Marianne Cosgrove, CRNA, DNAP, APRN

 Why?
 To prepare for the case
 Delineates procedure
• How it is performed
• Pt position
• Anesthetic considerations and plan for that specific type of surgery
• Anesthetic considerations for pt co-morbidities, meds
 To prepare for testing/boards!
 The initial portion of the care plan is done when you get your assignment → before the procedure

 Assignment:
 J. Doe, male, age 49
 Laparoscopic cholecystectomy
 General anesthetic
 Now what?

 To be prepared for the AM of surgery:
 Planned procedure:
 In a synopsized form, explain the procedure to be done.
Add details only if it directly impacts your anesthetic plan of care.
 If you are doing multiples of the same case, one cover sheet is acceptable for all cases scheduled; write the actual number of cases done that day on the cover sheet and attach each pt done to the procedure sheet before handing in

 Research the planned procedure
 Synopsize lap chole:
 i.e. Laparoscopic approaches are applied to an increasing number of procedures, including cholecystectomy, the surgical excision of the gallbladder. Surgery is performed for acute/chronic cholecystitis and/or cholelithiasis. Benefits of the laparoscopic approach to cholecystectomy include:
• smaller incision(s)
• reduced post-operative pain
• reduced incidence of ileus
• early ambulation
• shortened hospital stay
• earlier return to work and ADLs

 Synopsis cont’d
 Operative technique involves the intraperitoneal insufflation of CO
2 through a needle inserted through a small infraumbilical incision. Patient positioning in steep
Reverse Trendelenberg with a left side-tilt facilitates operative exposure of the gallbladder.
Pictures are OK but not necessary!! Check out Google
TM images

 Anesthetic considerations for the procedure:
 The most important part of your preparation for the case
 “bullet” list format vs. paragraph may be easier to follow
 “chunking” of information allows the adult learner to retain information better

Anesthetic implications for laparoscopic cholecystectomy
 Hemodynamic changes associated with insufflation:
 increase in MAP and SVR with no effect on CO in healthy patients
 a decrease in CO and hypotension in hypovolemic pts or those with pre-existing cardiac disease
 absorption of CO
2 across the peritoneum may result in hypercarbia with SNS stimulation, increased BP, CO, HR, and arrythmias
 controlled ventilation with cuffed ETT
 may note bradycardia due to vagal stimulation from peritoneal stretching during initial insufflation
 pretreat with anticholinergic
 periods of hypotension may occur with the pt in steep
Reverse Trendelenburg, especially if hypovolemic, betablocked, pre-existing cardiac dz, etc

Anesthetic implications for laparoscopic cholecystectomy
 Respiratory changes:
 reduction in FRC from cephalad movement of diaphragm, especially in Trendelenburg
 atelectasis leading to hypoxia
 need for PEEP if tolerated
 decrease in abdominal and chest wall compliance due to presence of pneumoperitoneum
 increases in peak airway pressures
 necessity for increased minute ventilation to offset hypercarbia from insufflation with CO
2
 May want to avoid N
2
O; may insufflate bowels making surgical exposure difficult; may add to hypoxia, may cause PONV

Anesthetic implications for laparoscopic cholecystectomy
Complications:
 vascular injury/hemorrhage from large vessel or organ penetration with the Veres needle, trocars, or instruments
 larger bore IV (at least #18g), T&S
 hypothermia from insufflation with cold gas
 actively warm pt
—fluid warmers, Upper body Bair
 brachial plexus injury from supine/Trendelenburg position
 secure arms
 increased incidence of emesis, PONV
 rapid sequence induction/intubation, antiemetics
 pneumomediastinum, pneumopericardium, or pneumothorax and subcutaneous emphysema of the face and neck
 venous gas (CO
2
 s/s
) embolism
Treatment:
• increased ETCO
2
• hypoxia/decreased SaO
2
• hypotension (may be severe)
• “mill-wheel” murmur
-stop insufflation
-head down, L lateral decubitus position
-FiO
2
1.0
-support with pressors

 GETA vs. general LMA, vs. regional vs. TIVA, etc.
 No need to delineate each step used to perform the type of anesthetic chosen; more important to know why the specific type of anesthesia was chosen for that case
 Could this be alternatively performed with regional or
MAC/TIVA?
 List drugs that you plan to use; be prepared re: dosage ranges for the agents that you have chosen.

 What is your proposed plan?
 Rapid sequence induction (RSI) with GETA
 Rapid sequence induction
• Know the rationale/steps —add to plan of care if applicable i.e.
• preoxygenate
•
HOB
↑ 30°
• working suction at HOB
• stylet in ETT
• induction med followed by rapid-acting NMB without testing airway
• cricoid pressure until intubation verified via ETCO
2
/auscultation
 Choose medications, why you want to use them, and KNOW YOUR
DOSAGES!


