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Chapter 14 Patient Monitoring and Local and Regional Anesthesia Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 1 Define terminology related to patient monitoring and anesthesia. ABG Arterial blood gases Auscultation Listening to the sounds of the body, especially the heart and lungs Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 1. Terms Bradycardia Capnometry Measure of expired carbon dioxide Dysrhythmia Slow heart rate Abnormal, disturbed cardiac rhythm Electrocardiography Process of recording electrical activity of the heart Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 1. Terms Exsanguination Intrathecally To render bloodless Pertaining to within the spinal canal Laryngospasm Involuntary contraction of the larynx Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 1. Terms Local anesthesia A method of anesthesia in which an agent is injected or applied topically to interrupt pain impulses at the nerve endings Pulse oximetry A measure of the oxygen saturation of the blood; also measures heart rate Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 1. Terms Regional anesthesia A method of anesthesia in which an agent is injected to block pain impulses at a nerve plexus; causes both pain and motor block Vasoconstrictor An agent that causes contraction (narrowing) of the walls of blood vessels Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2 Describe types of patient monitoring devices. To describe, remember to Define Explain purpose Provide additional detail Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. Electrocardiogram Define Instrument to record electrical activity of the heart Purpose Record heart rate and rhythm Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. Electrocardiogram Detail: Electrodes placed on the patient Attached to leads, which transmit impulses to the ECG device Impulses recorded and displayed on a screen May be set to record a tracing on paper and/or emit an audible signal to indicate heart rate Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. Pulse oximetry Define Noninvasive measure of the oxygen saturation of blood Purpose Assess respiratory function Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. Pulse oximetry Detail: Sensor probe is attached to a finger, toe, or earlobe Image pg 299 Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. Pulse oximetry Detail: Emits red and infrared light, which is absorbed while passing through tissue Remaining light is detected by the opposite side of the sensor probe Used to calculate the saturation of peripheral oxygen (SpO2 or SaO2) Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. Pulse oximetry Detail: Saturation should be above 95% An audible signal reflects pulse rate Signal tone indicates saturation Deeper the tone, the lower the saturation Readings may be affected by various factors Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. Blood pressure Device is called a Define Sphygmomanometer Measure of the force of blood against the vessel walls Purpose Monitor cardiovascular status Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. Blood pressure Detail: “Normal” adult < 130 mm Hg systolic and < 85 mm Hg diastolic Multiple variables affect BP Inflatable cuff on patient’s upper arm connected to unit Device automatically measures BP at set intervals Can be set to emit an audible alarm if BP not within preset limits Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. Thermometer Define Instrument to measure temperature Purpose Detect hypothermia and/or hyperthermia Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. Thermometer Detail: Pediatric and geriatric patients are most at risk for hypothermia Used to check effectiveness of heat loss prevention measures May be monitored at skin, axilla, bladder, esophagus, or ear Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. Thermometer Detail: Normal core temperature varies near 98° F (37° C) Baseline measurement is obtained, and changes are monitored and assessed Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. Capnometry Define Measurement of carbon dioxide (CO2) exhaled by the patient Purpose Assess respiratory function Early detection of compromised ventilation or MH Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. Capnometry Detail: Adapter connected to the breathing circuit Image pg 301 Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. Capnometry Detail: Tubing extends from the adapter to the analyzer Expired CO2 is measured and displayed as a continuous graph and in numerical value Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. BIS monitor Define Bispectral index monitor Modified EEG Purpose Used to assess patient’s level of awareness Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. BIS monitor Detail: Sensor placed on the patient’s forehead Interprets and displays a reading between 0 and 100 Near 100 = patient is fully awake Less than 60 = appropriate depth of general anesthesia with a low probability of explicit recall Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. Nerve stimulator Define Device that stimulates a nerve and measures response Purpose Assess neuromuscular function and blockade Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. Nerve stimulator Detail: A surface electrode or probe • At ulnar or facial nerve TOF: • 4/4 = no muscle relaxation • 0/4 = full muscle relaxation Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. Advanced monitoring Arterial lines used for: Potential for rapid changes in blood pressure Frequent sampling for ABGs Or when routine BP measurement is inaccurate Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. Advanced monitoring CVP lines Placed in vena cava Assess volume of blood returning to the heart Used to assess the need for fluid replacement and to prevent fluid overload Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. Advanced monitoring Pulmonary artery line Swan-Ganz catheter Measures multiple types of pressure and cardiac output Often used during • Cardiac surgery • Lung transplantation • Liver transplantation Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 3 Compare and contrast local anesthesia, monitored anesthesia care, and regional anesthesia. