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Anesthesia for diagnostic and Anesthesia for diagnostic and therapeutic procedurestherapeutic procedures

There are cases of minor surgery, There are cases of minor surgery, but there are no cases of minor but there are no cases of minor

anesthesiaanesthesia

Although most anesthetics are traditionally Although most anesthetics are traditionally given in the operating room, technology given in the operating room, technology advancements have moved many advancements have moved many procedures that still require patient procedures that still require patient relaxation outside of the operating room. relaxation outside of the operating room.

The anesthesia needed can range from The anesthesia needed can range from local anesthetics, MAC, or general local anesthetics, MAC, or general anesthesia.anesthesia.

Patient CharacteristicsPatient Characteristics

Patients often need anesthesia services Patients often need anesthesia services because they are confused, disoriented, because they are confused, disoriented, uncooperative, claustrophobic, anxious, uncooperative, claustrophobic, anxious, mentally disabled or just plain big babies!mentally disabled or just plain big babies!The test or procedure may require the The test or procedure may require the patient to lie still for an extended length of patient to lie still for an extended length of time.time.The procedure may cause moments of The procedure may cause moments of painful stimulation alternated with long painful stimulation alternated with long periods of no stimulation.periods of no stimulation.

Your working environment.Your working environment.

Remote work areaRemote work area

The operating room is ideal..for the most The operating room is ideal..for the most part.part.The workplace allotted for anesthesia is The workplace allotted for anesthesia is often often smallsmall, , crowdedcrowded and and differentdifferent from from our usual set up.our usual set up.Additionally the setup may not allow us Additionally the setup may not allow us access to our patient like we usually have.access to our patient like we usually have.We may not know the staff, and the staff We may not know the staff, and the staff doesn’t know us or our needs.doesn’t know us or our needs.

Remote work areaRemote work area

While the environment is not ideal, the same While the environment is not ideal, the same level of safety and high standards must be level of safety and high standards must be maintained.maintained.AANA, ASA standards for delivery of Anesthesia AANA, ASA standards for delivery of Anesthesia in remote locations include.in remote locations include.1)perform complete anesthetic assessment1)perform complete anesthetic assessment2)Obtain informed consent2)Obtain informed consent3) formulate a plan3) formulate a plan4)impliment the plan and adjust as needed4)impliment the plan and adjust as needed5)monitor the patients physiologic condition 5)monitor the patients physiologic condition

Monitoring IncludesMonitoring Includes

1) Ventilation (Etco2, visual, precordial)1) Ventilation (Etco2, visual, precordial)

2) Oxygenation (pulse Ox)2) Oxygenation (pulse Ox)

3) CV status (EKG)3) CV status (EKG)

4) Temp 4) Temp

5) Neuromuscular function (if given a 5) Neuromuscular function (if given a NMB)NMB)

6) Positioning (moving tables etc...)6) Positioning (moving tables etc...)

Guidelines for sedationGuidelines for sedation

Sedation is possible with oral, IV, and Sedation is possible with oral, IV, and inhaled medications.inhaled medications.

Remember that depth of sedation is a Remember that depth of sedation is a continuum of progressive changes in continuum of progressive changes in cognition, respirations, and protective cognition, respirations, and protective reflexes.reflexes.

Sedation does not have strict boundries.Sedation does not have strict boundries.

Guidelines for sedationGuidelines for sedation

JCAHO has guidelines for moderate JCAHO has guidelines for moderate and deep sedation and deep sedation

1) Qualified individuals (CRNA’s 1) Qualified individuals (CRNA’s Anesthesiologists) Anesthesiologists)

2) Monitor the patient2) Monitor the patient

3) Evaluate the patient3) Evaluate the patient

4) Rescue the patient4) Rescue the patient

5) Document5) Document

6) Supervise recovery6) Supervise recovery

JACHO levels of sedationJACHO levels of sedation

Another type of sedation we don’t Another type of sedation we don’t use much..you might use it use much..you might use it

somewhere though…many of you somewhere though…many of you probably already have???probably already have???

