surgicalexperienceanes-1233051991488803-3

8/8/2019 surgicalexperienceanes-1233051991488803-3

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ANESTHESIA

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IV line inserted

Receiving a sedating agent prior to induction

Losing consciousness Being intubated; if indicated

Receiving a combination of anesthetic agents

Has no recall of events

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Concurrent medications

Optimization of medical treatment for:

Diabetes Mellitus (DM) glycemic control Nutritional status malnourishment

Smoking cessation

Obesity weight loss COPD respiratory status, postop exercises



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class 1 - able to visualize soft palate, fauces, uvula, ant and post tonsillar pillars

class 2 - able to visualize all of the above, except anterior andposterior tonsillarpillars are hidden by the tongue

class 3 - only the soft palate and base of the uvula are visible

class 4 - only the soft palate can be seen (uvula not visualized)



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Common classification of physical statusatthe time of surgery

ASA 1 : healthy fit patient ASA 2 : with mild systemic disease ASA 3 : with severe systemic disease that limits

activity ASA 4 : with incapacitating disease that is a

constant threat to life ASA 5 : a moribund patient not expected to

survive 24 hours with/without surgery



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Levels Findings

Minimal SedationPatient responds normally to VERBAL

commands,Cognitive &Coordination Fxnmay be impaired, but Ventilatory &

Cardiovascular Fxns Unaffected

Moderate SedationMidazolam(Versed)/Diazepam(Valium) usedoften. Depressed LOC that does not impairpatients ability to maintain a patent airway

Deep SedationPatient cannot be easily aroused but can

respond purposefully after repeatedstimulation. IV or Inhalation. NO2 most

commonly used GAS Anesthetic

ANESTHESIAState of Narcosis (severe central nervous

system depression produced by

pharmacologic agents), analgesia, relaxation,and reflex loss. Not arousable.nursinglectures.blogspot.com


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Stages of ANESTHESIA Findings

Beginnning Anesthesia /

Induction

Patient feelsDIZZY,WARMTH andDETACHED. May have ringing, roaring,

or buzzing in the ears. AVOIDNOISE

ExcitementPR is rapid. Respirations maybe IRREGULAR.

SAFETY of the patient is the PRIMARY

CONCERN.

Surgical Anesthesia

Unconsciouspatient. RR is regular. PR and

BP is normal. SKIN is PINK and slightlyFlushed.Continuous administration of

Anesthetic agent.

Medullary DepressionToo much Anesthesia. Pulse is weak and

thready. Pupil become WIDELY

DILATED.Respiratory andCardio Support.DEATH rapidly follows.



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Inhalation administered with mixing the

vapors with OXYGEN. Via ET TUBE or MASK

Injectionno buzzing, roaring, or dizziness.THIOPENTAL, agent of choice. Useful in EYEsurgery(low Nausea and Vomiting)

Rectalobsolete but sometimes used in

Pediatric patients.



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Tranquilizers and Sedative Hypnoticsa. Benzodiazepines1. Midazolam (Versed) Monitor Respiratory Status

2. Diazepam (Valium) - may producedThrombophlebitis-Central vein is preferred

3. Chlordiazepoxide (Librium) hypnosis(induction)

4. Droperidol (Inapsine) Extramidal rigidity

5. Lorazepam (Ativan) Hepatoxic/Nephrotoxic

Flumazenil (ANEXATE) benzodiazepine antagonist



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b. Opiods1. Morphine (High Doses)

- not a myocardial depressant

- orthostatic hypotension(decreasing systemic vascularresistance)

2. Meperidine HCl(Demerol)

- Spasmolytic effect- DOC for bile duct, distal colon, and rectum surgery.- Ready diphenhydramine (benadryl) for Allergic

reaction.



