Principles of Anesthesia for Nursing Students

1. Anesthesia (1
Hr)
By Ame Mehadi(BSc, MSc in EMCCN)
Lecturer of ECCN
Trainer of Basic Emergency Care & Perioperative Nursing Training
School of Nursing & Midwifery
College of Health & Medical Sciences
Haramaya University

2. Out Line
Definition,
Types of anesthesia,
Stages,
Mechanism of action
By Ame M.

3. Learning Objectives
After completing this chapter, the learner will be able to:
Differentiate between local and general anesthesia.
Mention the routes of administering local anesthesia.
Identify three methods of administering general anesthesia.
Manage the adverse effects of local anesthesia.
List two agents used as local anesthesia.
Identify the stages of general anesthesia.
Mention two agents used for general anesthesia.

4. Introduction
Anesthesiology
is the branch of medicine that is concerned with the administration
of medication or anesthetic agent to relieve pain and support
physiologic function during a surgical procedure.
also defined as the practice of medicine dealing with the
management of procedures for rendering a patient insensible to
pain during surgical procedures, and with the support of life
functions under the stress of anesthetic and surgical manipulations.
(American Board of Anesthesiology)

5. Introduction
The OR team members should be
aware of the effects of anesthesia.
readily available to assist the anesthesia provider as needed
During several aspects of administration & maintenance of the
anesthetic process.
When the agent given causes unconsciousness, the anesthetic is
termed general (general anesthesia) when an agent is directed into a
specific area to cause analgesia, the absence of pain, it is called
conductive or local or regional.

