronic
coronary syndromes.
A notable side effect of abciximab is elevation of the ACT
independent of heparin.
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Coronary artery disease is assessed by detection of
stenoses after injection of contrast medium selectively
into each main coronary artery. Stenoses greater than
50%to 70%f the normal arterial diameter are considered
hemodynamically significant, although lesser stenoses
may be clinically important. Coronary artery disease is
classified as one-, two-, or three-vessel disease or left main
coronary disease.
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after dilation of the stenotic coronary artery, ventricular
arrhythmias may develop and require treatment.
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Pediatric Cardiac Catheterization
Medications administered for sedation include fentanyl,
midazolam, propofol, and ketamine.
Premedication with midazolam, 0.5 mg/kg orally, can be
particularly helpful. Some evidence has indicated that
ketamine can increase oxygen consumption, so care must be
taken to ensure that it does not impair diagnostic accuracy.
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complications
Hypothermia
Arrhythmia
Tamponad
Bleeding
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Elective Cardioversion
Elective cardioversion is uncomfortable, and general anesthesia
is required. Many medications have been used, including
barbiturates, propofol, etomidate, and benzodiazepines.
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It should be noted that muscle relaxants are not typically needed
for this procedure.
Etomidate cause myoclonus and interfere by EKG and airway
managment.
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ELECTROCONVULSIVE THERAPY
Indications for ECT include major depression, mania, certain forms
of schizophrenia, and perhaps Parkinson's syndrome.
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CONTRAINDICATION
Pheochromocytoma is a contraindication to ECT.
Relative contraindications include :
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Increased intracranial pressure,
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Recent cerebrovascular accident,
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Cardiovascular conduction defects,
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High-risk pregnancy,
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Aortic and cerebral aneurysms.
In these conditions, the risk of the patient's psychiatric illness
and the side effects of antidepressant medications must be
weighed against the risk associated with ECT and anesthesia.
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Mechanism
ECT therapeutic effects are thought to result from release of
neurotransmitters during the electrically induce grandmal
seizure.
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Complications
Seizure activity causes an initial parasympathetic discharge
manifested by bradycardia, occasional asystole, premature
atrial and ventricular contractions, or a combination of these
abnormalities. Hypotension and salivation may be noted and
then sympatric activity.
ECG changes, including ST-segment depression and T-wave
inversion, may also be seen after ECT without any of the
myocardial enzyme changes consistent with myocardial
infarction.
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Arrhythmias associated with ECT, even in patients with
preexisting arrhythmias, are self-limited and not in themselves
a contraindication to treatment.
ECT has been found to be relatively safe even in high-risk
cardiac patients, provided that careful management is
provided.
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The most common causes of death are MI and arrhythmia
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Neuroendocrine responses to ECT include increased levels of
stress hormones, including adrenocorticotropic hormone,
cortisol, and arginine vasopressin, as well as prolactin and
growth hormone.Norepinephrine and epinephrine increase
immediately after ECT,and epinephrine levels decrease more
rapidly thereafter. Glucose homeostasis is variably affected by
ECT.Improvement in control of non-insulin-dependent
diabetes is generally noted, whereas hyperglycemia may be
seen when the diabetes is insulin dependent.
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ECT
Pre-op the pt. These pt’s have often had this procedure multiple
time, therefore you can use old records as templates.
Place IV and give glyco (0.2 mg IV). Treats the bradycardia/ asystole
from the initial parasympathetic discharge from the seizure activity
Hyperventilate the pt. with 100% O2.
Inflate the manual BP cuff in the arm opposite the IV and then give
Sux.
Place the bite block.
Goal is a seizure 30-60 seconds long.
Ventilate until spontaneous respirations return.
The parasympathetic discharge is often followed by a sympathetic
discharge associated with HTN and tachycardia. This is treated
with esmolol.
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Antidepressant Drug Therapy
Antidepressants, monoamine oxidase inhibitors
(MAOIs),serotonin reuptake inhibitors, lithium carbonate, or a
combination of these drug.
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Tricyclic antidepressants block the reuptake of norepinephrine,
serotonin, and dopamine into presynaptic nerve terminals, thereby
increasing central sympathetic tone. Tricyclic antidepressants have
anti. histaminic, anticholinergic, and sedative properties and also
slow cardiac conduction. These side effects are less common with
the newer types of antidepressant drugs such as trazodone,
bupropion, and fluoxetine. The combination of centrally acting
anticholinergics, such as atropine, with tricyclic antidepressants can
increase postprocedural delirium.
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MAOIs can inhibit hepatic microsomal enzymes. They may
interact with opioid analgesics and cause excessive
depression. Used concomitantly with meperidine, MAOIs may
result in severe, possibly fatal excitatory phenomena.
