Page-by-Page Notes: Anesthesia and PACU (Markdown, Page-by-Page)

Page 1

• Objective overview
  • Analyze the principles of anesthesia administration and explain the necessity of each component of anesthesia preparation of the surgical patient.
  • Compare and contrast methods, agents and techniques of anesthesia administration and preparation.
  • Correlate anesthesia monitoring devices with patient homeostasis.
  • Explain anesthesia complications and interventions.
• What is Anesthesia?
  • Anesthesia means “without sensation”
  • Partial or complete loss of sensation
  • Can be with or without loss of consciousness
  • The absence of sensory awareness or medically-altered level of consciousness
• Goals of Anesthesia
  • Maintain homeostasis
  • Allow patient to tolerate surgery
• Achievement of Anesthesia
  • Alter patient’s level of consciousness
  • Interrupt nerve pathways that transmit sensation
  • Or a combination of both of the above
• Important Terms/Concepts
  • Sensation, Anesthetic, Analgesia, Consciousness, Unconsciousness
• Important Terms/Concepts (cont.)
  • Sedation, Central Nervous System Depression, Coma, Amnesia
• Anesthesia Personnel
  • Anesthesia Care Provider (ACP)
  • Anesthesiologist (MDA)
  • Certified Registered Nurse Anesthetist (CRNA)
  • Anesthesia Assistant (AA)
  • Anesthesia Technologist
• Role of the ACP
  • Maintain homeostasis
  • Monitor level of consciousness
  • Pain management
  • Administer and monitor medications
  • Maintain the airway
  • Monitor patient response
• Anesthesia equipment and devices
  • Anesthesia Equipment: Anesthesia Machine or Work Station
  • Anesthesia workstation
• Additional equipment and systems
  • Scavenging system for waste gases
  • Medical gas cylinders
  • Oxygen delivery systems
  • Anesthesia face mask
  • Airways Breathing systems
  • Four types of inhalation systems:
  • Semi-closed
  • Closed
  • Semi-open
  • Open Circle (closed) System
  • Unidirectional valves, in combination with CO2 absorber, allow for rebreathing of gases
  • Valves allow the continuous forward flow of inhaled and exhaled gas, preventing reflux of the gas and rebreathing of CO2
  • Rebreathing circuit allows for conservation of patient heat and humidity
  • To avoid hypercapnia, granules of soda lime in a canister absorb CO2 as exhaled gas passes through the canister
  • InsuZlation System: Inhalant allowed to flow across the patient’s face without forming a seal with the mask (often used for pediatric patients) – No rebreathing of exhaled gases
• Note on ventilation control
  • Ventilation cannot be controlled with InsuZlation System
• Types of Airways
  • Endotracheal tube (ET)
  • Laryngeal mask airway (LMA)
  • Oropharyngeal airway (OPA)
  • Nasopharyngeal airway (NPA)
• Endotracheal Tube (ET)
  • Invasive airway; intubation is placing an invasive airway
  • Delivers gas or vapor directly into the trachea for inhalation into the lungs
  • Placed through the mouth between the vocal cords into the trachea
  • Stylet used to support during placement (removed after ET placement)
  • Magill forceps may be used to grasp the tube during intubation
  • Some styles have an inflatable cuff consisting of a valve, pilot balloon and cuff; cuff inflated with air via Luer-lock syringe
• Endotracheal Tubes – equipment and technique
  • Laryngoscope used as an aid for placement of an ET tube
  • Intubation is routine during general anesthesia or during respiratory or cardiac arrest
  • During general anesthesia, intubation is performed immediately after induction
  • The type of laryngoscope depends on patient’s age and airway anatomy
• Laryngeal Mask Airway (LMA)
  • Oral and nasal airways
  • Open and maintain the airway by holding the tongue away from the posterior pharynx; less invasive
• Oropharyngeal Airway (OPA)
  • Inserted over tongue to prevent tongue or epiglottis from falling back against the pharynx
• (Page 1 continues into airway concepts; see Page 2 for more airway details)

