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Anesthetics, NMB, Narcotics, Sedatives & Anticonvulsants. Georgia Baptist College of Nursing Kathy Plitnick RN PhD CCRN. Anesthetics. Anesthesia – loss of sensation with/without loss of consciousness Analgesia - loss of pain sensation Types of Anesthesia

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anesthetics nmb narcotics sedatives anticonvulsants

Anesthetics, NMB, Narcotics, Sedatives & Anticonvulsants

Georgia Baptist College of Nursing

Kathy Plitnick RN PhD CCRN

anesthetics
Anesthetics
  • Anesthesia – loss of sensation with/without loss of consciousness
  • Analgesia - loss of pain sensation
  • Types of Anesthesia
    • General – controlled state of unconsciousness
    • Regional – nerve conduction is blocked to a region of the body
    • Local – blocking of pain impulses on peripheral nerves
    • Balanced – selection of several different drugs, without excessive CNS depression
stages of anesthesia
Stages of Anesthesia
  • Stage of Analgesia (I): distortion of sight, hearing, numbness, analgesia
  • Stage of Delirium (II): loss of consciousness, involuntary activity, psychomotor excitement
  • Stage of Surgical Anesthesia (III): end of delirium to occurrence of apnea
  • Stage of Medullary Depression (IV): begins with apnea, ends with circulatory collapse
parenteral agents propofol diprivan
Parenteral Agents: Propofol (Diprivan)
  • Hypnotic without analgesia, amnesia
  • IV rapid induction, short term sedation
  • Rapid acting, rapid emergence
  • Adverse: hypotension, bradycardia, apnea
  • Contraindicated: soybean, egg, L&D
  • Nursing:
    • Titrate to sedation level, aseptic technique (fat emulsion), emergency equipment, “wake up” assessment, patent airway, analgesics
inhalation anesthetics
Inhalation Anesthetics
  • Isoflurane (Forane) –volatile liquid
  • Induction and maintenance – given with Nitrous oxide
  • Depresses all levels of CNS, skeletal muscle relaxant
  • Potent respiratory depressant
  • Minimal depression of myocardium
  • Potential for malignant hyperthermia
  • Depresses kidney function
isoflurane
Isoflurane
  • Post operative shivering
  • IV Demerol, rewarming
  • Monitor vs, temperature frequently
  • Prevent aspiration
  • Monitor U/O
nitrous oxide
Nitrous Oxide
  • Nonflammable, inorganic gas, colorless, odorless
  • Cortical depression
  • Good analgesic, weak anesthetic
  • Rapidly absorbed through lungs
  • Adverse: depresses cardiac contractility, hypoxia
local lidocaine
Local: Lidocaine
  • Inhibits transport of ions across neuronal membranes
  • Prevents initiation & conduction of nerve impulses
  • Routes: topical, infiltration, mucosal, IV
  • Nursing: assess degree of numbness, ensure gag reflex intact after oral sprays
  • Infiltration: used with Epinephrine to prolong local effect
neuromuscular blockers
Neuromuscular Blockers
  • Cause muscle relaxation, paralyzation
  • Short term use: facilitate intubation, procedures in mech ventilated
  • Long term use: mechanical ventilation, control agitation, decrease tissue oxygen demands, increased ICP
  • Always administer with an analgesic &/or sedative
  • Patient is completely dependent
  • Protect the patient
depolarizing agents succinylcholine anectine
Depolarizing Agents: Succinylcholine (Anectine)
  • Depolarization of motor end plates, bind to receptors
  • Muscle contraction appear as fasciculations (tremors) followed by muscle relaxation
  • Complete paralysis in 2-3 minutes
  • No effect on CNS
succinylcholine
Succinylcholine
  • Adverse: stimulates vagal ganglia
    • Apnea
    • Histamine release
    • Increased intraocular pressure
    • Malignant hyperthermia
  • Never assume a paralyzed patient is asleep
  • Mechanical ventilation support
nondepolarizing agents
Nondepolarizing Agents
  • Block action of acetylcholine
  • Prevents depolarization of muscle membrane, muscle contraction cannot occur
  • Used in OR – to expose operative site, close wound
  • Anesthesiologist: facilitate intubation
tubocurarine tubarine
Tubocurarine (Tubarine)
  • Gradual paralysis over 1-5 minutes without fasciculation
  • Sequence of paralysis
  • Persists for 40-60 minutes
  • Reversed by anticholinesterases
  • Effects: hypotension, peripheral vasodilatation, myocardial depression, reflex tachycardia, increased secretions, decreased u/o, GI motility
tubocurarine
Tubocurarine
  • Toxic: prolonged apnea, cardiovascular collapse, recurarization
  • Nursing:
    • Hypotension profound in hypovolemia
    • Rehydrate
    • Avoid use in asthmatics
