ANESTHIOLOGY
and nursing in life threatening situations
ANESTHESIOLOGY NURSE
Anesthesiology nurse (ICU/theater/Outreach Team)– nurse who has completed a specialization in
anesthesia and intensive care nursing, or a nurse who has completed a qualifying course in
anesthesia and intensive care nursing, or a nurse in the course of specialization in anesthesia and
intensive care nursing.
OPERATING THEATER
Consists of:
operating rooms
SNP room (postoperative supervision room)
"clean" corridor
"dirty" corridor
nursing station
storage room
Sanitary facility
Tasks of an anesthesiology nurse:
OPERATING ROOM
• Care and supervision of the patient before, during and after anesthesia and after the
planned/conducted medical procedure.
• Conducting patient and family education.
• Assistance in meeting the individual needs of the patient.
• Assisting with induction, maintenance and awakening from anesthesia.
• Keeping medical records.
POST-OPERATION ROOM
• Patient monitoring.
• Specialist supervision of the patient after a medical procedure.
• Recognizing and responding to postoperative disorders in the patient.
• Monitoring and coordinating pain management.
• Recognition, monitoring and responding to irregularities during the procedure of
transfusion of blood and blood products.
• Proper handling of specialist substances (anaesthetics).
PAIN TREATMENT
• Preparation of an interview focused on pain complaints.
• Comprehensive analgesic management.
• Assisting and preparing methods of pain treatment.
• Evaluation and supervision of the effectiveness of the implemented pain treatment.
• Keeping medical equipment and medical supplies ready.
• Use non-pharmacological pain relief methods.
LIFE EMERGENCY STATES WITHIN THE MAIN UNIT - THE HOSPITAL
• Life threatening treatment (CPR).
• Maintenance of medical equipment and medical supplies used in life-threatening
emergencies.
• Controlling the necessary apparatus and medicinal substances in the resuscitation
bag/resuscitation trolley.
• CPR training for hospital staff.
EQUIPMENT – THEATRE
1) general anesthesia apparatus with an anesthetic respirator; the anesthetic equipment of the
general anesthesia station with the use of artificial lung ventilation is also equipped with:
2) self-expanding bag (AMBU bag);
3) source of oxygen, air and vacuum;
4) suction device
5) endotracheal intubation set with endotracheal tubes and two laryngoscopes;
6) defibrillator capable of performing cardioversion and electrostimulation;
7) light source;
8) equipment for intravenous administration of drugs;
9) stethoscope;
10) blood pressure measuring apparatus;
11) thermometer;
12) pulseoximeter
13) heart monitor;
14) capnometer;
15) muscle relaxation monitor (TOFF);
16) equipment for invasive blood pressure measurement;
17) a device for heating infusion fluids;
18) device for warming the patient - at least 1 out of 3 anesthesia stations;
19) equipment for rapid fluid transfusions;
20) at least 3 infusion pumps
TYPES OF ANESTHESIA
1. GENERAL ANESTHESIA
• General-means complete and reversible loss of consciousness caused by the introduction
of intravenous or inhalation anesthetics, causing:
• amnesia
• analgesia
• hypnosis
• Inhibition of spinal reflexes
• Anesthetic– these are drugs that, when administered, cause loss of consciousness
(hypnosis). Drug such as: barbiturates, benzodiazepines, propofol, ketamine. We divide
them into intravenous and inhaled.
2. REGIONAL ANESTHESIA
• Regional anesthesia blocks pain sensation from a specific region of the body while the
patient remains conscious.
• Types of regional anesthesia include:
• Epidural anesthesia: Injection of anesthetic into the epidural space surrounding the
spinal cord, commonly used for childbirth or surgical procedures involving the lower
body.
• Spinal anesthesia: Injection of anesthetic into the cerebrospinal fluid in the spinal
canal, often used for lower abdominal or lower limb surgeries.
• Peripheral nerve blocks: Injection of anesthetic around specific nerves to block
sensation in a particular body part.
EPIDURAL VS SPINAL ANESTHESIA
3. LOCAL ANESTHESIA
• Local anesthesia numbs a small, specific area of the body for minor procedures or surgeries.
• It is commonly administered via injection or topical application.
• Local anesthesia is often used for minor surgeries, dental procedures, or dermatological
interventions.
