Term
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Definition
| usually referring to sedation and analgesia by someone other than an anesthesia provider |
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Term
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Definition
Monitored Anesthesia Care – implies the potential for a deeper level of sedation
Administration of medications where protective airway reflexes and consciousness may be lost |
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Definition
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Term
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Definition
refers to sedation while surgeon infiltrates operative site with local anesthetic
Usually have shorter recovery time
Fun cases to do and good for patient (they are shorter |
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Term
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Definition
Must have surgeon with ability to administer local with local/MAC
Cooperative patient with reasonable expectations of procedure
Agreed upon decision with everyone involved |
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Term
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Definition
Some suggest that up to 50% of outpatient procedures could be done with MAC
Cost of perioperative care could be reduced by up to 80% |
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Term
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Definition
Same as someone receiving general anesthesia
Vigilant monitoring required |
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Term
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Definition
Pediatric population?
Mentally challenged patients usually not candidate
Potential for difficult airway
MAC Out of the OR
Children, mentally handicapped, and critically ill
Procedures in CT, ICU, MRI, etc.
Very challenging cases |
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Term
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Definition
Magnetic Resonance Imaging
Atomic nucleus behaves like a magnet of the hydrogen atom
Patient is supine within scanner
May use contrast (usually IV) |
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Term
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Definition
Can take one hour or longer
Must remain motionless
Limited access to patient
Watch for equipment malfunction |
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Term
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Definition
vertigo, nausea or headache
Loud vibrations or knocking sounds
Patients who are unable to lie still may require sedation or general anesthesia
No pain involved, generally no opioids |
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Term
MRI
Sedation with oral and IV |
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Definition
| ketamine (good for older people as long as they have a healthy heart), chloral hydrate, and propofol |
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Term
| MRI Sedation and general anesthesia |
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Definition
| need IV access and full monitoring |
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Term
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Definition
| pick which ever you think is appropriate |
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Term
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Definition
No iron containing items in room
Pens, eyeglasses, jewelry, watches, pagers, name badges, coins, calculators, credit cards
Medication vials, equipment and supplies that contain iron |
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Term
MRI - cautions
Metals that are safe |
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Definition
stainless steel, nonferrous alloys, nickel, titanium
Plastic is ok |
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Term
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Definition
| may become dislodged, heat up, or become inhibited or reprogrammed |
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Term
MRI - cautions
Use anesthesia equipment that is MRI compatible |
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Definition
Keep all tubing straight to avoid burns
If you are away from patient, make sure all airway, monitoring, and IV connections are secure
Use audible and visual alarms |
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Term
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Definition
| Use of flexible endoscopes to evaluate GI tract (examine, biopsy, dilate or cauterize or FB removal) |
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Term
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Definition
| esophagus, stomach, and duodenum |
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Term
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Definition
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Term
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Definition
| evaluation of pancreatobiliary structures |
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Term
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Definition
Sedation to general anesthesia
NPO
Topical 4% lidocaine, cetacaine
Midazolam, Fentanyl, Propofol
May use glycopyrolate
O2 via NC or FM
Fentanyl??yes or no if they have a heart history it may help. Its not necessary to give it though. |
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Term
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Definition
supine or lateral
can be stimulating for the patient inc sympathetic activation
we give medication so they can tolerate this.
may give general anesthetic (not common) |
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Term
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Definition
Sedation to general anesthesia
NPO
Midazolam, Fentanyl, Propofol
O2 via NC or FM
May have strong vagal effect-can give propofol 30-60 mg for this. Initial introduction of scope if highly stimulating. Most stimulating part. |
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Term
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Definition
lateral
Higher incidence of intestinal rupture under general anesthesia
will be hypotensive or hypovolemic d/t to bowel prep
about every 3-4 min give more meds keep these patient comfy steady state. Know when your procedure is close to being done too. |
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Term
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Definition
NPO
O2 via FM
Deep sedation to general anesthesia |
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Term
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Definition
Bowel rupture is a complication, be ready for immediate airway support, and expedite to OR
Possible dye allergies |
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Term
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Definition
Prone position-need to be pretty well sedated.
Usually general anesthetic because they cant move. |
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Term
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Definition
Involves minimally invasive radiological procedures – angiography, embolization of blood vessels, stent placement, removal of thrombi
Can be used for cerebral vascular aneurysm embolization |
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Term
Interventional Radiology
Improving technology |
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Definition
allows for more noninvasive procedures
Immobility of patient is required
May require periods of apnea-be very vigilant with this!
