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					  Foundations I

Krista Yoder, CRNA MSN
    January 13, 2009
     Code of Ethics for the CRNA

•   Responsibility to Patients
•   Competence
•   Responsibilities as a Profession
•   Responsibility to Society
•   Endorsement of Products and Services
•   Research
•   Business Practices
    AANA Position Statement on Substance
      Misuse and Chemical Dependency

•   Wearing Masks III
                 Signs of Addiction
•   Watch for any pattern or cluster of these:
    •   Unexpected professional behavior
    •   Isolates or withdraws from peers
    •   Decreased performance
    •   Often late
    •   Diverting drugs
    •   Mood alterations (unexplained anger)
    •   Increased irritability
    •   Overreacts to criticism
    •   Charting irregularities
    •   Wearing long sleeves all the time
    •   Missing in action
                 Signs of Addiction
•   Watch for any pattern or cluster of these:
    •   Frequent home crisis
    •   Unusual orders from pharmacy
    •   Frequent bathroom breaks
    •   Dilated or constricted pupils
    •   Forgetful, unpredictable
    •   Nodding off during a case
    •   Signs up for frequent extra call
    •   Slurred speech
    •   Tremors, shakes
    •   Dangerous to leave alone on case
    •   Increasing difficulty with peers, supervisors and/or authority
    •   Pocketing drugs
     Scope and Standards for Nurse
          Anesthesia Practice
•   Scope of Practice
    •   Guidelines for Core Clinical Privileges

    •   Standards for Nurse Anesthesia Practice
         •   Standard   I – Preanesthesia Assessment
         •   Standard   II – Informed Consent
         •   Standard   III – Patient Specific Plan
         •   Standard   IV – Implement and Adjust Plan
         •   Standard   V - Monitoring
Scope and Standards for Nurse
     Anesthesia Practice
•   Standards for Nurse Anesthesia Practice
     •   Standard VI – Documentation on the patient’s
         Medical Record
     •   Standard VII – Transfer of Care
     •   Standard VIII – Patient Safety
     •   Standard IX – Infection Control
     •   Standard X – Quality
     •   Standard XI - Patient Rights
Standards for Nurse Anesthesia Practice
Standard I -

•   Perform a thorough and complete
    preanesthesia assessment.
•   Interpretation
    The responsibility for the care of the patient
     begins with the pre-anesthetic assessment.
     Except in emergency situations, the CRNA has
     an obligation to complete a thorough
     evaluation and determine that relevant tests
     have been obtained and reviewed.
Preanesthesia Assessment:

•   Become familiar with the present surgical
    illness
•   Identify co-existing medical conditions
•   Establish a CRNA-patient relationship
•   Develop anesthetic management plan
       Preanesthesia Assessment
•   Review of systems
•   Current diagnosis
•   Pertinent lab data
•   Pertinent physical examination findings
•   Allergies/sensitivities
•   Airway Assessment
•   Surgical/anesthesia history
•   Medication history
•   Social history
•   Family problems with anesthesia
•   Other
Review of Systems

•   Use what you already know
•   Texts for Foundations I
•   AANA Pre-Anesthesia Questionnaire
Patient History:

•   General state of well-being
•   Daily activity level
•   The patient’s understanding of:
    •   Medical condition
    •   Coexisting medical conditions
    •   Present surgical condition
•   Review of old records
Present Surgical Illness:

•   Diagnostic studies
•   Presumptive diagnosis
    •   Treatments
    •   Responses to treatments
    •   Review available vital sign data
    •   Review available fluid balance data
Coexisting medical conditions:

•   Potential to complicate anesthetic
•   Evaluate in a systems approach
    •   Assess recent changes in symptoms
    •   Assess current treatment regimens
    •   Specialty consultation when needed
Medications:

•   Review medications, doses, schedules
    •   Cardiac
    •   Seizure
    •   Endocrine
    •   Anticoagulants
    •   Antidepressants
•   Decision to continue/discontinue
Allergies and drug reactions:

