NORA 1 – Flashcard
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Providing anesthesia care to more remote access areas of the hospital with little help and supplies, on increasingly sicker and sicker patients
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What is Non Operating Room Anesthesia?
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Outpost, Frontier or Satellite locations
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What is NORA also known as?
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- Dental Offices - Gastroenterology - Bronchoscopy - CV and IR - EP Lab/TEE/Cardioversion - Electroconvulsive Therapy - MRI/CT - Radiation Oncology
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Where is NORA performed?
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55%
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What is the percentage of procedures requiring anesthesia outside the OR?
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- Requires increase in vigilance - Layout may be small - Reduced amount of equiptment - Far away anesthesia personnel
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What are some disadvantages to NORA?
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- Where will the patient be induced? - Are the anesthesia equipment and 02 source close to the bed/table/stretcher? - Is it possible to monitor the patient from a further distance? - Will additional monitors be necessary? - Does everyone involved in the procedure know how to call a code? - Are all personnel aware of what constitutes an anesthetic emergency? - loss of airway, unplanned intubation, hemodynamic collapse.
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What questions should you ask yourself when being assigned to NORA
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- You must be comfortable with the setup, well equipped and as safe as you can possibly make it before you bring your patient back for the procedure. - stick with your plan and prepare for the worst
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What must you make sure of as the anesthesia provider of your surroundings?
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pre admission testing (PATS)
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Many patients bypass what on the day of their scheduled case?
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- Quick airway assessment...nasal cannula? ETT? Glidescope? - Labs - K+? - Succinylcholine? - How long is this procedure? - Patient may be urgent/emergent case
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Getting to know your patient, what will you be looking for?
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- Local/Regional? - MAC? - Enteral Minimal Sedation - Parenteral Moderate sedation/Analgesia - Deep Sedation/Analgesia - General
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What techniques will be appropriate house for your patient?
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- Minimal sedation (anxiolysis) - Moderate Sedation: aka conscious sedation - the patient is relaxed and able to respond to verbal and physical stimulus - Deep Sedation - General Anesthesia
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What are the four levels of sedation?
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Established written standards and professional commentary to provide for the basic rights and safety of patients along with the safety of anesthesia providers and ancillary personnel
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What are the AANA and ASA standards?
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Therapeutic and diagnostic procedures (like colonoscopies of the sigmoid colon), as well as for certain surgical procedures (breast biopsy under local).
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Licensed registered nurses who are not qualified anesthesia providers have become involved in the monitoring of patients and the administration of the medication for procedural sedations involving which kinds of procedures?
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- Promote adherence to AANA, ANA, and ASA standards and guide lines for RNS who practice conscious sedation and are NOT CRNAS - Promote state board of nursing scope of practice and legal intention in the administration of conscious sedation by non-anesthetist nurses - Promote ANA code of ethics - provide for the continuing profession and educational development of practitioners - Represent and speak for the nursing profession - Assume an active role as consumer health advocate - Collaborate with the other recognized organizations concerning moderate sedation - Board of Directors: - President/Treasurer Ron Eslinger, CRNA, APN, MA
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Functions of the American Association of Moderate Sedation Nurses shall be able to:
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Sedasys - stopped production in 2016 due to poor sales and cost cuts
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What machine did Johnson and Johnson create to substitute a monitor and delivery system of Propofil to an ASA 1 patient undergoing a "simple colonoscopy and/or upper endoscopy?'
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- Standard monitoring: O2, EKG, BP, ETCO2, Temp - Central O2 source is preferred with backup O2 tank - Reliable wall suction - Resuscitator Bag - Anesthetic drugs and supplies - Emergency Meds - Anesthesia Machine (If applicable) - Scavenger system (if applicable) - Defibrillator - Anesthesia support staff - Sufficient outlets - Adequate illumination - Space - Place for recovery
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What are the minimum requirements from the ASA for NORA?
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Severe Respiratory Events
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What is the most common NORA closed claim leading to death and permanent brain damage?
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Severe respiratory events occur twice as frequently as in the OR.
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How often do severe respiratory events occur in NORA as opposed to the OR?
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- Patients were sicker, case more likely to be emergent - MAC 50% in remote locations vs 6% in OR - Where do they occur? - 32% GI Suite - 25% Cardiac Cath/EP - Other claims: Lithotripsy, ED and Radiology
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Closed claim analysis remote cases:
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- ; 50% of GI Suite Cases - 70% of radiology cases - only 15% used capnography - 92% of cases resulted in death or severe hypoxic brain injury. - 75% of these claims result in payment to the plaintiff - mean 460k
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What percentage was categorized in closed claims as respiratory depression related to sedation?
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- Unfamiliar work environment - Infrequent assignment - Less efficient schedule - Awkward and incomplete set ups - Unavailable and incomplete patient records - Help is MINUTES AWAY - Inexperienced second pair of hands, in some cases is all you have --Will you have enough concentration to be assertive in what you need from a scared, green or weak set of hands AND provide care to the patient?
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What makes NORA feel like the short end of the stick?
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- Remember that the same standards that apply in the operating room, also apply here in these NORA rooms. - Set up the room the way you want it and make sure you plan for the best, but be prepared for the worst
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NORA - what to remember?
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- Cardioversions - TEE - Pacemaker insertions, generator changes, pacemaker wire extractions - Ablations (Afib, SVT)
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What kinds of cases are performed in the CV/Electrophysiology Lab?
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- It is the discharge of electrical energy, synchronized to the R wave of the QRS complex of the ECG. - Converts hemodynamically unstable supra ventricular rhythms such as atrial flutter or atrial fibrillation or hemodynamically stable SVT - life threatening if left untreated
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What is a Cardioversion?
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The development of CHF and stroke with the formation of thromboemboli
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What are A-fib and A-flutter associated with ?
