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Anesthetics, NMB, Narcotics, Sedatives & Anticonvulsants Georgia Baptist College of Nursing Kathy Plitnick RN PhD CCRN.

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Presentation on theme: "Anesthetics, NMB, Narcotics, Sedatives & Anticonvulsants Georgia Baptist College of Nursing Kathy Plitnick RN PhD CCRN."— Presentation transcript:

1 Anesthetics, NMB, Narcotics, Sedatives & Anticonvulsants Georgia Baptist College of Nursing Kathy Plitnick RN PhD CCRN

2 Anesthetics Anesthesia – loss of sensation with/without loss of consciousness Anesthesia – loss of sensation with/without loss of consciousness Analgesia - loss of pain sensation Analgesia - loss of pain sensation Types of Anesthesia Types of Anesthesia General – controlled state of unconsciousness General – controlled state of unconsciousness Regional – nerve conduction is blocked to a region of the body Regional – nerve conduction is blocked to a region of the body Local – blocking of pain impulses on peripheral nerves Local – blocking of pain impulses on peripheral nerves Balanced – selection of several different drugs, without excessive CNS depression Balanced – selection of several different drugs, without excessive CNS depression

3 Stages of Anesthesia Stage of Analgesia (I): distortion of sight, hearing, numbness, analgesia Stage of Analgesia (I): distortion of sight, hearing, numbness, analgesia Stage of Delirium (II): loss of consciousness, involuntary activity, psychomotor excitement Stage of Delirium (II): loss of consciousness, involuntary activity, psychomotor excitement Stage of Surgical Anesthesia (III): end of delirium to occurrence of apnea Stage of Surgical Anesthesia (III): end of delirium to occurrence of apnea Stage of Medullary Depression (IV): begins with apnea, ends with circulatory collapse Stage of Medullary Depression (IV): begins with apnea, ends with circulatory collapse

4 Parenteral Agents: Propofol (Diprivan) Hypnotic without analgesia, amnesia Hypnotic without analgesia, amnesia IV rapid induction, short term sedation IV rapid induction, short term sedation Rapid acting, rapid emergence Rapid acting, rapid emergence Adverse: hypotension, bradycardia, apnea Adverse: hypotension, bradycardia, apnea Contraindicated: soybean, egg, L&D Contraindicated: soybean, egg, L&D Nursing: Nursing: Titrate to sedation level, aseptic technique (fat emulsion), emergency equipment, “wake up” assessment, patent airway, analgesics Titrate to sedation level, aseptic technique (fat emulsion), emergency equipment, “wake up” assessment, patent airway, analgesics

5 Inhalation Anesthetics Isoflurane (Forane) –volatile liquid Isoflurane (Forane) –volatile liquid Induction and maintenance – given with Nitrous oxide Induction and maintenance – given with Nitrous oxide Depresses all levels of CNS, skeletal muscle relaxant Depresses all levels of CNS, skeletal muscle relaxant Potent respiratory depressant Potent respiratory depressant Minimal depression of myocardium Minimal depression of myocardium Potential for malignant hyperthermia Potential for malignant hyperthermia Depresses kidney function Depresses kidney function

6 Isoflurane Post operative shivering Post operative shivering IV Demerol, rewarming IV Demerol, rewarming Monitor vs, temperature frequently Monitor vs, temperature frequently Prevent aspiration Prevent aspiration Monitor U/O Monitor U/O

7 Nitrous Oxide Nonflammable, inorganic gas, colorless, odorless Nonflammable, inorganic gas, colorless, odorless Cortical depression Cortical depression Good analgesic, weak anesthetic Good analgesic, weak anesthetic Rapidly absorbed through lungs Rapidly absorbed through lungs Adverse: depresses cardiac contractility, hypoxia Adverse: depresses cardiac contractility, hypoxia

8 Local: Lidocaine Inhibits transport of ions across neuronal membranes Inhibits transport of ions across neuronal membranes Prevents initiation & conduction of nerve impulses Prevents initiation & conduction of nerve impulses Routes: topical, infiltration, mucosal, IV Routes: topical, infiltration, mucosal, IV Nursing: assess degree of numbness, ensure gag reflex intact after oral sprays Nursing: assess degree of numbness, ensure gag reflex intact after oral sprays Infiltration: used with Epinephrine to prolong local effect Infiltration: used with Epinephrine to prolong local effect

9 Neuromuscular Blockers Cause muscle relaxation, paralyzation Cause muscle relaxation, paralyzation Short term use: facilitate intubation, procedures in mech ventilated Short term use: facilitate intubation, procedures in mech ventilated Long term use: mechanical ventilation, control agitation, decrease tissue oxygen demands, increased ICP Long term use: mechanical ventilation, control agitation, decrease tissue oxygen demands, increased ICP Always administer with an analgesic &/or sedative Always administer with an analgesic &/or sedative Patient is completely dependent Patient is completely dependent Protect the patient Protect the patient

