Anesthesia: Delivery Systems and Client Care
Assessment of Risk American Society of Anesthesiologists Classification System
General Anesthesia Goals: -Analgesia -Anesthesia -Amnesia -Areflexia...
Measurement of Outcomes   “ Apgar” Gawande, A.A. (02/2007). An Apgar Scor...
<ul><li>Mailignant Hyperthermia </li></ul><ul><li>-Rapid rise in temp (40 °  C and above) </li></ul><ul><li>-Dark Brown Ur... Malignant hyperthermia sequence of events <ul><li>Trigger   </li></u... Epidural animation Epid...
http:// Post Anesthesia Client Care Immediately -C onnection...
CVPH. (2001).  Immedeate Post-Procedure Patient, the Nursing Management of (Phase I & Phase II)  [Brochure]. Plattsburgh, ...
So, Let’s Review….. Anesthesia is…. -Inhaled -IV -Intrathecal -Regional -Topical Client Care -ABC it’s easy as 123! -Requi...
References <ul><li>Cole, K. (2008). Malignant Hyperthermia. Retrieved March 09, 2009, from Medline Plus Medical Encycloped...
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  • Clients are assessed prior to receiving anesthetic to determine their level of risk, not to determine their outcome. This is usually recorded on operative paperwork.
  • When undergoing major surgery, some clients are made completely unconscious, though it goes deeper than that, and requires airway management as well as constant monitoring of physiological functions like blood pressure, heart rate and rhythm and oxygen saturation. General anesthesia is used when movement by the client would be detrimental to the outcome of their case. Narcotics- fentanyl, alfentanil, sufentanil, merperidine, morphine Sedative hypnotics (induction agents) given prior to intubation, these cause amnesia, but do nothing for pain. Propofol is pretty common, it is the only induction agent with antiemetic properties. The sedative hypnotics have a short onset and duration, other examples are phenothal, ketamine which can sometimes be used in combination with propofol, ketamine changes perception of pain which lends it an analgesic property. It is also a bronchodialator but it increases salivation and can give people pretty unpleasant “dreams” there is also amidate and brevital. Dep-succiynlcholine which may increase k+ levels and can be linked with malignant hyperthermia which will be discussed in a few slides, also this can lead to myalgias postoperatively Nondep- short, intermediate, and long acting. Crystalloids, colloids, and blood products also given here. Inhaled-don’t even ask how they work, just know they do. Isoflurane, intermediate induction/emergence Sevoflurane-rapid action, easier to titrate than isoflurane Desflurane- acts real real quick, but smells real terrible so probably don’t put it anywheres near a conscious person IV: propofol, ketamine, narcotics, benzos Anticholinesterases, i.e. neostigmine, which I saw given at CVPH and edrophonium these increase circulating aCH to restore fctn of SKM Anticholinergix- glycopyrrolate and atropine. Both are given together to reduce the rxn of cholinergic resp to inc aCH (slow hr, bronchospasm, salivation, tearing, urination, defecation, myosis, and sweating.)
  • This chart is based on a 2007 study done at brigham and women’s hospital. As with the APGAR score for infants, the higher the score for clients on a scale of 1-10, the better. The benefits of this system is that it is less subjective and easily measurable. There are other systems in place like the APACHE and POSSUM scores. Using a score such as this one can help identify clients at higher risk of postoperative complications.
  • An autosomal dominant disorder, one form is associated with a defect in the ryanodine receptor gene. Usually noticed after the first time a client is placed under general anesthesia, yet one more reason a family history is important prior to surgery. Renal failure is caused by protein destruction as a result of exposure to high, uncontrolled temperature. Rhabdomyolysis occurs and myoglobin can be detected in the urine Dantroline reduces calcium release and relaxes skeletal muscle, can be given PO preoperatively or IV intraoperatively. It can cause heptaotoxicity so liver labs should be monitored on clients receiving this medication Sore throats are real common
  • -under rigidity-masseter spasm or total body All potential inhalation agents- Succinylcholine Cell damage-Potassium Myoglobin CK (CPK) compensatory mechanisms-Sweating Cutaneous vasodilatation Increased circulating catecholamines-Increased heart rate Cutaneous vasoconstriction Increased systemic vascular resistance Increased CO-Decreased mixed venous oxygen content Decreased arterial oxygen content depends on shunt Lactic acidosis Increased ventilation - may not keep up with need Increased respiratory drive Increased end tidal carbon dioxide
