PERIOPERATIVE THEARTER

CLINICAL SERVICES
 OBJECTIVES
By the end of the unit students will be able to
1. Participate in patient and procedure verification
2. Prepare induction drugs
3. Prepare reversal drugs
4. Monitoring patient after operation
5. Prepare emergency trolley
6. Positioning patient for the procedure
and adding accessories to the operating bed
6. Decontamination of theatre equipment
7. Waste segregation and disposal
8. Documentation in theatre
Surgical technologists have a responsibility to
1. become familiar with drug
2. alert information
3. Communication of drug information—a common cause of drug errors.
Communication “barriers” must be eliminated for communication to flow
4. Drug packaging, labeling, and nomenclature—including look-alike, sound-
alike drugs, confusing labels (including those made by the scrub during surgery),
non-distinct packaging
5. Medication storage, stock, standardization, and distribution—non-
standardized methods used within the care facility or department can result in
errors.
6. Environmental factors—including poor lighting (e.g., when operating room
lights are dimmed during endoscopic surgery), loud conversation, music, and
other distracting environmental conditions that prevent concentration.
7. Drug device acquisition, use, and monitoring—includes any
devices used for drug delivery. These must be proven safe and
monitored in the clinical area to prevent device errors.
8. Staff competency and education—all staff must focus on new
medications being used at their health care facility, high-alert
medications, and protocols, policies, and procedures related to
medication use.
9. Patient education on medications—remains the responsibility
of the licensed primary health care provider.
10. Quality processes and risk management—this focuses
attention on improving practice as a means of attaining greater
reduction in drug errors.
 ADVERSE REACTION TO A DRUG-
• Whenever a drug is administered, many physiological
changes can take place in the body.
• Some of these are therapeutic (desirable) effects,
whereas others may be undesirable or potentially
harmful.
• Precautions against taking a drug under circumstances
known to be harmful are stated as contraindications.
• An adverse reaction is an undesirable or intolerable
reaction to a drug administered at the normal dosage.
• It is important to remember that the adverse
reaction occurs when the drug is given at the
normal dose. Adverse reactions are unexpected,
although they may be predictable in certain
individuals.
• When a drug is tested before its release, adverse
reactions are documented, and this becomes part
of the drug information available to clinicians and
patients. Examples of mild adverse effects include
nausea and dizziness.
• This type of effect is usually transient and
ceases when the drug is stopped.
• More serious adverse reactions might include
difficulty breathing or increased heart rate.
• Medical and nursing personnel are trained to
recognize the clinical signs and symptoms of
an adverse drug event.
 IMPORTANT ROLES IN PATIENT CARE

• 1. Keen observation of a patient’s normal behavior and appearance

2. Immediately reporting to medical or nursing personnel any signs
and symptoms that seem abnormal
When reporting a suspected drug reaction, follow these guidelines:
a) What sign or signs do you observe that you believe are not normal
for that patient?
b) When did it start?
c) What does the patient report (if applicable)?
d) What comfort measures did you initiate (e.g., providing warmth,
reassurance)?
 DRUG ALLERGY
• True allergy to a drug is mediated by the
immune system and requires previous
exposure to substances in the drug or a
genetic predisposition to allergy.
• An immune response that causes irritation,
respiratory failure, or death is called
hypersensitivity.
A. Allergic Reactions • Type I: Characterized by tissue inflammation caused by
the release of histamine in the body. This causes increased
permeability of blood vessels and constriction of bronchioles, leading to
difficulty breathing. The most extreme form of sensitivity is anaphylactic
shock, which can lead to death.
B. • Type II: Called a cytotoxic reaction, the results of interaction between
two antibodies and cell surface antigens. Results in the activation of
powerful immune defense mechanisms, causing injury or death.
Mismatched blood transfusion reactions and hemolytic disease in
newborns are type II reactions.
C. • Type III: Caused by antigen-antibody complexes, which cause tissue
damage when they trigger immune response. Allergy to antibiotics is
an example of a type III response. Symptoms include itching, rash,
severe tissue swelling, and fever. This type of reaction usually resolves
in several days.
D. • Type IV: Cell-mediated reactions (not related to antibodies) that occur
24 to 72 hours after exposure to the agent. An example of this
type of delayed hypersensitivity is a positive reaction to the tuberculin
skin test in which a small amount of killed Mycobacterium tuberculosis
is injected.
 DOCUMENTATION
• Documentation is required following administration of any drug
or pharmaceutical (including implants). Documentation may be
included in the patient’s electronic chart, written surgical report,
or anesthesia record, depending on the situation.
All elements of the drug administration must be included:
• The name of the drug
• Dose
• Amount
• The route (e.g., intravenous, intraperitoneal) and location
• Time of administration
• Name of person who administered the drug
• Patient assessment following administration
 PHARMACOKINETICS
• Pharmacokinetics is the study of movement of drugs through the
body (what the body does to the drug). Once a drug is introduced, it
moves through physiological paths.
• The individual’s age, genetics, physical condition, and many other
factors determine how quickly the drug moves through the body.
• Pharmacokinetics is described by mathematical formulas that take
into account the rate of absorption, the amount of drug in the body,
and the concentration of the drug in the plasma.
• For purposes of general study, the entire process of
pharmacokinetics is divided into four processes:
A. Absorption
B. Distribution
C. Biotransformation (metabolism)
D. Excretion (elimination)
• ABSORPTION- Absorption is the process by which a drug enters the body
tissues following administration.
• The rate of absorption and the amount of drug that actually reaches the target
tissue depend on many factors such as
A. the chemical structure of the drug,
B. the method of administration,
C. the condition of the patient.

• Absorption involves chemical and physical breakdown of the drug. For example, oral
drugs must dissolve before passing through the wall of the small intestine and liver.
• The substance then enters the bloodstream, where it is carried to the target tissue.
Drugs that are injected directly into a blood vessel do not require absorption and
thus reach the target tissue almost immediately, whereas one injected into the
muscle or connective tissue usually takes 15 to 30 minutes to take effect. Many drugs
contain components or additives that enhance (increase the rate or amount) or delay
absorption.
• DISTRIBUTION After the drug enters the bloodstream, it is carried
(distributed) to body tissues, where it exerts its pharmacological
effect. Not all of the drug administered reaches the target tissue.
• The amount of drug available and the rate of availability are called the
bioavailability. For example, some drugs may become tightly bound to
blood proteins and are released to the target tissue very slowly.
• Fat-soluble drugs move rapidly across the cell membranes and take
effect quickly but also tend to accumulate in fatty tissue, which
prolongs their effect.
• Water-soluble substances are much slower to act because they stay
in the bloodstream longer than those that are fat-soluble. In all cases,
only the free unbound drug is available to tissues for pharmacological
effect.
• BIOTRANSFORMATION (METABOLISM) Biotransformation,
or drug metabolism, is the chemical breakdown of a drug in the
body. Most drugs are broken down into smaller, less complex
chemical components by enzymes.
• This occurs mainly in the liver. Biotransformation prepares the
drug for excretion, or elimination from the body.
• Because most biotransformation occurs in the liver, conditions
that decrease liver function can alter drug metabolism, resulting
in toxicity.
• Liver disease and advanced age are two causes of altered liver
metabolism, which can affect drug metabolism. In pharmacology
and medicine, it is critical to know how long a drug is active.
• This is related to its rate of biotransformation, which is measured
by the drug’s half-life.
• The half-life is the time it takes for one half of the drug to be
cleared from the body. Some drugs, such as antibiotics, have a
short half-life and must be given repeatedly over a short period of
time so that the therapeutic amount stays constant for the
duration of treatment.
• Other drugs have a long half-life and can be given less frequently
to maintain therapeutic levels. The point in time when the drug
first takes effect is called the onset. The point when the drug has
the greatest effect is called the peak. From that point the effects
diminish until the drug is cleared from tissues. The total time the
drug is active is called the duration of action.
• EXCRETION (ELIMINATION) Drugs are mainly eliminated or
cleared from the body through the kidneys. A small percentage is
excreted through the biliary tract, breast milk, saliva, and intestine.
Volatile drugs and anesthetics are excreted through the lungs during
exhalation. Just as liver disease can alter drug metabolism, kidney disease
can severely retard or block drug elimination and result in life-threatening
toxicity.
• Drugs are mainly eliminated as the products of metabolism. In this
process, chemical reactions cause the drug to break down into smaller
molecules or components.
• Metabolic components of the drug are called metabolites. In a healthy
individual, the entire drug is excreted— in its intact form, or as
metabolites— as smaller components resulting from breakdown of the
drug.
 Emergency drugs
• ANTICHOLINERGICS Anticholinergic drugs are frequently used
during general anesthesia. In the past, potent anticholinergics such as
scopolamine and atropine were given routinely to all surgical patients.
Now, however, these agents are used more selectively and can be
administered intravenously during surgery for rapid results.
• They are used to control airway secretions and to regulate the heart
rate in selected patients. In ophthalmic surgery they are used to
produce mydriasis (dilation of the pupil) and cycloplegia (paralysis of
the ciliary muscles).
• Examples of anticholinergic agents include:
• • Atropine sulfate
• • Scopolamine
• • Glycopyrrolate
• The effects of anticholinergics include the following:
• • Increase in the heart rate
• • Relaxation of smooth muscles in selected
ophthalmic procedures
• • Reduction of gastrointestinal, bronchial, and
nasopharyngeal secretions
• • Emergency treatment of cardiac conduction
block and sinus bradycardia
• • Prevention of bronchospasm
• ADRENERGICS Adrenergic (also called sympathomimetic)
drugs are used in many different specialties.
• In the respiratory system, the smooth muscles of the
airways contain adrenoreceptors activated by adrenaline,
which causes relaxation of the muscle fibers and dilation
of the airways.
• Adrenergics are therefore used in the treatment of
asthma and during respiratory emergencies such as
anaphylactic shock. Some drugs are adrenergic to both
the lungs and the heart, resulting in increase heart rate
and expansion of the airways.
• ANTICOAGULANTS An anticoagulant is a drug that inhibits blood clot
formation, but does not dissolve clots. There are several types of anticoagulant
drugs. Heparins These are used for prevention of venous thromboembolism
• Low-molecular-weight heparin (LMWH) is administered by injection to prevent
venous thromboembolism after major orthopedic and gynecological surgery. It is
also used in the prevention of coagulation during renal dialysis and cardiac surgery.

• Warfarin (Coumadin) Oral anticoagulant therapy using vitamin K antagonists

(warfarin) is used in the treatment of venous thromboembolism, pulmonary
embolism, and cardiac abnormalities that increase the risk of embolism in conditions
such as valve disease.

• Patients on warfarin are usually required to stop therapy before surgery and then
resume it on the first postoperative day. Thrombolytic Agents Thrombolytic drugs are
used for the immediate breakdown of systemic blood clots, particularly in myocardial
infarction, ischemic stroke, and pulmonary embolism
• Cardiac drugs used during surgery are given as
needed to regulate heart muscle action, maintain
arterial pressure, and prevent thromboembolus.
• Emergency cardiac drugs are also found on the
emergency crash cart, which is a self-contained
unit with drugs and equipment immediately
available for physiological emergencies including
cardiac or respiratory arrest
• . Common cardiac drug categories include:
A. Inotrope: Increases (positive inotrope) or decrease (negative inotrope)
heart contractility
B. Chronotropic: Affects heart rate
C. Antiarrhythmic agents: Used to treat abnormal cardiac rhythm
D. Antianginal drugs: Used to treat angina, which is chest pain associated with
decreased oxygen supply to the heart muscle. Blood flow to the heart is
supplied by the coronary arteries. Antianginal agents increase oxygen
supply by decreasing cardiac demand for oxygen or by vasodilation
E. Diuretic: Increases urine output to balance sodium and intravascular
volume
F. Antilipemic: Cholesterol-lowering drug used in long-term treatment of
hypercholesterolemia
G. Antihypertensive: Lowers blood pressure
 INDUCTION DRUGS
• CENTRAL NERVOUS SYSTEM AGENTS Knowledge of nerve
transmission is basic to an understanding of how anesthetics and other
CNS drugs work.

• The following basic description of how stimuli are transmitted provides

useful background for the study of anesthetic drugs.
• The transmission of nerve impulses (signals) is a complex biochemical
process.
• In simple terms, impulses are chemical and electrical. Chemicals that
carry impulses from nerve cell to nerve cell are called neurotransmitters.

