3A
,Anesthesia and Moderate Sedation
Types of Anesthesia
● General Anesthesia: Depresses the central nervous system (CNS), causing a total loss of
consciousness, sensation, reflexes, and memory. Used for major surgeries requiring complete
muscle relaxation.
● Regional Anesthesia: Blocks peripheral nerves or the spinal cord to reduce sensation in selected
parts of the body (e.g., spinal, epidural, nerve blocks, field blocks).
● Local Anesthesia: Topical application or injection of an anesthetic agent (Lidocaine) directly to a
targeted area of skin or mucous membranes.
● Moderate Sedation (Monitored Anesthesia Care/MAC): Combines local anesthesia with
moderate sedation to control pain and anxiety during therapeutic procedures. The client remains
easily arousable, responds to verbal stimuli, retains protective reflexes (like the gag reflex), and
independently maintains a patent airway. Only qualified providers (anesthesiologists, CRNAs,
certified RNs under supervision) may administer it. An RN with no other responsibilities must be
present to monitor the client continuously before, during, and immediately after the procedure.
Stages of General Anesthesia
● Stage I (Beginning Analgesia): Relaxation, dizziness, detached feeling, reduced pain sensation;
client may be sensitive to noise.
● Stage II (Delirium/Excitement): Client can be loud, crying, or excited; pupils dilate but respond
to light. Bypassed if IV induction agents are given rapidly.
● Stage III (Operative/Surgical Anesthesia): Muscle relaxation, loss of reflexes, reduced vital
functions, sensation lost; pupils are small but reactive.
● Stage IV (Toxic Level): Severe depression of vital organs leading to respiratory failure and
cardiac arrest; pupils are fixed. Anesthesia must be stopped immediately; it requires stimulant
medications and narcotic antagonists.
Pharmacological Interventions & Reversal Agents
● Propofol (IV Anesthetic): Used for induction and maintenance of general anesthesia. Produces
sedation and amnesia but does not provide analgesia. Contraindicated if the client has a strict
allergy to eggs or soybean oil. Inject into a large vein to minimize localized pain.
● Opioids (Fentanyl, Sufentanil, Morphine): Used for sedation and pre-/postoperative pain relief.
Can cause CNS and respiratory depression, delayed awakening, constipation, urinary retention,
and nausea/vomiting. Reversal agent: Naloxone.
● Benzodiazepines (Midazolam, Diazepam, Lorazepam): Administered to reduce preoperative
anxiety, promote amnesia, and provide mild sedation. Rapid administration can cause cardiac or
respiratory arrest. Midazolam is contraindicated in clients with glaucoma. Reversal agent:
Flumazenil.
● Neuromuscular Blocking Agents (Succinylcholine, Vecuronium): Used to achieve skeletal
muscle relaxation for surgery and airway placement. Causes total flaccid paralysis; requires
mandatory mechanical ventilation because it paralyses the diaphragm and respiratory muscles.
● Anticholinergics (Atropine, Glycopyrrolate): Block muscarinic responses to acetylcholine,
decreasing salivation, GI secretions, and perspiration to reduce aspiration risks. Used to prevent
bradycardia triggered by parasympathetic stimulation during surgical manipulation. Adverse
, effects include tachycardia, dry mouth, and urinary retention. Contraindicated in clients with
glaucoma.
● Antiemetics (Ondansetron, Metoclopramide): Prevent postoperative nausea and vomiting
(PONV) and reduce aspiration risks. Metoclopramide enhances gastric emptying but can cause
extrapyramidal symptoms and tardive dyskinesia.
Complications & Management of Care
● Malignant Hyperthermia: A life-threatening hypermetabolic condition triggered by volatile
inhalation anesthetics and succinylcholine. Altered calcium activity in muscle cells causes severe
muscle rigidity, damage to the CNS, and hyperthermia.
○ First signs: Unexplained increase in end-tidal CO2, decreased O2 saturation, and
tachycardia.
○ Later signs: Muscle rigidity, dysrhythmias, tachypnea, hypotension, skin mottling,
cyanosis, myoglobinuria (muscle-cell protein in urine), and extreme temperature spikes
up to 41.7°C (107°F).
○ Interventions: Assist with immediate termination of surgery. Administer IV dantrolene
(muscle relaxant). Administer 100% oxygen. Infuse iced 0.9% sodium chloride; apply
cooling blankets and ice packs to the axillae, groin, neck, and head. Draw ABGs to
monitor for metabolic acidosis and check for hyperkalemia. Insert an indwelling urinary
catheter to monitor output and watch for myoglobinuria.
