anes 1501 ppt - m4:the surgical experience

THE SURGICAL THE SURGICAL EXPERIENCEEXPERIENCE

11The Surgical ExperienceThe Surgical Experience

SURGEON’S OFFICE/CLINICSURGEON’S OFFICE/CLINIC Need for surgeryNeed for surgery Urgency of procedureUrgency of procedure

Emergent – pathology threatening life or Emergent – pathology threatening life or limb within a relatively short time period limb within a relatively short time period (ruptured aneurysm of the aorta(ruptured aneurysm of the aorta

Urgent – pathology requiring treatment Urgent – pathology requiring treatment within a relatively short period of time within a relatively short period of time (unruptured ectopic pregnancy with (unruptured ectopic pregnancy with stable vital signs)stable vital signs)


SURGEON’S OFFICE/CLINIC SURGEON’S OFFICE/CLINIC (cont.)(cont.)

Cont’dCont’d Elective – intervention that does not have Elective – intervention that does not have

to be performed immediately or within a to be performed immediately or within a short period of time (if the surgical short period of time (if the surgical intervention can be scheduled at a future intervention can be scheduled at a future date, it is elective, ie, torn meniscus in the date, it is elective, ie, torn meniscus in the knee)knee)

Optional – surgical intervention that does Optional – surgical intervention that does not have to be performed in order to not have to be performed in order to preserve life or function preserve life or function (facelift/rhytidectomy)(facelift/rhytidectomy)


PREPARATIONPREPARATION

Pre-admission testPre-admission test Pre-op visitPre-op visit AdmissionAdmission Holding/day surgery (Preop)Holding/day surgery (Preop) The operating room (OR)The operating room (OR) Post anesthesia care (PACU)Post anesthesia care (PACU)


Anesthetic choices are made on a case by Anesthetic choices are made on a case by case basis considering the following:case basis considering the following:

Procedure & durationProcedure & duration

Age, size & weightAge, size & weight

Pt statusPt status

Emotional statusEmotional status

Mental statusMental status

Physical statusPhysical status

General healthGeneral health

Current medsCurrent meds

AllergiesAllergies

History of abuseHistory of abuse

Emergency conditionsEmergency conditions

Surgeon, anesthesia and pt Surgeon, anesthesia and pt preferencepreference


ASA CLASSIFICATIONSASA CLASSIFICATIONS

The American Society of Anesthesiologists has set The American Society of Anesthesiologists has set forth a classification system for assessing pt risk, forth a classification system for assessing pt risk, the classes are as follows:the classes are as follows:

Class 1 – no organic, physiological, biochemical or Class 1 – no organic, physiological, biochemical or psychiatric disturbancepsychiatric disturbance

Class 2 – mild to moderate systemic disease Class 2 – mild to moderate systemic disease disturbance, history of asthma, smoker, disturbance, history of asthma, smoker, controlled diabetes, mild obesity, age less than 1 controlled diabetes, mild obesity, age less than 1 or greater then 70or greater then 70


ASA CLASSIFICATIONS ASA CLASSIFICATIONS (cont.)(cont.)

Class 3 – severe systemic disturbance or Class 3 – severe systemic disturbance or disease, angina, post-myocardial infarction, disease, angina, post-myocardial infarction, poorly controlled hypertension, massive poorly controlled hypertension, massive obesity, symptomatic respiratory diseaseobesity, symptomatic respiratory disease

Class 4 – pt. with severe systemic disease, Class 4 – pt. with severe systemic disease, disorders, that are life threatening, disorders, that are life threatening, unstable angina, CHF, debilitating unstable angina, CHF, debilitating respiratory disease, hepatorenal failure.respiratory disease, hepatorenal failure.


ASA CLASSIFICATIONS ASA CLASSIFICATIONS (cont.)(cont.)

Class 5 – moribund patient with little Class 5 – moribund patient with little chance of survival who is operated on in chance of survival who is operated on in desperationdesperation

Class 6 – brain dead, life support provided, Class 6 – brain dead, life support provided, organ procurement intendedorgan procurement intended

Emergency modifier (E) – applies when Emergency modifier (E) – applies when doing and emergency surgerydoing and emergency surgery


GENERAL ANESTHESIAGENERAL ANESTHESIA

General anesthesia involves alterations General anesthesia involves alterations in the patients level of consciousness.in the patients level of consciousness.