•   True allergic reactions
•   Non-allergic responses
    •   Adverse reactions
    •   Side effects
    •   Drug-drug interactions
True Allergic Reactions:
•   Antibiotics
•   Induction agents
    •   Propofol
    •   Rocuronium
•   Shellfish and seafood
    •   Cross reaction with
         •   IV contrast dye
         •   Protamine
•   Reported allergy to anesthesia
    •   Malignant Hyperthermia
         •   Halogenated agents
         •   Anectine/succinylcholine
    •   Atypical Pseudocholinesterase
Rare anesthesia drug interactions:

•   Pentothal – acute intermittent porphyria

•   Demerol – hypertensive crisis if patient on
    MOA.
Difficulty with prior anesthetics:
•   “Has anyone in your family experienced unusual
    or serious reactions to anesthesia?”
    •   Malignant hyperthermia


•   Previous history of difficulty under anesthesia
    •   Difficult Intubation
    •   Significant PONV
    •   Review available old records
Social History:

•   Smoking
•   Alcohol
•   Recreational drug use
Smoking:

•   Productive Cough
•   Hemoptysis
•   How many pack years?
•   Eliminate cigarette use for 2-4 weeks prior
    to elective surgery to reduce complications
•   Assess need for further pulmonary
    evaluation
Alcohol:
•   Self-reporting of use typically underestimates
    actual use
•   Acute intoxication
    •   Lowers anesthetic requirements
    •   Predisposes to hypothermia and hypoglycemia
•   Withdrawal
    •   Increase anesthetic requirements
    •   Hypertension
    •   Tremors
    •   Delirium
    •   Seizures
    Recreational drugs:
•   Self-reporting typically underestimates
    actual use
•   Define types, routes, frequency, last used
•   Stimulant abuse
     •   Palpitations
     •   True angina
     •   Lowered threshold for serious arrhythmia
     •   Convulsions
Routine use of narcotics/benzodiazepines
(whether prescribed or illegal) may
significantly increase the dose required to
induce anesthesia or maintain anesthesia.




Routine use of recreational drugs will
impact post-op pain requirements.
Review of Systems:              (continued)



•   Respiratory
    •   Asthma
    •   Recent history of URI
Review of systems:                       (continued)


•   Cardiac
    •   HTN
        •   If associated with LVH greater risk for
            perioperative MI, CVA
        •   Diuretic use – hypovolemia, electrolyte imbalance
    •   Angina/MI
        •   At risk for MI with stress of surgery and anesthesia
        •   Evaluate current cardiac status
Review of Systems:                      (continued)

•   Gastro/intestinal
    •   GERD/ hiatal hernia
         •   Increased risk of pulmonary aspiration
         •   May consider Rapid Sequence Induction(RSI)
Review of Systems:                (continued)


•   Pregnancy
    •   All women of childbearing age should be
        questioned regarding last menses and the
        likelihood of current pregnancy.
    •   Anesthetic medications may adversely
        influence uteroplacental blood flow
    •   Anesthetics may be teratogenic
Physical Exam:

•   Focused, yet thorough
•   Direct attention to:
    •   Airway
    •   Heart
    •   Lungs
    •   Neuro
Physical Exam:                   (continued)


•   Specific to Regional Anesthesia
    •   Detailed assessment of extremity
    •   Detailed assessment of back
         •   Infection
         •   History of injury
         •   Previous back surgery
         •   Chronic pain issues
Physical Exam:              (continued)


•   Baseline Vital Signs:
    •   Height and weight
    •   Blood pressure
    •   Resting pulse
    •   Respirations
Physical Exam:             (continued)


•   Airway assessment
    •   Size of oral opening and tongue
    •   Observe/document loose or chipped teeth,
        “caps”, dentures, other orthodontic devices,
        piercings
    •   Observe/document range of cervical motion in
        flexion, extension, and rotation
    •   Observe/document tracheal deviation, masses
Airway Assessment
The loose tooth
Piercings:
Normal Airway Anatomy
The larynx
Mallampati Classification:
Difficult airways
Physical Exam:            (continued)