May last several hours
IR treatments are painful and physically invasive |
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Term
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Definition
Full monitors and IV access
Possibly need periods of alertness |
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Term
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Definition
hemorrhage, dye reactions, embolus of tissue, perforation of aneurysm
Out of room from patient, heavy door which may take >1 min to open |
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Term
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Definition
| Used to destroy lymphomas, pedi acute leukemias, Wilms’ tumor, retinoblastomas, CNS tumors |
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Term
| Radiation Therapy considerations |
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Definition
Maintain adequate airway
May last up to 60 min (10-40 avg)
GETA – must be motionless
May be prone position |
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Term
| Electroconvulsive Therapy |
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Definition
Induced generalized seizure
Utilized to treat psychiatric disorders
3-6 treatments/week (total 6-12)
NPO, IV, standard monitors
Methohexital is induction agent of choice
Bite block |
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Term
Electroconvulsive Therapy
considerations |
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Definition
Neuromuscular blocker – Succinylcholine or Atracurium
Seizure from 30-90 seconds
May need to use positive pressure ventilation until spont resp resume
Recovery standard, may be agitated and confused |
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Term
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Definition
Must be immobile!
Shockwave uses R wave on ECG
May use LMA or GETA for general
Deep sedation (painful procedure)
May do cysto and stent placement before litho
If immersed, consider hypothermia
Do 3000 hits and you want your heart rate a little higher.
VERY Painful! Most of the time do a general. |
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Term
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Definition
Evaluate patient preoperatively
Anticipate problems
Some may not meet criteria
You may be away from airway for extended periods |
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Term
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Definition
Head and Neck
– Dental extractions
– Node biopsy
– Cataracts
– Mohs repair |
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Term
Frequent MAC Cases
Thoracic Region |
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Definition
– Breast biopsy
– Chest tube insertion
– Bronchoscopy |
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Term
Frequent MAC Cases
Extremity |
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Definition
– Carpal tunnel
– Knee arthroscopy
– Amputations of digits |
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Term
Frequent MAC Cases
Gastrointestinal |
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Definition
– Hernia repair
– EGD
– Colonoscopy
– ESWL |
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Term
Frequent MAC Cases
Vascular |
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Definition
– AV graft/fistula
– Pacemaker
– Mediport |
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Term
Frequent MAC Cases
Gynecologic/Urologic |
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Definition
– D & C
– Cystoscopy
– Lesions |
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Term
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Definition
Preop evaluation is important and should not be overlooked or shortened
Any MAC case may end up as general and you should be prepared |
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Term
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Definition
Psychological preparation is essential
Consider factors that will prevent the patient from lying still
Provide good communication
Keep them warm and covered
Listen to music if they desire |
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Term
| Minimal Sedation Minimal Sedation (Anxiolysis) |
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Definition
| sedation in which patients respond normally to verbal commands |
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Term
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Definition
Vital Sign Changes
May have cognitive and coordination impairment
Respiratory and Cardiac usually maintained |
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Term
| Moderate Sedation/Analgesia |
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Definition
| Referred to as “conscious sedation” |
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Term
Moderate Sedation/Analgesia
considerations |
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Definition
Drug-induced depression of consciousness
Vital Sign Changes
Responsive to verbal or light stimulation
Respiratory and Cardiac usually maintained |
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Term
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Definition
Drug-induced depression of consciousness
Vital Sign Changes
Responsive to repeated or painful stimulation
Respiratory - may require intervention
Cardiac - usually maintained |
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Term
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Definition
Drug-induced loss of consciousness
Not responsive to painful stimulation
Respiratory – requires assistance
Cardiac – may be impaired |
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Term
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Definition
No single inhaled or intravenous drug can provide all the components of MAC
Combination of drug therapy provides ideal situation for MAC
Combining drugs allows for reduction in dosages of individual drugs
Method of Administration
Continuous infusion
Intermittent bolusing |
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Term
| No single inhaled or intravenous drug can |
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Definition
| provide all the components of MAC |
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Term
| Combination of drug therapy |
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Definition
provides ideal situation for MAC
allows for reduction in dosages of individual drugs |
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Term
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Definition
Continuous infusion
Intermittent bolusing |
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Term
Which is better?
