Principles of Anesthesiology Nursing V Anesthesia Service Outside the OR

1. Principles of Anesthesiology Nursing VAnesthesia Service Outside the OR Jeffrey Groom, MS, CRNA, ARNPClinical Associate ProfessorAnesthesiology Nursing ProgramSchool of Nursing – Florida International University

2. Anesthesia ServicesOutside of the Traditional OR Setting • Airway Management • Sedation • Anesthesia • Consultation

5. Airway ManagementANDSpecial Procedures Outside of the O.R.

6. ASA Closed Claims Study • 35 % of claims are RESPIRATORY events • 90 % resulted in brain damage or death • 90% resulted from Difficulty in INTUBATION or EXTUBATION

7. Difficult Airway Algorithm

9. Difficult Airway Management • Anticipated vs. Unanticipated • Operating Room vs. Remote Location • Elective vs. Urgent. Vs. Emergent • Airway - Ventilation • Patent Airway ? • Ability to Intubate ? • Ability to Ventilate ?

10. AIRWAY ASSESSMENT ?

11. AIRWAY ASSESSMENT • Mouth Opening • Oropharyngeal Classification • TM Distance • Neck Range of Motion • Jaw Mobility • Dentition • Mask Seal/Airway Access

12. Difficult Airway Algorithm • DIFFICULT AIRWAY • RECOGNIZED vs. UNRECOGNIZED • AWAKE INTUBATION • Proper Preparation • Drying Agent -EARLY • Appropriate Sedation • Topical Anesthetic-Oral/Nasal • Nerve Blocks • Supplemental O2 / Monitor • Fiber Optic, Laryngoscopy, Alternate Method

13. Peripheral Nerve Blocks • Awake Fiberoptic Intubation- Tracheal Blocks • Glossopharyngeal • Superior Laryngeal • Transtracheal • Oral Topicalization & Prep • 2 - 3 ml LIDO CAUTION: Following topical & block pt is without airway reflexes!

14. Laryngeal Innervation • The larynx and trachea are innervated by branches of the vagus nerve. The superior laryngeal nerve carries sensation from the base of the tongue and the inferior epiglottis to the vocal cords. The recurrent laryngeal nerve caries sensation distal to the vocal cords. • The superior laryngeal nerve travels inferior to the greater cornu of the hyoid bone and divides into internal and external branches. The internal branch pierces the thyrohyoid membrane with the laryngeal branch of the superior thyroid artery. • The muscles of the larynx are supplied by branches of the vagus nerve. The cricothyroid muscle is supplied by the external branch of the superior laryngeal nerve. All of the other intrinsic muscles of the larynx are supplied by the inferior laryngeal nerve, a continuation of the recurrent laryngeal nerve.

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18. Difficult Airway Algorithm • DIFFICULT AIRWAY • RECOGNIZED vs. UNRECOGNIZED • SUCCESSFUL • Confirmation of TUBE Placement • Documentation of Difficult Airway

19. Difficult Airway Algorithm • DIFFICULT AIRWAY • RECOGNIZED vs. UNRECOGNIZED • SUCCESSFUL • EXTUBATION • PLAN for REINTUBATION • AWAKE • JET STYLETTE over ETT

20. Difficult Airway Algorithm • If SUSPICIOUS of Trouble Awake Intubation • If you get into TROUBLE Wake the Patient Up • Have PLAN B, C… immediately available PLAN AHEAD / WILL to Move On • Intubation Choices - Alternative Choices Do what you do BEST

21. Airway Management Outside of the O.R. • ICU – Intubate patient in respiratory distress • Wards – Intubate for arrest • ER – Intubate difficult airway CRNA

22. Airway Management Outside of the O.R. • Historical Perspective • SAFETY 1st • Bag of Tricks • Urgent vs. Emergent • Assessment • Awake vs. Asleep • Confirmation - Documentation CRNA

23. Airway Management Outside of the O.R. • SAFETY 1st • Bag of Tricks • Airways, Meds, Gadgets • Suction - Monitors - O2 + Ambu • Access - Position Patient • Awake vs. Asleep • Confirmation - Documentation CRNA

24. RULE # 1 HOLD ON TO ONE STEP, UNTIL YOU HAVE A GOOD GRIP ON THE NEXT MEANING: DON’T…... ...Turn a BREATHING patient into an APENIC patient …Turn a COMPROMISED airway into NO airway …Turn a CV/CI patient into a Can’t Resuscitate patient

25. Anesthesia Services Outside of the O.R. • Private Offices and Clinics • In-Hospital Out of the OR Areas: • Radiology • Cardiology • GI / GU • Psychiatry • Other

26. Anesthesia Services Outside of the O.R. • SAFEST Routine is your USUAL Routine • PreAnesthetic Assessment • Standard Equipment & Monitors • Physical Space & Patient (Airway) Access • Availability of HELP - Backup Plan • PostAnesthetic Recovery Plan

27. Anesthesia Services Outside of the O.R. ASA Guidelines for Nonoperating Room Anesthetizing Locations • Primary and secondary oxygen source • Suction • Anesthesia machine, BVM, drugs, supplies, monitors, scavenging system equivalent to that in the main OR • Sufficient electrical outlets, GFI in wet areas, and emergency power outlets

28. Anesthesia Services Outside of the O.R. • Adequate illumination • Immediate access to the patient • Emergency resuscitation cart & defibrillator • Site must comply with building, fire, and safety codes • Two-way communication to summon help

29. RADIOLOGY • CAT Scan and MRI • Contrast media reaction (5-10% of patients) • Allergy history, type of dye, dose & method MILD- N&V, flush, chills, urticaria, fever MODERATE- bronchospasm, edema, low BP SEVERE- shock, seizure, arrest • Treatment- symptomatic relief to resuscitation • Contrast media causes anxiety but, too much sedation can mask reaction symptoms

30. Magnetic Resonance Imaging (MRI) • Special Problems • Special Equipment • Solutions are Unique to each MRI Facility

31. CARDIOLOGY • Cardiac Catheterization • AICD Placement / Pacemaker Placement • Monitored Anesthesia Care • Standby Pacer / Defibrillator (ElectroPads) • Cardioversion • IV & Monitors - Preoxygenate (ETT ready) • Sedation/Amnesia may be attained with: Propofol, Thiopental, Methohexital, Midazolam • Be prepared for anything…..

