Download Adult Health Lecture

BROOKS COLLEGE of HEALTH
SCHOOL of NURSING
Tammy Carroll, MSN, CRNA, ARNP
Assistant Program Director/Instructor
Nurse Anesthetist Program
Adult Health Lecture
Anesthesia : Concepts in Practice
Objectives
•
•
•
•
Basic Concepts in Anesthesia
Rationales for Choice of Anesthetic Technique
Discuss Surgical Risks
Differentiate: General, Regional and MAC/Local
Anesthetic
– Disadvantages
– Advantages
• Discuss surgical position and related risks
• Identify Perioperative Complications
Basic Concepts
• Anesthesia – Nursing Specialty
– Advanced Practice (ARNP-CRNA)
– MSN (DNP)
– Science & Art
– Highly technical
• Skills
• Knowledge base
– Critical Care Experience
– Professionalism
Basic Concepts
Subspecialties
in the
Practice of Anesthesia
–
–
–
–
Cardiothoracic
Critical Care
Neuroanesthesia
OB
•Pain Management
•Pediatric
•Ambulatory
Basic Concepts
Anesthesia
‘induced state of partial or total loss of sensation, occurring with or
without loss of consciousness’
– Utilization of drugs and/or inhalation agents
– Resulting in an insensibility to pain
Ignatavicius, Donna D.. Medical-Surgical Nursing: Critical Thinking for
Collaborative Care, Single Volume, 5th Edition. Saunders Book Company,
042005. 21.2.3.
<vbk:0-7216-0446-3#outline(21.2.3)>
Basic Concepts
• Anesthesia Techniques
– General
– Regional
– Peripheral nerve blocks
– MAC/Local
– Local only**
Rationale of Anesthetic Choice
• The Procedure
• The Surgeon/Anesthesia Provider
• The Patient
– Preference
– Medical History
– Surgical History
– Assessment
Rationale of Anesthetic Choice
• Degree of Risk: Anesthesia for surgical
procedures:
– Major (CABG)
– Minor (Cataract)
– Emergent (Appy,Trauma)
– Urgent (Cholecysectomy)
– Elective (Plastics, hernias)
Rationale of Anesthetic Choice
• Purpose for surgical procedures: :
– Diagnostic
– Cosmetic
– Ablative
– Transplant
– Palliative
– Constructive
– Reconstructive/Restoration
– Procurement
Rationale of Anesthetic Choice
• Can this procedure be accomplished without
going to sleep?
– Type and duration
– Pain
– Muscle Relaxation
– Length of procedure
Rationales: Surgeon and Anesthesia
Provider
• Preference/Ability
– Attitude
– Skill
– Patience!
Rationale for Choice: Patient
• Preference
• History
– Airway
– Previous anesthetic experience
– Coexisting Diseases & severity
• Present condition
• Assessment
Rationale for Choice: Patient
• Medical conditions
Airway
•
•
•
•
•
•
Difficult or Prolonged intubations
Cervical Spine
Neck radiation, tumor
OSA
Rheumatoid arthritis
Morbid Obesity
Rationale for Choice: Patient
• Medical conditions
Genetics
•
•
•
•
Down Syndrome
Pierre Robin Syndrome
Malignant Hyperthermia
Atypical pseudocholinesterase
Rationale for Choice: Patient
• Medical conditions
Cardiovascular
•
•
•
•
•
•
•
•
•
Exercise Intolerance
HTN
CHF
CAD
Valvular Disease
Cardiomyopathy
Angina
PVD
Dysrhythmia
Rationale for Choice: Patient
• Medical conditions
Pulmonary
•
•
•
•
Asthma
TB
URI
Dyspnea on Exertion
Rationale for Choice: Patient
• Medical conditions
– Medical History
Endocrine
• Diabetes
• Hyperthyroid
• Pheochromocytoma
• Steroid dependency
Rationale for Choice: Patient
• Medical conditions
– Medical History
Neurologic
• Carotid Artery Disease
• CVA/TIA
• Seizure
• Chronic Pain
• Motor/Sensory Loss
Take Home: Technique Choice
• Summary
– Preference of the patient, anesthesia provider and
surgeon
– Coexisting diseases that may or may not be
related to the reason for surgery (GERDS, DM,
asthma)
– Patient age
– Suspected difficult airway management and
tracheal intubation
– Elective or emergency surgery
Basic Concepts: Technique Choice
• Summary, cont.
– Duration of surgery or procedure
– Site of surgery
– Body position of the patient during surgery
– Likelihood of increased amounts of gastric
contents at the time of induction of anesthesia
– Anticipated recovery time
– Postanesthesia care unit discharge criteria
Anesthetic Choice & Patient Risks
• Informed Consent!
