Andi Stamper, NCANA 2016 Annual Meeting

1. Andi N. Stamper, DNP, CRNA
NCANA Annual Meeting
November 5, 2016

2. Objectives
 Compare providing non-operating room anesthesia
(NORA) vs inside the OR
 Review NORA procedures and anesthetic considerations
 Understand different stroke types and
treatment/intervention options
 Learn the Society for Neuroscience Anesthesiology and
Critical Care (SNACC) recommendations for stroke
management
 Discuss pros and cons of
different types of anesthetics
for stroke patients

3. Operating Room

4. Urological
Gastro-
enterology
Imaging
Procedures
Intensive
Care
Office-based
procedures
Psychiatric
Emergency
Room
Radiotherapy Cardiology
NORA Locations
Interventional
Radiology
Post
Anesthesia
Care Unit

5. Uncooperative/combative patient
Known/suspected difficult intubation
Severe GERD
Abnormal body habitus making positioning difficult
ASA > 3
OSA, morbid obesity
Known difficult to sedate
Chronic pain patients
Prolonged, difficult or painful procedures
Extremes of ages
When is Anesthesia Support Indicated?

6. Considerations Outside of the OR
Physical Space
Standardized Equipment
Needs
Stocking Supplies

7. Exposure to anesthetic gases

8. 
Drug Accessibility

9. Considerations Outside of the OR
Availability of Help for Emergencies
Lack of understanding of respective processes
Inefficient Scheduling
Post Anesthesia Care

10. Severity of Injury
Metzner, J., & Domino, K.B. (2011). Risks of Anesthesia Care in Remote Locations.

11. Mechanism of Injury
Metzner, J., & Domino, K.B. (2011). Risks of Anesthesia Care in Remote Locations.

12. Preventable by Better Monitoring
Metzner, J., & Domino, K.B. (2011). Risks of Anesthesia Care in Remote Locations.

13. Have Anesthesia Machine…
Will Travel…..

14. Very strong static magnetic field
High-frequency electromagnetic (radiofrequency)
waves
Time-varied (pulsed) magnetic field
High-level acoustic noise
Systemic and localized heating
Accidental projectiles
Contrast Allergy
Magnetic Resonance Imaging
(MRI) Concerns

16. Premedication for allergy to IV contrast
Elective Adult Patients (2 steroid options):
Prednisone
Methylprednisolone
(Optional) Diphenhydramine
Urgent Adult Patients (3 steroid options):
Hydrocortisone
Methylprednisolone
Dexamethasone
Elective Pediatric Patients:
Prednisone
(Optional) Diphenhydramine
Contrast Allergy
(2013 American College of Radiology Guidelines)

17. RADIATION SAFETY
More ionizing radiation than standard x-rays but
lower than fluroscopy
Single chest CT scan deliver more than
100 times the radiation dose of
anteroposterior and lateral chest
x-rays
Contrast Dye Anaphylactic
Response
Computed Tomography
(CT) Concerns

18. Personal Radiation Monitors
Who must be monitored?
Adults likely to receive 10% of any annual regulatory
limit
Declared pregnant women likely to receive (during the
entire pregnancy) a deep dose equivalent in excess of 1
mSv (0.1 rem)
Individuals entering a high or very
high radiation area
Individuals working
with medical
fluoroscopic
equipment

19. 
LIMIT ANNUAL ALLOWED DOSE
Whole Body (Deep) 5 rem 500 mSv
Lens of the Eye 15 rem 150 mSv
Extremities/Other Organs/Skin
(Shallow)
50 rem 500 mSv
Fetus of declared pregnant worker 0.5 rem during
gestation
5 mSv during
gestation*
Federal/State
Occupational Dose Limits
*Cannot give entire limit in one month; should be prorated to 50 mrem per
month, and exposure prior to declaration of pregnancy considered

20. TheKoretSchoolofVeterinaryMedicine

21. Interventional
Radiology (IR)
Line placements and exchanges
Transhepatic Intrajugular
Portosystemic Shunt (TIPS)
Nephrostomy tube placement
AV Malformations
G-J Tube placement
** contrast allergy

23. Neurology IR
Aneurysm Coiling and
Stenting
Carotid Artery Stenting
(CAS)
Pre-operative embolization
of brain tumors
Stroke
 Ischemic – Intervention
(mechanical thrombectomy)
 Hemorrhagic - Diagnostic

24. Aneurysm Coiling
 Considerations
 BP monitoring
 Procedure length
 Complications
 Thrombosis
 Aneurysm Rupture
 Vasospasm
 Perforation of normal
vessels
 Contrast reaction
Weiss,M.S.,Fleisher,L.A.,Rubin,D.,&Cutter,T.(2015).AdultAnesthesiaintheRadiologySuite.

