MODULE IV:

THE NURSES’ ROLE IN ANESTHESIA

INDUCTION

OBJECTIVES:
At the end of this module, the nurse participants will be able to:

1. Gain knowledge on the various concepts associated with anesthesia.

2. Be equipped with the right skills regarding perioperative nursing responsibilities
in the induction of anesthesia, so they can provide the best patient care during
the entire operation.
DEFINITION OF TERMS:

ANESTHESIA
Anesthesia is the use of medicines to prevent pain during surgery and other
procedures. These medicines are called anesthetics. They may be given by injection,
inhalation, topical lotion, spray, eye drops, or skin patch. They cause you to have a loss
of feeling or awareness.
It is a state of temporary induced loss of sensation or awareness. It may include
analgesia (relief from or prevention of pain), paralysis (muscle relaxation), amnesia
(loss of memory), or unconsciousness.

ANESTHETICS
Are drugs used to cause complete or partial loss of sensation. These drugs are
subdivided based on site of action and can either be general or local.

TYPES OF ANESTHESIA

1. General Anesthetics
Drugs that can cause central nervous system (CNS) depression to produce loss
of pain sensation and consciousness. It also blocks the autonomic reflexes governing
involuntary reflex response of the body to injury which can compromise cardiac,
respiratory, gastrointestinal, and immune status. Muscle reflexes are also blocked to
prevent jerking movements that might interfere with surgical procedures.
 General Anesthetic Agents
 Barbiturate Anesthetics: are intravenous drugs used to induce rapid
anesthesia, which is then maintained with an inhaled drug.
Therapeutic Action
 The desired and beneficial actions of barbiturate anesthetics depress the
CNS to produce hypnosis and anesthesia without analgesia.
 Barbiturate Anesthetics
 Methohexital (Brevital)
 Thiopental (Penthothal)
 Nonbarbiturate General Anesthetics
 Droperidol (Inapsine)
 Etomidate (Amidate)
 Fospropofol (Lusedra)
 Ketamine (Ketalar)
 Midazolam
 Propofol (Diprivan)
 Anesthetic Gasses
 Nitrous oxide (blue)
 Volatile liquids
 Desflurane (suprane)
 Enflurane (ethrane)
 Halothane (fluothane)
 Isoflurane (forane)
 Sevoflurane (sevorane, sojourn)

Risk Factors Associated with General Anesthesia

Widespread CNS depression can occur in individuals with the following risk factors:
 CNS Factors: neurological diseases that may produce an abnormal reaction to
the CNS-depressing and muscle-relaxing effects of general anesthetic agents
like epilepsy, stroke, and myasthenia gravis.
 Cardiovascular (CV) Factors: underlying CV diseases which can can be
worsened by severe reactions to anesthesia (shock, hypotension, dysrhythmia,
and ischemia) like coronary artery disease (CAD).
  Respiratory Factors: obstructive pulmonary diseases that can complicate delivery
of gas anesthetics, intubation, and mechanical ventilation like asthma, chronic
obstructive pulmonary disease (COPD), and bronchitis.
 Renal and hepatic function: conditions that interfere with metabolism and
excretion of anesthetics that could lead to prolonged anesthesia like acute renal
failure and hepatitis.

Administration of General Anesthesia

Patient undergo predictable stages during administration of anesthesia. These steps are
referred to as the depth of anesthesia:
 Stage 1 – Analgesia Stage: Characterized by loss of pain sensation and with the
patient still conscious and able to communicate.
 Stage 2 – Excitement Stage: Period of excitement and often combative behavior
with many signs of sympathetic stimulation.
 Stage 3 – Surgical Anesthesia: Involves muscle relaxation, regular respirations,
progressive loss of eye reflexes and pupil dilation. It is the stage in
which surgery can be safely performed.
 Stage 4 – Medullary Paralysis: Very deep CNS depression with loss of
respiratory and vasomotor center stimuli, in which death can occur rapidly. It is
considered a critical period because anesthesia has become too intense.

