Quiz 2: NORA (10/8/19) Kane

*Normal dibucaine number*

*80 % suppression* - when you give dibucaine someone with normal pseudo-cholinesterase will have 80 % suppression *atypical homozygous pseudo-cholinesterase* - they only get 20 % suppression - succinylcholine will last for 6 hrs. *heterozygous pseudo-cholinesterase* - dibucaine number will be 40 - 50 % - they will last for ~ 20 min.

Ventricular Tachycardia Ablation (3)

*Impella* - allows for forward flow during VT and it can pump anywhere from 1 - 5 L/min. and increases MAP, SBP and DBP and the CO and it allows them to stay in VT for 45 min. - 60 min.

Am I running off the pipelines or cylinders?

*O2 cylinders:* - 1900 psi - when it is totally full / 660 L - when it is totally full *N2O cylinders:* - 745 psi - when it is totally full and it stays @ 745 psi until there is no more gas - 1590 L - when it is totally full - the pressure stays the same until there is no more gas

Endoscopy (6)

*Topicalize - PROS:* - 4 % Lidocaine spray - gargle with 2 % Lidocaine - will blunt the SNS - will reduce the need to use another drug *Topicalize - CONS:* - vocal cords are anesthetized - risk of aspiration is increased if no intubation occurs - the airway is NOT protected and the airway will not respond to stimulation

It is considered

*battery* if you do anesthesia on somebody that *didn't signed the consent.*

When we call for help, we don't call for brawn, but for

*brains*. Our colleagues come to add their critical thinking skills to help solve the problem.

Ventricular Tachycardia Ablation (1)

*outflow track ablations* - which it means that pt. has PVCs - done under MAC - minimal anesthesia *Scar VT ablations* - runs of VTs or pulseless VT - people that come from CCICU and have external defibrillator pads on: - these pts. need A-line, GA/ETT, they need huge IV access, all the cardiac pressors ready to go - in some cases they will crack the chest because these pts. can get cardiac tamponade and very low CO

Electroconvulsive Therapy (6)

*pseudo-cholinesterase deficiency* these pts. will: - not wake up, - will be tachycardic, - BP will going up and they are not breathing they will have a low dibucaine number

Variceal Banding (2)

*thrombocytopenia* - they may have low platelets and now we are doing something involving bleeding and we are taking a liver biopsy we have to ask: Do we have to give them platelets before this procedure? Do we want to introduce a little bit of narcotics? Yes, it hurts a little bit.

Nora cases come with a different culture.

1. Different nursing cultures 2. OR circulator checks the if the *consent* is signed and the *surgery site* is marked. 3. Remote Location circulation may give their authority to the surgeon. 4. Assigned to place for a day, not to a room (radiology or GI)

Standards of care: 1. Patient...? 2. Pre-anesthesia...? 3. ________ ________ plan 4. _________ consent. Except...? 5. Documentation: ________, __________, ________

1. Patient rights: autonomy, privacy, safety. 2. Pre-anesthesia assessment/eval 3. Patient-specific plan. 4. Informed consent...make sure you document if case started before anesthesia was called! No consent=no pay check + lawsuit 5. Accurate, timely, legible.

Standards of care: (continued) 6. ________: verify _________ 7: ________/modification of ________ 8. Patient ________

6. Equipment: verify functioning. Mobile carts/machines (bring 2 of whatever you need) 7. Plan/modification of plan 8. Patient positioning...you probably won't have a jackson table and all the pillows to ensure proper c-spine positioning ETC.

Acalasia

A rare disorder making it difficult for food and liquid to pass into the stomach.

Patient factors requiring NORA

ACS PAIN Anxiety/Psych Cerebral palsy Seizures Pain Acute Trauma/Age Increased ICP Narcotics/drugs/alcohol

Endoscopy (2)

Advanced procedures such as *POEM - peroral endoscopic myotomy* - done for people who have problem getting the food down - they are relaxing the muscles, they are doing a cut *Necroscopy* - done also for people that have necrotic tissue that needs to be removed and washed out - may take hrs. Gastric peacemaker insertion

Special populations - *Critically ill*

Are they optimized enough for this remote procedure? If they are not optimized, maybe they need a stress test or a V/Q scan!

