Anesthesia effects on children By: Hunter, Erin, Marc, Elise, and Alexis

Introduction A nurse anesthetists responsibilities is to assess the patient before administering medication and producing a plan to recommend what medication should be given and the amount. Must give notes after the procedure to the post op team The medications given have an effect on the child relating to their oxygenation throughout the procedure Vital signs must be monitored throughout the procedure to ensure the patient is stable

How does anesthesia effect a child in surgery? Pico Question How does anesthesia effect a child in surgery? Population: Children Intervention: anesthesia medication Comparison: type of medication & amount given Outcome: patient has successful outcome after surgery

Nursing Research: Article “Effects of Anesthetic Agents on Blood Brain Oxygenation Level Revealed with Ultra-high Field MRI” Done because of conflicting results with Ketamine Why use an MRI? Done on rats isoflurane, ketamine-xylazine, and medetomidine How is this related to a nurse anesthetist’s job? The research was done because conflicting results have been found with ketamine. Some found that it decreased cerebral blood flow and some found that it increased it. So, the researchers wanted to figure out what was really going on. They predicted that the differences were due to the difference in doses, ventilation methods, and the different species that it was tested on could also be contributing to that. To do this study they used rats. They used an MRI because it is sensitive to blood oxygenation effects. And the animals were ventilated mechanically.   They did this test on rats and they used isoflurane, ketamine-xylazine, and medetomidine. They compared ketamine-xylazine and isoflurane at a field strength of 17.2 magnitude. They found that when they used ketamine-xylazine 5.4 times more pixels that corresponded with blood vessels showed up in the MRI than with the isoflurane. Thus, the ketamine-xylazine allowed for better blood flow. Then they compared medetomidine with isoflurane and found that the medetomidine had 4.8 times more blood vessels showing up than isoflurane did. The nurse anesthetist is responsible for deciding which drug to give the patient. And some considerations they may use could be the oxygenated blood flow to the brain would the patient get. The reason they might consider this is because oxygenated blood to the brain is important since a lack of it can kill the brain cells and the neurons. The more oxygenated blood the brain can receive the less risk there is for brain damage. The blood supply of the brain and spinal cord (2001). National Center for Biotechnology. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK11042/ Pain is something that nurses need to be aware of, especially after surgery. We need to remember that pain is subjective, not objective. So, if a patient says their pain is a 10 out of 10 then we have to treat it that way regardless of what we think it is.

Psychology research: propofol Background First used in 1977 Approved by FDA in 2008 Brand name is Diprivan It is a white, milk like, drug which makes it distinct lessening the number of med errors. Propofol is administered intervenes and can be felt in as little as 30 seconds after injection.

Psychology research: Propofol uses and side effects - Surgery - Medical exams Patients on ventilators Sedation during MRI’s Side effects - Pain at injection site Seizure Weak and shallow breathing Propofol is a quick acting short half-life anesthetic. Propofol can commonly be used for surgery, medical exams, or for people being put on ventilators. Also known to be used on little kid and infant for sedation during MRIs. common side effects can include Pain/swelling and injection site, Seizure, weak or shallow breathing, fast or slow heart rates, nausea, numbness, confusion, anxiety. Once the patient is taken of propofol there are little to no lingering effects

Psychology research: Half life of propofol Propofol is administered intervenes and can be felt in as little as 30 seconds after injection. The drug is quickly metabolized by the liver which can cause acute renal failure if used for an extensive length of time. Once the patient is taken of propofol there are little to no lingering effects. The patient is alert and not left drowsy like many other type of anesthesia. . Rare but fatal complications can include Propofol Related Infusion Syndrome which is only seen in patients with long continuous use of propofol.

Psychology Research: Anesthesia use in the Pediatric icu Objective: Evaluate Propofol anesthesia delivered to pediatrics in a PICU who undergo oncology procedures Testing: They studied fifty procedures on 28 pediatric patients ranging from 3 to 12 years old. The study recorded the time the patient entered the PICU, the time anesthesia administration, procedure start and end time, recovery time and discharge time. These tests were conducted over a 7 month period. The procedures conducted on the pediatric patients were lumbar puncture chemotherapy and bone marrow biopsys

Psychology Research: Results Time in Minutes Phase (Mean [+ or -] SD)  Admit to PICU to the start of 24.6 [+ or -] 9.9 Anesthesia   Start of anesthesia till 1.5 [+ or -] .7 anesthetized (Induction Time) Anesthetized to the start of 5.9 [+ or -] 2.6 Procedure Start of procedure to the end of 14.3 [+ or -] 11.3 procedure (procedure time) Anesthesia end time till awake 23.4 [+ or -] 11.5 (recovery time) Awake till discharge from PICU 23.5 [+ or -] 17.5 Length of stay 88.8 [+ or -] 27.7 32 out of the 50 procedures patients experienced a decrease in BP. 3 out of the 50 procedures patients complained about pain during injection of the drug which is a lot lower then normally reported. The chart above shows the break down of times throughout the procedure. The Average time a patient spent from entering the PICU till discharge was just 88 minutes.