32. PSYCHIATRY • General Anesthesia for Electroconvulsive Therapy (ECT) • Pre-Op Assessment • 50%+ are ASA III • Airway & Aspiration Concerns • Psych Meds • Coexisting Diseases • Location (OR vs. Psych Ward)

33. PSYCHIATRY • ANESTHESIA PLAN • Standard monitors, IV, isolate arm monitor, O2 • Anesthesia - Methohexital .5 - 1 mg/kg • Ventilate - SUX .5 - 1 mg/kg then hyperventilate • Mouth gag or OPA placed and electrodes applied • ECT applied • Ventilate & Oxygenate, Rx symptomatic response • Be prepared to terminate continued seizure(STP 1-2 mg/kg)

34. PSYCHIATRY Physiologic Response to ECT

35. Anesthesia for Ophthalmic Surgery

36. Anesthesia for Ophthalmic Surgery • Ophthalmic Surgical Procedures • Dynamics of Intraocular Pressure • Anesthetic & Ophthalmic Agents • Oculocardiac Reflex • Anesthesia Options and Care Plans

37. Ophthalmic Surgical Procedures • Cataract Excision & Intraocular Lens Implant • Phacoemulsification Technique • Corneal Transplant- w/ or w/o IOL Implant • Trabeculectomy • Open Globe Repair • Retinal Surgery - Scleral buckling, vitrectomy • Strabismus Surgery • Pterygium Excision, Eye Lid Procedures

38. Ophthalmic Surgical Procedures • Most patients will be pediatric or elderly • Most procedures will be done as Regional -> MAC -> GETA • Closed-Claims Analysis 30% of cases involve patient movement • “Potential Danger Area for the Part-Time Ophthalmic Anesthetist”

39. Dynamics of IO Pressure • Normal range 10 - 20 mmHg • Varies with EXTERNAL Pressure and with INTERNAL Volume • Subject to transient pressure changes - blinking, rubbing eye, cough etc. • Factors causing IOP to INCREASE during surgical procedures

40. Dynamics of IO Pressure VARIABLE EFFECT CVP INCREASE + + + DECREASE - - - Arterial BP INCREASE + DECREASE - PaCO2 INCREASE + + DECREASE - - PaO2 DECREASE +

41. Dynamics of IO Pressure VARIABLE EFFECT Inhaled Agents Volatile Agts. - - Nitrous Oxide - * IV Anesthetics Barbs, Benzos, Propofol, Narcs - - Ketamine ? Muscle Relaxants Depolarizers + + Nondepolarizers - - Agents that alter CVP or BP + or -

42. Ophthalmic Medications and Implications for Anesthesia May be administered topically, intraocularly, or systemically • Topicals are highly concentrated ie: phenylephrine drop gives 5mg vs typicial IV dose for low BP is often 0.1mg and absorption rate is between IV and SC • Air, sulfur hexafluoride, etc may be given IO and may expand 2-4 times upon D/C of nitrous oxide • Echothiophate (Phospholine) - anticholinesterase, may decrease plasma cholinesterase activity • See examples from text

43. Oculocardiac Reflex Vagus - X Efferent Afferent Trigeminal - V

44. Anesthesia Options • Considerations: Patient, Surgeon, Anesthetist • All patients need to be assessed pre-op for potential GETA irrespective of how case is booked • Special attention to co-existing diseases or risks • All patient pre-op, monitoring and anesthesia set-up should be as if the case were a GETA • Anesthesia Options: Regional Local GETA

45. Regional Anesthesia • The GOAL: Analgesia and Akinesis • The MIX: 2%LIDO + 0.75%Bupivacaine plus hyaluronidase & epi • The BLOCK: Retrobulbar Peribulbar • The COMPLICATIONS: Acute Anxiety, Hemorrhage, Trauma, OC Reflex, IV Injection, CNS Toxicity +/- Facial Nerve

46. Peripheral Nerve Blocks • Eye Block- Retrobulbar Peribulbar • Anatomy • Analgesia • Complications - hemorrhage, OCR, CNS

48. Local Anesthesia • The GOAL: Analgesia • The MIX: LIDO + / - Bupivacaine epi 1: 200, 400, -000 • The BLOCK: local infiltration at site • The COMPLICATIONS: Acute Anxiety, Pain on Injection, OC Reflex, IV Injection, CNS Toxicity

49. General Anesthesia • The GOAL: GETA w/o increasing IOP • The MIX: Lido / Narcs / Labetolol, then STP or Propofol, then Nondeoplarized and Deep ETI • The Problem: Open Globe RSI with SUX and Extubation • The COMPLICATIONS: Management of IOP, OCR and Movement post-op pain, N & V

50. The Problem: Open Globe Injury & Aspiration Risk ISSUES: 1) Aspiration Risk 2) Increase IOP and Excursion of Contents OPTIONS: 1) Wait…….Regional…….Turf……… 2) Aspiration Prophylaxis 3) Cricoid Pressure +/- true RSI or Modified