Anesthesia outside the operating room


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Anesthesia outside the operating room

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Use outdated ,old equipment 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