A small compilation of nurse anesthesia care plans

These anesthesia care plans are meant to inspire nurse anesthesia residents when they are making their care plans. Always make sure you fully understand and "own" your care plan. Your plan must be specific for your patient and should always be with the most up-to-date information.

CT/MRI Procedures out of the OR

CT - Computed Tomography

MRI - magnetic resonance imaging

The selection of imaging modality depends on the ease of identification of the target lesion and surrounding structures

Pt cooperation and stillness are crucial to obtaining the best image resolution

Most procedures can be done with conscious sedation, but some may need GA

CT and MRI use an automated table to transfer pt into the imaging device

Anesthetic Considerations

All equipment must be non-ferromagnetic

No metals on pt or staff

ECG - use MRI-compatible electrodes and place leads to avoid creating loops

V5 and V6 are least likely to develop artifacts

Pulse Ox - place it outside the MRI, possibly using the toe

NIBP - replace ferrous connections on the cuff and tubing with nylon connectors

A-line - use MRI-compatible tubing

Stethoscope - MRI-compatible, infrared, wireless stethoscope is available

Temperature - MRI compatible available if needed

Capnography - MRI compatible is available, but not accurate due to the long pathway. Suitable for trend and RR

Foley – if it has a temperature probe, it must be disconnected and placed straight on the MRI table to avoid any skin contact and risk of burn

Verbal/visual vigilance

Pad well to prevent any nerve damage

Check eyes

Positioning can be challenging - supine, prone, or lateral

Respiratory

  • Limited access to the airway may dictate elective intubation
  • History of GERD/sleep apnea may require ETT

Cardiovascular

  • Cardiac PM or ICD/PA catheter is a contraindication for MRI
  • Need special MRI-compatible scanner for PM patients
  • Some devices are MRI-compatible

Neurological

  • Pts with Increased ICP or cranial trauma need GA with ETT
  • Aneurysm clips/coils may be contraindicated in MRI, but check with the surgeon. (Some newer clips are non-ferromagnetic)

Musculoskeletal

  • Spinal instrumentation, metal plates, pins, screws joint replacements usually not contraindicated for MRI

MRI-Scanner

  • Need MRI-compatible equipment - nonferromagnetic as otherwise objects can turn into missiles
  • Use micro infusion drip
  • Noisy environment - offer pt earplugs/music
  • Gadolinium chelates used for contrast - adverse reactions include
    • Nausea, HA, dizziness, hemodynamic instability, and dysrhythmia

IV sedation

Propofol infusion 25-200 mcg/kg/min

Use micro drip infusion set

Midazolam 0.025-0.1 mg/kg titrated to effect

General anesthesia

Children, mentally retarded, claustrophobic, uncooperative, or critically ill patients require general anesthesia

Induction outside MRI in the anteroom

Propofol infusion with micro drip chamber

Extubation in the anteroom

To PACU for recovery with monitors/O2

Complications

Contrast related

Gadolinium - local and systemic reaction

N/V, itching, urticaria, sensation of warmth, pain, anxiety, rash

  • Treatment is reassurance, diphenhydramine 25-50 mg IV
  • Monitor for further symptoms

Neurotoxic Symptom

Hemiplegia, blindness, aphasia, and decreased consciousness - may be related to the hyperosmolarity of the agent. 

  • They may need steroids and vasopressors
  • Note symptoms masked with anesthesia

Major allergic reactions

Bronchospasm, low BP, cardiac arrest, pulmonary edema, laryngeal edema, dysrhythmias

Tx with epinephrine, 0.25-0.5 mg IV

Tx anaphylaxis with securing airway, 100% O2, IV fluids, epinephrine, diphenhydramine, ranitidine, steroids

Loss of airway

  • Prompt removal of pt to safe intubation area outside of MRI

Psychological

Panic attacks and claustrophobia seen in 5-10% of pts

Hearing loss

Temporary hearing loss and tinnitus may be expected in 40% of pts. Use earplugs. GA increased the risk of hearing damage secondary to stapedius muscle relaxation. The stapedius is the tiniest skeletal muscle in the human body. At just over one millimeter in length, its purpose is to stabilize the smallest bone in the body, the stapes. It reflexively dampens the vibrations of the stapes by pulling on the neck of that bone. It prevents excess movement by the stapes, helping to control the amplitude of sound waves from the general external environment to the inner ear.

Thermal injury

From induced current, heating of the oximeter probe, and unintentional looping of the cables