• The biochemical work of the neurotransmitter is to transport the signal

from one nerve cell to the next until the signal reaches the target tissue.
• Each nerve cell (neuron) is separated from an adjacent
nerve cell by a synapse (also called the synaptic cleft).
• The synapse is the small space in which the
neurotransmitter passes from one nerve cell to another.
• For the neurotransmitter to transport a signal, it must be
released from the presynaptic neuron (the neuron
before the synapse) and received by the next neuron in
line (the postsynaptic neuron).
• The neurotransmitter is contained in small vesicles (cell
sacs).
• NEUROTRANSMISSION The body has many different
types of neurotransmitters, each carrying a different
type of impulse. About 30 known neurotransmitters
occur in specific tissues of the body.
• One type of neurotransmitter can be blocked without
affecting the others.
• For example, the neurotransmitter for motor control can
be inactivated by a neuromuscular blocking agent while
the neurotransmitter for pain remains unaffected.
• This would result in the ability to feel pain but the
inability to move in response.
• . Likewise, sedation or loss of consciousness can be achieved without
reducing the sensation of pain.
• One method of blocking neurotransmission is to administer a competitive
antagonist drug that has an affinity for the postsynaptic receptor.
• These drugs limit the number of receptors available for the
neurotransmitter molecule.
• When the drug attaches to the receptor site, the neurotransmitter cannot
continue on its path, because no unbound receptors are available.
• The neurotransmitter remains in the space between the two neurons (the
synapse) and eventually is reabsorbed by the presynaptic cell or broken
down by enzymes. In this way, the path of transmission is broken.
Antagonist CNS drugs increase the availability of postsynaptic receptors
and the movement of neurotransmitters by increasing the release or
uptake (or both) of a particular neurotransmitter.
• ANESTHETICS CNS anesthetics provide the physiological conditions
necessary for surgery.
• This category of drugs causes
• the loss of primary CNS functions such as
A. consciousness,
B. sensation (including pain),
C. some autonomic responses,
D. and recall of events that occur while the drug is present in the body.
• The depth of the effect is dose dependent. However, selected adjunct
agents are administered during general anesthesia to produce a more
profound effect while protecting the patient from the risk of high-dose
anesthetic.
• Inhalation Anesthetics Inhalation (volatile) anesthetics are
formulated as liquids and administered as a vapor (gas).
• Only nitrous oxide is both formulated and delivered in
gaseous form.
• All other agents must be vaporized in the anesthesia
machine for administration by mask or through an artificial
airway inserted into the patient’s own upper airway.
• The agent enters the lungs, where it crosses the alveoli,
enters the circulatory system, and is made available to the
nervous system, producing deep sedation and
unconsciousness.
• Inhalation anesthetics are used to maintain a surgical level
of anesthesia after a fast-acting intravenous anesthetic
has been used to induce unconsciousness.
• Induction (the process of becoming unconscious) by gas
anesthetic is slow and can result in delirium and other
adverse reactions.
• However, this method is sometimes used in pediatric
patients for whom an intravenous injection might be
difficult. In the past, anesthetic gases such as
cyclopropane and vaporized ether were commonly used
during surgery.
• However, extended exposure to small
amounts of modern vaporized (gas)
anesthetics is unsafe, so all anesthetic
machines are manufactured with scavenging
systems that collect and remove waste
anesthetic gas from the operative
environment. (LIME )
• NITROUS OXIDE Nitrous oxide is a colorless
odorless gas in its natural state.
• It has low potency, but adjusting its
concentration provides a range of anesthetic
effects.
• It has strong analgesic properties and is
quickly dissipated from the body, usually
within minutes.
• Nitrous oxide is not flammable, but it supports combustion.
• In some patients nitrous oxide can cause severe
cardiovascular depression, leading to shock.
• It does not affect the respiratory system or the action of
neuromuscular blocking agents.
• It can be used for induction, but is commonly mixed with
other agents.
• The main advantages of nitrous oxide are minimal incidence
of nausea and rapid absorption and clearance from the body.
• Disadvantages are low potency and lack of muscle relaxation.
• . ISOFLURANE Isoflurane is widely used for many
different types of surgery.
• It causes rapid smooth induction and good muscle
relaxation.
• It is nonflammable and has a strong odor.
• The systemic effects of isoflurane are superior to
those of other inhalation agents.
• Cardiac and respiratory depression is minimal.
• Unlike many other agents, it does not cause bronchial
spasm.
• SEVOFLURANE Sevoflurane is very similar to isoflurane in
action. It can be used safely for induction in both pediatric and
adult patients. Patients emerge rapidly from sevoflurane,
making it useful for outpatient surgery. It does cause increased
postoperative nausea and vomiting compared with other
agents.
• DESFLURANE Desflurane provides rapid emergence, making it
suitable for outpatient surgery when a short recovery time is
important. It can be used as an induction agent in adults, but
not in pediatric patients, because of the high incidence of
bronchial spasm and laryngospasm associated with it.
Desflurane must be heated during vaporization.
• ENFLURANE Enflurane (Ethrane) is used for
induction and maintenance. It can also be
used in low doses for short surgical
procedures that do not require
unconsciousness.
• It produces rapid induction and emergence
and also has excellent muscle relaxing
properties.
 NEUROMUSCULAR BLOCKADE
• Neuromuscular blocking agents are used to paralyze skeletal muscles, an
essential component of general anesthesia.
• Even during profound general anesthesia, autonomic muscle responses
can interfere with the manipulation of tissues such as during intubation
and mechanical ventilation. Neuromuscular blocking is a complex,
controlled process that is chemically reversed at the close of surgery or
whenever necessary during an emergency.
• The drugs cause paralysis of the respiratory muscles, and mechanical
ventilation is required during their use. The effect of neuromuscular
blocking drugs is adjusted during surgery according to the level of
relaxation needed. ]
• Normal Nerve Transmission Nerve transmission to striated muscles
occurs at the neuromuscular junction where the motor neuron (nerve
cell to the skeletal muscle) and muscle cell communicate.
• The nerve cell and muscle (motor end plate) do not touch.
They are separated by a small gap called the synaptic cleft, as
described earlier. Activation of the muscle cell occurs when
the neurotransmitter acetylcholine is released by the nerve
cell where it crosses the cleft and binds to the acetalcholine
receptors at the motor end plate.
• This causes depolarization (electrochemical change necessary
for cell activation) of the muscle cells and muscle contraction.
• Neuromuscular Blocking Agents Neuromuscular blocking
drugs are used to interfere with normal muscle cell
depolarization, which results in muscle relaxation.
• Two types of drugs are used to prevent muscle contractions.
Both types attach to the acetylcholine binding sites and
prevent ACh from attaching.
• An agonist (depolarizing) drug has some of the properties
of ACh but does not permit the electrochemical changes
(particularly the resting phase of the muscle fiber)
necessary for muscle activation.
• A nondepolarizing agent (antagonist) also binds to the
motor end plate but works by simply blocking ACh. Only
one depolarizing agent is available—succinylcholine, which
is used primarily for intubation because it is short-acting
• Examples of non-depolarizing blocking agents:
• • Atracurium
• • Cisatracurium
• • Pancuronium
• • Rocuronium
• • Vecuronium
 Reversal drugs
• Neuromuscular blocking agents are reversed by administering an
anticholinesterase
• . Neostigmine is the primary reversal drug and has replaced edrophonium which
was used previously as a reversal agent in surgery. Sugammadex is used to
selectively reverse rocuronium.
• ANALGESICS This group of drugs is used to control pain. Pain is a
complex sensation that can be controlled through a number of
different neurological pathways. It is important to note that in
terms of nerve transmission and the use of analgesic drugs,
there are significant differences among analgesia (lack of pain),
sedation (sleep), and relaxation.
• For example, it is possible to produce a level of sedation
(sleepiness or somnolence) while retaining the sensation of pain.
• Opiates Opiates are among the most common drugs used for
moderate and severe pain control.
• All opiates (also known as narcotics) produce analgesia by
altering the perception of pain.
• Because they reduce the work of the heart, morphine
is often given in specific cardiac emergencies. Opiates
are derived directly from the natural psychoactive
substance in the opium plant, whereas opioids are
synthetic and semisynthetic drugs that resemble
opiates in pharmacological action.
• The most common opiate used in health care is
morphine. Other opiate drugs are often described by
their relative strength as an analgesic when
compared to natural morphine sulfate.
A. natural opiates are:
1. • Morphine
2. • Codeine
B..The semisynthetic opiates include:
3. • Hydromorphone
4. • Hydrocodone
5. • Oxycodone
6. • Oxymorphone
7. • Sunfentanil
8. • Alfentanil
9. • Remifentanil
10. pethidine (also known as meperidine),
11. and tramadol.

C.Completely synthetic opiates include

12. fentanyl,
• All opiates are addictive and, in high doses cause depression
of the CNS, hypotension, respiratory depression, profound
sedation, and coma. The opiate antagonists are used to treat
opiate toxicity and overdose.
• These include naloxone, nalmefene, and naltrexone.
• Nonopiate Analgesics Nonopiate drugs are used for mild and
moderate pain. These may be prescribed for mild
postoperative pain following superficial procedures under
local anesthesia.
• Ibuprofen and diclofenac are nonopiate antiinflammatory
agents. Acetaminophen is used for mild pain and as an
antipyretic.
• SEDATIVES AND HYPNOTICS Sedative or hypnotic drugs
are used in a variety of medical and surgical situations
to depress consciousness and induce drowsiness.
• Most do not have analgesic effects. Categories of
sedative drugs include the sedative-hypnotics,
barbiturates, and benzodiazepines.
• Sedatives are used to relax patients in the acute care
setting and in behavioral emergencies. Oral sedative-
hypnotic drugs are prescribed for short-term insomnia
and to reduce anxiety in the preoperative period.
• They are also used during induction of general
anesthesia to allow intubation (placement of an
artificial airway) at the start of general anesthesia
or in emergency situations requiring intubation.
• Intravenous sedatives are used with or without
analgesics for procedural sedation or moderate
sedation (previously called conscious sedation) for
short procedures when profound anesthesia is
not required.
• Under mild and moderate sedation, a person can
respond to verbal commands, and respiratory and
cardiovascular functions remain intact.
• However, a deeply sedated patient cannot be easily
roused, and ventilation may be decreased. Modern
sedatives are rapidly cleared from the body, making them
ideal for procedural sedation and anesthesia. Propofol is
the most common intravenous sedative used for
induction and maintenance of general anesthesia and
also as a general sedative. Examples: • Propofol •
Etomidate • Dexmedetomidine
• BARBITURATES This group of drugs was among the first to be used in
clinical situations requiring profound depression of the CNS. Oral
barbiturates are still used in the treatment of seizure disorders.
Intravenous barbiturates are commonly used for induction of general
anesthesia.
• They are rapidly effective, causing unconsciousness in 10 to 20 seconds.
Recovery from thiopental, which is the most commonly used agent, is 20
to 30 minutes.
• Barbiturates cause dose-related respiratory depression and apnea
(absence of breathing), which is transient during initial administration.
Laryngospasm and bronchospasm can occur with thiopental.
• Examples of intravenous barbiturates:
• • Thiopental
• • Methohexital
• BENZODIAZEPINES
• Benzodiazepines have many clinical uses because
of their versatility. This category of drugs is
anxiolytic (reduce anxiety and also provides muscle
relaxation.
• They cause desirable anterograde amnesia (loss of
recall of events) for up to 6 hours from the onset of
drug action and are commonly given intravenously
during procedures requring sedation
Examples of benzodiazepines:
• • Midazolam
• • Lorazepam
• • Alprazolam
• • Diazepam
• The benzodiazepine antagonist flumazenil is
used to reverse the effects of this category of
drugs.
• Dissociative Anesthesia Ketamine is a rapidly acting
sedative that produces isolation of the sensory parts
of the brain, resulting in a trancelike state
(dissociative anesthesia) and amnesia. Ketamine is
valuable for sedation requiring profound short-term
analgesia, such as during debridement of burns.
• However, it has distinctive adverse effects such as
increased intracranial pressure, delirium, and
hypertension. It is generally not used in adults
because it may precipitate emergence delirium.
 LOCAL ANESTHETICS
• Local anesthetics are used in regional anesthesia to block sensation with
or without sedative drugs that provide anxiolytics and relaxation..
• These drugs are formulated for a variety of applications, including: •
Infiltration injection: The drug is injected directly into the operative site
in small increments.
• • Regional nerve block: A major nerve is anesthetized to affect a larger
region.
• • Topical: Anesthetic is applied to the skin or mucous membrane for
short-term superficial procedures.
• • Spinal or epidural: Anesthetic is injected into the spinal canal or
epidural space for regional blockade of the lower body.
NB/ Handling local anesthetics on the surgical field requires extra attention
because of their high-alert status. Many agents are formulated with the
addition of epinephrine.
• As an adrenergic agonist, epinephrine causes vasoconstriction and
increased heart rate. It is used in conjunction with local anesthetic
to prevent the anesthetic from entering the vascular system, which
would shorten the peak effect of the drug.
• Epinephrine injection directly into blood vessels can be fatal, and
both epinephrine and local anesthetic have definite dose limits.
Therefore, extra attention must be given to labeling and keeping
track of the amount injected throughout the procedure.
• When the scrubbed surgical technologist dispenses local anesthetic
to the surgeon, he or she should share responsibility for ensuring
that maximum dosage is not exceeded.
• Local anesthetic agents are formulated as short- or long
acting, with or without added epinephrine or other
vasoconstrictor. The safe maximum dosage for agents depends
on the patient’s specific condition and its exact use.
• Agents with added vasoconstrictors are not used for
infiltration at end arterial sites such as the digits, because this
can result in ischemia and necrosis of the area.
• Topical anesthetics are used on surface tissues such as mucous
membranes, the surface of the eye, and the urogenital tract.
• NB/ These agents do require an order by a licensed patient
care provider.
• Case 1 Discuss how the concepts of team cooperation, shared communication,
and adhering to required protocols for drug handling in the operating room
could have changed the outcome of the following real case scenarios:
• • A pediatric patient undergoing surgery was injected with pure epinephrine
during the procedure because neither the medicine cup nor the syringe was
labeled. The child died.
• • A pediatric patient underwent surgery under local anesthetic with
epinephrine added. The correct dose was calculated and administered in the
operating room.
• At the close of surgery, the child was admitted to the post anesthesia care
unit for observation. However, during her stay in the PACU, she required
additional administration of epinephrine.
• The patient died in PACU as a result of epinephrine overdose. The surgical
team had failed to properly document the administration of anesthetic with
epinephrine during surgery.
 summary
• Anesthesia means “without sensation.” The goal of surgical
anesthesia is to allow the patient to tolerate surgery and maintain
the body in a balanced physiological state, called homeostasis.
These processes cannot be isolated from the principles of surgical
technique because one cannot exist without the other.
• Anesthesia personnel are responsible for physiological
management of the patient before, during, and after surgery.
• They provide the techniques and means to achieve anesthesia and
work closely with the other members of the surgical team to
maintain safety in techniques such as positioning and handling the
patient.
• The anesthesia care provider (ACP) uses highly technical
physiological monitoring devices to provide
• physiological responses to the surgery and anesthesia. The primary role of the
ACP includes the following:
• • Protects and manage the patient’s vital functions during surgery.
• • Manages the patient’s level of consciousness and ability to sense pain and
other external stimuli.
• • Provides an adequate level of muscle relaxation during general anesthesia.
• • Provides sedation as needed during regional anesthesia.
• • Communicates with the surgeon about the patient’s responses to
intraoperative stimuli. This includes information on homodynamic changes,
fluid and electrolyte balance, level of muscle relaxation, and level of
consciousness.
• • Reports and responds to any physiological or anesthetic emergency.
• • Provides psychological support to the patient throughout the perioperative
experience.
• The ACP monitors the patient from the time he or she
enters the surgical suite until discharge from the
hospital.
• Intraoperative care begins when the patient arrives in
surgery and continues through the duration of the
procedure and into the next phase, postoperative care.
• This begins when the patient is transported to the post-
anesthesia care unit and continues until discharge.
• The ACP is available to respond to medical problems
related to the anesthesia, including management of
postoperative pain.
• ANESTHESIA ASSISTANT The anesthesia
assistant (AA) assists the anesthesia care
provider in tasks that are delegated according
to the AA’s practice skills and knowledge. The
AA, who has a master’s degree, performs a
variety of functions on the anesthesia care
team.
• These include obtaining the patient history and performing the
pre-surgical examination of the patient.
• During surgery, the AA performs invasive and noninvasive
procedures such as drawing blood samples, administering
induction and adjunct agents, and applying invasive and
noninvasive physiological monitoring devices.
• The AA may also apply and interpret electroencephalographic
spectral analysis, evoked potential, and echocardiography.
• The AA also performs and monitors regional anesthesia such as
spinal, epidural, intravenous (IV), regional, and other techniques
under the direction of the supervising anesthesiologist and
according to state law.
 IMPORTANT ANESTHESIA CONCEPTS
• Anesthesia is achieved by altering the patient’s level of consciousness, by
interrupting nerve pathways that transmit sensation, or a combination of the
two.
• 1. supress sensation. Sensation is the awareness of stimuli. The nervous system
is capable of many sensations, including hearing, sight, smell, taste, touch,
temperature (heat and cold), pressure, and pain.
• 2. Analgesia is loss of pain sensation. Specialized nerves transmit signals from
the source of pain to the brain. Analgesic drugs interrupt these pain nerve
pathways.
• 3.loss of consciousness Consciousness is a state of awareness in which a person
is able to sense the environment and respond to it. In a fully conscious person,
all autonomic and sensory functions are intact and the patient is “awake.”
• 4. Sedation is a state of consciousness described along a continuum. At one end,
a person is fully aware of the surroundings and able to respond to stimuli.
• At the other end is unconsciousness, in which the patient is not aware of the
environment and cannot respond to external stimuli including those that are
noxious (e.g., pain, cold, heat).
• 5. Central nervous system depression refers to diminished mental, sensory,
and physical capacity. It is another way of expressing sedation.
• 6. Unconsciousness is severe depression of the central nervous system (CNS)
resulting in the inability to respond to external stimuli. Deep unconsciousness,
such as that achieved during general anesthesia, results in the absence of
protective mechanisms, such as swallowing, coughing, blinking, and shivering.
General (surgical) anesthesia produces reversible unconsciousness.
• 7. Coma is the deepest state of unconsciousness, in which most brain activity
ceases.
• 8. Amnesia is the loss of recall (memory) of events. Drugs that produce
amnesia are used during the process of anesthesia.
 Classification of Patients by Risk of Anesthesia-Related Complications

