Chapter 5: Perioperative Patient Care: Anesthesia & Nursing Implications

General Anesthesia
-Emergency Assessments
-Post Op Assessments
Unconsciousness with amnesia, analgesia, reflex suppression, and muscle relaxation.
– Cricoid Pressure may need to be used
– Apply warm blankets pre and post op for shivering
– Emergency assessments include airway patency, return of the reflexes, muscle strength, ability to follow commands.
– Post Op Assessment: LOC, airway patency, CV status, temp, fluid balance, return of neuro function. Assess for Nausea and vomiting, post-operative analgesia, operative site condition.

Cricoid Pressure
During induction of general anesthesia – may need to apply CRICOID pressure to displace the cricoid cartilage and close the esophagus when passing the ET tube to decrease the risk of aspiration – Assess for bilateral breath sounds after passing the ET tube.

Regional Anesthesia
2 types
Signs and Symptoms of Toxicity
Management of Toxicity
Local anesthetic acts on cell membrane, interrupting sensory pathways between surgical site & brain.
Lidocaine Hcl (Xylocaine) acts for 1-3 hours.
Bupivacaine (Marcaine) – 3-10 hours
Signs and Symptoms of toxicity: CNS first affected, THEN CV affected —> drowsiness, numbness tongue, blurred vision, tinnitus, dizziness, restlessness, slurred speech, muscular twitching, followed by convulsions. Also Hypotension, bradycardia, heart block, cardiac arrest can occur.

Management of the above includes: STOP administation of local anesthetic, resuscitation with epi, 02, IVF, aminophylline & hydrocortisone.

Lidocaine Hydrochloride (Xylocaine)
Regional anesthesia – Acts 1-3 hours – commonly used for infiltration, regional IV anesthesia, peripheral nerve block, epidurals, and spinal.

Bupivacaine (Marcaine)
Regional anesthesia – Acts for 3-10 hours – commonly used for infiltration, regional IV anesthesia, peripheral nerve block, epidurals, and spinal.

Infiltration Techniques: Local infiltration
Local: subcutaneous injection at the operative site. Provides sensory blockade of skin & subcutaneous tissue.

Infiltration Techniques: Intravascular Techniques & Nursing considerations.
aka Bier Block – Used for surgeries below elbow or knee. Double bladder tourniquet applied to operative extremity & inflated. Local anesthetic is injected into the distal peripheral vein which provides blockade to the level of the tourniquet.
Tourniquet Time is Crucial – Cannot be less than 30 minutes and greater than 90 minutes in UE and 2 hours in LE (can cause ischemia). Must deflate the tourniquet slowly to prevent systemic bolus.
Must assess for return of normal senstation, color, cap refill.

Peripheral Nerve Blockade
Name the block used for each type:
Upper Extremity
Foot & Toes
Sensory and motor nerve blockade due to local anesthetic injected around major nerve trunk that supplies the surgical site.
Upper Extremity: Brachial Plexus Block
Knee: Femoral Block
Foot and Toes: Ankle Block

Nursing Considerations: Postop: assess for return of sensory and motor function. If able to ambulate, support the LE until recovery is complete – use resistive device for ambulation.

Central Nerve Blockade
Local anesthesia injected into the spinal canal (subarachanoid space) with resultant sensory, motor, and autonomic blockade.

Central Nerve Blockade – Nursing Assessments IntraOp

– What are dermatomal landmarks?

Intraop- use dermatomal landmarks to assess level of sensory & motor blockade:
L1-2 = groin
T10 – umbillicus
T4 = nipple line

Assess for a high spinal by auscultating breathsounds – anesthetic may travel as high as C4.