10 Depolarizing Agents: Succinylcholine (Anectine) Depolarization of motor end plates, bind to receptors Depolarization of motor end plates, bind to receptors Muscle contraction appear as fasciculations (tremors) followed by muscle relaxation Muscle contraction appear as fasciculations (tremors) followed by muscle relaxation Complete paralysis in 2-3 minutes Complete paralysis in 2-3 minutes No effect on CNS No effect on CNS

11 Succinylcholine Adverse: stimulates vagal ganglia Adverse: stimulates vagal ganglia Apnea Apnea Histamine release Histamine release Increased intraocular pressure Increased intraocular pressure Malignant hyperthermia Malignant hyperthermia Never assume a paralyzed patient is asleep Never assume a paralyzed patient is asleep Mechanical ventilation support Mechanical ventilation support

12 Nondepolarizing Agents Block action of acetylcholine Block action of acetylcholine Prevents depolarization of muscle membrane, muscle contraction cannot occur Prevents depolarization of muscle membrane, muscle contraction cannot occur Used in OR – to expose operative site, close wound Used in OR – to expose operative site, close wound Anesthesiologist: facilitate intubation Anesthesiologist: facilitate intubation

13 Tubocurarine (Tubarine) Gradual paralysis over 1-5 minutes without fasciculation Gradual paralysis over 1-5 minutes without fasciculation Sequence of paralysis Sequence of paralysis Persists for minutes Persists for minutes Reversed by anticholinesterases Reversed by anticholinesterases Effects: hypotension, peripheral vasodilatation, myocardial depression, reflex tachycardia, increased secretions, decreased u/o, GI motility Effects: hypotension, peripheral vasodilatation, myocardial depression, reflex tachycardia, increased secretions, decreased u/o, GI motility

14 Tubocurarine Toxic: prolonged apnea, cardiovascular collapse, recurarization Toxic: prolonged apnea, cardiovascular collapse, recurarization Nursing: Nursing: Hypotension profound in hypovolemia Hypotension profound in hypovolemia Rehydrate Rehydrate Avoid use in asthmatics Avoid use in asthmatics Excreted by kidneys – slower recovery or repeated doses of anticholinesterases Excreted by kidneys – slower recovery or repeated doses of anticholinesterases

15 Narcotics – Morphine Opioid analgesic, binds to opiate receptors Opioid analgesic, binds to opiate receptors Alters perception to painful stimuli Alters perception to painful stimuli Produces CNS depression Produces CNS depression Uses: severe pain, pulmonary edema, acute MI Uses: severe pain, pulmonary edema, acute MI Available: oral, IM, IV, SC, rectal, epidural, intrathecal Available: oral, IM, IV, SC, rectal, epidural, intrathecal

16 Morphine Adverse: confusion, sedation, respiratory depression, arrest, hypotension, constipation, urinary retention, itching, dependence Adverse: confusion, sedation, respiratory depression, arrest, hypotension, constipation, urinary retention, itching, dependence Nursing: Nursing: Assess VS, type, location & intensity of pain Assess VS, type, location & intensity of pain Assess bowel function Assess bowel function Co-administration of nonopioid analgesics Co-administration of nonopioid analgesics Discontinue gradually Discontinue gradually Give IVP slowly, safety precautions Give IVP slowly, safety precautions

17 Codeine Mild narcotic agonist Mild narcotic agonist Decreases cough reflex, GI motility Decreases cough reflex, GI motility Completely absorbed from IM sites Completely absorbed from IM sites Use Cautiously in head trauma, increased ICP, undiagnosed abdominal pain Use Cautiously in head trauma, increased ICP, undiagnosed abdominal pain Often combined with analgesic (ASA, tylenol) Tylenol #2 – 15 mg Codeine Often combined with analgesic (ASA, tylenol) Tylenol #2 – 15 mg Codeine

18 Pentazocine (Talwin) Narcotic Agonist-Antagonist Narcotic Agonist-Antagonist Antagonist properties may result in opioid withdrawal Antagonist properties may result in opioid withdrawal Withdrawal symptoms: vomiting, restlessness, abdominal cramps, increased BP & temperature Withdrawal symptoms: vomiting, restlessness, abdominal cramps, increased BP & temperature Additional adverse: hallucinations, euphoria, lightheadedness Additional adverse: hallucinations, euphoria, lightheadedness IM injections deep into well-developed muscle IM injections deep into well-developed muscle

19 Narcotic Antagonist – Naloxone (Narcan) Antidote for opioid overdose Antidote for opioid overdose Reverses CNS depression Reverses CNS depression Results in sympathetic stimulation Results in sympathetic stimulation IVP: 0.02 – 0.2 mg q 3-5 minutes IVP: 0.02 – 0.2 mg q 3-5 minutes Always assess pain after IV Narcan Always assess pain after IV Narcan Resuscitation equipment readily available Resuscitation equipment readily available

20 CNS Depressants Benzodiazepines: Lorazepam (Ativan) Benzodiazepines: Lorazepam (Ativan) Potentiates GABA – inhibitory NT Potentiates GABA – inhibitory NT Sedation, amnesia Sedation, amnesia Uses: anxiety, seizures, insomnia, diagnostic procedures Uses: anxiety, seizures, insomnia, diagnostic procedures

