This document discusses anesthesia considerations for procedures performed outside the operating room. It notes that the number and complexity of such procedures has increased, bringing additional responsibilities for anesthesiologists. Special challenges include limited space, equipment, and support staff unfamiliar with patient management. Proper equipment, monitoring, and planning are important when providing anesthesia or sedation in remote locations. The document discusses various locations like radiology suites, specific procedures like ECT, and choices of anesthetic agents and techniques. Patient safety is the top priority for remote location anesthesia.
Neuromuscular monitoring, also known as train of four monitoring, is a technique used during recovery from the application of general anesthesia to objectively determine how well a patient's muscles are able to function. It involves the application of electrical stimulation to nerves and recording of muscle response using, for example, an acceleromyograph. Neuromuscular monitoring is typically used when neuromuscular-blocking drugs have been part of the general anesthesia and the doctor wishes to avoid postoperative residual curarization (PORC) in the patient, that is, the residual paralysis of muscles stemming from these drugs.
Neuromuscular monitoring, also known as train of four monitoring, is a technique used during recovery from the application of general anesthesia to objectively determine how well a patient's muscles are able to function. It involves the application of electrical stimulation to nerves and recording of muscle response using, for example, an acceleromyograph. Neuromuscular monitoring is typically used when neuromuscular-blocking drugs have been part of the general anesthesia and the doctor wishes to avoid postoperative residual curarization (PORC) in the patient, that is, the residual paralysis of muscles stemming from these drugs.
as the life expectancy has increased. more and more elderly patients are undergoing surgery. the burden of postoperative dysfunction has to be increased in future. There should be attempt to identify the risk factors and measures to prevent POCD.
A basic overview on the management of intra-operative bronchospasm: the risk factors, triggers, diagnosis, prevention and management. Includes a case scenario – discussion.
as the life expectancy has increased. more and more elderly patients are undergoing surgery. the burden of postoperative dysfunction has to be increased in future. There should be attempt to identify the risk factors and measures to prevent POCD.
A basic overview on the management of intra-operative bronchospasm: the risk factors, triggers, diagnosis, prevention and management. Includes a case scenario – discussion.
A Context-aware Patient Safety System for the Operating RoomJakob Bardram
This is the presentation of the paper entitled "A Context-aware Patient Safety System for the Operating Room" by Jakob E. Bardram and Niels Nørskov. Presented at UbiComp September 2008 in Seoul, Korea.
These are challenging times and we need to continue working while keeping patient safety and our own wellbeing into consideration as we proceed with our surgery planning.
Post-Operative Managment
• The post operative period begins from the time
• The patients leaves the operating room and ends with the
follow up visit by the surgeon.
• The post operative care is provided by
-- PACU
-- SICU
Xenon Health is a nationwide anesthesia management company, providing office-based surgical practices, ASCs, and hospitals with superior anesthesia services. With thorough credentialing, our top-notch recruiters work tirelessly to staff surgical facilities with the best anesthesia providers in the nation.http://xenonhealth.com/
Bronchoscopy is an endoscopic technique of visualizing the inside of the airways for diagnostic and therapeutic purposes. An instrument is inserted into the airways, usually through the nose or mouth, or occasionally through a tracheostomy.
Emergency sonography in Pediatrics has evolved to become one of the most versatile
modalities for diagnosing and guiding
treatment of critically ill patients.
Post Operative Care | PACU | Complications | Treatment Yashasvi Verma
Post operative period is the most crucial and
critical span of time after completion of surgery
In this period numerous complications occur and if not treated on time can prove fatal hence increasing the mortality rate .
The specialized care provided to the patient after completion of surgery till the patient is fully conscious
This specialized care is provided in a specialized area called PACU
SEVERAL POST OPERATIVE COMPLICATIONS LIKE
HYPOXIA , HYPERTENSION , HYPOTENTION , HYPO THERMIA , HYPERTHERMIA , MODIFIED ALDERT SCORE , PAIN ASSESMENT AND TREATMENT , POST OPERATIVE NAUSEA AND VOMITING , ETC. MIGHT OCCUR .
