1. Chapter 14 Patient Monitoring and Local and Regional Anesthesia
Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.

2. Objective 1
Define terminology related to patient monitoring and anesthesia.
ABG
Arterial blood gases
Auscultation
Listening to the sounds of the body, especially the heart and lungs

3. Objective 1. Terms Bradycardia Capnometry Dysrhythmia
Slow heart rate
Capnometry
Measure of expired carbon dioxide
Dysrhythmia
Abnormal, disturbed cardiac rhythm
Electrocardiography
Process of recording electrical activity of the heart

4. Objective 1. Terms Exsanguination Intrathecally Laryngospasm
To render bloodless
Intrathecally
Pertaining to within the spinal canal
Laryngospasm
Involuntary contraction of the larynx

5. Objective 1. Terms Local anesthesia Pulse oximetry
A method of anesthesia in which an agent is injected or applied topically to interrupt pain impulses at the nerve endings
Pulse oximetry
A measure of the oxygen saturation of the blood; also measures heart rate

6. Objective 1. Terms Regional anesthesia Vasoconstrictor
A method of anesthesia in which an agent is injected to block pain impulses at a nerve plexus; causes both pain and motor block
Vasoconstrictor
An agent that causes contraction (narrowing) of the walls of blood vessels

7. Objective 2 Describe types of patient monitoring devices.
To describe, remember to
Define
Explain purpose
Provide additional detail

8. Objective 2. Electrocardiogram
Define
Instrument to record electrical activity of the heart
Purpose
Record heart rate and rhythm

9. Objective 2. Electrocardiogram
Detail:
Electrodes placed on the patient
Attached to leads, which transmit impulses to the ECG device
Impulses recorded and displayed on a screen
May be set to record a tracing on paper and/or emit an audible signal to indicate heart rate

10. Objective 2. Pulse oximetry
Define
Noninvasive measure of the oxygen saturation of blood
Purpose
Assess respiratory function

11. Objective 2. Pulse oximetry
Detail:
Sensor probe is attached to a finger, toe, or earlobe

12. Objective 2. Pulse oximetry
Detail:
Emits red and infrared light, which is absorbed while passing through tissue
Remaining light is detected by the opposite side of the sensor probe
Used to calculate the saturation of peripheral oxygen (SpO2 or SaO2)

13. Objective 2. Pulse oximetry
Detail:
Saturation should be above 95%
An audible signal reflects pulse rate
Signal tone indicates saturation
Deeper the tone, the lower the saturation
Readings may be affected by various factors

14. Objective 2. Blood pressure
Device is called a
Sphygmomanometer
Define
Measure of the force of blood against the vessel walls
Purpose
Monitor cardiovascular status

15. Objective 2. Blood pressure
Detail:
“Normal” adult < 130 mm Hg systolic and < 85 mm Hg diastolic
Multiple variables affect BP
Inflatable cuff on patient’s upper arm connected to unit
Device automatically measures BP at set intervals
Can be set to emit an audible alarm if BP not within preset limits

16. Objective 2. Thermometer
Define
Instrument to measure temperature
Purpose
Detect hypothermia and/or hyperthermia

17. Objective 2. Thermometer
Detail:
Pediatric and geriatric patients are most at risk for hypothermia
Used to check effectiveness of heat loss prevention measures
May be monitored at skin, axilla, bladder, esophagus, or ear

18. Objective 2. Thermometer
Detail:
Normal core temperature varies near 98° F (37° C)
Baseline measurement is obtained, and changes are monitored and assessed

19. Objective 2. Capnometry Define Purpose
Measurement of carbon dioxide (CO2) exhaled by the patient
Purpose
Assess respiratory function
Early detection of compromised ventilation or MH

20. Objective 2. Capnometry Detail:
Adapter connected to the breathing circuit

21. Objective 2. Capnometry Detail:
Tubing extends from the adapter to the analyzer
Expired CO2 is measured and displayed as a continuous graph and in numerical value

22. Objective 2. BIS monitor Define Purpose Bispectral index monitor
Modified EEG
Purpose
Used to assess patient’s level of awareness

23. Objective 2. BIS monitor Detail:
Sensor placed on the patient’s forehead
Interprets and displays a reading between 0 and 100
Near 100 = patient is fully awake
Less than 60 = appropriate depth of general anesthesia with a low probability of explicit recall

24. Objective 2. Nerve stimulator
Define
Device that stimulates a nerve and measures response
Purpose
Assess neuromuscular function and blockade

25. Objective 2. Nerve stimulator
Detail:
A surface electrode or probe
At ulnar or facial nerve
TOF:
4/4 = no muscle relaxation
0/4 = full muscle relaxation

26. Objective 2. Advanced monitoring
Arterial lines used for:
Potential for rapid changes in blood pressure
Frequent sampling for ABGs
Or when routine BP measurement is inaccurate

27. Objective 2. Advanced monitoring
CVP lines
Placed in vena cava
Assess volume of blood returning to the heart
Used to assess the need for fluid replacement and to prevent fluid overload

28. Objective 2. Advanced monitoring
Pulmonary artery line
Swan-Ganz catheter
Measures multiple types of pressure and cardiac output
Often used during
Cardiac surgery
Lung transplantation
Liver transplantation

