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Anesthesia outside the operating room

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  • 1. Anesthesia Outside of the Operating Room Yujuan Li The Second Affiliated Hospital of Sun-yet Sen University [email_address]
  • 2. Some terms
    • Nonoperating room anesthesia (NORA)
    • Anesthesia at remote location
    • Outpatient anesthesia
    • Office-based anesthesia (OBA)
  • 3. Importance
    • Number of NORA activities has increased rapidly( CT, MRI, neuroradiologic procedure or electroconvulsive therapy)
    • More Complex of the procedure, and situation and patients
    • Who does the sedation?
  • 4. Mortality and Morbidity
  • 5.  
  • 6.  
  • 7. Special problem of NORA
    • Limited working place, limited access to the patient,
    • Electrical interference with monitors and phones, lighting and temperature inadequacy,
    • Use outdated ,old equipment
    • Less familiar with the management of patients
    • Lack of skilled personnel, drugs and supples
  • 8.  
  • 9. ASA guidelines for NORA patients
  • 10. AAP guidelines for NORA pediatric patients
  • 11.  
  • 12.  
  • 13. Anesthetic technique
    • General anesthesia : tracheal intubation or LMA
    • best prevention of motion
    • invasive, time and resource consuming,
    • atelectasis
    • Sedation/anagesia :
    • less invasive ,cost and time saving
    • high rate of failure, high airway and respiratory depression
    • No anesthesia
  • 14. Conscious sedation versus monitored anesthesia care
    • Conscious sedation : a medically controlled state of depressed consciousness that allows protective reflexes to be maintained and retains the patient's ability to maintain a patent airway and to respond appropriately to physical and verbal stimulation.
    • MAC: an anesthesiologist provide specific anesthesia services to particular patients with local or no anesthesia who undergoing a planned procedure.
  • 15. Levels of sedation
  • 16. Drugs for paediatric sedation
  • 17. Discharge criteria
  • 18.  
  • 19.  
  • 20.  
  • 21.  
  • 22.  
  • 23.  
  • 24.  
  • 25.  
  • 26. II. Contrast media
    • Allergic reaction
    • History
    • Symptoms: skin reactions, airway obstruction, angioedema, and cardiovascular collapse.
    • Treatment: corticosteroids, H1 and H2 blockers. Oxygen, epinephrine, β2-agonists, and intubation , IV fluids
    • Prevention: corticosteroids
  • 27. III. Anesthesia for CT
    • Less complex
    • Use standard monitoring
    • Less anesthetic time
    • Higher levels of radiation exposure
  • 28. IV. Anesthesia for MRI
    • A. Physical environment
    • High magnetic field
    • Need specialized compatible equipment
    • Radiofrequency noise
    • Metallic implants or implanted devices
    • Patients with implanted pacemakers, ICDs, or pulmonary artery catheters may not have MRI scans .
  • 29.
    • B. Uncertain duration
    • compatible Monitors
    • anesthesia machines , ECG , pulse oximeters , straight cables.
  • 30. V. Anesthesia for neuroradiologic procedures
    • A. Endovascular embolization
    • Indication : cerebral aneurysms, arteriovenous fistulas and malformations , vascular tumors
    • Methods : femoral artery puncture, a small catheter into the aneurysm
    • Anesthetic goals :stable hemodynamics, and rapid recovery
    • Other problem : Invasive arterial blood pressure monitoring , avoid hypertension, monitor anticoagulation, complications include rupture of the aneurysm
  • 31.
    • B. Embolization for control of epistaxis and extracranial vascular lesions
    • C. Balloon test occlusion
    • D. Cerebral and spinal angiography
    • E. Vertebroplasty and kyphoplasty
    • F. Thrombolysis of acute stroke
    • G. Cerebral vasospasm
  • 32. VI. Anesthesia for vascular, thoracic, and gastrointestinal/genito-urinary radiology procedures. VII. Anesthesia for cyclotron therapy and radiation therapy
  • 33. VIII. Electroconvulsive therapy (ECT)
    • Objection: treat major depression, no responded to medications, suicidal.
    • Periods: 6 to 12 treatments over 2 to 4 weeks
    • Physiologic effects:
    • a grand mal seizure tonic phase : 10 to 15 s,
    • clonic phase :30 to 50 s.
    • first reaction: bradycardia and hypotension
    • following reaction: hypertension , tachycardia,5-10min
    • ECG changes
    • ICP, intraocular and intragastric pressure increase
  • 34.
    • Anesthetic goals
    • amnesia and rapid recover
    • Prevent damage
    • Control hemodynamic response.
    • Avoid interference with initiation and duration of induced seizure.
  • 35.
    • Contraindication :
    • absolute contraindication: intracranial hypertension
    • Relative contraindications: intracranial mass or aneurysm , recent myocardial infarction, angina, congestive heart failure, untreated glaucoma, major bone fractures, thrombophlebitis, pregnancy, and retinal detachment.
  • 36.
    • Anesthetic management
    • No Sedative premedication , Anticholinergic drugs and Ondansetron by individual.
    • Standard monitors (ECG, SPO 2 , BP)
    • Induced with methohexital and succinylcholine or Mivacurium ventilated with 100% oxygen via mask and Ambu bag. labetalol or esmolol when necessary
    • Place rolled gauze pads
  • 37. Anesthetic management
    • 5. Electroencephalogram (EEG) monitor duration
    • 6. Patients ventilated with O 2
    • 7. Some special attention : gastroesophageal reflux, severe cardiac dysfunction , intracranial mass lesions , pregnancy
    • 8.Terminate seizure with propofol or enzodiazepines within 3 minutes
  • 38. IX. Upper and lower endoscopy ,ERCP and PEG
  • 39. Thank you!