Week 15 nora

Question 1

WEEK 15 LECTURE: OUTPATIENT, NORA AND PACU CONSIDERATIONS
CHAPTER 33 → Nonoperating Room Anesthesia

General Principles
- Nonoperating room anesthesia (NORA) refers to anesthesia that is provided at any location _______(1) from the traditional operating room.
- These locations include _______(2) departments, endoscopy suites, _______(3) (MRI), and _______(4) (CT) scanners.

3 Step Approach
- NORA presents unique challenges and a systematic approach using the simple three-step paradigm “the _______(5), the _______(6),” and the _______(7)” is recommended.
1. The Patient
- Patients presenting for NOR procedures tend to be _______(8) (above 50 years) and in the case of gastroenterologic, cardiology, and radiologic procedures, of _______(9) ASA status than patients cared for in the standard operating rooms.
- Patients presenting for NOR procedures are also more likely to receive _______(10) anesthesia care (MAC) or sedation than those undergoing OR procedures. Patients may require sedation or anesthesia to tolerate NOR procedures for a number of _______(11).
- Children commonly require sedation or _______(12) for diagnostic and therapeutic procedures.
- Palliative, less-invasive procedures are increasingly being offered to patients too ill to tolerate a major surgical procedure representing a continuing challenge for the NOR anesthesiologist.
- All patients presenting for NORA require a thorough _______(13) assessment, standard preanesthesia care, the development of a sound anesthetic plan with appropriate levels of monitoring, and the appropriate postanesthesia care.

Answer 1

Answers:
1. remote
2. radiology
3. magnetic resonance imaging
4. computerized tomography
5. PATIENT
6. PROCEDURE
7. ENVIRONMENT
8. older
9. higher
10. monitored
11. reasons
12. anesthesia
13. preanesthetic

Question 2

The patient, procedure, and environment
The Procedure
- Common NOR procedures for which the patient may require anesthesia or sedation are listed in Table 33-2.
- The anesthesiologist must understand the nature of the procedure, including the position of the patient, how painful the procedure will be, and how long it will last.
- The optimum anesthesia plan provides safe patient care and facilitates the _______(1).
- Discussions with the proceduralist must include contingencies for _______(2) and adverse outcomes.

The Environment
- The American Society of Anesthesiologists (ASA) has developed _______(3) for NORA.
- Prior to the anesthetic, the presence and proper functioning of all _______(4) needed for safe patient care must be established.
- The location of immediately available _______(5) equipment should be noted and protocols developed with the local staff for dealing with emergencies, including cardiopulmonary resuscitation and the management of anaphylaxis.

Answer 2

Answers:
1. procedure
2. emergencies
3. standards
4. equipment
5. resuscitation

Question 3

TABLE 33.1 → Patient Factors Requiring Sedation or Anesthesia for NORA Procedures (Read straight off this)

• Claustrophobia, anxiety, and _______(1)
• Cerebral palsy, developmental delay, and learning _______(2)
• Seizure disorders, movement disorders, and muscular _______(3)
• Pain, both related to the procedure and other _______(4)
• Acute trauma with unstable cardiovascular, respiratory, or _______(5) function
• Raised intracranial _______(6)
• Significant comorbidity and patient frailty (American Society of Anesthesiology physical status III, _______(7))
• Children, especially those below _______(8) years

Answer 3

Answers:
1. panic disorders
2. difficulties
3. contractions
4. causes
5. neurologic
6. pressure
7. IV
8. 10

Question 4

TABLE 33.3 → ASA Standards for NORA Locations (Read directly off this table)

1. Oxygen-reliable source—ideally piped and full backup _______(1)
2. Suction-adequate and _______(2)
3. Scavenging system if inhalational agents are _______(3)
4. Anesthetic equipment
   
   • Backup self-inflating bag capable of delivering at least 90% oxygen by positive-pressure _______(4)
   • Adequate anesthetic drugs, supplies, and equipment for intended _______(5) care
   • Adequate monitoring equipment to allow adherence to the ASA standards for basic _______(6)
   • Anesthesia machine with equivalent function to those in the operating rooms and maintained to the same _______(7)
5. Electrical outlets
   
   • Sufficient for anesthesia machine and _______(8)
   • Isolated electrical power or ground fault circuit interrupters if “wet location”
6. Adequate illumination of patient, anesthesia machine, and monitoring equipment; battery-operated backup _______(9) source
7. Sufficient space for:
   
   • Personnel and _______(10)
   • Easy and expeditious access to patient, anesthesia machine, and monitoring _______(11)
8. Resuscitation equipment immediately available
   
   • Defibrillator/emergency drugs/cardio-pulmonary _______(12)
9. Adequately trained staff to support the anesthesiologist and a reliable means of two-way _______(13)
10. All building and safety codes and facility standards should be _______(14)
11. Postanesthesia care facilities?
    
    • Adequately trained staff to provide postanesthesia _______(15)
    • Appropriate equipment to allow safe transport to main postanesthesia care _______(16)

Answer 4

Answers:
1. E-cylinder
2. reliable
3. administered
4. ventilation
5. anesthesia
6. monitoring
7. standards
8. monitors
9. light
10. equipment
11. equipment
12. resuscitation
13. communication
14. observed
15. care
16. unit

Question 5

Adverse Events in NORA Locations
- Significant adverse events occur infrequently in NOR locations, although the large multicenter studies needed to determine their true incidence are _______(1).
- A recent study of the NACOR database indicated that contrary to previous reports, NORA procedures appear to have a lower incidence of both minor and major complications and _______(2) than OR procedures.
- However, the continuing need for vigilance and attention to _______(3) remains high in NORA.
- The ASA closed claims database has identified NORA as an area of liability for the _______(4).
- The _______(a) suite, _______(b) laboratory, and the emergency department are sites where adverse events are likely to occur and the elderly, medically complex patients have been determined to be more at risk by both the closed claims and the NACOR _______(5).
- ______(d) secondary to oversedation was the most common type of adverse event in the closed claims _______(6).

• Capnography provides an early monitor of impending respiratory depression during sedation and is _______(7).
• Adverse events associated with NORA have been divided into minor and major and appear to be more frequent in patients undergoing radiology procedures and in cardiology _______(8).

