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Transcript of Anesthesia Orientations
Provide great anesthesia!
Make your obstetric rotation effective!
STEP 2: KNOW YOUR LOCATIONS AND CONTACTS
Liz Matheson-Chief CRNA
Anesthesia dept entrance door code
OB anesthesia CRNA phone
Anesthesia attending faculty phone
L&D front desk
L&D Triage desk
2nd floor PACU
Main OR front desk (3rd floor)
3rd floor PACU
STEP 1: REVIEW DIDACTIC MATERIAL
Maternal physiologic changes during pregnancy, labor, and postpartum period
Stages of labor
Anesthesia concerns for the obstetric patient
Pregnancy related complications
Pharmacology of local anesthetics and maximum safe doses
Let's take a quick tour of the unit!
STEP3: KNOW HOW TO START YOUR SHIFT!
Arrive early enough to be able to start work at 7 (in other words, you should probably arrive before 7 to give yourself time to set up; how early depends on how quickly you can set up)
Set up OR 13 & 14
Make sure a CMAC and/or Glidescope are available in their designated area
Set up 2 epidural carts (1 cart should be on each wing of L&D)
Contact the OB CRNA via 39325 for further instructions
Let's take a look at an appropriate set up!
OR SET UP
Always remember: the goal when setting up the OR is to prepare for the worst case scenario- an obstetric emergency
Anesthesia machine check
Drug box setup
MS B MAID (when all else fails go back to basics...)
Spinal cart set up
IV SET UP
HOT LINE SET UP
20, 18, AND 16 G CATHETERS
IV PIGTAIL EXT
IV START KIT
ALL IN AN EMESIS BASIN
BASIC AIRWAY SETUP
SIZE 6, 6.5, AND 7 ETT (cuff tested and 10cc syringe attached and stylette in place)
MAC 3 and Miller 2 BLADE (with working lights)
2 ORAL AIRWAYS
TAPE TO SECURE ETT
CIRCUIT MASK AND PORTABLE FACE MASK
DRUG BOX SETUP
1 VIAL SUCCINYLCHOLINE
1 VIAL PROPOFOL
1 20CC SYRINGE
1 10CC SYRINGE
ALL MEDICATIONS SHOULD BE UNOPENED
BED AND MONITOR SETUP
PLEASE USE OUR NEW GEL ROLLS AND BLUE HEAD SUPPORT PILLOWS FOR OPTIMAL POSITIONING(instead of blankets)
PREPARED ECG(electrodes on and lead wires split on bed)
ACCESSIBLE BP AND PULSE OX CABLES
EPIDURAL CART SET UP
3WAY STOP COCK
WHITE FINISHING TAPE
INFUSION PUMP(not shown)
OR SPINAL CART SET UP
2 TB SYRINGES (unopened)
Do not remove medications until there is an actual patient coming to the OR and a spinal is planned
TRIAGE/OB INTAKE (UNIT 2E): area of initial evaluation, observation, and assignment of treatment
L & D (UNIT 2D): area where patients are taken when delivery is determined to be imminent (> 4cm dilation, or progressively dilating and/or effacing, and/or ROM)
OR SUITE: Houses OR 13&14 (for obstetric cases) as well as PACU
Anesthesia storage room
Room 9 in L&D (alternative recovery area for surgical patients)
SCU (special care unit): Area for extended observation and/or treatment for preterm patients with complicated pregnancies (You may be called to preop these patients in preparation for possible urgent/emergent circumstances). Also utilized for complicated postpartum patients (i.e. patients on mag drips or those with postpartum hemorrhage ~ >500cc for vaginal delivery or >1000cc for c-section).
STEP 4: KNOW HOW TO PREPARE YOUR OBSTETRIC ANESTHETIC
1st- Consider your options!