About the newer drugs in anaesthesia. What are the problems with the existing drugs? Which all drugs failed commercially? And why? Which are the newer drugs in anaesthesia?
important points regarding ICU psychosis, role of dexmedetomidine in it's treatment, mortality associated with delirium, symptomatic and definitive management
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Flu Vaccine Alert in Bangalore Karnatakaaddon Scans
As flu season approaches, health officials in Bangalore, Karnataka, are urging residents to get their flu vaccinations. The seasonal flu, while common, can lead to severe health complications, particularly for vulnerable populations such as young children, the elderly, and those with underlying health conditions.
Dr. Vidisha Kumari, a leading epidemiologist in Bangalore, emphasizes the importance of getting vaccinated. "The flu vaccine is our best defense against the influenza virus. It not only protects individuals but also helps prevent the spread of the virus in our communities," he says.
This year, the flu season is expected to coincide with a potential increase in other respiratory illnesses. The Karnataka Health Department has launched an awareness campaign highlighting the significance of flu vaccinations. They have set up multiple vaccination centers across Bangalore, making it convenient for residents to receive their shots.
To encourage widespread vaccination, the government is also collaborating with local schools, workplaces, and community centers to facilitate vaccination drives. Special attention is being given to ensuring that the vaccine is accessible to all, including marginalized communities who may have limited access to healthcare.
Residents are reminded that the flu vaccine is safe and effective. Common side effects are mild and may include soreness at the injection site, mild fever, or muscle aches. These side effects are generally short-lived and far less severe than the flu itself.
Healthcare providers are also stressing the importance of continuing COVID-19 precautions. Wearing masks, practicing good hand hygiene, and maintaining social distancing are still crucial, especially in crowded places.
Protect yourself and your loved ones by getting vaccinated. Together, we can help keep Bangalore healthy and safe this flu season. For more information on vaccination centers and schedules, residents can visit the Karnataka Health Department’s official website or follow their social media pages.
Stay informed, stay safe, and get your flu shot today!
- Video recording of this lecture in English language: https://youtu.be/lK81BzxMqdo
- Video recording of this lecture in Arabic language: https://youtu.be/Ve4P0COk9OI
- Link to download the book free: https://nephrotube.blogspot.com/p/nephrotube-nephrology-books.html
- Link to NephroTube website: www.NephroTube.com
- Link to NephroTube social media accounts: https://nephrotube.blogspot.com/p/join-nephrotube-on-social-media.html
MANAGEMENT OF ATRIOVENTRICULAR CONDUCTION BLOCK.pdfJim Jacob Roy
Cardiac conduction defects can occur due to various causes.
Atrioventricular conduction blocks ( AV blocks ) are classified into 3 types.
This document describes the acute management of AV block.
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Lung Cancer: Artificial Intelligence, Synergetics, Complex System Analysis, S...Oleg Kshivets
RESULTS: Overall life span (LS) was 2252.1±1742.5 days and cumulative 5-year survival (5YS) reached 73.2%, 10 years – 64.8%, 20 years – 42.5%. 513 LCP lived more than 5 years (LS=3124.6±1525.6 days), 148 LCP – more than 10 years (LS=5054.4±1504.1 days).199 LCP died because of LC (LS=562.7±374.5 days). 5YS of LCP after bi/lobectomies was significantly superior in comparison with LCP after pneumonectomies (78.1% vs.63.7%, P=0.00001 by log-rank test). AT significantly improved 5YS (66.3% vs. 34.8%) (P=0.00000 by log-rank test) only for LCP with N1-2. Cox modeling displayed that 5YS of LCP significantly depended on: phase transition (PT) early-invasive LC in terms of synergetics, PT N0—N12, cell ratio factors (ratio between cancer cells- CC and blood cells subpopulations), G1-3, histology, glucose, AT, blood cell circuit, prothrombin index, heparin tolerance, recalcification time (P=0.000-0.038). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and PT early-invasive LC (rank=1), PT N0—N12 (rank=2), thrombocytes/CC (3), erythrocytes/CC (4), eosinophils/CC (5), healthy cells/CC (6), lymphocytes/CC (7), segmented neutrophils/CC (8), stick neutrophils/CC (9), monocytes/CC (10); leucocytes/CC (11). Correct prediction of 5YS was 100% by neural networks computing (area under ROC curve=1.0; error=0.0).