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- refers to combination of short-acting syntheticopiod agent(fentanyl) and a butyrophenone(droperidol)

1. Fentanyl (Sublimaze ) 75%-100% more potent than morphine

littleCardio effect

Respiratory depression 2. Sufentanil (Sufenta)

Onset extremely rapid

1/3 duration of fentanyl



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The patient appears to be asleep oranesthesized, but rather dissociated from

surroundings. Ketamine (Ketalar;Ketaject)

useful when Hypotension can be hazardous

may experience hallucinations

AVOIDVerbal, Visual, orTACTILEstimulation.(triggers psychic aberration)

Droperidolor Diazepam may eliminate suchpsychic phenomena.



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Thiopenthal sodium (Pentothal)

not for children

Rapid induction Powerful depressant for breathing

Methohexital sodium (Brevital)

rapid onset seizures

necrosis if IV infiltrates



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Etomidate (Amidate) Useful for FRAIL patients Transient ADRENAL suppression Involuntary muscle movements

Propofol (Diprivan) Rapid induction May have antiemetic effect

Pain on injection Myocardial depression Contraindicated in patients with allergyto EGGS and

SoybeanOil



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Anesthetic agent is injected around nerves.

Motor fibers have the thickest myelin sheath

Sympathetic fibers are the smallest and haveminimal covering

Sensory fibers are intermediate

An anesthetic is worn off until all three are no

longer affected.

A QUIET environment isTHERAPEUTIC



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Epidural Anesthesia injection of local

anesthetic into the spinal canal in the space

surrounding the dura mater. Absence of spinal headache

Difficult to introduce anesthetic agent into theepidural rather than the subarachnoid space.

HIGH spinalcan result(subarachnoid injection) causes severe hypotension, respiratory depressionand arrest (TREATMENT: Airway, IV, Vasopressor)



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Spinal Anesthesia local anesthetic is introducedinto the subarachnoid space at the lumbar level,usually between L4 and L5. Anesthesia of the lower extremities, perineum and

lower abdomen

Lumbar puncture procedure KNEE-CHEST(side)

Procaine,tetracaine(Pontocaine),lidocaine(Xylocaine),and bupivacane(Marcaine).

Respiratory Paralysis (Temporary/Complete) Highconcentrations of med reached the upper thoracicand cervical spinal cord



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RiskFactors Size of spinal needle used

Leakage ofCSF from the subarachnoid space Patients hydration status

DecreasingCerebrospinal pressure

TREATMENT

1. Keep patient LYING FLAT

2. QUIET

3. Well hydrated



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Brachial plexus block anesthesia of the arm

Paravertebral anesthesia

anesthesia of nervessupplying theChest, Abdominal wall & Extremities.

Transsacral (caudal) block anesthesia of the

perineum, and occasionally, the lower abdomen.



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The injection of a solution containing the localanesthetic into the tissues at theplanned incisionsite

Advantages Simple, Economical, non-explosive

Equipment needed is minimal

Post-operative recovery is brief

Undesirable effects of GA are avoided

Ideal for SHORT and SUPERFICIAL operations

Usually given with EPINEPHRINE



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maximum dose usually expressed as (mg ofLA) per (kg of lean body weight) and as a

total maximal dose (adjusted foryoung/elderly/ill) lidocaine maximum dose: 5 mg/kg(with

epinephrine: 7mg/kg)

chlorprocaine maximum dose: 11 mg/kg(with epinephrine: 14 mg/kg) bupivicaine maximum dose: 2.5 mg/kg(with

epinephrine: 3 mg/kg)



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Occurs by accidental IV injection, Overdose orunexpectedly rapid absorption

CNS effects Numbness of tongue, Perioral tingling

Disorientation, drowsiness

Tinnitus

VisualDistrubances Muscle twitching, tremors

Convulsions, seizures

GeneralizedCNS depression, coma, respiratory arrest



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CVS effects

Vasodilation, hypotension

Decreased myocardial contractility Dose-dependent delay in cardiac impulse

transmission

Prolonged PR, QRS intervals

Sinus bradycardia

CVS collapse



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Early recognition of signs

100% O2, manage ABCs

Diazepam may be used to increase seizurethreshold

If seizures are not controlled by diazepam,consider using :

Thiopental (increases seizure threshold)

SCh (stops muscular manifestations of seizures,facilitates intubation)



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Nausea & Vomiting

Turn to side, head lowered, provide basin

Pre-op Antiemetic drugs Suction for Saliva and vomited gastric contents

Aspiration of Vomitus can lead to Pneumonitisand Pulmonary Edema leading to HYPOXIA.