Most common anesthetic for labor and vaginal delivery
May be used for c-sections (if an epidural was already placed for labor, it can be used if a c-section becomes necessary)
Most common anesthetic for non-emergent c-sections
Utilized for stat/emergent c-sections
Utilized when neuraxial blockade is contraindicated
Utilized when massive blood loss and/or hysterectomy is expected during c-section
May be utilized when a spinal has failed or is inadequate during the c-section
Combined spinal epidural
Commonly utilized in labor and vaginal delivery
May be utilized for non-emergent c-sections that may be longer than usual (i.e. excessive adhesions expected from multiple surgeries; morbid obesity)
2nd- REVIEW THE CHART
Review the H&P
recent cbc- focusing on H&H and PLT count
low PLT counts should be discussed prior to neuraxil blockade, especially when less than 100,000
moderate to severe pre-eclampsia requires PLT count within 4-6hrs of epidural placement
type and screen- should be completed on all laboring patients
Review the nursing cheat sheet
3rd- Complete a FULL preoperative assessment
FYI- Translators are in limited supply on night shifts and weekend shifts. If you need a translator, you will more than likely need to use the double headset translation phones located at the bedside in each labor room. Just dial
and follow the prompts.
4th- CONSENT THE PATIENT FOR EPIDURAL, SPINAL, AND GA
Now that you have all the information about the patient, proceed with consent. Always consent for epidural, spinal, and GA. You and the patient should be prepared for any urgent or emergent situation!
*Please make sure that your preceptor signs the consent as the authorized provider
STEP 5 : BE FAMILIAR WITH THE STEPS OF EPIDURAL PLACEMENT
Open the patient's chart, create an "Epidural for labor" encounter, select "Anesthesia Start" and "Start Out of OR vitals"
Verify that BP's are cycled every 3-5 min and a pulse ox is in use
Initiate fluid bolus (500-1000cc)
Grab medications from pyxis
Put on a face mask, wash hands, and apply non-sterile gloves
Complete a "Time Out" then position the patient and get started!
click the box below for a visual demonstration
Common options used for epidural bolus and infusion are
Ropivicaine 0.2% or Ropivicaine 0.1% mixed with Fentanyl(2mcg/cc)
Appropriate sensory block level for Labor and vaginal delivery should be
Bolus the catheter with 1-2cc per segment (typically
depending on level of insertion site)
Bolus slow and incrementally
Start your infusion pump at a rate equal to your bolus in order to maintain the level
Let's set up an epidural infusion pump!
an infusion pump
a pump key(located at the OB front desk)
a 3 way stop cock
a medication cartridge (from pyxis)
Let's look at the kit and prep for placement!
1. Test dose- 1.5%Lido with epi 1:200,000 (5ml)
2. 1% Lido for anesthetizing insertion site(5ml)
3. Sterile saline
4. 20cc bolus syringe
5. 3cc syringe
6. Filter straw
7. 25G needle
8. 17G Tuohy needle
9. LOR syringe
10. 19G epidural catheter and epifuse cath connector
11. epidural catheter label
12. sterile gauze
13. sterile sheet
14. mastasol (not included in kit)
15. sterile sponge
16. sterile drape
Items needed but not included in the kit:
mastasol (will be carefully emptied on to tray)
steri strips (will be carefully emptied on to tray)
3 way stop cock
white finishing tape
ropivicaine bolus and/or cartridge
click the box below to start the video
What if there is a wet tap!!!!!
STEP 6: BE FAMILIAR WITH THE STEPS OF SPINAL PLACEMENT
Facemask, wash hands, non-sterile gloves
BP q 2-3 min, pulse ox, fluid bolus started
Time out and position the patient
Identify landmarks and insertion site
Prep the back with chloroprep and open tray while maintaining the sterility of it's content
Apply sterile gloves
Drape the back and re-verify insertion site
Prepare the tray and proceed with spinal placement
Once spinal completed, immediately place patient in the supine position (we don't want a saddle block right?)
Cycle BP, apply ECG, apply oxygen via simple face mask
Check for a T4 level. Once the level is achieved, notify the nurse so that she/he may begin to prep the patient for surgery
Continue to monitor your patient
Unfortunately, there is no spinal video at this time. However, one is coming soon!
Let's take a look at the tray and prep for placement
1. Syringe for intrathecal medication injection (5ml)
2. 20G Introducer needle
3. 25G Whitacre Spinal needle
4. 1% lidocaine (5ml) for anesthetizing the insertion site
5. 0.75% Bupivicaine for intrathecal injection (we routinely do NOT use the medication provided in the kit. Instead we obtain our bupivicaine directly from the pyxis)
6. Filter straw
7. 25 gauge needle for anesthetizing insertion site
8. 3cc syringe
9. Sterile sheet
10. Sterile gauze
11. Sterile drape
Betadine and sponges are also in the tray, but not commonly used. Chloroprep is our standard.
