CRNAs and their Patients

Honest and open communication between you and your nurse anesthetist prior to surgery is essential in order to enhance your safety and build a spirit of teamwork. Before surgery, a preoperative interview with your nurse anesthetist provides valuable information that helps determine your care. It is equally important to communicate with your anesthesia provider after your surgery. The medications you have been given can remain in your body for 24 hours or more after they have been administered, and you won’t be “back to your old self” until the anesthetic has been totally eliminated.

Please feel free to ask your nurse anesthetist any questions you might have — before and after your anesthesia is administered.

Your Role Before Surgery

Anesthesia is a major part of your surgery.

During the procedure, anesthesia allows you to be free of pain. All anesthesia care is provided with the highest degree of professionalism, including constant monitoring of every important body function. As changes occur in your reactions to anesthesia, the nurse anesthetist responds with modifications of the anesthetic to ensure your safety and comfort.

In addition to their role in the procedure itself, nurse anesthetists make many preparations for you before surgery. You can — and should — take an active role in these preparations by communicating and cooperating with your nurse anesthetist and your surgeon.

There are several kinds of anesthesia.

The one chosen for you is based on factors such as your physical condition, the nature of the surgery and your reactions to medications. Frank and open discussion with your nurse anesthetist is key in the selection of the best anesthetic for you.

In particular, you must speak freely and follow instructions closely regarding your intake of medications, food or beverages before anesthesia. Such substances can react negatively with anesthetic drugs and chemicals.

The preoperative interview is essential to effective communication.

This confidential discussion with the nurse anesthetist prior to surgery provides information vital to your care. You may be given a questionnaire to fill out and bring along to the preoperative interview. Information supplied by the questionnaire assists your nurse anesthetist in doing the interview thoroughly and efficiently.

Different types of patients or procedures may require different types of anesthesia.

Pregnant patients should prepare before the onset of labor for the possibility of having an anesthetic, even if a natural childbirth is planned. During pregnancy, keep accurate records of allergies, high blood pressure, prescriptions and over-the-counter medications. The use of drugs, including recreational drugs and alcohol, can increase the risk of anesthetic complications for both mother and baby.
Older adults go through complex physical changes while aging that may affect their bodies’ response to anesthesia. You or your family can assist the nurse anesthetist by providing a detailed list of all medications, including aspirin, taken regularly.
Patients with hereditary disorders such as diabetes and sickle cell anemia need special attention. These conditions can be managed properly if the nurse anesthetist knows about them before a procedure.
Children should be specially prepared for anesthesia, and for surgery in general. Allow them to bring favorite toys along for their stay. Make frequent reference to things children will enjoy after the procedure. If possible, take children on a hospital tour and let them talk with hospital personnel, particularly the nurse anesthetist.
Ambulatory care allows you to go home the same day as your surgery. It is mportant, however, to provide the same accurate information during the preoperative interview. In addition, preparations should be made before ambulatory surgery for another adult to accompany you to the healthcare facility, drive you home and monitor your recovery.

Remember:

Speak frankly. Ask questions. Follow instructions. Provide your nurse anesthetist with a medical history. And, notify your nurse anesthetist or doctor immediately of any change in your physical condition prior to surgery. Communication and cooperation are essential to the anesthesia process.

Your Role After Surgery

Anesthesia means freedom from pain during surgery.

All anesthesia care is provided with the highest degree of professionalism. Sensitive equipment monitors every important function of your body. In response to your body’s reactions, the nurse anesthetist modifies your anesthetic as needed.

But anesthesia care is not confined just to surgery. The process also refers to activities that take place — before and after — an anesthetic is given. Before anesthesia, a preoperative interview with your nurse anesthetist supplies valuable information that helps determine your care. Open communication and cooperation are essential during the interview.

Communication and cooperation are necessary after surgery as well.

The medications that you have been given can remain in your body for up to 24 hours after their administration. You are not completely “back to your old self” until the anesthetic has been totally eliminated.

Also during this time, it is still possible for substances entering your body to interact with the anesthetic. Certain substances may cause negative reactions. Therefore, check with your care provider about what medications you can take. Continue to cooperate with your nurse anesthetist and physician after surgery. Don’t hesitate to ask questions.

