anethetic agents and Nursing Care

1. PREPARED BY
SANAM KAMRAN
Sanam Kamran Palijo

2.  By the completion of this section the learners will be able to:
 1. Define the term anesthesia and anesthetic agents
 2. Differentiate between different types of anesthesia
 3. Identify the stages of general anesthesia
 4. Describe Characteristics of general and local anesthetic agents.
 5. Identify most commonly used anesthetic agents
Sanam Kamran Palijo

3.  Discuss factors considered when choosing anesthetic agents.
 Compare general and local anesthesia in terms of administration, client’s safety
and nursing care.
 Discuss the rationale for using adjunctive drugs before and during surgical
procedures.
 Describe the nursing role in related to anesthetics and adjunctive drugs.
 Discuss the action, indication and side effects of neuro-muscular blocking agent
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4.  Anesthesia
Anesthesia is a medical procedure performed by administering drugs that cause
loss of sensation.
 Anesthetic Agents:
Anesthetics are drugs used to cause complete or partial loss of sensation. These
drugs are subdivided based on site of action and can either be general or local.
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5.  Here is a table of commonly encountered anesthetic agents, their generic names, and brand names:
 General Anesthetic Agents
 Barbiturate Anesthetics
 methohexital (Brevital)
 thiopental (Penthothal)
 Nonbarbiturate General Anesthetics
 droperidol (Inapsine)
 etomidate (Amidate)
 fospropofol (Lusedra)
 ketamine (Ketalar)
 midazolam
 propofol (Diprivan)
 Anesthetic Gasses
 nitrous oxide (blue)
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6.  Volatile Liquids
 desflurane (Suprane)
 enflurane (Ethrane)
 halothane (Fluothane)
 isoflurane
 sevoflurane (Ultane)
 Local Anesthetic Agents
 Esters
 benzocaine (Dermoplast, Lanacane)
 chloroprocaine (Nesacaine)
 procaine (Novocaine)
 tetracaine (Pontocaine)
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7.  Amides
 bupivacaine (Marcaine, Sensorcaine)
 dibucaine (Nupercainal)
 lidocaine (Dilocaine, Xylocaine, Solarcaine, Lidoderm, Octocaine)
 mepivacaine (Carbocaine, Isocaine, Polocaine)
 prilocaine (Citanest)
 ropivacaine (Naropin).
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8. 1: Local Anesthesia
 Local anesthesia occurs when sensation is lost to a limited part of the body
without loss of consciousness. They are very powerful nerve blockers and should
not be absorbed systemically. Systemic absorption can lead to toxic effects on the
nervous system and the heart
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13. Contraindications and Cautions
 The following are contraindications and cautions for the use of local anesthetics:
 Allergy to anesthetics and parabens. To avoid hypersensitivity reactions.
 Heart block. Could be exacerbated with systemic absorption
 Shock. Can alter the local delivery and absorption of these drugs
 Decreased plasma esterase. Can result in toxic levels of ester-type local
anesthetics
 Pregnancy, lactation. Potential adverse effects to fetus and baby.
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14. Adverse Effects
 use of local anesthetics may result to these adverse effects:
 CNS: headache (especially with epidural and spinal anesthesia), restlessness,
anxiety, dizziness, tremors, blurred vision, backache
 CV: peripheral vasodilation, myocardial depression, arrhythmias, blood pressure
changes
 Respiratory: respiratory arrest
 GI: nausea, vomiting
 Loss of skin integrity, especially in patients who are unable to move
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15.  General anesthesia involves the administration of combined different general
anesthetic agents with the fewest adverse effects to achieve analgesia (loss of pain
perception), unconsciousness (loss of awareness of one’s own surroundings), and
amnesia (inability to recall what took place).
 It also blocks the autonomic reflexes governing involuntary reflex response of the
body to injury which can compromise cardiac, respiratory, gastrointestinal, and
immune status.
 Muscle reflexes are also blocked to prevent jerking movements that might
interfere with surgical procedures.
