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Manage a Patient Under General Parenteral Anesthesia 081-833-4549

OBJECTIVE. As a Special Forces Medic given a patient under general parenteral anesthesia, continually monitor the patients vital signs, apply corrective treatment to any life threatening changes in the patients vital signs, and maintain the patient at stage three of general anesthesia in accordance with JSOMTC student manual of anesthesia..

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Manage a Patient Under General Parenteral Anesthesia 081-833-4549

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    1. Manage a Patient Under General Parenteral Anesthesia 081-833-4549 INSTRUCTOR SFC HILL NONENONE

    2. Have a student read this slide out loud to the rest of the class.Have a student read this slide out loud to the rest of the class.

    3. REASON As a Special Forces Medic performing general parenteral anesthesia, you will be responsible for maintaining the patient at stage three of general anesthesia and maintaining the life of the patient through surgery and recovery from anesthesia. Have a student read this slide out loud to the rest of the class.Have a student read this slide out loud to the rest of the class.

    4. PROCEDURES Review the principles of monitoring and maintenance Review the components, clinical signs, and depth of anesthesia Apply the principles of monitoring and maintenance (Circle of Awareness) Have a student read this slide out loud to the rest of the class.Have a student read this slide out loud to the rest of the class.

    5. Review the Principles of Monitoring and Maintenance NONENONE

    6. Monitoring Tasks Level of Anesthesia A B C Keep it as simple as you can.Keep it as simple as you can.

    7. Monitoring Level of Anesthesia Unresponsive to pain stimuli Eyes fixed and pupils constricted Muscles relaxed This is the target zone. This is how we want the patient to appear during surgery. Unresponsive to pain stimuli = no sympathetic response to pain (sweating, tachycardia, ect.)This is the target zone. This is how we want the patient to appear during surgery. Unresponsive to pain stimuli = no sympathetic response to pain (sweating, tachycardia, ect.)

    8. Monitoring Airway Must maintain positive control over the patients airway (to include the tongue) Monitor the airway at all time while the patient is under general anesthesia. Protect and manage the tongue at all times. Ensure you do not pinch off the tongue’s oxygen (RBCs) supply. With Ketamine alone patient should be able to maintain his/her own airway for a short period of time. (suction may be required)Protect and manage the tongue at all times. Ensure you do not pinch off the tongue’s oxygen (RBCs) supply. With Ketamine alone patient should be able to maintain his/her own airway for a short period of time. (suction may be required)

    9. Monitoring Airway Oxygenation O2 should be humidified as long as the patient has clear breath sounds.O2 should be humidified as long as the patient has clear breath sounds.

    10. Monitoring Breathing The lungs and breathing must be continuously monitored. Rate and depth of respirations Dry versus wet lungs? QUESTION: What is the significance of wet lungs? ANSWER: Pulmonary edema.QUESTION: What is the significance of wet lungs? ANSWER: Pulmonary edema.

    11. Monitoring Breathing I Inspection A Auscultation P Palpation P Percussion You must IAPP the chest on arrival to the OR. If the patient has, or is suspected of having a compromised thoracic cavity you must do a complete IAPP Q5 minutes until a chest tube is put in and accessed. If the thoracic cavity is uncompromised then you will only IA the chest Q5 minutes after initial check.You must IAPP the chest on arrival to the OR. If the patient has, or is suspected of having a compromised thoracic cavity you must do a complete IAPP Q5 minutes until a chest tube is put in and accessed. If the thoracic cavity is uncompromised then you will only IA the chest Q5 minutes after initial check.

    12. Monitoring Circulation Heart rate, character, and rhythm = 68 strong and regular Tissue perfusion Body temperature Renal Function Check the perfusion of the tissues.Check the perfusion of the tissues.

    13. Components of General Anesthesia Muscle Relaxation Unconsciousness Analgesia Start thinking of the components of general anesthesia as a pie with three slices. Each slice of the pie requires the attention of a different pharmaceutical agent.Start thinking of the components of general anesthesia as a pie with three slices. Each slice of the pie requires the attention of a different pharmaceutical agent.

    14. Components of General Anesthesia Muscle Relaxation Amount of skeletal muscle relaxation requirements depend on the type of operation. QUESTION: What are the pharmacological agents that we are going to use to induce muscle relaxation. ANSWER: Diazepam or MidazolamQUESTION: What are the pharmacological agents that we are going to use to induce muscle relaxation. ANSWER: Diazepam or Midazolam

    15. Components of General Anesthesia Analgesia/ Areflexia Pain reflexes are subdued. QUESTION: What is the pharmacological agent that we are going to use to induce Analgesia. ANSWER: Ketamine and morphine.QUESTION: What is the pharmacological agent that we are going to use to induce Analgesia. ANSWER: Ketamine and morphine.

    16. Components of General Anesthesia Unconsciousness/Hypnosis The patient is oblivious to all sensation but pain reflexes can occur. QUESTION: What is the pharmacological agent that we are going to use to induce unconsciousness? ANSWER: Ketamine.QUESTION: What is the pharmacological agent that we are going to use to induce unconsciousness? ANSWER: Ketamine.

