Anesthetics, NMB, Anesthetics, NMB, Narcotics, Sedatives & Narcotics, Sedatives &

AnticonvulsantsAnticonvulsants

Georgia Baptist College of Georgia Baptist College of NursingNursing

Kathy Plitnick RN PhD CCRNKathy Plitnick RN PhD CCRN

AnestheticsAnesthetics

Anesthesia – loss of sensation with/without Anesthesia – loss of sensation with/without loss of consciousnessloss of consciousness

Analgesia - loss of pain sensationAnalgesia - loss of pain sensation Types of AnesthesiaTypes of Anesthesia

General – controlled state of unconsciousnessGeneral – controlled state of unconsciousness Regional – nerve conduction is blocked to a Regional – nerve conduction is blocked to a

region of the bodyregion of the body Local – blocking of pain impulses on peripheral Local – blocking of pain impulses on peripheral

nervesnerves Balanced – selection of several different drugs, Balanced – selection of several different drugs,

without excessive CNS depressionwithout excessive CNS depression

Stages of AnesthesiaStages of Anesthesia

Stage of Analgesia (I): distortion of sight, Stage of Analgesia (I): distortion of sight, hearing, numbness, analgesiahearing, numbness, analgesia

Stage of Delirium (II): loss of Stage of Delirium (II): loss of consciousness, involuntary activity, consciousness, involuntary activity, psychomotor excitementpsychomotor excitement

Stage of Surgical Anesthesia (III): end of Stage of Surgical Anesthesia (III): end of delirium to occurrence of apneadelirium to occurrence of apnea

Stage of Medullary Depression (IV): begins Stage of Medullary Depression (IV): begins with apnea, ends with circulatory collapsewith apnea, ends with circulatory collapse

Parenteral Agents: Propofol Parenteral Agents: Propofol (Diprivan)(Diprivan)

Hypnotic without analgesia, amnesiaHypnotic without analgesia, amnesia IV rapid induction, short term sedationIV rapid induction, short term sedation Rapid acting, rapid emergenceRapid acting, rapid emergence Adverse: hypotension, bradycardia, apneaAdverse: hypotension, bradycardia, apnea Contraindicated: soybean, egg, L&DContraindicated: soybean, egg, L&D Nursing:Nursing:

Titrate to sedation level, aseptic technique (fat Titrate to sedation level, aseptic technique (fat emulsion), emergency equipment, “wake up” emulsion), emergency equipment, “wake up” assessment, patent airway, analgesicsassessment, patent airway, analgesics

Inhalation AnestheticsInhalation Anesthetics

Isoflurane (Forane) –volatile liquidIsoflurane (Forane) –volatile liquid Induction and maintenance – given with Induction and maintenance – given with

Nitrous oxideNitrous oxide Depresses all levels of CNS, skeletal Depresses all levels of CNS, skeletal

muscle relaxantmuscle relaxant Potent respiratory depressantPotent respiratory depressant Minimal depression of myocardiumMinimal depression of myocardium Potential for malignant hyperthermiaPotential for malignant hyperthermia Depresses kidney functionDepresses kidney function

IsofluraneIsoflurane

Post operative shiveringPost operative shivering IV Demerol, rewarmingIV Demerol, rewarming Monitor vs, temperature frequentlyMonitor vs, temperature frequently Prevent aspirationPrevent aspiration Monitor U/OMonitor U/O

Nitrous OxideNitrous Oxide

Nonflammable, inorganic gas, Nonflammable, inorganic gas, colorless, odorlesscolorless, odorless

Cortical depressionCortical depression Good analgesic, weak anestheticGood analgesic, weak anesthetic Rapidly absorbed through lungsRapidly absorbed through lungs Adverse: depresses cardiac Adverse: depresses cardiac

contractility, hypoxiacontractility, hypoxia

Local: LidocaineLocal: Lidocaine

Inhibits transport of ions across neuronal Inhibits transport of ions across neuronal membranesmembranes

Prevents initiation & conduction of nerve Prevents initiation & conduction of nerve impulsesimpulses

