CHAPTER 18
Intraoperative Care
INTRAOPERATIVE C ARE (1 OF 2)
• Historically, took place in OR
• Now many are done as ambulatory
surgery
• ↑ Minimally invasive surgery (MIS)
• Endoscopes
• Robotics
• Other advanced technology
2
INTRAOPERATIVE C ARE (2 OF 2)
• MIS leads to decreased
• Blood loss
• Incision size
• Pain
• Recovery time
• Hospital length of stay
3
PHYSIC AL ENVIRONMENT
Surgical suite
Unrestricted Zone
Semi-restricted Zone
Restricted Area
Holding area
Admission, Observation, Discharge (AOD)
area
• PACU
•
•
•
•
•
•
4
TRADITIONAL OPERATING
ROOM
Fig. 18-2
5
Physical Environment

Operating room






Filters
Controlled airflow
Positive air pressure
Narrow range of
temperature and
humidity
Strict protocols for
cleaning
UV lighting




Adjustable, easy-to-clean,
and easy-to-move
furniture is used
Equipment is checked for
proper functioning and
electrical safety
Lighting provides low- to
high-intensity for precise
view of surgical site
Communication system is
used
Copyright © 2020 by Elsevier, Inc. All rights reserved.
6
SURGICAL TEAM
• Perioperative nurse
• Is a registered nurse (RN)
• Collaborates with rest of team
• Three domains
• Preoperative RN
• OR RN (Circulating)
• Serves as patient advocate throughout surgical experience
• Postanesthesia care unit (PACU) RN Scrub nurse
• Follows designated surgical hand antisepsis
• Gowned and gloved in sterile attire
• Prepares and manages the sterile field and instrumentation
7
Surgical Team
Surgeon
 Physician who does the
procedure
 Is responsible for
• Preoperative medical
history
• Physical assessment
• Directing preoperative
testing
• Postoperative
management
• Obtaining informed
consent
• Leading the surgical
team