    17. Depth of Anesthesia Stages and Planes of Ether Anesthesia Stage I Amnesia Stage II Excitement Stage III Surgical Anesthesia Plane 1 Plane 2 The Surgical Plane Plane 3 Plane 4 Stage IV Impending Death NONENONE

    18. Stages and Planes of Ether Anesthesia STAGE I Amnesia From the onset of drowsiness to the loss of the eyelash reflex. Pain perception threshold during this stage is not loweredPain perception threshold during this stage is not lowered

    19. Stages and Planes of Ether Anesthesia STAGE II Excitatory Stage Agitation, delirium, irregular respiration and breath holding . Pupils dilate, eyes diverge. Potentially dangerous responses to noxious stimuli can occur during this stage, including vomiting, laryngospasm, hypertension, tachycardia, and uncontrolled movement. The return of regular respiration marks the end of this stage.Potentially dangerous responses to noxious stimuli can occur during this stage, including vomiting, laryngospasm, hypertension, tachycardia, and uncontrolled movement. The return of regular respiration marks the end of this stage.

    20. Stages and Planes of Ether Anesthesia STAGE III Surgical Anesthesia Plane 1 From the return of regular respirations to the cessation of REM. Characterized by central gaze, constricted pupils, and regular respiration.Characterized by central gaze, constricted pupils, and regular respiration.

    21. Stages and Planes of Ether Anesthesia STAGE III Plane 2 The Surgical Plane From the cessation of REM to the onset of paresis of the intercostal muscles. Key Phrase: Onset of paresis.Key Phrase: Onset of paresis.

    22. Stages and Planes of Ether Anesthesia STAGE III Plane 3 From the onset to the complete paralysis of the intercostal muscles. Key Phrase: To complete paralysis.Key Phrase: To complete paralysis.

    23. Stages and Planes of Ether Anesthesia STAGE III Plane 4 From the paralysis of the intercostal muscles to the paralysis of the diaphragm - at the end of this plane the patient will be apneic. Key Phrase: Paralysis of diaphragm.Key Phrase: Paralysis of diaphragm.

    24. Stages and Planes of Ether Anesthesia STAGE IV Impending Death From the onset of apnea to circulatory failure. Onset of apnea, dilated and non-reactive pupils, hypotension to complete failure of the circulation.Onset of apnea, dilated and non-reactive pupils, hypotension to complete failure of the circulation.

    25. The Circle of Awareness is the anesthetist monitoring management tool. There are numerous task and principals that need to be applied with in a very short and intense time period. This is the tool that will allow you, as the anesthetist, to accomplish your tasks and apply the proper principals in a successful and timely manner. There are six step within the Circle of Awareness. This is how you are going to monitor and maintain your patient.There are numerous task and principals that need to be applied with in a very short and intense time period. This is the tool that will allow you, as the anesthetist, to accomplish your tasks and apply the proper principals in a successful and timely manner. There are six step within the Circle of Awareness. This is how you are going to monitor and maintain your patient.

    26. The circle helps the anesthetist to monitor and manage: Vital signs Stage of general anesthesia Airway, respiratory and cardiac systems Input and output of all fluids and drugs Time Recording Communications NONENONE

    27. The circle of awareness should begin a few moments after the patient is placed on anesthesia maintenance. The circle MUST begin within five minutes of placing the patient on anesthesia maintenance! QUESTION: Why do we start the circle within 5 minutes? ANSWER: Most of your check are Q5 minutes. You must utilize other personnel within the OR to assist you with intubation, application of the EKG monitor, obtaining IV access, insertion of the NG tube, insertion of the urinary catheter, and application of the BP cuff.The circle MUST begin within five minutes of placing the patient on anesthesia maintenance! QUESTION: Why do we start the circle within 5 minutes? ANSWER: Most of your check are Q5 minutes. You must utilize other personnel within the OR to assist you with intubation, application of the EKG monitor, obtaining IV access, insertion of the NG tube, insertion of the urinary catheter, and application of the BP cuff.

    28. PATIENT Patient should be unresponsive to painful stimuli Eye’s should be: Fixed, pupils constricted (dilated = caprine specific) and non-reactive to light Mandible and tongue: Relaxed Limbs: Relaxed, non-withdrawal to pain If being assisted by personnel within the OR, request a temperature and blood pressure be taken at this time As you begin to establish the patient’s level of anesthesia, these signs should help you keep the patient at stage 3, plane 2 of general anesthesia. NOTE: Initially and on occasion during Ketamine induced anesthesia, the patient might have some limb movement. This could be due to the effects of the Ketamine.As you begin to establish the patient’s level of anesthesia, these signs should help you keep the patient at stage 3, plane 2 of general anesthesia. NOTE: Initially and on occasion during Ketamine induced anesthesia, the patient might have some limb movement. This could be due to the effects of the Ketamine.