Preanesthetic visit
Goals:
• choice of anesthesia methods
• rating risk
• obtaining consent
• premedication (sedatives, antibiotics)
• interview and physical examination (assessment of the difficulty of anesthesia)
MALLAMPATI SCALE
ASA (American Society of Anesthesiology)
• ASA I- healthy patient
• ASA II - mild diseases general not affecting everyday life
• ASA III - severe general conditions that affect everyday life
• ASAIV- severe general diseases and emergency conditions (tonsillitis, pectoris, organ
failure)
• ASA V- dying, probability of death in the next 24 hours (perforation abdominal aortic,
aneurysm) - requires at least 2 anesthesiologists.
• ASA VI- brain death, organ donor
NYHA (New York heart Association)
• NYHA I – No cardiological symptoms
• NYHA2- Cardiological problems appear during heavy exertion
• NYHA 3- Cardiological problems appear with light exertion
• NYHA 4- Cardiological problems appear at rest, severe condition
PONV (Postoperative Nausea and Vomiting Risk Rating Scale)
Patient receives 1 point if:
• She is female
• Non-smoker
• Having motion sickness
• Patients in whom we will use narcotics after surgery
OPERATING THEATER
• Maintaining fluid and food grace period
• No smoking tobacco and products tobacco-like
• Preparation of the operating field
• Provide premedication in the evening before the procedure
• Control vital signs on the day of surgery
• Control blood glucose
• on 30 minutes before the procedure, administration of the ordered antibiotic (reduction of
operational infections)
PREMEDICATION
Premedication in the evening before the procedure, it aims to obtain:
• anxiolysis- elimination of fear
• sedation
• analgesia - pain relief
• antiallergic treatment
• preventing aspiration (nausea and vomiting)
PATIENT IN THE OPERATING ROOM.....
After identifying the patient and checking the type of procedure, upon admission to the
operating block, it is necessary to make sure that the patient is properly prepared for the
procedure, in order to do this, ask about:
• Maintaining fluid and food grace period 6hrs
• Allergies
• Previous procedures and anesthesias (ask about the course)
• Preparation of the operating field
• Removal of dentures
• Removal of all jewelry from the body
• Medications taken
The nurse admitting the patient to the block is also obliged to check the medical documentation
delivered with the patient. The documents delivered from the branch should include:
• Patient's blood group confirmed
• Blood tests not older than 2 days (coagulologymorphology, electrolytes)
• Medical orders from the ward
• Vascular Access Observation Chart
• Card of basic vital signs measurements with data from the day of the procedure
• medical history
• The results of imaging tests necessary for the procedure
• Signed by the patient compliant
WE'RE GOING FOR THE OPERATION
The patient enters the operating room in a disposable outfit with a cap on his head and a mask on
his face. The nurse who will be standing by for the procedure as an anesthesiologist is responsible
for:
• Help the patient to move to the operating table while maintaining safety rules
• Connect the patient to a cardiomonitor (HR, ECG, SpO2, RR, NIBP, BIS, TOF,
capnometry)
• Obtain patient venous access allowing for the delivery of large volumes (from 1.1 with
weak veins, standard 1.3 or 1.5) on the limb closest to the anesthesia station.
• Uphold the dignity of the patient
• Prepare the medications required for anesthesia
• Prepare the equipment necessary for anesthesia
Parameters measured during the procedure
• HR - heart rate
• NIBP - non-invasive blood pressure
• SpO2 - saturation
• RR- Number of breaths
• ECG - a graphic record of the heart's action
• capnometry - measurement of CO2 concentration in exhaled air (sensor at the mask)
• BIS-bispectral index - measure the depth of sedation by analyzing brainwaves
• TOF - muscle relaxation monitoring
BIS BISPECTRAL INDEX
TOF TRAIN OF FOUR
OPERATING THEATER
INTUBATION (SET)
Elective intubation kit- Mallampati I, II, III should contain:
• Appropriately sized endotracheal tube
• lubricant
• 20 ml syringe
• face mask
• guide Bugee
• bandage/holder for the endotracheal tube
• stethoscope
• laryngoscope
OPERATING THEATER
INTUBATION
Laryngoscope- allows to visualize the entrance to the larynx, hence its other name - laryngeal
speculum. It consists of a handle and a spatula/spoon. Batteries and a light source are placed in
the handle. The blades have light-conducting beams for better exposure of the laryngeal entrance.
