BROOKS COLLEGE of HEALTH SCHOOL of NURSING

Adult Health Lecture Adult Health Lecture Anesthesia : Concepts in PracticeAnesthesia : Concepts in Practice

Tammy Carroll, MSN, CRNA, ARNP Tammy Carroll, MSN, CRNA, ARNP Assistant Program Director/InstructorAssistant Program Director/InstructorNurse Anesthetist ProgramNurse Anesthetist Program

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 ConceptsSubspecialties

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.. Ignatavicius, Donna D.. Medical-Surgical Nursing: Critical Thinking for Medical-Surgical Nursing: Critical Thinking for Collaborative Care, Single Volume, 5th EditionCollaborative Care, Single Volume, 5th Edition. Saunders Book Company, . Saunders Book Company, 042005. 21.2.3. 042005. 21.2.3. <vbk:0-7216-0446-3#outline(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 conditionsAirway• Difficult or Prolonged intubations • Cervical Spine• Neck radiation, tumor• OSA• Rheumatoid arthritis• Morbid Obesity

Rationale for Choice: Patient

• Medical conditionsGenetics • 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 conditionsPulmonary• 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

SpinalEpiduralPeripheral blockWith/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 blockLocal 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

– More risks• Circulatory depression• Respiratory depression• CV response to ETT • Laryngospasms/

Bronchospasms• Dental/soft tissue

damage• Aspiration

– Postop complications– More drugs– Postop N/V

• Most Controlled• Any age• Any procedure• Less risk of awareness• Less risk of patient

movement• Rapid Reversal

Regional Anesthesia Advantages/Disadvantages

• 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

• Airway & Gag Intact• Less respiratory and cardiac

depression• Fewer systemic drugs• High risk of awareness• Decreased Postop N/V• Increased postop pain relief

MAC/Local Anesthesia Advantages/Disadvantages

• 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

• 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

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 injury2. 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 PatientPositioning 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 PatientBrachial 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 or

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

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