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Lithium carbonate prolongs the action of neuromuscular blocking
agents. Elevated lithium levels, higher than the therapeutic
range, can prolong the action of benzodiazepines and
barbiturates. Patients receiving lithium may demonstrate more
cognitive side effects after ECT. The American Psychiatric
Association recommends discontinuation of lithium therapy
before ECT.
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Hypothyroidism is known to occur in patients who have been
tacking lithium for long time (15 years or more) .
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Anesthetic Management of
Electroconvulsive Therapy
Anesthesia and neuromuscular blockade are necessary during
ECT to prevent psychological and physical trauma. Rapid
recovery is desirable.
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particular attention paid to coexisting neurologic and cardiac
disease, osteoporosis and other causes of bone fragility, and
medications that the patient may be receiving. The patient
may be a poor historian because of the psychiatric condition,
and accompanying caregivers may need to provide the
necessary history and assurance of fasting status.
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Glycopyrrolate (0.2 mg intravenously), which does not cross the bloodbrain barrier, can reduce the occurrence of bradycardia and the
amount of oral secretions associated with ECT. After
preoxygenation, anesthesia is administered by peripheral
intravenous catheter, and neuromuscular blockade is induced.
When relaxation is adequate and satisfactory mask ventilation with
oxygen is ensured, a bite block is placed and a stimulus is delivered
to induce the seizure.
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If the patient has a hiatal hernia and gastroesophageal reflux, rapidsequence induction and endotracheal intubation with cricoid
pressure may be a reasonable approach. Adequate ventilation is
ensured during the procedure because among other detrimental
effects, hypoxia and hypercarbia decrease seizure duration and thus
the efficacy of ECT.
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Many intravenous anesthetics have been used to induce
anesthesia for ECT, including methohexital, thiopental,
propofol, and ketamine. Methohexital (0.75 to 1.0 mg/kg) is
the most commonly used drug for ECT anesthesia and is
considered the "gold standard. "Propofol (0.75 mg/kg) was
found to reduce seizure duration, which was believed to
decrease the efficacy of ECT.
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Thiopental(1.5 to 2.5 mg/kg) avoids pain on injection, but it is
associated with more hypertension and tachycardia than
propofol .
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Etomidate may prolong seizures and recovery, but prolongation
of the seizure may be useful in patients in whom seizure
duration is deemed too short with other agents.
Benzodiazepines have anticonvulsant activity and should be
avoided before ECT.
Ketamine has been demonstrated to not increase seizure length
or produce excessive postprocedural agitation.
Given the hemodynamic response expected after ECT, ketamine
would seem to be a less desirable agent.
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Prophylactic medications have been advocated to avoid various
side effects of ECT. Transient asystole is rare during ECT, but it
may be prevented with anticholinergic pretreatment.
Glycopyrrolate is preferred over atropine because
glycopyrrolate has no central anticholinergic side effects. In
addition, glycopyrrolate is an effective antisialagogue.
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Both esmolol and labetalol have been successfully used to
control hypertension and tachycardia after ECT.Some
evidence has shown that esmolol reduces seizure
duration.Routine treatment with esmolol or labetalol is not
recommended because the hypertension and tachycardia are
usually self-limited, as are premature ventricular contractions.
Should treatment be necessary, these drugs can be
administered immediately after the stimulus.
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Extracorporeal shock wave lithotripsy
(ESWL)
ESWL used focused shock waves (high intensity pressured
wave of short duration) to pulverize renal and ureteral calculi
into very small fragment which are then washout by normal
urine flow.
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1.
2.
Electrohydrulic lithotripsy (immersion)
Nonimmersion lithotriptor (shock tube)
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Consideration
No pain
Immobile is necessary
Immersion cause increase CVP and increase WOB and shallow
breathing and rapid. Decrease VC and FRC.
Arrhythmia (best is shock delivered 20 mesc after Rwave )
Hypertension or hypotension
CHF ,MI
Hematuria
Pulmonary contusion and pancreatitis
Flank pain for several days
Petechia and soft tissue swelling (1%)
No interface with pacemaker
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Management of anesthesia
Sedation /analgesia
GA or RA (T6)
LMA
Adequate intravenous fluid for washout
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Dental surgery
Anesthesia is necessary for very young or mentally patients.
CHD (down )
EKG MONITORING IS VERY IMPORTANT BECAUSE TEEDTH
AND GUMS ARE VERY INNERVATE.KG
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Management of anesthesia
Rapid induction and prompt recovery
Ketamine IM for induction for IV line
STP, POFOL ,ETOMIDATE,
Sevoflurane
Intubation
Antiemetic drug
Short acting opioid
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