EVANGELISTA, Gabrielle Angela B.
NCMP112 – RLE (RR31)
Asynchronous Activity: Anesthesia
1. Types of Anesthesia (3pts)
Type of Anesthesia Site Advantages
1. Local Distal aspect of − avoids some of the risks and
the maxillary unpleasantness associated with
tuberosity above other forms of anesthesia, such
and behind the as nausea and vomiting.
third molar − the anesthetic action extends
for longer than required and
therefore provides pain relief
for several hours after the
operation.
− it gives the patient a sense of
being more "in control" as they
are awake during the procedure.
− the patient returns to normal
eating, walking and other
activities faster than in general
anesthesia.
2. Regional a. Spinal Cord − Better pain control than
a. Spinal b. Epidural Space intravenous narcotics,
b. epidural − Earlier recovery of bowel
function,
− Less need for systemic
opioids (narcotics) and less
nausea as a result,
− Easier breathing resulting
from better pain control,
− Easier participation in
physical therapy.
3. General - Inhalation ( − Reduces intraoperative patient
- Injection awareness and recall
(Intravenous, − Allows use of muscle
Intramuscular and relaxants
Subcutaneous) − Facilitates complete control of
the airway, breathing, and
circulation
Disadvantages
− Convulsions, tremors,
dizziness, blurred vision,
nervousness, nausea.
− Cardiovascular collapse and
cardiac arrest may also occur in
some cases.
− Paralysis of the injected area
− Complications or side effects
can occur
− Requires a skilled operator to
insert
− Risk of intravascular injection
− Difficult to cover multiple
sites of pain
− Redundant in the sedated
patient
− Risk of infection from
infusion catheter
− Risk of dislodgement with
confused patients
− Requires, at minimum, some
degree of preoperative patient
preparation
− Requires increased
complexity of care and
associated costs
− Requires some degree of
 − Can be used in cases of
sensitivity to local anesthetic
agent
− Can be administered without
moving the patient from the
supine position
− Can be adapted easily to
procedures of unpredictable
duration or extent
− Can be administered rapidly
and is reversible
preoperative patient preparation
− May induce physiologic
fluctuations that require active
intervention
− Associated with less serious
complications such as nausea
and vomiting, sore throat,
headache, and shivering
− Associated with malignant
hyperthermia, an exceedingly
rare, inherited muscular
condition in which exposure to
some (but not all) general
anesthetic agents results in
acute and potentially lethal
temperature rise, hypercarbia,
metabolic acidosis, and
hyperkalemia

2. Selected Regional and Local Anesthetics (4pts)

Agent Administration Advantages Disadvantages Implications/

Consideration

Lidocaine Epidural, spinal, Rapid Occasional allergic Useful topically for

(Xylocaine) peripheral IV Longer duration of reaction cystoscopy
anesthesia, and action (compared with Observe for untoward
local infiltration procaine) reactions−drowsiness,
Free of local initiative depressed respiration,
effect seizures

Bupivacaine Epidural, spinal, Duration is 2-3 times Use cautiously in A period of analgesia
(Marcain, peripheral IV longer than lidocaine patients with known persists after return of
Sensorcaine) anesthesia, and drug allergies or sensation; therefore, the
local infiltration sensitivities need for strong
analgesic agents is
reduced
Greater potency and
longer action than
lidocaine

Tetracaine Topical, Long acting, produces Occasional allergic >10 times as potent as
(Pontocaine) infiltration, and good relaxation reaction procaine (Novocaine)
nerve block
 Procaine Local Infiltration — Occasional allergic Commonly used in oral
(Novocaine) reaction or dental surgery

3. Inhalation Anesthetic Agents (7pts)

Agent Administration Advantages Disadvantages Implications/

Consideration

Halothane Induction and Potent, less irritant, Not an analgesic, Nursing care should
(Fluothane) Maintenance induction smooth and variable muscle include support and
rapid, quick recovery, relaxation, sensitizes reassurance;
non-inflammable, heart to assessment of child
compatible with soda catecholamines, for any skin
lime, bronchodilator, hypotension, breakdown related to
uterine relaxant bradycardia, hepatitis, immobility, and
respiratory safety precautions.
depression, shivering Halothane is widely
during recovery used for children,
especially those with
respiratory
dysfunction because
it tends to produce
bronchial dilation.

