safe administration of anesthesia Flashcards by Jennie Miller

2016 guidelines gave new recommendations for monitoring with moderate sedation, what was that?

use a capnograph

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What is capnograph?

measures end tidal co2

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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

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What are 4 things you can use for monitoring in moderate sedation?

capnograph
depth of sedation scale
consider BIS monitoring
audible alarms

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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

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What is an important question to ask for older adults when we are assessing their functional status?

do they need assistance with ADLs?

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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

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Assess for what 3 things prior to giving moderate sedation?

alcohol
cannabis
opioids

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Why do we assess for alcohol with moderate sedation?

alcohol and benzos act on the same receptors

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What are 2 specialty questions when we are assessing for alcohol, cannabis, and opiods?

cannabis ointments and drops
prescription and legalized usage too

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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

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Know your what with moderate sedation and nurses?

know your scope of practice

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Who defines the scope of practice for RNs in moderate sedation?

state board of nursing
AORN government affairs links to state BON

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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

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There cannot be competing what for moderate sedation?

competing responsibilities for monitoring RN

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There should be 2 of what in the room with moderate sedation?

2 RNs in the room with the pt. at all times

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Are brief interruptible tasks ok for monitoring RN?

yes; like tie gown and open suture

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Local anesthetics block what to prevent what? think pathophysiology

blocks the sodium potassium channels and prevent depolarization to make the nerve cells not work

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What 2 types of local anesthesia meds are there?

esters
amides

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Esthers are a what?

CYCLOPSE with one “i”

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What are 3 esthers we want to remember?

cocaine
procaine
tetracaine

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What are esthers metabolized by?

pseudocholinesterase

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When esters are broken down it releases what? why is it bad

para-aminobenzoic acid (PABA) and some people are allergic to that

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What are 3 amides we commonly use

bupivacaine
lidocaine
mepivacaine

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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?

1. heart rate/rhythm, pulse, BP 2. pulse oximetry 3. 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?

1. advanced age - don't have good renal or hepatic function that younger people have - don't stack doses 2. heart failure, ischemic heart disease, conduction abnormalities - we see cardiac effects sooner 3. liver disease - commonly people with addiction and have low albumin levels 4. low albumin levels 5. metabolic or respiratory acidosis 6. medications that inhibit sodium channels

What are the signs and symptoms in the initial phase of LAST?

1. metallic taste 2. numb tounge and lips 3. ringing in ears 4. light headedness 5. agitation

What are the signs and symptoms in the excitation phase?

1. shivering 2. slurred speech 3. confusion 4. seizures 5. 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?

1. coma 2. bradycardia/hypotension (progression) 3. ventricular arrhythmias 4. respiratory/cardiac arrest

If local is injected into the blood stream, what are the initial signs and symptoms of LAST?

1. seizures 2. 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?

1. hyperventilate with 100% O2 2. 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?

1. topical 2. local infiltration 3. 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?

1. interscalene 2. supraclavicular 3. infraclavicular 4. 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?

1. miosis 2. ptosis 3. 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