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Anesthesia patient care
This is a mind map about the care of anesthetized patients, which describes the classification of anesthesia, pre-anesthetic preparation and pre-anesthetic medication, local anesthesia, spinal anesthesia, etc.
Edited at 2022-03-25 13:13:05
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Anesthesia patient care
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- Outline
Anesthesia patient care
Classification of anesthesia
General anesthesia: including inhalation anesthesia and intravenous anesthesia
Local anesthesia: including topical anesthesia, local infiltration anesthesia, regional block, nerve or plexus block
Spinal anesthesia: including subarachnoid space block (spinal anesthesia), epidural space block, and combined subarachnoid space and epidural space block.
compound anesthesia
Preparation before anesthesia and medication before anesthesia
Pre-anesthesia assessment: ASA disease classification
Class I and II patients tolerate anesthesia and surgery well and are less risky Level III patients have weakened tolerance for anesthesia and surgery, and the risks are greater. They must be fully prepared before anesthesia. Level IV patients are at greater risk of anesthesia and have a high perioperative mortality rate. Level V is a dying patient and is not suitable for elective surgery. Level VI is diagnosed as brain death, and its organs are planned to be used for organ transplant surgery
Preparation before anesthesia
Psychological preparation: For those who are overly nervous, take medication before anesthesia and give diazepam the night before surgery.
physical preparation
Correct or improve the pathophysiological state (improve the malnutrition and supplementation status of patients, correct dehydration, electrolyte imbalance and acid-base balance imbalance, treat combined medical diseases, especially coronary heart disease, diabetes and hypertension, etc.
1) Correct anemia, hypoprotein and hypovolemia: Hemoglobin≥80g/L, plasma protein＞30g/L 2) Control high blood pressure and high blood sugar The blood pressure of hypertensive patients should be controlled within the normal range: systolic blood pressure is lower than 180mmHg, and diastolic blood pressure is lower than 100mmHg; diabetic patients should control fasting blood sugar before surgery: no higher than 8.3mmol/L, urine sugar less than 2, and urine ketone bodies are negative.
Fasting of digestible solid foods or non-breast milk for at least 6 hours before surgery is required Fasting for at least 8 hours is required for fried foods, fatty or meat-rich foods Newborns and infants should not eat (milk) for at least 4 hours, and digest easily solid food, non-breast milk or infant formula for at least 6 hours All patients can drink a small amount of water 2 hours before surgery (no water for 2 hours) Awake tracheal intubation may be considered in emergency patients with a full stomach to avoid vomiting and aspiration.
Pre-anesthetic medication
Purpose:
Eliminate patients' tension, anxiety and fear, and reduce the side effects of anesthetic drugs
Relieve or eliminate the pain and discomfort that may be caused by anesthesia procedures and enhance the effect of anesthesia
Inhibit respiratory gland secretion, reduce saliva secretion, and prevent aspiration
Eliminate adverse reflexes caused by surgery or anesthesia and maintain hemodynamic stability
Generally, patients under general anesthesia are mainly given sedatives and anticholinergics, and those with severe pain are given analgesics; patients under subarachnoid space anesthesia are mainly given sedatives, and those under epidural space anesthesia are given analgesics as appropriate.
The dosage should be reduced for patients with poor general condition, the elderly and infirm, cachexia and hypothyroidism. For patients with valvular heart disease, poor cardiac function, or severe illness, the dosage of sedatives and analgesics should be reduced. The dosage of medication may be increased as appropriate for young, strong and hyperthyroid patients. The dose of sedatives for patients with coronary heart disease and hypertension can be appropriately increased
Generally, intramuscular injection is given 30 to 60 minutes before anesthesia.
Nervous patients can take hypnotics or sedatives orally the night before surgery to relieve their nervousness.
Local anesthesia
Suitable for superficial and limited surgeries
Classification of local anesthetic drugs
Esters: including procaine (prone to allergic reactions) and tetracaine. drug allergy test
Amides: including lidocaine and bupivacaine. (Use with caution in patients with liver insufficiency)
Local anesthesia method
Topical anesthesia: applied to the surface of the mucosa to allow it to penetrate the mucosa and block the nerve endings under the mucosa.