21 Sleep Stages NREM: NREM: 1: Relaxed wakefulness 1: Relaxed wakefulness 2: Light sleep – 50% of sleep 2: Light sleep – 50% of sleep 3 & 4: Slow wave (delta), deep restorative, secrete hormones, enhance immune function, 15-50% 3 & 4: Slow wave (delta), deep restorative, secrete hormones, enhance immune function, 15-50% REM: REM: Mentally, emotionally restorative Mentally, emotionally restorative Psychological problems from deprivation Psychological problems from deprivation 90 minute cycles 90 minute cycles

22 CNS Depressants & REM sleep Barbiturates Barbiturates Suppress REM sleep Suppress REM sleep Rebound effect Rebound effect Benzodiazepines Benzodiazepines Do not suppress REM sleep Do not suppress REM sleep

23 Lorazepam (Ativan) Available oral, IM, IV (1-5 min) Available oral, IM, IV (1-5 min) Half-life hours Half-life hours Nursing: Nursing: Assess degree of anxiety Assess degree of anxiety Psychological, physical dependence Psychological, physical dependence Bedrest, safety precautions (IV) Bedrest, safety precautions (IV) Slow IVP Slow IVP Avoid ETOH Avoid ETOH Seizure management Seizure management Renal function Renal function

24 Anticonvulsant Therapy Seizures: abnormal electrical activity in nerve cells, discharges occur in cerebral cortex Seizures: abnormal electrical activity in nerve cells, discharges occur in cerebral cortex Localized areas or entire brain Localized areas or entire brain Idiopathic: no specific cause Idiopathic: no specific cause Nonidiopathic: abscess, trauma, encephalitis, CVA, uremia, ETOH, drug overdoses, sudden withdrawal, hypoglycemia, hypocalcemia, fever Nonidiopathic: abscess, trauma, encephalitis, CVA, uremia, ETOH, drug overdoses, sudden withdrawal, hypoglycemia, hypocalcemia, fever

25 Anticonvulsants Block movement of sodium ions, less excitable membranes Block movement of sodium ions, less excitable membranes Enhance GABA activity Enhance GABA activity Long term therapy Long term therapy Oral use, IV Oral use, IV Stop a seizure: Lorazepam, Diazepam Stop a seizure: Lorazepam, Diazepam Prevent seizure: phenobarbital, dilantin Prevent seizure: phenobarbital, dilantin

26 Phenytoin (Dilantin) Treatment/prevention tonic-clonic seizures Treatment/prevention tonic-clonic seizures Alters ion transport Alters ion transport Absorb slowly, hours Absorb slowly, hours Steady state 1-3 weeks Steady state 1-3 weeks Adverse: ataxia, drowsiness, hypotension, gingival hyperplasia, slurred speech Adverse: ataxia, drowsiness, hypotension, gingival hyperplasia, slurred speech

27 Phenytoin Nursing: Nursing: Characteristics of seizure Characteristics of seizure Oral hygiene Oral hygiene Hypersensitivity reaction Hypersensitivity reaction Seizure precautions Seizure precautions IVP precautions IVP precautions Patient identification Patient identification Urine: pink, red, reddish brown Urine: pink, red, reddish brown Avoid antacids Avoid antacids Therapeutic levels: mcg/ml Therapeutic levels: mcg/ml

28 Phenobarbital Produces CNS depression Produces CNS depression Decreases motor activity, alters cerebellar function Decreases motor activity, alters cerebellar function Anticonvulsant activity, sedation Anticonvulsant activity, sedation Uses: tonic-clonic, febrile seizures Uses: tonic-clonic, febrile seizures Half-life 2-6 days Half-life 2-6 days Adverse: hangover, delirium, drowsiness, excitation, hypotension Adverse: hangover, delirium, drowsiness, excitation, hypotension

29 Phenobarbital Frequent VS with IV use Frequent VS with IV use Resuscitation equipment Resuscitation equipment Dependence Dependence Suicide precautions Suicide precautions Seizure assessment, precautions Seizure assessment, precautions Evaluate hepatic, renal, CBC Evaluate hepatic, renal, CBC Therapeutic level: mcg/ml Therapeutic level: mcg/ml Slow IVP Slow IVP

30 Anticonvulsants Clonazepam (Klonopin): petit mal, myoclonic, long term treatment Clonazepam (Klonopin): petit mal, myoclonic, long term treatment Ethosuximide (Zarontin): absence seizures, peak levels in 3-7 hours, anorexia & gastric upset a problem Ethosuximide (Zarontin): absence seizures, peak levels in 3-7 hours, anorexia & gastric upset a problem Carbamazepine (Tegretol): tonic-clonic, partial seizures, related to TCA’s, watch LFT’s, BUN, bilirubin, plt ct. Carbamazepine (Tegretol): tonic-clonic, partial seizures, related to TCA’s, watch LFT’s, BUN, bilirubin, plt ct.

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