Anesthesia 2021.pptx

ANESTHESIA NUR 512  OBJECTIVES Differentiate between types of anesthesia. Identify risk factors to assess for clients having anesthesia. Describe medications used in conjunction with anesthesia and moderate sedation. Describe nursing care of clie...

ANESTHESIA NUR 512  OBJECTIVES Differentiate between types of anesthesia. Identify risk factors to assess for clients having anesthesia. Describe medications used in conjunction with anesthesia and moderate sedation. Describe nursing care of clients having anesthesia. Describe complications of general anesthesia, local, and regional. Define moderate sedation. Explain the role of the nurse in moderate sedation. Describe nursing care of the client undergoing moderate sedation. Identify complications of moderate sedation and nursing actions to address complications.  Reversible loss of consciousness induced by inhibiting neuronal impulses in areas of central nervous system GE NERAL Single agent or combination of ANESTHESIA agents CNS depression results in: Analgesia Amnesia Unconsciousness  Local: Delivered topically and by local infiltration (injection) R E G I O N A L / LO C A L ANESTHESIA Regional: Type of local anesthesia that blocks multiple peripheral nerves and reduces sensation in specific body region  RISK FACTORS Older adult More sensitive to anesthetic agents Cardiac and respiratory problems arise more quickly Condition can deteriorate rapidly  G E NE RA L A NES T H E S I A R I S K FACT O R S Family history of malignant hyperthermia Respiratory disease Cardiac disease Alcohol or substance use disorder Aspiration of gastric contents  LOCAL ANESTHESIA RISK FACTORS Allergy to ester-type anesthetics Alterations in peripheral circulation  G E NE RA L A NE S T H E S I A : I NH A L A NT S Halathone, isoflurane, nitrous oxide in combination with oxygen Exhalation eliminates inhalation anesthetics; postoperative oxygen and encouraging deep breaths are important interventions!  G E NERA L A NES T H E S I A: I V AG ENT S Benzodiazepines Etomidate Propofol: most common, contraindicated if allergic to eggs or soybean oil Ketamine Short acting barbiturates (methohexital) STAGES OF Induction GENERAL Maintenance ANESTHESIA Emergence  BAL ANCED ANESTHESIA Combination of agents to provide hypnosis, amnesia, analgesia, muscle relaxation, and reduced reflexes Provides safe and controlled delivery of anesthesia Example Propofol for induction Fentanyl for analgesia Pancuronium for muscle relaxation (used to relax jaw and vocal cords immediately after induction to place endotracheal tube) Other medications for symptoms (i.e. nausea)  A DJ U NCT MED IC AT I O NS : O PI O I D S Fentanyl, Sufentanil, Alfentanil Used for sedation and post operative pain Depresses CNS Respiratory depression Delays awakening Postoperative constipation and urinary retention Nausea and vomiting  ADJUNCT MEDICATIONS: BENZODIAZEPINES Diazepam, Midazolam Reduce preoperative anxiety Promote amnesia Produce mild sedation with little to no respiratory depression with careful titration Rapid administration can result in cardiac or respiratory arrest  ADJUNCT MEDICATIONS: ANTIEMETICS Ondansetron, metoclopromide, promethazine Decrease postanesthetic nausea and vomiting Enhance gastric emptying (metoclopromide) Induces sedation (promethazine) Decrease risk for aspiration Adverse effects Dry mouth Dizziness Extrapyramidal symptoms (metoclopramide) Respiratory depression and apnea (promethazine)  Atropine, glycopyrrolate Decrease risk of bradycardia during surgery and vagal slowing of heart due to manipulation Block muscarinic effect of acetylcholine by decreasing salivation, BM, GI secretions Slow motility of GI tract ADJUNCT M E D I C AT I O N S : ANTICHOLINERGICS Decrease saliva, perspiration, gastric and pancreatic secretions Decrease risk for aspiration Adverse effects Urinary retention, difficulty starting urination, tachycardia, dry mouth, decreased effects of levadopa Contraindicated in glaucoma  Pentobarbitol, secobarbitol Sedative effect for preanesthesia sedation or amnesia ADJUNCT Induction of general MEDICAT IONS anesthesia : SEDAT IVES Adverse effects: respiratory depression Avoid giving within 14 days of MAO inhibitor  AD J U N C T M E D I C AT I ON S : N E U ROM U S C UL A R B LO C K I N G AG E N TS Succinylcholine, vecuronium Skeletal muscle relaxation for surgery Airway placement Used with IV agents (propofol) Adverse effects Total flaccid paralysis Requires mechanical ventilation because it blocks contraction of all muscles (diaphragm and respiratory)  PATIENT S AFETY: BEFORE SEDATION Have patient sign consent. Have client urinate to avoid getting out of bed while sedated. Bed low, side rails up.  PAT I ENT S AF E T Y: MO NI T O RI NG DU R I NG S E DAT I O N Airway and O2 status Labs Cardiac status Temperature Drains, tubes, catheters, IV access LOC, vital signs Hypotension: lower head of bed, IV fluid bolus, monitor Notify surgeon and anesthesiologist of abnormalities  COMPLICATIONS OF GENERAL ANESTHESIA Malignant Hyperthermia Acute life-threatening medical emergency! Inherited muscle disorder that anesthesia induces chemically Hypermetabolic condition causing alteration in calcium activity in muscle cells (muscle rigidity, hyperthermia, CNS damage) Triggered by inhalation anesthetics and succinylcholine  Initial symptoms: Increased CO2 level, decreased O2 level, tachycardia Dysrhythmias, muscle rigidity, M AL I GN A NT hypotension, tachypnea, skin H Y P E RT H E R M I A mottling, cyanosis, muscle cell S I G NS A ND protein in urine S Y M P T OM S (myoglobinuria) Extremely elevated temperature is late manifestation!  