Lila Tri Harjana 1

Nama lain :
 Anesthesia at Remote Location
 Anesthesia outside operating room
 Non-operating Room Anesthesia (NORA)
 Office-based Anesthesia (OBA)

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Menurut Royal Collage of Anaesthetists,
mencangkup :
 Life support dan Resuscitation
 Intensive care
 Emergensi
 Radiologi
 Endoskopi
 Bronkoskopi
 Cardiac Catheter
 Cardioversi dan electroconvulsive therapy
(ECT)
 Transportasi intra- dan inter- RS

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 Pemintaan tindakan anestesi untuk
dilakukan diluar kamar operasi
semakin meningkat

 Menjadi tanggung jawab dari dokter

dan Perawat Anestesi untuk memenuhi
standar keselamatan pasien / patient
safety

 Standar Pelayanan Anestesi diluar

kamar operasi harus sama dengan di
kamar operasi
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 Memahami bahwa Standar Pelayanan
Anestesi dan Monitoring Pasien disemua
tempat adalah sama
 Mendalami bahwa Kunci Efisiensi dan
Keamanan Anestesi diluar kamar operasi
adalah Komunikasi Terbuka antara
dokter/perawat anestesi dengan personel /
tim / petugas / dokter / perawat ditempat
tersebut
 Memahami bahwa Anestesi diluar kamar
operasi memiliki tambahan perhatian
keamanan / keselamatan yang berbeda
dengan didalam kamar operasi 5
 Situasi diluar kamar operasi sangat jauh
berbeda dengan didalam kamar operasi

 Kebanyakan rekomendasi atau standar

pelayanan tidak terpenuhi di luar kamar
operasi

 Direkomendasikan “Jangan Lakukan

Sendirian”, perlu ada asisten yang
membantu 6
 Asisten belum tentu merupakan tenaga yang
terlatih atau terbiasa dengan tindakan
anestesi

 Bila diperlukan sedasi atau anestesi,

monitoring pasien harus baik oleh tenaga
yang terlatih

 Penanganan Post-Anesthetic Care harus ter-

standar

There is no safe anesthesia, there is a safe

anesthesiologist / anesthetists 7
 Pasien berasal dari tempat yang SDM-
nya tidak terbiasa melakukan
persiapan Pre-operatif Anestesi

 Asistant pendamping dan perawatan

peralatan anestesi jauh dari ideal
contoh : Tabung oksigen sering kosong
dan peralatan anestesi merupakan alat
anestesi yang paling “tua” di RS 9
 Alat tidak lengkap, dan bila ada, saat
diperlukan sulit didapat

 Kurangnya komunikasi antara petugas di

tempat tersebut dengan tenaga anestesinya

 Sering tidak ada ruang pulih sadar /

recovery

 Lokasinya sering jauh dari fasilitas yang lain,

seperti fasilitas emergensi (ICU, HCU, PACU, 10
dll.)
 Sumber Oksigen cukup beserta Backup
 Alat Suction
 Saluran pembuangan gas (scavenging)
 Alat Monitor yang lengkap
 Bag Valve Mask (BVM) atau Ambu Bag
 Sumber listrik yang memadai dan aman serta Backup
 Ruang Perawatan yang memadai (cukup luas)
 Troli Emergensi dengan defibrillator, obat dan peralatan
emergensi
 Peralatan Komunikasi yang memadai

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 SDM Anestesi yang Kompeten
 Monitoring Pasien secara Kontinue yang
meliputi fungsi oksigenasi, pernapasan,
sirkulasi dan suhu
 pulse oximetry
 ECG
 NIBP (Non Invasive Blood Pressure) /
Tensimeter

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 Perawat dan petugas lainnya Kurang
Terbiasa dengan penatalaksanaan
Anestesi

 Sulit saat terjadi emergensi  tidak

ada SDM yang terampil untuk
membantu

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 Vital Sign Pasien harus sudah stabil sebelum
pindah ke ruang pulih sadar / Recovery
room (RR)
 Pasien harus dimonitoring ketat di RR
 RR harus memiliki fasilitas dan SDM yang
memadai
 Saat memindahkan harus ada oksigen
transport dan monitoring yang cukup

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 Verbal Pain Airway
Breathing Circulation
Response Response Response

Anesthesia
0 0 0 0 0/+
Overdose

Anesthesia 0 0 0 0/+ ++

Deep
0 + + ++ +++
Sedation

Moderate
+ ++ +++ +++ +++++
Sedation

Minimal
+++ ++++ ++++ +++++ +++++
Sedation

No
+++++ +++++ +++++ +++++ +++++
Sedation
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 Includes: US, CT, MRI, RFA, and neuro-coiling.

 The rooms are often crowded with bulky equipment.

 Patients are often required to hold still for long periods

of time (moderate sedation Vs monitored anesthesia
care).

 Some patients still require anesthesia:

children, unconscious patients, movement disorders,
adults with learning difficulties.
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 Unique hazard: radiation exposure.
 Leukemia and fetal abnormalities.
 Dosimeters are required
 Lead aprons, thyroid shields, leaded
glass screens, and video monitoring.

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 Iodinated contrast media.
 Older ionized contrast media were hyperosmolar
and toxic.

 Newer non-ionized contrast media have lower

osmolality and improved side-effects.

 Predisposing factors to adverse reactions from

contrast media include a history of:
bronchospasm, allergy, cardiac disease,
hypovolemia, hematologic disease, renal
dysfunction, extremes of age, anxiety, and
medications (beta-blockers, aspirin, and NSAIDs).
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 Reactions to iodinated contrast media.
 Mild: nausea, perception of warmth, headache, itchy
rash, and mild urticaria.