6. Common Terms in Anesthesia
Anesthetist – a person who has been trained to administer an
anesthetics.
Anesthesiologist – a physician who specialized in anesthesia.
Anesthetic agent – a drug that produces local or general loss of
sensitivity.
Anesthesia – loss of feeling or sensation of pain.
Amnesia – loss of memory
Analgesia – lessening of insensibility to pain.
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7. Common Terms ………
 Depolarization – neutralization of polarity as in nerve or muscle cells in the
conduction of impulses.
 Fasciculation – it is uncoordinated skeletal muscle contraction in which groups of
muscle fibers innervated by the same neuron contract together.
 Hypnosis – a state of altered consciousness or sleep.
 Hypnotic – a drug or verbal suggestion that induces sleep.
 Induction – the period from the beginning of administration of anesthetics until the
pt loses consciousness.
 Biotransformation – metabolism of anesthetic drugs.
It occurs by one of the four mechanisms:
oxidation, conjugation, hydrolysis, reduction.
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8. Common Terms ………
Assisted respiration – maintenance of adequate alveolar
ventilation by supplementing the pts respiration by manual or
mechanical means.
RR is controlled by pt, tidal volume by an anesthesiologist.
Ventilation– the constant supply of O2 through the lungs.
PaO2 – partial pressure of arterial O2 tension.
Hypoxia – low blood O2, subnormal O2 content.
Anoxia – Absence of oxygen
Apnea – suspension or cessation of breathing.
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9. Common Terms ………
Hypocapnia – abnormally low level of CO2 in the blood;
can result from deep or rapid breathing.
Hypercapnia – abnormally high level of CO2 in the circulating blood.
Hyperkalemia – above normal elevation of potassium in the blood.
PH – expression of H2 ion concentration in the blood(alkalinity or acidity).
Normal – value 7.35–7.45
Alkalemia – blood pH value of above 7.45
Acidemia – blood pH value of below 7.35
Respiratory acidosis – the reduction of CO2 excretion through lungs
caused by respiratory depression or obstruction or pulmonary disease.
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10. Common Terms ………
Arrhythmia – Disturbance of cardiac rhythm.
Bradycardia – slow heart beat <60 bpm.
Hemodynamic – the study of how the physical properties of the blood
and its circulation.
Hypovolemia – Low or decreased blood volume.
Perfusion – introduction of fluids in to tissues by their injection in to
blood vessels/passage of a fluid through spaces.
Polarity – the state of having poles or regions intensity with mutually
opposite qualities.
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11. Types of Anesthesia
General Anesthesia
Regional Anesthesia
Local Anesthesia
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12. General Anesthesia
Anesthesia is produced as CNS is affected.
Association path way are blocked in cerebral cortex to produce more or less
complete lack of sensory perception and motor discharge.
Most anesthetic agents are potentially lethal substance.
The anesthetist/anesthesiologist must constantly observe the body reflex
responses to stimuli.
Causes unconsciousness, provides analgesia and muscle relaxation.
Depending upon the type and amount of agent used, the patient may be
slightly or not at all responsive to stimuli.
A combination of agents is frequently used to achieve the desired level of
muscle relaxation and analgesia.
Respiratory and circulatory depression observed during operation.
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13. General Anesthesia……
Continuous watching and appraisal of all clinical signs must be monitored.
The levels of anesthesia judged the light moderate and deep and provide
the pt with optimum care.
Characteristics of the ideal general anesthetics:
Produces analgesia.
Produces complete loss of consciousness.
Provides a degree of muscle relaxation.
Obtunds reflexes.
Is safe and has minimal side effects.
Consists of four stages:
induction, excitement, relaxation and danger.
Each stages presents definite group of S/Sx.
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14. Stage I: Induction Stage
 is stage of Beginning Anesthesia (analgesia and amnesia)
 The beginning of administration of the initial agent
 Characterized by
 Reflexes present,
 HR normal,
 slower rate and increased depth of respiration,
 normal BP,
 some dilation of eyes with reaction to light.
 As pt breathes in the anesthetic mixture, warmth, dizziness & feeling of detachment experienced
 Pt conscious but unable to move extremities.
 the pt retains an exaggerated sense of hearing until the last moment.
 Pt may have ringing, roaring, buzzing in ears.
 Unnecessary noises should be avoided.
 For this reason it is mandatory that all personnel in the room remain as quiet as possible during
induction.
 Lasts until the patient is unconscious.
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15. Stage II: Dreams and Excitement Stage
During this phase,
the patient is delirious and
sensitive to external stimuli
Involuntary muscle activity and
struggle may be seen
Patient is physiologically unstable
Ch’zed by
Active reflexes,
increased HR,
irregular breathing,
increased BP,
pupils widely dilated and divergent
but contract when exposed to
light.
Ch’zed variously by
struggling,
shouting,
talking,
singing,
laughing, crying.
When anesthesia smoothly and
quickly administered it will be
avoided.
Anesthetist is attended by some
one to help restrain the pt with
strap and secure arm board.
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16. Stage III: Relaxation Stage
is stage of Surgical Anesthesia
This phase is the level at which surgery may be performed safely.
Four planes, ranging from light to deep, with third or fourth plane usually
best for most types of surgery.
Characterized by
Progressive loss of reflexes,
Pulse rate and volume are normal.
Respiration is regular.
normal to decreased BP,
constricted to slightly dilated and centrally fixed pupils.
The pt is unconscious, lying quietly, on table.
This stage is reached when continuous anesthesia is given as vapor or gas.
With proper administration the stage maintained.
The patient is relaxed, unconscious of pain and is physiologically stable
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17. Stage IV: Danger Stage
is toxic or extreme medullary depression
is reached when too much anesthesia is administered.
begins when the amount of agent causes severe CNS depression and
the patient is in immediate danger of cardiopulmonary arrest.
Characterized by
No reflexes,
weak and thready pulse,
respiration completely flaccid,
decreased BP,
widely dilated pupils.
Prompt intervention is required to prevent irreversible coma and death.
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18. Methods of Administering GA
Three traditional administration method
Inhalation
Intravenous injection
Rectal installation

19. Methods of Administering GA……
Inhalation
The anesthesia machine is used to administer both compressed gas
anesthetics (available in tanks) and volatile liquids that are
vaporized within the machine before administration.
Since the anesthesia provider controls all gases that enter the
patient’s lungs,
the machine also conveys oxygen in the proper proportion.
The patient receives the anesthetic-oxygen mixture via:
Endotracheal tube to trachea
From a mask that fits snugly around the nose and mouth.
In either case, the tube or mask is connected to the machine by a set of
hoses through which the gases flow.

