safe administration of anesthesia Flashcards
2016 guidelines gave new recommendations for monitoring with moderate sedation, what was that?
use a capnograph
What is capnograph?
measures end tidal co2
What is a much better indicator of tissue perfusion than pulse oximetry? why?
end tidal co2, co2 measurement is the byproduct of oxygen being appropriately used in the body so it is much better than pulse ox
What are 4 things you can use for monitoring in moderate sedation?
- capnograph
- depth of sedation scale
- consider BIS monitoring
- audible alarms
what are 2 things you want to assess for in older adults with moderate sedation?
- assess for fraility (frail scale)
- assess for functional status
- assess for cognitive impairment or increased risk for delirium
What is an important question to ask for older adults when we are assessing their functional status?
do they need assistance with ADLs?
No matter where we are in the hospital, what should be the standard for moderate sedation?
same level of care and same equipment available if moderate sedation done outside fo the OR setting
Assess for what 3 things prior to giving moderate sedation?
- alcohol
- cannabis
- opioids
Why do we assess for alcohol with moderate sedation?
alcohol and benzos act on the same receptors
What are 2 specialty questions when we are assessing for alcohol, cannabis, and opiods?
- cannabis ointments and drops
- prescription and legalized usage too
When an infant or toddler is being discharged after moderate sedation, what do we want to make sure we have?
a 2nd responsible adult! they will ride in back seat with child
Know your what with moderate sedation and nurses?
know your scope of practice
Who defines the scope of practice for RNs in moderate sedation?
- state board of nursing
- AORN government affairs links to state BON
Can RN’s do monitoring for moderate sedation? with what exceptions?
yes, ASA I, II, and III. Anything ASA class 4 and higher requires an anesthesia provider, or they have difficult mask ventilation like beards, dentures, or history of sleep apnea
There cannot be competing what for moderate sedation?
competing responsibilities for monitoring RN
There should be 2 of what in the room with moderate sedation?
2 RNs in the room with the pt. at all times
Are brief interruptible tasks ok for monitoring RN?
yes; like tie gown and open suture
Local anesthetics block what to prevent what? think pathophysiology
blocks the sodium potassium channels and prevent depolarization to make the nerve cells not work
What 2 types of local anesthesia meds are there?
- esters
- amides
Esthers are a what?
CYCLOPSE with one “i”
What are 3 esthers we want to remember?
- cocaine
- procaine
- tetracaine
What are esthers metabolized by?
pseudocholinesterase
When esters are broken down it releases what? why is it bad
para-aminobenzoic acid (PABA) and some people are allergic to that
What are 3 amides we commonly use
- bupivacaine
- lidocaine
- mepivacaine
Where are amides metabolized ?
in the liver
If we are doing local anesthesia, what are the vital signs that we want at baseline and at every 5-15 minutes during case?
- heart rate/rhythm, pulse, BP
- pulse oximetry
- pain, anxiety and LOC
The monitoring nurse for a straight local case can also be what?
the circulator case
What is local anesthetic systemic toxicity (LAST)?
high serum levels of the local anesthetic
We want to use the lowest what of local to achieve what?
use the lowest dose to acheive the desired result
When do early signs of LAST usually appear?
around a minute after injection but can be delayed for up to 30 minutes
what should we be doing frequently to prevent or look for LAST?
frequent verbal communication with patient to assess for signs and symptoms
What are 6 patients at highest risk for LAST?
- advanced age - don’t have good renal or hepatic function that younger people have - don’t stack doses
- heart failure, ischemic heart disease, conduction abnormalities - we see cardiac effects sooner
- liver disease - commonly people with addiction and have low albumin levels
- low albumin levels
- metabolic or respiratory acidosis
- medications that inhibit sodium channels
What are the signs and symptoms in the initial phase of LAST?
- metallic taste
- numb tounge and lips
- ringing in ears
- light headedness
- agitation
What are the signs and symptoms in the excitation phase?
