The Peri-operative Patient

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The Peri-operative Patient

• John Carmichael, CRNA

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Anxiety
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Anesthesia Man
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Types of Anesthesia

• General-unconscious state
• Regional-reversible loss of sensation in area to
  block nerve fibers (includes spinal, epidural)
• Monitored Anesthesia Care- local IV drugs for
  sedation
• Conscious Sedation/Analgesia- sedation
• Local Anesthesia- anesthetic agent by local
  infiltration or topical application.

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General Anesthesia
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Open Drop Ether Anesthesia
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ASA Classification

• Class I- Normal, healthy patient
• Class II- Patient with mild systemic disease
• Class III-Patient with systemic disease that is
  not incapacitating
• Class IV- Patient with an incapacitating systemic
  disease that is a constant threat to life
• Class V- Moribund patient not expected to survive
  for 24 hours with or without surgery
• See page 23 in handout in binder.

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Typical Sequence leading up to Induction
ofAnesthesia

• Admission after pre-work up
• Anesthesiologist sees patient in pre-op holding
  and has talked with the patient the night before
  to review history and plan for anesthesia. Chart
  and patient checked for consents, ID, labs, HP.
  Sedation.
• In OR-Monitors applied, Time-out occurs
• Sedation, Induction

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The Three Phases of General Anesthesia

• Induction- begins with placing of monitors
  through intubation.
• Maintenance- begins after intubation to near
  completion of the procedure (titrated doses of
  anesthetic agents)
• Emergence- begins with turning off the
  maintenance agent(usually a volatile gas in the
  Ether family) and culminates with the patient
  regaining consciousness.

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Process of Induction

• Monitors applied (EKG, Pulse Oximetry, Blood
  Pressure)
• Meds given IV for beginning sedation
• Pt pre-oxygenated with 100 O2 for 3-5 minutes
  to supply pt with reserve supply of oxygen in the
  lungs.
• Sleep dose of induction agent given. Usually
  Propofol, Sodium Pentothal or Etomidate.
• Followed by a Neuromuscular Blocking Agent.

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Visualizing Vocal Cords Prior to Intubation
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Endotracheal Tube with Cuff
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Vocal Cords with Endotracheal Tube
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Maintenance of Anesthesia
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Maintenance of Anesthesia

• Maintenance of anesthesia is usually
  accomplished with one of several volatile gasses
  which are related to Ether.
• During the maintenance phase we monitor end tidal
  Carbon Dioxide as a means of determining how well
  we are ventilating the patient and end tidal
  anesthetic gas which gives us one indicator of
  anesthetic depth.
• Total Intravenous Anesthesia or TIVA can also be
  used in the maintenance phase of anesthesia.
  This is usually accomplished with a combination
  of Versed, Propofol, which is a sedative
  hypnotic, a narcotic and muscle relaxant.

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Emergence

• Emergence from anesthesia usually includes
  extubation and continues in the PAR. Where the
  drugs used for anesthesia gradually wear off .
• The patients postsurgical pain is also addressed
  at this time.

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Regional Anesthesia

• Accomplished by injecting a local anesthetic
  anywhere along the pathway of a nerve from the
  spinal cord.
• Examples Spinal, Epidural, Peripheral Nerve
  Blocks
• Patients need to be monitored appropriately while
  receiving these medications. Pulse oximetry,
  EKG, BP, supplemental O2 prn.
• Provide reassurance and possibly sedation as
  ordered.

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Spinal/Epidural Anesthesia
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Epidural Space
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Spinal/Epidural Anesthesia
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Physiologic Responses to Spinal Anesthesia

• Hypotension occurs secondary to sympathetic
  nerves that control vasomotor tone are blocked.
  Tx crystalloid bolus, 5 degree head-down
  position to improve venous return, Vasopressor
  (Ephedrine).
• Total Spinal (inadvertently high block) may
  result in paralysis of the respiratory muscles
  and necessitate immediate intubation and
  ventilation.
• Spinal Duramorph Administered by the
  anesthesiologist. Nursing needs to be aware of
  effects on the respiratory rate and sedation as
  this med is not broken down by the liver. Have
  an ambu bag and Narcan available at the bedside

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Monitored Anesthesia Care

• Uses Procedures that combine MAC with a
  peripheral nerve block or local anesthetic.
• Useful for normal, healthy people and sicker,
  unstable patients that are high risk for general
  anesthesia.
• Meds used may be local IV analgesic (fentanyl)
  sedative and amnestic drugs (midazolam or
  propofol).
• Anesthesiologist monitors VS, respiratory and
  cardiovascular status and positioning. May give
  low flow supplemental oxygen.
• Can quickly be changed into General Anesthesia.

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Conscious Sedation/ Analgesia

• Administration of IV medications to produce
  sedation at a level that pt is able to maintain
  airway and respond appropriately to verbal
  commands or physical stimulation.
• Performed by peri-operative nurses with
  additional training under the direction of a
  physician.