MA LI G NANT H Y PE RT H E R MI A NU R S ING ACT I O NS Terminate surgery Administer IV dantrolene (muscle relaxant) Administer 100% oxygen Obtain labs and ABGs Infuse iced 0.9% NaCl Apply cooling blanket, ice to axillae, groin, neck, and head, iced lavage Insert urinary catheter (if not present)  Anesthesia overdose Unrecogniz OTHER ed C O M P L I C AT I O N S OF hypoventila ANESTHEISA tion Intubation problems  J O U R N A L A RT I C L E : A D V E R S E E V E N T S I N A N E S T H E S I A : A N I N T E G R AT E D R E V I E W ( S A N TA N A L E M O S & B R I T O P O V E D A , 2 0 1 8 ) PICO: “What adverse anesthetic events occur in the perioperative period?” 21 articles, 4 categories: Respiratory, drug error, cardiology, neurology Respiratory: Aspiration, inadequate ventilation, difficult intubation Drug error: Wrong drug, wrong dose Cardiology: Hemorrhage, hemodynamic instability, arrhythmias Neurology: Pain, intraoperative awareness, awake paralysis  Lack of attention Inadequate care planning Limitations of work environment R E A S ON S F O R Incorrect clinical judgment FAI LU R E S A ND Delayed identification of ADV E R S E EVENTS changes and decision making Stress and fatigue  Development of guidelines, protocols, and checklists Culture of patient safety R E C O M M E N D AT I O N S Improvement in work conditions Establishing respectful environments Fatigue management systems Better communication  REGIONAL ANESTHESIA Used when Depending on prevention of type, emergency post-operative surgery when pain is desired client has not (total joint been NPO for replacement) sufficient time  Anesthetic injection into CSF in subarachnoid space to provide autonomic, sensory, and motor blockade below level of innervation Motor function Sense of touch returns first, then pain, warmth, cold, and movement Complications of autonomic SP INA L blockade ANESTHE SI A Hypotension, bradycardia, nausea, vomiting Lower head of bed, increase IV fluids, monitor VS CSF leak Headache Head of bed flat, quiet environment, adequate hydration  EPIDURAL ANESTHESIA Anesthetic injection into the epidural space in thoracic or lumbar areas of spine to block sensory pathways, but leave motor function intact Complications High spinal anesthesia Depressed respirations, respiratory arrest, severe hypotension IV fluids, vasopressors, airway support Headache DIFFERENCE BETWEEN SPINAL AND EPIDURAL ANESTHESIA  NERVE AND FIELD BLOCKS Nerve block: Field block: injection of injection of anesthetic in anesthetic near a proximity of main larger nerve peripheral nerve trunk  Topical: applied directly to skin LOCAL Local infiltration: injected into tissues through ANESTHESI which incision will be A made (lidocaine) Concurrent administration of vasoconstrictor (epinephrine) prolongs effects and decreases risk of systemic toxicity.  Edema and inflammation of injection site; risk for tissue necrosis and gangrene Systemic toxicity Restlessness, altered speech, COMPLICATION blurred vision, metallic taste, S tremors, tachycardia; can lead to cardiac arrest, apnea, and death Airway support and administration of rapid-acting barbiturate (thiopental sodium or pentathol)  MODERATE SEDATION Administration of opioids and sedatives so that client: Relaxes enough for minor procedures Can respond to verbal stimuli Retains protective reflexes Is easily arousable Maintains airway Requires credentialing and regular competency assessment Client must be monitored continuously during sedation  MEDICATIONS Opioids: morphine, fentanyl, alfentanil Benzodiazepines: midazolam, diazepam Anesthetics: propofol, etomidate Reversal agents Opioids: naloxone Benzodiazepines: flumazenil PROCEDURES THAT US E MODERAT E SE DATI ON Minor surgical procedures Diagnostic procedures Cardioversion Wound care Reduction and immobilization of fractures Placement of implanted devices and tubes  Obtain history, especially experience with moderate sedation or anesthesia Educate about procedure and medications Perform a full assessment PRE-PROCEDURE Determine last time client ate or NURSING CARE drank Establish IV access, administer fluids Verify consent has been signed Attach monitoring equipment Remove dentures  INTRA- PROCEDURE Remain with client at all times! Monitor VS, LOC, cardiac and respiratory status Maintain safe environment Have emergency equipment available Crash cart Oxygen source Monitoring equipment for cardiac rhythm, BP, SaO2, temperature Stethoscope Suction  Discharge criteria LOC baseline VS stable for 30-90 minutes Ability to POST Cough and deep breathe PROCEDURE Urinate Tolerate oral fluids No nausea, vomiting, shortness of breath, dizziness No obvious bleeding  Respiratory depression Administer reversal agent Insert oral airway and suction Cardiac arrhythmias COMPLICATION Obtain 12 lead ECG, administer S fluids Hypotension Fluids and vasopressors Anaphylaxis Epinephrine A LITTLE HUMOR….