ANESTHESIA /

SEDATION OUTSIDE
OPERATING ROOM

Dr.P.NARASIMHA REDDY
NARAYANA MEDICAL COLLEGE.
 INTRODUCTION
 PROCEDURES DONE OUTSIDE O.R.
 PLACES WHERE PROCEDURES ARE
DONE.
 PROBLEMS OF ANESTHETIST
 GENERAL PROBLEMS.
 SPECIFIC PROBLEMS.
 WHAT ARE THE SAFETY STANDARDS?
 MONITORING AIDS.
 EQUIPMENT REQUIRED.
 TYPES OF ANESTHESIA ? SEDATION.
 DISCHARGE CRITERIA.
 INTRODUCTION:
 Ultra short acting potent drugs.
 Portable monitoring aids.

 PERIPATETIC: “who walks from place to

place”
Essential criteria to anesthetist outside O.R.
1.Applicability – is it appropriate to provide service?
2. Ability - does an anesthetist have to be present?
3. Affordability – is it cost effective?
4.Availability – can we provide the service outside?
5.Affability – is it the desire of the doctor to have
anesthetist services?
6.accountability – are we responsible for the
quality & outcome results?

7.Altruism – is it devotion to humanity or

selfishness?
 O.R – sterile,serene,peaceful.
 Anesthetist--
comfortable,comprehensive,conducting
procedures.
 He is familiar with
equipment,medical,paramedical persons,available
drugs.
 He can expect & delegate powers to suitable
persons.
 Outside O.R - known & unknown problems .

 Vulnerable to mishaps.
 PROCEDURES OUTSIDE O.R
1. Diagnostic,interventional& therapeutic
radiology.
2. Cardiac catheterisation,implantation of
defibrillators,coronary angiography,stent
replacements.
3. Cardioversions.
4. E.C.T.
5.Bonemarrow aspiration & L.P.
6.Emergency airway management.
7.Transport of critically ill patients.
8.Ortho procedures.
9.Removal of patients from rubble or accident
vehicles.
 PLACES WHERE PROCEDURES
ARE DONE
1. Radiology suit..
2. Cath lab.
3. I.C.U.
4. Psychiatry O.P.
5. Cancer wards.
 Contd..
6.Paediatric wards.
7.Field situations.
8.Ortho O.P’s.
9.Transport vehicles – road/air.
 PROBLEMS OF
ANESTHETIST.
 GENERAL PROBLEMS:
- environment – new place,remote area,narrow
lanes,low lighting,no back-up facility.

- personnel – not trained & less number.

-equipment – anesthesia machine may be present

or absent.
 Contd..
- May be old or not used for long time.
- Cyllinders – less or empty.
- Outlets for power – O2,N2O may not be
present.
- Laryngoscope may be present / absent, may not
be working.
- Proper size of tubes & airways – not available.
 Contd..
- Suction – present /not working.
- Parking – narrow crowded places,difficult to
transport the patient in case of emergency.
- Communication system may not be good.
- Resuscitation facilities – not adequate.
- Post anesthetic care – not available.
 PATIENT PROBLEMS:
- Not well prepared.
- No fasting guidelines.
- PAC not done.
- May be on some medications.
- Comorbid conditions present
patient must be ASA 1 & 2.
 SPECIFIC PROBLEMS:

-C.T SCAN :
-Needs immobile patient for 20-40 mts.
-children,unconscious,noncooperative,head
injury,convulsions,communication problems –
requires sedation / anesthesia.
-airway obstruction
-kinking of tube
 Contd..
- apnoea.
- cyanosis & cardiac arrest.
-radiation to anesthetist.
- allergic reactions to contrast dyes.
 M.R.I:
- Narrow tunnel.
- Access to the patient is difficult.
- Claustrophobia.
- Strong magnetic fields.
- Ferromagnetic implants,monitoring aids.
- Loud noise.
 Contd..
- Image degradation.
- Absolute immobility for long time.
- Cannot see the airway & chest movements.
- Modified anesthesia machine & monitors.
- No coil cables.
- Alluminium trolleys & alluminium cyllinders.
- Plastic laryngoscope with batteries which are
wrapped with plastic covers.
 Interventional radiology:
- Laporotomies & craniotomies for accurate
tumor resection.
- Intermittent imaging.
- Scanning time may be significantly longer.
- Patient access limited.
- Contrast dyes produce diuresis.
- Hypo-hypertensive.
 Neuro radiology:
-Embolisation :
- long procedures, embolic events.
- airway management urgent.
- G.A ideal.
- hemorrhage ,hemodynamic disturbances &
aspiration can occur.
 Trigeminal neuralgia:
- Local block induced
- Neurolytic agent.
- Brief period of loss of consciousness is induced.
- Neurologic examination on awake patient.
- Airway support may be difficult when block
needle is in place.
 Cyclotron therapy:
- Proton beam radiation is used in the treatment
of A.V malformations,pituitary tumors &
retinoblastomas.
- Radiation is painless but positioning may take
several hours.
- Head fixation may be painful.
- Standard T.V with CCTV.
 Radiation therapy:
- Children often require G.A.
- 3-4 times a week for 4 weeks.
- Planning of radiation on first day takes long
time.
- Standard monitoring with CCTV.
 E.C.T:
- Used in patients with depression not controlled
by the drugs.
- Initial vagal discharge,later sympathetic
discharge.
- HTN for 5-10 mts.
- E.C.G – prolonged PR & QT intervals, T wave
inversion.
 Contd..
- inc.intraocular & intra gastric pressures.
- Absolute contraindication :
- intracranial HTN.
- Relative contraindications:
- intracranial mass with normal ICT
-aneurysms
- recent M.I,angina , CCF
- untreated glaucoma
 Contd..
- Major bone fractures.
- Thrombophlebitis.
- Pregnancy.
- Retinal detatchment.