CONCLUSIONS: 5YS of LCP after radical procedures significantly depended on: 1) PT early-invasive cancer; 2) PT N0--N12; 3) cell ratio factors; 4) blood cell circuit; 5) biochemical factors; 6) hemostasis system; 7) AT; 8) LC characteristics; 9) LC cell dynamics; 10) surgery type: lobectomy/pneumonectomy; 11) anthropometric data. Optimal diagnosis and treatment strategies for LC are: 1) screening and early detection of LC; 2) availability of experienced thoracic surgeons because of complexity of radical procedures; 3) aggressive en block surgery and adequate lymph node dissection for completeness; 4) precise prediction; 5) adjuvant chemoimmunoradiotherapy for LCP with unfavorable prognosis.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
2. • Physicians are doing many things, which
were surgeons areas previously.
• E. g. Interventional
radiologists, gastroenterologists, or
interventional cardiologists
• And this means, we are getting additional..
RESPONSIBILITIES
3. Away from familiar territories…
• The indifferent reflexes shown by the non
operating room staff in emergency situation
• Insecurity due to a very realistic anticipation
of lack of equipment and staff support
• Despite these factors, we should be held
responsible if something happens…!
4. What is there in a name….?
• Nonoperating room anesthesia (NORA)
• Anesthesia at remote location
• Outpatient anesthesia
• Office-based anesthesia (OBA)
5. A very busy innings
expected….
• Number of NORA activities has increased rapidly ( CT,
MRI, neuroradiologic procedure or electroconvulsive
therapy)
• And the procedures have become more complex
6. Special problems of NORA
• Limited working place, limited access to the patient,
• Electrical interference with monitors and phones, lighting and temperature
inadequacy,
• Use outdated , old equipment
• Staff less familiar with the management of patients
• Lack of skilled personnel, drugs and supplies
• there is often no regular check up of the anaesthesia inventory
Patient desaturating..I need a mask quickly…
Sure sir…here it is…
7. Hello..hello ...
Who are you..?
• A trained anaesthesiologist should provide anaesthesia in
remote locations within the hospital.
• However non anaesthesiologists are allowed to provide
‘conscious sedation'.
• It is mandatory that all providers should be Adult Cardiac
Life Support (ACLS) certified.
8. Tour destinations!
• Radiology suites e.g. cardiac angiography, interventional
radiology, CTscan, MRI
• Endoscopy suites
• The dental clinic
• The burns unit
• Psychiatric unit for electroconvulsive therapy
• Renal unit for lithotripsy
• The gynaecology unit for in vitro fertilisation.
9. OUR AIMS
• Guard the patient's safety and welfare
• Minimise physical discomfort and pain
• Control anxiety, minimise psychological trauma
and maximize the potential for amnesia
• Control movement to allow safe completion of the
procedure
• Return the patient to a state in which safe
discharge from medical supervision is possible.
11. Don't expect Volks Wagens! But ensure the
Ambassador is not leaking petrol !
• The design of the anaesthesia machine may not be
familiar
• do routine safety checks, such as ensuring that the
oxygen failure alarm is working
• Make sure that we can see the anaesthetic machine
during the case – e.g. radiology procedures are
invariably undertaken in darkened rooms
12. DEXMEDITOMIDINE
.
Equipment check list for anaesthesia or sedation in a remote location
away from the operating theatre
Remember the acronym S O A P M E
S (suction) – Appropriate size suction catheters & functioning suction apparatus.
O (oxygen) – Reliable oxygen sources with a functioning flow meter.
At least one spare E-type oxygen cylinder.
A (airway) – Size appropriate airway equipment:
• Face mask• Nasopharyngeal and oropharyngeal airways• Laryngoscope blades• ETT•
Stylets• Bag-valve-mask or equivalent device.
P (pharmacy) – Basic drugs needed for life support during emergency:
• Epinephrine (adrenaline)• Atropine• Glucose• Naloxone• Flumazenil
M (monitors):
• Pulse oximeter• NIBP• End-tidal CO2 (capnography)• Temperature• ECG
E (equipment):
• Defibrillator with paddles• Gas scavenging• Safe electrical outlets (earthed)• Adequate
lighting (torch with battery backup)• Means of reliable communication to main theatre site.
13. Sisterrrrrrrrrr......…. I meant
LARYNGOscope , not this…
ENDOscope…,
please get me one…..
• emergency trolley with a defibrillator should be immediately
available.
• always check O2 source, cylinder keys, illumination of
laryngoscopes,working suction, emergency and resuscitation
drugs enough number of extension lines (high pressure and low
pressure), operating table functionality soon after you enter
the room….