EGD (2)

Ask everyone in endo: Do you have any trouble with food going down or staying down? Do you feel that the food does come up and is stuck in your esophagus? Is dysphagia, acalasia or decreased GI motility always intubate. Do not let them do it in these cases if pt. is not intubated!!!

4 indications for electroconvulsive therapy Induces...? Treatment schedule?

Bipolar disease Schizophrenia Extreme depression Suicidal behavior Induces tonic/clonic seizure=Release of neurotransmitters Treatment 3x/week for 12 treatments then weaned

How are seizures induced? What is seen with initial seizure? Make sure the patient has done what prior to coming into procedure room? Precautions?

Bitemporal or monotemporal probes...most first ECTs will get bitemporal. Induces tonic/clonic seizure ◦Release of neurotransmitters Parasympathetic activity followed by sympathetic activity. Parasympathetic will show bradycardia...you won't always see this because you are pre-treating with robinul or atropine. Or the transition into sympathetic activity is too quick. Make sure patient has peed, they will be incontinent Emergence agitation=pad rails etc

Endoscopy (1)

Bronchoscopy EGD EUS with or without FNA Variceal banding ERCP Double ballon PEG for all of these procedures we have to share the airway with the MD - gag reflex, very stimulation Colonoscopy - not very stimulation

How do I improve timing of ECT?

Caffiene and hyperventilation

What should you do if someone has a difficult airway or LA toxicity or MH ? (board answer)

Call for the intubation cart or MH cart or for intralipid rescue.

Common interventional cardiology procedures that anesthesia is involved in.

Cardiac catheterization Electro-physiologic procedures Cardio-version TEE

Common cerebral endovascular procedure that we are involved in? What type of anesthesia? What may we have to manipulate? How? How does CO2 affect cerebral pressures?

Cerebral aneurysm coiling GETA usually recommended. (volatiles, propofol, precidex) May need to manipulate BP &/or ETCO2. Neo/ephedrine/nitro/nipride...use what works for you & your CRNA. Increased CO2=cerebral vasodilation and increased CPP

TIPS procedure does what? What is the anesthetic concern?

Decompression of portal circulation in patients with portal hypertension and recurrent GI bleeds who have failed medical therapy....Cirrhotic livers create azygous/hemiazygous veins dilate showing esophogeal varices. The walls of the esophagus will also look like a reptile...this is from portal hypotension. Shunts placed inbetween hepatic vein and portal vein result in decreased portal hypotension. Shunting blood flow means that the liver is bypassed...increased endogenous waste product toxins & also anesthetic drugs....versed/fentanyl/rec/vec is all metabolized in the liver.

DCCV (1)

Direct Current Cardioversion (for pts. in SVT, A Fib, A Flutter) basic airway management - we just need to support their airway for a few minutes until they come back we are going to push some propofol, they are going to cardiovert them and we just need to support their airway for a minute or two until they come back

Anesthesia considerations of ERCP: Position? _______ recommended Have what medications ready?

Done prone...but the docs can do lateral... GETA recommended Glucagon for spasm of sphincter of oddi and zofran

Common GI procedures

EGD/Colonoscopy ERCP

What is the difference between EGD and ERCP from an anesthetic standpoint? Remind GI lab that...?

ERCPs have a higher incidence of aspiration so most are done general...there is more air involved, more spasms, more vomiting. They do not need muscle relaxant so use succs or nothing, volatiles & zofran. Remind GI lab PACU that they need to be watched 30 minutes to 1 hr, not like propofol EGDs that only hang in PACU for 5 minutes or less

EUS/FNA (1)

Endoscopic Ultrasound with or without Fine Needle Aspiration we are doing this because someone has a stomach mass, or an esophageal mass, or a pancreatic mass We want to find out if the mass has gone through the mucosa or through the tissue can this be resected surgically or it needs to be radiated or the pt. need chemotherapy