29. Objective 3
Compare and contrast local anesthesia, monitored anesthesia care, and regional anesthesia.

30. Objective 3. C/C anesthesia
Define each type
Explain how the types are similar
Explain how the types are different
Give examples as needed

31. Objective 3. C/C anesthesia
Local
Injected at surgical site or placed topically
Interrupts pain message at nerve endings

32. Objective 3. C/C anesthesia
(Local with) MAC
Monitored anesthesia care
Same mechanism as local
Anesthesia provider is present for advanced monitoring and medications PRN

33. Objective 3. C/C anesthesia
Regional
Injected at nerve plexus
Blocks entire nerve bundle
Motor and sensory

34. Objective 3. C/C anesthesia
How are local, MAC, and regional alike?
Same agents
Same vital signs monitored
Sedatives may be given IV
Patient remains awake

35. Objective 3. C/C anesthesia
How are local, MAC, and regional different?
Different surgical applications
MAC and regional have an anesthesia provider present
Local has RN monitor

36. Objective 3. C/C anesthesia
How are local, MAC, and regional different?
Local and MAC have same administration routes, regional routes are different

37. Objective 3. C/C anesthesia
How are local, MAC, and regional different?
When choosing MAC over local:
Patient ASA status  = MAC
 complex procedure = MAC

38. Objective 3. C/C anesthesia
How are local, MAC, and regional different?
Regional is used when both sensory and motor block is necessary for surgical procedure

39. Objective 4
List surgical procedures that may be performed under local or regional anesthesia.

40. Objective 4. List surgical proc
Local
Excision/biopsy soft tissue
Repair of finger laceration
Toenail excision
Septoplasty
Cystoscopy

41. Objective 4. List surgical proc
Local with MAC
Insertion of
Transvenous pacemaker
Venous access port/catheter
Dialysis access graft

42. Objective 4. List surgical proc
Regional: Spinal
TURP/bladder tumors
Embolectomy
Total knee arthroplasty
Cesarean section

43. Objective 4. List surgical proc
Regional: Epidural
Relieve pain of labor/delivery
Cesarean section
Adjunct to general (rare)
Post-op pain control for thoracotomy

44. Objective 4. List surgical proc
Regional: Caudal block
Vaginal childbirth (in OB)
With general anesthesia for lower-extremity procedures in children
For post-op pain management

45. Objective 4. List surgical proc
Regional: Retrobulbar block
Ophthalmology procedures
Cataract extraction
Less common now
More are being done under local/MAC

46. Objective 4. List surgical proc
Regional: Extremity block
Varies by type/location of block
Closed reduction/casting
Carpal tunnel, trigger finger, or Dupuytren’s contracture

47. Objective 5
Identify common agents used in local anesthesia and regional anesthesia.

48. Objective 5. Common agents
lidocaine
(Xylocaine)

49. Objective 5. Common agents
Bupivicaine
(Marcaine, Sensorcaine)
Mepivacaine
(Carbocaine, Polocaine)

50. Objective 6
Discuss the use of epinephrine in local anesthetic agents.

51. Objective 6. Use of epi in local
Local anesthetics may be combined with dilute epinephrine
1:100,000 or 1:200,000
Causes local vasoconstriction slowing the absorption of the agent into the circulatory system
Keeps the local agent at surgical site longer,  duration of effect

52. Objective 6. Use of epi in local
Use utmost caution because
Epinephrine also available in dose of 1:1000
100 or 200 times more potent
Intended for topical application, not injection
Patient deaths have occurred

53. Objective 7
Describe types of regional blocks.

54. Regional note
Regional anesthesia provides both sensory and motor block.

55. Objective 7. Types of regional
Spinal
Injected into subarachnoid space

56. Objective 7. Types of regional
Spinal
Anesthetizes entire lower body
Positioning (various)

57. Objective 7. Types of regional
Spinal
Positioning (various)

58. Objective 7. Types of regional
Epidural
Injected outside dura (upon)

59. Objective 7. Types of regional
Epidural
Anesthetizes entire lower body
Positioning (various)
Labor and delivery
Cesarean section
Adjunct to general
Post-op pain control

60. Objective 7. Types of regional
Caudal
Injected epidural space; sacrum
Labor and delivery

61. Objective 7. Types of regional
Retrobulbar
Injected behind eye, into muscle cone, around optic nerve

62. Objective 7. Types of regional
Retrobulbar
Cataract extraction
Being replaced with topical MAC

63. Objective 7. Types of regional
Extremity block
Arm
Axillary (brachial)
Median, radial, ulnar
Bier block (IV regional)

64. Objective 7. Types of regional
Extremity block
Leg
Femoral (most common)
Obturator
Tibial

65. Objective 7. Types of regional
Extremity block
Digital
Finger
Toe

66. Objective 7. Types of regional
Extremity block: discussion
Injected at a plexus of nerves
Applications
 risk of complications w/ general
Extremity procedures

67. Objective 7. Types of regional
Bier block (IV) discussion
Insert IV, exsanguinate arm

68. Objective 7. Types of regional
Bier block (IV) discussion
Tourniquet 
Agent injected IV
Applications
Extremity procedures

69. In summary All patients are monitored during anesthesia
Various methods are used
ST handles local agents on back table
Understand epinephrine