Enflurane Maintenance of Non-inflammable, Produces convulsions Not recommended in

(Ethrane) anesthesia non-irritant, stable and involuntary children & epileptics
with soda lime, movements during
medium rate of onset induction or recovery,
and recovery slow induction and
recovery

Isoflurane Maintenance of Non-inflammable, Expensive, irritant, Anesthesia providers

(Forane) anesthesia medium rate of onset respiratory depression use inhalation
and recovery, less anesthetics widely in
incidence of their daily practice.
hypotension, less The choice of
toxic inhalation anesthetic
is based on several
factors such as the
pharmacokinetic
profile, preexisting
medical conditions,
and history of
previous reactions.
Sevoflurane Outpatient anesthesia Non-inflammable, Can cause malignant Check the name of
(Ultane) and induction non-irritant, rapid hyperthermia the patient and the
induction and time of
recovery administration.
Monitor vital signs.
Monitor all the body
systems.
Continuous
monitoring of pulse
oximetry.
Postural BP should be
taken.
Take note of that time
that the drug has
expired

Desflurane Maintenance of Non-inflammable, Can cause respiratory Assess for the

(Suprane) anesthesia non-explosive, rapid irritation, irritant mentioned cautions
induction and and contraindications
recovery (e.g. drug allergies,
hepatic and renal
impairment, etc.) to
prevent any untoward
complications.
Perform a thorough
physical assessment
(e.g. weight,
neurological status,
vital signs, heart
sounds, skin color
and lesions, bowel
sounds, etc.) to
establish baseline
data before drug
therapy begins, to
determine
effectiveness of
therapy, and to
evaluate for
occurrence of any
adverse effects
associated with drug
therapy.
Monitor laboratory
test results (e.g. liver
and renal function
tests) to determine
possible need for a
reduction in dose and
evaluate for toxicity.
Gases

Nitrous Oxide Analgesia, Sedation, Non-inflammable, Not a potent Assess for the
(N2O) induction and non-irritating, rapid anesthetic & muscle mentioned cautions
maintenance of induction and relaxant, violent and contraindications
anesthesia recovery, short- excitement, carbon (e.g. drug allergies,
duration procedures, dioxide accumulation hepatic and renal
strong analgesic, cost and hypoxia, impairment, etc.) to
effective megaloblastic anemia prevent any untoward
on prolonged complications.
administration Perform a thorough
physical assessment
(e.g. weight,
neurological status,
vital signs, heart
sounds, skin color
and lesions, bowel
sounds, etc.) to
establish baseline
data before drug
therapy begins, to
determine
effectiveness of
therapy, and to
evaluate for
occurrence of any
adverse effects
associated with drug
therapy.
Monitor laboratory
test results (e.g. liver
and renal function
tests) to determine
possible need for a
reduction in dose and
evaluate for toxicity.

Oxygen (O2) Maintenance of Inexpensive Epistaxis Assess for the

anesthesia mentioned cautions
and contraindications
(e.g. drug allergies,
hepatic and renal
impairment, etc.) to
prevent any untoward
complications.
Perform a thorough
physical assessment
(e.g. weight,
neurological status,
vital signs, heart
 sounds, skin color
and lesions, bowel
sounds, etc.) to
establish baseline
data before drug
therapy begins, to
determine
effectiveness of
therapy, and to
evaluate for
occurrence of any
adverse effects
associated with drug
therapy.
Monitor laboratory
test results (e.g. liver
and renal function
tests) to determine
possible need for a
reduction in dose and
evaluate for toxicity.

4. Commonly Used Intravenous Medications (1pt each)

OPIOID

AGENT COMMON USAGE ADVANTAGES DISADVANTAGES NURSING

RESPONSIBILITY

Alfentanyl Surgical analgesia in Ultra−short-acting — Assess vital signs,

ambulatory patients (5−10 min) analgesic especially respiratory
agent; duration of status and ECG,
action 0.5 h; bolus or frequently during and
infusion following
administration. Notify
health care
professional
immediately of
significant
changes.
Postoperative pain
may require treatment
relatively early in
recovery period due
to short duration of
alfentanil.
Fentanyl Surgical analgesia: Good cardiovascular May cause muscle or 1. Naloxone should
epidural infusion for stability; duration of chest wall rigidity be readily available to
post-operative action 0.5 h reverse the adverse
analgesia; add to effects.
SAB 2. Monitor respiratory
and cardiovascular
status continuously
3. Observe for
abdominal distention,
loss of bowel sounds,
or urinary retention.
4. Keep ventilatory
support (O2, bag,
mask) available at
bedside
5. Two RN signatures
are required to verify
that the physician
order is calculated
within guidelines.