• ASA 1 The patient is normal and healthy.

• ASA 2: The patient has mild systemic disease that does not
limit the individual’s activities (e.g., controlled hypertension or
controlled diabetes without systemic sequelae).
• ASA 3: The patient has moderate or severe systemic disease
that does limit the individual’s activities (e.g., stable angina
or diabetes with systemic sequelae).
• ASA 4: The patient has severe systemic disease that is a
constant potential threat to life (e.g., severe congestive heart
failure, end-stage renal failure).
• ASA 5: The patient is morbid and is at substantial risk of
death within 24 hours, with or without intervention. E:
Emergency status; any patient undergoing an emergency
procedure is identified by adding “E” to the underlying ASA
status .
• AIRWAY AND DENTAL STATUS
• Any abnormality of the airway or potential
obstruction can create an anesthesia emergency.
• General anesthesia requires complete
assessment of the airway to evaluate conditions
that might lead to an airway obstruction or make
intubation difficult and may represent the most
important aspect of the preoperative assessment.
• • MUSCULOSKELETAL ASSESSMENT
• Impaired mobility, skeletal injuries, and other
structural problems can result in restricted
range of motion during surgical positioning.
• The ACP therefore documents any joint
replacements, previous skeletal injury,
disease, and areas of nerve damage
• MENTAL AND NEUROLOGICAL STATUS
• An evaluation of the patient’s mental and neurological
status, including cognition, speech, gait, and motor
and sensory functions, is important for the diagnosis
and also for establishing a baseline before surgery.
• Baseline evaluation allows comparison of neurological
deficit before surgery in order to establish or defend
against claims or injury or adverse events during the
procedure.
•
• Many patients fear anesthesia and pain more than the
surgery itself. Common concerns are that they will have
inadequate medication for pain or that they will become
addicted to pain medication.
• Misinformation from various media sources and lack of
knowledge about the pharmacology of analgesics often
contribute to these fears.
• The ACP or perioperative registered nurse can answer the
patient’s questions about the action and duration of
postoperative medication, which frequently allays the
patient’s fears.
• SOCIAL ASSESSMENT
• The patient’s emotional and social well-being is important to
recovery.
• The ACP inquires about the patient’s family and whether the
patient will have a caregiver or helper after surgery.
• This affects not only the physical care of the patient, but also
the psychological support available in the postoperative
period.
• Patients who are fearful or anxious about their surgery and the
possible consequences for work, family, and social
environment may have a higher threshold for sedation and
anxiolytic (anxiety-reducing) medications.
• PREOPERATIVE INVESTIGATIONS
• Diagnostic testing to determine the patient’s risk level has been
routine for many decades.
• In current practice, fewer investigations are performed than
previously. This has been influenced by managed care and the
streamlining of hospital stay and preoperative routines.
• Institutions vary in their requirements for preoperative assessment,
and the rationale for ordering investigations generally is based on
the patient’s ASA (Anesthesia Society of America) classification,
which considers the findings of the history and physical
examination.
• In these cases, the tests are intended to confirm or elaborate on a
finding or diagnosis rather than to discover an
• Comorbid Conditions Important to Risk Assessment in
Anesthesia Category Conditions include:
• Cardiovascular disease
• Hypertension Ischemic heart disease Heart
• failure Murmurs and valve deformities Hypertrophic
cardiomyopathy Prosthetic heart valve Rhythm
disturbances Pulmonary disorder Asthma Chronic
obstructive pulmonary disease Restrictive pulmonary
disorder Dyspnea Pulmonary hypertension Smokers
(and secondhand smokers) Endocrine disorder
Diabetes mellitus Thyroid or parathyroid disease
• The patient with a difficult airway presents a challenge
during intubation and may require additional
personnel or specific type of airway during general
anesthesia (discussed later).
• The airway assessment includes the following:
• • Neck circumference and length
• • Range of motion of the head and neck
• • Size or presence of the uvula
• • Tongue size
• • Position of the thyroid
 ANESTHESIA SELECTION
• Following the patient evaluation, an appropriate type and method
of anesthesia are selected. This is a cooperative and informed
decision made by the ACP, the surgeon, and the patient. The
decision is based on the following:
1. The patient’s assigned ASA classification
2. The patient’s current physical status
3. The presence or history of metabolic disease
4. The patient’s psychological status
5. The type of surgery, including positioning requirements
6. The length of the procedure
7. Any history of adverse reactions to anesthetics and drug
allergies.
• The patient’s safety and well-being are always the primary
considerations in the selection of the method of anesthesia.
• The medical and surgical goals are to provide the appropriate level
of anesthesia without compromising the patient’s safety.
• This means that not only the patient’s physical condition and past
history are considered, but also the requirements of the surgical
procedure.
• The surgeon may participate in the decision based on his or her
knowledge of the time required for surgery and the extent of the
procedure.
• Patients participate in their own anesthesia care by expressing
preferences. However, these must be informed choices based on
safety and environmental considerations.
• The ACP helps the patient choose among the “best choices.” This
is especially important for patients who have moderate or high
risk factors to consider.
• Patients differ in their desire to be awake during the procedure,
fully sedated, or only partly conscious.
• An informed consent to anesthesia including risks and
alternatives is necessary for surgery to take place.
• The choice between general anesthesia and regional (local)
anesthesia often depends on the anatomical extent of the
surgery and the anticipated anesthesia time required.
• Very long procedures and those involving the abdominal and
thoracic cavities are not suitable for regional anesthesia.
 Pre operative care
• Immediate preoperative preparation of the
patient admission documentation and
preoperative checklist
• Every precaution is taken to ensure the
patient’s safety in the perioperative period.
When the patient arrives in surgery,
• the surgical checklist is used to ensure that all
preoperative preparations are done .
• This includes any special procedures such as evacuation of the bowel
(bowel prep) before surgery. Patients are also advised to remove makeup,
including nail polish, before surgery.
• The admission procedure is also important to the patient’s emotional well-
being. Reassurance and physical comfort are critical in this first encounter.
In the ambulatory setting, patient teaching is done before the day of
surgery, and the patient is made aware of special precautions and
procedures.
• Inpatients are prepared in the ward. Hospitals and other surgical facilities
have individual check-in protocols. However, specific details are always
verified:
• 1. Patient identity is meticulously checked. The health care provider asks
the patient his or her name and verifies this with the patient’s unique
identifiers, the surgery schedule, and the medical records at hand.
• 2. Correct procedure, side, and site are validated with the patient, the
medical record, the surgical schedule, and the consent form.
Preoperative procedures include the surgeon’s skin markings on the
operative side showing the location of the incision. These are matched
with all other information available.
• 3. Surgical and anesthesia consent forms must be signed according to
facility protocol
• 4. Resuscitation orders and any other legal documents are checked.
• 5. Patient allergies must be noted on all medical records, and the patient
is asked about allergies again in the holding area.
• 6. Preoperative medications are documented in the patient’s medical
and preoperative records. Any medication ordered but not yet given may
be administered in the holding area as directed by the surgeon or ACP
• . 7. Prostheses, including dentures and hearing aids, must be
removed before surgery whenever possible. In the event a
prosthesis is removed in the holding area, extreme care is taken
to protect it from loss or misidentification.
• 8. Jewelry, including body-piercing jewelry, is removed before
anesthesia or any procedure in which electrosurgery is used. Any
jewelry removed in the holding area is placed in a container,
labeled, and placed in a secure location until it can be safely
returned to the patient. A wedding ring may be taped in place.
• 9. Medical records accompanying the patient are noted.
Diagnostic results accompanying the patient, such as
radiographs or other imaging studies, are clearly labeled
• PHYSIOLOGICAL MONITORING DURING SURGERY
• In a state of well-being, the body responds readily to
stimuli to maintain life. Many complex biochemical,
physical, and metabolic processes control the
balance between stimuli and responses.
• Examples are shivering (uncontrollable muscle
tremor) when the body’s temperature drops and
vasoconstriction (constriction of blood vessels) when
blood pressure falls. This maintenance of
physiological balance is called homeostasis.
• During surgery, the ACP assess and control the body’s normal
responses to noxious (harmful or painful) stimuli. Physiological
monitoring provides the basis on which personnel assess
homeostasis and respond to the patient’s needs.
• Physiological monitoring is assessment of the patient’s vital
metabolic functions. All anesthetics (regional, general, or
sedative) require physiological monitoring. However, the
complexity and type of monitoring depend on the type of
anesthesia, the patient’s physical condition, the known risks,
and the anticipated complications. Monitoring is necessary
because anesthetic drugs, position changes, and the trauma of
surgery itself alter in some cases
• MONITORING PROCESS The standards for monitoring patients are
set by the ASA. The level of monitoring—whether invasive
methods are needed or not—depends on the patient’s ASA
numerical classification. The routine parameters that must be
monitored include the following:
• • Oxygenation: The oxygen-carrying capacity of the blood (also
called oxygen saturation).
• • Ventilation: The exchange of gases in the respiratory system.
Two types of ventilation occur—alveolar and pulmonary. Alveolar
refers to exchange of oxygen for carbon dioxide at the cellular
level, whereas pulmonary refers to the exchange of environmental
gas (air) for exhaled gas containing carbon dioxide.
• Cardiac function: Electrical activity of the heart, continuously
monitored using a standard digital cardiac monitor or more invasive
device according to the patient’s physiological needs.
• • Perfusion: Blood supply to the capillaries in the peripheral circulation
where oxygen exchange takes place.
• • Body temperature: The patient’s core temperature; must be assessed
and maintained within a range compatible with normal homeostasis.
• • Neuromuscular response: Measured during surgery to determine the
level of neuromuscular blockade resulting from specific drugs given to
induce paralysis (neuromuscular blocking agents).
• • Fluid and electrolyte balance: Electrolyte and fluid balance, including
total intravascular fluid volume; continually monitored, especially
during lengthy cases or in very ill patients.
• Ventilation, Oxygenation, and Perfusion Pulmonary ventilation is the total
mechanism for drawing air into the lungs (muscular activity, negative
pressure in the thoracic cavity, lung capacity). Adequate ventilation results
in oxygen reaching the alveoli of the lungs where gas exchange takes place.
• Insufficient or poor ventilation results in low oxygen in the blood
(hypoxia). Perfusion is the movement of oxygenated blood to the
peripheral capillaries where oxygen is exchanged for carbon dioxide at the
cellular level. Methods of monitoring ventilation and perfusion include:
• • Capnography: The partial pressure of expired carbon dioxide, which is
produced by the cells and expired during ventilation, is measured and the
value displayed as a waveform on a monitor. The SARA (Smart Alarm
Respiratory Analysis) is a branded capnography system used in some
facilities.
• Pulmonary artery catheter: The PAC is used for critical care monitoring in
selected patients. The PAC is sometimes referred to as a Swan Ganz catheter, but
this is only one of many different types of PACs. The PAC is no longer commonly
used because safer and more advanced technology is available. The catheter
provides direct assessment of pulmonary artery pressure and indirect left
ventricular filling pressures.
• The PAC is inserted into the pulmonary artery via the subclavian, internal jugular,
or femoral vein. Multiple ports (openings) are used for withdrawing blood or
injecting drugs. Internally, the catheter measures pressure through a transducer
and temperature via a thermistor. The PAC is used to assess the following:
• • Central venous pressure (CVP) (1 to 6 mm Hg)
• • Mean pulmonary artery pressure (PAP) (systolic 15 to 30 mm HG, diastolic 6 to
12 mm Hg)
• • Pulmonary capillary wedge pressure (PCWP) (6 to 12 mm Hg), which estimates
the left arterial heart pressure and left ventricular end-diastolic pressure
• Function Kidney function can be grossly measured by observing
renal output during surgery. More specific tests such as blood
urea nitrogen (BUN) are used to measure substances in the
blood that are not effectively filtered by the kidneys.
• Selected surgical patients are catheterized before surgery so that
fluid balance (input and output) can be measured during lengthy
procedures. Body Temperature The normal body temperature is
97° F to 99.5° F (36° to 37.5° C). The body can tolerate
environmental temperatures outside this range, but only with
protection.
The core Pulmonary artery catheter: The PAC is used for critical care
• MAINTAINING NORMOTHERMIA The patient’s normal
temperature (normothermia) is maintained using
medical devices that provide convectional heat.
• The most common method is with a forced air blanket.
This is a baffled air mattress that rests lightly on the
patient’s body.
• Warmed air is pumped into sections of the blanket via a
flexible hose. The warm air blanket must be monitored
to prevent burns.
• These risks are greatest when the patient is unconscious
or semiconscious and unable to respond to pain
• DELIBERATE HYPOTHERMIA Deliberate hypothermia
(lowering of the patient’s core body temperature) is used
during malignant hyperthermia.
• This is a physiological reaction to specific anesthetics and
neuromuscular blocking agents in which the body
temperature is critically elevated.
• Hypothermia may also be initiated when normal blood flow
presents a severe, uncontrollable risk. In cardiac surgery,
surgical repair of large vessels, organ transplantation, and
neurosurgery, controlled hypothermia produces a margin of
safety while particular surgical procedures are performed.
• METHODS OF ACHIEVING HYPOTHERMIA Hypothermia
is obtained by a number of methods. Blood may be
diverted to a cooling system, as during
cardiopulmonary bypass. Other methods include IV
administration of a cold solution and irrigation of body
cavities with a cold fluid.
• During cardiac surgery, saline ice slush is packed
around the heart to produce localized cooling. Target
temperatures are no lower than 78.8° F (26° C).
Complications of induced hypothermia include cardiac
arrhythmia.
• METHODS OF ANESTHESIA GENERAL ANESTHESIA
• General anesthesia is reversible loss of consciousness, which
is accompanied by the absence of:
• • Pain
• • Sensory perception
• • Cognition (awareness, ability to interpret the environment)
• • Memory of experiences during the period of
unconsciousness
• • Some autonomic reflexes During general anesthesia,
different types of drugs are used to achieve the effects
needed for surgery.
 Equipment maintanace
• Maintanace of medical equipments is very important and its
performed by the bioengineering department.
• All equipment that comes in contact with the patient must be
decontaminated to prevent cross-contamination. Standard
Precautions are followed whenever equipment is handled and used.
• The hoses, soda canister, masks, and airways are sources of high
bacterial contamination.
• The intricate valve mechanisms may also harbor large colonies of
pathogenic bacteria.
• The use of disposable patient air hoses, masks, and airways is
preferred whenever possible. Non-disposable items are
decontaminated and sterilized before use.
• AIRWAY MANAGEMENT Managing the patient’s airway is a
primary concern during general anesthesia or an emergency in
which the patient is unable to maintain ventilation.
• During an emergency, such as cardiac or respiratory arrest,
securing the patient’s airway is the first priority.
• During surgery, the unconscious patient requires an invasive
artificial airway to provide a sealed connection between the
source of air, oxygen and anesthetic gases, and the patient’s lungs.
• It also supports the patient’s natural airway structures. The
process of placing the invasive airway is called intubation. Less
invasive airways are used to maintain the position of the tongue
and support the soft tissues of the pharynx and larynx.
 TYPES OF AIRWAYS