Routes: topical, infiltration, mucosal, IVRoutes: topical, infiltration, mucosal, IV Nursing: assess degree of numbness, Nursing: assess degree of numbness,

ensure gag reflex intact after oral spraysensure gag reflex intact after oral sprays Infiltration: used with Epinephrine to Infiltration: used with Epinephrine to

prolong local effectprolong local effect

Neuromuscular BlockersNeuromuscular Blockers

Cause muscle relaxation, paralyzationCause muscle relaxation, paralyzation Short term use: facilitate intubation, Short term use: facilitate intubation,

procedures in mech ventilated procedures in mech ventilated Long term use: mechanical ventilation, Long term use: mechanical ventilation,

control agitation, decrease tissue oxygen control agitation, decrease tissue oxygen demands, increased ICPdemands, increased ICP

Always administer with an analgesic &/or Always administer with an analgesic &/or sedativesedative

Patient is completely dependentPatient is completely dependent Protect the patientProtect the patient

Depolarizing Agents: Depolarizing Agents: Succinylcholine (Anectine)Succinylcholine (Anectine)

Depolarization of motor end plates, Depolarization of motor end plates, bind to receptorsbind to receptors

Muscle contraction appear as Muscle contraction appear as fasciculations (tremors) followed by fasciculations (tremors) followed by muscle relaxationmuscle relaxation

Complete paralysis in 2-3 minutesComplete paralysis in 2-3 minutes No effect on CNSNo effect on CNS

SuccinylcholineSuccinylcholine

Adverse: stimulates vagal gangliaAdverse: stimulates vagal ganglia ApneaApnea Histamine releaseHistamine release Increased intraocular pressureIncreased intraocular pressure Malignant hyperthermiaMalignant hyperthermia

Never assume a paralyzed patient is Never assume a paralyzed patient is asleepasleep

Mechanical ventilation supportMechanical ventilation support

Nondepolarizing AgentsNondepolarizing Agents

Block action of acetylcholineBlock action of acetylcholine Prevents depolarization of muscle Prevents depolarization of muscle

membrane, muscle contraction membrane, muscle contraction cannot occurcannot occur

Used in OR – to expose operative Used in OR – to expose operative site, close woundsite, close wound

Anesthesiologist: facilitate intubationAnesthesiologist: facilitate intubation

Tubocurarine (Tubarine)Tubocurarine (Tubarine)

Gradual paralysis over 1-5 minutes without Gradual paralysis over 1-5 minutes without fasciculationfasciculation

Sequence of paralysisSequence of paralysis Persists for 40-60 minutesPersists for 40-60 minutes Reversed by anticholinesterasesReversed by anticholinesterases Effects: hypotension, peripheral Effects: hypotension, peripheral

vasodilatation, myocardial depression, vasodilatation, myocardial depression, reflex tachycardia, increased secretions, reflex tachycardia, increased secretions, decreased u/o, GI motilitydecreased u/o, GI motility

TubocurarineTubocurarine

Toxic: prolonged apnea, Toxic: prolonged apnea, cardiovascular collapse, cardiovascular collapse, recurarizationrecurarization

Nursing:Nursing: Hypotension profound in hypovolemiaHypotension profound in hypovolemia RehydrateRehydrate Avoid use in asthmaticsAvoid use in asthmatics Excreted by kidneys – slower recovery Excreted by kidneys – slower recovery

or repeated doses of anticholinesterasesor repeated doses of anticholinesterases

Narcotics – MorphineNarcotics – Morphine

Opioid analgesic, binds to opiate Opioid analgesic, binds to opiate receptorsreceptors

Alters perception to painful stimuliAlters perception to painful stimuli Produces CNS depressionProduces CNS depression Uses: severe pain, pulmonary edema, Uses: severe pain, pulmonary edema,

acute MIacute MI Available: oral, IM, IV, SC, rectal, Available: oral, IM, IV, SC, rectal,

epidural, intrathecalepidural, intrathecal

MorphineMorphine

Adverse: confusion, sedation, respiratory Adverse: confusion, sedation, respiratory depression, arrest, hypotension, constipation, depression, arrest, hypotension, constipation, urinary retention, itching, dependenceurinary retention, itching, dependence