Morphine Sulfate Preoperative pain; Inexpensive; duration Nausea and vomiting; History:
pre-medication; of action 4−5 h; histamine release; Hypersensitivity to
postoperative pain euphoria; good postural  BP and  opioids; diarrhea
cardiovascular SVR caused by poisoning;
stability labor or delivery of a
premature infant;
biliary tract surgery
or surgical
anastomosis; head
injury and increased
intracranial pressure;
acute asthma, COPD,
cor pulmonale,
preexisting
respiratory
depression; acute
abdominal conditions,
CV disease,
supraventricular
tachycardias,
myxedema, seizure
disorders, acute
alcoholism, delirium
tremens, cerebral
arteriosclerosis,
ulcerative colitis,
fever, kyphoscoliosis,
Addison disease,
prostatic hypertrophy,
 urethral stricture,
recent GI or GU
surgery, toxic
psychosis, renal or
hepatic impairment;
pregnancy; lactation
Physical: T; skin
color, texture, lesions;
orientation, reflexes,
bilateral grip strength,
affect; P,
auscultation, BP,
orthostatic BP,
perfusion; R,
adventitious sounds;
bowel sounds, normal
output; urinary
frequency, voiding
pattern, normal
output; ECG; EEG;
LFTs, renal and
thyroid function tests

Remifentanil IV Infusion for Easily Titrated; very Expensive; requires Monitor vital signs
surgical analgesia; short duration; good mixing; may cause during postoperative
small boluses for cardiovascular muscle rigidity period; observe for
brief, intense pain stability. Ultiva is and immediately
rapidly metabolized report any S&S of
by hydrolysis of the respiratory distress or
propanoic acid- respiratory
methyl ester linkage depression, or
by nonspecific blood skeletal and thoracic
and tissue esterase muscle rigidity and
weakness.
Monitor for adequate
postoperative
analgesia.

Sufentanil Surgical analgesia Duration of action 0.5 Prolonged respiratory Monitor the efficacy
h; prolonged depression of pain management.
analgesia Pain assessment and
exceptionally potent measurement as per
(5−10 times more the clinical nursing
than fentanyl); guideline, and to
provides good recognize and prevent
stability in adverse effects such
cardiovascular as sedation and
surgery respiratory
depression. More
frequent observations
 should be undertaken
in patients receiving
an administration of
an opioid bolus.

MUSCLE RELAXANTS

AGENT COMMON ADVANTAGES DISADVANTAGES NURSING

USAGE RESPOSIBLITY

SUCCINYLCHOLINE Relax skeletal Short duration; rapid No known effect on Monitor symptoms of
muscles for onset consciousness, pain high plasma
surgery and threshold, or potassium levels
orthopedic cerebration; (hyperkalemia),
manipulations; fasciculations, including
short procedures; postoperative bradycardia, fatigue,
intubation myalgias, weakness, numbness,
dysrhythmias; raises and tingling. Notify
serum K in tissue physician or nursing
trauma, muscular staff immediately
disease, paralysis, because severe cases
burns; histamine can lead to life-
release is slight; threatening
requires refrigeration arrhythmias and
paralysis.

ATRACURIUM Intubation; No significant Requires Monitor ECG, heart

BESYLATE maintenance of cardiovascular or refrigeration; slight rate, and BP
(TRACRIUM) skeletal muscle cumulative effects; histamine release; throughout
relaxation good with kidney pregnancy risk administration.
injury category C; do not Observe the patient
mix with lactated for residual muscle
Ringer’s solution or weakness and
alkaline solutions respiratory distress
such as barbiturates during the recovery
period. Monitor
infusion site
frequently. If signs of
tissue irritation or
extravasation occur,
discontinue and
restart in another
vein.