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Local Anesthesia

• Administration of an anesthetic agent to a
  specific area of the body by the following
  methods topical application, local
  infiltration, regional nerve block or field
  block.
• Administered by the surgeon or anesthesiologist
  if surgeon prefers.

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Considerations for Recovery

• Length of surgery/positioning of patient during
  surgery.
• Hydration status in relation to surgery.
• Blood glucose control pre-op, intra-op and
  post-op (Optimal wound healing and decreased rate
  of infection if maintained in the normal range
  80-110).
• Temperature control intra-op and post-op (Optimal
  wound healing if gt96.8 maintained).

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Malignant Hyperthermia

• Rare, life-threatening complication triggered by
  common anesthetic agents (Inhalational agents and
  Succinylcholine).
• May be induced by trauma, strenuous exercise or
  emotional stress.
• Genetic disorder Autosomal dominant trait.
• Syndrome is a hypermetabolic condition in the
  skeletal muscle cells involving an altered
  mechanism of calcium function at the cellular
  level.
• Usually presents in OR or PACU.
• Temperature increase is a late sign.

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Malignant Hyperthermia
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Malignant Hyperthermia
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Admission to PACU

• Immediately determine airway, breathing and
  circulation.
• Apply humidified O2, count RR and apply pulse
  oximeter.
• Apply cardiac monitor, assess cardiac rate and
  rhythm.
• Obtain VS, assess breath sounds.
• Peri-op nurse and Anesthesiologist give
  report-pre-op vs, labs, O2 sat, allergies and
  relevant hx, anesthesia technique and agents,
  length of anesthesia, reversal agents, surgical
  procedure, EBL and volumes in, complications and
  ASA classification.

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Nursing Dx in PACU

• Ineffective breathing pattern
• Decreased Cardiac Output
• Risk for altered body temperature
• Altered thought processes
• Pain

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Postoperative Complications

• Airway obstruction- commonly the tongue secondary
  to anesthetic agents and muscle relaxants (chin
  lift, jaw thrust).
• Laryngospasm-muscles of the larynx contract to
  cause airway obstruction. Result of irritable
  airway (remove irritating stimulus, suction,
  hyperextend head, O2,aerosol with racemic
  epinephrine, positive pressure ventilation per
  mask and bag). May need succinylcholine.

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Post-Op Complications

• Bronchospasm-(bronchodilators)
• Cardiovascular-hypotension, hypertension,
  dysrhythmias
• Hypotension-usually caused by hypovolemia in this
  setting, we will usually try a fluid bolus if it
  isnt cardiac in etiology.
• Hypertension- May be caused by volume overload,
  pulmonary edema, pain, anxiety or reflex
  vasoconstriction from hypothermia.

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Post-Op Complications

• Dysrhythmias- sinus tachycardia common. Causes
  pain, hypoxemia, hypovolemia, increased
  temperature and anxiety. Treat underlying cause.
  
• Bradycardia-hypoxemia, hypothermia,
• high spinal, vagal stimulation.
• PVCs-hypoxemia, hypokalemia.

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Post-Op Complications

• Hypothermialess than 36 degrees Celsius, or 96.8
  degrees Fahrenheit.
• 60 of PACU patients are hypothermic. Causes
  physiologic stress, prolongs recovery time and
  contributes to post-op morbidity.
• Shivering increases oxygen needs by 300-400.
• Depresses CNS resulting in longer duration of
  anesthesia.

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Post-op Complications

• Hyperthermia-may indicate infection, sepsis, MH
• Altered Thought Processes
• Nausea and Vomitting
• Aspiration
• Pain

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Discharge from PACU
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Discharge from PACU

• Discharge order written by anesthesiologist.
• Patient needs to meet discharge criteria
• Common scoring system Aldrete Score-factors in
  activity, respiration, circulation, consciousness
  and O2 saturation level. Need a total score of
  8-10 to discharge.

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Discharge from PACU

• Report to nurse who will be assuming care of the
  patient upon transfer.
• Given via telephone or face-to-face.
• Includes pre-op history, pertinent information
  about the surgery and recovery, meds the patient
  received, physicians orders and other
  information as appropriate.

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Transfer to Unit

• Maintain patient safety side-rails, PCA use.
• Nurse accepting report needs to do an immediate
  assessment. Include head-to-toe and focused
  assessment with consideration to UOP and bowel
  sounds.

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Nursing Diagnosis

• Risk for infection
• Ineffective breathing pattern (secretions,
  decreased lung expansion, RR, aspiration)
• Pain
• Altered nutrition, less than body requirements
  (wound healing)
• Impaired physical mobility (venous stasis)

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References

• Meeker MH, Alexanders Care of the Patient in
  Surgery, Mosby, 1999.
• Bishop J., Sprague M., Gelber MS, Krol M,
  Rosenblatt MA, Gladstone J, Flatow EL.
  Interscalene Regional Anesthesia for Shoulder
  Surgery. Journal of Bone and Joint Surgery. 2005
  87-A,5974-979.