20. Methods of Administering GA……
Intravenous (IV) and intramuscular (IM) administrations
Injections are also used in general anesthesia.
Liquid agents may be administered directly into the blood stream.
A cannula is inserted into the vein and a continuous IV drip is maintained
throughout surgery.
The cannula/catheter is attached to flexible IV tubing.
Solutions such as saline or dextrose in saline are attached to the tubing
to keep access to the vein open at all times.
Other agents such antibiotics or muscle relaxants may also be given
through the IV cannula.
Some anesthetic agents, such as Ketamine, may be administered IM.
These agents are usually injected by the anesthesia provider about 15
minutes prior to surgery.

21. Induction of General anesthesia
Induction and emergency from GA are two crucial periods
requiring maximum attention from operating team.
 Key Points during induction
The circulating nurse should remain at the pt’s side.
Should be quite, excitement, cough, vomiting, laryngospasm should be
avoided.
Absolute avoidance of stimulation of the pt is mandatory.
Precautions during induction
Continuous electrocardiography.
Use of chest stethoscope.
Ready availability of resuscitative equipment including defibrillator.
Induction is individualized
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22. Inhalational Anesthesia
The most controllable method in the up take.
The most controllable method of eliminating anesthetic agents.
Are mainly accomplished by pulmonary ventilation.
The blood and lungs functioning as the transport system.
Inhalational take up has two phases:-
Transfer of anesthetics from alveoli to blood.
Transfer of anesthetics from blood to tissue.
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23. Technique of Inhalational Anesthesia
Performed after administration of general anesthesia.
It can however be performed in the awake patient with
local or topical anesthesia, or in an emergency without
any anesthesia at all
Facilitated by using a conventional laryngoscope, or
bronchoscope
Inhalation gases can be delivered from anesthetic
machine through:
Face mask inhalation – in closed system of anesthesia
machine.
Laryngeal mask inhalation
Endotracheal tube inhalation – inhaled in to trachea
through nasal or oral tube insertion.
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24. Advantages of ET tube:
Ensure patent airway and control of respiration.
Protects lungs from aspiration of blood, vomiting of gastric content.
Helps in minimizing scape of gas into room.
Complications of Intubations
Trauma to teeth
Trauma to pharynx, larynx
Laryngospasm
Trauma to vocal cord
Trauma to trachea
Esophageal or bronchial intubations
Pulmonary aspiration of stomach contents
Hypoxia and hypoxemia during intubation or extubation.
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25. Inhalational Anesthetic Agents
I. Nitrous oxide (N2O)
Commonly used.
Has pleasant sweet fruit like odder.
Advantage
comfortable, rapid induction and
recovery
Rapid inhalation and elimination.
non toxic, none irritating.
Few hrs effect except headache
Excellent analgesia for minor operation
Disadvantage
Poor relaxation
Excitement
Laryngospasm
Hypoxia
II. Cyclopropane
Very potent gas
very seldom used.
Highly explosive
Advantages
pleasant
Rapid induction
Moderate relaxation
Supports circulation.
Disadvantage
flammable, explosive

26. Inhalational Anesthetic Agents
III. Halothane (fluthane)
Volatile liquids.
Very widely used.
Advantage
Has a pleasant odor.
non flammable
Potent
Chemically stable
Smooth & Rapid
induction
None irritating
Does not stimulate
respiratory secretion.
Useful for pts with
bronchial asthma
Disadvantage
Potentially liver toxicity
Respiratory depression
hypothermia
CVS depression:
Hypotension
Bradycardia
Cardiac arrest
IV. Isoflurane
 Advantages
 Rapid induction and
recovery.
 More patent muscle
relaxant.
 Used for asthmatic
pt.
 Disadvantages:
 Expensive
 Respiratory
depressant.
Enflorane
similar to halothane
Advantages
Rapid induction & recovery.
Muscle relaxant is produced.
Disadvantages
Depression of BP and respiration.
Contraindication in renal failure.