Our c-section standard currently includes the use of intrathecal 0.75% Bupivicaine, Fenanyl, and Duramorph mixed and given as one injection
1.5cc of 0.75% Bupivicaine
10mcg (0.2cc) of fentanyl
150mcg (0.3cc) of Duramorph
This standard is for c-sections only
STEP 7: BE FAMILIAR WITH THE PRIORITIES OF A C-SECTION
IDENTIFY THE INDICATION FOR THE C-SECTION
VERIFY COMPLETED PREOP, CONSENT, NPO STATUS, AND EVALUATE AIRWAY
REVIEW H&P AND LABS (make sure you check your T&S, PLTs, and starting H&H)
CONSIDER YOUR ANESTHETIC OPTIONS (which anesthetic is appropriate)
PREMEDICATE WITH PEPCID, REGLAN, AND BICITRA
ONCE IN THE OR, OPEN THE PYXIS AND THE EPIC RECORD. CLICK "START ANESTHESIA" AND "START DATA COLLECTION"
ASSIST PATIENT TO THE OR TABLE IF NURSES HAVE NOT ALREADY DONE SO
IF YOU ARE DOING A SPINAL OR CSE, START BP Q 2-3 MIN AND PLACE A PULSE OX.
NOTE THE BASELINE FETAL HEART TONES
POSITION PT IN SITTING POSITION FOR SPINAL OR CSE PLACEMENT
ONCE ANESTHETIC IS COMPLETED AND PT IS POSITIONED SUPINE, APPLY ECG, OXYGEN VIA NRBM, AND UTILIZE CO2 SAMPLE LINE
CHECK PATIENT FOR T4 LEVEL AND NOTE POST SPINAL FETAL HEART TONES
NOTIFY NURSE WHEN LEVEL IS ACHIEVED AND POSITION PT IN LEFT UTERINE DISPLACEMENT
SECURE ARMS, TURN ON UNDERBODY WARMER, AND GIVE ANTIBIOTICS (Ancef 2 gms; 3gms if pt over 100kg; recently added to the regimen is 500mg of Azythromycin IVPB)
PRIME AND PREPARE FIRST BAG OF OXYTOCIN (30 units in 500cc LR~provided to you by the nurse)
NOW YOU MAY CATCH UP CHARTING!!
ONCE THE SURGICAL DRAPE IS UP THE SURGEONS WILL COMPLETE A "TIME OUT" AND SURGEON WILL COMPLETE AN "ALLIS TEST" TO ENSURE YOUR BLOCK IS WORKING. ASSESS YOUR PATIENT'S RESPONSE AND COMMUNICATE TO THE SURGEON THAT THEY MAY PROCEED
OBSERVE YOUR PATIENT'S RESPONSE TO INCISION TO FURTHER ENSURE THAT THE BLOCK IS ADEQUATE, THEN NOTIFY THE NURSE THAT IT IS OKAY TO BRING IN A FAMILY MEMBER
CONTINUE MONITORING THE PATIENT AND CHARTING UNTIL UTERINE INCISION
NOTE UTERINE INCISION TIME AND BABY DELIVERY TIME, START OXYTOCIN INFUSION, AND NOTE PLACENTA DELIVERY TIME
OBSERVE BLOOD LOSS AND EVALUATE URINE FOR HEME (possibly indicates bladder injury, always make surgeons aware if new heme in urine is observed)
ASK SURGEONS ABOUT THE QUALITY OF UTERINE TONE AND BE READY TO GIVE IM METHERGINE AND/OR HEMABATE IF NECESSARY (be familiar with these medications)
CONTINUE TO MONITOR PT AND BLOOD LOSS WHILE CHARTING UNTIL THE END OF THE CASE
**Your preceptor should always be with you during stat/emergent c-sections**
Once you are in the OR...
