NCM 112: ANESTHESIA 3.

DEEP SEDATION
– A drug induced state during which patient cannot
THE SURGICAL EXPERIENCES
be easily aroused but can respond purposely after
repeated stimulation.
SEDATION & ANESTHESIA
– The difference between deep sedation &
anesthesia is that the anesthetized patient is not
ANESTHESIA arousable.
– Greek word anaisthesis, meaning “no sensation”
– Deep sedation & anesthesia are achieved when an
– a partial or complete loss of sensation, with or without
loss of consciousness as a result of the administration of an anesthetic agent is inhaled or administered
anesthetic agent. intravenously.
– Inhaled anesthetic agents includes Volatile liquid
ANALGESIA agents & gases
– lessening of or creating insensibility to pain. – Volatile liquid anesthetic produced anesthesia
when vapor are inhaled.
ANESTHETIC – Gas anesthetic are administered by inhalation &
– an agent that produces anesthesia; subdivided into are always combined with oxygen
general an regional, according to their actions – When anesthetic administration is discontinued,
the vapor & the gas is eliminated through the
LEVELS OF SEDATION & ANESTHESIA
lungs.
1. MINIMAL SEDATION
– uses sedatives & anxiolytics that allows the patient
4. ANESTHESIA
to remain responsive & breath independently.
– Is a state of narcosis (severe central nervous
– Indications are for minor surgeries or as a
system depression produced by pharmacologic
supplement to local or regional anesthesia
agents), analgesia, relaxation, and reflex loss.
– Advantages for the patient include anxiety relief,
– Patients under general anesthesia are not
amnesia, analgesia, comfort & safety
arousable even to painful stimuli.
– The loss of the ability to maintain ventilatory
2. MODERATE SEDATION (CONSCIOUS)
function & require assistance in maintaining a
– a form of anesthesia that maybe produced
patent airway.
intravenously
– Cardiovascular function may also be impaired.
– A depressed level of consciousness that does not
impair the patient’s ability to maintain a patent
GENERAL CATEGORIES OF ANESTHESIA
airway & to respond appropriately to physical
stimulation & verbal command.
I. GENERAL ANESTHESIA
– Goal: a calm tranquil amnesic patient who, when
– is the depression of the CNS by administration of
sedation is combined with analgesic agents, is
drugs or inhalation agents, resulting in loss of
relatively pain free during the procedure to be able
consciousness, sensory perception and motor
to maintain protective reflexes.
function
– Can be administered by an anesthesiologist,
– Patients are not arousable even with painful
anesthetist, moderate sedation is referred to as
stimuli. CP functions are often impaired.
monitored anesthesia care.
– Produces total loss of consciousness, analgesia and
– Midazolam (Versed) or Diazepam (Valium) is used
muscle relaxation
frequently for IV sedation.
– Patient’s receiving this form of anesthesia is never
METHODS OF GENERAL ANESTHESIA
left alone, and is closely monitored for respiratory,
ADMINISTRATION
cardiovascular & CNS depression (pulse oximetry,
ECG, V/S monitoring)
1. INTRAVENOUS
– Maybe used alone or in the combination with local,
o Agents that produce anesthesia in large doses
regional, or spinal anesthesia.
through sedative-hypnotic analgesic action.
o Agents are administered as a bolus or continuous
drip infusion directly into the systemic circulation
for rapid effects.
o It is used primarily as an induction agent or can
use as maintenance of anesthesia.
o Thiopental (Pentothal Na) agent of choice