Local infiltration anesthesia: It is the most widely used local anesthesia method in clinical practice. Inject anesthetic along the surgical incision to block the nerve endings
Notes: 1) Withdraw before each injection to prevent injection into the blood vessel 2) Wait 4 to 5 minutes after the injection to make it fully effective 3) Add an appropriate amount of epinephrine to the local anesthetic (1:200,000~1:400,000) It can slow down the absorption of drugs and prolong the action time. 4) Local infiltration anesthesia should not be used in infected and cancerous areas.
Regional block: local anesthetic is injected around and under the surgical area. Suitable for local mass resection, such as benign breast tumor resection
Nerve and plexus block: Inject local anesthetic around nerve trunks, plexuses, and nodes
Common nursing diagnoses
toxic reactions
Reasons: 1) The dosage at one time exceeds the patient's tolerance 2) The drug is accidentally injected into the blood vessel (the most common) 3) No vasoconstrictor is added 4) The patient's general condition is poor and his tolerance to local anesthetics is reduced.
People who experience symptoms of toxic reactions after using a small amount of local anesthetics are called hypersensitivity reactions.
Performance
Central toxic reactions: numbness of tongue or lips, headache and dizziness, tinnitus, blurred vision, slurred speech, muscle twitching, unconsciousness, convulsions, coma, and even respiratory arrest.
Cardiovascular toxic reactions: conduction block, vascular smooth muscle and myocardial depression, arrhythmia, weakened myocardial contractility, reduced cardiac output, decreased blood pressure and even cardiac arrest.
Prevention: 1) The amount of medicine used at one time should not exceed the limit 2) Withdraw before injecting the medicine. Only those who have no blood return can inject. 3) Reduce the dose according to the patient's condition and the site of medication. 4) If there are no contraindications, add an appropriate amount of epinephrine to the local anesthetic. 5) Anesthesia Give barbiturates or benzodiazepines before treatment to raise the toxicity threshold
deal with
If it occurs, stop the medication immediately, give oxygen as soon as possible, and strengthen ventilation.
Symptomatic treatment
For patients with mild toxic reactions, diazepam 0.1mg/kg or midazolam 3~5mg can be injected intravenously to prevent and control convulsions.
If convulsions and convulsions occur, intravenously inject sodium thiopental 1~2 mg/kg, and perform tracheal intubation if necessary.
If hypotension occurs, ephedrine or metahydroxylamine can be used to maintain blood pressure.
Intravenous atropine for patients with slow heart rate
Once breathing and heartbeat stop, perform cardiopulmonary resuscitation immediately
allergic reaction
neuraxial anesthesia
Subarachnoid space block (spinal anesthesia)
Indications: Suitable for lower abdominal, pelvic, lower limb and anus-perineum surgeries within 2 to 3 hours
Contraindications: 1) Central nervous system disease 2) Sepsis, skin infection at or near the puncture site 3) Shock, spinal trauma or tuberculosis and severe spinal deformity 4) Coagulation disorder 5) Acute heart failure or coronary heart disease attack 6) Mental illness and uncooperative people
Anesthesia method
Lumbar puncture: generally choose the 3rd to 4th or 4th to 5th lumbar spinous process space as the puncture point. Disinfect the puncture point and the surrounding 15cm area of skin. When the ligamentum flavum is pierced, there is often an obvious sense of failure. When the needle is inserted to break through the dura mater, a second sense of failure occurs. When you pull out the needle core and see cerebrospinal fluid dripping out, it means the puncture was successful.
Adjustment of anesthesia level: The anesthesia level refers to the limit where skin sensation disappears. Adjustment of the anesthesia level is the most important step in subarachnoid space block. If the level is too low, anesthesia failure may occur. Drug dose is the main factor, the higher the dose, the higher the plane.
