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. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 1. Terms  Bradycardia  Slow heart rate  Capnometry  Measure of expired carbon dioxide  Dysrhythmia  Abnormal, disturbed cardiac rhythm  Electrocardiography  Process of recording electrical activity of the heart

4. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 1. Terms  Exsanguination  To render bloodless  Intrathecally  Pertaining to within the spinal canal  Laryngospasm  Involuntary contraction of the larynx

5. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 1. Terms  Local anesthesia  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. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 1. Terms  Regional anesthesia  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. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2  Describe types of patient monitoring devices.  To describe, remember to  Define  Explain purpose  Provide additional detail

8. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. Electrocardiogram  Define  Instrument to record electrical activity of the heart  Purpose  Record heart rate and rhythm

9. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. 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. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. Pulse oximetry  Define  Noninvasive measure of the oxygen saturation of blood  Purpose  Assess respiratory function

11. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. Pulse oximetry  Detail:  Sensor probe is attached to a finger, toe, or earlobe

12. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. 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 (SpO 2 or SaO 2 )

13. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. 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. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. 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. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. 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. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. Thermometer  Define  Instrument to measure temperature  Purpose  Detect hypothermia and/or hyperthermia

17. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. 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. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. Thermometer  Detail:  Normal core temperature varies near 98° F (37° C)  Baseline measurement is obtained, and changes are monitored and assessed

19. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. Capnometry  Define  Measurement of carbon dioxide (CO 2 ) exhaled by the patient  Purpose  Assess respiratory function  Early detection of compromised ventilation or MH

20. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. Capnometry  Detail:  Adapter connected to the breathing circuit

21. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. Capnometry  Detail:  Tubing extends from the adapter to the analyzer  Expired CO 2 is measured and displayed as a continuous graph and in numerical value

22. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. BIS monitor  Define  Bispectral index monitor  Modified EEG  Purpose  Used to assess patient’s level of awareness

23. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. 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. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. Nerve stimulator  Define  Device that stimulates a nerve and measures response  Purpose  Assess neuromuscular function and blockade

25. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. Nerve stimulator  Detail:  A surface electrode or probe At ulnar or facial nerve At ulnar or facial nerve  TOF: 4/4 = no muscle relaxation 4/4 = no muscle relaxation 0/4 = full muscle relaxation 0/4 = full muscle relaxation

26. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. 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. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. 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. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 2. Advanced monitoring  Pulmonary artery line  Swan-Ganz catheter  Measures multiple types of pressure and cardiac output  Often used during Cardiac surgery Cardiac surgery Lung transplantation Lung transplantation Liver transplantation Liver transplantation

29. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 3  Compare and contrast local anesthesia, monitored anesthesia care, and regional anesthesia.

30. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. 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. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 3. C/C anesthesia  Local Injected at surgical site or placed topically Injected at surgical site or placed topically Interrupts pain message at nerve endings Interrupts pain message at nerve endings

32. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. 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. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 3. C/C anesthesia  Regional Injected at nerve plexus Injected at nerve plexus Blocks entire nerve bundle Blocks entire nerve bundle Motor and sensory Motor and sensory

34. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. 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. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. 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 Local has RN monitor

36. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 3. C/C anesthesia  How are local, MAC, and regional different?  Local and MAC have same administration routes, regional routes are different

37. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 3. C/C anesthesia  How are local, MAC, and regional different?  When choosing MAC over local: Patient ASA status  = MAC Patient ASA status  = MAC  complex procedure = MAC  complex procedure = MAC

38. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. 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. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 4  List surgical procedures that may be performed under local or regional anesthesia.

40. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 4. List surgical proc  Local  Excision/biopsy soft tissue  Repair of finger laceration  Toenail excision  Septoplasty  Cystoscopy

41. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 4. List surgical proc  Local with MAC  Insertion of  Transvenous pacemaker  Venous access port/catheter  Dialysis access graft

42. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 4. List surgical proc  Regional: Spinal  TURP/bladder tumors  Embolectomy  Total knee arthroplasty  Cesarean section

43. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. 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. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. 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. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 4. List surgical proc  Regional: Retrobulbar block  Ophthalmology procedures  Cataract extraction  Less common now  More are being done under local/MAC

46. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. 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. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 5  Identify common agents used in local anesthesia and regional anesthesia.

48. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 5. Common agents  lidocaine  (Xylocaine)

49. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 5. Common agents  Bupivicaine  (Marcaine, Sensorcaine)  Mepivacaine  (Carbocaine, Polocaine)

50. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 6  Discuss the use of epinephrine in local anesthetic agents.

51. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. 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. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. 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. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7  Describe types of regional blocks.

54. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Regional note Regional anesthesia provides both sensory and motor block.

55. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Types of regional  Spinal  Injected into subarachnoid space

56. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Types of regional  Spinal  Anesthetizes entire lower body  Positioning (various)

57. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Types of regional  Spinal  Positioning (various)

58. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Types of regional  Epidural  Injected outside dura (upon)

59. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. 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. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Types of regional  Caudal  Injected epidural space; sacrum  Labor and delivery

61. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Types of regional  Retrobulbar  Injected behind eye, into muscle cone, around optic nerve

62. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Types of regional  Retrobulbar  Cataract extraction  Being replaced with topical MAC

63. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Types of regional  Extremity block  Arm Axillary (brachial) Axillary (brachial) Median, radial, ulnar Median, radial, ulnar Bier block (IV regional) Bier block (IV regional)

64. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Types of regional  Extremity block  Leg Femoral (most common) Femoral (most common) Obturator Obturator Tibial Tibial

65. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Types of regional  Extremity block  Digital Finger Finger Toe Toe

66. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Types of regional  Extremity block: discussion  Injected at a plexus of nerves  Applications   risk of complications w/ general  Extremity procedures

67. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Types of regional  Bier block (IV) discussion  Insert IV, exsanguinate arm

68. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. Objective 7. Types of regional  Bier block (IV) discussion  Tourniquet   Agent injected IV  Applications  Extremity procedures

69. Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc. In summary  All patients are monitored during anesthesia  Various methods are used  ST handles local agents on back table  Understand epinephrine