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 3. C/C anesthesia Define each type Explain how the types are similar Explain how the types are different Give examples as needed Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 3. C/C anesthesia Local • Injected at surgical site or placed topically • Interrupts pain message at nerve endings Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 3. C/C anesthesia (Local with) MAC Monitored anesthesia care Same mechanism as local Anesthesia provider is present for advanced monitoring and medications PRN Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 3. C/C anesthesia Regional • Injected at nerve plexus • Blocks entire nerve bundle • Motor and sensory Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 3. C/C anesthesia How are local, MAC, and regional alike? Same agents Same vital signs monitored Sedatives may be given IV Patient remains awake Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 3. C/C anesthesia How are local, MAC, and regional different? Different surgical applications MAC and regional have an anesthesia provider present • Local has RN monitor Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 3. C/C anesthesia How are local, MAC, and regional different? Local and MAC have same administration routes, regional routes are different Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 3. C/C anesthesia How are local, MAC, and regional different? When choosing MAC over local: • Patient ASA status = MAC • complex procedure = MAC Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 3. C/C anesthesia How are local, MAC, and regional different? Regional is used when both sensory and motor block is necessary for surgical procedure Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 4 List surgical procedures that may be performed under local or regional anesthesia. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 4. List surgical proc Local Excision/biopsy soft tissue Repair of finger laceration Toenail excision Septoplasty Cystoscopy Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 4. List surgical proc Local with MAC Insertion of Transvenous pacemaker Venous access port/catheter Dialysis access graft Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 4. List surgical proc Regional: Spinal TURP/bladder tumors Embolectomy Total knee arthroplasty Cesarean section Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 4. List surgical proc Regional: Epidural Relieve pain of labor/delivery Cesarean section Adjunct to general (rare) Post-op pain control for thoracotomy Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 4. List surgical proc Regional: Caudal block Vaginal childbirth (in OB) With general anesthesia for lower-extremity procedures in children For post-op pain management Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 4. List surgical proc Regional: Retrobulbar block Ophthalmology procedures Cataract extraction Less common now More are being done under local/MAC Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 4. List surgical proc Regional: Extremity block Varies by type/location of block Closed reduction/casting Carpal tunnel, trigger finger, or Dupuytren’s contracture Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 5 Identify common agents used in local anesthesia and regional anesthesia. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 5. Common agents lidocaine Bupivicaine (Xylocaine) (Marcaine, Sensorcaine) Mepivacaine (Carbocaine, Polocaine) Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 5. Common agents Image pg 304 Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 6 Discuss the use of epinephrine in local anesthetic agents. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 6. Use of epi in local Local anesthetics may be combined with dilute epinephrine 1:100,000 or 1:200,000 Causes local vasoconstriction slowing the absorption of the agent into the circulatory system Keeps the local agent at surgical site longer, duration of effect Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 6. Use of epi in local Use utmost caution because Epinephrine also available in dose of 1:1000 100 or 200 times more potent Intended for topical application, not injection Patient deaths have occurred Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7 Describe types of regional blocks. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Regional note Regional anesthesia provides both sensory and motor block. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Types of regional Spinal Injected into subarachnoid space Image pg 309 Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Types of regional Spinal Anesthetizes entire lower body Positioning (various) Image pg 309 Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Types of regional Spinal Positioning (various) Image pg 310 Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Types of regional Epidural Injected outside dura (upon) Image pg 311 Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Types of regional Epidural Anesthetizes entire lower body Positioning (various) Labor and delivery Cesarean section Adjunct to general Post-op pain control Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Types of regional Caudal Injected epidural space; sacrum Image pg 312 Labor and delivery Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Types of regional Retrobulbar Injected behind eye, into muscle cone, around optic nerve Image pg 312 Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Types of regional Retrobulbar Cataract extraction Being replaced with topical MAC Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Types of regional Extremity block Arm • Axillary (brachial) • Image pg 313 • Median, radial, ulnar • Bier block (IV regional) Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Types of regional Extremity block Leg • Femoral (most common) • Obturator • Tibial Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Types of regional Extremity block Digital • Finger • Toe Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Types of regional Extremity block: discussion Injected at a plexus of nerves Applications risk of complications w/ general Extremity procedures Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Types of regional Bier block (IV) discussion Insert IV, exsanguinate arm Image pg 314 Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Types of regional Bier block (IV) discussion Tourniquet Agent injected IV Applications Extremity procedures Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. In summary All patients are monitored during anesthesia Various methods are used ST handles local agents on back table Understand epinephrine Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.