“Be careful with drug interactions”

 Cardioversion:
- Painful procedure.
- Must be unconscious.
- Others should not touch the patient during
shock.
- Patient is ventilated with 100% O2 till recovery.
 Contd..
Endoscopic suite:
- Patient must be evaluated.
- Ideal fasting guidelines.
- Glyco + topical L.A + benzo / propofol.
- Contraindications :
- achalasia,esophageal stricture,corrosive
esophagitis,intestinal obstruction,esophageal
discoordination.
 ESSENTIAL REQUIREMENTS

1. O2 Piped / cylinders.
2. Anesthesia machine.
3. Sufficient electrical outlets.
4. Adequate space & access to the patient.
5. Adequate illumination.
6. Emergency resuscitation cart.
 Contd..
7.Adequate monitoring equipment.
8.Defibrillator.
9.2way communication.
10.Qualified anesthesiologist.
11.Transportation facility.
 MONITORING EQUIPMENT
1. ECG.
2. Pulse oximeter.
3. Blood pressure.
4. ETCO2.
5. Oxygen analyser.
 OTHER EQUIPMENT
 Bag mask ventilation.
 Airways – all sizes.
 Laryngoscope with all blades.
 Correct size E.T tubes.
 Drugs – anesthetic & resuscitation drugs.
 TYPES OF ANESTHESIA
 INHALATIONAL
 I.V anesthetics
 M.A.C
 Regional
 Sedation
 Contd..
 Is the procedure painful?
 What is the duration of procedure?
 Patient needs to be motionless?
 Many times procedures are done under sedation.
 Rarely G.A with E.T tube with relaxant.
 SEDATION:
- Guidelines for sedation:
- chloral hydrate :
-non-narcotic.
- no resp.depression.
- no addiction.
-50-70 mg/kg orally 30-60 mts before the procedure.
- not analgesic.
-15% failure rate.
 Rectal methohexital:
- 20-30 mg/kg
- Rapid onset 5-10 mts.
- Prolonged action 30-60 mts.
- Unpredictable sedation.
 Benzodiazepines:
- Midazolam -0.01mg/kg.
can be given by all routes.
sedative ,anxiolytic,anticonvulsant.
amnesia .
minimal hemodynamic effects.
not an analgesic.
 I.V anesthetic agents:
- Pentothol sodium:
5-7mg/kg.
careful with full stomach & airway.
- ketamine:
1-2 mg/kg i.v, 2-4 mg/kg i.m
perfect analgesia.
reflexes retained.
 Contd..
- Broncho dilator.
- Resp.activity maintained.
- Raised i.c.t
- Ketatonia.
- Emergency delirium.
 Propofol:
- 1-2 mg/kg.
- Shorter duration of action.
- Complete recovery.
- Early apnea & hypotension.
- Pain during injection.
 G.A:
- Premed – atropine/ glyco.
- Rapid sequence induction.
- Induction agents – thio/propo/ketamine.
- Muscle relaxants – succi/ vec/E.T tube.
- Reversal – neo+ glyco.
 REGIONAL:
- EMLA ( ligno+ prilo)
- Occlusive dressing for 60mts.
- L.P ,bone marrow aspiration,ICD,i.v cannula.
- Methemoglobinemia.
 DISCHARGE CRITERIA
1. Stable C.V.S .
2. Satisfactory airway.
3. Patient easily arousable.
4. Reflexes intact.
5. Patient can talk, can sit up.
6. Patient can void urine.
7. Young & handicapped – preanesthetic level.
8. Hydration must be adequate.