Anesthesia for diagnostic and therapeutic procedures

1. Anesthesia for diagnostic and therapeutic procedures

2. There are cases of minor surgery, but there are no cases of minor anesthesia Although most anesthetics are traditionally given in the operating room, technology advancements have moved many procedures that still require patient relaxation outside of the operating room. The anesthesia needed can range from local anesthetics, MAC, or general anesthesia.

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

4. Your working environment.

5. Remote work area The operating room is ideal..for the most part. The workplace allotted for anesthesia is often small, crowded and different from our usual set up. Additionally the setup may not allow us access to our patient like we usually have. We may not know the staff, and the staff doesn�t know us or our needs.

6. Remote work area While the environment is not ideal, the same level of safety and high standards must be maintained. AANA, ASA standards for delivery of Anesthesia in remote locations include. 1)perform complete anesthetic assessment 2)Obtain informed consent 3) formulate a plan 4)impliment the plan and adjust as needed 5)monitor the patients physiologic condition

7. Monitoring Includes 1) Ventilation (Etco2, visual, precordial) 2) Oxygenation (pulse Ox) 3) CV status (EKG) 4) Temp 5) Neuromuscular function (if given a NMB) 6) Positioning (moving tables etc...)

8. Guidelines for sedation Sedation is possible with oral, IV, and inhaled medications. Remember that depth of sedation is a continuum of progressive changes in cognition, respirations, and protective reflexes. Sedation does not have strict boundries.

9. Guidelines for sedation JCAHO has guidelines for moderate and deep sedation 1) Qualified individuals (CRNA�s Anesthesiologists) 2) Monitor the patient 3) Evaluate the patient 4) Rescue the patient 5) Document 6) Supervise recovery

10. JACHO levels of sedation

11. Another type of sedation we don�t use much..you might use it somewhere though�many of you probably already have??? Start of procedure: 4mg Versed 500mcg Fentanyl 20mg Morphine IV Continuous: Propofol gtt @ 150-175 mg/kg/min Fentanyl gtt @ 25mcg/hr Balanced: 1/3 Mac of Agent No N2O Narcotic Infusion Induction Agent Sm Dose of Versed @ Intervals

12. Cardiac procedures

13. AICD and PACEMAKERS Patients who experience sudden cardiac death are usually around 60yo and their most common underlying rhythm is VT or VF. Ventricular defib. First repoted in 1947 Is the application of electrical flow through the appropriate chambers of the heart in order to restore a sustainable rhythm.

14. AICD + PACEMAKERS The first AICD 1980. Designed to last 120 shocks/3-6 yrs. Shock delivered within 10-15 seconds of detection A pacemaker is used to treat bradycardia, AV block, nodal dsfxn, some arrhythmias. First conceived in 1950 Lasts 6-10 yrs.

15. PACEMAKER

16. ANESTHETIC CONCERNS You may be in cath lab, special cardiac procedure room. Get your EKG leads on correctly, the surgeon and pacemaker representitive need this information.

17. ANESTHETIC CONCERNS Procedure can be done with a local anesthetic and moderate sedation, some people may ask for a general anesthetic. AICD placement requires a run of VF to test the thresholds and functioning of the AICD The insertion pocket is closed at the end and the rep. will program the device.

18. CARDIOVERSION

19. CARDIOVERSION! Cardioversion- is a synchronized discharge of electrical energy to convert hemodynamically unstable rhythms such as a-flutter or a-fib. Closes an excitable gap in the myocardium which causes currents to reenter and excite the electrical system of the heart This is usually a scheduled or planned procedure for the anesthesia team.

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

21. CATHETER ABLATION

22. CATHETER ABLATION Uses a catheter with an electrode at the tip. Guided under fluoroscopy to area of the heart muscle that has demonstrated accessory electrical conductive pathways. Success rates are about 95% Patients no longer need antiarrhytmic meds.

23. ANESTHETIC CONSIDERATIONS The electro physiologic studies before the procedure can be time consuming and may require some moderate sedation for adults/ general sedation in kids. Catheter is guided via femoral artery and vein to the area Patient must remain perfectly still

24. ANESTHETIC CONSIDERATIONS Children get GA with ETT or LMA Adults moderate sedation, local by surgeon TIVA recipe is a popular choice, less N/V after Pay careful attention to the EKG, these patient stopped taking their antiarrhythmic drugs yesterday!