Administration of general anesthesia is divided into three phases:

 Induction: from beginning of anesthesia to stage 3. The most dangerous period
of induction is stage 2 because of the systemic stimulations that occur.
 Maintenance: from stage 3 to completion of surgical procedure.
 Recovery: from discontinuation of anesthetic to regained consciousness,
movement, and ability to communicate of the patient.

2. Regional Anesthetics
Regional anesthesia makes a specific part of the body numb to relieve pain or
allow surgical procedures to be done. It is often used for orthopedic surgery on an
extremity (arm, leg, hand, or foot), for female reproductive surgery (gynecological
procedures and cesarean section) or male reproductive surgery, and for operations on
the bladder and urinary tract.

Types of Regional Anesthesia

A. Spinal Anesthesia
 After carefully preparing the skin on the lower back with an antiseptic solution,
local anesthesia is injected into the skin to numb the area.
 An extremely small needle is placed through the skin, soft tissue, and ligaments
surrounding the spine until it reaches the subarachnoid space, which is
where cerebrospinal fluid (CSF) is found. A small amount of local anesthetic
specifically designed to go into the CSF is given, and the needle is taken out.
 Numbness usually starts at the feet and moves upward. The spread of numbness
is determined by many things, including the amount and type of local anesthetic
given, the patient's height, and the position of the patient once the medication is
given.

B. Epidural Anesthesia
 Epidural anesthesia is similar to but not the same as spinal anesthesia.
 For epidural anesthesia, a larger needle that does not reach the CSF is used, and
a catheter is placed through that needle into the epidural space.
 Using the catheter, longer-term anesthesia and pain relief can be obtained.
 Complications from both spinal and epidural anesthesia are rare. They include
difficulty breathing and bleeding or infection where the needle is inserted.
Medication for both spinal and epidural anesthesia is given only under monitored
conditions.
 Commonly used to ease the pain of labor and childbirth but can also be used to
provide anesthesia for other types of surgeries.

C. Peripheral Nerve Blocks

  Nerves start in the spinal cord and travel to different body parts. These nerves
may be blocked at several points along their paths. This can provide pain relief as
well as blocking motor function (the ability to move). Local anesthetic solution is
given as close to the nerve as possible without entering the nerve itself. Locating
nerves is made easier using a nerve stimulator or a portable ultrasound device.
Single injections or catheters may be used, depending on the purpose of the
nerve block.

Local Anesthetic Agents

 Esters
 benzocaine (Dermoplast, Lanacane)
 Procaine (Novocaine)
 Tetracaine (Pontocaine)
 Amides
 Bupivacaine (Sensorcaine, Marcaine)
 Ropivacaine (Naropin)
 Lidocaine (Xylocaine, Lidoderm, Eurocaine)
 Prilocaine ( Citanest)

3. Local Anesthetics
Drugs that can cause the same sensation and feeling in a certain area of the
body without producing the systemic effects related to severe CNS depression.
A. Infiltration: involves injecting the anesthetic directly into the tissues to be
treated. It brings the anesthetic into contact with the nerve endings in the area
and prevents them from transmitting nerve impulses to the brain.
B. Topical administration: involves the application of cream, lotion, ointment, or
drop of local anesthetic to traumatized skin to relieve pain. It can also involve
application of these forms to the mucous membranes in the eyes, nose,
throat, mouth, urethra, anus, or rectum.
NURSING RESPONSIBILITIES DURING ANESTHESIA INDUCTION
In preparing of a medical procedure, the anesthetist or anesthesiologist giving
anesthesia chooses and determines the doses of one or more drugs to achieve the
types and degree of anesthesia characteristics appropriate for the type of procedure
and the particular patient.