Rationales for Anesthesia Technique:
Questions
Basic Concepts
• Anesthesia
• General
• Regional
• MAC/Local
Anesthesia Techniques: Terms
• Preparation
– Patient
– OR
•
•
•
•
•
Preinduction
Induction
Intraoperative management
Emergence
Postoperative management
Anesthesia Techniques: Concepts
• Management of Airway
–
–
–
–
Spontaneous
ETT
LMA
Mask
• Maintain anesthetic level
– Inhalation Agent
– IV Drugs
• Maintain Patient Hemodynamics
– Anesthetist!
Differentiating AnesthesiaTechniques
• General Anesthesia: To Sleep!
– All of the body
‘…a reversible depression of the CNS sufficient to
permit surgery to be performed without
movement, obvious distress, or recall’ (Evers)
i.e. Cardiothoracic, intracranial, upper abdominal
(movement)
Differentiating Anesthesia Techniques
General Anesthesia: Goals
• Analgesia: lack of pain
• Anesthesia: lack of sensation
• Amnesia: lack of memory (immediate perioperative
events)
• Areflexia: lack of reflexes
• Anxiolysis: lack of anxiety
• Antiemesis: lack of emesis
• Muscle relaxation
• Physiologic stability: hemodynamic, respiratory,
hepatic, renal, etc.
Differentiating AnesthesiaTechniques
• Regional: To Sleep, or not!
– Part of the body by region/area
Spinal
Epidural
Peripheral block
With/without sedation
i.e. Amputation, L & D, carpal tunnel repair
Differentiating Anesthesia Techniques
Regional Anesthesia: Goals
• Analgesia: lack of pain
• Anesthesia: lack of sensation
• Amnesia: lack of memory (immediate perioperative
events) **
• Areflexia: lack of reflexes
• Anxiolysis: lack of anxiety**
• Antiemesis: lack of emesis
• Muscle relaxation
• Physiologic stability: hemodynamic, respiratory,
hepatic, renal, etc.
Differentiating AnesthesiaTechniques
• MAC/Local: To Sleep, or not!
– Specific area of the body
Peripheral block
Local Anesthetic to surgical site
With/without sedation
i.e. Amputation (toe), carpal tunnel repair, breast
biopsy, AV Fistula, Eye surgeries, small plastics,
hernia repair
Differentiating Anesthesia Techniques
MAC/Local Anesthesia: Goals
• Analgesia: lack of pain
• Anesthesia: lack of sensation
• Amnesia: lack of memory (immediate perioperative
events) **
• Anxiolysis: lack of anxiety**
• Antiemesis: lack of emesis
• Physiologic stability: hemodynamic, respiratory,
hepatic, renal, etc.
General Anesthesia
Advantages/Disadvantages
•
•
•
•
•
Most Controlled
Any age
Any procedure
Less risk of awareness
Less risk of patient
movement
• Rapid Reversal
– More risks
•
•
•
•
Circulatory depression
Respiratory depression
CV response to ETT
Laryngospasms/Bronchos
pasms
• Dental/soft tissue
damage
• Aspiration
– Postop complications
– More drugs
– Postop N/V
Regional Anesthesia
Advantages/Disadvantages
• Airway & Gag Intact
• Less respiratory and cardiac
depression
• Fewer systemic drugs
• High risk of awareness
• Decreased Postop N/V
• Increased postop pain relief
• Requires more skill
• Is not appropriate for all
procedures or patients
• May result in higher levels of
anxiety
• May result in longer recovery
time
• Awake patient
• Hypotension
• PDPH
• Infection at site
MAC/Local Anesthesia
Advantages/Disadvantages
• Less respiratory and cardiac
depression
• Fewer systemic drugs
• High risk of awareness
• Decreased Postop N/V
• Increased postop pain relief
• May result in shorter
recovery time
• Requires more skill
• Is not appropriate for all
procedures or patients
• May result in higher levels of
anxiety
• Awake patient
• May result in intraop
conversion
Anesthesia
• Pharmacology Adjuncts
– Preop
• Reduce Anxiety (benzodiapines)
• Reduce risk of aspiration (H2 blocker, prokinetic, 5HT3,
anticholinergic
• Reduce Pain (narcotic)
Anesthesia
• Pharmacology Adjuncts
– Intraop
• Induction
– Oxygen
– Blunt CV response to ETT (lidocaine)
– Induction Agents (propofol, etomidate, Ketamine, sodium
pentothal)
Anesthesia
• Pharmacology Adjuncts
– Intraop
• Intubation Agents (DMR, NDMR)
» Succincylcholine
» Zemuron, Vecuronium, Nimbex
• Maintenance (Inhalation/IV)
» 02, Isoflurane, Sevoflurane, Desflurane, N2O
Anesthesia
• Pharmacology Adjuncts
– Emergence
• Reversal
– MR
• Pain
• Postop N/V
GA, Regional, MAC/Local:
Questions
Positioning the Surgical Patient
All positioning schemes have 3 goals:
1. Maximum exposure to the surgical area while
maintaining homeostasis and preventing injury
2. Position must provide the Anesthetist with
adequate access to the patient for airway
management, ventilation, medications, and
monitoring
3. Promote the enhancement of a satisfactory surgical
result
Positioning the Surgical Patient
• Positioning and Anesthesia
– Blunted or obtunded reflexes prevent patients from
repositioning themselves for comfort
– Anesthesia may blunt compensatory sympathetic nervous
system reflexes that would minimize systemic BP changes
with abrupt position changes
– Rendering patients unconscious and relaxed may permit
placement in position they may not have normally
tolerated in an awake state
Positioning the Surgical Patient
Preexisting patient attributes associated with
increased incidence of perioperative
neuropathies:
– extremes of age or body weight,
– preexisting neurologic symptoms,
– diabetes mellitus,
– peripheral vascular disease,
– alcohol dependency,
– smoking,
– and arthritis.