25. 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. Some precedure may be aided by ct scan ie tube placementsSome precedure may be aided by ct scan ie tube placements

26. Intravenous Contrast Media An unexpected allergic reaction can occur when iodine is injected. Reactions vary from itching to anaphylactiod Renal 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

27. Magnetic Resonance Safety

28. Patient Problems

29. Anesthetic Techniques Our goals ? Patient Sedation Inadequate sedation � patient movement Deep sedation � airway compromise General anesthesia TIVA Inhalation anesthesia � LMA, ETT

31. 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.

32. Anesthesia for GI Procedures Pre anesthetic assessment: Age, cooperative, anxiety, allergies, fluid status, electrolytes, cardiac history, GERD Type 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.

34. Dental Procedures Pediatric Dentistry- fillings, crowns, pulpotomies, tooth extractions and space maintainers Oral and Maxillofacial Surgery- extractions of impacted teeth, insertion of dental implants, treatment of infections of the head and neck and facial cosmetics Peridontics- 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 Know maximum doses for injected anesthetics based on your pt weight( with and with out epi.) Check for need for antibiotics if mitral valve problems. Usually pt and dentist are well aware before hand and the pt has taken oral doses. Know maximum doses for injected anesthetics based on your pt weight( with and with out epi.) Check for need for antibiotics if mitral valve problems. Usually pt and dentist are well aware before hand and the pt has taken oral doses.

36. 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

38. 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.

40. Goals to Pediatric Anesthesia Provide safety Minimize discomfort Minimize psychological consequences of procedure Control uncooperative behavior Minimize complications

42. Anesthesia Considerations for the Pediatric Patient in a Remote Location Anxiety 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

43. Pediatric Premedication Midazolam Good sedative agent for MRI 0.25-0.75 mg/kg PO 0.05-0.15 mg/kg IV Incomplete sedation ? movement Higher doses ? paradoxical excitation and agitation Chloral Hydrate Most effective in children < 3 y/o 75-100 mg/kg PO Lasting up to 1 hour May cause airway obstruction

44. Ketamine Extensively used in children 5 mg/kg IM 5mg/kg Given orally produces sedation in 10-15 minutes Synergistic with Versed Nonpurposeful motion � limited use in MRI ? prior to general anesthesia if no IV Avoid: intracranial pathology Coadministered antisialogogue-robinul,atropine Midazolam: reduce emergence hallucination

45. Study On Pediatric Sedation 258 infants who required MRI Chloral hydrate vs Pentobarbital vs Propofol Anesthesia and Analgesia. 2006; 103: 863-8

47. Other Options Methohexital (brevital)20-30 mg/kg rectal Pentobarbital 4-5 mg/kg PO, rectally, IV Oral transmucosal Fentanyl 5-15mcg/kg Sedation and Analgesia Dexmedetomidine (Precedex)

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

49. Dexmedetomidine Alpha-2-agonist Similar levels of sedation compared with propofol, but with less opioid requirements Can be used for sedation in critically ill medical and pediatric patients Common adverse effects: hypotension, hypertension, bradycardia

50. TIVA Propofol infusion Initial dose of 2-3 mg/kg IV, followed by an infusion of 100 �g/kg/min Maintenance of spontaneous respiration If airway management is necessary ? laryngeal mask airway or endotracheal intubation

51. Case presentation 37 yo Male, severely mental retardation and cerebral palsy. Coming in for CT scan guided gastro tube/drain placement for partial bowel obstruction. What are the concerns? What do you need?

52. Concerns Airway control Increase in oral secretions Increase in anxiety Wont be able to follow commands Wont be able to lay still

53. Need to Have A Plan Pre-assessment Monitors Heart ETCO2 Resp. O2Sat Temp. Vent/airway equipment/suction Drugs Help of staff

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

55. Answer Remote work area While the environment is not ideal, the same level of safety and high standards must be maintained. AANA, ASA standards for delivery of Anesthesia in remote locations include. 1)perform complete anesthetic assessment 2)Obtain informed consent 3) formulate a plan 4)impliment the plan and adjust as needed 5)monitor the patients physiologic condition

56. 2. Pick the best 2 that describe �moderate sedation� by JACHO No intervention for the airway is needed. Spontaneous ventilation may be adequate. Cardiovascular function is usually maintained. Normal response to verbal stimulation. Airway intervention may be required.

57. Answer

58. 3. When going to remote areas for sedation you should always bring.. Remifentanil Naloxone Norcuron Flumazenil kefzol

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

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