chapter 14 patient monitoring and local and regional anesthesia elsevier items and derived items ©...

Chapter 14Chapter 14

Patient Monitoring and Patient Monitoring and Local and Regional Local and Regional

AnesthesiaAnesthesia

Elsevier items and derived items © 2006 by Saunders, an imprint of Elsevier Inc.


Objective 1Objective 1

Define terminology related to patient monitoring Define terminology related to patient monitoring and anesthesia.and anesthesia.

ABGABG Arterial blood gasesArterial blood gases

AuscultationAuscultation Listening to the sounds of the body, especially the Listening to the sounds of the body, especially the

heart and lungsheart and lungs


Objective 1. TermsObjective 1. Terms BradycardiaBradycardia

Slow heart rateSlow heart rate CapnometryCapnometry

Measure of expired carbon dioxideMeasure of expired carbon dioxide DysrhythmiaDysrhythmia

Abnormal, disturbed cardiac rhythm Abnormal, disturbed cardiac rhythm ElectrocardiographyElectrocardiography

Process of recording electrical activity of the heartProcess of recording electrical activity of the heart


Objective 1. TermsObjective 1. Terms

ExsanguinationExsanguination To render bloodlessTo render bloodless

IntrathecallyIntrathecally Pertaining to within the spinal canalPertaining to within the spinal canal

LaryngospasmLaryngospasm Involuntary contraction of the larynxInvoluntary contraction of the larynx



Local anesthesiaLocal anesthesia A method of anesthesia in which an agent is injected A method of anesthesia in which an agent is injected

or applied topically to interrupt pain impulses at the or applied topically to interrupt pain impulses at the nerve endingsnerve endings

Pulse oximetryPulse oximetry A measure of the oxygen saturation of the blood; also A measure of the oxygen saturation of the blood; also

measures heart ratemeasures heart rate



Regional anesthesiaRegional anesthesia A method of anesthesia in which an agent is injected A method of anesthesia in which an agent is injected

to block pain impulses at a nerve plexus; causes both to block pain impulses at a nerve plexus; causes both pain and motor blockpain and motor block

VasoconstrictorVasoconstrictor An agent that causes contraction (narrowing) of the An agent that causes contraction (narrowing) of the

walls of blood vessels walls of blood vessels



Describe types of patient monitoring devices.Describe types of patient monitoring devices. To describe, remember toTo describe, remember to

DefineDefine Explain purposeExplain purpose Provide additional detailProvide additional detail


Objective 2. ElectrocardiogramObjective 2. Electrocardiogram

DefineDefine Instrument to record electrical activity of the heartInstrument to record electrical activity of the heart

PurposePurpose Record heart rate and rhythmRecord heart rate and rhythm


Objective 2. ElectrocardiogramObjective 2. Electrocardiogram

Detail:Detail: Electrodes placed on the patientElectrodes placed on the patient Attached to leads, which transmit impulses to the ECG deviceAttached to leads, which transmit impulses to the ECG device Impulses recorded and displayed on a screenImpulses recorded and displayed on a screen May be set to record a tracing on paper and/or emit an audible May be set to record a tracing on paper and/or emit an audible

signal to indicate heart ratesignal to indicate heart rate


Objective 2. Pulse oximetryObjective 2. Pulse oximetry

DefineDefine Noninvasive measure of the oxygen saturation of Noninvasive measure of the oxygen saturation of

blood blood PurposePurpose

Assess respiratory functionAssess respiratory function



Detail:Detail: Sensor probe is attached to a finger, toe, or earlobe Sensor probe is attached to a finger, toe, or earlobe



Detail:Detail: Emits red and infrared light, which is absorbed while Emits red and infrared light, which is absorbed while

passing through tissuepassing through tissue Remaining light is detected by the opposite side of the Remaining light is detected by the opposite side of the

sensor probe sensor probe Used to calculate the saturation of peripheral oxygen Used to calculate the saturation of peripheral oxygen

(SpO(SpO22 or SaO or SaO22) )



Detail:Detail: Saturation should be above 95%Saturation should be above 95% An audible signal reflects pulse rateAn audible signal reflects pulse rate Signal tone indicates saturationSignal tone indicates saturation Deeper the tone, the lower the saturationDeeper the tone, the lower the saturation Readings may be affected by various factors Readings may be affected by various factors