  • So, the blockade can spread both up and down from the injection site. A larger volume of fluid is injected here (about 5-20 mL) with a larger needle (17 gauge) and, in most cases a small indwelling catheter. Spinal- catheter may be used, in fact spinal may be in conjunction with epidural or other methods. Uses- c-sections, lower extremity fractures, knee arthroscopy, TURP They both have similar risks like post-dural headaches resulting from a leak of CSF, and hypotension
  • Immediatly, you need to COIN your client Connection-client is placed on proper monitoring equipment Oxygenation/Ventilation-assess the adequacy of the client’s airway/breathing. all that good stuff Institution of emergency ventilatory support measures as needed iNitiate-oxygen therapy asap for all phase one clients. Airway/Breathing-02 sat, resp r8/depth, breath sounds, as well as any artificial airways/ventilatory support Circulation-pulses, bp, temp, cardiac rhythm, hemodynamic pressure readings, CAST of extremities when applicable PARS-next slide Everything else- Respiratory, Cardiovascular (capillary refill), Neuro i.e. movement/sensation, intugumentary- site appearance, general skin color/condition, signs of labor/FHR, patency, type, condition and position for all drainage tubes and dressings…and of course level of comfort!!!!! Know happy-sad faces, 1-10 or any acceptable pain scale. My post op client referred to his pain as a “low simmer” that could “turn into a boil” Phase one, stir it up basically encourage deep breathing and coughing q5-10 minutes, assist the client to change position every hour, good ones are side lying/semi-prone, encourage client movement of extremities “ watch” monitor vitals, pressure readings and cardiac rhythm until they meet d/c criteria, give 02 2-4 LPM as ordered by MD so what would we use? (nasal canula) as client grows more and more stable, wean to room air so long as they don’t drop below 92%. If they’ve had regional anesthesia, assess their sensory dermatome levels ( this just refers to innervation of specific muscles and limbs on the level of the spine the block was on. Keep watching, vs q15 til stable, assess urine output/ability to void, measure bodily fluid drainage and check the dressing to make sure it is still intact/usable reorient them to person/place (general or sedating meds) I had my wisdom teeth out with IV sedation and demanded to see my teeth in order to make a necklace from them, so obviously anesthesia can be pretty disorienting to people. Maintain the patency of IV lines/monitor IV therapy Analgesia, do I need to say more? Do a focused assessment, give meds as ordered, reassess pain. While we’re talking about it, now is the time you begin to implement the rest of the doctor’s orders “ care”-your client has unique age specific, psychosocial, religious/cultural needs and restrictions, know what these are and remember to treat your client they way you’d want someone to treat you or your mother/family/SO The five rights still apply here, make sure they’re in a position they can breathe in, keep side rails up and the bed locked, suction prn, maintain an open airway-tilt, artificial airways, bag-valve-mask, call MD if airway problems occur, vital signs declining/unstable, significant abnormality detected by lab/radiology, client’s sensory status changes/decreases, no pain relief, unexpected events, not improving w/i time frame Obviously document everything ever
  • In the CVPH pacu, you are either “in” or you are “out.” This is a table attached to the post anesthesia care protocol, as you can see, it uses several markers to determine client advancement. Systems like this one help to eliminate subjectivity and objectively measure client outcomes with easily measurable items that lend themselves well to standardization.
  • Carla is right about a lot of things, hypnosis has been proven effective in things like weight loss, and smoking cessation. There is even a Hypnobirth movement which promises a “pain free labor” we do use distraction and other methods like visualization to help our clients alleviate pain.
  • Anesthesiapresentation

    1. 1. Anesthesia: Delivery Systems and Client Care By Jessica Whittemore
    2. 2. Assessment of Risk American Society of Anesthesiologists Classification System
    3. 3. General Anesthesia Goals: -Analgesia -Anesthesia -Amnesia -Areflexia -Anxiolysis -Antiemesis -Muscle relaxation -Physiologic Stability <ul><li>Phases: </li></ul><ul><li>Induction </li></ul><ul><li>-Narcotics </li></ul><ul><li>-Sedative/Hypnotics </li></ul><ul><li>- Muscle Relaxants </li></ul><ul><li>-depolarizing </li></ul><ul><li>- nondepolarizing </li></ul><ul><li>Maintenance </li></ul><ul><li>Intraoperative period </li></ul><ul><li>Inhaled/IV </li></ul><ul><li>Muscle Relaxants/Narcotics </li></ul><ul><li>Emergence </li></ul><ul><li>-Anticholinesterases </li></ul><ul><li>-Anticholinergics </li></ul>Cole, K. (2006).
