Anesthesia on Safari: How to Survive a Stroke Code

Anesthesia on Safari: How to Survive NORA for Elective and Emergency Cases Including a Stroke CodeAndi N. Stamper, DNP, CRNANCANA Annual MeetingNovember 5, 2016

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ObjectivesCompare providing non-operating room anesthesia (NORA) vs inside the ORReview NORA procedures and anesthetic considerationsUnderstand different stroke types and treatment/intervention optionsLearn the Society for Neuroscience Anesthesiology and Critical Care (SNACC) recommendations for stroke managementDiscuss pros and cons of different types of anesthetics for stroke patients

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Operating Room

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Urological Gastro- enterology

Imaging Procedures

Intensive CareOffice-based procedures

Psychiatric

Emergency Room

Radiotherapy

Cardiology

NORA LocationsInterventional Radiology

Post Anesthesia Care Unit

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Uncooperative/combative patientKnown/suspected difficult intubationSevere GERDAbnormal body habitus making positioning difficultASA > 3OSA, morbid obesityKnown difficult to sedateChronic pain patientsProlonged, difficult or painful proceduresExtremes of agesWhen is Anesthesia Support Indicated?

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Considerations Outside of the ORPhysical SpaceStandardized Equipment NeedsStocking Supplies

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Exposure to anesthetic gases

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Drug Accessibility

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Considerations Outside of the ORAvailability of Help for EmergenciesLack of understanding of respective processesInefficient SchedulingPost Anesthesia Care

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Severity of Injury

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

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Mechanism of Injury

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

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Preventable by Better Monitoring

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

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Have Anesthesia Machine Will Travel..

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Very strong static magnetic fieldHigh-frequency electromagnetic (radiofrequency) wavesTime-varied (pulsed) magnetic fieldHigh-level acoustic noiseSystemic and localized heatingAccidental projectilesContrast AllergyMagnetic Resonance Imaging (MRI) Concerns

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Premedication for allergy to IV contrast Elective Adult Patients (2 steroid options): PrednisoneMethylprednisolone(Optional) DiphenhydramineUrgent Adult Patients (3 steroid options): HydrocortisoneMethylprednisoloneDexamethasoneElective Pediatric Patients: Prednisone (Optional) DiphenhydramineContrast Allergy(2013 American College of Radiology Guidelines)

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RADIATION SAFETYMore ionizing radiation than standard x-rays but lower than fluroscopySingle chest CT scan deliver more than 100 times the radiation dose of anteroposterior and lateral chest x-raysContrast Dye Anaphylactic ResponseComputed Tomography (CT) Concerns

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Personal Radiation MonitorsWho must be monitored?Adults likely to receive 10% of any annual regulatory limitDeclared 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 areaIndividuals working with medical fluoroscopic equipment

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LIMITANNUAL ALLOWED DOSEWhole Body (Deep)5 rem500 mSvLens of the Eye15 rem150 mSvExtremities/Other Organs/Skin (Shallow)50 rem500 mSvFetus of declared pregnant worker0.5 rem during gestation5 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

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The Koret School of Veterinary Medicine

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Interventional Radiology (IR)Line placements and exchangesTranshepatic Intrajugular Portosystemic Shunt (TIPS)Nephrostomy tube placementAV MalformationsG-J Tube placement

** contrast allergy

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Neurology IRAneurysm Coiling and StentingCarotid Artery Stenting (CAS)Pre-operative embolization of brain tumorsStrokeIschemic Intervention (mechanical thrombectomy)Hemorrhagic - Diagnostic

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Aneurysm CoilingConsiderationsBP monitoringProcedure lengthComplicationsThrombosisAneurysm RuptureVasospasmPerforation of normal vesselsContrast reaction

Weiss,M.S., Fleisher,L.A., Rubin,D., & Cutter,T. (2015). Adult Anesthesia in the Radiology Suite.