• Endotracheal Tube The endotracheal tube (ET tube) is an

invasive airway that extends from the mouth to the
trachea. It is inserted orally or, less commonly, through
the nose. The tube has a balloon or cuff at the tip that
acts as a barrier between the upper and lower airways
and prevents aspiration of fluid into the respiratory tract).
• The ET tube is inserted with the aid of a rigid or flexible
laryngoscope, a lighted instrument that is inserted into
the trachea during intubation Laryngeal Mask The
laryngeal mask airway (LMA) is inserted without the aid
of a laryngoscope and fits snugly over the larynx
• INTUBATION Intubation is a routine procedure during general
anesthesia and is also performed as an emergency procedure to
establish and maintain the airway.
• The patient usually is unconscious (e.g., during general
anesthesia). However, conscious intubation also is performed
when the patient is awake but requires airway support.
• Intubation with an ET tube requires a rigid or flexible laryngoscope
to guide the ET tube into the trachea (A flexible metal stylet may
be inserted into the tube to make it more rigid and facilitate
placement.
• This procedure is also performed using a nasal laryngoscope.
During general anesthesia, the patient is intubated immediately
after induction.
• During general anesthesia, the circulating nurse or anesthesia
assistant stands at the patient’s head and assists as needed
during intubation.
• The scrubbed surgical technologist should always be ready to
assist in case of cardiac arrest, aspiration, or other anesthetic
emergency during intubation.
• The exact role of the surgical technologist during any
emergency depends on the nature of the event. This is a
critical period during surgery, and the scrub shares
responsibility for the patient’s safety.
• Attention should be focused on the patient and ACP until an
airway is secured and the patient is stabilized
• Adverse events related to a difficult airway are hypoxia leading to
brain injury or death. Patients undergoing elective surgery who are
known to have or are at risk for a difficult airway are critically
evaluated by the ACP before surgery to determine the extent of the
risk and to prepare for interventions in the event of airway blockage.
• Preparations include having extra trained personnel available to
assist and an emergency airway cart close to or in the operating
room suite. Positioning devices that provide hyperextension of the
neck are placed near the operating table before induction.
• The airway cart is managed by the ACP, anesthesia technologist,
and circulator, who must be familiar with the types, names, and
sizes of all equipment on the cart and also the emergency drugs that
might be needed.
• The ASA has developed a grading system for airway difficulty and provides
• Having the emergency crash and airway carts available at all times
decreases the risk of adverse events. A difficult airway is usually related to
the patient’s specific neck anatomy. The patient with heavy muscle and
fatty tissue in the throat and neck regions are prone to a difficult airway
because of the pressure from these tissues collapsing on the airway during
anesthesia induction or deep sedation.
• These conditions are most common in obese patients and in those who
are of short, heavy stature. Other predisposing factors are neck and throat
pathology including facial fractures.
• Patients who lack most of their teeth may also be difficult to intubate
because without the support of teeth, the cheeks tend to collapse inward.
The most critical time for the patient with a difficult airway is during
intubation and ex-tubation.
• Patients known to have a difficult airway are positioned with the
neck in hyperextension (sniffing position) with the head tilted back
during intubation. Three anterior neck maneuvers for manipulating
the larynx are recognized as beneficial for successful visualization of
the throat structures and intubation in patients with difficult airway.
• All three require training, which anesthesia and nursing personnel
undertake as part of perioperative study. Performed blindly without
training, the maneuvers can result in poor patient outcomes
• . Poor technique that is ineffective can result in the loss of precious
time, which quickly leads to hypoxia, hypercapnia, and brain
damage. Other adverse outcomes include rupture of the tracheal
structures. The most effective of the three techniques is the
bimanual or BURP technique.
 PHASES OF GENERAL ANESTHESIA
• The most prominent physiological effect of general anesthesia is reversible
loss of consciousness, which is maintained while the anesthetic agent is
administered. When the anesthetic is withdrawn, the patient quickly regains
consciousness. The time- and event-related phases of general anesthesia are
as follows:
• 1. Induction: General anesthesia begins with loss of consciousness.
• An induction agent (IV drug, inhalation gas, or combination of the two) is
administered.
• 2. Maintenance: This phase involves continuation of the anesthetic agent;
unconsciousness is maintained with the inhalation agent and adjunct agents.
• 3. Emergence: This phase is the cessation of the anesthetic. Reversal drugs
may be administered, and the patient regains consciousness.
• 4. Recovery: Post-anesthesia care is provided in this phase, which ends with
clearance of anesthetic drugs from the body.
• PREINDUCTION The process of general anesthesia starts when all
perioperative team members are present and preparations to start
surgery have been completed.
• The patient is brought into the surgical suite, and noninvasive
monitoring devices are put in place. If the patient does not have
an IV line, the ACP inserts one when the patient arrives and
ensures that the patient is comfortable and relaxed.
• The patient is positioned supine (lying face up), and the head is
elevated slightly to facilitate respiration and immediate intubation
after induction. General anesthesia begins only after patient
monitoring devices are in place and the operating team is present.
•
• The ACP assembles all needed drugs and equipment and
reassures the patient while evaluating the individual’s
physiological status. Preoperative drugs that provide sedation
and reduce anxiety may be given during this period.
• Suction must be available to the ACP at all times. As long as
the patient is in the operating suite, suction must remain
operative
• The purpose of this is to ensure that tissues are fully
oxygenated from the start of the procedure.
• If a temporary airway obstruction occurs, the reserve oxygen
will already be in the system for rapid uptake into tissues.
• INDUCTION During induction, the patient passes through stages from
consciousness to deep surgical anesthesia. Modern anesthetics and
adjunct drugs allow the patient to pass through these stages very quickly,
and they are seldom distinct.
• The stages are:
• • Stage 1: Begins with the administration of induction drug and ends with
loss of consciousness (usually within moments).
• • Stage 2: Historically called the delirium stage, it is marked by
unconsciousness and exaggerated reflexes. The airway remains intact and
under the patient’s control. Hearing is maintained. The pupils are dilated.
This stage is almost never demonstrated with modern anesthetics.
• • Stage 3: Surgical plane. The patient is relaxed, and protective reflexes
(gagging, blinking, and swallowing) are lost. The patient is unable to
maintain an open airway, and the respiratory response fails.
• • Stage 4: Anesthesia overdose resulting in severe respiratory
and circulatory collapse. This stage is never purposefully achieved
because of its lethality. The patient is induced with an inhalation
anesthetic by mask or with an IV sedative, which causes
unconsciousness within seconds. During induction, perioperative
staff members must carry out their tasks as quietly as possible.
• Although induction takes place very quickly, the patient is able to
hear well into the induction period. Conversation should stop,
and care should be taken to minimize noise. The patient can
easily misinterpret sounds and verbal exchanges during
induction, because the ability to interpret the environment
accurately recedes. Immediately after induction, the patient is
intubated.
• MAINTENANCE Anesthesia maintenance begins when the
patient’s airway is secured and inhalation drugs can be
administered. During maintenance, which represents the period
of surgery itself, the ACP titrates (calculates and measures) the
appropriate ratio of anesthetic agents and oxygen.
• These are delivered into the ventilatory system of the anesthesia
machine and delivered to the patient via the airway. The levels
of consciousness, analgesia, and sedation are continually
monitored, along with physiological parameters.
• All drugs and procedures are documented in the anesthesia
record throughout the procedure.
• As the inhalation anesthetic is delivered through the airway (mask, laryngeal
mask, or ET tube). The patient’s ventilation is controlled by the ACP using a
respirator. The ratio of oxygen to other anesthetic gases is adjusted and
controlled through the anesthesia machine’s ventilation system.
Neuromuscular Blockade (“Muscle Relaxation”)
• Adequate muscle relaxation is necessary during general anesthesia to allow
manipulation of the body wall and other tissues in the operative site.
Anesthetic agents vary in their effect on skeletal muscles. Most do not provide
sufficient relaxation for surgery, and a separate drug must be administered.
• A muscle relaxant drug is called a neuromuscular blocking agent. This category
of drugs causes paralysis by blocking neurotransmission to the muscle tissue.
The level of paralysis is monitored continually throughout the procedure with
a nerve stimulator. The level of relaxation is maintained at a minimum to
prevent overdose. If increased relaxation is needed (e.g., during deep
retraction), incremental doses can be administered.
• EMERGENCE Termination of anesthesia and the process of regaining
consciousness is called emergence. The ACP controls emergence by
withdrawing (stopping) the anesthetic agents and reversing the effects
of adjunct drugs as necessary.
• When the patient regains consciousness, protective airway responses
resume, and the ACP may remove the artificial airway. Removal of the
airway is called ex-tubation. A nasal or oral airway may be inserted at
this time. Emergence can occur quickly and generally proceeds
smoothly.
• Reversal drugs may be administered to hasten emergence. Occasionally
the patient (especially a child) may enter a state of temporary delirium
during emergence. The older person may experience persistent
reversible delirium which might require several days to resolve.
However, this is a postoperative complication, not a routine occurrence.
• RECOVERY When stable, the patient is transferred to a stretcher and
transported to the postanesthesia recovery unit (PACU).
• During transportation, oxygen may be administered from a portable tank.
Patients who require continuous cardiac monitoring are transported with a
portable monitoring unit. According to The Joint Commission policy, any patient
requiring continuous cardiac monitoring must be accompanied to the PACU by a
licensed perioperative nurse. On arrival in the PACU, the staff nurse receives the
patient.
• Oxygen tubing is transferred from the portable unit to a wall outlet, and cardiac
leads or other monitoring devices are connected to the PACU system. Suction is
made immediately available for airway clearance.
• The nurse receives a report of the operative procedure, the patient’s
physiological status, and the anesthesia process from the ACP. The patient
remains in the PACU until physiologically stable and conscious so that critical
care personnel can respond to any emergency that may arise during
• DISSOCIATIVE ANESTHESIA Dissociative anesthesia is induced
with the drug ketamine, which blocks sensory
neurotransmission and associative pathways. The patient’s
eyes remain open and the person appears to be awake, but he
or she is unaware of the environment. The drug also produces
anterograde amnesia. Ketamine is administered intravenously
or intramuscularly and is used for short procedures.
• It is used mainly in pediatric surgery in combination with other
drugs to produce desired effects and reduce side effects such
as excessive salivation and delirium during emergence. Muscle
relaxants often are used in conjunction with ketamine to
decrease muscle tone.
• The advantages of ketamine are rapid
induction and metabolism. The disadvantages
are related mainly to cardiac stimulation and
potential psychological effects, including
delirium and hallucinations, which occur in
adults more often than in children.
• Ketamine is contraindicated in surgery of the
upper respiratory system because it does not
suppress laryngeal and tracheal reflexes.
• CONSCIOUS SEDATION Conscious sedation is used for short diagnostic and minor
surgical procedures that do not require deep anesthesia. In this process, a
combination of sedatives, hypnotics, and analgesics is administered intravenously.
• The patient can respond to verbal commands and breathe independently but is
sedated to tolerate the procedure. Patients undergoing conscious sedation are
monitored continuously throughout the procedure. Minimal sedation is a state in
which the patient can respond to verbal commands. Cognitive function and
muscular coordination may be impaired.
• The patient’s ventilatory and cardiovascular systems remain unaffected. In
moderate sedation, the patient’s consciousness is depressed. However, the person
can respond to verbal commands when stimulated.
• Airway support is not needed, and the patient can breathe independently. The
cardiovascular system usually is unaffected. During deep sedation, the patient
cannot be roused easily but responds to pain stimulation. Ventilatory function is
intact but may be depressed. Cardiovascular functions remain intact. Table 14-4
shows the levels of sedation.
• REGIONAL ANESTHESIA
• Regional anesthesia provides reversible loss of sensation
in a specific area of the body without affecting
consciousness. Regional anesthesia is also called
conductive or local anesthesia. The term regional is
preferred because it describes the process accurately.
• This type of anesthesia can be used in a small superficial
area of skin and subcutaneous tissue or in an entire
region of the body, such as during spinal anesthesia.
• Patient monitoring is always provided during regional
anesthesia.
• patient’s condition and whether sedation is used during the
procedure.
• The most common uses of regional anesthesia are:
1. Limb surgery in which complete nerve block is possible
2. Procedures in which consciousness is desirable or required (e.g.,
obstetrical procedures)
3. Minor superficial procedures
4. Patients for whom general anesthesia poses a significant
physiological risk Regional anesthesia can be provided to a single
nerve, to a group of nerves, or to an area of the spinal cord. When
sensory nerve transmission is interrupted, tissues that transmit
signals along that nerve are unable to receive pain signals.
• DRUG DOSAGE The effective dosage of anesthetic is calculated
