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What are the goals of anesthesia?
- controlled, reversible state of unconsciousness
- maintenance of physiologica homeostais
- --function of all systems during peri-operative period to minimize adverse outcomes
- amnesia - result of general anasthesia
- analgesia
- neruomuscular blockade
- --allows muscle relaxation for proglonged period of time
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What are the two types of anestesia?
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What are the 4 components of general anasthesia?
- amneisa
- analgesia
- inhibition of noxious reflexes (keep from gaging on trach tube)
- skeletal muscle relaxation
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What are the three phases of general anasthesia?
- induction
- used to relax and start process
- IV meds used
- --propotol is most common
- --less common - sodium pentothal, ketamine, etomidate (risk of adrenal insufficiency)
- maintenancevilitile gases - sevoflurane, desflurane, nitrous oxide
- TIVA (total IV anesthesia) - meds released on a timer based on HR and BP
- emergenceautonomic hyper-responsivencess may result in:
- --HTN, tachycardia, broncho/laryngospasm
- --can be blunted with short acting narcotics, beta blockers, lidocaine
- coming out of anesthesia
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What are the advantages of general anasthesia?
- total control
- reduced intra-operative patient awareness and recall
- control of airway, breathing, and circulation
- can be used in cases of sensitivity to local anesthetic sites
- adapted easily to procedures of unpredictable duration
- --can extened if something goes wrong
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What are the disadvantages of general anesthesia?
- complexity of care and costs
- physiological fluctuations (HR, RR, BP)
- less serious complications:
- --vomitting
- --sore throat
- --HA
- -- shivering
- --delayed return to normal functioning
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What are the general effects of general anesthesia?
- neurological
- cortical
- --brain
- --"paralysis" - relaxation of the muscles
- autonomic
- --decreased in HR, BP, hot/cold temperatures
- metabolic
- hypothermia
- cardiovascular
- decreased cardiac output
- arrythmia
- peripheral vascular
- decreased BP - less blood returns to the brain
- respiratory
- decreased of altered:
- --arterial oxygenation
- --hypoxia
- --respiratory patter
- --residual capacity (can't expell air completely)
- potential atelectasis or pneumothorax
- pneumonia
- PMH could play a role
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What are the risk factors of general anesthesia?
- COPD, emphysema, Hx smoking, obesity
- prolonged time = increased risk for complications
- los of blood = decreased blood count
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What is regional anesthesia used for?
- used for specific site surgical procedures
- --lower abdominal
- --UE and LE
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What are the different types of regional anesthesia?
- spinal (subarachnoid)
- epidural (thoracic and lumbar)
- peripheral nerve blocks
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Describe spinal anesthesia
- small-gauge needle inserted into L3-L4 or L4-L5
- reaches subarachnoid space
- local anestheisa is injected (temporary numbness and relaxation)
- most common for LE procedures
- doesn't affect body and doesn't have same body effects
- effects C-fibers which control pain
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Describe epidural anesthesia
- small-gauge flexible catheter into epidural space
- may remain in place during and post-op
- can be used in combo with GA to decrease peri-op stress
- used with IV like method
- can control more "going in/out"
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Complications of regional anesthesia
- post-dural puncture headache (PDPH)
- --more common with large needles (epidural)
- --less common with spinal anesthesia
- spinal hematoma
- --anti-platelet medication considerations
- --prevent clotting
- epidural abscess
- --infection, wound can spread
- hypotension
- --8-11% (especially hypovalemia)
- motor impairment
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What is a nerve block?
- commonly used when involving LE or UE
- most common sites: femoral, brachial plexus, sciatic
- major advantage: avoid hemodynamic instability associated with GA and neuraxial blockade
- localized
- --feel pressure, not pain
- --less blood loss
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What are the complications of a nerve block?
- local effects: pain, weakness, echymosis, hematomy, infection and numbness
- systemic tocicity (CNS, CV)
- allergic reactions
- pneumothoras (supraclavicular)
- phrenic nerve paralysis: diaphragm, unable to breathe properly
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Other types of regional anesthesia
- monitored anesthesia care
- no complete LOC
- need adequate local anesthesia
- sedation
- should be able to maintain airway integrity
- conscious sedation "twilight state"
- multimodal analgesia
- one modality of pain control while avoiding side effects of opoid
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Complications of endotracheal intubation
- after anesthesia induction, endotracheal tube placed in mouth and trachea using laryngoscopre
- most commone side effect: post-op soar throat
- dislocation arytenoid cartilage
- damage to teeth or tracheal mucosa
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Other side effects of anesthesia
- GI issues: nausea/vomitting
- incisional pain
- neurological complications (mental status)
- cardivascular/hematologic (cardiac arrythmias, MI, CVA)
- respiratory (aspirating gastric contents)
- integumentary (wound infection)
- musculoskeletal (secondary to positioning)
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What are the medications used for sedation in the ICU?