    4. 4. Measurement of Outcomes “ Apgar” Gawande, A.A. (02/2007). An Apgar Score for Surgery. Journal of the American College of Surgeons , 204 , Retrieved 03/04/09 < 55 56-65 66-75 76-85 >85 Lowest Heart Rate (bpm) ----- > 70 55-69 40-54 < 40 Lowest Mean Arterial Pressure (mmHG) ------ < 100 101-600 601-1,000 > 1,000 Estimated Blood Loss (mL) 4 3 2 1 0
    5. 5. <ul><li>Mailignant Hyperthermia </li></ul><ul><li>-Rapid rise in temp (40 ° C and above) </li></ul><ul><li>-Dark Brown Urine </li></ul><ul><li>► Repeated or untreated -> Renal failure </li></ul><ul><li>-Tx </li></ul><ul><li>-Cooling Blanket </li></ul><ul><li>-Dantrolene </li></ul><ul><li>- IV fluids </li></ul><ul><li>Respiratory </li></ul><ul><li>Airway obstruction/Respiratory Depression </li></ul><ul><li>Resultant Hypoxemia </li></ul><ul><li>Sore throat </li></ul><ul><li>Neurologic </li></ul><ul><li>- Muscle weakness </li></ul><ul><li>- Pain </li></ul><ul><li>-Over-Sedation </li></ul>Complications Cardiovascular -HTN -Hypotension - Hypothermia -Dysrhythmias GI - Naus/Vom Cole, K (2004). (2008). Malignant Hyperthermia. Retrieved March 09, 2009, from Medline Plus Medical Encyclopedia Web site:
    6. 6. Malignant hyperthermia sequence of events <ul><li>Trigger  </li></ul><ul><ul><li>-All potent inhalational agents </li></ul></ul><ul><li>Increased Cytoplasmic Free calcium </li></ul><ul><li>-Rigidity - may or may not be present </li></ul><ul><li>Hypermetabolism </li></ul><ul><ul><li>-Increased oxygen consumption </li></ul></ul><ul><ul><li>-Increased carbon dioxide production </li></ul></ul><ul><ul><li>-Increased heat production </li></ul></ul><ul><li>Cell damage </li></ul><ul><ul><li>-Leakage of cell contents </li></ul></ul><ul><li>Compensatory mechanisms </li></ul><ul><ul><li>-Heat loss </li></ul></ul><ul><ul><li>Increased circulating catecholamines </li></ul></ul><ul><ul><li>Increased cardiac output - may not keep up with O2 demand </li></ul></ul><ul><li>Temperature rise </li></ul><ul><ul><li>-Severity of stimulus </li></ul></ul><ul><ul><li>-Environmental temperature </li></ul></ul><ul><ul><li>-Starting temperature </li></ul></ul><ul><ul><li>-Amount of vasoconstriction vs vasodilatation </li></ul></ul><ul><li>Secondary systemic manifestations </li></ul><ul><ul><li>-Cardiac arrhythmias </li></ul></ul><ul><ul><li>-Disseminated intravascular coagulation </li></ul></ul><ul><ul><li>-Hemorrhage </li></ul></ul><ul><ul><li>-Cerebral edema </li></ul></ul><ul><ul><li>-Renal failure </li></ul></ul><ul><ul><li> </li></ul></ul>
    7. 7. Epidural animation Epidural and Spinal Anesthesia Spinal “ Neural Blockade” Pros Smaller needle Cons Limited duration Uses Lower extremity/abdominal issues Epidural “ Segmental Neural Blockade” Pros Catheter allows for continuous or intermittent administration Can be combined with other methods Cons -Large volume of medication -Technically more difficult Uses Longer cases Post-op Pain Management
    8. 8. http:// Post Anesthesia Client Care Immediately -C onnection -O xygenation/Ventilation -I nstitution - i N itiation Assessment -Know your ABC’s -Make sure they’re “PARS” for the course -And of course… everything else <ul><li>Interventions </li></ul><ul><li>“ Phase I” </li></ul><ul><li>-Stir it up and watch </li></ul><ul><li>“ Phase II” </li></ul><ul><li>-Keep watching </li></ul><ul><li>- You gotta maintain </li></ul><ul><li>- Analgesia </li></ul><ul><li>- “Care” </li></ul><ul><li>-”Play it safe” </li></ul>CVPH. (2001). Immedeate Post-Procedure Patient, the Nursing Management of (Phase I & Phase II) [Brochure]. Plattsburgh, NY: Lisa Rabideau, RN.
    9. 9. CVPH. (2001). Immedeate Post-Procedure Patient, the Nursing Management of (Phase I & Phase II) [Brochure]. Plattsburgh, NY: Lisa Rabideau, RN.
    10. 10. Hypnosis surgery Just for Funzies
    11. 11. So, Let’s Review….. Anesthesia is…. -Inhaled -IV -Intrathecal -Regional -Topical Client Care -ABC it’s easy as 123! -Requires careful assessment Any Questions???? Activity Time!
    12. 12. References <ul><li>Cole, K. (2008). Malignant Hyperthermia. Retrieved March 09, 2009, from Medline Plus Medical Encyclopedia Web site: </li></ul><ul><li>2. CVPH. (2001). Immedeate Post-Procedure Patient, the Nursing Management of (Phase I & Phase II) [Brochure]. Plattsburgh, NY: Lisa Rabideau, RN. </li></ul><ul><li>3. Awande, A.A., Kwaan, M.R., Regenbogen, S.E., Lipsitz, S.A., & Zinner, M.J. (2007). An Apgar Score for Surgery. American College of Surgeons , 204 , Retrieved 03/09/09,from </li></ul><ul><li>4. Badrinath, S, Amarov, M.N., Shadrick, M., Witt, T.R., & Ivankovitch, A.D. (2000). The Use of a Ketamine-Propofol Combination During Monitored Anesthesia Care. Ambulatory Anesthesia . 90 , 858-862. </li></ul><ul><li>5. CVPH. (2001). Immedeate Post-Procedure Patient, the Nursing Management of (Phase I & Phase II) [Brochure]. Plattsburgh, NY: Lisa Rabideau, RN. </li></ul>