according to the individual patient’s ability to absorb and
metabolize the drug.
• The “normal” or safe dosage depends on many factors.
Therapeutic ranges for all local anesthetics are considered with
knowledge of the patient’s physical condition, especially the
presence of cardiac disease, concurrent use of other drugs, and
the patient’s age, weight, and vascular status.
• The rate of metabolism and response to the drug determine
whether toxic levels are being reached.
• External monitoring is an objective method of detecting signs of
toxicity. This is especially important in patients who require large
amounts of anesthetic.
• MONITORING Monitored anesthesia care (MAC) is continuous
patient monitoring provided during regional anesthesia.
• In addition to non invasive physiological monitoring, the ACP
administers sedative and anxiolytic (antianxiety) drugs as
needed and manages any anesthetic or physiological
emergencies.
• Monitored care is particularly important for patients receiving
regional anesthesia who have underlying systemic disease or
respiratory or cardiovascular risks.
• Basic monitoring includes the parameters listed previously
and may include others, depending on the type of drugs
administered.
• ROLE OF THE SURGICAL TECHNOLOGIST
• Local infiltration takes place after the patient
has been prepped and draped as part of the
surgical procedure. The scrubbed technologist
assists the surgeon during infiltration as
follows:
• • Make sure supplies (including the
anesthetic) are available before the
procedure.
• Receive the anesthetic drug from the circulator and verify the
amount and strength using proper technique (
• • Label the drug and syringe on the instrument table and protect
it from contamination.
• • Provide the following: At least two 25-, 26-, or 30-gauge
needles Two 10- or 25-mL syringes Gauze sponges
• • Fill one syringe to capacity and have another ready to use as
necessary. Do not fill syringes partway. This may cause confusion
about the amount of anesthetic used during the procedure.
• • Separate all syringes and needles used for infiltration from
others on the instrument table. Do not use the equipment for
any purpose except infiltration of the local anesthetic.
• • Note the total amount of anesthetic used and report this to the
surgeon or circulating nurse as required.
• Nerve Block A peripheral nerve block provides anesthesia to a
specific area of the body supplied by a major nerve or nerve plexus
(group).
• The anesthetic agent is injected into the adjacent tissue, not into
the nerve itself. The difference between a peripheral nerve block
and local infiltration is that the objective of the nerve block is to
anesthetize a single nerve, which results in blockade of its branches.
• Local infiltration is used to anesthetize a group of fine, usually
superficial nerves in a small area. The surgical technologist assists in
the procedure using the same techniques as described for
infiltration.
• PROCEDURE The peripheral block is performed after a surgical skin prep of the injection area.
The nerve block may be performed as part of the surgical procedure or separately before the
surgical skin prep and draping.
• The procedure for injection is similar to infiltration anesthesia. The scrub assists when the
nerve block is carried out as part of the surgery. Intravenous (Bier) Block Intravenous regional
anesthesia is often referred to as a Bier block (Figure 14-10). In this procedure, blood is
temporarily displaced from a limb and replaced by a local anesthetic drug. To displace the
venous blood, an air-filled pneumatic tourniquet is placed around the proximal end of the
limb.
• The ACP then displaces blood in the limb using a latex bandage (Esmarch bandage). The
bandage is wrapped around the entire length of the extremity, starting at the distal end and
extending to the proximal end.
• The tourniquet is then inflated, and the Esmarch bandage is removed. Anesthetic is injected
into the major vein through a previously placed IV catheter. Double tourniquets also may be
used, one proximal and one distal.
• The tourniquet “time” starts at the beginning of inflation and continues until the tourniquet
is released. The safe tourniquet time and pressure depend on the patient’s age, general
condition, and size and surgical site.
• ROLE OF THE SURGICAL TECHNOLOGIST The circulating surgical
technologist assists in a Bier block by having the necessary
prepared, and in the skin prep.
• The Bier block is an IV procedure and is performed using aseptic
technique including skin prep and draping. The hand may be
excluded from the prep with an occlusive drape.
• The scrubbed technologist assists in draping the patient’s arm
and preparing the sterile equipment. The anesthesia care
provider usually directs and performs the procedure.
• The surgeon or surgical technologist assists as required. The
surgical technologist may be required to re-gown and re-glove
after the Bier block is performed and before the surgery begins.
• PATIENT PREPARATION To facilitate exact
placement of the spinal needle for injection,
the patient must be positioned in a way that
opens the intervertebral space.
• Two positions are used to achieve this, lateral
(side-lying) or sitting.
• A lateral position used with the patient’s
knees drawn up to facilitate exposure of the
intervertebral spaces.
• The circulator stabilizes the patient’s shoulders with one hand while
providing support to the midleg with the other, A. The patient also may
sit on the edge of the operating table and bend forward to create a
rounded back. In this case, the circulator should support the patient. The
patient is covered with a blanket or sheet so that only the injection area
is exposed. This provides warmth and protects the patient’s modesty.
• PROCEDURE When the patient has been positioned correctly, the ACP
prepares the injection site with antiseptic and applies a small sterile
drape. The spinal injection site is infiltrated with a small amount of
anesthetic. A spinal needle is then inserted into intervertebral and
subarachnoid space, and the anesthetic injected. The patient is placed in
the supine position with a slight downward tilt (Trendelenburg position)
to maintain a safe level of anesthesia. The patient given spinal anesthesia
receives continuous physiological monitoring
• throughout the procedure and is given adjunct drugs to provide mild sedation
and relaxation.
• ROLE OF THE SURGICAL TECHNOLOGIST The surgical circulating surgical
technologist assists in the procedure by preparing the spinal tray and correct
size of spinal needles, prep solution, and drape as needed. The circulator helps
the patient maintain his or her position during the procedure and verifies the
type and strength of anesthetic used.
• RISKS OF SPINAL ANESTHESIA Risks associated with spinal anesthesia include
the following:
• • Hypotension: A severe decrease in blood pressure may occur, resulting in
pooling of blood in the lower extremities.
• • Pos-tspinal headache: This condition is related to decreased cerebrospinal
pressure resulting from a leak at the injection site in the dura mater.
• • Total spinal anesthesia: This occurs when the hyperbaric spinal anesthetic
blocks the nerves controlling the diaphragm and accessory breathing muscles.
• Epidural and Caudal Block Epidural anesthesia is
produced when the anesthetic agent is injected into
the epidural space that surrounds the dural sac. The
space contains connective tissue, an extensive
vascular system, and the spinal nerve roots.
• Caudal and epidural anesthesia target the epidural
space. However, in epidural anesthesia, the approach
is through the lumbar interspace, whereas in caudal
anesthesia, the caudal canal is used.
• A caudal epidural blockade produces analgesia of the perineum
and groin and is therefore commonly administered during labor.
• After injection, the anesthetic agent is very slowly absorbed into
the cerebrospinal fluid through the dura mater. It spreads both
caudally (toward the feet) and cephalad (toward the head).
• For a single-injection epidural, the patient’s position and the
molecular weight of the anesthetic have no effect on its
distribution. However, with a continuous epidural, the position
of the patient may affect the spread of the local anesthetic.
• Epidural anesthesia is often used in obstetrical, gynecological,
urological, and rectal surgery. It also is used for postoperative
pain control
• PROCEDURE The patient’s skin is prepped as for spinal
anesthesia. A thoracic, lumbar, or caudal puncture site is used,
depending on the target site of anesthesia.
• The epidural needle is advanced through the skin until it
enters the epidural space, and the anesthetic is injected
Continuous or intermittent epidural anesthesia is provided
through a small catheter placed in the epidural space for the
duration of the surgery.
• This technique also is used for postoperative pain relief and
for chronic pain management in selected patients. In contrast
to spinal anesthesia, epidural anesthesia requires a much
larger amount of anesthetic agent.
• The role of the circulating surgical technologist
is the same as for spinal anesthesia.
• All regional anesthetics are absorbed into the
body and metabolized.
• This means that although regional anesthetics
are relatively safe, exceeding the maximum
dose may cause toxic reactions.
• If absorption is more rapid than metabolism,
the risk of toxic reaction increases.
 EMERGENCIES
• The role of the surgical technologist at all times
during an emergency is to protect the surgical field
and provide assistance as directed.
• The surgical technologist may also be required to
assist in cardiopulmonary resuscitation (CPR).
However, CPR is meant to be a stopgap measure
until biomedical intervention and medical care begin.
• Because these interventions are already in place in
surgery, the patient is in the best location possible
for a positive outcome.
• REGIONAL DRUG TOXICITY AND ALLERGIC RESPONSE Toxic reactions
to local anesthetics arise most often during regional block and
epidural anesthesia.
• This is because of the large amount of drug administered and the
proximity to the vascular system. Toxic reactions related to regional
anesthetics occur in two forms, central nervous system toxicity and
cardiovascular toxicity.
• Central Nervous System CNS toxicity occurs in three phases. The
excitation phase produces light headedness, restlessness, confusion,
perioral tingling (tingling around the mouth), a metallic taste,
tinnitus (ringing in the ears), and a sense of impending doom.
• The patient may become talkative. This phase is followed by the
convulsive phase. Seizures can occur in this phase
• . The depressive phase is characterized by drowsiness, respiratory
depression, and apnea. Cardiovascular System The first phase of
cardiovascular toxicity is the excitation phase.
• The patient develops tachycardia, hypertension, and convulsions. This is
followed by the depressive phase, which is characterized by decreased
blood pressure, bradycardia, and possibly cardiac arrest. Allergic
Reaction A true allergic reaction, which differs from reactions caused by
toxicity, ranges from local skin irritation and itching to severe
anaphylaxis, which produces life-threatening changes in the
cardiovascular and respiratory systems.
• Maintaining verbal contact with the patient helps in the identification
of symptoms
• Resuscitative equipment must be immediately available whenever a
local anesthetic is administered. During any
• AIRWAY EMERGENCY An airway emergency is one
in which the unconscious patient cannot be
intubated. In this case an artificial airway cannot
be established as described earlier because of a
difficult airway. The window of treatment to
prevent hypoxia and subsequent brain damage is
several minutes. The exact time depends on
whether the patient was given extra oxygen
before the event, such as during induction to
general anesthesia
• Emergency response may include repeated attempts by more
than one individual to intubate the patient either by
endotracheal tube or LMA.
• An emergency airway cart containing all necessary equipment
is maintained by the anesthesia department. If repeated
attempts fail tracheotomy can be performed to establish the
airway transcutaneously. In this case, the surgical technologist
should be prepared to assist.
• Emergency tracheotomy is an incision over the anterior wall of
the trachea through the skin and strap muscles, and insertion
of a tube to provide immediate access to air or anesthesia
circuit. Refer to Chapter 28 for a description of a tracheotomy
• LARYNGOSPASM Spasm of the larynx is usually is
associated with airway secretions or stimulation of the
laryngeal nerve during intubation or extubation. The
condition may lead to complete airway obstruction. It is
treated with mechanical ventilation or, in severe cases,
administration of succinylcholine to paralyze the
muscles. Laryngospasm constitutes an emergency when
an airway cannot be immediately established by
positive-pressure ventilation. Patients with a difficult
airway, such as those who are obese, have the highest
risk for laryngospasm.
• ANAPHYLAXIS Anaphylaxis is a true allergic reaction to a substance or
drug that can lead to shock (see next section). In surgery, this is most
commonly associated with regional anesthesia.
• Signs and symptoms include rash, abnormal lung sounds detected during
auscultation, wheezing, and difficulty breathing. In the event of
anaphylaxis, the ACP, nurse, or surgeon immediately administers multiple
doses of epinephrine.
• Other respiratory drugs and antihistamines are administered as needed.
Airway assistance may be required. The on-call resuscitation team is
alerted if no physician is in the room, and an airway and oxygen
administration are quickly established.
• The preoperative examination and preanesthesia evaluation often can
predict allergic response to substances or drug groups, and preventive
measures are very valuable.
• SHOCK During severe shock, the supply of oxygen
and nutrients to all body tissues is inadequate.
• This is caused by a cascade of physiological
events that begins with a variety of conditions in
which the body’s compensatory mechanisms
focus on shunting blood (and oxygen) to the most
vital organs.
• In hypovolemic shock (caused by decreased
vascular volume),
• the heart rate increases initially, and there is widespread
vasoconstriction. Capillary flow diminishes or is shut down. The body
tries to conserve fluid by reducing renal blood flow and increasing
water retention in the kidneys. Urinary output is diminished or ceases.
Eventually multiple organ failure occurs as a result of oxygen and
nutrient starvation at the cellular level. and other clotting factors,
leading to continuous hemorrhage and death. Treatment for shock is
targeted at restoring circulatory function, electrolyte balance, and
oxygenation of tissues. The immediate emergency response is related
to the cause. However, in all cases, Anaphylaxis circulatory balance is a
priority. This may necessitate administration of fluid or blood
components and drug therapy to improve the systemic blood pressure.
The exact cause of the crisis is determined early in treatment so that
appropriate emergency measures can be initiated.
 Types of Shock

