Clinical Coach for Effective Perioperative Nursing Care

Davis’s CLINICAL COACH Series F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com Copyright...

Author: Kim Litwack

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Davis’s

CLINICAL COACH

Series

F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com Copyright

© 2009 by F. A. Davis Company

Copyright © 2009 by F. A. Davis Company. All rights reserved. This book is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Printed in the United States of America Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1 Publisher, Nursing: Joanne P. DaCunha, RN, MSN Senior Developmental Editor: William Welsh Project Editor: Kim DePaul Art and Design Manager: Carolyn O’Brien As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes. The author(s) and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs. Library of Congress Cataloging-in-Publication Data Litwack, Kim. Clinical coach for effective perioperative nursing care/Kim Litwack. p. ; cm. Includes bibliographical references and index. ISBN-13: 978-0-8036-2121-3 ISBN-10: 0-8036-2121-3 1. Surgical nursing. I. Title. [DNLM: 1. Perioperative Nursing—methods. WY 161 L782c 2009] RD99.L48 2009 617'.0231—dc22 2008030783 Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F. A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.10 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of the Transactional Reporting Service is: 8036-2121-3/09 0 ⫹ $.25.

Dedicated to the specialty of Perianesthesia Nursing and to Jamie, Jordan, and Daniel, my true support team

Reviewers Lynn H. Buckalew, RN, MSN Instructor Mississippi College School of Nursing Clinton, Mississippi Michelle M. Byrne, RN, PhD, CNOR Associate Professor of Nursing North Georgia College & State University Dahlonega, Georgia Shirley P. Clarke, RN, BSN, MS Faculty, Practical Nursing Program Perianesthesia Continuing Education Program Vancouver Community College, Thompson River University Vancouver, BC, Canada Sydney Fulbright, RN, MSN, CNOR. PhD Candidate Assistant Professor/Program Director University of Arkansas—Fort Smith Fort Smith, Arkansas Sandra Galura, MSN, RN, CCRN, CPAN Assistant Professor, Level III Coordinator Florida Hospital College of Health Sciences Orlando, Florida Deborah B. Hadley, RN, MSN, CNOR Instructor Alcorn State University Natchez, Mississippi Janet C. Kinkade, RN, MSN Department Head and Nursing Instructor Illinois Eastern Community College/Frontier Community College Fairfield, Illinois

vii

Brenda G. Larkin, RN, MS, APRN-BC, CNOR, TNCC Clinical Nurse Specialist West Allis Memorial Hospital West Allis, Wisconsin Genelle Leifso, RN, MSN, CPN(C) Faculty, Perioperative Specialty Nursing BC Institute of Technology Burnaby, BC, Canada Staff Nurse Vancouver General Hospital Vancouver, BC, Canada Martha Olson, RN, BSN, MS Nursing Instructor; Assistant Professor Iowa Lakes Community College Emmetsburg, Iowa Julie Osness-Thorson, RN, MSN, CNOR Surgical Technologist Program Director/Instructor Northcentral Technical College Wausau, Wisconsin Martin Phillips, RN, BSN, CNOR, RNFA Manager Clinical Registries Quality & Patient Safety Institute Cleveland Clinic Cleveland, Ohio Carla E. Randall, RN, PhD Assistant Professor College of Nursing and Health Professions University of Southern Maine Lewiston, Maine Patricia A. Shaner-Christy, RN, BSN, CNOR Faculty The Reading Hospital School of Health Sciences Nursing Program Reading, Pennsylvania

viii

Marjorie R. Simon, RN, CPAN Clinical Instructor, Peri-operative Program, Continuing Education Conestoga College Institute of Technology and Advanced Learning Kirchener, ON, Canada Marilyn Smith Stoner, RN, PhD, CHPN Associate Professor of Nursing California State University San Bernardino San Bernardino, California Rose Utley, RN, PhD Associate Professor Director, Nurse Educator Graduate Programs Missouri State University Department of Nursing Springfield, Missouri Steven W. Wherrey, CST Surgical Technology Program Director Career Centers of Texas – El Paso El Paso, Texas

ix

Table of Contents CHAPTER

1

Preoperative Assessment and Care ................................1 CHAPTER

2

Perioperative Patient Teaching .....................................29 CHAPTER

3

Anesthesia.....................................................................45 CHAPTER

4

Intraoperative Considerations.......................................73 CHAPTER

5

Fluid, Electrolytes, and Acid-Base...............................107 CHAPTER

6

Post-anesthetic Assessment and Care.........................129 CHAPTER

7

Pain Management .......................................................171 CHAPTER

8

Wound Assessment and Care .....................................195 CHAPTER

9

Perioperative Complications .......................................213 CHAPTER

10

Special Populations: The Elderly and Pediatric Patient..........................................................257

xi

CHAPTER

11

Special Populations: The Pregnant, Diabetic, and Obese Surgical Patient.........................................285 CHAPTER

12

Tools............................................................................313 Illustration Credits............................................................333 References........................................................................334 Index.................................................................................343

xii Contents

CHAPTER

1

Preoperative Assessment and Care

P

atients scheduled for surgery bring with them a history of medical problems and prior surgeries, family histories of disease or illness, and personal histories or indications for surgery. It is important that all members of the anesthesia care team be aware of these histories when preparing for and administering anesthesia. If you are involved in admitting patients to the operating room (OR), you will assist in obtaining this information. If you are a nurse working in the post-anesthesia care unit (PACU), you will use this information in planning and instituting post-anesthesia care.

Presurgical Assessment Many patients will have the majority of their preoperative assessment done in advance of the day of surgery through the surgeon’s office. The surgeon will determine the need for surgery, and request the appropriate presurgical evaluation, which may include sending the patient to • His or her primary care physician for clearance • Preanesthetic clinic for evaluation • The laboratory for appropriate tests Through a patient interview and physical examination, it is possible to identify factors that may increase a patient’s perioperative risk. As you interview your patient, you may discover things that require you, the surgeon, or the anesthesia provider to modify the intended plan of care. ALERT For example, if you discover that your patient The primary goal does not speak English, you will be required to of presurgical assessment obtain a translator. You may discover that your is patient safety. patient wears a hearing aid, or uses mobility assistance devices such as a cane. 1

Surgical Scheduling Presurgical screening will help the surgeon determine whether the patient should be scheduled at a freestanding ambulatory facility, as a 23-hour admission, as a same-day admission, or as an inpatient. Patients scheduled at hospital facilities have a greater degree of perioperative risk, either due to their preexisting medical conditions or their need for more invasive surgery. Ambulatory surgery, also known as day surgery, is designed for patients to be admitted from home on the morning of surgery to an OR, and to be discharged to home following surgery. Ambulatory surgery may be performed at a freestanding surgery center or at an ambulatory unit incorporated within a hospital facility. The surgery centers may be multi-specialty and serve a variety of providers or single specialty, such as an eye surgery center. These centers are accredited and governed by federal and state regulations. Also, all preprocedural work-ups need to be done in advance of surgery. This type of surgery is preferred by • Patients, as it is minimally disruptive to home routines • Surgeons, as it is associated with minimal delays • Insurers, as it is associated with reduced costs when compared with hospital-based surgery Medical offices provide an additional option for ambulatory surgical procedures. Although surgery is performed in a medical office, the patient may receive local, monitored anesthesia care; regional anesthesia; or general anesthesia. Office-based surgery is designed for patient and provider convenience at a reduced cost. Because inpatient facilities will be off-site, patients will require careful screening to determine the COACH appropriateness of both patients and procedures CONSULT to keep risk minimal. Examples of procedures Hospital and ambulatory performed in offices include the following: surgery standards do not • Vasectomy apply to medical offices, so • Liposuction it is essential to ensure that minimal safety standards • Arthroscopy are met, including personnel 23-hour surgery refers to ambulatory surgery and monitoring, and to followed by up to 23 hours of monitored care by ensure for the availability nurses. This type of scheduling is useful for of emergency resources procedures in which minimal risks exist that and facility for transfer in event of problems. can be anticipated within 23 hours of a procedure. Nurses can monitor patients in a supervised

2 Preoperative Assessment and Care

setting until the patient is fit for discharge. This type of care allows for pain relief and for admission if untoward outcomes such as bleeding develop. Examples of 23-hour surgery include the following: • Tonsillectomy • Cardiac catheterization Discharge prior to 23 hours avoids inpatient charges, keeping costs down. Surgery can occur independently of inpatient bed availability pressures. As these patients are admitted from home the morning of surgery, preprocedural work-ups are done in advance of surgery. Same-day admission surgery has the patient admitted as a planned admission to an inpatient room following elective or semi-elective surgery. Examples include the following: • Total hip replacement • Coronary artery bypass graft All preprocedural work-ups are done in advance of surgery. This decreases costs associated with unnecessary admission in advance of surgery. Inpatient, hospital-based surgery has the patient being sent to surgery from an inpatient bed, laboratory, or emergency room with a plan to return to an inpatient bed or intensive care unit (ICU) after surgery. These patients tend to be sicker, requiring inpatient stabilization, evaluation, and monitoring before surgery, as well as after surgery. Examples include the following: • Exploratory laparotomy following admission for gastrointestinal (GI) bleed • Tracheotomy placement after prolonged intubation in ICU • Amputation following admission for a COACH motor vehicle accident CONSULT Scheduling at a hospital facility allows for In the interest of patient • More invasive procedures safety, the location of where • More complex procedures a surgery is performed is • Possible inpatient admission following not nearly as important as the determination that the procedure patient is appropriate for • Immediate access to diagnostic testing the location, in consideration • Immediate access to specialty consults of preexisting diseases, For example, a patient may be scheduled control of these conditions, for a breast biopsy or possible mastectomy, medications, and anticipated procedure to be performed. depending on biopsy results. If the procedure remains limited to a biopsy, the patient can be

Preoperative Assessment and Care 3

COACH CONSULT Presurgical screening will help the surgeon determine the urgency of the procedure to allow for appropriate scheduling of the OR.

discharged to home following the procedure. If the procedure is extended to include a mastectomy, the patient can be admitted following surgery.

Timing of Surgery

Elective surgery is surgery to improve a patient’s quality of life—either physically or psychologically. The surgery may be medically indicated, such as a cataract removal or repair, or may be optional and desired by the patient, such as breast augmentation. Elective surgeries are scheduled according to patient and surgeon convenience. Although planned, time is not of the essence in scheduling. By scheduling the procedure, this allows sufficient time for adequate patient preparation, evaluation, and planning. The risks of elective surgery are dependent upon the procedure to be performed, in addition to the general risks associated with surgery, and include the following: • Bleeding • Infection • Anesthetic exposure Because the procedures are planned with complete patient preparation, these procedures are associated with a low morbidity and mortality. Semi-elective surgery is more time sensitive than elective surgery. Although not required within 24 hours, scheduling should be considered a priority, especially by the patient. Examples of semi-elective surgeries include the following: • Cholecystectomy for gallstones and repeated episodes of cholecystitis • Uterine artery ablation for postmenopausal bleeding from fibroids Semi-elective surgery allows for adequate patient preparation, evaluation, and planning. The risks of the procedure will be dependent upon the procedure, as well as the general risks associated with surgery. Like elective surgery, these procedures carry a relatively low morbidity and mortality. Urgent surgery is surgery required within 24 hours of diagnosis, and is done so to prevent unnecessary complications that can occur with waiting. Examples of urgent surgery include the following:


• Hip fracture • Appendectomy Scheduling within 24 hours allows for adequate patient evaluation, but may not allow for maximizing patient status of conditions not well controlled preoperatively. For example, it may be determined that the patient has preexisting hypertension, but that condition has never been treated. Emergency surgery cannot be delayed, and must occur within 24 hours. Ideally, the surgery will be scheduled within 2 hours. Any delay may promote critical injury or systemic deterioration, and surgery is required as the result of an urgent medical condition. Examples include the following: • Stable GI bleed • Subdural hematoma The preoperative goal is stabilization before admission to the OR to prevent threats to life or well-being. This urgency may prevent adequate patient preparation and evaluation. The management of these patients requires rapid decision-making with limited time for extensive history taking and diagnoses. Emergency surgery is associated with an increased morbidity and mortality due to risks associated with underlying conditions, as well as surgery and anesthesia, and includes the following: COACH • Bleeding CONSULT • Infection • Renal failure • Myocardial infarction Salvage surgery is required when cardiopulmonary resuscitation is in progress on the way to the OR or in the OR itself. Either a patient’s life or limb is threatened, requiring immediate surgery for survival. Examples include the following: • Penetrating trauma • Ruptured aneurysm • Perforated ulcer Death is an inevitable outcome unless the patient is brought immediately to the OR. Even with immediate admission to surgery, death remains a very real risk.

Surgical procedures are classified by necessity, by location of where the surgery will be performed, and by length of stay. These classifications will help you to determine the relative risk of the procedure. For example, a surgery that is performed on an emergency basis in an inpatient facility is of higher risk for perioperative complications than a scheduled surgery at a free-standing facility where no overnight stay is required.


Patient Interview You will begin your preoperative assessment with the goal of obtaining a detailed patient history. The history is one of the best measures of patient status, so it is important that your questioning be targeted and specific.

Patient History Taking the patient’s history comprises eight steps: 1. Explore the patient’s understanding of the need for surgery to be performed. This will help you make sure that the patient has a good understanding of the procedure, as well as providing you with clues to priorities that will need attention postoperatively. For example, if your patient tells you he or she is having a mitral valve replacement, you COACH will ask about symptoms of dyspnea, angina, CONSULT and increased fatigue. A patient scheduled for a total hip replacement may tell you he A patient who takes or she is doing it so he can play golf again, aspirin, Coumadin, or ibuprofen is at an increased and you are provided with a motivator to risk for bleeding. A patient help in postop rehab and physical therapy. taking Coumadin will need 2. Ask about any previous surgeries and to be told to stop this anesthetics that the patient may have and medication before surgery how those procedures were tolerated. The to decrease the risk for bleeding and will need an patient may tell you he or she had a problem international normalized with extreme nausea, or had an allergic ratio (INR) on the day of reaction to a medication. Maybe the patient surgery to make sure clotting experienced a spinal headache after an studies are within normal limits before surgery. epidural anesthetic. If so, these will be Knowing about medication important things to tell the anesthesia use will help determine provider. which preoperative labora3. Ask about the patient’s family health tory tests need to be history. Include any adverse reactions to ordered. If a patient is taking medications for glucose anesthesia. Anesthesiologists were first control, it is important to made aware of a phenomenon, later to be obtain a fasting preoperaknown as malignant hyperthermia, when a tive glucose. patient reported that 10 of his family members had died undergoing anesthesia. 4. Ask about current medication use, including prescription medications, over-the-counter medications, and herbal medications. Having a current list of these medications is


important, as there may be medication-anesthetic interactions that might compromise the safety of surgery and anesthetic administration. It is important that you ask about over-the-counter medications, as many patients will not report their use because they were not prescribed by a doctor. These agents also may result in adverse anesthetic-medication interactions. Aspirin can cause excessive bleeding. Benadryl taken for sleep can promote delayed awakening. One of the newest over-the-counter medications, orlistat (Alli), decreases absorption of fat-soluble vitamins, A, E, D, and K. Herbal medications are particularly problematic, as little research exists to confirm or refute evidence about potential interactions. As many as 25% of patients presenting for surgery have used some type of herbal medicine. Much of what is known about herbal medicines is anecdotal at best, meaning someone reported a case suggesting a connection between an herbal medication and an anesthetic. Examples include the following: • Ginkgo biloba taken to improve memory increases bleeding by inhibiting clotting • Feverfew taken for migraine headaches also increases bleeding • Kava taken for relaxation potentiates COACH the effects of sedatives used in the OR CONSULT • Ephedra taken for weight loss increases An easy way to inquire the risks of arrhythmias about herbal medicine use • Garlic taken to lower lipids enhances the is to simply ask, “What effect of warfarin, increasing bleeding herbal or vitamin supplements do you currently • Ginseng taken for energy causes sedatake?” tion, tachycardia, and hypertension 5. Ask about medication allergies and intolerances. You should document any positive allergies in the medical record, and on the day of surgery, make sure ALERT that a red allergy identification band is applied to the patient’s wrist. Ask about Patients with a history of allergic responnondrug allergies, too. siveness have a greater 6. Ask about illicit drug use, abuse, and potential for demonstrating addiction in the same way you asked hypersensitivity reactions about current medication use. Alto drugs administered during anesthesia. though you may find asking about drug use uncomfortable, once you explain to


patients that there are drug interactions between these drugs and anesthetic agents, patients will usually respond honestly. The categories of drugs most likely to be used and abused include the following: • Alcohol • Opiates COACH • Marijuana CONSULT • Cocaine 7. Ask the patient about tobacco use. In When asking about alcohol people who smoke, 15% of the oxygen binduse, ask the patient to tell you how much he or she drinks ing sites on hemoglobin are occupied by in a typical day or week. carbon monoxide, resulting in a decreased Making the judgment that oxygen carrying capacity of hemoglobin. the patient is a social, light, Smokers also have a higher incidence of moderate, or heavy drinker reactive airway disease, which may result is usually based on a comparison to your own drinkin laryngospasm on induction. If you can, ing. Document the specifics, encourage patients to stop smoking a minifor example, glass of wine mum of 6 weeks before surgery to decrease nightly with dinner, six-pack perioperative morbidity. of beer over the weekend. 8. Ask about the possibility of pregnancy, specifically to determine the date of the patient’s last menstrual period. This is needed to prevent unnecessary exposure of the fetus to anesthetic agents, particularly COACH CONSULT during the first trimester of pregnancy. Although it may be difficult to ask the parents to step out of the room, tell the teen that you need her to void before going to surgery and that you will show her where the bathroom is. As you walk her to the bathroom, you can ask about the possibility of pregnancy and the date of her last period without her being embarrassed in front of her parents. Then you can obtain a urine sample for testing to be sure.

Review of Systems The last component of the interview is the review of systems, with its sole purpose to determine the presence or absence of disease. It is especially important to assess organ systems that affect the actions of anesthetics, such as the pulmonary, hepatic, and renal systems, and organ systems that can be affected by anesthetics, such as the central nervous and cardiovascular systems. Cardiovascular System Ask about a history of dysrhythmias, chest pain, or myocardial infarction (heart attack, MI) or if the patient has ever seen a cardiologist. This is


particularly important because of the potential for re-infarction with surgery. COACH Ask about hypertension, and if blood presCONSULT sure is well controlled by medications. Patients As every medication given are generally encouraged to take their blood for anesthesia has the pressure medications on the morning of surpotential to have an impact gery with a sip of water to keep pressures under on the cardiovascular system and the surgical procedure control. Poor preoperative control increases itself places the patient at the risks of anesthesia and surgery. Poorly risk for bleeding, you must controlled hypertension is often a precursor to ask about preexisting renal dysfunction, and suggests the need to cardiac disease. obtain baseline renal function studies including a blood urea nitrogen (BUN) and a creatinine laboratory test before surgery. Hypertension increases the risk for coronary artery disease, ALERT stroke, congestive heart failure, and renal If a patient has failure. had a heart attack more It is recommended in medical literature that than 6 months before a patients with preexisting hypertension have a surgical procedure, the risk of reinfarction is about 6%. medical evaluation and clearance before surIf the MI was between 3 and gery. If the hypertension is mild and controlled, 6 months before a procethe evaluation can take place up to 2 months dure, the risk increases to before surgery. If moderate, evaluation and 15%. However, if the clearance should be within 2 weeks. If severe, surgery is taking place within 3 months of the MI, surgery should be postponed with immediate the risk of reinfarction evaluation and intervention. increases to 30% with a Ask the patient about a history of heart 50% mortality! failure and edema. If they do, make sure you assess breath sounds and the lower extremities for signs of fluid retention. Listen for rales that do not clear with coughing, and for pitting edema. Both are a sign of symptomatic congestive heart failure, and surgery will be postponed until the patient’s symptoms have been controlled. Respiratory System Ask about dyspnea (difficulty breathing) both at rest and with exertion. This can provide a clue about both respiratory and cardiac disease. A patient who states that he sleeps with three pillows or who has to sleep in a recliner to make breathing easier is at substantial risk of respiratory difficulty if exposed to general anesthetic agents that are respiratory depressants, while being laid flat for a surgical procedure.


Ask about the presence of a cough, and if the cough is productive. This can be a clue to an upper respiratory infection, which commonly leads to cancellation of surgery, especially if an The patient with normal elective procedure. Patients with an upper respulmonary function runs a piratory infection are at a greater risk for peri6% to 10% risk of developoperative bronchospasm, laryngospasm, decreased ing postoperative pulmonary complications. As the risk oxygen saturations, and problems with secreincreases with preexisting tions. A dry cough may simply be a side effect pulmonary disease, and in to the use of an angiotensin-converting enzyme consideration of the type (ACE) inhibitor medication used to treat hyperof surgery to be performed, tension. A cough that brings up blood may you must be aggressive in determining any potential provide you with the indication for surgery. for increased risk. After Ask the patient about his or her smoking surgery, you will be just as history. If the patient is a current smoker, docaggressive in providing ument use with the number of years smoked postoperative pulmonary care. and number of packs or parts of a pack per day. Ask about a history of chronic obstructive pulmonary disease (COPD), and any current treatment including antibiotics, bronchodilators COACH or nebulizer treatments, or use of home oxygen CONSULT therapy. The patient with a history of COPD, including emphysema and chronic bronchitis, One study estimated that 60% of patients with COPD is at risk for pulmonary complications includdevelop postoperative ing infection, hypoxemia, and hypercarbia. pulmonary complications Ask about a history of asthma. If asthma is when given no special acknowledged, ask if the patient knows his or postoperative respiratory her normal peak flow values. Peak flow monicare. In the same study, the incidence of postoperative toring is becoming a standard of care for primary complications dropped to care management of asthma. Known values 22% when antibiotics, will help you and the anesthesia provider to bronchodilators, and chest detect any increase in bronchospasm if a physical therapy were included in the PACU decline in the peak flow is detected, often routine. occurring before the patient becomes symptomatic. Ask the patient what medications are used to control the asthma, and if the medications are used daily or only as needed. If used daily, ask about the use of any steroid medications, particularly the use of oral steroids that may have been used to control an acute exacerbation. The anesthesia provider may give the patient a nebulizer treatment before induction. COACH CONSULT


Central Nervous System Ask questions to determine the patient’s ability COACH to respond to questions, follow commands, and CONSULT maintain ordered thought patterns. AppropriIf you don’t identify deficits ateness of response and thoughts must be preoperatively, when they determined and any deficits carefully evalupresent after surgery, you ated. For example, the inability to respond may will be unable to compare with a baseline. This will simply be the result of a language barrier that force you to subject the can be readily corrected by the use of a translapatient to unneeded tor, or it may be a sign of a patient’s inability to testing and yourself and understand due to neurologic deficit, which the surgical team to may compromise your ability to obtain informed unneeded anxiety. consent signatures before surgery. If the patient is unresponsive, is it due to a correctable condition such as electrolyte imbalance, or is it due to trauma or disease? Ask about any history of seizures, paralysis, or motor deficit or weakness. Methohexital and enflurane, which are not commonly used agents, lower the seizure threshold. Paralysis and motor deficits and weakness are considered relative contraindications to regional anesthetics, such as spinal, epidural, and caudal anesthetics. Knowing about motor deficits that exist before surgery is important, as motor function will be assessed postoperatively, and a comparison made to preoperative findings. Special care will need to be taken when positioning and transferring any patient with muscle weakness or paralysis. COACH Ask about the presence of any neuromuscular CONSULT diseases or conditions requiring special attention. For example, a child with mental retardaApproximately 12 million tion might benefit by having a parent present people in the United States are affected by renal disease, for induction of anesthesia. A patient with a hisso it is important to ask tory of cerebral palsy often has an unpredictable about renal dysfunction. response to muscle relaxants, sedatives, analThis may include renal gesics, and hypnotics. Parkinson’s disease often insufficiency or renal failure. These patients are at an causes gait disturbances and increases the risk increased risk of infection of falls. A history of stroke increases the risk of and sepsis, bleeding, cardiac disease. cardiovascular dysfunction, Renal System and hyperkalemia. Response The patient with renal dysfunction is almost to medications is often unpredictable. always anemic, with an average hematocrit of 15% to 18% and a hemoglobin of 5 to 8 g/dL.


Anemia affects the oxygen-hemoglobin relationship in the body, shifting the oxyhemoglobin dissociation curve to the right, thereby increasing the oxygen supply to the tissues. Cardiac output increases the oxygen supply to the kidney, so drugs that decrease cardiac output should be avoided. Patients with renal dysfunction, especially those on dialysis, will have alterations in coagulation, including platelet dysfunction and systemic heparinization, which will increase prothrombin and thromboplastin times, increasing bleeding. This may be a limiting factor in an anesthesia provider’s decision to not use a regional technique in a patient, where hypocoagulation exists as a contraindication. Patients in acute renal failure are not candidates for any surgical procedure, unless emergent, due to the presence of acidosis, fluid status instability, electrolyte imbalances, and blood pressure irregularities, as well as the presence of the underlying event that precipitated the renal failure. Patients in chronic renal failure may present for surgery of any nature, so asALERT sessment of electrolytes, fluid status and hydration, date of last dialysis, frequency and type The greatest (hemodialysis or peritoneal), and anemia status perioperative risk for the should be determined, to decrease perioperapatient with renal disease is the risk of infection. tive morbidity and mortality. Hepatic System Impairments in glucose homeostasis contribute to hypoglycemia. Alterations in fat metabolism contribute to the development of metabolic COACH acidosis. Alterations in protein synthesis cause CONSULT hypoalbuminemia, decreasing protein binding sites and increasing drug effects. Protein defiIf you remember the many ciencies also contribute to failed wound healroles of the hepatocyte, you will quickly understand ing. Coagulation factors are produced in the why the patient with preliver, specifically prothrombin, fibrinogen, and existing liver disease is at factors V, VII, IX, and X. Deficiencies in these such an increased periclotting factors increase the risk of bleeding in operative risk. Hepatocytes contribute to, or are surgery. Alterations in liver function will proresponsible for, glucose long the action of drugs that require the liver homeostasis, fat metabolism, for metabolism and clearance, including benzoprotein synthesis, drug and diazepines, lidocaine, and narcotics. hormone metabolism, Ask about any history of hepatitis, cirrhosis, bilirubin formation and excretion, and clotting. and alcoholism. Acute hepatitis is most commonly caused by a viral infection of the hepatocytes or


by ingestion or injection of toxic drugs. Acute hepatitis may also be caused by sepsis, congestive heart failure, and, rarely, pregnancy. The most significant problem is the transmission of the infection to health-care workers. Because everyone associated with the surgical procedure will be exposed to blood, saliva, and potentially vomit, attention to universal precautions is mandatory. Acute hepatitis is associated with a surgical mortality of 9.5% and a morbidity of 11.9%. These rates are high enough for many surgeons to delay elective surgical procedures. Chronic hepatitis is the most serious form of hepatitis, often resulting in cirrhosis and liver failure. Liver function will be greatly compromised. Alcoholism is the most common cause of cirrhosis. Not only is physiologic functioning of the liver compromised, hepatic blood flow is reduced, as blood meets increasing resistance in moving through the portal vein, known as portal hypertension. The patient will require monitoring for bleeding, drug toxicity, and cardiovascular compromise. Musculoskeletal System Ask about arthritis, focusing on affected joints. Osteoarthritis affects between 40 and 60 million Americans. Rheumatoid arthritis affects 1% of all adults in the United States, with 100,000 to 200,000 new cases diagnosed each year. Arthritis is a chronic inflammatory disease of the joints, and is characterized by pain, swelling, and impaired mobility. The most common drugs taken to control the discomfort of arthritis, nonsteroidal anti-inflammatory agents (NSAIDs) and aspirin, have the potential to increase bleeding due to their effect on platelet function. Scoliosis will affect not only mobility and positioning, but with greater curvatures, will affect respiratory functioning as well by compromising vital capacity and potentially cardiovascular

COACH CONSULT As a large percentage of patients presenting for surgery are elderly, attention to the musculoskeletal system is of particular importance. Arthritis will impact positioning, transferring, and ambulation pre-, intra-, and postoperatively.

COACH CONSULT Myasthenia gravis is a chronic, autoimmune disease that compromises the neuromuscular junction. It is characterized by muscle weakness and fatigability and periods of exacerbation and remission. Multiple sclerosis is a chronic neuromuscular disease caused by demyelination of neurons. It is characterized by sensory and motor neurological deficits and is episodic in its frequency and severity of exacerbation and remission. GuillainBarré syndrome is an inflammatory disease that may affect all motor, sensory, autonomic, and cranial nerves. It is characterized by ascending, symmetric muscle weakness, particularly of facial and ventilatory muscles.


functioning. Vital capacities of less than 30% of predicted values will suggest the need for postoperative controlled ventilation. Neuromuscular disease, including muscular dystrophy and myasthenia gravis, multiple sclerosis, and Guillain-Barré syndrome all will affect neuromuscular functioning and anesthetic decision-making. Muscular dystrophy is a hereditary disease characterized by painless degeneration and atrophy of skeletal muscles. Degeneration of cardiac and respiratory muscles will contribute to cardiopulmonary compromise intraoperatively and postoperatively. In addition, research suggests a relationship between muscular dystrophy and malignant hyperthermia. With all of these neuromuscular disorders, airway maintenance and ventilatory management will be the number-one intraoperative and postoperative priority. Frequently, these patients will be admitted to the PACU, intubated, and ventilated. Weaning to extubation will be slow, secondary to respiratory muscle compromise and enhanced sensitivity to the neuromuscular effects of inhalation agents and neuromuscular relaxants. In the case of myasthenia gravis, the neurologist will often become involved not only with weaning, but in restarting and titrating anticholinesterase agents. Gastrointestinal System Malnutrition is best assessed by the evaluation of serum albumin levels, reflecting hypoalbuminemia. Low serum albumin levels reflect poor protein stores and decreased protein binding sites. If drugs are unable to bind to proteins, plasma concentrations of drugs will COACH remain elevated, increasing the potential CONSULT for drug reactions and adverse effects. For example, midazolam (Versed) is highly proBoth malnutrition and tein bound. If fewer sites are available for this obesity have the potential to affect surgery and the drug to bind, the patient will experience selection of anesthetic profound sedation and potentially respiratory agents and techniques. depression. Protein is also necessary for The malnourished and wound healing. undernourished patient is at risk for exaggerated Obesity is another risk factor for both anesdrug effects, whereas the thesia and surgery. The risks are due to the obese patient is at risk for associated impairments in respiratory, cardiovasdelayed drug metabolism cular, and GI systems. Hypoxemia commonly and exaggerated respiraaccompanies obesity, secondary to the following: tory and cardiovascular effects. • Increased minute ventilation • Increased work of breathing


• Closure of small airways • Ventilation-perfusion mismatch during normal breathing • Reduced functional residual capacity • Reduced vital capacity • Reduced total lung capacity Postoperative hypoxemia is a significant risk and common postoperative problem. Obesity is an important predictor of cardiovascular disease, particularly in obese individuals younger than age 50. Increased risks include the following: • Coronary artery disease • Myocardial infarction • Sudden death • Stroke • Thromboembolism • Congestive heart failure The risk of hypertension is 10-times greater than in non-obese individuals. Gastric volume and acidity also are increased, increasing the risk of aspiration. Preoperative assessment is focused on not just weight, but the effect of the weight on vital organ functioning. Preoperative medications with known respiratory depressant effects should be avoided. The patient should be positioned with the head of the bed elevated, unless contraindicated by the surgery. Medications to increase gastric emptying and to increase pH, such as metoclopramide and H2 antagonists, will need to be ordered and administered preoperatively. Antiembolic stockings will also need to be ordered and applied before the patient is anesthetized. The patient also should be asked about any history of reflux or heartburn. For many patients, being NPO and lying flat will worsen the symptoms, both of which will occur on the day of surgery. As reflux can mimic the pain associated with chest pain, knowing about a history of reflux preoperatively is particularly important. These patients will also benefit from the administration of medications that increase gastric emptying and increase pH, such as metoclopramide and H2 antagonists. Endocrine System Diabetes is a systemic disease characterized by a relative unresponsiveness to insulin (type 2, adult onset, nonketotic) or by an absolute lack of insulin (type 1, juvenile onset, ketosis-prone). Diabetes is diagnosed clinically by


COACH CONSULT In the perioperative period, the major endocrine concern remains maintenance of normoglycemia. This is acutely important in the diabetic patient. With the epidemic of obesity in this country, there has been a consistent and steady rise in the diagnosis of diabetes, affecting, in some places, as many as one out of every four individuals.

ALERT Patients with poor glucose control have an increased risk of long-term complications of hyperglycemia, including neuropathy, nephropathy, and retinopathy. Findings of a history of myocardial infarction, hypertension, congestive heart failure, voiding dysfunction, renal disease, and neuropathies, both autonomic and peripheral, suggest end-organ damage.

its “classic” signs of polyuria, polydipsia, and fatigue, the manifestations of hyperglycemia, glycosuria, and cellular glucose deprivation. It is considered to be a risk factor for both anesthesia and surgery. Postoperative wound healing may be compromised with poor glucose control, and the risk of infection is greater than in the nondiabetic. Preoperative evaluation of the diabetic patient centers on the determination of the type of diabetes, medications used in management, and the degree of relative control of glucose values. The anesthesia provider will determine the optimal management strategy for glucose control on the day of surgery. Ideally these patients will be scheduled early in the day to avoid prolonged periods of no oral intake. Insulin dose may be cut in half, or held completely, with insulin management by sliding scale before, during, and after surgery. Oral hypoglycemic agents are generally held on the day of surgery. It should be mentioned to patients that the stress of surgery may result in transient glucose fluctuations, requiring insulin administration in patients who normally do not require insulin. This is generally temporary. Nausea and vomiting are especially problematic in diabetic patients, as diet is an important part of glucose regulation. Administration of antiemetic agents is particularly important and should be used as prophylaxis, as opposed to waiting until emesis has occurred.

Hematologic System Ask about unusual or excessive bleeding as a clue to anemia. This bleeding may be an indication for surgery. For example, heavy menstrual bleeding may be the reason for an exploratory laparotomy for fibroid removal. The patient may be coming in for a colonoscopy for rectal bleeding. Check a hematocrit before the patient goes to surgery to establish a baseline.


Ask about any recent infections, or if the patient is currently taking antibiotics. Current antibiotic use will reduce a white blood cell count, but may not have yet removed the source of infection. Active infection is usually grounds to cancel elective surgery. Ask about unexplained bruising as an indicator of clotting abnormalities. Also ask specifically about the use of any medications, aspirin, NSAIDs, Plavix, and Coumadin, that will directly affect platelets causing bleeding. These medications are usually stopped in advance of surgery except in very exceptional circumstances.

Physical Examination

COACH CONSULT The hematologic system consists of red blood cells, while blood cells, and platelets. Each plays an important role in the perioperative period. Red cells carry oxygen, so any deficiency, known as anemia, will compromise oxygenation. White blood cells mobilize with infection, so any elevation seen preoperatively requires investigation as to cause, with likely cancellation of any elective surgery. Platelets are required for clotting, so any deficiency, most commonly due to medications such as aspirin products, nonsteroidal antiinflammatory agents, Plavix, or Coumadin, will increase the risk of bleeding.

Prior to admission to the OR, a physical examination must be performed. This may be done in advance of the day of surgery, particularly if the patient requires medical clearance, or may be done on the morning of surgery, most commonly by the anesthesia provider. As a result, the physical examination is not usually a comprehensive head to toe examination, but a targeted examination of anesthetic importance. The surgeon has already assessed the surgical site in determining the need for surgery. The anesthesia provider will assess cardiopulmonary function by inspection and auscultation. COACH The assessment will include observation for CONSULT overt signs of distress, poor color, and auscultation of heart and lung sounds for abnormalities. Any chest or spinal abnormalities will be noted, particularly if they are likely to affect ventilation. The condition of veins or arteries that might be cannulated will be inspected, and peripheral pulses might be palpated. If regional anesthesia is to be considered, the site of injection will be assessed to identify the ease of landmark identification and the

After completing the patient interview, and in advance of the physical examination, it is a good habit to end the interview by asking the patient, “Is there anything else you would like to share with me or think I should know?”


presence of any anatomic alteration that might interfere with the success of the injection. Prior to admission to the OR, vital signs will be obtained, including temperature. An elevated temperature, in consideration with other physical findings, may result in cancellation of elective surgery. The patient’s height and weight should be obtained and documented. This is particularly important in the pediatric patient, as calculation of drug dosages is frequently based on weight.

Determination of Physical Status After the patient history and physical examination are complete, the patient will be assigned a physical status rating. Defined by the American Society of Anesthesiologists, the assignment of a physical status rating is designed to be a predictor of perioperative risk and overall outcome (see Table 1–1). Table 1–1

PHYSICAL STATUS

Physical Status Classification (Adapted from American Society of Anesthesiologists) DEFINITION

EXAMPLE

I

Healthy patient with no systemic disease

Patient with no significant past or present medical history

II

Mild systemic disease without functional limitations

Patient with a history of well-controlled asthma with prn albuterol use

III

Severe systemic disease associated with definite functional limitations

Patient with a history of moderate persistent asthma who uses daily steroid and bronchodilator inhalers; activity limited

IV

Severe systemic disease that is an ongoing threat to life

Patient with poorly controlled asthma experiencing acute episode of falling saturations requiring oral steroid rescue and frequent nebulizer treatments

V

Patient unlikely to survive for more than 24 hours with or without surgery

Patient in status asthmaticus, intubated

VI

Brain dead patient awaiting organ removal for donation


Laboratory Testing Ideally the ordering and obtaining of preoperative laboratory tests should be based on the individual patient’s history and examination, in consideration of the surgery to be performed, as opposed to being arbitrarily determined by “policy.” The one exception might be preoperative pregnancy tests in all females who have started menstruation up until menopause and obtaining either a hematocrit or hemoglobin as baseline. Laboratory tests should serve as an adjunct to the history and examination, and should be used to evaluate the extent of disease progression, disease control, and as an assessment of risk. The use of a preoperative patient checklist can help to determine the need for preoperative laboratory testing (see Box 1–1).

Box 1–1

Checklist for Ordering Preoperative Laboratory Tests

HEMOGLOBIN/HEMATOCRIT Potentially bloody operation Known anemia Bleeding disorder Radiation or chemotherapy Severe, chronic disease Excessively heavy menstrual periods WHITE BLOOD CELL COUNT WITH DIFFERENTIAL Infection Known disease of WBC Radiation/chemotherapy Aplastic anemia Unexplained fever PLATELETS Known platelet abnormality Excessive bleeding identified Known blood disease: anemia, leukemia History of radiation or chemotherapy Use of NSAIDs, aspirin, Plavix, Coumadin Unexplained bruising PT/PTT/INR (CLOTTING FUNCTION) Known or suspected clotting abnormality Anticoagulant therapy Hemorrhage or anemia Continued Preoperative Assessment and Care 19

Box 1–1

Checklist for Ordering Preoperative Laboratory Tests—Cont’d

Liver disease Thrombosis Malnutrition or poor nutrition ELECTROLYTE PANEL (SODIUM, POTASSIUM, CHLORIDE, TOTAL CO2, CREATININE, BUN) Age ⬎60 Use of diuretics Renal disease History of diarrhea, SIADH, fever, liver disease, vomiting, malabsorption CHEMISTRY PANEL (GLUCOSE, CALCIUM, PHOSPHORUS, URIC ACID, TOTAL BILIRUBIN, TOTAL PROTEIN, ALBUMIN, CHOLESTEROL, SGOT, LDH, ALK PHOSPHATASE, SGPT) Age ⬎60 Diabetes mellitus Hypoglycemia Pancreatic disease Pituitary disease Adrenal disease/steroid therapy Liver disease Radiation/chemotherapy Malnutrition ECG Age >40 Known cardiac abnormality URINALYSIS Unexplained fever Hematuria Complaints of frequency/urgency/dysuria CXR Productive cough with fever

Factors in Selecting the Type of Anesthesia In addition to the data gained from the history, physical examination, and laboratory testing, there are a number of other factors that the anesthesia provider will consider when selecting the type of anesthesia for a patient. These include the following:


• • • • • • •

Age of the patient Physical status of the patient Type of surgery to be performed Preference of the surgeon Inpatient versus outpatient status Skill and requirements of the anesthesia provider Patient preference and needs

Age of the Patient For the adult patient, depending on the type of surgery, there are a number of anesthetic options, including general anesthesia, regional anesthesia, IV conscious sedation, or local anesthesia. The pediatric patient may well tolerate general anesthesia, but anatomic and cooperation factors may limit regional anesthetic techniques to those that can be performed while the child is sleeping, such as a penile ring block following circumcision.

Physical Status of the Patient The patient who has been deemed a Class I patient, being a patient with no preexisting disease, may be a candidate for any type of anesthesia, whereas a Class 4 or 5 patient with a history of renal, respiratory, or cardiac disease and increasing dysfunction may benefit from a general anesthetic in which the airway is well controlled with intubation, allowing for use of inhalation agents and minimizing the need for IV agents that increase sedation and the potential for hypoxemia.

Type of Surgery to be Performed Intra-abdominal surgery, for example, requires intubation, as these procedures require the use of muscle relaxants. Knee arthroscopy may lend itself very well to a regional epidural or spinal, however, the speed of the surgery may warrant use of a general anesthetic for faster OR turnover and faster patient recovery and discharge to home.

Preference of the Surgeon The surgeon may also have preferences based on his or her skill and familiarity with the procedure, the need for conversation during the procedure when teaching surgical residents, and the position the patient will be in for surgery.

Inpatient versus Outpatient Status Although inpatient versus outpatient status used to influence the type of anesthetic to be performed, its impact is lessening. Regional anesthesia Preoperative Assessment and Care 21

COACH CONSULT To better understand patient needs about anesthesia, consider this: If you have ever faced the need for surgery since you became a nurse, you likely knew exactly which surgeon you were going to go to, which anesthesia provider you wanted or did not want, and gave specific instructions such as not waking up with an endotracheal tube, wanting something for nausea, and wanting pain medication on board when you woke up. Patients do not want to give up their control either, but do not have the ability to make demands. Help them to understand that decisions being made are for their safety, with their specific individual needs in mind. Encourage patients to ask questions to their surgeon and anesthesia provider along the way.

is being performed in outpatients. The only modification is that discharge criteria must now reflect home-going status, as opposed to discharge status to an inpatient unit.