Start of procedure:Start of procedure:– 4mg Versed4mg Versed– 500mcg Fentanyl500mcg Fentanyl– 20mg Morphine20mg Morphine

IVIV ContinuousContinuous: : – Propofol gtt @ 150-175 mg/kg/minPropofol gtt @ 150-175 mg/kg/min– Fentanyl gtt @ 25mcg/hrFentanyl gtt @ 25mcg/hr

BalancedBalanced::– 1/3 Mac of Agent1/3 Mac of Agent– No N2ONo N2O– Narcotic InfusionNarcotic Infusion– Induction AgentInduction Agent– Sm Dose of Versed @ IntervalsSm Dose of Versed @ Intervals

Cardiac proceduresCardiac procedures

AICD and PACEMAKERSAICD and PACEMAKERS

Patients who experience sudden Patients who experience sudden cardiac death are usually around cardiac death are usually around 60yo and their most common 60yo and their most common underlying rhythm is VT or VF.underlying rhythm is VT or VF.Ventricular defib. First repoted in Ventricular defib. First repoted in 19471947Is the application of electrical flow Is the application of electrical flow through the appropriate chambers through the appropriate chambers of the heart in order to restore a of the heart in order to restore a sustainable rhythm.sustainable rhythm.

AICD + PACEMAKERSAICD + PACEMAKERS

The first AICD 1980.The first AICD 1980.

Designed to last 120 shocks/3-6 yrs.Designed to last 120 shocks/3-6 yrs.

Shock delivered within 10-15 seconds of detectionShock delivered within 10-15 seconds of detection

A pacemaker is used to treat bradycardia, AV A pacemaker is used to treat bradycardia, AV block, nodal dsfxn, some arrhythmias.block, nodal dsfxn, some arrhythmias.

First conceived in 1950First conceived in 1950

Lasts 6-10 yrs.Lasts 6-10 yrs.

PACEMAKERPACEMAKER

ANESTHETIC CONCERNSANESTHETIC CONCERNS

You may be in cath You may be in cath lab, special cardiac lab, special cardiac procedure room.procedure room.

Get your EKG leads Get your EKG leads on correctly, the on correctly, the surgeon and surgeon and pacemaker pacemaker representitive need representitive need this information.this information.

ANESTHETIC CONCERNSANESTHETIC CONCERNS

Procedure can be done with a local Procedure can be done with a local anesthetic and moderate sedation, some anesthetic and moderate sedation, some people may ask for a general anesthetic.people may ask for a general anesthetic.

AICD placement requires a run of VF to AICD placement requires a run of VF to test the thresholds and functioning of the test the thresholds and functioning of the AICDAICD

The insertion pocket is closed at the end The insertion pocket is closed at the end and the rep. will program the device.and the rep. will program the device.

CARDIOVERSIONCARDIOVERSION

CARDIOVERSION!CARDIOVERSION!

Cardioversion- is a synchronized Cardioversion- is a synchronized discharge of electrical energy to convert discharge of electrical energy to convert hemodynamically unstable rhythms hemodynamically unstable rhythms such as a-flutter or a-fib.such as a-flutter or a-fib.

Closes an excitable gap in the Closes an excitable gap in the myocardium which causes currents to myocardium which causes currents to reenter and excite the electrical system reenter and excite the electrical system of the heartof the heart

This is usually a scheduled or planned This is usually a scheduled or planned procedure for the anesthesia team.procedure for the anesthesia team.

ANESTHETIC CONSIDERATIONSANESTHETIC CONSIDERATIONS

Because it is usually planned, patient Because it is usually planned, patient conditions are usually optimized.conditions are usually optimized.Standard monitors and IV accessStandard monitors and IV accessMidazolam before the procedure and ultra Midazolam before the procedure and ultra short acting agent such as propofol.short acting agent such as propofol.Patient is on NRB may switch to AMBU if Patient is on NRB may switch to AMBU if loss resp.loss resp.Loss of eyelid reflex..”all clear” move Loss of eyelid reflex..”all clear” move away…away…

CATHETER ABLATIONCATHETER ABLATION

CATHETER ABLATIONCATHETER ABLATION

Uses a catheter with an electrode at the Uses a catheter with an electrode at the tip. Guided under fluoroscopy to area of tip. Guided under fluoroscopy to area of the heart muscle that has demonstrated the heart muscle that has demonstrated accessory electrical conductive pathways.accessory electrical conductive pathways.

Success rates are about 95%Success rates are about 95%

Patients no longer need antiarrhytmic Patients no longer need antiarrhytmic meds.meds.

ANESTHETIC CONSIDERATIONSANESTHETIC CONSIDERATIONS

The electro physiologic studies before the The electro physiologic studies before the procedure can be time consuming and procedure can be time consuming and may require some moderate sedation for may require some moderate sedation for adults/ general sedation in kids.adults/ general sedation in kids.

