Objective and Management of OT VII

Types and route of anesthesia

Anesthesia is a condition of partial or complete loss of feeling with or without loss of consciousness that is medically induced. In the course of surgery or another medical operation, anesthesia manages discomfort. When necessary, it can also assist in controlling respiration, blood pressure, heart rate, and rhythm.

Types

• General anesthesia
  • A gaseous or injectable anesthetic is used to sedate the patient, who has muscle paralysis and needs mechanical ventilation to control breathing.

• Regional anesthesia
  • This can be described as central where anesthetic drugs are a cord, blocking the nerves of the spinal cord. The Main of this method in that ventilation is not needed. It can also be peripheral such as:
  • Plexus blocks 
    • e.g. brachial plexus
  • Nerve block 
    • e.g. femoral
  • Intravenous block
    • e.g. Bier’s block
• Local anesthesia
  • The anesthetic is applied to one site, usually topically or subcutaneously. Drugs used for local anesthesia are:
  • Procaine 1-2%solution
    • used for injection
  • Lignocaine 0.5-2%
    • injection and topical application
  • Benzocaine 5%
    • used as an ointment on painful wounds, skin ulcers, mucous membrane.

Stages of anesthesia

• Stages 1 
  • The time between the first dose of the induction agents and consciousness losses is sometimes referred to as the induction period. The patient moves from analgesia without amnesia to analgesia with amnesia at this stage. A patient may now engage in conversation.
• Stage 2 anesthesias
  • The phase immediately after losing consciousness, also referred to as the excitement stage, is characterized by delirious and enthusiastic behavior. Respiration and heart rate may be erratic at this point. Additionally, uncontrollable movements, vomiting, breath holding, and uneven respiration may endanger the airway. Rapidly acting medicines are utilized to reduce the amount of time in this stage and advance as quickly as possible to stage 3.
• Stage 3 anesthesia
  • The phase immediately after losing consciousness, also referred to as the excitement stage, is characterized by delirious and enthusiastic behavior. Respiration and heart rate may be erratic at this point. Additionally, uncontrollable movements, vomiting, breath holding, and uneven respiration may endanger the airway. Rapidly acting medicines are utilized to reduce the amount of time in this stage and advance as quickly as possible to stage 3.
    • Rolling eyeballs, ending with fixed eyeballs.
    • Loss of corneal and laryngeal reflexes
    • Pupils dilates and loss of light reflex
    • Intercostals paralysis, shallow abdominal respiration, dilated pupils
• Stage 4 anesthesia
  • When a patient receives an excessive amount of medication in comparison to the level of surgical stimulation and develops severe brain stem or medullary depression, this condition is also referred to as an overdose. As a result, breathing stops and a cardiovascular collapse may occur. Without support for the cardiovascular and respiratory systems, this stage is fatal.

Types of anesthetic agent

• Inhalation anesthetics
  which are substances that enter the body through the lungs and are transported by the blood tissues. They are also known as volatile anesthetics. In modern clinical practice, inhalation anesthetics are used more frequently in conjunction with intravenous anesthetics and less frequently on their own. The most often used inhalation anesthetics are as follows:
  • Halothane typically administered along with analgesics induces unconsciousness but offers minimal pain relief. Adults may develop liver toxicity from it.
  • Enflurane has a lower potency but causes anesthesia to start working quickly, and it may also hasten recovery. Patients with renal failure cannot take enflurane.
  • Although isoflurane does not harm the liver, it can cause abnormal cardiac rhythms.
  • To induce surgical anesthetic, nitrous oxide (laughing gas) is combined with other such medications like thiopental. Its induction and recovery times are the quickest.
  • Since sevoflurane does not irritate the airway, it can be delivered using a mask and begins to work quickly.
  • Desflurane, a second-generation isoflurane alternative, irritates the airway and cannot be utilized for mask induction, particularly in young patients.
• Intravenous anesthesia
  Ketamine, thiopental, methohexital, etomidate, and propofol are examples of commonly used intravenous general anesthetics.

Effects of anesthesia

Effects on respiratory system

• Following surgery, pneumonia can develop due to aspiration, infection, and a suppressed cough reflex.
• Chest pain, a high body temperature, and the flu-like symptoms of pneumonia are frequent signs and symptoms.

Effects on the cardiovascular system

• The possibility of unstable blood pressure is increased by the possibility that anesthesia will alter cardiac output.

Effects on urinary system:

• Urinary retention may result from anesthesia.
• Dehydration can result from less fluid consumption.
• Watch the drainage if a catheter is in place.