“Don’ts” After Anesthesia

After receiving anesthesia during a surgical procedure, you can play an active role in your recovery by heeding the straightforward list of do’s and don’ts that follows:

Don’t drive a car for at least 24 hours. After anesthesia, your reactions and judgment may be impaired. Such impairment makes driving a car dangerous to you and others. It is especially important that you make arrangements for someone else to drive you home from the healthcare facility after your surgery.
Don’t operate complex equipment for at least 24 hours. The same logic that applies to driving a car similarly applies to the operation of other equipment. This includes equipment used at home, such as a lawnmower, as well as that used on the job, such as a forklift truck.
Don’t make any important decisions or sign any legal documents for the day. The potential for impairment relates not only to physical activities but to your mental state also. Moreover, avoid the anxiety that frequently accompanies making important decisions. The day should be spent resting.
Don’t take any medications unless prescribed by or discussed with your physician. Some medications may adversely interact with anesthetic drugs or chemicals remaining in your body. Included are prescription drugs, such as sleeping pills or tranquilizers, and over-the-counter medications, such as aspirin.
Don’t drink alcohol for at least 24 hours. Alcohol is also considered a drug, meaning that an alcoholic drink has the potential to negatively react with the anesthetic in your system. This includes hard liquor, beer and wine.

“Do’s” After Anesthesia

Do leave the healthcare facility accompanied by a responsible adult. This person will ensure that you travel home safely as well as provide immediate care at home. You should continue to have this adult with you for 24 hours after surgery.
Do remain quietly at home for the day and rest. You need rest both because you have received anesthesia and because you have undergone a surgical procedure — even one that is considered minor. If, after a day, you still do not feel recovered, you may want to continue your rest for an additional day or two. Discuss your planned return to work with your physician.
Do arrange for someone to care for your small children for the day. Even if given instructions to play peacefully and not overtax you, children sometimes forget such directions or have trouble staying quiet for an entire day. The most predictable course of action is to leave small children and babies in the care of another responsible individual.
Do take liquids first and slowly progress to a light meal. Heavy foods can be difficult for your system to digest, thereby increasing the chance for discomfort. For your nourishment, start by taking liquids, then eat light foods, such as broth or soup, crackers or toast, plain rice, Jell-O and yogurt.
Do call your nurse anesthetist, your physician or the facility where you were treated if you have any questions. These professionals are interested in your welfare and want your care to go as planned. If you have questions, or feel your recovery is not progressing to your satisfaction, call them.

Remember:

Communication and cooperation are essential to the anesthesia process. Active participation in your care helps ensure your safety and comfort.

Conscious Sedation

Conscious sedation induces an altered state of consciousness that minimizes pain and discomfort through the use of pain relievers and sedatives. Patients who receive conscious sedation usually are able to speak and respond to verbal cues throughout the procedure, communicating any discomfort they experience to the provider.

Conscious sedation provides a safe, effective option for patients undergoing minor surgeries or diagnostic procedures. The number and type of procedures that can be performed using conscious sedation have increased significantly as a result of new technology and state-of-the-art drugs.

Conscious sedation allows patients to recover quickly and resume normal daily activities in a short period of time. A brief period of amnesia may erase any memory of the procedure.

Administration

Conscious sedation is administered in hospitals and outpatient facilities (for example, ambulatory surgery centers and doctors’ offices) to facilitate procedures such as the following:

Breast biopsy
Vasectomy
Minor foot surgery
Minor bone fracture repair
Plastic/reconstructive surgery
Dental prosthetic/reconstructive surgery
Endoscopy (examples: diagnostic studies and treatment of stomach, colon and bladder)

Conscious sedation is extremely safe when administered by qualified providers: Certified Registered Nurse Anesthetists (CRNAs), anesthesiologists, other physicians, dentists and oral surgeons. Specifically trained registered nurses may assist in the administration of conscious sedation.

Monitoring Conscious Sedation

Because patients can slip into a deep sleep, proper monitoring of conscious sedation is necessary. Healthcare providers monitor the patient’s heart rate, blood pressure, breathing, oxygen level and alertness throughout and after the procedure. It is important that the provider who monitors the patient receiving conscious sedation has no other responsibilities during the procedure and remains with the patient at all times during the procedure.

A qualified provider monitors the patient immediately following the procedure. Written postoperative care instructions should be given to the patient to take home. Patients should not drive a vehicle, operate dangerous equipment or make any important decisions for at least 24 hours after receiving conscious sedation. A follow-up phone call usually is made by the healthcare provider to check on the patient’s condition and answer any remaining questions.