Common IR anesthesia

Endovascular treatments Radiofrequency ablations TIPS Angiograms MRI

Atrial Fibrillation Ablation (2)

Esophageal temperature is important - because an Atrial Esophageal Fistula can appear and that is deadly they will look with the fluoroscope to see where the T probe was and have anesthesia pushing in further or taking it out more and when the T got to around 38.2, they would stop and let it cool down But now they have an S-cath with metallic points = temperature sensors which are connected to a monitor

Endoscopy (4)

Every case we do in endoscopy is a GA - we lose the ability to communicate with the pt. We say this is MAC, but it is really GA

DCCV (3) - What is the difference between defibrillation and cardioversion?

For cases where electrical shock is needed: - if the patient is unstable, and you can see a QRS-t complex use (LOW ENERGY) synchronized cardioversion. - If the patient is pulseless, or if the patient is unstable and the defibrillator will not synchronize, use (HIGH ENERGY) unsynchronized cardioversion (defibrillation). if you use unsynchronized cardioversion for A Fib. pts. that might send them into V-Fib and you will need to synchronize them back to A fib and then to SR - This will generate an incident report. we are synchronizing the QRS and the R wave

EUS/FNA (3)

For some long EUS/FNA we need to intubate have a conversation with the surgeon and decide how long the procedure is going to take use some sux, put them on SIMV, or PCV-VG, let them breath or breath for them, but if they breath, make sure they are not going to buck these is like a transesophageal cardiogram, but they are looking at the stomach, the esophagus or the pancreas

Conscious sedation vs GA?

GA=may have impaired airway Moderate sedation responds to verbal stimuli. If patient loses ability to respond purposefully then the anesthesia is general...the point is that a general anesthetic doesn't necessarily have to have an endotracheal tube (***If a patient loses consciousness and the ability to respond purposefully, the anesthesia care is a general anesthetic, irrespective of whether airway instrumentation is required.)

What type of anesthetic is usually given to TIPS procedure? Why RSI? Maintain BP with...?

GETA Fluid from ascites pushes up on stomach...always considered a "full stomach".. Maintain BP with albumin

Bronchoscopy (1)

Good news: - we usually aren' t there - 99 % of the cases does not involve anesthesia - they usually go in nasally - less stimulation Bad news: the 1 % of the cases they need anesthesia, the sickest and most difficult pts. - OSA, chronic cough, infectious process, strictures, lung cancers - removing tumors or biopsies

Special populations - *Obstetric*

How many weeks? Do we need fetal heart rate monitoring? Document *fetal heart rate* before giving maternal medicine. You don't want to take a pregnant pt. to the OR without documenting fetal HR. Document FHR after the procedure is over also.

ICDs and AICDs (1)

Implantable Cardiac Defibrillator Automated Implantable Cardiac Defibrillator Not all ICDs have a pacing function (those implanted in the chest do NOT have a pacing function)

Physical Protection

Ionizing radiation - wear shields

Anesthetic considerations for EGD/Colonoscopy: What position? Why? ______ _______ ______ is usually sufficient Intubate or MAC? Avoid...?

Lateral position (better for aspiration precautions) Biflow nasal cannula usually sufficient Typically sedation...unless it is for foreign object/esophogeal obstruction...aspiration is a higher risk when sedated so you need to place ETT Avoid lidocaine/fentanyl/versed synergism..

A Flutter Ablation (3) - OSA pts.

Little Versed and little Fentanyl will make someone obstruct and go apneic So if I don't want to hold their chin to keep their airway open, I going to design a drugs that not lead them to obstruct and still give them analgesia and sedation - PRECEDEX *Precedex* - alpa - 2 agonist - centrally action - decreases BP - causes vasodilation - might need to balance it with an infusion of alpha - 1 agonist to keep the BP from dropping too low Precedex bolus - 1 mcg/kg/10 min. (in geriatric population start with 0.25 mcg/kg/10 min.)