Answer 5

Answers:
1. lacking
2. mortality
3. detail
4. anesthesiologist
a. gastroenterology
b. cardiac
c. emergency
5. analyses
d. Respiratory depression
6. study
7. recommended
8. locations

Question 6

TABLE 33-4 → Complications of NORA (Read right off this table)

Minor Complications (in order of frequency)
- Postoperative nausea and _______(1)
- Inadequate postoperative pain _______(2)
- Hemodynamic _______(3)
- Minor neurologic complications such as postdural puncture _______(4) (cardiology and radiologic locations)
- Minor respiratory complications (cardiology and radiologic _______(5))
- Complications related to central/intravenous lines (cardiology _______(6))
- Need for opioid reversal (cardiology and radiologic _______(7))

Major Complications
- Unintended patient awareness (gastroenterologic _______(8))
- Anaphylaxis (radiology procedures and cardiology _______(9))
- Need for upgrade of _______(10)
- Serious hemodynamic _______(11)
- Respiratory _______(12)
- Need for resuscitation
- Central and peripheral nervous system injury (radiology procedures and cardiology _______(13))
- Vascular access-related complications (radiology procedures and cardiology _______(14))
- Wrong patient/wrong site (radiology procedures and cardiology _______(15))
- Fall or burn (radiology procedures and cardiology _______(16))

Answer 6

Answers:
1. vomiting
2. control
3. instability
4. headache
5. locations
6. locations
7. locations
8. locations
9. locations
10. care
11. instability
12. complications
13. locations
14. locations
15. locations
16. locations

Question 7

Patient Transfer
- _______(1), unstable patients may be transferred back and forth between the intensive care unit, the operating rooms, and NOR locations for imaging, therapeutic, or diagnostic procedures.
- During transport the patient should be accompanied by _______(2) to evaluate, monitor, and support the patient’s medical condition.
- A specialized transport team may contribute to reducing the number of critical incidents that occur during the transport of ventilated and critically ill patients. Patients are often mechanically ventilated and receiving a number of drug infusions for both sedation and hemodynamic support.
- Consider which drips you need; which can be _______(3)
- _______(4) are useful for transport; these are often oxygen powered, and _______(5) supplies of oxygen must be available for the transfer.
- A manual self-inflating bag is essential in the event of ventilator failure. Infusion pumps and portable monitors should have adequate battery power for transit.
- The transport team should carry spare anesthetic and emergency drugs, equipment for intubation or reintubation, portable suction, and if the patient’s condition requires, a portable defibrillator.
- It is vital to notify the destination area that the patient is in transit, so that appropriate preparations to receive the patient can be made in _______(6).
- It is also useful to send personnel ahead to secure the elevators to prevent delays during _______(7).

Answer 7

Answers:
1. Sick
2. skilled personnel
3. paused
4. Portable ventilators
5. adequate
6. advance
7. transfer

Question 8

Sedation and Anesthesia
- Many NOR procedures are performed under sedation and MAC for which the ASA developed guidelines.
- A consistent definition of these terms is essential for clear communications between the various stakeholders involved in provision of _______(1).
- Interpretive Guidelines defines “anesthesia,” to mean general anesthesia, regional anesthesia, deep sedation/analgesia, or _______(2)
- Nurses, ER doctors, Intensivists: CANNOT give _______(3)
- “Analgesia/sedation” is defined as local/topical anesthesia, minimal sedation, and moderate sedation/analgesia (“_________(4)”).

Environmental Considerations for NORA
- X-Rays and Fluoroscopy
- Large, C-shaped, mobile fluoroscopy devices (C-arms) are used to provide images in multiple _______(5).
- The C-arm moves back and forth around the patient during the procedure, taking up large amounts of space, limiting access to the patient, and serving as a means of dislodging intravenous lines and _______(6).

Answer 8

Answers:
1. NORA
2. MAC
3. anesthesia
4. conscious sedation
5. dimensions
6. endotracheal tubes

Question 9

Hazards of Ionizing Radiation
- The effects of ionizing radiation on biologic tissues are classified as deterministic (_______(1)) and _______(a) (the development of cancer from direct DNA ionization or the creation of hydroxyl radicals from x-ray interactions with water molecules).
- Patient exposure to radiation during imaging and treatment varies depending on the type of procedure as well as patient- and operator-related factors.
- For example, the radiation a patient receives from a simple chest x-ray is 0.02 millisieverts (mSv), and between 20 and 40 mSv for pulmonary angiography.
- Exposure from fluoroscopy is _______(2) and _______(3) greater than from simple x-rays.
- Standard procedures exist to minimize patient exposure to radiation and efforts to reduce occupational exposure for staff including anesthesiologists working in radiology suites are an important _______(4).

• Staff, including the anesthesiologists, must be aware of the hazards of occupational exposure to ionizing radiation and take appropriate measures to protect themselves.
• Exposure to ionizing radiation may come from direct exposure and scatter.
  
  • Patients are subjected to direct exposure where the beam enters the skin
  • Staff members working in fluoroscopy suites are more at risk from _______(5) radiation.
  • As a general rule the exposure to staff is ______(b) the entrance skin exposure at 1 m from the fluoroscopy _______(6).

Answer 9

Answers:
1. dose related
a. stochastic
2. 100
3. 1,000
4. consideration
5. scattered
b. 1/1,000th
6. tube

Question 10

A recent study of radiation exposure to operating room personnel during fluoroscopic-guided endovascular repair of thoracoabdominal aortic aneurysms using fenestrated endografts (FEVAR) identified that anesthesiologists were likely to receive 15 times the dose of radiation compared to the scrub nurses even though both types of practitioners were at the same distance (7 feet) from the C-arm.
- This finding was attributed to anesthesiologists being less likely to use the protective shielding during their patient care activities.
- “Different Angle, closer to the source of the _______(1)”

Another recent study demonstrated that anesthesiologists working in the neurointerventional suite were at equal risk of developing _______(2) as neuroradiologists, and that the radiation may even be directed away from the neuroradiologists and toward the anesthesiologist.