Objective 2. Blood pressure Objective 2. Blood pressure

Device is called aDevice is called a SphygmomanometerSphygmomanometer

DefineDefine Measure of the force of blood against the vessel walls Measure of the force of blood against the vessel walls

PurposePurpose Monitor cardiovascular statusMonitor cardiovascular status


Objective 2. Blood pressureObjective 2. Blood pressure

Detail:Detail: ““Normal” adult Normal” adult < 130 mm Hg systolic and < 85 mm Hg diastolic < 130 mm Hg systolic and < 85 mm Hg diastolic Multiple variables affect BPMultiple variables affect BP Inflatable cuff on patient’s upper arm connected to unitInflatable cuff on patient’s upper arm connected to unit Device automatically measures BP at set intervalsDevice automatically measures BP at set intervals Can be set to emit an audible alarm if BP not within preset limits Can be set to emit an audible alarm if BP not within preset limits


Objective 2. ThermometerObjective 2. Thermometer

DefineDefine Instrument to measure temperatureInstrument to measure temperature

PurposePurpose Detect hypothermia and/or hyperthermiaDetect hypothermia and/or hyperthermia



Detail:Detail: Pediatric and geriatric patients are most at risk for Pediatric and geriatric patients are most at risk for

hypothermiahypothermia Used to check effectiveness of heat loss prevention Used to check effectiveness of heat loss prevention

measuresmeasures May be monitored at skin, axilla, bladder, esophagus, May be monitored at skin, axilla, bladder, esophagus,

or earor ear



Detail:Detail: Normal core temperature varies near 98° F (37° C)Normal core temperature varies near 98° F (37° C) Baseline measurement is obtained, and changes are Baseline measurement is obtained, and changes are

monitored and assessedmonitored and assessed


Objective 2. CapnometryObjective 2. Capnometry

DefineDefine Measurement of carbon dioxide (COMeasurement of carbon dioxide (CO22) exhaled by the ) exhaled by the

patient patient PurposePurpose

Assess respiratory functionAssess respiratory function Early detection of compromised ventilation or MHEarly detection of compromised ventilation or MH



Detail:Detail: Adapter connected to theAdapter connected to the

breathing circuit breathing circuit



Detail:Detail: Tubing extends from the adapter to the analyzerTubing extends from the adapter to the analyzer Expired COExpired CO22 is measured and displayed as a is measured and displayed as a

continuous graph and in numerical value continuous graph and in numerical value


Objective 2. Objective 2. BIS monitorBIS monitor

DefineDefine Bispectral index monitorBispectral index monitor Modified EEGModified EEG

PurposePurpose Used to assess patient’s level of awarenessUsed to assess patient’s level of awareness


Objective 2. BIS monitorObjective 2. BIS monitor

Detail:Detail: Sensor placed on the patient’s foreheadSensor placed on the patient’s forehead Interprets and displays a reading between 0 and 100Interprets and displays a reading between 0 and 100 Near 100 = patient is fully awake Near 100 = patient is fully awake Less than 60 = appropriate depth of general anesthesia with a Less than 60 = appropriate depth of general anesthesia with a

low probability of explicit recall low probability of explicit recall


Objective 2. Nerve stimulatorObjective 2. Nerve stimulator

DefineDefine Device that stimulates a nerve and measures Device that stimulates a nerve and measures

responseresponse PurposePurpose

Assess neuromuscular function and blockadeAssess neuromuscular function and blockade


Objective 2. Nerve stimulatorObjective 2. Nerve stimulator

Detail:Detail: A surface electrode or probeA surface electrode or probe

• At ulnar or facial nerve At ulnar or facial nerve

TOF: TOF: • 4/4 = no muscle relaxation4/4 = no muscle relaxation

• 0/4 = full muscle relaxation 0/4 = full muscle relaxation


Objective 2. Advanced monitoringObjective 2. Advanced monitoring

Arterial lines used for:Arterial lines used for: Potential for rapid changes in blood pressurePotential for rapid changes in blood pressure Frequent sampling for ABGsFrequent sampling for ABGs Or when routine BP measurement is inaccurate Or when routine BP measurement is inaccurate



CVP linesCVP lines Placed in vena cavaPlaced in vena cava Assess volume of blood returning to the heartAssess volume of blood returning to the heart Used to assess the need for fluid replacement and to Used to assess the need for fluid replacement and to

prevent fluid overload prevent fluid overload



Pulmonary artery linePulmonary artery line Swan-Ganz catheterSwan-Ganz catheter Measures multiple types of pressure and cardiac Measures multiple types of pressure and cardiac

output output Often used during Often used during

• Cardiac surgeryCardiac surgery

• Lung transplantationLung transplantation

• Liver transplantationLiver transplantation



Compare and contrast local anesthesia, Compare and contrast local anesthesia, monitored anesthesia care, and regional monitored anesthesia care, and regional anesthesia. anesthesia.