Skill and Requirements of the Anesthesia Provider Some centers limit regional techniques to physician anesthesiologists, as opposed to nurse anesthetists. An anesthesia provider might have skill and experience in complicated nerve blocks, making that an additional option for procedures.

Patient Preference and Needs Many patients fear loss of control with a general anesthetic, and would prefer a regional technique. Others will simply tell the anesthesia provider to “put me to sleep and wake me when it’s over.” Although patients may have a preference, the ultimate decision will be up to the anesthesia provider and will be made for patient safety.

Preoperative Teaching

Another purpose of preoperative screening is to provide a final opportunity for patient and family teaching about • The day of surgery • Postoperative expectations and routines • Purpose of post-anesthesia care • Preoperative preparation required • Preoperative medication use • Preoperative fluid and food restrictions See Chapter 2, Perioperative Patient Teaching, for more specific information.

Legal Concerns The preoperative period also is a time for you to address legal concerns regarding surgical consent and advance directives.


Informed Consent Obtaining informed consent is the obligation and responsibility of the physician. Providing informed consent mandates providing complete and sufficient information for a patient or a patient’s proxy to make an educated decision about health care, and usually begins with first patient contact with a surgeon or surgeon’s office. Consent for surgery may or may not cover consent for anesthesia. Informed consent requires providing complete disclosure of the following: • Working or presumed diagnosis • Differential diagnosis • Purpose of proposed intervention/surgery • Risks of proposed intervention/surgery, even if the common risks are not serious and the serious risks are uncommon • Alternative treatments and risks • Risks of not treating • Short- and long-term costs • Short term: pain, length of stay, recovery time • Long term: loss of function, restriction of activity, scarring. Threats to informed consent include coercion and manipulation. Coercion is the application of a threat. Manipulation involves deliberate altering or omission of facts. Persuasion, on the other hand, is expected and not faulted, as the surgeon presents the rationale for recommending surgery, allowing the patient to make an informed choice.

High-Risk Patients and Informed Consent

COACH CONSULT Obtaining informed consent is the responsibility of the physician. Education of a patient about a procedure can be delegated to a nurse. Obtaining the signature of patient on a consent form can be delegated to a nurse. You should determine and follow hospital or facility policy.

COACH CONSULT You can help in the consent process by making sure that all of the patient’s questions have been answered prior to the signing of the consent form.

COACH CONSULT Patients who do not speak English as their first language and patients who are developmentally immature may also be incapable of understanding.

For consent to be informed, patients must be capable of understanding what is being presented. This implies that information must be presented in a manner that patients can understand. There are high-risk patients who may be incapable of understanding, either because of preexisting conditions such as mental


COACH CONSULT Failure to obtain informed consent has legal consequences. Performing surgery without informed consent may be viewed as assault and battery. Lack of informed consent may be viewed as malpractice.

illness and organic brain syndrome, or induced conditions, such as a patient who has received premedication or who is in labor or under stress. Each facility needs a plan to address highrisk patient situations. As a nurse, you can assist in identifying these patients and help to ensure that consent is truly informed prior to the signing of the surgical consent.

Advance Health-Care Directives

A durable power of attorney for health care is a legal document that allows an individual to appoint an agent, also called an attorneyin-fact, health-care proxy, and patient advocate, COACH to make all decisions regarding health care CONSULT when the patient is unable to speak for him- or herself, including choices regarding Although a do-not• Health-care providers resuscitate order may exist • Medical treatment prior to a patient going into the OR, depending • End-of-life decisions upon hospital policy, that It is commonly used in conjunction with a order may be rescinded living will. and need to be rewritten A living will is a legal document that after surgery. It is important expresses an individual’s decision to choose or for the surgeon to clarify the order with the family or refuse medical decisions and the use of artifiperson acting as the cial life support systems if patients are unable health-care proxy to deterto speak for themselves due to physical or menmine wishes in the event of tal incapacitation in the event of terminal an intraoperative or postoperative cardiac arrest. illness or accident or under the circumstance of You can help to make sure incurable conditions. that this conversation takes The documents must be executed when indiplace. viduals are competent. The documents may or may not be recognized as legally binding, but they can serve as a guide to an individual’s wishes, and may become the basis for do-not-resuscitate orders.

Preoperative Medications The administration of preoperative medications is now designed to address a specific patient need, as opposed to routine administration of a sedative


medication to reduce anxiety and to promote relaxation. The goal of premedication will dictate medication choice. Most will be administered intravenously when the patient arrives in the holding area before surgery. Goals of premedication include the following: • Relief of apprehension and anxiety • Sedation • Analgesia • Amnesia • Decreasing anesthetic requirements • Decreasing gastric volume and acidity • Preventing of nausea and vomiting • Antisialagogue (dry secretions) • Preventing autonomic reflex response • Facilitating induction • Decreasing allergic reaction • Decreasing stress of parental separation • Preventing infection • Preventing clot formation If reduction of anxiety is the primary goal, a benzodiazepine will be the ideal premedication. Midazolam, in particular, is used for this purpose, as well as for its sedation and amnestic properties. When given orally to children, the stress of separation is reduced. Medications used to increase gastric pH and to increase gastric emptying include H2 antagonists such as the following: • ranitidine (Zantac), • famotidine (Pepcid), • cimetidine (Tagamet), • nizatidine (Axid) • metoclopramide (Reglan) Patients who would benefit from this type of premedication include those with a history of peptic ulcer disease, gastroesophageal reflux disease, diabetes, and pregnancy for nonobstetric surgery. Nonparticulate antacids (Bicitra) may be given to decrease gastric acidity. Taken orally, they must be administered 15 to 30 minutes before induction of anesthesia to be beneficial. Anticholinergics such as atropine, scopolamine, and glycopyrrolate may be given preoperatively to dry secretions, thereby decreasing the risk of aspiration and increased airway irritability. These drugs are indicated for patients who may have a preexisting problem with secretions, such as toddlers, small children, patients following a stroke, and patients


with Parkinson’s disease, and to patients whose surgery will result in stimulation of oral mucous membranes. Stimulation of the oral mucosa can increase salivation tenfold, potentially placing the airway at risk. Antiemetics may be given preoperatively, especially to patients who reported a history of postoperative nausea and vomiting. Other indications for premedication include the desire to decrease intraoperative anesthesia requirements and the desire to induce analgesia, especially when preoperative patient preparation may prove uncomfortable, as may be the case with placement of central or peripheral intravenous lines or the injections associated with regional blockade. An opioid is usually the medication of choice indicated for this purpose. Antibiotics may be given prior to surgery to decrease the risk of infection, particularly of wounds, in the surgical patient. Antibiotics are also used to prevent bacterial endocarditis in patients with a history of congenital, rheumatic, or valvular disease with regurgitation. Many hospitals have developed written protocols regarding the use of antibiotic prophylaxis, both to ensure use in appropriate patients and to prevent inappropriate use when unnecessary. The decision to use antimicrobial therapy should be based on the probability of and degree of likely microbial contamination. A classification system has been developed to aid the decision-making process (see Box 1–2). The use of low-dose subcutaneous heparin administered 6 to 12 hours preoperatively has been shown to decrease the rate of deep venous thrombosis by 60% and to decrease the rate of pulmonary embolism in patients after general surgery, urologic surgery, neurosurgery, and moderate to high-risk gynecologic surgery. It appears less beneficial in orthopedic patients. As most patients are not admitted to the hospital the night before surgery, it has also been shown that heparin therapy may be started as long as 2 days after surgery with similar outcomes. Additional prevention against deep venous thrombosis is the application of antiembolic stockings (TED hose) and sequential compression devices. You will assist the patient with putting the stockings on prior to surgery, and the sequential compression devices will be applied after the patient is on the OR table, before induction of anesthesia. Patients identified as being at an increased risk for thromboembolism are identified in the Box 1–3.


Box 1–2

Wound Classification and Antibiotic Prophylaxis

Clean: No entry into the oropharyngeal cavity, respiratory system, alimentary canal, or genitourinary tract 75% of all surgical cases No inflammation Wounds closed Seldom are drainage devices placed Incidence of infection 5% Antibiotics not recommended Clean-Contaminated: Entry into the oropharynx, respiratory tract, GI tract or genitourinary tract 15% of all surgical cases No spillage of secretions Incidence of infection 10% Antibiotics recommended only for neck dissection, gastric resection or biliary exploration Contaminated: Entry into the genitourinary tract or biliary tract Spillage of urine or bile Infected urine or bile Fresh traumatic wounds Incidence of infection 15% to 20% Antibiotic prophylaxis recommended Dirty Wounds: Devitalized tissue, old traumatic wound infections, or perforated viscus Incidence of infection 100% Antibiotic prophylaxis mandatory

Box 1–3

Patients at Risk for Thrombus Formation and Embolism

Older than 40 years of age Multiple trauma Prolonged surgery Prolonged immobilization Previous thromboembolic disease Varicose veins

Malignant disease Obesity Heart disease Infection Pregnancy Birth control pills


Sending the Patient to the Operating Room As a nurse, your final responsibility to the patient is to confirm that all preoperative tasks have been completed and that the patient is, indeed, ready to go into surgery. The use of a preoperative checklist can facilitate a last minute confirmation, as well as providing documentation. Having the checklist placed on top of the chart makes it readily available for the anesthesia provider, as well as the OR nurses. A quick look for a completed checklist will confirm that the patient is ready for surgery (see Box 1–4).

Box 1–4

Preop Checklist

Use the following checklist to confirm that the patient is ready for surgery. If a category is not applicable to the patient, indicate so by writing N/A in the space provided. Identification band on Allergy band on (if applicable) Procedure confirmed Consent signed Advance directives signed or declined (circle one) NPO status confirmed Specify if not required_____________________ Patient voided Pregnancy test negative Preop prep/orders completed Specify____________________________ Preop medication(s) given Specify medication/dose/time__________________________________ Patient dressed for OR Valuables secured Specify______________________________________ Surgical site marked by patient Specify___________________________ Preop teaching completed Family teaching completed/Family to waiting room Chart complete, including laboratory tests


CHAPTER

2

Perioperative Patient Teaching

P

erioperative patient teaching is an important role of the perianesthesia nurse. The purpose of preoperative teaching is to prepare the patient for the surgical experience. Intraoperatively, teaching will focus on immediate needs. Postoperatively, the goal of teaching is risk reduction.

Preoperative Patient Teaching Providing information helps the patient and family to maintain some sense of control over a situation in which there is little they can control. Your skill in anticipating their knowledge needs will help allay their fears of the unknown while also acknowledging their feelings about the impending surgery. The most common fears of the surgical patient include the following: • Fear of the unknown • Fear of death • Fear of the surgical outcome (diagnosis, disfigurement). A major benefit of good preoperative teaching is that the patient will show up on the day of surgery prepared, with preoperative preparations complete, ready to go. He or she will have • Followed instructions to be NPO • Completed any necessary preps • Arranged for a driver if scheduled for an ambulatory surgical procedure • Brought the needed paperwork As a result, the surgical schedule benefits from smooth transitions and fewer cancellations. Preoperative teaching also helps to decrease

29

postoperative complications by introducing the tasks in which a patient will be required to participate after surgery.

What To Teach: Process and Content The focus of your teaching will include what will happen before, during, and after surgery. You will need to outline patient and family responsibilities clearly and ensure understanding.

Before Surgery Prior to surgery, and as part of obtaining informed consent, the surgeon will already have discussed the following: • Surgical procedure • Whether the patient will be an inpatient or outpatient • Expected risks and benefits and recovery Your role will focus on day of surgery events. This conversation with patients may take place in advance of surgery during a visit for preoperative clearance, or you may be having this conversation with patients over the phone when confirming the time of surgery. Some of this information may even be delivered in written format in a letter to patients in advance of surgery. If a letter format is used, patients should still be given the opportunity to discuss any additional concerns or questions they may have before the day of surgery. You need to provide the specific information needed by the patient to successfully prepare for surgery. You are really teaching them the who, what, why, when, where, and how of surgery. The Who COACH Confirm the name of the person scheduled for CONSULT surgery and try to talk directly to him or her, unless the patient is a minor child or unable to Prior to surgery, remember understand your instruction. Confirm who will to teach your patient the be accompanying the patient, either as support following specifics: • Who or as the needed driver for patients having • What ambulatory surgery. • Why The What • When Confirm with the patient the needed things • Where • How to bring with him or her on the day of surgery. This usually includes a photo ID, copy of the insurance card, advance directive documents if applicable, and anything specific to the surgery. For example, patients scheduled for a vasectomy are often asked to provide an athletic 30 Perioperative Patient Teaching

supporter to wear after surgery to decrease swelling. Patients may be asked to bring a button down shirt to wear after shoulder surgery, as it will be nearly impossible to pull a shirt on over their head after surgery. Patients who are scheduled as inpatients should be encouraged to leave valuables at home. The Why You should provide the patient with a rationale for all instructions. When provided with a rationale, the instructions become more meaningful and the patient becomes aware of their importance. For example, patients will be instructed to mark the surgical site with a permanent marker for any surgery that has a “side” involved, such as an arthroscopy of the right knee. Explain to the patient that you have asked him to mark the surgical side to ensure that everyone is aware of the correct side of the procedure to reduce errors. As another example, patients may be told that they will be asked to put on antiembolic stockings to prevent the development of clots. Patients scheduled for colonoscopy or sigmoidoscopy will need to complete a bowel prep to promote emptying of the bowel. Stress the importance of this preparation as a means to optimize visualization of the colon as well as a means to prevent infection. This is particularly important with adult learners, who will learn best when they perceive a need for information. Thrombus, or clot, formation is a significant perioperative risk that increases with obesity, prolonged surgery, pelvic or long bone trauma, positioning in lithotomy position, or any position that involves elevation of the leg, and vasodilatation that accompanies the administration of most inhalation agents, as well as spinal anesthesia. The thrombus may obstruct blood flow in a distal extremity, but the major concern is the clot becoming dislodged and mobile. A mobile clot is known as an emboli. Moving from the leg, the embolism may lodge in the lung, obstructing pulmonary blood flow and causing significant respiratory distress or arrest. Antiembolic stockings, known commonly as TED hose, are applied preoperatively, before the administration of any anesthetic agent (see Fig. 2–1). Antiembolic stockings are used to compress the veins and to promote venous return to the heart. Make sure you select the correct size for the patient. They may be used alone, but are frequently used together with sequential compression devices (SCD machines), which work to intermittently compress the lower extremity, promoting blood flow (see Fig. 2–2). Although the TED hose are applied preoperatively, the SCD devices are more commonly applied after the patient has moved onto the operating room (OR) table. Perioperative Patient Teaching 31

F I G U R E 2 - 1 : Antiembolism stockings.

F I G U R E 2 - 2 : Sequential compression device.

Patients should also be told that there are additional interventions to prevent clot formation, including range of motion exercises and early ambulation, which will start after surgery. The When Patients need to be told what time surgery is scheduled and what time they should present ALERT for the procedure. For example, a patient scheduled for surgery at 11 a.m. may be asked to be Aspiration greatly at the facility by 10 a.m. If laboratory tests need increases perioperative morbidity and mortality. to be drawn and results obtained before surgery, as might be the case with coagulation 32 Perioperative Patient Teaching

studies, the patient may be asked to be at the facility even earlier than 10 a.m. If you do not yet have this information, instruct the patient about when they will be able to find out the time, and how that will occur. Patients will also need to be told when to stop eating and drinking before surgery, and what medications they can take on the day of surgery. The anesthesiologist will usually request or order that the patient have nothing to eat or drink, including water, after midnight on the day of surgery. These times will be less rigid in pediatric patients and infants. By having the patient NPO, the risk of intraoperative vomiting and aspiration is minimized, as is the risk of postoperative nausea, vomiting, and aspiration. Box 2–1 specifies current NPO evidencedbased recommendations. Box 2–2 discusses aspiration. The Where Patients should be told where to park and where to present on arrival to the hospital. Providing a map in the mail in advance is helpful to patients who may be unfamiliar with the area and hospital. If you know where the patient will be transferred after surgery, you can instruct the family. Also tell the family where they can wait for the patient while surgery is in progress. Most facilities have a surgical waiting room. Families should be told that information will be relayed to the waiting room, and the

Box 2–1

COACH CONSULT The only exception to the NPO after midnight rule is to allow patients to take their usual morning medications on the morning of surgery with a sip of water. When taken with a small amount of water, between 30 and 60 mL, there is no evidence of an increased risk of aspiration. In fact, morbidity may actually be increased if patients are denied their routine medications, particularly their antihypertensive and antianginal agents.

COACH CONSULT Lack of compliance with NPO requirements will commonly result in cancellation of surgery or a significant delay, which compromises the surgical schedule and makes a lot of folks very angry.

American Society of Anesthesiologists EvidencedBased NPO Guidelines

Clear fluids: 2 hours Breast milk: 4 hours Infant formula: 6 hours Nonhuman milk: 6 hours Light meal: 6 hours Perioperative Patient Teaching 33

Box 2–2

Aspiration

Aspiration appears clinically as bronchospasm, hypotension, and hypoxemia, and if severe, may develop into pulmonary edema and respiratory distress syndrome. The severity of aspiration will increase with the volume and the pH of the aspirate. A volume of 0.4 to 1.0 mL/kg is associated with an increase in perioperative morbidity and mortality, as is a pH of less than 2.5. Aspiration of gastric contents is essentially a chemical burn of the pulmonary mucosa. In addition to keeping the patient NPO, the risk of aspiration can be further reduced by the administration of an H2 histamine-receptor antagonist to increase pH and by the administration of metoclopramide (Reglan) to increase gastric emptying.

waiting room is usually where a surgeon will go after surgery to communicate surgical outcome. The How This is not a discussion of how the surgeon will perform the procedure, but a schedule of how the day will go. For example, you might tell the family and patient: “Things begin in the holding area, where you will meet the anesthesiologist and usually see your surgeon. In the holding area, you will be asked a lot of questions, your chart will be reviewed, and that is usually the place where the IV is started. You will go from there to the OR, where you will again be asked more questions, sometimes, the exact same ones you have already answered. We do this for your safety. Everyone in the OR will be dressed in scrubs and will be wearing masks. Your surgery is scheduled for about an hour and a half, after which you will be transferred to the post-anesthesia care unit (PACU) for approximately 1 hour. This is an approximate time only, as your discharge requires that you are warm, comfortable, and stable after surgery. Sometimes the delay has nothing to do with you. We might be waiting on a bed assignment or for an x-ray to be completed. We ask your family to wait in the waiting room, so that the surgeon can find them after surgery, and we can keep them advised when you are about to be transferred to your room, or if there are delays.”

During Surgery Teaching during surgery is fairly limited due to the fact that the patient will be anesthetized. Teaching is usually limited to immediate needs and may include the following: • Introduction of the staff in the room • Instructions on how to aid in positioning for an IV start • Transfer from the cart to the OR table 34 Perioperative Patient Teaching

Depending on the needs of the anesthesiologist, additional teaching may be done specific to the technique. For example, positioning for an epidural or other regional block, or for an awake intubation. If the patient is awake during surgery, the patient may receive information about progress. In some cases, for example during an arthroscopy, the patient may even be able to watch the procedure on a TV screen and to ask questions about what is being seen.

After Surgery

COACH CONSULT Although not commonly started in the PACU, if your patient is destined to remain in the PACU for an extended period of time as a result of lack of a bed, starting incentive spirometry, if ordered, will be important (see Fig. 2–3). The physician will usually write an order for incentive spirometry to be used at least 10 times every hour while the patient is awake. You will need to explain to the patient the purpose of incentive spirometry, and that the goal is not to simply “get the balls in the air,” but to hold the balls in the air for as long as possible, even if it only means getting one of the two or three balls up. Sustaining elevation promotes deep breathing and deep lung expansion, whereas quick inhalations will get the balls in the air without sustaining lung volumes. After performing the exercises 10 times, the patient should be encouraged to cough.

Teaching after surgery focuses on postoperative risk reduction and preparing the patient for discharge. You will begin by simply explaining to the patient the purpose of the recovery room in helping the patient move from an anesthetized state in the OR to a more independent one that will allow for discharge to a surgical floor or to home. These teaching points, although part of the postoperative care of any patient receiving general anesthesia, require the nurse to assess readiness to learn and the ability of the patient to understand the teaching and rationale. Prevention of Atelectasis and Pneumonia One important risk reduction strategy is promotion of optimal ventilation to prevent atelectasis and pneumonia. This is important for any patient who has received general anesthesia and particularly important for patients who smoke or who are undergoing abdominal or thoracic surgery. Simply promoting early ambulation, mandatory in ambulatory patients, is an important strategy in preventing atelectasis. For most PACU patients, encouragement for them to “take a deep breath” will promote deep breathing. Not only does this help to prevent atelectasis, the act of deep breathing helps with the elimination of anesthetic gases. Explaining the rationale behind the repeated instruction to “take a deep breath” will help the patient understand that this intervention is designed to aid in the elimination of anesthetic gases and to promote gas exchange. Perioperative Patient Teaching 35

F I G U R E 2 - 3 : Incentive spirometry.

For patients who may be limited to bed, or who have limited mobility, incentive spirometry will be instituted to promote deep breathing, to increase lung volume, and to encourage Patients may require coughing to clear mucus from the airway. administration of small Sometimes just the action of using the spiromdoses of pain medication eter will cause the patient to cough, particularly to use the incentive spirometer and to cough. You if the patient is a smoker. Elevating the head of must be careful to titrate the bed, unless contraindicated by the surgery, the medication, as pain will help make performing these breathing exmedication can cause ercises easier. respiratory depression. Patients frequently hesitate to deep take breaths because of pain, particularly following abdominal or thoracic surgery. You can help to promote deep breathing by teaching the patient to “splint” the chest and abdomen with a pillow (see Fig. 2–4). The patient should be encouraged to hold a pillow against the abdomen or chest and, when coughing or forcibly exhaling, to squeeze the pillow tightly against the abdomen or chest as a means of decreasing pain. A final step in the prevention of atelectasis and pneumonia is progressive and early ambulation. For outpatients, this is usually not a problem, as they will need to ambulate to the bathroom to void, must COACH CONSULT

36 Perioperative Patient Teaching

F I G U R E 2 - 4 : Splinting.

stand to dress, and then walk into their homes after a car ride home. Patients should be encouraged to be as active as they can be, while still allowing time for rest as need be. For inpatients, ambulation may be a bit more limited, by either physical condition or the limits of the surgery. You would not, for example, want to encourage independent ambulation for a patient who has just undergone a total knee replacement. At this point you are not likely to begin ambulation in the PACU. You can, however, let the patient know that it is likely that the floor nurses will be getting the patient out of bed later that evening, with progressive ambulation. If you find that the patient is unable to be transferred to a surgical floor after surgery because of lack of a bed, make sure that you do get the patient out of bed, up into a chair, or, if possible, to ambulate a little during his or her prolonged PACU stay. All of the interventions to prevent atelectasis will prevent the development of pneumonia, a pulmonary infection. Prevention of Clot Formation and Embolism Instruct the patient in the use of antiembolic stockings and SCD devices. Applied prior to induction, antiembolic stockings will provide major contributions to the reduction of clot formation. Progressive ambulation will also decrease the risk for thrombus formation and the development of an embolism. For patients who will be limited in their ability to move from bed to chair readily or often, antiembolic stockings and SCD devices will continue postoperatively until such time as the patient is able to spend an increasing amount of time out of bed, both in a chair and ambulating. Perioperative Patient Teaching 37

Also teach leg exercises to your patient as another means of preventing clot formation. Teach the patient exercises designed to flex and extend the leg muscles as a way to increase Ideally, the patient will peripheral circulation and to prevent venous perform exercises at least stasis. Patients should be taught to perform the 10 times every hour while following: awake and on bedrest (see Fig. 2–5). If the patient • Ankle circles with toes extended, in both is unable to perform these clockwise and counter-clockwise directions exercises alone, you can • Ankle pumps, alternating ankle flexion and assist with passive range extension of motion. An additional intervention designed to reduce clot formation is the administration of an anticoagulant agent such as heparin or enoxaparin sodium (Lovenox). Heparin inactivates clotting factor X, inhibits the conversion of prothrombin to thrombin and fibrinogen to fibrin, and blocks activation of fibrin stabilizing factor. Enoxaparin sodium acts as a Factor X antagonist and also inhibits thrombin formation. Both agents prevent clot development and, as a result, reduce the risk of pulmonary embolism. They are commonly used with patients whose mobility will be limited after surgery, such a hip and knee replacement. With heparin in particular, you will want to monitor postoperative clotting studies prior to the administration of additional doses, and to consult with the surgeon in dosing. Excessive dosing can promote bleeding, both at the surgical site and internally. Prevention of Infection to Promote Wound Healing Surgical wound infection is a major cause of delayed healing, dehiscence, extended stay, and readmission. One of the most important strategies for the prevention of infection is hand washing. This is important in the PACU, where one nurse may be responsible for more than one patient and may help repeatedly in the admission and discharge of COACH CONSULT

F I G U R E 2 - 5 : Range of motion.


others. Washing your hands between patient contacts is important (see Fig. 2–6). The use of COACH CONSULT alcohol-based hand cleansers may substitute. It is also possible to wear gloves if you remember Hand washing and the to change them when moving from one patient use of gloves is particularly to another. important when handling If antibiotics have been ordered, you may and working with surgical dressings, drains, and need to start them or to administer a second drainage systems, includdose in the PACU. Confirm the order for the aning NG tubes, urinary tibiotic, and check the anesthesia record to see catheters, and surgical if a first dose was administered preoperatively. drains. Not only are you It is common practice to start the antibiotic on helping to prevent infection in your patient, the induction, before the surgical incision. You can use of personal protective set the time of the next dose, knowing the time equipment such as gloves the anesthesia provider gave the first dose. If and masks help to protect the patient is an outpatient going home with you from infections that may be spread by body antibiotics, stress the importance of taking all of fluids, including hepatitis the antibiotics as ordered, to prevent infection and HIV. Patients who will and to prevent the development of antimicrobe doing any dressing bial resistance. changes at home should It is important to teach the patient and family be taught to wash their hands both before and the signs of infection, and the need to report after any dressing changes these signs promptly to the surgeon. These to prevent infection. signs include: • Redness • Heat at the site or fever • Swelling • Pain at the site that does not improve with time • Loss of function as a result of these symptoms Patients should have a means of reaching the surgeon during business hours and after hours. Another strategy to prevent infection is good nutrition. As a PACU nurse, your nutritional responsibilities will likely be limited to the administration of apple juice or ginger ale and saltine crackers after surgery to ambulatory patients before discharge. Encouraging patients to resume a normal diet will be important for all patients, with emphasis on extra protein to promote healing, unless contraindicated by preexisting renal failure. Lastly, wound healing and the prevention of infection is promoted with good rest and sleep habits.

Perioperative Patient Teaching 39

F I G U R E 2 - 6 : Hand washing.


Promotion of Surgical Success Although prevention of infection and promotion of wound healing is certainly part of surgical success, patients need to be provided with specific care routines that they must complete after discharge. This may include the need for site irrigation, eye drops, dressing changes, use of ice bags, elevation, heat, pain medications, and follow-up care.

How to Teach There are a number of different strategies that you might try when planning your teaching. Your choice will depend on the • Patient • Material to be taught • Time you have to teach • Available resources Before you being teaching, however, you need to set objectives. Do this by determining what exactly your patient needs to know and what he or she should be able to do at the end of the teaching session. A way to develop your objectives is to ask yourself one question: What exactly does my patient need to know? After you are able to answer that question, you can develop your teaching plan. For example, a preoperative patient needs to know at least the following for the day of surgery: • Where to park • What to bring • What to wear • NPO requirements • Medications to take The reason that objectives are so useful is that upon completion of your teaching, you can evaluate your effectiveness by asking the patient the following: • Can you tell me where you will park on the day of surgery? • Can you tell me what time you should stop eating and drinking before surgery? If the patient answers correctly, you have done a great job. If not, you will need to reteach that material and reassess comprehension. Just because a patient did not get an answer correct does not mean that you did not do a good job. It just means you have to try again.

Teaching Strategies A lecture format is a great way to provide a lot of information to an audience with similar needs. One example might be a preoperative hip Perioperative Patient Teaching 41

and knee replacement class in which information can be provided to a large number of patients and their families on all of the common features of this type of surgery. Another example is the labor and delivery classes taught to pregnant parents before delivery. Many hospitals run classes for patients who will be having open heart surgeries. It is a cost-efficient way to reach a large audience with common learning needs. In perioperative teaching, a lecture format is of limited use as much of the information that you need to teach needs to be individualized to the patient. With a large audience, it is difficult for you to assess whether or not material has been understood. Patients and their families may be hesitant to ask questions in a large group. Adding time for group discussion gives you a perfect time to ask each patient individually if their concerns and questions have been answered. Care must be taken so as not to make the group too large. Providing written information is another strategy to provide information. If the patient instruction material is written clearly and at no greater than a fifth-grade level, it can provide information to a patient and family that can be readily accessed and retained. This format is useful when information to be taught is fairly standardized and applicable to most patients. Many surgi-centers use patient discharge instruction sheets so that patients have a record of instructions to refer to after discharge. Also, it is important to remember that one of the most common medications used in surgery is midazolam (Versed), a benzodiazepine that causes profound retrograde amnesia; patients who have been given midazolam can easily forget all verbal patient teaching instructions they received. The use of written information allows the patients to review their instructions when they are feeling more awake. Care must be taken so as to not overwhelm the patient with material. Information should be printed clearly, in no smaller than a 12 font, with appropriate use of bold and capital letters. Material can be developed for children as well, using picture books, coloring books, and games. A major disadvantage of written material is the potential for language barriers for patients who do not read English. If you regularly work with a patient population that does not read or speak English, involving a translator to develop teaching sheets in common languages will prove very useful to you and your patients. Some hospitals and surgery-centers use DVDs to teach patients. Given the relatively low cost of DVDs and assuming that the patient speaks the language on the DVD and has access to a DVD player, patient-instruction DVDs might even be sent directly to the patient to view at home.


However, with this method, you have no means to assess comprehension or to answer questions. Scheduling a follow-up visit can reduce misunderstanding and allow an opportunity for the patient to ask questions. Demonstration and return demonstration is a useful method of teaching when you need to teach a patient a psychomotor skill, such as changing a dressing or emptying a drainage bag. This method allows you to demonstrate one on one with your patient while using the appropriate equipment; following the demonstration, you are immediately able to verify the patient’s comprehension by having the patient demonstrate back to you the skill you have taught.

When to Teach The patient scheduled for surgery needs information to adequately allow him or her to make decisions and to be appropriately prepared. The teaching will begin in the surgeon’s office when the patient is told of the need for surgery and given the information necessary to make an informed decision whether or not to proceed. The surgeon will discuss the options for treatment, outcome for nontreatment, alternatives for treatment, and risks and benefits of all choices. Your teaching will be directed toward providing the patient and family with the needed information to adequately prepare for surgery, and then to be adequately prepared for discharge. Care must be taken to not overwhelm the patient and family with so much information that they cannot retain the important information.

Barriers to Teaching For teaching to be effective, there are a number of factors that you must assess in developing your teaching plan. Being able to control these factors will make you a better teacher and increase your likelihood of success in teaching. If you fail to control these variables, you will be setting up barriers to the teaching-learning process. Most importantly, you need to know what it is the patient must know, and you need the information. For example, you would never send a student nurse in to teach a patient about preop preparation for a total hip replacement if the student had never provided such care before and did not know the facility and surgical routines. Develop a list of the required information, and then review it to make sure you know it. Seek assistance from others if you are not sure, so that

Perioperative Patient Teaching 43

when you sit down to teach, you are prepared with complete and correct information. Lack of preparation and knowledge is a major barrier, and does little to set up a relationship with your patient if you appear unprepared and unknowledgeable. Not only should you assess what it is that you need to know before you begin teaching, but you should assess what the patient and family already know before you begin teaching. If, for example, the patient is coming in for a cataract extraction with lens implant in the right eye, there will be no need to go through everything, if 2 weeks earlier, the patient had the left eye done. Make sure that you have enough time to teach. Trying to rush through information invariably leads to missed information and frustration for both you and the patient. Make teaching just as much of a priority as your other nursing interventions. Just because you and the surgical team know what to expect, your patient does not. Providing information is an important step in reducing anxiety and fear. Make sure that you have privacy to teach and that your patient is comfortable before you begin teaching. Draw curtains or close doors to allow for not only privacy, but quiet, as you begin your teaching. If your patient is too cold, exposed, nauseated, or in pain, his or her ability to listen will be diminished. Also pay attention to personal needs before you begin teaching. Make sure that you know what language your patient and family speak before beginning your teaching. If their primary language is not English, and you do not speak their language, you are required by law to obtain a medical translator. You should not depend on a family member. A family member may not understand the medical terminology, may be uncomfortable talking about sensitive topics, and may incorrectly paraphrase what you have said because of their own lack of understanding.


CHAPTER

3

Anesthesia

K

nowledge of anesthetic agents, including their indications for use and physiologic characteristics, should be part of your everyday working knowledge. This includes knowing about all of the medications used to provide general anesthesia and regional anesthesia, as well as agents that may be used to reverse the effects of these agents. Although new medications may be released, understanding the basic principles of the class of medications to which the new agent belongs, will allow you to make generalizations about the new agents, maintaining your clinical excellence.

General Anesthesia There are four objectives of general anesthesia: 1. Provide amnesia, or loss of consciousness and awareness 2. Provide analgesia 3. Eliminate somatic, autonomic, and endocrine reflexes, including coughing, gagging, vomiting, and sympathetic responsiveness 4. Skeletal muscle relaxation The ideal anesthetic will • Cause loss of sensation, especially pain • Cause loss of noxious reflexes • Induce muscular relaxation • Induce smooth onset and recovery • Induce retrograde amnesia • Cause no systemic toxicity • Cause no systemic amnesia • Present no hazard to others It should be noted that no one anesthetic currently can be considered to be the “ideal anesthetic,” therefore requiring the administration of multiple agents to achieve the objectives of general anesthesia. The use of multiple 45

COACH CONSULT General anesthesia is often referred to as “balanced anesthesia,” as the goal of the anesthesia provider is to achieve a balance between hypnosis, analgesia, and immobility.

agents increases side effects and potential toxicity. You will need to be familiar with each class of agent, as well as information specific to each agent used within a particular class. The classes of anesthetic agents include the following: • Inhalation agents • Intravenous agents • Propofol • Ketamine • Benzodiazepines • Narcotics • Muscle relaxants • Reversal agents

Inhalation Agents All inhalation agents have a number of common characteristics: • All induce rapid loss of consciousness, making them ideal agents for induction of anesthesia • All are absorbed directly from alveoli into pulmonary circulation, allowing for rapid onset • All agents work by altering neuronal activity in the central nervous system (CNS) • All agents are eliminated via ventilation, making elimination hepatorenal independent To date, almost 20 different inhalation agents have been used to provide anesthesia. Most have been eliminated from the market because of issues with toxicity (to the patient and provider), flammability, side effects, and the development of newer and better agents. Nitrous Oxide Nitrous oxide is the most widely used inhalation agent. It is consid-ered a “carrier gas” for other agents because it potentiates other inhalation agents and increases speed of induction. Nitrous oxide • Is always administered with oxygen to ALERT prevent hypoxemia • Causes minimal myocardial depression, Because nitrous keeping cardiac output, stroke volume, heart oxide is such a weak rate, and blood pressure stable analgesic, you should be prepared to administer • Is a weak analgesic pain medication if this • May be sufficient for minimally invasive agent is used as the sole procedures, such as dental surgery inhalation agent. • Has been called “laughing gas” 46 Anesthesia

Desflurane Desflurane (Suprane) is a newer agent used for ALERT its cardiovascular stability. It is a safe agent, Desflurane is irricausing no hepato-renal toxicity. tating to the airway on Sevoflurane induction, causing breathSevoflurane (Ultane) is the agent that comes holding, laryngospasm, and the closest to the ideal inhalational anesthetic. coughing. This frequently requires induction with Known for its cardiovascular stability, sevofluanother agent and then a rane protects the myocardium by acting as change to desflurane. a coronary vasodilator. Mask induction is well tolerated, causing no airway irritation. It causes no hepatotoxicity. Isoflurane ALERT Isoflurane (Forane) used to be considered the gold standard of inhalation agents, but has been Sevoflurane has replaced by desflurane and sevoflurane the potential for causing renal toxicity with prolonged because of their speed of induction, stability, exposure due to its fluoride and recovery speed. Isoflurane is associated metabolite. with myocardial stability, acting to increase heart rate and decrease systemic vascular resistance, thereby causing a stable cardiac output. Induction is smooth. There is no hepatotoxicity. Cerebral blood flow is only minimally increased, and the agent causes good skeletal muscle relaxation. Halothane Currently, halothane is very limited in its use, but it is used for its unique benefit of acting as ALERT a bronchodilator. It may be used for mask Halothane’s negainduction in pediatrics, as induction is rapid tive effects clearly outweigh and well tolerated.

Intravenous Anesthetics Intravenous anesthetics are used for • Smooth, rapid induction • Maintenance of anesthesia • Sedation in monitored anesthesia care

Barbiturates Barbiturates are generally used to produce rapid, pleasant sleep induction prior to the

its usefulness. Halothane • Depresses mucociliary function for up to 6 hours postoperatively, increasing the risk of atelectasis and pneumonia • Is a myocardial depressant, causing a decrease in heart rate and contractility, as well as dosedependent hypotension (Continued)

Anesthesia 47

administration of other slower, less pleasant anesthetic agents. They may be used to supplement regional anesthesia or as the sole • Causes a slight neuromusanesthetic for extremely short, minor procecular irritation, producing dures such as electroconvulsive therapy and the “halothane shakes” cardioversion. postoperatively Sodium Pentothal and Methohexital • Sensitizes the myocardium to catecholamines Sodium penthothal and methohexital (Brevital) • Has been associated with are two agents used for induction of anesthesia, hepatic necrosis and as they reliably block the wakefulness center hepatitis in the cerebral cortex and reticular activating system, producing sleep, hypnosis, and amnesia. On the downside, these agents have no analgesic effects. They cause direct myocardial depression, causing a decrease in cardiac output, BP, and peripheral vascular resistance, as well as increasing the incidence of dysrhythmias. The agents cause respiratory depression by decreasing sensitivity to CO2, causing apnea, as well as causing progressive hypercarbia and hypoxemia. Postoperative drowsiness and sedation is often severe. They have a low to moderate emetic effect. Etomidate Etomidate (Amidate) is an intravenous anesCOACH thetic used because of its cardiovascular stability CONSULT for emergency induction of unstable patients. It is considered a cerebral protector, as it decreases When providing care to a cerebral blood flow and oxygen consumption. On patient who has received an the downside, it causes uncontrolled muscle inhalation agent, it is important you remember that movements known as myoclonia, hiccoughs, and • All inhalation agents are postoperative nausea and vomiting. respiratory depressants, Propofol so all patients will require Propofol (Diprivan) is the newest and most oxygen therapy and monitoring with a pulse popular induction agent. This agent produces a oximeter smooth induction and a rapid recovery, with no • All patients require postoperative “barbiturate hangover.” Propofol assessment of their also has antiemetic effects, and may decrease airway and ventilatory the need to administer an antiemetic after surstatus, and you should encourage deep breathing gery. Interestingly, the agent looks like milk in • Inhalation agents have no a syringe. residual analgesic effects, Ketamine so you should also perKetamine is used to provide for dissociative form a pain assessment and manage accordingly anesthesia, causing a trance-like state of unconsciousness as well as amnesia. Given by either ALERT—cont’d

48 Anesthesia

intravenous (IV) or intramuscular (IM) routes, this agent is a respiratory stimulant, keeping airway reflexes, such as cough and gag, intact. Patients generally do not require intubation. The agent also causes cardiovascular stimulation through excitation of the sympathetic nervous system. Blood pressure (BP) peaks 10% to 50% above baseline and normalizes within 15 minutes, making this a useful agent for patients in shock states as organ perfusion improves with elevation of BP. Ketamine produces profound analgesia; it may be the sole agent used for painful procedures such as a closed reduction of fracture. The major negative effect of ketamine is the postoperative agitation seen following its administration. Ketamine is pharmacologically related to phencyclidine (PCP) and causes emergent reactions, including unpleasant dreams, hallucinations, and delirium. These side effects are most commonly seen in patients aged 16 to 65 years and may be prevented with concomitant benzodiazepine administration.

COACH CONSULT When providing care to a patient who has received any intravenous anesthetic agent, it is important you remember that • All agents are extremely short-acting with limited residual effects in the postanesthesia care unit (PACU) • If administered in the PACU for short procedures, you should monitor for respiratory depression with pulse oximetry and ongoing respiratory assessment • You should allow patients who have received ketamine to awaken without tactile or auditory stimulation • Ketamine will potentiate the effects of any additional narcotics administered in the PACU

Benzodiazepines Benzodiazepines are used for premedication before surgery to reduce anxiety, intraoperatively for induction and maintenance of anesthesia, for IV sedation, and as a supplement with regional or local anesthesia. Midazolam Midazolam (Versed) is the most widely used benzodiazepine. It is used preoperatively, intraoperatively, and postoperatively because of its COACH rapid onset of action, rapid recovery, and CONSULT amnestic effects. The renal clearance of Midazolam may be administered orally, IM, midazolam is 10-times or IV, and it has the benefit of being waterfaster than diazepam, soluble, so it does not burn during IV administramaking it the drug of tion. Of all the currently used benzodiazepines, choice during the perioperative period. midazolam comes the closest to being the ideal agent. Anesthesia 49

COACH CONSULT When dosing midazolam, start with a low dose and go slow in administration, particularly in elderly patients.

ALERT Diazepam crosses the placenta, with adverse effects in the newborn, including hypotonia and altered thermoregulation. When administered during the first trimester of pregnancy, this agent has adverse effects in the fetus, causing birth defects.