Psychology research: versed Also known as Midazolam Falls in the category of benzodiazepines Often combined with Fentanyl -Causes relaxation, sleepiness, and partial or complete loss of memory while it is being used -Benzodiazepines: Psychoactive drugs that enhance GABA receptors, which in turn causes hypnotic, anti-anxiety, anticonvulsant, and muscle relaxant properties. -97% of it binds to proteins, mainly albumin. -Onset is 10-20 minutes so it’s a bit longer than Propofol.

Versed uses and side effects Procedures that do not require general anesthesia “Twilight sleep” In ICU to induce a “coma” SIDE EFFECTS Respiratory depression Tachycardia or bradycardia Swelling Nausea -Used for colonoscopies, to keep patient’s calm while on a ventilator, and for after surgery sedation. -When combined with Fentanyl it creates “conscious sedation” or “twilight sleep”- together the two drugs provide pain relief, relaxation, and amnesia. -Side effects: Loss of memory during the time that the drug is administered as well as the time immediately following is expected. -Not recommended for patient’s with COPD seeing as it causes respiratory depression. Also not intended for patient’s with hypotension because it can cause a decrease in blood pressure. Other side effects can include vision disturbances, loss of balance, pain at the injection site, excessive salivation, and dizziness with slurred speech.

midazolam vs. propofol -Study done to find out the different effects Midazolam and Propofol had on Dynamic Cerebral Autoregulation (the transient response of Cerebral Blood Flow to rapid changes in blood pressure. -10 men used in the experiment: each received Midazolam once, Propofol once, and a placebo once. -Both drugs significantly reduced cerebral blood flow upon administration, but they affected the autonomic nervous system very differently. -Midazolam created sympathetic dominance (nerves direct more blood to the muscles and brain, heart rate and blood pressure increase, blood flow to digestive organs decrease). -Propofol created a parasympathetic dominance (nerves stimulate digestion in the eliminative organs and therefore reduce activity in the brain and muscles). -In simplest terms, Midazolam had an improvement in dynamic cerebral autoregulation because by causing the body’s sympathetic nervous system to react, blood was at least trying to be redirected to the brain to counter the decrease of cerebral blood flow. Propofol had the opposite effect by actually directing blood away from the brain.

Nursing Theory Sr. Callista Roy Sister Callista did a little bit of everything when it came to nursing.  She practiced, she taught, she lectured, she researched, and she wrote.  Sister Callista graduated with her Bachelor's degree in 1963 and her masters in 1966.  She also  received her masters and PhD in Sociology.  Sister Callista implemented her Adaptation Model in the 1970's.   Application to clinical practice- "Nursing interventions are required when individuals demonstrate ineffective adaptive responses." This relates to our topic based on a patient's response to medications. If a patient is not responding appropriately to a suggested medication, as evidence by them becoming unconscious after administration of suggested dose, more medication can and will be given to get the desired response. There are 5 main concepts of Roy's Theory.  The major concepts are adaptation, person, environment, health and nursing. The major concepts of Roy's theory that I will relate to our topic is adaptation. The description about adaptation is that a patient should respond positively to environmental changes.  Sometimes these environmental changes can be as simple as a room change during the procedure. Get put under in one room and wake up in another.  Often as the anesthesia begins to wear off a patient can become confused and agitated not knowing where he or she is at and in pain.  It is important to help the patient remain calm, oriented and comfortable.

Cognitive theory : Jean piaget Ranges from infancy to adolescent - Stages: Sensorimotor (birth- two years) Preoperational (2-7 years) Concrete operational (7-11 years) Formal Operational (11- older) Relates: Human brain grows and develops over the life span Each stage of life people act differently to medications depending on their brains abilities and reactions Young children are more likely to have a negative reaction to the medication than an adult because their brains may not always be developed Sensorimotor- more reaction, very little drug needed and most likely not used concrete- most likely to has less of a reaction because brain is more developed Formal- brain is most likely well developed so less of a reaction Sensorimotor (birth- two years) develops reflexes multiple things thought at once Reasoning & predicts upcoming events Preoperational (2-7 years) Start to understanding language & objects in pictures Concrete operational (7-11 years) Logical thinking developing understanding of others perspectives Formal Operational (11- older) Able to establish meaning of life Able to use deductive reasoning and abstract thinking

