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Anesthesia at Remote Locations

Anesthesia at Remote Locations. Dr Abdollahi. Remote anesthesia. Anesthesiologists are increasingly being asked to provide anesthetic care in locations outside of the OR. It is the responsibility of the anesthesiologist to ensure that the location meets the ASA guidelines for safety.

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Anesthesia at Remote Locations

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  1. Anesthesia at RemoteLocations Dr Abdollahi

  2. Remote anesthesia Anesthesiologists are increasingly being asked to provide anesthetic care in locations outside of the OR. It is the responsibility of the anesthesiologist to ensure that the location meets the ASA guidelines for safety.

  3. Locations • Radiology suites (MRI, CTSCAN) • Cardiac catheterization laboratories • Psychiatric units • Radiation therapy • Gastroentrology • Pulmonary medicine • Urology (ESWL) • General dentistry

  4. Anesthesiologists must maintain the same high standardof anesthetic care provided in the operating suite.

  5. Large, mobile pieces of radiologic equipment, radiation hazards, intense magnetic fields, paramedical personnel not familiar with the anesthesia team, and other factors may make the delivery of quality anesthetic care problematic.

  6. Remember that the key to efficient and safe remote anesthetic relies on open communication between the anesthesiologist and non-operating room personnel

  7. 1994 Guidelines for non-operating room anesthetizing locations Reliable oxygen source with backup. Suction source. Waste gas scavenging. Adequate monitoring equipment. Self-inflating resuscitator bag. Sufficient safe electrical outlets. Adequate light and battery-powered backup. Sufficient space. Emergency cart with defibrillator, emergency drugs, and emergency equipment. Means of reliable two-way communication. Compliance with safety and building codes.

  8. Remote monitoring Qualified anesthesia personnel must be present for the entire case. Continuous monitoring of patient’s oxygenation, ventilation, circulation, and temperature. Oxygen concentrations of inspired gas: low concentration alarm. Blood oxygenation: pulse oximetry. Ventilation: end-tidal carbon dioxide detection and disconnect alarm. Circulation: EKG, ABP (q 5min), invasive BP, and oximetry.

  9. Anesthesia techniques used in non-operating room anesthetizing locations range from no anesthesia, to sedation/ analgesia, to general anesthesia.

  10. RADIOLOGY SUITE Radiologic procedures that may require sedation/analgesia include a number of imaging modalities such as radiology, ultrasonography, CT, and MRI, as well as various interventions that may be directed by the imaging modalities.

  11. Advances in imaging capability, as well as the availability of advanced endovascular devices and RF probes, has increased the use of radiology suites and increased the demand for anesthesia services in these areas

  12. Intervention Percutaneous drain placement, Nephrostomy tube placement, Percutaneous placement of feeding tubes, Placement of intravascular access catheters, Thrombolysis, Dilation of stenotic vessels, Embolization of tumors or arteriovenous malformations (AVMs), Tissue biopsy specimens may be obtained under radiologic guidance

  13. Conditions may be treatable in the radiology suite • Some solid tumors may be treated by guided tissue ablation. • Painful metastases may be treated by guided radiofrequency (RF) ablation. • Cerebrovascular lesions may be treated endovascularly with guidance by digital subtraction angiography.

  14. General consideration Medical history Immobile Claustrophobia Environment (Crowded, Bulky radiology equipment ,high voltage,change of position ) Lack of gas scavenging

  15. Radiation Safety Radiation exposure is potentially harmful both in terms of its somatic effects during an exposed individual's lifetime (e.g., production of leukemia) and in terms of genetic injury resulting in fetal abnormalities caused by damage to the gonadal cells or developing fetus.

  16. The maximal permissible radiation dose for occupationally exposed persons is 5O millisieverts (mSv) annually, a lifetime cumulative dose of 10 mSv x age, and monthly exposure of 0.5 mSv for pregnant women.

  17. Radiation exposure can be limited by wearing appropriate lead aprons and thyroid shields, using movable leaded glass screens, and using innovative techniques such as video monitoring and remote mirroring of monitor data to allow remote conduct of anesthesia when appropriate and required for the safety of anesthesia personnel. Clearly, open communication between the radiology and anesthesia teams is essential to minimize radiation exposure. Adequate warning of initiation of imaging by the radiology team allows the anesthesia personnel to take appropriate precautions in a timely fashion

  18. Iodinated Contrast Media Iodinated contrast agents are often used in diagnostic and therapeutic radiologic procedures to assist imaging. Adverse reactionsto contrast media range from mild to immediately life-threatening, and etiologies include direct toxicity,idiosyncratic reactions, and allergic reactions, either anaphylactic or anaphylactoid Crable

  19. Predisposing factorsinclude a history of bronchospasm, history of allergy, underlying cardiac disease, hypovolemia, hematologic disease, renal dysfunction, extremes of age, anxiety, and medications such as B-blockers, aspirin, and nonsteroidal anti-inflammatory drugs. Prompt recognition plus treatment of contrast media reactions is important to prevent progression of less severe reactions and lessen the impact of severe reactions

  20. Treatment Treatment is symptomatic, for example, oxygen and bronchodilators to treat bronchospasm. Severe or resistant bronchospasm may require treatment with epinephrine. Typically, corticosteroids and antihistamines are given to symptomatic patients under the assumption that the etiology is immunologic.

  21. Prophylaxis pretreatment with prednisolone, 5O mg 12 hours before a procedure requiring contrast media, and diphenhydramine, 5O mg immediately before the procedure.