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16.  Widespread CNS depression can occur in individuals with the following risk factors:
 CNS Factors: neurological diseases that may produce an abnormal reaction to the
CNS-depressing and muscle-relaxing effects of general anesthetic agents like epilepsy,
stroke, and myasthenia gravis.
 Cardiovascular (CV) Factors: underlying CV diseases which can can be worsened by
severe reactions to anesthesia (shock, hypotension, dysrhythmia, and ischemia) like
coronary artery disease (CAD).
 Respiratory Factors: obstructive pulmonary diseases that can complicate delivery of
gas anesthetics, intubation, and mechanical ventilation like asthma, chronic
obstructive pulmonary disease (COPD), and bronchitis.
 Renal and hepatic function: conditions that interfere with metabolism and excretion of
anesthetics that could lead to prolonged anesthesia like acute renal failure and
hepatitis.
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17.  patient undergo predictable stages during administration of anesthesia. These
steps are referred to as the depth of anesthesia:
 Stage 1 – Analgesia Stage: Characterized by loss of pain sensation and with the
patient still conscious and able to communicate.
 Stage 2 – Excitement Stage: Period of excitement and often combative behavior
with many signs of sympathetic stimulation.
 Stage 3 – Surgical Anesthesia: Involves muscle relaxation, regular respirations,
progressive loss of eye reflexes and pupil dilation. It is the stage in which surgery
can be safely performed.
 Stage 4 – Medullary Paralysis: Very deep CNS depression with loss of respiratory
and vasomotor center stimuli, in which death can occur rapidly. It is considered a
critical period because anesthesia has become too intense.
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19.  Administration of general anesthesia is divided into three phases:
 Induction: from beginning of anesthesia to stage 3. The most dangerous period of
induction is stage 2 because of the systemic stimulations that occur.
 Maintenance: from stage 3 to completion of surgical procedure.
 Recovery: from discontinuation of anesthetic to regained consciousness,
movement, and ability to communicate of the patient.
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20. General Anesthetic Agents
 General anesthetic agents can be classified into: barbiturate anesthetics,
nonbarbiturate general anesthetics, anesthetic gases, and volatile liquids.
 Barbiturate Anesthetics
 Barbiturate anesthetics are intravenous drugs used to induce rapid anesthesia,
which is then maintained with an inhaled drug.
 Therapeutic Action
 The desired and beneficial actions of barbiturate anesthetics are as follows:
 Barbiturate anesthetics depress the CNS to produce hypnosis and anesthesia
without analgesia.
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21. Contraindications and Cautions
 The following are contraindications and cautions for the use of barbiturate
anesthetics:
 Silicon (e.g. Rubber stoppers, disposable syringes). Methohexital will cause an
immediate breakdown of the silicone.
 Pregnancy, lactation. CNS depressive effects to baby and fetus.
 Neither drug should be used until the anesthesiologist nor are staff ready and
equipped for intubation and respiratory support. The rapid onset of action of these
drugs can cause respiratory depression and apnea.
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22.  Adverse Effects
 Use of barbiturate anesthetics may result to these adverse effects:
 CNS: CNS suppression
 CV: bradycardia, hypotension
 Respiratory: respiratory depression
 GI: decreased GI activity
 Nausea and vomiting are common after recovery.
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23. Nonbarbiturate Anesthetics
 Nonbarbiturate anesthetics are the other parenteral drugs used for intravenous
administration in anesthesia.
Therapeutic Action
 The desired and beneficial actions of nonbarbiturate anesthetics are as follows:
 Nonbarbiturate anesthetics are very potent amnesiacs that are thought to be
acting in the reticular activating system and limbic system to potentiate the
effects of GABA.
 It has little effect on cortical function.
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24.  Indications
 Nonbarbiturate anesthetics are indicated for the following medical conditions:
 Midazolam, the prototype nonbarbituare anesthetic, is widely used to produce amnesia
or sedation for many diagnostic, therapeutic, and endoscopic procedures. It can also be
used to induce anesthesia and to provide continuous sedation for intubated and
mechanically ventilated patients.