Page 2

• Nasopharyngeal airway
  • Placed into passage between nostril and nasopharynx
• Oxygen Delivery Devices
  • Nonocclusive mask
  • Nasal cannula
• Bite block and bougie
  • Bite block: may be inserted into patient’s mouth to prevent biting ET tube and occluding it; also protects tongue, cheek, lips
  • Bougie: a thin plastic rod passed into the trachea over which the endotracheal tube is inserted; used for difficult intubations
• Double-curled pneumatic tourniquet
  • Used by anesthesia personnel for Bier Blocks
• Infusion pump
  • Electronic device that delivers a programmed amount of IV solution over a designated time period
• Other anesthesia devices
  • Fluid-warming devices
  • Hypo- and hyperthermia unit
  • Nerve stimulator
• Patient monitoring devices
  • Blood pressure cuff
  • Electrocardiogram (ECG/EKG)
  • Pulse oximeter
  • Temperature probes
  • Transesophageal echocardiogram (TEE)
  • Urinary catheter
• Patient preparation and preoperative relationship-building
  • Relationship of trust established between patient and anesthesia personnel to reduce anxiety
  • Preoperative visit can be as effective as medications in reducing anxiety
  • An anesthetic plan is developed for each surgical patient
  • Interviewer discusses anesthetic options with patient
  • Informed consent for anesthesia is obtained
• Preoperative fasting / ERAS
  • Preoperative fasting to prevent aspiration
  • ERAS – Early Recovery After Surgery protocols
• Preoperative evaluation
  • Medical history and physical (H&P)
  • Comorbidity and anesthesia classification
  • Current medications and allergies
  • Anesthesia history
  • Airway and dental status evaluation
  • Family history (including anesthetic complications)
  • Musculoskeletal assessment
  • Mental and neurological status
  • Social assessment
  • Preoperative testing
  • Pre-operative evaluation summarized

Page 3

• Nasopharyngeal airway (continued)
  • Oxygen delivery devices: Nonocclusive mask, nasal cannula
• Bite block and bougie (continued)
• Additional devices
  • Double-curled pneumatic tourniquet (Bier blocks)
  • Infusion pump (IV fluids)
  • Other devices: fluid-warming, nerve stimulator, etc.
• Patient monitoring devices (continued)
  • Blood pressure cuff, ECG, pulse oximeter, temperature probes, TEE, urinary catheter
• Preoperative patient interaction
  • Interviewer discusses anesthetic options with patient
  • Informed consent for anesthesia obtained
• Preoperative fasting / ERAS (revisited)
• Pre-operative evaluation (revisited)
  • Physical status: ASA status (see Page 4 for ASA classifications)
  • Additional preoperative evaluations as needed

Page 4

• ASA physical status classifications
  • ASA $1$: A normal healthy patient
  • ASA $2$: A patient with mild systemic disease
  • ASA $3$: A patient with severe systemic disease
  • ASA $4$: A patient with severe systemic disease that is a constant threat to life
  • ASA $5$: A moribund patient who is not expected to survive without the operation
• Admission pre-operative checklist
  • Patient education completed
  • Identification verified
  • Correct procedure, side and site verified
  • Consents verified
  • Resuscitation orders verified
  • Allergies verified
  • Preoperative medications documented
  • Prostheses and jewelry removed
  • Medical records accompany the patient
• Anesthesia Selection
  • Patient factors to consider:
  • Age, Allergies, ASA classification, Co-morbid conditions (e.g., diabetes, hypertension, heart disease)
  • Current medications and supplements
  • Emergency conditions
  • General health
  • Height and Weight
  • Psychological state
  • Substance abuse history
  • History of adverse reaction
  • Procedure type and duration
  • Surgical position
  • Preference of anesthesia provider, patient, and surgeon
• Anesthesia options (General to Regional)
  • General anesthesia
  • Inhalation (inhalational agents)
  • Intravenous
  • Regional
  • Bier Block
  • Caudal
  • Epidural
  • Monitored Anesthesia Care (MAC)
  • Regional (continued)