•   Heart
    •   Murmur
    •   Pericardial rub
Physical Exam:              (continued)


•   Lungs
    •   Wheezes
    •   Rhonchi
    •   Rales
    •   Correlate what you hear with observation of
        how patient is breathing…. easy vs. labored
    •   Use of accessory muscles
Physical Exam:               (continued)


•   Abdomen
    •   Distention
    •   Ascites
    •   Predisposition to regurgitation
    •   Compromise ventilation
Physical Exam:                   (continued)


•   Extremities
    •   Clubbing
    •   Cyanosis
    •   Cutaneous infection
         •   No IV cannulation
         •   No regional nerve block
Physical Exam:              (continued)


•   Neuro
    •   Document neuro status
    •   Cranial nerve function
    •   Cognition
    •   Peripheral sensorimotor function
Preoperative labs:

•   Hematocrit and Hemoglobin
    •   Presurgical “Standard of Care”
    •   Hcts of 25-30% tolerated in healthy pt.
    •   May result in ischemia in pt. with history of
        CAD
    •   Evaluate each pt. individually for the etiology
        and duration of their anemia
Preoperative labs:

•   Serum Chemistry
    •   Hypokalemia/hyperkalemia
•   Coagulation Screen
    •   When indicated
EKG:
•   All patients over 40 years old
•   New Q waves
•   ST-segment depression/elevation
•   T-wave inversions
•   Rhythm disturbances
    •   PVC’s
    •   A-fib, a-flutter
    •   LBBB
    •   2nd or 3rd degree AV block
Chest x-ray:
•   When clinically indicated
•   History of heavy smoking
•   Elderly
•   History of major organ system disease
The CRNA-patient relationship:
A stressful time for the patient -
•   Surgery          •   Anesthesia
    •   Cancer           •   Loss of control
    •   Pain             •   Fear of not waking up
    •   Disability       •   PONV
    •   Death            •   Pain
NPO status: Preop Fasting Guidelines

•   Recommendations – for all age groups
    Ingested Material    Fasting Period(hrs)
       Clear liquids           2 hrs
       Breast milk             4 hrs
       Infant formula          6 hrs
       Non-human milk          6 hrs
       Light solid foods       6 hrs
NPO guidelines:
•   Clear liquids include; water, sugar water, apple juice,
    non-carbonated soda, pulp-free juices, clear tea, black
    coffee.

•   Medications can be taken PO with up to 150ml of water
    in the hour preceding anesthesia induction.

•   Recommendations apply to healthy patients, elective
    surgery. Following the recommendations does not
    guarantee that gastric emptying has occurred.
    ASA Physical Status Classification
•   ASA I – a normal healthy patient

•   ASA II – a patient with mild systemic disease (mild diabetes, controlled
    HTN, obesity).

•   ASA III – a patient with severe systemic disease that limits activity (COPD,
    angina, prior MI).

•   ASA IV – a patient with an incapacitating disease that is a constant threat
    to life (CHF, renal failure).

•   ASA V – a moribund patient not expected to survive 24 hours (ruptured
    AAA).

•   ASA VI – brain dead patient whose organs are being harvested.

•   “E” – for emergent operations add the letter E after the classification.
Standards for Nurse Anesthesia Practice
Standard II -
 Informed consent – Obtain informed consent for
 the planned anesthetic intervention from the
 patient and/or legal guardian.
 Interpretation – The CRNA shall obtain or verify
 that an informed consent has been obtained by
 a qualified provider. Discuss anesthetic options
 and risks with the patient and/or legal guardian
 in language the patient and/or guardian can
 understand. Document in the patient’s medical
 record that informed consent was obtained.
Informed Consent:
•   The anesthetic plan, alternatives, and potential
    complications must be discussed in terms that
    are understandable to a layperson.
•   Aspects of care outside of realm of common
    experience:
    •   Intubation
    •   Post op ventilation/ICU
    •   Invasive monitoring
    •   Regional anesthesia techniques
    •   Potential for blood product use
Informed Consent:

•   Alternative plan
    •   Necessary if planned procedure fails or there
        is a change in clinical circumstance.
•   Associated Risks
    •   Discuss in a manner that a reasonable person
        would find helpful in making a decision.
    •   Complications that occur with high frequency.
Informed Consent – Associated Risks
General Anesthesia:
  •   Sore throat
  •   Hoarseness
  •   Nausea and vomiting
  •   Dental injury
  •   Allergic reactions
  •   Intraoperative awareness
  •   Pulmonary or cardiac injury
  •   Stroke or death
  •   Postoperative intubation
  •   ICU admission (when appropriate)
Informed Consent – Associated Risks

Regional Anesthesia:
  •   Infection
  •   Local bleeding
  •   Nerve injury
  •   Headache
  •   Drug reaction
  •   Failure of planned regional anesthetic
Informed Consent – Associated Risks
Blood Transfusion:
   •   Fever
   •   Infectious hepatitis
   •   HIV
   •   Hemolytic reaction

Vascular Cannulation:
   •   Peripheral nerve, tendon, blood vessel injury
   •   Hemothorax
   •   Pneumothorax
   •   Infection
Informed Consent – Extenuating Circumstances

•   Anesthesia procedures may proceed
    without consent in emergency situations.
Anesthesia Consult Note:
•   A medico-legal document in permanent hospital
    record. Should contain the following information:
    •   Date and time of interview
    •   Planned procedure
    •   Description of extraordinary circumstances
    •   Allergies, Medications, Labs
    •   Disease processes/treatments
    •   ASA status
Standards for Nurse Anesthesia Practice
Standard III-
  Formulate a patient-specific plan for anesthesia
  care.
Interpretation – The plan of care developed by the
  CRNA is based upon comprehensive patient
  assessment, problem analysis, anticipated
  surgical or therapeutic procedure, patient and
  surgeon preferences, and current anesthesia
  principles.
The Anesthesia Plan:

What is anesthesia???
The Anesthesia Plan:

•   Review of anesthetic options
    •   General Anesthesia

    •   Regional Anesthesia

    •   Monitored Anesthesia Care (MAC)
General Anesthesia:

•   Inhalation

•   Intravenous

•   TIVA
Regional Anesthesia: (Conduction)

•   Spinal / Subarachnoid Block (SAB)

•   Epidural

•   Blocks
    •   Bier
    •   Axillary
    •   Femoral nerve
    •   Ankle
Monitored Anesthesia Care: (MAC)

•   Conscious Sedation

•   Deep Sedation
Ideal Anesthetic:
•   Assures patient safety and satisfaction
•   Provides excellent operating conditions for
    surgeon
•   Rapid patient recovery
•   Minimal post-op side effects
•   Optimal post-op pain control
•   Permits quick transfer/discharge from PACU
•   Optimizes operating room efficiency
•   Low cost
Considerations that influence
choice of anesthetic technique:
•   Preference of patient, surgeon, anesthesia
•   Site of surgery
•   Body position required for surgery
•   Elective or emergency surgery
•   Co-existing disease
•   Duration of surgery
•   Age of patient
•   Suspected difficult airway
•   Suspected increased gastric contents at time of induction
Required for ALL Anesthetics!!!

•   Means to give positive pressure ventilation
•   Means to break laryngospasm
•   Airway equipment
•   Suction
•   Monitors
Pre-op Medications:
• Goals
  •Anxiety relief
  •Sedation
  •Analgesia
  •Amnesia
  •Antisialagogue
Pre-op Medications:
• Goals

  •Attenuate sympathetic
  nervous system response

  •Decrease anesthetic
  requirements

  •Prevent bronchospasm
Pre-op Medications:
Goals
 •   Prophylaxis
     against allergy

 •   Decrease PONV

 •   Increase gastric
     fluid pH

 •   Decrease gastric
     fluid volume
Sedatives and analgesics:

•   Goals
    •   Reduce anxiety
    •   Reduce pain during regional anesthesia
        procedures
    •   Assist with positioning
    •   Facilitate smooth induction of anesthesia
Sedatives and analgesics:
•   Doses should be reduced in:
    •   Elderly
    •   Debilitated
    •   Acute intoxication
    •   Airway obstruction/trauma
    •   Central apnea
    •   Neurologic deterioration
    •   Severe pulmonary disease
    •   Severe valvular heart disease
Sedatives and analgesics:

•   Patients addicted to opioids and
    barbiturates and patients on chronic pain
    therapy should receive enough
    premedication to overcome tolerance and
    to prevent withdrawal during surgery.
Benzodiazepines:

•   5 principle pharmacologic effects:
    •   Anxiolysis
    •   Sedation
    •   Anticonvulsant actions
    •   Spinal cord-mediated skeletal muscle
        relaxation
    •   Anterograde amnesia (acquisition or encoding
        of new information)
Benzodiazepines -

•   As a class of drugs, are unique in the
    availability of a specific pharmacologic
    antagonist, flumazenil (romazicon)
Benzodiazepines-
•   Produce all of their pharmacologic effects
    by facilitating the actions of gaba -
    aminobutyric acid (GABA).
•   GABA is the principle inhibitory
    neurotransmitter in the CNS.
•   Benzodiazepines do not activate GABAA
    receptors, but enhance the affinity of the
    receptors for GABA.
GABAA receptor -
GABAA receptor -
GABAA receptor -
Midazolam-
•   A water-soluble benzodiazepine with an
    imidazole ring in its structure that
    accounts for its stability in aqueous
    solutions and its rapid metabolism.
•   Compared with diazepam, midazolam is
    2-3 times as potent.
•   Amnestic effects are more potent than
    sedative effects.
Midazolam - pharmacokinetics
•   Undergoes rapid absorption from the
    gastrointestinal tract and achieves prompt
    passage across the blood-brain barrier.

•   Effect-site equilibration time (0.9-5.6 minutes).
    •   IV doses of midazolam should be sufficiently spaced
        to permit the peak clinical effect before a repeat dose
        is considered.
Midazolam – metabolism

•   Rapidly metabolized by hepatic and small
    intestine cytochrome P-450 (CYP3A4)
    enzymes to active and inactive
    metabolites.
    •   1-hydroxymidazolam – may accumulate in
        critically ill patients
Midazolam - metabolism

•   Metabolism of midazolam is slowed in the
    presence of drugs that inhibit cytochrome
    P-450 enzymes, this may result in
    unexpected CNS depression.
    •   Cimetidine
    •   Erythromycin
    •   Calcium channel blockers
    •   Antifungal drugs
Midazolam - clearance

•   Renal clearance

•   Elimination half-time, volume of
    distribution (Vd), and clearance are not
    altered by renal failure.
Midazolam (versed):
•   Adult dosing
    •   1-5mg IV
    •   2.5-5mg IM
•   Onset: 30-60 seconds
•   Time to peak effect: 3-5 minutes
•   Duration of sedation: 15-80 minutes
    •   Effect – site equilibrium & redosing
Midazolam (versed):

•   Midazolam induced depression of
    ventilation is exaggerated (synergistic
    effects) in the presence of opioids and
    other CNS depressant drugs.
•   Appreciate that increasing age greatly
    increases the pharmacodynamic sensitivity
    to the hypnotic effects of midazolam.
Midazolam (versed): Pediatrics
    The most commonly used oral preoperative
    medication for children. Oral midazolam
    syrup(2mg/ml) is effective for producing
    sedation and anxiolysis at a dose of 0.25 mg/kg
    with minimal effects on ventilation and oxygen
    saturation.

•   Pediatric dosing
    •   0.4-1.0mg/kg PO
    •   0.05mg/kg IV
    •   0.1-0.2mg/kg IM

				
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