Catheter is guided via femoral artery and Catheter is guided via femoral artery and vein to the areavein to the area

Patient must remain perfectly stillPatient must remain perfectly still

ANESTHETIC CONSIDERATIONSANESTHETIC CONSIDERATIONS

Children get GA with ETT or Children get GA with ETT or LMALMA

Adults moderate sedation, local Adults moderate sedation, local by surgeonby surgeon

TIVA recipe is a popular choice, TIVA recipe is a popular choice, less N/V afterless N/V after

Pay careful attention to the Pay careful attention to the EKG, these patient stopped EKG, these patient stopped taking their antiarrhythmic taking their antiarrhythmic drugs yesterday!drugs yesterday!

Radiologic and Diagnostic Procedures

Computed Tomography (CT scan)- X-rays penetrate tissues according to the anatomic numbers of atoms within the tissue. MRI (Magnetic Resonance Imaging)- Uses the dipole moment of an hydrogen atom which allows the atomic nucleus to act as a magnet. Radiofrequency energy is received from a patients water containing tissues. This is detected by machine and gives diagnostic information. Patient may need to be motionless for longer periods of time than the CT scanner.

Intravenous Contrast Media

An unexpected allergic reaction can occur when iodine is injected. Reactions vary from itching to anaphylactiodRenal toxicity- adequately hydrate one hour prior to procedure and continue for 24 hours post procedure.Local tissue damage- If contrast media infiltrates this can cause moderate to severe irritation to patient.Contraindicated in pregnant patients

Magnetic Resonance SafetyMagnetic Resonance SafetyStatic and gradient magnetic fields with radiofrequency (RF) pulses

Implanted ferromagnetic objectsImplanted ferromagnetic objectsAneurysm clipsProsthetic heart valvesTissue expanders with metallic portsCardiac pacemakersImplantable defibrillators Implantable infusion pumps

Patient ProblemsPatient Problems

Anesthetic TechniquesAnesthetic Techniques

Our goals ?Our goals ?

Patient SedationPatient Sedation– Inadequate sedation – patient movementInadequate sedation – patient movement– Deep sedation – airway compromiseDeep sedation – airway compromise

General anesthesia– TIVA– Inhalation anesthesia – LMA, ETT

GI Procedures

Endoscopy- An endoscope is passed into the GI tract. EGD evaluates the mucosa of the esophagus, stomach and duodenum. If required, dilation is done to any strictured areas.

Colonoscopy- A scope is inserted into the rectum. This test is done to evaluate the colon.

ERCP(Endoscopic retrograde cholangiopancreatography) – Diagnosed obstructive, neoplastic, or inflammatory pancreatobillary structures.

Anesthesia for GI Procedures

Pre anesthetic assessment: Age, cooperative, anxiety, allergies, fluid status, electrolytes, cardiac history, GERDType of anesthesia:– Moderate sedation- Versed and Fentanyl– Deep sedation- Addition of propofol – Some cases required general anesthesia

Anesthetic considerations:– Strong vagal nerve stimulation as result of stimulation

to colon– Most patients tolerate these procedures well.

Dental Procedures

Pediatric Dentistry- fillings, crowns, pulpotomies, tooth extractions and space maintainersOral and Maxillofacial Surgery- extractions of impacted teeth, insertion of dental implants, treatment of infections of the head and neck and facial cosmeticsPeridontics- surgery of teeth, gingiva, connective tissue, periodontal ligament and alveolar bone– Anesthesia : general anesthesia, minimal

sedation,moderate sedation with local anesthetic for particular areas of surgery

Ophthalmology

Cataract extraction is the most common procedure done for the elderly.Strabismus operations are the most common pediatric procedures.Requirements for anesthesia:– Unmoving globe– Minimal bleeding– Smooth emergence– Usually done under MAC

Urologic Procedures

Extracorporeal Shock Wave Lithotripsy- sound waves are focused on kidney and ureteral stones. The R wave of the ECG triggers each shock wave. The stone located by flouroscopy.Cystoscopy/ ureteroscopy- are performed to diagnosis and treat lesions of the lower (urethra,prostate,bladder) and upper (ureter,kidney) urinary tracts. Type of Anesthesia– Depending on the pt and procedure anesthesia can range from

topical lubrication ,MAC, or regional. If regional is used T-6 level of blockade is required for upper tract instrumentation and T-10 for lower-tract surgery.