Page 5

• Pre-operative medications
  • Primary goal: decrease anxiety; may improve post-operative recovery; provide comfort; smoother induction
  • Analgesics: Natural opioid morphine; synthetic opioids (alfentanil, fentanyl, meperidine, remifentanil, sufentanil)
  • Antacid/H2-receptor blocking agents: cimetidine, famotidine; sodium citrate with citric acid
  • Anti-cholinergic: atropine, glycopyrrolate, scopolamine
  • Antiemetic: metoclopramide, ondansetron, promethazine
  • Sedative-hypnotic agents: diazepam, lorazepam, midazolam
• Arrival at the surgical suite
  • Patient is transferred to OR table
  • Patient is warmed
  • Safety strap applied
  • Intravenous line started if not already present
  • Monitoring devices placed
  • Anesthesia of choice is administered with patient in supine position
• Intraoperative monitoring and preparation
  • Physiological monitoring during surgery
  • Oxygenation (pulse oximeter)
  • Ventilation/respiration
  • Body temperature (normothermia)
  • Neuromuscular response
• Pre-induction and anesthesia plan execution (themes)
  • Equipment check and readiness
  • Ensure airway access and ventilation planning

Page 6

• Intraoperative physiological monitoring (cont’d)
  • Fluid and electrolyte balance
  • Intravascular fluid volume and pressure
  • IV infusion pump for medications and fluid administration
  • Blood loss calculation
  • Cardiac and circulatory function and perfusion: ECG, arterial BP, and possibly invasive monitoring
  • Transesophageal monitoring and intravascular monitoring
  • Arterial line and Central venous pressure (CVP) catheter; Swan-Ganz pulmonary catheter (where indicated)
  • Fluid management and assessment of body fluid volume using physiologic indicators:
  • Heart rate, blood pressure, urine output
  • Peripheral pulse
• IV fluids types
  • Lactated Ringer’s Solution (LR)
  • Normal Saline (NS)
  • 5% Dextrose in Water (D5W)
  • Colloids: Dextran (volume expander), Hetastarch (plasma expander)
• Deliberate hypothermia
  • Used during cardiac surgery; used to help treat malignant hyperthermia
• Difficult airway (Difficult airway or DiZiCulT airway)
  • Associated with challenging ventilation; related events include hypoxia and possible brain injury
  • Evaluation by ACP prior to surgery
  • Additional trained personnel; emergency airway cart nearby
  • Modern techniques: Bimanual laryngoscopy or optimal external laryngeal manipulation (OELM)
• Techniques to optimize laryngoscopy and airway management
  • BURP maneuver (Backward upward right pressure) to improve laryngoscopic view
  • Sellick maneuver (cricoid pressure) during Rapid Sequence Induction and Intubation (RSI)
• RSI (Rapid Sequence Induction and Intubation)
  • Prepare the patient pre-oxygenated with 100% oxygen
  • Apply cricoid pressure while patient is awake (Sellick's maneuver)
  • Induction drugs administered; muscle relaxant follows immediately; patient intubated
• Extubation considerations
  • Extubation is safest when patient is near wakefulness
  • Eye movement and attempts to remove ET tube indicate an awake patient
  • Patient must recover from neuromuscular blockade prior to extubation
  • Pharynx suctioned to remove secretions to prevent aspiration or laryngospasm
  • Re-verify airway patency; 100% O2 delivered by face mask during transport to PACU/ICU
• ET tube complication risks
  • Trauma to airway, tooth damage, sore throat, tracheal stenosis, vocal cord paralysis (recurrent laryngeal nerve damage)
• General anesthesia concepts
  • General anesthesia: an anesthetic state of unconsciousness and insusceptibility to pain produced by an anesthetic agent or combination of agents (IV or inhalation)
  • Reversible loss of consciousness with absence of pain, sensory perception, cognition, memory, and some autonomic reflexes
  • Current approach: balanced anesthesia (combination of drugs to achieve homeostasis, analgesia, amnesia, sedation, muscle relaxation)
• Keys to good anesthesia
  • Rapid, smooth induction

