ANE 550 Principles Of Anesthesia

							      Principles of Anesthesiology Nursing V
Anesthesia Service Outside the OR

         Jeffrey Groom, MS, CRNA, ARNP
           Clinical Associate Professor
         Anesthesiology Nursing Program
School of Nursing – Florida International University
        Anesthesia Services
Outside of the Traditional OR Setting

         •Airway Management
         •Sedation
         •Anesthesia
         •Consultation
Airway Management
        AND
Special Procedures
 Outside of the O.R.
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
 Difficult
 Airway
Algorithm
 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 ?
AIRWAY ASSESSMENT
AIRWAY ASSESSMENT
 Mouth Opening
  Oropharyngeal Classification
   TM Distance
     Neck Range of Motion
        Jaw Mobility
        Dentition
        Mask Seal/Airway Access
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
               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!
        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.
+ glycopyrrolate
Difficult Airway Algorithm
DIFFICULT AIRWAY
 ? RECOGNIZED vs. UNRECOGNIZED
   SUCCESSFUL

   Confirmation of TUBE Placement
   Documentation of Difficult Airway
Difficult Airway Algorithm
DIFFICULT AIRWAY
 ? RECOGNIZED vs. UNRECOGNIZED
   SUCCESSFUL

 EXTUBATION
   PLAN for REINTUBATION
   AWAKE
   JET STYLETTE over ETT
  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
    Airway Management
     Outside of the O.R.

ICU – Intubate patient
       in respiratory distress   CRNA



Wards – Intubate for arrest

ER – Intubate difficult airway
  Airway Management
   Outside of the O.R.
Historical Perspective
SAFETY 1st
Bag of Tricks
Urgent vs. Emergent CRNA
Assessment
Awake vs. Asleep
Confirmation - Documentation
Airway Management
 Outside of the O.R.
SAFETY 1st                 CRNA
Bag of Tricks
  Airways, Meds, Gadgets
Suction - Monitors - O2 + Ambu
Access - Position Patient
Awake vs. Asleep
Confirmation - Documentation
          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
    Anesthesia Services
     Outside of the O.R.
Private Offices and Clinics
In-Hospital Out of the OR Areas:
  – Radiology
  – Cardiology
  – GI / GU
  – Psychiatry
  – Other
   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
    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
    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
        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
              Magnetic
              Resonance
              Imaging (MRI)


Special Problems
Special Equipment
Solutions are Unique   to
   each MRI Facility
                  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…..
   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)
                    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)
    PSYCHIATRY

Physiologic Response to ECT
Anesthesia for Ophthalmic Surgery

•   Ophthalmic Surgical Procedures
•   Dynamics of Intraocular Pressure
•   Anesthetic & Ophthalmic Agents
•   Oculocardiac Reflex
•   Anesthesia Options
      and Care Plans
    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
    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”
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
Dynamics of IO Pressure
VARIABLE           EFFECT
 CVP
        INCREASE   +++
        DECREASE   ---
 Arterial BP
        INCREASE   +
        DECREASE   -
 PaCO2
        INCREASE   ++
        DECREASE   --
 PaO2 DECREASE     +
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 -
       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
Oculocardiac Reflex

                  Vagus - X
             Efferent


            Afferent

 Trigeminal - V
     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
   Regional Anesthesia
• The GOAL: Analgesia and Akinesis
• The MIX: 2%LIDO + 0.75%Bupivacaine
                plus hyaluronidase & epi
• The BLOCK: Retrobulbar
                Peribulbar +/- Facial Nerve
• The COMPLICATIONS: Acute Anxiety,
  Hemorrhage, Trauma, OC Reflex, IV
  Injection, CNS Toxicity
 Peripheral
Nerve Blocks
 Eye Block-
    Retrobulbar
    Peribulbar
 Anatomy
 Analgesia
 Complications -
hemorrhage, OCR, CNS
      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
     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
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
                 Monitored
               Anesthesia Care
• Preop Assessment-can patient
  communicate, lie supine, lie still ?
• H & P, Meds, Labs, Medically “Tuned”
• Pre-op meds, IV, sedation, monitors (N/C -CO2)
• Sedation options:barbs, narcs, benzo,N2O
• Positioning - Ventilation - Temp - HTN
AIRWAY
MANAGEMENT
becomes a
shared
responsibility
Endoscopic Otorhinolaryngology
 Pre-op Assessment - AIRWAY, Co-Existing Diseases
 Management       ? Awake Intubation ?
    Drying Agent

