Chapter 35 Procedures Performed Outside the Operating Room
Characteristics of remote locations
1. What are some fundamental capabilities available in the operating room that must also be available for the delivery of anesthesia in remote locations?
2. What are some special challenges facing the anesthesiologist when delivering anesthesia and at the conclusion of anesthesia in remote locations?
3. What are some safety concerns facing the anesthesiologist delivering anesthesia in remote locations?
Noninvasive x-ray procedures
7. What is magnetic resonance imaging (MRI)? For what evaluations is it useful?
8. What are some contraindications to undergoing MRI?
9. What are some features of MRI that make it difficult for the patient to tolerate?
10. How should the patient be monitored when undergoing an anesthetic for MRI?
11. How must anesthetic equipment and monitors in the MRI center be altered for MRI compatibility? What are the risks of using standard operating room monitors?
12. How must accidental extubation of the trachea during MRI be managed?
13. Why is there an increased risk of hypothermia for patients in the MR imager?
14. What is computed tomography?
15. How does the management of anesthesia for patients undergoing computed tomography compare with the management of anesthesia for patients undergoing MRI?
Invasive x-ray procedures
16. Why more so in interventional radiology procedures than in diagnostic radiology procedures can there be a need for the anesthesiologist to suddenly change to the management of blood coagulation parameters by giving medications or taking new actions?
17. What drug should be immediately available for injection, and at what dose, in invasive radiology procedures where there has been administration of a full anticoagulation dose of heparin?
18. Patients taking antiplatelet drugs are often asked to stop taking those drugs several days before a surgical procedure to allow the body to generate new platelets unaffected by the drugs. However, interventional radiology procedures must sometimes be done in such patients before the effects of antiplatelet drugs have completely worn off. What action must the anesthesiologist take if serious bleeding occurs before antiplatelet agents have worn off, and the international normalized ratio, prothrombin time, partial prothrombin time, and fibrinogen are all normal?
Electroconvulsive therapy
21. What patients are candidates for electroconvulsive therapy (ECT)? How is ECT accomplished?
22. What are some cardiopulmonary effects of ECT? In what sequence might these effects occur?
23. What are the most common causes of mortality after ECT?
24. How is cerebral blood flow affected by ECT?
25. How is intragastric pressure affected by ECT?
26. What are some contraindications and relative contraindications to ECT?
27. What are some post-ECT manifestations in the patient?
28. What is the recommendation for the ingestion of solids and liquids before the performance of ECT?
29. Why is preoperative medication not recommended for the patient who is to undergo ECT?
30. What agents might be used for the induction of anesthesia in a patient undergoing ECT?
31. After unconsciousness results from the induction of anesthesia, why might succinylcholine be administered to the patient? Before this is done, why might a tourniquet be applied to an extremity of the patient?
32. How can the airway of the patient undergoing ECT be managed? What equipment should be available to the anesthesiologist?
33. What monitors should be used during the administration of an anesthetic for ECT?
Cardiac catheterization
34. Why might patients require anesthesia for cardiac catheterization? What adverse effects might the anesthetic have on cardiac function during these procedures?
35. What PaCO2 should be maintained during anesthesia for cardiac catheterization?
36. What complications can occur as a result of cardiac catheterization procedures?
37. How might anxiety be allayed during cardiac catheterization procedures?
38. Why might the onset of action of inhaled or injected anesthetics be altered in patients undergoing cardiac catheterization procedures?
Extracorporeal shock wave lithotripsy
42. What is extracorporeal shock wave lithotripsy (ESWL)?
43. What are the shock waves timed with during ESWL to avoid cardiac dysrhythmias?
44. Why is anesthesia required for patients undergoing ESWL?
45. What are some advantages of general anesthesia for patients undergoing ESWL?
46. What sensory level of regional anesthesia is recommended for patients undergoing ESWL with this anesthetic technique?
47. Why is intravenous fluid administration important during ESWL?
Dental surgery
49. What patients might require anesthesia for a dental procedure?
50. Why might an anticholinergic be administered to a patient before a dental procedure?
51. What agents can be used for the induction of anesthesia in patients requiring anesthesia for a dental procedure? What agent can be used in uncooperative patients when there is no intravenous access before the induction of anesthesia?
52. How is tracheal intubation usually accomplished to facilitate the dentist’s ability to perform dental procedures in patients requiring general anesthesia for the procedure?
53. What are some special concerns for the patient during emergence and in the recovery period after having undergone a dental procedure under general anesthesia?
Answers*
Characteristics of remote locations
1. Fundamental capabilities for monitoring, the delivery of supplemental oxygen, mechanical ventilation of the lungs, the delivery and scavenging of inhaled anesthetics, anesthesia equipment, and the availability of suction must all be available for the delivery of anesthesia in remote locations. (618)
2. Special challenges facing the anesthesiologist when delivering anesthesia in remote locations include limited access to the patient’s airway, poor availability of accessory help, and the potential difficulty in quickly obtaining emergency equipment. Special challenges facing the anesthesiologist at the conclusion of anesthesia in remote locations are based on the greater amount of distance the anesthesiologist must transport the patient before reaching the postanesthesia care unit. These may include a greater need for a supplemental oxygen supply and continuous monitoring. (618-619)
3. Some safety concerns that may face the anesthesiologist delivering anesthesia in remote locations include the possibility of exposure to increased radiation and the scavenging of waste anesthetic gases. (618-619)