 Gather equipment and supplies ready for procedures

 Assist in monitoring the patient’s vital signs and communicate the information to
the anesthesiologist
 Nurse must also be able to prepare medications appropriately and recognize
their actions and untoward reactions
 During preoperative assessment, the anesthesia nurse reviews the patient’s
chart and assessment data and assesses the patient’s readiness for surgery,
plans for the intraoperative care and identifies data pertinent to anesthesia such
as comorbidities, history of asthma, previous surgeries, experiences related to
anesthetics and complications.
 Family history of adverse reactions with anesthetics such as malignant
hyperthermia.
 Drug allergies and information about the patient’s current medications including
herbal medications is essential to prevent the use of anesthesia medications that
might react unfavorably with current medications or cause an allergic reaction.
 Allergies to contrast dyes, iodine solutions, adhesive tape, food allergies and
sensitivity to latex are relevant.
 History of smoking, drug and alcohol use can alter the effect of anesthesia
medications.
 Patients who will be intubated should be assessed for cracked lips, lacerations in
or around the mouth and loose or chipped teeth. Dentures should be removed
prior to general anesthesia because they can become dislodged and interfere
with intubation and anesthetic delivery.
 Alcoholic drinkers and smokers have also been documented to need increased
anesthetic dosages and greater amounts of postoperative pain medications.
 Check to ensure that any diagnostic tests ordered were actually performed and
that the results are present in the chart. Ensure that all team members are aware
of any abnormalities in the tst results.
 Before giving any preoperative medications, make sure the patient does not have
any drug allergies and that the surgical permit has been signed, witnessed and is
on the patient’s chart or electronic record.
 Let the patient void or urinate before he or she is taken to the operating room.
 Any jewelry not removed shall be secured with tape and documented as such.
 Assist to conduct a pre- and post- anesthesia and pre- and post- analgesia visit
and assessment with appropriate documentation;
 Assist to develop a general plan of anesthesia care with the physician;
 Select the method for administration of anesthesia or analgesia
 Help to administer appropriate medications and anesthetic agents during
the peri-anesthetic or peri-analgesic period
 Support life functions during the peri-anesthetic or peri-analgesic period
 Recognize and take appropriate action with respect to patient responses
during the peri-anesthetic or peri-analgesic period
 Manage the patient’s emergence from anesthesia or analgesia
 Participate in the life support of the patient.
 The circulating nurse and the anesthesiologist both document relevant times
related to the procedure (e.g., time in the room, time of induction, time of
incision, end of operation). It is essential that the documentation of these times
be consistent in all of the various patient records.
 As much as possible, the room should be ready and preparations for surgery is
completed before the patient is brought into the operating room suite and
transferred to the operating bed.
 Once the patient is in the operating room, the anesthesia nurse must focus
attention on providing emotional support, ensuring patient dignity, instituting
safety measures and assisting the anesthesia provider.
 Confirm that the safety strap, electrocardiographic leads, blood pressure cuff,
pulse oximeter probe and intravenous line are patent and in place.
 Prior to anesthesia induction, there should be a working suction with catheter in
place within easy reach of the anesthesia provider.
 The anesthesia nurse must be present and available to assist the anesthesia
provider and if necessary, to restrain the patient ( particularly children).
 Just prior to induction, patients often become anxious. Remain at the patient’s
side, speak calmly, explain the process and answer any questions; be
reassuring. Nonverbal support such as making eye contact and holding the
patient’s hand can be the most supportive interventions in preparation for
induction.
 The anesthesia nurse might assist with intubation by pulling gently on the corner
of the patient’s mouth to increase visualization of the vocal cords and facilitate
placement of the endotracheal tube.
 The anesthesia nurse might also pass the endotracheal tube to the anesthesia
provider so he or she does not have to look up to pick up the tube.
 Following the induction of anesthesia and positioning for the surgical procedure,
the perioperative nurse should scan the patient cephalocaudally to ensure that
the body alignment is maintained and padding is adequate to prevent pressure
damage. This is a critical review—once the patient is draped, it’s difficult to
assess and adjust the patiemt’s position.
 Before positioning or repositioning the patient, the anesthesia nurse should
confer with the anesthesia provider to determine that the patient can be moved
without compromise to the airway or ventilation and that he or she is ready to
assist in repositioning by guiding and securing the patient’s head to prevent
accidental extubation or disconnection from ventilator.
 During the surgical procedure, the anesthesia nurse helps the anesthesia
provider assess fluid balance by monitoring fluid output and replacement, blood
loss, blood and blood product replacement and the amount of irrigating solution
used.
  Anesthesia nurse must also knowledgeable and demonstrate competence in the
use of monitoring equipment and in the interpretation of the data. The nurse
must also be familiar with anesthetic agents and techniques to anticipate patient
events, implement nursing interventions quickly and assist the anesthesia
provider.