Page 7

• Airway management techniques (continued)
  • BURP: Backward pressure applied to improve laryngoscopic view
  • Sellick maneuver: Cricoid pressure during RSI
• RSI details (revisited)
  • Pre-oxygenation with 100% O2
  • Immediate sequence: induction agent, then muscle relaxant, then intubation
• Extubation and post-extubation care
  • Smooth extubation when patient wakes
  • Monitor for respiratory adequacy and airway protection post-extubation
• Complications related to endotracheal intubation
  • Airway trauma, tooth damage, sore throat, tracheal stenosis, vocal cord injury, laryngeal edema leading to airway obstruction
• Physiologic responses to anesthesia
  • Hypertension
  • Tachycardia
  • Laryngospasm and depression of laryngeal reflexes
• General anesthesia (recap)
  • Anesthetic state: unconsciousness with insusceptibility to pain
  • Reversibility and the standard concept of balanced anesthesia
  • Induction and maintenance strategies

Page 8

• Phases of general anesthesia
  • Phases: Preinduction, Induction, Maintenance, Emergence, Recovery
• Stages of general anesthesia
  • Stage $1$ – Amnesia
  • Stage $2$ – Delirium
  • Stage $3$ – Surgical anesthesia
  • Stage $4$ – Overdose
• Anesthetic agents used in general anesthesia
  • Antagonists/Reversal agents:
  • Benzodiazepine reversal: Flumazenil
  • Opioid reversal: Nalmefene, Naloxone, Naltrexone
  • Inhalation agents:
  • Desflurane, Isoflurane, Nitrous oxide, Oxygen, Sevoflurane
  • Intravenous agents:
  • Benzodiazepines, Dissociatives (Ketamine), Etomidate, Methohexital, Propofol, Thiopental
  • Neuromuscular blocking agents
  • Depolarizing: Succinylcholine
  • Non-depolarizing: Atracurium, Cisatracurium, Rocuronium, Vecuronium
  • Neuroleptic: Droperidol
  • Reversal agents (non-depolarizing): Edrophonium, Neostigmine
  • General anesthesia muscle relaxants: Drugs used to paralyze skeletal muscles including the diaphragm
• Role and purpose of neuromuscular blockade
  • Facilitates surgical exposure and apnea control, enabling better operating conditions

Page 9

• Aids for smoother intubation and anesthesia
  • Ketamine: Dissociative anesthesia; blocks neurotransmission and associative pathways
  • Regional anesthesia (conductive/local anesthesia)
  • Monitoring and sedation as needed with regional techniques
• Regional anesthesia overview
  • Also called conductive or local anesthesia
  • Use agents to prevent transmission of sensory nerve impulses (nerve conduction blocking agents)
  • Patient monitoring always provided
  • May be used with or without sedation
• Regional anesthetic agents
  • Amides: Bupivacaine, Lidocaine, Mepivacaine, Ropivacaine
  • Esters: Cocaine, Tetracaine, Cetacaine
• Delivery methods for regional anesthesia
  • Injection
  • Topical
• Regional anesthesia – topical and local infiltration
  • Topical regional anesthesia: mucous membranes or skin and superficial eye tissues
  • Local infiltration: injection of nerve conduction blocking agent into superficial tissues around nerves serving the surgical site; anesthetizes a small tissue area
• Regional anesthesia – nerve blocks and blocks at large
  • Peripheral nerve block: anesthesia to a specific body region supplied by a major nerve or plexus; injected into adjacent tissue, not the nerve itself; aims to block a nerve and its branches
  • Regional anesthesia – IV (Bier) block: IV regional anesthesia; vascular space in a limb is temporarily displaced with local anesthetic via tourniquet
• Role of the ST (Surgical Technologist) when using regional anesthesia
  • Prepare and verify supplies before procedure
  • Verify anesthetic drug and labeling; ensure asepsis
  • Provide needles and syringes; ensure sterile technique

Page 10

• Regional Anesthesia – Spinal
  • Injection of anesthetic agent into cerebrospinal fluid in the subarachnoid space via sterile technique
  • Results in loss of sensation to the body below the level of the diaphragm; commonly used for lower abdomen and lower extremities procedures
  • Risks: hypotension, post-spinal headache, total spinal anesthesia
• Patient positioning for spinal anesthesia
  • Lateral position
  • Sitting position (arch back like a “mad cat”)
• Role of the ST for spinal anesthesia
  • Prepare supplies, help maintain position, ACP directs and performs the procedure
• Regional Anesthesia – Epidural and Caudal
  • Epidural: injection into the epidural space (most common site is lumbar interspace)
  • Caudal: injection into the caudal canal
  • Slowly absorbed into CSF through the dura mater
  • Commonly used for vaginal, perineal, anorectal procedures and C-sections
• Regional Anesthesia – Epidural and Caudal (role and practice)
  • ST role similar to spinal; supplies and equipment prepared; patient positioned; ACP directs and performs