COACH CONSULT The half-life of diazepam is age-dependent in adults. As an example, in a patient who is 80 years old, the half-life would be 80 hours, causing profound sedation postoperatively.

Diazepam Diazepam (Valium) is an older agent, limited primarily to oral administration for preoperative sedation and relaxation. When given orally, the onset of action is between 30 and 60 minutes. Amnestic effects are minimal with oral administration, facilitating preparation of the patient for surgery. Very anxious patients may be prescribed a dose of diazepam to be taken at home on the morning of surgery. The use of diazepam is limited to intraoperative and postoperative use because of profound sedation. Its slow oral onset limits its use as an induction agent. The onset, when given IM, is unpredictable, and when given IV, the burning during administration further limits its use. The recovery time is long, and can be further prolonged in patients with hepatic dysfunction. Respiratory depression may be profound when given with narcotics. Lorazepam Lorazepam (Ativan) is rarely used in the perioperative setting because of its long duration of sedation. This agent is 5 to 10 times more potent than diazepam. It is still used to prevent emergent reactions that might be anticipated with ketamine administration. The drug’s primary benefit is its profound amnesia, and that it can be administered either IM or IV.

Narcotics

Narcotics are used • Preoperatively for sedation and analgesia • Intraoperatively for induction and maintenance of anesthesia as well as to blunt autonomic responses • Throughout the perioperative period for analgesia Fentanyl Fentanyl (Sublimaze) is the most commonly used narcotic in the perioperative period. Intraoperatively, it may be given IV, via an epidural or

50 Anesthesia

intrathecal (spinal) route. The onset of action is 1 to 3 minutes when given IV, with peak effects COACH seen within 3 to 5 minutes. Its duration is CONSULT between 1 and 2 hours. This agent, unlike morWhen providing care to a phine, causes no histamine release. Its only patient who has received drawback is its potency. any benzodiazepine, it is Morphine important you remember that benzodiazepines Morphine is limited primarily to postop use for • Potentiate the effects of pain control. Similar to fentanyl, its onset when narcotics, particularly resadministered IV is between 1 to 3 minutes. The piratory depression, so drug does not peak for 15 to 30 minutes, and its pulse oximetry monitoring duration is 3 to 4 hours. The primary drawback is essential • Change responsiveness of morphine is that the agent causes histamine to CO2, causing release, leading to vasodilation; hypotension; hypercarbia pruritus, especially of face and nose; and may • Can cause hemodynamic cause bronchospasm in asthmatics. In addichanges, including a decreased BP, increased tion to IV use, this agent may be administered heart rate, and IM or via the epidural or intrathecal route as decreased systemic Duramorph, which is long-acting, preservativevascular resistance free morphine. • Cause sedation and Sufentanil amnesia so teaching must include written Sufentanil (Sufenta) is limited to intraoperative instructions use, primarily in cardiac surgery, because of its • Are reversible with potency; it is 1000 times more potent than flumazenil (Romazicon); morphine. Although this agent causes no histaremember that the reversal agent may not last as mine release, its small margin of safety can long as depressant rapidly cause profound respiratory depression. effects of benzodiSufentanil may also be administered epidurally azepine, requiring or, uncommonly, intranasally. that you continue Remifentanil monitoring the patient for up to 2 hours Remifentanil (Ultiva) is the newest narcotic to postadministration be used intraoperatively. With a potency equal to fentanyl, Ultiva has the advantage of extremely rapid onset, less than 1 minute, and offset, 5 to 10 minutes. There is no concern about prolonged recovery with this agent, as it essentially can be thought of as “instant on– instant off.” That said, there is no residual analgesic effect when the agent is discontinued. The drug promotes hemodynamic stability, causes no histamine release, and requires no dosage adjustment in hepatorenal insufficiency.

Anesthesia 51

COACH CONSULT As the patient is not likely to remember patient teaching because of the amnestic effects of a benzodiazepine, you need to include a family member when conducting the teaching.

Alfentanil Alfentanil (Alfenta) is 25 times more potent than morphine, with a shorter IV onset of action of 30 to 90 seconds and a much shorter duration of action of 15 minutes. This drug is very limited in its use because of this short duration of effect, and the extreme severity of nausea and vomiting associated with its use.

Muscle Relaxants ALERT Fentanyl is 100 times more potent than morphine, making dosing extremely important.

COACH CONSULT When providing care to a patient who has received any narcotic, it is important you remember that narcotics • Cause respiratory depression, so pulse oximetry monitoring is essential; you should also encourage deep breathing • Potentiate benzodiazepines, which can increase both sedation and respiratory depression • Cause sedation • Cause pruritus due to histamine release • May cause nausea and vomiting, so you need to protect patient airway

52 Anesthesia

Muscle relaxants are used intraoperatively to facilitate endotracheal intubation, for skeletal muscle relaxation and, when needed, for paralysis for mechanical ventilation. They work by interrupting transmission of nerve impulses at the neuromuscular junction. Based on their specific action at the neuromuscular junction, they are classified as either depolarizing agents or nondepolarizing agents.

Depolarizing Agents Depolarizing agents work by mimicking the action of acetylcholine at the neuromuscular junction. These agents bind to cholinergic receptor sites on muscle cells causing depolarization of the cellular membrane. As long as the cell is depolarized, it is incapable of responding to further stimulation by acetylcholine, causing neuromuscular blockade. As depolarization has occurred, these agents are nonreversible. Normal muscle activity can only resume as the drug is metabolized and cholinergic receptor sites opened. Succinylcholine Succinylcholine (Anectine) is the only depolarizing agent used clinically. It has a rapid onset of 30 to 60 seconds and a rapid offset of 3 to 5 minutes. It is metabolized by an enzyme in blood called plasma cholinesterase (pseudocholinesterase), making metabolism hepatorenal

independent. Patients with atypical pseudocholinesterase, either deficient or abnormal, may have prolonged blockade. Adverse effects associated with succinylcholine have limited its usefulness in the perioperative setting. The drug causes histamine release, is a trigger agent for malignant hyperthermia, and causes bradycardia, hyperkalemia, and an increase in intraocular and intracranial pressure. It is also associated with myalgias, or postoperative muscle soreness.

COACH CONSULT—cont’d • May cause muscle rigidity in high doses, affecting muscles of ventilation • Are reversible with naloxone (Narcan), but reversal of respiratory depression will also cause loss of analgesic effects

Nondepolarizing Agents Nondepolarizing agents work by competing with acetylcholine at the cholinergic receptor site to block acetylcholine from reaching the motor end plate. Neuromuscular transmission is inhibited, causing a neuromuscular blockade or paralysis. As long as the cholinergic receptor site is occupied by the nondepolarizing agent, the cell cannot respond to acetylcholine. Return of responsiveness requires either time for the agent to be metabolized or the administration of a reversal agent that will allow acetylcholine levels to rise to the point where the competition is shifted in favor of acetylcholine, allowing for return of function. Agents differ in their duration of action, route of elimination, patient stability, and side effects. Muscle relaxants like Vecuronium, Cisatracurium, and Rocuronium are agents of choice for procedures lasting less than 30 minutes and can be redosed for longer procedures. Agents like pancuronium, pipecuronium, and doxacurium are agents of choice for procedures lasting longer than 90 minutes (see Table 3–1).

Reversal Agents Reversal agents are used to reverse a negative effect of an agent. It should be noted that reversal of a negative effect such as respiratory

COACH CONSULT When providing care to a patient who has received any muscle relaxant, it is important you remember that muscle relaxants will generally be worn off or reversed in the operating room prior to PACU admission unless prolonged mechanical ventilation is anticipated. To assess recovery from the use of muscle relaxants, or following the administration of agents to reverse relaxation, the patient should be assessed for overall muscle strength. You can do this by asking the patient to lift his or her head off of the pillow for a sustained head lift of longer than 5 seconds, to demonstrate a strong hand grasp, or to follow commands to move their feet and legs against resistance.

Anesthesia 53

Table 3–1

Nondepolarizing Neuromuscular Blocking Agents DURATION OF ACTION

ROUTE OF ELIMINATION

SIGNIFICANT INFORMATION

Vecuronium (Norcuron)

Intermediate

Hepatic

CV stability No histamine release

Cisatracurium (Tracrium)

Intermediate

Hoffman elimination*

CV stability Slight histamine release

Rocuronium (Zemuron)

Intermediate

Hepatic

Rapid onset ↑ pulmonary vascular resistance

Pancuronium (Pavulon)

Long

Renal

↑ HR No histamine release

Pipecuronium (Arduan)

Long

Renal

CV stability No histamine release

Doxacurium (Nuromax)

Long

Renal

Minimal to no histamine release CV stability

AGENT

* Hoffman elimination is a hepatorenal independent degradation of agent occurring spontaneously within plasma at a normal body temperature and pH. Key: CV, cardiovascular; HR, heart rate; BP, blood pressure

depression also results in reversal of the desired effect, such as pain control or sedation. Caution must be taken with any reversal agent so that Flumazenil may the reversal agent’s duration of action and induce seizures in patients dosing match closely with those of the agent to with benzodiazepine be reversed. dependency. Flumazenil Flumazenil (Romazicon) is a specific benzodiazepine antagonist that works directly at benzodiazepine receptor sites to reverse the sedative, amnestic, muscle relaxant, anticonvulsant, anesthetic, and respiratory effects of benzodiazepines. It can also be used in the emergency department (ED) to reverse accidental or intentional overdose. Flumazenil is given IV in doses of 0.2 to 1.0 mg. The agent has a rapid onset, and peaks within 5 minutes. It is well tolerated and is associated with minimal nausea and vomiting. The duration of action ALERT

54 Anesthesia

will be dependent on the dose of benzodiazepine administered, dose of flumazenil, and time between dosing of the two agents. Naloxone Naloxone (Narcan) is a specific competitive narcotic antagonist that works directly at the mu (μ) receptor to reverse the respiratory depression and muscle rigidity associated with narcotic administration. It is usually administered in titrated doses of 0.1 to 0.4 mg IV. The reversal of analgesia causes sympathetic stimulation, increasing HR and BP, and may cause the development of dysrhythmias. Extreme caution must be taken in managing pain with narcotics after reversal. Anticholinesterase Agents Anticholinesterase agents provide specific reversal for nondepolarizing muscle relaxants. These agents bind to the enzyme acetylcholinesterase and inactivate it, thereby allowing levels of acetylcholine to build up. Acetylcholine displaces muscle relaxant, restoring normal neuromuscular function. There are three agents used clinically: neostigmine, pyridostigmine, and edrophonium. These agents vary by onset and duration of action, metabolism, and side effects (see Table 3–2). There are also studies investigating a new type of reversal agent for nondepolarizing muscle relaxants, one that is not dependent upon the inhibition of acetylcholinesterase (see Box 3–1).

COACH CONSULT Naloxone should be titrated to minimize reversal of desired effects such as analgesia while addressing the need to reverse respiratory depression. Its short duration of action of less than 45 minutes may mean that the duration of action of the narcotic may outlast the effects of naloxone, requiring redosing or IV infusion of naloxone. Pulse oximetry monitoring should be continuous, as respiratory depression may reoccur.

ALERT Anticholinesterase agents cause muscarinic side effects of bradycardia, hypotension, bronchoconstriction, and excessive salivation. To prevent these untoward effects, the agents are always administered with an anticholinergic agent such as atropine or glycopyrrolate (Robinul).

Regional Anesthetic Techniques The objective of regional anesthesia is to block pain impulses through the application of local anesthetics. Local anesthetics may be applied • Locally (topically, infiltration) • Via injection to a specific nerve (intercostal) • Via injection to a group of nerves (brachial plexus) • Regionally (epidural or intrathecal) Anesthesia 55

Anticholinesterase Agents

Table 3–2

ONSET OF ACTION

DURATION OF ACTION

IMPORTANT INFORMATION

Neostigmine (Prostigmin)

6–8 minutes

60 minutes

50% renal excretion May cause dysrhythmias Strong muscarinic effects

Pyridostigmine (Regonol, Mestinon)

12–15 minutes

90 minutes

75% renal excretion Less muscarinic effects

Edrophonium (Tensilon)

2–4 minutes

60 minutes

75% renal excretion Minimal muscarinic effects Must be given with atropine (glycopyrrolate causes bradycardia because of delayed onset of action)

DRUG

Box 3–1

On the Horizon: Cyclodextrin-Mediated Reversal

Organon (Sugammadex) is currently being studied as a new type of reversal agent for nondepolarizing muscle relaxants, one that is not dependent upon the inhibition of acetylcholinesterase. This new agent works through immediate inactivation of the nondepolarizing muscle relaxant through direct binding with the agent, not a competitive binding against the agent.

For some surgical procedures and patients, regional anesthesia has advantages that make it an alternative to general anesthesia (see Box 3–2). Local anesthetics work by inhibiting nerve conduction by preventing increases in cellular permeability to sodium ions. The decrease in sodium ions slows cellular depolarization. No action potential is generated, causing a conduction blockade. The first blockade to occur is the autonomic blockade, which causes vasodilation. This is followed by the sensory blockade, which blocks pain impulses, and the motor blockade, which creates an inability to move voluntary muscles. The blocks wear off in reverse order. Local anesthetics are classified as esters or amides. Ester anesthetics are metabolized by plasma cholinesterase. The PABA metabolite

56 Anesthesia

Box 3–2

Advantages and Disadvantages of Regional Anesthesia

ADVANTAGES • No loss of consciousness • Avoids postop “hangover” • May decrease need for additional pain medication • Useful if physiologically compromised • Avoids intubation DISADVANTAGES • High anxiety in nonsedated patient • Additional IV agents may delay recovery and compromise stability • Limited by surgical site • Limited by length of surgery • Limited by expertise of anesthesia provider/surgeon • Long block may limit discharge

from ester anesthetics may cause a histamine-type allergic reaction. Amide anesthetics are metabolized in the liver, and rarely cause allergy. Local anesthetics are also classified by potency and duration of action (see Table 3–3). The selection of agent should be tailored toward duration of required analgesia. The duration of action of the agent will be influenced by the pharmacology of the agent selected and the site of use. For example, Bupivacaine when given intrathecally has an onset of 5 minutes; duration 3 to 4 hours. When used for brachial plexus block, onset is 20 to 30 minutes; duration 10 hours. The addition of epinephrine to the local anesthetic will prolong blockade by 50%. In addition to knowing the pharmacologic characteristics of local anesthetics, it is important to be able to calculate the dose used (see Box 3–3).

Systemic Toxicity Systemic toxicity from local anesthetics is most commonly due to accidental intravascular injection of the agent selected, as opposed to the administration of an excessive dose. Toxic effects are seen in the CNS and cardiovascular systems (see Box 3–4). No reversal is possible and care is supportive until the agent is metabolized and eliminated.

ALERT Epinephrine is never added to local anesthetic blocks of the fingers, nose, penis, or toes because the potent vasoconstriction caused by epinephrine can lead to ischemia, resulting in necrosis.

Anesthesia 57

Table 3–3

Pharmacologic Properties of Local Anesthetics

DRUG

TYPE

POTENCY

SPEED OF ONSET

DURATION

Procaine

Ester

Low

Moderate

Short

Chloroprocaine

Ester

Low

Fast

Very short

Mepivicaine

Amide

Intermediate

Moderate

Moderate

Prilocaine

Amide

Intermediate

Moderate

Moderate

Lidocaine

Amide

Intermediate

Fast

Moderate

Tetracaine

Ester

High

Very slow

Long

Ropivacaine

Amide

High

Fast

Long

Bupivacaine

Amide

High

Fast

Long

Etidocaine

Amide

High

Very fast

Long

Box 3–3

Dosage Calculation of Local Anesthetics

Dosage calculation requires knowing the volume and concentration of the local anesthetic used. Example: 20 mL of 0.5% lidocaine 0.5% ⫽ 5mg/mL ⫻ 20 mL ⫽ 100 mg total dose Example: 15 mL of 1% lidocaine 1.0% ⫽ 10 mg/mL ⫻ 15 cc ⫽ 150 mg total dose Example: 10 cc of 0.75% lidocaine 0.75% ⫽ 7.5 mg/mL ⫻ 10 cc ⫽ 75 mg total dose

Cocaine Cocaine is used topically as a local anesthetic when vasoconstriction is desired. It is most commonly used in highly vascular mucous membranes, such as for nose and throat surgery, to decrease bleeding associated with surgical trauma. Cocaine is classified as an ester

58 Anesthesia

Box 3–4

Systemic Toxicity: Signs and Symptoms

CENTRAL NERVOUS SYSTEM Mild Lightheadedness Dizziness Tinnitus Drowsiness Disorientation CARDIOVASCULAR SYSTEM Mild ↑ PR Interval ↑ QRS duration ↓ Cardiac output ↓ Blood pressure

Severe Muscle Twitching Tremors Unconsciousness Convulsions Respiratory arrest Severe ↑↑ PR Interval ↑↑ QRS duration Sinus bradycardia AV block ↓↓ Cardiac output Hypotension Asystole

anesthetic, and is detoxified by plasma and liver cholinesterases. It is a highly potent agent, with significant cardiac stimulation (hypertension and tachycardia) as its major untoward side effect.

Topical Use of Local Anesthetics Local anesthetics may be administered topically to mucous membranes to decrease discomfort before IV insertion or used prior to awake intubation to diminish laryngeal reflexes. Two topical anesthetics include the following: • EMLA cream or patch: This eutectic mixture of the local anesthetics lidocaine (2.5%) and prilocaine (2.5%) is used prior to IV insertion; it requires application 1 hour before desired effect, as it must be absorbed through the skin • Cetacaine spray: This spray is used prior to awake intubation. Cetacaine spray has a more rapid onset of anesthesia of 5 to 10 minutes because it is applied directly to highly vascular mucous membranes.

Local Infiltration When injected intracutaneously or subcutaneously, local anesthetics are designed to achieve a sensory blockade without blocking a specific nerve. Local infiltration is designed to block nerve stimuli at their origin. Lidocaine

Anesthesia 59

is the most commonly used agent, used prior to IV insertion. Its onset of effect is almost instantaneous, allowing for immediate placement of the IV.

Peripheral Nerve Block Local anesthetics can be injected into or around a specific nerve or group of nerves in a procedure known as a peripheral nerve block. These blocks provide intraoperative anesthesia and postoperative analgesia. Common peripheral nerve blocks include the following: • Head and Neck • Trigeminal nerve: Diagnosis and treatment of chronic pain • Cervical plexus: Anesthesia for neck surgery such as carotid endarterectomy • Retrobulbar: Anesthesia for ophthalmic surgery • Upper Extremity • Brachial plexus: Anesthesia for upper extremity surgery • Radial, ulnar, and medial nerve: Simultaneous blocks for hand surgery • Trunk • Intercostal: Postoperative analgesia after thoraco-abdominal surgery • Paravertebral: Segmental anesthesia, pain from herpes zoster, or rib fracture • Stellate ganglion: Diagnosis and treatment of chronic regional pain syndrome • Celiac plexus: Analgesia from abdominal organ malignancy pain • Ilioinguinal: Anesthesia for hernia repair • Penile: Analgesia following circumcision • Lumbar sympathetic: Treatment of sympathetic dystrophies or herpes zoster • Lower extremity • Psoas compartment: Anesthesia for one leg • Sciatic nerve: Anesthesia for sole of foot and lower leg • Lateral femoral cutaneous nerve: Sensory anesthesia to obtain lateral thigh skin graft • Femoral nerve: Anesthesia for knee surgery • Obturator nerve: Anesthesia for knee surgery • Lumbar plexus: Anesthesia for knee surgery • Ankle blockade: Anesthesia for foot surgery

60 Anesthesia

IV Regional Block The IV regional block, also known as a Bier block or an IV sympathetic block, involves the administration of a local anesthetic into the venous circulation of an extremity. The local anesthetic diffuses from the blood vessel into nearby nerves, achieving regional anesthesia. This block may be used for a surgical procedure on an extremity or as a sympathetic block for chronic pain therapy. A tourniquet is used to keep the field bloodless and to trap the anesthetic in the extremity. The major concern of an IV regional block is systemic toxicity if tourniquet fails or is released prematurely (see Fig. 3–1).

Epidural Anesthesia An epidural anesthetic involves the injection of a local anesthetic into the epidural space through either a thoracic or lumbar approach (see Fig. 3–2A & B). The local anesthetic may be combined with a narcotic for greater analgesic effect. Local anesthetics work in the epidural space by binding to nerve roots as they enter and exit the spinal cord. When low concentrations of local anesthetic are used, sensory pathways are blocked. With higher concentrations of local anesthetic, motor pathways are also blocked. The epidural anesthetic may be done via injection or catheter placement. Leaving a catheter in place allows for postoperative pain control, as may be needed following a total joint replacement, or for a follow-up procedure such as a tubal ligation following vaginal delivery or c-section. Major benefits from epidural anesthesia are seen with thoracic epidurals used in major surgeries (see Box 3–5).

F I G U R E 3 - 1 : Bier block.

Anesthesia 61

Opioid receptors (at site of dorsal horn)

Spinal Epidural cord CSF space T8 T9 T10 T11 T12

Subarachnoid space

Epidural catheter

L1 L2 L3

Dura mater

L4 L5

Epidural injection at T12-L1 interspace

(A) Epidural space

Spinal cord

Epidural catheter

Spinal fluid

(B)

F I G U R E 3 - 2 : Epidural anesthesia. (A) Placement of an epidural needle and catheter. (B) Continuous epidural anesthesia using catheter.

62 Anesthesia

Box 3–5

Advantages and Disadvantages of Epidural Anesthesia

ADVANTAGES • Allows for segmental anesthesia • Useful for postoperative analgesia • Provides an alternative to general anesthesia • Avoids cardiopulmonary compromise of general anesthesia • Patient satisfaction of not having to “go to sleep” • Low dose of local anesthesia affects only sensory nerves, keeping motor fibers intact • Useful in labor and delivery, as a low dose allows mother to push without pain • Allows for postoperative ambulation with decreased pain • Allows for postoperative deep breathing and coughing with decreased pain • ↓ stress response of surgery, ↓ pneumonia, ↓ postop myocardial infarction • ↓ postop ileus and ↓ thromboembolic events DISADVANTAGES • Use of epidural for postop pain control may be limited by hospital resources • Time consuming for short procedures • Contraindicated in hypovolemia, local infection, septicemia, and hypocoagulopathy • May increase anxiety if the patient is awake* *The addition of an IV sedation agent to decrease anxiety will increase monitoring needs.

Side Effects of Epidural Anesthesia Side effects of epidural anesthesia are due to the effects of both the local anesthetic and narcotic used. They include the following: • Respiratory depression • Pruritus • Nausea and vomiting • Urinary retention • Hypotension Respiratory Depression Respiratory depression occurs secondary to the effects of narcotics on the brainstem. Pulse oximetry monitoring will be an essential component of monitoring. With any fall in oxygen saturation, you should promptly intervene with patient stimulation, encouragement of deep breathing, and notification of the anesthesia provider. Naloxone should be readily available. To prevent respiratory depression, all other pain medication orders Anesthesia 63

should be cancelled while the epidural is in place, and you should notify the anesthesia provider or surgeon if additional pain medication is required. Pruritus Pruritus occurs secondary to the histamine release from the narcotic used and is more common when morphine is included in epidural infusion. You should report pruritus to the anesthesia provider. Pruritus can be readily treated with naloxone, diphenhydramine (Benadryl), dose reduction, or by changing medications. Nausea and Vomiting Nausea and vomiting occur secondary to stimulation of the chemoreceptor trigger zone in the medulla by the narcotic. This can be treated by the administration of an antiemetic, preferably one with minimal sedation, so you should notify the anesthesia provider to obtain an order for an antiemetic. Urinary Retention Urinary retention occurs secondary to the sympathetic and sensory blockade of nerves that innervate the bladder, and is caused by both the local anesthetic and the narcotic. This is such a common side effect that a urinary catheter is often part of the postop protocol while an epidural catheter is in place. If no catheter is in place and the patient is unable to void, you should assess the bladder for distention and notify the anesthesia provider. Treatment is bladder catheterization. Hypotension Hypotension is usually minimal unless an excessive dose of local anesthetic has been given, causing sympathetic blockade. You should monitor blood pressure. Falls in blood pressure usually occur gradually, requiring only fluid administration to correct.

Complications of Epidural Anesthesia Complications of epidural anesthesia occur most commonly because of technique, rather than the effects of the agents used, and include the following: • Subarachnoid puncture: Also known as a “wet-tap,” this occurs during placement of the epidural needle. During placement, the needle is accidentally directed beyond the epidural space, entering or “tapping” the dura. The large needle used in epidural anesthesia causes a hole in the dura, resulting in leakage of cerebrospinal fluid (CSF) • Postdural puncture headache: Also known as a “spinal headache,” this condition is caused by the loss of CSF following a subarachnoid puncture. These headaches are usually severe 64 Anesthesia

and worsen with standing. They may be accompanied by nausea, tinnitus, and photophobia. You should notify the anesthesia provider in the event that a patient complains of severe headache following an epidural. Treatment may be conservative, including bed rest, fluids, and analgesics, or may be more invasive, requiring an epidural blood patch to seal the leak. A blood patch involves taking a sample of venous blood, generally from the arm, with the subsequent injection of that same blood into the epidural space to act as a sealant against the dura • Total spinal: If the dura is punctured, and the puncture is not detected, injection of the local anesthetic can produce a total spinal, causing profound hypotension, respiratory depression, or paralysis. This is a rare complication, as the anesthesia provider will aspirate the epidural space prior to injecting any medication. If CSF is aspirated, no medication will be injected. Hypotension will require fluid administration and titrated doses of Neo-Synephrine IV to promote vasoconstriction. Respiratory failure will require intubation and mechanical ventilation • Intravascular injection: An inadvertent intravascular injection is the result of the medications being injected intravascularly as opposed to into the desired epidural space. The high doses of medications used to provide epidural anesthesia will produce systemic toxicity, with CNS and cardiovascular effects, requiring supportive intervention. This is a rare complication, as the anesthesia provider will inject a “test dose” of medication that contains epinephrine. If blood pressure or heart rate increases after injection of the test dose, the needle is considered to be intravascular. If the epidural needle were truly in the epidural space, the injected test dose would cause no change in heart rate or blood pressure • Epidural hematoma: This is a rare complication, because epidural needles and catheters are not placed in anticoagulated patients or patients with coagulation disorders. Bleeding causes pressure on the spinal cord with paresthesias or progressive paralysis. If detected, you should notify the anesthesia provider immediately, as the patient will require computed tomography (CT) evaluation and prompt surgical evacuation of the hematoma if present to avoid permanent damage See Box 3–6 for points to pay attention to when caring for the patient receiving epidural anesthesia. Anesthesia 65

Box 3–6

Care for a Patient Receiving Epidural Anesthesia

When providing care for patient receiving epidural anesthesia, it is important to determine if the catheter is present and to be used for postop pain control. If so, you should • Label the catheter as epidural and cover any ports in tubing that may be present with tape or Tegaderm to prevent inadvertent use • Make sure all other pain medication orders are cancelled • Have naloxone readily available at the bedside • Secure both the IV catheter and the epidural catheter to prevent loss • Establish the epidural infusion according to hospital policy • Maintain pulse oximetry monitoring to detect respiratory compromise early, allowing you to intervene immediately with the administration of naloxone • Assess sensory and motor function of lower extremities and document your findings • Evaluate the level of pain control and notify the anesthesia provider if additional pain medication is required; the infusion may have to be increased per protocol; the patient may require evaluation of placement by the anesthesia provider; poor pain control may be the result of catheter migration, requiring catheter to be discontinued • Evaluate for side effects and treat as needed; the use of a standardized order sheet can allow for rapid intervention • Follow the protocol established by your institution if asked to remove the catheter • Confirm the catheter tip is intact when removed, and document removal and confirmation

Spinal Anesthesia Spinal anesthesia, also known as intrathecal anesthesia, involves the injection of a local anesthetic into the lumbar intrathecal space. The The importance of labeling local anesthetic mixes with CSF causing segthe epidural catheter cannot mental anesthesia, determined by dermatome be overemphasized. Some level (see Figs. 3–3 and 3–4). As the onset of the facilities use labels of a bright color, limited only local anesthesia occurs, three types of blockade to epidural use. develop: 1. The autonomic, or sympathetic, nerves are the smallest and first affected by the local anesthetic, causing venous pooling and potentially hypotension. Because this is a known potential, an IV should be in place before COACH CONSULT

66 Anesthesia

injection of the local anesthetic to allow for fluid administration. The anesthesia provider will often administer a fluid bolus prior to injection to prevent a decrease in blood pressure. 2. The sensory nerves are blocked next, causing anesthesia, assessed by evaluation of the dermatome level. You can easily make this assessment by gently touching the patient at varying levels on the trunk and lower extremities using a sterile needle. Begin centrally and move distally. As you touch the patient with the needle tip, ask the patient if a sharp sensation is felt. If present, the block is no longer present at that level. Continue to assess the patient over time, starting centrally and moving distally, until the block is fully resolved. Regression of the block and full return of function should be documented. 3. Blockade of the motor nerves follows, causing paralysis. Return of function occurs in reverse order. You can evaluate return of function by asking the patient to move his or her feet and legs and to lift the hips off of the bed. Spinal cord

Needle (a)

Spinal fluid

Anesthetic solution injected into spinal fluid

F I G U R E 3 - 3 : Spinal anesthesia.

Anesthesia 67

C3 C4

T1

C6

C7

C8

L2 L3

L4

L4

L5

L5

S1

F I G U R E 3 - 4 : Dermatome chart.

C7

S2

C8

L2 L3

68 Anesthesia

C6

T2 T3 T4 T5 T6 T7 T8 T9 T10 T11 T12 L1

S1

Box 3–7 discusses the advantages and disadvantages of spinal anesthesia. Side Effects of Spinal Anesthesia Side effects are most commonly due to the sympathetic blockade caused by the direct effects of the local anesthetic, and include the following • Arterial hypotension • Bradycardia • Nausea and vomiting • Urinary retention Arterial Hypotension Arterial hypotension occurs secondary to the sympathetic block, causing venous pooling. As this is an anticipated event, an IV is usually started, and a fluid bolus given, before the spinal injection to prehydrate in anticipation of venous pooling that will occur to prevent hypotension. If hypotension does develop despite the fluid bolus, it will be treated with additional fluid administration and ephedrine or phenylephrine (neoSynephrine) titrated to cause vasoconstriction. Bradycardia COACH Bradycardia occurs secondary to a blockade of CONSULT the cardioaccelerator fibers and venous pooling from the administration of the local anesthetic. Symptoms of bradycardia If the patient becomes symptomatic or hypotenproducing hypotension include clammy skin, sive, treatment will require the administration of agitation, and difficulty atropine to increase heart rate. If not already in in arousal, in addition to place, you should assist in establishing oxygen a fall in blood pressure. administration.

Box 3–7

Advantages and Disadvantages of Spinal Anesthesia

ADVANTAGES • Sensory dermatome levels can be targeted for optimal surgical anesthesia • May be done as single injection or continuous infusion via a catheter • Useful for surgery of the lower extremity, urologic procedures, and orthopedic surgery of lower extremity • May be used in labor and delivery DISADVANTAGES • Absolute contraindications include patient refusal, uncorrected hypovolemia, patient uncooperativeness, inability to provide informed consent, and localized infection • Relative contraindications include generalized sepsis, history of bleeding, use of anticoagulants, and history of spinal neurologic disease

Anesthesia 69

Nausea and Vomiting Nausea and vomiting occur secondary to the hypotension caused by the sympathetic blockade. Treatment will be directed toward improving blood pressure and will include oxygen, hydration, and possibly ephedrine or atropine and not an antiemetic. Urinary Retention Urinary retention occurs secondary to the sympathetic blockade of bladder nerves, the sensory block inhibiting the urge to void, and the motor block that COACH coordinates the emptying of the bladder. CONSULT Treatment of urinary retention requires bladder catheterization. When providing care for patients receiving spinal anesthesia, it is important that you • Ensure the IV is secure. Management of any acute cardiac or respiratory complication or side effect will require the administration of fluid or medications through the IV. You do not want to be trying to start an IV emergently • Assess and document the return of sensory and motor function of lower extremities. Use of a dermatome chart will facilitate assessment and documentation • Evaluate level of pain control and administer additional analgesics as needed. You can expect that the patient’s pain level will increase as the spinal recedes • Evaluate for side effects and treat as needed. The use of a standardized order sheet can allow for rapid intervention

70 Anesthesia

Complications of Spinal Anesthesia Complications of spinal anesthesia are due to both the agents and technique used, and include extensive spread of the anesthetic agent as well as a postdural puncture headache. Extensive Spread of the Anesthetic Agent This complication presents as respiratory and cardiovascular compromise, including apprehension, agitation, nausea and vomiting, arterial hypotension, respiratory insufficiency, apnea, and unconsciousness. It occurs secondary to rostral, or upward, spread of the local anesthetic and may be due to dose or patient positioning. Treatment centers on improving oxygenation, assisting ventilation, and restoration of blood pressure. Postdural Puncture Headache Also known as “spinal headache,” this complication may develop secondary to a leak of CSF from the dural puncture site. This headache becomes worse with standing and is frequently accompanied by nausea, tinnitus, and photophobia. Conservative management will include bedrest, fluids, and analgesics. More invasive treatment may require placement of an epidural blood patch to “seal the leak.”

Caudal Anesthesia Caudal anesthesia involves the injection of a local anesthetic into the epidural space via the sacral hiatus, also known as the sacral canal. This technique is more commonly used in pediatric patients, in whom anatomic landmarks are more easily identified. It is generally done after induction and the initiation of general anesthesia, for postoperative pain control for procedures involving the lower extremity, perineum for circumcision, and lower abdomen for herniorrhaphy. It is not a popular technique in adults because of the difficulty in palpating landmarks and the need for a large volume of injectate.

Regional Anesthesia in Children Regional anesthesia in children is usually performed as an adjunct to general anesthesia as most children will not cooperate with a pure regional anesthetic technique. As a result of smaller landmarks, this technique requires a skilled practitioner. It remains a good alternative technique for • Premature infants at risk for apnea • Older children with respiratory dysfunction • Older children who fear loss of consciousness • Children at risk for malignant hyperthermia, as it avoids the exposure to inhalational triggering agents

Anesthesia 71

CHAPTER

4

Intraoperative Considerations

T

he operating room (OR) is a specialized environment, created with one primary goal in mind: patient safety. The nurses working in the OR play a specialized role in patient care, advocating for the patient who is unable to advocate for themselves as a result of the administration of anesthesia. Patient care is the responsibility of the surgical team, which consists of, at a minimum, the • Surgeon • Anesthesia provider • Circulating nurse • Scrub nurse

Surgeon The surgeon is a physician who has been granted surgical privileges to perform a surgical procedure in a facility based on education, experience, licensing, and credentialing. The surgeon may perform the procedure independently, or may have assistive personnel, who may be other physicians or physicians in training, surgical technicians, physician assistants, or registered nurses.

Registered Nurse First Assistant The Association of Perioperative Registered Nurses describes the registered nurse first assistant (RNFA) as a registered nurse who has “gone through additional extensive education and training to deliver surgical care. The RNFA directly assists the surgeon by controlling bleeding, using instruments/medical devices, handling and cutting tissue, and suturing during the procedure. The RNFA may also be involved with patient care before and after surgery.” 73

Anesthesia Provider The anesthesia provider may be a • Medical Doctor Anesthesiologist (MDA): A physician who has been granted anesthesia privileges in a facility based on education, experience, licensing, and credentialing • Certified Registered Nurse Anesthetist (CRNA): A registered nurse who has gone through extensive education and training to deliver anesthesia care, most commonly through completion of a master’s degree in nursing; the CRNA administers anesthetics under the supervision of a physician, who may be an MDA or may be the surgeon performing the procedure • Anesthesiologist assistants (AAs): Allied health professionals who work under the direction of licensed anesthesiologists to develop and implement anesthesia care plans; all AAs possess a premedical background, baccalaureate degree, and complete a comprehensive didactic and clinical program at the graduate school level

Circulating Nurse The Association of Operating Room Nurses (AORN) describes the circulating nurse as a registered nurse who “is responsible for managing the nursing care of the patient within the OR and coordinating the needs of the surgical team with other care providers necessary for completion of surgery. The circulating nurse observes the surgery and the surgical team from a broad perspective and assists the team to create and maintain a safe and comfortable environment for the patient. The circulating nurse assesses the patient’s condition before, during, and after the operation to ensure an optimal outcome for the patient. “Circulating during surgery is a perioperative nursing function. The role of the circulator COACH may not be delegated to unlicensed assistive CONSULT personnel (UAP), a licensed practice nurse (LPN), or a licensed vocational nurse (LVN).” The circulating nurse is (www.aorn.org). responsible for patient safety during the surgical procedure. The scrub nurse supports the surgeon by passing instruments during the operation while also maintaining patient safety.

Scrub Nurse According to AORN, the scrub nurse “works directly with the surgeon within the sterile field, passing instruments, sponges, and other

74 Intraoperative Considerations

items needed during the procedure. This is a nursing role that may be delegated to a UAP, LPN or LVN.”

Before the Procedure Before any surgical procedure begins, the OR nursing staff is responsible for preparing the surgical environment. This will first involve preparation of the room by ascertaining that the room has been cleaned, and is ready to accept a patient. All equipment needed for the procedure will be brought into the room and set up as much as the room will allow prior to the introduction of both patient and personnel. This is important, for once room set up begins, it will be the responsibility of the OR nursing staff to make sure that the equipment remains sterile. Frequently, the OR nursing staff will work from both experience and prepared “cheat sheets” that contain information about equipment needed for a particular type of surgery, as well as individual surgeon preferences for equipment and glove sizes. To set up the room, the scrub nurse must first scrub, so that he or she is in a position to begin working with and setting up sterile supplies.

Surgical Scrub The surgical scrub is designed with the primary goal of prevention of infection through the most cost-effective, simplest method known to reduce wound infection: hand washing. Using antimicrobial soap, the surgeon, surgical assistants, and scrub nurse will scrub • Each finger • Both hands • Both arms to above the elbows The goal is to remove contamination from those sites, decrease microbial counts, and inhibit rapid rebound growth. The anesthesia provider and circulating nurse will not scrub, as they will function outside of the sterile field. The surgical scrub is done either as a stroke count per each side of each finger, palm, back of hand, and then the arm to 3 to 4 inches above the elbow, or as a timed surgical scrub of 5 minutes. Usually a 10 count is used, with each up stroke counting as one, and each down stroke counting as one. In the 5-minute scrub, 2 minutes will be spent on the fingers, covering each side of each finger, including the spaces between the fingers, along with the front and back of the hand, followed by 1 minute for each arm from the hand to above the elbow, followed by a rinse. Intraoperative Considerations 75

In either case, when scrubbing, the hands are always held above the elbows to prevent dirty water from running onto the cleaned sites. For the rinse, the hands are moved in one direction, only from the fingertips to the elbows, again holding the hands above the elbows. When complete, the team members who have scrubbed will enter the OR without touching the OR door, where they will dry their hands on sterile towels, followed by gowning and gloving. Before the patient is brought into the OR, the circulating nurse will confirm the identity of the patient in the holding area, making sure that allergy and identification bands are in place. The nurse will confirm completion of preoperative orders and preparation, as well as checking for the presence of the signed consent form and ordered labs. Only when this has been completed will the patient be brought into the room.

Sponge, Sharp, and Instrument Counts An additional intervention to promote patient safety is the counting and recording of sponges, needles and other sharps, and instruments used during a procedure to prevent the unintentional retention of foreign items in a surgical wound. The count is • First performed and documented between the scrub nurse and the circulating nurse as ALERT the room is set up, before the procedure is started The x-ray may be • Repeated before wound closure of each and a routine part of an any surgical cavity emergency procedure in which counts may be • Performed if there is a change in the scrub impossible to do prior to nurse during the procedure incision, as may be the If a discrepancy in the count is identified, the case with a crash c-section, surgeon is notified immediately, and a recount a bleeding aneurysm, or a initiated. If the recount fails to correct the dispatient “crashing from the cath lab.” crepancy, x-rays should be taken to check for the presence of retained objects. Because of the potential need for x-ray detection, surgical sponges and towels are radio-opaque to allow for detection on x-ray.

Surgical Time-out As another step in patient protection, a “time-out” is called when a patient enters the OR. Initiated by the circulating nurse, a time-out is designed to prevent the risk of the wrong patient, wrong site, and wrong surgery.


WHY IS A TIME-OUT IMPORTANT? The time-out is not a risk-reduction strategy, but a strategy to eliminate risk. It is considered a universal procedure, required before any invasive procedure, including puncture or incision into the skin or insertion of any instrument or foreign material into the patient.

The registered nurse (RN) will verify and document verification of the • Patient’s identify and date of birth • Correct site of surgery, with surgical site marked with a permanent marker if the surgery has a left or right distinction, involves multiple structures such as fingers or multiple levels such as in spinal surgery • Correct procedure • Presence of correct x-ray or other radiologic films • Presence of needed special equipment If at any time one of the previous criteria cannot be verified, everything stops until the discrepancy is resolved, and then the “time-out” begins again until verification of all criteria is confirmed and documented.

