Step Right Up! The Traveling Anesthesia Show - PowerPoint Presentation

1. Step Right Up!The Traveling Anesthesia ShowThomas Corey Davis, PhD, CRNAVCU College of Health ProfessionsDepartment of Nurse Anesthesia

2. DISCLAIMER Thomas Corey Davis, PhD, CRNAI have no current or past relationships w/ commercial entitiesPlease silence your cell phone & devicesThis means you, too, Davis!

3. Non-Operating Room AnesthesiaRapidly developing into a new sub-specialtyMay make up to 30% of all cases!Likely even greater than 30%!Increase in frequency due to:Advances in medical technology now permit more noninvasive or minimally invasive procedures (ICD, TAVR, etc)The Joint Commission requires moderate – deep sedation to be provided by qualified individuals with the ability to rescue patients at any level of sedation (typically requires anesthesia staff)

4. “Engineering Excellence”Most areas where NORA is practiced are NOT engineered with anesthesia care in mindAccess to patient hindered by equipmentInadequate access to necessary ancillary devices Suction / evacuation of waste gasAvailability of backup ventilation/airway management equipmentElectrical Outlets (NOT the back of the anesthesia machine)Pipeline gasesUnfamiliar or outdated anesthesia equipment

5. Human RelationsUnfamiliarity of staff With anesthesia providersWith the needs/concerns of anesthesia providersCommunication issuesRole uncertaintyRemoteness of locationAccess to emergency assistance (Calling for help)

6. Patient PopulationAll PS classifications, often with multiple medical problems“What’s the big deal? It’s just a little sedation for a quick MRI!”Problem areas:ClaustrophobiaMental impairment/developmental delayMovement disordersYoung children/InfantsSerious medical problems/trauma

7. Standards All the same as the Operating RoomFull anesthetic evaluation of non-emergency patientsAll essential equipment & medications readily available Where is the MH cart?All equipment should be of same quality as main OR, with the same preventative maintenanceAll the same Post-Op recovery standards as main OR

8. SolutionsMany issues can be addressed upon initial consultation with new NORA locationClearly list the requirements for anesthesia deliveryEnsure availability and access to required elements (suction, evacuation of waste gases, pipeline gases, physical space issues for anesthesia equipment/personnel in relation to the patient)Establish checklists/protocols to ensure safetyClearly indicate the availability of anesthesia services If schedule is inefficient, cases may be rushed, production pressure increased

9. SolutionsOn Day of Surgery“Daily Huddle”Clearly introduce all staff – write names on board visible to allClearly establish roles – for procedure, and for emergenciesWho will call for help? How will you call? What number?Who will assist anesthesia provider?Where are the emergency supplies? Who will retrieve these supplies?Clearly discuss plan for each case, and be prepared to communicate any unexpected alterations in the plan

10. Specific ProceduresRadiographic procedures and Contrast Media Iodine-based CM – common effects:Warmth, flushing, altered tasteEffects usually self-limiting, minimal clinical significanceHypersensitivityMild/Minor - Nausea, mild vomiting, urticaria, itchingModerate – severe vomiting, marked urticaria, bronchospasm, facial/laryngeal edema, vasovagal rxnsSevere – hypotensive shock, pulmonary edema, respiratory arrest, cardiac arrest, convulsions

11. Risk Factors for CM rxnPrevious CM reactionAsthmaAllergy – hay fever, eczema, allergy to foods, drugs, other substances Beta-blockers (controversial; can impair response to treatment of a rxn)Female gender, Indian or Mediterranean ethnicity

12. Prophylaxis? Premedication, while common in the past, is controversial with modern agentsMay prevent mild skin reactionsWill not prevent anaphylactic shock from a true allergic hypersensitivity. Higher risk of rxn = higher likelihood of premedicationSteroids, H1 & H2 blockersGive steroids 12 hours before CM, minimal time unlikely to be less than 6 hours

13. Radiation OncologyVery high dose (and very narrow beam) radiation for treatment of tumorsInfants & Children frequently require anesthesia to tolerate procedureVery short, non-painful procedure, patient must be absolutely immobile for duration of procedureAnesthesia provider NOT permitted to remain in room with patient (separated by some distance in control room, patient may be monitored via cameras in room)

14. Radiation OncologyFor head/neck cancers, a unique “mask” is created to hold the head stationary at the proper position for the beam to target the tumor.A ‘simulation’ is a CT guided procedure in which this mask is created specifically for the individual patient.It is critical that the patient can be ventilated or maintain an open airway in the proper position in which this mask is created.