CISATRACURIUM Intubation; Similar to atracurium No histamine release Note: Personnel and

BESYLATE maintenance of equipment required
skeletal muscle for endotracheal
relaxation intubation,
administration of
oxygen under positive
pressure, artificial
respiration, and
assisted or controlled
ventilation must be
immediately
available.
Evaluate degree of
neuromuscular
blockade and muscle
paralysis to avoid risk
of overdosage by
qualified individual
using peripheral
nerve stimulator.
Monitor BP, pulse,
and respirations and
evaluate patient's
recovery from
neuromuscular
blocking (curare-like)
effect as evidenced
by ability to breathe
naturally or to take
deep breaths and
cough, keep eyes
open, lift head
keeping mouth
closed, adequacy of
hand-grip strength.
Notify physician if
recovery is delayed.
Note: Recovery from
neuromuscular
blockade usually
begins 35–45 min
after drug
administration and is
almost complete in
about 1 h. Recovery
time may be delayed
in patients with
cardiovascular
disease, edematous
states, and in older
adults.
MIVACURIUM Intubation; Short acting; rapid Expensive in longer Assess patients with
(MIVACRON) maintenance of metabolism by cases neuromuscular
skeletal muscle plasma disease carefully and
relaxation cholinesterase; used adjust drug dosage
as bolus or infusion using a peripheral
nerve stimulator
when they experience
prolonged
neuromuscular
blocks.

ROCURONIUM Intubation; Rapid onset (dose No known effect on Monitor ECG, heart
(ZEMURON) maintenance of dependent); consciousness, pain rate, and BP
relaxation elimination via threshold, or throughout
kidney and liver cerebration; administration.
vagolytic; may  HR Observe the patient
for residual muscle
weakness and
respiratory distress
during the recovery
period. Monitor
infusion site
frequently. If signs of
tissue irritation or
extravasation occur,
discontinue and
restart in another
vein.

VECURONIUM Intubation; No significant Requires mixing Monitor ECG, heart

(NORCURON) maintenance of cardiovascular or rate, and BP
relaxation cumulative effects; no throughout
histamine effects administration.
Observe the patient
for residual muscle
weakness and
respiratory distress
during the recovery
period. Monitor
infusion site
frequently. If signs of
tissue irritation or
extravasation occur,
discontinue and
restart in another
vein.

TUBOCURARINE Adjunct to — No known effect on Nursing Implications

anesthesia; consciousness, pain Monitor BP, vital
maintenance of threshold, or signs, and airway
 relaxation cerebration; might until assured of
cause histamine patient's recovery
release and transient from drug effects.
ganglionic blockade Ganglionic blockade
(hypotension) and
histamine liberation
(increased salivation,
bronchospasm) and
neuromuscular
blockade (respiratory
depression) are
known effects of
tubocurarine.

METOCURINE Intubation; Good cardiovascular Slight histamine Complete recovery

maintenance of stability release from IV dose may
relaxation require several hours.
Use a peripheral
nerve stimulator to
monitor response.

PANCURONIUM Intubation; — May cause  HR and Observe patient

maintenance of  BP closely for residual
relaxation muscle weakness and
signs of respiratory
distress during
recovery period.
Monitor BP and vital
signs. Peripheral
nerve stimulator may
be used to assess the
effects of
pancuronium and to
monitor restoration of
neuromuscular
function.

OTHER INTRAVENOUS ANESTHETIC AGENTS

AGENT COMMON USAGE ADVANTAGES DISADVANTAGES NURSING

RESPONSIBLITY

DIAZEPAM Amnesia; hypnotic; Good sedation Long acting Observe patient

(VALIUM, DIZAC) relieves anxiety; closely and monitor
preoperative vital signs when
 diazepam is given
parenterally;
hypotension,
muscular weakness,
tachycardia, and
respiratory depression
may occur. Lab tests:
Periodic CBC and
liver function tests
during prolonged
therapy. Supervise
ambulation.

ETOMIDATE Induction of general Short-acting May cause brief Implement breathing

anesthesia; indicated hypnotic; good period of apnea; pain activities and other
to supplement low- cardiovascular with injection and therapeutic exercises
potency anesthetic stability; fast, smooth myotonic movements to encourage
agents induction and ventilation and help
recovery overcome any
residual effects of the
anesthetic.