Positioning the Patient One of the most important tasks of the OR team is appropriate and safe positioning of the patient. Most commonly, the patient will be positioned after the induction of anesthesia, so positioning is the responsibility of the entire surgical team. The team may use straps, wedges, pillows, and surgical table attachments to maintain positioning. Some surgeries require a special table, for example, to facilitate turning of the patient from supine to prone. Variables to be considered in positioning of the patient include the need for • Access to the surgical site • Access to the patient’s airway • Monitoring of vital signs • Patient safety • Patient comfort Failure to position without consideration of all of these variables will delay the surgery, potentially compromise the airway, and expose the patient to complications associated with positioning, including soft tissue injuries, eye injuries, and nerve compression. As a result, all members of the surgical team will assist with positioning, as each team member has

Intraoperative Considerations 77

specific concerns. Unfortunately, priorities may be conflicting at times. For example, a surgeon may need the patient positioned in a prone position to complete a spinal procedure. For that to occur, the anesthesiologist must secure the airway, and then assist in repositioning the patient from his or her back to stomach without losing the endotracheal tube and jeopardizing the airway. This may require crawling under the OR table to make sure the tube did not kink, and to reposition blood pressure cuff tubing and the pulse oximeter. The OR nurse will ensure patient comfort and safety by making sure that extremities and bony prominences are padded. This is extremely important in obese patients, and other patients at risk for pressure injuries. (See Chapter 9 for a discussion of complications of positioning.) The most common positions used in the OR include the following: • Supine • Lithotomy • Sitting • Prone • Lateral Supine Position In the supine position, also known as the dorsal recumbent position, patients are placed flat on their backs, with arms at sides and palms down; legs are straight and feet slightly separated. The supine position, as well as its variations, is commonly used for abdominal, mediastinal, and cardiac surgical procedures. Modifications of the supine posiALERT tion include the following: Although most • Contoured supine (back flat, thighs flexed patients tolerate the 15º on the trunk, knees flexed 15º in the supine position with little opposite direction) cardiac or respiratory • Scultetus (10º–15º Trendelenburg) compromise, the obese patient or a patient with an • Reverse Trendelenburg intra-abdominal growth, • Sitting (upright) such as a tumor or devel• Lithotomy oping fetus, may have The scultetus, or Trendelenburg, position supine occlusion of the inferior vena cava, causing is used to increase visualization of the pelvic hypotension. A towel organs or to improve circulation to the brain placed under the right when blood pressure is suddenly lowered. The lower back and hip will reverse Trendelenburg position is used to proshift the patient to the left vide access to the head and neck and to faciliside and correct caval occlusion. tate the pull of the viscera away from the diaphragm (see Fig. 4–1). 78 Intraoperative Considerations

F I G U R E 4 - 1 : Supine position.

Obese patients and patients with large intraabdominal masses may have respiratory diffiCOACH culties as the weight of abdominal contents CONSULT forces the diaphragm upward, limiting respiraThe supine position offers tory excursion and reducing functional residual the greatest degree of capacity (FRC). The patient will likely require patient stability, surgical controlled ventilation to maximize oxygenation accessibility, and patient and gas exchange. Elevating the head of the safety. operating table helps to displace abdominal contents from the thorax; however, surgical accessibility may be compromised. Lithotomy Position The lithotomy position is the most extreme variation of the supine position. The lithotomy position places the patient on the back with the buttocks at the end of the table. Both thighs and legs are flexed simultaneously into stirrups and the arms are crossed across the abdomen or extended laterally on arm boards. This position is used for gynecologic, urologic, perineal and perianal surgeries, and for vaginal deliveries. As the legs are flexed back against the abdomen, intra-abdominal contents are forced against the diaphragm by the thighs. Intrathoracic pressure is increased, with a decrease in FRC. If the patient has been intubated, ventilation is usually controlled by the anesthesia provider. Hypotension may occur after surgery when the patient’s legs are lowered to the table. To decrease the risk of sudden hypotension as the vascular volume returns to the lower extremities, the legs should first be returned to the sagittal plane, and then slowly lowered to the baseline. To prevent venous pooling, these patients will have TED hose applied. Sitting Position The sitting position is most commonly used for ALERT neurosurgery and exists as a variation of the supine position. In this position the patient The sitting may be sitting upright or semi-reclining with position is rarely used the legs elevated to the level of the heart. The because of the possibility of cerebral air embolism. head is secured ventrally on the neck by a face rest or a skull-fixation frame (see Fig. 4–2). Intraoperative Considerations 79

F I G U R E 4 - 2 : Sitting position.

The sitting position is associated with a number of cardiovascular complications, including the following: • Hypotension, which is a major complication due to blood shifting downward from the upper body • Decreased cardiac output of 20% to 40% • Compensatory tachycardia, which may result in a 30% increase in heart rate • Increased systemic vascular resistance of 30% to 60% as the body attempts to maintain a mean arterial pressure of greater than 60 mm Hg Respiratory effort is maximally enhanced by this position, as respiratory excursion remains uncompromised by any abdominal pressure. Prone Position In the prone position, the patient lies on the abdomen with the face turned toward one side. Arms are positioned at the sides, with the palms up. The elbows are slightly flexed, and the feet are elevated slightly on a pillow to prevent plantar flexion (see Fig. 4–3). The prone position is most commonly used for procedures on the back, spine, and rectal area. Modifications of this position include the following: • Prone jackknife, in which the thighs are placed on the trunk, as may be used for rectal and perirectal procedures • Kneeling, in which the patient is flexed at the hips and knees and supported on a kneeling frame

F I G U R E 4 - 3 : Prone position.


The primary intraoperative alteration in the prone position is chest and abdominal compression from the body weight of the anesthetized patient. Respiratory excursion and the movement of the diaphragm are reduced. Ventilation must be controlled. In addition, the patient is intubated in a supine position, and then turned prone. Care must be taken to protect the endotracheal tube, IV lines, and arterial lines when turning the patient. Precautions must also be taken to guard against excessive pressure on the eyes, ears, nose, breasts, and male genitalia. The use of foam padding is helpful. When the prone position is modified to the kneeling position, venous pooling in the legs can become significant. The weight of the body also causes a decrease in stroke volume and cardiac index. Because of the increased vascular resistance, little change is noted in the mean arterial pressure, central venous pressure, and pulmonary artery pressure. Lateral Position In the lateral position, the patient is positioned on the side (see Fig. 4–4). This position is usually used for upper ureter or renal surgery, such as nephrectomy, and chest surgery. The major problems with the lateral position include the following: • Venous pooling of the dependent extremities • Ventilation-perfusion mismatch (V-Q) These problems occur because the dependent lung is well perfused but poorly ventilated and the upper lung is well ventilated but not well perfused. Venous pooling can be prevented with the use of compression stockings (TED hose). Ventilation problems may be minimized with the use of controlled, positive pressure ventilation.

Skin Preparation and Surgical Draping The goal of surgical skin preparation may have actually begun the evening before surgery or the morning of surgery, when the patient was asked to take a shower using an antimicrobial cleanser to decrease microbial count. Skin preparation may then continue in the holding area, with hair removal over the surgical site, if indicated. Hair removal remains a controversial topic, for both need and technique. The overriding goal of

F I G U R E 4 - 4 : Lateral position.


skin preparation is the prevention of infection. Hair removal using a razor, which is no longer recommended practice, may expose the skin to If hair removal is injury, compromising skin integrity and actually indicated, it should be increasing the risk of infection. Hair removal done using a battery using depilatory lotions or creams may cause operated clipper with a localized reactions, also compromising skin disposable head or a head that can be sterilized before integrity. re-use. Hair removal should After the patient enters the OR, has been take place outside of the anesthetized, and positioned appropriately and OR to control shedding. secured, skin cleansing can continue with an antimicrobial wash and paint. The combination of an antiseptic agent with the friction of application helps to further reduce the microbial count. The antiseptic solution should be applied using a sponge or sterile instrument, working from the center of the surgical site to the periphery. A combination alcohol-iodine solution (DuraPrep) is the most commonly used agent. Alcohol is used for a rapid kill with fast drying, whereas the iodine provides for a water-insoluble persistent film. Skin preparation should be documented by the circulating nurse in the intraoperative record, and should include, at minimum: • Condition of the skin at the surgical site before preparation, whether intact, or the presence of a rash or other lesion • Hair removal, if performed, including the method of removal • Cleansing agent used • Development of any localized reaction, if applicable • Name of the person completing the preparation After the skin is cleansed and dried with a sterile towel, surgical draping can begin. The drape allows for isolation of the surgical site and localizes the sterile field to the surgical site. Draping also will maintain patient privacy. Drapes should be applied in a way that allows for the full possibility of surgical incisions, any potential additional incisions, and for the placement of surgical drains that might be placed at the end of surgery. ALERT

During Surgery As the surgeon performs the procedure, the scrub nurse will assist the surgeon by providing instruments and needed supplies within the sterile field. For any equipment or supplies needed that are not present in the


field, the circulating nurse, who is not scrubbed, can leave the room if needed, or obtain supplies from cabinets within the room, opening them directly onto the sterile field. Any additional supplies will need to be counted, as packs are opened and introduced into the sterile field. If tissue samples are obtained for biopsy or other testing, or cultures obtained for laboratory analysis, the scrub nurse will assist in placing the sampled tissue into collection medium, and will make the transfer of collected samples to the circulating nurse, who will prepare patient labels for the bottle and appropriate requisitions. The circulating nurse will be responsible for the transfer of collected samples to the appropriate laboratory. This includes not only samples collected from the patient by the surgical team, but any blood samples obtained by the anesthesia provider, including arterial blood gases, blood glucose samples, or other laboratory tests.

The Surgical Procedure Although it is difficult to provide a detailed description of every surgical procedure, it is possible to identify descriptors that help to explain the procedure. For example, suffixes in procedure names offer the following information: • –ectomy: To remove, as in tonsillectomy, removal of tonsils, or lobectomy, removal of lobe of the lung • –otomy: To cut or separate, as in craniotomy, cutting of bones of the cranium or skull • –ostomy: To create an opening, as in colostomy, opening into the colon for elimination of wastes • –transplant: To uproot and replant, as in kidney transplant, removal of kidney from donor to recipient • –ablation: To remove from, as in surgical ablation of heart tissue for atrial fibrillation More and more surgeries are being performed using endoscopic techniques, which, although more technically difficult, minimize surgical ALERT trauma, speed recovery and discharge, and reAs all thoracic duce postoperative complications. What follows surgeries will involve the here is a list of common surgical procedures. airway or organs of ventilaWhere appropriate, procedures most comtion, assessment and care monly performed on children appear in a sepaof the airway is the overriding priority. rate list. A surgical systems listing is used to classify procedures.


Thoracic Surgical Patients Patients scheduled for thoracic surgery may be undergoing diagnostic procedures to correct pathologies or procedures to repair mediastinal or vascular structures.

Thoracic Surgical Procedures • Bronchoscopy: Direct visualization of the trachea, main bronchi, and most of the segmental bronchi. Allows for removal of secretions, fluid, foreign bodies, tissue for biopsy, and lavage, and for application of medication or radio-opaque medium. Considered a diagnostic procedure for patients presenting with symptoms including persistent cough, hemoptysis, wheezing, obstruction and/or abnormal chest x-ray • Mediastinoscopy: Direct visualization and possible biopsy of tumors or lymph nodes at the tracheobronchial junction, subcarinal, or upper lobe bronchi or subdivisions. A diagnostic procedure for patients with identified changes on chest x-ray • Thoracoscopy: Direct visualization of the pleural cavity. May be diagnostic, as in biopsy, or therapeutic, as in allowing for resection of tumors, drainage of pleural effusion, or pericardial effusion • Lung biopsy: Removal of lung tissue for diagnosis. May be accomplished via open or percutaneous approach • Wedge resection: Removal of wedge-shaped section of a lobe of the lung that includes identified lesion. Used with small, peripherally located benign lung tumors • Segmentectomy: Removal of a subdivision of a pulmonary lobe. Conserves healthy tissue while allowing for removal of localized benign lesions • Lobectomy: Removal of a lobe of the lung. Used for metastatic tumors, bronchiectasis, emphysematous blebs, large benign tumors, fungal infections, and congenital anomalies • Pneumonectomy: Removal of the entire lung. Most commonly done for malignant neoplasms, but may be performed for chronic abscess or large benign tumors • Lung transplant: Removal of recipient’s diseased lung and immediate replacement with donor lung as treatment for cystic fibrosis, idiopathic pulmonary fibrosis, emphysema, or sarcoidosis


• Sleeve resection: Removal of the tracheobronchial tree and associated lung segment or lobe. May be combined with pneumonectomy. Used with metastatic disease • Decortication: Removal of restrictive fibrous membrane on the visceral or parietal pleura that compromises ventilation. Fibrous membrane is most commonly due to chronic inflammation “fibrothorax.” The goal is to restore normal lung function • Drainage of empyema: Treatment for a pleural effusion associated with an acute or chronic infection. Without treatment, may require decortication • Thoracostomy: Resection of one or more ribs to allow for healing or reinflation of diseased lung. Also used to provide a mechanism for drainage of chronic empyemic lesions • Thymectomy: Removal of the thymus gland as treatment for myasthenia gravis

Cardiac Surgical Patients Patients may be candidates for cardiac surgery to correct congenital anomalies, treat coronary artery disease, repair damage following myocardial infarction, or treat valvular disease or arrhythmias. Many of these procedures will be performed in the cath laboratory by cardiologists, and not in the OR.

ALERT The priorities for cardiac surgery will focus on maintaining cardiopulmonary stability and maintaining oxygen transport.

Cardiac Surgical Procedures • Pacemaker insertion: Placement of an artificial pulse generator and electrode (pacemaker) to control conduction alterations, most commonly heart block and bradyarrhythmias • Insertion of automatic implantable defibrillator: Placement of a device to monitor electrical activity in the heart and to initiate defibrillatory shocks in the event of malignant arrhythmias, ventricular fibrillation, or ventricular tachycardia. May be done percutaneously • Cardiac ablation: Using an energy source such as radio frequency or laser energy to destroy a small area of the heart and prevent further arrhythmias, including atrial fibrillation, supraventricular tachycardia, ventricular tachycardia, and Wolff-Parkinson-White syndrome


• Pericardectomy: Excision of thickened, restrictive pericardium to relieve constriction of the heart and large blood vessels • Coronary artery bypass graft: Revascularization of ischemic myocardium using grafts from the saphenous vein or internal mammary artery. Possible to do multiple bypasses during procedure • Valve replacement: Removal of diseased heart valve with replacement with a prosthetic valve. Any of the four valves may be replaced, although the mitral and aortic valves are the most commonly done • Valve repair: Designed to repair valve without replacement. Commissurotomy separates fused valve leaflets under direct visualization. Annuloplasty reduces a dilated valve opening with sutures or a prosthetic ring. Valvuloplasty repairs valve leaflets • Aneurysmectomy: Excision of outpouching of left ventricle with reinforcement of ventricle. Aneurysm may develop spontaneously or after a myocardial infarction • Thoracic aortic aneurysmectomy: Excision of outpouching of the ascending arch or descending thoracic aorta by replacement with a graft, valve-graft conduit, or intra-aortic prosthesis. Aneurysm may be the result of trauma, disease, infection, or degeneration • Heart transplant: Removal of recipient’s diseased heart with immediate replacement with a donor heart. Indications include heart failure due to coronary artery disease, cardiomyopathy, congenital disease, and severe valve disease. May be combined with lung transplant

Pediatric Cardiac Procedures • Ventricular septal defect (VSD) repair: Correction of a congenital defect in the ventricular septum. Small VSDs do not generally require repair. Large defects, may, if untreated, result in left-to-right shunting, high ventricular pressures, pulmonary hypertension, increased pulmonary blood flow, and an enlarged heart. Commonly a pediatric procedure, but may also be done in adults • Atrial septal defect (ASD) repair: Correction of a congenital defect in the atrial septum. Without intervention, ASD may result in left-to-right shunting, increased workload of the right heart, enlargement of the right heart and pulmonary artery, 86 Intraoperative Considerations

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pulmonary hypertension, and right-sided heart failure. Commonly a pediatric procedure, but may also be done in adults Correction of tetralogy of Fallot: A pediatric cardiac procedure to correct a congenital anomaly resulting in four alterations: pulmonary stenosis, VSD, overriding aorta, and right ventricular hypertrophy Correction of shunt: A pediatric cardiac procedure to divert poorly oxygenated blood from one of the major arteries back through one of the pulmonary arteries for reoxygenation. Includes Blalock-Taussig, Potts-Smith, Waterson, and Glenn procedures Repair of transposition of the great vessels: Transposition is a congenital anomaly in which the aorta arises from the right ventricle and the pulmonary artery arises from the left ventricle. To sustain life, the patient will also have a patent foramen ovale, patent ductus arteriosus, ASD, VSD, or partial transposition of the pulmonary veins to allow blood to be oxygenated and to enter systemic circulation. Also known as a Mustard procedure, atrial switch, or arterial switch Closure of patent ductus arteriosus: Closure of abnormal opening between the aorta and pulmonary arteries Repair of coarctation of the aorta: Excision of constricted segment of the aorta, with anastomosis, with or without graft ALERT

Peripheral Vascular Patients Patients may be scheduled for peripheral vascular surgery to increase perfusion to an extremity or organ or to circumvent abnormalities in a blood vessel.

The priorities for peripheral vascular patients will be to promote circulatory integrity and perfusion through the assessment of peripheral pulses.

Peripheral Vascular Surgical Procedures • Abdominal aortic aneurysm: Removal of an outpouching in the abdominal aorta with placement of a synthetic graft to restore vessel patency • Aneurysmectomy: Removal of an outpouching or weakened area in an artery with insertion of a prosthetic graft to reestablish blood flow • Aortic stent grafts: Placement of an endovascular stent to correct thoracic or abdominal aortic aneurysms


• Femoral-popliteal bypass: Restoration of blood flow to the leg with a graft bypassing an occluded section of the femoral artery • Femoral-femoral bypass: Extra-anatomic bypass procedure designed to divert blood flow from one femoral artery to another subcutaneously across the suprapubic area via a prosthetic graft • Vessel-to-vessel bypass: Anastomosis of two communicating arteries to improve circulation. May include carotid-subclavian, aortocarotid-subclavian, aortoiliac-aortofemoral, aortorenal, and axillofemoral arterial bypass • Balloon angioplasty: Surgical treatment of a diseased vessel using a balloon catheter, with or without laser assistance to open and dilate an occluded vessel. Designed to prevent need for more invasive surgery. If procedure fails or vessel ruptures, will require immediate invasive surgery • Arterial embolectomy: Entrance into an occluded artery to remove thromboembolic material • Endarterectomy: Removal of an occlusion of fat, known as an atheroma, in an artery, thereby increasing blood flow to areas distal to the occlusion. Most commonly performed in the carotid artery, but may be performed in the subclavian, iliac, or femoral arteries • Arteriovenous (AV) shunt: Connection of an artery to a vein to facilitate hemodialysis in patients with acute or chronic renal failure. Commonly done between the radial and the cephalic vein in ALERT the arm • Vein stripping: Surgical removal of variThe priority for cose veins in the leg neurosurgical patients will be on assessment of neurologic functioning by establishment of a baseline before surgery, which will be compared with assessments done after surgery, and sometimes during surgery.

Neurosurgical Patients Patients may require neurosurgical intervention to • Decrease intracranial pressure • Repair damage from trauma • Remove intracranial growths • Reconstruct congenital malformations

Neurosurgical Procedures • Burr holes: Placement of holes into the skull to remove localized fluid beneath the dura mater, to relieve intracranial pressure, to


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treat brain abscess by direct installation of antibiotics, to localize a subdural hematoma, or to introduce air for x-ray studies Craniotomy: Incision into the skull to expose and surgically treat intracranial disease. Surgical approach may vary depending on pathology to include parietal, frontal occipital, or temporal approach. May be used to remove tumors, intracranial aneurysms, or AV malformations, or for intracranial revascularization Transsphenoidal hypophysectomy: Removal of a pituitary tumor through incision in upper gum margin and sphenoidal cavity Craniectomy: Incision into the skull with removal of bone by enlarging one or more burr holes. Used to remove tumors, hematomas, scarring, or infected bone. Also used to relieve increased intracranial pressure, and in infants for craniosynostosis, premature closure of suture lines in the skull Rhizotomy: Interruption of branches of the ophthalmic, maxillary, and mandibular nerves by injection of alcohol or surgical sectioning. Used to treat trigeminal neuralgia Cranioplasty: Repair of skull defect secondary to trauma, congenital malformation, or surgical procedure Microneurosurgery: Use of operating microscope for cranial, spinal, or peripheral nerve operations Stereotaxic procedures: Use of landmark guides to locate and destroy targeted tissue in the brain. May incorporate use of computed tomography (CT) or magnetic resonance imaging (MRI) scan, x-ray, or fluoroscopy. Commonly used to target tumors, basal ganglia, aneurysms, epileptic foci, and areas of intractable pain Cryosurgery: Use of subfreezing temperatures to treat intracranial diseases, including pituitary tumors, and the thalamus gland in the treatment of Parkinson’s disease Cordotomy: Division of the spinothalamic tract for treatment of intractable pain Sympathectomy: Excision of a portion of the sympathetic division of the autonomic nervous system. Used in the treatment of vascular disorders of the extremities and for intractable pain from nerve injury Peripheral nerve repair: Surgical restoration of nerve continuity caused by nerve injuries due, most commonly, to trauma


Pediatric Neurosurgery • Shunt: Procedure to divert flow of excess cerebrospinal fluid away from the ventricles in the cranial cavity to another body cavity to reduce intracranial pressure. May utilize a ventriculoatrial or, more commonly, COACH a ventriculoperitoneal shunt. Ventricle is conCONSULT nected to the right atrium or to the peritoneal cavity via placement of a catheter

Neurovascular preservation remains the overriding priority for spinal surgical patients.

Spinal Surgical Patients Spine surgery may be performed by either a neurosurgeon or an orthopedic surgeon.

Spinal Surgical Procedures • Spinal fusion: Application of rods or instrumentation to maintain spinal alignment until vertebral body fusion is complete. May be done via posterior approach, with Harrington or Luque rods; anterior approach, with Dwyer or Zielke instrumentation; or combination. May be done as single or multilevel fusion • Laminectomy: Removal of one or more vertebral lamina to expose the spinal cord to treat compression fractures, dislocations, herniated disks, and spinal cord tumors. May also be done to insert implantable pumps for pain control • Diskectomy: Removal of part of a herniated disk to relieve pressure of a spinal nerve root. May be performed using a microscope, called microdiskectomy. Access to disk will require a laminotomy, where a portion of the lamina is removed to permit the surgeon to access the disk • Untethering of tethered cord: Detachment of spinal cord from abnormal attachment within spinal canal. Most commonly done in children • Intrathecal pump placement: Placement of an implantable pump within the abdomen, with a catheter threaded to the intrathecal space for the delivery of medications for chronic pain management • Spinal cord stimulator placement: Implantation of neurostimulator within the gluteus muscle, with threading and placement of either 4 or 8 leads to spinal nerves as treatment for chronic pain


Orthopedic Surgical Patients Patients may be candidates for orthopedic surgery for the correction of trauma or injury, for diagnosis of injury, for removal or replacement of bone destroyed by disease or trauma, or for repair of structural defects. Surgery may also be indicated to realign structures or to remove dysfunctional or disease structures that cause pain or restrict mobility.

Orthopedic Surgical Procedures

COACH CONSULT Primary importance for orthopedic surgical procedures will be placed on maintenance of surgical and anatomic alignment, as well as on neurovascular assessment of the extremity. If the surgery involves the spine, neurologic assessment will also be a priority.

• Closed reduction: Method of reducing a limb fracture by manipulation of bones without excising the skin. May be done under local anesthesia, IV regional anesthesia, regional anesthesia, or general anesthesia. Less risk of infection as skin integrity is not compromised • Open reduction: Method of reducing a fracture through a surgical approach. • External fixation: Method of stabilizing a joint, bone, soft tissue injury, and defects. Used with severe open fractures, difficult closed fractures, arthrodesis, infected joints, nonunion fractures, fracture stabilization to protect vasculature, congenital deformities, and alignment and lengthening procedures. May be accomplished by pins, rods, and connecting elements • Internal fixation: Surgical approach with placement of pins, plates, screws, or grafts to stabilize a joint, bone, or soft tissue. May be accomplished percutaneously or via an open reduction • Arthroscopy: Direct visualization of intra-articular structures of a joint. Used for diagnostic evaluation, or as an operative approach to remove loose bodies, to obtain synovial fluid biopsies, or to repair joint/ligament damage. Most commonly performed on the knee, but may be done on the shoulder, elbow, ankle, or other joints • Arthrotomy: Open approach to evaluate a joint. Uncommon now with arthroscopy and planned arthroplasty • Osteotomy: Cutting and realigning bones of a joint to create a more normal relationship between two surfaces, most commonly done at the hip between the femoral head and acetabulum • Arthroplasty: Joint replacement surgery whereby the diseased joint is removed and replaced with a prosthetic joint. Commonly


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done on the hip and knee, but may be done on the shoulder, elbow, and other joints. Most commonly done for osteoarthritis or rheumatoid arthritis Hip resurfacing: Also known as Birmingham hip, this procedure is designed to maintain structure and stability while preserving bone by shaving only a few millimeters of bone and recapping either the femoral head alone, known as partial resurfacing, with a metal cap or both the femoral head and acetabulum, known as total resurfacing. Partial resurfacing indicated for avascular necrosis of the hip. Total resurfacing is indicated for osteoarthritis, rheumatoid arthritis, and severe avascular necrosis Rotator cuff repair: Surgical repair of the tendons and muscles surrounding the shoulder. Tear is usually the result of trauma or degeneration. May be done open or via arthroscopy Carpal tunnel release: Release of the medial nerve from compression within the wrist. Compression may be the result of thickened synovium, trauma, or aberrant muscles Intramedullary nailing: Method of repairing fractures of long bones, such as the femoral shaft, which can fracture as a result of high impact trauma. May be done via open or closed approach Anterior cruciate ligament (ACL) repair: Reconstruction of the ACL in the knee that has been damaged as a result of trauma. May be done via open or arthroscopic approach. Ligament is repaired with a graft for stability Arthrodesis: Used to correct inversion or eversion deformities of the feet. May be referred to a triple arthrodesis as three joints, the talocalcaneal, talonavicular, and calcaneocuboid, must be fused Bunionectomy: Removal of a bunion, either soft tissue or bony mass, on the medial side of the big toe

Renal and Genitourinary Patients COACH CONSULT The priority for renal and genitourinary surgical patients will be on urinary output and prevention of infection.

Patients may be candidates for urologic or renal surgery to repair a congenital finding, correct problems with voiding, correct problems that cause swelling in the urogenital area, or correct problems that cause changes in urine concentration or output. Surgery may also be indicated in cases or urologic trauma, due to either injury or the presence of a foreign body.


Genitourinary and Renal Surgical Procedures • Cystoscopy: Endoscopic examination of the interior of the urethra, the bladder, and the urethral orifices using a cystoscope. Used in pediatrics to evaluate for cause for frequent infections • Urethral dilatation and internal urethrotomy: Gradual dilatation and lysis of a urethral stricture to relieve lower urinary obstruction • Urethroplasty: Reconstructive surgery of the urethra to repair strictures, urethral fractures, or narrowing that may be congenital, acquired, or traumatic in origin • Penectomy: Surgical removal of all or part of a cancerous penis • Penile implant: Surgical placement of a prosthesis for treatment of sexual impotence • Hydrocelectomy: Surgical excision of abnormal fluid accumulation within the scrotum. May be due to infection or trauma • Vasectomy: Excision of a section of the vas deferens as a permanent method of male sterilization • Spermatocelectomy: Removal of a spermatocele, a cystic mass attached to the head of the epididymis caused by an obstruction in the tubular system that carries sperm • Varicocelectomy: Ligation of the gonadal veins of the testes designed to reduce backflow of blood into the venous plexus around the testes with the goal of improving spermatogenesis and fertility • Testicular biopsy: Excision of tissue from the testes for diagnostic evaluation • Orchiectomy: Surgical removal of a testis or testes. Done bilaterally to control metastatic carcinoma of the prostate, or unilaterally for testicular cancer, trauma, or infection • Testicular detorsion: Untwisting of the spermatic cord that compromises blood flow to the testes. Considered a surgical emergency. Seen most commonly in teenage boys and young males • Prostatic needle biopsy: Sampling of prostatic tissue transperitoneally or transrectally to diagnose prostate cancer • Transurethral resection of the prostate: Removal of the prostate gland, except the prostatic capsule, through the urethra using a surgical approach. Used in the treatment of obstructive enlargement of the prostate gland. Also known as TURP procedure


• Transurethral laser incision of the prostate: Removal of the prostate gland through the urethra using a laser beam to destroy prostatic tissue. Also known as TULIP procedure • Prostatectomy: Removal of hypertrophic prostatic tissue through a retropubic, suprapubic, or perineal approach. Also known as an open prostatectomy • Suprapubic cystotomy and cystostomy: Opening made into the urinary bladder (cystotomy) with placement of a drainage tube (cystostomy) • Transurethral resection of bladder: Removal of carcinogenic bladder lesions using a through-the-urethra surgical approach. Also known as TURB procedure • Laser treatment for bladder tumors: Using an neodymium: yttrium-aluminum-garnet laser to destroy bladder tumors using a transurethral approach • Stamey procedure: Suspension of the vesical neck of the bladder as surgical treatment for stress incontinence in women. Also known as bladder neck suspension • Cystectomy: Surgical excision of the urinary bladder for treatment of malignancy. Requires permanent urinary diversion, such as ileal conduit. If lymph nodes are also removed, procedure is known as a radical cystectomy • Ileal conduit: Surgical diversion of urine to an isolated loop of bowel. One end will be brought out to the surface of the skin through an ostomy for collection into a drainage bag • Diversionary surgery of the ureter: Variety of surgical techniques designed to divert flow of urine away from the ureter or around a ureteral obstruction. Includes ureterostomy, ureterectomy, and ureterolithotomy • Nephrectomy: Surgical removal of the kidney for treatment of renal disease, including hydronephrosis, renal tumor, pyelonephritis, abscess, or infection, or may be done to obtain donor kidney for transplant. If surrounding tissue and lymph nodes are also removed, procedure is known as a radical nephrectomy • Kidney transplant: Transplantation of a living related or cadaveric kidney into a recipient as treatment for end-stage renal disease • Extracorporeal shock wave lithotripsy: Noninvasive approach using shock waves transmitted through water to destroy kidney stones


• Adrenalectomy: Partial or total removal of the adrenal glands as treatment for adrenal hypersecretion, adrenal tumors, or tumors of other organs that require adrenal hormones, such as breast or prostate tumors. Adrenal gland sits on top of the kidney

Pediatric Genitourinary and Renal Procedures • Circumcision: Excision of the foreskin of the penis • Meatotomy: Incisional enlargement of the external urethral meatus to relieve stenosis or stricture that may be congenital or acquired • Hypospadias repair: Repair of the urethral meatus that is proximal to its normal position at the tip of the penis • Epispadias repair: Correction of the absence of the dorsal wall of the urethra and the position of the corpora cavernosa, ventral to the urethra • Orchiopexy: Surgical placement and fixation of the testicle into normal anatomic position in the scrotal sac as treatment for an undescended testicle

Plastic and Reconstructive Surgical Patients Patients may have plastic surgery to reconstruct a congenital or acquired deformity or for cosmetic reasons to enhance appearance. Surgery may be to skin, face, thorax, or abdomen.

Plastic and Reconstructive Surgical Procedures

COACH CONSULT Surgical priorities for the patient undergoing plastic or reconstructive surgery will focus on optimizing appearance and prevention of infection.

• Skin graft: Use of donor skin to cover a wound. Skin may be taken from patient or donor. Split thickness grafts contain epidermis and a portion of the dermis. Full thickness grafts contain dermis and epidermis • Flap: Tissue is detached from one area of the body and transferred to another part of the body with its original vasculature reestablished or maintained. The base, or pedicle, of the flap is the portion through which the blood supply is maintained • Breast reconstruction: Surgical reforming of the breast using an implant, tissue expanders, or myocutaneous flaps. Indicated after mastectomy, either immediately or in a second surgery at a later date


• Mammoplasty: Reforming of the breast tissue, either with augmentation or reduction of tissue. Augmentation is indicated with hypomastia, breast asymmetry, or after mastectomy. Reduction is indicated in gigantomastia or macromastia resulting in back or neck pain • Rhinoplasty: Surgical approach to improve the appearance of the external nose • Blepharoplasty: Surgical approach to improve the appearance around the eyes • Rhytidectomy: Surgical approach to improving a patient’s overall facial appearance by removing loose skin and fat; also known as a face lift • Dermabrasion: Sanding or planing the skin to smooth scars and surface irregularities • Abdominoplasty: Removal of excess skin and fat of the lower abdomen. Common after large weight loss. Also known as a tummy tuck • Liposuction: Body-contouring technique whereby fat is aspirated from subcutaneous tissue and removed. May be done on buttocks, legs, abdomen, upper arms, and chin • Microsurgery: Surgical technique to reconstruct or replant tissue lost to trauma or disease. Allows for reattachment of digits and other amputated body parts

Pediatric Plastic Surgical Procedures • Cleft lip repair: Surgical correction of congenital malformation of the lip, most commonly performed in infants 1 to 3 months of age • Cleft palate repair: Surgical restoration of congenital malformation of the hard and soft palate. Most commonly done in infants younger than 1 year of age • Pharyngeal flap: Tissue is taken from the pharynx in the form of a flap and added to the soft palate. Secondary procedure after palate repair to improve speech or as a part of the primary procedure to eliminate need for second surgery • Craniofacial surgery: Correction of congenital malformations of the face and skull. Usually requires several surgeries involving a team approach to repair


Ophthalmic Surgical Patients Patients scheduled for ophthalmic surgery may be undergoing procedures to • Correct congenital abnormalities • Repair damage • Correct pathophysiologic conditions • Provide cosmetic reconstruction Surgeries are most commonly performed on pediatric and geriatric patients, and most will be performed on an ambulatory basis.

Ophthalmic Surgical Procedures

COACH CONSULT Priorities for ophthalmic surgical patients will focus on patient education, and prevention of problems such as coughing, nausea, and vomiting, which may increase intraocular pressure, compromising surgical integrity.

• Removal of chalazion: Incision and curettage of a granulomatous inflammation of the eyelid • Lacrimal duct probing: Surgical opening of the lacrimal drainage system to prevent infection • Dacryocystorhinostomy: Surgical creation of a new tear drainage system directly into the nasal cavity • Enucleation: Surgical removal of the entire eyeball, usually due to eye disease or trauma • Corneal transplant: Grafting of corneal tissue from one human eye to another. Most commonly done as treatment for cataracts; also known as keratoplasty • Cataract extraction: Removal of opaque lens from the eye through an extracapsular approach or an intracapsular approach. Lens is replaced with an intraocular lens (IOL) implant to improve vision • Iridectomy: Removal of iris tissue in the treatment of acute, subacute, or chronic angle-closure glaucoma • Surgery for retinal detachment: Reattachment of the neural retina to the epithelial layer of the retina. Detachment may be caused by trauma, neoplasms, or degeneration. Common in diabetic patients. Classified as an emergent procedure to preserve vision. Also known as scleral buckle surgery • Vitrectomy: Removal of all or part of the vitreous gel to improve vision • Laser surgery: Use of an argon or Nd-YAG laser to treat acute and open-angle glaucoma


• Radial keratotomy: Placement of a series of partial thickness radial incisions into the cornea to flatten the cornea and reduce refractive error. Goal is to eliminate need for glasses or contact lens

Pediatric Eye Surgical Procedures • Strabismus repair: Corrective surgery to modify extraocular eye muscles with the goal of improving eye coordination and vision

Ear, Nose, and Throat Surgical Patients COACH CONSULT Despite the fact that ENT surgery may involve three anatomically distinct areas, almost all of the surgeries are performed in or through the airway, making airway maintenance a number one priority.

Indications for ear, nose, and throat (ENT) surgery include reconstruction, need to remove diseased or damaged tissue, promote healing by decreasing or removing infection, and need to maximize the airway.

Ear Surgery

• Tympanoplasty: Reconstruction of a damaged tympanic membrane • Mastoidectomy: Removal of diseased bone of the mastoid. Simple mastoidectomy involves removal of only diseased bone. Modified radical mastoidectomy involves COACH CONSULT removal of diseased bone, some of the ossicles, and the ear wall canal. Radical Ear surgery is also known mastoidectomy involves removal of disas otologic surgery. eased bone, all of the ossicles, and the ear wall canal • Stapedectomy: Removal of the stapes with subsequent replacement with a prosthesis as treatment for otosclerosis with overall goal of improving hearing • Removal of an acoustic neuroma: Removal of benign tumor from the vestibular apparatus of the 8th cranial (acoustic) nerve. May be performed by an ENT surgeon or neurosurgeon • Submucous resection: Removal of the cartilaginous or bony portions of the septum, performed for deformed, fractured, or injured nasal septum; also known as septoplasty • Intranasal antrostomy: Opening made into the lateral wall of the nose with the goal of relieving edema or infection of the sinus membranes; also known as antral window


• Radical antrostomy: Incision into the upper jaw with removal of diseased portions of the antral wall and contents of the sinus. Used in treatment of chronic sinusitis to establish drainage. Also known as Caldwell-Luc • Nasal polypectomy: Removal of polyps from the nasal cavity • Endoscopic sinus surgery: Endoscopic resection of inflammatory and anatomic defects of the sinuses to restore mucociliary clearance in the sinuses • Ethmoidectomy: Removal of diseased portions of the middle turbinate, ethmoidal cells, and diseased tissue through a nasal approach to improve ventilation and drainage • Sphenoidectomy: Creation of a surgical opening into one or both of the sphenoidal sinuses • Repair of nasal fracture: Manipulation and mobilization of nasal bones

Pediatric Otologic Surgery • Myringotomy: Incision into the tympanic membrane to treat chronic otitis media with exudates. Commonly involves placement of tympanostomy tubes to facilitate drainage

Neck and Throat Surgery • Thyroidectomy: Removal of the thyroid gland for hyperthyroidism or goiter threatening airway obstruction • Subtotal thyroidectomy: Removal of most of the thyroid gland, leaving the posterior portion of each lobe to prevent damage to the recurrent laryngeal nerve and parathyroid glands • Thyroid lobectomy: Removal of a lobe of the thyroid gland • Parathyroidectomy: Removal of one or more lobes of the parathyroid gland as treatment for adenoma, hyperplasia, or carcinoma • Laryngoscopy and microlaryngoscopy: Direct visualization of the larynx using a laryngoscope. Also allows for biopsy or removal of vocal cord polyps • Tonsillectomy and adenoidectomy: Removal of tonsils and adenoids • Parotidectomy: Removal of part or all of the parotid gland as treatment for benign salivary gland tumor, inflammatory lesions, vascular anomalies, and metastatic cancer involving lymph nodes over gland


• Tracheostomy: Opening in the trachea and insertion of a cannula through a midline incision in the neck below the cricoid cartilage to establish an airway. May be an emergency procedure to preserve an airway, or to protect the airway during other ENT surgery, or to allow for removal of nasal or oral endotracheal tubes for prolonged ventilator patients • Uvulopalatopharyngoplasty: Resection and reconstruction of the soft palate and pharynx as treatment for obstructive sleep apnea. Many of the patients who undergo this procedure are extremely obese and will require a simultaneous tracheostomy • Laryngectomy: Removal of the larynx, usually as treatment for laryngeal cancer; Supraglottic approach excises tissue above the level of the vocal cords maintaining respiratory, phonation, and sphincter functions of the larynx. A total laryngectomy involves complete removal of the larynx, hyoid bone, and laryngeal muscles. Patients will lose speaking ability and will require a tracheostomy • Radial neck dissection: Removal of a tumor in the neck, as well as surrounding structures, including the sternocleidomastoid muscle, internal jugular vein, 11th cranial nerve, and lymph nodes • Modified radical neck dissection: Removal of neck tumor leaving the sternocleidomastoid muscle, internal jugular vein, and 11th cranial nerve intact

Gastrointestinal Surgical Patients Patients scheduled for gastrointestinal surgery may be undergoing procedures to • Establish a diagnosis • Correct pathophysiologic conditions, includCOACH ing obesity CONSULT • Correct congenital malformations Surgery may involve the esophagus, stomThe major priority for the ach, biliary or hepatic systems, small and large gastrointestinal surgical intestines, and the rectum or anus. patient will be prevention of infection and protection of the airway by prevention of aspiration and vomiting, as well as ensuring a means for elimination.

