Foundations I

1. Foundations I Krista Yoder, CRNA MSN January 13, 2009

2. Code of Ethics for the CRNA Responsibility to Patients Competence Responsibilities as a Profession Responsibility to Society Endorsement of Products and Services Research Business Practices

3. AANA Position Statement on Substance Misuse and Chemical Dependency Wearing Masks III

4. Signs of Addiction Watch for any pattern or cluster of these: Unexpected professional behavior Isolates or withdraws from peers Decreased performance Often late Diverting drugs Mood alterations (unexplained anger) Increased irritability Overreacts to criticism Charting irregularities Wearing long sleeves all the time Missing in action

5. Signs of Addiction Watch for any pattern or cluster of these: Frequent home crisis Unusual orders from pharmacy Frequent bathroom breaks Dilated or constricted pupils Forgetful, unpredictable Nodding off during a case Signs up for frequent extra call Slurred speech Tremors, shakes Dangerous to leave alone on case Increasing difficulty with peers, supervisors and/or authority Pocketing drugs

6. Scope and Standards for Nurse Anesthesia Practice Scope of Practice Guidelines for Core Clinical Privileges Standards for Nurse Anesthesia Practice Standard I � Preanesthesia Assessment Standard II � Informed Consent Standard III � Patient Specific Plan Standard IV � Implement and Adjust Plan Standard V - Monitoring

7. Scope and Standards for Nurse Anesthesia Practice Standards for Nurse Anesthesia Practice Standard VI � Documentation on the patient�s Medical Record Standard VII � Transfer of Care Standard VIII � Patient Safety Standard IX � Infection Control Standard X � Quality Standard XI - Patient Rights

8. Standards for Nurse Anesthesia PracticeStandard I - Perform a thorough and complete preanesthesia assessment. Interpretation The responsibility for the care of the patient begins with the pre-anesthetic assessment. Except in emergency situations, the CRNA has an obligation to complete a thorough evaluation and determine that relevant tests have been obtained and reviewed.

9. Preanesthesia Assessment: Become familiar with the present surgical illness Identify co-existing medical conditions Establish a CRNA-patient relationship Develop anesthetic management plan

10. Preanesthesia Assessment Review of systems Current diagnosis Pertinent lab data Pertinent physical examination findings Allergies/sensitivities Airway Assessment Surgical/anesthesia history Medication history Social history Family problems with anesthesia Other

11. Review of Systems Use what you already know Texts for Foundations I AANA Pre-Anesthesia Questionnaire

12. Patient History: General state of well-being Daily activity level The patient�s understanding of: Medical condition Coexisting medical conditions Present surgical condition Review of old records

13. Present Surgical Illness: Diagnostic studies Presumptive diagnosis Treatments Responses to treatments Review available vital sign data Review available fluid balance data

14. Coexisting medical conditions: Potential to complicate anesthetic Evaluate in a systems approach Assess recent changes in symptoms Assess current treatment regimens Specialty consultation when needed

15. Medications: Review medications, doses, schedules Cardiac Seizure Endocrine Anticoagulants Antidepressants Decision to continue/discontinue

16. Allergies and drug reactions: True allergic reactions Non-allergic responses Adverse reactions Side effects Drug-drug interactions

17. True Allergic Reactions: Antibiotics Induction agents Propofol Rocuronium Shellfish and seafood Cross reaction with IV contrast dye Protamine Reported allergy to anesthesia Malignant Hyperthermia Halogenated agents Anectine/succinylcholine Atypical Pseudocholinesterase

18. Rare anesthesia drug interactions: Pentothal � acute intermittent porphyria Demerol � hypertensive crisis if patient on MOA.