These studies highlight the need for anesthesiologists to be aware of the risks and the means to protect themselves from radiation, especially in areas where fluoroscopy is used.

Staff exposure to radiation can be minimized by a number of precautions:
1. Limiting the time of exposure to _______(3).
2. Increasing the _______(4) from the source of radiation. (Dose rates increase or decrease according to the inverse square of the distance from the source.)
3. Using protective _______(5) (lead-lined garments and fixed and/or movable shields).
- Lead aprons, thyroid shields, and leaded eyeglasses are recommended despite being bulky and contributing to staff fatigue.
- Anesthesiology staff should consider using movable or fixed lead-lined glass shields so that they can gain easy access to their patients while protecting themselves from radiation.

Answer 10

Answers:
1. radiation
2. cataracts
3. radiation
4. distance
5. shielding

Question 11

4. Measuring occupational exposure to radiation.
   
   • The dose limits for occupational exposure to radiation established by the International Commission on Radiological Protection (IRCP) have been adopted in most countries.
   • In the United States, the National Council on Radiation Protection and Measurements (NCRP) recommends an occupational limit of ______(a)mSv in any 1 year and a lifetime limit of ______(b) mSv multiplied by the individual’s age in years.
   • Health-care workers including anesthesiologists should be issued individual dosimeter badges to monitor their cumulative exposure to radiation.
   • These data should be regularly reviewed by the facility’s radiation safety section or medical physics _______(1).

IV Contrast Agents
- Intravenous contrast agents are commonly used in radiologic and MRI to enhance vascular imaging.
- Radiologic contrast media are iodinated compounds classified according to their osmolarity (high, low, or iso-osmolar), their ionicity (_______(2) or nonionic), and the number of benzene rings (monomer or _______(3)).
- ______(c) contrast agents cause less discomfort on injection and have a lower incidence of adverse _______(4).

• MRI contrast agents are also divided into ionic and nonionic compounds.
• They are chelated metal complexes containing gadolinium, iron, or manganese.
• Adverse reactions to contrast agents may be divided into renal adverse reactions and hypersensitivity _______(5).

Answer 11

Answers:
a. 50
b. 10
1. department
2. ionic
3. dimer
c. Nonionic
4. reactions
5. reactions

Question 12

Renal Adverse Reaction
- Contrast agents are eliminated via the kidneys, and contrast-induced nephropathy (CIN) associated with their use is estimated to account for nearly _______(1) of hospital-acquired acute renal failure.
- CIN is defined as an increase in serum creatinine of _______(2) mg/dL or a _______(3) increase from the baseline within 48 to 72 hours after iodinated contrast medium administration.
- ______(a) disease is the most important predictor of CIN, increasing the risk by 20 times; other risk factors for CIN include history of renal disease, prior renal surgery, proteinuria, diabetes mellitus, hypertension, gout, and use of nephrotoxic drugs.
- Preventative measures to avoid CIN include adequate hydration, maintaining a good urine output, and using sodium bicarbonate infusions to improve elimination of the contrast agent. Nephrotoxic medications such as ______(c) should be avoided for _______(4) before and after the use of intravenous contrast agents.

Answer 12

Answers:
1. 10%
2. 0.5
3. 25%
a. Chronic kidney
b. sodium bicarbonate
c. nonsteroidal anti-inflammatory drugs, aminoglycosides, and diuretics
4. 24 to 48 hours

Question 13

Hypersensitivity Reactions
- Hypersensitivity reactions to contrast media are divided into immediate (<______(a) hour) and nonimmediate (>1 hour) reactions. Mild immediate reactions occur in about _______(1) to _______(2) and severe reactions occur in _______(3) to _______(4).
- Fatal hypersensitivity reactions may occur in about 1 per 100,000 contrast administrations.
- The frequency of nonimmediate reactions is much more variable (0.5% to 23%) related partly to difficulty in determining whether symptoms relate to contrast agents or not.
- The clinical manifestations of various hypersensitivity reactions to contrast media are outlined in Table 33-7.
- Although widely used, the effectiveness of ______(b) in preventing hypersensitivity reactions to contrast agents in unselected patients is _______(5).
- old tylenol and dexamethasone can prevent reactions, new: not true! you were just lucky
- Treatment of severe hypersensitivity reactions includes discontinuing the causative agent and supportive therapy, oxygen, intubating the trachea, cardiovascular support with fluids, vasopressors, and inotropes, and if required, bronchodilators.

Answer 13

Answers:
a. 1
1. 0.5%
2. 3%
3. 0.01%
4. 0.04%
b. corticosteroids and antihistamines
5. doubtful

Question 14

TABLE 33-7 → Clinical Manifestations of Immediate and Nonimmediate Hypersensitivity Reactions to RadioContrast Agents (Read right off this table) Contrast

Immediate Reactions
- Pruritus
- Urticaria
- Angioedema/facial edema
- Abdominal pain, nausea, _______(1)
- Rhinitis (sneezing, _______(2))
- Hoarseness, _______(3)
- Dyspnea (bronchospasm, _______(4))
- Respiratory arrest
- Hypotension, cardiovascular _______(5)
- Cardiac arrest

Nonimmediate Reactions
- Pruritus
- Exanthema (mostly macular or maculopapular drug _______(6))
- Urticaria, angioedema
- Erythema multiforme _______(7)
- Fixed drug eruption
- Stevens–Johnson syndrome
- Toxic epidermal necrolysis
- Graft-versus-host _______(8)
- Drug-related eosinophilia with systemic symptoms (DRESS)
- Symmetrical drug-related intertriginous and flexural exanthema (SDRIFE)
- _______(9)

Answer 14

Answers:
1. diarrhea
2. rhinorrhea
3. cough
4. laryngeal edema
5. shock
6. eruption
7. minor
8. reaction
9. Vasculitis

Question 15

Specific Non Operating Room Procedures
- Angiography
- Angiography causes minimal discomfort and may be performed under local anesthesia with or without light sedation.
- Patients are required to remain completely motionless during these procedures, which may be lengthy, particularly spinal angiography.
- Neurologic disorders such as recent subarachnoid hemorrhage, stroke, and depressed level of consciousness or raised ICP may necessitate anesthesia with intubation for airway protection.
- Angiography is often performed via the _______(1); the femoral vein may also be accessed when imaging arteriovenous malformations (AVMs) or _______(2).
- Liberal use of local anesthetic at the puncture site precludes the need for intravenous analgesia.
- The injection of contrast media into the cerebral arteries may cause discomfort, burning, or pruritus around the face and eyes.
- _______(3) and bradycardia may also occur and discomfort from a full _______(4) as a result of fluid and IV contrast administration is a consideration in nonanesthetized patients.
- During angiography and other interventional radiologic procedures, the patient is placed on a moving gantry and the radiologist positions the patient to track catheters as they pass from the groin into the vessels of interest.
- It is vital to have extensions on all anesthesia breathing circuits, infusion lines, and monitors to prevent these implements from being accidentally dislodged as the radiologist swings the x-ray table back and forth.