Gastrointestinal Surgical Procedures • Esophagectomy: Removal of the esophagus, usually for carcinoma • Esophagogastrectomy: Removal of cancerous portion of esophagus and stomach


• Hiatal hernia repair: Restoration of the cardioesophageal junction with the goal of correcting esophageal reflux (also referred to as a Nissen fundoplication) • Gastroscopy: Direct visualization of the stomach, with possible aspiration of contents and biopsy using a gastroscope passed through the mouth • Vagotomy: Resection of the vagal nerves, either at the distal esophagus or at the bifurcation into the gastric and extragastric divisions, known as selective vagotomy. Selective vagotomy maintains innervation of the stomach. Truncal vagotomy is usually combined with pyloroplasty to minimize problem with gastric stasis. Both result in postoperative problem of diarrhea known as dumping syndrome. Parietal cell, or highly selective, vagotomy denervates only the parietal section of the stomach to minimize or avoid dumping syndrome • Pyloroplasty: Formation of a larger passageway from the stomach into the duodenum to facilitate gastric emptying. May be used for treatment of peptic ulcer or in conjunction with a vagotomy • Gastrojejunostomy: Establishment of a passageway between the proximal jejunum and the stomach to treat gastric obstruction • Partial gastrectomy: Resection of a diseased portion of the stomach. Billroth I: Designed to treat benign or metastatic growths in the upper half of the stomach. Billroth II: Designed to treat benign or metastatic growths in the distal portion of the stomach or duodenum • Gastrectomy: Removal of the stomach with subsequent attachment of the esophagus to the jejunum. Curative or palliative for metastatic carcinoma of the stomach and surrounding lymph nodes • Gastric banding: Type of bariatric surgery where the size of the opening from the esophagus to the stomach is reduced by a gastric band. Surgeon can adjust size of the opening by inflating or deflating the band via an adjustment port placed in the abdominal wall. Can be removed if desired. Done via laparoscopy. Also known as Lap-Band® and adjustable banding • Gastric bypass: Type of bariatric surgery in which the stomach is permanently reduced in size to an egg-shaped pouch that is connected directly to the intestine, bypassing the duodenum as well as part of the jejunum to decrease absorption. May be done as open or laparoscopic procedure. Also known as Roux-en-Y Intraoperative Considerations 101

• Biliopancreatic diversion bypass: Less common type of bariatric surgery in which portions of the stomach are removed and the bypass is attached to the distal ilium. Not common because of a high risk of nutritional deficiencies • Laparotomy: Incision through the abdominal wall into the peritoneal cavity. May be diagnostic for bleeding or pain, therapeutic to treat disease or remove an organ, palliative to debulk a tumor, or prophylactic to prevent spread of tumor • Appendectomy: Removal of the appendix from the cecum. May be removed for inflammation of may be removed when the abdomen is opened for another procedure • Colonoscopy and sigmoidoscopy: Direct visualization of the large intestine, with possible removal of polyps or tissue for biopsy using a colonoscope passed through the rectum • Ileostomy: Formation of a temporary or permanent opening into the ileum with drainage diverted through an ostomy to an external drainage device. May be secondary procedure during large bowel resection. May utilize a Kock pouch or a continent ileostomy • Colostomy: Formation of a temporary or permanent opening into the colon with drainage diverted through an ostomy to an external drainage device. May be temporary for bowel rest or permanent • Hemicolectomy: Resection of the right half of the colon, usually combined with an ileostomy as treatment for colon cancer • Transverse colectomy: Excision of the transverse colon as treatment for malignant lesion. May also require total gastrectomy if lesion has invaded the stomach • Abdominoperineal resection: Removal of diseased portion of the lower bowel as treatment for carcinoma of the lower sigmoid colon, rectum, and anus. Requires formation of a colostomy • Hemorrhoidectomy: Removal of dilated rectal veins causing bleeding and pain • Cholecystectomy: Removal of the gallbladder for inflammation, stones, polyps, or carcinoma. May be done via open or laparoscopic technique • Cholangiogram: Use of x-ray to visualize the common bile duct and hepatic ductal branches. Commonly done in conjunction with open-approach cholecystectomy


• Choledochojejunostomy: Anastomosis between the common bile duct and either the jejunum or duodenum. May be required as a secondary procedure after a cholecystectomy to facilitate drainage of bile into the intestinal tract. Also known as choledochoduodenostomy • Drainage of pancreatic cysts: Drainage of pancreatic cysts either internally into the small intestine or stomach, or externally • Pancreatoduodenectomy: Removal of the head of the pancreas, duodenum, part of the jejunum, distal third of the stomach, lower half of the common bile duct, with subsequent reanastomosis of the biliary, pancreatic, and gastrointestinal tracts as treatment for metastatic cancer. Also known as Whipple procedure • Pancreas transplant: Implantation of a donor pancreas • Pancreatectomy: Removal of the pancreas • Hepatic resection: Removal of a lobe or segment of the liver as treatment for tumors. Also known as hepatic lobectomy, segmentectomy, or partial hepatectomy • Liver transplant: Removal of diseased liver, such as from cirrhosis or cancer, with implantation of donor liver • Splenectomy: Removal of the spleen done in cases of trauma or as treatment for hemolytic or splenic anemia or tumors, cysts, or splenomegaly • Herniorrhaphy: Procedure used to repair defect in the abdominal wall. Used to treat inguinal, abdominal, ventral, and umbilical hernias

Pediatric GI Procedures • Laparoscopic pyloromyotomy: Procedure to enlarge pyloric sphincter to correct pyloric stenosis in the newborn

Gynecologic Surgical Patients Patients scheduled for gynecologic surgery may undergo diagnostic procedures, procedures to remove growths or organs, or procedures to correct anatomic deviations of pathology. Surgery may also be scheduled to prevent or terminate pregnancy, or for assisted delivery (c-section).

ALERT The priority for gynecologic surgical patients will be on the prevention of infection and attention to detail so that the bladder or bowel is not inadvertently perforated.


Gynecologic Surgical Procedures • Vulvectomy: Removal of malignant disease of the vulva • Vaginal repair: Done to correct a cystocele, a herniation of bladder that causes anterior vaginal wall to bulge forward, or a rectocele, a protrusion of the anterior rectal wall into the vagina • Vaginal reconstruction: Correction of congenital or surgical defects of the vagina • Dilatation of the cervix and curettage: Use of instruments to dilate the cervix with subsequent evacuation of uterine contents. Used diagnostically to terminate a pregnancy or following an incomplete abortion; also known as D&C • Suction curettage: Vacuum aspiration of uterine contents for termination of pregnancy or for an incomplete abortion • Cerclage: Treatment of an incompetent cervix during pregnancy by closing cervical os with a suture to prevent premature dilation and birth; also known as Shirodkar procedure • Conization and biopsy of the cervix: Removal of diseased cervical tissue to treat strictures, cervicitis, and carcinoma • Marsupialization of Bartholin’s cyst: Removal or drainage of a cyst in the Bartholin’s gland through vaginal outlet • Hysteroscopy: Endoscopic visualization of the uterine cavity and tubal orifices. Done diagnostically to evaluate infertility, polyps, and for bleeding, or to remove an IUD, adhesions, or for tubal sterilization • Hysterectomy: Removal of the uterus through either a vaginal or abdominal approach; the abdominal approach may be either open or laparoscopic • Laparoscopy: Endoscopic visualization of the peritoneal cavity through the anterior abdominal wall. Done to diagnose pelvic pain, infertility, bleeding, and pelvic masses • Pelvic exenteration: Removal of the rectum, distal sigmoid colon, bladder, distal ureters, internal iliac vessels, all pelvic reproductive organs and their lymph nodes, and the entire pelvic floor as treatment for cervical carcinoma that is unresponsive to radiation. Usually requires urinary and bowel diversion • Uterine suspension: Repositioning of the uterus as treatment for uterine prolapse • Oophorectomy: Removal of an ovary, usually for an ovarian cyst


• Salpingo-oophorectomy: Removal of a fallopian tube and all or part of the associated ovary • In vitro fertilization and embryo transfer: Retrieval of oocytes (eggs) from the ovary, followed by fertilization outside of the body with sperm and implantation of the fertilized embryos into the uterine cavity • Cesarean section: Surgical delivery of a fetus through an abdominal approach • Tubal ligation: Procedure to cut the fallopian tubes for permanent sterilization

After the Procedure At the end of the case, the circulating nurse and scrub nurse will confirm instrument, sharp, and sponge counts prior to the closure of the surgical incision, and with skin closure. The circulating nurse will then assist the anesthesia provider in the safe transfer of the patient to the PACU, while the scrub nurse begins breaking down the room and bringing instruments back for cleaning and resterilization. Documentation will be completed, and the patient escorted to the PACU, where report will be given to the receiving PACU nurse by the anesthesia provider, and frequently, the OR nurse.

Cleaning, Disinfection, and Sterilization of Equipment Also in the interest of patient safety, any object that is used in surgery must be either disposable and limited to single patient use, or if nondisposable, must be able to be cleaned, disinfected, and sterilized. Cleaning refers to the removal of surface contaminants through physical scrubbing, commonly with soap and water, and occasionally ultrasound to loosen debris. This will be used to remove blood, tissue, and other visible substances on a piece of equipment, prior to more intensive decontamination. Cleaning does not kill microorganisms, but is used to prepare the surface of items. Disinfection involves the killing or inactivation of microorganisms through immersion of the object in a liquid disinfectant. This may be referred to as “germicidal” cleaning, and does not result in the complete elimination of all microorganisms. Soaking of instruments in a germicidal solution, such as Cidex, is done as the intermediate step just prior to sterilization of the object.


Sterilization renders the object free of all microorganisms, most commonly through the use of an autoclave, which combines heat, steam, pressure, and time. The sterilized objects are then packaged individually or wrapped as part of a surgical tray, such as a laparotomy tray, which will contain multiple instruments required for a specific procedure. The use of prepared trays speeds OR prep and set-up time, as they can be tailored not only to specific surgeries, but to the needs of particular surgeons as well. Only sterile objects will enter the surgical field, again with the goal of patient safety and prevention of infection.


CHAPTER

5

Fluid, Electrolytes, and Acid-Base

O

ne of the most important responsibilities you will have in managing the postoperative patient is the management of fluid therapy, and the anticipation of electrolyte and acid-base abnormalities. In the surgical patient, IV access is necessary for the administration of anesthetic agents, fluid, and potentially blood products.

Anatomy of Body Fluids Approximately half of an individual’s weight is solid, with the other half fluid. The solid portion is made up of bone, muscle, and other organ tissue. The fluid portion consists of three functional compartments: 1. Plasma volume (PV) 2. Interstitial fluid (ISF) 3. Intracellular fluid (ICF) Together, these three volumes are referred to as total body water (TBW). Total body water is estimated as percentage of body weight and varies with age, gender, and body style. For example • An infant’s total body water is estimated at 70% to 80% of total body weight • For adult males, total body water is estimated at 55% • For adult females, total body water is estimated at 45% • For lean, muscular individuals, total body water is estimated at 75%. PV combined with ISF make up the extracellular fluid volume (ECF), which accounts for 20% of body weight. Some references will refer to an additional contributor to extracellular fluid: transcellular fluid. This fluid type includes fluids such as cerebrospinal fluid, pleural and peritoneal fluids, synovial fluids, and digestive juices. 107

Fluid Regulation COACH CONSULT

Control over fluid balance is regulated by three control mechanisms: It is easy to remember the 1. Renin-angiotensin-aldosterone system (RAAS) functional fluid compart2. Anti-diuretic hormone (ADH) ments by using the rule 3. Sympathetic nervous system of thirds: TBW is two-thirds Decreased blood flow to the kidney in ICF and one-third ECF. Of hypovolemia activates the renin-angiotensinthe ECF, two thirds is ISF and one-third is plasma. aldosterone system. The kidney releases renin, causing activation of angiotensin I and its conversion to angiotensin II. Concurrently, the adrenal glands release aldosterone. The outcome is vasoconstriction and increased arterial pressure. ADH is secreted in response to decreased perfusion and changes in osmolality. When the osmolality of ECF increases, as seen with hypovolemia, the pituitary gland secretes ADH. When ECF osmolality decreases, ADH secretion is inhibited. ADH acts on the distal tubules of the kidney to increase their permeability to water, allowing for increased water reabsorption and increased arterial pressure and increased perfusion. The sympathetic nervous system, in conjunction with the cardiovascular system, responds to changes in fluid volume, which directly affects arterial blood pressure and urinary output. Increased blood volume increases cardiac output. The increase in cardiac output causes an increase in arterial pressure, improving renal perfusion, causing an increase in urine output. A decrease in blood volume causes a fall in cardiac output, hypoperfusion of the kidneys, and a fall in urine output.

Plasma Proteins Within the ECF, the electrolyte concentration is similar between plasma and the ISF; however, plasma has an albumin concentration four times that of the ISF. This concentration of plasma proteins, primarily albumin, exerts an osmotic pressure that opposes the transcapillary filtration of plasma. Plasma proteins, in order of abundance, include the following: • Albumin: Maintains colloidal osmotic pressure • Globulins: Responsible for immune functioning • Fibrinogen: Responsible for blood clotting Because plasma osmotic pressure exceeds the ISF osmotic pressure, fluid is drawn from the ISF into the plasma compartment. This same osmotic pressure prevents the continual loss of fluid from blood into the interstitial spaces. 108 Fluid, Electrolytes, and Acid-Base

Objectives of Fluid Therapy When an anesthesiologist or surgeon orders a specific fluid, it is done with a specific objective in mind. The fluid may be for • Maintenance of fluid balance • Replacement of fluid losses The physician will also determine whether an isotonic, hypotonic, or hypertonic fluid is needed to meet that goal. Isotonic solutions have a sodium concentration of 130 to 150 mEq/L and an osmolality of 280 to 310 mOsm/L. Hypotonic solutions have a sodium concentration of less than 130 mEq/L and an osmolality of less than 280 mOsm/L, whereas hypertonic solutions have a sodium concentration of greater that 150 mEq/L and an osmolality of greater than 310 mOsm/L. Isotonic solutions are distributed within the ECF, whereas hypotonic solutions are distributed throughout the TBW. Hypertonic solutions remain primarily in the ECF and draw fluid from the ICF. Only the circulating extracellular fluid, primarily that in plasma, is capable of supporting cardiac function.

Choice of Fluids The first choice that a surgeon or anesthesiologist must make after determining the objective of fluid therapy is to select between a crystalloid and a colloid solution.

Crystalloids Crystalloids are electrolyte solutions that move freely between the intravascular and interstitial compartments. Common crystalloids include the following*: COACH • D5W CONSULT • D5LR • Lactated Ringer’s Fluid losses from the lungs • D5NaCl 0.45% and skin are referred to as insensible losses, as they • D5NaCl 0.9% are fluid losses that cannot • 0.9% NaCl be directly measured, but • 0.45% NaCl are known to exist. In the *Note: D ⫽ dextrose; W ⫽ water; NaCl ⫽ adult, approximately sodium chloride. 1000 mL of ECF are lost daily, with approximately Crystalloids are generally used 600 mL through the skin, • As maintenance fluids to compensate and another 400 mL for fluid losses from the lungs during through respiration. Fluid, Electrolytes, and Acid-Base 109

respiration, skin from perspiration and evaporation, as well as urine and feces • As replacement solutions to correct body fluid deficits • To correct specific fluid or electrolyte alterations Lactated Ringer’s is the crystalloid solution that most closely resembles the electrolyte composition of ECF. Table 5–1 compares ECF and commercial fluids. Table 5–2 identifies the primary role for each fluid, as well as its osmolality type. Table 5–1

Comparison of Extracellular Fluid and Commercial Fluids

SOLUTION SODIUM

POTASMAGNEBICARSIUM CALCIUM SIUM CHLORIDE BONATE

OSMOLALITY

ECF

142

4

5

3

103

27

270–300

Lactated Ringer’s

130

4

3

—

109

28

273

0.9% NaCl

154

—

—

—

154

—

308

D5 45% NaCl

77

—

—

—

77

—

407

D5W

—

—

—

—

—

—

253

Na, sodium; Cl, chloride; D, dextrose; W, water

Table 5–2

Crystalloid Fluids: Purpose and Osmolality

FLUID TYPE

PRIMARY PURPOSE

OSMOLALITY (mEq/L)

D5W

Maintenance

Hypotonic

D5LR

Replacement

Hypotonic

Lactated Ringer’s

Replacement

Hypotonic

D5NaCl 0.45%

Maintenance

Hypotonic

0.9% NaCl

Replacement

Hypertonic

D5NaCl

Replacement

Hypertonic

Na, sodium; Cl, chloride; D, dextrose; W, water; LR, Lactated Ringer’s

110 Fluid, Electrolytes, and Acid-Base

Colloids Colloids are natural or synthetic solutions that COACH CONSULT maintain colloid osmotic pressure within the intravascular space, helping to maintain circuThe concept of colloid lating volume and pressure. Available colloidal osmotic pressure is central solutions include the following: to the debate over the use • Albumin 5% of colloids versus crystalloids in the resuscitation • Albumin 25% of patients in shock and the • Hetastarch 6% development of pulmonary • Dextran 40 edema associated with • Dextran 70 fluid resuscitation. Colloids are more osmotically active Albumin is obtained from pooled human than crystalloids, and draw plasma, pasteurized and chemically stabilized. water from the interstitial It is packaged in either normal saline, as a space into plasma. This is 5% solution; or as a 25% salt-poor solution. beneficial when trying to Hetastarch is a synthetic, waxy starch solution, maintain a circulating volume to maintain blood composed primarily of amylopectin. This solupressure and perfusion. tion produces a 6% solution with an osmolality of 310 mOsm/L. Dextrans are also synthetic. Dextran 40 is available as a 10% solution in 0.9% sodium chloride with an osmolality of 258 mOsm/L, whereas Dextran 70 comes in a 6% solution of 0.9% sodium chloride with an osmolality of 308 mOsm/L. Colloids are generally used for fluid replacement, shock resuscitation, and fluid challenges. Table 5–3 summarizes the advantages and disadvantages of using crystalloids in comparison to colloids. Table 5–3

Crystalloids

Crystalloids vs Colloids: Advantages and Disadvantages ADVANTAGES

DISADVANTAGES

Inexpensive Restores urinary flow Restores third space losses

Dilution of plasma proteins Reduces colloidal oncotic pressure Peripheral edema Pulmonary edema Transient effect

Continued

Fluid, Electrolytes, and Acid-Base 111

Table 5–3 Crystalloids vs Colloids: Advantages and Disadvantages—Cont’d

Colloids

ADVANTAGES

DISADVANTAGES

Sustained increase in plasma volume Smaller volume for resuscitation Less peripheral edema Remains intravascular More rapid resuscitation

Expensive Coagulopathy (Dextran > Hetastarch) Anaphylactic reaction (Dextran) Decreased calcium (Albumin) Renal failure (Dextran) Osmotic diuresis

Calculation of Fluid Rates Maintenance fluid requirements differ with age. For example • Adults require 1.5 to 2 mL/kg/hour • Children require 2 to 4 mL/kg/hour • Infants require 4 to 6 mL/kg/hour The amount of fluid required to maintain fluid balance can be calculated according to the following formula: Water deficit ⫽ 0.6 ⫻ Weight (kg) ⫻

Serum Na⫹⫹ ⫺ 140

140 Water deficit refers to the amount of fluid required to replace insensible losses. Half of the water deficit is usually replaced within the first 8 hours after surgery, with the remaining fluid replaced over the next 16 hours. In addition to maintenance and deficit fluid correction, ongoing fluid losses must be replaced, usually at the rate of 3 cc of crystalloid for every cc of blood lost.

Fluid Therapy in the Perioperative Period Fluid therapy in the perioperative period is directed at optimizing the patient’s volume status before surgery. This requires correction of • Volume changes due to hypovolemia and low preload • Concentration changes as manifested by electrolyte abnormalities • Miscellaneous abnormalities, such as glucose alterations Fluid therapy intraoperatively is directed toward providing fluid for maintenance requirements, deficits caused by bleeding and other fluid losses, and surgical trauma.


Box 5–1

Principles of Perioperative Fluid Administration

• Use a maintenance solution to replace insensible losses for the interval since the last oral intake at the rate of 2 cc/kg/hour • Use a replacement-type solution of intraoperative insensible losses at the same rate of 2 cc/kg/hour • Estimate surgical blood loss and replace with crystalloids at the rate of 3 cc for every cc lost • Infuse colloids, cc for cc, for blood loss exceeding 20% of the patient’s estimated blood volume

Fluid therapy may range from minimal to no fluid replacement in the instances of surgery with minor to no blood loss, such as in cataract extraction and arthroscopy, to the use of multiple blood products in the event of extreme hemorrhage. There is no one specific protocol for fluid administration that will apply under all circumstances. That said, there are principles that govern intraoperative fluid administration, as identified in Box 5–1.

Evaluation of Volume Status One of your responsibilities in caring for postoperative patients will be to maintain ordered fluid therapy, and to monitor the patient’s response to this therapy. Evaluation of the fluid status in the post-anesthesia care unit (PACU) requires assessment of the following: • Heart rate • Pulse quality • Blood pressure (lying and orthostatic) • Skin color and turgor • Mucous membrane moisture • Urine output The patient at risk for hypovolemia is a patient who has experienced a recent volume loss, for example, a surgical blood loss. If hypovolemic, the patient will present with tachycardia as a compensatory response to low volume, decreased intensity pulses, low blood pressure with orthostatic variation, pallor, decreased skin turgor, dry mucous membranes, and oliguria, defined as a urine output of less than 1 cc/kg/hour. If present, the patient will also present with low filling pressures, including a low central venous pressure and low pulmonary artery occlusion pressure.


If severe, hypovolemic shock will develop, evidenced by • Altered neurologic status, including confusion and lack of responsiveness • Oliguria or anuria • Systolic blood pressure of less than 90 mm Hg • Tachycardia that becomes bradycardia with progressive decompensation The normovolemic patient will have a stable heart rate and blood pressure consistent with preoperative values, no orthostatic changes, good skin color, brisk turgor, and a urine output of at least 1 cc/kg/hour. The hypervolemic patient will present with signs of fluid overload, usually in the form of edema. Pulmonary edema will cause the patient to present with moist rales and dyspnea, and signs of compromised oxygenation, such as a decreased saturation. Peripheral edema will compromise myocardial function as the heart has to pump against an increased afterload with a decreased preload. The patient may present with bounding pulses, increased blood pressure until the point of failure, and then decreased pressure, widening pulse pressure, and increased weight gain. COACH CONSULT You can assess for edema in peripheral tissues by looking for and palpating for dependent edema, particularly in the ankles. In the lungs, pulmonary edema will manifest as crackles, hypoxemia, and decreased saturation. Third spacing of fluids, fluid that is neither intracellular nor extracellular, but lodged in tissues, will not be seen until the third postoperative day, and may be a cause of hypotension.

Edema Edema is an accumulation of fluids within tissues caused by • An increase in hydrostatic pressure due to venous obstruction • Sodium and water retention • Decreased plasma oncotic pressure through the loss of plasma proteins • Increased capillary permeability associated with inflammation • Lymphatic obstruction Fluid status can also be evaluated using laboratory studies for concentration status, including the following: • Serum sodium concentration • ⬍135 mEq/L hemodiluted, volume overload • ⬎145 mEq/L hemoconcentrated, volume depletion

• Serum osmolality • ⬍270 mOsm/L hemodiluted, volume overload • ⬎300 mOsm/L hemoconcentrated, volume depletion 114 Fluid, Electrolytes, and Acid-Base

Electrolytes Electrolytes in the body, dissolved in both extracellular and intracellular fluid, are referred to as “charged ions.” A positively charged ion is known as a cation. A negatively charged ion is an anion. The electrolyte composition of the fluid compartments is different, particularly for sodium (Na⫹⫹) and potassium (K⫹) concentrations. In ECF, sodium is the predominant electrolyte, along with chloride and bicarbonate. In ICF, potassium is the predominant electrolyte, along with magnesium and phosphate. Electrolytes maintain cell structure by their osmotic effect, and have specialized roles in maintaining metabolic and cellular functions. Each has a specific regulatory mechanism to keep the electrolyte within a normal range to maintain homeostasis. Prior to going to surgery, laboratory tests may be ordered and drawn to verify that electrolytes are within normal limits, particularly when fluid shifts or major physiologic disruption is anticipated. The electrolyte alterations seen in the PACU are more likely to be a consequence of the type of surgery and intraoperative management. The electrolytes most likely to be affected by surgical intervention and fluid administration include sodium, chloride, potassium, calcium, magnesium, phosphate, and bicarbonate. Normal values for these electrolytes are listed in Table 5–4.

Table 5–4

Normal Electrolyte Values

ELECTROLYTE AND CHEMICAL SYMBOL

NORMAL RANGE

Sodium Na⫹⫹

135–145 mEq/L

Chloride Cl⫺

95–108 mEq/L

Potassium K⫹

3.5–5.0 mEq/L

Calcium Ca⫹⫹

8.5–10.5 mg/dL

Magnesium Mg⫹⫹

1.5–2.0 mEq/L

Phosphate PO4⫺

1.7–2.6 mEq/L

Bicarbonate HCO3⫺

22–26 mEq/L


As a result of the effects of anesthesia and medications given for pain management, many of the traditional signs and symptoms of electrolyte abnormalities will not be seen in the PACU.

Sodium Sodium is the primary ECF cation. The normal serum sodium concentration ranges from 135 mEq/L to 145 mEq/L. Sodium is regulated in proportion with water and chloride, which is why osmolality, as well as serum sodium, can be used to estimate volume status. Sodium has a few roles: • Working with potassium to support impulse transmission in nerve and muscle fibers • Influencing levels of potassium and chloride • Influencing acid-base balance by combining with chloride and bicarbonate • Regulating of blood volume in conjunction with chloride Hyponatremia in the perioperative period may occur when sodium is lost in excess of water, as may be seen with prolonged diuretic therapy, excessive burns, excessive diaphoresis, prolonged vomiting or nasogastric suction, and renal disease. Water gain in excess of sodium may produce a dilutional hyponatremia. This may be seen in patients who have undergone transurethral resection of the prostate (TURP). As many as 10% of patients undergoing a TURP will present with dilutional hyponatremia. In this procedure, the surgical field is continuously irrigated with 1.5% glycine solution to keep the surgical field free of tissue fragments and blood. Because of the vascularity of the prostate, as much as 6 to 8 liters of the irrigant may be absorbed into circulation. The amount of fluid absorbed will be directly related to the amount of bleeding and the length of the surgical procedure. Glycine is used as it is isotonic, and nonconductive when combined with electrocautery. Postoperatively, patients may present with complaints of headache and visual changes or, if severe, neurologic changes, including changes in pupillary reflexes, confusion, and agitation. The confusion and agitation may be attributed to awakening from anesthesia and the pupillary changes due to the effects of narcotics. Hyponatremia may not be initially suspected. Likewise, cardiac signs of hyponatremia, including bradycardia, widening QRS complexes, ST elevations, and T-wave inversion may be attributed to bradycardia seen with a high spinal anesthetic or a developing myocardial infarction. Drawing a serum sodium will confirm the diagnosis of hyponatremia, which will be treated with the administration of diuretics to eliminate excess fluid, and the controlled administration of 116 Fluid, Electrolytes, and Acid-Base

normal saline IV fluids. Serial serum sodium levels will confirm restoration of a normal level. Hypernatremia is rare in the perioperative period, as hypertonic solutions are rarely used perioperatively, excepting 0.9% normal saline used when administering blood products. Tube feedings can also contribute to hypernatremia, however, those will have been stopped prior to surgery to facilitate gastric and intestinal emptying. Rarely will the patient present with any signs or symptoms of sodium alterations in the PACU. Alterations are most commonly detected when laboratory tests are drawn postoperatively to compare with a preoperative baseline. This will only be done in anticipation of a prolonged hospital stay, or following fluid resuscitation in the operating room.

Potassium Potassium is the primary ICF cation. The normal serum potassium level ranges from 3.5 mEq/L to 5.0 mEq/L. Potassium is regulated primarily through the renal system. Roles of potassium include the following: • Regulating osmolarity of ECF by exchanging with sodium • Maintaining the electric membrane potential between the ECF and ICF • Maintaining neuromuscular contractility • Maintaining cardiac contractility. Hypokalemia in the perioperative period may occur as a result of prolonged diuretic therapy, prolonged vomiting and nasogastric suctioning, severe diaphoresis, and renal tubule defects. As potassium moves readily between the intracellular and extracellular spaces, any extracellular loss is usually rapidly corrected by an intracellular shift. This requires the PACU nurse to be astute in recognizing potential causes of potassium loss, and to monitor serum potassium levels, as acute changes can cause adverse, and potentially lethal, myocardial and neuromuscular effects. Hypokalemia is most commonly suspected in the PACU when aberrant electrical activity is noted on ECG. This may include premature ventricular contractions, ST-segment depression, and flattened T waves. Correction of hypokalemia requires the administration of IV potassium. Hyperkalemia is uncommon in the perioperative period, except in patients with a history of chronic renal failure, who may be presenting for surgery to correct a clotted AV shunt so that they may resume scheduled dialysis. Although a hyperkalemic cardioplegic solution is used in cardiac bypass surgery, most of these patients develop hypokalemia Fluid, Electrolytes, and Acid-Base 117

ALERT IV potassium will never be administered via IV push, no matter how low the serum potassium may be. Potassium must be diluted, usually 20 mEq or 40 mEq in a minimum of 100 or 250 cc of IV fluid, and administered over an hour, using an infusion pump. This is done to prevent inadvertent rapid administration, which could produce cardiac arrest. Cardiac monitoring should be maintained during potassium replacement. It is also important to assess renal function prior to the administration of IV potassium supplements. As potassium is regulated through the kidneys, a reduced dose will be given in patients with renal insufficiency to prevent hyperkalemia from developing.

following surgery, due to either increased catecholamines causing potassium to move intracellularly or the administration of a loop diuretic such as furosemide. Unexplained hyperkalemia detected in preoperative laboratory testing is grounds for cancellation of surgery pending medical evaluation to determine cause, which is most commonly renal disease.

Chloride

Chloride is the major anion of ECF. Normal values range from 95 to 108 mEq/L. Chloride levels are regulated by renal and extrarenal mechanisms. Chloride will be reabsorbed or excreted along with sodium. Like sodium, a change in the serum chloride level may be due to a change in dilution or absolute concentration. Any alteration in sodium will result in an abnormality of chloride. The regulation of chloride is dependent upon the regulation of sodium, with reabsorption or excretion by the kidneys, as needed to maintain serum concentrations. Chloride has the following roles: • To work with sodium to maintain serum osmolality of ECF • To maintain fluid balance • To maintain acid-base balance by shifting in and out of red blood cells in exchange for bicarbonate • To facilitate release of oxygen from hemoglobin • As a major component of hydrochloric acid in the stomach Hypochloremia is defined as a serum chloride of less than 95 mEq/L, and most commonly accompanies hyponatremia. The most common causes of hypochloremia in the perioperative period include the following: • Vomiting • Nasogastric suction • Irrigation • Diuretic therapy There are no specific signs or symptoms that support a diagnosis of hypochloremia. Hypochloremia may be a concomitant finding with


hyponatremia, and should be suspected in any patient following excessive intraoperative fluid irrigation, such as a TURP. Correction of the accompanying hyponatremia will also correct hypochloremia. Hyperchloremia, evidenced by a chloride level of greater than 108 mEq/L, as with hypernatremia, is rare in the PACU, as the use of hypertonic IV fluids is uncommon in the perioperative period. Hyperchloremia may manifest as metabolic acidosis, either due to a decrease in bicarbonate, which results in an increase in chloride or as an increase in hydrogen ions due to an accumulation of acids.

Calcium Calcium is another major cation, with almost 95% being found within bone, nails, and teeth. Calcium not bound to bones and teeth is bound to either plasma proteins, primarily albumin, or is ionized. Ionized calcium is also referred to as free calcium. Free calcium is what is measured when obtaining a serum calcium level. A normal serum calcium level is 8.5 mg/dL to 10.5 mg/dL. Free calcium is responsible for • Aiding in blood clotting • Capillary membrane integrity • Neuromuscular contractility • Cardiac contractility • Hormonal secretion • Development of bones and teeth As calcium levels are maintained through diet, hypocalcemia can be an expected finding in anorexia, or in any condition that might result in malabsorption of calcium, such as gastrointestinal (GI) disease and alcohol abuse. Excessive use of the diuretic furosemide (Lasix) can cause excessive elimination of calcium as well. As calcium is heavily bound to plasma proteins, the finding of low serum calcium should require obtaining a serum albumin level to assess for hypoalbuminemia. The most common cause of hypocalcemia in the postsurgical patient is a low level of parathyroid hormone (PTH), which reduces calcium absorption. This may be seen in patients presenting for parathyroid surgery, with a preoperative diagnosis of hyperparathyroidism. Although PTH levels are usually high-normal, or high preceding surgery, following a parathyroidectomy there is the potential for a precipitous fall in PTH levels, which may produce clinical signs of hypocalcemia, including tetany. It used to be required that nurses keep


an ampule of calcium for IV administration at the bedside for any patient undergoing a parathyroidectomy, to treat any acute signs of hypocalcemia, including complaints of perioral numbness, of tingling of the fingers and toes, and seizure activity. Now that patients are generally discharged to home on the day of surgery, this is no longer required, and most surgeons have an established protocol for their patients to follow with oral supplemental calcium. The hypocalcemia following parathyroidectomy usually develops on postoperative day three. See Box 5–2 for tests to assess for hypocalcemia. Hypercalcemia is an uncommon finding in the perioperative period, as it is caused by excessive use of calcium supplements, or the use of medications that decrease calcium excretion, such as thiazide diuretics. It may also occur as a result of prolonged immobility, which triggers bone demineralization that causes calcium normally held by bone to be released into the serum.

Magnesium Magnesium is the second most abundant cation in intracellular fluid. The normal serum magnesium is 1.5 to 2.0 mEq/L. Only 1% of magnesium is ionized, with the reminder bound to bone (⬎60%) or contained within cells. Magnesium is rapidly being recognized for its important role in acute and chronic illness. Currently the regulation of magnesium within the body is not well understood, but it is affected by levels of vitamin D, the kidney, influence of the parathyroid glands, and potassium levels. The role of magnesium is to • Stabilize the neuromuscular junction • Assist in cardiac contractility • Support skeletal muscle contractility • Contribute to vasodilatation, affecting blood pressure and cardiac output • Facilitate sodium-potassium transport across COACH cell membranes CONSULT Hypomagnesemia, defined as a serum Fluids lost from the colon magnesium level of less than 1.5 mEq/L, have a higher magnesium may occur as a result of severe GI losses due content than fluids lost from to vomiting, diarrhea, gastric suctioning, and the upper GI system and loop diuretics. Inadequate absorption seen will cause hypomagnesemia to occur more rapidly. with malnutrition and malabsorption syndromes may also be potential causes. In the


Box 5–2

Testing for Hypocalcemia

Two bedside tests have been used to assess for hypocalcemia: the Trousseau’s test and the Chvostek’s test. Both are tests of neuromuscular irritability. To perform the Trousseau’s test, apply a blood pressure cuff and inflate it to 20 mm Hg above the patient’s systolic blood pressure. Allow the cuff to remain inflated for 3 to 5 minutes. Flexion of the wrist and hand constitutes a positive sign. This test is more specific than the Chvostek’s test, but it can be negative in the presence of symptomatic hypocalcemia (see Fig. 5–1). To perform the Chvostek’s test, tap the facial nerve in front of the ear and below the zygomatic bone. Facial twitching constitutes a positive sign. 10% of patients with hypocalcemia will have a positive Chvostek’s sign, but it is not diagnostic of hypocalcemia (see Fig. 5–2).

F I G U R E 5 - 1 : Trousseau’s sign.

F I G U R E 5 - 2 : Chvostek’s sign.


United States, chronic alcoholism is the most common cause of hypomagnesemia, occurring due to GI loss, malabsorption, and increased renal elimination. As magnesium is required for cardiac and skeletal muscle contractility, hypomagnesemia should be suspected in any patient presenting with dysrhythmias and hypotension, particularly in the presence of GI fluid losses. The ECG may reflect prolonged PR and T intervals, depressed ST segments, and inverted T waves. The patient may also present with signs of tetany, seizures, confusion, hyperactive deep tendon reflexes, and tremors—all signs of neuromuscular irritation. The patient may present with positive Trousseau’s and Chvostek’s tests. Hypomagnesemia will be confirmed with a serum level, commonly occurring with hypocalcemia and hypokalemia. Patients presenting with hypokalemia should be monitored for signs of impending hypomagnesemia. Treatment for hypomagnesemia will require administration of magnesium sulfate (MgSO4) intravenously. If less severe, hypomagnesemia may be treated with oral supplements. See Box 5–3 for tips on administering magnesium sulfate intravenously. Box 5–3

Administering Magnesium Sulfate

The administration of magnesium sulfate intravenously must be done with extreme caution, because rapid administration can cause cardiac arrest. Cardiac monitoring should be maintained during infusion. The patient may sweat or report feeling flushed during its administration, due to the vasodilation effects of the magnesium. The order for magnesium administration must contain the concentration of the solution to be administered, amount and type of fluid for the medication to be diluted, as well as the time frame for administration. For example: Administer 1 gram of MgSO4, diluted in 100 cc of 0.9% normal saline over 1 hour. If you are mixing up the infusion, remember to check the concentrations of magnesium very carefully, as magnesium comes in 10% solution, 20% solution, and 50% solution. One gram of magnesium sulfate is contained in 10 mL of a 10% solution, 5 mL of a 20% solution, and 2 mL of a 50% solution. Magnesium must always be given in diluted form. Renal function, specifically a serum creatinine, should also be checked prior to the administration of magnesium, because magnesium is primarily eliminated through the kidney. Any patient with renal insufficiency or renal failure will be at risk for developing hypermagnesemia, and therefore a reduction in dose will be ordered. Urine output monitoring is essential during the administration of magnesium. Output should be at least 30 mL/hour.


Hypermagnesemia, as defined as a serum magnesium level of greater than 2.0 mEq/L, is COACH rare in the perioperative patient. It occurs most CONSULT commonly in patients with advanced renal In symptomatic hypermagfailure or those with glomerular filtration rates nesemia, where the patient of less than 30 mL/min who may be exposed to is exhibiting cardiac effects medications containing magnesium, such as of respiratory distress, intravenous calcium antacids. Any patient with diagnosed renal disgluconate will be given ease will have laboratory tests drawn prior as a temporary measure. to surgery, and any abnormalities corrected. Calcium gluconate antagoCorrection begins with the elimination of any nizes the toxic effects of offending medications. If severe, the goal will magnesium by electrically opposing magnesium at be to promote the excretion of magnesium the sites of action. through the kidneys through fluid administration and the administration of loop diuretics such as furosemide (Lasix). Fluid administration must be done cautiously, as these patients have preexisting renal disease, which readily predisposes them to fluid overload.

Phosphate Phosphate is the most abundant intracellular anion. The normal phosphate level is 1.7 to 2.6 mEq/L or 2.5 to 4.5 mg/dL. Phosphate located within extracellular fluid is known as phosphorus. Phosphorus levels are regulated through the kidney and exist in a reciprocal relationship with calcium. As one increases, the other decreases. It can be expected that high serum phosphorus levels will decrease the movement of calcium from bone. Phosphorus • Acts as a buffer to maintain acid-base balance • Creates adenosine triphosphate (ATP) for cellular metabolism • Maintains bones and teeth • Maintains cell membrane integrity • Aids in metabolism of protein, fats, and carbohydrates • Acts as a component of deoxyribonucleic (DNA) acid and ribonucleic acid (RNA) Hypophosphatemia, characterized by a serum phosphorus level of less than 2.5 mg/dL or 2.6 mEq/L, is uncommon in the perioperative period unless accompanied by a concomitant finding of other electrolyte shifts including hypokalemia and hypermagnesemia, or acid-base alterations of metabolic acidosis and respiratory acidosis.


Symptoms of phosphorus deficiency center on signs of ATP deficiency, including altered neurologic signs of confusion, fatigue, weakness, and possibly seizures if severe. Oxygen transport may be impaired as red blood cell function becomes altered, presenting as a decreased oxygen saturation. Look for hypercalcemia as an accompanying sign. Treatment is centered on correction of hypoxemia, as well as correction of the concomitant electrolyte and acid-base alteration. Hyperphosphatemia, characterized by a serum phosphorus level of greater than 4.5 mg/dL or 2.6 mEq/L, also is uncommon in the perioperative period, unless accompanied by the finding of hypocalcemia. The most common causes of hyperphosphatemia outside of the perioperative period include excessive intake of foods or medications containing phosphorus, cellular destruction due to chemotherapy or trauma, and osteoporosis, in which low serum calcium levels cause phosphorus to be pulled from bone. Treatment can include the administration of medications that will bind with phosphate, such as aluminum-containing antacids, or dialysis to remove excess phosphorus. Neither treatment will be instituted in the PACU.

Bicarbonate Bicarbonate exists within both the intracellular fluid and the extracellular fluid. The normal range of bicarbonate is 22 to 26 mEq/L. Bicarbonate levels are regulated by the kidneys, directly in response to serum pH. The role of bicarbonate is to regulate pH through the carbonic acidbicarbonate buffer system. The body requires a narrow steady pH for optimal cellular and organ system functioning. The carbonic acidbicarbonate system buffers almost 90% of biochemical reactions in the body, maintaining a pH of 7.35 to 7.45. Understanding the role of bicarbonate, including deficits and excesses, requires an understanding of acid-base regulation in the body.

Acid-Base Balance Chemical reactions are ongoing in the body, producing acids and bases, as part of normal metabolism. An acid is any solution that contains, and is capable of releasing, hydrogen (H⫹) ions. An example of an acid within the body is hydrochloric acid, a gastric acid produced by the stomach. A base, or alkaline solution, is any solution that accepts hydrogen ions. Bicarbonate is an example of a base. Through buffer systems, the body will regulate acids and bases to maintain the pH between the narrow range of 7.35 to 7.45. 124 Fluid, Electrolytes, and Acid-Base

Measurement of pH requires obtaining a blood gas, usually arterial, to allow for assessment of oxygenation as well as acid-base status.

COACH CONSULT

Acid-Base Alterations

Remember, pH reflects the

amount of acid or base in a The condition called respiratory acidosis occurs solution, and is measured when blood pH falls as a result of decreased on a scale of 1 to 14. A pH respiration. When respiration is restricted, the of less than 6.9 is an acid. concentration of dissolved carbon dioxide in A pH of 7 is neutral, and a pH between 7.1 and 14 is the blood increases, making the blood too basic, or alkaline. In the acidic. In the PACU, respiratory depression body, the normal range may be caused by the effects of general of 7.35 to 7.45 is slightly anesthesia, narcotics, or benzodiazepines, as alkaline. A pH of less than 7.35 or greater than 7.45 well as preexisting medical conditions such as alters enzymatic activity asthma, emphysema, or in patients who and increases myocardial smoke. These patients will present with a pH irritability. A pH of less of less than 7.45, and a PCO2 of greater than than 6.8 or greater than 45. Treatment will require improvement of 7.8 is usually fatal. oxygenation and ventilation through correction of the underlying cause. In addition, you may need to encourage the patient to take deep breaths, increase the rate of mechanical COACH ventilation, decrease use of narcotics, or CONSULT administer reversal agents. See Chapter 9 for An arterial blood gas will additional discussion about the assessment provide you with 4 values: and management of hypoventilation. pH, PCO2, PO2, and HCO3. Metabolic acidosis is the decrease in blood pH The pH will indicate the overall acid-base balance. that results when excessive amounts of acidic The PCO2 reflects the respisubstances are released into the blood. In the ratory control of pH. The perioperative period, this is uncommon, but PO2 level reflects adequacy may be due to hyperglycemia, prolonged hyof oxygenation. The HCO3 potension or cardiac arrest, or septicemia. The reflects the renal control mechanisms. Normal ranges normal body response to this condition is ininclude the following: creased breathing to reduce the amount of • pH: 7.35–7.45 dissolved carbon dioxide in the blood. These • PCO2: 35–45 mm Hg patients will present with a pH of less than • PO2: 80–100 mm Hg • HCO3: 22–26 mEq/L 7.45, and an HCO3 of less than 22. Treatment requires management of the underlying cause, and frequently requires the administration of intravenous sodium bicarbonate as an immediate corrective measure.