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Yes
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Is Cardioversion usually a planned procedure?
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-Placed on Plavix for 3 weeks prior to ensure that no thrombus may be released from the atrial appendage - if unstable patient most likely will not be optimized
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What medication are patients placed on for planned cardioversions?
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Synchronous Cardioversion - when compared to asynchronous defibrillation
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Less energy is required for which type of cardioversion?
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It is the unplanned and usually emergent application of unsynchronized electrical energy
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What is defibrillation?
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It closes an excitable gap in the myocardium which causes currents to reenter and excite the electrical system of the heart.
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How is Cardioversion therapeutic?
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- 50-100 Joules and up to 360 Joules - Multiple attempts can be initiated if failure to convert to SR
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What is an optimal shock for cardioversion of atrial fibrillation/flutter and other supra ventricular tachycardias?
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A TEE, to assure that no blood clot is present.
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What test may be performed from to cardiovesion?
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Once a more efficient rhythm is established, if a clot is present it may dislodge and cause a stroke, cardiovascular collapse or death
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WHY are we looking for clots with a TEE before cardioversion?
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Utilized echocardiography to assess how well the heart works
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What does a Transesopageal Echocardiogram do ? (TEE)
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Ultrasound waves emanating from a transducer probe placed in the esophagus provide a picture of structures of the heart non invasively and in real time.
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HOW does a TEE work?
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mitral valve disorders, blood clots or masses inside the heart, a tear in the lining of the aorta and artificial heart valves are better seen with TEE.
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What conditions are better seen with a TEE?
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- Patient should be NPO planned procedure - IV access in PreOp holding - Zoll Pads placed on patient, shaving contact sites may be necessary - Standard monitors apply - Nasal cannula with ETCO2 - Suction - Atropine have it ready!
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What are some anesthetic considerations for Cardiovascular/Electrophysiology?
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Cardioversion can sometimes provoke other fast or slow arrhythmias. The shock is timed with the heartbeat to avoid provoking a dangerous arrhythmia. In an occasional patient, the sinus node may not work properly after cardioversion and a very slow heart rate may result. A temporary pacemaker may be necessary to correct this problem.
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Why should you have Atropine ready in a cardioversion?
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- 50-70mg Propofol IV - Account for circulation time in older patients - may give anxiolytics for retrograde amnesia for those especially nervous prior to cardioversion
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What medications do you give for a Cardioversion?
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- Simple chin lift - HOB 30 degrees - NO NASAL Trumpet: Plavix for 3 weeks
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What do you do to support the airway during cardioversion?
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- The application of a flow of electric current through the appropriate chambers of the heart to completely depolarize the entire myocardium to restore a suitable heart rhythm to sustain life. - Reestablishes normal contraction and rhythm of the heart.
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What is a Defibrillator ?
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- Stands forStands for Automatic Implantable Cardiac Defibrillator. -Designed to bypass the delay patients experienced before receiving defibrillation.
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What is an AICD?
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1 - Pulse Generator 2- Lead Electrode - Together they detect dysrhythmias, deliver a defibrillating shock, cardiac pacing, telemetry, and provision of diagnostic data.
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What are the two parts of an AICD?
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It is designed to deliver 120 shocks and usually lasts for 3-6 years.
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How long does the AICD battery last?
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- The computer is programmed with algorithms to detect VT and VF. - If VF occurs, an electric shock is administered within 10-15 seconds of detection (much of the time delay results from the charging of the capacity.)
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How does the AICD programmed?
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To treat bradycardia, AV block, sinus node dysfunction and other dysrhythmias
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What is a cardiac pacemaker used to treat?
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a pulse generator containing a computer and a battery that is designed to last 6-10 years.
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What does the pacemaker consist of?
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Attached to the pulse generator is a lead, which delivers the current used to depolarize the myocardium, and an anode, which completes the electrical circuit.
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How does the pacemaker work?
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- A unipolar pacemaker lead uses ONE lead as the cathode AND the pulse generator as the anode. - Unipolar leads are LESS likely to fail
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Unipolar Pacemaker
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-Uses two separate leads that are close together. - The advantage of which is a SHARPER signal with less noise. - The leads are inserted under fluoroscopic guidance via the cephalic vein or the subclavian vein into the cardiac chamber, usually the RIGHT ventricle in the case of an AICD and the right atrium and the right atrium and right ventricle for a cardiac pacemaker. TEST QUESTION ON THIS SLIDE - confused by this wording
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Bipolar Pacemakers
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- AICD or pacemakers are inserted in a special fluoroscopy room. - Routine monitors with special placement. - Two EKG monitors. - MAC or General
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Anesthetic Considerations for an AICD/pacer?
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- PURPOSEFUL triggering of VF to test the function of the AICD. - Anesthesia is surgeon's preference. - Once patient has an AICD, for future anesthetics, a magnet should be placed over the generator so it is not mistakenly fired during the procedure. - Any device that has been deactivated by a magnet should be interrogated and reenabled before the patient leaves the recovery room.
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What happens with AICD insertion?
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After insertion of the cardiac pacemaker and before wound closure, the device is threshold tested by the pacemaker manufacturer's technical service representative to ensure adequate contact between the leads and the myocardium.
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What happens with pacer insertion?
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- After wound closure and dressing application, all computer-function programming of either the AICD or the cardiac pacemaker can then be performed with a pacemaker programmer that connects to a portable wand. - The wand is then placed within close proximity to the implanted pulse generator by the manufacturer's technical service representative, which allows a telemetric connection to properly program or interrogate the AICD or cardiac pacemaker. - LIMIT range of motion of ipsilateral arm to generator insertion site. - Keep below 90 degrees to keep from dislodging the wires!
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Post procedure of AICD/Pacemaker
