Anesthetic Considerations for General Surgery Flashcards
CRNA’s responsibility in the preoperative evaluation
determining medical status of the patient
developing a plan of anesthesia care
reviewing with the patient the proposed plan of care
Goals in determining our anesthetic technique
patient safety and comfort and ability of the surgeon
Ideal anesthetic goals (8)
- optimal patient safety and satisfaction
- excellent operating conditions for the surgeon
- rapid recovery
- avoid postop side effects
- low in cost
- allow early discharge from PACU
- optimize pain control
- allow for optimal OR efficiency
Advantages of General Anesthesia for General Surgery
rapid onset of unconsciousness controlled ventilation allows paralysis more safely allows positioning extremes lower failure rate
Disadvantages of General Anesthesia for General Surgery
increased stress response
if full stomach - risk of aspiration
PONV
postop sedation
Goals of maintenance of anesthesia
amnesia, analgesia, skeletal muscle relaxation, and SNS response control
Advantages of regional anesthesia for general surgery
maintenance of consciousness skeletal muscle relaxation contraction of the GI tract lower insufflation pressure decreased stress response faster recovery
Disadvantages of regional anesthesia for general surgery
occasional failure to produce adequate levels of sensory anesthesia
hypotension d/t SNS blockade
Peripheral nerve block advantages
good option for superficial operations of extremities
consciousness
protective upper airway reflexes
isolated anesthetic effect
peripheral nerve block disadvantages
unpredictable sensory and motor anesthesia
success rate related to experience of provider
patient cooperation
Monitored anesthesia care (MAC) considerations
not benign! held to the same standard as any other anesthetic
*can lead to unexpected general anesthetic!
local anesthesia toxicity
provides anxiolysis, analgesia, sedation
Positioning possible complications
hypotension from impaired venous return
oxygen desaturation d/t VQ mismatch
peripheral nerve injuries
Positioning general considerations
ensure patient safety! peripheral joint extremities well padded support normal lumbar spine curvature head midline no pressure on the eyes safety straps/prevent falling
Positioning CV considerations
going supine = increased VR –> preload, SV, CO augmentation
increased BP = afferent baroreceptors –> decrease SNS outflow
PPV increases intrathoracic pressure
Supine positioning
arms: tucked (adducted) or abducted <90 degrees with palms supinated
hips/knees: flexed slightly
Supine complications
pressure alopecia, backache, soft tissue ischemia, peripheral nerve injury
Trendelenburg considerations
nonsliding mattress, don’t use shoulder braces, significant CV/respiratory effects
Trendelenburg physiologic changes
increase CVP, ICP, IOP
swelling in face, larynx, and eyes
decreased FRC and compliance
increased work of breathing
Reverse trendelenburg considerations
facilitates upper abdominal surgery by shifting abdominal contents caudad
decreased venous return and CPP
Lithotomy considerations
used for gynecologic, rectal, urologic surgeries
hips are flexed
legs abducted and held by stirrups
raise and lower both legs together
Which position can cause crush injury to the fingers?
lithotomy
what is the most common nerve injury in lithotomy position?
peroneal nerve
lithotomy physiologic changes
increased preload, reduced lung compliance, decreased tidal volume, increased abdominal pressure
lateral decubitus considerations
used for thorax, retroperitoneal, hip surgeries anterior and posterior support flex dependent leg arms positioned in front of patient axillary roll and kidney rest
Why do we place an axillary roll for lateral decubitus positioning?
avoid compression injury to the dependent brachial plexus
lateral decubitus physiologic changes
can compromise pulmonary function
favors ventilation of nondependent lung and blood flow to underventilated, dependent lung
prone positioning considerations
used for posterior spine, buttocks, perirectal, and lower extremities
arms tucked or superman