ASA guidelines for NORA patients

Look at 2 adequate and i reliable

Anesthetic consideration/choice for EPA All patients will have ______ _______ _____ on What helps the EP doc narrow down where the ablation needs to happen? Hold what medications for patients? Why? How is the heat of cautery mitigated? What am I watching with the esophogeal temp probe? Why? What is barium used for?

Patients need to be immobile but the cardiologist also believe that the propofol and volatiles will suppress the study. All patients will have external defibrillation pads on. The magnets...so no magnetized equipment (O2 tankes on defibrillator cart, IV pumps have to be different)...many hospitals don't use the magnets anymore, there is newer equipment. Hold anti-arrhythmics so that it won't block the pathway that needs to be found & ablated. Thermocools infuse saline to cool the area. Be mindful of I's & O's. Pulmonary veins are very close to the esophagus...an increase of 1/10th to 2/10ths degree increase on esophogeal temp probe will make EP doc stop and wait for area to cool down. Helps visualization...concern for aspiration if pt isn't intubated.

Electrophysiology - Devices

Permanent Pacemakers (PPM) ICDs - Internal Cardio Defibrillator Generator change Upgrade Device Lead Removal Watchman or Left Atrial Device

Bronchoscopy (2)

Pharmacology - TIVA, inhalation anesthetics not recommended - we may contaminate the room - there is no scavenging system if I give a gas and they are in the lung working, i might not be able to give a good TV uncontrolled bleeding can also affect your ability to ventilate Fluoroscopy risks Extubation might not happen immediately after the procedure is completed

Pros/cons of EP ablation

Pros: ◦Minimally invasive ◦60-85% curative on 1st attempt Cons: ◦Often lengthy ◦Often uncomfortable ◦May induce Vtach and Vfib...not always responsive to defibrillation

Co-morbidities for patients receiving TIPS procedure

Recent GI bleed Hepatic encephalopathy Ascites Pleural effusion Alcoholic cardiomyopathy Coagulopathy Decreased protein binding

Complications of cerebral aneurysm coiling

Rupture, dissection Contrast hypersensitivity, anaphylaxis Groin hematoma

Complications of abdominal aneurysm

Rupture, dissection Contrast sensitivity, anaphylaxis

What monitors are standard of care? What are 2 other standards of care: _______ control policies. __________ of _______

Same as OR: Oxygenation, ventilation, cardiovascular status, thermoregulation neuromuscular response. Infection control policies Transfer of care

What was the result of the evidence based article re: curative ablation of atrial fibrillation for deep sedation vs GA

Sedation had higher end-tidal CO2, lower pH, increased incidence of coughing GA: No problems with respiratory acidosis & coughing, but had lower MAP and decreased HR. This study did not determine the ideal anesthetic.

EUS/FNA (2)

Sometimes they have to take cells with a needle (especially with pancreatic masses) to confirm diagnosis of pancreatic cancer cytology comes up and they usually take the cells and they are set up sometimes with a hair dryer These pts. cannot move - they use a needle to get through the pancreas or through the liver or somewhere else and they need really good anesthesia they can be breathing, but they can't be bucking, they can't be responding to stimulation

Abdominal aneurysms are treated with? How do I prepare?

Synthetic graft placed over wire At least 2 large bore IVs. A-line. Will get heparin intra-op and protamine at end. Trend ACTs...you will be doing your own.

EPS/EPA is what procedure?

The identification and subsequent (usually) ablation of dysrhythmias caused by aberrant conduction paths. EPA is Ablation...EPS is Study

Electroconvulsive Therapy (3)

What do we do? Put monitors on give some induction agents and some sux. mask ventilate, or intubate (if they have a full stomach), or LMA

Ventricular Tachycardia Ablation (2)

What do you think is going to happen when they induce VT in these pts.? decreased CO and BP - we give a bolus a pressors when they induce VT to help maintain perfusion to the vital organs. We need to monitor brain perfusion - *cerebral oximeter* will be on their forehead and we need to document the cerebral perfusion (right and left) when the cerebral perfusion goes under 50, anesthesia calls those numbers and they will stop and let the saturation go up

Electroconvulsive Therapy (5)

What drugs? *Methohexital* - Brevital (barbiturate) *Propofol*, but it depresses the EEG activity - if someone has a seizure that you gave too much LAs, giving Propofol would help because it will make the brain more isoelectric studies show that propofol or methohexital have similar effects when used with ECT, but old school people prefer Brevital *Succinylcholine* - not an intubating dose (an ED 95) - it is usually 50 % of the dose - we just need them to be flaccid and relaxed ... we don't need the, to fully fasciculate

When is cardioversion more successful? What needs to be done prior to conversion? Make sure that I have...?