25.  Stroke is the FIFTH leading cause of death in the U.S.
 More than 795,000 people effected each year
 25% of people who recover from their first stroke will
have another stroke within 5 years
 Stroke is the leading cause of
long-term disability
 In 2010, stroke cost about $73.7
billion in both direct and indirect
costs in the U.S. alone
Acute Stroke Numbers

26. 
Why does North Carolina Care?

27. Ischemic
Stroke
Clot occluding
artery
85%
Intracerebral
Hemorrhage
Bleeding
into brain
10%
Subarachnoid
Hemorrhage
Bleeding
around brain
5%www.acponline.org/about_acp/chapters/o
k/gordon.ppt
What are the Different Stroke Types?

28. 
North Carolina Stroke Center

29. Program Concept PSC CSC
Program Medical Director Sufficient knowledge of
cerebrovascular disease
Extensive expertise; available 24/7
Acute Stroke Team SAME SAME
Stroke Unit Stroke unit or designated beds for
the acute care of stroke pts
Dedicated neuro ICU for complex stroke pts
available 24/7
Initial Assessment of Pt SAME SAME
Diagnostic Testing
Capability
CT, MRI, CTA, MRA 24/7, and
cardiac imaging when necessary
CT, MRI, labs, CTA, MRA, other cranial and
carotid duplex ultrasound, TEE, TTE,
catheter and angiography 24/7 and cardiac
imaging when necessary
Neurologist Accessibility 24/7 via in person or telemedicine Meets concurrently emergent needs of
multiple complex stroke patients; written call
schedule for attending MDs providing
availability 24/7
Neurosurgical Services Within 2 hours; OR is available 24/7
in PSCs providing neurosurgical
services
24/7 availability; neurointerventionalist;
neuroradiologist; neurosurgeon
Treatment Capabilities IV thrombolytics; May have ability
to perform: neurovascular
intervention for aneursyms, stenting
of carotid arteries, Carotid
endoarterectomy, and endovascular
therapy
IV thrombolytics; microsurgical
neurovascular clipping of aneurysmsl
neuroendovascular coiling of aneurysms;
stenting of extracranial carotid arteries;
carotid endarterectomy; endovascular
therapy

30. Anterior vs Posterior
http://classconnection.s3.amazonaws.com/386/flashcards/2744386/png/circle_of_willis-13EC400AB5613D14690.png

31. http://classconnection.s3.amazonaws.com/1700/flashcards/701384/png/anterior-circulation.png

32. Subarachnoid
Hemorrhage
Ischemic
Stroke

33. 
Time is Brain

34. 
Acute Stroke Revascularization
From Nogueira RG, Schwamm LH, Hirsch JA. Endovascular approaches to acute stroke. I. Drugs, devices, and data. AJNR Am J Neuroradiol. 2009;30[4]:654

36. Anesthesia Considerations
 What’s the best anesthetic options?
 Sedation vs General Anesthesia
 Similar to a trauma set-up
 Dry Set Up
 Drug “packages”
 Develop protocol with
multidisciplinary team
 Monitoring
 Set-up/Considerations

37. What’s the best Anesthetic?
 General Anesthesia vs Sedation
 GA gets a bad wrap
 Delay Time to Intervention
 Worse Outcomes at 90 days
 Duke vs MR Clean Trial
 Door to groin stick time was almost half for the GA cohort
 78 minutes vs. 162 minutes
 Good functional outcome at 90 days
 Achieved by 33% of patients at Duke
 Non-GA cohort (38%) vs GA cohort (23%) in the MR Clean trial

38. Stroke Trauma Set-Up

39. 
Stroke Drugs
Stroke Code Tray
• Vasopressin 20units/mL – 1mL vial
• Phenylephrine 80mg/250mL bag
• Nicardipine 40 mg/200 mL bag
• ** Clevidipine 25mg/50mL vial
• Insulin 1 unit/mL – 250 mL bag
• Dextrose 50% - 50mL vial
• Acetaminophen 10mg/mL – 100mL
vial
• Propofol 10mmg/mL – 100 mL vial

40. 
 Surgical Considerations
 Time is brain (<10 min until arterial puncture upon
IR arrival)
 Neuro check ASAP post procedure
 Avoid SBP > 140 mmHg prior
to revascularization; <180 mmHg
if tPa administered
IR Stroke Anesthesia
Considerations

41. 
Anesthesia Considerations
 Case Setup
 Anterior Circulation
 MAC vs GETA
 Posterior Circulation
 GETA
 Supine position with arms tucked
bilaterally
 2 PIV’s, Aline (Left preferable due to
easier access during procedure
 Foley (contrast induced forced diuresis)