Central Nerve Blockade – Nursing Assessments PostOp

-how to assess return of function
-what to monitor for/check for
-rare complications

Monitor for return of sensory and motor function. May Vary – One Leg may regain sensation before the other. Assess motor by having patient: wiggle toes, dorsiflex, raise/flex legs

Return of sensation to both extremities & rectal area = good indication recovery is complete

Check for HYPOTENSION (due to residual autonomic blockade). URINARY RETENTION (nerves supplying bladder are affected). SPINAL HEADACHE

other possible/rare complications: meningeal irritation, cord compromise (fever, pain, tenderness, weakness, paralysis)

Spinal Headache
– Cause
– When do you check for this?
Can be caused from central nerve blockade (Epidural)
Cause: Dural Puncture with CSF leak
Check for this on the second post op day
Prevention: 25 gauge needle, adequate hydration, — early ambulation doesnt have effect on incidence.

Symptoms: severe frontal/occipital pain that worsens in upright position, nausea, vomiting double vision, tinnitus, dizziness

Treatment: 1st line (conservative) – BR, hydration, analgesics. If ineffective, must have a Blood Patch – 10ml of own venous bloos injected sterile into spinal puncture site to seal the leak. Relief is usually instantaneous.

IV Conscious Sedation

-Reversal Agent
-Side Effects

Used to promote a depressed level of consciousness but allows patients to maintain patent airway and respond appropriately to verbals instruction & physical stimuli.

GOALS: relaxation, sedation, amnesia, analgesia

Monitoring: Pulse ox, frequent VS checks,
If RN performs, must be his/her only task

Use supplemental 02 for nausea and vomiting control and decrease post op infections (02 helps the alveoi release immune defenses).

Reversal agent: Flumazenil (Romazicon) Also Narcan
Side Effects: N/V, Urinary Retention

IV Conscious Sedation:

Name the Two Classes of Drugs used and the specific meds per each class

Diazepam (Valium)
Midazolam (Versed)

Merperidine (Demerol)
Fentanyl (Sublimaze)

Induction Agents
Thiopental Sodium ( Pentothal)
Methohexital Sodium (Brevital)
Propofol (Diprivan)
Midazolam (Versed) — reversed by Flumazenil (Romazicon), FYI

Induction Agents
– What is used for maintenance of anesthesia?
– Which drug should you use cautiously with egg white allergy?
– Which 2 can cause burning on injection
Hypnotic agents, used to render the patient unconscious
Propofol and Versed may be used for maintenance of anesthesia
Use propofol cautiously in patients with egg white allergy because it is dissolved in lecithin.
Propofol and etomidate can cause burning sensation on injection.
Some studies show that patients emerge more quickly with propofol rather than with inhalation anesthesia.

Inhalation Agents
Halothane (Fluothane)
Isoflurane (Forane)
Enflurane (Ethrane)
Desflurane (Suprane)
Nitrous Oxide (N20)

Inhalation Agents
-What organ absorbs and eliminates?
-What disease process can it trigger?

Which drug does the following:
_______ – Do not use for patients with hx of Seizure
_______- non irritating to respiratory tract, does not predispose to arrhythmia, kidney or liver function
________- shivering is common
________- Higher chance for bronchospasm/laryngospasm

Potent Respiratory depressant agents absorbed and eliminated primarily through the lungs.
MAY TRIGGER MH – malignant hypothermia (except N20)
– Usually given in combo with 02, narcotics, muscle relaxants for balanced anesthesia.
– All potent inhalation agents can cause transient elevation in liver enzymes.

Ethrane – Do not use for patients with hx of Seizure
Sevoflurane – non irritating to respiratory tract, does not predispose to arrhythmia, kidney or liver function
Halothane – shivering is common
Forane – Higher chance for bronchospasm/laryngospasm

Neuromuscular Blockers (Paralyzing Agents)
Succinylcholine chloride (Anectine)

Mivacurium (Micacron)
Atracurium (Tracrium)
Vercuronium (Norcuron)
Tubocurarine chloride (Curare)
Pancuronium bromide (Pavulon)
Pipercuronium bromide (Arduan)
Doxacurium chloride (Nuromax)

Neuromuscular Blockers (Paralyzing Agents)
– Who may give these meds and why
– Mechanism of Action
– Which one can cause malignany hypothermia
– Reversal Agent for the non-depolarizing NM Blockers
All of these render the patient APNEIC. Only for use by anesthesia providers
-All of these meds interfere with action of acetylcholine at the neuromuscular junction, they do NOT affect CNS. – Therefore, these drugs should be used only with other sedatives and narcotics to prevent patient awareness/distress.
-Succinylcholine has been identified as the primary triggering agent for Malignant Hypothermia – So if a patient has history of MH, use any other agent in this class.