    • Excreted by kidneys – slower recovery or repeated doses of anticholinesterases
narcotics morphine
Narcotics – Morphine
  • Opioid analgesic, binds to opiate receptors
  • Alters perception to painful stimuli
  • Produces CNS depression
  • Uses: severe pain, pulmonary edema, acute MI
  • Available: oral, IM, IV, SC, rectal, epidural, intrathecal
morphine
Morphine
  • Adverse: confusion, sedation, respiratory depression, arrest, hypotension, constipation, urinary retention, itching, dependence
  • Nursing:
    • Assess VS, type, location & intensity of pain
    • Assess bowel function
    • Co-administration of nonopioid analgesics
    • Discontinue gradually
    • Give IVP slowly, safety precautions
codeine
Codeine
  • Mild narcotic agonist
  • Decreases cough reflex, GI motility
  • Completely absorbed from IM sites
  • Use Cautiously in head trauma, increased ICP, undiagnosed abdominal pain
  • Often combined with analgesic (ASA, tylenol) Tylenol #2 – 15 mg Codeine
pentazocine talwin
Pentazocine (Talwin)
  • Narcotic Agonist-Antagonist
  • Antagonist properties may result in opioid withdrawal
  • Withdrawal symptoms: vomiting, restlessness, abdominal cramps, increased BP & temperature
  • Additional adverse: hallucinations, euphoria, lightheadedness
  • IM injections deep into well-developed muscle
narcotic antagonist naloxone narcan
Narcotic Antagonist – Naloxone (Narcan)
  • Antidote for opioid overdose
  • Reverses CNS depression
  • Results in sympathetic stimulation
  • IVP: 0.02 – 0.2 mg q 3-5 minutes
  • Always assess pain after IV Narcan
  • Resuscitation equipment readily available
cns depressants
CNS Depressants
  • Benzodiazepines: Lorazepam (Ativan)
  • Potentiates GABA – inhibitory NT
  • Sedation, amnesia
  • Uses: anxiety, seizures, insomnia, diagnostic procedures
sleep stages
Sleep Stages
  • NREM:
    • 1: Relaxed wakefulness
    • 2: Light sleep – 50% of sleep
    • 3 & 4: Slow wave (delta), deep restorative, secrete hormones, enhance immune function, 15-50%
  • REM:
    • Mentally, emotionally restorative
    • Psychological problems from deprivation
    • 90 minute cycles
cns depressants rem sleep
CNS Depressants & REM sleep
  • Barbiturates
    • Suppress REM sleep
    • Rebound effect
  • Benzodiazepines
    • Do not suppress REM sleep
lorazepam ativan
Lorazepam (Ativan)
  • Available oral, IM, IV (1-5 min)
  • Half-life 10-20 hours
  • Nursing:
    • Assess degree of anxiety
    • Psychological, physical dependence
    • Bedrest, safety precautions (IV)
    • Slow IVP
    • Avoid ETOH
    • Seizure management
    • Renal function
anticonvulsant therapy
Anticonvulsant Therapy
  • Seizures: abnormal electrical activity in nerve cells, discharges occur in cerebral cortex
  • Localized areas or entire brain
  • Idiopathic: no specific cause
  • Nonidiopathic: abscess, trauma, encephalitis, CVA, uremia, ETOH, drug overdoses, sudden withdrawal, hypoglycemia, hypocalcemia, fever
anticonvulsants
Anticonvulsants
  • Block movement of sodium ions , less excitable membranes
  • Enhance GABA activity
  • Long term therapy
  • Oral use, IV
  • Stop a seizure: Lorazepam, Diazepam
  • Prevent seizure: phenobarbital, dilantin
phenytoin dilantin
Phenytoin (Dilantin)
  • Treatment/prevention tonic-clonic seizures
  • Alters ion transport
  • Absorb slowly, 18-24 hours
  • Steady state 1-3 weeks
  • Adverse: ataxia, drowsiness, hypotension, gingival hyperplasia, slurred speech
phenytoin
Phenytoin
  • Nursing:
    • Characteristics of seizure
    • Oral hygiene
    • Hypersensitivity reaction
    • Seizure precautions
    • IVP precautions
    • Patient identification
    • Urine: pink, red, reddish brown
    • Avoid antacids
    • Therapeutic levels: 10-20 mcg/ml
phenobarbital
Phenobarbital
  • Produces CNS depression
  • Decreases motor activity, alters cerebellar function
  • Anticonvulsant activity, sedation
  • Uses: tonic-clonic, febrile seizures
  • Half-life 2-6 days
  • Adverse: hangover, delirium, drowsiness, excitation, hypotension
phenobarbital1
Phenobarbital
  • Frequent VS with IV use
  • Resuscitation equipment
  • Dependence
  • Suicide precautions
  • Seizure assessment, precautions
  • Evaluate hepatic, renal, CBC
  • Therapeutic level: 10-40 mcg/ml
  • Slow IVP
anticonvulsants1
Anticonvulsants
  • Clonazepam (Klonopin): petit mal, myoclonic, long term treatment
  • Ethosuximide (Zarontin): absence seizures, peak levels in 3-7 hours, anorexia & gastric upset a problem
  • Carbamazepine (Tegretol): tonic-clonic, partial seizures, related to TCA’s, watch LFT’s, BUN, bilirubin, plt ct.