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 o The medication maybe administered for
introduction often used along with inhalation
anesthetics but maybe used alone
o Can also be used to produce moderate sedation.
o Duration of action is brief and the patient
awakens with little nausea & vomiting
o IV anesthetics are non explosives, require little
equipment & are easy t administer
o Advantage: Onset of anesthesia is pleasant;
preferred by patents who have experienced
various methods.
o Disadvantage: Thiopental: Powerful respiratory
depressant effect.
o Sneezing, coughing & laryngospasm are
sometimes noted w/ its use.
2. INHALATION
o Gases and oxygen are administered into the
systemic circulation through the alveolar
membranes of the lungs, with diffusion to the
pulmonary circulation and finally to the brain.
o Halothane (Flouthane), Isoflurane (Forane),
Sevoflurane (Ultane), Enflurane (Ethrane),
Desflurane (Suprane)
o Liquid anesthetic maybe administered by mixing
the vapors with oxygen or nitrous oxide-oxygen &
then having the patient inhale the mixture through
tube or a mask, or through a laryngeal mask.
o ET tube can be inserted either through the nose or
mouth.
2 TYPES OF INHALATION ANESTHESIA
VOLATILE AGENTS
– liquid that are easily vaporized & produce
anesthesia when inhaled like Ether (Diethyl Ether),
Trichloroethylene, Chloroform, halothane,
enflurane, methoxylflurane, and isoflurane
GASEOUS AGENTS
– Nitrous Oxide or laughing gas – a colorless
odorless nonexplosive gas that has been referred
to as a “carrier of gases.” It is the most commonly
used gas anesthetic. When inhaled, the gas
anesthetic enters the blood though the pulmonary
capillaries & act on cerebral centers to produce
loss of consciousness & sedation.
– Ethylene, Cyclopropane
3. RECTAL (PEDIATRICS)
o Metohexital Na, Anectine, Penthotal Na 5-10%
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II. REGIONAL ANESTHESIA
• Referring to a technique that temporary interrupts the
transmission of nerve impulses to and from a specific area
or region.
• Reduce all painful sensations in one region of the body
without inducing unconsciousness.
• Patent is awake & aware of his/her surrounding when
regional or spinal anesthesia is given – unless medication is
given to produce mild sedation or to relieve anxiety
• Nurse must avoid careless conversation, unnecessary
noise & unpleasant odors – may produce a negative view of
the surgical experience
• A quiet environment is therapeutic
• Diagnosis must not be stated aloud if the patient is not to
know it at all this time
METHODS OF ADMINISTRATION FOR REGIONAL
ANESTHESIA
1. EPIDURAL ANESTHESIA
o Anesthetic injected extradurally to produce
anesthesia below level of diaphragm, used in
obstetrics.
o Is achieved by injecting local anesthetic into the
spinal canal in the space surrounding the dura
mater.
o Also blocks the sensory motor & automatic
functions but it is differentiated from the spinal
anesthesia by the injection site & the amount used
o Epidural dose are much higher because it does not
make direct contact with the cord or nerve roots.
o Advantage: Absence of headache that occasionally
results from subarachnoid injection
2. SPINAL ANESTHESIA
o anesthetic introduced into subarachnoid space of
spinal cord producing anesthesia below the level
of diaphragm.
o A type of extensive conduction nerve block that is
produced when local anesthetic is introduced into
the subarachnoid space at the lumbar level,
usually between L4 & L5.
o Produces anesthesia at the lower extremities,
perineum, & lower abdomen for a lumbar
puncture procedure, the patient usually lies on
the side in a knee chest position
o Agents used: Procaine hydrochloride
(Novocaine), Tetracaine (Pontocaine), Lidocaine
(Xylocaine), and Bupivacaine (Marcaine,
Sensorcaine)
o Few minutes after the introduction of the spinal
anesthetic, anesthesia & paralysis affect the toes
& perineum them gradually legs & the abdomen.
o Nausea, vomiting & pain may occur during
surgery when spinal anesthesia is used – occurs
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 due to manipulation of various structures in the
abdominal cavity.
o Headache may be an after effect of the spinal
anesthesia, several factors involved: size of spinal
needle used, leakage of the fluid from the
subarachnoid space through the puncture site,
and the patient’s hydration status.
o Keep patient lying flat quiet & well hydrated.
3. LOCAL INFILTRATION ANESTHESIA
o Infiltration anesthesia is the injection of the
solution containing the local anesthetic into the
tissues at the planned incision site
o Is often combined with a local regional block by
injecting the nerves immediately supplying the
area
ADVANTAGES:
✓ It is simple, economical & non explosive
✓ Equipment needed is minimal
✓ Postoperative surgery is brief
✓ Undesirable effects of general anesthesia is
avoided
✓ It is deal for short &superficial surgical procedure
o often administered in combination with
epinephrine
o Anesthesia of choice in any surgical procedure in
which it can be used.
o Action is almost immediate, so surgery may begin
as soon as injection is complete.
o Anesthesia last 45 minutes to 1 hour, depending
on the anesthetic the use & the use of
epinephrine.
OTHER TYPES OF NERVE BLOCKS INCLUDE:
• BRACHIAL PLEXUS BLOCK
– produces anesthesia of the arm
• PARA VERTEBRAL ANESTHESIA
– produces anesthesia of the nerves supplying the
chest, abdominal wall & extremities
• TRANSSACRAL (CAUDAL) BLOCK
– produces anesthesia of the perineum &
occasionally the lower abdomen, commonly used
in obstetrics.
• TOPICAL
– cream, spray, drops, or ointment applied
externally, directly to area to be anesthetized.
• FIELD BLOCK
– area surrounding the surgical site injected with
anesthetic
• NERVE BLOCK
– injection into nerve plexus to anesthetize part of
body
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• LOCAL INFILTRATION BLOCK
– injected into subcutaneous tissue of surgical area
• SADDLE BLOCK
– similar to spinal, but anesthetized area is more
limited, commonly used in obstetrics
• BIER BLOCKS
– used most often for procedures involving the arm,
wrist, and hand
• IV REGIONAL
STAGES OF ANESTHESIA
STAGE 1: BEGINNING
ANESTHESIA/ONSET/INDUCTION
– Extends from the administration of anesthesia to the time
of loss of consciousness.
– As the patients breathes the anesthetic mixture, warmth,
dizziness & a feeling of detachment maybe experienced.
– The patient may have a ringing, roaring, or buzzing in the
ears & though still conscious may seem to have the inability
to move extremities.
– During the stages noises seem to be exaggerated; even
low voices or minor sound seem loud & unreal.
– Nurse avoids making unnecessary noises or motions
when anesthesia begins.
STAGE 2: EXCITEMENT/DELIRIUM
– Extends from the time of loss of consciousness to the
time of loss of lid reflex.
– Characterized variously by struggling, shouting, talking,
singing, laughing or crying
– avoided if anesthetic is administered quickly & smoothly.
– Pupils dilate but contract if exposed to light, pulse rate is
rapid & respiration maybe irregular.
– Restraint patient for possibility of uncontrolled
movements.
STAGE 3: SURGICAL ANESTHESIA
– Extends from the loss of lid reflex to the loss of most
reflexes. Surgical procedure is started.
– Reached by continued administration of the anesthetic
vapor or gas.
– Pupils are small but contract when exposed to light.
– Respirations are irregular, the pulse rate and volume are
normal, and the skin is pink or slightly flushed.
– With proper administration of the anesthetic, this stage
maybe maintained four hours in several planes.
STAGE 4: MEDULLARY DEPRESSION/STAGE OF
DANGER
– It is characterized by respiratory/cardiac depression or
arrest. It is due to overdose of Anesthesia. Resuscitation
must be done.
– This stage is reached when too much anesthesia is
administered.
– Respiration becomes shallow, pulse is weak & thready, &
pupils become widely dilated & no longer contract when
exposed to light.
– Cyanosis develops, ad without prompt
attention/intervention death rapidly follows
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– anesthetic is discontinued immediately & respiratory &
circulatory support is initiated to prevent death.
– Stimulants (rarely used) maybe administered; narcotic
antagonist can be used if over dosage is due to opioids