● Local Anesthetic Systemic Toxicity (LAST): Early signs include restlessness, altered speech,
blurred vision, a metallic taste, tremors, and tachycardia. Can progress to seizures, hypotension,
cardiac arrest, and apnea. Management: Support the airway and administer a rapid-acting
barbiturate.
● Spinal Anesthesia Headaches: Caused by cerebrospinal fluid (CSF) leakage or hypovolemia.
Management: Keep the head of the bed flat and maintain adequate fluid intake.
Preoperative and Intraoperative Nursing Care
Risk Factors across the Lifespan
● Older Adults: Increased vulnerability due to decreased hepatic and renal clearance of drugs,
reduced physiological reserve, decreased muscle mass, and lower total body water (high
dehydration risk). Fragile, dry skin requires precautions like paper tape and gentle lifting. Sensory
decline (hearing/vision) and oral alterations (dentures, loose teeth) complicate communication
and intubation. They have a higher risk of postoperative delirium (which can last 2+ days) and
hypothermia due to less subcutaneous fat.
● Co-morbidities: Obstructive sleep apnea (airway obstruction), respiratory disease like COPD or
asthma (hypoventilation), cardiovascular disease (dysrhythmias, fluid overload), and diabetes
(altered glucose control, delayed wound healing, infection).
● BMI > 30: High risk for hypoventilation, respiratory complications, altered anesthesia
elimination, PONV, and wound dehiscence/evisceration.
Preoperative Assessment, Diagnostics, and Documentation
● Detailed History: Assess baseline vitals, medical/surgical history, anesthesia tolerance, substance
use, and home medications. Anticoagulants must be withheld at least 48 hours before surgery, and
acetylsalicylic acid (aspirin) must be stopped 1 week before elective surgery to lower bleeding
risks.
, ● Cross-Reactive Allergies: Banana, avocado, or kiwi allergies signal latex sensitivity. Shellfish
allergies warrant careful evaluation regarding contrast media/iodine use. Egg/soybean oil allergies
preclude propofol.
● Diagnostics Checklist:
○ Urinalysis: Evaluates renal status and rules out infection.
○ CBC: Checks fluid status, anemia (Hgb/Hct), and immune function (WBC).
○ Clotting Studies (PT, INR, aPTT, Platelets): Determines bleeding risk.
○ Renal Labs (Creatinine, BUN) & Electrolytes: Assesses metabolic status.
○ Pregnancy Test: Essential to rule out fetal risk from anesthesia.
○ 12-Lead ECG: Required for all clients older than 40 to establish baseline heart rhythm.
Health Promotion and Preoperative Teaching
● Respiratory Practices: Teach the client how to use an incentive spirometer (every 1–2 hours
while awake post-op) and how to perform coughing and deep breathing. Crucial: Teach the client
to splint abdominal or chest incisions with a pillow when coughing to prevent dehiscence. (Note:
Coughing is contraindicated in eye, cosmetic, or intracranial surgeries.
● VTE Prevention: Educate on range-of-motion leg exercises, calf pumping, early ambulation,
anti-embolism stockings, and sequential compression devices.
● Preoperative NPO Compliance: Strictly enforce NPO status (6 hours for solids, 2 hours for
clear liquids) to avoid pulmonary aspiration.
Documentation & Informed Consent
● Informed Consent: The provider is legally responsible for discussing the procedure description,
participating professionals, anesthesia risks, benefits, potential harms, alternative treatments, and
the right to refuse.
○ Nurse's Role: The nurse acts strictly as a witness to the signature. The nurse verifies that
the client understands the provider's explanation, confirms competency, and ensures
voluntariness. If the client has further questions, the nurse must notify the provider to
clarify.
○ Restrictions: Consent cannot be signed if the client is under the influence of
mind-altering medications (opioids, sedatives). Clients must be at least 18 or an
emancipated minor. Two witnesses are required if the client can only sign with an "X, or
if there are severe vision/hearing impairments or language barriers.
● Preoperative Checklist Verification: Ensure jewelry, prosthetics, makeup, nail polish, and
glasses are removed. Have the client void before administering preoperative medications (like
sedatives or prophylactic antibiotics, which are given within 1 hour of the surgical incision).
Raise side rails immediately after sedative administration for safety.
Intraoperative Safety Protocols
● Surgical Safety Checklist (Joint Commission/WHO):
○ Sign-in occurs in the preoperative area before anesthesia induction.
○ Time-Out: Performed immediately before the skin incision. The entire team pauses to
actively verify the correct patient, correct procedure, and correct surgical site (which
must be clearly marked beforehand).
○ Sign-Out: Completed before the patient leaves the operating suite.
● Nursing Roles: The Circulating Nurse handles overall coordination, safety, and documentation
outside the sterile field. Scrub nurses/technicians manage the sterile field and instruments.