INSTRUMENTS AND EQUIPMENT USED IN INDUCTION OF ANESTHESIA

1. Anesthesia Machine
 Anesthesia machine is a medical device used to generate and mix a fresh gas
flow of medical gases and inhalational anaesthetic agents for the purpose of
inducing and maintaining anaesthesia.
 The machine is commonly used together with a mechanical ventilator, breathing
system, suction equipment, and patient monitoring devices; strictly speaking, the
term "anaesthetic machine" refers only to the component which generates the
gas flow, but modern machines usually integrate all these devices into one
combined freestanding unit, which is colloquially referred to as the "anaesthetic
machine" for the sake of simplicity. In the developed world, the most frequent
type in use is the continuous-flow anaesthetic machine or "Boyle's machine",
which is designed to provide an accurate supply of medical gases mixed with an
accurate concentration of anaesthetic vapour, and to deliver this continuously to
the patient at a safe pressure and flow. This is distinct from intermittent-flow
anaesthetic machines, which provide gas flow only on demand when triggered by
the patient's own inspiration.

COMPONENTS OF A TYPICAL ANESTHESIA MACHINE

A modern anaesthetic machine includes at minimum the following components:

 Connections to piped oxygen, medical air, and nitrous oxide from a wall supply in
the healthcare facility, or reserve gas cylinders of oxygen, air, and nitrous oxide
attached via a pin index safety system yoke with a Bodok seal
 Pressure gauges, regulators and 'pop-off' valves, to monitor gas pressure
throughout the system and protect the machine components and patient from
excessive rises
 Flowmeters such as rotameters for oxygen, air, and nitrous oxide
 Vaporisers to provide accurate dosage control when using volatile anaesthetics
 A high-flow oxygen flush, which bypasses the flowmeters and vaporisers to provide
pure oxygen at 30-75 litres/minute
 Systems for monitoring the gases being administered to, and exhaled by, the
patient, including an oxygen failure warning device
 Systems for monitoring the patient's heart rate, ECG, blood pressure and oxygen
saturation may be incorporated, in some cases with additional options for
monitoring end-tidal carbon dioxide and temperature.[1] Breathing systems are also
typically incorporated, including a manual reservoir bag for ventilation in combination
with an adjustable pressure-limiting valve, as well as an integrated mechanical
ventilator, to accurately ventilate the patient during anaesthesia.

Figure 1: Anesthesia Machine Setup

2. Laryngoscopes
 It is an instrument used for intubation and direct laryngoscopy.
 It consists of two parts – the blade and the handle. The handle contains the
battery container, which acts as an energy source for the light source.
  The blades are of two varieties, straight and curved blades. Straight blade is
used to depress the tongue whereas the curved blade pushes the epiglottis to
one side to visualize the glottis.
 There are various sizes of the laryngoscope available in different numbers e.g.
0,1,2,3,4. The numbers increases with the size of the blade.
 Care has to be taken while doing laryngoscopy to prevent injury to the oral
structures especially dislocation and aspiration of the tooth. Maximum trauma is
caused by utilization of upper anterior teeth or gums as a fulcrum point.

Figure 2: Laryngoscope with Different Blade Sizes

2.1: Curved blade set 2.2: Straight blade set

3. Guedel Airways
 Is a rigid plastic tube which sits along top of mouth and ends at base of tongue
(an adjunct to help keep airway open).
 An oxygen mask or bag mask ventilation can be applied over the top if needed.
 Main purpose of the device is to prevents tongue covering epiglottis in patients
with reduced GCS
Figure 3: Guedel Airways (different sizes)
4. Suction Catheters
 Is a type of medical supplies that is attached to a suction machine suitable for
removal of secretions from mouth, trachea and bronchial tubes.
 Suction catheter can help clear the airway, especially when patients are unable
to clear secretions on their own.

