Anesthesia outside the operating room

1. Anesthesia outside the operating room By Hala S. El-Ozairy,MD. Lecturer of anesthesia and ICU

2. Objectives • Understanding that the standards of anesthesia care and patient monitoring are the same regardless of location (There are cases of minor surgery, but there are no cases of minor anesthesia). • Remember that the key to efficient and safe remote anesthetic relies on open communication between the anesthesiologist and non-operating room personnel. • Realize that remote locations have different safety concerns, such as radiation and powerful magnetic fields.

3. Remote anesthesia • Anesthesiologists are increasingly being asked to provide anesthetic care in locations outside of the OR. • These locations include: radiology suites, cardiac labs, psychiatric units, GI lab, MRI, dental, ophthalmic, ENT and urology clinics. • It is the responsibility of the anesthesiologist to ensure that the location meets the ASA guidelines for safety. • The anesthesia needed can range from local anesthetics, MAC, or general anesthesia.

4. Problems related to ‘isolated’ environment • Equipment might be old, not regularly serviced and not in standard use as in the rest of the hospital. • Monitoring standards may not be adequate. • Piped medical gases may not be supplied. • Other personnel may be unaware of the problems facing the anesthetist. • Space may be limited by bulky equipment making access to the patient difficult. • Poor environmental conditions (e.g. Lighting, temperature). • Recovery facilities may not be available. • Inadequate ventilation/scavenging causing pollution. • Problem related to transferring patients.

5. Problems related to patient Patients who require general anesthesia are: • Infants or uncooperative children. • Older children or adults with psychological, behavioral or movement disorders. • Intubated patients such as acute trauma victims and patients receiving intensive care. • Interventional procedures under radio-guidance or painful procedures like ECT, cardioversion which require amnesia.

6. Problems related to the procedure • MRI related problems. • Bleeding. • Conversion from sedation to anesthesia. • Contrast related problems. • Radiation.

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: ECG, ABP, invasive BP, and oximetry.

9. Remote facilities and equipment • Know the physical layout of the location, unfamiliar anesthetic equipment, and anesthetic implications of the procedure being performed prior to the induction of anesthesia. • Verify the availability of assistance. • Check piped-in gases and gas tanks. • Check suction. • Check power outlets (i.e. grounding and electrical requirements).

10. Remote personnel • Nurses and radiology techs are often less familiar with the management of anesthesia, therefore they are often unable to provide skilled assistance in an emergency.

11. Remote recovery care • Patient must be medically stable before transport. • Patient must be accompanied to the recovery area. • Provisions for O2 delivery and monitoring on the transport cart are required. • Appropriate recovery facilities and staff must be provided.

12. Procedural sedation Procedural sedation is defined as "a technique of administering sedatives or dissociative agents with or without analgesics to induce a state that allows the patient to tolerate unpleasant procedures while maintaining cardiorespiratory function."

13. Levels of Procedural Sedation • Analgesia: Decreased perception of painful Stimuli. • Anxiolysis: Decreased anxiety. • Sedation: Decreased awareness of environment. • Conscious sedation: Decreased level of awareness that allows toleration of an unpleasant procedure while maintaining the ability to spontaneously breathe and protect the airway. • Deep sedation: Unconscious state during which patients do not respond to voice or light touch; minimal spontaneous movement; may be accompanied by partial or complete loss of protective reflexes. • General anesthesia: Loss of response to painful stimuli and loss of protective reflexes.

14. JCAHO Guidelines for sedation • ASA class I & II. • Responsible adult to accompany the patient. • Responsible physician (anesthetist). • Support personnel. • Facilities: Immediate availability to manage emergency situations as (apnea, vomiting, seizures, anaphylactoid reactions and cardiac arrest). • Back up emergency service. • On-site equipments: monitors, emergency cart,.. • IV access. • Health evaluation and consent. • Proper monitoring & documentation: ECG, BP, pulse oximetry, capnography, consciousness.

17. Radiology suite • Includes: US, CT, RFA, and neuro-coiling. • The rooms are often crowded with bulky equipment. • Patients are often required to hold still for long periods of time. • Unique hazard: radiation exposure. • Leukemia and fetal abnormalities. • Dosimeters are required (maximum exposure 50 mSv annually). • Lead aprons, thyroid shields, leaded glass screens, and video monitoring.

18. Radiology suite, contd. • Iodinated contrast media. • Older ionized contrast media were hyperosmolar and toxic. • Newer non-ionized contrast media have lower osmolality and improved side-effects. • Predisposing factors to adverse reactions from contrast media include a history of: bronchospasm, allergy, cardiac disease, hypovolemia, hematologic disease, renal dysfunction, extremes of age, anxiety, and medications (beta-blockers, aspirin, and NSAIDs).

19. Radiology suite, contd. • Reactions to iodinated contrast media. • Mild: nausea, perception of warmth, headache, itchy rash, and mild urticaria. • Severe: vomiting, rigors, feeling faint, chest pain, severe urticaria, bronchospasm, dyspnea, arrythmias, and renal failure. • Life-threatening: glottic edema/bronchospasm, pulmonary edema, arrythmias, cardiac arrest, and seizures/unconsciousness. • Treatment: O2, bronchodilators, epinephrine, corticosteroids, and antihistamines.

20. CT • Two-dimensional, cross-sectional image. • Each cross-section requires a few seconds of radiation exposure. • Pt immobility is required. • It is often noisy, warm, and claustrophobic. • CT can be used for diagnostic and therapeutic purposes. • Number one problem: inaccessibility to the patient.

21. Anesthesia for CT • Anesthetist can remain in the room wearing X-ray protection or view the patient and monitors from the control room. • The CT scanner does not interfere with monitoring equipment. • The scans are short and can be interrupted. • The patient couch moves during examination. • Temporarily interruption of ventilation to improve image quality – immediately re-ventilate. • Patient positioning.