,Anesthesia and Moderate Sedation
Types of Anesthesia
● General Anesthesia: Depresses the central nervous system (CNS), causing a total loss of
consciousness, sensation, reflexes, and memory. Used for major surgeries requiring complete
muscle relaxation.
● Regional Anesthesia: Blocks peripheral nerves or the spinal cord to reduce sensation in selected
parts of the body (e.g., spinal, epidural, nerve blocks, field blocks).
● Local Anesthesia: Topical application or injection of an anesthetic agent (Lidocaine) directly to a
targeted area of skin or mucous membranes.
● Moderate Sedation (Monitored Anesthesia Care/MAC): Combines local anesthesia with
moderate sedation to control pain and anxiety during therapeutic procedures. The client remains
easily arousable, responds to verbal stimuli, retains protective reflexes (like the gag reflex), and
independently maintains a patent airway. Only qualified providers (anesthesiologists, CRNAs,
certified RNs under supervision) may administer it. An RN with no other responsibilities must be
present to monitor the client continuously before, during, and immediately after the procedure.
Stages of General Anesthesia
● Stage I (Beginning Analgesia): Relaxation, dizziness, detached feeling, reduced pain sensation;
client may be sensitive to noise.
● Stage II (Delirium/Excitement): Client can be loud, crying, or excited; pupils dilate but respond
to light. Bypassed if IV induction agents are given rapidly.
● Stage III (Operative/Surgical Anesthesia): Muscle relaxation, loss of reflexes, reduced vital
functions, sensation lost; pupils are small but reactive.
● Stage IV (Toxic Level): Severe depression of vital organs leading to respiratory failure and
cardiac arrest; pupils are fixed. Anesthesia must be stopped immediately; it requires stimulant
medications and narcotic antagonists.
Pharmacological Interventions & Reversal Agents
● Propofol (IV Anesthetic): Used for induction and maintenance of general anesthesia. Produces
sedation and amnesia but does not provide analgesia. Contraindicated if the client has a strict
allergy to eggs or soybean oil. Inject into a large vein to minimize localized pain.
● Opioids (Fentanyl, Sufentanil, Morphine): Used for sedation and pre-/postoperative pain relief.
Can cause CNS and respiratory depression, delayed awakening, constipation, urinary retention,
and nausea/vomiting. Reversal agent: Naloxone.
● Benzodiazepines (Midazolam, Diazepam, Lorazepam): Administered to reduce preoperative
anxiety, promote amnesia, and provide mild sedation. Rapid administration can cause cardiac or
respiratory arrest. Midazolam is contraindicated in clients with glaucoma. Reversal agent:
Flumazenil.
● Neuromuscular Blocking Agents (Succinylcholine, Vecuronium): Used to achieve skeletal
muscle relaxation for surgery and airway placement. Causes total flaccid paralysis; requires
mandatory mechanical ventilation because it paralyses the diaphragm and respiratory muscles.
● Anticholinergics (Atropine, Glycopyrrolate): Block muscarinic responses to acetylcholine,
decreasing salivation, GI secretions, and perspiration to reduce aspiration risks. Used to prevent
bradycardia triggered by parasympathetic stimulation during surgical manipulation. Adverse
, effects include tachycardia, dry mouth, and urinary retention. Contraindicated in clients with
glaucoma.
● Antiemetics (Ondansetron, Metoclopramide): Prevent postoperative nausea and vomiting
(PONV) and reduce aspiration risks. Metoclopramide enhances gastric emptying but can cause
extrapyramidal symptoms and tardive dyskinesia.
Complications & Management of Care
● Malignant Hyperthermia: A life-threatening hypermetabolic condition triggered by volatile
inhalation anesthetics and succinylcholine. Altered calcium activity in muscle cells causes severe
muscle rigidity, damage to the CNS, and hyperthermia.
○ First signs: Unexplained increase in end-tidal CO2, decreased O2 saturation, and
tachycardia.
○ Later signs: Muscle rigidity, dysrhythmias, tachypnea, hypotension, skin mottling,
cyanosis, myoglobinuria (muscle-cell protein in urine), and extreme temperature spikes
up to 41.7°C (107°F).
○ Interventions: Assist with immediate termination of surgery. Administer IV dantrolene
(muscle relaxant). Administer 100% oxygen. Infuse iced 0.9% sodium chloride; apply
cooling blankets and ice packs to the axillae, groin, neck, and head. Draw ABGs to
monitor for metabolic acidosis and check for hyperkalemia. Insert an indwelling urinary
catheter to monitor output and watch for myoglobinuria.
