Anesthetics, NMB, Narcotics, Sedatives & Anticonvulsants

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Anesthetics, NMB, Narcotics, Sedatives
Anticonvulsants

• Georgia Baptist College of Nursing
• Kathy Plitnick RN PhD CCRN

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Anesthetics

• Anesthesia loss of sensation with/without loss
  of consciousness
• Analgesia - loss of pain sensation
• Types of Anesthesia
• General controlled state of unconsciousness
• Regional nerve conduction is blocked to a
  region of the body
• Local blocking of pain impulses on peripheral
  nerves
• Balanced selection of several different drugs,
  without excessive CNS depression

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Stages of Anesthesia

• Stage of Analgesia (I) distortion of sight,
  hearing, numbness, analgesia
• Stage of Delirium (II) loss of consciousness,
  involuntary activity, psychomotor excitement
• Stage of Surgical Anesthesia (III) end of
  delirium to occurrence of apnea
• Stage of Medullary Depression (IV) begins with
  apnea, ends with circulatory collapse

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Parenteral Agents Propofol (Diprivan)

• Hypnotic without analgesia, amnesia
• IV rapid induction, short term sedation
• Rapid acting, rapid emergence
• Adverse hypotension, bradycardia, apnea
• Contraindicated soybean, egg, LD
• Nursing
• Titrate to sedation level, aseptic technique (fat
  emulsion), emergency equipment, wake up
  assessment, patent airway, analgesics

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Inhalation Anesthetics

• Isoflurane (Forane) volatile liquid
• Induction and maintenance given with Nitrous
  oxide
• Depresses all levels of CNS, skeletal muscle
  relaxant
• Potent respiratory depressant
• Minimal depression of myocardium
• Potential for malignant hyperthermia
• Depresses kidney function

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Isoflurane

• Post operative shivering
• IV Demerol, rewarming
• Monitor vs, temperature frequently
• Prevent aspiration
• Monitor U/O

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Nitrous Oxide

• Nonflammable, inorganic gas, colorless, odorless
• Cortical depression
• Good analgesic, weak anesthetic
• Rapidly absorbed through lungs
• Adverse depresses cardiac contractility, hypoxia

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Local Lidocaine

• Inhibits transport of ions across neuronal
  membranes
• Prevents initiation conduction of nerve
  impulses
• Routes topical, infiltration, mucosal, IV
• Nursing assess degree of numbness, ensure gag
  reflex intact after oral sprays
• Infiltration used with Epinephrine to prolong
  local effect

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Neuromuscular Blockers

• Cause muscle relaxation, paralyzation
• Short term use facilitate intubation, procedures
  in mech ventilated
• Long term use mechanical ventilation, control
  agitation, decrease tissue oxygen demands,
  increased ICP
• Always administer with an analgesic /or sedative
• Patient is completely dependent
• Protect the patient

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Depolarizing Agents Succinylcholine (Anectine)

• Depolarization of motor end plates, bind to
  receptors
• Muscle contraction appear as fasciculations
  (tremors) followed by muscle relaxation
• Complete paralysis in 2-3 minutes
• No effect on CNS

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Succinylcholine

• Adverse stimulates vagal ganglia
• Apnea
• Histamine release
• Increased intraocular pressure
• Malignant hyperthermia
• Never assume a paralyzed patient is asleep
• Mechanical ventilation support

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Nondepolarizing Agents

• Block action of acetylcholine
• Prevents depolarization of muscle membrane,
  muscle contraction cannot occur
• Used in OR to expose operative site, close
  wound
• Anesthesiologist facilitate intubation

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Tubocurarine (Tubarine)

• Gradual paralysis over 1-5 minutes without
  fasciculation
• Sequence of paralysis
• Persists for 40-60 minutes
• Reversed by anticholinesterases
• Effects hypotension, peripheral vasodilatation,
  myocardial depression, reflex tachycardia,
  increased secretions, decreased u/o, GI motility

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Tubocurarine

• Toxic prolonged apnea, cardiovascular collapse,
  recurarization
• Nursing
• Hypotension profound in hypovolemia
• Rehydrate
• Avoid use in asthmatics
• Excreted by kidneys slower recovery or repeated
  doses of anticholinesterases

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Narcotics Morphine

• Opioid analgesic, binds to opiate receptors
• Alters perception to painful stimuli
• Produces CNS depression
• Uses severe pain, pulmonary edema, acute MI
• Available oral, IM, IV, SC, rectal, epidural,
  intrathecal