Nursing:Nursing: Assess VS, type, location & intensity of painAssess VS, type, location & intensity of pain Assess bowel functionAssess bowel function Co-administration of nonopioid analgesicsCo-administration of nonopioid analgesics Discontinue graduallyDiscontinue gradually Give IVP slowly, safety precautionsGive IVP slowly, safety precautions

CodeineCodeine

Mild narcotic agonistMild narcotic agonist Decreases cough reflex, GI motilityDecreases cough reflex, GI motility Completely absorbed from IM sitesCompletely absorbed from IM sites Use Cautiously in head trauma, Use Cautiously in head trauma,

increased ICP, undiagnosed abdominal increased ICP, undiagnosed abdominal painpain

Often combined with analgesic (ASA, Often combined with analgesic (ASA, tylenol) Tylenol #2 – 15 mg Codeinetylenol) Tylenol #2 – 15 mg Codeine

Pentazocine (Talwin)Pentazocine (Talwin)

Narcotic Agonist-AntagonistNarcotic Agonist-Antagonist Antagonist properties may result in opioid Antagonist properties may result in opioid

withdrawal withdrawal Withdrawal symptoms: vomiting, Withdrawal symptoms: vomiting,

restlessness, abdominal cramps, increased BP restlessness, abdominal cramps, increased BP & temperature& temperature

Additional adverse: hallucinations, euphoria, Additional adverse: hallucinations, euphoria, lightheadednesslightheadedness

IM injections deep into well-developed muscleIM injections deep into well-developed muscle

Narcotic Antagonist – Naloxone Narcotic Antagonist – Naloxone (Narcan)(Narcan)

Antidote for opioid overdoseAntidote for opioid overdose Reverses CNS depressionReverses CNS depression Results in sympathetic stimulationResults in sympathetic stimulation IVP: 0.02 – 0.2 mg q 3-5 minutesIVP: 0.02 – 0.2 mg q 3-5 minutes Always assess pain after IV NarcanAlways assess pain after IV Narcan Resuscitation equipment readily Resuscitation equipment readily

availableavailable

CNS DepressantsCNS Depressants

Benzodiazepines: Lorazepam (Ativan)Benzodiazepines: Lorazepam (Ativan) Potentiates GABA – inhibitory NTPotentiates GABA – inhibitory NT Sedation, amnesiaSedation, amnesia Uses: anxiety, seizures, insomnia, Uses: anxiety, seizures, insomnia,

diagnostic proceduresdiagnostic procedures

Sleep StagesSleep Stages

NREM:NREM: 1: Relaxed wakefulness1: Relaxed wakefulness 2: Light sleep – 50% of sleep2: Light sleep – 50% of sleep 3 & 4: Slow wave (delta), deep restorative, 3 & 4: Slow wave (delta), deep restorative,

secrete hormones, enhance immune function, secrete hormones, enhance immune function, 15-50%15-50%

REM:REM: Mentally, emotionally restorativeMentally, emotionally restorative Psychological problems from deprivationPsychological problems from deprivation 90 minute cycles90 minute cycles

CNS Depressants & REM CNS Depressants & REM sleepsleep

BarbituratesBarbiturates Suppress REM sleepSuppress REM sleep Rebound effectRebound effect

BenzodiazepinesBenzodiazepines Do not suppress REM sleepDo not suppress REM sleep

Lorazepam (Ativan)Lorazepam (Ativan)

Available oral, IM, IV (1-5 min)Available oral, IM, IV (1-5 min) Half-life 10-20 hoursHalf-life 10-20 hours Nursing:Nursing:

Assess degree of anxietyAssess degree of anxiety Psychological, physical dependencePsychological, physical dependence Bedrest, safety precautions (IV)Bedrest, safety precautions (IV) Slow IVPSlow IVP Avoid ETOHAvoid ETOH Seizure managementSeizure management Renal functionRenal function

