Anaesthesia outside operating room
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  • 1. ANESTHESIA / SEDATION OUTSIDE OPERATING ROOM Dr.P.NARASIMHA REDDY NARAYANA MEDICAL COLLEGE.
  • 2.
    • INTRODUCTION
    • PROCEDURES DONE OUTSIDE O.R.
    • PLACES WHERE PROCEDURES ARE DONE.
    • PROBLEMS OF ANESTHETIST
      • GENERAL PROBLEMS.
      • SPECIFIC PROBLEMS.
  • 3.
    • WHAT ARE THE SAFETY STANDARDS?
    • MONITORING AIDS.
    • EQUIPMENT REQUIRED.
    • TYPES OF ANESTHESIA ? SEDATION.
    • DISCHARGE CRITERIA.
  • 4.
    • INTRODUCTION :
      • Ultra short acting potent drugs.
      • Portable monitoring aids.
      • PERIPATETIC : “who walks from place to place”
      • Essential criteria to anesthetist outside O.R.
      • 1.Applicability – is it appropriate to provide service?
  • 5.
    • 2. Ability - does an anesthetist have to be present?
    • 3. Affordability – is it cost effective?
    • 4.Availability – can we provide the service outside?
    • 5.Affability – is it the desire of the doctor to have anesthetist services?
  • 6.
    • 6.accountability – are we responsible for the quality & outcome results?
    • 7.Altruism – is it devotion to humanity or selfishness?
  • 7.
    • O.R – sterile,serene,peaceful.
    • Anesthetist-- comfortable,comprehensive,conducting procedures.
    • He is familiar with equipment,medical,paramedical persons,available drugs.
    • He can expect & delegate powers to suitable persons.
  • 8.
    • Outside O.R - known & unknown problems .
    • Vulnerable to mishaps.
  • 9. PROCEDURES OUTSIDE O.R
    • Diagnostic,interventional& therapeutic radiology.
    • Cardiac catheterisation,implantation of defibrillators,coronary angiography,stent replacements.
    • Cardioversions.
    • E.C.T.
  • 10.
    • 5.Bonemarrow aspiration & L.P.
    • 6.Emergency airway management.
    • 7.Transport of critically ill patients.
    • 8.Ortho procedures.
    • 9.Removal of patients from rubble or accident vehicles.
  • 11. PLACES WHERE PROCEDURES ARE DONE
    • Radiology suit..
    • Cath lab.
    • I.C.U.
    • Psychiatry O.P.
    • Cancer wards.
  • 12. Contd..
    • 6.Paediatric wards.
    • 7.Field situations.
    • 8.Ortho O.P’s.
    • 9.Transport vehicles – road/air.
  • 13. PROBLEMS OF ANESTHETIST.
    • GENERAL PROBLEMS :
    • - environment – new place,remote area,narrow lanes,low lighting,no back-up facility.
    • - personnel – not trained & less number.
    • -equipment – anesthesia machine may be present or absent.
  • 14. Contd..
    • May be old or not used for long time.
    • Cyllinders – less or empty.
    • Outlets for power – O2,N2O may not be present.
    • Laryngoscope may be present / absent, may not be working.
    • Proper size of tubes & airways – not available.
  • 15. Contd..
    • Suction – present /not working.
    • Parking – narrow crowded places,difficult to transport the patient in case of emergency.
    • Communication system may not be good.
    • Resuscitation facilities – not adequate.
    • Post anesthetic care – not available.
  • 16.
    • PATIENT PROBLEMS :
    • Not well prepared.
    • No fasting guidelines.
    • PAC not done.
    • May be on some medications.
    • Comorbid conditions present
    • patient must be ASA 1 & 2.
  • 17.
    • SPECIFIC PROBLEMS :
    • - C.T SCAN :
    • -Needs immobile patient for 20-40 mts.
    • -children,unconscious,noncooperative,head injury,convulsions,communication problems – requires sedation / anesthesia.
    • -airway obstruction
    • -kinking of tube
  • 18. Contd..
    • - apnoea.
    • - cyanosis & cardiac arrest.
    • -radiation to anesthetist.
    • - allergic reactions to contrast dyes .
  • 19.
    • M.R.I :
    • Narrow tunnel.
    • Access to the patient is difficult.
    • Claustrophobia.
    • Strong magnetic fields.
    • Ferromagnetic implants,monitoring aids.
    • Loud noise.
  • 20. Contd..
    • - Image degradation.
    • - Absolute immobility for long time.
    • - Cannot see the airway & chest movements.
    • - Modified anesthesia machine & monitors.
    • - No coil cables.
    • - Alluminium trolleys & alluminium cyllinders.
    • - Plastic laryngoscope with batteries which are wrapped with plastic covers.
  • 21.
    • Interventional radiology :
    • Laporotomies & craniotomies for accurate tumor resection.
    • Intermittent imaging.
    • Scanning time may be significantly longer.
    • Patient access limited.
    • Contrast dyes produce diuresis.
    • Hypo-hypertensive.
  • 22.
    • Neuro radiology :
    • -Embolisation :
    • - long procedures, embolic events.
    • - airway management urgent.
    • - G.A ideal.
    • - hemorrhage ,hemodynamic disturbances & aspiration can occur.
  • 23.
    • Trigeminal neuralgia :
    • Local block induced
    • Neurolytic agent.