- shivering
- slurred speech
- confusion
- seizures
- tachycardia/hypertension - caused from seizures not from the local
What happens during the excitation of the phase?
when the nerve cells in their brain begin to shut down, so they start to act drunk
What are signs and symptoms of depression phase in LAST?
- coma
- bradycardia/hypotension (progression)
- ventricular arrhythmias
- respiratory/cardiac arrest
If local is injected into the blood stream, what are the initial signs and symptoms of LAST?
- seizures
- tachycardia/hypertension - caused from seizure not from local
(excitation phase symptoms)
Know and calculate what to prevent LAST?
know and calculate maximum doses of local anesthesia agent
Always do what to prevent LAST?
aspirate prior to injection
Ask patient about what to prevent LAST?
ask patient about symptoms after injection
What is the maximum dose of local a patient can have per day?
4-5 mg/kg/day
what do you have to be careful with as far as parts of body with local?
serial repairs of large or multiple wounds
In any emergency, what are first 3 things you want to do? but in regard to LAST…
oxygen, monitors, IV fluids or OMI
For OMI, you want to do what?
- hyperventilate with 100% O2
- establish IV access fi not already there
You want to take what kind of measures during LAST?
ACLS and BLS measures
What is the reversal agent for amides and esthers?
20% lipid emulsion.
You can repeat bolus of lipids up to how many times?
3 times
What is the dose of 20% lipid emulsion for LAST?
1-1.5 ml/kg bolus over a minute
What can you set infusion at for 20% lipids with LAST?
0.25 mL/kg/min
20% lipid emulsion is truly a what?
a reversal agent like sugammadex
What does lipid do for ester and amide?
directly covers the ester and amides, and then sucks those out of the sodium channels
What are 3 types of regional anesthesia?
- topical
- local infiltration
- regional nerve block
What are 2 types of topical regional anesthesia?
drops or ointment
Local infiltration is injected into what?
directly into the incision site
What is epinephrine for with local infiltration?
delays absorption of local for post op pain control
What is the max dose of 1% lidocaine?
4-5 mg/kg per day
What is the max dose of 1% lidocaine with epi?
7 mg/kg
What is a regional nerve block?
the injection onto or near nerves for temporary control of pain
What are the 4 brachial plexus blocks?
- interscalene
- supraclavicular
- infraclavicular
- axillary
What are interscalene blocks for?
is for your shoulder (shoulder arthroplasty, arthroscopy)
What is supraclavicular block for?
index, middle finger, thumbs
What is infraclavicular block for?
for the palm of your hand (dupuytren’s release)
What is axillary block for?
circumferentially just above the elbow down. any kind of hand procedure or carpal tunnel procedure
What is a syndrome commonly associated with interscalene block?
horner’s syndrome
Horner’s syndrome is characterized by what 3 things?
- miosis
- ptosis
- anhidrosis
Signs of horner’s syndrome are on the same what?
same side as the block
What is miosis?
constricted pupil
What is ptosis?
droopy eyelid
what is anhidrosis?
decreased sweating
What is also common with interscalene blocks?
phrenic nerve paresis
what is the phrenic nerve controlling?
controls the diaphragm
What is common with patients that have gotten an interscalene to feel?
feel like they can’t breathe because a lot of their chest wall has not sensation. One side of their diaphragm is paralyzed
What are common with supraclavicular?
pneumothorax; because the apex of the lung is right there
Can you have phrenic nerve paresis common with supraclavicular blcoks?
no not as common but can still happen
Can you have horner’s syndrome with supraclavicular block?
less common but yes
Infraclavicular blocks occur over a short what?
short duration
Infraclavicular is good for what?
pain control
What are common with axillary?
hematomas
What is the 2nd most common injection site for LAST?
axillary
The reliability of axillary blocks is improving with what?
ultrasound technique
Bier block is used in what?
hand procedures
Bier blocks are ideal for procedures that are how long?
20-60 minutes