• • Circulatory shock is a state of inadequate blood volume for supplying the whole
body. This type of shock can be caused by hemorrhage, burns (in which a dramatic
shift of body fluids occurs), or severe diuresis (excretion of fluids through the renal
system).
• • Cardiogenic shock is caused by heart failure, which disables the vascular system
because blood cannot be pumped adequately throughout the body.
• • Anaphylactic shock is caused by true allergy, resulting in vasodilation and pooling
of blood, which slows or halts normal circulation.
• • Neurogenic shock is caused by failure of the autonomic nervous system to
maintain vascular tone. This type of shock can be caused by specific drugs, brain
injury, anesthesia, or spinal cord injury.
• • Septic shock is caused by severe infection, which results in hypovolemia.
Bacterial infection most often is the cause of septic shock, which can be rapidly
fatal. Disseminated intravascular coagulation (DIC) is a complication of septic shock
in which microcoagulation occurs in the cells. This depletes the body’s platelets
• MALIGNANT HYPERTHERMIA Malignant hyperthermia (MH) is a rare
physiological response to all volatile anesthetic agents and
succinylcholine. MH causes a severe immediate or delayed
hypermetabolism.
• The patient exhibits an extremely high core temperature, tachycardia,
tachypnea, and increased muscle rigidity.
• Metabolic crises accompany the physical signs and include an increase in
intracellular calcium ions, respiratory acidosis, metabolic acidosis, and
hemodynamic instability, which may lead to cardiac arrest and death.
• MH is related to a familial genetic trait. Patients with family members
known to have experienced MH usually report this to the ACP during the
preoperative evaluation. However, no method has been devised of
predicting MH when the patient has no family or personal history of the
co
• A malignant hypothermia cart is maintained in the surgical
department so that all emergency equipment and drugs can be
brought in immediately, because time is extremely important.
• The cart contains cooling equipment, including Foley catheters,
plastic bags, tubing, peritoneal lavage equipment, and nasogastric
tubes.
• Emergency drugs for MH treatment include dantrolene (Dantrium)
and agents to treat specific metabolic disorders. If MH symptoms
occur during surgery, the ACP alerts the team immediately.
• Treatment requires immediate cessation of anesthesia and drug
therapy to treat the adverse metabolic symptoms. The scrub
remains sterile to help protect the surgical incision.
• HEMORRHAGE In the event of severe hemorrhage during surgery, blood
volume is restored by giving blood substitutes, blood components, or
autologous blood (the patient’s own blood previously banked or harvested at
the surgical site).
• Allogeneic (donor) blood transfusions may also be provided. Packed red cells
are mostly commonly used for transfusion, because the patient’s immediate
need is oxygen-carrying capacity.
• All blood products must be matched with the patient’s blood type. A precise
protocol has evolved to prevent the administration of blood of the wrong type.
• Whether the patient’s own blood or banked blood is used, meticulous
attention is given to patient identification, blood group, registration number,
and date of expiration.
• Blood usually is brought from the blood bank shortly before surgery; in an
emergency, it is brought immediately
• . Blood must be stored in a location known to all personnel and
protected from direct heat.
• Unused blood must be returned to the blood bank as soon as
possible. Intraoperative cell salvage (autotransfusion) is the
immediate harvesting of blood on the surgical field and reinfusion
into the patient.
• This may be planned in advance of a high risk surgery or
implemented in an emergency. Special equipment is required for
this procedure.
• The prototype autotransfusion system is the Cell Saver. However,
other systems have now been developed. Scrubs must be familiar
with the cell salvage device used in their facility, because special
training is required.
• HEMOLYTIC REACTION Hemolysis is the rupture of red
blood cells. It is associated with ABO factor
incompatibility during blood transfusion.
• Before any transfusion, the ABO and Rh systems are
tested and crossmatched against the donor blood.
However, mistakes in recording and reading blood
registrations do occur, with serious consequences.
• Patients under anesthesia do not show the heart rate
increases initially, and there is widespread vaso
• the signs and symptoms seen in a fully conscious
patient. ABO mismatch during transfusion outside
of surgery produces the following symptoms: •
Back pain • Chills • Hypotension • Dyspnea These
can lead to complete vascular collapse or renal
failure. In surgery, the only symptoms likely to
appear are oliguria (cessation of renal output) and
generalized bleeding. Treatment requires stopping
the transfusion and immediate hydration with IV
fluids and forced diuresis.
• DEEP VEIN THROMBOSIS An embolus is any moving particle within the vascular
system. Risk factors for emboli include trauma, orthopedic fracture, burns, surgical
procedures involving flexion and rotation of the hip, and use of a pneumatic
tourniquet.
• Venous stasis, or “pooling,” occurs when the patient is immobile for long periods,
which can lead to clotting. A thrombus may form in proximal deep veins and
subsequently break loose, preventing circulation to a vital organ such as the lung
(pulmonary embolism [PE]). Symptoms may become apparent at any point in the
perioperative period.
• Prevention of deep vein thrombosis (DVT) includes preoperative application of
antiembolic stockings, use of a sequential compression device, and prophylactic
medication when appropriate.
• Other preventive measures include slow, deliberate movement of limbs during
positioning and following DVT and PE protocols according to hospital policy.
Treatment for DVT includes drug therapy to prevent further embolization and
treatment for the specific emergency condition, such as shock and respiratory arrest.
 PATIENT ASSESSMENT AND CARE
• After accepting the handover, the PACU nurse performs a
patient assessment. This can be either a focused assessment
or a head to toe assessment.
• The focused assessment, as the name implies, focuses on
specific criteria, such as respiration, circulation, pain, and
level of consciousness.
• The head to toe assessment covers all or most body systems.
Standard procedures are used to assess specific functions.
General assessment procedures are carried out to obtain
baseline information.
• All findings are documented in the PACU record Respiratory
System .
• • The airway is assessed by auscultation (listening with a stethoscope) and by
observation for signs of airway obstruction. • The respiratory rate and rhythm
(patterns) are measured by observation of the thorax and accessory muscles
during breathing.
• Circulation • Perfusion (flow of blood to tissue) is measured by pulse
oximeter. • The color of the patient’s skin and mucous membranes is
observed for signs of hypoxia (inadequate oxygen to tissues). • The heart is
monitored for rate and rhythm using ECG leads and a cardiac monitor, which
produces a digital waveform. • Heart sounds are assessed with the
stethoscope and may be amplified by the cardiac monitor. • The arterial
pressure is measured directly with an arterial line or indirectly by taking the
patient’s blood pressure with a digital sphygmomanometer. • Arterial blood
gases (ABGs) (the ratio of oxygen to carbon dioxide and the blood pH) may be
measured by taking a blood sample from an artery. In the modern PACU, the
sample can be analyzed immediately
• . • The central venous pressure may be measured with an
inline catheter or subjectively by observing the jugular veins. •
The presence or absence of a peripheral pulse is determined
by palpation or by Doppler.
• Core Temperature • The patient’s temperature is assessed
continuously or intermittently using a digital thermometer or
temperature probe. • Hypothermia is a serious postoperative
complication. The patient is continually observed for signs
such as shivering.
• Abdomen • The abdomen is assessed for distention (which
may indicate the presence of fluid, including blood or air). This
is done by observation, palpation, and radiographs.
• Bowel sounds are assessed by auscultation. A persistent lack
of bowel sounds may indicate surgical paralytic ileus—
cessation of peristalsis in the bowel leading to obstruction.
Persistent paralytic ileus is a serious postoperative
complication. Fluid and Electrolyte Balance • Fluid shifts from
the vascular space to the intracellular space can occur after
surgery, and the patient must be evaluated carefully for this. •
Assessment for dehydration includes physical signs and
symptoms. Replacement fluids are administered intravenously
as needed. • Electrolyte imbalance is assessed through blood
tests and specific physiological signs of imbalance, such as
alteration in consciousness or cardiac dysrhythmia.
• Neurological Function LEVEL OF CONSCIOUSNESS • The patient’s level of
consciousness is assessed using the Glasgow Coma Scale (GCS).
• In this system, points are assigned to the response to specific stimuli
(shown here). The GCS score is calculated as the total of all parameters. A
score of 15 indicates the best prognosis (medical outcome), whereas a
minimum score of 3 indicates a poor prognosis.
• The following parameters are evaluated:
• Eye Opening (4) Spontaneously (3) To voice (2) To pain (1) No response
• Best Verbal Response (5) Oriented and converses (4) Disoriented and
converses (3) Inappropriate words (2) Incomprehensible sounds (1) No
response
• Best Motor Response (6) Obeys simple command (5) Localizes to pain (4)
Flexion—withdrawal or abnormal (3) Abnormal flexion (2) Extension (1)
No response Pain •
• Pain is assessed using the following tools: Alertness:
Asleep to hyperalert Level of calmness:
• Calm to panicky Movement: No movement to
vigorous movement
• Facial expression: Face relaxed to contortion or
grimacing Blood pressure:
• Baseline or below to 15% or more elevation Heart
rate: At or below baseline to 15% or more elevation
Vocalization: No vocalization to crying out
• PAIN Although pain is expected in the postsurgical phase, not
all patients respond to pain in the same way. A patient’s
response to pain is affected by previous experience, level of
anxiety, the drugs used during surgery, and environmental
factors.
• Patients also respond to pain according to what is acceptable
in their culture. For example, in some cultures, crying out is
acceptable, whereas in others it is not.
• Pain management requires assessment and planning to
ensure a smooth recovery. Analgesics are administered
according to the patient’s level of consciousness,
cardiopulmonary status, and age.
• POSTOPERATIVE COMPLICATIONS Postanesthesia
complications occur because patients are
physiologically unstable during the immediate
postoperative period and may react to the
procedure or drugs administered intraoperatively.
• They are vulnerable to pain, hemorrhage, reaction
to the anesthetic agents, and rapid changes in
homeostasis. The PACU staff is specially trained in
critical care monitoring and response..
• RESPIRATORY Respiratory problems are the most frequent life-threatening
postoperative complication. Inadequate ventilation can be related to the effects of
anesthetic drugs, pain, muscle relaxants, or fluid-electrolyte imbalance. Inadequate
intake of air and oxygen results in the accumulation of carbon dioxide in the blood.
• Normally, a high carbon dioxide level triggers the autonomic nervous system to
stimulate breathing. However, drugs administered during the intraoperative period
suppress this reflex. Pain at the operative site is another cause of hypoventilation,
resulting in low oxygen saturation.
• For example, patients with abdominal or thoracic incisions do not breathe deeply
because of the pain at the operative site. Airway Obstruction Airway obstruction
most often is caused by anatomical structures or by aspiration of fluids.
• The tongue or soft palate can obstruct the airway in a state of deep relaxation
related to anesthetic agents and adjunct drugs. Contraction of the laryngeal muscles
(laryngospasm) can occur whenever the larynx is irritated or stimulated by
secretions, intubation, extubation, or suctioning. Bronchospasm is partial or
complete closure of the bronchial tubes. It can be
• CARDIOVASCULAR Many anesthetic agents are cardiac irritants that
can sensitize the heart muscle to disturbances in rhythm, rate, and
cardiac output. Hypotension and hypertension can occur as a result
of fluid or electrolyte imbalance. Hemorrhage Hemorrhage can
occur during surgery or in the postoperative period. The patient is
continually monitored for signs of hemorrhage, which include
pallor, hypotension, an increased heart rate, diaphoresis (sweating),
cool skin, restlessness, and pain. Hemorrhage may be caused by the
loss of a ligature placed during surgery, inadequate hemostasis,
leakage from a vascular anastomosis, or a clotting disorder. If
hemorrhage is suspected, emergency assessment measures are
initiated, and the patient may be returned to surgery. Chapter 14
presents a complete discussion of shock and hemorrhage
• . METABOLIC COMPLICATIONS
• Hypothermia Hypothermia is a persistently
low core body temperature (less than 98.6° F
[37.5° C]). Older, pediatric, and frail patients
are most vulnerable.
• Hypothermia can result in a longer
postoperative recovery period, surgical wound
infection, cardiac arrest.
• ALTERATIONS OF CONSCIOUSNESS Anesthetic agents,
adjunct medications, and environmental factors may cause
patients to become disoriented, confused, or delirious during
the immediate postoperative period. Preexisting psychiatric
illness or drug abuse may contribute to these effects, which
may also be due to organic causes such as electrolyte
imbalance. Postoperative delirium is more common in
pediatric patients and older patients. Risk factors include the
following: • Cognitive impairment • Sleep deprivation •
Immobility • Sensory impairment (e.g., vision, hearing) •
Advanced age • Electrolyte imbalance • Dehydration •
Substance abuse • Depression
 ELEMENTS OF DISCHARGE PLANNING
• Before an ambulatory (day case) patient is discharged
to home or to an extended care facility, the PACU staff,
ACP, and surgeon must determine that the patient will
be safe. The patient must be able to perform activities
of daily living (ADLs) with some degree of
independence or have help in dressing, eating,
mobilizing, and toileting.
• Discharge planning is needed to prepare the patient
and caregivers for possible problems. Discharge
planning and implementation follow established roles
and tasks according to hospital policy
• : 1. Discharge criteria: These are standards that reflect the patient’s
physiological status and objectives for care once the patient leaves the facility.
• 2. Transport or transfer plans: Safe patient transportation is arranged, and an
escort is identified.
• 3. Home nursing care: Home care objectives for the patient’s recovery are
established, and those who will be involved in the care are identified.
• 4. Patient education: Patients are informed and educated about their own
care so that they can fully participate in their recovery. The family is instructed
in specific care objectives and how to meet the patient’s physical needs.
• 5. Referral and follow-up: The patient is informed of follow-up appointments.
Referral numbers for emergencies or further advice are provided on a written
document.