19. Difficulty with prior anesthetics: �Has anyone in your family experienced unusual or serious reactions to anesthesia?� Malignant hyperthermia Previous history of difficulty under anesthesia Difficult Intubation Significant PONV Review available old records

20. Social History: Smoking Alcohol Recreational drug use

21. Smoking: Productive Cough Hemoptysis How many pack years? Eliminate cigarette use for 2-4 weeks prior to elective surgery to reduce complications Assess need for further pulmonary evaluation

22. Alcohol: Self-reporting of use typically underestimates actual use Acute intoxication Lowers anesthetic requirements Predisposes to hypothermia and hypoglycemia Withdrawal Increase anesthetic requirements Hypertension Tremors Delirium Seizures

23. Recreational drugs: Self-reporting typically underestimates actual use Define types, routes, frequency, last used Stimulant abuse Palpitations True angina Lowered threshold for serious arrhythmia Convulsions

24. Routine use of narcotics/benzodiazepines (whether prescribed or illegal) may significantly increase the dose required to induce anesthesia or maintain anesthesia. Routine use of recreational drugs will impact post-op pain requirements.

25. Review of Systems: (continued) Respiratory Asthma Recent history of URI

26. Review of systems: (continued) Cardiac HTN If associated with LVH greater risk for perioperative MI, CVA Diuretic use � hypovolemia, electrolyte imbalance Angina/MI At risk for MI with stress of surgery and anesthesia Evaluate current cardiac status

27. Review of Systems: (continued) Gastro/intestinal GERD/ hiatal hernia Increased risk of pulmonary aspiration May consider Rapid Sequence Induction(RSI)

28. Review of Systems: (continued) Pregnancy All women of childbearing age should be questioned regarding last menses and the likelihood of current pregnancy. Anesthetic medications may adversely influence uteroplacental blood flow Anesthetics may be teratogenic

29. Physical Exam: Focused, yet thorough Direct attention to: Airway Heart Lungs Neuro

30. Physical Exam: (continued) Specific to Regional Anesthesia Detailed assessment of extremity Detailed assessment of back Infection History of injury Previous back surgery Chronic pain issues

31. Physical Exam: (continued) Baseline Vital Signs: Height and weight Blood pressure Resting pulse Respirations

32. Physical Exam: (continued) Airway assessment Size of oral opening and tongue Observe/document loose or chipped teeth, �caps�, dentures, other orthodontic devices, piercings Observe/document range of cervical motion in flexion, extension, and rotation Observe/document tracheal deviation, masses

33. Airway Assessment

35. The loose tooth

36. Piercings:

37. Normal Airway Anatomy

38. The larynx

44. Difficult airways

51. Physical Exam: (continued) Heart Murmur Pericardial rub

52. Physical Exam: (continued) Lungs Wheezes Rhonchi Rales Correlate what you hear with observation of how patient is breathing�. easy vs. labored Use of accessory muscles

53. Physical Exam: (continued) Abdomen Distention Ascites Predisposition to regurgitation Compromise ventilation

54. Physical Exam: (continued) Extremities Clubbing Cyanosis Cutaneous infection No IV cannulation No regional nerve block

55. Physical Exam: (continued) Neuro Document neuro status Cranial nerve function Cognition Peripheral sensorimotor function

56. Preoperative labs: Hematocrit and Hemoglobin Presurgical �Standard of Care� Hcts of 25-30% tolerated in healthy pt. May result in ischemia in pt. with history of CAD Evaluate each pt. individually for the etiology and duration of their anemia

57. Preoperative labs: Serum Chemistry Hypokalemia/hyperkalemia Coagulation Screen When indicated

58. EKG: All patients over 40 years old New Q waves ST-segment depression/elevation T-wave inversions Rhythm disturbances PVC�s A-fib, a-flutter LBBB 2nd or 3rd degree AV block

59. Chest x-ray: When clinically indicated History of heavy smoking Elderly History of major organ system disease

60. The CRNA-patient relationship:A stressful time for the patient - Surgery Cancer Pain Disability Death Anesthesia Loss of control Fear of not waking up PONV Pain

61. NPO status: Preop Fasting Guidelines Recommendations � for all age groups Ingested Material Fasting Period(hrs) Clear liquids 2 hrs Breast milk 4 hrs Infant formula 6 hrs Non-human milk 6 hrs Light solid foods 6 hrs

62. NPO guidelines: Clear liquids include; water, sugar water, apple juice, non-carbonated soda, pulp-free juices, clear tea, black coffee. Medications can be taken PO with up to 150ml of water in the hour preceding anesthesia induction. Recommendations apply to healthy patients, elective surgery. Following the recommendations does not guarantee that gastric emptying has occurred.