27. IV/IM Anesthetic Agents
 Thiopental sodium (pentothal sodium)
Administration – Intravenous
Most commonly used barbiturate
Short acting in small doses
Used for induction.
Advantage-
Pleasant rapid induction (30- 60 sec)
Nonflammable, Non irritant.
nausea, vomiting are rare
Disadvantage
Large doses cause:
Rapid, prolonged respiratory
depression
Circulatory depression
Coughing, laryngeal-spasm.
 Ketamine hydrochloride
administration IV or IM
Produces rapid induction 30 sec. IV, 2-4
minutes
Advantage
For short procedure in children (2-
10yrs)
For plastic and eye procedures.
Disadvantage
Emergence rxns with psychological
manifestations in recovery.
Delirium
Hallucination
Increases B/P

28. Regional Anesthesia
Nerve block
Field block
Epidural
Caudal
Spinal
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29. Regional Anesthesia
Nerve block – anesthetizing of a selected nerve at a given point.
Field block – blocking off of operative site with wall of anesthetic
solution by series of injection
e.g.
Abdominal wall block for herinorrhaphy
Brachial nerve block for hand surgery
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30. Epidural Anesthesia
Introduced into the epidural space of the
spine
The agent baths the nerve roots of the
spinal cord and the area supplied by these
nerves is anesthetized.
The anesthetic is injected outside the
spinal canal
no direct contact b/n spinal fluid and
anesthetic.
Lumbar approach – epidural block.
Caudal approach – epidural sacral block.
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Caudal
Type of epidural anesthesia
Directed into the caudal
canal at the sacrum
Ideal for obstetrics and
procedures on the perineum
Indication
Anorectic
obstetrics
Vaginal
intractable pain
Perineal

31. Spinal Anesthesia
Introduction of the anesthetic into the subarachnoid space at the 4th or
5th lumbar interspace.
Here the agent does come into contact with the spinal fluid
 Intrathecal block – is usually refereed to as spinal anesthesia.
 Currently there are only three medications approved for use via the intrathecal route.
i.e., morphine, ziconotide, and baclofen
 The agent is injected in to the subarachnoid space using the lumber interspace.
 Desensitizing of the spinal ganglia and motor roots.
 The absorption in the nerve fiber is rapid.
 Depends on Various Factors:
Positioning during and immediately after injection.
CSF pressure.
Site and rate of injection.
Volume, dosage and specific gravity (baricity) of solution
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32. Spinal Anesthesia………
 Indications
Ideal for surgery of the lower abdominal or pelvis, such as
Intestinal obstruction,
cesarean section or
hernia repair (Inguinal);
lower extremities.
 Complication of SA
Transient or permanent neurological sequale from trauma irritation by the agent.
Lack of asepsis, loss of spinal fluid.
Decreased intracranial pressure syndrome.
e.g. spinal head ache
Auditory and ocular disturbances such as tinnitus diplopic, arachnoiditis, meningitis.
Caudal equine syndrome (failure to regain use of legs or control of urinary or bowel
function.
Temporary parenthesis such as numbness and tingling.
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33. Spinal Anesthesia……
Procedure
Lateral position- the most common.
Sitting position.
Prone position.
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Spinal and Epidural Anesthesia