Surgeon’s assistant can be a
physician, RN first assistant
(RNFA), PA, surgical resident or
fellow, certified first assistant
 Holds retractors
 Helps with hemostasis and
suturing
 May perform portions of
procedure under surgeon’s
direct supervision
Copyright © 2020 by Elsevier, Inc. All rights reserved.
8
SURGICAL TEAM
Anesthesia care provider (ACP)
• Administers anesthetic agents
• Manages vital life functions during perioperative period
• Anesthesiologist has medical specialty
• Nurse anesthetist (CRNA) has master’s or doctorate
• Anesthesiologist assistant (AA) has master’s degree
9
SURGICAL ATTIRE
Fig. 18-3
10
SURGICAL TEAM
• Communication
• Situation
• Background
• Assessment
• Recommendations
11
TABLE 18.2
PAGE 316
COMMON
PERIOPERATIVE
NURSING ACTIVITIES
12
NURSING MANAGEMENT
After surgery
• ACP anticipates end of procedure
• Gives proper types and doses of anesthetic agents
so that effects will be minimal at end of surgery
• ACP goes with patient to PACU
• Hand-off includes
• Patient’s status
• Procedure done
13
ANESTHESIA
14
ANESTHESIA
• Anesthetic technique and agents are
chosen by the ACP
• Contributing factors include
• Physical and mental status
• Age
• Allergies and pain history
• Expertise of the ACP
• Factors related to the procedure
15
CLASSIFICATION OF
ANESTHESIA
• Moderate to deep sedation
• Procedures done outside the OR
• Presence of ACP not needed
• May be administered by an RN under direct supervision of a
physician
16
CLASSIFICATION OF
ANESTHESIA
Monitored Anesthesia Care (MAC)
• Used for diagnostic or therapeutic
procedures done in or outside the OR
• Includes varying levels of sedation,
analgesia, and anxiolysis
• Must be administered by an ACP
• Assessment and management of physiologic
problems is critical
17
CLASSIFICATION OF
ANESTHESIA
General anesthesia
• Total IV anesthesia (TIVA)
• Newer inhalation agents
• Used for
•
•
•
•
Procedures of significant duration
Need skeletal muscle relaxation
Require uncomfortable operative positions
Require control of ventilation
18
CLASSIFICATION OF
ANESTHESIA
General anesthesia
• IV agents
• Beginning of all routine general anesthesia
• Hypnotic, anxiolytic, or dissociative agent
• Induce sleep with rapid onset of action
• Long enough for placement of LMA or ET tube
19
CLASSIFICATION OF
ANESTHESIA
General anesthesia
• Inhalation agents
•
•
•
•
•
Volatile liquids or gases
Easy administration and rapid excretion
Irritating to respiratory tract
Once initiated, use ET tube or LMA
Complications include coughing,
laryngospasm, and increased secretions
20
CLASSIFICATION OF
ANESTHESIA
General anesthesia
• Rarely limited to one agent
• Adjuncts
• Drugs added to the anesthetic regimen
• Synergistic or antagonistic effects
• Dissociative anesthesia
• Interrupt associative brain pathways while blocking
sensory pathways
• Ketamine (Ketalar)
21
CLASSIFICATION OF
ANESTHESIA
• Adjuncts to general anesthesia
• Opioids
• Sedation and analgesia
• Induction and maintenance
intraoperatively
• Pain management postoperatively
• Respiratory depression
22
CLASSIFICATION OF
ANESTHESIA
Adjuncts to general anesthesia
• Benzodiazepines
• Premedication for amnesia
• Induction of anesthesia
• Monitored anesthesia care
23
CLASSIFICATION OF
ANESTHESIA
Adjuncts to general anesthesia
• Neuromuscular blocking agents
• Facilitate endotracheal intubation
• Relaxation/paralysis of skeletal muscles
• Interrupt transmission of nerve impulses
at neuromuscular junction
24
CLASSIFICATION OF
ANESTHESIA
Neuromuscular blocking agents
• Classified as depolarizing or
nondepolarizing muscle relaxants
• Duration of effects may be longer than
the procedure
• Reversal agents may not be effective in
eliminating residual effects
25
CLASSIFICATION OF
ANESTHESIA
Neuromuscular blocking agents
• Observe closely for airway patency and
adequacy of respiratory muscle movement
• Lack of movement or poor return of
reflexes and strength may indicate need for
ventilator
26
CLASSIFICATION OF
ANESTHESIA
Adjuncts to general anesthesia
• Antiemetics
• Prevent nausea and vomiting associated
with anesthesia
27
CLASSIFICATION OF
ANESTHESIA
Local anesthesia
• Loss of sensation without loss of
consciousness
• Types
•
•
•
•
Topical
Ophthalmic
Nebulized
Injectable
28
CLASSIFICATION OF
ANESTHESIA
Regional anesthesia (Block)
• Injection to a central nerve or group of
nerves
• Innervates a site remote to the point
of injection
• Used as preoperative analgesia, during
surgery, and after surgery
29
CLASSIFICATION OF
ANESTHESIA
Local and regional anesthesia
• Little systemic absorption
• Rapid recovery
• Discharge with continued postoperative
analgesia
• No accompanying cognitive dysfunction
30
CLASSIFICATION OF
ANESTHESIA
Regional anesthesia
• Disadvantages
• Possible technical problems
• Discomfort at injection site
• Inadvertent vascular injection leading to
local anesthetic systemic toxicity (LAST)
• Confusion, metallic taste, dizziness
• Seizures, coma, and dysrhythmias may occur
31
CLASSIFICATION OF
ANESTHESIA
Methods of administration
• Topical
• Apply 30 to 60 minutes before
procedure
• Local infiltration
• Inject agent into tissues through which
incision will pass
32
CLASSIFICATION OF
ANESTHESIA
Methods of administration
• Regional nerve block
• RN may aid ACP in administering block
• Must be familiar with drugs, including
• Methods of administration
• Adverse and toxic effects
• Properly position the patient, monitor vital signs,
apply oxygen therapy, and use supporting devices
33
CLASSIFICATION OF
ANESTHESIA
Methods of administration
• Spinal anesthesia
• Injection of local anesthetic into CSF in
the subarachnoid space
• Usually below L2
• Autonomic, sensory, and motor blockade
34
SPINAL AND EPIDURAL
ANESTHESIA
Fig. 18-6
35
CLASSIFICATION OF
ANESTHESIA
Methods of administration
• Epidural block
• Injection of local anesthetic into epidural space
• Does not enter CSF
• Binds to nerve roots as they enter and exit the
spinal cord
• Sensory pathways blocked but motor fibers are
still intact
36
CLASSIFICATION OF
ANESTHESIA
Spinal and epidural anesthesia
• Observe closely for signs of autonomic
nervous system (ANS) blockade
• Bradycardia
• Hypotension
• Nausea/vomiting
37
GERONTOLOGIC
CONSIDERATIONS
• Anesthetic drugs need be carefully titrated
• Postoperative delirium common
• Possible communication difficulties
• Risk for injury from tape, electrodes
• Osteoporosis or osteoarthritis
38
C ATASTROPHIC EVENTS IN THE OR
Anaphylactic reactions
• Anesthetic agents, antibiotics, and latex
may cause allergic reactions
• Vigilance and rapid intervention are
essential
• Symptoms include hypotension,
tachycardia, bronchospasm, pulmonary
edema
39
C ATASTROPHIC EVENTS IN THE
OR
Malignant hyperthermia (MH)
• Rare disorder
• Autosomal dominant trait
• Inherited hypermetabolism of skeletal
muscle resulting in altered control of
intracellular calcium
40
C ATASTROPHIC EVENTS IN THE
OR
• Malignant hyperthermia
• Succinylcholine (Anectine), especially given
with volatile inhalation agents, is primary
trigger
• Other factors include stress, trauma, and
heat
• Usually occurs under general anesthesia
but may also occur in recovery
41
C ATASTROPHIC EVENTS IN THE
OR
Malignant hyperthermia
• Tachycardia
• Tachypnea
• Hypercarbia
• Ventricular dysrhythmias
• Rise in body temperature NOT an early sign
• Can result in cardiac arrest and death
42
C ATASTROPHIC EVENTS IN THE
OR
• Malignant hyperthermia
• Definitive treatment is prompt
administration of Dantrolene
• Slows metabolism
• Reduces muscle contraction
• Mediates catabolic processes
• Prevention includes taking careful family
history
43