BROOKS COLLEGE of HEALTH

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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
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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

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Basic Concepts

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

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Basic Concepts

• Subspecialties
• in the
• Practice of Anesthesia

• Cardiothoracic
• Critical Care
• Neuroanesthesia
• OB

• Pain Management
• Pediatric
• Ambulatory

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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. ltvbk0-7216-0446-3outline(21.2.3
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Basic Concepts

• Anesthesia Techniques
• General
• Regional
• Peripheral nerve blocks
• MAC/Local
• Local only

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Rationale of Anesthetic Choice

• The Procedure
• The Surgeon/Anesthesia Provider
• The Patient
• Preference
• Medical History
• Surgical History
• Assessment

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Rationale of Anesthetic Choice

• Degree of Risk Anesthesia for surgical
  procedures
• Major (CABG)
• Minor (Cataract)
• Emergent (Appy,Trauma)
• Urgent (Cholecysectomy)
• Elective (Plastics, hernias)

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Rationale of Anesthetic Choice

• Purpose for surgical procedures
• Diagnostic
• Cosmetic
• Ablative
• Transplant
• Palliative
• Constructive
• Reconstructive/Restoration
• Procurement

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Rationale of Anesthetic Choice

• Can this procedure be accomplished without going
  to sleep?
• Type and duration
• Pain
• Muscle Relaxation
• Length of procedure

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Rationales Surgeon and Anesthesia Provider

• Preference/Ability
• Attitude
• Skill
• Patience!

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Rationale for Choice Patient

• Preference
• History
• Airway
• Previous anesthetic experience
• Coexisting Diseases severity
• Present condition
• Assessment

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Rationale for Choice Patient

• Medical conditions
• Airway
• Difficult or Prolonged intubations
• Cervical Spine
• Neck radiation, tumor
• OSA
• Rheumatoid arthritis
• Morbid Obesity

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Rationale for Choice Patient

• Medical conditions
• Genetics
• Down Syndrome
• Pierre Robin Syndrome
• Malignant Hyperthermia
• Atypical pseudocholinesterase

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Rationale for Choice Patient

• Medical conditions

• Cardiovascular
• Exercise Intolerance
• HTN
• CHF
• CAD
• Valvular Disease
• Cardiomyopathy
• Angina
• PVD
• Dysrhythmia

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Rationale for Choice Patient

• Medical conditions
• Pulmonary
• Asthma
• TB
• URI
• Dyspnea on Exertion

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Rationale for Choice Patient

• Medical conditions
• Medical History
• Endocrine
• Diabetes
• Hyperthyroid
• Pheochromocytoma
• Steroid dependency

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Rationale for Choice Patient

• Medical conditions
• Medical History
• Neurologic
• Carotid Artery Disease
• CVA/TIA
• Seizure
• Chronic Pain
• Motor/Sensory Loss

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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

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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

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Anesthetic Choice Patient Risks

• Informed Consent!

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Rationales for Anesthesia Technique Questions
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Basic Concepts

• Anesthesia

• General
• Regional
• MAC/Local

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Anesthesia Techniques Terms

• Preparation
• Patient
• OR
• Preinduction
• Induction
• Intraoperative management
• Emergence
• Postoperative management

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Anesthesia Techniques Concepts

• Management of Airway
• Spontaneous
• ETT
• LMA
• Mask
• Maintain anesthetic level
• Inhalation Agent
• IV Drugs
• Maintain Patient Hemodynamics
• Anesthetist!

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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)

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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.

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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

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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.

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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

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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.

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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

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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

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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

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Anesthesia

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

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Anesthesia

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

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Anesthesia

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

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Anesthesia

• Pharmacology Adjuncts
• Emergence
• Reversal
• MR
• Pain
• Postop N/V

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GA, Regional, MAC/Local Questions
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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

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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

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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.

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Positioning the Surgical Patient

• 1999 - 670 claims for anesthesia-related nerve
  injuries
• 1 - Ulnar nerve (28)
• 2 - Brachial plexus (20)
• 3 - Common peroneal (13)

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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.

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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.

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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.

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Positioning the Surgical Patient

• Positons which require special care
• Prone
• Lateral
• Lithotomy
• Sitting

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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.

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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.

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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

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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 patients body to
  prevent maceration.
• Other straps or positioning devices placed only
  over padded body parts.

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Perioperative Complications

• Minor to Major
• Sore throat
• Teeth,soft tissue injury
• Bleeding
• Hemodynamic instability
• Stroke
• MI
• Death

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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

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MH Treatment

• Diagnose Early!
• Stop the trigger
• Lots of staff
• Dantrolene
• Ice
• IV fluids
• Treat arrhythmias

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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.

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Questions