Principles of Anesthesiology Nursing IV Anesthesia Service Outside the OR

1. Principles of Anesthesiology Nursing IVAnesthesia Service Outside the OR Jeffrey Groom, PhD, CRNADirector and Clinical Associate ProfessorNurse Anesthetist ProgramFlorida International University

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5. Airway ManagementANDSpecial Procedures Outside of the O.R.

6. ASA Closed Claims Study • 35 % of claims are RESPIRATORY events • 90 % resulted in brain damage or death • 90% resulted from Difficulty in INTUBATION or EXTUBATION

7. Difficult Airway Algorithm

10. Difficult Airway Management • Anticipated vs. Unanticipated • Operating Room vs. Remote Location • Elective vs. Urgent. Vs. Emergent • Airway - Ventilation • Patent Airway ? • Ability to Intubate ? • Ability to Ventilate ?

11. AIRWAY ASSESSMENT ?

12. AIRWAY ASSESSMENT • Mouth Opening • Oropharyngeal Classification • TM Distance • Neck Range of Motion • Jaw Mobility • Dentition • Mask Seal/Airway Access

13. Difficult Airway Algorithm • DIFFICULT AIRWAY • RECOGNIZED vs. UNRECOGNIZED • SUCCESSFUL • Confirmation of TUBE Placement • Documentation of Difficult Airway

14. Difficult Airway Algorithm • DIFFICULT AIRWAY • RECOGNIZED vs. UNRECOGNIZED • SUCCESSFUL • EXTUBATION • PLAN for REINTUBATION • AWAKE • JET STYLETTE over ETT

15. Difficult Airway Algorithm • If SUSPICIOUS of Trouble Awake Intubation • If you get into TROUBLE Wake the Patient Up • Have PLAN B, C… immediately available PLAN AHEAD / WILL to Move On • Intubation Choices - Alternative Choices Do what you do BEST

16. Airway Management Outside of the O.R. • ICU – Intubate patient in respiratory distress • Wards – Intubate for arrest • ER – Intubate difficult airway CRNA

17. Airway Management Outside of the O.R. • Historical Perspective • SAFETY 1st • Bag of Tricks • Urgent vs. Emergent • Assessment • Awake vs. Asleep • Confirmation - Documentation CRNA

18. Airway Management Outside of the O.R. • SAFETY 1st • Bag of Tricks • Airways, Meds, Gadgets • Suction - Monitors - O2 + Ambu • Access - Position Patient • Awake vs. Asleep • Confirmation - Documentation CRNA

19. RULE # 1 HOLD ON TO ONE STEP, UNTIL YOU HAVE A GOOD GRIP ON THE NEXT MEANING: DON’T…... ...Turn a BREATHING patient into an APENIC patient …Turn a COMPROMISED airway into NO airway …Turn a CV/CI patient into a Can’t Resuscitate patient

20. Anesthesia Out of the O.R. • Private Offices, Clinics, Surgi-Centers • In-Hospital Out of the OR Areas: • Interventional Radiology, MRI, CAT • Interventional Cardiology, EP Lab • GI / GU / Bronch • Pedi Heme/Onco • Ophthalmology Clinic • Psychiatry • Oncology • Dental • IVF Clinic

21. Anesthesia Services Outside of the O.R. • SAFEST Routine is your USUAL Routine • PreAnesthetic Assessment • Standard Equipment & Monitors • Physical Space & Patient (Airway) Access • Availability of HELP - Backup Plan • PostAnesthetic Recovery Plan

22. Anesthesia Services Outside of the O.R. ASA Guidelines for Nonoperating Room Anesthetizing Locations • Primary and secondary oxygen source • Suction • Anesthesia machine, BVM, drugs, supplies, monitors, scavenging system equivalent to that in the main OR • Sufficient electrical outlets, GFI in wet areas, and emergency power outlets

23. Anesthesia Services Outside of the O.R. • Adequate illumination • Immediate access to the patient • Emergency resuscitation cart & defibrillator • Site must comply with building, fire, and safety codes • Two-way communication to summon help(Code-button and Phone numbers**)

24. Procedural sedation and analgesia • Traditional – some combination of versed, fentanyl and propofol • Propofol – Initial: (-1+)mg/kg and maintained w/ 0.5mg/kg q 3-5 min • “Ketofol" (ketamine/propofol combination) • a single-syringe 1:1 mixture of: 10 mg/mL ketamine and 10 mg/mL propofol (ketofol) • 1 – 3 ml / titrated to effect for an average dose given of: ketamine at 0.75 mg/kg and propofol at 0.75 mg/kg • Nitrous oxide – 30% to 50% to 70% • Precedex (Dexmedetomidine) - precedex.com • 1 mcg/kg over 10 minutes then -/+ 0.4 mcg/kg/hr

25. To O2 or Not to...

26. RADIOLOGY • CAT Scan and MRI • Contrast media reaction (5-10% of patients) • Allergy history, type of dye, dose & method MILD- N&V, flush, chills, urticaria, fever MODERATE- bronchospasm, edema, low BP SEVERE- shock, seizure, arrest • Treatment- symptomatic relief to resuscitation • Contrast media causes anxiety but, too much sedation can mask reaction symptoms

27. Magnetic Resonance Imaging (MRI) • Special Problems • Special Equipment • Solutions are Unique to each MRI Facility

28. CARDIOLOGY • Cardiac Catheterization • AICD Placement / Pacemaker Placement • Monitored Anesthesia Care • Standby Pacer / Defibrillator (ElectroPads) • Cardioversion • IV & Monitors - Preoxygenate (ETT ready) • Sedation/Amnesia may be attained with: Propofol, Thiopental, Methohexital, Midazolam • Be prepared for anything…..

