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					                                                                                         Clinical Site: Logan Regional
                                                                                         Date: __9-10-07
                                                                                         Case ID: 910-5

Student Name:                                                   Preceptor Name:
Melinda Hensley                                                 Cyd Gagnor
Pt. ID CS                                                       Anesthesia Start:                 Anesthesia End:
Procedure: Cataract extraction with intraocular lens             Age 77    Gender     Height       Weight        BMI   IBW
                                                                    Mo.     Male        66 IN         241   Kg
implant by PHACO ( phacoemulsification- ultrasound                  Yrs.   female            CM
energy is used to fragment the lens, allowing aspiration
of lens material.

ASA: 3 Why:                                                     Allergies: cipro
HNT                                                             Reaction: _______________________________________
COPD
Arthritis
 Preop Vital Signs              Airway Evaluation               Preop Labs:

 BP:        RR:             MP 1 2 3 4                          Hgb           PT           NA               BUN
                            TMD _3 fb                           Hct           PTT           K               CREAT
 HR:       SAO2:            neck ROM : OK                       WBC           INR          CL               ABG’s
                            Jaw ROM good                        Glu           PLT          CO2
                            Dentition
                            ____________________                Type & Xmatch         Type & Screen Blood Available
Position / Anesthetic Considerations:                           Anesthetic Considerations R/T Procedure / Proposed
                                                                Interventions
  Supine    Prone   Lateral   Sitting   Jackknife   Lithotomy

Considerations:




Monitors & supplies                                             Diagnostic Studies:
 Pulse Ox x A-line               OG / NG            ETCO2
 EKG x        CVP                Bair Hugger        BIS         EKG: _________________________________________
 BP Cuff x PA                    Fluid              02/agent    CXR: _________________________________________
                                 Warmer             analyzer    PFT’s:_________________________________________
 Temp         Esophageal         Precordial                     Other:_________________________________________
Past Medical History:                                            Past Surgeries:          Medications:
 CV

 Resp

 Neuro

 GI / Hep

 GU
                                                                 Anesthetic Problems:             Anesthetic Implications:
 Metabolic
 Other:                                                                   Resolution:


Fluid Plan                                                               Fluid Plan:                            Ventilation:
                        st               nd              rd
                       1 hour           2 hr           3 hr               EBV              cc / kg              TV =
 Deficit                                                                                                        RR =
 Maintenance                                                              ABL              to HCT ___           I:E =
 3rd Space                                                                                                      P02 =
 Total Fluids                                                             EBL                cc                 PIP =

Anesthetic Plan A:                                                       Anesthetic Plan B:
 GA /          GA /          GETA         Mask          TIVA              GA /         GA /          GETA          Mask         TIVA
 Mask          LMA                        Case                            Mask         LMA                         Case
               Size:         ETT:                                                      Size:         ETT:
                                          Peripheral                                                               Peripheral
 MAC           SAB           Epidural     Block         Other             MAC          SAB           Epidural      Block        Other

PERIBULBAR BLOCK BY MD
Peribulbar block is executed by directing the needle to less depth       Premed:
and minimal angulations, parallel to the globe, toward the greater
wing of the sphenoid bone. Is theoretically safer because the
needle tip is kept at a greater distance from intraorbital structures
and the brain. This is an extraconal is placed further from the optic    Induction:
nerve and other orbital nerves requires larger volume of LA and
has longer latency of onset. Can take as long as 10-20 minutes
where the retrobulbar blocks onset is within 2 minutes.

TOPICAL ANESTHESIA
                                                                         Maintenance:
Lowered risk of bleeding
Can be done in patients on anticoagulants

                                                                         Emergence:
Premed: Versed 1-2 mg.
Induction: Fentanyl 50-100 mcg as tolerated
Maintenance:
Emergence:



Skills Performed during CASE:             Circle All that Apply

Preop Evaluation          Pacu Report Charting                IV Start     Administer Drugs          Intubation       Extubation
SAB Epidural              Peripheral Nerve Block              LMA          Fast Track                Fiberoptic       Arterial Line
CVP     Swan              Post Op Visit