• back-up of at least one full E type oxygen cylinder is advisable;
14. Monitors
• Pulse Oximeter, NIBP, ECG and ETCO2 are a minimum
requirement.
• In a non-intubated patient, ETCO2 monitoring can be achieved
by taping the sampling line to the patient’s upperlip
• The expired CO2 is sensed along with the graphic display of
respiration.
• peripheral nerve stimulator
15. "Nero Fiddled While Rome
Burned." try to prevent
emergence of Neros within us
• In remote areas, where darkness and big machines
prevails, ETCO2 can be very helpful.
• If possible, mobilise end-tidal CO2 monitoring from the
operating theatres.
• Monitoring may be a particular challenge in the MRI
suite
16. DON’T DONATE THE ETT TO SURGEON…
• Certain procedures require circuits and monitors
with long extension tubings e.g. Interventional
neuroradiology….
• An AMBU should also be available to provide
positive pressure ventilation in case of oxygen
failure.
19. Lonely walk through
dangerous paths!
• Staff trained only in their speciality
• sole responsibility of the anaesthesiologist to check and ensure
safety
• ensure that rapid communication to colleagues in the main
theatre suite is possible.
• identify an assitant to help
• Check consent
20. Think , Plan and Communicate
• Think and plan the moment you get the call
• Anticipate problems before starting the case;
• Help from main theatre may be slow to arrive.
22. Poor illumination
• Many procedures are carried out in darkened rooms
[e.g. interventional radiology or endoscopy]
• Should be able to visualise the flow meters and to check
accurate gas flows.
• we must be vigilant to detect unexpected events such as
cessation of oxygen delivery and ETT disconnection
23. WEL[L]COME…….
We have arranged a very
nice trap , both for you and
our patient….
• Beware of the situation where the anesthesiologist is called
after the intervention has started and the patient is found to
be uncooperative.
• Without a prior plan or airway assessment the situation is
hazardous – if situation allows, it is better to abort the
procedure and come back another day when things can be
planned properly.
24. The extremes…!
• Some areas are poorly equipped to deal with any
kind of emergency
• E.g. Burn dressings, muscle biopsies etc done at
bedside
25. Positioning
• Patients undergoing ERCP, Endoscopy and CT guided biopsies
lateral or prone position.
• ? pillows are available for safe prone positioning ? All other
routine precautions for prone position..
• Prone position becomes difficult if the patient requires routine
resuscitation – reposition the patient rapidly if this is the case.
26. Duration of the procedure
• Duration : difficult to predict
• They may finish very abruptly : Avoid long-acting
muscle relaxants and maintain close communication
with the specialist performing the procedure.
27. Post-procedure care
• Transport to a standard recovery room with the
monitors along with the anaesthesiologist
• oxygen during transport.
• Patients who require elective postoperative ventilation
must be transferred with continuous monitoring
28. Post-procedure care
• Patients undergoing aneurysm coiling may need to be
ventilated in the postoperative period.
• The availability of an ICU bed has to be confirmed prior
to the procedure.
29. SOME SPECIAL CONSIDERATIONS
• Anaphylaxis to iodinated dyes is possible. All the drugs
for Rx of anaphylaxis should be immediately available.
• Radiation exposure - anaesthesia personnel should be
aware of the radiation hazards and take precautions to
avoid radiation exposure.
• Intermittently check, whether your syringe pump is
running and adequate amount of drug is remaining, 3-
ways are turned in the proper direction, breathing
pattern is normal,
31. Dealing with the most
important person in any
setting...
• the reason for which they require the intervention,
• associated co-morbidities.
• Fasting status
• a quick airway assessment : unanticipated difficult
airway is very challenging in remote
• Presence of dentures
32. I won't cooperate man.......
• Children
• anxious patients
• Claustrophobic patients (especially in MRI suites)
• • Elderly or confused patients
• Patients undergoing painful procedures
• Patients requiring burns dressings.
34. CHOICE OF ANAESTHESIA
• Monitoring only [do not require an anaesthesiologist]
• Sedation
• Regional anaesthesia
• Total intravenous anaesthesia
• General anaesthesia.
35. Sedation/anagesia:
easier ; but ensure frequently
that you are not in trouble!