    • Brief period of loss of consciousness is induced.
    • Neurologic examination on awake patient.
    • Airway support may be difficult when block needle is in place.
  • 24.
    • Cyclotron therapy :
    • Proton beam radiation is used in the treatment of A.V malformations,pituitary tumors & retinoblastomas.
    • Radiation is painless but positioning may take several hours.
    • Head fixation may be painful.
    • Standard T.V with CCTV.
  • 25.
    • Radiation therapy :
    • Children often require G.A.
    • 3-4 times a week for 4 weeks.
    • Planning of radiation on first day takes long time.
    • Standard monitoring with CCTV.
  • 26.
    • E.C.T :
    • Used in patients with depression not controlled by the drugs.
    • Initial vagal discharge,later sympathetic discharge.
    • HTN for 5-10 mts.
    • E.C.G – prolonged PR & QT intervals, T wave inversion.
  • 27. Contd..
    • inc.intraocular & intra gastric pressures.
    • Absolute contraindication :
    • - intracranial HTN.
    • Relative contraindications :
    • - intracranial mass with normal ICT
    • -aneurysms
    • - recent M.I,angina , CCF
    • - untreated glaucoma
  • 28. Contd..
    • Major bone fractures.
    • Thrombophlebitis.
    • Pregnancy.
    • Retinal detatchment.
    • “ Be careful with drug interactions ”
  • 29.
    • Cardioversion :
    • Painful procedure.
    • Must be unconscious.
    • Others should not touch the patient during shock.
    • Patient is ventilated with 100% O2 till recovery.
  • 30. Contd..
    • Endoscopic suite :
    • Patient must be evaluated.
    • Ideal fasting guidelines.
    • Glyco + topical L.A + benzo / propofol.
    • Contraindications :
    • - achalasia,esophageal stricture,corrosive esophagitis,intestinal obstruction,esophageal discoordination.
  • 31. ESSENTIAL REQUIREMENTS
    • O2 Piped / cylinders.
    • Anesthesia machine.
    • Sufficient electrical outlets.
    • Adequate space & access to the patient.
    • Adequate illumination.
    • Emergency resuscitation cart.
  • 32. Contd..
    • 7.Adequate monitoring equipment.
    • 8.Defibrillator.
    • 9.2way communication.
    • 10.Qualified anesthesiologist.
    • 11.Transportation facility.
  • 33. MONITORING EQUIPMENT
    • ECG.
    • Pulse oximeter.
    • Blood pressure.
    • ETCO2.
    • Oxygen analyser.
  • 34. OTHER EQUIPMENT
    • Bag mask ventilation.
    • Airways – all sizes.
    • Laryngoscope with all blades.
    • Correct size E.T tubes.
    • Drugs – anesthetic & resuscitation drugs.
  • 35. TYPES OF ANESTHESIA
    • INHALATIONAL
    • I.V anesthetics
    • M.A.C
    • Regional
    • Sedation
  • 36. Contd..
    • Is the procedure painful?
    • What is the duration of procedure?
    • Patient needs to be motionless?
    • Many times procedures are done under sedation.
    • Rarely G.A with E.T tube with relaxant.
  • 37.
    • SEDATION :
    • Guidelines for sedation:
    • - chloral hydrate :
    • -non-narcotic.
    • - no resp.depression.
    • - no addiction.
    • -50-70 mg/kg orally 30-60 mts before the procedure.
    • - not analgesic.
    • -15% failure rate.
  • 38.
    • Rectal methohexital :
    • 20-30 mg/kg
    • Rapid onset 5-10 mts.
    • Prolonged action 30-60 mts.
    • Unpredictable sedation.
  • 39.
    • Benzodiazepines :
    • Midazolam -0.01mg/kg.
    • can be given by all routes.
    • sedative ,anxiolytic,anticonvulsant.
    • amnesia .
    • minimal hemodynamic effects.
    • not an analgesic.
  • 40.
    • I.V anesthetic agents :
    • Pentothol sodium :
    • 5-7mg/kg.
    • careful with full stomach & airway.
    • ketamine :
    • 1-2 mg/kg i.v, 2-4 mg/kg i.m
    • perfect analgesia.
    • reflexes retained.
  • 41. Contd..
    • Broncho dilator.
    • Resp.activity maintained.
    • Raised i.c.t
    • Ketatonia.
    • Emergency delirium.
  • 42.
    • Propofol :
    • 1-2 mg/kg.
    • Shorter duration of action.
    • Complete recovery.
    • Early apnea & hypotension.
    • Pain during injection.
  • 43.
    • G.A :
    • Premed – atropine/ glyco.
    • Rapid sequence induction.
    • Induction agents – thio/propo/ketamine.
    • Muscle relaxants – succi/ vec/E.T tube.
    • Reversal – neo+ glyco.
  • 44.
    • REGIONAL :
    • EMLA ( ligno+ prilo)
    • Occlusive dressing for 60mts.
    • L.P ,bone marrow aspiration,ICD,i.v cannula.
    • Methemoglobinemia.
  • 45. DISCHARGE CRITERIA
    • Stable C.V.S .
    • Satisfactory airway.
    • Patient easily arousable.
    • Reflexes intact.
    • Patient can talk, can sit up.
    • Patient can void urine.
    • Young & handicapped – preanesthetic level.
    • Hydration must be adequate.
  • 46. THANK U.