29. PSYCHIATRY • General Anesthesia for Electroconvulsive Therapy (ECT) • Pre-Op Assessment • 50%+ are ASA III • Airway & Aspiration Concerns • Psych Meds • Coexisting Diseases • Location (OR vs. Psych Ward)

30. PSYCHIATRY • ANESTHESIA PLAN • Standard monitors, IV, isolate arm monitor, O2 • Anesthesia - Methohexital .5 - 1 mg/kg • Ventilate - SUX .5 - 1 mg/kg then hyperventilate • Mouth gag or OPA placed and electrodes applied • ECT applied • Ventilate & Oxygenate, Rx symptomatic response • Be prepared to terminate continued seizure(STP 1-2 mg/kg)

31. PSYCHIATRY Physiologic Response to ECT

32. Anesthesia for Ophthalmic Surgery

33. Anesthesia for Ophthalmic Surgery • Ophthalmic Surgical Procedures • Dynamics of Intraocular Pressure • Anesthetic & Ophthalmic Agents • Oculocardiac Reflex • Anesthesia Options and Care Plans

34. Ophthalmic Surgical Procedures • Cataract Excision & Intraocular Lens Implant • Phacoemulsification Technique • Corneal Transplant- w/ or w/o IOL Implant • Trabeculectomy • Open Globe Repair • Retinal Surgery - Scleral buckling, vitrectomy • Strabismus Surgery • Pterygium Excision, Eye Lid Procedures

35. Ophthalmic Surgical Procedures • Most patients will be pediatric or elderly • Most procedures will be done as Regional -> MAC -> GETA • Closed-Claims Analysis 30% of cases involve patient movement • “Potential Danger Area for the Part-Time Ophthalmic Anesthetist”

36. Dynamics of IO Pressure • Normal range 10 - 20 mmHg • Varies with EXTERNAL Pressure and with INTERNAL Volume • Subject to transient pressure changes - blinking, rubbing eye, cough etc. • Factors causing IOP to INCREASE during surgical procedures

37. Dynamics of IO Pressure VARIABLE EFFECT CVP INCREASE + + + DECREASE - - - Arterial BP INCREASE + DECREASE - PaCO2 INCREASE + + DECREASE - - PaO2 DECREASE +

38. Dynamics of IO Pressure VARIABLE EFFECT Inhaled Agents Volatile Agts. - - Nitrous Oxide - * IV Anesthetics Barbs, Benzos, Propofol, Narcs - - Ketamine ? Muscle Relaxants Depolarizers + + Nondepolarizers - - Agents that alter CVP or BP + or -

39. Ophthalmic Medications and Implications for Anesthesia May be administered topically, intraocularly, or systemically • Topicals are highly concentrated ie: phenylephrine drop gives 5mg vs typicial IV dose for low BP is often 0.1mg and absorption rate is between IV and SC • Air, sulfur hexafluoride, etc may be given IO and may expand 2-4 times upon D/C of nitrous oxide • Echothiophate (Phospholine) - anticholinesterase, may decrease plasma cholinesterase activity • See examples from text

40. Oculocardiac Reflex Vagus - X Efferent Afferent Trigeminal - V

41. Anesthesia Options • Considerations: Patient, Surgeon, Anesthetist • All patients need to be assessed pre-op for potential GETA irrespective of how case is booked • Special attention to co-existing diseases or risks • All patient pre-op, monitoring and anesthesia set-up should be as if the case were a GETA • Anesthesia Options: Regional Local GETA

42. Regional Anesthesia • The GOAL: Analgesia and Akinesis • The MIX: 2%LIDO + 0.75%Bupivacaine plus hyaluronidase & epi • The BLOCK: Retrobulbar Peribulbar • The COMPLICATIONS: Acute Anxiety, Hemorrhage, Trauma, OC Reflex, IV Injection, CNS Toxicity +/- Facial Nerve

43. Peripheral Nerve Blocks • Eye Block- Retrobulbar Peribulbar • Anatomy • Analgesia • Complications - hemorrhage, OCR, CNS

45. Local Anesthesia • The GOAL: Analgesia • The MIX: LIDO + / - Bupivacaine epi 1: 200, 400, -000 • The BLOCK: local infiltration at site • The COMPLICATIONS: Acute Anxiety, Pain on Injection, OC Reflex, IV Injection, CNS Toxicity

46. General Anesthesia • The GOAL: GETA w/o increasing IOP • The MIX: Lido / Narcs / Labetolol, then STP or Propofol, then Nondeoplarized and Deep ETI • The Problem: Open Globe RSI with SUX and Extubation • The COMPLICATIONS: Management of IOP, OCR and Movement post-op pain, N & V

47. The Problem: Open Globe Injury & Aspiration Risk ISSUES: 1) Aspiration Risk 2) Increase IOP and Excursion of Contents OPTIONS: 1) Wait…….Regional…….Turf……… 2) Aspiration Prophylaxis 3) Cricoid Pressure +/- true RSI or Modified

48. Monitored Anesthesia Care • Preop Assessment-can patient communicate, lie supine, lie still ? • H & P, Meds, Labs, Medically “Tuned” • Pre-op meds, IV, sedation, monitors (N/C -CO2) • Sedation options:barbs, narcs, benzo,N2O • Positioning - Ventilation - Temp - HTN

49. Anesthesia for ENT Surgery

50. AIRWAY MANAGEMENT becomes a shared responsibility