Respiratory alkalosis results from hyperventilation that produces an increase in blood pH. Hyperventilation causes too much dissolved carbon dioxide to be removed from the blood, which decreases the carbonic acid concentration, which raises the blood pH. In the PACU, the most common causes of hyperventilation are pain and anxiety. These patients will present with a pH of greater than 7.45 and a PCO2 of less than 35. Treatment of the underlying cause will correct this alteration. As pain and anxiety are the most common causes in the PACU, the administration of titrated doses of narcotic will treat both of these underlying causes. Compassionate nursing care that acknowledges and addresses the patient’s anxiety through comfort and teaching will also help. Metabolic alkalosis is an increase in blood pH resulting from the release of alkaline materials into the blood. This can result from the ingestion of alkaline materials, and through overuse of diuretics, both uncommon in the PACU. The body usually responds to this condition by slowing breathing. These patients will present with a pH of greater than 7.45 and an HCO3 greater than 26. Treatment of this alteration requires treatment of the underlying cause.

Regulation of Acid-Base Balance There are three mechanisms to regulate acid-base within in the body. The most rapid systems are the buffer systems. Respiratory control mechanisms are the second fastest, followed by the renal control mechanisms.

Chemical Buffer Systems There are three chemical buffer systems within the body that work to regulate pH. A buffer acts to keep things they way they should be, to maintain a normal state. In the body, the goal is a pH as close to 7.4 as possible. These rapidly acting buffer systems will work together to continually release and accept free hydrogen ions to maintain a constant pH. The three systems are the 1. Carbonic acid–bicarbonate system 2. Phosphate buffer system 3. Protein buffer system Carbonic Acid–Bicarbonate Buffer System The carbonic acid–bicarbonate system is the primary buffer system of the ECF, buffering 90% of the metabolic reactions of the ECF. Buffering occurs in the body fluids and within the renal tubules. Carbon dioxide (CO2), as a byproduct of metabolism, combines with water (H2O) to form


carbonic acid (H2CO3). Carbonic acid dissociates into hydrogen (H⫹) and bicarbonate (HCO3⫺). This is represented by the chemical formula: CO2 ⫹ H2O ↔ H2CO3 ↔ H⫹ ⫹ HCO3⫺ Hydrogen can then be conserved when pH is excessively alkalotic or eliminated when the pH is excessively acidic. Bicarbonate can be conserved when the pH is excessively acidic, or eliminated when the pH is excessively alkalotic. The elimination of excess hydrogen ions can occur through either the lungs or the kidneys. Each system will work to aid the other. For example, when the patient is not breathing well and is retaining carbon dioxide, excess acid will accumulate. The kidneys will attempt to compensate for the failure of the lungs to eliminate the carbon dioxide, and will subsequently conserve bicarbonate to balance the excess acid. If the kidneys were to fail to eliminate excess bicarbonate, the lungs would compensate by increasing respirations to eliminate excess carbon dioxide. Phosphate Buffer System This system helps regulate pH in intracellular fluid, as phosphates are present in relatively large amounts in ICF and relatively small amounts in ECF. The phosphate system works in the same way as the carbonic acid–bicarbonate system, converting alkaline sodium phosphate (Na2HPO4) to acid sodium phosphate (NaH2PO4). Protein Buffer System Hemoglobin is one of the best protein buffers, maintaining acid-base by a process known as the chloride shift. The electrolyte chloride shifts in and out of red blood cells according to the level of oxygen in blood. For each chloride ion that leaves a red blood cell, a bicarbonate ion enters the cell. For each chloride ion that enters the cell, a bicarbonate ion is released. This system helps buffer intracellular fluid and plasma pH.

Respiratory Control Mechanisms The lungs, which control the body’s carbonic acid supply through the merger of carbon dioxide and water, are the second control mechanism to normalize pH. When the serum pH is too acidic, the lungs respond by deep, rapid breathing known as Kussmaul respirations. This helps eliminate carbon dioxide, making it less available to bind with water to make carbonic acid. If serum pH is too alkaline, the lungs respond with shallow, rapid respirations, designed to conserve carbon dioxide. This system maintains the carbonic acid–bicarbonate balance of 20:1, base to acid ratio. This system can respond to pH changes within minutes.


Renal Control Mechanisms COACH CONSULT Compensation is a term used to indicate the attempt of the body to normalize pH by using the system not affected by disease, medications, or other physiologic stressors, to stand in place of deficiencies within the opposite system. For example, if the lungs are not adequately maintaining oxygenation and effective ventilation, the renal control mechanisms will respond to normalize pH. If the body, as evidenced by the accumulation of acids or the depletion of bicarbonate, fails to control pH through renal regulation, the lungs will alter the pattern of respiration to compensate for the failure of the kidneys. If abnormalities are seen in either PCO2 or HCO3, yet the pH is normal, compensation has fully occurred.

The kidneys are capable of neutralizing more acid and more base than either the chemical buffer systems or the respiratory control mechanisms. Renal control focuses on bicarbonate reabsorption, bicarbonate production and excretion, and hydrogen ion excretion. If the serum pH is too acidic, the kidneys will reabsorb additional bicarbonate within the proximal renal tubule and will excrete hydrogen ions. If the serum pH is too alkaline, the kidneys will respond by excreting additional bicarbonate in the form of ammonium (NH4), which is a base. Renal control mechanisms, although very effective in normalizing pH, engage a slower process than either the chemical buffer systems or respiratory control mechanisms, and can take many hours, up to 3 days, to be fully effective. pH will be normalized, but PCO2 and HCO3 levels will reflect the attempt of the lungs and kidneys to compensate for the alterations in pH. After the underlying problem causing the imbalance is corrected, these levels will normalize.


CHAPTER

6

Post-anesthetic Assessment and Care

A

dmission to the post-anesthetic care unit (PACU) is designed to ensure a smooth transition from the operating room (OR) to the PACU. Your immediate priority will be to verify respiratory and circulatory adequacy through the initiation of pulse oximetry and cardiac monitoring. You should obtain a blood pressure (BP) measurement to compare with intraoperative and preoperative values. Look carefully for any signs of inadequate oxygenation and inadequate ventilation, as well as for signs of inadequate tissue perfusion (see Boxes 6–1, 6–2, and 6–3).

Box 6–1

Signs of Inadequate Oxygenation

CENTRAL NERVOUS SYSTEM • Restlessness • Agitation • Confusion • Coma • Muscle twitches or seizures CARDIOVASCULAR SYSTEM • Hypertension and tachycardia • Hypotension and bradycardia • Dysrhythmias • Poor capillary refill SKIN • Cyanosis PULMONARY SYSTEM • Increased to absent respiratory effort • SaO2 ⬍90% 129

Box 6–2

Signs and Symptoms of Inadequate Ventilation

SPONTANEOUS VENTILATION • ↑ or ↓ respiratory frequency • Nasal flaring • Suprasternal or intercostal retractions • ↓ to absent movement of air • ↓ to absent breath sounds • Abnormal airway sounds • Diminished chest wall movement • Diaphragmatic breathing ASSISTED OR CONTROLLED VENTILATION • ↑ frequency of respiratory efforts • ↓ chest wall movement • Abnormally high inflation pressures • ↓ to absent movement of air in ET tube • ↓ to absent breath sounds • ↓ air movement assessed by monitors

Box 6–3

Signs of Inadequate Tissue Perfusion

CENTRAL NERVOUS SYSTEM • Confusion • Impaired motor/sensory function CARDIOVASCULAR SYSTEM • Dysrhythmias • Complaints of chest pain SKIN • Cool and clammy • Cyanosis RENAL SYSTEM • Urine production ⬍1mL/kg/hour PULMONARY SYSTEM • SaO2 ⬍90%

It is important to initiate oxygen therapy for all patients who have had general anesthesia. If the patient is admitted with any invasive monitoring lines such as an arterial line or pulmonary artery catheter, these lines should be calibrated and monitoring established. Any drainage systems should also be established as appropriate. 130 Post-anesthetic Assessment and Care

Anesthesia Report COACH Once you have established monitoring and CONSULT quickly verified cardiopulmonary adequacy, The immediate PACU you can then obtain report from the anesthesia admission assessment is provider in preparation for continued care. designed to verify the The anesthesia provider will provide report ABCs of airway, breathing, to you, giving you important patient, surgical, and circulation. Once and anesthetic information. Providing a report established, a more in-depth postsurgical and is a Standard of Care for the American Society post-anesthetic assessment of Anesthesiologists and the American Society can be initiated. of Perianesthesia Nurses. The purpose is to promote patient safety and continuity of care. The report should contain information about the patient’s preoperative condition and the surgical and anesthetic course. You should document the report information on the PACU record. The anesthesia provider should not leave the bedside until you accept responsibility for care. The report should contain the following information: • General information • Patient name: Means to identify patient • Age: Recognition of physiologic changes of aging • Surgical procedure: Identifies surgical care • Name of surgeon: Responsible caregiver identified • Name of anesthesia provider: Responsible caregiver identified • Patient history • Acute: Identifies indication for surgery • Chronic: Identifies medical history • Current medication use: Identifies current medication use • Allergies: Identifies medications that should not be administered • Intraoperative management • Anesthetic agents used: Identifies drug-specific priorities • Intraoperative medications: Allows timing of next dose and intraoperative problems • Estimated blood loss: Potential need for transfusion • Fluid and blood administration: Identifies potential overload/volume deficit • Urine output: Identifies fluid balance baseline • Intraoperative course • Response to surgery and anesthesia: Identifies unexpected problems • Intraoperative laboratory results: Establishes current status Post-anesthetic Assessment and Care 131

Box 6–4

Sample PACU Report

Hannah Stollerman is a 62-year-old female, admitted following a cholecystectomy. Anesthesia included nitrous oxide, desflurane, 2 cc fentanyl, 1 mg of midazolam. She was paralyzed with vecuronium, and reversed with neostigmine and atropine. She received 1.25 mg of droperidol at the end of surgery to prevent nausea, and 1 gram of Ancef at 8 a.m. Estimated blood loss was 100 mL. Fluid replacement included 1800 mL of crystalloids. No blood products were given, no urine output. No intraoperative problems. No significant history. She is allergic to aspirin. No postoperative problems are anticipated. The attending surgeon was Browne, and the anesthesia team was Jordan and Cessie.

• PACU plan • Expected problems: Identifies anticipated areas of difficulty • Suggested interventions: Provides interventions for expected problems • Discharge plan: Identifies goals to be met before discharge See Box 6–4 for a sample PACU report. Once you have received report, it is time for you to complete a more in-depth assessment targeted toward postsurgical and post-anesthetic care. The findings from your assessment will be charted on the PACU record in a timely manner, with any changes from previous assessments noted.

Approaches to Assessment There are two approaches to assessment that can be used to organize your assessment. Picking one approach and using it consistently will improve your examination skills and prevent you from missing something important. They are the: 1. Major body systems approach 2. Head to toe approach

Major Body Systems Approach The most popular approach is the major body systems approach. In this approach, you will assess the systems most affected by anesthesia and surgery. You will begin with the respiratory system, assessing for rate, rhythm, breath sounds, pulse oximetry, and presence of artificial airways, as well as the type and flow of any oxygen delivery system. You will then move on to the cardiovascular system, assessing heart rate and rhythm, blood pressure, and peripheral pulses. The central nervous system follows. You will assess the patient’s level of consciousness, ability to 132 Post-anesthetic Assessment and Care

follow commands, movement of extremities, and orientation. You will then move onto the renal system, assessing intake and output, including assessment of all IV lines, catheters, and drains, including rates, output, color, and type of drainage. The last system you will assess is the surgical system or the system affected by surgery (see Fig. 6–1).

Airway Breathing Circulation

Cardiovascular Cardiac rate Cardiac rhythm Blood pressure Temperature Skin condition Renal Intake and output IV lines/infusions Irrigation Drains/catheters

Neurologic Responsiveness to stimuli Moves all extremities Follows commands Orientation Respiratory Rate Rhythm Breath sounds Pulse oximetry Airways Oxygen delivery system

F I G U R E 6 - 1 : PACU major body systems assessment.

Post-anesthetic Assessment and Care 133

Head to Toe Approach Benefits of this approach are that it is comprehensive and easy to teach new practitioners, but its major benefit is its organization. You begin at the “top” of the patient with a neurologic assessment, moving downward to, ultimately, genitourinary functioning. However, this approach is not perfect, and has been criticized as being cumbersome, difficult to chart, and overly excessive.

PACU Scoring Systems Some PACUs have incorporated the use of a scoring system designed to provide an objective measure of patient status as part of their assessment. The patient is “scored” against set criteria on admission and at regular intervals through the PACU stay. The scoring system may become part of the PACU discharge criteria. The Aldrete scale is the most widely known. This scale assesses: • Circulation: Blood pressure compared with preoperative • Respiratory status: Ability to deep breathe • Movement: Of extremities • Consciousness: Arousability • Color Although the scale has been revised, with oxygen saturation replacing color as being too subjective and unreliable, some centers still use the old scale (see Table 6–1). Although the use of scoring systems is advocated as objective, the original scale has never been validated prospectively as being a reliable indicator of the recovery from anesthesia. It should be noted that in the absence of actually “scoring” a patient, you are already assessing each of the criteria as part of your admission and ongoing PACU assessments. Table 6–1

Aldrete Score, Revised

Activity

Able to move four extremities voluntarily on command ___________________ 2 Able to move two extremities voluntarily on command ___________________ 1 Able to move no extremities voluntarily on command _____________________ 0

Respiration

Able to breathe deeply and cough freely ____________________________________ 2 Dyspnea or limited breathing _______________________________________ 1 Apneic ___________________________________________________________ 0

Circulation

BP ⫹20 of preanesthetic level _______________________________________ 2 BP ⫹21 to +49 of preanesthetic level ________________________________ 1 BP ⫹50 of preanesthetic level ______________________________________ 0

134 Post-anesthetic Assessment and Care

Table 6–1

Aldrete Score, Revised—Cont’d

Consciousness Fully awake _______________________________________________________ 2 Arousable on calling _______________________________________________ 1 Not responding ___________________________________________________ 0 O2 saturation

Able to maintain O2 saturation ⬎92% on room air ____________________ 2 Needs O2 inhalation to maintain O2 saturation ⬎90% _________________ 1 O2 saturation ⬍90% even with O2 supplement _______________________ 0

PACU Care Plan After you have completed your admission assessment, you will use the data obtained as the basis for your nursing diagnoses. The conclusions you reach about the meaning of the data will guide your plan of care. Ongoing and frequent assessments will help you to monitor the patient’s response to surgery and anesthesia. Generally, you will reassess your patient every 15 minutes, documenting any changes. Nursing diagnoses will become the basis for interventions. With each intervention, you will evaluate of the effectiveness of your interventions with a reassessment, and modify your plan as need be. Nursing diagnoses may be reflective of actual or potential problems. The following is a list of the most common PACU nursing diagnoses: • Ineffective breathing pattern as evidenced by obstruction, hypoventilation, hypoxemia • Alterations in cardiac output as evidenced by hypotension, hypertension, dysrhythmias • Alterations in comfort as evidenced by pain, nausea, and vomiting • Altered thought processes as evidenced by delayed awakening, emergence delirium • Ineffective thermoregulation as evidenced by hypothermia

Ineffective Breathing Pattern When you see signs of inadequate oxygenation or ventilation as evidenced by obstruction, hypoventilation, or hypoxemia, you have made the nursing diagnosis of ineffective breathing pattern. Now, you must look to identify the cause of the problem. Anesthetic agents can compromise adequate ventilation and perfusion. Inhalation agents and narcotics are respiratory depressants. Barbiturates decrease the sensitivity of the respiratory center to increasing carbon dioxide levels, thereby reducing respiratory drive. Muscle relaxants Post-anesthetic Assessment and Care 135

interfere with the functioning of the intercostals and diaphragmatic muscles required for inspiration. The surgical procedure may compromise the Your nursing interventions patient’s ability to oxygenate and to take deep will be directed toward the breaths. Any surgery that enters the thoracic maintenance of ventilation cavity will cause pain with inspiration. A chest and perfusion and toward elimination of the cause. tube may have been placed to re-expand a lung. Fluid overload may have caused pulmonary edema. Hypothermia and shivering may increase oxygen demand by 400% to 700%. Your actions may be independent nursing actions, such as stimulating the patient to take deep breaths or elevating the head of the bed, or may be collaborative with the surgeon or anesthesia provider, such as placement of an artificial airway. The postoperative, post-anesthetic complications of obstruction, hypoxemia, and hypoventilation are detailed in Chapter 9: Perioperative Complications. COACH CONSULT

Alterations in Cardiac Output When you see signs that the patient cannot maintain an adequate cardiac output as evidenced by hypotension, hypertension, or dysrhythmias, you can make the nursing diagnosis of alterations in cardiac output. Now you must look for the cause of the problem. Anesthetic agents can compromise cardiac output. Drugs such as halothane, sufentanil, and succinylcholine are direct myocardial depressants. Muscle relaxants such as pancuronium and gallamine are vagolytic and cause tachycardia. Preoperative medications such as atropine also cause tachycardia. Hypoxemia and other ventilatory disorders will contribute initially to hypertension, and ultimately to hypotension. Dysrhythmias, particularly ventricular, are commonly seen secondary to hypoxemia. Orthostatic blood pressure changes drop cardiac output and may result from preoperative medications such as diuretics and antihypertensive agents, or intraoperative medications such as midazolam. Fluid overload may cause hypertension and the development of congestive heart failure (CHF). Myocardial contractility will be diminished in CHF. Volume deficits, secondary to dehydration or hemorrhage, will result in a low cardiac output state. Peripheral pooling of blood secondary to decreased peripheral vascular resistance may be caused by


medications, such as morphine sulfate or spinal anesthesia, sepsis, or anaphylaxis. COACH Electrolyte abnormalities, particularly disturCONSULT bances of potassium, will affect myocardial conYour nursing interventions tractility. Secondary to hypoxemia, hypokalemia will be directed toward is the most common cause of postoperative maintenance of cardiac ventricular ectopy. output and elimination of the cause. The surgical procedure itself may compromise cardiac output. A cardiac tamponade following a valve or bypass procedure will interfere with myocardial contractility. Baroreceptor stimulation after a carotid endarterectomy may cause hypertension. Actions taken may be independent, such as encouraging deep breathing, lowering the head of the bed to improve blood pressure, and careful monitoring of intake and output, or may be collaborative with the surgeon and anesthesia provider, such as administering fluid boluses, atropine, or potassium replacement. The postoperative, post-anesthetic complications of hypotension, hypertension, dysrhythmias, chest pain, and bleeding are detailed in Chapter 9: Perioperative Complications.

Alterations in Comfort COACH When you make a judgment that your patient CONSULT is experiencing physical pain or psychologic discomfort, evidenced by complaints of pain, Separation from family nausea, and vomiting, or behavioral or physiomembers will be particularly logic indicators, the diagnosis of alterations in distressing for children. comfort is made. The cause of the discomfort must also be determined. Psychological discomfort may be the result of • Disorientation COACH CONSULT • Fear of the unknown • Anxiety about the outcome of surgery Your nursing interventions • Body image changes as a result of will be directed toward surgery increasing patient comfort Physical discomfort or pain may be the result and eliminating the cause of pain. of surgical manipulation, positioning, shivering, or the presence of binders, casts, tight dressings, or invasive lines. Pain may also be the result of inadequate analgesia. Nausea and vomiting may be the result of anesthesia exposure, or the movement associated with position changes.


Interventions may be independent nursing actions, including the use of teaching, touch, repositioning, and bringing family members to the bedside, or may be collaborative with the surgeon and anesthesia provider, such as administering ordered analgesic agents or antiemetics or applying heat or ice to a wound. The postoperative, post-anesthetic problem of pain is addressed in Chapter 7: Pain Management. The postoperative, post-anesthetic problem of nausea and vomiting is addressed in Chapter 9: Perioperative Complications.

Alterations in Thought Processes When you make a judgment that a patient is disoriented, delirious, or unresponsive, as evidenced by behavior or delayed awakening, the diagnosis of alterations in thought processes can be made. The cause of the agitation or delayed awakening must be determined. Anesthetic agents contribute to central nervous system depression and unconsciousness. Ketamine may cause psychogenic reactions, including hallucinations and delirium. Benzodiazepines contribute to central nervous system depression. Hypoxemia is the most common cause of postoperative agitation, until proven otherwise. Postoperative agitation may also be the result of pain, discomfort, or extreme anxiety. Patients with a history of substance abuse, including alcohol abuse, often awaken from anesthesia disoriented or delirious. Viscous disCOACH tention, including gastric and bladder distenCONSULT tion, may contribute to postoperative agitation Your nursing interventions and uncooperativeness. will be directed toward Interventions may be independent, includrestoration of appropriate ing reorientation, use of touch, and continued neurologic functioning and elimination of the cause of stimulation, or may be collaborative with the any dysfunction. surgeon and anesthesia provider, including the administration of a reversal or sedating agent, or the application of restraints. The postoperative, post-anesthetic complications of delayed awakening and emergence delirium are detailed in Chapter 9: Perioperative Complications.

Ineffective Thermoregulation When you determine that the patient is hypothermic, as evidenced by a body temperature of less than 96ºF or 35.5ºC, the diagnosis of ineffective thermoregulation is made. The decrease in body temperature 138 Post-anesthetic Assessment and Care

is most certainly due to intraoperative events, such as surgical exposure, use of IV or irrigaCOACH tion fluids, and the amount of time spent in a CONSULT cold OR. The pediatric and geriatric patient Your priority when caring will be more susceptible to heat loss. for a patient who is Nursing interventions may be independent, hypothermic centers on including application of warm blankets or rewarming and the prevention of further heat loss. rewarming devices or collaborative with the surgeon and anesthesia provider, including the administration of small doses of narcotics to stop shivering or the use of fluid warmers. The postoperative complication of hypothermia is detailed in Chapter 9: Perioperative Complications.

Setting Priorities As you plan your nursing care, you must set appropriate priorities. You must determine COACH which problem needs your immediate attenCONSULT tion and which problem can wait. For example, if a patient is admitted demonstrating signs Actual problems take priority over potential of being unable to maintain an airway indeproblems. Problems of the pendently as evidenced by falling saturations airway and cardiovascular and increased work of breathing, and is also system take priority over hypothermic, the respiratory distress takes problems of pain, thermoregulation, and delayed priority over rewarming. awakening. As you provide care to the patient, you also will address any physician orders that may have been written for completion in the PACU. This may include obtaining x-rays, administration of antibiotics, starting a patient-controlled analgesia (PCA) pump, and applying ice bags—as just a few examples. When all PACU orders have been completed, and your patient has met your PACU discharge criteria for oxygenation, cardiovascular stability, awakening, and pain control, you can prepare your patient for discharge. Discharge may be to the surgical floor, to an ambulatory unit, or to home.

Surgical-Specific Care Although there are care priorities that apply to any surgical patient, there are most certainly surgical-specific care priorities that you as the nurse must make part of your postoperative care plan. Post-anesthetic Assessment and Care 139

ALERT

Assessment of the Thoracic Surgical Patient

Inspection will be the first physical assessment skill you will use to evaluate the patient who has experienced thoracic surgery. Your observations will begin the moment the patient is admitted to the PACU. You will observe the patient’s level of consciousness. Is the patient awake? Unresponsive? Agitated? You will assess the patient’s breathing pattern. Is the patient breathing? Is the chest rising and falling? Is breathing assisted or spontaneous? Note the presence of any artificial airways. Observations should also be made about the respiratory rate. In the adult patient, a rate of 10 to 20 breaths per minute is considered normal. A rate of greater than 20 is considered tachypnea. A rate of less than 10 is considered bradypnea. If the patient is not breathing, the patient is apneic. Tachypnea may be secondary to pain, hypoxemia, hypoventilation, or secretions. Bradypnea may be secondary to anesthetic and narcotic administration, or secretions. Epidural anesthesia is commonly combined with general anesthesia for invasive thoracic procedures with the goal of providing postoperative analgesia with little or no respiratory depression. Look at the respiratory pattern. Are the respirations shallow, regular, or deep? Chest movement is assessed as bilateral, equal, or restricted. You should look for the use of accessory respiratory muscles, including intercostal retractions, suprasternal retractions, and nasal flaring, as signs of distress. The regularity of breathing is assessed as regular, irregular, or periodic. Observations will also be made about overall chest wall anatomy. Does the patient have any COACH chest wall deformities? Does the patient have a CONSULT chest tube, drains, or nasogastric tube present? If the patient has a chest tube, is it mediastiA patient who is recovering nal or pleural? A mediastinal tube is designed from a pneumonectomy requires a wound drainage for wound drainage and is usually attached to system. A patient recoverlow, continuous wall suction. A pleural tube is ing from a lobectomy or designed to reinflate the lung or to drain a segmentectomy requires wound, and will also be attached to low, continplacement of a pleural uous wall suction. chest tube to promote lung If your patient is not breathing, stop your assessment and begin resuscitation.

expansion.


The pleural drainage system has three basic compartments, each with its own specific function: • The first compartment, the collection chamber, receives air and fluid from the chest cavity • This compartment is vented to a second chamber, known as the water-seal chamber. This chamber acts as a one-way valve so that air can enter from, but not back into, the collection chamber. If bubbling is noted in this chamber, the lung has not yet reexpanded. Bubbling is an expected finding in the PACU. It will diminish as reexpansion of the lung occurs. If no bubbling is detected in the water-seal chamber, it is important to evaluate the drainage system for kinks or blockage of the drainage tubing • The third chamber is the suction control chamber, which is used to apply controlled suction to the system to facilitate the evaluation of air and fluid and to promote reexpansion of the lung. Some systems are also equipped to be utilized as an autotransfusion system COACH See Figure 6–2 for a representation of a pleural CONSULT drainage system. Hemorrhage is a potential early complicaWhen turning a patient tion following thoracotomy. When monitoring who is recovering from chest tube drainage, output should be measured lobectomy or segmentectomy, the operative side every 15 minutes. If drainage exceeds 100 should remain in the mL/hour, if fresh bleeding is noted, or if a suduppermost position to den increase in drainage occurs, hemorrhage promote lung expansion. should be suspected, and you should promptly If the patient has had a notify the surgeon. pneumonectomy, the patient should be posiThe positioning of the patient is important. tioned operative side down Usually the head of the bed is elevated 30 to to promote maximum 45 degrees to maximize ventilation. expansion of the remaining You will also use palpation to assess the tholung, keeping any drainage dependent. racic surgical patient. Palpation will be used to identify any area of tenderness or observed abnormalities. Swelling or bulges can be palpated to assess consistency and pain. The chest COACH tube insertion site should be palpated for crepiCONSULT tus, also known as subcutaneous emphysema, which is caused by the presence of air trapped Crepitus will feel like “Rice Krispies” under the skin. in subcutaneous tissue.


F I G U R E 6 - 2 : Pleural drainage system. With permission from Atrium Medical Corporation.


You will use percussion to determine if underlying thoracic tissues are air-filled, fluid-filled, or solid. Dullness will be heard when fluid or solid tissue replaces air-containing tissue. Hyperresonance is heard over hyperinflated, emphysematous lung tissue when air is trapped in distal alveoli. Auscultation of breath sounds is part of the post-anesthetic and postthoracic assessment. Auscultation is used to • Estimate air flow through the tracheal-bronchial tree • Detect obstruction • Assess the condition of the lungs and the pleural space Breath sounds should be auscultated bilaterally. Normal breath sounds are clear (see Table 6–2). Abnormal breath sounds may be superimposed over normal sounds, and include the following: • Crackles: Heard when air moves through fluid-filled airways. Crackles, previously called rales, are nonconCOACH tinuous, lessen with coughing, and CONSULT are usually heard during early or late If you are unfamiliar with inspiration the sound of crackles, rub • Rhonchi: Low-pitched, continuous the hair next to your ear snoring sounds usually heard on with your fingers. The sound of crackles is very expiration as air moves through narrow similar to this sound. airways. Rhonchi may be heard in patients with bronchitis, and chronic obstructive pulmonary disease (COPD) Table 6–2

Normal Breath Sounds

SOUND

DESCRIPTION

REPRESENTATION OF PATTERN*

Vesicular

Heard over majority of lung fields Low pitched, soft Long inhalation, short exhalation

Bronchovesicular

Heard over main bronchus Medium pitch Inhalation equals exhalation

Bronchial

Heard only over the trachea High pitched and loud Short inhalation, long exhalation

*Peak represents end of inhalation/beginning of exhalation.


• Wheezes: High-pitched, continuous or deep, snoring sounds that may be heard throughout the respiratory cycle. Wheezing occurs as air moves through narrow airways. Wheezing may be heard in patients with asthma, bronchitis, and COPD • Friction rub may be heard as the visceral and parietal pleura rub together. Patients will usually complain on inspiration and when taking deep breaths. A friction rub is most clearly heard around the lower anterolateral chest as a creaking or grating sound that does not clear with coughing. It may be heard in patients with pleurisy, tuberculosis, and pneumonia. This is uncommon in the PACU, as patients with active infections are usually not candidates for surgical procedures unless it is an emergency procedure

Nursing Priorities for the Thoracic Surgical Patient Three nursing priorities can be identified for the patient who is recovering from thoracic surgery: 1. Optimize respiratory function 2. Monitor for signs of complications 3. Promote ventilation of available lung tissue and reexpand the lungs Nursing interventions that may be used to assist the patient to an optimal level of functioning are identified in Table 6–3.

Table 6–3

Nursing Interventions for the Thoracic Surgical Patient

NURSING ACTION

PURPOSE

Deep breathing

Maintain patent airway Maximize ventilation Decrease pulmonary complications Re-expand collapsed lung tissue

Coughing (controversial)

Maintain patent airway Mobilize secretions Prevent atelectasis

Turning/positioning

Maintain patent airway Maximize ventilation and perfusion Decrease pooling of secretions Increase excursion


Table 6–3

Nursing Interventions for the Thoracic Surgical Patient—Cont’d

NURSING ACTION

PURPOSE

Suctioning

Remove secretions Increase oxygenation and ventilation Decrease pulmonary infection

Postural drainage

Maintain patent airway Increase drainage from lungs

Chest physical therapy

Loosen secretions Promote oxygenation

Intermittent positive pressure breathing

Maintain slow, deep inspiration Decrease work of breathing Increase lung expansion Mobilize secretions

Spirometry

Maintain slow, deep inspiration Prevent atelectasis Visual feedback of effort

Mechanical ventilation

Promote oxygenation/ventilation Decrease work of breathing Increase lung expansion

Assessment of the Cardiac Surgical Patient Many of the cardiac surgical procedures are actually classified under the category of interventional procedures, performed by cardiologists and not cardiac surgeons, taking place in the cardiac catheterization laboratory, bypassing the PACU. Patients whose surgery takes place in the OR are most commonly undergoing more invasive procedures, and as a result, admission of the patient after cardiac surgery requires cooperation among nursing, anesthesia, and surgical personnel because several tasks must occur simultaneously. Airway and oxygenation needs require ventilatory support because the patient will frequently be anesthetized and paralyzed. Breath sounds should be auscultated bilaterally to ensure that the endotracheal tube has not become dislodged, or has not slipped into the right mainstem bronchi during transport. The patient will need to be attached to the ECG monitor, and an admission rhythm strip obtained. It is important to obtain a baseline strip to include in the chart for comparison if dysrhythmias develop later in the Post-anesthetic Assessment and Care 145

postoperative period. The patient should also have arterial blood pressure monitoring initiated and calibrated. A cuff pressure should be obtained for comparison. It may be difficult to obtain a cuff A large urine output, pressure if the patient is hypothermic or vasoconsecondary to the adminisstricted. If the patient has a pulmonary artery tration of intraoperative catheter in place, it too should be connected, diuretics, should alert you to the possible need for calibrated, and monitored. potassium replacement, so The chest tubes (usually mediastinal, occabe prepared to obtain sionally pleural) should be connected to admission laboratory tests, suction immediately in case bleeding should including a potassium start. The sternal dressing and leg dressings, if level. after bypass surgery, should be inspected for bleeding. After these initial tasks and observations have been completed, you should complete the admission assessment by palpating peripheral pulses to assess the patency of the vessels and the adequacy of cardiac output. Body temperature should also be assessed, and rewarming initiated as necessary (temp ⬍96º or 36.5ºC). Urine output should also be assessed and monitored. It is not unusual to detect blood in the urine, because of lysis of red blood cells by the cardiopulmonary bypass pump. You will also draw admission laboratory tests, to include the following: • Arterial blood gases to assess for the adequacy of ventilation • Complete blood count to assess for excessive blood loss intraoperatively, which may compromise gas exchange • Coagulation studies—prothrombin time (PT), partial thromboplastin time (PTT), international normalized ratio (INR)—because of the administration of heparin intraoperatively while the patient is on bypass • Electrolytes because of the potential for potassium alterations from diuretics and sodium alterations as a result of fluid shifts • Cardiac enzymes to assess for intraoperative myocardial damage/infarction Lastly, obtain an ECG and chest x-ray. COACH CONSULT

Nursing Priorities for the Cardiac Surgical Patient Your overriding goal in providing care to the patient following cardiac surgery is maintaining adequate oxygen transport. This is dependent upon pulmonary function, hemoglobin level, and cardiac output.


Pulmonary function may be compromised by preexisting disease, as well as the adminisCOACH tration of anesthetics. Patients may need to be CONSULT intubated and ventilated for an extended period Chest tube outputs of of time, well into the evening, and extubated greater than 50 mL after only after demonstration of adequate pulmonary the first hour is cause for function and neurologic awareness. further evaluation, and you should notify the surgeon. Assess and monitor hemoglobin levels. Hemoglobin may have fallen as a result of hemorrhage, hemodilution, or lysis of red blood cells on bypass. An evaluation of coagulation function COACH is mandatory. With significant postoperative CONSULT bleeding, the cause may be loss of surgical integrity or alterations in coagulation. Think of preload and afterMaintenance of oxygen transport is dependent load this way: Preload is on an adequate cardiac output. Maintenance of the amount of blood that enters the heart that must cardiac output is dependent on stroke volume be moved through the and heart rate. Stroke volume is dependent heart. It might be low on preload, afterload, and contractility. These because of blood loss or three terms are defined here: peripheral pooling of blood. • Preload: The force that stretches the Fluid overload increases preload. Afterload reflects ventricle during diastole. The degree of the tone of peripheral stretch depends on the volume of blood vessels. If the peripheral filling the ventricle. The greater the vessels make it easy for the ventricular volume, the greater the left ventricle to eject blood, afterload is low. If force of contraction required to empty the vessels are clamped the ventricle (Starling’s law) down, making the left • Afterload: The degree of pressure ventricle work hard, afteropposing cardiac ejection; this pressure load is high. is imposed by vascular resistance, blood pressure, and blood viscosity • Contractility: The rate and force of cardiac ejection Heart rate changes include tachycardia and bradycardia, both of which can decrease cardiac output. Bradycardia occurs secondary to disruptions in the conduction system and may be seen in patients recovering from valve surgery or in those having experienced an intraoperative myocardial infarction. Beta blockers may also cause bradycardia. Tachycardia is caused by sympathetic stimulation, which may be caused by pain, anxiety, hypovolemia, hyperthermia, and medications such as dopamine and epinephrine.


Maintenance of stroke volume is dependent upon preload. Right ventricular preload is measured by central venous pressure (CVP). Left ventricular preload is measured by the pulCardiac tamponade is a monary artery occlusion pressure, or “wedge surgical emergency. The pressure.” Preload will be decreased as a result patient must be returned of fluid shifts, positive end expiratory pressure, or to the OR immediately to reopen the chest to drain tamponade. Clinically, the patient will present the pericardium. It may be with hypotension, tachycardia, oliguria, and a necessary for the surgeon decreased CVP and wedge pressure. Treatment to open the patient’s chest is aimed at improving circulating volume within the intensive care unit if out compromising overall myocardial function, no OR is immediately available. Although not the and may include fluids, inotropic medications, or ideal, it is considered a lifeother vasoactive medications. saving maneuver when no The exception to this clinical picture is carother options are available. diac tamponade. Clinical signs of hypotension, tachycardia, and oliguria will occur, but the CVP and wedge pressures will rise, and will ultimately equal each other. Cardiac tamponade is caused by an accumulation of blood in the pericardium. As blood accumulates, the effectiveness of the heart as a pump declines. Treatment usually consists of a return to the OR, evacuation of pericardial fluid, and reexploration to determine the cause of bleeding, with repair. Increased preload may occur with fluid overload. The patient will have elevated CVP and wedge pressures, and often, hypertension. Treatment involves fluid restriction to less than 100 mL/hour, diuretics, and electrolyte monitoring, particularly for sodium and potassium. Afterload is measured by systemic vascular resistance (SVR), which is calculated as Mean arterial pressure ⫺ Central venous pressure ⫻ 80 Cardiac output COACH CONSULT

In cases of increased SVR, the myocardium must empty against resistance, thereby increasing myocardial work. Hypertension is the most common cause of increased SVR; it may result from increased sympathetic tone, hypothermia, ALERT and baroreceptor response. Treatment will include rewarming and the use of vasodilators, If the dysrhythmia including morphine, nitroglycerin, and sodium is life threatening, nitroprusside (Nipride). advanced cardiac lifeFinally, treatment will be directed toward support protocols should be instituted. correction of dysrhythmias. Dysrhythmias are usually transient; they may be caused by 148 Post-anesthetic Assessment and Care

underlying disease, electrolyte imbalance, cardiac manipulation, hypoxemia, hypothermia, or acid-base disturbances. Treatment will be directed toward correction of the underlying cause. See Chapter 9 for identification and management of dysrhythmias.

Assessment of the Peripheral Vascular Surgical Patient The overall goal of the PACU nurse in caring for the peripheral vascular surgical patient is maintenance and ongoing assessment of circulatory integrity and perfusion. Assessments must be made at regular intervals, usually every 15 minutes, and documented. The assessment should be compared with the baseline preoperative assessment, and with previous postoperative assessments. The vascular assessment begins with observation of the surgical dressing, any drains, and any drainage. Signs of bleeding should be evaluated and documented. Skin color is also visually assessed. Skin color may be described as pink or ruddy, a sign of venous congestion; or as mottled, dusky, or pale, signs of inadequate perfusion. Palpation is perhaps the most useful skill in the assessment of the peripheral vascular surgical patient. Skin should be palpated to assess temperature. Cool or cold extremities or digits are a sign of circulatory compromise. Warm extremities are a sign of good perfusion. Capillary refill of the affected extremity should be assessed and compared with that of the unaffected extremity. Capillary refill should be brisk, usually less than 2 seconds, and equal to that of the unaffected extremity. Pulses should be palpated for their presence and equality. The location of the peripheral pulses is shown in Figure 6–3. To aid in future assessments, the location of the pulses can be marked with a magic marker. Pulses distal to the surgical site should be assessed, and their presence or absence should be noted. The quality of the pulses should also be described. Words such as weak, easily palpable, or bounding may be used. You should also ask about pain in the COACH affected extremity. Pain is an indicator of possiCONSULT ble circulatory impairment. If the surgery involved the cerebral circulaIf a pulse is absent to tion, as in a carotid endarterectomy, you should palpation, you should also complete a neurological assessment. (See attempt to find the pulse with a Doppler. If absent the section on care of the neurosurgical patient.) to Doppler, the vascular Vital signs should be monitored in all vascusurgeon should be notified lar surgical patients. Hypertension in these immediately. patients may cause hemorrhage, hematoma Post-anesthetic Assessment and Care 149

Temporal

Right Subclavian

Carotid Left Subclavian

Aortic arch Coronary Celiac

Abdominal aorta

Superior mesenteric Renal Inferior mesenteric

Brachial

Common iliac Internal iliac

Radial

External iliac Ulnar

Volar arch

Femoral Popliteal

Posterior tibial

Dorsalis pedis

F I G U R E 6 - 3 : Peripheral arterial system. Pulse sites in red.

formation, or edema, and may compromise the integrity of the surgical suture line. Pharmacologic intervention, such as via sodium nitroprusside or labetalol, may be initiated. Hypotension may be problematic in these patients too, as low blood pressure will compromise blood flow through the graft and bypassed artery, making it difficult to palpate 150 Post-anesthetic Assessment and Care

pulses. The treatment will usually be IV fluids, possibly colloids, such as hetastarch, to increase intravascular volume. It is also important to monitor urine output, particularly after repair of an aortic abdominal aneurysm. During the surgical procedure, the descending aorta may be clamped, compromising blood flow to the renal arteries. Postoperatively, urine output should be greater than 30 mL/hour. Blood urea nitrogen (BUN) and creatinine levels should be followed, as should trends in any invasive hemodynamic monitoring, such as CVP.

Nursing Priorities for Peripheral Vascular Surgical Patients Your goal in providing care to the peripheral vascular surgical patient should be to promote circulatory integrity and perfusion. Circulatory assessments must be made at regular intervals, and the surgeon notified immediately of any changes in pulses, in color, skin temperature, or vital signs. Postoperative bleeding should be evaluated carefully. Hematoma formation may compromise vascular integrity. In the carotid endarterectomy patient, hematoma formation may compromise the airway. Excessive bleeding may indicate loss of vascular integrity along a suCOACH CONSULT ture line, requiring return to the OR, or it may indicate alterations in coagulation, secondary If the patient is recovering to intraoperative anticoagulation with heparin. from a carotid endarterecYou should obtain a coagulation profile: PT, tomy, neurologic functionPTT, INR. Alterations may be treated with proing should be evaluated and documented. Acute tamine sulfate.

Assessment of the Neurosurgical Patient Although a neurologic assessment is part of the PACU admission, the neurosurgical patient will require a more in-depth assessment of neurologic functioning. Ideally, a complete assessment has been made preoperatively and documented in the patient’s chart to provide you with a baseline for comparison. The neurologic assessment begins with an evaluation of the patient’s level of consciousness. The anesthesia team will try to bring the patient to the PACU as awake as possible to allow for a more complete and accurate evaluation. You should first assess the patient’s response to

changes should be promptly reported to the surgeon.

COACH CONSULT Decorticate posturing, flexion of the arms across the chest, and decerebrate posturing, extension of arms, are signs of neurologic deterioration (see Figs. 6–4A and B).