• less invasive
• cost and time saving
• high rate of failure
• high chance of airway and respiratory depression
36. Definition of general anesthesia and levels of sedation
/analgesia [Approved by the ASA,2009]
37. MAINTAIN THE BALANCE…
• The degree of safety in conscious sedation
is much higher than deep sedation.
• The patient can easily drift from a state of
conscious sedation to deep
sedation, depending on his age, sensitivity to
drugs, health status etc.
• Titration and adjustment of the doses of the
sedative agents requires skill and experience.
38. Total intravenous anaesthesia
(TIVA)
• Drugs are used intravenously, for hypnosis and analgesia.
• Airway chin lift/jaw thrust / an oropharyngeal airway
/ LMA may be used if the patient is deeply anaesthetised.
• oocyte retrieval, in vitro fertilisation and foetal reduction
in ultrasound rooms usually fentanyl + propofol
39. General Anaesthesia
E.g. Interventional Neuro radiology, MRI suite etc
tracheal intubation / LMA
best prevention of motion
invasive, time and resource consuming
atelectasis
40. …….Regional anaesthesia
• Combined spinal-epidural anaesthesia e.g. for EVAR -
Endovascular aneurysym repair.
• The conscious patient can communicate and this is a
major safety consideration.
41. DOCUMENTATION OF
ANAESTHESIA
• A time-based anaesthesia flow sheet
• Drugs administered – time and dose
• SaO2 , Heart rate , Respiratory rate , NIBP – can omit if minimal
sedation, e.g. during MRI/CT
• Level of sedation
• Observations should be performed at 15 minute intervals for conscious
sedation, and 5 minute intervals for deep sedation and general
anaesthesia.
HAZARDOUS
IF OMITTED
FOR ANAESTHETIST
42. CHOICE OF DRUGS
• This depends on the procedure being performed, and
whether this is painful or painless.
• e.g. MRI scan compared to endoscopy compared to a
change of burns dressings.
43. DRUGS
• Midazolam: In paediatric patients, intranasal
midazolam has also been tried successfully.
• Fentanyl : 0.25-0.5mcg.kg-1 is usually sufficient.
• Propofol : A careful and slow intravenous
injection of propofol is an ideal choice.
• Ketamine
• Ketofol: provides good hemodynamic stability.
• Remifentanil : An ideal drug but not available in
India
• Prilox cream
47. PROPOFOL- an easy method….
Load with 2 mg/kg over 10 minutes in a 50
mL syringe-pump
For e.g. 10 kg child: 20mg=2mL X 6 =
12mL/hr (for first 10 mins) ; then…
If you set the maintenance as half this dose
(i.e. 6 mL/hr)
This will be equivalent to 100 ug/kg/min
infusion of propofol…..
48. There is substantial variability in the
response to each agent between
individuals.......
Change your tactics according to the ‘opponent’.
52. 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
53. Anesthesia for CT
• Less complex
• Use standard monitoring
• Less anesthetic time
• Higher levels of radiation exposure
54. Anesthesia for MRI-Physical environment
• High magnetic field
• Uncertain duration
• 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.
55. Special circumstances -
Magnetic resonance imaging
(MRI)
• NEVER take any ferrous metal into the MRI suite – includes
laryngoscopes, scissors and stethoscopes and mobile phones.
• In an emergency, take the patient out of the MRI room, do not
take the emergency equipment to the patient.
• can keep noise blockers in patients ears
57. MRI- Conduct of anaesthesia
• In the MRI centre Anaesthesia is induced outside the MRI room
and the patient is transferred to the MRI compatible machine
in the room.
• Slave monitors must always be kept outside the MRI room.
• From these monitors we can see the respiratory
tracing, ETCO2, PR, BP etc
60. Electroconvulsive therapy (ECT)
• Mainly to treat major depression
• Typically, ECT is performed twice weekly until there is a
lack of further improvement [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.
61. Electroconvulsive therapy (ECT)
• > first reaction: parasympathetic discharge lasting 10–15 s.
This can result in bradycardia, hypotension, or even
asystole
>following reaction:
hypertension,arrhythmias, tachycardia, lasts for 5-
10min↑O2 consumptionM.I.