• 6. Documentation: Nursing care documentation is completed and signed off.
Discharge checklists are prepared and completed.
• DISCHARGE CRITERIA Discharge criteria are
physiological, psychological, and social
conditions that serve as a measure of the
patient’s readiness for discharge. Patients are
discharged from the PACU only when they
meet discharge criteria. These are primarily
• physiological objectives, which are necessary to
ensure patient safety outside the critical care unit. The
health care facility establishes the discharge criteria.
• A number of organizations have written suggested
criteria; however, the Aldrete scale often is used to
determine whether a patient is ready for discharge to
the hospital ward or unit.
• This is a numerical scale used to evaluate activity,
respiration, circulation, consciousness, and oxygen
saturation.
• Modified versions of the scale have been developed
for special circumstances. Criteria for discharge
include physiological criteria and the patient’s
psychosocial status. Physiological Criteria
• 1. Vital signs are stable and reflect the patient’s
baseline normal.
• 2. Nausea and vomiting are controlled.
• 3. Patient is mobile with assistance or by self (the
patient must be able to walk without signs of
dizziness or weakness).
• 4. Patient is able to void (this establishes that no evidence
exists of urinary retention).
• 5. Skin color reflects patient’s baseline normal.
• 6. Incision site is dry, and drainage is absent or within
expected limits.
• 7. Patient is oriented to time, place, and person.
• 8. Pain is controlled (patients are discharged when the level
of pain is acceptable to the patient).
• 9. Patient is able to drink fluids.
• 10. Discharge orders have been written and signed by the
anesthesia care provider and surgeon.
• . Psychosocial Status
• 1. Patient has transportation home (not public
transport).
• 2. Responsible escort is available.
• 3. Home care is available as needed.
• 4. Home environment is suitable for the
recovering patient
• 1 Modified Postanesthesia Discharge Scoring System
• Vital Signs Within
• 20% of the preoperative value 2
• 20%–40% of the preoperative value 1
• 40% of the preoperative value 0
• Ambulation Steady gait/no dizziness 2
• With assistance 1
• No ambulation/dizziness 0
• Nausea and Vomiting Minimal 2
• Moderate 1
• Severe 0
• Surgical Bleeding Minimal 2
• Moderate 1
• Severe 0
• GENERAL PLANNING Arrangements for discharge are sometimes
complex. PACU nurses not only must care for the patient during the
recovery period, they also must ensure that care is in place and that
safe transport has been arranged. Patients deserve a safe discharge
and transfer from the providing facility.
• Discharge planning must be started at the time of admission to
ensure a safe and event-free return home at the end of the recovery
period.
• Home health service providers are notified, and a preoperative
conference may be held with the family and discharge nurse. When
the patient is to be transferred to another care facility, a verbal and
written hand-off is provided to a designated person at the receiving
facility.
• The hand-off includes all information about the patient’s physical and
psychosocial status, the details of the surgery, and the care plan, including
prescriptions, dressings, and drainage.
• Transport Patient transport to home or another care facility is arranged
before surgery whenever possible. The patient is not discharged to public
transportation, and a responsible escort must accompany the patient.
• Home Nursing Care In the past, patients anticipated a long recovery period,
both in the hospital and at home. Because of advanced surgical technology
and health care economics, patients are now discharged as soon as
possible after surgery.
• Many procedures that used to require days of hospitalization are now
performed as day surgery with discharge within 1 or 2 hours of recovery.
• Home care during the immediate postoperative period is now more
focused and has specific outcome objectives.
• Discharge planning includes specific written instructions
for home care and goals for the patient. This new health
care philosophy has shifted the responsibility of recovery
from inpatient nursing to the patient and family.
• In the event the patient has no assistance available,
community resources, including social services and
professional home nursing services, must be brought in.
• Patient Education Patient teaching is the responsibility of
trained nursing personnel. Current surgical practice with
same-day discharge and fast tracking requires that
patients understand all aspects of their recovery
• . In theory, this allows them to be active participants in their
recovery. However, the postoperative patient may not be able to
understand or remember new information.
• Therefore, patient teaching takes place before surgery and may
include the family members who will assist in care. The elements
of patient teaching include both verbal and written instructions. In
some facilities, video demonstration and education are available.
• Access to electronic information via the Internet has transformed
the field of consumer medicine. However, not all patients have
access to these types of resources or the ability to interpret them.
Also, many more patients are too sick to achieve a level of self-
education.
• these reasons, patients’ family members (when applicable)
are taken through the recovery process, step by step, with
thorough explanations of what to expect and what to do.
• This is especially important for patients who will have
drains, dressing changes, and surgical appliances to
maintain. Written information is intentionally simple and
easy to understand. It is written in lay language, often with
illustrations for clarification.
• It may include information about the surgery, what it
entails, and exactly what anatomical changes were made (if
any). All anticipated and unanticipated events are explained.
• Signs of infection or other complications are written out so that
patients can refer to them. Knowing the expected effects of
surgery helps give the patient confidence and eases anxiety when
they occur.
• Patients are educated fully about their prescriptions and how to
take them. Polypharmacy is a clinical scenario in which patients
are prescribed many different medications, sometimes by
different primary health care providers who have no knowledge of
other drugs the patient is taking.
• It is not unusual for a patient with a chronic disease to be taking
15 or 20 prescribed medications. Therefore, it is very important
that education about drugs be covered fully. The patient’s ADLs
are discussed in full.
• These activities of daily living often determine the patient’s
quality of life. Even if the recovery period is rapid, patients must
be able to cope with activity restrictions, special toileting needs
(or problems), and meal preparation.
• Patients who require dressing changes or have appliances, drains,
or catheters need particular assistance and teaching to prevent
infection.
• Patients and family may be given supplies to take home with them
at the time of discharge. Patients and family receive referral
numbers for emergency care or further information. Upcoming
appointments for surgical follow-up are clearly written, along with
any preparation for further testing or treatment.
• UNANTICIPATED PACU OUTCOME FAILURE TO MEET
DISCHARGE CRITERIA Some patients may not meet discharge
criteria after ambulatory or inpatient recovery. Further
observation and care may be required, especially if the patient
entered the PACU in a deteriorated condition or an adverse
event occurred during recovery.
• Examples of such individuals are patients who are
hypothermic or post hemorrhagic, or those whose vital signs
cannot be stabilized. Inpatients are transferred to the ICU for
critical care observation and nursing. Ambulatory patients may
be admitted to the ICU or surgical unit for overnight care (or
longer if necessary).
• DISCHARGE AGAINST MEDICAL ADVICE
Occasionally a patient may opt for self-
discharge against the advice of medical and
nursing personnel; this is known as discharge
against medical advice (AMA).
• Patients have a right to leave the health care
facility as long as they do not pose a threat to
themselves or others.
• allowed to leave. However, if possible, the facility
tries to obtain a signed waiver from the patient
and explain the possible outcomes of both the
surgery and the consequences of early discharge.
The waiver states that the consequences of early
discharge have been explained, that discharge
was not advised, and that the patient takes
responsibility for the consequences.
• .
• DEATH IN THE PACU Death of a patient during surgery is unusual.
In the event of impending death or a rapidly deteriorating
patient, surgery may be terminated and the patient taken to the
PACU. Death may be pronounced (formally) in the PACU after
resuscitative means have been exhausted.
• The patient’s family is notified, and PACU staff members arrange
for an immediate conference with the family and surgeon.
• A designated staff member stays with the family to provide
emotional support. Further care may be implemented through
hospital chaplaincy and social services. Chapter 16 presents a
complete discussion of death and dying
 KEY CONCEPTS
• • The post anesthesia care unit is designed for immediate access to
patients recovering from anesthesia. The open space design allows
patient gurneys and large equipment to be positioned quickly and
efficiently.
• • Equipment and supplies used in the PACU are similar to other intensive
care units. Inline oxygen, suction, and monitoring equipment are
available in each patient bay for immediate use.
• • As patients are admitted to the PACU, care of the patient is transferred
from the anesthesia care provider to the PACU nurse. The protocol for
handover includes details of the patient’s condition, type of anesthesia,
surgical procedure, medications and agents administered, drains and type
of dressings placed, and any complications that occurred during surgery.
The handover is a formal procedure that requires concise information
and clear communication among professional staff.
• • The Glasgow Coma Scale (GCS) is a basic assessment tool that
can be used to determine level of consciousness.
• • Postoperative complications can occur any time in the
recovery period. Emergencies are handled according to hospital
protocol using the normal emergency system. Acute
hemorrhage may require the patient to be returned emergently
to the operating room for wound exploration.
• • Some health care facilities utilize the PACU for outpatient
recovery and discharge. In this case, discharge planning must
take place on the unit.
• • Patient education is an important phase of discharge planning
that requires thorough under
• Unanticipated, usually uncommon patient
outcomes include failure to meet criteria for
discharge from the PACU, death of a patient,
and discharge against medical advice.
• • Early discharge is the discharge is the
patients’ right, but they must sign a self-
discharge release.
 POSITIONING PATIENTS ON OPERATION
BED
• Positioning for a surgical procedure is
important to the patient’s outcome.
• Proper positioning facilitates preoperative
skin preparation and appropriate draping with
sterile drapes.
• Positioning requires a detailed knowledge of
anatomy and physiologic principles and
familiarity with the necessary equipment.
Safety is a prime consideration.
• Patient position and skin preparation are determined by the
procedure to be performed, with consideration given to the
surgeon’s choice of surgical approach and the technique of
anesthetic administration.
• Factors such as age, height, weight, cardiopulmonary status,
and preexisting disease condition (e.g., arthritis, allergies) also
should be incorporated into the plan of care.
• Preoperatively, the patient should be assessed for alterations in
skin integrity, for joint mobility, and for the presence of joint or
vascular prostheses.
• The expected outcome is that the patient will not be harmed by
positioning, prepping, or draping for the surgical procedure.
• Efficiency of the patient preparation process
can be attained by organizing activities in a
logical sequence.
• The main objectives for any surgical or
procedural positioning are as follows:
1. • Optimize surgical-site exposure for the
surgeon.
2. • Minimize the risk for adverse physiologic
effects.
3. • Facilitate physiologic monitoring by the
anesthesia provider.
4. • Promote safety and security for the patient.
• Responsibility for patient positioning
• . In essence, patient positioning is a shared responsibility
among all team members. The anesthesia provider has
the final word on positioning when the patient’s
physiologic status and monitoring are in question.
• In cases of complex positioning or positioning patients
who are obese, the plan of care includes the need for
additional help in lifting or positioning. Special devices or
positioning aids may be necessary. The weight tolerance
of the mechanism and balance of the OR bed should be
considered
• Timing of patient positioning and anesthetic administration
• Moving the patient from the transport cart to the OR bed or vice
versa requires that both surfaces are securely locked and stable.
Someone should be stationed on the far side of the receiving
surface to prevent the patient from tumbling off the edge.
• For any patient under the influence of an anesthetic agent or
narcotic medication, personnel should be at the head, foot, and
both sides of the patient to prevent dependent parts from
sliding off the table.
• The neck of the patient’s gown should be untied to prevent
entanglement and choking as the patient moves or is moved
from one surface to another
• Some patients are positioned and then anesthetized
if their physiologic status requires special care.
• If patients undergo a procedure in a prone position
and with general anesthesia, they are anesthetized
and intubated on the transport cart.
• A minimum of four people is required to place the
patient safely in the prone position on the OR bed.
• Commonly, more personnel are needed for a safe
transfer between surfaces when the patient is fully
under anesthesia.
• factors that influence the time at which the patient is
positioned:
1. the site of the surgical procedure;
2. the age and size of the patient;
3. the technique of anesthetic administration;
4. whether the patient is conscious;
5. and in pain on moving.
6. The patient is not moved, positioned, or prepped
until the anesthesia provider indicates it is safe to do
so.
• Preparations for positioning
• Before the patient is brought into the OR, the circulating nurse should
do the following:
• 1. Review the proposed position by referring to the procedure book
and the surgeon’s preference card in comparison with the scheduled
procedure.
• 2. Ask the surgeon for assistance if unsure how to position the patient.
• 3. Assess for any patient-specific positioning needs.
• 4. Check the working parts of the OR bed before bringing the patient
into the room.
• 5. Assemble and test all table attachments and protective pads
anticipated for the surgical procedure and have them immediately
available for use
• 1 Body Areas That Need Padding During Positioning
• Supine position
• Occiput
• Heels
• Elbows
• Sacrum
• Prone or other face-down position
• Anterior knees of kneeling patient
• Face (particularly the forehead) and ears
• Dorsum of foot to protect toes
• Genitalia and breasts
• Lateral position
• Face and ears
• Medial knees
• Axilla
• Ankles and feet
• Arms
 Safety measures