Answer 15

Answers:
1. femoral artery
2. dural venous abnormalities
3. Hypotension
4. bladder

Question 16

Interventional Neuroradiology
- A variety of neurosurgical conditions, especially neurovascular diseases are effectively managed by interventional neuroradiology.
- These procedures may be subdivided as “occlusive” and “opening” procedures (Table 33-2).
- Cerebral aneurysms and AVMs are particularly amenable to occlusive endovascular treatments.
- A commonly employed technique is to insert detachable platinum coils into the abnormal vessel(s).
- Other occlusive agents include cyanoacrylates, “Onyx liquid embolic system” (Micro therapeutics Inc., USA), a biocompatible liquid embolic agent, and polyvinyl alcohol particles.
- These particles may also be used to produce temporary occlusion of blood vessels for preoperative embolization of vascular tumors, _______(1).

• The International Subarachnoid Aneurysm Trial (ISAT) reported better outcomes in patients with ruptured anterior and posterior circulation aneurysms undergoing interventional neuroradiology compared to surgical clipping.
  
  • The benefits of coiling appear to be prolonged with the most recent follow-up of ISAT reporting the probability of disability-free survival to be significantly greater in the endovascular group compared to the neurosurgical group at 10 years.
• The World Federation of Neurosurgical Societies’ (WFNS’s) poor grade for cerebral aneurysms in elderly patients did not clearly establish the superiority of one treatment or the other.
  
  • The management of an unruptured intracranial aneurysm depends on many factors including aneurysm size, shape, location, and patient _______(2).

Answer 16

Answers:
1. particularly meningiomas
2. comorbidity

Question 17

Procedural and Anesthetic Technique Considerations in Interventional Neuroradiology
- For most interventional neuroradiologic procedures, arterial access is gained using a ______(a) French gauge sheath via the femoral or, rarely, the carotid or axillary artery.
- The umbilical vessels are an alternative route in neonates.
- Anticoagulation is required during and up to ______(b) hours after interventional radiologic procedures to prevent thromboembolism.
- Heparin, between ______(c) IU (50 to 70 IU/kg), followed by an infusion is used to keep the activated clotting time (ACT) between _______(1) the patient’s baseline.
- At the end of the procedure or in case of hemorrhage heparin may be reversed with _______(2).

Answer 17

Answers:
a. 6 or 7
b. 24
c. 3,000 and 5,000
1. two and three times
2. protamine

Question 18

General anesthesia and conscious sedation are both suitable techniques for interventional neuroradiology depending on the complexity of the procedure, the need for blood pressure manipulation, and the need for intraprocedural assessment of neurologic function.
- Cases performed under general anesthesia and associated with _______(1) have been related to poorer neurologic outcome compared to cases performed under local anesthesia and no hypotension.
- The anesthesiologist may facilitate the procedure by manipulating systemic blood pressure and controlling _______(2) tension.
- Controlled ______(a) is often requested to facilitate embolization of AVMs and moderate hypertension may help reduce cerebral ischemia by maintaining cerebral perfusion.

Answer 18

Answers:
1. hypotension
2. end-tidal carbon dioxide
3. hypotension

Question 19

• The ______(a) test (injection of a small dose of a barbiturate or other anesthetic drug directly into one) is used to determine the dominant side for cognitive functions such as _______(1) and _______(2).
  
  • This procedure may be used prior to surgery for → non-life-threatening conditions such as epilepsy.
• Permanent neurologic deficits follow embolization of AVMs in approximately _______(3) of cases.
• Major complications of interventional neuroradiology are hemorrhagic, such as aneurysm rupture, intracranial vessel injury, or dissection; occlusive, such as displacement or fragmentation of embolic materials or vasospasm; or non-CNS complications, such as contrast hypersensitivity, anaphylaxis, CIN, and hemorrhage at the peripheral vessel puncture site causing groin or retroperitoneal _______(4).

Answer 19

Answers:
a. Wada
1. speech
2. memory
3. 10%
4. hematoma

Question 20

Computed Tomography
- Computed tomography (CT) scanners obtain a cross-sectional image in a few seconds, and spiral scanners can image a slice of the body in less than 1 second, minimizing problems with motion artifacts.
- The procedure is painless and most adults do not require sedation or anesthesia.
- There is an absolute requirement for the patient to remain motionless while the study is being performed and children or adults with psychological or neurologic disorders preventing immobility _______(1) (Table 33-1).
- Contrast agents for CT imaging may be administered orally and the anesthesiologist needs to be aware of the possibility of a full stomach.
- CT scanning may be employed to facilitate invasive procedures such as abscess localization and drainage, ablation of bony metastases, and radiofrequency ablation (RFA) of malignancies.
- Patients with acute thoracic, abdominal, and cerebral trauma often require urgent imaging to facilitate diagnosis.
- These patients may develop hemorrhagic shock, raised ICP, depression of consciousness, and cardiac arrest in the CT scanner and must be adequately resuscitated and stabilized _______(2) transportation to the radiology department.

Answer 20

Answers:
1. may require sedation or anesthesia
2. before

Question 21

Radiofrequency Ablation
- Percutaneous RFA is carried out in the radiology suite for treatment of primary and metastatic tumors in the liver, lung, adrenal gland, breast, thyroid, prostate, kidney, and spleen.
- A high-frequency alternating current is used to generate a localized heat source directly into the tumor causing coagulative necrosis and tumor cell death while avoiding injury to the surrounding tissues.
- The majority of these procedures are tolerated _______(1).