Figure 4: Disposable Suction Catheters (different sizes)

5. Endotracheal Tubes
 It is a tube constructed of polyvinylchloride (PVC) that is placed between the
vocal cords through the trachea to provide oxygen and inhaled gases to the
lungs.
 It also serves to protect the lungs from contamination such as gastric contents
and blood.
 Additional equipment necessary to optimize the use and function of the ET tube
 Stylet
 Syringe for cuff/pilot balloon
 Universal 15mm connector
 End-tidal CO2 device

Figure 5: Endotracheal Tube

6. Laryngeal Mask Airways (LMA)

 Are single-use or reusable supraglottic airway devices which may be used as a
temporary method to maintain an open airway during the administration of
anesthesia or as an immediate life-saving measure in a difficult or failed airway.
 LMAs are easier to use and more effective than a bag-valve-mask in the hands
of basic life support providers and may be used as an alternative to intubation by
advanced life support providers.

Figure 6: Laryngeal Mask Airway

7. Anesthesia Breathing Circuit

 Are single-use accessories to anesthesia machine that is used to deliver oxygen
and anesthetic gases and eliminmate carbon dioxide. These most often include a
mixture of fresh gas (oxygen, air) and anesthetic gases, both volatile agents
(e.g., isoflurane) and non-volatile agents (nitrous oxide).
 Carbon dioxide may be eliminated by either washout with fresh gas flow (FGF) or
by soda lime absorption.

Figure 7: Anesthesia Breathing Circuit

8. Nasal Cannula and Oxygen Mask

 Nasal cannulas and face mask are used to deliver oxygen to people who don’t
otherwise get enough. They are commonly used to provide relief to people with
respiratory disorders.
 Nasal cannula consists of a flexible tube that is placed under the nose. The tube
includes two prongs that go inside the nostrils.
 Face mask covers the nose and mouth.
 Nasal cannulas and simple face masks are typically used to deliver low levels of
oxygen.
 Another type of mask, the Venturi mask, delivers oxygen at higher levels.

Figure 8: Nasal Cannula and Oxygen Mask

8.1: Nasal Cannula 8.2: Face Mask

9. Spinal and Epidural Needle

 Spinal needles are used to inject anesthesia and/or analgesia directly into the
CSF usually at a point below the second lumbar vertebra.
 Epidural needles (such as the Tuohy needle) are larger, hollow needles that
enter the epidural space. The curve of the needle is designed to enable an
inserted cannula to be threaded into the epidural space at an angle. Once the
cannula is in place the epidural needle is removed. Anaesthesia and analgesia
can be administered via the epidural cannula.

Figure 9: Spinal and Epidural Needle

 9.1: Spinal Needle 9.2: Epidural Needle

References:
https://nurseslabs.com/general-local-anesthetic-agents/#h-general-anesthesia
https://www.slideshare.net/HIRANGER/role-of-anesthesia-nurse-in-operation-theatre
https://jamanetwork.com/journals/jama/fullarticle/1104234
https://medlineplus.gov/anesthesia.html#:~:text=What%20is%20anesthesia%3F,loss
%20of%20feeling%20or%20awareness.
https://en.wikipedia.org/wiki/Anaesthetic_machine
https://www.pediatriconcall.com/medical-equipment/critical-care/8/laryngoscope/24
https://en.wikipedia.org/wiki/Instruments_used_in_anesthesiology
https://www.ncbi.nlm.nih.gov/books/NBK539747/#:~:text=In%20its%20simplest%20form
%2C%20the,as%20gastric%20contents%20or%20blood.
https://www.ncbi.nlm.nih.gov/books/NBK482184/#:~:text=Laryngeal%20mask
%20airways%20(LMA)%20are,a%20difficult%20or%20failed%20airway.
https://www.ncbi.nlm.nih.gov/books/NBK574503/