15. Hematology/OncologySedation for lumbar puncture for drawing CSF, injection of intrathecal chemotherapy agentsSedation by anesthesia providers often required for infants/childrenSome as old as teenagers!Moderate-deep sedation with spontaneous ventilationTypically do NOT have access to anesthesia machine, make certain to have emergency airway management equipment/devices readily available

16. Computed Tomography (CT)

17. CTProduces an image using ionizing radiation to detect variations in the density of various body tissuesRequires a still patientNot painful, nor particularly loud or anxiety-provoking

18. CT - ConcernsRequires still, cooperative patient who can lie flatInfants, developmentally delayed/mentally challenged patients, obese patients, patients with postural orthopneaMay have limited access to patient, room not typically designed for anesthesia/anesthesia machine/equipmentCM may be usedProcedure may involve needle biopsy of organs (risks of bleeding)

19. MRI

20. MRINon-invasive diagnostic test employing a static magnetic field, a time-varied magnetic field, and radio frequency pulses to generate high-contrast, clinically useful images

21. MRI - ConcernsRequires a still, cooperative patient – all concerns with CT also applyScanner is a long, narrow tube – often induces claustrophobia requiring sedation of even more cooperative patientsSignificant concerns re: magnetic field generatedRequires non-ferrous equipment & montiorsDo not bring ferrous material of any kind into the scanner

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23. Interventional RadiologyAngiography and IR proceduresStenting, coiling, etc.Insertion sites – brachial, femoral arteries/veinsPain upon injection, potential for arterial bleeding or vascular injuryMay involve intracranial lesions (aneurysms, stenting of cerebral or carotid vessels, angioplasty of vessels)

24. Cardiac Catheterization/EPRight & Left heart catheterizationUsually from femoral vessels, rarely brachialMust lie still, often light sedation is preferredAngioplasty/Stent placementFor patients with known CAD

25. EPElectrophysiologyLocalization/ablation of A-fib/Ventricular arrhythmiasDFT – Defibrillation testing – for ICD placement/generator/battery/lead changesWill usually require general anesthesiaCardioversionBrief period of deep sedationPatients often with significant cardiac disease or cardiomyopathy

26. Cath Lab/EP - ConcernsEstablish good IV access, thorough preop- patients often have significant CV disease and/or cardiomyopathyDiscuss plan with cardiologists/teamIs GA required? Is sedation preferred?NO Lidocaine on induction for EP patients!Arrhythmias common (often intended for EP)STAND BACK when shocks delivered

27. Electroconvulsive TherapyTreatment for certain types of depression and/or schizophrenia that have not responded to medicationHistory: Patients with these conditions were observed to have improvement after spontaneous seizuresFirst techniques were chemically induced, often with overdose of insulin – results were unpredictable1938 – electrical stimulation, initially WITHOUT anesthesia! (long bone and even vertebral fractures were commonplace – up to 40%)

28. ECTPhysiologic effects:CV HR - initial decrease (short periods of asystole could be seen), then increase (may be dramatic)BP – significant elevations are common, may require beta-blockadeCerebralIncreased CBF, O2 consumption, ICPOther – Increase IOP, intragastric pressure

29. ECTAbsolute contraindicationsRecent MI (<3 months)Recent CVA (<1 month)Intracranial massRelative contraindicationsAngina, CHF, severe pulmonary disease, severe osteoporosis, major bone fracture, glaucoma, retinal detachment, thrombophlebitis, pregnancy

30. ECTMay not have informed consent (court ordered)History/Physical/IV access may be challengingGMA most commonRapid induction, alleviate physiologic effects of ECT (immobility, autonomic effects), rapid recovery, minimal medication effects on seizuresMethohexital, Propofol, Etomidate + Succinylcholine (relaxant of choice) – IV caffeine to promote seizure, beta-blocker for control of autonomic effectsIsolate one lower limb (foot) & monitor EEG to evaluate duration of seizure

31. LithotripsyDeveloped by German aerospace corporation after decades of flight physics researchDiscovered that shock waves created by raindrops during supersonic aircraft flight resulted in cratering of metalShock waves pass through a liquid medium without damaging tissues (similar acoustic density), change in acoustic impedance at tissue-stone interface results in shear and tear forces, fragmenting the stoneExtra-corporeal Shock Wave lithotripsy (ESWL)

32. LithotripsyEarly lithotripsy involved immersion of the patient into a water bathRequired GA or regional (central neuraxial blockade)Modern litotripters use a gel interface and do not require immersionSedation or GA – must lie still through 2,000 – 3,000 shocksLoud, uncomfortable, may induce arrythmiasSynchronization of shock waves to R-wave of ECG reduces incidence of arrhythmias, may slow procedure

33. LithotripsySedation vs. GAGenerous fluid administration – consider small dose of diuretic to maintain brisk urinary flow and flush debris and blood clots

34. Endoscopy/ColonoscopyEGDGERD, Barrett’s esophagus/esophageal cancerERCPCommon bile duct stones, pancreatic cancer

35. Endoscopy/ColonoscopyU.S. Preventative Services Task Force – mandates screening colonoscopies for all patients between 50 - 75 yearsWhy involve anesthesia?Multiple comorbidities; airway concerns; pediatric patients; highly complex, long, or high-risk procedures; failed GI-administered sedation.