POTENTIAL INTRA OPERATIVE COMPLICATIONS

NAUSEA & VOMITING OR REGURGITATION

o turn to side if gagging occurs, head of the table is
lowered, and a basin is provided for the vomitus
o an antiemetic is administered preoperatively or
intra operatively to counteract possible aspiration

ANAPHYLAXIS
o Is a life-threatening allergic action that causes
vasodilation, hypotension & bronchial constriction.

HYPOXIA & OTHER RESPIRATORY COMPLICATION

o Inadequate ventilation, occlusion of the airway,
inadvertent intubations of the esophagus, and
hypoxia are significant potential problems of
general anesthesia.

Factors that can contribute to inadequate ventilation that

can compromise gas exchange:
✓ Respiratory depression caused by anesthetic agent
✓ Aspiration of respiratory tract secretions of
vomitus
✓ Asphyxia caused by foreign bodies in the mouth
✓ Spasm of the vocal cords
✓ Relaxation of the tongue

o peripheral perfusion is checked frequently, and

pulse oximetry values are monitored

HYPOTHERMIA
o a condition where glucose metabolism is reduced
& a resultant metabolic acidosis developed & are
indicated by a core body temperature below
normal 36.6 lower

MALIGNANT HYPERTHERMIA
o An inherited muscle disorder chemically induced
by anesthetic agents.
o Mortality rate more than 50%

DESSEMINATED INTRAVASCULAR COAGULOPATHY

o a life-threatening condition characterized by
thrombus formation & depletion of select
coagulation proteins.

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