34. Spinal Anesthesia
Advantage:-
Pt is conscious.
throat reflexes are maintained
None irritating to respiratory
tract.
No difficulty with airway
problems.
Quiet breathing.
Contracted bowel.
Decreased bleeding
Disadvantage
Circulatory depressant
Hypotension.
Nausea and Vomiting
Danger of trauma, infection
Risk of infection in the spinal
canal if the puncture site and/or
the plastic tube, etc. is
contaminated.
Pt can hear.
Distress.
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35. Local Anesthesia
 The local anesthesia depresses superficial nerves.
 The agent used during local anesthesia acts on a single nerve, a group of nerves or on
superficial nerve endings.
 During all types of local the patient remains conscious.
 Blocks the conduction of pain.
 Advantages:-
 Infiltrated of anesthetic agents are non explosive.
 It needs minimal simple equipment.
 Loss of consciousness does not occur.
 It does not need fasting.
 Surgeon can do operation with out anesthesiologist.
 Contra Indication.
 Allergic sensitivity.
 local infection.
 Septicemia.
 Highly nervous, apprehensiveness.
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36. Local Anesthesia
 Include local infiltration, nerve block and topical.
 Local infiltration
 The agent is injected intracutaneously and subcutaneously into tissues at and around the
incisional site to block peripheral sensory nerve stimuli at their origin.
 The surgery should not be extensive
 It is used to suture superficial lacerations or for excision of minor lesions
 Addition of Adrenaline (Epinephrine) to the anesthetic agent causes vasoconstriction to
slow circulatory uptake and absorption, thus prolonging anesthesia
 Use a calibrated syringe to avoid over dosage
 The patient receiving Adrenaline should be well oxygenated
 Agents with Adrenaline are contraindicated for operative procedures involving fingers and
penis
 High levels of local anesthetic are toxic
 Administration of it takes place as part of the sterile procedure - use sterile needle and
syringe.
 When highly vascularized areas are to be injected, epinephrine is sometimes added to the
anesthetic (to minimize local bleeding, prolong the effect of the agent).
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37. Local Anesthesia
Nerve block
Anesthesia of a large single nerve or nerves
Injection is done not necessarily at the immediate surgical site
Commonly used in surgery that is performed on fingers and toes
The supplying nerve is anesthetized
Topical
Used to numb superficial nerve endings particularly those of the mucous
membranes.
The agent may be–swabbed, sprayed or applied in drops as for eye
surgery.
Useful in preparing the patient for endoscopic procedures, such as
bronchoscopy and esophagoscopy.
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38. Local Anesthesia
Adverse reactions to LA
Proper monitoring of BP, pulse rate, and heart rhythm is essential.
Monitor the patient Q15min during the procedure.
All team members should be aware of the danger signals that
accompany an adverse rxn.
Adverse rxns occurs when the patient receives overdose, which is
by far the most common complication.
Relative overdose occurs when the patient receives too much
anesthetic too quickly, as when a vein or artery is punctured during
the administration of the anesthetic.
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39. Local Anesthesia
Adverse reactions to LA
The anesthetic travels quickly to the brain and the following
symptoms may be observed:
Stimulation: patient may become very talkative or anxious, signs of
tachycardia thready pulse, convulsion.
Depression: patient may appear sleepy and unresponsive,
bradycardia, hypo tension.
Other signs:
patient may develop cyanosis, sweating feel cold, act restless
(signs of shock).
Fainting, itching, nausea or sudden headache may also occur.
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40. Local Anesthesia
Treatment of the Reaction
Discontinue the anesthetic immediately
Oxygen administration may be needed
Cardiopulmonary resuscitation is initiated, if necessary.
* Epinephrine may be used.
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41. Local Anesthetic Agents
Agents of spinal, epidural and local
anesthesia:
Lidocaine 1.0%–2.0%
Tetracaine 0.5%–1.0%
Cocaine
the 1st local anesthetics introduced
Most toxic.
Procaine hydrochloride (Novocain)
less toxic
Lidocaine hydrochloride/xylocaine)
More toxic.
Potent.
Rapid onset.
Tetracaine hydrochloride
(pontocaine)
Very potent agent
Slow onset of anesthesia
Duration of effect is long
Toxic
Bupivacaine hydrochloride
(Marcaine)
more potent
long acting
High toxicity.
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42. Choice of Anesthesia
Selection of anesthesia is made by the anesthesia provider in
consultation with the surgeon and the patient.
The primary consideration with any anesthetic is that it should be
associated with low morbidity and mortality.
Choosing the safest agent and technique is a decision predicated on
thorough knowledge, sound judgment, and evaluation of each
individual situation.
The anesthesia provider uses the lowest concentration of anesthetic
agent compatible with patient analgesia, relaxation, and facilitation of
the surgical procedure.