Reversal agent for the non depolarizing NM Blockers: anticholinesterase inhibitors.

Anticholinesterase Inhibitors
— Use
— Name the 2 types
–Side effects
Neostigmine methylsulfate (Prostigmin)
Pyridostimine Bromide (Mestinon, Regonal)

Reversal agent for nondepolarizing neuromuscular blocking agents (NOT Succinylcholine since that type is depolarizing)
Act by allowing more acetylcholine to be available to compete with the NM blockers for receptor sites.

Side effects: parasympathetic nervous system effects such as : increased secretions, bronchospasm, bradycardia – Should be given with atropine or glycopyrrolate (Robinul).

– Use
– What to observe for when administering
Effective to reverse narcotics only.
-Patient must be observed carefully for renarcotization, as the action of the narcotic may last longer than the action of the narcan. Use careful titration because abolishing all analgesia may produce tachycardia, sweating, nausea, vomiting.

Flumazenil (Romazicon)
– What does this reverse
– Caution to take
Benzodiazepine Inhibitor – Reverses Benzos only.
Effect of the flumazenil may be shorter than the effect of the midazolam – Dose may make patient awake for 15-30 minutes and then they are back to being sedated again.
— Patients who routinely take benzodiazepines have increased risk for seizure activity when they are reversed with flumazenil.

List two
– Why given?
-Sife Effect
-What disease is one contraindication?
Atropine Sulfate
Glycopyrrolate (Robinul)

– Given to dry oral secretions, decrease gastric acidity, possibly to prevent preinduction vagally mediated bradycardia
-May cause tachycardia
– Do NOT use in patients with narrow angle glaucoma.

List – There are 6

Which one is short acting, which one is intermediate acting

Fentanyl citrate (Sublimaze) -intermediate acting
Sufentanil citrate (Sufenta)
Alfentanil hydrochloride (alfenta) -very short acting
Morphine sulfate -long acting
Merperidine chloride (Demerol)
Hydromorphone (Dilaudid)

Narcotic Agonist-Antagonists
Pentazocine (Talwin)
Butorphanol (Stadal)
Nalbuphine (Nubain)
Dezocine (Dalgan)

Opiod Agonist-Antagonist
Actions range from potent analgesia to sedative effects, varying respiratory and cardiac depressive effects.

LIST – (7)
Prochlorperazepine (Compazine)
Trimethobenzamine (Tigan)
Metoclopramide (Reglan)
Promethazine (Phenergan)
Odansetron (Zofran)
Droperidol (Inapsine)

Zofran is “quite expensive” !
Reglan in combination with narcotics will decrease effectiveness
Droperidol should be used with care, may increase BP and cause respiratory depression.

Miscellaneous Adjuncts

Ketamine hydrochloride (Ketalar, Ketaject)

Ketamine: useful nonopiod IV anesthetic related chemically to LSD and PCP – has been associated with vivid dreams, hallucinations, accompanying wild behavior in early postoperative period.
-benzos decrease incidence of hallucinations for patients on ketamine.

Stimulates the sympathetic nervous system, good for a patient experiencing bronchospasm or hypotension.

Can be used alone for short procedure because respiratory function remains intact — Patients receiving Ketamine in this fashion become dissociated with pain and amnesic for the event.

Miscellaneous Adjuncts

Ketorolac tromethamine (Toradol)

Nonsteroidal antiinflammatory drug – Injection can help with post op pain.
Can be used on regular schedule for short term post operative pain control.
No side effect of Respiratory Depression

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