Transcript General Anesthesia - the California Ambulatory Surgery Association

Implementing a
Successful Sedation
Program
Elizabeth Wong, CRNA
(nurse anes-the-tist)
Learning Objectives
Define Anesthesia.
Summarize what are the stages of anesthesia
and how they differ from natural sleep.
Compare and contrast the 4 types of anesthesia.
Explain the components of the anesthesia
continuum and who or what can safely deliver
sedation.
Definition of
Anesthesia
 Anesthesia
is the partial or complete loss of
sensation, with or without loss of
consciousness, that occurs on a temporary
or permanent basis, as a result of disease,
injury, or due to the administration of an
anesthetic agent, usually by inhalation or
injection.

Taber’s Cyclopedic Medical Dictionary, 18th edition, 1997. F. A Davis Co.
Four Types of Anesthesia
Local
Anesthesia
Regional Anesthesia
Sedation
General Anesthesia
Local Anesthesia
 Local
anesthesia is
used to provide
loss of sensation to
an area or locale
of the body using
local anesthetics
such as lidocaine or
bupivacaine.
Regional Anesthesia
 Regional
anesthesia is used
to provide loss of
sensation to a large
section or region
of the body using
local anesthetics
such as lidocaine or
bupivacaine.
Types of Regional
Anesthesia
 Interscalene
Block (shoulder & arm)
 Axillary Block (elbow & lower arm)
 Bier Block (lower arm)
 Spinal Block (lower half of body)
 Epidural Block (thoracic & lumbar)
 Ankle Block
 Field Block (hernia repair or breast biopsy)
Conscious Sedation
 Sedation
refers to the
administration of
sedatives, hypnotics,
or narcotics in an
effort to produce
sedation (allay
nervous excitement),
amnesia, and/or
analgesia.
Methods for Conscious
Sedation
 Medications
for
sedation can be
administered via
the intravenous,
oral, or rectal
routes.
Who is a Candidate for
Sedation?
• Risk Classification (co-morbidities)
• NPO Status (fasting status)
• Type of Surgery they will undergo
Anesthesia Continuum
• Sedation occurs on
a
• continuum
General
Anesthesia
Deep Sedation
Moderate Sedation
Minimum Sedation
Awake
End Point
 The
end point of
the conscious
sedation continuum
is slurred speech
and nystagmus
(constant,
involuntary, jerky
movement of the
eyeball).
Courtesy: imagesmd.com
Indications for Sedation
Type
of surgery or procedure
Patient cooperation
Anxious patient
Can be given in combination
with local anesthesia or regional
anesthesia
Contraindications for Sedation
Patient
refusal
Uncooperative patient
Patient with communication
difficulties (hard of hearing,
deaf, language barriers)
Complications of Sedation
Allergic
reaction to medication
Seizures
Bradycardia
Cardiovascular collapse
Need to progress to general
anesthesia
General Anesthesia
 General
anesthesia
is the act of
complete loss of
consciousness and
loss of protective
airway reflexes
following the use of
anesthetics that
effect the brain.
General
Anesthesia
Deep Sedation
Moderate Sedation
Minimum Sedation
Awake
Important Considerations in Sedation
 Knowledge
of the depth of anesthesia
 Knowledge of the location of emergency
drugs, suction, oxygen
 Maintenance of NPO status
 Assist in the conversion of sedation to
general anesthesia
Natural Sleep
 Natural
sleep is a
condition that is
characterized by
willful loss of
consciousness that
is accompanied by
reduced cortical
and physical
activity.

Courtesy: auburn.edu
Natural Sleep versus General
Anesthesia

Sleep

Amnesia
Amnesia

Unconscious
Unsconscious

Spontaneous breath



General Anesthesia
+/-
Spon. Breathing
Relaxed muscles
Relaxed muscles
+/- self-maintained hemodynamics
Self-maintained
hemodynamics and airway Loss of airway reflexes
reflexes
Not arousable
Easily aroused
Early versus Modern Anesthesia
Balanced Anesthesia
Amnesia
Sedatives or General Anesthetics
Narcotics
Neuromuscular
Blocking Agents
Anesthesia Care Plan
Knowledge of the patient (preop eval)
• Knowledge of the surgeon
• Knowledge of the surgery
• Knowledge of nurse anesthesia
• Knowledge of the anesthetics
• _________________________
• Anesthesia Care Plan
Healthcare Professionals
That Provide Sedation or General
Anesthesia
Registered Nurses (Conscious Sedation only)
Certified Registered Nurse Anesthetists
(CRNAs)
Medical Doctors (MDs - Anesthesiologists)
Doctors of Osteopathy (DOs - Anesthesiologists)
Dental Anesthesiologists (dental offices only)
Propofol vs Midazolam Sedation
• Propofol for sedation during colonoscopy: A
survey of a Cochrane review. Vilmann et al.
•
Faster patient recovery, higher patient satisfaction, and unchanged
complication rate compared to traditional sedatives
• Propofol vs. traditional sedative agents for GI
endoscopy: a meta-analysis. Clinical Gastroenterology
and Hepatology. Qadeer et al.
•
Propofol has lower odds of cardiopulmonary complications compared
to traditional agents.
RN Administered Propofol Sedation
Physician
pressure
Surgery center/Office-based
practice wanting to save money
of anesthesia costs
Some insurers will not
reimburse MAC
Anesthesia provider shortage
NAPS...
The California BRN has not issued a declaratory or advisory statement on NAPS
Nurse Administered Propofol
Sedation
(NAPS)
 Propofol
is usually not part of conscious
sedation policy of hospitals.
 Administration of propofol is beyond most
Board of Nursing’s RN scope of practice.
 In most states Propofol is a drug
administered by trained anesthesia
providers only (recommended guideline by
manufacturers).
 There is no reversal agents for propofol.
NAPS Study
• Patient-controlled versus nurse-administered
sedation with propofol during colonoscopy. A
prospective randomized controlled trial. Heuss et al.
American Journal of Gastroenterology.
•
114 patients, 22-90 years old
•
visual analog scales followed patient anxiety, tolerability, pain, and
satisfaction
•
Conclusion: Higher doses of propofol given with higher associated
costs in PC. Greater patient and endoscopist satisfaction with
NAPS.
Computer Assisted Propofol Sedation
(CAPS) Type #1
March, 2008 -Ethicon
Endo-Surgery (a
subsidiary of J & J)
submitted an
application to the
FDA for approval of
Sedasys™
Computer Assisted Propofol Sedation
(CAPS) Type #2
June 2008 “McSleepy”
introduced by
researchers at
McGill
University
Studies
• CAPS sedation for upper endoscopy and
colonoscopy: a comparative multicenter
randomized study. Gastrointestinal Endoscopist. Pambianco et
al.
•
1000 patients were evaluated for oxygen desaturation, patient/clinician
satisfaction, level of sedation, and recovery time in endoscopist/nurse vs
CAPS.
•
Conclusion: Sedasys system could provide an effective alternative to
endoscopist/nurse
There is only one
standard of care for
anesthesia delivery
regardless of who (or
what) delivers it!!
T
Acknowledgement
• Sam Martinez, Administrator for Channel Islands
Surgery Center, for inviting me to present this
lecture at the annual CASA meeting!!
• Donna Funke, CRNA
•
California Association of Nurse Anesthetists
Board of Directors.