It is accomplished through 3 techniquesIt is accomplished through 3 techniques When several methods for general When several methods for general

anesthesia are used in combination, the anesthesia are used in combination, the technique is called balancedtechnique is called balanced

The 3 techniques are:The 3 techniques are:


GENERAL ANESTHESIA GENERAL ANESTHESIA (cont.)(cont.)

Agent inhalation-involves the delivery of Agent inhalation-involves the delivery of gases across the alveolar membrane. Agents gases across the alveolar membrane. Agents are delivered via a closed circuit connected to are delivered via a closed circuit connected to a vaporizera vaporizer

Agent injection – involves the administration Agent injection – involves the administration of meds directly into the bloodstream of meds directly into the bloodstream intravenously.intravenously.

Agent instillation – involves the Agent instillation – involves the administration of meds into an area such as administration of meds into an area such as the rectum, where it is absorbed via the the rectum, where it is absorbed via the mucous membranemucous membrane


DEPTH OF ANESTHESIADEPTH OF ANESTHESIA

Stage I – amnesia stage, begins with Stage I – amnesia stage, begins with initial administration of an anesthetic initial administration of an anesthetic agent to loss of consciousnessagent to loss of consciousness

Stage II – consists of the period from the Stage II – consists of the period from the loss of consciousness to the return of loss of consciousness to the return of regular breathing and loss of the eyelid regular breathing and loss of the eyelid reflex. This stage is often referred toas reflex. This stage is often referred toas the excitement or delirium stage.the excitement or delirium stage.


DEPTH OF ANESTHESIA DEPTH OF ANESTHESIA (cont.)(cont.)

Stage III – consists of the period between Stage III – consists of the period between the onset of regular breathing and loss of the onset of regular breathing and loss of eyelid reflex to the cessation of breathing. eyelid reflex to the cessation of breathing. This is know as the surgical anesthesia This is know as the surgical anesthesia stagestage

Stage IV – is referred to as the Stage IV – is referred to as the overdosage stage, dilated and nonreactive overdosage stage, dilated and nonreactive pupils, cessation of respiration and pupils, cessation of respiration and marked hypotension.marked hypotension.


PHASES OF GENERAL PHASES OF GENERAL ANESTHESIAANESTHESIA

Induction phase – induction involves Induction phase – induction involves altering the pt’s level of altering the pt’s level of consciousness from the conscious to consciousness from the conscious to the unconscious state. Hearing is the the unconscious state. Hearing is the last sense to leave.last sense to leave.

Maintenance phase – surgical Maintenance phase – surgical intervention takes place during this intervention takes place during this phasephase


PHASES OF GENERAL PHASES OF GENERAL ANESTHESIA (cont.)ANESTHESIA (cont.)

Emergence phase – occurs as the surgical Emergence phase – occurs as the surgical intervention is being completed, the goal intervention is being completed, the goal is to have the patient as awake as possible is to have the patient as awake as possible at the end of the surgery. Restoration of at the end of the surgery. Restoration of the “gag” reflex.the “gag” reflex.

Recovery phase – the period of time Recovery phase – the period of time during which the pt returns to the during which the pt returns to the optimum level of consciousness and well optimum level of consciousness and well being.being.


ADVANTAGES OF GENERAL ADVANTAGES OF GENERAL ANESTHESIAANESTHESIA

Patient is unawarePatient is unaware Adequate airway is secured, less Adequate airway is secured, less

chance of aspirationchance of aspiration Meds can be titratedMeds can be titrated Muscle relaxation helps with Muscle relaxation helps with

retractionretraction


RISKS AND COMPLICATIONSRISKS AND COMPLICATIONS

AspirationAspiration Aspiration pneumoniaAspiration pneumonia Cricoid pressure of Sellick’s maneuver – external Cricoid pressure of Sellick’s maneuver – external

pressure to the cricoid cartilage – can prevent pressure to the cricoid cartilage – can prevent aspiration during intubationaspiration during intubation

See figure 9-6 (pg 228)See figure 9-6 (pg 228) See table 9-7 (pg 228) for fasting See table 9-7 (pg 228) for fasting

recommendationsrecommendations Laryngospasm and bronchospasm – slight trigger Laryngospasm and bronchospasm – slight trigger

of the gag reflex results in a spasm or rigidity of of the gag reflex results in a spasm or rigidity of the upper resp tract, pt cant move air in or outthe upper resp tract, pt cant move air in or out


FINAL STAGESFINAL STAGES

Room turnoverRoom turnover Equipment sterilizationEquipment sterilization


anes 1501 ppt - m4:the surgical experience

Education