Spatula types:
• Macintosh - commonly used for adults
• Miller - straight with a bent tip
• McCoy- arched with a movable end
• Magill- straight
• Polio - for intubation of women with large breasts or obese people
• Bullard-fiberscopicanatomically adapted to the respiratory tract
Spoon sizes:
1,2,3,4,5
OPERATING THEATER
The course of general anesthesia:
1. Pre-oxygenation
2. supply of painkillers (fentanyl) + Atropine???
3. Administer sedative drug (propofol, etomidate, thiopental)
4. Administer a drug that induces muscle relaxation (chlorsucillin)
5. Intubation (60 seconds)
6. Administer long-term working miorelaxant (cis-atracurium, pancuronium,
rocuronium, atracurium)
7. Conducting sedation using gases (sevoflurane, desflurane, isoflurane, halothane)
8. Obtaining full general anesthesia
9. The course of general anesthesia:
10. Closing the skin by surgeons - waking up
11. Reduction of anesthetic gases
12. Return of defensive reflexes, muscle tone, independent breathing
13. Give atropine
14. Give musclerelaxant antagonist (Polstigmine, Bridion)
15. Patient finally awaken - return of consciousness and logical contact (post surgical
room)
OPERATING THEATRE
The course of regional anesthesia (subarachnoid):
1. IV fluid supply (PWE)
2. Assisting the patient in positioning for puncture (L3-L4)
3. Preparation of the spinal anesthesia kit
4. Assist doctor in this procedure
5. Helping the patient to take required position for the procedure
6. Careful observation of vital signs
7. Use of broomage scale to check the effect of anesthesia
8. Procedure
9. End of the procedure - continued anesthesia
10. Transferring a patient to the bed
POST ANESTHESIA SUPERVISION ROOM
According to rules, each patient after the procedure and waking up should be directed to
the post operative room, where nurses and doctors will be observing patient’s condition in case of
early side effect of anesthesia or performed medical procedure. The discharge is possible if
patient collects at least 9 points in Aldret scale.
POST ANESTHESIA SUPERVISION ROOM
Criteria for discharge of the patient from the wardafter anesthesia:
• Achieve at least 9 points twice in Aldret scale in the last 30 minutes.
• Patient oriented allopsychically and allosterically,
• Efficient all systems (circulatory and respiratory),
• No hypothermia,
• Early complications of anesthesia excluded or cured,
• Nausea and vomiting (PONV) under control,
• VAS <3,
• No bleeding,
PAIN MANAGEMENT
Pain is otherwise an unpleasant subjective experience resulting from the stimulation of the
sympathetic system, giving consequences such as:
• Hypertension
• Tachycardia
Prolonged ailments and pain may contribute to the extension of the patient's stay in the
hospital as well as the transformation of acute pain into chronic pain. Each patient should be
discharged to the ward with as much pain control as possible.
After surgeries in the post operating room all groups of anelgetics are used:
• NSAIDs (Non Steroidal Anti-Inflamantory Drugs)
• Opioids
Rout of administration of analgesics depends on the performed anesthesia:
• p.o
• iv.
• directly into epidural catheter
•
ANALGESIC LADDER
PCA
PCA- or Patient Controlled Analgesia/ controlled analgesia. It consists in administering
painkillers in accordance with the needs of the patient's body. The drugs of choice are usually
opiates, which are administered by intravenous/epidural/subcutaneous/inhalation via a pump.
The pumps are equipped with a button for the supply of controlled anesthesia, which can be
pressed by the patient when the intensity of pain increases, receiving a bolus of pain
medication.
Advantages:
• The patient gets exactly the amount of painkiller he needs.
• The patient does not require (and does not have to wait) help from the staff every time he
needs the drug.
• The possibility of mistakenly administering the wrong drug to the wrong patient decreases.
• Some patients are very happy to be able to actively participate in their treatment.
Defects:
• Necessity of the patient's cooperation - physically and mentally able to use the device (it is
necessary to inform the patient precisely about the principle of the system's operation so that
he feels safe and confident during treatment).
• The price of automatic syringes.
• Possibility of syringe malfunction.
• Incorrect programming of the syringe - usually the total dose of the drug available to the
patient is too low, which may result in ineffective treatment.
ICU
• A patient qualified for ICU treatment (Aldrett scale) requires intensive pharmacotherapy,
ventilation and monitoring, and is admitted based on the severity of the condition and not the
medical diagnosis.
• The term Intensive Care generally means the support or replacement of one or more organs.