 Plan: GETA with a rapid-sequence induction
 Midazolam 1-2 mg IV for sedation
 Fentanyl 50-100 mcg IV pre-induction
 Glycopyrrolate 0.2 mg IV pre-induction
 Propofol 2 mg/kg IV for induction
 Succinylcholine 1 mg/kg for laryngoscopy/intubation
 Sevoflurane/O
2
/air for maintenance
 Rocuronium for ongoing relaxation
 Ondansetron 4 mg for PONV prophylaxis
 Neostigmine 0.04 mg/kg matched 1:1 with glycopyrrolate for reversal

 Must have at least two references
 1 web reference is acceptable
 Hurford, W.E. Clinical Anesthesia Procedures of the
Massachusetts General Hospital. Philadelphia,
Lippincott, Williams & Wilkins, 2002. pp 318-320
 Roizen MF, Fleisher, LA. The Essence of
Anesthesia Practice. Philadelphia: W.B. Saunders
Company, 2002. pg 384

 Now what?
 Patient contact is made, chart review is done
 Wt 198# / 90 kg Ht 6’0”
 Pt history remarkable for smoking, major depression,
OSA
 Medications: Prozac, loratidine and percocet PRN, nicotine patch
 Labs all WNL
• transcribe all pertinent history onto care plan

 note anesthetic technique used
 note medications/dosages used
 at the end of the care plan, you will list these meds as
“actual”; note if there is a deviation from your original plan
 jot down any interesting, unexpected, untoward events (including mishaps!)
 anecdotal information will be added to finalize the CP before handing in —makes it more personalized and meaningful
 will end up with a “journal” of anesthetic experiences

 Revisit the care plan to review and add anesthetic implications for patient co-morbidities and meds, i.e.
 OSA-obstructive sleep apneaa disorder in which excessive soft tissue in the upper airway intermittently obstructs the airway during sleep. Prevalence is more common in obese pts. Pts report snoring, daytime somnolence, intellectual impairment, repeated AM headaches. More serious cases may lead to RVH from increases in pulmonary vascular resistance during apneic/hypoxic periods.
May lead to cor pulmonale and eventual L-sided heart failure. Other resultant co-morbidities may include HTN, cardiac arrythmias, polycythemia, and vascular disease.
 may be a difficult airway
—both bag/mask ventilation, laryngoscopy/intubation, and after extubation
• have a variety of airway implements on hand
• may use a nasal airway before extubation
 may be sensitive to the respiratory depressant effects of opioids
• use opioids/sedatives with caution

 Smoking
 Cigarette smoke contains > 3000 identifiable constituents, many of which are toxic (most notable are nicotine, CO, and cyanide). Smokers have:
 increased airway irritability and secretions, decreased ciliary activity; potential for post-op pulmonary complications
• humidify gases
• lidocaine pre-intubation and extubation
• hydration
•
? use of anticholinergics
• ET suction before extubation
• ? deep extubation

COPD
• I:E ratio which allows for longer expiratory phase
• watch PIP
 carboxyhemoglobinemia (COHb)
• Monitor SaO
2
 ↑ incidence of HTN, CAD, PVD, from SNS stimulation from nicotine
• ? use of β-blockers

 Fluoxetine (Prozac)
 A selective inhibitor of serotonin reuptake used to treat major depression, OCD, bulemia
 anesthetic considerations:
 pt may be ↑anxious
• use of benzodiazepenes
 pt may have extrapyramidal reactions
• avoid dopaminergic blockers (droperidol, metoclopramide)
• serotonin syndrome with concomitant use of MAOIs, tricyclics, meperidine
 monitor temperature
 avoid use of meperidine
 SIADH
• watch U/O if applicable
 may inhibit cytochrome P-450 and potentiate the effects of phenytoin, benzos, beta-blockers due to increased plasma levels of these drugs

 Please complete these sections before re-submitting to your preceptor for signature
 Post-op visit *If the pt is in STS, make an attempt to re-connect before their discharge to home; assess for pain,
PONV, untoward reaction to anesthesia, etc.
 extremely important

Use the bottom of the preanesthesia assessment sheet to note the post-op visit

 Save all of your co-morbidities and medications in a file folder on your computer
 may re-submit on future care plans —work will already be done!
 do not “trade” with peers
 want to build your own library
 Ultimate goal —to formulate a plan of care off of the top of your head

 Keeps track of cases
 Based on the CCNAs outline for boards
 All case types not mandatory but will give you an idea as to what needs to be focused on for studying later
 Mandatory to have 3 OB rotation (1 C/S, 1 co-morbidity, 1 laboring epidural/vaginal delivery and 1 care plan/WEEK from rotation sites

 Before graduation, you must have at least one CP completed for each of the categories listed
 Will upload/submit to the school as an electronic file, either separately or as a component of your e-portfolio