Page 11

• Regional Anesthesia – Epidural and Caudal (cont.)
  • Drug dosage: Maximum recommended doses vary by agent; rule of thumb – no more than $30\,\text{cc}$ in $1\,\text{hour}$
• Monitoring in MAC (Monitored Anesthesia Care)
  • Antinausea and antiemetic prophylaxis
  • Vomiting risks in pre- and post-operative periods; physiological dangers of vomiting include Aspiration, increased intra-abdominal, intracranial, and intraocular pressures; worsens wound healing risk in some surgeries
• Antibiotics in anesthesia
  • Anesthesia personnel may administer IV antibiotics per surgeon order to treat existing infection or as prophylaxis before skin incision; more common in orthopedic procedures
• Anesthesia complications and interventions
  • Adverse Reactions: Anaphylactic, Hemolytic, Idiosyncratic, Aspiration, Cardiac Arrest, Dysrhythmias, Airway emergencies, Oliguria, Malignant Hyperthermia, Injury (corneal, oral), Shock, Cardiogenic, Hemorrhagic, Spasm, Bronchospasm, Laryngospasm, Drug Toxicity, Hemolytic reactions

Page 12

• Malignant hyperthermia (MH)
  • A rare physiological response to succinylcholine and inhalation agents used in anesthesia
  • Characterized by a sudden rise in body temperature with accelerated muscle metabolism
  • Four main signs/symptoms:
  • Sudden rise in body temperature
  • Rapid increase in oxygen consumption
  • Increased CO2 production
  • Jaw muscle rigidity
• MH treatment (Initial steps)
  • Immediately stop anesthesia administration
  • Bring MH cart into OR
  • Hyperventilate with 100% oxygen
  • Administer Dantrolene (Ryanodex is a form of Dantrolene)
  • Begin cooling procedures
  • Call MH Hotline
• Cardiac arrest duties during a cardiopulmonary incident
  • Remain calm and sterile; maintain sterile field unless unsterile capacity is needed
  • Have sterile suction and sponges available
• Surgical team roles during anesthesia administration
  • Assisting anesthesia personnel (General, Local, Regional, Spinal or Epidural)
  • Documentation; handling medications and solutions; adherence to facility policies
• Post-anesthesia duties overview
  • Transition to PACU and handover to PACU staff

Page 13

• Postanesthesia Care Unit (PACU): Introduction
  • Patients are transported to PACU following surgical procedures
  • Patient transport is performed by a member of the anesthesia team; circulating RN accompanies patient and anesthesia team
  • PACU staff are critical care nurses
  • PACU is close to surgical suites; may function as ambulatory recovery area
• PACU layout
  • Typically one large room with beds arranged in individual patient care areas
  • Layout supports efficient patient care and privacy
  • Isolation area for patients with active infection
• PACU equipment and supplies
  • Monitoring and airway equipment
  • Dressings, ECG, glucometer, IV setup, oxygen, pulse oximeter, sphygmomanometer, stethoscope, urinary catheter
  • Patient accessories: bedpan, emesis basin, side rail pads
• PACU specialty considerations
  • Crash cart, malignant hyperthermia cart, suction, suture and emergency trays, sterile supplies as needed
• PACU procedures – Admission and handover
  • Handover includes:
  • Brief patient history
  • Exact surgery and site
  • Total length of time, amount, and route of anesthesia
  • Estimated blood loss
  • Condition of wound, drains, and devices
  • ASA score
  • Any complications
  • Information about family members present