When AFIB <7 days TEE to check atrial appendage (r/o "mural thrombus) because cardioversion is more likely to release thrombus into circulation causing stroke. Enough sedation to do TEE, and potentially multiple cardioversions if 1st isn't successful.

Questions to ask yourself:

Where is my patient? Where is the holding area? Are they optimized? Assess!!! What type of pt. I have? Outpatient or inpatient? Inpatients will take more time to assess!!! Do I need more information? Don't let anyone to rush you!

ERCP (endoscopic retrograde cholangiopancreatography) (1)

Why do we do it? they have *stones* - maybe they have a lap chole and the surgeon did a intraoperative cholangiogram and he found this stone in the common bile duct maybe they are having *abdominal pain and jaundice* ask yourself: Is this a liver pt. or a non-liver pt.? liver pts. tend to have liver strictures after a transplant and they come in jaundice and they need for that stricture to be ballooned open and they need to be stented

*PEG tube* - Percutaneous Endoscopic Gastronomy (1)

Why would somebody have a peg? they are malnourished, or they are at risk for aspirating or someone that is having a big head and neck procedure and they will get a trach, a PEG tube is done preoperatively

Permanent Pacemaker (1)

Why would someone need a pacemaker? - sick sinus syndrome or symptomatic bradycardia - syncope, pacing to prevent tachycardia like a overdrive pacing a fascicular block *Anesthetic* - they can do these pts. with only local anesthetic: - very minimal anesthetic - we are there to keep the pt. calm and relaxed - *would never run propofol, but just a little Versed and Fentanyl* - we can do some Precedex but watch the BP

ICDs and AICDs (2)

Why would someone need an ICD? these are pts. at risk for potential lethal ventricular arrhythmias maybe they had an MI and their EF is not < 35 % maybe they have systolic heart failure and their EF is < 30 % maybe they have a history of V-Tach or V-fib arrest maybe they were young and they had obstructive cardiomyopathy and their cardiac cellular structure is messed up and they are at an increased risk for sudden cardiac death

Legal Protection

Write your *preop notes* before starting the case: - teeth condition Learn to say "I am uncomfortable doing this!"

To prevent Atrial Esophageal Fistula we use (1)

an esophageal T probe Esophageal deviation - esophagus is moved away from the pulmonary veins were they are working so it doesn't get burned - they use to take a chest tube,put some barium in it and stylet it and physically forced the esophagus to the side and it was little bit traumatic and they had to go for an EGD the next day to make sure that there was no damage.

Variceal Banding (1)

as soon as we say liver pts. we think of very sick pts they have *portal HTN*, they have multiple banding, this procedure is painful post op so they need a very good amount of anesthesia maybe they have *ascities* and we have to ask: Do we need to tap this pt. before we do the variceal banding because they can't lay flat and they are a high risk for aspiration?

Main reason geriatrics come into the hospital is

aspiration pneumonia as they are at greater risk for aspirating at home It take more stimulation to close the vocal cords and they are less aware of an obstruction about to go into their vocal cords.

If you peop. someone and they are

complaining of myalgia from sux., ketorolac or acetaminophen might help

Special populations - *Obese*

decreased FRC OSA If you can't elevate the head of bed, you may be in trouble with these pts. - they can't tolerate a flat bed May need to use a nasal CPAP.