Left ventricular systolic and diastolic function can remain
decreased up to 6 h after ECT
ICP, intraocular and intragastric pressure increase
62. Contraindication :
• absolute contraindication: intracranial hypertension
• Relative contraindications:
Untreated intracranial mass,
aneurysm,
within 3 months of either a MI or cerebrovascular accident,
uncontrolled cardiac failure
untreated glaucoma
unstable major fracture
thrombophlebitis, pregnancy
retinal detachment,
DVT (until anticoagulated)
severe osteoporosis,
phaeochromocytoma,
Cochlear implants
63. ECT-Anesthetic goals
1. amnesia and rapid recover
2. Prevent damage
3. Control hemodynamic response.
4. Avoid interference with initiation and
duration of induced seizure.
64. Anaesthetic technique
No Sedative premedication
Patients should be encouraged to empty their
bladder as incontinence is common
Standard monitors (ECG, SPO2 , BP)
Place rolled gauze pads
65. U R THE , NOT THE DRUG
Objective : a rapid onset and offset of both
unconsciousness and muscle relaxation for the duration
All currently available induction agents are suitable for
ECT , except ketamine.
Whichever drug is used, it is preferable to utilize the
same one throughout a course of treatment to avoid
interfering with the seizure threshold (which generally
increases over a course of ECT).
67. Was there 4 quite some time; now a hero!
Preoperative α-2 agonists such as
dexmedetomidine also blunt the hyperdynamic
response as does glyceryl trinitrate, which should
be considered in patients at high risk of myocardial
ischaemia.
Can use labetalol or esmolol when necessary.
.
68. Done it!
Succinylcholine (0.5 mg kg−1) is most commonly
used. Larger doses up to 1.5 mg kg−1 may be
required
Glycopyrrolate has superior anti-sialogogue
effects, no adverse central nervous system
effects, and results in less post-ECT tachycardia.
Routine atropine premedication is not
recommended due to detrimental effects on
myocardial work and oxygen demand.
Deleterious sympathetic effects may be controlled
with β-blockers either pre- (atenolol) or intra-
procedurally (labetalol and esmolol)
69. Anaesthetic technique
Intubation- not routinely required, ventilation can
be gently assisted with a face mask.
Hyperventilation lowers the seizure threshold and
can prolong seizure duration.
a bite block protects the patient's teeth, lips, and
tongue.
During initial treatments, the stimulus magnitude
may be titrated until an adequate seizure is
generated. In such circumstances, further boluses
of induction agent are required to maintain
anaesthesia.
70. ECT- adverse effects
• confusion, agitation, violent
behaviour, amnesia, headache, myalgia, and
nausea and vomiting.
• Emergence agitation can be the most
challenging problem to treat.
• Small doses of midazolam may be useful if
simple measures such as a secluded, calm
recovery environment do not help.
• The presence of a trained escort familiar to
the patient can be reassuring.
71. ECT- adverse effects
• arrhythmia
• myocardial infarction
• laryngospasm
• aspiration
• Transient ischaemic deficits,
• intracranial haemorrhage,
• cortical blindness
• status epilepticus; Terminate seizure with propofol or
benzodiazepines within 3 minutes
• Disorientation,
• impaired attention, and
• memory problems
What anaesthesia you ve
given? Patient is
disoriented…..
72. 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
73.
74.
75.
76.
77. OTHER NEURO RADIOLOGICAL INTERVENTIONS
B. Embolization for control of epistaxis and extracranial vascular
lesions
C. Balloon occlusion test
D. Cerebral and spinal angiography
E. Vertebroplasty and kyphoplasty
F. Thrombolysis of acute stroke
G. Cerebral vasospasm
78. ESWL CONCERNS
• PAIN: stinging,sharp
• [1] @cutaneous level + visceral and [2] due to
the movement of the stone
• CLAUSTROPHOBIA
• GA usually not necessary
• Spinal / epidural
• NSAIDS, PARACETAMOL, FENTANYL, EMLA
cream for analgesia + MIDAZOLAM may suffice
• Need to mobilize the operating table
• Ensure in the operating position, you can
access for any emergency intervention
83. References
• Updates in Anaesthesia ,Volume 25 Number 1 June 2009, Anaesthesia Outside the Operating
Theatre Lakshmia Jayaraman*, Nitin Sethi, Jayashree Sood
• Anaesthesia for electroconvulsive therapy,Vishal Uppal, Jonathan Dourish, Alan
Macfarlane, oxfordjournals.org