Chapter 16: Priorities for the Intraoperative Patient PDF

Chapter 16 Priorities for the Intraoperative Patient OVERVIEW OF THE SURGICAL EXPERIENCE \*\*\*\*\*\*\*\*\*\*\*Surgical Settings Surgical technology is changing every day. As new equipment is developed and evidence-based practice is integrated into surgical protocols, the setting of surgery also...

Chapter 16 Priorities for the Intraoperative Patient OVERVIEW OF THE SURGICAL EXPERIENCE \*\*\*\*\*\*\*\*\*\*\*Surgical Settings Surgical technology is changing every day. As new equipment is developed and evidence-based practice is integrated into surgical protocols, the setting of surgery also changes. Surgical procedures are not only performed in the traditional inpatient hospital setting but also in outpatient surgical centers that offer the same amenities. Inpatient surgical settings perform surgical procedures that require admittance to a hospital unit postoperatively. Inpatient procedures are often very invasive and long. Patients require close monitoring and recovery for more than 24 hours after completion. Examples include procedures such as cardiac surgeries, which may require intensive care unit (ICU) care postoperatively with continuous monitoring. Joint replacements may require complex pain management. Inpatient surgery may also be indicated if admittance to the hospital after the procedure for rehabilitation is required. Ambulatory or outpatient surgery is performed without admittance to a hospital unit before or after the procedure. The surgery center may be freestanding or located in a hospital. Also known as "same-day surgery," outpatient surgery is often less invasive, shorter in operating time, and requires less than 24 hours of monitored recovery time. Patients are often admitted 2 hours prior to surgery and discharged directly to their homes. Candidates for outpatient procedures typically have no other comorbidities, such as substantial medical histories. They do not need additional recovery care beyond postanesthesia. Successful recovery at home requires the patient to be receptive to teaching prior to discharge from the surgical center and to have a caregiver who will be present with the patient at all times for at least 24 hours. Advances in surgical science have greatly increased the number of procedures that are done on an outpatient basis. Outpatient surgical examples include some ear, nose, and throat (ENT) procedures and oral and orthopedic surgeries. More complex procedures such as mastectomies can also be performed in an outpatient setting. Ambulatory surgery centers follow the same safety and clinical guidelines as an inpatient setting. These include the presence of an anesthesiologist, a sterile operating environment, and a postanesthesia care unit (PACU). Before a patient is discharged from the outpatient settings, goals are met regarding pain control and recovery education. Freestanding outpatient surgery is a rapidly expanding option for many patients. Freestanding surgical centers tend to be located in a more convenient setting, away from the intimidating hospital setting. They allow more flexibility in scheduling for the patient. Family members are only separated from the patient during the actual procedure and are able to participate in the postoperative care and education. Freestanding surgical centers are less expensive than inpatient settings and often provide more face-to-face time with the nurse during the patient's stay. Outpatient operative nursing poses unique challenges. The nurse needs to quickly identify and prioritize the patient's learning needs because there is a shorter recovery time and therefore less time to complete postoperative education. Also, patient education may need to be completed during the preoperative time when the patient is more alert rather than sleepy after undergoing anesthesia. \*\*\*\*\*\*\*\*\*\*\*\*Surgical Categories Types of surgery can be divided into six subcategories. Diagnostic surgeries, such as biopsies, exploratory procedures, and laparotomies/arthroscopies, are performed to determine sources of disorders. Curative surgeries repair or remove causes of disorders. Restorative surgeries are those that repair disorders, such as a total hip replacement; they improve patient function by reconstructing mechanical parts of the body. Palliative procedures are for comfort and help relieve pain or symptoms of a disease process. Cosmetic surgeries restore or improve personal appearance. Lastly, transplant surgery is done to replace nonfunctioning or poorly functioning organs to improve or sustain life. Examples of transplant surgeries include kidney or heart transplants. Often the name of the surgery describes the nature of the procedure (Table 16.1). Surgical procedures may be further classified as elective, urgent, or emergency. Elective surgery is surgery that the patient chooses to have. It is performed for their well-being but is not absolutely necessary. Most elective surgeries are scheduled at the patient's convenience, and many are performed in the outpatient setting. These often include plastic surgeries, oral surgeries, and orthopedic surgeries. Urgent surgery, although necessary, may be scheduled rather than done immediately. Examples include hysterectomies, laminectomies, and hip or knee replacements. Emergency surgery is unscheduled and is done immediately to save a patient's life or limb. The need for this type of surgery is always unanticipated. Gunshot wounds, stabbings, and auto accidents often require emergency surgery. Procedures can have a minor or major degree of risk. Minor procedures such as oral surgeries and dilations and curettage (D&C) are often performed under local anesthesia, hold less surgical risk for the patient's well-being, and require minimal postanesthesia recovery. Major procedures are longer, more complex, and have a higher degree of risk. They are performed under general anesthesia and require overnight stays in the hospital, sometimes in the ICU setting. Cardiac procedures, neurological procedures, or thoracic procedures typically fall into this category. Finally, surgical procedures are defined as simple or radical in extent. A simple procedure means that the surgeon is working within a small defined affected area. A radical procedure involves not only the small defined affected area but also the surrounding tissue. For example, a surgeon may only need to perform a simple tumor removal. Alternatively, a radical procedure involves removing the tumor and the surrounding tissues. A gynecologist may perform a simple hysterectomy where only the uterus is removed or may remove the fallopian tubes and ovaries in what is known as a radical total hysterectomy. \*\*\*\*\*\*\*\*\*\*\*\*\*OVERVIEW OF THE SURGICAL TEAM MEMBERS Each day, several million individuals worldwide face a surgical procedure of some kind. Surgical patients must depend on the knowledge and skills of surgical team members who work in the OR. As in other healthcare settings, an efficiently functioning team in the surgical environment is of extreme importance to the patient. Respect for others' expertise, the ability to work harmoniously, and the art of communicating effectively are necessary ingredients for a well-functioning OR team. The surgical procedure dictates the number and type of members on the surgical team. Normally, this team includes a surgeon; an anesthesia provider; a perioperative registered nurse (RN who works in the OR); and perhaps a variety of unlicensed assistive personnel, such as surgical technologists, OR associates, and critical care technicians. Team members are categorized as sterile, individuals who perform a surgical scrub and don a gown and gloves to work inside the sterile field (the identified surgical area considered free from microorganisms), and/or nonsterile, individuals who function outside the identified sterile field. Sterile Team Members Sterile team members are those who work within the sterile field and have the responsibility of maintaining asepsis (controlling the sterile field to avoid contamination by microorganisms) throughout the surgical procedure. The sterile field includes the OR table and the area closely surrounding it, an equipment stand called the Mayo stand that is conveniently positioned close to the patient, and the instrument table. The team members scrub their hands and arms with special disinfecting soaps and wear surgical gowns, caps, eyewear, gloves, and sturdy footwear with shoe covers. Sterile team members include: The surgeon Surgical assistants The scrub nurse or surgical technologist/operating room technician Surgeon The surgeon is considered the leader of the surgical team and has the ultimate responsibility for performing the surgery in an effective and safe manner. Depending on the complexity of the surgical procedure, the surgeon may have one or more providers assisting. These providers may be interns or hospital residents who are participating in the surgery as part of their advanced training. There may also be other surgeons who are specialists in a particular field and part of the interprofessional team caring for the patient. Surgical Assistants Surgical assistants are practitioners with specialized training that allows them to assist with surgical procedures. These roles include physician assistants (PAs), surgical first assistants (SFAs), nurse practitioners (NPs), and RN first assistants (RNFAs). The PA's primary role is to assist licensed providers. In addition to helping in the OR, the PA provides both preoperative and postoperative care for patients, freeing the surgeon to perform the more specialized care appropriate to their training and expertise. The PA's duties may include ensuring the acquisition of patient diagnostic films, records, laboratory studies, and history and physical examinations (also known as an H&P) and reporting any issues or concerns to the appropriate parties. The SFA is typically a certified surgical technologist with additional specialized education or training. Under the surgeon's direction, the SFA provides aid in exposing the surgical site, hemostasis (controlling blood flow and stopping or preventing hemorrhage), and other technical intraoperative functions as directed by the provider. The RNFA or NP is an RN who has gone through extensive education beyond the traditional nursing preparation. The actual scope of the RNFA's/NP's practice in the perioperative environment is dependent on specific state regulations. In most instances, similar to the PA, the RNFA/NP functions interdependently with the surgeon during the procedure to assist in performing the operation. Scrub Nurse, Surgical Technologist, and Operating Room Technician The scrub nurse, surgical technologist, or OR technician are also known as the scrub. This individual works directly with the surgeon within the sterile field by passing instruments, sponges, and other items needed during the surgical procedure. Before an operation, scrubs help prepare the OR by setting up surgical instruments and equipment, sterile drapes, and sterile solutions. They assemble both sterile and nonsterile equipment, checking to ensure that it is working properly. The scrub is also responsible for helping the surgical team don sterile gowns and gloves in preparation for the surgical