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BROOKS COLLEGE of HEALTH SCHOOL of NURSING

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

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BROOKS COLLEGE of HEALTH SCHOOL of NURSING

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  1. 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

  2. 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

  3. Basic Concepts • Anesthesia – Nursing Specialty • Advanced Practice (ARNP-CRNA) • MSN (DNP) • Science & Art • Highly technical • Skills • Knowledge base • Critical Care Experience • Professionalism

  4. Basic Concepts Subspecialties in the Practice of Anesthesia • Cardiothoracic • Critical Care • Neuroanesthesia • OB • Pain Management • Pediatric • Ambulatory

  5. 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)>

  6. Basic Concepts • Anesthesia Techniques • General • Regional • Peripheral nerve blocks • MAC/Local • Local only**

  7. Rationale of Anesthetic Choice • The Procedure • The Surgeon/Anesthesia Provider • The Patient • Preference • Medical History • Surgical History • Assessment

  8. Rationale of Anesthetic Choice • Degree of Risk: Anesthesia for surgical procedures: • Major (CABG) • Minor (Cataract) • Emergent (Appy,Trauma) • Urgent (Cholecysectomy) • Elective (Plastics, hernias)

  9. Rationale of Anesthetic Choice • Purpose for surgical procedures: : • Diagnostic • Cosmetic • Ablative • Transplant • Palliative • Constructive • Reconstructive/Restoration • Procurement

  10. Rationale of Anesthetic Choice • Can this procedure be accomplished without going to sleep? • Type and duration • Pain • Muscle Relaxation • Length of procedure

  11. Rationales: Surgeon and Anesthesia Provider • Preference/Ability • Attitude • Skill • Patience!

  12. Rationale for Choice: Patient • Preference • History • Airway • Previous anesthetic experience • Coexisting Diseases & severity • Present condition • Assessment

  13. Rationale for Choice: Patient • Medical conditions Airway • Difficult or Prolonged intubations • Cervical Spine • Neck radiation, tumor • OSA • Rheumatoid arthritis • Morbid Obesity

  14. Rationale for Choice: Patient • Medical conditions Genetics • Down Syndrome • Pierre Robin Syndrome • Malignant Hyperthermia • Atypical pseudocholinesterase

  15. Rationale for Choice: Patient • Medical conditions Cardiovascular • Exercise Intolerance • HTN • CHF • CAD • Valvular Disease • Cardiomyopathy • Angina • PVD • Dysrhythmia

  16. Rationale for Choice: Patient • Medical conditions Pulmonary • Asthma • TB • URI • Dyspnea on Exertion

  17. Rationale for Choice: Patient • Medical conditions • Medical History Endocrine • Diabetes • Hyperthyroid • Pheochromocytoma • Steroid dependency

  18. Rationale for Choice: Patient • Medical conditions • Medical History Neurologic • Carotid Artery Disease • CVA/TIA • Seizure • Chronic Pain • Motor/Sensory Loss

  19. 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

  20. 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

  21. Anesthetic Choice & Patient Risks • Informed Consent!

  22. Rationales for Anesthesia Technique: Questions

  23. Basic Concepts • Anesthesia • General • Regional • MAC/Local

  24. Anesthesia Techniques: Terms • Preparation • Patient • OR • Preinduction • Induction • Intraoperative management • Emergence • Postoperative management

  25. Anesthesia Techniques: Concepts • Management of Airway • Spontaneous • ETT • LMA • Mask • Maintain anesthetic level • Inhalation Agent • IV Drugs • Maintain Patient Hemodynamics • Anesthetist!

  26. 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)

  27. 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.

  28. 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

  29. 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.

  30. 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

  31. 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.

  32. 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

  33. 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

  34. 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

  35. Anesthesia • Pharmacology Adjuncts • Preop • Reduce Anxiety (benzodiapines) • Reduce risk of aspiration (H2 blocker, prokinetic, 5HT3, anticholinergic • Reduce Pain (narcotic)

  36. Anesthesia • Pharmacology Adjuncts • Intraop • Induction • Oxygen • Blunt CV response to ETT (lidocaine) • Induction Agents (propofol, etomidate, Ketamine, sodium pentothal)

  37. Anesthesia • Pharmacology Adjuncts • Intraop • Intubation Agents (DMR, NDMR) • Succincylcholine • Zemuron, Vecuronium, Nimbex • Maintenance (Inhalation/IV) • 02, Isoflurane, Sevoflurane, Desflurane, N2O

  38. Anesthesia • Pharmacology Adjuncts • Emergence • Reversal • MR • Pain • Postop N/V

  39. GA, Regional, MAC/Local: Questions

  40. Positioning the Surgical Patient All positioning schemes have 3 goals: • Maximum exposure to the surgical area while maintaining homeostasis and preventing injury • Position must provide the Anesthetist with adequate access to the patient for airway management, ventilation, medications, and monitoring • Promote the enhancement of a satisfactory surgical result

  41. 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

  42. 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.

  43. Positioning the Surgical Patient • 1999 - 670 claims for anesthesia-related nerve injuries • #1 - Ulnar nerve (28%) • #2 - Brachial plexus (20%) • #3 - Common peroneal (13%)

  44. 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.

  45. 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.

  46. 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.

  47. Positioning the Surgical Patient • Positons which require special care: • Prone • Lateral • Lithotomy • Sitting

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