43. Choice of Anesthesia………
The patient’s ability to tolerate stress and adverse effects of
anesthesia and the surgical procedure depends on:
Respiration,
Circulation, and
Functions of the liver, kidneys, endocrine system, and CNS.
made by anesthetist/anesthesiologist or surgeon.
The primary consideration with any anesthetic is that
it should be associated with low morbidity and mortality.
Anesthetic drugs are not specific but depress activities of all cells.
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44. Choice of Anesthesia………
Important Factors during choice of Anesthesia:
Age and size/weight of the body
Physical, mental, and emotional status of the patient
Presence of complicating systemic disease or concurrent drug therapy
Presence of infection at the site of the surgical procedure
Previous anesthesia experience
Anticipated procedure
Position required for the procedure
Type and expected length of the procedure
Local or systemic toxicity of the agent
Expertise of the anesthesia provider
Preference of the surgeon and patient
Preference of the pt.
Preference of anesthesia provider
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45. Choice of Anesthesia………
An ideal anesthetic agent or technique suitable for all patients does
not exist, but the one selected should include the following
characteristics:
Provides maximum safety for the patient
Provides optimal operating conditions for the surgeon
Provides patient comfort
Have a low index of toxicity.
Provides potent predicable analgesia extending to post- operative
period.
Produces adequate muscle relaxation
Provides amnesia
Has a rapid onset and easy reversibility
Produces minimum side effects

46. PREOPERATIVE MEDICATIONS/ PRE
MEDICATION
Pre medication
Pre medication is administered to the patient approximately one
hour before surgery.
These medications are used in order to relax the patient and
provide smooth induction.
given to the client prior to operation
in order to alleviate anxiety for operation.
It is also important that mucous membranes be dry to prevent
aspiration of mouth secretions into the lungs.
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47. PREMEDICATION
Purposes
To facilitate the administration of any anesthetic
To minimize respiratory tract secretions and changes in HR
To relax the client and reduce anxiety
To allay pre- operative anxiety.
To produce some amnesia.
To have dull awareness of the OR environment.
To counteract undesirable side effects of anesthetic.
To raises pain threshold.
Prolog the effect of anesthetics and are respiratory depressant
effect.
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48. PREMEDICATION
The four common classes of pre medications and their effects:
1. Barbiturates (Nembutal, Secobarbital)
Produces a hypnotic effect
Acting as sedatives
2. Opiates (Metapon, Demerol, Morphine)
Produces narcosis
Act as analgesia
3. Belladonna Derivatives (Atropine, scopolamine)
Inhibit mucous secretion
4. Tranquilizers (valium, vistaril, chlorpromazine)
These relax and allay apprehension and allow for smooth induction.
The patient who has received pre op medications should be watched for
signs of respiratory or circulatory depression.
Any unusual rxns to the medication should be reported to the anesthesia
provider immediately.
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49. Choice of Drugs for pre-medication
Pre-medication Drugs are Classified into:
Sedatives and hypnotics
Tranquilizers
Narcotics
Anticholinergic
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50. PREMEDICATION
Narcotics
Also known as Opiates
Analgesia; enhancement of postoperative pain relief
Produces narcosis
Act as analgesia
Opiates (Metapon, Demerol, Morphine)
e.g.
Morphine sulfate – commonly used
Meperidine(Demerol) – Deemed – synthetic narcotic
Fentanyl (Sublimaze)

51. PREMEDICATION……
Tranquilizers
relax and allay apprehension and allow for smooth induction.
allays anxiety
relieves tension
calming effect
e.g.
Benzodiazepine
Diazepam/Valium
Droperidol
Haloperidol (haldol)
Valium, vistaril, chlorpromazine

52. PREMEDICATION……
Antianxiety and sedative
hypnotics
Sedation; anxiety
reduction
Benzodiazepine
Diazepam (Valium)
Lorazepam (Ativan)
Midazolam (Versed)
Hydroxyzine HCl (Vistaril)
Hypnotics and sedatives
Produces a hypnotic effect
Acting as sedatives
Barbiturates
e.g.
Nembutal,
Seco–barbital,
Pentobarbital,
Phenobarbital sodium

