U of A NURS 2032 - Stages and Planes of Anesthesia

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Stages and Planes of Anesthesia Stage 1 period between administration of an anesthetic and loss of consciousness Stage 2 period after loss of consciousness uncontrolled movement delirium breath holding irregular respiration and dilation of the pupils worrisome and want to make short without endangering the patient Stg 2 delirium or excitement pupils not midline make this stg quick Laryngospasm possible esp if moved Stage 3 surgical level the transition from Stage 2 to Stage 3 is return of regular respiration constriction of the pupils and the stopping of involuntary motion or vocalization by the patient Stage 3 anesthesia is divided into four planes Plane 1 Stage 3 pt still has blink reflexes and swallowing reflexes but has regular resp with good chest motion This stage would be considered light for surgical anesthesia moving Plane 2 Stage 3 pt loses the blink reflexes the pupils become fixed in one position usually central and resp is still regular with good use of the chest muscles and diaphragm most sx done at this level Plane 3 Stage 3 pt starts to lose the ability to use the chest muscles and abd muscles for resp efforts Breathing shallow and assisted ventilation is best This allows for control of pain in surgeries that are unusually painful such as extensive abd exploratories Big cases Plane 4 Stage 3 no use of chest muscles and abdominal muscles at all All respiratory effort is by the diaphragm very close to the point where the patient will stop breathing entirely should be avoided Stage 4 anesthetic crisis time between resp arrest and death from circulatory collapse Need vent and IV support for circulatory and heart BAD Goals of MAC monitored anesthesia care Maintain patient safety and sense of well being Alleviate pain minimize discomfort Minimize psychological response Anxiolysis decrease anxiety Analgesia Amnesia To control behavior To return to pre procedural state Recognized criteria Safe discharge What drugs suited for mac cases Benzo Midazolam PreOp Ativan or Valium Hypnotics Propofol Pentothal Brevitol Ketamine Opioids Fentanyl Alfenta Remifentanyl Dilaudid What s better for what Midazolam Usually given first Dose titrated to effect Anxiolysis amnesia sedation May have paradoxical effect in elderly patients Synergistic with opioids Opioids Fentanyl Alfentanil Remifentanil Demerol Morphine Synergistic with benzos and hypnotics Respiratory depression Bradycardia Enhancement of pain control due to inadequate local anesthesia or uncomfortable position Will not compensate for lack of surgical pain control Consider non narcotics or pre emptive analgesia Hypnotics Propofol Bolus vs continuous infusion Bolus Technique 10 20mg prn titrate to desired effect Infusion 25 75ug kg min per literature for MAC Frequently will use more than that Titrate to effect and allow time for adjustment Loss of lash reflex is usually a sign you have also lost protective airway reflexes Continuous infusion less fluctuation of drug conc and decrease total drug in pt which means quicker recovery from drug Monitoring during mac systematic and respiratory Capnography is not reliable only looking for the waveform Nasal cannula Non rebreather masks The other standard monitors apply Must watch pt depth verbal and visual contact Major problems with mac cases Failure to consider the procedure Failure to consider the patient Failure to consider MAC skills of the surgeon Failure to consider MAC skills of the anesthetist Difference between spinal and general epidurals contrast and compare Spinal SAB subarachnoid blockade Local anesthetic is injected into the subarachnoid space and mixes with the CSF causing blockade of spinal nerves Usually administered as a single injection Midline or paramedian approach Advantages over GA Reduced stress response to surgery Less blood loss hip surgery decrease DVT decrease pulmonary comp less cardiac comp Better in obstetrics less meds administered to mother and fetus Decrease N V urinary retention total opioids and increase mental alertness allows patients to eat void and ambulate sooner Factors affecting Spinal Time of anesthesia varies with drug 60 to 150 minutes of anesthesia Characteristics of patient height position gender Type of needle site of injection and the direction of the needle Dosage amount most influential factor Characteristics of the local anesthetic baricity Volume of CSF in the spinal canal Volume of CSF 500 ml is produced each day Approx 140 ml in bulk flow 30 to 80 ml in the spinal canal Mechanism of action The injected local anesthetic interrupts the transmission of impulses in the nerve roots or the spinal cord The preganglionic B fibers are small and more permeable to local anesthetics than the larger sensory C fibers Sympathetic blockade is found 1 2 segments higher than sensory and motor blockade 1 2 segments below the sensory block 1st loss of autonomic function perceptions of superficial pain touch temperature motor function and proprioception Level assessed by pinprick alcohol pad or PNS T1 T4 Cardiac accelerators Complications of Spinal anesthesia Hypotension Bradycardia Cardiac arrest Nausea and vomiting Total spinal Postdural puncture headache Post dura headach Due to CSF leakage causing traction on the meninges and cranial nerves The headache starts 24 48 hours after the puncture Localized at the occipital region and neck It improves with the patient in the supine position It may be accompanied by double vision blurred vision and tinnitus Lower incidence when a rounded needle pencil point Sprotte or Whitacre and 25 ga rather than a 22 ga Structures of spinal column what u pass through Skin Subcutaneous structures Supraspinous ligament Interspinous ligament Ligamentum flavum Dura Mater Arachnoid membrane Epidurals vs Spinals Spinal small amount of local anesthetic is injected directly into the CSF It produces an intense rapid and predictable neural blockade Epidural it requires a tenfold increase in dose to fill the epidural space and penetrate the nerve roots It has a slower onset Epidural Anesthesia Advantages over GA There is no airway manipulation good for asthmatics Less hypertension and tachycardia Less thrombogenesis Less postoperative nausea and vomiting Better pain control Less pulmonary dysfunction Dose and site of injection are the most important factors in determining the extent of dermatomal blockage Potential complications of Epidural anesthesia Hypotension sympathetic blockade Intravascular injection of local anesthetic


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U of A NURS 2032 - Stages and Planes of Anesthesia

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