  22. Renal dysfunction is well documented in association with radiologic contrast media, particularly in patients with preexisting renal dysfunction and most especially in patients with preexisting renal dysfunction related to diabetes.

  23. Most cases of new or worsened renal function related to contrast media are self-limited and resolve within 2 weeks. However, some patients may progress to the point of requiring dialysis.

  24. Recent studies have demonstrated a reduction in contrast media nephrotoxicity by the administration of acetylcysteine.Life- threatening lactic acidosis may develop in non-insulin-dependent diabetic patients who are receiving metformin and have preexisting renal dysfunction if their renal function declines further. Extra care is needed when patients taking metformin receive radiologic contrast media.

  25. Anesthesia in the Radiology Suite Minimal to moderate sedation/analgesia is the technique used for most patients undergoing these procedures.

  26. For most adults, combinations of intravenous benzodiazepines and opioids (i.e., titration of midazolam and fentanyl) are sufficient to ensure comfort during the procedure. The use of more potent anesthetic agents such as propofol, methohexital, and ketamine is best reserved for specialists in anesthesia.However, understanding the procedure in question is important in selection of the appropriate anesthetic technique. The patient's condition, the anticipated level of stimulation, and patient position during the procedure are all important considerations.

  27. A patient undergoing ultrasound-guided hepatic biopsy might have ascites, which would render that patient prone to aspiration if sedated, and penetration of the hepatic capsule by the biopsy needle would be anticipated to be quite painful. Such a patient might benefit from general anesthesia rather than sedation/analgesia.

  28. Procedures that might be anticipated to last several hours may best be performed with general anesthesia at the outset rather than late conversion after failure of sedation/ analgesia, when patient access might be limited by catheter placement and radiologic equipment.

  29. Pediatric patients merit special consideration. Some radiologic procedures require patients to remain still for prolonged periods, which may not be possible for infants and children, even with sedation/analgesia. (chloral hydrate orally for radiologic procedures 25 to 5O mg/kg for infants younger than 4 months, 5O mg/kg for older children)

  30. Patients with difficult airways, whether anticipated or not, can be problematic in settings outside the operating suite . I prefer to perform anticipated difficult endotracheal intubations in the operating suite with its improved availability of skilled assistants and specialized equipment. Once the airway is controlled, the patient can be transported to the site of the planned procedure should it be necessary to perform the procedure outside the operating suite.

  31. MAGNETIC RESONANCE IMAGING The most significant risk posed in the MRI suite is the effect of the magnet on ferrous objects.

  32. MRI MRI scanning has a number of limitations. Imaging is time consuming, and individual scans may take up to 20 minutes, with an entire examination lasting more than 1 hour. Switching on and off of the RF generators produces loud noises (>90 dB).

  33. MRI Hearing protection is mandatory for both the patient and health care personnel who must be present in the scanning room. Heating resulting from the RF energy of nonferromagnetic prosthetic devices has not proved to be a problem. Body surfaces do absorb this RF energy, but it is unlikely that the patient's temperature will increase by more than 1°C.

  34. MRI The most significant risk posed in the MRI suite is the effect of the magnet on ferrous objects. Dislodgement and malfunction of implanted biologic devices or other objects containing ferromagnetic material are also real possibilities. Such items include shrapnel, vascular clips and shunts, wire spiral endotracheal tubes, pacemakers,automatic implantable cardioverter-defibrillators (ICDs), mechanical heart valves, and implanted biologic pumps.

  35. MRI Tattoo ink may contain high concentrations of iron oxide. Burns at tattoo sites have been reported after exposure to MRI magnetic fields, but such incidents are very rare and the presence of, for example, permanent eyelinershould not exclude the patient from MRI examination.

  36. Anesthetic Management for MRI Anesthesia in the MRI suite poses several unique problems, including the following: 1. Limited patient access and visibility, especially when the patient must be placed head first into the magnet 2. Absolute need to exclude ferromagnetic components 3. Interference/malfunction of monitoring equipment produced by the changing magnetic field and RF Currents 4. Potential degradation of the imaging caused by the stray RF currents produced by the monitoring equipment and leads 5. The necessity to not move the anesthetic and monitoring equipment once the examination has started to prevent degradation of magnetic field homogeneity 6. Limited access to the MRI suite for emergency personnel in accordance with the recommended policies noted earlier

  37. A common approach now is to induce anesthesia in an induction area adjacent to the MRI suite outside the magnetic field by using conventional equipment with the patient on a dedicated MRI transport table that is not ferromagnetic.

  38. MRI Because the patient's airway is not easily accessed during the MRI scan and because patient assessment and communication are limited by both the magnet bore in which the patient is placed and the loud noise associated with MRI scanning, deep sedation/analgesia is not advisable. Patients requiring more than moderate sedation/analgesia are probably most safely administered a general anesthetic with airway control by either endotracheal intubation or a laryngeal mask airway (LMA).

  39. Contraindications for MRI include: Shrapnel, vascular clips and shunts, wire spiral ETT’s, pacemakers, ICDs, mechanical heart valves, recently placed sternal wire, implanted biological pumps, tattoo ink with high concentrations of iron-oxide (permanent eyeliner), and intraocular ferromagnetic foreign bodies.

  40. Ferromagnetic items should never be allowed in the vicinity of the MRI magnet, including: scissors, pens, keys, gas cylinders, anesthesia machine, syringe pump, beeper, phone, and steel chairs. Cards with magnetic strips will be de-magnetized, including credit cards and ID badges.

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