 Droperidol produces marked sedation and produces a state of mental detachment. It
also has antiemetic effect which reduces the incidence of nausea and vomiting in
surgical and diagnostic procedures.
 Ketamine is useful in situations when cardiac depression is dangerous because it
causes sympathetic stimulation with increase in blood pressure and heart rate.
 Propofol is used for short procedures because it has a very rapid clearance and
produces much less of a hangover effect and allows for quick recovery.
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26.  Contraindications and Cautions
 The following are contraindications and cautions for the use of nonbarbiturate
anesthetics:
 Conditions that can be compromised by vomiting. Midazolam is more likely to
cause nausea and vomiting than other anesthetics.
 Renal or hepatic failure, prolonged QT intervals. Contraindicated with use of
droperidol.
 Respiratory depression and arrest is associated with use of nonbarbiturate
anesthetics so life support equipment should be readily available always.
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27. Contraindications and Cautions
 The following are contraindications and cautions for the use of nonbarbiturate
anesthetics:
 Conditions that can be compromised by vomiting. Midazolam is more likely to
cause nausea and vomiting than other anesthetics.
 Renal or hepatic failure, prolonged QT intervals. Contraindicated with use of
droperidol.
 Respiratory depression and arrest is associated with use of nonbarbiturate
anesthetics so life support equipment should be readily available always.
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28.  Adverse Effects
 Use of nonbarbiturate anesthetics may result to these adverse effects:
 Midazolam: CNS suppression, respiratory depression
 Droperidol: chiils, hypotension, hallucinations, drowsiness, QT prolongation
 Etomidate: myoclonic and tonic movements
 Ketamine: hallucinations, dreams, psychotic episodes (can cross blood-brain
barrier)
 Propofol: local burning on injection sites, bradycardia, hypotension, pulmonary
edema
 Fospropofol: sensation of perianal burning, stinging, tingling, rash (do not usually
require intervention and will usually pass)
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29.  Anesthetic Gases
 Anesthetic gases enter the bronchi and alveoli, pass the capillary system and is
transported to the heart to be pumped throughout the boyd. It has high affinity for
fatty tissue (including the lipid membrane of the nerves in the CNS), and is lipophilic.
 Passes quickly to the brain and causes CNS depression.
 Very flammable and associated with toxic adverse effects.
 Therapeutic Action
 The desired and beneficial actions of anesthetic gases are as follows:
 Moves quickly in and out of the body that it can accumulate in closed body
compartments (e.g. sinuses) and cause pressure there.
 Very potent analgesic.
 Do not cause muscle relaxation.
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31.  Indications
 Anesthetic gases are indicated for the following medical conditions:
 Nitrous oxide is usually used for dental surgery. It is also combined with other agents
for anesthetic use.
 Only one anesthetic gas, nitrous oxide (blue cylinder), is still used.
 Contraindications and Cautions
 The following are contraindications and cautions for the use of anesthetic gases:
 Conditions which are at risk for hypoxia. Oxygen is always given with nitrous oxide
because the drug can block the reuptake of oxygen after surgery. Susceptible patients
should be monitored for signs of hypoxia, chest pain, and stroke.
 Pregnancy. Potential adverse effects to the fetus.
 Lactation. Should wait 4 hours after administration of nitrous oxide before nursing a
baby.
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32.  Adverse Effects
 Use of anesthetic gases may result to these adverse effects:
 Respiratory: pneumothorax
 GI: bowel obstruction
 EENT: acute sinus pain, middle ear pain
 Inactivates Vitamin B12.
Interactions
 The following are drug-drug interactions involved in the use of anesthetic gases:
 Ketamine and halothane can cause severe cardiac depression with hypotension
and bradycardia.
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33.  Volatile Liquids
 Volatile liquids are also inhaled anesthetics because they are unstable at room
temperature and release gases.