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Stroke is the FIFTH leading cause of death in the U.S.More than 795,000 people effected each year25% of people who recover from their first stroke will have another stroke within 5 yearsStroke is the leading cause of long-term disabilityIn 2010, stroke cost about $73.7 billion in both direct and indirect costs in the U.S. alone

Acute Stroke Numbers

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Why does North Carolina Care?

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IschemicStroke

Clot occludingartery85%

Intracerebral Hemorrhage

Bleedinginto brain10%

Subarachnoid Hemorrhage

Bleeding around brain5%

www.acponline.org/about_acp/chapters/ok/gordon.ppt

What are the Different Stroke Types?

This is a break down of the types of stroke and what percentage of total strokes they make up.

You have a majority of the strokes that are ischemic and then there are intracerebral and subarachnoid hemorrhage that make up the rest.

Most of what we are going to continue to discuss are the treatment of ischemic stroke,

but I do want you to remember this picture when we talk about ischemic stroke treatment.27

North Carolina Stroke Center

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Program ConceptPSCCSCProgram Medical DirectorSufficient knowledge of cerebrovascular diseaseExtensive expertise; available 24/7Acute Stroke TeamSAMESAMEStroke UnitStroke unit or designated beds for the acute care of stroke ptsDedicated neuro ICU for complex stroke pts available 24/7Initial Assessment of PtSAMESAMEDiagnostic Testing CapabilityCT, MRI, CTA, MRA 24/7, and cardiac imaging when necessaryCT, MRI, labs, CTA, MRA, other cranial and carotid duplex ultrasound, TEE, TTE, catheter and angiography 24/7 and cardiac imaging when necessaryNeurologist Accessibility24/7 via in person or telemedicineMeets concurrently emergent needs of multiple complex stroke patients; written call schedule for attending MDs providing availability 24/7Neurosurgical ServicesWithin 2 hours; OR is available 24/7 in PSCs providing neurosurgical services24/7 availability; neurointerventionalist; neuroradiologist; neurosurgeonTreatment CapabilitiesIV thrombolytics; May have ability to perform: neurovascular intervention for aneursyms, stenting of carotid arteries, Carotid endoarterectomy, and endovascular therapyIV thrombolytics; microsurgical neurovascular clipping of aneurysmsl neuroendovascular coiling of aneurysms; stenting of extracranial carotid arteries; carotid endarterectomy; endovascular therapy

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Anterior vs Posterior

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

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

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Subarachnoid Hemorrhage

IschemicStroke

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Time is Brain

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

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Anesthesia ConsiderationsWhats the best anesthetic options?Sedation vs General AnesthesiaSimilar to a trauma set-upDry Set UpDrug packagesDevelop protocol with multidisciplinary teamMonitoringSet-up/Considerations

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Whats the best Anesthetic?General Anesthesia vs SedationGA gets a bad wrapDelay Time to InterventionWorse Outcomes at 90 daysDuke vs MR Clean TrialDoor 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 DukeNon-GA cohort (38%) vs GA cohort (23%) in the MR Clean trial

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Stroke Trauma Set-Up

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Stroke Drugs

Stroke Code TrayVasopressin 20units/mL 1mL vialPhenylephrine 80mg/250mL bagNicardipine 40 mg/200 mL bag ** Clevidipine 25mg/50mL vialInsulin 1 unit/mL 250 mL bagDextrose 50% - 50mL vialAcetaminophen 10mg/mL 100mL vialPropofol 10mmg/mL 100 mL vial

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Surgical ConsiderationsTime is brain ( 140 mmHg prior to revascularization; 140 mmHg but < 180mmHgPost-revascularization: SPB goals 92% and PaO2 > 60mmHgMaintain normocapnia (PaCO2 35-45 mmHg)Respiratory depression induced hypercarbia should be avoided during procedural sedationFluids Maintain euvolemnia, avoid glucose containing fluids unless treating serum glucose values