Answer 21

Answers:
1. without sedation

Question 22

Transjugular Intrahepatic Portosystemic Shunt (TIPS)- SICK PATIENTS

• The transjugular intrahepatic portosystemic shunt (TIPS) is a connection between the hepatic portal and systemic circulations created via a percutaneous catheter inserted in the internal jugular vein and directed into the liver.
• The TIPS functions to _______(1) in patients with _______(2).
• Beneficial effects include reduction in bleeding from varices and control of refractory cirrhotic ascites.
• The TIPS is often performed in patients who have failed to _______(3) and may be used as a bridge to _______(4) in patients with poor liver function.
• The procedure causes minimal stimulation, lasts between 2 and 3 hours, and may be performed under sedation or general anesthesia.
• Patients presenting for a TIPS procedure, in general, have significant hepatic dysfunction, and require careful preoperative assessment and intraoperative management.

Answer 22

Answers:
1. decompress the portal circulation
2. portal hypertension
3. respond to medical therapy
4. transplant

Question 23

TABLE 33-8 → Considerations in Patients Presenting for the TIPS Procedure (Read right from table)

Airway—risk of aspiration
- Recent gastrointestinal bleeding
- Raised intragastric pressure due to _______(1)
- Decreased level of consciousness due to hepatic _______(2)

CNS
- Hepatic encephalopathy
- Altered mental status
- Variable response to anesthetic _______(3)

Respiratory system
- Decreased functional residual capacity due to _______(4)
- Pleural effusion
- Intrapulmonary shunts
- Pneumonia

Cardiovascular system
- Associated alcoholic cardiomyopathy
- Altered volume status
- Acute hemorrhage from esophageal _______(5)

Hematologic system
- Coagulopathy
- Thrombocytopenia

Fluid balance
- _______(6)
- Risk of hepatorenal syndrome

Endocrine system
- Tendency to hypoglycemia

Pharmacokinetics
- Increased volume of distribution
- Decreased protein binding, drug metabolism, and elimination

Answer 23

Answers:
1. ascites
2. encephalopathy
3. agents
4. ascites
5. varices
6. Ascites

Question 24

Magnetic Resonance Imaging
- Physical Principles
- Briefly, when atoms with an odd number of protons in their nuclei, notably ______(a), are subjected to a powerful static magnetic field, they align themselves with the magnetic field.
- As the radiofrequency pulses are discontinued, the protons return to their original alignment (“relax”) within the magnetic field and, as they do, they release energy.
- The release of energy over time (the relaxation time) is specific for given tissues and is used to generate the _______(1).

• Hazards of MRI
  
  • MRI is devoid of the risks related to ionizing radiation; however, peripheral nerve stimulation (_______2) has been reported in biologic tissues exposed to radio frequencies greater than ______(b)Hz.
  • PNS results in sensory phenomena ranging from mild tingling to intolerable pain.
  • MRI workers may experience _______(3) vertigo-related symptoms and a _____(c) taste in the mouth when working in high (>3 T) magnetic fields.
  • Ferromagnetic implantable medical devices may move in the magnetic field with disastrous consequences.
    
    • This issue is a particular concern in patients with cardiac pacemakers, which may also malfunction, and cerebral _______(4).
    • Before entering the vicinity of the magnet, patients and staff need to complete a rigorous checklist to ensure that they have no ferro-metallic objects in their bodies.
    • ______(d) equipment such as IV poles, gas cylinders, laryngoscopes, and pens become potentially lethal projectiles if brought too close.

Answer 24

Answers:
a. hydrogen
1. MRI signal
2. PNS
b. 60
3. transient
c. metallic
4. aneurysm clips
d. Ferromagnetic

Question 25

Magnetic Resonance Imaging

• Considerable noise is generated by the rapidly alternating currents of the MRI scanner.
  
  • Patients and staff should wear ear protection and staff should minimize time spent in the scanner.
  • Cables and wires wound in loops may cause induction-______(a) effects and ______(b) injury may also occur in skin with large tattoos, especially those with _______(1).
• Patient monitors, ventilator equipment, and electrical infusion pumps may all ______(c) when they come too close to the magnetic field.
  
  • The electrocardiogram is sensitive to the changing magnetic signals, and it is nearly impossible to eliminate all artifacts.
  • The electrodes should be placed close together and toward the center of the magnetic field and the leads insulated from the patient’s skin to avoid causing thermal injury.
• _______(2) have been developed; however, in the absence of MRI-compatible monitors, tube extensions can be used to keep standard infusion pumps and monitors at a distance.

Anesthetic Technique
- ______(d) is a real concern for up to 15% of all adult patients undergoing MRI necessitating sedation or even general anesthesia for them to complete the imaging studies.
- Sedation may be provided by the oral route with _______(3), as intravenous sedation or MAC.
- Interventions including the design of the MRI scanner, cognitive-behavioral strategies, prone positioning, and fragrance administration have also been reported to reduce anxiety during MRI scan.
- Anesthesiologists may become involved with more complex patients such as those with obesity, obstructive sleep apnea, raised ICP, movement disorders, developmental delay, and when there is a potential for a difficult airway.

Answer 25

Answers:
a. heating
b. thermal
1. ferromagnetic inks
c. malfunction
2. MRI-compatible devices
d. Claustrophobia
3. benzodiazepines

Question 26

Positron Emission Tomography
- Positron emission tomography (PET) scanning is a newer imaging modality using radiolabeled _______(1) to measure tissue ______(a) uptake thereby estimating tumor extent.
- Anesthesia concerns are those for CT; studies typically take longer to complete which may affect choice of technique/agent.
- Patients are typically exposed to greater ionizing _______(2) from both isotope and CT sources.

Answer 26

Answers:
1. isotopes
a. glucose
2. radiation

Question 27

Gastroenterology
- Procedures may be performed under general anesthesia or sedation.
- The American Gastroenterological Association reports that 98% of patients for upper and lower endoscopies receive sedation.
- Of these, over one-third are performed in ambulatory surgery centers and only 29% of these procedures involve anesthesia care providers.