    29. AIRWAY Inspect Oxygen Tubing: From the wall to the patient Inspect Endotracheal Tube: Secured, bulb inflated, bite block present, and suction PRN Inspect Patients Respiratory Effort: Note rate and rhythm, one deep ventilation All lines into patient should be in complete view of the anesthetist at all times. O2 should be humidified and anesthetist should note rate of O2 flow. Patients tongue should be moist and not pinched between bite block and jaw. The ET tube can be replaced during anesthesia when necessary. AMBU bag need to be disconnected to note respiratory effort and ET tube placement. Then place the bag back on the ET tube. At this time, deep ventilate the patient (Q5) to help prevent atelectasis.All lines into patient should be in complete view of the anesthetist at all times. O2 should be humidified and anesthetist should note rate of O2 flow. Patients tongue should be moist and not pinched between bite block and jaw. The ET tube can be replaced during anesthesia when necessary. AMBU bag need to be disconnected to note respiratory effort and ET tube placement. Then place the bag back on the ET tube. At this time, deep ventilate the patient (Q5) to help prevent atelectasis.

    30. BREATHING Inspect Trachea: Look for Tracheal deviation or jugular vein distention (JVD) Inspect Chest: Rise and fall Auscultate Chest: Clear breath sounds, note rate and rhythm (again) Inspect trachea on the way to the chest.Inspect trachea on the way to the chest.

    31. CIRCULATION Auscultate Heart: Note rate and rhythm Inspect All IV’s : Read labels and check fluid levels, check drip rate, inspect tubing to catheter, inspect IV site for infiltration Blanch (capillary refill) the patients finger (gums or tongue for Caprine) to check tissue profusion. As always, all lines should be in complete view of the anesthetist at all times. Anesthetist should start checking IV’s with the maintenance IV line. The anesthetist should be able to read all IV labels at all times. Anesthetist should note drug/fluid (to include blood products) input/output.Blanch (capillary refill) the patients finger (gums or tongue for Caprine) to check tissue profusion. As always, all lines should be in complete view of the anesthetist at all times. Anesthetist should start checking IV’s with the maintenance IV line. The anesthetist should be able to read all IV labels at all times. Anesthetist should note drug/fluid (to include blood products) input/output.

    32. RECORD Record on the SF 517: Time, drug input, suction, oxygenation, ventilation, level of consciousness, vitals signs, fluid input/output, all complications throughout surgery in other remarks The SF 517 is a legal document. If you did not write it on the SF 517, it did not happen. What ever you do write, did happen. The SF 517 must be updated Q5 minutes. If you miss a 5 minute block, then leave it blank. If you fill in the SF 517 after the 5 minute interval, that will be considered falsifying documentation. Fluid input/output includes: Blood products, urine, saliva, vomit and IV solutions. All significant occurrences or complications must be logged in remarks column. These could be code, needle decompression, chest tube, bloating, etc.The SF 517 is a legal document. If you did not write it on the SF 517, it did not happen. What ever you do write, did happen. The SF 517 must be updated Q5 minutes. If you miss a 5 minute block, then leave it blank. If you fill in the SF 517 after the 5 minute interval, that will be considered falsifying documentation. Fluid input/output includes: Blood products, urine, saliva, vomit and IV solutions. All significant occurrences or complications must be logged in remarks column. These could be code, needle decompression, chest tube, bloating, etc.

    33. REPORT Communicate: Communication the patients status and vitals to surgical team. Insure you receive a response from the surgeon At this point, make improvements, adjustments and corrections to any deficiencies that you discovered during the circle Good communication between the anesthetist and the surgeon is essential for a successful procedure. Must be loud enough for the whole OR team to hear. Make sure you receive a response from the surgeon. If you discover during circle, in circulation for example, that an IV is no longer patent, do not stop the circle to correct the problem at that point. Note the deficiencies and continue the circle (Stay in the circle). Once the circle is complete, then make your corrections. The exception to this rule would be a code or any other immediate life threatening condition.Good communication between the anesthetist and the surgeon is essential for a successful procedure. Must be loud enough for the whole OR team to hear. Make sure you receive a response from the surgeon. If you discover during circle, in circulation for example, that an IV is no longer patent, do not stop the circle to correct the problem at that point. Note the deficiencies and continue the circle (Stay in the circle). Once the circle is complete, then make your corrections. The exception to this rule would be a code or any other immediate life threatening condition.

    34. SUMMARY OF PROCEDURES Review the principles of monitoring and maintenance Review the components, clinical signs, and depth of anesthesia Apply the principles of monitoring and maintenance (Circle of Awareness) Have a student read this slide out loud to the rest of the class.Have a student read this slide out loud to the rest of the class.

    35. RESTATED OBJECTIVE As a Special Forces Medic given a patient under general parenteral anesthesia, continually monitor the patients vital signs, apply corrective treatment to any life threatening changes in the patients vital signs, and maintain the patient at stage three of general anesthesia in accordance with JSOMTC student manual of anesthesia. Have a student read this slide out loud to the rest of the class.Have a student read this slide out loud to the rest of the class.

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