By Justine Barry 3rd year student (October 2008)

For many children and young people having surgery, this may be their first and only experience of a hospital environment. Admissions must be carefully planned to avoid any distress to the child and family, so care needs to be provided by staff who are educated in the needs of the child/young person and their carers (RCN 2004). Recommendations by the Royal College of Nursing suggest: Specialist knowledge is needed to assess, plan, evaluate and implement the care required to meet the needs of the child/young person and family. Information must be pitched at a correct level to patient and parent so they can make an informed choice about the procedures. The nurse must ensure the parent understands what to expect at the time of induction, offer support during and after this procedure, and keep them fully informed of progress.

The aim of this presentation is to provide a basic introduction to anaesthetics so you can relate this to your practice on the ward. This will help you understand the need for Pre and post operative observations, to gain a better understanding of drugs used in theatres and become familiar with the MDTs involved.

Justine Barry 2008

The word anaesthesia means the loss of the sensations of touch, pressure, pain and temperature in any part of the body, or in the whole of it. Anaesthesia can be given in various ways and does not always make you unconscious; it can just be used to stop pain in an area of the body, this is called a local anaesthetic.
A general anaesthetic is used when you need to be in a state of controlled unconsciousness and free of pain during a test or operation. A combination of drugs given either as gas to breathe into the lungs, or as an injection (NHS
2008).
Justine Barry 2008

The Triad of Anaesthesia was developed to describe the three basic requirements of an anaesthetic that must be achieved to ensure a successful outcome. (Davey 1999, pg 143)

Hypnosis Refers to the alterations in the patients conscious -ness. General anaesthetics are given to render the patient unconscious, whereas with local anaesthetics a sedative may be given to produce a state of drowsiness.

Hypnosis

AnalgesiaRefers to the use of drugs and other techniques used to ensure the patient recovers with as little pain as possible and to also suppress the physiological reflexes, that occur following surgical stimulation.

Relaxation refers to the need for reduction or elimination of muscle tone, which can be retained even when the patient is unconscious. Muscle relaxants are necessary for certain types of surgery or procedures i.e. intra-abdominal surgery and intubation.

Analgesia

Relaxatio n

Justine Barry 2008

(Davey 1999)

ANAESTHETICS: HOW THEY WORK

Type Names Halothane, Sevoflurane, Isoflurane, Ketamine, Nitrous Oxide, Thiopental Administered Affect

General

Intravenously, Inhalation

Produces total unconsciousness affecting the entire body

Regional

Bupivacaine Chloroprocaine, Lidocaine

Procaine, Lidocaine, Bupivacaine
Benzocaine, Lidocaine Dibucaine, Pramoxine, Butamben, Tetracaine

Injection

Temporarily interrupts transmission of nerve impulses (temperature, touch, pain) and motor functions in a large area to be treated; does not produce unconsciousness Temporarily blocks transmission of nerve impulses and motor functions in a specific area; does not produce unconsciousness

Local

Injection

Topical

Dermal (Sprays, Drops, Ointments, Creams, Gels)

Temporarily blocks nerve endings in skin and mucous membranes; does not produce unconsciousness

KRAPP (2002)

Justine Barry 2008

Information is moved around the brain, from nerve cell to nerve cell, by means of chemical substances, called neurotransmitters 1 2 3 4 A message travels along the nerve and when it approaches the nerve ending a neurotransmitter is released. The neurotransmitter is received by the next cell some of the neurotransmitter gets reabsorbed When enough neurotransmitter is received by the next nerve cell the message moves forward message The activation of a nerve impulse is an electrical phenomena in which a series of connected nerve fibres are sequentially polarised and depolarised. A nerve impulse is passed from one nerve cell to the other across the cleft by a "neurotransmitter". This voltage comes about due to the differences between the ionic composition of inside the cell (where potassium ions, K+, are in higher concentration) and outside the cell (where sodium ions, Na+, are in higher concentration). When stimulus is applied to these cells, Na+ ions flow into the cell, voltage increases, thereby causing K+ to flow out of the cell. This change in voltage is referred to as depolarization.