Pharmacological Agents |
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Definition
Benzodiazepines (Midazolam)
Opioids (Fentanyl, Demerol)
Sedative Hypnotics (Propofol)
Remifentanil
Ketamine |
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Term
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Definition
| Opioid and Benzodiazepine are frequently used to achieve MAC This combination places patients at high risk for hypoxemia and apnea Depth of sedation is significant with smaller increments of drugs when used as a combination |
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Term
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Definition
| Midazolam and Diazepam Midazolam used more widely, diazepam falling out of favor (mostly due to long half life) No active metabolites with Midazolam Diazepam more painful on injection |
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Term
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Definition
| Shorter half-life (2 hours) Enhance patient comfort Facilitate operating conditions Provide amnesia (essential to patients and surgeons) Provides anxiolysis Limited cardiovascular effects |
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Term
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Definition
| Mostly used for specific analgesic component Used if local anesthesia not indicated or inadequate Ideal for block placement Reduce dose in elderly patients |
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Term
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Definition
| Extremely potent analgesic Metabolized by esterases Easily titrated Continuous infusion more effective(0.1 mcg/kg/min and wean down) Bolus administration associated with chest wall rigidity and respiratory depression |
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Term
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Definition
| Phencyclidine derivative Intense analgesic Dissociative agent – eyes are open with nystagmic gaze Increases oral secretions – may induce laryngospasm Hallucinations are likely Elevates ICP and intraocular pressure |
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Term
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Definition
| Dose – IM – 2-4 mg/kg Dose – IV – 0.25-1 mg/kg Great for placing spinals in elderly patients with hip fractures |
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Term
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Definition
| Ideal for sedation and hypnosis Easily titratable Low incidence of nausea and vomiting Less postoperative sedation Lacks amnestic component Dose – 25-75 mcg/kg/min |
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Term
| Propofol Painful during administration |
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Definition
| Pretreat with lidocaine May be used alone for MAC No reversal agent May inadvertently convert to general Rapid recovery |
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Term
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Definition
| Alpha-2 agonist Sedative with analgesic properties Controls stress, anxiety and pain |
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Term
| Dexmedetomidine Single agent with many properties |
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Definition
| Used primarily in ICU for ventilated patients Stable CV and resp responses |
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Term
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Definition
| Dose dependent sedation Dose dependent decrease in B/P and HR No resp depression Maintains arousability |
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Term
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Definition
| Loading dose – 1 mcg/kg over 10 minutes Maintenance dose – 0.4 mcg/kg/hr (0.2-0.7) Max time for infusion is 24 hours |
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Term
| Dexmedetomidine May produce |
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Definition
| sympatholysis Hypotension and bradycardia If this occurs, stop infusion, IV fluid bolus Consider pressor agents |
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Term
| Dexmedetomidine Do not use in |
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Definition
| pts with shock or hypovolemia May potentiate actions of other drugs |
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Term
| Local Anesthesia Toxicity |
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Definition
| Know max dose of local anesthetics Recognize S/S of toxicity – restlessness, vertigo, tinnitus, confusion Could proceed to cardiovascular compromise |
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Term
| Local Anesthesia Toxicity Airway Reflexes |
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Definition
| Depressed by anesthesia and sedation Advanced age and poor health Potential for aspiration Opioids depress the respiratory drive and response to hypercapnia Combination of opioids and benzodiazepines have negative effect on respiratory drive |
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Term
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Definition
| Hypoxia is relatively common with sedation Administer supplemental oxygen to patients receiving MAC May deliver via NC/Blow-by/Mask Titrate to need |
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Term
| Monitors Single most vital monitor - ?? |
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Definition
We are the most important monitor. We know our patient best.
Auscultation with precordial stethoscope Pulse Oximetry – Has had greatest impact on anesthesia Other factors – obesity, advanced age, preexisting resp disease or obstruction, positioning |
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Term
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Definition
| Monitor continuously the ventilatory status of the patient Includes resp rate, tidal volume, and pattern Observe for partial or complete airway obstruction |
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Term
| Risk Factors for Hypoxemia |
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Definition
| Obesity Advanced Age Lithotomy Position |
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Term
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Definition
| Most effective with ETT Can use with NC or Face Masks Special NC with port are available Pulse oximetry with capnometry are helpful in preventing adverse outcomes |
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Term
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Definition
| Pulse oximeter Precordial ETCO2 monitoring |
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Term
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Definition
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Term
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Definition
| AANA Standards – qualified personnel shall be present for MAC Standards are highest mandate Same standard applies for MAC as does general anesthesia |
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Term
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Definition
Most common cause of adverse event with MAC?