procedure. Scrubs help count sponges, needles, instruments, and other miscellaneous supplies and help prepare, care for, and dispose of specimens taken for laboratory study. Depending on the institution's policies, scrubs may hold retractors, cut sutures, and assist with the application of surgical dressings. After an operation, scrubs disassemble the sterile field and return instruments to the decontamination area for proper cleaning and sterilization for future surgical procedures. In some institutions, scrubs assist with readying the room for the next procedure by cleaning and restocking the OR. \*\*\*\*\*\*\*\*\*\*Nonsterile Team Members Nonsterile team members perform their duties outside the sterile field. These team members include but are not limited to: The anesthesia provider The circulating RN Unlicensed assistive personnel The OR director/coordinator/manager Anesthesia Provider The anesthesia provider is responsible for maintaining and sustaining the physiological status of the patient throughout the surgical process. This person may be an anesthesiologist or certified registered nurse anesthetist (CRNA). An anesthesiologist is a physician, whereas CRNAs are advanced practice RNs trained to administer anesthetics. They can work independently or in collaboration with an anesthesiologist. The anesthesia provider must be constantly aware of the surgeon's actions, doing everything possible to ensure the safety of the patient and reduce the stress of the operation. Specific responsibilities include providing smooth induction of the patient's anesthesia (temporary induced loss of sensation or awareness) to prevent pain; maintaining satisfactory degrees of relaxation of the patient; providing continuous monitoring of the patient's life functions, including oxygen exchange, circulatory functions, systemic circulation, and vital signs; and advising the surgeon of impending complications and independently intervening as necessary. The anesthesia provider has contact with the patient during all phases of the surgical process: preoperative, intraoperative, and postoperative. During the preoperative phase, the anesthesia provider meets with the patient and conducts a preoperative interview. At this time, the patient's medical history and medications are reviewed, facilitating the development of a plan for managing these conditions during surgery. The upcoming surgery and options for anesthesia are also discussed. During the intraoperative phase, the anesthesia provider administers anesthetic agents and carefully monitors the patient's vital signs, including heart rate and rhythm, blood pressure, and respiratory status. As the surgical procedure progresses, adjustments in anesthesia agents may be made to compensate for changes in the patient's physical condition. At the completion of surgery, the recovery phase begins. If a general anesthetic has been used, the anesthesia provider gradually stops the anesthesia administration to allow for the metabolism of the medications, thereby allowing the patient to regain consciousness. The postoperative phase begins when the patient is transported from the operative suite to a PACU or ICU. If to the ICU, responsibility for patient care is assumed by the ICU medical team after a thorough hand-off from the surgical team. If to a PACU, the anesthesia care provider maintains the oversight of patient management. This includes but is not limited to airway management; pain, nausea, and vomiting management; and monitoring of physiological outliers, such as changes in vital signs. When PACU discharge criteria are met, the anesthesia provider approves the movement of the patient to the predetermined postsurgical destination (i.e., home, floor bed, or unit bed). Circulating Registered Nurse The circulating registered nurse (RN) observes the surgical procedure from a broad perspective, assisting the team in creating and maintaining a safe and comfortable environment for the surgical patient. The scope of the nurse's responsibilities includes: Initial assessment of the patient in the preoperative area. During this time, an essential role of the perioperative nurse is to establish a therapeutic relationship with the patient, attempting to calm fears and establish trust. Initial assessment upon admission to the OR. Assisting the anesthesia provider with positioning, monitor placement, line placement, and patient monitoring. Assisting the surgeon and scrub nurse/technologist with donning of sterile gowns, gloves, and other protective gear. Anticipating the need for equipment, instruments, and medications. Assisting the scrub nurse or technician by opening packages of sterile supplies necessary for the procedure. Ensuring specimens are appropriately labeled and sent to the laboratory for analysis. Counting the number of sponges, needles, instruments, and other miscellaneous supplies used during the operation to prevent accidental retention or loss of an item in the surgical wound. Documenting information pertinent to the surgery and the surgical patient. Unlicensed Assistive Personnel Unlicensed assistive personnel are accountable to and work under the supervision of perioperative RNs. Their duties include patient transport to the OR and helping with the positioning and securing of patients on the operating table in preparation for their procedures. They may also be assigned other tasks, such as delivery of specimens to the laboratory, blood pickup, and equipment retrieval and housekeeping duties. Operating Room Director/Coordinator/Manager The OR director/coordinator/manager is responsible for oversight of the business aspect of the OR. This individual is accountable