53. PREMEDICATION……
Antibiotic
Prevention of post op infection
e.g.
Cefazolin (Ancef)
Ampicillin (Omnipen
 Anti cholinergics
Secretion reduction
Inhibit mucous secretion
Are Belladonna Derivatives
e.g.
Atropine
Scopolamine
Antiemetic
Ondansetron (Zofran)
Metoclopramide (Reglan)
Promethazine HCl (Phenergan)
Control nausea and vomiting; may
be effective into the post op period
H2 antagonist
Cimetidine (Tagamet)
Ranitidine (Zantac)
Famotidine (Pepcid)
Reduction of acidic gastric secretions
in case aspiration occurs

54. Choice of Drugs for pre-medication
Made by anesthetic sinologist/anesthetist.
Based on pt’s physical and emotional status including age and weight.
The surgeons’ requirements for minimal or maximal relaxation.
The anesthetist anesthetic sinologist own skills and personal
experience.
Right time Given
Time is calculated then maximum effect is reached before
induction.
It is usually given 45-60 minutes prior to induction.
Adequate action is desired for induction and maintenance.
54

55. Neuromuscular Blocking Agent
Non depolarizing agents
1. Tubocuranine chloride (curare)
Derived from a poison from certain south American plants.
1st used centuries ago by the Indians.
Their poison arrows caused death by suffocation from respiratory
paralysis.
The action is predominately a paralysis at voluntary muscle by
blocking of the trans mission of nerve impulses to muscle fibers.
The muscle relaxation is potentate by curtained anesthetizes
(halothane, effleurage, diethyl ether, matchbox flurane and by
some antibiotics.)
55

56. Neuromuscular Blocking Agent……
Pancuronium bromide-
a long acting systemic muscle relaxant similar in action to curare
but & more potent.
 Gallamine triethiodide (flaxedil)
Similar to curare in mechanism and duration of action.
It advantages over curare is an absence of hypotension and
bronchus spasm.
It may cause tachycardia and of in arterial pressure
56

57. Your Role in Anesthetized Patient
positioning the patient’s
Evaluating patient’s ability to detoxify anesthetic agents and tolerate
stress.
Patient’s respiratory and circulatory care.
Measuring the pt’s urinary out put.
Constantly aware of potential trauma to the patient.
57

58. Post Anesthesia Care Unit (PACU)
Nurse’s major considerations:
Transfer of pt from the operation room to PACU.
Referred to as the post anesthesia recovery room/ PACU.
Special consideration of the pt’s incision site vascular changes and
exposure.
Wounds are closed under considerable tension.
While positioning or transferring the pt not lying on and obstructing
drains or drainage tubes.
Serious arterial hypotension way occur when the pt is moved from
one position to another such as:
From lithotomy position to horizontal.
From lateral to supine.
From prone to supine.
58

59. Transferring the post-operative pt is
the responsibility of anesthesiologist
with members of other surgical team.
59

60. Sites of PACU
usually located adjacent to the operating room.
Because of nurses and surgeons to care for the post operative pt in
theatre.
Because of availability of monitoring and special equipments,
emergency medications, and replacement of fluids in theatre.
60

61. PACU………
PACU painted quiet in soft, pleasing colors and have:-
Indirect lighting
sound proof ceiling
equipments that controls or eliminates noise
PACU have
Isolated quarters/gas encased/for disruptive pts to decrease anxiety.
Room temperatures should be 20’c to 22. 2 0C.
Room should be well ventilated.
Pt should stay in PACU until adequate respiratory function, a minimum
of 95% of 02 saturation.
Pt should gain reasonable degree of consciousness.
61

62. Immediate Post OP Assessment
Review of
Medical diagnoses and types of surgery performed
Pts age and general condition, airway potency, vital-signs.
Anesthetic and other medications used muscle relaxants, antibiotic, IV fluids.
Vital signs- presence of artificial airway, o2 sat,BP,pulse, temperature.
LOC- ability to follow command, pupillary response.
Urinary output.
Skin integrity.
Pain.
Condition of surgical wound.
Presence of IV lines.
Position of patient.
62