Special populations - *Geriatrics*

decreased muscle mass, increase fat tissue, decreases water >>> consider changes in their Vd think about how your drug is going to distribute, how it is going to metabolize, how is going to get excreted they have greater risk for aspiration - their vocal cords need more stimulation to close and they are not aware when obstruction touches their vocal cords

Electrophysiology - rhythm problem

done for someone with arrhythmia and we are trying to fix it 1. DCCV - direct current cardioversion (Afib) 2. EP study - to see why the pt. is running PVCs 3. Ablations: - Atrial flutter - A fib. - V-tach

Electroconvulsive Therapy is utilized for...? Describe therapy course Why do they need anesthesia? What can be challengin?

done on severely depressed people - less than 15 min. - inducing a seizure from 30 - 90 sec. 3 treatments/week and 6 - 12 treatments overall. because pts. used to have violent seizures and compression fractures, vertebral fractures, dental injuries, but now, just by giving a muscle relaxant and an induction agent we smooth all that out. Getting *consent on psych pts. may be a challenge* - may need to call the person responsible for -

*PEG tube* - Percutaneous Endoscopic Gastronomy (2)

fragile population - you can give a small amount of propofol to this population and you will have to wait longer for it to work think about EF - it is lower, it will take longer for the drug to work if you topicalize, use no sedation if you will do awake intubation Who is signing the consent? DNR/DNI - it used to be suspended when they came to the OR - call the next of kin and ask what they want to be done and document pharmacology - less is more, but definitely antibiotics

EGD (3)

full stomach - intubate risk for aspiration - intubate small bowel obstruction - *intubation ALWAYS*

Regarding *equipment and NORA cases*

have what you need and what you don't need because the supply rooms are far away. Have ET tubes ready, but also LMA because LMAs have a 95 - 98 % success rate. you may need to set up the anesthesia machine: - hook it up to suction - to pipe line - to scavenging system - full machine check Don't let them rush you: tell them "I need to do a few more safety checks! I am not ready to start this case!"

ERCP (endoscopic retrograde cholangiopancreatography) (3)

if they have to put a scope into the pancreatic duct, they are concerned about the pt. getting pancreatitis they want them to have a lot of fluid - at least 3 L to minimize the effects of pancreatitis have *Levaquin* on board or available have *Glucagon* available - it slows down the GI motility, so when they have the scope down there, it slows down the peristalsis so it is easier for them to work

For NORA cases create an anesthetic plan that

leave you multiple ways out! Use drugs that have reversals or use only short acting drugs!

Atrial Fibrillation Ablation (1)

looooong cases arterial line ? - based on pt. need (some places everyone gets an ART line) any movement - they have to start over, any bucking is not good - even respiratory variation experimented with jet ventilation to keep the pts. from bucking now I:E ratio is changed to 1:4 and try to keep TV and RR up, but sometimes they ask for TV to be lowered and ETCO2 ends up being higher (like it is with pts. that have an LMA)

To prevent Atrial Esophageal Fistula we use (2)

now they have a device with some barium in it - they inflate it and push the esophagus to the right, these pts. need a smooth wake up - maybe remifentanil - because they had these giant lines in their groin and if they start moving or coughing and bucking when they wake up they will be an increase for bleeding

ERCP (endoscopic retrograde cholangiopancreatography) (2)

people that have *cancers*, the mass may be obstructing the common bile duct, so the ERCP may be done for this reason also usually there are two teams of endoscopist: those who take care of their liver pts. (who are sicker) and those who are doing the cases for non-liver pts. prone vs. supine secured airway or non-secured airway

AFib/Flutter Ablation (1)

pretty fast true MAC - no intubation but it may require intubation for pts. with: - chronic back pain - or OSA These pts. need to lie flat ... they not might tolerate it - we may use a nasal CPAP - it can help use to ventilate the pt. by squeezing the bag on the circuit

Endoscopy (3)

shared airway: - hard to do a chin lift or jaw thrust - hard to support the airway - very stimulating - we give Fentanyl, but still maintain spontaneous ventilation (remember Fentanyl takes 1-2 min. to work so time it to match the beginning of the procedure Consider secured airway vs. unsecured airway