Side Effects

A brief period of amnesia after the procedure may follow the administration of conscious sedation. Occasional side effects may include headache, hangover, nausea and vomiting or unpleasant memories of the surgical experience.

Questions to Ask about Conscious Sedation

Following is a list of questions patients should ask prior to the surgical or diagnostic procedure:

Will a trained and skilled provider be dedicated to monitoring me during conscious sedation?
Will my provider monitor my breathing, heart rate and blood pressure?
Will oxygen be available and will the oxygen content of my blood be monitored?
Are personnel trained to perform advanced cardiac life support?
Is emergency resuscitation equipment available on-site and immediately accessible in case of an emergency?
Will a trained and skilled provider stay with me during my recovery period and for how long?
Should a friend or family member take me home?

Labor and Delivery

Every woman experiences childbirth in her own unique way. In preparing for labor and delivery, some women are quite certain they will want pain relief. Some are unsure of their pain relief options and how they will affect their labor and delivery. Others would prefer to give birth without any pain relief.

No matter which category you fall into, it is important for you to know how anesthesia and pain relief are used in labor and delivery. Even if you fall into the latter category, you should know your options. Every woman should be prepared for the possibility of needing an anesthetic should an emergency arise.

This information will attempt to answer many of the questions you may have about the use of anesthesia in labor and delivery and give you a general overview of the various types of anesthetics available today. After reading this material, you may also want to meet with your obstetrical provider (obstetrician, family practitioner, nurse midwife) or an anesthetist to discuss the best pain relief and anesthesia options for you and your baby.

General Thoughts on Anesthesia

Obstetrical anesthesia is different from any other type of anesthesia in that there are two patients involved — you and your baby. It is important that you take both individuals into account when considering your anesthesia choices.

Another factor to be considered is that labor is unpredictable. It can range anywhere from relatively quick and easy to painful and exhausting. An important point to remember is that everyone experiences pain differently. Only you will know the level of pain you’re experiencing, so you should never feel guilty about asking for pain relief.

Anesthesia Options for Labor and Delivery

The ideal anesthetic should:

Provide enough pain relief to allow you to deliver your baby with minimal pain and anxiety, leaving you free to fully participate in the experience.
Allow you to push when it is time to do so.

The ideal anesthetic should not:

Stop contractions
Make your baby sleepy

Commonly Used Obstetrical Anesthetics

There are several different forms of anesthesia administered for childbirth. They may be used independently or in conjunction with one another. Some of the most commonly administered anesthetics include:

Local anesthesia:

Local infiltration – This series of local injections can make you more comfortable for delivery and for the placement of sutures if you need them.

Sedation:

Narcotics or tranquilizers – Administered as an injection or intravenously, narcotics or tranquilizers can help reduce the pain of labor but will not eliminate the pain entirely. They are also used to ease the anxiety that sometimes accompanies the delivery process.

Regional anesthesia:

Pudendal block – Administered as injections of local anesthetics to numb your vaginal area in preparation for delivery.

Epidural:

An epidural is a local anesthetic delivered through a tiny tube called a catheter placed in the small of the back, just outside the spinal canal. An advantage of the epidural is that it allows most women to fully participate in the birth experience (continue to feel touch and pressure) while relieving most, if not all, of the pains of labor. In most cases, the anesthetist will start the epidural when cervical dilation is 4 to 5 centimeters. Under certain circumstances, it may be desirable to place the epidural earlier.

Spinal:

This anesthetic is similar to an epidural, but because it is administered with a needle into the spinal canal, its effects are felt much faster. You may feel numb and need assistance in moving during the delivery. Spinal anesthetics are sometimes used for delivery by cesarean section or when forceps use is indicated.

Epidurals or spinals cannot be used if the patient:

Uses blood thinners or has a bleeding tendency.
Is hemorrhaging or in shock.
Has an infection in the back or the blood.
Has an unusual anatomic condition or spinal abnormality.
Additionally, if time is of the essence.

General anesthesia:

General anesthesia is administered by giving anesthetic drugs intravenously and having the patient breathe anesthetic gases. A general anesthetic may be necessary if complications arise during delivery. Because general anesthetics can be administered quickly, they’re considered the best choice when time is of the essence. Also, general anesthesia enables the uterus to relax if your obstetrical provider finds it necessary.