Respiratory failure |
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Term
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Definition
| Minimum – ECG B/P – Measured and recorded every 5 minutes May require more depending on patient health status |
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Term
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Definition
| Potential for significant hypothermia Extremes of age have impaired thermoregulation Ask patient if awake May use forced air warming blankets Shivering may interfere with surgery or procedure |
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Term
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Definition
| Same monitors as for general anesthesia Same standard of care applies |
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Term
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Definition
Processed EEG Monitor Evaluates patient level of awareness BIS values less than 80 are associated with no recall
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Term
| General anesthesia – 40-60 |
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Definition
| Should be used as an adjunct |
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Term
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Definition
| Caution patients about recovery time following MAC Assess residual effects of medication “Pain is stimulus to breathe” |
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Term
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Definition
| Monitored anesthesia care enables patients to have painful procedures done Provides safe environment for surgeons to work More procedures are being performed under MAC More nonsurgical sites will require MAC |
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Term
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Definition
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Term
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Definition
Wide QRS>0.12 sec
Notched R and absent q in I, aVL, V5, V6 |
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Term
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Definition
Wide QRS>0.12 sec
RSR’ in V1 w/ R’ taller than R in V1 |
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Term
| EKG norm interval and measurements |
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Definition
QRS=3 little box wide & 4 big box tall
QRS >3 little boxes=BBB or conduction delay
QRS >4 big boxes =hypertrophy
Q >1/3 of QRS=dead tiss
T should be pointed up
Pointed down w/ normal QRS=ischemia
Tall & pointed=infracting or hyperK |
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Term
normal axis?
What does Axis mean? |
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Definition
Upward deflection of both lead I and aVF
Electrical activity is down and to the left |
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Term
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Definition
=dying
ST depression 1mm or more below baseline
Abnormally tall T waves with prolonged QT |
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Term
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Definition
=injury
ST elevation 1mm or more above baseline |
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Term
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Definition
1st deg AV block=wide PR interval
2nd deg type 1 (Wenkebach)=gradual prolong PR interval until drop QRS
2nd deg type 2=constant PR interval, drop QRS
High deg AV block=P to QRS ration 4:1 (occas P w/ QRS)
3rd deg=no relationship btw P and QRS; march out; atrial rate>vent rate |
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Term
| pacemaker classification and types |
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Definition
Transcutaneous
Epicardial
Transvenous
Permanent (single or dual chamber or rate responsive) |
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Term
| The QRS what each part means |
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Definition
QRS—ventricular depol
QRS interval—begin Q to end S (0.06-0.10 sec)
QT interval—begin Q to end T
Q—downward deflection before R
R—upward deflection
S—downward deflection after R
QS—downward deflection w/o upward |
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Term
| Where are the leads connected and where do they look? |
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Definition
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Term
Which leads correspond to the part of the heart on the 12 lead
Lead 1 |
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Definition
| Lead 1- starts on R arm--> L arm. + end on the L arm. Looks at L side of heart. (high left side of the heart) |
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Term
| Which leads are the best to monitor in the OR? Why? |
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Definition
Lead II—best to see P
V5—best for vent rhythm |
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Term
| 12 lead criteria for Tamponade |
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Definition
Small complexes
Electrical alternans |
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Term
| 12 lead pattern for ventricular strain patterns |
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Definition
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Term
| 12 lead criteria for PE ? |
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Definition
Staircase ascent” of ST in I or II
Transient RBBB
Sinus tach & atrial arrhythmias |
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Term
| 12 lead criteria for COPD? |
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Definition
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Term
| 12 lead pattern for pericarditis ? |
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Definition
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Term
| 12 lead pattern for Puml HTN |
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Definition
Multifocal atrial rhythm
Irregular rate with 3 diff P waves, Rt atrial enlarge |
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Term
| 12 lead pattern for left and right ATRIAL hypertrophy? |
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Definition
Tall=rt atrial enlargement
Right-height
Left-long |
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Term
| Left and Right VENTRICULAR hypertrophy ? |
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Definition
| QRS >4 big boxes =hypertrophy |
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Term
| 12 lead pattern for old MI? |
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Definition
Pathologic q in leads corresponding to affected artery
ST isoelectric |
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Term
| 12 lead pattern for NEW MI? |
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Definition
Pathologic q in leads corresponding to affected artery
ST elevation |
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Term
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Definition
Irregularly irregular
No discernible P waves |
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Term
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Definition
Saw tooth appearance (flutter waves)
Regular atrial rate |
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Term
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Definition
starts at right hand and goes down.
looks at bottom wall of the heart.
+ end down at the bottom. |
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Term
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Definition
Left arm to bottom of the heart.
+ end at the bottom of the heart
- end at the left arm. |
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Term
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Definition
AVR- center of chest to right hand. Right hand is + end. Right hand isnt worth anything on the left handed male. AVR not that useful to us!
AVL-center of chest to Left arm. Looks at high lateral wall of the heart.
AVF-center of chest to bottom of heart. + at bottom of heart. inf wall of heart |
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