for budgets, staffing, and other areas critical in ensuring the efficient running of the OR. PRIORITY ASSESSMENTS AND PROCEDURES There are several priority assessments and procedures that are essential in ensuring a safe operative experience for the patient. These include: The preoperative assessment The surgical pause, and a fire risk assessment The surgical (hand/arm) scrub The donning of surgical attire The surgical count \*\*\*\*\*\*\*\*\*\*Preoperative Assessment The preoperative assessment is done by the perioperative nurses, typically in the preoperative area, and must accomplish, at a minimum, four goals: Determine the patient's level of knowledge related to the planned surgery, potential complications, and interventions, such as insertion of an indwelling catheter, and provide education as appropriate. This time also allows the patient to voice specific concerns or questions regarding the procedure. Confirm that informed consent for the proposed surgical procedure has been obtained. Informed consent discussions are intended to explain the proposed procedure in terms the patient can understand and is able to articulate. Determine the patient's level of anxiety to support their management of preoperative fears and postoperative concerns. This is done by openly discussing the causes of anxiety, such as fear of death or disability, fear of pain, fear of poor prognosis, and fear of rejection if a transplant is the planned procedure. Obtain relevant information about the patient, which may include: Verification of the patient's name and date of birth; verifying that the medical record numbers match the patient's name band and paperwork and verification and documentation of the patient's preferred name and pronoun Verification of NPO status prior to surgery Determination of medications taken in the morning prior to surgery Assessment of skin color, temperature, and integrity (i.e., tattoos, bruises) Verification of health history, including current medications Verification of allergy status and specific allergic reactions the patient experiences, such as a rash or itching Verification of placement of any metal implants, especially automatic implanted cardioverter defibrillators and pacemakers Assessment of family support Verification of patient's religious and cultural preferences \*\*\*\*\*\*\*\*\*\*\*\*\*\*Surgical Pause The surgical pause, or time-out, is done prior to the start of the procedure to verify correct patient, correct procedure, correct surgeon, correct position, correct equipment, and correct imaging studies (radiography, etc.). The presence of implants, such as a pacemaker, is confirmed. If antibiotics were indicated, their administration is verified. If the surgical site involves laterality, the correct site is verified and clearly marked with the operating surgeon's initials. Finally, a fire risk assessment is completed at this time. This universal time out protocol developed by The Joint Commission also includes the introduction of all team members in the room; thus, it involves active communication among all members of the interprofessional team (see Evidence-Based Practice). It is consistently initiated by a designated member of the team and is conducted in a "fail-safe" mode, which means the surgical procedure does not commence until every question or concern has been resolved. \*\*\*\*\*\*\*\*\*\*\*\*Surgical Scrub The surgical scrub is another key element of patient care in the OR that is done to prevent surgical site infections. Although the human hand represents a vital tool in the care of a patient, it also may act as a portal and transmitter of infection. The warm, moist conditions inside surgical gloves are an ideal environment for the rapid growth of microorganisms. To minimize the risk of infection to the patient, it is essential that OR personnel who will be directly involved in invasive surgical procedures follow appropriate hand-hygiene and hand-scrub procedures. A systematic approach to this procedure is an efficient way to ensure proper technique is completed. Prior to performing the hand scrub, ensure that nails are short and clean, with no chips in nail polish (acrylic overlays and chips in nail polish have the potential to harbor bacteria), and that all jewelry is removed. The traditional surgical scrub starts with washing the hands thoroughly. This is followed by washing with a disposable scrub sponge from a clean area (the hand) to a less clean area (the arm). Scrubbing with a long-acting, powerful antimicrobial sponge for at least 3 to 5 minutes allows adequate time to remove, inhibit, or kill as many microorganisms as possible and protect against infection if gloves develop holes, tears, or nicks during the operative procedure (Fig. 16.1). An alternative hand rub using a waterless alcohol-based preparation may be used. \*\*\*\*\*\*\*\*\*Surgical Attire Wearing of appropriate surgical attire is another important step in reducing the risk of postoperative infections. There are several levels of surgical attire. The first level is worn by everyone working in the OR. This apparel is popularly referred to as scrubs because it is usually worn in a scrubbed or sterile environment. Scrubs are the shirts and pants or dresses worn as uniforms by surgeons, nurses, and other support staff in the OR. The next level of attire, which is typically referred to as surgical attire, consists of the sterile gown and gloves worn by staff working directly within the sterile field. This attire includes gloves, caps, masks, gowns, protective eyewear, and sturdy footwear \*\*\*\*\*\*\*\*\*\*\*ANESTHESIA The term anesthesia is derived from the ancient Greek