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Anaphylaxis

Reaction of the body to foreign substances

Meds common cause of anaphylaxis Latex reaction can also occur

Life-threatening vasodilation, hypotension, andbronchial constriction

Fibrin sealants and cyanoacrylate adhesives canalso cause anaphylactic reaction



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Hypoxia and RespiratoryComplications

Patients oxygenation status is the PRIMARY

FUNCTION of the ANESTHESIA PROVIDER andtheCIRCULATING NURSE.

Pulse Oximetry Values are monitoredcontinuously.

Anatomic variation, ET tube may be inserted

Surgical POSITIONING (Trendelenburg)



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Hypothermia

Glucose metabolism is reduced,TEMP decreases

results in METABOLICACIDOSIS Below 36.6C[98.0F] below Normal core temp

Low temp in OR (Set at 25 to 26.6Celsius)

Infusion of cold fluids (Warm to 37.6Celsius)

Warming should be gradual



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Malignant Hyperthermia inherited MUSCLE

DISORDER chemically induced by anesthetic

agents. Susceptible People

Those with strong and bulky muscles

History of muscle cramps or muscle weakness

Unexplained temperature elevation

Unexplained death of a family member aftersurgery



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Stress:

Trigger

Release ofCa++MUSCLE

CONTRACTION

PumpingMechanism

FAILS

Ca++ NOTRETURNED;

Ca++accumulates

Hypermetabolism ,hyperthermia,damage to thecentralnervous

system

IncreasesMUSCLE

contraction(rigidity)



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Tachycardia (150 beats/min), early sign Ventricular dysrhytmia Hypotension DecreasedCardiac Output Oliguria Cardiac Arrest Rigidity , tetanus-like movements Rise in temp, usually a late sign, develops fast 1to 2C every 5 mins, can exceed 40C Trismus (masseter spasm) common not specific

forMH, occurs 1% in children given SCh w/ Halo



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Death /ComaDisseminated intravascular

coagulation (DIC) Muscle Necrosis / weakness

Myoglobinuric renal failure Electrolyte abnormalities (i.e.

iatrogenic hypokalemia)



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Suspect possible MH with family history of

problems/death with anesthetic

Dantrolene prophylaxis no longer routine Avoid all triggers

Central Body temp and ETCO2 monitoring

Use regional anesthesia if possible

Use equipment clean of trigger agents



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Discontinue inhaled anesthetic agent andSCh, terminate procedure

Hyperventilate with 100% O2 Dantrolene 1mg/kg, repeating until stable or10mg/kg maximum reached

Treat metabolic/physiologic derangements

accordingly Control body temperature Diligent monitoring (especiallyCVS, lytes,

ABGs, urine output)



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Life-threatening, characterized by thrombusformation and depletion ofselect coagulation

proteins, Idiopathic Predisposing factors:

Emergency surgery

Massive trauma

Head Injury Massive transfusion

Liver/kidney involvement

Embolic events or shock



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AVOID Derogatorycomments Patient is treated as a person Respecting cultural and spiritual

values

Providing physical privacy MaintainingConfidentiality



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1. A patient in the holding area awaitingsurgery indicates thathe hadnot received

instructions not to take his usual medications

(antihypertensive agent, diuretic, digoxin,potassium chloride, and insulin injection); as a

result, he took them a few hours ago. What

implications does this have for the patientscare and well-being while awaiting surgery,during surgery, and in the immediate

postoperative period?nursinglectures.blogspot.com


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2. What are the differences inresponsibilityof the operating room

nurse for care of patients who receivegeneral anesthesia, conscioussedation, spinal anesthesia, and

regional anesthesia?



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3. While she is being transferred fromthe stretcher to the operating table, a

female patient says she is veryanxious about her surgery because of

previous negative experiences. What

assessmentandinterventions areindicated at this time?



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