 Severe: vomiting, rigors, feeling faint, chest pain,

severe urticaria, bronchospasm, dyspnea, arrythmias,
and renal failure.

 Life-threatening: glottic edema/bronchospasm,

pulmonary edema, arrythmias, cardiac arrest, and
seizures/unconsciousness.

 Treatment: O2, bronchodilators, epinephrine,

corticosteroids, and antihistamines. 22
 Does not produce ionizing radiation, is non-
invasive, and does not produce biologically
deleterious effects.

 Is often very time-consuming and any patient

movement, including physiologic motion, can
produce artifacts.

 Obese patients can often not fit within the

magnet.

 Hearing protection is mandatory (produces

loud noises >90 dB).
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 Thermal injury has been reported at site of ECG
electrodes and areas where skin contacts the
machine.

 Not all monitoring device allowed near MRI

machine

 Most significant risk in the MRI suite is the effect

of the magnet on ferrous objects.

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 MRI magnet
 Contraindications for MRI include:
 Shrapnel, vascular clips and shunts, wire spiral
ETT’s, pacemakers, ICDs, mechanical heart valves,
recently placed sternal wire, implanted biological
pumps, tattoo ink with high concentrations of iron-
oxide (permanent eyeliner), and intraocular
ferromagnetic foreign bodies.
 Ferromagnetic items should never be allowed
in the vicinity of the MRI magnet, including:
scissors, pens, keys, gas cylinders, anesthesia
machine, pro-pak monitor, syringe pump,
beeper, phone, and steel chairs.
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 MRI magnet
 Cards with magnetic strips will be de-
magnetized, including credit cards and ID
badges.
 There is a yellow line within the MRI room
which cannot be crossed with any
ferromagnetic materials. Your syringe pump,
pen, and monitor can be within this room as
long as they are behind this line.

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 What to bring:
 Cart (peds vs. adult)

 Monitors : noninvasive BP and cuffs

 Airway
 NC/LMA/ETT
 Long corrugated ventilation tubing
 Jackson-Rees / Mapleson tubing

 Syringe pump and 3 extension sets (this stays at the

foot of the MRI table, far from the machine)

 Meds: propofol, ketamine, midazolam, fentanyl,

NDMB, ephedrine, atrophine as needed.
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 IV tubing and IV fluids

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 During transport, airway management
equipment, including a face mask and an
Ambu bag or a Jackson-Rees circuit, should
be immediately available for providing
positive-pressure ventilation

 It is not unusual to maintain an intravenous

sedation regimen (propofol infusion) during
transport or to have given additional
medications just before transport
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 Before transport, communication between
transport team and unit (for intra-) or referral
hospital must be done and cleared

 For long distance transportation, prepared

for the worse scenario, ex: Oxygen capacity,
patient condition, traffic, road, weather, etc.

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RADIATION THERAPY
 Patient immobility during radiation therapy is the
primary goal of sedation or general anesthesia so that
the delivered radiation can be precisely targeted

 Radiation therapy may involve daily treatments for

several weeks

 Treatments frequently take very little time, and patients

want to quickly resume normal daily activities

 In such instances, sedation or general anesthesia

should be achieved with fast-onset, short-acting drugs
appropriate for brief duration and rapid emergence
while keeping in mind that sedation or anesthesia will
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be repeated daily
RADIATION THERAPY
Anesthesia may also be required for lengthy or
complex cases

All personnel must leave the room during the

radiation treatment, but thick shielding walls
are not Necessary

Physiologic monitoring is accomplished via two

or more remote video connections

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It is important that an electrically induced
seizure be of sufficient duration (>20
seconds) for optimal therapeutic effect

In this regard, the anesthesiologist must

consider the impact of selected anesthetic
drugs on the duration of seizure activity

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The two goals of anesthetic management are
to:
1. provide partial neuromuscular blockade
because unmitigated motor activity can result
in long bone fractures and skeletal muscle
injury
2. render the patient briefly unconscious for
application of the electrical stimulus

Recently, propofol (1mg/kg IV) have become popular

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Although the overall risk of aspiration in ECT
cases is very small (less than 1 per 2000
cases), esophageal reflux and hiatal hernia
are common findings in ECT patients

Some centers use drugs before the

procedure to increase gastric fluid pH or
decrease gastric fluid volume, or both

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 Indications
 Major depression
 Mania
 Certain forms of schizophrenia
 Parkinson’s syndrome

 Contraindications
 Pheochromocytoma
 Increased ICP
 Recent CVA
 Cardiovascular conduction defects
 High risk pregnancy
 Aortic and cerebral aneurysms 39
 What you need:
 Cart
 Suction
 Ambu bag
 Bite block
 O2 NC
 #22g IV
 Meds: STP, Sux, atropine, and esmolol (Poss.
Caffeine)
 Paper charts: pre-op, OR records, charge sheet,
and PACU order forms
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 These pt’s have often had this procedure multiple time,
therefore you can look at old records.
 Place IV and give atropine/glyco. Give caffeine if the
psychiatrist requests.
 Treats the bradycardia/ asystole from the initial
parasympathetic discharge from the seizure activity
 Hyperventilate the pt. with 100% O2.
 STP
 Inflate the manual BP cuff in the arm opposite the IV and then
give Sux.
 Place the bite block.
 Goal is a seizure 30-60 seconds long.
 Ventilate until spontaneous respirations return.
 The parasympathetic discharge is often followed by a
sympathetic discharge associated with HTN and tachycardia. 41
This is treated with esmolol.
The standards of anesthesia care and
patient monitoring are the same
regardless of location

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