Positioning the Surgical Patient
• 1999 - 670 claims for anesthesia-related nerve
injuries
• #1 - Ulnar nerve (28%)
• #2 - Brachial plexus (20%)
• #3 - Common peroneal (13%)
Positioning the Surgical Patient
•
•
•
•
Ulnar nerve injury
Caused by arms along side patient in pronation
Ulnar nerve compressed at elbow between table
and medial epicondyle.
Prevented by positioning arms in supination.
Hypotension and hypoperfuison increase risk.
Positioning the Surgical Patient
•
•
•
•
Brachial Plexus
Abduct arms to no more than 90 degrees.
Minimize simultaneous abduction, external arm
rotation, and opposite lateral head rotation.
In prone position, maintain abduction and anterior
flexion of arms above head to no more than 90
degrees.
In lateral position, place chest roll under lateral
thorax to minimize compression of humerus into
axilla.
Positioning the Surgical Patient
Peroneal nerve
• Caused by direct pressure on the nerve with
the legs in lithotomy position.
• Nerve compressed against neck of fibula.
• Prevented by adequate padding of lithotomy
poles.
Positioning the Surgical Patient
• Positons which require special care:
– Prone
– Lateral
– Lithotomy
– Sitting
Positioning the Surgical Patient
• Most are nerve injuries due to overstretching and/or
compression.
• 90% undergo complete recovery.
• 10% are left with residual weakness or sensory loss.
• Many injuries can produce lasting disability.
• Many injuries lead to litigation.
• General anesthesia removes many of the bodies natural
protective mechanisms.
• Recognition of risks and prevention is essential.
Positioning Checklist
•
•
•
•
•
Head, neck and cervical spine supported in a straight line.
Scalp, head, and face protected from tight anesthesia
mask/straps.
Ears protected from traumatic pressure/objects.
Chest and torso kept in physiological position for adequate
full, bilateral respiratory exchange and expansion.
Breasts & genitalia protected from excessive pressure.
Positioning Checklist
• Arms in physiological position and supported.
- not to exceed 90 degree extension at
shoulder
- in flexion not hyperextension
- upper arm not hanging over edge of table
rubbing on metal part of table
- elbow area protected from ulnar pressure
- hands free of pressure and compression
- fingers in slight flexion or neutral extension
- wrist restraints loose or padded
- palms up on armboard
- palms towards body when arms at side
or
Positioning Checklist
•
•
•
•
•
•
Genitals free of trauma, pressure, or rubbing.
Back in physiological position, spine in straight line
- slight sacral curvature
- soft small positioning devices under sacral area and knees to
relieve pressure, pain, or stretching.
Thighs/legs in straight line of flexed position; no pressure to iliac
crests, greater trochanters, area bt back & knees, peroneal nerve on
lateral aspects of knees, or to patellas.
Heels/ankles/toes free of pressure or rubbing trauma.
Safety belt placed snugly over patient w/blanket or towel between
strap and patient’s body to prevent maceration.
Other straps or positioning devices placed only over padded body
parts.
Perioperative Complications
• Minor to Major
– Sore throat
– Teeth,soft tissue injury
– Bleeding
– Hemodynamic instability
– Stroke
– MI
– Death
Perioperative Complications
• Uncommon- but Major
– Malignant Hyperthermia
• Acute, life threatening
• Volatile anesthestics/Succinylcholine exposure
• s/s
–
–
–
–
–
–
–
–
Tachycardia
Dysrhythmias
Muscle rigidity
Hypotension
Tachypnea
Skin mottling
Cyanosis
Myoglobinuria
– ETCO2, temperature
MH: Treatment
•
•
•
•
•
•
•
Diagnose Early!
Stop the trigger
Lots of staff
Dantrolene
Ice
IV fluids
Treat arrhythmias
References
Nagelhout, J., Zaganiczny, K. Nurse Anesthesia.
Stoelting, R.K., Miller, R.D. Basics of Anesthesia.
Fleisher, L.A. Anesthesia and Uncommon Diseases.
Ignatavicius, Donna D.. Medical-Surgical Nursing:
Critical Thinking for Collaborative Care, Single
Volume, 5th Edition. Saunders Book Company,
042005. 21.2.3.
Questions