word an-aisthesis, meaning "lack of or no sensation." Without anesthesia, most surgical procedures performed today would not be possible. The goals of anesthesia are amnesia, analgesia, depression of reflexes, muscle relaxation, and manipulation of physiological systems and functions. These are accomplished through the use of balanced anesthesia, which consists of one to several agents, each with a different action. The agents used depend on the patient, the procedure, and the anesthesia provider's preference. Prior to surgery, each patient is given a preoperative physical examination and evaluation by the anesthesia team. On the basis of that evaluation, the patient is assigned a physical (P) status from the scale developed by American Society of Anesthesiologists (ASA) providers to assess and assign a perioperative risk, which helps in determining the anesthesia to be administered. This may also be called the ASA status using the same numbering system Types of Anesthesia There are four major types of anesthesia. They are general, regional, and local anesthetics and monitored anesthesia care (MAC). \*\*\*\*\*\*\*\*\*\*General Anesthesia General anesthesia is what the layperson calls "being put to sleep." Under general anesthesia, a patient is in a reversible unconscious state. General anesthesia provides all of the goals stated previously, including manipulation of physiological systems and functions. It is achieved using a variety of methodologies, either alone or together. These include inhalation of volatile agents (gases), IV agents, and muscle relaxants. The patient receiving a general anesthetic that includes the administration of a muscle relaxant requires ventilatory support in the form of an endotracheal tube (ETT). General anesthetics can also be administered without the use of muscle relaxants. In such instances, the airway is frequently supported with supraglottic airways, such as a laryngeal mask airway (LMA), oral airway, or nasal airway. Airway management is discussed later in this chapter. Volatile Agents Volatile (inhalation or gas) anesthetic agents used in the United States include isoflurane, sevoflurane, desflurane, and nitrous oxide. The potency of the gases is identified as the minimum alveolar concentration needed to achieve the desired effect (the lower the minimum alveolar concentration, the more potent the gas). For example, sevoflurane has a minimum alveolar concentration of 2, whereas nitrous oxide has a minimum alveolar concentration of 105. Although these gases have been used for more than 100 years, their exact mechanism of action is not yet clearly understood. Some studies indicate that the synaptic transmission of nerve impulses is reversibly inhibited in areas of the central nervous system. Intravenous Agents Current IV anesthetics include: Barbiturates Benzodiazepines Opioids Propofol Ketamine Sedative-hypnotics Barbiturates are central nervous system depressants. Examples include thiopental sodium, sodium methohexital, thiamylal, and pentobarbital (Nembutal). They are excellent anesthetics and amnestics with a short onset and duration of action. Benzodiazepines increase receptor availability for the inhibitory neurotransmitter gamma-aminobutyric acid. Examples include midazolam, diazepam, and lorazepam. They have a longer time to onset but have a longer duration than barbiturates. They are excellent amnestics but provide no analgesia. Opioids bind to G-protein receptors as ligands or signaling molecules, producing analgesia. They also decrease the perception of pain. Examples include morphine, fentanyl, hydromorphone (Dilaudid), sufentanil, and remifentanil. They are excellent analgesics, but adverse effects include respiratory depression. Propofol, sometimes referred to as "milk of anesthesia" because of its white color, is a hypnotic agent. It has a fast onset of action. The effects wear off quickly when the medication is discontinued. The patient is awake more quickly than with other sedatives. It is a good amnestic but provides no analgesia. For this reason, it is typically used in conjunction with analgesics. Ketamine is a phencyclidine hydrochloride (PCP) derivative. It causes a dissociative state, which means the patient appears to be "dissociated" from the external environment but not necessarily asleep. Patients may experience hallucinations, so it is generally used in conjunction with amnestics for sedation. It is an excellent analgesic and sedative. Etomidate, a sedative-hypnotic, causes the least detrimental cardiovascular changes of all nonopioid induction medications. It may be used as an alternative to ketamine for induction in hypovolemic patients. Dexmedetomidine (Precedex) is an anxiolytic, analgesic, and sedative. Unlike fentanyl and midazolam, it provides semiarousable sedation without respiratory depression. Muscle Relaxants Muscle relaxants are categorized as depolarizing or nondepolarizing agents. Depolarizing agents, such as succinylcholine, act by occupying the acetylcholine-binding sites at the neuromuscular junction. The membrane becomes depolarized; thus, no impulses can be transmitted, and paralysis ensues. The depolarizing action causes muscle fasciculation (twitching) prior to relaxation. Succinylcholine has a fast onset (30--40 seconds), quickly producing paralysis. Adverse effects include hyperkalemia, cardiac dysrhythmias, masseter spasm, and malignant hyperthermia (MH). Depolarizing agents cannot be reversed; they are metabolized and must "wear off." Ventilatory support is not withdrawn until the medication effects are no longer apparent. Nondepolarizing agents, such as pancuronium, vecuronium, cisatracurium, and