36. Endoscopy/ColonoscopyPreop EvalInpatients likely far more debilitated than outpatientPossible comorbidities:HTN, CAD, cardiac rhythm abnormalities, Pacemakers/VAD/ICDIf recent stent, weigh risk of postponement vs. risk of procedure for cancer staging or therapeutic ERCP – consult cardiologistRisk of bleeding with fine-needle aspiration cytology or other interventions w/ potential bleeding should be thoroughly discussed with gastroenterologist

37. Endoscopy/ColonoscopyPreop EvalInpatients likely far more debilitated than outpatientPossible comorbidities:COPD, OSAConsider elective intubation for prolonged ERCPConsider use of LMA Gastro Airway or similar deviceBr J Anaesth. 2018 Feb;120(2):353-360. doi: 10.1016/j.bja.2017.11.075. Epub 2017 Dec 1.Efficacy of a new dual channel laryngeal mask airway, the LMA®Gastro™ Airway, for upper gastrointestinal endoscopy: a prospective observational study.Terblanche NCS1, Middleton C2, Choi-Lundberg DL3, Skinner M4.

38. Anesthetic Technique Propofol is cornerstone when anesthesia is provided for EGD/ERCPConsider Etomidate for patients w/ true allergy to Propofol or severe egg allergiesMinimal CV depression; increased incidence of PONV or tonic/clonic movementDexmedetomidine? Effective, yet expensiveEndoscopy/Colonoscopy

39. Drug Site of Action Time of Onset (min) Notable Clinical Effects Notable Drawbacks Time for Recovery (min) Propofol GABA receptor ½-1 Amnesia, hypnosis PK/PD variability, apnea, hypotension 5-7 (for a 30- to 45-min procedure) Remifentanil μ Receptor 1-2 Analgesia Bradycardia, hypoxemia, rigidity 2-3 Ketamine NMDA receptor 1-2 Dissociative anesthesia Tachycardia, salivation 5-10 Dexmedetomidine α 2 Receptor 8-10 Sedation Slow loading and offset, bradycardia 15-20 Remimazolam GABA receptor 3-5 Sedation None so far 10-15

40. Questions?

41. Nagrebetsky, A., Gabriel, R. A., Dutton, R. P., & Urman, R. D. (2017). Growth of Nonoperating Room Anesthesia Care in the United States: A Contemporary Trends Analysis. Anesthesia and Analgesia, 124(4), 1261–1267. https://doi.org/10.1213/ANE.0000000000001734Rao, S. L., & Rajan, N. (2018, September). Common controversies surrounding anesthesia for procedures in the interventional pulmonology suite. Minerva Anestesiologica, Vol. 84, pp. 1219–1225. https://doi.org/10.23736/s0375-9393.18.12673-3Chang, B., Kaye, A. D., Diaz, J. H., Westlake, B., Dutton, R. P., & Urman, R. D. (2018). Interventional Procedures Outside of the Operating Room. Journal of Patient Safety, 14(1), 9–16. https://doi.org/10.1097/PTS.0000000000000156Woodward, Z.G., Urman, R.D., & Domino, K. B. (2017). Safety of Non–Operating Room Anesthesia- ClinicalKey. Anesthesiology Clinics, 35(4), 569–581. Retrieved from https://www.clinicalkey.com/#!/content/playContent/1-s2.0-S1932227517300721?returnurl=null&referrer=nullBeg, Y. (2018). Non-operating room anesthesia. In Preoperative Assessment and Management, Third Edition (Vol. 122, pp. 628–632). https://doi.org/10.1213/ANE.0000000000001002Bernard, A. M. (2019). Anesthesia Outside the Operating Room, 2nd ed. Anesthesia & Analgesia, 129(1), e29. https://doi.org/10.1213/ANE.0000000000004189Lu, A. C., Wald, S. H., & Sun, E. C. (2017). Into the Wilderness? Anesthesia & Analgesia, 124(4), 1044–1046. https://doi.org/10.1213/ANE.0000000000001965Weiss, Mark S., MD; Fleisher, Lee A., M. (2015). Non-Operating Room Anesthesia (1st ed.). Retrieved from https://www.clinicalkey.com/#!/browse/book/3-s2.0-C20120021734