63. ASA Physical Status Classification ASA I � a normal healthy patient ASA II � a patient with mild systemic disease (mild diabetes, controlled HTN, obesity). ASA III � a patient with severe systemic disease that limits activity (COPD, angina, prior MI). ASA IV � a patient with an incapacitating disease that is a constant threat to life (CHF, renal failure). ASA V � a moribund patient not expected to survive 24 hours (ruptured AAA). ASA VI � brain dead patient whose organs are being harvested. �E� � for emergent operations add the letter E after the classification.

64. Standards for Nurse Anesthesia PracticeStandard II - Informed consent � Obtain informed consent for the planned anesthetic intervention from the patient and/or legal guardian. Interpretation � The CRNA shall obtain or verify that an informed consent has been obtained by a qualified provider. Discuss anesthetic options and risks with the patient and/or legal guardian in language the patient and/or guardian can understand. Document in the patient�s medical record that informed consent was obtained.

65. Informed Consent: The anesthetic plan, alternatives, and potential complications must be discussed in terms that are understandable to a layperson. Aspects of care outside of realm of common experience: Intubation Post op ventilation/ICU Invasive monitoring Regional anesthesia techniques Potential for blood product use

66. Informed Consent: Alternative plan Necessary if planned procedure fails or there is a change in clinical circumstance. Associated Risks Discuss in a manner that a reasonable person would find helpful in making a decision. Complications that occur with high frequency.

67. Informed Consent � Associated Risks General Anesthesia: Sore throat Hoarseness Nausea and vomiting Dental injury Allergic reactions Intraoperative awareness Pulmonary or cardiac injury Stroke or death Postoperative intubation ICU admission (when appropriate)

68. Informed Consent � Associated Risks Regional Anesthesia: Infection Local bleeding Nerve injury Headache Drug reaction Failure of planned regional anesthetic

69. Informed Consent � Associated Risks Blood Transfusion: Fever Infectious hepatitis HIV Hemolytic reaction Vascular Cannulation: Peripheral nerve, tendon, blood vessel injury Hemothorax Pneumothorax Infection

70. Informed Consent � Extenuating Circumstances Anesthesia procedures may proceed without consent in emergency situations.

71. Anesthesia Consult Note: A medico-legal document in permanent hospital record. Should contain the following information: Date and time of interview Planned procedure Description of extraordinary circumstances Allergies, Medications, Labs Disease processes/treatments ASA status

72. Standards for Nurse Anesthesia PracticeStandard III- Formulate a patient-specific plan for anesthesia care. Interpretation � The plan of care developed by the CRNA is based upon comprehensive patient assessment, problem analysis, anticipated surgical or therapeutic procedure, patient and surgeon preferences, and current anesthesia principles.

73. The Anesthesia Plan: What is anesthesia???

74. The Anesthesia Plan: Review of anesthetic options General Anesthesia Regional Anesthesia Monitored Anesthesia Care (MAC)

75. General Anesthesia: Inhalation Intravenous TIVA

76. Regional Anesthesia: (Conduction) Spinal / Subarachnoid Block (SAB) Epidural Blocks Bier Axillary Femoral nerve Ankle

77. Monitored Anesthesia Care: (MAC) Conscious Sedation Deep Sedation

78. Ideal Anesthetic: Assures patient safety and satisfaction Provides excellent operating conditions for surgeon Rapid patient recovery Minimal post-op side effects Optimal post-op pain control Permits quick transfer/discharge from PACU Optimizes operating room efficiency Low cost