Effects on gastrointestinal system

• Constipation and abdominal distension come from anesthesia's slowing or stopping of the intestine's peristaltic movement.
• A fluid imbalance brought on by anesthesia may also result in nausea and vomiting.
• Check for abdominal distension in the patient.

Complications of anesthesia

Anaphylaxis

• Any anesthetic agent and all forms of anesthesia are susceptible to it.
• Rashes, urticaria, hypotension, angioedema, and vomiting are just a few possible symptoms, depending on how severe the reaction is.
• Patients who appear to be having an allergic reaction should be referred for additional testing to attempt and pinpoint the precise cause.

Aspiration pneumonitis

• A compromised degree of consciousness may result in an open airway.
• The patient may aspirate the vomitus into their lungs if they vomit. This may lead to infection and lung irritation.

Peripheral nerve damage

• This can happen with any anesthetic type and causes nerve compression.
• Exaggerated positioning for extended periods of time is the main culprit.
• The ulnar and common peroneal nerves are the most often impacted nerves.

Damage to teeth

• It is the most frequent reason for complaints expressed about anesthetics.
• The upper left incisor is the tooth that is most frequently impacted.

Embolism

• Although it is uncommon during anesthesia, it can be lethal.
• It usually happens during pelvic surgery or neurosurgery treatments.

Some specific complication of regional anesthesia

Post-dural puncture headache

• It happens frequently during spinal anesthesia, especially in young individuals and during childbirth.
• The headache is a result of CSF leakage from the wound. The use of larger gauze needles improves it, while pencil-tipped needles have a negative impact.
• Headache, photophobia, nausea, and dizziness are among possible symptoms.

Total spinal block

• When several anesthetic drugs are injected into the spinal cord, it is possible for it to happen.
• A high sensory sensitivity and quick muscle paralysis are indicators of its presence.

Hypotension

• This typically responds to prompt fluid replacement, typically beginning with crystalloids and moving on to collides.
• Patients who have had a cardiac history require special attention because even small blood pressure drops can cause myocardial ischemia.

Neurological deficits

• A patient will frequently object to spinal anesthesia for this reason.
• The spinal cord could sustain a traumatic injury as well.

Important complication of local anesthesia

• Pain
• Bleeding and hematoma formation
• Nerve injury due to direct injury
• Infection
• Ischaemic necrosis
• Cardiac arrest/ arrhythmias
• Diminished circulation
• Respiratory depression
• Vomiting aspiration
• Hypotension
• Postoperative headache
• Hallucination
• Loss of response to pain

Nursing care of anesthetic patient

• Keep track of the patient's heart rate, ECG, and SPO2 to continuously measure the blood's oxygen content.
• Regularly check and properly record vital indicators, such as blood pressure, heart rate, and respiration rate.
• While keeping an eye on the patient's state of awareness, administer oxygen therapy.
• Maintain airway by, for example, positioning the patient and, if necessary, suctioning. To avoid aspiration following general anesthesia, keep to the side.
• Patients' bodies are kept warm and at a constant temperature. Take your temperature frequently to check for fever or hypothermia.
• Examine the patient for allergies and other conditions that might develop after the anesthetic medication has taken effect.
• Ensures that the oxygen emergency resuscitation equipment is available and functioning properly.
• During induction anesthesia, keep the area quiet and peaceful.
• During this time, the client should be protected from mechanical and thermal harm because their sensory awareness is impaired.
• To prevent a severe headache following spinal anesthetic, keep the client flat for a set amount of time—typically 12 hours—avoid using pillows, and keep an eye on their blood pressure.
• Use safety precautions, maintain bed rest until lower extremity motor and sensory function returns following spinal anesthesia, and closely follow input and output chart maintenance.
• After 12 hours of general anesthesia and when the capacity to swallow has returned, oral intake is typically administered.
• Keep the side rails up to prevent falls and never leave the patient alone.
• Keep a record and report the anesthetic kind used.
• Keep an eye out for the anesthetic agent's adverse effects and problems.
• After surgery, the patient should be transferred safely.