Objective 3. C/C anesthesiaObjective 3. C/C anesthesia

Define each typeDefine each type Explain how the types are similarExplain how the types are similar Explain how the types are differentExplain how the types are different Give examples as neededGive examples as needed



LocalLocal• Injected at surgical site or placed topicallyInjected at surgical site or placed topically• Interrupts pain message at nerve endingsInterrupts pain message at nerve endings



(Local with) MAC(Local with) MAC Monitored anesthesia careMonitored anesthesia care Same mechanism as localSame mechanism as local Anesthesia provider is present for advanced Anesthesia provider is present for advanced

monitoring and medications PRNmonitoring and medications PRN



RegionalRegional• Injected at nerve plexusInjected at nerve plexus

• Blocks entire nerve bundleBlocks entire nerve bundle

• Motor and sensoryMotor and sensory


Objective 3. C/C anesthesiaObjective 3. C/C anesthesia How are local, MAC, and regional alike?How are local, MAC, and regional alike?

Same agentsSame agents Same vital signs monitoredSame vital signs monitored Sedatives may be given IVSedatives may be given IV Patient remains awakePatient remains awake



How are local, MAC, and regional different?How are local, MAC, and regional different? Different surgical applicationsDifferent surgical applications MAC and regional have an anesthesia provider presentMAC and regional have an anesthesia provider present

• Local has RN monitorLocal has RN monitor



How are local, MAC, and regional different?How are local, MAC, and regional different? Local and MAC have same administration routes, Local and MAC have same administration routes,

regional routes are differentregional routes are different



How are local, MAC, and regional different?How are local, MAC, and regional different? When choosing MAC over local:When choosing MAC over local:

• Patient ASA status Patient ASA status = MAC = MAC complex procedure = MACcomplex procedure = MAC



How are local, MAC, and regional different?How are local, MAC, and regional different? Regional is used when both sensory and motor block is Regional is used when both sensory and motor block is

necessary for surgical procedurenecessary for surgical procedure



List surgical procedures that may be List surgical procedures that may be performed under local or regional anesthesia. performed under local or regional anesthesia.


Objective 4. List surgical procObjective 4. List surgical proc

LocalLocal Excision/biopsy soft tissueExcision/biopsy soft tissue Repair of finger lacerationRepair of finger laceration Toenail excisionToenail excision SeptoplastySeptoplasty CystoscopyCystoscopy



Local with MACLocal with MAC Insertion of Insertion of

Transvenous pacemakerTransvenous pacemaker Venous access port/catheter Venous access port/catheter Dialysis access graft Dialysis access graft



Regional: SpinalRegional: Spinal TURP/bladder tumorsTURP/bladder tumors EmbolectomyEmbolectomy Total knee arthroplastyTotal knee arthroplasty Cesarean section Cesarean section



Regional: Regional: Epidural Epidural Relieve pain of labor/deliveryRelieve pain of labor/delivery Cesarean section Cesarean section Adjunct to general (rare)Adjunct to general (rare) Post-op pain control for thoracotomyPost-op pain control for thoracotomy



Regional: Regional: Caudal blockCaudal block Vaginal childbirth (in OB)Vaginal childbirth (in OB) With general anesthesia for lower-extremity With general anesthesia for lower-extremity

procedures in childrenprocedures in children For post-op pain managementFor post-op pain management



Regional: Regional: Retrobulbar block Retrobulbar block Ophthalmology proceduresOphthalmology procedures Cataract extractionCataract extraction

Less common nowLess common now More are being done under local/MACMore are being done under local/MAC



Regional: Regional: Extremity block Extremity block Varies by type/location of blockVaries by type/location of block

Closed reduction/castingClosed reduction/casting Carpal tunnel, trigger finger, or Dupuytren’s contracture Carpal tunnel, trigger finger, or Dupuytren’s contracture



Identify common agents used in local Identify common agents used in local anesthesia and regional anesthesia. anesthesia and regional anesthesia.


