True/False
True/False
Some ASA/AANA standards of anesthesia are different in the non-OR setting.
False! All ASA/AANA standards apply to the NORA setting.
Name four places you might provide NORA.
**Bonus points if you remember what percentage of anesthesia cases are NORA cases according to Our Lord and Savior John Nagelhout
Medical Imaging (CT, fluro, IR, MRI, nuclear medicine) Radiation therapy, Cardiology (EP, ECHO), GI (upper and lower endoscopy), Pulmonary (bronchoscopy), Dental, Psychiatry (ECT), Urology, Gynecology (family planning <<<but not IUDs>>>>)
**Up to 55% of cases requiring anesthesia services are outside of the OR
Select All That Apply: Which of the following are considered equipment that must be present at a NORA site.
a) positive pressure ventilation sources. b) warming devices. c) blankets, towels or foam padding. d) syringe pump. e) motorized stretcher. f) suction source
All except E
What is the incidence of allergies and anaphylaxis after MRI contrast?
a) 5-6%
b) 0.01-3%
c) 1-2%
d) 0.001-0.01%
B) 0.01-3%
MRI is one setting in which we might give anesthesia. What is one reason a patient might be more hypotensive or bradicardic in MRI than they would be during a surgery when getting the same anesthesia?
Lack of surgical stimulus
True/False: If a patient displays nausea and vomiting and/or urticaria after getting MRI contrast, this is considered a moderate reaction.
False
mild: N/V, urticaria, rash
moderate: severe vomiting
severe: pulmonary edema, cardiac arrest
During a patient transport from the NORA setting to the recovery setting, what three things do you likely want to have with you?
1. Airway Supplies (mask, Ambu or Mapleson, LMA/ETT/Stylet/OA)
2. Monitors
3. Emergency Medications (he listed succinylcholine, doesn't seem like my first choice of emergency med, but sure)
Which of the following are true about non-ionizing radiation? (select all that apply)
a) has a lower frequency
b) has a higher frequency
c) causes vibrations of the electrons in an atom
d) has enough energy to remove electrons from an atom
e) found in microwaves and visible lights
a) c) and e)
Which of the following materials stops Gamma rays?
a) paper, clothing
b) lead or thick concrete
c) Nurse Anesthesia by John Nagelhout (2020)
d) heavy clothing
b) lead or thick concrete
alpha: stopped by paper, clothing (says on ppt 'helium nucleus)
beta: heavy clothing (electron)
gamma rays and x-rays: lead or thick concrete
Which type of imaging is being described with this description (tad redundant I suppose)
"A computerized x-ray imaging procedure in which a narrow beam of x-rays is aimed at a patient and quickly rotated around the body, producing signals that are processed by the machine's computer to generate cross-sectional images -or slices- of the body"
CT!
True/False: There is no standardized guidelines on pretreatment for MRI allergy/anaphylaxis.
True!
Make sure you have benedryl, epi, and steroids available
Give examples of two questions you should ask your MRI tech before starting an MRI.
Hint: What maneuvers might need to be done during the scan? How will that change your anesthesia? What might the patient receive during an MRI?
Might need the patient to do breath-holds-->This might require a paralytic or bolus of propofol
Ask if this scan will require contrast, when and what kind?
a) Primary x-ray beam
b) computers and other technology commonly found on hospital unit
c) scattered radiation from patients body
d) leakage v-rays emitted from the x-ray tube in areas other than the primary beam
*Bonus points for which is the largest contributing factor for anesthesia*
a) c) and d) with the highest being scattered radiation from the patient's body surface
(this highlights that utilizing a lead shield as the only means of personal protective equipment may be less effective than the combination of a lead shield and lead apron to minimize personal expose to scattered radiation)
Safe dose standards for radiation were developed by epidemiologic studies of the atomic bomb survivors and radiation workers. What is the recommended effective dose limit per year?
a) 100 mSv
b) 25 mSv
c) 100-150 mSv
d) 50 mSv
d) 50 mSv
(and a lifetime limit of 10mSv times the individual's age in years)
**Fun Fact: True to form, the US uses a different unit of measurement than evvvveryone else. The US uses milirem and everyone else uses millisievert. 1 mSv=100 mrem
Yikes! Its a math problem!
In IR it is likely you might be administering some heparin. Tyler says that the usual dosing for Heparin in these cases is 50-70u of Heparin to prolong the ACT by 2-3x the baseline.
What medication will you use to reverse this? Assuming you gave 1,000u of Heparin, how much of the reversal would you give?
10 mg of Protamine
1mg of Protamine for every 100 u of Heparin
True/False: Pacemakers are a contraindication to ESWL (extracorporeal shock wave lithotripsy).
False!
This was a 'key takeaway' when Tyler talked about this seemingly very random procedure I have never heard of
What are the two most common causes of adverse events in NORA cases?
- Respiratory depression
- Inadequate monitoring
Which medications are very likely to be included in a 'dart' for your intellectually disabled patient here for dental work? (select all that apply)
a) epi
b) versed
c) dex
d) ketamine
e) lidocain
b) versed and d) ketamine
+/- glyco/robinol
Which of the following is FALSE about lithotripsy?
a) Pain at skin is commonly intolerable and requires concious sedation
b) High intensity waves of short duration are used to pulverize renal and urethral calculi into small fragments
c) Endoscopic lithotripsy can also be performed
d) Modern lithotripters deliver precisely focused simultaneous shock waves generated in water filled cushions at surface of special table
a)
Pain at skin IS usually tolerable or amenable to short-acting drugs
You are providing MAC for a patient in the GI suit for an endoscopy. Upon reading the patient's chart, you see that they have GERD, COPD, and a known bundle branch block. Which of these might be appropriate to keep this patient safe?
a) place an NG tube in pre-OP and suction out their stomach before giving anesthesia
b) switch to GA
c) cancellectomy
d) perform the base in a beach-chair position to lower the chances of the patient aspirating
b) switch to GA
This was Tylers 'main takeaway, on the Endoscopy suite slide #23
"If you patient is at greater risk for aspiration or if they have issues with their heart or lungs, it may be appropriate to switch to GA for those cases"
True/False: NORA procedures are increasing in complexity but decreasing in popularity.
False: NORA procedures are increasing in complexity AND in popularity
Ohhh baby its a throwback!
Name ASA standards 7 and 9:
7: Anesthesia Plan Implementation and Management
9: Alarms and Monitors
Which of the following are anesthetic considerations for dentistry cases? (select all that apply)
a) premedications
b) nasal ETT
c) peripheral neuropathy
d) throat pack
a) b) and d)
Which of the following is NOT a procedure you might see in IR?
a) Endovascular neurosurgery
b) Fine needle aspiration
c) Vascular access
d) Lithotripsy
d) Lithotripsy
What class of medications might you avoid in an ablation case?
a) anti-arrhythmic medications
b) benzos
c) opioids
d) anti-emetics
a) anti-arrhythmic medications
you will likely need to induce an arrhythmia as part of the case so you don't want to give a bunch of lido and make this harder to do