Next nerve cell

neurotransmitter

Local anaesthetics - act by preventing the normal depolarisation/re-polarisation of nerve cells. Local anaesthetic
drugs do this by blocking conduction of the electrolytes and therefore block the normal action of the nerve. After absorption of the drugs into the systemic circulation, metabolism occurs either in the liver or in the plasma and the drug is then excreted by the kidneys (ONeil 2006). Justine Barry 2008 (Grant 2006) (http://www.cdhb.govt.nz/totara/brain.htm)

Topical anaesthetic preparations reduce the pain of a venepuncture and facilitates IV induction, whilst reducing the necessity for sedative pre-medication. (Allman 2006) The Royal College of Nursing (2004) recommends the use of Emla and Ametop as fear of needles is always a concern for children and young people

Emla is a mixture of Lidocaine and Prilocaine and is applied over the site under an occlusive dressing for at least an hour (no more than 5 hours) before the planned procedure. It is usually applied to at least two sites in case the first attempt fails. (BNFC 2008 and Aitkenhead et al 2003). Emla is a vasoconstrictor and works by numbing the skin, preventing pain signals passing from the area of application to the brain. Side effects include: paleness, redness and swelling of the site. Mild burning, tingling or itching sensation and methaemoglobinaemia. Should not be used in children under 1 year of age.

Ametop is a local anaesthetic gel which is applied in the same way as Emla, but is left on the skin for 30 minutes for venepuncture and 45 minutes for venous cannulation, and lasts for 4-6 hours ( BNF 2008). Ametop is a vasodilator and works by blocking the message from the pain receptors to the brain and hence blocks the sensation of pain. Ametop should only be applied to intact healthy skin and should not be used on broken skin or open wounds. Side effects include: flushing of the skin, due to widening of the small blood vessels (erythema). oedema, pruritis, sensitisation, and blistering of the

skin at the site of application.

Justine Barry 2008 BNFC 2008)

Local anaesthetic drugs are injected near to the set of nerves which carry signals from that area of the body to the brain (NHS 2008). They reversibly block nerve initiation and transmission when applied locally to nerve tissue (ONeil 2006), blocking nerve fibres with the smallest diameter first (Wood 1998). They are also used to infiltrate surgical wounds at the end of an operation.

Lidocaine/Lignocaine
Is a quick and short acting local anaesthetic used for surface infiltration, intravenous blocks and spinal/ epidural anaesthesia. Its length of action is 1-2 hours. Side effects include: slurred speech, psychosis, tremors, agitation and difficulty swallowing.

Bupivacaine/Levobupivcaine
Is a slow and long acting local anaesthetic used for infiltration, intravenous blocks and spinal/epidural anaesthesia. Its length of action is 4-8 hours. Side effects include: Nausea, vomiting, nervousness, disorientation, dizziness and blurred vision.
www.littonbio.com Justine Barry 2008

Regional anaesthesia is used for operations on larger or deeper parts of the body. Local anaesthetic drugs are injected near to the set of nerves which carry signals from that area of the body to the brain.
Epidural anaesthesia requires a fine tube catheter to be left in the epidural space, through which further injections or an infusion of anaesthetic drugs can be given. Drugs can also be given down the epidural catheter after the operation to provide continuing pain relief in the postoperative period
(NHS 2003, pg 16).

Spinal Block Spinal anaesthesia is a major form of regional

anaesthesia, performed by injecting an anaesthetic drug between two of the vertebrae of the lower back into the fluid between the discs. This blocks the nearby spinal nerves, causing a complete loss of feeling from that point down the body (NHS 2008).