• The ICU department deals with the diagnosis and treatment of patients in life-threatening
conditions caused by potentially reversible failure (circulatory, respiratory, nervous).
Mechanical ventilation
Mechanical ventilation is the complete replacement of the patient's breathing using a ventilator.
This device enforces correct and controlled breathing.
INDICATIONS:
• respiratory failure (hypoxemia/hypercapnia)
• respiratory rate > 35 BPM
• symptoms of respiratory muscle exhaustion
• PaO2 < 60 mmHg despite the implementation of non-invasive oxygen therapy
• PaCO2 > 55 mmHg (except COPD patients)
• Protection against aspiration during intubation
• Loss of consciousness with a Glasgow score below 8.
METHODS OF ARTIFICIAL VENTILATION
• Non-invasive ventilation - otherwise ventilation without intubation, through a mask,
including CPAP.
• Invasive ventilation - in other words, ventilation with the creation of an artificial airway
• controlled volume ventilation (IMV)
• pressure controlled ventilation (PVC)
• In ICUs, oxygen therapy with spontaneous breathing is preferred (CPAP, BIPAP,
SIMV)
TYPES OF MECHANICAL VENTILATION
• Assist-Control Ventilation (ACV):
• In ACV mode, the ventilator delivers a preset tidal volume (amount of air) at a set rate
with each breath.
• If the patient initiates a breath, the ventilator delivers the preset tidal volume, ensuring
a minimum number of breaths per minute. If the patient does not initiate a breath, the
ventilator delivers breaths at the set rate regardless.
• ACV is commonly used in patients who require full ventilatory support.
• Synchronized Intermittent Mandatory Ventilation (SIMV):
• SIMV mode combines mandatory breaths set by the ventilator with patient-initiated
breaths.
• The ventilator delivers a preset tidal volume at a set rate (mandatory breaths), but the
patient can also initiate additional breaths at their own rate.
• SIMV is often used to provide partial ventilatory support while allowing the patient
some control over their breathing effort.
• Pressure-Controlled Ventilation (PCV):
• In PCV mode, the ventilator delivers breaths at a set inspiratory pressure for a
specified duration.
• The tidal volume achieved depends on factors such as lung compliance and airway
resistance.
• PCV may be preferred in patients with variable lung compliance or those at risk of
barotrauma.
• Pressure Support Ventilation (PSV):
• PSV mode provides support during spontaneous breathing efforts by delivering a
preset level of pressure support.
• The ventilator augments the patient's inspiratory effort, reducing the work of
breathing.
• PSV is commonly used as a weaning mode to facilitate the transition from mechanical
ventilation to spontaneous breathing.
• Continuous Positive Airway Pressure (CPAP):
• CPAP mode delivers a constant positive airway pressure throughout the respiratory
cycle.
• CPAP helps keep the airways open, improves oxygenation, and reduces the work of
breathing.
• CPAP is often used to treat conditions such as obstructive sleep apnea or respiratory
distress syndrome in newborns.
SIDE EFFECTS OF MECHANICAL VENTILATION
• circulatory
• decreased cardiac output
• decreased diuresis
• decreased hepatic flow
• increased intracranial pressure
• pulmonary
• VAP
• mechanical damage to the lungs
• barotrauma
• volutraum
VENTILATOR-ASSOCIATED PNEUMONIA
VAP(ventilator-associated pneumonia) is pneumonia associated with mechanical ventilation,
most often defined as inflammation of the lung parenchyma caused by infectious agents, which
was not present at the time of initiation of ventilator therapy. Langer assigns the classification of
pneumonia as VAP after 4 days from the start of ventilator therapy, while Chaste to 7 days from
the start. VAP affects 8-28% of people requiring mechanical ventilation, and as many as 27-30%
of people in ICUs. Increases the risk of death in an ICU patient up to 10x.
DRUGS IN THE ICU
1. Circulatory drugs
• Ketecholamines:
• adrenalin
• noradrenaline
• dopamine
• dobutamine
2. B-blockers:
• esmolol
• metoprolol
3. Analgesics:
• sufentanil
• fentanyl
• morphine
4. Sedatives:
• midazolam
• clonidine
• propofol
• dexdor
5. Antibiotics:
• bacteriostatic:
• tetracyclines
• sulfonamides
• bactericidal:
• penicillins
• cephalosporins
• quinolones
• carbapenems