Goals to Pediatric Anesthesia

Provide safety

Minimize discomfort

Minimize psychological consequences of procedure

Control uncooperative behavior

Minimize complications

Anesthesia Considerations for the Pediatric Patient in a Remote

LocationAnxiety– Pediatric premedication greatly reduces anxiety and

prevents movement for necessary procedures

Qualified personnel to assist in care of the pediatric patient. – An extra pair of hands allows for safer care

Frequently encountered problems– Respiratory depression– Respiratory obstruction– Apnea

Pediatric Premedication

Midazolam– Good sedative agent for MRIGood sedative agent for MRI– 0.25-0.75 mg/kg PO0.25-0.75 mg/kg PO– 0.05-0.15 mg/kg IV0.05-0.15 mg/kg IV– Incomplete sedation Incomplete sedation movement movement– Higher doses Higher doses paradoxical excitation and agitation paradoxical excitation and agitation

Chloral HydrateChloral Hydrate– Most effective in children < 3 y/oMost effective in children < 3 y/o– 75-100 mg/kg PO75-100 mg/kg PO– Lasting up to 1 hourLasting up to 1 hour– May cause airway obstructionMay cause airway obstruction

KetamineKetamine

Extensively used in childrenExtensively used in children5 mg/kg IM5 mg/kg IM– 5mg/kg Given orally produces sedation in 10-15

minutes– Synergistic with Versed

Nonpurposeful motion – limited use in MRINonpurposeful motion – limited use in MRI prior to general anesthesia if no IVprior to general anesthesia if no IVAvoid: intracranial pathologyAvoid: intracranial pathologyCoadministered antisialogogue-robinul,atropineCoadministered antisialogogue-robinul,atropineMidazolam: reduce emergence hallucinationMidazolam: reduce emergence hallucination

Study On Pediatric SedationStudy On Pediatric Sedation

258 infants who required MRI258 infants who required MRI

Chloral hydrate vs Pentobarbital vs Chloral hydrate vs Pentobarbital vs PropofolPropofol

Anesthesia and Analgesia. 2006; 103: 863-8

Other OptionsOther Options

Methohexital (brevital)20-30 mg/kg rectalMethohexital (brevital)20-30 mg/kg rectal

Pentobarbital 4-5 mg/kg PO, rectally, IVPentobarbital 4-5 mg/kg PO, rectally, IV

Oral transmucosal Fentanyl– 5-15mcg/kg– Sedation and Analgesia

Dexmedetomidine (Precedex)

MethohexitalMethohexital

Ultrashort-acting barbiturate anesthetic. This Ultrashort-acting barbiturate anesthetic. This barbiturate medication is used, either alone or barbiturate medication is used, either alone or with other drugs, for anesthesia.with other drugs, for anesthesia. (IV injection or continuous infusion) IV (IV injection or continuous infusion) IV administration of methohexital results in rapid administration of methohexital results in rapid uptake by the brain (within 30 seconds) and uptake by the brain (within 30 seconds) and rapid induction of sleep.rapid induction of sleep.IM administration to pediatric patients, the onset IM administration to pediatric patients, the onset of sleep occurs in 2 to 10 minutes. of sleep occurs in 2 to 10 minutes. PR administration, the onset of sleep occurs in 5 PR administration, the onset of sleep occurs in 5 to 15 min. to 15 min.

DexmedetomidineDexmedetomidine

Alpha-2-agonistAlpha-2-agonist

Similar levels of sedation compared with Similar levels of sedation compared with propofol, but with less opioid requirementspropofol, but with less opioid requirements

Can be used for sedation in critically ill Can be used for sedation in critically ill medical and pediatric patientsmedical and pediatric patients

Common adverse effects: hypotension, Common adverse effects: hypotension, hypertension, bradycardiahypertension, bradycardia

Ann Pharmacother. 2007; 41(2): 245-52

TIVATIVA

Propofol infusionPropofol infusion

Initial dose of 2-3 mg/kg IV, followed by an Initial dose of 2-3 mg/kg IV, followed by an infusion of 100 μg/kg/mininfusion of 100 μg/kg/min

Maintenance of spontaneous respirationMaintenance of spontaneous respiration

If airway management is necessary If airway management is necessary laryngeal mask airway or endotracheal laryngeal mask airway or endotracheal intubationintubation

Case presentationCase presentation

37 yo Male, severely mental retardation 37 yo Male, severely mental retardation and cerebral palsy. Coming in for CT scan and cerebral palsy. Coming in for CT scan guided gastro tube/drain placement for guided gastro tube/drain placement for partial bowel obstruction. partial bowel obstruction.