Biers Block- Local Anaesthetic is injected into the limb, where the
blood flow is impeded by the application of a tourniquet, the drug is then rapidly taken up from the venous system by the peripheral nerves (Anaesthesia UK 2008). http://surgerycenter.spinalmedicine.com https://healthlibrary.epnet.com. Justine Barry 2008

General anaesthesia is the induction of a balanced state of unconsciousness, accompanied by the absence of pain sensation and the paralysis of skeletal muscle over the entire body. It is induced through the administration of anaesthetic drugs and is used during major and other invasive surgical procedures (Krapp, K. Cengage, G. (2002).
There are two major types of anaesthetics used for general anaesthesia, inhalation and intravenous anaesthetics.
Inhalation anaesthetics, which are sometimes called volatile anaesthetics, are compounds that enter the body through the lungs and are carried by the blood to body tissues (NDA 1998). The most commonly used anaesthetic vapours used in paediatrics are Sevoflurane, Halothane and Isoflurane. Inhalation anaesthetics act either by amplifying inhibitory function or decreasing excitatory transmission at the nerve endings in the brain. Volatile anaesthetics are seldom used alone, a combination of inhalation anaesthetics and intravenous drugs is called balanced anaesthesia. Ideally, inhalation agents should provide a quick induction and emergence from anaesthesia, good analgesia, muscle relaxation, quick changes and easy maintenance of anaesthesia (Wenker 1999). Intravenous anaesthetics may be used to either induce anaesthesia or for the maintenance of anaesthesia throughout a surgical procedure. TIVA is a total intra-venous anaesthesia, a technique where all drugs are given IV (BNFC 2008).
Justine Barry 2008

Nitrous Oxide (laughing gas) is used as a carrier gas to supplement inhalation agents. Produces light anaesthesia, And some analgesia

Oxygen inhalation anaesthetics must be given with concentrations of oxygen greater than 21%, to prevent hypoxia.

Sevoflurane
Most commonly used vapour Rapid acting anaesthetic Rapid emergence and recovery Non irritant Pleasant smell Produces low levels of respiratory depression. Little or no nephrotoxicity.

Halothane
Causes unconsciousness, but provides little pain relief Induction is smooth and vapour is usually non-irritant, rarely induces coughing or breath-holding. Is not widely used as it is associated with severe hepatotoxicity. Depresses cardiac muscle fibres, causing bradycardia.

Isoflurane
rarely used vapour as Sevoflurane has replaced the use of Isoflurane. causes muscle relaxation Used to maintain a state of general anaesthesia. can induce irregular heart rhythms Systemic arterial pressure can fall and cardiac output can decrease. (BNFC 2008, Krapp 2002, ONeil 2006)

Justine Barry 2008

Justine Barry 2008

Ketamine Propofol
Most commonly used induction agent painful on injection- rapid recoveryhas good analgesic properties at sub-anaesthetic dosage and it causes less hypotension than Thiopental and Propofol during induction. Can cause hallucinations, Nightmares and Psychotics effects

causes significant decreases in blood pressure and heart rate, it also contains anti-emetic properties

Thiopentone Etomidate
Why not look In the British National Formulary (BNF) To see more side effects and the dosages Of these drugs. Rapid recovery- Less Incidence of hypotension -no hang Over effects-May Cause muscle spasm on induction -Should not be used for The maintenance of anaesthesia Enables smooth, rapid induction- slow recoveryno analgesic propertiesCardio-respiratory depression Can occur

(BNFC 2008)

Guedals classification of General Anaesthesia STAGE 1 begins with the induction of anaesthesia and ends with the patient's loss of consciousness. The patient still feels pain this stage.

STAGE 2 Excitement- reflexes remain and coughing, vomiting and Struggling may occur. Respiration can be irregular with Breath holding.

STAGE 3 ( divided into four planes) Plane 1- Eyelid reflex lost, swallowing reflex disappears Plane 2- eyeball movement ceases, laryngeal reflex lost, Corneal reflex disappears, secretion of tears increases Plane 3- diaphragmatic respiration. Pupils dilated Plane 4 complete intercostal paralysis

STAGE 4
Medullary paralysis with respiratory arrest and vasomotor Collapse as a result of anaesthetic overdose. Death may result if the patient cannot be revived quickly.

