Anesthesia Outside of the Operating Room Yujuan Li The Second Affiliated Hospital of Sun-yet Sen University

Some terms Nonoperating room anesthesia (NORA) Anesthesia at remote location Outpatient anesthesia Office-based anesthesia (OBA)

Importance Number of NORA activities has increased rapidly( CT, MRI, neuroradiologic procedure or electroconvulsive therapy) More Complex of the procedure, and situation and patients Who does the sedation?

Mortality and Morbidity

Special problem of NORA Limited working place, limited access to the patient, Electrical interference with monitors and phones, lighting and temperature inadequacy, Use outdated,old equipment Less familiar with the management of patients Lack of skilled personnel, drugs and supples

ASA guidelines for NORA patients

AAP guidelines for NORA pediatric patients

Anesthetic technique General anesthesia: tracheal intubation or LMA best prevention of motion invasive, time and resource consuming, atelectasis Sedation/anagesia: less invasive,cost and time saving high rate of failure, high airway and respiratory depression No anesthesia

Conscious sedation versus monitored anesthesia care Conscious sedation : a medically controlled state of depressed consciousness that allows protective reflexes to be maintained and retains the patient's ability to maintain a patent airway and to respond appropriately to physical and verbal stimulation. MAC: an anesthesiologist provide specific anesthesia services to particular patients with local or no anesthesia who undergoing a planned procedure.

Levels of sedation

Drugs for paediatric sedation

Discharge criteria

II. Contrast media Allergic reaction History Symptoms: skin reactions, airway obstruction, angioedema, and cardiovascular collapse. Treatment: corticosteroids, H1 and H2 blockers. Oxygen, epinephrine, β2-agonists, and intubation, IV fluids Prevention: corticosteroids

III. Anesthesia for CT Less complex Use standard monitoring Less anesthetic time Higher levels of radiation exposure

IV. Anesthesia for MRI A. Physical environment High magnetic field Need specialized compatible equipment Radiofrequency noise Metallic implants or implanted devices Patients with implanted pacemakers, ICDs, or pulmonary artery catheters may not have MRI scans.

B. Uncertain duration compatible Monitors anesthesia machines, ECG, pulse oximeters, straight cables.

V. Anesthesia for neuroradiologic procedures A. Endovascular embolization Indication: cerebral aneurysms, arteriovenous fistulas and malformations, vascular tumors Methods: femoral artery puncture, a small catheter into the aneurysm Anesthetic goals :stable hemodynamics, and rapid recovery Other problem: Invasive arterial blood pressure monitoring, avoid hypertension, monitor anticoagulation, complications include rupture of the aneurysm

B. Embolization for control of epistaxis and extracranial vascular lesions C. Balloon test occlusion D. Cerebral and spinal angiography E. Vertebroplasty and kyphoplasty F. Thrombolysis of acute stroke G. Cerebral vasospasm

VI. Anesthesia for vascular, thoracic, and gastrointestinal/genito-urinary radiology procedures. VII. Anesthesia for cyclotron therapy and radiation therapy

VIII. Electroconvulsive therapy (ECT) Objection: treat major depression, no responded to medications, suicidal. Periods: 6 to 12 treatments over 2 to 4 weeks Physiologic effects: a grand mal seizure tonic phase : 10 to 15 s, clonic phase :30 to 50 s. first reaction: bradycardia and hypotension following reaction: hypertension, tachycardia,5-10min ECG changes ICP, intraocular and intragastric pressure increase

Anesthetic goals 1. amnesia and rapid recover 2. Prevent damage 3. Control hemodynamic response. 4. Avoid interference with initiation and duration of induced seizure.

Contraindication : absolute contraindication: intracranial hypertension Relative contraindications: intracranial mass or aneurysm, recent myocardial infarction, angina, congestive heart failure, untreated glaucoma, major bone fractures, thrombophlebitis, pregnancy, and retinal detachment.

Anesthetic management 1. No Sedative premedication, Anticholinergic drugs and Ondansetron by individual. 2. Standard monitors (ECG, SPO 2, BP) 3. Induced with methohexital and succinylcholine or Mivacurium ventilated with 100% oxygen via mask and Ambu bag. labetalol or esmolol when necessary 4. Place rolled gauze pads

Anesthetic management 5. Electroencephalogram (EEG) monitor duration 6. Patients ventilated with O 2 7. Some special attention : gastroesophageal reflux, severe cardiac dysfunction, intracranial mass lesions, pregnancy 8.Terminate seizure with propofol or enzodiazepines within 3 minutes

IX. Upper and lower endoscopy,ERCP and PEG