What are the concerns?What are the concerns?

What do you need?What do you need?

ConcernsConcerns

Airway controlAirway control

Increase in oral secretionsIncrease in oral secretions

Increase in anxietyIncrease in anxiety

Wont be able to follow commandsWont be able to follow commands

Wont be able to lay stillWont be able to lay still

Need to HaveNeed to Have

A PlanA PlanPre-assessmentPre-assessmentMonitorsMonitors– HeartHeart– ETCO2ETCO2– Resp.Resp.– O2SatO2Sat– Temp.Temp.

Vent/airway equipment/suctionVent/airway equipment/suctionDrugsDrugsHelp of staffHelp of staff

1. In remote areas a complete 1. In remote areas a complete anesthesia assessment is not anesthesia assessment is not necessary. True or False necessary. True or False

AnswerAnswerRemote work areaRemote work area

While the environment is not ideal, the same While the environment is not ideal, the same level of safety and high standards must be level of safety and high standards must be maintained.maintained.AANA, ASA standards for delivery of Anesthesia AANA, ASA standards for delivery of Anesthesia in remote locations include.in remote locations include.1)perform complete anesthetic assessment1)perform complete anesthetic assessment2)Obtain informed consent2)Obtain informed consent3) formulate a plan3) formulate a plan4)impliment the plan and adjust as needed4)impliment the plan and adjust as needed5)monitor the patients physiologic condition 5)monitor the patients physiologic condition

2. Pick the best 2 that describe 2. Pick the best 2 that describe “moderate sedation” by JACHO“moderate sedation” by JACHO

a.a. No intervention for the airway is needed.No intervention for the airway is needed.

b.b. Spontaneous ventilation may be Spontaneous ventilation may be adequate.adequate.

c.c. Cardiovascular function is usually Cardiovascular function is usually maintained.maintained.

d.d. Normal response to verbal stimulation.Normal response to verbal stimulation.

e.e. Airway intervention may be required.Airway intervention may be required.

AnswerAnswer

3. When going to remote areas for 3. When going to remote areas for sedation you should always bring.. sedation you should always bring..

a.a. RemifentanilRemifentanil

b.b. NaloxoneNaloxone

c.c. NorcuronNorcuron

d.d. FlumazenilFlumazenil

e.e. kefzolkefzol

AnswerAnswerd. flumazenil (Remazicon) antagonizes the d. flumazenil (Remazicon) antagonizes the actions of actions of benzodiazepinesbenzodiazepines on the central on the central nervous system. Flumazenil competitively nervous system. Flumazenil competitively inhibits the activity at the benzodiazepine inhibits the activity at the benzodiazepine recognition site on the GABA recognition site on the GABA /benzodiazapine receptor complex. /benzodiazapine receptor complex. Dose- 0.2mg IV-over 15 sec. Q 1min-max Dose- 0.2mg IV-over 15 sec. Q 1min-max total dose of 1 mg (10 mL). Usually see total dose of 1 mg (10 mL). Usually see results with 0.6mg. For resedation may results with 0.6mg. For resedation may redose with max 1mg Q 20min – max redose with max 1mg Q 20min – max 3mg/hr.3mg/hr.

References Anesthesia for magnetic resonance imaging. Int Anesthesiol Clin. 2003; 41(2): Anesthesia for magnetic resonance imaging. Int Anesthesiol Clin. 2003; 41(2): 29-3729-37

Longnecker, D.E., Murphy, F.L.(1992). In References troduction to Anesthesia; 8th ed. W.B. Saunders Company.

Morgan, G.E., Mikhail, M.S., Murray, M.E.(2006). Clinical Anesthesiology;4th ed. Mcgraw Hill Medical Publishing.

Nagelhourt, J.J., Zaglaniczny, K.L.(2001). Nurse Anesthesia; W.B. Saunders Company.

Sedation and anesthesia protocols used for magnetic resonance imaging Sedation and anesthesia protocols used for magnetic resonance imaging studies in infants. Anesth Analg. 2006; 103: 863-8studies in infants. Anesth Analg. 2006; 103: 863-8

The nature of anesthesia and procedural sedation outside of the operating room. Curr Opin Anaesthesiol. 2007; 20: 347-351