ANESTHETIC CONSIDERATIONS                                                     PEARLS:
                                                                              “five and dime reflex” 5th (trigeminal nerve) and the
    1. Monitor resp status closely. Do not want to over                       10th (vagus nerve) are primarily responsible.
       sedate and lose the airway                                             The oculocardiac reflex (Barash p. 908) is a
    2. Always provide continuous EKG monitoring                               bradycardia or arrhythmia in response to traction on
    3. Avoid acidosis, hypoxia, hypercarbia                                   the extraocular muscles or other stimulus on the eye.
    4. Ensure adequate depth of anesthesia                                    It may occur immediately or 1-1.5 hrs. after a
    5. IF OCR persists administer IV atropine .007mg/kg                       retrobulbar block.
       given in increments.                                                   May occur during local or general anesthesia
                                                                  **Afferent pathway is the ciliary branch of the
Factors that may increase intraocular pressure                    ophthalmic division of the trigeminal nerve.
                                                                  ***Efferent impulses leave the brain stem by way of
   •   HTN, hypercarbia, laryngospasm, intubation.                the vagus nerve.
   •   Venous congestion, vomiting, coughing, straining
   •   Succs, ketamine
                                                                  Manifested by:
COMPLICATIONS OF NEEDLE BASED BLOCKS
  1. Bleeding may be superficial, deep, venous or arterial           •   Sinus bradycardia (most common)
  2. superficial hemorrhage may result in a circumorbital            •   Ectopic beats
     hematoma                                                        •   Junctional rhythm
  3. Arterial retrobulbar may result in bleeding and a               •   Ventricular bgeminy
     dramatic increase in intraocular pressure, globe                •   PVC’s
     Proptosis and upper lid entrapment.                             •   Arrhythmias generally persist as long as the
  4. Globe penetration with intraocular injection results in             stimulation is present
     loss of vision from retinal detachment
  5. Orbital epidural anesthesia                                  Management
  6. Extraocular muscle injury leading to postop                  Stop maneuver
     strabismus, diplopia                                         Observe
  7. Intra-arterial injection producing immediate                 Dependent on severity of reaction
     convulsions  neurocardiopulmonary compromise.               Tachyphylaxis- subsequent stimulation tends to elicit
     LA flows from the needle via a branch of the                 a diminished response.
     opthalalmic artery in retrograde fashion to the              Is triggered by traction on the extraocular muscles,
     internal carotid and then to the circle of Willis. Is less   direct pressure on the globe, ocular manipulation or
     common with Peribulbar than retrobulbar block.               ocular pain. The use of retrobulbar block may
  8. Central retinal artery occlusion                             trigger the OCR but it also may prevent arrhythmias
  9. Inadvertent brainstem anesthesia. Is a consequence of        by blocking the afferent lim of the reflex.
     direct spread of LA to the brain along the meningeal
     sheath surrounding the optic nerve. Symptoms are             Oculogastric Reflex
     not always immediate.
                                                                  Suspected reflex only
   ANESTHESIA AND GERIATRICS                                      May explain high incidence of PONV
                                                                  Especially in strabismus surgery
        In absence of coexisting disease  resting                  • Intraocular pressure – normal is 10 - 22 mm
         cardiac function appears to be preserved, even in               Hg, determined by the rate of production of
         octogenarians.                                                  aqueous humor in relation to the rate of
        Increased vagal tone and decreased sensitivity of               drainage.
         receptors lead to a decline in heart rate.

        High incidence of diastolic dysfunction detected
         by Doppler echo.
        Diminished cardiac reserve is manifested by
         exaggerated drop in BP during induction of GA.
        Prolonged circulation time exhibits a delay of
         onset of IV drugs but speed induction of
         inhalation agents
        Elasticity in lungs is decreased. Allows for
         overdistention of alveoli and collapse of small
         airways. This increases the residual volume and
         the closing capacity.

        Decreased response to beta blockers
         (“ENDOGENOUS BETA-BLOCKADE)
 Impairment of sodium handling, concentrating
  ability and diluting capacity; this predisposes the
  elder to dehydration or fluid overload.
 Decline in renal function and thus a decrease in
  the kidneys ability to excrete drugs.
 Hepatic function (RESERVES) declines in
  proportion to the decrease in liver mass.
 ANESTHETIC RISK CORRELATES MUCH
  BETTER WITH PRESENCE OF COEXISTING
  DISEASE THAN CHRONOLOGICAL AGE
 Dosage requirements for local and general
  anesthetics are reduced.
 Administration of given volume of epidural
  anesthetics tend s to result in more extensive
  cephalad spread in elderly patients but shorter
  duration of anesthesia and motor.
 Longer duration of action from spinal anesthesia.
 Principal pharmcodynamics change is a reduced
  anesthetic requirement represented by a lower
  MAC. Need careful titration to avoid adverse side
  effects and prolonged duration.
 MAC FOR INHALATION AL AGENTS
  REDUCED BY 4% PER DECADE OF AGE
  OVER 40 YEARS
 Onset of action is more rapid because of reduced
  cardiac output but is delayed if significant VQ
  abnormality exists.
 Myocardial depressant effects of volatile
  anesthetics are exaggerated in elderly patients
  whereas tachycardic tendencies of Iso and Des
  are attenuated
 Isoflurane reduces cardiac output and heart rate
  in elderly patents
 Prolonged recovery from volatile anesthetics
  related to increased volume of distribution,
  decreased hepatic function and decreased
  pulmonary gas exchange.
 Rapid elimination of Des may make it the
  inhalation of choice for elders.
 Progressive decrease in muscle mass and increase
  in body fate  decreased total body water 
  REDUCED VOLUME OF DISTRIBUTION
  FOR WATER-SOLUBLE DRUGS  increased
  plasma concentrations
      o Increased volume distribution for lipid-
          soluble drugs can lower their plasma
          concentration
      o Changes in volume of distribution affect
          the elimination half life; prolongs the rate
          of clearance.
      o Also affected by the decline in renal and
          liver function and altered plasma protein
          binding
     o RESPONSE TO SUCCINYLCHOLINE
        AND NONDEPOLARIZING AGENTS
        UNALTERED WITH AGING
     o Decreased cardiac output and slow muscle
        blood flow may cause up to a 2 fold
        prolongation in onset of neuromuscular
        blockade. Recovery is delayed for renal or
        liver clearance dependent medications.
 Lowered dose requirements of propofol,
  Etomidate, barbiturates, opioids and BZD’s
     o ENHANCED SENSITIVITY TO
        FENTANYL, ALFENTANIL, AND
        SUFENTANIL  PRIMARILY R/T
        PHARMACODYNAMICS

 SIMILARITIES B/W ELDERLY & INFANTS:

      o DECREASED ABILITY TO INCREASE
        HEART RATE IN RESPONSE TO
        HYPOVOLEMIA, HYPOTENSION, OR
        HYPOXIA

      o DECREASED LUNG COMPLIANCE


      o DECREASED ARTERIAL OXYGEN
        TENSION

      o IMPAIRED ABILITY TO COUGH


      o DECREASED RENAL TUBULAR
        FUNCTION

      o INCREASED SUSCEPTIBILITY TO
        HYPOTHERMIA

				
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