Because of the risk of

arrhythmias and
abnormal BP
responses, use
caution during
aerobic exercise and
other forms of
therapeutic exercise.
Assess exercise
tolerance frequently
(BP, heart rate,
fatigue levels), and
terminate exercise
immediately if any
untoward responses
occur

Guard against falls

and trauma (hip
fractures, head injury)
during the immediate
postoperative period.
Implement fall
prevention strategies
especially if patient
exhibits sedation,
dizziness, or blurred
vision.
KETAMINE Induction; occasional Short acting; Large doses may Need darkened room
(KETALAR) maintenance (IV or profound analgesia; cause hallucinations for recovery; often
IM) patient maintains and respiratory used in trauma care
airway; good in small depression; chest wall
children and burn rigidity; laryngeal
patients spasm

MIDAZOLAM Hypnotic; anxiolytic; Excellent amnesia; Slower induction than Before administering,
sedation; often used water soluble (no thiopental have oxygen and
as adjunct to pain with IV resuscitation
induction injection); short equipment available
acting in case of severe
respiratory
depression.
Monitor and record
patient response to
medication.
Observe site closely
for extravasation.
Monitor for adverse
reactions.
Continuous
cardiorespiratory
monitoring.

PROPOFOL Induction and Rapid onset; May cause pain when Maintain patent
maintenance; awakening 4−8 min; injected; suppresses airway and adequate
sedation with regional produces cardiac output and ventilation. Propofol
anesthesia or MAC sedation/hypnosis respiratory drive should be used only
rapidly (within 40 s) by individuals
and smoothly with experienced in
minimal excitation; endotracheal
decreases intraocular intubation, and
pressure and systemic equipment for this
vascular resistance; procedure should be
rarely is associated readily available.
with malignant Assess level of
hyperthermia and sedation and level of
histamine release consciousness
throughout and
following ad-
ministration.

METHOHEXITAL Induction; Ultra−short-acting May cause hiccups Hiccups are common,

SODIUM methohexital slows barbiturates particularly with
(BREVITAL) the activity of brain rapid injection; they
and nervous system sometimes persist
after anesthesia.
Keep facilities for
assisting respiration
 and administration of
oxygen readily
available in the event
of respiratory
distress.

THIOPENTAL Induction; stops — May cause Monitor vital signs

SODIUM seizures laryngospasm q3–5min before,
(PENTOTHAL) during, and after
anesthetic
administration until
recovery and into
postoperative period,
if necessary.
Report increases in
pulse rate or drop in
blood pressure. ...
Shivering,
excitement, muscle
twitching may
develop during
recovery period if
patient is in pain.

5. Discuss Malignant Hyperthermia (5pts)

a. Cause
b. Susceptible people
c. Medication
d. Nursing Responsibilities

Malignant Hyperthermia
Malignant hyperthermia is a severe reaction to certain drugs used for anesthesia. This severe reaction typically includes
a dangerously high body temperature, rigid muscles or spasms, a rapid heart rate, and other symptoms. Without prompt
treatment, the complications caused by malignant hyperthermia can be fatal.
Cause Susceptible People Medication Nursing Responsibilities
Malignant hyperthermia Your risk of having A drug called Dantrolene The nurse must identify
susceptibility (MHS) is malignant hyperthermia (Dantrium, Ryanodex, patients at risk, recognize
caused by a genetic defect disorder is higher if Revonto) is used to treat the signs and symptoms,
(mutation). The abnormal someone in your family has the reaction by stopping the have the appropriate
gene increases your risk of it. release of calcium into the medication and equipment
malignant hyperthermia • If one of your muscle. Other medications available, and be
when you're exposed to parents has the may be given to correct knowledgeable about the
certain anesthesia abnormal gene, you your body's metabolic protocol to follow.
medications that trigger a have a 50% chance imbalance and treat Preparation may be
reaction. The abnormal of having it too complications. lifesaving for the patient.
gene is most commonly (autosomal
 inherited, usually from one dominant
parent who also has it. Less inheritance pattern).
often, the abnormal gene is • If you have other
not inherited and is the relatives with this
result of a random gene genetic disorder,
mutation. your chance of
having it is also
Different genes can cause increased.
the disorder. The most Your risk of having
commonly affected gene is malignant hyperthermia is
RYR1. More rarely affected also higher if you or a close
genes include CACNA1S relative has:
and STAC3. • A history of an
event that is
suspected to be
malignant
hyperthermia
during anesthesia
• A history of muscle
tissue breakdown
called
rhabdomyolysis,
which can be
triggered by
exercise in extreme
heat and humidity
or when taking a
statin drug
• Certain muscle
diseases and
disorders caused by
inherited abnormal
genes

References:
https://www.mayoclinic.org/diseases-conditions/malignant-hyperthermia/diagnosis-treatment/drc-20353752
Med-Surg Book