42. Anesthesia Considerations
Monitoring
Blood Pressure
 Pre-revascularization: SBP > 140 mmHg but < 180mmHg
 Post-revascularization: SPB goals <140 mmHg after confirmation
with interventionalist
 Fluid and vasoactive agents (phenylephrine,
nicardipine, clividiepne, etc.) for management
ACT
 Goal ACT 250-350 seconds
Glucose
 Q 60 min surveillance; Q 30 min if receiving IV insulin
 Goal 80-140 mg/dL
Temperature
 35-37 °C

43.  Intraoperative Considerations
 Femoral artery puncture < 10 minutes after arrival in IR
 If difficult radial artery cannulation communicate need for
femoral a-line off side port of IR femoral sheath
 Oxygenation and Ventilation
 FiO2 should be titrated to maintain SpO2 > 92% and PaO2 >
60mmHg
 Maintain normocapnia (PaCO2 35-45 mmHg)
 Respiratory depression induced hypercarbia should be avoided
during procedural sedation
 Fluids
 Maintain euvolemnia, avoid glucose containing fluids unless
treating serum glucose values <50mg/dL
Anesthesia Considerations

44. 
Anesthesia Considerations
Postoperative Considerations
Extubation based on clinical criteria after
communication with NICU team
Rapid neuro exam should be able to be completed
(intubated or extubated)
Transfer to NICU
Continued BP control
 SBP 120-140mmHg

45. Summary
 Non–operating room anesthesia (NORA) sites
pose challenges
 Implementation of standard monitoring
 Oxygen, Supplies, and Suction should be readily
available
 Emergency Plan in Place
 Stroke
 Interventions
 Protocols
 Time is Brain!!!!

46. 
Questions???

47.  American Society of Anesthesiologists. Statement on nonoperating room anesthetizing locations,
amended in 2008. http://www.asahq. org/For-Members/Standards-Guidelines-and-Statements
 Certification for Acute Stroke Ready Hospital | Joint Commission. (n.d.). Retrieved October 1,
2016, from https://www.jointcommission.org/certification/acute_stroke_ready_hospitals.aspx
 Metzner, J., & Domino, K.B. (2011). Risks of Anesthesia Care in Remote Locations. The Official
Journal of the Anesthesia Patient Safety Foundation Newsletter, 26(1), 5-6.
 Weiss, M. S., & In Fleisher, L. A. (2015). Room Setup, Critical Supplies, and Medications. In Non-
operating room anesthesia (1st ed., pp. 18-29). Philadelphia, PA: Elsevier.
 Weiss, M. S., In Fleisher, L. A., & Scott, J. P. (2015). Critical Monitoring Issues for Non–Operating
Room Anesthesia. In Non-operating room anesthesia (1st ed., pp. 43-49). Philadelphia, PA: Elsevier.
 Weiss, M. S., Fleisher, L. A., Rubin, D., & Cutter, T. (2015). Adult Anesthesia in the Radiology
Suite. In Non-Operating Room Anesthesia (1st ed., pp. 151-160). Philadelphia, PA: Elsevier.
 Weiss, M. S., Fleisher, L. A., & Martin, R. (2015). Anesthesia Concerns in the Magnetic Resonance
Imaging Environment. In Non-Operating Room Anesthesia (1st ed., pp. 171-175). Philadelphia, PA:
Elsevier.
 Witherspoon, B. (2013). Diagnosis and Management of Acute Stroke [PowerPoint Slides].
Retrieved from:
http://www.mc.vanderbilt.edu/documents/ccapp/files/4_%20stroke%20final.ppt
References

48.  Premedication for allergy to IV contrast
 Elective Adult Patients (2 steroid options):
 Prednisone 50 mg PO 13, 7 , and 1 hr prior to procedure
 Methylprednisolone 32 mg PO 12 and 2 hrs prior to procedure
 (Optional) Diphenhydramine 50 mg PO 1 hr prior to procedure
 Urgent Adult Patients (3 steroid options):
 Hydrocortisone 200 mg IV 5 and 1 hr prior to procedure
 Methylprednisolone 40 mg IV 5 and 1 hr prior to procedure
 Dexamethasone 7.5 mg IV 5 and 1 hr prior to procedure
 Elective Pediatric Patients:
 Prednisone 0.5-0.7 mg/kg PO 13, 7, and 1 hr prior to procedure
(max 50 mg)
 (Optional) Diphenhydramine 1.25 mg/kg PO 1 hr prior to
procedure (max 50 mg)
Contrast Allergy
(2013 American College of Radiology Guidelines)

49. 
ASA NORA Guidelines

50. 
ASA NORA Guidelines