1. General and Local Anesthetics
Chapter 11
General and Local Anesthetics
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Anesthetics
Drugs that reduce or eliminate pain by depressing nerve function in the central nervous system (CNS) and peripheral nervous system (PNS)
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Anesthesia
A state of depressed CNS activity
Two types
General anesthesia
Local anesthesia
Balanced anesthesia
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General Anesthetics
Drugs that induce a state in which the CNS is altered to produce varying degrees of:
Pain relief
Depression of consciousness
Skeletal muscle relaxation
Reflex reduction
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5. General Anesthetics (cont’d)
Inhalational anesthetics
Volatile liquids or gases that are vaporized in oxygen and inhaled
Parenteral anesthetics
Administered intravenously
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6. Classroom Response Question
The nurse anesthetist is planning to use balanced anesthesia during a surgical procedure. A characteristic of this type of anesthesia is the
administration of minimal doses of multiple anesthetic drugs.
administration of inhaled anesthetics.
IV administration of anesthetics.
administration of anesthetics to cause muscle relaxation.
Correct answer: A
Rationale: The use of a combination of drugs allows less of each drug to be used and a more balanced, controlled state of anesthesia to be achieved.
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Inhaled Anesthetics
Used to induce anesthesia
Inhaled gas
nitrous oxide (“laughing gas”)
Inhaled volatile liquids
enflurane (Ethrane)
halothane (Fluothane)
isoflurane (Forane)
methoxyflurane (Penthrane)
Others
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8. Parenteral Anesthetics
Used:
To induce or maintain general anesthesia
To induce amnesia
As an adjunct to inhalation-type anesthetics
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9. Parenteral Anesthetics (cont’d)
etomidate (Amidate)
ketamine (Ketalar)
methohexital (Brevital)
propofol (Diprivan)
thiopental (Pentothal)
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Adjunct Drugs
Sedative-hypnotics
Barbiturates (pentobarbital, secobarbital)
Benzodiazepines (diazepam, midazolam)
hydroxyzine
promethazine
Opioid analgesics
fentanyl, sufentanil, meperidine, morphine
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11. Adjunct Drugs (cont’d)
Neuromuscular blocking drugs (NMBDs)
Depolarizing drugs (succinylcholine, d-tubocurarine)
Nondepolarizing drugs (pancuronium, vecuronium)
Anticholinergics
atropine, glycopyrrolate, scopolamine
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Mechanism of Action
Varies according to drug
Overton-Meyer theory
Overall effect
Orderly and systematic reduction of sensory and motor CNS functions
Progressive depression of cerebral and spinal cord functions
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13. Classroom Response Question
When assessing a patient under general anesthesia, which change to organ systems does the nurse expect?
Nystagmus
Skeletal muscle constriction
Hypertension
Decreased intracranial pressure
Correct answer: A
Rationale: Nystagmus can occur as a result of the use of general anesthesia. Other findings include skeletal muscle relaxation, hypotension, and increased intracranial pressure.
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Indications
General anesthetics are used during surgical procedures to produce:
Unconsciousness
Skeletal muscular relaxation
Visceral smooth muscle relaxation
Rapid onset; quickly metabolized
Also used in electroconvulsive therapy treatments for depression
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Adverse Effects
Vary according to dosage and drug used
Sites primarily affected
Heart, peripheral circulation, liver, kidneys, respiratory tract
Myocardial depression is commonly seen
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16. Adverse Effects (cont’d)
Malignant hyperthermia
Occurs during or after general anesthesia or use of the NMBD succinylcholine
Sudden elevation in body temperature (greater than 104° F)
Tachypnea, tachycardia, muscle rigidity
Life-threatening emergency
Treated with cardiorespiratory supportive care and dantrolene (skeletal muscle relaxant)
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17. Classroom Response Question
During surgery, the anesthetist notes that the patient’s heart rate is gradually increasing and becoming more irregular, the patient’s blood pressure is becoming unstable, and the patient is starting to sweat profusely. What other assessment should the anesthetist note immediately?
Pupillary reactions
Respiratory effort
Temperature
Urinary output
Correct answer: C
Rationale: These are indications of malignant hyperthermia, which can progress rapidly.