Upper GI Endoscopy
- Upper GI endoscopy is performed for diagnostic procedures, such as biopsy, and for therapeutic procedures, such as retrieval of foreign bodies, treatment of esophageal varices with sclerotherapy or band ligation, dilation of esophageal strictures, and placement of a percutaneous endoscopic gastrostomy.
- Patients may have a number of comorbidities, or a risk of gastroesophageal reflux, hepatic dysfunction, coagulopathy, and ascites.
- Under general anesthesia, _______(1) is the gold standard to protect the airway and facilitate passage of the endoscope; however, a-LMA may serve as an alternative device for airway management.
- Intubate patients with a BMI >50 (She said this multiple times)- 50 is so much bro
- Local anesthetic is sprayed into the oropharynx to facilitate passage of the endoscope, which can abolish the gag reflex, increasing the risk of aspiration.
- A bite block is inserted to prevent the patient from biting down on the endoscope and damaging both the teeth and the endoscope.
- let bite block insertion/removal be the nurses job, liability issue with loose teeth
- Procedures are performed in the _______(2) or semi prone position with the patient’s head rotated to the side, making the airway less accessible.

Answer 27

Answers:
1. tracheal intubation
2. prone

Question 28

Endoscopic Retrograde Cholangiopancreatography (ERCP)
- ERCP is important in the diagnosis and treatment of both _______(1) and _______(2) diseases.
- During the procedure, the biliary and pancreatic duct systems are identified, instrumented, and therapeutic maneuvers such as the passage of stents or removal of stones are carried out.
- Complications include _______(3).
- Patients usually experience discomfort during ERCP and general anesthesia or deep sedation techniques are recommended for the procedure, which usually lasts between 20 and 80 minutes.
- usually conducted _______(4)
- Sphincter of Oddi manometry may be performed, in which case drugs that affect sphincter pressure such as ______(a) should be avoided.
- Transient ______(b) may occur during endoscopy, and _______(5) is recommended for patients with cardiac valvular abnormalities.
- Gastroenterologists frequently use antispasmodics such as ______(c) to reduce duodenal motility and improve operating conditions during endoscopy; sinus tachycardia may occur.

Answer 28

Answers:
1. biliary
2. pancreatic
3. acute pancreatitis, hemorrhage, and perforation
4. prone
a. atropine, glycopyrrolate, glucagon, and various opioids
b. bacteremia
5. antibiotic prophylaxis
c. glucagon and intravenous hyoscyamine

Question 29

Cardiology and Interventional Cardiology
- Percutaneous Intervention
○ For patients with evidence of _______(1), _______(2) and coronary angiography is an essential step in the diagnosis of _______(3).
■ Often this step is followed by coronary angioplasty with stenting for intracoronary luminal obstructions that are more than _______(4).
○ The procedures are usually done with mild sedation administered by the catheterization laboratory team: blood pressure, EKG, and pulse oximetry are monitored and the patient breathes spontaneously with oxygen administered by nasal prongs or a _______(5).

• Percutaneous Ventricular Assist Devices
  ○ Patients in cardiogenic shock or having high-risk PCI or EP procedures may benefit from the hemodynamic support provided by percutaneous ventricular assist devices.
  ○ The _______(6) is a left atrial to femoral bypass system that offers flow rates up to _______(7) through an external centrifugal pump.
  ■ It is designed for short duration support (14 to 162 hours for cardiogenic shock and 1 to 24 hours for high-risk PCIs).
  ○ The _______(8) 2.5 and 5.0 (Abiomed Inc., Danvers, MA, USA) are similar devices but allow for easier implantation as there is no requirement for a transseptal puncture and the device is smaller.
  ■ A microaxial pump supports either 2.5 or 5.0 L/min.
  ○ Patients who are unable to keep still or lie flat will require _______(9); the rest can be managed with light sedation using agents such as _______(10) or propofol.

Answer 29

Answers:
1. myocardial ischemia
2. cardiac catheterization
3. coronary artery disease
4. 70%
5. facemask
6. TandemHeart
7. 4.0 L/min
8. Impella
9. general anesthesia
10. dexmedetomidine

Question 30

• Percutaneous Closure of Septal Defects
  ○ A number of different devices have been introduced for the closure of patent _______(1) (PFOs) and _______(2) (ASDs).
  ○ These devices are placed by the cardiologist under the guidance of _______(3) and ultrasound.
  ○ Special attention should be paid to avoiding air in any intravenous tubing as left to right shunts can be reversed with the drop in systemic vascular resistance that accompanies many _______(4).
• Alcohol Septal Ablation
  ○ Alcohol septal ablation offers an alternative to open heart myomectomy for patients with hypertrophic cardiomyopathy with equivalent mortality outcomes.
  ○ Specific septal perforator vessels are identified using coronary angiography and injection of approximately _______(5) mL of absolute _______(6) into these vessels causes a controlled infarction of the hypertrophic septum.
  ■ “Controlled MI” → but feels like a _______(7) MI
  ■ This infarction can be visualized in real time on live _______(8).
  ○ Although the majority of the procedure requires only minimal sedation the alcohol injection can be very painful.
  ○ A controlled myocardial infarction feels very much like an uncontrolled one so _______(9) sedation will be necessary for the injection portion of the procedure.

Answer 30

Answers:
1. foramen ovales
2. atrial septal defects
3. fluoroscopy
4. anesthetic agents
5. 3
6. ethanol
7. real
8. echocardiography
9. deep

Question 31

• Structural Heart Procedures
  ○ _______(1)
  ■ Transcatheter aortic valve replacements (TAVRs) use a sophisticated catheter delivery system to deploy a folded replacement valve through a sheath in the _______(2),
  ______(a) artery, or via a minithoracotomy directly into the aorta or left ventricular apex.
  ■ Rapid ventricular pacing is used to minimize _______(3) ejection so that the new valve can be deployed into the correct position.
  ■ The CoreValve ReValving System (Medtronic, Inc., Minneapolis, MN) is self-expanding and is made of bioprosthetic porcine pericardial tissue sutured into a malleable metal stent that is rigid at body temperature.
  ● The compressed CoreValve is slowly deployed as its delivery system is pulled back and allows for some repositioning before the valve is fully released.
  ■ The Edwards SAPIEN XT transcatheter heart valve (Edwards Lifesciences, Irvine, CA) is a bovine pericardial tissue valve in a cobalt chromium alloy stent, which has a smaller diameter delivery system.
  ● This valve expands with a balloon within the native valve with the goal of displacing the native leaflets.
  ■ These patients are at high risk for cardiac death during the procedure and experience frequent hemodynamic instability during the _______(4) that is required for balloon valvuloplasty and for valve deployment.
  ● Cardiopulmonary bypass standby is recommended for many patients.