• Safety measures, including the following, are observed

while transferring, moving, and positioning of patients:
• 1. The patient is properly identified before being
transferred to the OR bed, and the surgical site is
confirmed according to facility policy. The surgeon is
required to label the correct site.
• 2. The patient is assessed for mobility status, which
includes determination of the patient’s ability to transfer
between the transport cart and the OR bed. Do not plan
to have patients move themselves toward an affected
limb or toward the blinded eye.
• 3. The OR bed and transport vehicle are securely
locked in position, with the mattress stabilized
during transfer to and from the OR bed.
• Untie the ties of the patient’s gown, and take care
not to allow the patient’s gown or blanket to become
lodged between the two surfaces or under the
bottom of a moving patient.
• Velcro strips or other means should be used to
maintain the stability of the mattresses of the two
surfaces.
• 4. Two people should assist an awake patient
with the transfer by positioning themselves on
each side of the patient’s transfer path.
• The person on the side of the transport cart
assists the patient in moving toward the OR
bed.
• The person on the opposite side prevents the
patient from falling over the edge of the OR
bed.
• 5. Adequate assistance in lifting unconscious, anesthetized,
obese, or weak patients is necessary to prevent injury.
• A minimum of four people is recommended, and transfer
devices and lifters may be used.
• The patient is moved on the count of three, with the anesthesia
provider giving the signal.
• Sliding or pulling the patient may cause dermal abrasion or injury
to soft tissues.
• Dependent limbs can create a counterbalance and cause the
patient to fall to the floor.
• Examination gloves should be worn if the patient is incontinent
or offers other risk of exposure to blood and body substances.
• 6. The anesthesia provider guards the head of
the anesthetized patient at all times and
supports it during movement.
• The head should be kept in a neutral axis and
turned as little as possible to maintain the
airway and cerebral circulation.
• 7. The physician assumes responsibility for
protecting an unsplinted fracture during
movement.
• 8. The anesthetized patient is not moved
without permission of the anesthesia provider.
• 9. The anesthetized patient is moved slowly
and gently to allow the circulatory system to
adjust and to control the body during
movement.
• 10. No body part should extend beyond the
edges of the OR bed or contact metal parts or
unpadded surfaces.
• 10. No body part should extend beyond the
edges of the OR bed or contact metal parts or
unpadded surfaces.
• 11. Body exposure should be minimal to
prevent hypothermia and preserve dignity.
• 11. Body exposure should be minimal to
prevent hypothermia and preserve dignity.
• 12. Movement and positioning should not
obstruct or dislodge catheters, intravenous
(IV) infusion tubing, oxygen cannulas, and
monitors.
• 13. The armboard is protected to avoid
hyperextending the arm or dislodging the IV
cannula.
• The surface of the armboard pad and the
mattress of the OR bed should be of equal
height. Hyperabduction is avoided to prevent
brachial plexus stretch.
• 14. When the patient is supine (on the back),
the ankles and legs must not be crossed.
• Crossing of the ankles and legs creates
occlusive pressure on blood vessels and
nerves, and pressure necrosis may occur. The
patient is then at risk for deep vein thrombosis
(DVT).
• 15. When the patient is prone (on the
abdomen), the thorax is relieved of pressure
by using chest rolls (subclavicle to iliac crest)
to facilitate chest expansion with respiration.
• The chest rolls should be adequately secured
to the table to prevent shifting.
• The abdomen should remain dependent to
decrease abdominal venous pressure. Padding
should be placed at the dorsum of the feet to
prevent pressure on the toes.
• In the event of cardiac arrest, a transport cart
should be available for immediate emergency
repositioning into the supine position and for
subsequent resuscitation.
• 16. When the patient is positioned lateral (on
the side), a pillow is placed lengthwise
between the legs to prevent pressure on bony
prominences, blood vessels, and nerves.
• This positioning also relieves pressure on the
superior hip. Pressure reduction padding is
placed beneath the axilla on the unaffected
side to protect the arm from body weight.
• 17. During articulation of the OR bed, the
patient is protected from crush injury at the
flex points of the OR bed.
• 18. When the OR bed is elevated, the patient’s
feet and protuberant parts are protected from
compression by overbed tables, Mayo stands,
and retractor frames. An adequate clearance
of 2 to 3 inches is maintained.
• 19. Surfaces should not create pressure on any
body part. Alternating or pressure-relieving
surfaces should be used.
• Rolled blankets and towels can create
pressure because they do not allow for relief
of compression at the contact surface.
• A gel pad or other alternating pressure pad
should be used.
• Anatomic and physiologic considerations
• A patient’s tolerance of the stresses of the surgical
procedure depends greatly on normal functioning of the
vital systems.
• The patient’s physical condition is considered, and proper
body alignment is important.
• Criteria are met for physiologic positioning to prevent
injury from pressure, crushing, pinching, obstruction, and
stretching.
• Each body system is considered when planning the
patient’s position for the surgical procedure.
 Complications Caused by Positioning
• • Hemodynamic instability from orthostatic
position
• • Poor ventilation from thoracic compression
• • Peripheral nerve injury from compression or
stretch
• • Tissue damage from crush or shearing force
• • Ischemia of hair-bearing scalp, which causes
bald spots
• Compartment syndrome
• Pressure necrosis
• Digit amputation in table bends
• Blindness from optic nerve ischemia
• Corneal abrasion
• Ischemic limbs from arterial occlusion
• Venous emboli
• Vertebral injury
• Panic attacks and feelings of claustrophobia in awake
patient
• Respiratory considerations
• Unhindered diaphragmatic movement and a patent airway
are essential for maintaining respiratory function, preventing
hypoxia, and facilitating induction by inhalation anesthesia.
• Chest excursion is a concern because inspiration expands
the chest anteriorly.
• Some positions limit the amount of mechanical excursion of
the chest.
• Some hypoxia is always present in a horizontal position
because the anteroposterior diameter of the ribcage and
abdomen decreases.
• The tidal volume, the functional residual capacity of air
moved by a single breath, is reduced by as much as one
third when a patient lies down because the diaphragm
shifts cephalad. Therefore, there should be no
constriction around the chest or neck.
• The patient’s arms should be at his or her side, on
armboards, or otherwise supported—not crossed on
the chest, unless absolutely necessary for the
procedure. Patients have additional respiratory
compromise if they are obese, smoke, or have
pulmonary disease.
• Circulatory considerations
• Adequate arterial circulation is necessary for maintaining
blood pressure, perfusing tissues with oxygen, facilitating
venous return, and preventing thrombus formation.
• Occlusion and pressure on the peripheral blood vessels are
avoided. Body support and restraining straps must not be
fastened too tightly.
• Anesthetic agents alter normal body circulatory
mechanisms, such as blood pressure. Some drugs cause
constriction or dilation of the blood vessels, which is
further complicated by positioning.
• Peripheral nerve considerations
• Prolonged pressure on or stretching of the peripheral
nerves can result in injuries that range from sensory
and motor loss to paralysis and muscle wasting. 11 The
extremities, and the body, should be well supported at
all times. The most common sites of injury in the upper
body are the divisions of the brachial plexus and the
ulnar, radial, peroneal, and facial nerves; the axons may
be stretched or disrupted. Extremes of position of the
head and arm greater than 90 degrees can easily injure
the brachial plexus.
• Peripheral nerve injury of the lower body can involve the
sciatic, ilioinguinal, and peroneal nerves. If the patient is
improperly positioned, the ulnar, radial, and peroneal nerves
may be compressed against bone, stirrups, upright retractor
posts, or the OR bed.
• Arthroscopy leg holders and tourniquets can cause crushed or
transected nerve injury. Femoral nerve injury can be caused by
retractors during pelvic procedures. Sciatic nerve injury may
be caused by tissue retraction or manipulation during hip
surgery or extremes of lithotomy position. Facial nerve injury
may result from a head strap that is too tight or from manually
elevating the mandible too vigorously to maintain the airway.
• Musculoskeletal considerations
• A strain on muscle groups results in injury or needless
postoperative discomfort.
• A patient who is anesthetized lacks protective muscle tone. If
the head is extended for a prolonged time, the patient may
have more pain from the resulting stiff neck than from the
surgical wound.
• Care is taken not to hyperextend a joint, which not only
causes postoperative pain but also may contribute to
permanent injury to an extremity. Elderly or debilitated
patients with osteoporosis or other bone disease may suffer
fractures.
• When turning a patient, always keep the spine
in alignment by grasping the shoulder girdle
and hip in a logrolling fashion.
• Do not turn or elevate a patient by grasping
only a hip or shoulder and twisting the spine.
Proper body alignment is maintained
• Soft tissue considerations
• Body weight is distributed unevenly when the patient lies
on the OR bed. Weight that is concentrated over bony
prominences can cause skin pressure ulcers and deep
tissue injury.
• These areas should be protected from constant external
pressure against hard surfaces, particularly in patients who
are thin or underweight.
• In addition, tissue that is subjected to prolonged
mechanical pressure (e.g., a fold in the skin under an obese
or malnourished patient) is not adequately perfused.
• Wrinkled sheets and the edges of a
positioning or other device under the patient
can cause pressure on the skin.
• Foam pads are not adequate to relieve
pressure because they compress and do not
alternate pressure.
• Towels and sheet rolls do not relieve pressure
because they are unyielding to the patient’s
body weight. Gel pads are preferred
• . Blood flow and tissue perfusion are restricted at
higher pressures.
• Pressure injuries are more common after surgical
procedures that last 1 hour or longer.
• During lengthy procedures, the head and other body
parts should be repositioned if possible.
• Patients who are debilitated, poorly nourished, or
diabetic are at particularly high risk for pressure
ulcers and alopecia (permanent bald spots from
pressure).
• Accessibility of the surgical site
• The surgical procedure and patient condition
determine the position in which the patient is
placed.
• To minimize trauma and operating time, the
surgeon must have adequate exposure of the
surgical site.
• Accessibility for anesthetic administration
• The anesthesia provider should be able to attach
monitoring electrodes, administer the anesthetic and
observe its effects, and maintain IV access.
• The patient’s airway is of prime concern and must be
patent and accessible at all times.
• The anesthesia provider needs to continuously assess
urinary output, blood loss, and irrigation use.
• Consideration for visibility of measuring devices and
drainage bags should be incorporated in the plan for
positioning.
• Individual positioning considerations
• If patients are extremely obese (e.g., the torso occupies the width of
the OR bed), their arms may be placed on armboards.
• Heavy-duty OR beds are available with side extenders to
accommodate wide patients.
• Patients with arthritis or previous joint surgery may need special
individualized care because of limited range of motion in their joints.
• A patient who has cardiac problems or is obese may experience
orthopnea or dyspnea when lying flat.
• Pediatric patients, especially infants, need less OR bed length.
• Some surgeons like the foot portion of the bed lowered to decrease
the length of the working surface for accessibility.
• Equipment for positioning
• OR bed
• Many different OR beds with suitable attachments
are available, and practice is necessary to master
the adjustments.
• OR beds are versatile and adaptable to a number
of diversified positions for many surgical
specialties; orthopedic, urologic, and fluoroscopic
tables are often used for specialized procedures.
• General-purpose OR bed.
• 1, Movable head section;
• 2, x-ray cassette tunnel; 3, kidney elevation bar;
• 4, perineal cutout;
• 5, lower extremity section;
• 6, control box;
• 7, pedestal;
• 8, base;
• 9, casters;
• 10, power cord;
• 11, side rails;
• 12, pads.
• The patient’s body habitus may necessitate
the use of a specialty OR bed with an
increased weight limit.
• Manufacturer recommendations should be
consulted for the operation of each model of
OR bed.
EMERGENCY CRUSH CART
• A crash cart or code cart ,crash trolley or "MAX
cart" is a set of trays/drawers/shelves on wheels
used in hospitals for transportation and dispensing
of emergency medication/equipment at site of
medical/surgical emergency for life support
protocols to potentially save someone's life.
• The cart carries instruments for cardiopulmonary
resuscitation and other medical supplies while also
functioning as a support litter for the patient.
• Recommended Equipment
• • Airway (oral and nasal) all sizes
• • McGill forceps, large and small
• • 3 laryngoscope and endotracheal tubes
• • Bag valve mask (adult and pediatric)
• • Nasal cannula (adult and pediatric)
• • Non rebreather oxygen face masks (3 sizes)
• • IV start packs
• • Normal saline solution (1000ml bags)
• • IV tubing
• • Angiocaths (various sizes)
• • 10ml normal saline flush syringes (3)
• • Gauze
• • Alcohol preps
• • Monitor with defibrillator (preferred) or AED
• • Syringe nasal adaptor (nasal narcan atomizer)
• • A checklist confirming everything that should be on
the cart
• (print this page, or buy our laminated checklist)
• *Follow manufacturer guidelines on use of equipment
• Recommended Medication
• • Aspirin 81mg Tablets (4)
• • Nitroglycerin spray or 0.4mg sublingual tablets (3)
• • Dextrose 50% (dextrose 25% if treating pediatrics)
• • Epinephrine 1:10,000 auto injector (10)
• • Atropine Sulfate 1mg (3)
• • Amiodarone 150 mg Vial (3)
• • EpiPen® or Epinephrine 1:1,000 (2)
• • Epicene Jr® or Epinephrine 1:1,000 (2)
• • Solumedrol 125 mg (1)
• • Benadryl 50 mg vial (2)
• • Adenosine 6 mg (3)
• • Lopressor 10 mg (2)
• • Cardizem 20 mg vial (2)
• • Pronestyl (procainamide) 1g (1)
• • Lidocaine 100 mg (3)
• *Follow your organization’s guidelines for
administering and mixing medication.
• The crash cart was originally designed and
patented by ECRI Institute founder, Joel J.
Nobel, M.D., while a surgical resident at
Philadelphia's Pennsylvania Hospital in 1965.
• MAX helped enhance hospital's efficiency in
emergencies by enabling doctors and nurses
to save time, thereby increasing the chances
of saving a life.
• The contents and organization of a crash cart
vary from hospital to hospital, country to
country, and specialty to specialty, but
typically contain the tools and drugs needed
to treat a person in or near cardiac arrest or
another life-threatening condition.[1][2][3]
These include but are not limited to:
• Monitor/defibrillators, suction devices, and bag valve masks (BVMs) of
different sizes
• Advanced cardiac life support (ACLS) drugs such as epinephrine, atropine,
amiodarone, lidocaine, sodium bicarbonate, dopamine, and vasopressin
• First line drugs for treatment of common problems such as: adenosine,
dextrose, epinephrine for IM use, naloxone, nitroglycerin, and others
• Drugs for rapid sequence intubation: succinylcholine or another paralytic,
and a sedative such as etomidate, propofol or midazolam; endotracheal
tubes and other intubating equipment
• Drugs for peripheral and central venous access
• Pediatric equipment (common pediatric drugs, intubation equipment,
etc.)
• Other drugs and equipment as chosen by the facility
• The worst thing ever is to reach for a piece of
emergency equipment emergency medication
and find it inoperable or expired .
• It is important that the crash cart be checked
regularly an maintained by the biomedical
egeneering so that its contents are there
when neededand functioning.
 ROUTENE MAINTANANCE OF A CRUSH
CART

• Expiration dates on medications should be checked on the

first day of the month . Expired medications should be
promptly removed and replaced
• The defibrillation pads on the AED or the defibrillator
should be checked for expiration date
• The battery charge on the monitor and/or AED should be
checked and documented
• The equipment should be regularly checked by biomedical
engineers to ensure that they are functioning properly