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Morphine

• Adverse confusion, sedation, respiratory
  depression, arrest, hypotension, constipation,
  urinary retention, itching, dependence
• Nursing
• Assess VS, type, location intensity of pain
• Assess bowel function
• Co-administration of nonopioid analgesics
• Discontinue gradually
• Give IVP slowly, safety precautions

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Codeine

• Mild narcotic agonist
• Decreases cough reflex, GI motility
• Completely absorbed from IM sites
• Use Cautiously in head trauma, increased ICP,
  undiagnosed abdominal pain
• Often combined with analgesic (ASA, tylenol)
  Tylenol 2 15 mg Codeine

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Pentazocine (Talwin)

• Narcotic Agonist-Antagonist
• Antagonist properties may result in opioid
  withdrawal
• Withdrawal symptoms vomiting, restlessness,
  abdominal cramps, increased BP temperature
• Additional adverse hallucinations, euphoria,
  lightheadedness
• IM injections deep into well-developed muscle

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Narcotic Antagonist Naloxone (Narcan)

• Antidote for opioid overdose
• Reverses CNS depression
• Results in sympathetic stimulation
• IVP 0.02 0.2 mg q 3-5 minutes
• Always assess pain after IV Narcan
• Resuscitation equipment readily available

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CNS Depressants

• Benzodiazepines Lorazepam (Ativan)
• Potentiates GABA inhibitory NT
• Sedation, amnesia
• Uses anxiety, seizures, insomnia, diagnostic
  procedures

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Sleep Stages

• NREM
• 1 Relaxed wakefulness
• 2 Light sleep 50 of sleep
• 3 4 Slow wave (delta), deep restorative,
  secrete hormones, enhance immune function, 15-50
• REM
• Mentally, emotionally restorative
• Psychological problems from deprivation
• 90 minute cycles

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CNS Depressants REM sleep

• Barbiturates
• Suppress REM sleep
• Rebound effect
• Benzodiazepines
• Do not suppress REM sleep

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Lorazepam (Ativan)

• Available oral, IM, IV (1-5 min)
• Half-life 10-20 hours
• Nursing
• Assess degree of anxiety
• Psychological, physical dependence
• Bedrest, safety precautions (IV)
• Slow IVP
• Avoid ETOH
• Seizure management
• Renal function

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Anticonvulsant Therapy

• Seizures abnormal electrical activity in nerve
  cells, discharges occur in cerebral cortex
• Localized areas or entire brain
• Idiopathic no specific cause
• Nonidiopathic abscess, trauma, encephalitis,
  CVA, uremia, ETOH, drug overdoses, sudden
  withdrawal, hypoglycemia, hypocalcemia, fever

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Anticonvulsants

• Block movement of sodium ions , less excitable
  membranes
• Enhance GABA activity
• Long term therapy
• Oral use, IV
• Stop a seizure Lorazepam, Diazepam
• Prevent seizure phenobarbital, dilantin

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Phenytoin (Dilantin)

• Treatment/prevention tonic-clonic seizures
• Alters ion transport
• Absorb slowly, 18-24 hours
• Steady state 1-3 weeks
• Adverse ataxia, drowsiness, hypotension,
  gingival hyperplasia, slurred speech

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Phenytoin

• Nursing
• Characteristics of seizure
• Oral hygiene
• Hypersensitivity reaction
• Seizure precautions
• IVP precautions
• Patient identification
• Urine pink, red, reddish brown
• Avoid antacids
• Therapeutic levels 10-20 mcg/ml

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Phenobarbital

• Produces CNS depression
• Decreases motor activity, alters cerebellar
  function
• Anticonvulsant activity, sedation
• Uses tonic-clonic, febrile seizures
• Half-life 2-6 days
• Adverse hangover, delirium, drowsiness,
  excitation, hypotension

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Phenobarbital

• Frequent VS with IV use
• Resuscitation equipment
• Dependence
• Suicide precautions
• Seizure assessment, precautions
• Evaluate hepatic, renal, CBC
• Therapeutic level 10-40 mcg/ml
• Slow IVP

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Anticonvulsants

• Clonazepam (Klonopin) petit mal, myoclonic, long
  term treatment
• Ethosuximide (Zarontin) absence seizures, peak
  levels in 3-7 hours, anorexia gastric upset a
  problem
• Carbamazepine (Tegretol) tonic-clonic, partial
  seizures, related to TCAs, watch LFTs, BUN,
  bilirubin, plt ct.

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