63. Immediate Post- Op----
Any problem that occurred in operating room that might influence
post care. e.g. extensive hemorrhage, shock, cardiac arrest.
Pathology encountered (if Malignant suspected)
Types of fluid administered; blood loss and replacement, blood pH.
Any tubing, draining catheters, or supportive aids.
Specific information’s for which surgeon or anesthetist wishes to be
notified.
63

64. Post Operative Complication
Airway obstruction
Cardiac arrest
Hypoventilation.
Atelectasis/pulmonary
collapse.
Pulmonary embolism.
Pulmonary edema.
Venous stasis.
HTN/hypotension.
Shock.
Hemorrhage.
Post OP wound infection.
Urinary retention/full
bladder.
64

65. Gerontologic considerations
Mental status – attributed to medications, pain, anxiety,
depression.
Delirium – infection, malignancy, trauma, MI, CHF, opioid
use.
Dementia – sundowning = sleep disturbances, lack of
structure in the afternoon or early morning, sleep apnea.
65

66. Nursing Intervention
V/s are monitored every 15 minutes.
Potency of airway and respiratory function.
Cardiovascular function.
Clearing secretion from airway.
Proper positioning of pt.
IV solution drip rate setting.
Level of responsiveness.
Pain mgt.
66

67. Nursing Intervention
Quite environment
Drainage management
Body temperature
Above 37.7c0
Below 36.1c0
BP
SBp < 90 mmHg
DBp < 60 mmHg
67

68. Questions for Study and Review
1. What is the difference between anesthesia and analgesia?
2. Define local anesthesia.
3. Mention three different kinds of local anesthesia.
4. What effect does epinephrine has on the surgical site?
5. Discuss the various ways a patient might react adversely to the local
anesthesia.
6. What is the maximum safe dosage of xylocaine?
7. What are the various methods in which a general anesthesia might be
administered?
8. Identify the four stages of general anesthesia.
9. List four types of preoperative medications and give an example of each.

69. Summary
1. A 34-year-old man was scheduled to undergo open repair of multiple
fractures in one hand. The anesthetic management was brachial
plexus anesthesia with bupivacaine. During the injection of the
anesthetic the patient suddenly exhibited nystagmus, slurred speech,
tremors, muscle twitching, followed by tonic-clonic convulsions.
Which of the following statements best explain the neurophysiologic
mechanism of the excitatory state Induced by the drug in this
patient?
A. The drug caused cardiotoxic effects which in turn triggered the
CNS excitation.
B. The drug mediated an allergic reaction in a sensitized patient.
C. The drug inhibited glutamate reuptake into glutamatergic
neurons.
D. The drug activated the mesolimbic pathway in the CNS. 69

70. 2. You are the recovery room nurse who is admitting a patient
from the OR. What is the first assessment you would make
on a newly admitted patient?
A. Heart rate
B. Nail perfusion
C. Core temperature
D. Patency of the airway
70

71. 3. You are discharging your patient home from day surgery
after a general anesthetic. What instruction would you give
the patient prior to the patient leaving the hospital?
A. The patient is not to drive a vehicle.
B. The patient should have a glass of brandy the first night home to
help him or her sleep.
C. Eat a large meal at home.
D. Do not sign important papers for the first 12 hours after surgery.
71

72. References
1. Kleinman, W. & Mikhail, M. (2006). Spinal, epidural, & caudal blocks. In G.E.
Morgan et al Clinical Anesthesiology, 4th edition. New York: Lange Medical
Books.
2. Morgan, G.E., Mikhail, M.S., Murray, M.J. (2006). Peripheral nerve blocks. In G.E.
Morgan et al Clinical Anesthesiology, 4th edition. New York: Lange Medical
Books.
3. Warren, D.T. & Liu, S.S. (2008). Neuraxial anesthesia. In D.E. Longnecker et al
(eds) Anesthesiology. New York: McGraw-Hill Medical.