Assessment of physical and mental status of patient

Before surgery, it is important to assess the patient's physical and mental health. A client should be physically prepared for surgery as soon as they are mentally. In order to prepare the client both physically and mentally, nurses must do the following:

• Psychological preparation
  • Accept the patient politely and maintain a positive relationship with them.
  • If the patient has any misconceptions, clear them up and keep providing emotional support.
  • Be respectful to the patient's beliefs, culture, and religion.
  • Adescription of the operation process and standard preparation steps.
  • Help with any domestic problems
  • Arrange visitors.
• Physical preparation
  • Preparation of the skin
    Preoperative care aims to reduce bacteria without endangering the skin. If the surgery is not an emergency, the patient might be told to clean their skin region with soap that contains a detergent-germicide for a few days prior to surgery to lessen the amount of skin organisms. This preparation could be done at home.
  • Pre-operation of GI tract
    The night before surgery, the GI system requires particular preparation.
    • lessen the chance of aspiration, intestinal blockage, and vomiting.
    • to provide bowel/intestine vision during bowel surgery
    • to avoid fecal contamination during bowel or abdominal surgery due to fecal debris in the gut.
    • Eight to ten hours before to surgery, no food should be consumed.
  • Managing nutrition and fluids
    • Withholding food and liquids prior to surgery is mostly done to avoid aspiration. Adults are advised to fast 8 hours following the consumption of fatty foods and 4 hours following the consumption of milk products.
  • Administering pre-anaesthetic medication
    • If preoperative medicine is given, the patient should be kept in bed with the side rails lifted since it may make them dizzy or sleepy.
  • Maintaining the preoperative records
    • Important items that must be checked before surgery are listed on a preoperative checklist.
  • Transporting the patient to the presurgical area
    • About 30 to 60 minutes prior to the scheduled anesthesia, the patient is moved to the holding area or presurgical suite in a bed or on a stretcher.
    • Usually, a tiny head cushion is included.
    • To ensure that the preoperative drug has the greatest possible impact, the surrounding area should be kept quiet.
    • Priority one in the preoperative setting is patient safety.
• Psychological preparation of patient for surgery
  • The night before surgery, patients should take a shower or a bath using soap and water.
  • Only necessary medications should be administered during surgery, and those taken orally should be ingested with the least quantity of water possible; reviewing prescribed medications prior to surgery;
  • When the patient is ready for the theater, drowsy-inducing medications should be given, and the patient should be told to stay on the bed with a call bell;
  • On the day of operation, hair around the incision site should be cut, if necessary, with electric clippers equipped with disposable, single-use heads;
  • When patients are getting dressed for the theater, their comfort and dignity should be preserved;
  • Patients may wear pants depending on the procedure, although ladies should be requested to take their bras off before operation;
  • Depending on the risk of VTE, anti-embolism stockings should be measured and fitted either at check-in or right before transfer to the theater;
  • When possible, jewelry should be taken off, although depending on local regulations, tape may be used to cover difficult-to-remove jewelry;
  • Hearing aids and dentures should be taken out; some patients may prefer to do this in the anesthesia room; these items should then be brought to the recovery area, where they should be labeled and stored;
  • To avoid choking while under anesthesia, loose teeth, caps, or crowns should be detected;
  • Patients' wristband information should be compared to patient records, medication records, X-rays, and test findings;
  • Recording vital signs and reporting unusual readings are necessary;
  • Allergies ought to be recorded;
  • Prior to patients entering a theater or receiving premedication, the location of the procedure should be noted on the ward or day unit. When filling out the pre-operative checklist in the ward or day unit, the nurse should check this;
  • According to Department of Health (2009) recommendations, consent should have been obtained and verified right before operation. This entails making sure patients comprehend the process and are willing to move through with it. A person's age and mental capacity will determine how consent is obtained and validated.

• Physical preparation of skin for various operations
                     Preoperative care aims to reduce bacteria without endangering the skin. If the surgery is not an emergency, the patient might be told to use soap with a detergent-germicide to clean the skin area for a few days prior to surgery in                           order to lessen the amount of skin organisms. This preparation could be done at home.
  • In most cases, hair at or around the incision site is not removed prior to surgery unless it is likely to interfere with the procedure. Electric clippers are utilized for safe hair removals right before surgery if the hair needs to be removed.
  • Describe the washing and bathing procedures to follow the night before a surgery.
  • The night before surgery, the surgical site is typically cleansed with soap and water or an antibacterial treatment to lessen the amount of microorganisms on the skin.

Taking consent for operation preoperative counseling

At the time of admission, informed consent should be given; if this is not possible, the nurse should inform the surgeon or anesthesiologist. It should be simple and clear how you gave your informed permission. Before the patient is sedated, a signature is obtained with their full understanding of what will happen, and it is then securely taken without applying pressure.