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Moderate Sedation
Also called conscious sedation and procedural sedation
Combination of an IV benzodiazepine (e.g., midazolam) and an opiate analgesic (e.g., fentanyl or morphine)
Anxiety and sensitivity to pain are reduced, and patient cannot recall the procedure
Preserves the patient’s ability to maintain own airway and to respond to verbal commands
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19. Moderate Sedation (cont’d)
Used for diagnostic procedures and minor surgical procedures that do not require deep anesthesia
Rapid recovery time and greater safety profile than general anesthesia
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20. Classroom Response Question
Which statement regarding conscious sedation does the nurse identify as being accurate?
The intravenous route of drug administration is commonly used in pediatric patients to provide conscious sedation.
Mild amnesia is a common effect of midazolam.
Patients receiving conscious sedation must be intubated with an endotracheal tube.
Effects of propofol include relief of anxiety and pain.
Correct answer: B
Rationale: Midazolam allows the patient to relax and have markedly reduced or no anxiety, yet still maintain his or her open airway and response to verbal commands while producing mild amnesia. The oral route of drug administration for conscious sedation is preferred for pediatric patients; patients receiving conscious sedation are able to maintain their own airway. Propofol will relieve anxiety; however, pain medications must be used along with propofol therapy for situations that can cause a pain response.
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Local Anesthetics
Also called regional anesthetics
Used to render a specific portion of the body insensitive to pain
Interfere with nerve impulse transmission to specific areas of the body
Do not cause loss of consciousness
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22. Local Anesthetics (cont’d)
Topical
Applied directly to skin or mucous membranes
Creams, solutions, ointments, gels, ophthalmic drops, powders, suppositories
Parenteral
Injected intravenously or into the CNS by various spinal injection techniques
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23. Types of Local Anesthesia
Spinal or intraspinal
Intrathecal
Epidural
Infiltration
Nerve block
Topical
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24. Parenteral Anesthetics
lidocaine (Xylocaine)
mepivacaine (Carbocaine)
procaine (Novocain)
tetracaine (Pontocaine)
Others
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25. Drug Effects: Paralysis
First, autonomic activity is lost
Then pain and other sensory functions are lost
Last, motor activity is lost
As local drugs wear off, recovery occurs in reverse order (motor, sensory, then autonomic activity are restored)
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Indications
Local anesthetics are used for:
Surgical, dental, and diagnostic procedures
Treatment of certain types of chronic pain
Spinal anesthesia: to control pain during surgical procedures and childbirth
Local anesthetics are given by:
Infiltration anesthesia
Nerve block anesthesia
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Indications (cont’d)
Infiltration anesthesia
Minor surgical and dental procedures
Injection of the anesthetic solution intradermally, subcutaneously, submucosally, or intramuscularly across the path of nerves supplying target area
May be given in a circular pattern around operative area
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Indications (cont’d)
Infiltration anesthesia and epinephrine
Some local anesthetics used for infiltration or nerve block are combined with vasoconstrictors
To prevent systemic absorption of anesthetic
To help confine local anesthetic to injected area
To reduce local blood loss during procedure
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Indications (cont’d)
Nerve block anesthesia
Used for surgical, dental, and diagnostic procedures
Also used for therapeutic management of pain
The anesthetic drug is injected directly into or around the nerve trunks or nerve ganglia that supply the area to be numbed
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Adverse Effects
Usually limited
Adverse effects result if:
Inadvertent intravascular injection
Excessive dose or rate of injection
Slow metabolic breakdown
Injection into highly vascular tissue
“Spinal headache”
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31. Classroom Response Question
When teaching a patient about spinal headaches, which statement will the nurse include?
Spinal headaches can be prevented with bed rest after the epidural procedure.
Patients who have a spinal headache should have very limited fluid intake.
A graft of skin from the patient’s hand can be used to seal the leaking area causing the headache.
High Fowler’s positioning should be used for patients who have a spinal headache.
Correct answer: A
Rationale: Adequate hydration using IV fluids is often used to increase cerebral spinal fluid pressure. A “blood patch” is often used to help close up or seal the leak. A small amount of blood is taken from the patient and injected into the epidural space. The patient should be positioned flat to prevent spinal headache and if a patient has a spinal headache, relief is often obtained by lying flat.
