FOR AESTHETIC SURGERY & SURGERY OUTSIDE OF THE OPERATING ROOM


ANESTHESIA OUTSIDE THE OPERATING ROOM


General Considerations/Safety


•  Thorough preoperative evaluation of every pt is essential


•  All patients receiving any form of anesthesia must have ASA monitors during anesthesia care


•  Transport equipment should be available (bag-valve-mask with O2 tank)


•  Emergency drugs should be available & IV access assessed


•  Postop care & standards are the same as for OR-based anesthesia


•  Pay attention to possible allergies to contrast dye



CT/MRI/INTERVENTIONAL NEURORADIOLOGY


CT: General Considerations


•  Pt should wear lead with thyroid shield at all times while in CT scanner


CT: Monitors


•  Regular OR anesthesia monitors may be used


• Standard ASA monitors required if any anesthesia given


CT: Anesthetic Considerations


•  Anesthetic options range from mild sedation to general anesthesia


•  Patient factors to consider: Pt cooperation, claustrophobia, comorbidities, age, mental status, length of scan


•  Ensure adequate length of IV lines, anesthesia circuit, monitoring wires


Special Procedures in the CT Suite


Stereotactic Brain Biopsy


•  Metal frame placed to perform procedure (usu with local + benzodiazepine)


•  Technique: MAC, titrate sedation carefully to avoid airway compromise if GA necessary, awake fiberoptic intubation may be the safest technique


Percutaneous Vertebroplasty


•  Indication: Reverse vertebral collapse in osteoporotic patients


•  Technique: Usually MAC (or GA if pt in excessive pain)


•  Patient is in prone position → consider pelvic/chest support to avoid impinging on abdomen and interfering with ventilation


MRI: General Considerations


•  Indications for anesthesia care: Children, mentally challenged, claustrophobic pts, pts with resp difficulty, hemodynamically unstable pts, chronic pain pts


•  Distinct features of anesthesia in MRI:


• Powerful magnet


• Remove ferromagnetic equipment: Stethoscopes, credit cards, USB drives, pens, keys, IDs, beepers, cell phones


• Metals safe: Beryllium, nickel, stainless steel, tantalum, & titanium


• Difficulty accessing airway


• Carefully titrate sedatives & have monitors facing clinician at all times


MRI: Monitors


•  Nonferrous monitoring equipment needed


•  Nonmagnetic laryngoscopes for emergencies


•  Ensure adequate length of IV lines, anesthesia circuit, monitoring wires


Interventional Neuroradiology


General Considerations


•  Standard ASA monitors; if arterial line necessary, can be radial or through femoral sheath


• Femoral sheath a-lines → only MAP is useful


•  Technique: GA if motionless state required; sedation if rapid neurologic testing essential or for most diagnostic scans


Deliberate Hypertension


•  May be necessary to help radiology catheters flow to desired location


•  Usually 20–40% above baseline; phenylephrine infusion may be useful


Deliberate Hypotension


•  May be required in carotid endarterectomy/arteriovenous malformation (AVM) procedures


•  Various approaches may be used (↑ anesthesia, labetalol, vasodilators—nitroprusside/nitroglycerin/hydralazine)


Embolization of Arteriovenous Malformation (AVM)


•  Polyvinyl alcohol (PVA) injected into feeding vessels of AVM


•  Approach: MAC (can continuously monitor neuro status) or GA


•  Systemic heparinization may be required


•  Complications: Hemorrhage 2° to anticoagulation (can reverse with protamine), hemorrhage 2° to thrombus (can ↑ BP by 20–40 mm Hg); ↑ ICP (treat with hyperventilation, head ↑, mannitol, furosemide)


Cerebral Aneurysms


•  Uses balloons, coils, or liquid polymer solution to endovascularly treat the aneurysm


•  Usually performed under general anesthesia, a-line should be placed


•  Important to have OR available in case of rupture & urgent need for surgical repair


Central Intraarterial Thrombolysis


•  Treatment of stroke if <6 hrs from onset of symptoms


•  Usually performed under MAC (neurologic assessment is desirable)


Endoscopy & ERCP (Endoscopic Retrograde Cholangiopancreatography)


General Considerations


•  Most upper and lower endoscopies are performed without an anesthesiologist


•  Lateral position for lower endoscopy; lateral/supine for upper endoscopy


•  Important to have access to airway at all times


Technique


•  Anesthetic options range from mild sedation to general anesthesia


• For anesthesia sedation cases: Midazolam/fentanyl/propofol combination often used


•  Patient factors to consider: Pt cooperation, comorbidities, age, mental status, length of procedure


•  Upper endoscopy: Consider pharyngeal topical anesthesia (lidocaine, benzocaine) prior to endoscope insertion


•  Postop pain: Relatively low, usually from air used for inflation


•  ERCP: May be performed in supine, lateral, or prone position; pt can have significant pain during bile duct dilatation


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Aug 28, 2016 | Posted by in ANESTHESIA | Comments Off on FOR AESTHETIC SURGERY & SURGERY OUTSIDE OF THE OPERATING ROOM

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