What Your Anesthetist Should Know

In order for your anesthetist to determine which type of anesthesia is best for you and your baby, it is important that you inform your anesthetist about:

Food and drink intake for the last several hours.
History of difficulty breathing after anesthesia.
History of lower back problems.
Family history of high fevers.
Any respiratory problems such as asthma, bronchitis, pneumonia, or if you have a cold, sore throat or flu.
Special medical concerns such as cardiac disease, diabetes, asthma and other medical conditions.

If you are a woman with any of these conditions, it is especially important that you meet with an anesthetist prior to going into labor.

Common Questions about Anesthesia

Here are some of the questions frequently asked by pregnant women about the use of anesthesia in labor and delivery:

“Will I remember everything?”
“Will it affect my baby?”
“Will I be able to breast feed?”

Because no two women experience pain or react to drugs in quite the same way, and because different anesthetic techniques have different effects, the answers to these questions will vary. There is no ideal anesthesia for everyone. This makes it very important for you to be informed — and discuss your options with your obstetrical provider and anesthetist. The purpose of anesthesia during labor and childbirth is to help you have the most positive birth experience possible. Anesthesia should not hinder you from enjoying your baby as soon as possible after delivery. You should be able to bond with and breast feed your baby, if you so desire. The better prepared you are before labor and delivery, the more rewarding the entire birth experience will be for you.

Acknowledgment: We gratefully acknowledge the assistance provided by Divina J. Santos, MD, and Carolyn J. Nicholson, CRNA, BSEd, Department of Obstetrical Anesthesiology, University of Cincinnati, Cincinnati, OH, and their videotape, “What Anesthesia Is Best for Me and My Baby?”

Anesthesia for Children

Surgery can be an emotional time. Surgery that is to be performed on your child can be especially stressful. There are things you can do to reduce the chance that your fears and anxieties, as a parent, will be transferred to your child. Children who are less anxious and less fearful have an easier time before and after surgery.

Remember your emotions and anxiety level influence your child. Keep calm and in control of your emotions to help your child do the same. Follow the recommendations listed to accomplish this goal. For more information, talk with your child’s physician, surgeon and nurse as well as staff at the hospital or surgicenter.

To Help You and Your Child Before Surgery and Anesthesia:

Obtain accurate information about your child’s procedure and about what to expect.
Talk with the surgeon, without your child, to get all the information you need.
Ask if there is a pre-admission program for children and, if so, participate in it.
Allow your child to share fears and concerns with you. Do not interrupt, minimize or belittle your child. Let your child know that it is okay to feel afraid.
Answer your child’s questions honestly. If you don’t know the answer, find out.
Discuss the separation procedure with your doctor or nurse. How will your child be transferred from you to the healthcare provider? For example, if your child is an infant, will you be able to hold your child until the sedative takes effect?
Compare the time your child will be in surgery to the length of a favorite cartoon or video.
Let your child know to expect some pain after the surgery by saying, “When they wake you up, it will probably hurt.”
Be present for your child’s immediate postoperative recovery period, if recommended by the anesthesia provider. In some settings it may be possible to be present for the beginning of the anesthesia.
Be there with your child. Sit at the bedside and comfort your child. If appropriate, snuggle, cuddle, hold and touch your child.
Ask about rooming-in with your child.
Control your emotions and your behavior. Remember, although you may be very upset and anxious, display a calm, soothing, trusting manner.
Try to avoid crying in front of your child.
Take “2” for you! Take two minutes (or longer) out of sight of your child to express your emotions and focus yourself on what your child needs from you — support!
Be honest. It is wrong to tell your child “it won’t hurt” or that he/she is going to a birthday party when they are really going to the hospital. Telling your child that he or she is going to take a “nap” may raise fears later when the word “nap” is mentioned to your child. Instead, tell your child, “The doctor or nurse will give you medicine to make you sleep so it won’t hurt when the doctor fixes your _____. The doctor and nurse will wake you up when they are done.”
Alleviate your child’s fears. In no way should you threaten your child by saying something like “If you’re bad, they’re going to stick you with a needle.”
Give some facts calmly, but without being too graphic or detailed about what your child will experience. If you don’t know the answer, say, “We’ll ask.”
Remember your role as a parent. Your emotions and behavior can have an impact on your child’s outcome, so take your role as the parent very seriously.

Going Home

Ask your child’s doctor and nurse what you can do to care for your child after surgery and anesthesia.

Note:
The above information was provided by the American Association of Nurse Anesthetists.
For more information visit www.aana.com or www.AnesthesiaPatientSafety.com.

CRNAs

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