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NURS 412 Midterm #1 > General and Regional Anesthesia and Postoperative Pain Management > Flashcards

General and Regional Anesthesia and Postoperative Pain Management Flashcards

1
Q

General Anesthesia

A

a reversible state of unconsciousness produced by drugs with sufficient depression of reflexes to allow a surgical procedure to be performed

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2
Q

Goals of General Anesthesia

A

Unconsciousness
Analgesia
Muscle Relaxation
Depression of autonomic/endocrine reflexes

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3
Q

Phases of General Anesthesia (4)

A
  1. Pre-Operative
  2. Intra-Operative
    - Induction
    - Maintenance
  3. Reversal
  4. Recovery
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4
Q

General Surgery Phase 1: Preoperative - Primary goal

A

Optimizing their medical status
Guarding against potential surgical complications

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5
Q

Medications given in the preoperative stage

A

Anxiety relief
Decreased risk of acid aspiration (PPI)
Pre-emptive analgesia
Depress reflex activity

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6
Q

Phase 2: Intraoperative two sub-phases

A

Induction
Maintenance

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7
Q

Induction

A

During the induction of anaesthesia the patient is taken from an awake to an unconscious state using IV medications (Propofol, Midazolam - short acting)

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8
Q

Maintenance

A

once induced, the patient is maintained (via inhaled and IV meds) so that all the body systems are protected while allowing the surgery to be performed

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9
Q

The primary goals during the intraoperative phase are:

A
  1. Unconsciousness
  2. Muscle relaxation
  3. Analgesia
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10
Q

Phase 3: Reversal

A

The goal of the reversal phase is to return the patient to a conscious, spontaneously breathing state while maintaining a state of analgesia

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11
Q

Phase 4: Recovery - the goals (6)

A
  • airway maintenance and adequate ventilation
  • cardiovascular stability
  • normothermia
  • consciousness
  • freedom from nausea and vomiting
  • analgesia
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12
Q

Regional Anaesthesia (Neuraxial Blocks)

A

Spinal Anesthesia
Epidural Anesthesia (epidural space)

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13
Q

Where does spinal anesthesia go?

A

into the subarachnoid space like a lumbar puncture
Is directly in contact with the CNS. Because of this, it takes effect very quickly. A complete motor and sensory block. Do not need a lot of medication in this space to get this effect. No catheter taht sits in the space. it is a one time dose

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14
Q

Spinal Anesthesia

A

The injection of local anaesthetic and/or opioids into the CSF of the subarachnoid space, usually below the level of L2.
A SINGLE DOSE of opioid and local anesthetic is injected into the subarachnoid space producing an autonomic, sensory and motor blocks.

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15
Q

Where is the spinal space located

A

between the arachnoid mater and the pia mater and contains CSF. this is known as the subarachnoid space

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16
Q

Where does the spinal cord end

A

in adults the spinal cord ends at L1-L2. A fine gauge spinal needle is inserted at the L2-3 level or lower to avoid the spinal cord (don’t want to hit the spinal cord)

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17
Q

What do patients experience with Spinal Anesthesia

A

vasodilation/hypotension - autonomic block
no pain - sensory block
unable to move - motor block

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18
Q

Dosage of spinal vs epidural analgesia

A

The dose of subarachnoid analgesia is only 1/10 of the dose used in epidural space

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19
Q

Post-Operative Monitoring (spinal)

A
  • Vital Signs
  • Motor and sensory block
  • Urinary output/bladder distention
  • Headache assessment
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20
Q

Epidural Anesthesia

A

a catheter is placed in the epidural space just outside the dura (the special covering enclosing the spinal canal)
local anaesthetic agents works by binding to nerve roots as they enter and exit the spinal cord
allows for better titration and control of the extent of sensory and motor blockage
May be the sole anaesthetic for surgery or a catheter may be placed to allow for intra- and post-op analgesia using lower doses of epidural local anaesthetic and opioid

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21
Q

Where is an epidural catheter placed?

A

catheter may be in thoracic OR lumbar spine
thoracic is better because it prevents bladder and bowel dysfunction and allows for walking and provides better nerve block

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22
Q

Post-Operative Monitoring (Epidural) (6)

A

Urinary output/bladder distention
Assessment for pruritis, nausea, or vomiting
Pain assessment
Assessment for catheter migration (ie numbness or tingling)
Assessment of dressing and insertion site
Headache assessment

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23
Q

Regional Anesthesia will cause nerve function to disappear in the following order:

A

Sympathetic (vasomotor): dilation of skin and blood vessels including arteries and veins (causes drop in BP)
Temperature discrimination
Pain recognition
Touch and pressure sense
Motor function

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24
Q

How does nerve function return

A

As the anesthetic wears off, the nerve functions will return in reverse order to how they disappeared. This is good for the patient because they gain motor function, while still having pain management.
This is why dermatome checks are done with temperature. it should precede the experience of pain