    Ventilation/Oxygenation - ET Tube
    Muscle Relaxation
    Anesthetic Agent
    Intra-op Management of CV Alterations
    Laser Precautions
          LASER Precautions
Light Amplification of Stimulated Emission of Radiation
> wavelength - > absorption by H2O = superficial/local
Eye Protection and Inhalation Protection - staff & pt.
Greatest risk - AIRWAY FIRE and/or EXPLOSION
   ETT Precautions / Options
   Lowest possible FiO2 + air or helium
   Cuff filled w/ saline or water, wet 4x4’s
   Fire risk also to drapes, circuit tubing
   Know Fire & Evacuation procedures
    AIRWAY FIRE PROTOCOL

•   STOP Ventilation - Remove ET Tube
•   D/C oxygen and remove circuit from machine
•   Submerge tube in water
•   Assure no residual in airway - Ventilate Patient
•   Reintubate
•   Assess ABG’s and Fiberoptic Airway Exam
•   Consider Bronchial lavage, steroids, ICU
  Nasal and Sinus Surgery
• Pre-op Assessment - AIRWAY, Co-Existing Diseases
• Management     ? Local or GETA ?
  – Sympathomimetic agents / Local

  – Ventilation/Oxygenation - ET Tube
  – Muscle Relaxation
  – Anesthetic Agent
  – Positioning, Eye Protection
  – Laser Precautions and Endoscope Precautions
  – Controlled Hypotension
  – Emergence / Extubation / Post-op Nasal Packs
   Head and Neck Surgery
• Pre-op Assessment - AIRWAY, Co-Existing Diseases
• Management     ? Local or GETA ?
  – Co-existing Disease Ramifications ie: carotids

  – Ventilation/Oxygenation - ET Tube
  – Muscle Relaxation +/ -
  – Anesthetic Agent
  – Turning OR Table, Positioning, Eye Protection
  – Tracheostomy - Awake vs. Asleep
  – Monitors, Fluids, Blood
  – Emergence / Extubation
       Oral (OMF) Surgery
• Pre-op Assessment - AIRWAY
• Management
  – Pre-op, Drying Agent, Nasal Intubation vs Oral
  – Nasal ET Tube Prep - Vasoconst/Lido/Lube/Dilate
  – Muscle Relaxation +/ -
  – Anesthetic Agents - ? Hypotensive technique?
  – Turning OR Table, Positioning, Eye Protection
  – IntraOp Monitoring- Disconnects, Extub, VS
  – Emergence / Extubation - Spasm / Post-op
    Bleeding, ? Will Patient be Wired ?
    Anesthesia for Other
Non-Operating Room Settings
              Conscious
               Sedation
               versus
             Monitored
             Anesthesia
               Care
    Anesthesia for Other
Non-Operating Room Settings
          Standard Routine
             What if….
             Don’t MIX
          Role of Reversals
           Plan for PACU
Decisions, Decisions,
  ?? Decisions ??
   Most Critical Personal Choices
 for your Professional Career will be
     the decisions you make about
      AIRWAY management and
Anesthesia Services outside of the OR
What is currently the biggest danger
 in providing anesthesia services
        outside of the OR ?
            -DANGER-


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? QUESTIONS ?

Airway Management
        AND
Special Procedures
 Outside of the O.R.