rocuronium, work by competing with native acetylcholine for binding at the neuromuscular junction without causing depolarization. When these medications are administered, progressive paralysis results as a chemical response. The reaction starts in the smaller muscles of the eyelids and face, then moves to the larger muscle groups, including the tongue, neck, and shoulder, and finally to the respiratory muscles: the intercostals, larynx, and diaphragm. The onset of action is longer, minutes compared to seconds. Nondepolarizing agents do not cause muscle fasciculation. Different agents have differing lengths of onset, duration, and hemodynamic effects. All nondepolarizing muscle relaxants can be reversed, which must be done before ventilatory support and airway protection are withdrawn. Some reversal agents are called cholinergic agents. They increase the amount of acetylcholine at the neuromuscular junction and reverse the relaxation. Examples include neostigmine, pyridostigmine edrophonium, and sugammadex. Because of cholinergic side effects such as bradycardia and increased secretions, anticholinergic medications are usually given concurrently. Examples of these are atropine and glycopyrrolates. See Table 16.2 for a list of anesthetic medications and Table 16.3 for the sequencing of anesthesia. \*\*\*\*\*\*\*\*\*\*Complications of General Anesthesia Untoward effects or complications of general anesthesia include: Hypoxia Respiratory and cardiovascular dysfunction Hypotension Hypertension Fluid and electrolyte imbalances Residual muscle paralysis Neurological problems such as dementia, prolonged awakening, paresthesias Malignant hyperthermia \*\*\*\*\*\*\*\*\*\*\*\*\*Malignant hyperthermia (MH) is a hypermetabolic state that can be caused by exposure to a triggering agent, such as a volatile gas anesthetic (except nitrous oxide) and/or succinylcholine. The triggering agent causes sustained muscular contractions related to an increase in intracellular calcium ion concentration. The sustained contractions result in signs of hypermetabolism. These include acidosis, tachycardia, hypercarbia, glycolysis, hypoxemia, and hyperthermia. The reaction usually begins to occur soon after the exposure, but it has been known to be delayed until the patient is in the recovery area. The most specific sign of MH is skeletal muscle rigidity. However, the first sign noted by the anesthesia or nursing staff is an unexplained tachycardia. For the anesthesia provider, hypercarbia is the most sensitive indicator of potential MH. Myoglobinuria is another early sign. The patient's urine turns from dark amber to brown. Hyperthermia, the classic sign of MH, is usually a late sign. \*\*\*\*\*\*\*\*\*\*\*Regional Anesthesia Regional anesthesia is a local anesthetic used to block or anesthetize a nerve or nerve fibers. Types of regional anesthesia or blocks include spinal, epidural, caudal, and nerve blocks. Spinal medication is injected into the spinal canal or intrathecal space surrounding the spinal cord, typically in the lower back or lumbar region (Fig. 16.3A). The injection lasts for several hours. It may also be given as continuous spinal anesthesia via a catheter. It is important to keep the head of the patient's bed flat after spinal anesthesia to avoid a headache. Epidural medication is injected into the epidural space into the lumbar region or thoracic region (Fig. 16.3B). A catheter is inserted for periodic or continuous injection. Spinal headache is avoided because the intrathecal space is not entered. Caudal is a form of epidural anesthetic where the medication is injected into the epidural space through the caudal canal in the sacrum (Fig. 16.3C). A nerve block, anesthetizing of a nerve in an extremity, is done to allow surgery in a specific area (e.g., performing a block on the axillary nerve to allow surgery in the arm). Untoward effects of epidural or spinal anesthesia may include the following: A rapid decrease in blood pressure due to vasodilation of the sympathetic nerves that control vasomotor tone, causing peripheral pooling and decreasing venous return. A vasopressor may be used to counteract this effect. Spinal headache is a risk with intrathecal anesthesia because of potential leakage of cerebrospinal fluid. It usually resolves in 1 to 3 days. Respiratory paralysis is a risk with a high intrathecal injection. Seizure is a risk if medication is injected intravascularly. Finally, nerve damage and epidural hematoma/abscess occur rarely. Local Anesthetics Local anesthetics cause a reversible conduction blockade of nerve impulses when they are placed in proximity to nerve membranes. The anesthetic diffuses into the nerves and inhibits the propagation of signals for pain and muscle contractions. Pain fibers are affected first, then sensory fibers and motor fibers. High concentrations inhibit all qualities of sensation as well as muscle control. Lower concentrations selectively inhibit pain sensation, with minimal effect on muscle power. Adverse reactions are due to overdosage, rapid absorption, and hypersensitivity. Reactions vary from mild (hives, itching, and rash) to severe (acute anaphylactic reaction). Examples include amides and esters, which are defined by their chemical composition. Amides Lidocaine has a rapid onset and a short to intermediate duration of 60 to 120 minutes. The maximum dose is 4.5 mg/kg (30 mL in an average 70-kg adult). It has excellent spreading ability and is the main local anesthetic. Bupivacaine has a slow onset and a long duration of 4 to 8 hours. The maximum dose is 2 mg/kg (50 mL in an average 70-kg adult). It provides excellent postoperative analgesia. Both