Justine Barry 2008

(www.tpub.com, Dougherty 2004)

Drugs are sometimes, given to reduce fear and anxiety in the pre-operative patient, to relieve pain and discomfort when present, and to increase the action of anaesthetic agents. Sedative pre-medication is rarely used in day-case patients as the effects can be unpredictable and can cause excessive drowsiness postoperatively (RCN 2004). A number of the drugs used also provide some degree of pre-operative amnesia. The choice will vary with the individual child, the nature of the operative procedure and the anaesthetic to be used. The choice also varies between elective and emergency operations. Oral administration is preferred where possible but it is not altogether satisfactory; the rectal route should only be used in exceptional circumstances. (BNFC 2008) Anticipation of the need for analgesia and pre-emptive treatment should be the norm (Doyle 2007, pg 146). The following are common drugs used for paediatric premedication.

Midazolam

- (Benzodiazepines) is a oral premedicant commonly used to sedate children and given 30-60 minutes before the procedure. This sedative relieves anxiety and causes amnesia, useful for reducing the likelihood of unpleasant memories of the procedure. - used to treat mild-moderate pain, do not depress respiration or impair gastro-intestinal motility and dont cause dependence. They are a useful alternative to opioids (side effects of which include respiratory and cardiovascular depression) for the relief of post-operative pain. Onset of action is approx 30 minutes. - Has anti-pyretic and analgesic properties, do not cause respiratory depression (unlike opioid analgesics), are less irritant to the stomach than NSAIDs. Given orally, rectally and intravenously. Onset of action is approx 30 minutes.

Brufen

Paracetamol

Justine Barry 2008

(BNFC 2008)

http://labs.ansci.uiuc.edu

Motor end plate

Axon of motor nerve Muscle fibres

Drugs in this group induce muscle paralysis by affecting Acetylcholine (a neurotransmitter) metabolism. Normally, stimulation of a motor nerve causes the nerve endings to release Acetylcholine, which binds to the motor-end plate. Depolarisation than occurs and the muscle contracts. Acetylcholinesterase then metabolises the Acetylcholine, allowing the muscle to repolarise and relax, ready for the next contraction (ONeil 2006, Grant 2006) Artificial ventilation is required when using muscle relaxants as they affect the muscles used for respiration.

Suxamethonium is a depolarising muscle relaxant

which means it acts directly on the motor end plate of voluntary muscles. While this drug remains attached to the motor end plate, muscle fibres remain inhibited, so therefore cannot respond to nerve stimulation. This action causes paralysis in around 90 seconds and lasts for 2-5 minutes until the drug Is metabolised by the body. Repolarisation then occurs, which reactivates the muscle (Wickers 2006). This process Cannot be reversed and recovery is spontaneous. Side effects include: flushing of the skin, excessive salivation, bradycardia, tachycardia, post-operative muscle pain and prolonged respiratory depression.
Justine Barry 2008

Atracuriam is a non-depolarising muscle relaxant which

acts as a barrier to Acetylcholine, preventing it reaching the receptors on the motor end plate and causing depolarisation. The muscle remains paralysed and unresponsive since the drug nor Acetylcholine can depolarise the fibres. This action lasts for 15-35 minutes until the amount of Acetylcholine increases and overcomes this barrier restoring muscle contractibility. (Wood 1998). Neostigmine is the specific drug for reversal of nondepolarising blockade. It acts within one minute of intravenous injection and its effects last for 20-30 minutes a second dose may then be necessary. Atropine is given with neostigmine to prevent bradycardia, excessive salivation, and other effects of neostigmine.
(BNFC 2008)

Opiates such as Morphine and Fentanyl, are potent analgesics which play a major role in the management of moderate and severe pain in children. They are used for reducing pain, anaesthetic and surgical distress and they are often used pre, Intra and postoperatively. Opiates can be given via intramuscular, intravenous,oral topical and intrathecal routes. The side effects of opiates include: euphoria, respiratory depression, depression of the coughing reflex, nausea and vomiting, reduction of smooth muscle contraction and cardiovascular depression. Opiate Antagonists, such as Naloxone and Nalorphine, support the patients respiratory and cardiovascular system during reversal of anaesthesia and postoperative care.