(A)

(B) F I G U R E 6 - 4 : (A) Abnormal flexion (decorticate posturing). (B) Abnormal extension (decerebrate posturing) .

verbal stimuli, for example, by asking the patient to follow a command. The appropriateness of the response should be evaluated. If the patient does not respond to verbal stimuli, tactile stimuli should be tried. Use a sternal rub or pressure on a nail bed to elicit a response. Assess the appropriateness of the response. Did the patient pull away from painful stimulation? If not, did you notice that the patient responded by posturing? A change in the level of consciousness should raise suspicions of bleeding, hypoxia, and edema, all cases of increased intracranial pressure. Before determining true unresponsiveness, fluid and electrolyte balance should be checked and alterations corrected, normothermia restored, anesthetics metabolized or reversed, and adequacy of oxygenation confirmed via pulse oximetry or arterial blood gases. Increasing intracranial pressure (ICP) results from an increase in any or all three components of the skull: brain tissue, blood, and cerebrospinal fluid (CSF). Normally, brain tissue compromises 78% of intracranial volume; blood, 12%; and CSF, 10%. A normal ICP is considered to be 0 to 15 mm Hg. An increase in brain tissue may be the result of brain edema, head trauma, swelling, or tumor growth. Increased blood flow may be a result of an intracranial hematoma, hypercarbia, hypoxia, or acidosis. An increase in CSF may occur secondary to blockage of intracranial ventricles or an improperly functioning shunt. (See Table 6–4 for manifestations of ICP.) Vital signs should be obtained. Changes may be seen in pulse, blood pressure, and respirations because of neurologic influence. A slow, bounding pulse may be indicative of increased ICP. A rapid, thready pulse may be a late sign of decompensation. A widening pulse pressure 152 Post-anesthetic Assessment and Care

Table 6–4

Manifestations of Increased Intracranial Pressure

DIMENSION

CLINICAL SIGNS

CAUSE

Level of consciousness

Decreased level of consciousness Changes in affect Changes in attention Coma

Impaired cerebral blood flow

Vital signs

Increased systolic blood pressure Widening pulse pressure* Bradycardia* Full, bounding pulse Irregular respiratory pattern* Changes in temperature

Increasing pressure on pons, medulla, hypothalamus, and thalamus

Ocular signs

Dilatation of ipsilateral pupil Sluggish to no response to light Inability to move eye upward Ptosis of eyelid Blurred vision Diplopia Changes in extraocular eye movements

Compression of oculomotor nerve (cranial nerve III)

Compression of optic nerve (II), trochlear nerve (IV), and abducens nerve (VI)

Motor function

Contralateral hemiparesis or hemiplegia Pain response Posturing

General increases in intracranial pressure

Headache

Patient complaint of pain

Compression of walls of arteries and/or veins and cranial nerves

Vomiting

Emesis

Nonspecific sign of increased intracranial pressure

*Cushing’s triad.

may indicate increased intracranial pressure. An abnormally deep and slow pattern of respiration interspersed with periods of apnea, called Cheyne-Stokes respirations, usually indicates cerebral damage. Apneic or ataxic breathing is seen with damage to the pons and medullary respiratory center. Examine the patient’s pupils for size, equality, and reaction to light. Pupil size may range from pinpoint to dilated. Use a visual scale to aid in assessment (see Fig. 6–5). Reactivity is rated as sluggish to brisk. Post-anesthetic Assessment and Care 153

F I G U R E 6 - 5 : Pupil assessment scale.

Sensorimotor function also should be assessed. Ask your patient to smile, frown, and to stick out his or her tongue. Hand grasp and strength should be assessed, as should the The major complication of patient’s ability to dorsiflex and plantarflex the increasing intracranial presfeet. Equality of the right and left sides should sure is death, secondary to be evaluated. cerebral herniation. Clinical Formal assessment of cranial nerve funcmanifestations of increasing intracranial pressure tioning may be part of the PACU assessment. include changes in level of Table 6–5 identifies the 12 cranial nerves and consciousness, vital signs, the tests for their assessment. ocular signs, motor funcFigure 6–6 illustrates the progression of tion, headache, and vomiting. Report any and all of events resulting from uncontrolled increases in these signs immediately. ICP. Treatment of increased ICP is both prophylactic and therapeutic. Prophylactic treatment may include elevating the head of the bed 30 degrees unless contraindicated by the surgery, hyperventilating the patient if intubated to COACH keep the CO2 level less than 35 mm Hg, utilizCONSULT ing diuretics to decrease circulating volume, To remember plantar and using steroids to decrease cerebral edema. flexion, think of planting ICP monitoring also may be employed to detect something into the ground. early increases in ICP. Therapeutic intervenWhen you plant, you put tions may include aggressive application of presomething down into the ground, so feet push ventive measures not previously used and, if downward. necessary, surgical intervention to relieve the increased pressure. Surgical intervention might include placement or replacement of a shunt, evacuation of an intracranial hematoma, or debulking or removal of a tumor. If seizure activity is noted, you should carefully observe the type of seizure. Focal seizures are localized areas of motor activity. Tonic-clonic, or grand mal, seizures are generalized convulsions. Respiratory adequacy COACH CONSULT


Table 6–5

Cranial Nerve Assessment

CRANIAL NERVE

FUNCTION TEST FOR ASSESSMENT

I Olfactory

Sensory

Ask patient to identify smell (e.g., alcohol on swab)*

II Optic

Sensory

Hold up fingers, ask patient to count;.assess vision in each eye

III Oculomotor

Motor

Check pupil constriction to light

IV Trochlear

Motor

Assess patient’s ability to look downward and inward

V Trigeminal

Sensory Motor

Assess facial response to touch Assess patient’s ability to clench jaw

VI Abducens

Motor

Assess lateral deviation of eye

VII Facial

Sensory Motor

Check taste on anterior two-thirds of tongue* Assess patient’s ability to smile, frown, and elevate eyebrows

VIII Acoustic

Sensory

Whisper sentence into patient’s ear; ask patient to repeat sentence; assess both ears

IX Glossopharyngeal Sensory Motor

Check taste on posterior tongue* Ask patient to swallow. Check gag reflex

X Vagus

Sensory Motor

Ask patient to speak Ask patient to swallow

XI Spinal accessory

Motor

Ask patient to shrug shoulders against resistance

XII Hypoglossal

Motor

Ask patient to stick out his or her tongue

*Uncommon in the PACU

should be assessed during seizure activity. Anticonvulsants may be ordered.

Nursing Priorities for Neurosurgical Patients The goal of the neurologic assessment is to provide an objective account of patient functioning. Each assessment is compared with the preoperative, or baseline, assessment, as well as the assessment immediately preceding the current one. Documentation should be kept current. Any acute changes or signs of increased ICP should be reported immediately to the neurosurgeon. Post-anesthetic Assessment and Care 155

Increased cerebral blood flow

Increased cerebrospinal fluid

Cerebral edema

Increased intracranial pressure Compression of arteries Decreased cerebral blood flow Decreased oxygen with death of brain cells Edema around necrotic tissue Increased intracranial pressure with compression of brainstem and respiratory center Increased carbon dioxide and vasodilitation

Increased intracranial pressure due to increased blood flow

Death F I G U R E 6 - 6 : Progression of increased intracranial pressure.

Pain management is also a priority. Try not to administer agents that will cause extreme sedation, making assessments difficult. Narcotics also may cause pupillary constriction.

Assessment of the Renal and Urologic Surgical Patient Inspection will be the first physical assessment skill used to evaluate the patient who has experienced renal and urologic surgery. On admission, the surgical site or dressing will be inspected, with a notation made of the type and location of dressings, presence of drains, and presence and type of drainage. The dressing may be abdominal, suprapubic, or lateral. If the surgery was transurethral, as with a cystoscopy or prostatectomy, no dressing will 156 Post-anesthetic Assessment and Care

be present. The meatus should be inspected for bleeding. A suprapubic, ureteral, or urethral catheter may be present (Figs. 6–7 and 6–8). Catheters are designed to collect urine and wound drainage and to allow for monitoring of output for amount and color. They may also be placed to provide traction at the surgical site, which will help to decrease bleeding and promote healing. The color and amount of drainage should be noted. If the drain is part of an irrigation system, as it is for prostatectomy patients, you should verify the solution and rate of infusion and maintain accurate output records, calculating urine output from irrigation output. The output catheters should be assessed for patency. Output also may occur via an ostomy outlet, as seen with patients undergoing a ureterostomy. Palpation may be used to assess for bladder distention. The catheter may be palpated to dislodge clots and to maintain patency. Percussion and auscultation are not used in the assessment of the renal and urologic surgical patient.

Nursing Priorities for Renal and Urologic Surgical Patients You should make the patency of the output system your first postoperative priority. Catheters should be assessed for patency. Output should

Urine drainage

Catheter tip

Cross section

(a) Balloon inflation Urine drainage Catheter tip

Inflated balloon

Cross section

(b) Irrigation Balloon inflation Urine drainage Catheter tip

Inflated balloon

Cross section

(c) F I G U R E 6 - 7 : Types of catheters. (A) A single-lumen catheter is used to obtain sample or immediately drain the bladder. (B) A double-lumen catheter is the most commonly used indwelling catheter. (C) A triple-lumen catheter is inserted when the patient requires irrigation of the bladder.


Removable trocar cannula Abdominal wall

Bladder Suprapubic catheter

Spine

F I G U R E 6 - 8 : Suprapubic catheter.

be assessed for color and consistency, Maintenance of intake and output records is essential. If an irrigation system is part of the drainage system, carefully monitor and maintain flow. Temperature monitoring, and rewarming as needed, are important. Irrigation solutions are administered at room temperature, and can frequently cause core cooling. Irrigation may also contribute to dilutional hypontremia, so you should be prepared to obtain postoperative electrolyte levels. If the patient has no catheter, any attempts to void should be COACH noted. Inability to void over time will require CONSULT that you notify the surgeon. Most times, ambulatory surgical patients will be required If the patient uses the to void before discharge. bathroom to void, as opposed to a urinal, ask Ice packs may be ordered to decrease the patient not to flush swelling. Likewise, after procedures like hydrothe toilet so that you can celectomy, varicocelectomy, or spermatocelecassess the output for tomy, a scrotal support may be ordered to prevent bleeding or clots. edema and to decrease discomfort.


You should recognize that patients may experience embarrassment from the procedure and the continued assessments required postoperatively. Care should be provided professionally and directly, maintaining patient privacy at all times. If the patient is post-renal transplant, either living related or cadaveric, it is important that you follow institutional protocols and/or postoperative orders specific to IV fluids and rate of administration, laboratory tests to be obtained, criteria for fluid replacement, intake and output monitoring, and pain control. Care of the patient post-transplant is commonly not only specific to the institution, but to the surgeon who performs the operation.

COACH CONSULT Although IV narcotics are most commonly used for pain management in patients following renal and genitourinary surgical procedures, you may see an order for belladonna and opium (B&O) suppositories. B&O suppositories work well to control bladder spasms that may be experienced after transurethral surgery in which the catheter is left in place with irrigation.

Assessment of the Orthopedic and Spinal Surgical Patient Inspection is the first skill used in the assessment of the orthopedic and spinal surgical patient. The site of surgery should be assessed for the type of dressing, presence of drains and/or drainage, and extremity status. If the extremity is casted or Ace-wrapped, the digits should be assessed for color, capillary refill, temperature, sensation, and mobility. Pale color and cool temperature may reflect arterial insufficiency, and should be reported to the surgeon. The operative side should be compared with the unaffected side. Capillary refill is assessed by depressing the patient’s nailbed until blanching occurs. The nailbed is then released, and the speed of color refill is observed. Refill should occur in less than 3 seconds. Again, compare the operative side with the nonoperative side. Deficits in sensation or mobility should raise concern about the possibility of nerve damage. Nerve function tests commonly used to assess the postoperative orthopedic and spinal surgery patient are described in Box 6–5. If the patient is unable to respond to sensory testing, or motor function tests, you need to consider whether the patient is still under the influence of a spinal anesthetic. If a motor or sensory anesthetic block is still present, you will continue to assess the patient until such a time as the block is expected to resolve, in consideration


Box 6–5

Tests of Nerve Function

RADIAL • Sensory: Pinch web space between thumb and index finger • Motor: Hyperextend thumb or wrist MEDIAN • Sensory: Pinch distal surface of index finger • Motor: Oppose thumb and little finger; flex wrist ULNAR • Sensory: Pinch distal end of little finger • Motor: Abduct all fingers PERINEAL • Sensory: Pinch lateral surface of great toe and medial surface of second toe • Motor: Dorsiflex ankles; extend toes TIBIAL • Sensory: Pinch medial and lateral surfaces of sole of foot • Motor: Plantarflex ankles; flex toes

of the type of block and anesthetic agent used. If not, you should notify the surgeon immediately.

Nursing Priorities for Orthopedic and Spinal Surgery Patients Of primary importance is the need to maintain surgical and anatomic alignment. Casts may be used to immobilize an extremity and to promote healing. Traction may be used to maintain positioning and to promote healing. Depending on the procedure, some position changes should be avoided. For example, adduction, external rotation, and acute hip flexion are contraindicated in the patient recovering from hip arthroplasty. Adduction and external rotation are contraindicated in the patient following total knee arthroplasty. After spinal surgery, the patient is usually kept flat and log-rolled from side to side. An x-ray may be ordered in the PACU to confirm surgical alignment. Make sure the x-ray is seen by the surgeon prior to disCOACH charge. CONSULT The surgeon may order elevation of the extremity to minimize or prevent swelling. If Carefully review the chart the extremity is casted with a plaster cast that for specific positioning may still be damp to touch, pillows or blanconsiderations that may be ordered by the surgeon. kets should be placed to support the cast and to prevent hard surfaces from coming in


contact with the cast. Hard surfaces may cause no change in the external appearance of the cast, but may result in pressure points within the cast. The extremity should be elevated about the level of the heart. You might even see a surgeon tie an extremity to an IV pole, particularly in the case of shoulder or arm surgery to keep it elevated. Ice packs may also be ordered to reduce swelling and pain. Ongoing monitoring of extremity color, capillary refill, sensation, and mobility should continue throughout the patient’s stay in the PACU, as it will continue on the surgical unit. A final assessment should be made before discharge. All assessments should be documented, with any deviations reported to the surgeon. The dressing should be assessed for drainage. “Bleed-throughs” on casts should be noted, circled, and timed. Drainage in HemoVac’s or other wound drainage systems should be noted and recorded. If an autotransfusion system has been placed, you can expect a larger output. Plan on reinfusing the drainage once it exceeds specified parameters, usually 400 mL in 4 hours or less. Although compartment syndrome is an uncommon problem in postoperative patients, it is important that you be aware of its potential occurrence. Compartment syndrome develops when pressure in a fascial compartment increases and venous return is occluded. Subsequently, although pulses may be present, perfusion is interrupted. Muscle and nerve ischemia ensues and, if untreated, progresses to necrosis. Compartment syndrome can occur in any of the fascial compartments of the limbs. In the upper extremity, it occurs most commonly in the anterior, or flexor, compartment of the forearm. In the lower extremity, it is most common in the anterior and deep posterior compartments. The patient may have extreme pain during stretch of the involved compartment or pain that is not responsive to analgesics. Classically, the diagnosis of compartment syndrome is based on five Ps: • Pain • Paresthesias COACH • Pallor CONSULT • Paralysis • Pulselessness You should remember that Treatment of compartment syndrome pulseless is an extremely involves prompt recognition of symptoms. Nonpoor prognostic sign, and is indicative of severe surgical intervention may include cast removal compromise. or splitting of the cast. Surgical intervention


will be decompression via a fasciotomy, in which the compartment is excised to release pressure.

Assessment of the Plastic and Reconstructive Surgical Patient It is important to remember that plastic or reconstructive surgical procedures may involve skin and the face, thorax, or abdomen. Despite the anatomic variations, PACU care has some clear similarities for any patient recovering from plastic surgery. If the surgery involves or has the potential to involve or threaten the airway, as with a rhinoplasty or cleft lip or palate repair, you must first assess the patient for airway patency and adequacy. Breath sounds should be auscultated bilaterally. Apply high humidity oxygen, especially in patients who are mouth breathers. Suction equipment should be available at the bedside in case of bleeding. The surgical site should be assessed for the presence of drains, drainage, or edema. The dressing should be intact, and any drainage noted. Drains should be patent and should be placed to self or wall suction. Admission findings should be documented. If changes occur later in the postoperative period, baseline data can be used for comparison.

Nursing Priorities for Plastic and Reconstructive Surgical Patients Maintenance of a patent airway and oxygenation will be a priority in any patient undergoing COACH surgery in or around the airway. You will monCONSULT itor respiratory effort and adequacy continuously. Airway protection equipment such as Your major nursing priority airways, suction, and Ambu-bag should be imshould mirror the surgeon’s priority: promotion of mediately available at the bedside. wound healing without Ice or iced saline pads may be placed to infection or inflammation. decrease swelling and to keep suture lines free of coagulated blood and serum. Positioning the head of the bed upward promotes drainage of secretions and decreases swelling after facial procedures. If a graft was performed on an extremity, the extremity is usually elevated to decrease swelling. To prevent wound infection, you should use good hand-washing techniques before touching dressings, suture lines, and saline pads. Infection can compromise healing and cause disfigurement. Other nursing priorities are surgery specific. For example, if the patient has undergone placement of a flap, you may be required to assess 162 Post-anesthetic Assessment and Care

circulation of the flap via an opening in the surgical dressing. Infants following cleft lip, cleft palate, or pharyngeal flap repair will require careful attention to pain control, as crying can increase surgical site bleeding. Involving the parents will help to calm these children, in addition to administering pain medication as ordered. Patients who have undergone liposuction may have experienced a fairly significant intraoperative blood loss. These patients may have problems with postoperative hypotension, and may require laboratory testing for hematocrit and hemoglobin values. If a large intraoperative blood loss was anticipated, the patient may have been asked to donate a unit of autologous blood preoperatively, to be given as needed in the PACU. Hypothermia may be a problem if the procedure was of any significant length.

Assessment of the Ophthalmic Surgical Patient Assessment of the patient who has undergone ophthalmic surgery is rooted in skills of inspection. On admission to the PACU, the patient will often be wearing an eye patch, covered with a metal or rigid plastic shield. Make sure the dressing is secure. Take care not to dislodge the dressing when applying the oxygen mask or when repositioning the patient.

COACH CONSULT If the patient is a pediatric patient, care will be needed to protect the dressing from inquisitive fingers and frustrated personalities.

Nursing Priorities for Ophthalmic Surgical Patients The goals of nursing care for ophthalmic surgical patients include ongoing evaluation and prevention of the postoperative problems of coughing, nausea, and vomiting, all of which may increase intraocular pressure (IOP). If the patient is admitted to the PACU with an endotracheal tube in place, a rare occurrence, it will be important to prevent coughing or bucking on the tube for the same reason. Increases in IOP may disrupt suture lines. Most eye surgery procedures are performed under IV sedation with local anesthetic blockade of the eye. This avoids the need for intubation. In addition, as many patients undergoing eye surgery are elderly, the use of a local anesthetic technique minimizes the exposure of patients to the side effects of general anesthetic agents, including potential increases in IOP. Vomiting may also increase IOP, so if the patient complains of nausea, you should obtain an order for, and promptly administer, an antiemetic. Antiemetics are often given prophylactically in the OR to prevent nausea, as opposed to therapeutically in the PACU. Post-anesthetic Assessment and Care 163

Dressing care has already been addressed. However, the effects of decreased vision secondary to the surgery and the eye patch must be considered. Visual impairment may contribute to disorientation and postoperative agitation. The patient may have an increased level of anxiety or fear of injury, either potential or actual. Gentle reorientation will assist the patient in regaining awareness and maintaining a personal sense of well-being. There will be times when it is important for you to maintain specific postoperative positioning after surgery. Patients who have undergone cataract surgery may assume positions of comfort and choice. Remember, these patients will be going home where no one will monitor their positioning. Patients who ALERT have undergone a scleral buckle, vitrectomy, or retinal surgery will have their position specified Moderate to mild by the surgeon. For these types of surgery, the discomfort is expected and surgeon will often inject air or an expandable may be treated with analgesics. Severe eye pain may gas behind the retina. The patient will be posibe indicative of increased tioned so that the air, when it rises, will hold the IOP or hemorrhage. The retina against the choroid blood supply. Patients ophthalmologist should be may even arrive in the PACU face down. It will notified immediately in either case. be important to consult the surgeon or postoperative orders for positioning requirements.

Assessment of the Ear, Nose, and Throat Surgical Patient Immediately on admission to the PACU, you should assess the patient’s airway. Airway patency should be confirmed by the presence or absence of an artificial airway, auscultation of bilateral breath sounds, evaluation of respiratory rate and effort, and oxygen saturation using pulse oximetry. Vital signs should be obtained and oxygen therapy initiated. The secondary priority should be assessment of the operative site. The presence or absence of a dressing should be noted. If a suture line is visible, it should be intact. The surgical site should be assessed for drainage and the presence of drains and packing. Any swelling or discoloration also should be noted. Careful, accurate documentation of the admission assessment is important, because baseline data may be needed for comparison if problems develop later in the postoperative period.

Nursing Priorities for the Ear, Nose, and Throat Surgical Patient The first priority in caring for the patient who is recovering from ear, nose, and throat (ENT) surgery is maintenance of the airway. The airway 164 Post-anesthetic Assessment and Care

may be threatened as a result of edema, laryngospasm, or bleeding. Ideally, maintenance of the airway stems from a preventative approach, rather than a treatment approach. If the patient has no artificial airway in place, as will most likely be the case with ear and nasal surgery, maintenance of the airway is achieved through positioning and ongoing assessment of respiratory adequacy. Usually the patient will be positioned in a semi-Fowler’s position with the head of the bed elevated. This position minimizes eustachian tube edema, especially after mastoid procedures, decreases nasal swelling, and promotes sinus drainage. In addition, this position promotes respiratory excursion. If the patient has an artificial airway in place, COACH including an endotracheal tube, tracheostomy CONSULT tube, or nasal airway, placement of the airway should always be confirmed by repeated ausculWatch closely for any signs tation of breath sounds. A chest x-ray examinaof airway obstruction, tion may be performed to confirm placement of including snoring, increased respiratory effort, absent an endotracheal tube. breath sounds, and falling Confirm whether the surgeon has ordered oxygen saturation. If you additional airway equipment to be kept at the suspect obstruction, interbedside in case of emergency. A reintubation ventions will include stimulating your patient to take tray and a tracheostomy set should also be readdeep breaths, and opening ily available. the patient’s airway by jaw Oxygen therapy is a priority. Because thrust on the mandible, trachea or mouth breathing replaces nasal chin lift, or placement of an breathing after ENT surgery, the oxygen should artificial airway. be humidified. Monitoring of oxygen saturation is essential. Management of bleeding and secretions also is a priority. Tissue in the airway is extremely COACH vascular and, as a result, bleeding may become CONSULT a problem postoperatively. If wound drainage devices are in place, their patency should be If the patient has a new tracheostomy, a spare evaluated and the adequacy of suction maintracheal airway is usually tained. If the wound has packing in place, as kept at the bedside. If the with nasal surgery, some bleeding is to be patient’s jaws are wired, as expected because the packing acts as a wick to may be case in a fracture remove blood from the operative site. The repair, a wire cutter should be kept at the bedside. cover dressings may need to be changed or reinforced. The packing should be left in place.


If the patient is bleeding into the mouth or oropharynx, suctioning may be required. Suctioning should be done gently with a soft, flexible catheter. If the tracheostomy or endotracheal If the patient is able to tube needs to be suctioned, sterile technique self-suction, provide a must be maintained to prevent infection. soft catheter, reminding Secretions may be problematic after ENT the patient to self-suction gently. surgery. Normally, 20 to 50 ml of saliva are produced every hour. However, irritation of the mucous membranes may increase this to 200 ml per hour. If the patient is unable to clear the secretions independently, gentle suctioning may be required. Postoperative edema may occur as a result of surgical manipulation and bleeding. Edema may threaten the patient’s airway. To prevent edema formation, ice packs may be ordered for up to 48 hours after surgery. Steroids may be ordered to decrease inflammation. Steroids are commonly ordered after tonsillectomy, radial neck dissection, or maxillary fracture repair, for example, Le Fort procedures. Voice rest may be ordered to decrease vocal cord irritation. The surgeon should be notified immediately in the event of airway compromise, excessive bleeding, secretions, or edema. An additional postoperative priority is prevention and treatment of nausea and vomiting. Nausea and vomiting may occur because of changes in equilibrium, common after middle ear surgery; or because of swallowed blood, intolerance to anesthetic agents, pain, or hypoxia. Prevention of nausea and vomiting increases patient comfort and promotes patient safety by decreasing the risk of aspiration. Nothing should be administered by mouth until the gag and swallow reflexes are confirmed and an order is present to advance fluids. Many patients, particularly those who have undergone throat surgery, will be kept NPO for a specified period of time postoperatively. Finally, make sure the patient has a means of communication. If the patient has been placed on voice rest, or is intubated, the patient may need a pencil and paper to allow for writing out needs or questions. A picture board with words and pictures for common patient needs, such as pain, bathroom, family, and need to turn, may also be used. Patients who are limited in their communication may be particularly anxious. Try to anticipate their questions and needs, provide explanations in advance, and make sure that they have access to the call bell. All of these measures will help to promote patient comfort. COACH CONSULT


Assessment of the Dental Surgical Patient Dental surgical procedures are most commonly performed in a dentist’s office. It may be necessary, however, to utilize an OR with general anesthesia for children and adults with behavioral, physical, or emotional disabilities that prevent their cooperation with dental cleanings and examinations, fillings, extractions, and treatment of gum disease. Knowing the patient’s baseline skill level, language and communication skills, and level of caregiver dependence will be an important part of preoperative assessment. Plan on involving caregivers in postoperative care.

Nursing Priorities for Dental Surgical Patients Nursing priorities for dental surgical patients center on airway protection, as surgery occurs in the mouth. The mouth and oropharynx should be inspected for bleeding. Bleeding can result in laryngospasm and, if blood is swallowed, in nausea and vomiting.

Assessment of the Gastrointestinal Surgical Patient

COACH CONSULT Remember, these patients could not tolerate a procedure in the dentist’s office, so you will need to be particularly attentive to their unique needs. Involving their primary caregiver will aid efforts to decrease postoperative agitation and to promote patient comfort.

Inspection will be the first physical assessment skill used to evaluate the patient who has undergone gastrointestinal (GI) surgery. The surgical site dressing will be evaluated for location, type, presence of drains, drainage, and bleeding. Drains may be placed to self-suction, as in the Hemovac or Jackson-Pratt drain; wall suction, as in a nasogastric tube or Davol drain; or to a dressing, as in a Penrose drain. Palpation will be used to assess for abdominal distension. It is also used to maintain drain patency. Percussion is used to assess abdominal or gastric distention. Auscultation may be used to confirm the placement of the nasogastric tube. Depending on the surgery, the surgeon may request abdominal girth measurements.

Nursing Priorities for Gastrointestinal Surgical Patients Unless a minimally invasive endoscopic procedure, most patients who have undergone GI surgical procedures will have a nasogastric (NG) tube in place on admission to the PACU. The NG tube is designed to provide gastric decompression. You should place the NG tube to low, intermittent suction.


Placement of the NG tube should be confirmed on arrival in the PACU by injecting air into the NG tube while auscultating over the stomach. Correct placement will be confirmed by the sound of a “whoosh” of air. Check the pH of the aspirate. It should be acidic, between 1 and 4. The gold standard for confirmation of NG placement remains x-ray. Proper functioning of the NG tube will prevent reflux, nausea, vomiting, and abdominal distention. You should check with the surgeon before repositioning or irrigating the NG tube. The tube may lie in close proximity to an anastomosis, or suture line. Repositioning the tube could cause perforation or disruption of surgical integrity. It is also important to maintain NPO status while the NG tube is in place. Good mouth care should be given. Always check with the surgeon before giving ice chips. Follow postoperative orders for all other drains. Some may be set to self suction, but many will require wall suction. In the case of major abdominal surgeries, such as a pancreatoduodenectomy, or following trauma, you may find that your patient has multiple drains. As you attach each to suction, carefully label the suction canister to allow for easier monitoring and documentation. You should evaluate for respiratory adequacy. Large abdominal incisions are extremely painful, and can cause the patient to limit respiratory excursion, causing hypoventilation. Hypoventilation will predispose the patient to atelectasis and pneumonia. Pain management will be important. IV narcotics may COACH be used, or paravertebral nerve blocks such as CONSULT intercostal nerve blocks may be used to decrease splinting and to promote ventilation. Local If the NG tube is not to be anesthetics may be injected along the incision repositioned, it is helpful line. Epidural analgesia and patient-controlled to post a sign over the patient’s bed stating “NO analgesia are popular pain control intervenREPOSITIONING OF NG tions in these patients. TUBE.” Although you To prevent thrombus formation and the might not post this sign in development of pulmonary embolism, antiemthe PACU, because you will be the only one caring for bolism stockings such as TED hose may be this patient until discharge, applied prior to surgery, with or without the this information will be addition of sequential compression devices. This important on the surgical will be especially true for long surgical proceunit, and is often written as dures on high-risk patients, such as patients who a postoperative surgical order by the surgeon. are obese. Encouraging the patient to perform active range of motion exercises will promote


venous return. Subcutaneous heparin will further decrease the risk of clot formation. This drug may be started in the OR or in the PACU. Fluid status should be evaluated, considering intraoperative fluid intake, output, and blood loss. Accurate intake and output records are important, and will assist in the management of fluid status once, and if, third-spacing develops,

Assessment of the Gynecologic Surgical Patient Inspection will be the first skill used to assess the patient who is recovering from gynecologic surgery. The surgical site should be inspected, and the condition of dressings noted. A diagnostic laparoscopy patient may have only two abdominal band-aids, whereas a patient following an abdominal hysterectomy may have a large suprapubic dressing. The presence of drains should be noted, and an assessment of the type and amount of output recorded. A drain should alert you to the fact that drainage is expected. Drains are also used to decrease swelling. A urinary catheter may have been placed to promote bladder emptying and to monitor urine output more closely on an hour-by-hour basis.

COACH CONSULT Loss of intravascular volume, known as “thirdspacing,” is not usually seen until the third postop day.

COACH CONSULT Occasionally, the urine in the drainage bag may contain methylene blue dye. This dye is injected into the bladder intraoperatively to observe for any movement of dye into the surgical field. If dye is detected in the surgical field, a bladder perforation will be suspected. This observation and subsequent repair will be done in the OR.

Nursing Priorities for Gynecologic Surgical Patients Wound care and assessment of drainage will be a priority for the patient who is recovering from gynecologic surgery. You should evaluate and document evidence of bleeding, which may occur via a drain or onto a perineal pad. Although it is difficult to quantify blood loss onto a pad, it is possible to document the number of pads used over a specific time period, such as two pads saturated in 20 minutes. Maintain patient privacy when checking and changing perineal pads. If the incision is abdominal and not laparoscopic, pain may interfere with respiratory adequacy. Hypoventilation may occur secondary to splinting. Pain management is important. Elevation of the head of the


COACH CONSULT It should be noted that generalizations for surgical care are just that, generalizations. Care of the surgical patient is often very specialized, particularly for transplant patients. You should always follow any existing surgical protocols, care maps, or standardized care plans, as well as all postoperative orders written by the surgeon, clarifying anything that you do not understand or that seems to be a discrepancy or exception.

bed will promote respiratory excursion. High humidity oxygen will promote gas exchange. Antiembolism stockings such as TED hose, with or without sequential compression devices, may have been applied in the OR, especially for high-risk patients and those patients who were positioned in the lithotomy position. Subcutaneous heparin may be ordered to further prevent clot formation postoperatively.


CHAPTER

7

Pain Management

T

he management of pain in the perioperative period is one of the most important nursing interventions provided to a patient. Pain arises not only from physical damage to tissue caused by surgical trauma, with a subsequent response to the peripheral and central nervous system, but it also is important to realize that there is an emotional component to pain. Pain is extremely personal and management requires recognizing the subjective nature of the pain experience.

Types of Pain Pain can be defined as acute pain or as chronic pain. Acute pain is defined as pain of a brief duration that diminishes with healing. It may range from mild to severe intensity. Postsurgical pain is an example of acute pain. Common causes of acute postoperative pain include the • Site, nature, and duration of the surgery COACH • Patient’s physiologic and psychologic CONSULT make-up • Preoperative pharmacologic and psyPatients who have underchologic preparation of the patient gone abdominal and • Anesthetic management before, intrathoracic surgery generally experience the during, and after surgery most postoperative pain. • Presence of postoperative Posterolateral incisions complications tend to be more painful • Quality of postoperative nursing care than anterolateral ones. Surgery on the joints, back, Specific contributing factors to postoperative and anorectal areas also pain may be found in Table 7–1. are quite painful.

171

Table 7–1

Causes of Postoperative Pain

TYPE

EXAMPLES

Incisional

Skin and subcutaneous tissue

Deep tissue

Cutting, coagulation, retraction, manipulation

Positional

On operating table, operative position, x-ray, traction

Respiratory tract

Endotracheal tube, extravasation, venous irritation

IV site

Needle trauma, extravasation, venous irritation

Ancillary

Casts, tight dressings, catheters, nasogastric tubes

Rehabilitation activity

Coughing, ambulating, voiding, deep breathing

Chronic pain is prolonged, lasting between 3 and 6 months or longer. Pain persists beyond the expected healing period and is no longer classified by ongoing or potential tissue damage. Three types of chronic pain have been identified: 1. Recurrent acute pain is best described as pain episodes separated by pain-free periods. Examples of this type of chronic pain include sickle cell pain and migraine headache pain. 2. Ongoing time-limited pain has a foreseeable end with either death or control of the disease. An example of this type of chronic pain includes malignancy. 3. Chronic nonmalignant (chronic benign) is an ongoing pain not due to malignancy, not time-limited, and not life-threatening. This type of pain persists beyond the expected period for healing following injury. Examples of this type of chronic pain include low back pain and chronic regional pain syndrome. Patients with chronic pain may present for procedures to address their pain, including regional blocks, or implantable therapies, or following surgical procedures unrelated to their chronic pain.

Effects of Untreated Pain Pain has an effect on multiple organ systems, including neuroendocrine function, respiration, renal function, gastrointestinal activity, circulation,

172 Pain Management

and autonomic nervous system activity. Untreated, severe postoperative pain • Decreases respiratory movement with an increase in splinting and decreased ability to cough, resulting in atelectasis and pneumonia • Makes early ambulation difficult, increasing the risk of thromboembolic events • Exaggerates the catecholamine response, increasing systemic vascular resistance (SVR), cardiac work, myocardial oxygen demand, heart rate, and blood pressure, and ischemia • Increases sympathetic tone and increases SVR, further increasing clot risk • Delays the return of normal gastric and bowel function • Causes the psychologic consequences of anger, distrust, helplessness, frustration, and fear

Pain Assessment “The single most reliable indicator of the existence and intensity of pain, and any resultant distress, is the patient’s self-report,” according to the AHCPR Pain Management Clinical Practice Guidelines. This seemingly simple definition emphasizes the subjective nature of pain and challenges nurses to become skilled in looking for evidence and balancing objective findings, such as physiologic and behavioral signs, against subjective findings, such as the patient’s self-report.

Subjective Assessment Using the patient’s report of pain and his or her descriptions of the pain is referred to as a subjective assessment. Assessment begins by asking the patient to evaluate his or her pain. The most common screening tool is to ask the patient to rate their pain on a scale of 1 to 10, with 10 being the worst possible pain imaginable. This rating helps to • Establish a baseline • Evaluate the effectiveness of interventions in reducing pain • Evaluate healing over time

Objective Assessment Unfortunately, although the subjective report of pain is considered the best indicator of pain, the nurse is unable to confirm or refute this selfreport. Pain medication and the institution of other relief measures may

Pain Management 173

COACH CONSULT If the patient does confirm the existence of pain, it is important to ask two more questions: 1. Where is your pain? Do not assume that a postoperative patient is experiencing pain at the surgical site. For example, it would be improper to assume that a patient who had a total hip replacement and is complaining of pain is experiencing pain at the surgical site. The pain may in fact be myocardial, due to a dysrhythmia and imminent infarction. 2. Can you describe your pain? A patient may describe postsurgical incisional pain as sharp and burning, but a report of crushing pain that limits the ability to take a deep breath describes very different pain.

ALERT Restlessness may be indicative of hypoxemia, so careful evaluation must be made.

be withheld if the report of pain is not accompanied by behavioral or physiologic signs of distress.

Behavioral Indicators Behavioral indicators of pain include crying, moaning, or grimacing. Pain may also be suspected when the patient demonstrates guarding by pulling back from touch to protect an area, restlessness, and frequent repositioning. These behavioral indicators of pain can assist the post-anesthesia care unit (PACU) nurse in determining the reality of pain, particularly in the preverbal or nonverbal patient.

Physiologic Indicators Physiologic indicators of pain include manifestations of sympathetic stimulation, including tachycardia, hypertension, tachypnea, dilated pupils, and increased muscular tone. It has been recommended by clinical practice guidelines to utilize physiologic measures only as adjuncts to the patient’s self-report and not as sole indicators of pain. This is because physiologic indicators are neither sensitive to nor specific as indicators of pain. For example, the signs of tachycardia, hypotension, and tachypnea can be signs of hypoxemia or hypovolemia, which would be treated much differently than pain, and actually result in a significant deterioration if treated as pain with narcotics.

Pain Assessment Tools

A number of useful pain assessment tools have been developed to quantify or qualify pain in all ages of patients, from premature infants to elderly patients with dementia. They include the • Verbal rating scale • Visual analog scale • Descriptive pain intensity scale

174 Pain Management

• • • • • • •

Premature infant pain profile CRIES scale Neonatal Pain, Agitation and Sedation Scale Riley Infant Pain Scale FLACC Scale Wong Baker FACES Pain Rating Scale Pain Assessment in Advanced Dementia Scale

Verbal Rating Scale The verbal rating scale, as previously discussed, asks patients to rate their pain on a scale of 1 to 10, with 10 being the worst possible pain. This scale is easily explained to patients and provides a means for the nurse to rapidly understand the intensity of a patient’s pain. It can be easily used in older children and adults.

Visual Analog Scale The visual analog scale requires patients to look at a pain rating scale and to determine the numeric value of their pain or to approximate the intensity of their pain. These scales are more useful with adult patients who are able to make comparisons and judgments (see Figs. 7–1, 7–2A and B).

NO PAIN

PAIN AS BAD AS IT COULD POSSIBLY BE

F I G U R E 7 - 1 : Visual Analog Scale.

0 No pain

1

2

3

4

5 6 Moderate pain

7

8

9

10 Worst pain

F I G U R E 7 - 2 A : 0 to 10 numeric pain intensity scale.

Pain Management 175

10 WORST PAIN 9 8 7 6 5 MODERATE PAIN 4 3 2 1 F I G U R E 7 - 2 B : 0 to 10 vertical numeric pain intensity scale.

0 NO PAIN

Descriptive Pain Intensity Scale The descriptive pain intensity scale is useful for verbal adults because it requires the ability to describe the quality of pain. It is limited in usefulness with non-English speakers (see Fig. 7–3).

Premature Infant Pain Profile The Premature Infant Pain Profile is useful in premature infants, using physiologic responses as evidence of pain. This scale requires the assessment of physiologic parameters indicative of pain and scoring the signs against the parameters indicated on the scale. The higher the score, the higher the intensity of the pain, and greater the need for intervention (see Table 7–2).

CRIES Scale The CRIES scale is used for infants 32 weeks’ gestation to 20 weeks post-term (see Table 7–3). This scale also uses physiologic indicators, 176 Pain Management

NO PAIN

MILD PAIN

MODERATE PAIN

NONE

ANNOYING

SEVERE PAIN

VERY SEVERE PAIN

WORST POSSIBLE PAIN

UNCOMFORTABLE DREADFUL

HORRIBLE

AGONIZING

F I G U R E 7 - 3 : Descriptive pain intensity scale.

as well as the ability of the infant to quiet with comforting. Infants are scored using the parameters indicated on the scale. The higher the score, the higher the pain intensity, and greater the need for intervention.

Neonatal Pain, Agitation, and Sedation Scale The Neonatal, Pain, Agitation, and Sedation Scale (N-PASS) is for neonates from term to infants 100 days post-term. This scale assesses Table 7–2

Premature Infant Pain Profile 0

1

2

3

Gestational Age

≥ 36 wks

32–35 6/7th wks

28–31 6/7th wks

ⱕ 28 wks

Behavioral state

Active/ Awake

Quiet/ Awake

Active/ Sleep

Quiet/ Sleep

Heart rate

0–4 beats/ minute increase



25 beats/ minute increase or ⬎

02 Sats

0%–2.4% decrease

2.5%–4.9% decrease

5%–7.4% decrease

7.5% or ⬎ decrease

Brow bulge

None

Minimum

Moderate

Maximum

Eye squeeze

None

Minimum

Moderate

Maximum

Nasolabial furrow

None

Minimum

Moderate

Maximum

Source: From: Stevens, B., Johnston, C., Petryshen, P., & Taddio, A. B. (1996). Premature infant pain profile: Development and initial validation. Clinical Journal of Pain, 12(1):13–22.

Pain Management 177

Table 7–3

CRIES Scale 0

1

2

Crying

No

High pitch consolable

Inconsolable

Required FiO2

No

⬍30%

⬎30%

Increased HR and BP

No

11%–20% higher

⬎20% higher

Expression

None

Grimace

Grimace/Grunt

Sleepless

No

Wakes frequent intervals

Constantly awake

(Reprinted with permission from author, S. Krechel).

physiologic parameters determined to be indicative of pain, each scored using the parameters as defined on the scale. The higher the score, the higher the pain intensity and greater the need for intervention (see Table 7-4).

Riley Infant Pain Scale The Riley Infant Pain scale is designed for children younger than 36 months. Infants are scored against the parameters defined on the scale. The higher the score, the greater the pain intensity, and greater the need for nursing intervention (see Table 7–5).