- lorazapam: usually used if sedated > 24 hours
- midazoiam: rapid reliable anesthesia
- minimal CV complicationshypotension and hypovelemic pts can occur
- psychotic rreactions are rare
- dexamedetomidine: easily arousable to participate in PT without irritation, low HR
- propofol: deeper levels of sedation, more rapid awakening
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What are some behaviors due to disorientation in the ICU
- not as much psychotic because they aren't there as long
- aggressiveness due to
- medications
- sepsis
- fever
- encephalopathy
- paranoia
- withdrawl syndrome
- pain
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What is a thoracentesis
- therapeutic or diagnostic removal of the pleural fluid via percuaneous needle aspiration
- "pleural tap"
- post procedure CXR
- bronchiopulmonary hygeine
- mobility/ambulation
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Complications of thoracentesis
- pneumothorax
- (air pushed in before removing fluid)
- can be painful and not want to breath on that side
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What is a thoracotemy?
- removal of part of the lung
- wedge resection, segmentectomy, lobectomy
- --peripheral bronchial or parenchymal lesion
- pneumonectomy: removal of total lung
- --bronchial carcinoma, emphysema, multipule lung abscesses, bronchiectasis, or TB
- incision through thoracotemy (into chest)
- many different possible approches
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Complications with a thoracotemy?
- atelectasis
- pneumonia
- excess bleeding
- infection
- rib Fx
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What are the PT implications for a thoracotemy?
- pulmonary hygiene
- deep breathing
- mobilization
- ROM/positioning
- manual techniques
- relaxations techniques
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Who is considered a candidate for a lung transplantation?
- end stage lung disease < 1year to live
- most commonly COPD and cystic fibrosis
- single or double lung
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Pre-operative measures for a lung transplant
- medical
- PTF, V/Q scan (checks for PE), BiPAP, pulmonary hygiene
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Physical therapy for lung transplantation
- comprehensive evaluation
- 6MWT
- pulmonary hygiene
- conditioning as able
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Post-operative measures for a lung transplant
- infection:
- open thoracic procedure
- immunosuppression
- S/S consistant with pulmonary infection
- rejection:
- decreased SaO2 at rest
- CXR changes demonstrate inflammation
- PT role for rejection:
- continue pulmonary hygiene if needed
- defer activity progression until rejection resolves
- PT Implications:
- strict standard precaustions
- pulmonary hygiene
- functional activity progression/edurance training
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Idications for a living donor lobar transplant
- cystic fibrosis
- bronchiopulmonary dysplasia
- primary pulmonary HTN
- pulmonary fibrosis
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Procedure and outcomes of a living donor lobar transplantation
- procedure:
- bilateral implantation of lower lobes from two blood-group compatible living donors into one recepient
- donors must be 3-6" taller than recepiant
- outcome:
- comparable to cadaveric double lung transplant
- --78% survival 1 year after
- --48% survivale 5 years after
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What do you document after a lung transplant?
- RPE/dyspnea scale
- pt education
- need and duration of seated rest
- bitals pre, during, and post
- O2 amount
- positioning of comfort
- level of inceptive spirometry
- response to exercise
- productive cough/sputum
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What is a laparoscopy?
- fiber-optic tube inserted into abdominal cavity through small incision
- diagnostic procedures:
- vizualization
- biopsy
- gluid aspiration
- therapeutic procedures:
- lysis of adhesions
- laser ablation
- cholycystectomy
- appendectomy
- hernia repair
- gastrectomy
- colectomy
- reproductive procedures
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Colectomy - indications, procedure, PT implications
- indications:
- cancer
- diverticulitis
- chronic ulcerative colitis
- chronic constipation
- procedure:
- a portion or all of color is removed
- may or may not need colostomy or ileostomy
- open procedure vs. laparoscopic
- PT implications:
- splinting
- sit at angle to prevent from stretching
- avoid valsalva
- log roll
- malabsorption
- huffing - forced expiration
- abdominal binder
- protein levels
- medication
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Gastric Bypass
- NIH criteria:
- BMI > 40+
- BMI > 35 with one or more related comorbid conditions
- post-op nutrition concerns:
- weight los of 65-80% excess weight typical
- roux-en-y procedure:
- small puch created at top of stomach using surgical staples and/or plastic band
- "new stomach connected directly to middle portion of jejunum bypassing rest of stomach and upper portion of small intestine
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What is a whipple procedure?
- indication:
- severe or urremitting chronic pancreatitis or cancer
- procedure:
- remove duodenum, portion of stomach and jejunum, gallbladder, common bile duct, and regional lymph nodes
- followed by anastomosis of remaining components
- NO PT UNLESS COMPLETELY NECESSARY
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After a surgical procedure, when is PT not appropriate?
- nausea/vomitting
- bed rest
- complications
- contraindications
- pain
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