Page 14

• Patient assessment in PACU
  • Airway status
  • Vital signs; respiratory rate and rhythm
  • Circulation; temperature
  • Abdomen; fluid and electrolyte balance
  • IV line status; skin condition
  • Patient comfort level and pain
  • Positioning; nausea and vomiting
  • Neurological function; renal function
  • Wound assessment; drainage and dressings; catheters and tubing
• Glasgow Coma Scale (GCS)
  • Neurological function – level of consciousness
  • GCS scoring components:
  • Eyes opening (E)
  • Verbal response (V)
  • Motor response (M)
  • GCS score is the sum $GCS = E + V + M$; typical ranges and specific scoring criteria are used to assess consciousness
• Physiological care in PACU
  • Reassure patient; orient them; address anxiety and emotional needs
• Respiratory post-operative complications
  • Airway occlusion, aspiration, atelectasis, pulmonary embolism (risk higher with deep vein thrombosis)
• Other post-op complications
  • Cardiac arrest, hemorrhage, wound disruption, malignant hyperthermia relapse, neurological deficits, patient injury, pain, nausea/vomiting, hypothermia, hypotension/hypertension, altered consciousness due to anesthetics

Page 15

• Post-anesthesia recovery outcomes and discharge planning
  • Uncomplicated recovery to discharge applies; failure to meet criteria may require ICU or 24-hour observation
• Elements of discharge planning
  • PACU stay for a minimum of 1 hour (longer if necessary)
  • Discharge criteria per facility policy
  • Discharge on physician order when criteria are met
  • Transport or transfer plan; home nursing care; patient education; follow-up
• Documentation and patient evaluation
  • Patient must meet physiological and psychosocial criteria
  • Aldrete scale is often used to determine readiness for discharge; it evaluates activity, respiration, circulation, consciousness, and oxygen saturation
• Patient education
  • Responsibility of nursing staff to ensure understanding of recovery and discharge instructions (postoperative instructions or discharge instructions)
  • Discharge against medical advice (AMA): patients may leave against advice if no immediate harm; must be informed of potential risks and may sign a waiver
• Death in the PACU
  • Death during surgery is rare; if impending death or rapid deterioration occurs, surgery may be terminated and patient moved to PACU
• Postanesthesia duties of the anesthesia care provider (ACP)
  • Airway maintenance and patient ventilation during transport
  • Provide verbal patient status to PACU staff; ensure airway patency; remain available for unexpected events and discharge
• Postanesthesia duties of circulator
  • Guide transport to PACU; lock transport device in place; assist PACU with monitoring devices and handover; provide verbal status reports
• Postanesthesia duties of PACU caregiver
  • Direct OR team to proper cubicle; prepare suction and monitoring equipment; obtain baseline vital signs; provide airway support and administer medications/fluids as ordered; monitor dressings and drains; provide emotional support
• Postanesthesia duties of surgeon
  • Complete written postoperative orders; speak with patient’s family as needed; remain available for unexpected events; write post-PACU orders
• Postanesthesia duties of surgical technologist
  • Although not in PACU, recognize continuity of care after surgery; observe the patient and communicate with them; respond in emergencies if needed

Page 16

• Summary and exam-focused takeaways
  • Understand the full spectrum of anesthesia from induction to recovery: preparation, administration, monitoring, and post-anesthesia care
  • Recognize the key roles of ACPs, anesthesia team, surgeons, PACU staff, circulators, and surgical technologists in patient safety
  • Be able to explain common airway strategies (ET, LMA, OPA, NPA) and the scenarios in which each is used, including RSI and extubation criteria
  • Recall major regional anesthesia techniques (spinal, epidural, caudal, Bier block, peripheral nerve blocks) and the responsibilities of the ST
  • Identify common preoperative medications and their purposes (analgesia, anxiolysis, antiemesis, antacid, anticholinergic, sedatives)
  • Understand intraoperative monitoring (MAC, BIS, ABG, hemodynamics) and fluid management (LR, NS, D5W; colloids)
  • Recognize warning signs of malignant hyperthermia and the immediate management steps (stop triggers, administer dantrolene, cooling, MH hotline)
  • Be prepared for common postoperative PACU assessments (Airway, Breathing, Circulation, Consciousness, Oxygenation) and discharge criteria using Aldrete scoring
  • Grasp discharge planning, AMA considerations, and handover communication to ensure safe patient transitions