Allow the nurses to start moving the patient over to the OR bed while you prepare breadbox medications, open epic chart to click "anesthesia start" and "start data collection", and open pyxis
Position pt on shoulder roll and apply pulse ox, high flow 100% oxygen with circuit ( use head strap), BP q 2 min, and ECG
Place laryngoscope, ETT, and suction at the head of the bed
At this time you should be waiting for the surgeons to let you know they are ready to make incision (Note: you should never proceed with induction until the surgeons are completely gowned and gloved and the patient is prepped and draped; The goal is for incision to immediately follow induction)
Clearly confirm that surgeons are ready then proceed with RSI with cricoid pressure
Intubate and verify ETCO2 then notify surgeons to proceed with incision
Verify BBS, vent on, flows down, agent on
Secure the ETT and tape the eyes
Place gastric tube, give antibiotics, secure arms, and apply temp probe (hopefully there are extra hands helping you do all of these things almost simultaneously)
Prepare pitocin infusion
listen and watch for uterine incision and delivery of the baby
Start pitocin infusion, listen for placenta delivery
observe the EBL and observe the urine for heme
Inquire on uterine tone and be ready to give methergine or hemabate if needed
Continue to monitor patient and EBL as you catch up the charting (confirm all times with nurses)
This patient will require an awake extubation
**Clear communication with the surgical team and proper prioritizing of tasks are key during emergent situations**
HOW TO BOLUS AN EPIDURAL FOR USE DURING A NON EMERGENT C-SECTION:
Prior to the OR...
Question the patient about how effective the epidural has been (pain, pressure, etc)
Check for optimal sensory block level with ice
Assess the insertion site and ensure that the catheter is still in place and secured as documented after initial placement, and dressing is intact
Aspirate the catheter to verify absence of blood or CSF
Once pt is in the OR...
Apply all monitors (pulse ox, BP, and ECG
Apply oxygen and CO2 sample line
Aspirate epidural catheter and bolus with Duramorph 2mg (4cc)
Then bolus catheter with 2%Lidocaine with epinephrine in 5cc increments not to exceed 20cc (aspirate prior to each injection)
Assess the level and notify the nurse when a T4 level is reached
Proceed with the standard tasks for non-emergent c-section
Make sure to remove the epidural catheter at the end of the surgery and document removal of catheter intact and without complications
STEP 8: KNOW HOW TO RECTIFY ADMINISTRATIVE ISSUES
For schedule conflicts...
For pharmacy discrepancies...
If you are in danger of not making your required number of spinals and/or epidurals...
If you have a problem with a preceptor...
This presentation is NOT a substitute for classroom instruction. It is an orientation of the current locations, protocols, and suggested practices within our facility. It is ultimately YOUR responsibility to review all didactic material related to the topics of OB anesthesia, neuraxial blockade, and pharmacology of local anesthetics prior to this rotation.
A few last pearls of wisdom!
As you know, there is a small window of time to prepare you to be a safe and effective anesthesia provider. Therefore, don't cheat yourself! Take every opportunity possible to practice and learn! OB anesthesia is the priority on this rotation, but when OB is quiet you are expected to work in the Main OR. You will gain experience pre-oping patients and administering anesthesia that you did not prepare for the night before. You can never have too much OR experience!
Ask questions, even if you feel like you should already know the answer! Believe it or not, we can tell when you don't really have a clue what's going on. Embrace being naive at this time. It is better to ask the questions now than to graduate and never know the answers!
Get adequate rest when you are off. Night shifts are not easy. You may work all night and you still have to be alert and vigilant.
Be curious. Put yourself in the worst cases and situations now while you have a preceptor to guide you. Don't wait until you are alone and independent to be exposed. Your enthusiasm to learn is infectious. If you are motivated and work hard, preceptors will go out of their way to provide interesting experiences for you.
Lastly, every clinical site you rotate through will be hiring at some point. Therefore, consider your rotation as an opportunity to show the anesthesia community your work ethic, social skills, assets, and abilities. After all, this community is smaller than you think!
Click the video above for demonstration of pump set up
Contact Liz Matheson, Chief CRNA via email and/or phone
Access the chart in question via epic, correct the discrepancy, then notify pharmacy of the correction via email. Do not hesitate to seek assistance from your preceptor if you have questions or difficulties.
Contact Liz Matheson, Chief CRNA (sooner rather than later)
Contact Liz Matheson, Chief CRNA
There are currently two options utilized when an accidental dural puncture occurs:
A. immediately remove the epidural needle and replace the epidural at a different level
B. thread an epidural catheter into the intrathecal space at the dural puncture location (see the images below for further explanation)