Analgesics are a complex group of drugs.they act by either reducing capacity of the nerve fibres to sense pain or by reducing pain recognition by the higher Centres of the brain. (ONeil 2006, pg 109)

Paracetamol and Non-Steroidal Anti Inflammatory Drugs (NSAIDs) are commonly used non-opioids used for managing pain following minor surgical procedures or when the pain following major surgery begins to subside. NSAIDs such as Diclonfenac and Ibuprofen, provide better pain relief than paracetamol and can be used alone or in combination with paracetamol and opioids. Side effects of NSAIDs include coagulation problems,Renal impairment, diarrhoea, nausea and gastrointestinal disturbances limit their use. Paracetamol remains the most popular and widely used prescribed analgesic and antipyretic and forms the mainstay of almost all analgesic regimens (Doyle 2007, pg 156). Paracetamol has a very good safety record and can be given orally, IV and rectally. Side effects are rare, but can include: rashes, blood disorders and hypotension reported on infusion.
Justine Barry 2008

(BNFC 2008, Dougherty 2004, Doyle 2007 and ONeil 2006)

An Anaesthetist is A medically qualified doctor who cares for a patient during a surgical procedure and administers either a general or regional anaesthetic. Anaesthetists also assess the state of a patients health before a planned surgical procedure, and are often involved in caring for the patient post-surgery. Most specialists in intensive care and pain management are anaesthetists (NHS 2003, pg 50).

Anaesthetists are supported in their work by other members of the healthcare team. The following are just four of the many professionals involved.
Operating Department Practitioners (ODPS) and Anaesthetic Nurse are integral to operating practice and safe, effective care. (Wicker and ONeil 2006, pg 243). Their duties include: assisting the anaesthetist in maintaining anaesthesia, recording fluid balance, transfusions and recording the patients vital signs. (Moss 2007) Recovery Nurse is post-operatively responsible for maintaining a safe patient airway, monitoring of vital signs, checking wound sites, assessing the patients pain level and if necessary, administering analgesia. After complete recovery, completion of documentation and a concise handover is delivered to ward staff. (Moss 2007) Pain Team- are staffed by consultant anaesthetists and registered specialist nurses offering guidance on pain control for patients with: surgical, medical, trauma and acute post-operative pain. All patients with epidural analgesia and morphine infusions are followed up by the pain team. The acute pain service also provides continuing education and support for the other ward -based staff who may be involved in the monitoring and provision of pain relief. (AAGBI 2001)
Justine Barry 2008

All patients should have had a basic physical examination of the cardiovascular and respiratory systems conducted by a medical practitioner. The anaesthetic room is not the appropriate place for an anaesthetist to see an un-assessed patient for the first time prior to surgery. The hospital system must allow time for patients to be seen pre-operatively by the anaesthetist. If this is not the case, elective operations may have to be cancelled. The pre-operative visit also provides an ideal opportunity for teaching trainees and other healthcare staff about pre-anaesthetic assessment (AAGBI 2001 pg 4). Ward staff, the collecting/receiving staff from theatres, the Anaesthetist and the surgeon/surgical team have linked, but separate responsibilities. The potential for human error is such that patient checking must be a shared responsibility that can never be delegated to a single person (Digger 2005, pg 5).

The Objectives of Pre-Operative assessment

The aim in assessing patients before anaesthesia and Surgery is to improve outcome. This is achieved by: identifying potential anaesthetic difficulties identifying existing medical conditions improving safety by assessing and quantifying risk allowing planning of peri-operative care providing the opportunity for explanation and discussion allaying fear and anxiety Good pre-operative assessment will help to: reduce costs increase efficiency of operating theatre time Such action should: reduce the number of patients who fail to attend on the day of surgery reduce cancellation of surgery for clinical reasons

Pre-operative checklist
the Patient Agreement to Investigation/Treatment form is completed and signed. side and site of the operation is marked and this is documented. the patient should be starved as per the trust preoperative guidelines and the times of the last food/fluids noted on the checklist. any jewellery needs to be removed to prevent possible burns from the diathermy or loss into an open wound. (Digger 2005)

Patients should have access to easily understood information. Such information may be conferred through patient advocates or via information sheets in an appropriate language. (AAGBI 2001, pg 6)

The ward staff must take all the patients medical records and documents to the anaesthetic room in order for theatre staff to correctly check the patients details.
Justine Barry 2008