 Most volatile liquids are halogenated hydrocarbons.
 Therapeutic Action
 The desired and beneficial actions of volatile liquids are as follows:
 Depresses the CNS, causing anesthesia. It also relaxes muscles.
 It sensitizes the myocardium to the effects of norepinephrine and epinephrine.
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35.  Indications
 Volatile liquids are indicated for the following medical conditions:
 Halothane, the prototype drug, is used for maintenance of anesthesia and can be
effective as an induction agent.
 Desflurane is widely used to in outpatient surgery because of its rapid onset and
quick recovery time.
 Isoflurane is widely used to maintain anesthesia after inductions. It can cause
muscle relaxation.1
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36.  Contraindications and Cautions
 The following are contraindications and cautions for the use of volatile liquids:
 Hepatic impairment. Can contribute to hepatic toxicity.
 Cardiovascular disease. Associated with bradycardia and hypotension
 Respiratory depression and increased sensitivity. Has tendency to cause
respiratory depression and it is an irritant to the airways.
 Pregnancy, lactation. Potential adverse effects to the fetus and the baby.
 All of these drugs have the potential to trigger malignant hyperthermia. In such
cases, dantrolene is the preferred treatment and should be readiily available.
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37.  Adverse Effects
 Use of volatile liquids may result to these adverse effects:
 Halothane’s recovery syndrome: fever, anorexia, nausea, vomiting, hepatitis (can
progress to fatal hepatic necrosis). It is not used for more than 3 weeks to reduce the
patient risk.
 Desflurane is associated with a collection of respiratory reactions: cough, increased
secretions, laryngospasm.
 Interactions
 The following are drug-drug interactions involved in the use of volatile liquids:
 Caution should be used when any of these drugs is combined with other CNS
suppressants.
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38.  Regional anesthesia is used to numb only the portion of the body that will undergo
the surgery. Usually an injection of local anesthetic is given in the area of nerves
that provide feeling to that part of the body. There are several forms of regional
anesthetics:
 Spinal anesthetic. This type of anesthetic involves injecting a single dose of the
anesthetic medicine into the area that surrounds the spina
 Epidural anesthetic. this type of anesthesia involves continually infusing an
anesthetic medicine through a thin catheter (hollow tube). The catheter is placed
into the space that surrounds the spinal cord in the lower back, causing numbness
in the lower body. Epidural anesthesia may also be used for chest or abdominal
surgery.
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39.  A number of drugs are used either to complement the effects of general
anesthetics or to treat anticipated side effects of the anesthesia.
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40. The rationale for using adjunctive drugs before and during surgical procedures.
Preoperative drugs are given to relieve anxiety and to provide mild sedation.
Opioids such as morphine may be given to counteract pain that the patient will
experience after surgery.
Anticholinergics such as atropine may be administered to dry secretions and to
suppress the bradycardia caused by some anesthetics.
Sedative–hypnotic drugs help reduce fear, anxiety, or pain associated with the
surgery.
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41.  During surgery, the primary adjuncts are the neuromuscular blockers .
Neuromuscular blockades cause paralysis without loss of consciousness which
means that without a general anesthetic, patients would be awake and without
the ability to move. Remember, breathing muscles are skeletal muscle. This is why
patients require intubation and mechanical ventilation. Administration of these
drugs also allows a reduced amount of general anesthetic
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42.  The following important patient monitoring steps are necessary:
 ● Baseline neurologic assessment should be performed before neuromuscular
blocking drugs are administered.
 ● Dosage of the neuromuscular blocking drugs should be maintained by using
peripheral nerve stimulation during the surgical procedure.
 ● To ensure adequate sedation and continued need for neuromuscular blockade,
the nurse and health care staff should monitor the patient during the entire
surgery.
 ● Neuromuscular blockade should be discontinued after surgery and as soon as it
is clinically possible.
 ● Postneurologic evaluation and continued patient monitoring are necessary steps
after surgery is completed.
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