Anesthetic Considerations in Homeland Disasters

Based on these assumptions and in keeping with the theme of this book, this chapter will focus primarily on anesthetic considerations in homeland disasters likely to require the presence of the anesthesiologist in the out-of-hospital or pre-hospital environment. Although most anesthesiologists are adept at handling multiple trauma casualties in the familiar setting of the operating room, even during disasters, this fact does not necessarily apply to anesthesiologists’ expertise in the management of casualties of earthquakes or chemical or biological incidents outside the operating room.2 In order to understand the context within which anesthesiologists might be asked to function in the out-of-operating room setting during disaster response, we will devote a part of this monograph to a brief review of the disaster management functions of prehospital emergency medical services (EMS)/trauma systems. We will also describe the reorganization of hospital and intensive care services necessary to handle a surge of incoming critically injured or ill casualties. Our focus will be the role of the anesthesiologist, working in partnership with community or local EMS/trauma system and its network of hospitals, since the local EMS/ambulance system constitutes the functional unit of disaster medical response in the United States. We will end with a brief description of the major challenges we face in the delivery of intensive care services in mass and catastrophic casualty disasters.

Pediatric Anesthesia Outside of the Operating Room

The anesthesiologist is increasingly being called on to provide pediatric anesthesia care for children in settings outside the operating room (OR). Providing anesthesia in these off-site venues challenges us to gain a familiarity with the procedures, tailor an anesthesia plan to the procedure and location, as well as to plan for the management of life-threatening situations. This chapter will review the different off-site locations and discuss the unique aspects of patient management associated with each area. Typical locations are outlined in Table 24.3.

Office-Based Anesthesia

There are many advantages to office-based procedures for both patients and practitioners. The patient is afforded more privacy with a more personal experience, as well as decreased facility fee if paying out of pocket and less risk of exposure to nosocomial infections. The practitioner will generally have improved ease in scheduling of cases, the convenience of being able to perform surgery within the same office as preoperative and postoperative care, and in some cases will receive an enhanced professional fee.5 An office practice cannot provide the same level of care as a tertiary care medical center or even a small community hospital. For this reason, not all surgical procedures or patient populations are appropriate for this venue. For example, procedures associated with large fluid shifts, blood loss, excessive postoperative pain, or respiratory compromise should continue to be performed in the hospital setting. Likewise, patients with significant comorbidities, potentially difficult airways, or those at risk for aspiration should not be considered suitable candidates for an office-based procedure. The American Society of Anesthesiologists (ASA) has published specific recommendations regarding what types of surgery and patient populations should be excluded from this venue.6

Anesthesia for Procedures in the Emergency Department

The practice of emergency medicine has changed significantly over the past several decades, having evolved into a separate and distinct specialty with a unique knowledge base and training program. As the specialty has evolved, so have the types of patients being cared for in the emergency department (ED), as well as the range of therapies and procedures being performed. For many of these patients, the acute management of pain and anxiety will be an essential component of their ED care and fundamental to the performance of many diagnostic and therapeutic interventions. Possessing an arsenal of anesthesia techniques is invaluable to the practice of emergency medicine. This chapter reviews anesthesia techniques that have special relevance in the ED setting.

Anesthesia for Urologic Procedures

Because more procedures are being performed in outpatient and outside of the OR (OOOR) settings, it is important for the anesthesiologist to not only provide an optimal anesthetic for these patients but also ensure patient and personnel safety. This chapter will discuss anesthesia for common urologic outpatient/OOOR procedures, including cystourethroscopy, ureteroscopy, transurethral procedures except TURP, laser use, percutaneous renal procedures, and extracorporeal shock wave lithotripsy.

Anesthesia for In Vitro Fertilization

In vitro fertilization (IVF) is a broad term used to describe the process of obtaining an egg and uniting it with sperm in a laboratory setting, and subsequently placing the fertilized egg into the uterus in hopes of achieving a live birth. In terms of anesthesiology, IVF primarily means oocyte retrieval. Historically the oocytes were retrieved laparoscopically. With the introduction of the vaginal ultrasound, the method of retrieval changed to a less invasive and costly procedure. Transvaginal ultrasound-guided oocyte aspiration changed the requirements of anesthesia. In this chapter, the anesthesia for oocyte retrieval and related IVF procedures are described.

Anesthesia in the Radiation Oncology Suite

Cancer continues to be a leading cause of death in the developed world, with physicians and scientists constantly devising new weapons to combat it. Chemotherapy, surgery, nutrition, and holistic medicine all have a place in the multimodal approach that can prolong longevity and ameliorate quality of life. As part of this armamentarium, radiation therapy (XRT) has proven to be a safe and effective technique for the management of various malignant (and occasionally nonmalignant) lesions. XRT can be used for both curative and palliative purposes; in the latter case, patients benefit from decreased pain, preserved organ function, and the maintenance of lumen patency in hollow organs.1 The medical team, led by a radiation oncologist, often includes a physicist, a dosimetrist, several radiation therapists (technologists), and the patient’s primary care physician.2 Anesthesiologists are increasingly being asked to join this team, as our services are recognized as a vital component for patient safety and comfort.

Anesthesia for Diagnostic and Therapeutic Radiologic Procedures

As minimally invasive techniques in radiology suites become more common, the need for anesthesia support will increase. While recognizing and addressing a patient’s comorbidities and other concerns are similar to what is already done in the surgical setting, the additional requirements and constraints of the imaging environment and the procedure are unique and call for specific solutions. Just as in the operating room, there is frequently no single best anesthetic technique for a given procedure. The anesthetic should be aligned with the demands of the procedure and the skill sets of the providers. Patient safety always takes precedence, and the location should never be permitted to compromise care.

Recovery and Discharge for Procedures Conducted Outside of the Operating Room

Continued advances in procedural techniques, anesthetic pharmacology, and regional anesthesia allow more prolonged diagnostic and therapeutic interventions to be conducted at an increasing variety of locations outside of the operating room (OOOR). However, recovery and discharge process may vary according to the patient’s condition and the specifics of the procedure. Generally, most patients are sent to the postanesthesia care unit (PACU) and ambulatory surgery unit (ASU) or a medical post-procedure recovery unit not staffed by an anesthesiologist, while some patients receive special postoperative care in a step-down or intensive care unit. Therefore, ensuring rapid postoperative recovery and safe discharge are important components following these OOOR procedures.

Preoperative Patient Evaluation for Anesthesia Care Outside of the Operating Room

Preoperative evaluation and optimization of medical status of patients are important components of anesthesia practice. Increasing numbers of patients with serious comorbidities undergo procedures that require anesthesia services outside of the operating room (OOOR). Often the location alters the challenges of caring for these patients. Surgical, anesthesia, or nursing personnel who can assist with airway and resuscitation management may not be available; equipment and medications may be limited. Many OOOR locations will not have the usual support of an intensive care unit (ICU), skilled postanesthesia recovery personnel, respiratory therapy, or ready access to an inpatient bed, blood banking, interventional cardiology, or diagnostic services. Many of the patients are elderly, ill, and even unlikely candidates for conventional surgery (e.g., transmucosal resection of gastric tumors, transjugular intrahepatic portosystemic shunts). Yet patients and/or providers may be reluctant to expend time and energy in extensive preoperative evaluation before a seemingly minor procedure. This chapter will outline the basics of preprocedure preparation of patients scheduled to receive anesthesia in OOOR settings.