Objective 5. CObjective 5. Common agents ommon agents lidocaine lidocaine

(Xylocaine)(Xylocaine)


Objective 5. Objective 5. Common agents Common agents BupivicaineBupivicaine

(Marcaine, Sensorcaine)(Marcaine, Sensorcaine) MepivacaineMepivacaine

(Carbocaine, Polocaine) (Carbocaine, Polocaine)



Discuss the use of epinephrine in local Discuss the use of epinephrine in local anesthetic agents. anesthetic agents.


Objective 6. Objective 6. Use of epi in local Use of epi in local Local anesthetics may be combined with dilute Local anesthetics may be combined with dilute

epinephrineepinephrine 1:100,000 or 1:200,0001:100,000 or 1:200,000 Causes local vasoconstriction slowing the absorption of Causes local vasoconstriction slowing the absorption of

the agent into the circulatory systemthe agent into the circulatory system Keeps the local agent at surgical site longer, Keeps the local agent at surgical site longer, duration duration

of effectof effect


Objective 6. Objective 6. Use of epi in local Use of epi in local Use utmost caution becauseUse utmost caution because

Epinephrine also available in dose of 1:1000Epinephrine also available in dose of 1:1000 100 or 200 times more potent100 or 200 times more potent Intended for topical application, not injectionIntended for topical application, not injection Patient deaths have occurredPatient deaths have occurred



Describe types of regional blocks. Describe types of regional blocks.


Regional noteRegional note

Regional anesthesia provides both sensory and Regional anesthesia provides both sensory and motor block.motor block.


Objective 7. Types of regionalObjective 7. Types of regional

SpinalSpinal Injected into subarachnoid spaceInjected into subarachnoid space



SpinalSpinal Anesthetizes entire lower bodyAnesthetizes entire lower body Positioning (various)Positioning (various)



SpinalSpinal Positioning (various)Positioning (various)



EpiduralEpidural Injected outside dura (upon)Injected outside dura (upon)



EpiduralEpidural Anesthetizes entire lower bodyAnesthetizes entire lower body Positioning (various)Positioning (various) Labor and deliveryLabor and delivery Cesarean sectionCesarean section Adjunct to generalAdjunct to general Post-op pain controlPost-op pain control



CaudalCaudal Injected epidural space; sacrumInjected epidural space; sacrum

Labor and deliveryLabor and delivery



RetrobulbarRetrobulbar Injected behind eye,Injected behind eye,

into muscle cone, into muscle cone, around optic nervearound optic nerve



RetrobulbarRetrobulbar Cataract extractionCataract extraction Being replaced with topical MACBeing replaced with topical MAC



Extremity blockExtremity block ArmArm

• Axillary (brachial)Axillary (brachial)

• Median, radial, ulnarMedian, radial, ulnar

• Bier block (IV regional)Bier block (IV regional)



Extremity blockExtremity block LegLeg

• Femoral (most common)Femoral (most common)

• ObturatorObturator

• TibialTibial



Extremity blockExtremity block DigitalDigital

• FingerFinger

• ToeToe



Extremity block: discussionExtremity block: discussion Injected at a plexus of nervesInjected at a plexus of nerves

ApplicationsApplications risk of complications w/ generalrisk of complications w/ general Extremity proceduresExtremity procedures



Bier block (IV) discussionBier block (IV) discussion Insert IV, exsanguinate armInsert IV, exsanguinate arm



Bier block (IV) discussionBier block (IV) discussion Tourniquet Tourniquet Agent injected IVAgent injected IV

ApplicationsApplications Extremity proceduresExtremity procedures


In summaryIn summary

All patients are monitored during anesthesiaAll patients are monitored during anesthesia Various methods are usedVarious methods are used ST handles local agents on back tableST handles local agents on back table

Understand epinephrineUnderstand epinephrine

chapter 14 patient monitoring and local and regional anesthesia elsevier items and derived items ©...

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derived items

imprint of elsevier

heart slide

heart rate slide

rhythm slide

larynx slide

earlobe slide

respiratory function