Answer 31

Answers:
1. Transcatheter Aortic Valve Replacement (TAVR)
2. common femoral artery
a. subclavian
3. left ventricular
4. rapid ventricular pacing

Question 32

MitraClip
■ _______(1) (MR) is the most common valvular disorder in the aging population in the United States.
■ Cardiac surgical mitral valve repair should be offered to all surgical candidates with symptomatic MR.
■ In North America, the MitraClip (Evalve, San Francisco, California) is intended to treat patients with moderately severe to severe symptomatic degenerative MR who are considered too high risk for open heart surgery.
■ The MitraClip delivers a clip device percutaneously that mimics the _______(2) repair to create a double orifice mitral valve.

Answer 32

Answers:
1. Mitral regurgitation
2. Alfieri edge-to-edge

Question 33

○ Left Atrial Appendage Occlusion
■ The _______(1) (LAA) is a source of clot formation in patients with _______(2) and patients require lifelong _______(3) to prevent this source of embolism.
● If the LAA can be removed, then anticoagulation is no longer necessary.
■ Traditionally LAA closures have been performed through median sternotomy; however, the Watchman (Boston Scientific, Minneapolis, MN) is a novel device that can be deployed directly into the LAA via a transfemoral catheter.
■ Presently the Watchman is offered to patients with nonvalvular _______(4) and at least one risk factor (_________(5), hypertension, diabetes, or _______(6)).
● An additional indication for this device is patients who have a major contraindication to long-term _______(7).
● The device has been shown to reduce hemorrhagic stroke and cardiovascular death when compared to warfarin although there is an increased incidence of ischemic stroke as a periprocedural event.

Answer 33

Answers:
1. Left Atrial Appendage
2. atrial fibrillation
3. anticoagulation
4. atrial fibrillation
5. age ≥75 years
6. prior stroke/transient ischemic attack
7. anticoagulation

Question 34

● Electrophysiology
○ Like many catheterization laboratory procedures, sedation for EP procedures can sometimes be managed by cardiologists; however, both patient and procedure complexity often necessitate general anesthesia to facilitate a safe and comfortable experience for the patient.
○ EP studies can be divided into cardiac implantable electronic devices (CIEDs) and EP studies with _______(1).
○ Cardiac Implantable Electronic Devices
■ CIEDs include pacemakers for symptomatic bradycardia and for chronic resynchronization therapy (CRT) and implantable cardiac defibrillators (ICDs).
■ These devices are usually implanted in the left pectoral area with one to three transvenous leads inserted into the _______(2), _______(3), or _______(4) veins.
■ Pacemakers can generally be placed under _______(5) sedation with local anesthetic to the skin for the pacemaker pocket; if significant patient comorbidities exist it may be necessary to administer general anesthesia for this procedure.
■ ICDs decrease the risk of sudden cardiac death by both primary and secondary prevention of _______(6) and _______(7).
■ Primary prevention ICDs are indicated for those with an EF less than _______(8), with NYHA class II–III symptoms who are on optimal heart failure medical therapy.
■ Secondary prevention ICDs are for patients who have had a documented ventricular fibrillation cardiac arrest or an episode of sustained ventricular tachycardia.
■ The implantation of the device is similar to the process for placing a pacemaker; however, the _______(9) requires much deeper sedation.
■ CRT pacemakers are indicated for those with cardiomyopathy, an EF less than _______(10), a left bundle branch block (LBBB), QRS duration less than _______(11) milliseconds, and NYHA class II–IV symptoms.
● “We used 10% as the floor: Refused when the EF is below _______(12);
● _______(13) might even be safer”
■ A lead is placed transvenously into the _______(14) which allows for simultaneous pacing of the left and right ventricles; this reduces mortality and may be necessary for life.

Answer 34

Answers:
1. ablation
2. axillary
3. subclavian
4. cephalic
5. light
6. ventricular tachycardia
7. ventricular fibrillation
8. 35%
9. defibrillation threshold testing
10. 35%
11. 120
12. 10%
13. 20%
14. coronary sinus

Question 35

EP Studies with Ablations
■ The most common ablation procedures performed currently are for _______(1) such as atrial fibrillation or atrial flutter and for _______(2) like polymorphic ventricular tachycardia.
■ Patients with atrial fibrillation should be effectively anticoagulated or have a TEE assessment preablation to _______(3).
■ Ablation catheters are inserted via the _______(4) veins into the right heart to try to induce arrhythmias.
■ Complex mapping techniques localize the source of the arrhythmia and an energy source is applied to ablate this source.
■ Ablations can be performed with either _______(5) or cryotherapy with the former being much more stimulating for the patient.
■ The _______(6) lies close to the right upper pulmonary veins and is at risk during ablation.
● Avoidance of _______(7) will alert the electrophysiologist to phrenic irritation when this area is being ______(8).
■ The ablation process can also be painful and general anesthesia may be required.

Answer 35

Answers:
1. narrow complex tachycardias
2. wide complex tachycardias
3. rule out an LAA thrombus
4. femoral
5. radiofrequency
6. phrenic nerve
7. neuromuscular blockade
8. ablated

Question 36

Laser Lead Extractions
■ As pacemakers and ICDs become more widespread, so does the need for lead extractions.
■ Device infections, lead endocarditis, thrombosis or venous stenosis, chronic pain due to leads/device, and nonfunctional leads are all reasons for lead removal.
■ Leads become well adhered to the subclavian vein and/or the endocardium which makes this particular procedure very anxiety provoking for all involved.
■ Need _______(1), Large IV
■ Vascular injury causing significant blood loss and _______(2) is rare but the involved clinicians should be prepared for it.
■ General anesthesia with large bore intravenous access and _______(3) pressure monitoring is essential; _______(4) is usually advisable for prompt evaluation of hemodynamic changes.