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32. Neuromuscular Blocking Drugs
Also known as NMBDs
Prevent nerve transmission in certain muscles, resulting in muscle paralysis
Used with anesthetics during surgery
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33. Neuromuscular Blocking Drugs (cont’d)
When used during surgery, artificial mechanical ventilation is required
These drugs paralyze respiratory and skeletal muscles
Patient cannot breathe on his or her own
Do not cause sedation or pain relief
Patient may be paralyzed yet conscious
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34. Neuromuscular Blocking Drugs (cont’d)
Depolarizing drugs
Nondepolarizing drugs
Short-acting
Intermediate-acting
Long-acting
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35. NMBDs: Depolarizing Drugs
Succinylcholine
Works similarly to neurotransmitter acetylcholine (ACh), causing depolarization
Metabolism is slower than ACh, so as long as succinylcholine is present, repolarization cannot occur
Result: flaccid muscle paralysis
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36. NMBDs: Nondepolarizing Drugs
Short-acting
mivacurium (Mivacron)
Intermediate-acting
atracurium (Tracrium)
vecuronium (Norcuron)
rocuronium (Zemuron)
Long-acting
pancuronium (Pavulon)
doxacurium (Nuromax)
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37. NMBDs: Nondepolarizing Drugs (cont’d)
Prevent ACh from acting at neuromuscular junctions
Nerve cell membrane is not depolarized; muscle fibers are not stimulated
Skeletal muscle contraction does not occur
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38. Neuromuscular Blocking Drugs
First sensation is muscle weakness, followed by total flaccid paralysis
Small, rapidly moving muscles affected first (fingers, eyes), then limbs, neck, trunk
Finally, intercostal muscles and diaphragm affected, resulting in cessation of respirations
Recovery of muscular activity usually occurs in reverse order
Transient muscle fasciculations may result in later muscle soreness
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NMBDs: Indications
Main use: facilitating controlled ventilation during surgical procedures
Endotracheal intubation (short-acting)
To reduce muscle contraction in an area that needs surgery
Diagnostic drugs for myasthenia gravis
Other uses
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40. NMBDs: Adverse Effects
Few when used appropriately
May cause:
Hypotension (blockade of autonomic ganglia)
Tachycardia (blockade of muscarinic receptors)
Hypotension (release of histamine)
Effects vary according to site
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NMBDs: Safety
Respiratory muscle paralysis occurs with these drugs
Emergency ventilation equipment must be immediately available
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42. Classroom Response Question
A patient is to receive a neuromuscular blocking drug while on mechanical ventilation. While the patient is receiving this medication, the nurse should expect the patient to be:
sedated.
resisting the ventilator.
awake but unable to move.
pain free.
Correct answer: C
Rationale: Neuromuscular blocking drugs make the patient unable to move, but they do not cause sedation or relieve pain.
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NMBDs: Overdose
Overdose causes prolonged paralysis requiring prolonged mechanical ventilation
Cardiovascular collapse may occur
Several conditions may increase sensitivity to NMBDs
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Nursing Implications
Always assess past history of surgeries and response to anesthesia
Assess past history, allergies, medications
Assess use of alcohol, illicit drugs, opioids
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45. Nursing Implications (cont’d)
Assessment is vital during preoperative, intraoperative, and postoperative phases
Vital signs
Baseline lab work, ECG
Oxygen saturation
ABCs (airway, breathing, circulation)
Monitor all body systems
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46. Nursing Implications (cont’d)
Each perioperative phase has its own complex and very specific nursing actions
Provide preoperative teaching about the surgical procedure and anesthesia
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47. Nursing Implications (cont’d)
Perform close and frequent observation of the patient and all body systems
During a procedure, monitor vital signs, ABCs
Watch for sudden elevations in body temperature, which may indicate malignant hyperthermia
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48. Classroom Response Question
A patient in the intensive care unit will be receiving a neuromuscular blocking drug. Which piece of equipment is essential to have nearby when the nurse initiates this therapy?
Defibrillator
Sphygmomanometer
Mechanical ventilator
Oxygen source  
Correct answer: C
Rationale: Neuromuscular drugs paralyze the respiratory muscles; it is essential to have sufficient ventilator support nearby in case the medication causes the patient to lose the ability to breathe. Oxygen alone is not sufficient.
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49. Nursing Implications (cont’d)
During recovery, monitor for cardiovascular depression, respiratory depression, and complications of anesthesia
Implement safety measures during recovery, especially if motor or sensory loss occurs because of local anesthesia
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50. Nursing Implications (cont’d)
Reorient patient to his or her surroundings
Teach the patient about postoperative turning, coughing, deep breathing
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