Anesthesia In remote locations

Question 1

What would be considered”Remote” locations

for anesthesia providers?

Answer 1

 Availability of large complex equipment for diagnosis and treatment.
 JCACHO requires anesthesia to deliver same uniform quality of care
anywhere in the hospital.
 Anesthesia plan should be designed around patient-environmentprocedure.

Question 2

ASA GUIDELINES FOR NON-OPERATING ROOM
ANESTHETIZING LOCATIONS (NORA)

Answer 2

 Oxygen
 Suction
 Scavenging system for inhaled agents
 Anesthetic equipment
 Electrical outlets
 Adequate illumination (not always possible)
 Sufficient space
 Resuscitation equipment immediately available
 Adequately trained staff to assist anesthesia
 Observe building and safety standards
 Postanesthesia care facilities

Question 3

 ASA basic standards of monitoring

 Standard I-

Answer 3

a qualified anesthesia provider should
be present in the room throughout the conduct of
anesthesia

Question 4

 ASA basic standards of monitoring

Standard II-

Answer 4

Continual evaluation of oxygenation,

ventilation, circulation, and temperature (why?).

Question 5

How many times do you bag with RSI

Answer 5

Zero

Question 6

PATIENT (HEALTH STATUS)

Answer 6

 Ability to tolerate sedation vs. general anesthesia
 ASA grade and co-morbidity
 Airway assessment (morbid obese)
 Allergies-IV contrast
 Monitoring requirements-simple vs. advanced

Question 7

Minimal sedation anxiolytic responsiveness

Answer 7

Responsiveness Normal response

to verbal stimulation

Question 8

Moderate sedation/ analgesia

“conscious sedation” responsiveness

Answer 8

Purposeful response to verbal or tactile stimulation

Question 9

Deep sedation analgesia responsiveness

Answer 9

Purposeful response following repeated or painful

stimulation

Question 10

Unarousable even with painful stimulus

Answer 10

General anesthesia

Question 11

Airway Unaffected

Answer 11

Minimal sedation

Question 12

NO intervention required airway

Answer 12

Moderate sedation

Question 13

Intervention may be required for airway

Answer 13

Deep sedation

Question 14

Intervention required airway

Answer 14

General anesthesia

Question 15

Spontaneous ventilation Unaffected

Answer 15

Minimal sedation

Question 16

Never give

Answer 16

Midazolam on ECT

Question 17

Midazolam

Answer 17

Increase the seizure threshold

Question 18

Spontaneous ventilation adequate

Answer 18

Moderate

Question 19

Spontaneous ventilation May be inadequate

Answer 19

Deep sedation and analgesia

Question 20

Spontaneous ventilation Frequently

inadequate

Answer 20

General anesthesia

Question 21

Cardiovascular function Unaffected

Answer 21

Minimal sedation

Question 22

Usually maintained : CV function

Answer 22

Moderate and Deep sedation

Question 23

May be impaired: CV function

Answer 23

General sedation

Question 24

GI endoscopy drug of Choice

Answer 24

Propofol

Question 25

In all other NORA site make sure GI Suite:

Answer 25

RN in suite available for help Check IV Check Suction Emergency drugs ready Have 2U of blood ready for active GI bleed(some of these cases are done in the ICU at the bedside) Atropine might be needed for Vagal response

Question 26

What does the 3 step approach involve in NORA (PPE)

Answer 26

Patient Procedure Environment

Question 27

Three step approach: The patient

Answer 27

the patient: may require sedation or anesthesia to tolerate NORA procedures Anxiety, panic disorder, claustrophobia, Cerebral Palsy and movement disorders, pain, trauma, child, seizures, raised ICP

Question 28

Three step approach: The procedure

Answer 28

``` NPPL Nature of the procedure Position Pain associated with procedure Length of procedure ```

Question 29

```  MRI NORA limits  Magnetic field  Keep your  Make sure you have  Keep your patient warm  Keep an eye on possible  Be ready for transport (what would you need for it?) ```

Answer 29

- limits accessibility of anesthesia equipment - cell phone, pager, and wallet out of the room - drugs and airway ready in locked anesthesia cart (orient RN about their location) - airway complications and IV disconnection

Question 30

``` Pediatric patients  Airway________  General anesthesia with_________  Drugs _____________  Drugs ready for________  Observe for drug allergic reaction after______ ```

Answer 30

``` LMA vs. ETT small requirements Propofol and Sux, or just inhaled agents bradycardia and airway complications IV contrast administration ```

Question 31

Pediatric patients in NORA 2 biggest concerns

Answer 31

IV access and airway management

Question 32

Pediatric patients : Try to “judge” the length of the procedure to make a plan for

Answer 32

keeping your patient warm

Question 33

``` For NICU Evaluate patient’s status  Dilute your  Albumin_____  Normal saline syringes for IV flush  Check IV access  Have RT in room during surgical procedure for ventilatory settings (jet ventilators)  Have NICU RN available for extra help ```

Answer 33

wt, respiratory status, hemodynamic status, drips, sepsis) emergency drugs (Epi at 1mcg/cc) 5% 5cc/kg over 10-15 min

Question 34

Pediatric Cancer Center

Answer 34

Emergency drugs (atropine and Sux for airway)  RN in suite  Drug of choice- Propofol Oxygen , AMBU bag