22. Radiology RFA • Often done in CT but occasionally MRI. • Kidney, lung, and liver. • Currently requesting general anesthesia with ETT secondary to prone positioning and the need to lay still for extended periods of time. • It is our job to check pressure points and padding. Radiology techs are not trained to be concerned.

23. Interventional Radiology • Embolization of cerebral and dural AVM’s, coiling of cerebral aneurysms, angioplasty of sclerotic lesions, and thrombolysis of acute thromboembolic stroke. • These procedures often require deliberate hypotension and deliberate hypocapnia. • Radiologist may request rapid transition between deep sedation and an awake responsive state.

24. Cerebral Coiling • The anesthetist should prepare: • Arterial line set up. • Fluid warmer. • Infusion pump. • Medications: NTG, nipride, esmolol, labetalol, heparin, and protamine. • ACT machine. • Radiologist may request anything from deep IV sedation to GA with ETT. • Always have 2 large-gauge IV’s in place. One for drug infusion and one for rapid fluid administration. • Stay in constant communication with OR in case of an emergency. • Pt often transported to the ICU post-op.

25. Remote Cardiac Lab • Elective cardioversion: • Cart with emergency drugs. • Induction drug (Etomidate). • Standard monitoring. • Preoxygenate. • Give small incremental doses of etomidate until the eyelash reflex is abolished. • Remove the mask immediately before the shock and confirm no one is touching the pt. • Ventilate with 100% O2 post-shock until consciousness is regained. • Consider RSI with ETT if high risk for aspiration.

26. Remote Cardiac Lab contd. • Cardiac RFA • IV sedation to GA with ETT depending on the pt’s co-morbidities. • Possible need for an arterial line setup. • Propofol is oftenly used. • Midazolam and fentanyl are used to titrate in during the more painful parts of the procedure (esp. the ablation).

27. Remote Cardiac Lab contd. • Pacemaker/ ICD placement: • We are often called just for the ICD check, in which case proceed like an elective cardioversion. • If the pt. is very sick, they may require GA. Therefore, proceed like RFA. • These pt’s will often need an arterial line for BP monitoring. • These ICD checks are not without risk. Check pulses and watch the ECG, pulse oximetry and arterial wave-forms closely. People have been known to code and require CPR.

28. GI Lab • Endoscopy, Colonoscopy and ERCP. • Pt’s are often uncooperative or very sick. • Current rooms in the GI lab are very small.

29. Anesthesia for GI Procedures • Pre anesthetic assessment: Age, cooperative, anxiety, allergies, fluid status, electrolytes, cardiac history, GERD. • Type of anesthesia: • Moderate sedation- midazolam andFentanyl. • Deep sedation- Addition of propofol. • Some cases may require general anesthesia. • Anesthetic considerations: • Strong vagal nerve stimulation as result of stimulation to colon. • Most patients tolerate these procedures well.

30. ECT Indications Contraindications • Major depression. • Mania. • Certain forms of schizophrenia. • Parkinson’s syndrome. • Pheochromocytoma. • Increased ICP. • Recent CVA. • Cardiovascular conduction defects. • High risk pregnancy. • Aortic and cerebral aneurysms.

31. Physiologic effects of ECT • Electrical stimulus: brief period of muscular contraction followed by the tonic and then clonic phases of the seizures. • Cardiovascular effects of ECT: immediate parasympathetic response followed within seconds by a sympathetic response. • The muscular activity of the seizure and the increased sympathetic activity causes a rise in myocardial oxygen consumption, increases CMRO2, cerebral blood flow, intracranial, intra-ocular intra-gastric pressure briefly.

32. Anesthesia for ECT • General anesthesia is used to provide a brief period of amnesia and modify the motor effects of the seizure to protect the patient. • Don’t forget the suction and the Bite block.

33. ECT contd. • Pre-op: These pt’s have often had this procedure multiple times, therefore you can use old records as templates. • Place IV and give glyco (0.2 mg IV). Give caffeine if the psychiatrist requests. • Treats the bradycardia/ asystole from the initial parasympathetic discharge from the seizure activity. • Hyperventilate the pt. with 100% O2. • Thiopentone and suxamethonium are commonly used. • Place the bite block. • Goal is a seizure 30-60 seconds long. • Ventilate until spontaneous respirations return. • The parasympathetic discharge is often followed by a sympathetic discharge associated with HTN and tachycardia. This is treated with esmolol.

34. Dental Procedures • Pediatric Dentistry: fillings, crowns, pulpotomies, tooth extractions and space maintainers. • Oral and Maxillofacial Surgery: extractions of impacted teeth, insertion of dental implants, treatment of infections of the head and neck and facial cosmetics. • Peridontics: surgery of teeth, gingiva, connective tissue, periodontal ligament and alveolar bone. • Anesthesia : general anesthesia, minimal sedation, moderate sedation with local anesthetic for particular areas of surgery.

35. Ophthalmology • Cataract extraction is the most common procedure done for the elderly. • Strabismus operations are the most common pediatric procedures. • Requirements for anesthesia: • Unmoving globe. • Minimal bleeding. • Smooth emergence. • Usually done under MAC.

36. Urologic Procedures • ESWL: sound waves are focused on kidney and ureteral stones. The stone located by flouroscopy. • Cystoscopy/ ureteroscopy: are performed to diagnosis and treat lesions of the lower (urethra, prostate, bladder) and upper (ureter, kidney) urinary tracts. • Type of Anesthesia • Depending on the pt and procedure anesthesia can range from topical lubrication ,MAC, or regional. • If regional is used T-6 level of blockade is required for upper tract instrumentation and T-10 for lower-tract surgery.

37. Thank you