ANE 550 Principles Of Anesthesia V Course Overview

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Principles of Anesthesiology Nursing VAnesthesia
Service Outside the OR Jeffrey Groom, MS, CRNA,
ARNPClinical Associate ProfessorAnesthesiology
Nursing ProgramSchool of Nursing Florida
International University
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Anesthesia ServicesOutside of the Traditional OR
Setting

• Airway Management
• Sedation
• Anesthesia
• Consultation

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Airway ManagementANDSpecial Procedures Outside
of the O.R.
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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

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Difficult Airway Algorithm
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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 ?

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AIRWAY ASSESSMENT
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AIRWAY ASSESSMENT

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

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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

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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!
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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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glycopyrrolate
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Difficult Airway Algorithm

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

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Difficult Airway Algorithm

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

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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

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Airway Management Outside of the O.R.

• ICU Intubate patient in respiratory
  distress
• Wards Intubate for arrest
• ER Intubate difficult airway

CRNA
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Airway Management Outside of the O.R.

• Historical Perspective
• SAFETY 1st
• Bag of Tricks
• Urgent vs. Emergent
• Assessment
• Awake vs. Asleep
• Confirmation - Documentation

CRNA
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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
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RULE 1
HOLD ON TO ONE STEP, UNTIL YOU HAVE A GOOD GRIP
ON THE NEXT
MEANING DONT... ...Turn a BREATHING patient
into an APENIC patient Turn a COMPROMISED airway
into NO airway Turn a CV/CI patient into a Cant
Resuscitate patient
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Anesthesia Services Outside of the O.R.

• Private Offices and Clinics
• In-Hospital Out of the OR Areas
• Radiology
• Cardiology
• GI / GU
• Psychiatry
• Other

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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

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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

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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

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RADIOLOGY

• CAT Scan and MRI
• Contrast media reaction (5-10 of patients)
• Allergy history, type of dye, dose method
• MILD- NV, 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

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Magnetic Resonance Imaging (MRI)

• Special Problems
• Special Equipment
• Solutions are Unique to each MRI Facility

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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..

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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)

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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)

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PSYCHIATRY
Physiologic Response to ECT
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Anesthesia for Ophthalmic Surgery
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Anesthesia for Ophthalmic Surgery

• Ophthalmic Surgical Procedures
• Dynamics of Intraocular Pressure
• Anesthetic Ophthalmic Agents
• Oculocardiac Reflex
• Anesthesia Options and Care Plans

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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

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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

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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

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

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Oculocardiac Reflex
Vagus - X
Efferent
Afferent
Trigeminal - V
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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

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Regional Anesthesia

• The GOAL Analgesia and Akinesis
• The MIX 2LIDO 0.75Bupivacaine plus
  hyaluronidase epi
• The BLOCK Retrobulbar Peribulbar
• The COMPLICATIONS Acute Anxiety, Hemorrhage,
  Trauma, OC Reflex, IV Injection, CNS Toxicity

/- Facial Nerve
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Peripheral Nerve Blocks

• Eye Block- Retrobulbar Peribulbar
• Anatomy
• Analgesia
• Complications - hemorrhage, OCR, CNS

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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

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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

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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
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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 optionsbarbs, narcs, benzo,N2O
• Positioning - Ventilation - Temp - HTN

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Anesthesia for ENT Surgery
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AIRWAY MANAGEMENT becomes a shared responsibility
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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

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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 4x4s
• Fire risk also to drapes, circuit tubing
• Know Fire Evacuation procedures

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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 ABGs and Fiberoptic Airway Exam
• Consider Bronchial lavage, steroids, ICU

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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

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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

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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 ?

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Anesthesia for Other Non-Operating Room Settings
Conscious Sedation versus Monitored Anesthesia
Care
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Anesthesia for Other Non-Operating Room Settings
Standard Routine What if. Dont MIX Role of
Reversals Plan for PACU
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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

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What is currently the biggest danger in providing
anesthesia services outside of the OR ?
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- D A N G E R -




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? QUESTIONS ?
Airway ManagementANDSpecial Procedures Outside
of the O.R.