Anticonvulsant TherapyAnticonvulsant Therapy

Seizures: abnormal electrical activity in Seizures: abnormal electrical activity in nerve cells, discharges occur in cerebral nerve cells, discharges occur in cerebral cortexcortex

Localized areas or entire brain Localized areas or entire brain Idiopathic: no specific causeIdiopathic: no specific cause Nonidiopathic: abscess, trauma, Nonidiopathic: abscess, trauma,

encephalitis, CVA, uremia, ETOH, drug encephalitis, CVA, uremia, ETOH, drug overdoses, sudden withdrawal, overdoses, sudden withdrawal, hypoglycemia, hypocalcemia, feverhypoglycemia, hypocalcemia, fever

AnticonvulsantsAnticonvulsants

Block movement of sodium ions , less Block movement of sodium ions , less excitable membranesexcitable membranes

Enhance GABA activityEnhance GABA activity Long term therapyLong term therapy Oral use, IVOral use, IV Stop a seizure: Lorazepam, DiazepamStop a seizure: Lorazepam, Diazepam Prevent seizure: phenobarbital, dilantinPrevent seizure: phenobarbital, dilantin

Phenytoin (Dilantin)Phenytoin (Dilantin)

Treatment/prevention tonic-clonic Treatment/prevention tonic-clonic seizuresseizures

Alters ion transportAlters ion transport Absorb slowly, 18-24 hoursAbsorb slowly, 18-24 hours Steady state 1-3 weeksSteady state 1-3 weeks Adverse: ataxia, drowsiness, Adverse: ataxia, drowsiness,

hypotension, gingival hyperplasia, hypotension, gingival hyperplasia, slurred speechslurred speech

PhenytoinPhenytoin

Nursing:Nursing: Characteristics of seizureCharacteristics of seizure Oral hygieneOral hygiene Hypersensitivity reactionHypersensitivity reaction Seizure precautionsSeizure precautions IVP precautionsIVP precautions Patient identificationPatient identification Urine: pink, red, reddish brownUrine: pink, red, reddish brown Avoid antacidsAvoid antacids Therapeutic levels: 10-20 mcg/mlTherapeutic levels: 10-20 mcg/ml

PhenobarbitalPhenobarbital

Produces CNS depressionProduces CNS depression Decreases motor activity, alters Decreases motor activity, alters

cerebellar functioncerebellar function Anticonvulsant activity, sedationAnticonvulsant activity, sedation Uses: tonic-clonic, febrile seizuresUses: tonic-clonic, febrile seizures Half-life 2-6 daysHalf-life 2-6 days Adverse: hangover, delirium, Adverse: hangover, delirium,

drowsiness, excitation, hypotensiondrowsiness, excitation, hypotension

PhenobarbitalPhenobarbital

Frequent VS with IV useFrequent VS with IV use Resuscitation equipmentResuscitation equipment DependenceDependence Suicide precautionsSuicide precautions Seizure assessment, precautionsSeizure assessment, precautions Evaluate hepatic, renal, CBCEvaluate hepatic, renal, CBC Therapeutic level: 10-40 mcg/mlTherapeutic level: 10-40 mcg/ml Slow IVPSlow IVP

AnticonvulsantsAnticonvulsants

Clonazepam (Klonopin): petit mal, Clonazepam (Klonopin): petit mal, myoclonic, long term treatmentmyoclonic, long term treatment

Ethosuximide (Zarontin): absence Ethosuximide (Zarontin): absence seizures, peak levels in 3-7 hours, seizures, peak levels in 3-7 hours, anorexia & gastric upset a problemanorexia & gastric upset a problem

Carbamazepine (Tegretol): tonic-Carbamazepine (Tegretol): tonic-clonic, partial seizures, related to clonic, partial seizures, related to TCA’s, watch LFT’s, BUN, bilirubin, plt TCA’s, watch LFT’s, BUN, bilirubin, plt ct.ct.