medications may be mixed with epinephrine for its vasoconstrictive effects to help control bleeding at the procedure site. It also prolongs the action of the medications. Esters Cocaine has a slow onset and medium duration. It is used in nasal surgery more for its vasoconstrictive effects than as an analgesic. It can cause hypertension and tachycardia as a result of increased catecholamine release. \*\*\*\*\*\*Monitored Anesthesia Care Monitored anesthesia care (MAC) provides anesthesia without unconsciousness. The patient has a decreased level of consciousness but maintains a patent airway and responds appropriately to verbal commands and physical stimulation. Objectives for the patient receiving MAC are: Maintenance of consciousness Elevation of pain threshold Enhanced cooperation Some degree of amnesia Minimal variation in vital signs Quick and safe return to activities of daily living MAC couples sedation/analgesia with local anesthetics. The usual medications utilized are benzodiazepines, such as diazepam and midazolam, and narcotics, such as fentanyl and meperidine. During the administration of both local anesthesia and MAC, signs are posted outside the OR alerting staff that the patient is awake. It is important that OR staff are mindful of conversations in the room and keep them to the minimum needed to communicate needs or to comfort the patient. \*\*\*\*\*\*\*\*\*\*AIRWAY MANAGEMENT Airway management is the process of protecting and ensuring adequate oxygenation and ventilation during an operative procedure. This is not only an essential component of care for patients receiving general anesthesia but also an important consideration with any kind of anesthesia that can potentially compromise the airway. Airway compromise can be caused by relaxation of the soft tissues of the oropharynx. This relaxed effect may create an occlusion of the trachea or trigger a laryngospasm, where the larynx constricts and cannot easily be re-expanded. The airway may also be compromised in patients who present with anatomical abnormalities such as a small mouth, short neck, inability to open the mouth fully, obesity, or facial or cervical injuries. See Table 16.4 for the different methods of managing airway patency in the OR. Airway complications include: Laryngospasm: This is a reflexive and prolonged closure of the vocal folds in response to a trigger. It is most common during anesthesia induction/intubation or extubation. It is caused by stimulation of the airway by airway devices, secretions, or gastric contents. Bronchial intubation: This occurs when an ETT is passed below the carina into one of the mainstem bronchi, resulting in hyperinflation of the intubated lung and collapse (deflation) of the opposite lung. Tracheal and esophageal perforation: This may occur during intubation if excessive force is applied or as a complication of the use of a stylet or other stiff intubation-assisting device. Aspiration: This occurs when the patient regurgitates, and stomach contents or other secretions go into the lungs, resulting in pneumonia or airway obstruction. POSITIONING THE PATIENT IN THE OPERATING ROOM Patient positioning for surgical procedures is done to provide for optimal anatomical exposure and patient safety. There are a variety of positioning devices utilized to ensure safe alignment of anatomical structures while contributing to surgical outcomes. The use of these devices may place the patient at risk for temporary or permanent injury. The challenge in positioning is to provide the exposure the surgeon needs to perform the procedure, allow for access to IV lines and monitoring equipment, while also ensuring a safe, comfortable position for the patient. Patient positioning is a collaborative activity involving all surgical team members. The surgeon determines the position that is appropriate for a specific procedure, and after consultation with the surgical team, the patient is placed in the appropriate position. The RN documents all positioning aids used and the team members assisting with patient positioning. The RN ensures that the patient is treated in a dignified manner throughout the positioning activity. The patient's dignity and right to privacy cannot be overlooked before, during, and after positioning activities. \*\*\*\*\*\*\*\*\*\*\*\*\*\*Common Intraoperative Positions There are four standard positions commonly used for surgical procedures. These positions are often modified according to the surgeon's preferences and surgical approaches and the patient's physiological requirements (Fig. 16.6). These positions are: Supine (Trendelenburg, reverse Trendelenburg, and Fowler's are modifications) Prone (jackknife is a modification) Lateral Lithotomy Supine The supine position (Fig. 16.6A) is the most frequently used patient position and the most natural position for the body at rest. This position is used for procedures on the anterior surface of the body, including abdominal, abdominothoracic, vascular, orthopedic, head/neck, and ophthalmic operations. The patient is placed on their back with the legs extended and uncrossed and the arms on arm boards or at the sides with the palms up. Proper arm placement with extension at less than a 90-degree angle is necessary to avoid brachial plexus stretching and compression. The arms must not be positioned lower than the spinal column, and the spinal column should be in a straight line, with the legs parallel to the OR bed. The patient's head is in line with the spine, and the face is upward. The hips are parallel with the spine. Trendelenburg In the Trendelenburg position (Fig. 16.6B), the patient is placed in the supine position, and