79. Considerations that influence choice of anesthetic technique: Preference of patient, surgeon, anesthesia Site of surgery Body position required for surgery Elective or emergency surgery Co-existing disease Duration of surgery Age of patient Suspected difficult airway Suspected increased gastric contents at time of induction

80. Required for ALL Anesthetics!!! Means to give positive pressure ventilation Means to break laryngospasm Airway equipment Suction Monitors

83. Pre-op Medications: Goals Prophylaxis against allergy Decrease PONV Increase gastric fluid pH Decrease gastric fluid volume

84. Sedatives and analgesics: Goals Reduce anxiety Reduce pain during regional anesthesia procedures Assist with positioning Facilitate smooth induction of anesthesia

85. Sedatives and analgesics: Doses should be reduced in: Elderly Debilitated Acute intoxication Airway obstruction/trauma Central apnea Neurologic deterioration Severe pulmonary disease Severe valvular heart disease

86. Sedatives and analgesics: Patients addicted to opioids and barbiturates and patients on chronic pain therapy should receive enough premedication to overcome tolerance and to prevent withdrawal during surgery.

87. Benzodiazepines: 5 principle pharmacologic effects: Anxiolysis Sedation Anticonvulsant actions Spinal cord-mediated skeletal muscle relaxation Anterograde amnesia (acquisition or encoding of new information)

88. Benzodiazepines - As a class of drugs, are unique in the availability of a specific pharmacologic antagonist, flumazenil (romazicon)

89. Benzodiazepines- Produce all of their pharmacologic effects by facilitating the actions of gaba -aminobutyric acid (GABA). GABA is the principle inhibitory neurotransmitter in the CNS. Benzodiazepines do not activate GABAA receptors, but enhance the affinity of the receptors for GABA.

90. GABAA receptor -

91. GABAA receptor -

92. GABAA receptor -

93. Midazolam- A water-soluble benzodiazepine with an imidazole ring in its structure that accounts for its stability in aqueous solutions and its rapid metabolism. Compared with diazepam, midazolam is 2-3 times as potent. Amnestic effects are more potent than sedative effects.

94. Midazolam - pharmacokinetics Undergoes rapid absorption from the gastrointestinal tract and achieves prompt passage across the blood-brain barrier. Effect-site equilibration time (0.9-5.6 minutes). IV doses of midazolam should be sufficiently spaced to permit the peak clinical effect before a repeat dose is considered.

95. Midazolam � metabolism Rapidly metabolized by hepatic and small intestine cytochrome P-450 (CYP3A4) enzymes to active and inactive metabolites. 1-hydroxymidazolam � may accumulate in critically ill patients

96. Midazolam - metabolism Metabolism of midazolam is slowed in the presence of drugs that inhibit cytochrome P-450 enzymes, this may result in unexpected CNS depression. Cimetidine Erythromycin Calcium channel blockers Antifungal drugs

97. Midazolam - clearance Renal clearance Elimination half-time, volume of distribution (Vd), and clearance are not altered by renal failure.

98. Midazolam (versed): Adult dosing 1-5mg IV 2.5-5mg IM Onset: 30-60 seconds Time to peak effect: 3-5 minutes Duration of sedation: 15-80 minutes Effect � site equilibrium & redosing

99. Midazolam (versed): Midazolam induced depression of ventilation is exaggerated (synergistic effects) in the presence of opioids and other CNS depressant drugs. Appreciate that increasing age greatly increases the pharmacodynamic sensitivity to the hypnotic effects of midazolam.

100. Midazolam (versed): Pediatrics The most commonly used oral preoperative medication for children. Oral midazolam syrup(2mg/ml) is effective for producing sedation and anxiolysis at a dose of 0.25 mg/kg with minimal effects on ventilation and oxygen saturation. Pediatric dosing 0.4-1.0mg/kg PO 0.05mg/kg IV 0.1-0.2mg/kg IM