Major Research findings Medications can affect people in several different ways and it is really important to know what medication is right for your patient. Propofol is a commonly used anesthetic due to its relatively low risk factor and short half life which allows the patient to be awake with little or no side effects in little as 20 minutes from the end of administration. Versed, or Midazolam has a slower onset than other drugs, but when it is carefully combined with other anesthetics it can be highly effective in providing ideal comfort for a patient. There are many ways to use Sr Callista Roy's Adaptation Model. It can be applied to the disease process, new diagnoses and day to day nursing care. Every person might react differently to drugs no matter what age but younger people are more likely to have a reaction due to the brain not fully developed

Concept map Anesthesia Effects Diversity Ethics Do not give patient medication faster than recommended time - Always check drug compatibility Health Promotion -Educating the patient on the possible side effects before surgery -Educate the patient on how to have a safe recovery Information Systems Access to latest drug studies Document all findings Review patient history Anesthesia Effects Diversity -medication effects everyone differently Leadership Main caregiver during surgery Researching the best drug and does Lifespan consideration -different dosages based on weight and age - Monitor infants and elderly more frequently Resources Consult another nurse about drug Consult with anesthesiologist Research

Clinical implication Asses the patient before administering medication Brain damage could be caused Patient comfort during surgery Make sure the patient receives the correct dosage

Conclusion

References Taylor, C. (2011). Theory, Research, and Evidence-based practice. Fundamentals of nursing: the art and science of nursing care(7th ed., ). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. Roy's Adaptation Model. (2013, September 9).Roy's Adaptation Model. Retrieved April 20, 2014, from http://currentnursing.com/nursing_theory/Roy_adaptation_model.html Anderson, B. D., Dalton, H. J., Gootenberg, J. E., Hauser, G. J., Hertzog, J. H., & Shad, A. T. (2000, October). Prospective Evaluation of Propofol Anesthesia in the Pediatric Intensive Care Unit for Elective Oncology Procedures in Ambulatory and Hospitalized Children. Pediatrics, 106(4), 742. Retrieved from http://go.galegroup.com/ps/i.do?id=GALE%7CA66665100&v=2.1&u=lom_ferrissu&it=r&p=AONE&sw=w&asid=610dc4b08a1e1ed899bcd420eb 220e9a Propofol Official FDA information, side effects and uses.. (March, 2003). Propofol Official FDA information, side effects and uses.. Retrieved April 24, 2014, from http://www.drugs.com/pro/propofol.html Diprivan (Propofol) Patient Information: Side Effects and Drug Images at RxList. (n.d.). RxList. Retrieved April 24, 2014, from http://www.rxlist.com/diprivan-drug/patient- images-side-effects.htm Ciobanu L, Reynaud O, Uhrig L, Jarraya B, Le Bihan D (2012) Effects of Anesthetic Agents on Brain Blood Oxygenation Level Revealed with Ultra-High Field MRI. PLoS ONE 7(3): e32645. doi:10.1371/journal.pone.0032645 Lamdin, R., & Shaw, S. (2011, August). Nurses have an ethical imperative to minimize procedural pain. Kai Tiaki: Nursing New Zealand, 17(7), 12+. Retrieved from http://go.galegroup.com/ps/i.do?id=GALE%7CA266344840&v=2.1&u=lom_ferrissu&it=r&p=AONE&sw=w&asid=2e190fb6b16b1538a38842d1d854e7c Taylor, C., Lillis, C., LeMone, P., & Lynn, P. (2011). Fundamentals of nursing: The art and Science of nursing care (7th ed.). Philadelphia, PA: Lippincott Williams & Wilkins.364. The blood supply of the brain and spinal cord (2001). National Center for Biotechnology. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK11042/

More References (2013). Medazolam. Drugs.com. Retrieved from http://www.drugs.com/cdi/midazolam.html Aoki, K., Gokan, D., Hirose, N., Iwasaki, K., Kato, J., Ogawa, S., Ogawa, Y. (2010). The Different Effects of Midazolam and Propofol Sedation on Dynamic Cerebral Autoregulation. Anesthesia & Analgesia, 111(5). Retrieved from http://journals.lww.com/anesthesia- analgesia/Fulltext/2010/11000/The_Different_Effects_of_Midazolam_and_Propofol.30.aspx Heisler, J. (2014). Versed (Medazolam). About.com Surgery. Retrieved from http://surgery.about.com/od/beforesurgery/qt/VersedMidazolamVersed.htm Roth, M. (2011). Parasympathetic Nervous System Dominance. Dr. Michael Roth’s Weblog. Retrieved from http://drmichaelroth.wordpress.com/2011/08/03/parasympathetic-nervous-system-dominance/ Roth, M. (2011). Sympathetic Nervous System Dominance. Dr. Michael Roth’s Weblog. Retrieved from http://drmichaelroth.wordpress.com/2011/07/05/sympathetic-nervous-system-dominance/