the OR bed is modified to a head-down tilt of 35 to 45 degrees. This position is used for procedures in the lower abdomen or pelvis when it is desirable to move the abdominal viscera away from the pelvic area for better exposure. Although exposure is increased, careful patient monitoring is required as lung volume is decreased, and the pressure of the organs against the diaphragm mechanically compresses the heart. Reverse Trendelenburg In the reverse Trendelenburg position (Fig. 16.6C), the entire OR bed is tilted so that the patient's head is higher than their feet. This position is used for procedures on the head and neck to facilitate exposure, aid breathing, and decrease blood supply to the operative area. A padded footboard is used to prevent the patient from sliding toward the foot of the bed. Fowler's For the Fowler's position (Fig. 16.6D), also called the sitting, lawn-chair, or beach-chair position, the patient is first placed in the supine position. The foot of the OR bed is lowered slightly, flexing the patient's knees. The body section is raised to 35 to 45 degrees, thereby becoming the backrest. The entire OR bed is tilted slightly, with the head end downward to prevent the patient from sliding. The patient's feet rest on a padded footboard. For cranial procedures, the head is supported in a headrest. This position can also be used for shoulder or breast reconstruction procedures. Prone In the prone position (Fig. 16.6E), also known as the ventral recumbent or ventral decubitus position, the patient is placed facedown, resting on their abdomen and chest. Chest rolls under the clavicles to the iliac crests raise the weight of the body from the abdomen and thorax. The arms may be supported along the sides of the body. The head is turned to one side, resting on a padded donut to prevent pressure on the ears, eyes, and face. Female breasts should be moved laterally to reduce pressure on them, and male genitalia must be positioned to be free from pressure. Jackknife The jackknife position, or Kraske position (Fig. 16.6F), is a modification of the prone position in which the patient is placed in the prone position on the OR bed and then inverted in a V position. The hips are over the center break of the OR bed between the body and leg sections. This position is used for gluteal and anorectal procedures. Lateral The lateral (lateral decubitus) position (Fig. 16.6G) is used primarily for thoracic, renal, and orthopedic (hip) procedures. The patient is placed in the supine position for anesthetizing and then turned to the unaffected side. Lithotomy In the lithotomy position, the patient is in the supine position, with the legs raised and abducted to expose the perineal region. The legs and feet are placed in stirrups that support the lower extremities. The lithotomy position is used for vaginal, obstetrical, urological, and rectal procedures and for radical resections of the groin, the vulva, and the rectal areas. There are two variations of the lithotomy position. High Lithotomy The high lithotomy position (Fig. 16.6H) is frequently used for procedures that require a vaginal or perineal approach. Low Lithotomy The low lithotomy position (Fig. 16.6I) is used in vaginal procedures and routinely for most laparoscopic surgeries. See Table 16.5 for risks and interventions related to surgical positions. \*\*\*\*\*\*\*\*\*\*Positioning Devices The choice of a particular positioning device for a surgical procedure depends on many variables. Patient variables such as height, weight, age, and physiological condition and the position required for the procedure influence which devices are used. The surgeon's preference affects the selection of a positioning device as well. Routine positioning devices used for most surgical procedures include but are not limited to the following: OR bed, headrest, arm boards, arm restraints, padding for bony prominences, blankets, pillows, safety straps, sandbags, bean bags, towels and sheets, foam pads, and gel-type devices. \*\*\*\*\*\*\*\*Positioning Complications Preoperative assessment of the patient is crucial in providing information about the patient's individual risk factors that may influence the selection of positioning devices and any alterations to a proposed position. Patients at high risk for complications due to positioning include: Geriatric patients, whose thin skin layer and impaired circulation make them susceptible to skin breakdown due to pressure and moisture Pediatric patients (immature systems) Extremely thin patients who may be malnourished, anemic, or hypovolemic Obese patients with an overabundance of fat tissue Paralyzed patients Diabetic patients who are already prone to skin breakdown Patients with prosthetic or arthritic joints Patients with edema and circulatory limitations Patients with medical conditions such as cancer that can alter cardiac, respiratory, or immune reserves Patients with infections Patients who have existing or previous trauma Improper positioning may contribute to the development of a pressure injury. Also referred to as a decubitus ulcer, a pressure injury is localized damage to the skin and/or underlying tissue, generally over a bony prominence. Pressure due to prolonged contact causes constriction of the blood vessels feeding the area and consequent damage to the skin and possibly underlying areas. High-risk situations include but are not limited to: Long surgical procedures Vascular surgery in which blood perfusion may be already compromised Demineralizing bone conditions (e.g., malignant metastasis or osteoporosis) Excessive sustained pressure on body parts due to surgical procedures or retraction