● Local Anesthetic Systemic Toxicity (LAST): Early signs include restlessness, altered speech,
blurred vision, a metallic taste, tremors, and tachycardia. Can progress to seizures, hypotension,
cardiac arrest, and apnea. Management: Support the airway and administer a rapid-acting
barbiturate.
● Spinal Anesthesia Headaches: Caused by cerebrospinal fluid (CSF) leakage or hypovolemia.
Management: Keep the head of the bed flat and maintain adequate fluid intake.
Preoperative and Intraoperative Nursing Care
Risk Factors across the Lifespan
● Older Adults: Increased vulnerability due to decreased hepatic and renal clearance of drugs,
reduced physiological reserve, decreased muscle mass, and lower total body water (high
dehydration risk). Fragile, dry skin requires precautions like paper tape and gentle lifting. Sensory
decline (hearing/vision) and oral alterations (dentures, loose teeth) complicate communication
and intubation. They have a higher risk of postoperative delirium (which can last 2+ days) and
hypothermia due to less subcutaneous fat.
● Co-morbidities: Obstructive sleep apnea (airway obstruction), respiratory disease like COPD or
asthma (hypoventilation), cardiovascular disease (dysrhythmias, fluid overload), and diabetes
(altered glucose control, delayed wound healing, infection).
● BMI > 30: High risk for hypoventilation, respiratory complications, altered anesthesia
elimination, PONV, and wound dehiscence/evisceration.
Preoperative Assessment, Diagnostics, and Documentation
● Detailed History: Assess baseline vitals, medical/surgical history, anesthesia tolerance, substance
use, and home medications. Anticoagulants must be withheld at least 48 hours before surgery, and
acetylsalicylic acid (aspirin) must be stopped 1 week before elective surgery to lower bleeding
risks.
, ● Cross-Reactive Allergies: Banana, avocado, or kiwi allergies signal latex sensitivity. Shellfish
allergies warrant careful evaluation regarding contrast media/iodine use. Egg/soybean oil allergies
preclude propofol.
● Diagnostics Checklist:
○ Urinalysis: Evaluates renal status and rules out infection.
○ CBC: Checks fluid status, anemia (Hgb/Hct), and immune function (WBC).
○ Clotting Studies (PT, INR, aPTT, Platelets): Determines bleeding risk.
○ Renal Labs (Creatinine, BUN) & Electrolytes: Assesses metabolic status.
○ Pregnancy Test: Essential to rule out fetal risk from anesthesia.
○ 12-Lead ECG: Required for all clients older than 40 to establish baseline heart rhythm.
Health Promotion and Preoperative Teaching
● Respiratory Practices: Teach the client how to use an incentive spirometer (every 1–2 hours
while awake post-op) and how to perform coughing and deep breathing. Crucial: Teach the client
to splint abdominal or chest incisions with a pillow when coughing to prevent dehiscence. (Note:
Coughing is contraindicated in eye, cosmetic, or intracranial surgeries.
● VTE Prevention: Educate on range-of-motion leg exercises, calf pumping, early ambulation,
anti-embolism stockings, and sequential compression devices.
● Preoperative NPO Compliance: Strictly enforce NPO status (6 hours for solids, 2 hours for
clear liquids) to avoid pulmonary aspiration.
Documentation & Informed Consent
● Informed Consent: The provider is legally responsible for discussing the procedure description,
participating professionals, anesthesia risks, benefits, potential harms, alternative treatments, and
the right to refuse.
○ Nurse's Role: The nurse acts strictly as a witness to the signature. The nurse verifies that
the client understands the provider's explanation, confirms competency, and ensures
voluntariness. If the client has further questions, the nurse must notify the provider to
clarify.
○ Restrictions: Consent cannot be signed if the client is under the influence of
mind-altering medications (opioids, sedatives). Clients must be at least 18 or an
emancipated minor. Two witnesses are required if the client can only sign with an "X, or
if there are severe vision/hearing impairments or language barriers.
● Preoperative Checklist Verification: Ensure jewelry, prosthetics, makeup, nail polish, and
glasses are removed. Have the client void before administering preoperative medications (like
sedatives or prophylactic antibiotics, which are given within 1 hour of the surgical incision).
Raise side rails immediately after sedative administration for safety.
Intraoperative Safety Protocols
● Surgical Safety Checklist (Joint Commission/WHO):
○ Sign-in occurs in the preoperative area before anesthesia induction.
○ Time-Out: Performed immediately before the skin incision. The entire team pauses to
actively verify the correct patient, correct procedure, and correct surgical site (which
must be clearly marked beforehand).
○ Sign-Out: Completed before the patient leaves the operating suite.
● Nursing Roles: The Circulating Nurse handles overall coordination, safety, and documentation
outside the sterile field. Scrub nurses/technicians manage the sterile field and instruments.