Care for intraoperative complications
A drop in blood pressure or a slowdown in heart rate
Cause: Spinal anesthesia often occurs in high planes
Treatment: For patients with decreased blood pressure, 200~300ml can be quickly infused to expand blood volume; if necessary, intravenous injection of ephedrine can constrict blood vessels and maintain blood pressure. Patients with slow heart rate can be given intravenous atropine
Respiratory depression
Common in thoracic spinal nerve block, because the anesthesia level is too high
If breathing stops, perform tracheal intubation and artificial respiration immediately
feel sick and vomit
The level of anesthesia is too high, resulting in hypotension and respiratory depression; vagus nerve hyperactivity; intra-operative traction of abdominal viscera
Atropine can be used as prophylaxis before surgery
Postoperative Complication Care
Headache after spinal anesthesia
The incidence rate is 3% to 30%, often occurring 2 to 7 days after surgery. One of the most common complications of spinal anesthesia
Mainly due to puncture of the dura mater and arachnoid mater during lumbar puncture, resulting in loss of cerebrospinal fluid
Prevention: 1) Use fine puncture needles to improve puncture techniques, avoid repeated punctures, and reduce puncture holes. 2) Ensure adequate fluid intake during the perioperative period to prevent dehydration 3) After surgery, you should routinely remove pillows and lie down for 6 to 8 hours.
epidural space block
Indications: It is most commonly used for various abdominal, waist and lower limb surgeries below the diaphragm; it can also be used for neck, upper limb and chest wall surgeries to strengthen the management of respiratory circulation.
Contraindications: Similar to spinal anesthesia. It should be used with caution in patients with severe anemia, hypertension and poor compensatory cardiac function; it is contraindicated in patients with hypovolemia, infection at the injection site, bacteremia, coagulation dysfunction or during anticoagulation treatment.
Adjustment of anesthesia level: The anesthesia level of epidural anesthesia is different from that of spinal anesthesia and is segmental.
Care for intraoperative complications
total spinal anesthesia
The most dangerous complication of epidural anesthesia
All or part of the local anesthetic is injected into the subarachnoid space to block all spinal nerves
Prevention: Aspirate the cerebrospinal fluid before injecting the medicine
local anesthetic toxic reactions
Before injecting the medicine, it must be withdrawn to check whether there is blood returning in the epidural catheter.
blood pressure drops
It is caused by the blockage of sympathetic nerves and the dilation of resistance blood vessels and capacitance blood vessels. Especially upper abdominal surgery
Epidural anesthesia will not cause headaches, but blood pressure is often affected after sympathetic nerve block, so you need to lie on your back (without removing the pillow) for 4 to 6 hours. Purpose: To prevent blood pressure fluctuations.
Care for postoperative complications: nerve damage, epidural hematoma.
general anesthesia
General anesthesia is the most commonly used anesthesia method in clinical practice.
Category: Inhalation anesthesia: respiratory inhalation; intravenous anesthesia: intravenous injection
Complication care
Reflux and aspiration: reduce gastric content retention; lower gastric juice pH; reduce intragastric pressure; strengthen respiratory tract protection
airway obstruction
Upper respiratory tract obstruction: Cause: Mechanical obstruction is common, such as tongue drop, oral secretion obstruction, foreign body obstruction, laryngeal edema, laryngospasm Manifestations: Incomplete obstruction presents with dyspnea and snoring; complete obstruction presents with nasal flaring and three-concave sign. Treatment: Quickly lift the lower jaw, put in the ventilation tube, and remove throat secretions and foreign bodies For laryngeal edema, glucocorticoids are given, and in severe cases, tracheotomy is performed. For patients with laryngospasm, the inducement should be removed, pressurized oxygen should be given, succinylcholine should be injected intravenously, and tracheal intubation should be performed if necessary.
Upper airway obstruction: refers to airway obstruction below the glottis Causes: Kink of the tracheal tube, excessively long bevel of the tube sticking to the organ wall, aspiration of secretions or vomitus, bronchospasm, etc. Manifestations: In mild cases, pulmonary rales appear; in severe cases, difficulty breathing, reduced tidal volume, increased airway resistance, cyanosis, accelerated heart rate, and decreased blood pressure
Hypotension: systolic blood pressure drops by more than 30% of the basic value or the absolute value is less than 80mmHg during anesthesia
Hypertension: systolic blood pressure higher than 160mmHg during anesthesia or systolic blood pressure higher than 30% of the basic value
Hypoventilation, hypoxemia, cardiac arrhythmias, hyperthermia, convulsions and convulsions