The gastric pacemaker

signals the stomach to contract to try to improve patients' gastroparesis,

Endoscopy (5)

some Versed some Fentanyl (it takes 2-3 min. to work - time it to peak when the scope goes down, otherwise the pt. will buck some Lidocaine - to blunt SNS response to intubation Induction - we can topicalize and keep them awake

Colonoscopy

the least stimulation Why would someone get a colonoscopy? surveillance for polyps, colorectal cancer screening, removal of polyps, melena, GI bleed straight propofol, if they are anxious give some Versed if they are small females and had abdominal surgery, the scope may hit some adhesions and some Fentanyl or Ketamine (5 mg boluses but make sure you use Midazolam with it) may be recommended

DCCV (2) - anticuagulation

the pt. is usually anti-coagulated if this is a new onset because they are increased risk for clots and if we put them into SR, they are going to through a clot if not anti-coagulated they usually go for a TEE before they have a cardioversion to make sure they don't have a clot

If the the pt. didn't sign the consent

the pt. might say "I never agreed to this!"

Permanent Pacemaker (3)

there are BI-V pacemakers that can pace both ventricles because their ventricles are not in sync they do this therapy called *CRT - cardiac re-synchronization therapy* and they actually can improve cardiac output by keeping the two ventricles pumping together that makes for a better hemodynamic situation

Permanent Pacemaker (2)

there are leadless pacemakers - the size of a capsule and they can drop it in the R ventricle and when that stops they can drop another one in when someone has a pacemaker they put 2 leads in so they can pace both ventricle and atria, but they are usually pace one ventricle

Electroconvulsive Therapy may cause what neuro stimulation?

there might be some *parasympathetic stimulation* (before the procedure give Robinul or Atropine to block the parasympathetic effects) there might be *sympathetic stimulation* (during or after) - give labetolol, esmolol, remifentanil or CCBs done usually in PACU - have drugs you need available, have ambu bag available, oral airways, LMAs, ETT

Special populations - *Pediatrics*

they don't have a lot of reserve! The difference between therapeutic and lethal is *a wide distance*: - you can give too much fluid, too much narcotic, too much muscle relaxant to an adult, but with PEDE is different - we have to calculate everything and use tuberculin syringes. warm the room up - don't let the baby get cold

Electroconvulsive Therapy (4)

they may ask you to *hyperventilate* - enhances seizure activity - they will probably ask us to hyperventilate - *hypoventilate* - moderate hypercapnia improves the quality of the seizure

Don't leave your pt. where you know

they will not be taken good care of. Recovery areas are not always the same as PACU!!! Nurses are not all trained the same!!!

EGD (1) - esophago-gastro-duodenoscopy

unsecured airway Why would thy have a EGD? maybe they had melena, GI bleed or abdominal pain, Barrett's esophagus or peptic ulcer disease and we are doing surveillance or maybe they have a food impaction

Electrophysiology studies

we probably won't be there unless it is listed as an EP study with possible ablation if we are involved, this is a no anesthesia anesthetic - maybe a little propofol for the groin stick, but then nothing else because our drugs may obliterate the arrhythmia or making it hard to induce and making it harder for them to do what they want to do Ask them - what exactly do you want ? Even a little Propofol may make PVCs go away and harder or impossible to induce

To prevent Atrial Esophageal Fistula we use (3)

when they give the protamine at the end of the case to reverse the heparin, they will have us extubate, but they don't pull the sheets until the pt. is wide awake and they inject local when they are pulling it out and then apply pressure with the pt. laying completely flat.

A Flutter Ablation (2)

with a 6 hrs. A Fib ablation - you may need to call respiratory to put them on a CPAP while they are transported to PACU - especially if they were already using CPAP at home OSA pts. have their Closing Capacity higher than FRC and that leads to closure of their small airway faster than in other pts. OSA pts. are very sensitive to CNS depressant drugs - way out of proportion to their body size

Permanent Pacemaker (4)

with any of these we are putting something foreign in pt.'s body and we wanna make sure they have antibiotics prior they start inpatients get vancomyocin