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25
Q

Spinal
onset and duration:
space:
needle dose:
quality of sensory and motor nerve block:
toxicity:

A

rapid onset and limited duration
lumbar space
small sharp needle 1-4 ml
more liable
sudden toxicity ++

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26
Q

Epidural
onset and duration:
space:
needle dose:
quality of sensory and motor nerve block:
toxicity:

A

slow onset and continuous duration (use catheter)
Can be used in analgesia
Any space usually lumbar or thoracic
Curved long and blunt 10-30ml needle
less quality block
Hypotension gradual total spinal +++ systemic toxicity +++

27
Q

Why Control Postoperative Pain?

A

Under-treated acute pain can lead to chronic pain

28
Q

Risk Factors for CPOP (6)

A
  • having preop pain
  • psychological factors
  • female and younger age
  • open surgical approach
  • length of surgery > 3 hrs
  • intensity of pain in the immediate postop period (first few days)
29
Q

Possible harmful effects of undertreated acute pain: cardiovascular

A

tachycardia, hypertension, increased myocardial oxygen consumption, DVT, MI

30
Q

Possible harmful effects of undertreated acute pain: Respiratory

A

Decreased lung volumes, atelectasis, decrease cough, sputum retention, hypoxemia

31
Q

Possible harmful effects of undertreated acute pain: GI and GU

A

decreased gastric and bowel motility, urinary retention

32
Q

Possible harmful effects of undertreated acute pain: Metabolic

A

Increase catabolic hormones (cortisol) and decrease anabolic hormones (insulin)

33
Q

Possible harmful effects of undertreated acute pain: Psychological

A

Anxiety, fear and sleeplessness

34
Q

What is Epidural Analgesia?

A
  • Epidural analgesia is the administration of opioids and/or local anesthetics into the epidural space
  • It can be used to manage pain in pediatric, adult, and older adult patients on a short-term (hours to days) or long-term (weeks to months) basis
35
Q

Epidural Anatomy

A

Located outside the 3 membranes covering the spinal cord between the dura mater and the ligamentum flavum
Epidural space is normally filled with blood vessels, lymphatic vessels, fatty tissue and spinal nerve roots
Epidural space is a space so tiny air bubbles are not a danger and it is ok to stop infusions for hours and be ok to restart without catheter becoming occluded

36
Q

A&P of the Nervous System

A

Made up of central and peripheral nervous systems
- CNS: brain and spinal cord
- PNS: cranial nerves, spinal nerves and autonomic nervous system

37
Q

4 segments of the spinal cord

A

cervical
thoracic
lumbar
sacral

38
Q

how many in the PNS
1. cranial nerves
2. spinal nerves

A

12 cranial nerves
31 spinal nerves

39
Q

What are cranial nerves

A

The cranial nerves are 12 pairs of nerves arising from the BRAIN STEM to supply mainly the head and neck. The cranial nerves are not affected in the event of a continuous epidural overdose.

40
Q

Spinal Nerves

A

31 pairs of nerves arising from the spinal cord supply the trunk and limbs. Each spinal cord segment is referred to as a level and when blocked with local anesthetic results in characteristic decrease in sensory (dermatome) and occasionally motor (myotome) function. Only nerves from the thoracic, lumbar and sacral levels are routinely affected by continuous epidural analgesia.

41
Q

Efferent vs afferent nerve fibers

A

Afferent (Sensory) - TOWARDS the CNS
Efferent (motor) - AWAY from the CNS

42
Q

3 types of fibers carried in spinal nerves

A
  1. motor
  2. sensory
  3. sympathetic
43
Q

KEY POINT about CEA

A

In most cases of CEA with a local anesthetic, it is desirable that the patient have a decrease in cold sensation (to ice test) in the dermatome of the surgical incision

44
Q

What should NEVER happen in lumbar CEA

A

In LUMBAR CEA, the sensation level should NEVER be at or above the nipple line (T4). DONT WANT TO LOSE THE DIAPHRAGM)

45
Q

What to monitor in THORACIC CEA

A

In THORACIC CEA there should be a band of decreased sensation in the thorax with normal sensation in the lower abdomen. The upper aspect of the inner arm or 5th finger (T1) should NEVER be affected. THERE ARE INDICATORS OF A HIGH BLOCK!!!

46
Q

Motor Nerve Assessment

A

Motor fibres go to various muscle groups and are responsible for initiating movement. these nerves are the thickest and most heavily myelinated fibers. this makes them most resistant to the effects of local anesthetic
A myotome is a group of muscles innervated by a single spinal cord segment. An understanding of the myotomes is necessary to assess the level of motor block a patient is experiencing while receiving continuous epidural analgesia with local anesthetic
The Motor Assessment Scale is used to monitor the level of motor block in a patient receiving CEA with a local anesthetic

47
Q

What should NOT be seen in a Motor Nerve Assessment?

