Anesthesia

ASA Physical Status Classification

used to assess and communicate a patient's pre-anesthesia medical co-morbidities

ASA PSC 1

-normal healthy patient
-healthy, non-smoking, no or minimal alcohol abuse

ASA PSC 2

patient with mild systemic disease without substantive functional limitations

ASA PSC 3

-patient with severe systemic disease + substantive functional limitations
-one or more moderate to severe diseases

ASA PSC 4

patient with severe systemic disease that is a constant threat to life

ASA PSC 5

moribund patient who is not expected to survive without the operation

ASA PSC 6

declared brain-dead patient whose organs are being removed for donor purposes

NPO diet is utilized before surgery bc a full stomach increases the risk of ____ during surgery

aspiration

In case of an ______, NPO status may be bypassed after discussion with patient/family regarding risks of aspiration vs risks of not having surgery

emergency

___ hours preop stop fatty foods, meats, or non-human milk

eight

___hours pre-op stop light foods, non-fat small meals

six

___ hours pre-op stop human breast milk

four

___ hours pre-op stop clear liquids (water, pulp-free juice, soft drinks, tea/coffee)

2

GLP-I Agonists (Ozempic)

delay gastric emptying and reduce hunger > increases risk of full stomach > risk of aspiration

hold an injectable GLP-1 agonist _________ before surgery or hold oral ____

one week; on day

SGLT2 Inhibitors (Jardiance)

-can cause ketoacidosis
-noticeable hypotension with anesthesia

hold SGLT2 inhibitors ____ of surgery and give fluid bolus preop

on day

Anesthesia

state of controlled, temporary loss of sensation and awareness that is induced for medical purposes

Balanced Anesthetic

-use of multiple anesthetic modalities or medications in attempts to achieve a perfect anesthetic
-benefits: reduces pt stress, minimizes pain, decreases side effects

Procedural Sedation

-administered by nursing staff by oral or IV
-still monitor patient closely
-still need supplemental O2
-used in: cataracts, LASIK, some endoscopic procedures

common meds used in procedural sedation

opiates and benzos

most common opiate used for procedural sedation

fentanyl

Monitored Anesthesia Care (MAC)

-administered by anesthesiologists or nurse anesthetists

-titrated continuum of light to heavy sedation

-ASA monitors and supplemental O2

-used in: endoscopy, chronic pain procedures, etc

MC med used in MAC

propofol (bc quick turnaround)

MAC Complications

-oversedation
-hypoventilation/apnea
-itching
-nausea
-prolonged amnesia
-allergic reactions

Other MAC Meds

-diphenhydramine
-ketamine
-dexmedetomidine
-opiates
-benzodiazepines

General anesthesia is the ___ level of anesthesia

deepest (pt is fully unconscious > CNS suppressed)

General Anesthesia

-IV and inhaled anesthetics
-airway always secured (breathing spontaneously or vented)
-often use paralytics in conjunction
-used in: transplant and general surgeries

there can be significant ___ effects during induction/beginning and emergence/end of procedure with general anesthesia

hemodynamic

____ anesthetics can cause peripheral vasodilation and cardiac depression during general anesthesia

volatile

respiratory issues are associated with ___________ during general anesthesia

controlled ventilation

General Anesthesia Meds

-sedatives/ amnestics (propofol, etomidate)
-inhaled anesthetics (nitrous oxide and -ane meds)
-analgesics (opiates, ketamine)
-paralytics (succ, -ium)

General Anesthesia Complications

-hemodynamic changes esp during induction and emergence
-hypoventilation/ apnea
-nausea and vomiting
-allergic reactions

Local Anesthesia

-used to provide loss of nociception at specific site
-caine meds
-topical, local injection, regional, neuraxial

Neuraxial Anesthesia

types: epidural and spinal anesthesia

Epidural Anesthesia

-catheter placed into thoracic or lumbar epidural space
-can be used as sole anesthetic (labor, C/S, lower extremity)
-can be used for post op pain control

Spinal Anesthesia

-single injection into subarachnoid space
-can be used as sole anesthetic (C/S, imminent vaginal delivery, lower abdominal surgeries)
-can have significant hemodynamic changes (HoTN, tachycardia, bradycardia, nausea)

Topical meds for local anesthesia

benzocaine and tetracaine

Injectable meds for local anesthesia

-procaine
-lidocaine
-mepivacaine
-bupivacaine
-ropivacaine

Neuraxial meds for local anesthesia

-lidocaine
-bupivacaine

Local Anesthesia Systemic Toxicity (LAST)

-tinnitus
-agitation
-seizures
-coma
-bradycardia
-hypotension
-arrhythmias

Periop Considerations

-type and location of surgery scheduled
-patient comborbidities
-med allergies
-prior anesthesia history
-pseudocholinesterase deficiency
-risk factors for malignant hyperthermia

most common inhalational anesthetic

sevoflurane

Malignant Hyperthermia

-Genetic disease; mutation in RYR1 gene
-exposure to anesthetic agent > mutated ryanodine receptor causes uncontrolled release of Ca from skeletal muscle > excess build up > prolonged muscle contraction > breakdown of tissues

Malignant hyperthermia causing meds

-volatile anesthetic gases (sevo-, des-, isoflurane)
-succinylcholine

Life Threatening Malignant Hyperthermia S/S

-muscle rigidity
-tachycardia
-hypercarbia/kalemia/thermia
-acidosis
-myoglobinuria
-DIC

Malignant Hyperthermia Treatment

-stop offending agents

-initiate cooling measures

-DANTROLENE

-supportive care

Intraop Instability Etiology

-large hemodynamic shifts on induction and emergence
-vasodilation and cardiac depressive effects of anesthetics
-respiratory system issues (spasms, obstructive diseases)
-allergic reactions

PACU

-1st stop after surgery/anesthesia
-high level of nursing acuity
-respiratory management, monitor vitals, manage pain, nausea, shivering, eval for complications

Common PACU Problems

-PONV
-pain
-hypothermia
-respiratory distress (residual paralysis, laryngospasm, pulmonary edema)
-CV issues (hyper or hypotension, arrhythmias)