Cardioversions and Diagnostic TEEs
○ Cardioversion and TEE procedures are brief procedures but are exquisitely stimulating.
○ Elective electrical cardioversions are ideally performed with a bolus of _______(5) on fully monitored patients under the supervision of an anesthesiologist.
■ just give them a bolus and shut them up
○ _______(6) is the most common reason for an elective cardioversion, so it is necessary to rule out the presence of an LAA clot if the patient is not on therapeutic anticoagulation to avoid embolic complications.
■ _______(7) is the gold standard for evaluating the Left Atrial Appendage.
○ The anesthesiologist may also be involved in elective TEEs for specific indications under the American Society of Echocardiography (ASE) guidelines including evaluation of suspected aortic dissection, determining suitability for valve repair, diagnosis of endocarditis, evaluation of persistent fever with an intracardiac device, and evaluation for LAA thrombus.
○ Anesthesiologists caring for these patients should ensure that there are no contraindications to TEE related to known esophageal pathology (strictures, varices, malignancy, recent ulcer or hemorrhage, Zenker diverticulum) or those with a history of unevaluated dysphagia.

Answer 36

Answers:
1. TEE
2. cardiac tamponade
3. invasive blood
4. TEE
5. propofol
6. Atrial fibrillation
7. TEE

Question 37

Table 33-11 → Anesthetic Consideration for Electroconvulsive Therapy (Read right from table)
Discussed - airway management, moderate hypocapnia, analgesia to relieve post seizure myalgia

Anesthetic Requirements

• Amnesia
  
  • With induction _______(1) of choice
• Airway management
  
  • Usually with bag–mask ventilation, although the _______(2) has been used with success
• Moderate hypocapnia
  
  • Improves the quality and duration of _______(3)
• Protection of the teeth and tongue during the seizure
  
  • Using a soft bite _______(4)
• Prevention of seizure-related injuries (fractures and dislocations)
  
  • Small doses of muscle relaxant, e.g., _______(5) (0.75–1.5 mg/kg) are most commonly used unless there are contraindications
• Control of hemodynamic responses
  
  • Labetalol; esmolol; and the calcium channel antagonists nifedipine, diltiazem, and nicardipine all attenuate the hemodynamic responses to ECT. Dexmedetomidine (1 µg/kg administered over 10 minutes just before induction of anesthesia) has been shown to be effective in controlling blood pressure without affecting _______(6).
• Control or prevention of the parasympathetic effects of ECT (salivation, transient bradycardia, and asystole)
  
  • Can be prevented with glycopyrrolate or _______(7)
• Analgesia to relieve postseizure myalgia
  
  • Ketorolac 15–30 mg is effective in younger patients
  • Acetaminophen or aspirin may be used in older patients or where NSAIDs are contraindicated

Answer 37

Answers:
1. agent
2. laryngeal mask
3. seizures
4. block
5. succinylcholine
6. seizure duration
7. atropine

Question 38

Electroconvulsive Therapy
- Electroconvulsive therapy (ECT) has had an important role in the management of depression, mania, and affective disorders since the 1930s.
- Typically it is performed three times a week for _______(1) treatments, followed by weekly or monthly maintenance therapy to prevent relapses.
- Physiologic Response to Electroconvulsive Therapy
○ The physiologic response to ECT includes generalized motor seizures and an acute cardiovascular response.
○ The seizure usually lasts several minutes and a minimum seizure duration of _______(2) is recommended to ensure adequate antidepressant efficacy.
■ The cardiovascular response includes _______(3) (“makes you nervous obviously but don’t worry, normal finding”)
giving way to more prominent _______(4) and tachycardia.
● Increased cerebral blood flow, raised ICP and cardiac dysrhythmias, myocardial ischemia, infarction, or neurologic vascular events may be precipitated. Short-term _______(5) is also common following ECT.

Answer 38

Answers:
1. 6 to 12
2. 25 seconds
3. transient bradycardia and occasional asystole
4. hypertension
5. memory loss

Question 39

Anesthetic Considerations for ECT
- Scalp electrodes are placed to monitor the electroencephalogram and a blood pressure cuff is applied to an extremity and inflated before muscle relaxant is administered to monitor the seizure.
- ______(a) inhibitors have the most significant interactions with anesthetic agents.
- The anesthetic requirements for ECT are described in Table 33-11.
■ Most of the intravenous induction agents have been used for ECT, despite their anticonvulsant effects.
■ ______(b) (1 to 1.5 mg/kg) → historically considered the _______(1), appears to have less anticonvulsant activity than the other agents.
● also gives SUX and glyco (prevent them from being juicy)
● Glyco is good for preventing _______(2)
● Hypoventilate to decrease seizure threshold → moderate _______(3)
● Brevital works the best!
● No ______(c) → stops seizures → that’s the point of an ECT
● Use ambubag
■ ______(d) (0.15 to 0.3 mg/kg) → generally associated with longer seizure duration and is the preferred agent of some psychiatrists, despite a slightly longer recovery and associated myoclonus.
■ ______(e) → more effective at attenuating the acute hemodynamic responses than etomidate and in small doses (0.75 mg/kg) seizure duration is usually acceptable.
■ Short-acting opioids (__________(4)) → can be used to decrease the dose of an induction agent and prolong seizure duration without reducing the depth of anesthesia.
■ ______(f) → has been attributed to intrinsic antidepressant effects when used as an anesthetic agent for ECT, although its effects are far from certain.
■ ______(g) for transient hypertension

Answer 39

Answers:
a, Monoamine oxidase
b. Methohexital
1. “gold standard”
2. bradycardia
3. hypocapnia
c. Midazolam/Versed
d. Etomidate
e. Propofol
4. remifentanil
f. Ketamine
g. labetalol/esmolol