The immediate postoperative care is as critical as the intra-operative care and the child should be taken to a recovery area with trained staff (NDA 1998) The recovery nurse will obtain a full account of: the operation that has been performed instructions from the anaesthetist with regards to positioning of the patient, O2 therapy, IV fluids and pain management. Instructions from the surgeon about drains, packs, catheters and recommencement of oral feeding. Children are observed on a 1:1 nurse to patient ratio and are continuously monitored for oxygen saturation (Sa02), temperature, blood pressure (BP), colour, respirations, and consciousness . All vital signs are recorded at five minute intervals to detect any signs of deterioration, distress or pain. Children are nursed on a tilting trolley to protect the childs airways should they vomit. Oxygen is given initially to post-operative patients on reversal of anaesthesia to encourage the transport of anaesthetic gases across the alveolar/capillary membrane in the lungs and out of the body. Supplemental oxygen is often required in higher concentrations because of the increase in the metabolic rate caused by surgery, since it results in physiological stress and trauma (Hughes 2004).

This is essential in order to gain and relay accurate information to ward staff, which will facilitate smooth and on going transition of care. (CMMC 2004)
Justine Barry 2008

Why not look at effects Of post-operative Complications PONV And Hyperthermia?

D H ISC ER E
By Justine Barry 3rd year student (October 2008)

Please return this CD for the next person to use. If you require a copy either print or save to a pen-drive. Thank you.
Justine Barry 2008

AAGBI (2001) Pre-operative assessment and the role of the Anaesthetist. AAGBI. London Aitkenhead, A.R, Rowbotham, D.J, and Smith. G. (2003) Textbook of Anaesthesia. 4 th Ed. Churchill Livingstone. London. Allman K.G and Wilson, I.H.(2006) Oxford Handbook of Anaesthesia. 2 nd Ed. Oxford University Press. Oxford. British National Formulary. (2008) BNF for Children. British Medical Journal. London. Central Manchester and Manchester Childrens University Hospitals (2004) procedure for the care of the child in the recovery room following general anaesthesia. NHS. Davey A, Ince, C,S (1999) Fundamentals of Operating Theatre Practice. Cambridge University Press. Cambridge. Davis, P.J Motoyama, E.K (2006) Smiths Anaesthesia for Infants and Children. 7 th Ed. Mosby Elsevier. USA. Dougherty L, Lister S (2004) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. 6 th Ed. Blackwell. Oxford Doyle, E (2007) Paediatric Anaesthesia. Oxford University Press. Oxford. Grant A, Waugh A (2006) Ross and Wilson- Anatomy and Physiology in Health and Illness. 10th Ed. Churchill Livingstone. London. Digger T (2005) The Dudley Group Of Hospitals NHS Trust- Policy For Safe Patient Preparation Prior To Surgery. Hughes E (2004) Principles of post-operative patient care. Nursing Standard. 19, 5, 43-51. Date of acceptance: July 12 2004. Krapp, K. Cengage, G. (2002)."Anesthesia, General." Encyclopaedia of Nursing & Allied Health. Ed. 2002. Moss, M (2007) Central Manchester and Manchester Childrens University Hospitals- Student Welcome pack (surgical). CMMC. NHS (2003) Clinical standards for Anaesthesia-Scotland. NHS Quality Improvement Scotland. Glasgow. ONeill J, Wicker P (2006) Caring For The Perioperative Patient. Blackwell Publishing. Oxford Royal College of Nursing (2004) Children/young people in day surgery. RCN. London Wenker O: Review of Currently Used Inhalation Anaesthetics; Part I. The Internet Journal of Anaesthesiology 1999; Vol3N2: http://www.ispub.com/journals/IJA/Vol3N2/inhal1.htm ; Published April 1, 1999; Last Updated April 1, 1999 . https://healthlibrary.epnet.com Spinal and Epidural Anaesthesia by Rosalyn Carson-DeWitt, MD http://www.nwfsc.noaa.gov http://www.frca.co.uk Anaesthesia UK-Guanethidine Biers blocks (2008) www.nda.ux.ac.uk- (1998) Paediatric Anaesthesia Review. Issue 8 Article 2.