A

There should be NO upper or lower extremity weakness when a thoracic epidural catheter is used

48
Q

Hip

A

L2/L3 - flex
L4/L5 - extend

49
Q

Knee

A

L3/L4 - ext
L5/S1 - flex

50
Q

Ankle

A

L4/L5 - dorsiflex
S1/S2 - plantar flex

51
Q

Goal of CEA with local anesthetic r/t motor nerve function

A

In most cases of CEA with a local anesthetic, it is desirable that the patient be able to flex the knees and the ankles against gravity. The ideal CEA results in minimal or NO motor block

52
Q

Indications for Epidural Analgesia (3)

A
  • Pain relief after surgery or trauma to the chest, abdomen, pelvis, or lower limbs, where epidural anesthesia has been used entirely or to supplement general anesthesia
  • Epidurals help reduce the risk of post-operative complications (those with co-morbidities)
  • Where acute pain is anticipated for 2-5 days
53
Q

Contraindications for Epidural Anesthesia (7)

A
  1. Bleeding abnormalities or when patients are receiving anticoagulant therapy
  2. local skin infection (at the potential puncture site) or systemic sepsis
  3. Abnormal anatomy (patient may still receive a CEA after assessment by anesthesia)
  4. Allergy to the opioid, or local anesthetic agent being used
  5. Increased ICP
  6. Patient with fluctuating neurological status
  7. Pt refusal to consent to the procedure. The consent is part of the anesthetic record unless the epidural is inserted as a separate procedure, in which case a separate consent form is obtained
54
Q

Typical Epidural Analgesia

A
  • Bupivacaine and Ropivacaine (drugs of choice for epidural anesthesia)
  • Fentanyl
  • Hydromorphone
55
Q

Assessment Continuous Epidural Analgesia (infusion) (6)

A
  • Resp rate
  • Sedation
  • VS
  • Motor block
  • Sensory block
  • Always know where the epidural is inserted (L or T)
56
Q

Sensory Block Dermatome

A
  • Dermatome is an area of skin that is mainly supplied by a single spinal nerve. Each of these nerves relays sensation from a particular region of skin to the brain
  • Apply ice to an unaffected area (cheek) so the patient knows what it feels like
  • Start at the upper anterior chest and work downwards until the patient cannot feel it as cold (this is the top dermatome)
  • Continue downwards until patient can feel it again (bottom dermatome)
  • Repeat on both sides and dermatomes can be different
56
Q

Sedation Scale

A

1 = awake and alert
2 = slightly drowsy, easily roused
3 = Frequently drowsy, arousable, drifts off to sleep during conversation (UNACCEPTABLE)
4 = Somnolent, minimal or no response to verbal or physical simulation (UNACCEPTABLE)
S = sleep, easy to rouse

57
Q

Motor Block Assessment: Degree of block (0-3)

A

0 = no block and full flexion of feet, knees and hips
1 = just able to move knees and feet (unable to raise extended legs)
2 = able to move feet only (unable to bend knees)
3 = unable to move hips, knees or feet

58
Q

Removing Epidural

A
  • ensure there is an order from Anesthesiologist
  • check recent PTT and INR (within 2 days)
  • check heparin (10 hrs) and dalteparin (22 hrs) last dose and wait 2 hours to give dose after removal
  • position the patient in “fetal position”
  • remove tape and dressing
  • apply sterile gauze over the insertion site and slowly pull
  • apply pressure until any oozing stops
  • apply band-aid to insertion site
59
Q

Assessments after Epidural Removal

A

Continue routine vitals
Assess q4hx24 hrs for potential signs of epidural hematoma
Hip/dorsi/plantar flexion and extension
Monitor for changes in sensation to abdomen and legs and/or new onset of back pain or headache
Document removal date, time, catheter intactness, ease of difficulty, bleeding at site, redness or swelling

60
Q

Complications of Epidural: Opioid Related (6)

A
  • Respiratory depression
  • N&V
  • Pruritus
  • Urinary retention
  • Decreased gastric motility
  • Hypotension
61
Q

Complications of Epidural: Local Anesthetics

A
  • hypotension
  • high block
  • urinary retention
  • nausea
  • local anesthetic Toxicity (early signs: perioral numbness, tinnitus and dizziness)
62
Q

Patient Controlled Analgesia (PCA)

A

A method of pain control that gives patients the power to control their pain
A computerized pump contains a syringe of pain medication and connected directly to a patient’s IV line or epidural.
The patient can control when they receive the pain medication
PCA pumps have built in safety features that will only allow a safe dose of analgesic

NURS 412 Midterm #1 (14 decks)

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