FLACC Postoperative Pain Tool The FLACC Postoperative Pain Tool is designed for infants aged 2 months to children aged 7 years and for children with cognitive impairment. Infants and children are scored using the parameters of the scale. The higher the score, the greater the pain intensity and greater the need for nursing intervention (see Tables 7–6 and 7–7).

Wong Baker FACES Pain Rating Scale The Wong Baker Faces Pain Rating Scale is designed for children older than 36 months of age. The higher the score, the greater the pain intensity and greater the need for nursing intervention (see Fig. 7–4).

Pain Assessment in Advanced Dementia Scale The Pain Assessment in Advanced Dementia (PAINAD) scale can be used to assess pain in persons with advance dementia. Individuals are scored according to parameters on the scale. The higher the score, the greater the pain intensity and greater the need for nursing intervention (see Table 7–8).

178 Pain Management

Table 7–4

N-PASS Scale

ASSESSMENT CRITERIA

SEDATION

NORMAL

PAIN/AGITATION

Pain Management 179

–2

–1

0

1

2

Crying Irritability

No cry with painful stimuli

Moans or cries with painful stimuli

Appropriate crying Not irritable

Irritable or crying at intervals Consolable

High-pitched or silent-continuous cry Inconsolable

Behavior state

No arousal to any stimuli No spontaneous movement

Arouses minimally to stimuli Little spontaneous movement

Appropriate for gestational age

Restless, squirming Awakens frequently

Arching, kicking Constantly awake or arouses minimally/ no movement (not sedated)

Facial expression

Mouth is lax No expression

Minimal expression with stimuli

Relaxed Appropriate

Any pain expression intermittent

Any pain expression continual

Extremities tone

No grasp reflex Flaccid tone

Weak grasp reflex Decreased muscle tone

Relaxed hands and feet Normal tone

Intermittent clenched toes, fists, or finger splay Body is not tense

Continual clenched toes, fists, or finger splay Body is tense

Continued

180 Pain Management

Table 7–4

N-PASS Scale—Cont’d

ASSESSMENT CRITERIA

Vital signs: HR, RR, BP, SaO2

SEDATION

NORMAL

PAIN/AGITATION

–2

–1

0

1

2

No variability with stimuli Hypoventilation or apnea

⬍10% variability from baseline with stimuli

Within baseline or normal for gestational age

10%–20% from baseline SaO2 76%–85% with stimulation— quick recovery

⬎20% from baseline SaO2 ⱕ75% with stimulation—slow recovery Out of sync with vent

Premature Pain Assessment

⫹3 if ⬍28 weeks gestation/corrected age ⫹2 if 28–31 weeks gestation/corrected age ⫹1 if 32–35 weeks gestation/corrected age

Source: Hummel, P., et al. (2008). Clinical reliability and validity of the N-PASS: Neonatal pain, agitation and sedation scale with prolonged pain. Journal of Perinatology, 28, 55–60.

Table 7-5

Riley Infant Pain Scale Assessment Tool

BEHAVIOR

SCORING 0

1

2

3

Facial

Neutral/ smiling

Frowning/ grimacing

Clenched teeth

Full cry expression

Body movement

Calm, relaxed

Restless/ fidgeting

Moderate agitation or moderate mobility

Thrashing, flailing, incessant agitation, or strong voluntary immobility

Sleep

Sleeping quietly with easy respirations

Restless while asleep

Sleeps intermittently (sleep/awake)

Sleeping for prolonged periods of time interrupted by jerky movements or unable to sleep

Verbal/vocal

No cry

Whimpering, complaining

Pain crying

Screaming, high-pitched cry

Consolability

Neutral

Easy to console

Not easy to console

Inconsolable

Response to movement/ touch

Moves easily

Winces when touched/ moved

Cries out when touched/ moved

High-pitched cry or scream when touched or moved

Source: From Comparison of Three Preverbal Scales for Post Operative Pain Assessment in a Diverse Pediatric Sample, by JG Schade, BA Joyce, J Gerkensmeyer, and JF Keck, 1996, J of Pain and Symptom Management 12(6) p. 348-359. Copyright 1996 Elsevier Science Inc. Reprinted with permission.

Pain Management 181

Table 7–6

FLACC Behavioral Scale

CATEGORIES

SCORING 0

1

2

Face

No particular expression or smile

Occasional grimace or frown, withdrawn, disinterested

Frequent to constant frown, clenched jaw, quivering chin

Legs

Normal position or relaxed

Uneasy, restless, tense

Kicking, or legs drawn up

Activity

Lying quietly, normal position, moves easily

Squirming, shifting back and forth, tense

Arched, rigid, or jerking

Cry

No cry (awake or asleep)

Moans or whimpers, occasional complaint

Crying steadily, screams or sobs, frequent complaints

Consolability

Content, relaxed

Reassured by occasional touching, hugging, or being talked to, distractible

Difficult to console or comfort

Each of the five categories (F) Face; (L) Legs; (A) Activity; (C) Cry; (C) Consolability is scored from 0–2, which results in a total score between zero and 10. © 2002, The Regents of the University of Michigan. All Rights Reserved.

Table 7–7

FLACC Behavioral Scale for Children with Cognitive Impairment

CATEGORIES

Face

SCORING 0

1

2

No particular expression or smile

Occasional grimace or frown; withdrawn, disinterested; appears sad or worried

Consistent grimace or frown; clenched jaw, frequent/constant quivering chin; distressed-looking face; expression of fright or panic

Does your child have other facial expressions that indicate pain? Describe. Continued

182 Pain Management

Table 7–7

FLACC Behavioral Scale for Children with Cognitive Impairment—Cont’d

CATEGORIES

Legs

SCORING 0

1

2

Normal position or relaxed; usual tone and motion to limbs

Uneasy, restless, tense; occasional tremors

Kicking, or legs drawn up; marked increase in spasticity, constant tremors or jerking

Does your child move his/her arms/legs in a manner that indicates pain? Describe. Activity

Lying quietly, normal position, moves easily. Regular, rhythmic respirations

Squirming, shifting back and forth, tense or guarded movements; mildly agitated (e.g. head back and forth, aggression); shallow, splinting respirations; intermittent sighs

Arched, rigid, or jerking; severe agitation; head banging; shivering (not rigors); breath holding, gasping or sharp intake of breaths, severe splinting

Are there other bodily movements/activities that indicate pain in your child? Describe. Cry

No cry

Moans or whimpers, occasional complaint; occasional verbal outburst or grunt

Crying steadily, screams or sobs, frequent complaints; repeated outbursts, constant grunting

Are there specific sounds or words that your child uses to indicate pain or hurt? Describe. Consolability

Content, relaxed

Reassured by occasional touching, hugging, or being talked to, distractible

Difficult to console or comfort; pushing away caregiver, resisting care or comfort measures

What activities best comfort or console your child when he/she is hurting? Describe. Each of the five categories (F) Face; (L) Legs; (A) Activity; (C) Cry; (C) Consolability is scored from 0–2, which results in a total score between zero and 10. © 2002, The Regents of the University of Michigan. All Rights Reserved.

Pain Management 183

Wong-Baker FACES Pain Rating Scale

0 No hurt

5 1 2 3 4 Hurts little Hurts little Hurts even Hurts whole Hurts worst bit more more lot

Explain to the person that each face is for a person who feels happy because he has no pain (hurt) or sad because he has some or a lot of pain. Face 0 is very happy because he doesn't hurt at all. Face 2 hurts a little more. Face 3 hurts even more. Face 4 hurts a whole lot. Face 5 hurts as much as you can imagine, although you do not have to be crying to feel this bad. Ask the person to chose the face that best describes how he is feeling. Rating scale is recommended for persons age 3 and older. F I G U R E 7 - 4 : Wong-Baker FACES pain rating scale. (From Hockenberry, M. J., Wilson, D., Wilkelstein, M. L. (2005). Wong’s essentials of pediatric nursing (7th ed., p. 1259). St. Louis: Moseby. Used with permission. Copyright, Mosby.)

Table 7–7

PAINAD Scale 0

1

2

Breathing Independent of vocalization

Normal

Occasional labored breathing Short period of hyperventilation

Noisy labored breathing Long period of hyperventilation Cheyne-Stokes respirations

Negative vocalization

None

Occasional moan or groan Low level speech with a negative or disapproving quality

Repeated troubled calling out Loud moaning or groaning Crying

Facial expression

Smiling, or inexpressive

Sad; frightened; frown

Facial grimacing

Score

Continued

184 Pain Management

Table 7–8

PAINAD Scale—Cont’d 0

1

2

Score

Body language

Relaxed

Tense Distressed pacing Fidgeting

Rigid Fists clenched Knees pulled up Pulling or pushing away Striking out

Consolability

No need to console

Distracted or reassured by voice or touch

Unable to console, distract, or reassure

TOTAL Source: From Lane, P. (2004). Assessing pain in patients with advanced dementia. Nursing, 34(8), p. 17

Pain Management Management of acute pain begins with the affirmation that patients should have access to the best level of pain relief that can be provided safely. This becomes especially challenging in the PACU, when dealing with residual anesthetics, and in managing acute pain in the patient with chronic pain, who takes daily opioids. As a result, pain management in the PACU is a team effort involving the PACU nurse, anesthesiologist, and surgeon, with the PACU nurse as the cornerstone to the management team. When the patient is transferred, the ambulatory surgical nurse or inpatient unit nurse will replace the PACU nurse as the nursing representative on the team. As soon as the need for pain management has been determined, it is necessary to determine the most appropriate intervention, whether pharmacologic or nonpharmacologic. If the choice is pharmacologic, the decision will focus not only on which medication, but which route of delivery.

Pharmacologic Interventions There are a number of different classes of medications available to manage pain, including nonsteroidal anti-inflammatory agents, opioids, and local anesthetics. Each has specific indications and limitations.

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NSAIDs (Nonsteroidal Anti-inflammatory Drugs) Pharmacologic management of mild to moderate pain should begin, unless otherwise contraindicated, with a nonsteroidal anti-inflammatory drug (NSAID). These drugs work by inhibiting cyclo-oxygenase, an enzyme that is responsible for catabolizing arachidonic acid into prostaglandins. Prostaglandins incite inflammatory responses and activate nerve fibers responsible for the transmission of pain. By inhibiting this reaction, NSAIDs inhibit pain transmission. All NSAIDs are analgesics, antipyretics, and anti-inflammatories; though not all are equal in these properties. Of all the currently available NSAIDs, only ketorolac (Toradol) is available for parenteral use. The others, including ibuprofen, ketoprofen, Naprosyn, and acetaminophen are only available for oral use, which is limited in the NPO, postsurgical patient. NSAIDs offer the following advantages: • No respiratory depression (beneficial after anesthesia exposure) • Little physical tolerance • No withdrawal symptoms COACH NSAIDs have the following disadvantages: CONSULT • Only agent indicated for parenteral use, ketorolac (Toradol), is limited to 5-day Only acetaminophen maximum use due to concerns about renal (Tylenol) does not affect toxicity platelet function. As a result, this medication may • Requires cautious use in patients with be used in patients with thrombocytopenia or coagulopathies coagulopathies. • Requires cautious use in patients at risk for GI ulceration or bleed Opioids The mainstay of moderate to severe postoperative pain management is opioid therapy. Opioids bind to opiate receptors in the central nervous system, specifically in the brain and spinal cord. These opiate receptors are classified as mu, kappa, sigma, and delta receptors. The mu and kappa receptors are associated with analgesia and gastrointestinal side effects. The sigma receptors are associated with dysphoria and psychomimetic effects. The delta receptors are associated with alterations in affective behaviors. Opiate Agonists Opiate agonists bind to and activate opiate receptors, thereby causing pain relief and causing other side effects commonly seen with these agents: nausea, constipation, euphoria. The most commonly used opiate agonists in the PACU include the following:

186 Pain Management

• Morphine • Fentanyl • Hydromorphone (Dilaudid) These medications may be administered intravenously, most commonly in the PACU by the nurse or by the patient using a regulated, programmed infusion pump delivering patient-controlled analgesia. They may also be administered via epidural infusion. Intramuscular injections are uncommon, as absorption is unpredictable, titration impossible, and the injections themselves cause pain. Other less commonly used injectable agonists include meperidine (Demerol). Oral agents, uncommonly used in the PACU, include levorphanol (Levo-Dromoran); oxycodone (Percocet, Percodan, and Tylox); methadone, hydrocodone (Vicodin); and propoxyphene (Darvon). See Box 7–1 for a discussion on meperidine. Mixed Agonist-Antagonists Mixed agonist-antagonists act as agonists at some receptors and as antagonists at others. The action of the mixed agonist-antagonists is determined by the relative actions at the sites that are activated or blocked. The advantages of mixed agonist-antagonists over pure agonists are fewer side effects and lower abuse potential. Examples of mixed agonistantagonists that can be given parenterally include butorphanol (Stadol),

Box 7–1

Indications for Using Meperidine

Although Meperidine (Demerol) is one opioid option, this medication has very specific recommendations for use. It has been recommended that meperidine be reserved for very brief courses in patients who have a documented allergy or intolerance to other opioids. Recommended dosage limits are not to exceed 600 mg in 24 hours. These recommendations are based on clinical evidence that finds meperidine: • Being too short-acting for postoperative pain relief, with its less than 3-hour duration of action and lasting just 90 minutes in adolescents and young adults • Irritating to the tissues, as it may cause fibrosis of muscle tissue • Having a toxic metabolite called normeperidine, a cerebral irritant known for causing effects ranging from euphoria to seizures Normeperidine can be particularly problematic for patients with impaired renal function, as the drug is excreted through the kidney, and for patients receiving more than 300 mg/day for 6 or more days, and those already at risk for seizures.

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nalbuphine (Nubain), and buprenorphine (Buprenex). In the PACU, their use is limited, although they can be used in the management of moderate to severe pain. Butorphanol (Stadol) is frequently used in obstetrics, in the management of labor pain in the absence of an epidural.

Local Anesthetics Local anesthetics may be used for postoperative pain control because they work by interfering with nerve conduction, thereby blocking transmission of pain impulses. The use of local anesthetics for postoperative pain control avoids the side effects of opioids, including sedation, respiratory depression, nausea, and depression of gastrointestinal function. Local anesthetics may be delivered by a variety of techniques, and depending upon the route and agent chosen, pain relief may last as long as 12 hours. These drugs may be administered topically, as with local anesthetic creams such as eutectic mixture of local anesthetics (EMLA) cream applied to a circumcision site or to the meatus to minimize the discomfort of an indwelling urinary catheter. They may also be administered via infiltration to decrease pain associated with IV catheter placement, such as with 1% lidocaine. Local anesthetics such as bupivacaine (Marcaine) may be infiltrated into a wound at the time of skin closure, as with herniorrhaphy. Regional blockade is one of the most effective means for providing relief of acute postoperative pain. Single injection techniques may be useful after outpatient or minor surgery, such as intercostal nerve block. A catheter may be placed for both outpatients and inpatients to deliver continuous local anesthetic into a wound, such as following rotator cuff surgery, or as a continuous epidural, brachial plexus, intercostal or femoral nerve block (see Fig. 7–5).

Postoperative Epidural Anesthesia The use of epidural infusions for postoperative pain control continues to increase. Epidural catheters are designed to remain in place for 1 to 4 days postoperatively. Patients who have undergone thoracic, orthopedic, or intra-abdominal surgeries are provided with pain relief in such a way as to maintain mobility and awareness with minimal side effects. A common technique is for the catheter to be placed in the preoperative period. Although the catheter may or may not be used as the primary anesthetic in the operating room (OR), a test dose of local anesthetic plus epinephrine is given to confirm its placement. It is very common for the patient to be given a general anesthetic for the surgical procedure, with a

188 Pain Management

Shoulder Interscalene plexus block Local infiltration Arm Brachial block Local infiltration Groin (hernia) Ilioinguinal Iliohypogastric blocks Hand Brachial block Elbow block

Neck Superficial cervical plexus block Infiltration Chest Intercostal blocks Epidural Cryothermy Abdomen Upper intercostal blocks Wound perfusion Epidural Lower wound perfusion Epidural

Fingers Digital block Wrist block Anterior thigh (skin graft) Lateral femoral cutaneous

Varicose vein strip Femoral nerve block

Toes Digital block Ankle block

Loin (nephrectomy) Epidural Intercostal block Paravertebral somatic block Anogenital Caudal Epidural Penile block Knee Femoral block Epidural Local infiltration Feet Local infiltration Ankle block Epidural

F I G U R E 7 - 5 : Possible regional blocks for management of postoperative pain. (Adapted from Pither C, Hartrick C: Postoperative Pain. In Raj P, editor: Handbook of regional anesthesia, Chicago, 1985, Churchill-Livingstone).

Pain Management 189

plan to utilize the epidural catheter for postoperative pain relief. The exception might be in labor and delivery for cesarean delivery, where the catheter is used as the primary anesthetic. The test dose uses a comAnticipating that the ideal approach to pain bination of a local anesmanagement is prevention, not treatment, the thetic and epinephrine to anesthesiologist will begin the epidural infusion assess for correct placement. The local anesthetic shortly after the induction of anesthesia. If the is used to assess for the surgery is expected to take less than 2 hours, it development of a motor is common practice to bolus the catheter prior blockade, indicating to starting the infusion. This is done in recogniintrathecal as opposed to tion of the fact that it frequently takes 2 hours epidural placement. Epinephrine is used to to infuse enough medication to provide adeassess for the development quate analgesia. By beginning the infusion preof tachycardia and an operatively or intraoperatively, the patient may increase in blood pressure. awaken in the PACU relatively pain free. which is indicative of intravascular injection, as An alternative approach is for the bolus to be opposed to epidural placegiven in the OR, with the infusion started by the ment on the catheter. The PACU nurse. If a bolus is not given, the PACU test dose is done prior to nurse will likely have to supplement the epidural the administration of anesinfusion with small, titrated doses of narcotic thetic agents, to allow the patient to be fully until an adequate pain level has been achieved. capable of responding, Not only do epidural catheters offer the without the blunting of any advantage of excellent pain control, they offer a effects due to the adminisnumber of physiologic benefits, including the tration of any anesthesia. If either a motor block or following: tachycardia occurs, the • Improved pulmonary function catheter will need to be • Increased blood flow to the lower repositioned and retested extremities prior to use. • Decreased incidence of thromboembolic complications • Diminishing the neuroendocrine response to surgery • Decreasing myocardial oxygen demand • Stimulation of gastrointestinal motility The major concern about the use of epidural analgesia in the postoperative period is the potential for untoward side effects, particularly respiratory depression. This is particularly true when morphine (Duramorph) is used. Morphine, as opposed to fentanyl, is hydrophilic, and as a result, tends to remain in the cerebrospinal fluid (CSF), thereby increasing the concentration of drug in the CSF. The higher CSF concentrations of COACH CONSULT

190 Pain Management

morphine permit rostral or upward ascension of the drug, producing a higher incidence of side effects, most notably respiratory depression. Fentanyl is lipophilic, and moves preferentially into the spinal cord. To avoid this problem, it may be preferable to use lipophilic drugs such as fentanyl, rather than the more hydrophilic narcotics such as morphine, to decrease the risk of side effects. The use of pulse oximetry monitoring will also be helpful in monitoring for signs of respiratory depression, evidenced by a falling oxygen saturation level. Box 7–2 offers a checklist of items that should be confirmed when managing postoperative epidural anesthesia. Other potential side effects include the following: • Pruritus without rash • Nausea and vomiting • Urinary retention • Paresthesia

Box 7–2

COACH CONSULT Infusions must always be delivered via an infusion pump because epidural infusions need to be delivered under pressure in a controlled manner. A Buretrol volume control chamber should also be utilized to limit available infusion to no more than 20 mL, as a safety precaution in the event of a pump failure.

Items to Confirm When Managing Postoperative Epidural

ANESTHESIA • Technique and agents used, documented negative test dose • Physician order for medication, concentration, and rate • Potential side effects and adverse reactions and their management • Postoperative monitoring parameters of vital signs, including level of pain relief • Presence of continuous pulse oximetry • Use of a volume limiting device and infusion pump • Use of tubing with no injection ports • Availability of naloxone with a syringe and needle at the bedside • Clear labeling of pump and tubing as EPIDURAL • Cancellation of all other pain medication orders while epidural is in place • Presence of preprinted order sheets outlining responsibilities for care • Name of responsible physician to call in the event of questions or an emergency

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COACH CONSULT If the epidural infusion seems to be inadequate in controlling a patient’s pain, the anesthesia provider may bolus the catheter with the epidural infusion and reassess the patient in 30 to 60 minutes. If analgesia remains inadequate, a test dose of local anesthetic and epinephrine, usually 2% lidocaine and 1:200,000 epinephrine, will be injected through the catheter to confirm placement. The test dose will generally yield one of three results. (1) If a bilateral sensory block occurs in a few segmental dermatomes, correct placement of the epidural is confirmed. In this case, insufficient volume of the infusion mixture is the likely cause of inadequate analgesia and may be corrected by increasing the rate of the infusion. (2) A unilateral sensory block indicates that the catheter tip has advanced too far into the epidural space, with a lateral migration into the neural foramen. The condition may be corrected by withdrawing the catheter 1 to 2 cm and repeating the test dose. This is usually done by the anesthesia provider or pain management nurse.

When the patient is discharged to the surgical floor, a pulse oximeter should be in place to continue monitoring. In addition, naloxone (Narcan) should be readily available at the bedside, along with a syringe, for administration in the event of apnea or respiratory depression. Many centers have standing orders for the administration of naloxone to allow the nurse to administer the medication without delays that may occur while trying to notify the physician.

Nonpharmacologic Interventions Pain management in the PACU will certainly center on the use of pharmacologic interventions. That said, there will be times when nonpharmacologic interventions may be more appropriate or used as adjuncts to medications. For example, a 6-month-old infant who underwent a herniorrhaphy in which the local anesthetic bupivacaine had been injected into the wound for pain control would benefit greatly from being reunited with his or her parents or another primary caregiver, as parental support is a powerful adjunct to pain control. The application of warm blankets to control shivering is another adjunct. The use of music therapy has been shown to reduce postoperative pain and anxiety. Patients who are already skilled in relaxation and biofeedback will benefit from using these tools to help control pain.

Evaluation of Pain Management

The final step in the pain management process is the evaluation of the effectiveness of interventions in controlling or reducing pain. The evaluation process begins with a reassessment (Continued) of pain levels or intensity, using the same screening tool used to make the decision to administer pain medications, and comparing premedication pain scores

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with postmedication pain scores. A score of zero, or no pain, is not necessarily the goal of pain management. The goal is to reduce the pain to a level tolerable for the patient, with no adverse side effects or patient compromise. After evaluation, the nurse may decide to administer additional pain medication, to continue to monitor the patient, or to discharge the patient to home or a surgical floor, assuming all other discharge criteria have been met.

Challenges in Pain Management

COACH CONSULT—cont’d (3) The complete absence of any sensory block indicates that the catheter is no longer in the epidural space. The catheter should be removed and replaced, or the patient may be switched to an alternative form of postoperative pain control, such as patientcontrolled analgesia.

One of the biggest challenges in pain management is attempting to control acute surgical pain in the patient who chronically uses opioids in the management of a chronic pain condition. These COACH patients may be taking high doses of opioids to CONSULT control baseline pain, and now an acute pain event has occurred, requiring additional doses of It will be extremely helpful pain medication. If, for example, a patient is to the floor nurse, and in the interest of patient already taking 140 mg extended release morsafety, to order the pulse phine (Kadian) BID, using 2-mg doses of moroximeter and to confirm phine IV for postoperative pain management that it is in place before may be grossly ineffective, particularly on postdischarging the patient to operative day two when the effects of the last the surgical floor. The PACU nurse maintains dose of extended release morphine have expired, 1:1 or 1:2 staffing ratios, unless the morphine has been restarted. If the whereas the floor nurse patient is taking oral medications every 4 hours, may have 1:6 plus, making instead of every 12 as with extended release follow-up more difficult. Sending the naloxone and morphine, pain control will be problematic on syringe also will be helpful. day one, 4 hours after the last dose of the usual oral medication. Developing a pain management plan for these patients will require determining what medication the patient uses daily and how frequently, and calculation of the total daily dose of pain medication. It is also important to determine the time of the last dose, and whether the patient will be able to resume taking his or her medication by mouth after surgery, or if the patient will remain NPO. Working together with the anesthesiologist and surgeon, a management plan should be developed.

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Dosing Conversion Tables COACH CONSULT Rarely will nonpharmacologic interventions be used in place of medications to control pain. The exception might be following extubation or the administration of naloxone or other reversal agent for respiratory depression, when the administration of opioids would further depress ventilation and compromise patient safety. Once respiratory adequacy has been confirmed, pain medications can be judiciously administered, with pulse oximetry monitoring in place.

COACH CONSULT

There are numerous dosing conversion tables available in textbooks and on the Internet allowing calculation of dosing when converting one narcotic to another; for example, oral morphine to parenteral (injectable) fentanyl or oral methadone to injectable hydromorphone (Dilaudid). The problem is that these tables do not take into account that patients will restart their oral medications once they are able to tolerate oral fluids and food, and that the nature of the acute surgical pain is intense immediately following surgery, improving over time. Also, these tables will indicate the need for very high dose narcotic administration in the immediate postoperative period, which can be done safely in the PACU with 1:1 or 1:2 staffing and monitoring, but is less safe when done on the postoperative surgical floor with increased staffing ratios and less monitoring. These patients may require an overnight stay in the intensive care or subacute care unit to benefit from the lesser staffing ratios and closer monitoring.

When Patients Are Not Opiate-naive

High-dose narcotic administration in the patient chronically using opioids is not uncommon, and it is important to remember that these patients are NOT opiate-naive, meaning they will have a high tolerance for narcotics. Doses that would cause concern in the opiatenaive patient following surgery will have little to no effect on the patient who is opioid dependent. The administration of these high doses may take you out of your comfort zone. Remember to consider and monitor for the side effects of excess dosing: respiratory depression, falling oximetry, bradycardia or arrhythmias, and excessive sedation. If these signs and symptoms are not present, you can continue to dose your patient safely, even if high doses are required.

Patient-controlled analgesia remains one of the most effective strategies in the management of acute pain in the chronic pain patient, as it allows the patient to have some control over medication use, something that patients are very used to doing in the management of their chronic pain.

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CHAPTER

8

Wound Assessment and Care

T

he skin serves a number of vital functions, including providing • Barrier against infection • Feelings of sensation and touch • Regulation of body temperature • Excretion of waste • Synthesis of vitamin D • Filtering against ultraviolet radiation Surgery jeopardizes the skin’s ability to protect against infection by disrupting skin integrity. In fact, the leading threat to an uneventful surgical recovery is infection. As a nurse, your role will be to prevent infection through risk reduction. Risk reduction includes good hand-washing practices, proper administration of ordered antibiotics, and performance of astute wound and dressing care. Although most surgical incisions will be covered with a dressing when the patient arrives in the post-anesthesia care unit (PACU), having an understanding of surgical wounds and wound care is essential, particularly when managing surgical drains associated with surgical wounds and performing discharge teaching for a patient or family member being discharged to home with dressings or drains in place.

Classification of Surgeries by Degree of Contamination Surgeries and surgical wounds can be classified by their degree of contamination. This classification system, developed by the American College Board of Surgeons, is used to • Assess risk of infection • Guide antibiotic administration in the perioperative period

195

• Guide postoperative assignments for degree of isolation precautions required • Influence patient care assignments of patients in isolation

Clean Surgery Clean surgery has the least potential for contamination during surgery. Characteristics include the following: • No inflammation or infection • Respiratory, gastrointestinal (GI), biliary, or genitourinary (GU) tracts not entered • Nontraumatic wound • No breaks in sterile technique • Antibiotics not required Examples of clean surgery include ear surgery, eye surgery, and mastectomy.

Clean-Contaminated Surgery Clean-contaminated surgery is clean but may involve bacterial exposure. Characteristics include the following: • GI, GU, or respiratory tracts entered under controlled condition (operating room) • No contamination • No inflammation • Only minor break in sterile technique • Usually given one IV dose of antibiotics prior to incision, usually a cephalosporin, assuming no allergy Examples of clean-contaminated surgery include hysterectomy, lung surgery without infection, and gastrectomy.

Contaminated Surgery Contaminated surgery comes with an increasing chance of postoperative infection or infectious complications. Characteristics include the following: • Acute inflammation without overt pus • Operations with major break in sterile technique • Gross spillage from GI tract • GU or biliary tract entered with evidence of infection • Traumatic wound less than 8-hours old from relatively clean source • Antibiotics given before incision and continued postoperatively Examples of contaminated surgery include acute appendicitis, acute cholecystitis, and rectal surgery.

196 Wound Assessment and Care

Dirty Surgery Dirty surgery is surgery with an existing bacterial infection or perforated viscera. Clean tissue is often transected to gain access to pus. Characteristics include the following: • Traumatic wound more than 24-hours old • Fecal contamination • Retained foreign body • Devitalized tissue • Antibiotics given before incision and continued postoperatively Examples of dirty surgery include ruptured appendix and exploratory laparotomy with peritonitis.

Process of Wound Healing Wound healing is a four-step process: 1. Hemostasis 2. Inflammation 3. Proliferation 4. Remodeling/Maturation At the point of initial surgical incision, skin trauma initiates the activation of the coagulation cascade and the subsequent release of clotting factors. The goal of hemostasis is the formation of a fibrin clot, which will ultimately be the basis for the collagen matrix and tissue reformation. Within 1 to 3 days of surgery, the wound enters the inflammatory phase. This phase is characterized by the classic signs of inflammation: • Redness • Warmth • Swelling • Pain • Loss of function During this phase, neutrophils, monocytes, and fibroblasts collect around the fibrin clot and begin to phagocytize bacteria and other cellular debris, as they release factors causing migration and division of cells involved in the proliferation phase. The third phase of wound healing, the proliferation phase, overlaps the inflammation phase and begins 2 to 3 days after surgery. In this phase, tissue growth factors that have migrated to the site initiate the formation of new blood vessels, known as angiogenesis, collagen deposition, granulation tissue formation, epithelialization to cover the wound, and wound contraction.

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Finally, 1 to 6 weeks following surgery, and assuming no complications, wound healing completes in the final phase of remodeling/maturation. This phase features wound closure, scar formation, and resolution of healing. See Figure 8–1 for all the stages of wound healing.

Injury to tissue

Inflammatory phase

Occur simultaneously

Hemostasis

Inflammation

Severed vessels constrict

Release of bradykinin, histamine, serotonin, prostaglandins

Platelet and fibrin clots form

Vasodilation and increased permeability of capillaries

Contraction of clot

Migration of WBCs

Proliferative phase

Fibroblasts enter wound

Collagen synthesis

New blood and lymph vessels form

Epithelial proliferation and migration

Maturation phase

• Collagen fibers remodeled • Tensile strength increases

Contraction (shrinkage) of wound

Healing

F I G U R E 8 - 1 : Stages of wound healing.


Classification of Wounds by Wound Healing Wound healing is a three-step process of events that begins at the moment of injury or surgical incision and can continue for months to 2 years, with the goal of forming strong, healthy replacement tissue. The process of wound healing is known as intention, also called the manner of healing. • Primary Intention: Primary intention involves bringing edges of a wound together and securing them with sutures, surgical glue, staples, or skin closure strips. It is associated with minimal tissue loss, and is the most common type of healing following surgical operation. The wound surface forms within 24 to 48 hours with a straight scar • Secondary Intention: Secondary intention involves some loss of tissue at the wound site following injury or excision. The wound is left open to allow for free drainage of exudates, and the wound base is treated to promote granulation. It may require debridement of necrotic tissue and skin grafting • Tertiary Intention: Tertiary intention, also called “delayed surgical closure,” occurs when there is gross loss of tissue. There is intentional delayed closure of the wound to allow for drainage of exudates, control of contamination, or COACH CONSULT for further surgical procedures. The patient will be returned to operating The patient will be returned room (OR) for wound closure, and the to the OR within 7 days for wound base treated to promote granuwound closure as bacterial lation. See Figure 8–2 for examples of contamination increases sharply after the 8th day. wound healing by primary, secondary, and tertiary intention

Surgical Dressings In the PACU, most wounds have the original surgical dressing, limiting direct observation of the wound. Surgical dressings have a number of different purposes. They should • Protect the wound • Prevent infection • Aid hemostasis • Protect surrounding tissue


(a) Primary intention

Clean wound

Sutured early

Results in hairline scar

Granulation occurring

Epithelium fills in scar

Granulation partially fills in wound

Granulating tissue sutured together

(b) Secondary intention

Wound gaping and irregular (c) Tertiary intention

Wound not sutured

F I G U R E 8 - 2 : Wound healing by primary, secondary, and tertiary intention.

Surgical dressings should also have the following characteristics: • Sterile when applied • Nonadherent to the wound • Absorbable • Easy to apply


Adhesive portion

Nonadhesive portion

F I G U R E 8 - 3 : Montgomery straps.

Types of Surgical Dressings Most surgical dressings are made of gauze and secured with tape. Paper tape can be used for patients allergic or sensitive to adhesive tape. Large wounds that require frequent changing or irrigation may require securing with Montgomery straps (see Fig. 8–3).

ALERT Original surgical dressings should not be removed unless ordered.

Wound Assessment Actual assessment of the wound may be limited in the PACU because of placement of the original surgical dressing. There may be times, however, when you must remove the dressing as a result of excessive bleeding, malfunction of a drain, or prolonged stay in the PACU. Assessment begins with observation and ends with documentation. COACH When assessing, make sure to assess the CONSULT wound’s location, as well as its: • Size: At presentation; it should diminWell approximated implies ish with healing edges that are clean and tightly closed together. • Edges: Should be well-approximated with sutures, staples, or glue • Color: Wound bed should be pink with healthy granulation tissue. A yellow wound bed indicates fibrous,


infected, or necrotic tissue. A black wound bed indicates eschar or necrotic tissue. A beefy red wound bed indicates infection Odor is a sign of • Presence of any drains and, if present, infection. If a malodor is type of drainage: noted, look carefully for • Serous: Clear to straw-colored, watery other signs of infection, • Serosanguineous: Thin, watery, pale red including purulent drainage, fever, and increasing to pink redness of the surrounding • Sanguinous: Bloody, bright red tissue. • Purulent: Thick, yellowish, pus, malodorous • Condition of surrounding skin: Should be pink, dry, clean • Odor: Should be none COACH • Depth: Should become more shallow with CONSULT healing • General condition of patient: Look espeIf the wound is pink or red, protect the wound. If the cially for the presence of a fever or malaise wound is yellow, clean the that does not improve with time wound. If the wound is The use of a wound checklist can help to black, débride the wound. make sure your assessment is comprehensive and that you don’t miss anything. Remembering the components of the checklist also can help to ensure that your documentation is complete. Box 8–1 is an example of a wound assessment checklist. ALERT

Surgical Drains Surgical drains have a number of different purposes. They are inserted to • Evacuate established collections of pus, blood, or other fluids such as lymph Box 8–1

Wound Assessment Checklist

Location _______________ Size _______________ Wound edges Approximated _______________ Color _______________ Presence of drains _______________ Type of drainage _______________ Condition of surrounding skin _______________ Odor _______________ Depth _______________ General Condition of Patient _______________


• Drain potential collections of fluid • Allow for accurate monitoring of output Not all surgeons support drain use in the surgical wound. As a result, you may see different surgeons in your facility placing drains while others do not, for the very same surgery. Surgeons and infectious disease specialists supporting drain use argue that drains • Remove potential sources of infection • Guard against fluid accumulation • May allow for early detection of leak or hemorrhage • Provide a tract for continued drainage following removal ALERT • Remove fluid that causes swelling and pain The potential for Those arguing against drain use argue that causing an anastomotic drains leak is the major reason you • Increase risk of infection may receive a postoperative order to not reposition • Using suction may cause tissue trauma a nasogastric (NG) tube, • May induce an anastomotic leak and to post such a sign • Are ineffective within 24 hours over a patient’s bed. • Have the potential to malfunction

Types of Surgical Drains There are two basic types of surgical drains: Active drains and passive drains. Active drains are low pressure systems allowing for continuous removal of fluid via a closed system. An active drain is attached to a collapsible reservoir that, as it expands, collects drainage. Passive drains provide an exit for fluids, including blood, pus, and necrotic tissue debris. They are usually placed in a stab wound near the incision site. Drainage is free-flowing and not connected to suction. Active Drains • Jackson Pratt: Thin drainage tube with multiple perforations placed inside the body, usually sutured at skin, with tubing connected to a self-suction reservoir. When the bulb is squeezed empty, it applies constant suction to the drainage site. Also called bulb suction or grenade drain. A Davol drain is another example of a bulb suction device • Hemovac: Drainage tube placed inside wound and connected to round drainage collection system with springs inside reservoir that must be compressed to establish suction. May be used for autotransfusion (see Fig. 8–4) Wound Assessment and Care 203

F I G U R E 8 - 4 : Hemovac drain.

Passive Drains

COACH CONSULT You can expect 300 to 500 cc of drainage from a T-tube for the first 24 hours following surgery. Output of ⬎500 cc should be reported to the surgeon. After 4 days, drainage will decrease to ⬍200 cc/day.

• Penrose: Soft flat tube of latex or silicon placed when drainage is expected. Usually free drains to gauze, but can be inserted into a collection bag to measure output. Frequently secured with a sterile safety pin to prevent dislodgement or migration into the wound (see Fig. 8–5) • T-tube: Placed to drain bile from common bile duct following surgical exploration, to relieve blockage of bile duct, or to bypass an opening in the system. Anchored in place to prevent dislodgement

Nursing Management of Surgical Drains You will be expected to manage surgical drains from admission to the PACU, with the surgical floor nurse continuing management until such 204 Wound Assessment and Care

F I G U R E 8 - 5 : Penrose drain.

point as the drain is discontinued. In managing surgical drains, you should • Note the presence of any and all drains in your assessment documentation • Maintain drain in dependent position to facilitate drainage • Keep drains free of kinks and obstructions. Assess drain for patency • Empty drains at regular intervals, accurately recording type and amount of drainage • Wear gloves for this procedure. Devices with self-suction should be emptied when half full, and suction reactivated, to maintain function • Change dressing around passive drain systems to protect underlying skin • Assess underlying skin when performing dressing changes • Expect drainage to initially be serosanguineous or sanguinous, except T-tube biliary drainage, which may range from green to brown • Instruct patients discharged to home with drains in place about drain management and wound care • Be aware that removal of the drains will usually be done by a member of the surgical team • Immediately cover the wound with a sterile dressing if the drain is accidentally dislodged and notify the surgeon Wound Assessment and Care 205

COACH CONSULT Prophylactic antibiotics may be given in the OR prior to incision to decrease risk of postop infection. It is important to verify the antibiotic was administered, and to continue any antibiotics ordered postoperatively.

COACH CONSULT Wound healing requires tissue O2 levels of greater than 40 mm Hg. One of the biggest detriments to wound healing is smoking, as it causes vasoconstriction and localized tissue hypoxemia. Encouraging a patient to stop smoking is important in the perioperative period.

COACH CONSULT Protection of the wound is essential to promote healing. This will be particularly important if a regional anesthetic or block is used, with residual anesthesia blocking sensation of excess pressure, thereby increasing the risk of unintentional injury.

Wound Complications Delaying Healing Delayed healing can be caused by local causes, such as infection, tissue hypoxia, and repeated trauma; and systemic causes such as diabetes mellitus, malnutrition, and immunosuppression; advanced age; and abnormal laboratory values reflective of disease.

Local Causes Delaying Wound Healing Infection is the most common cause of delayed healing. It interferes with new granulation tissue and tissue growth factors delaying collagen deposition. The risk of wound infection is higher in hospitalized patients in comparison with patients discharged to home. Staph. aureus is the most commonly cultured organism, followed by the gram-negative bacilli. Tissue hypoxia leading to tissue necrosis is another cause of delayed healing. An inadequate blood supply, due to hypotension, arterial occlusion, vasoconstriction, or hypothermia will slow the production of collagen and will inhibit the migration of fibroblasts, increasing the risk of infection. Repeated trauma due to poor surgical opposition or excessive mobility of the wound can also lead to poor wound closure and an increased risk of infection.

Systemic Causes Delaying Wound Healing

Diabetes mellitus, particularly when poorly controlled, blocks neutrophil and macrophage function, increasing the risk of infection. Glycosylation of red blood cells, seen with poor control, leads to hypoxia and ischemia.


Malnutrition, particularly protein-calorie malnutrition (PCM), decreases fibroblast proliferation and neovascularization, increasing the risk of infection. Vitamin C is required for collagen synthesis. Immunodepression, immunodeficiency, and immunosuppression due to chemotherapy, radiation, malignancy, or HIV, and use of immunosuppressive medications such as steroids, NSAIDs, and aspirin will delay healing and increase the risk of infection. Steroids suppress inflammation, blunting healing, whereas NSAIDs and aspirin interfere with platelet aggregation and hemostasis. Advanced age is another risk factor for delayed healing and infection. T-cell function declines after the age of 40, and the presence of concomitant diseases increases. Abnormal laboratory tests indicative of systemic disease also may provide a reason for impaired wound healing or may provide evidence of underlying infection not previously detected. Box 8–2 identifies laboratory tests that should be checked in the event of delayed wound healing, along with the underlying condition that may be interfering with healing.

Box 8–2

COACH CONSULT Knowing a patient’s hemoglobin A1c value will provide you with information about his or her level of glucose control. Poor glucose control leads to increased glycosylation of red blood cells. The target hemoglobin A1c is less than 7%, reflecting good glucose control over time.

COACH CONSULT The best indicator of malnutrition is the serum albumin level. A serum albumin of 3.5 to 5 g/dL (35 to 50 g/L) is considered normal. A serum albumin of less than 3.5 g/dL (35 g/L) is diagnostic of protein calorie malnutrition, which may be present, even with a normal body weight.

Labs to Check in the Event of Delayed Wound Healing

Hemoglobin: Anemia if ⬍12 g/dL female or ⬍13.2 g/dL male WBC: Infection if ⬎10 ⫻ 103 Platelets: Poor clotting if ⬍140 ⫻ 103 Erythrocyte Sedimentation Rate: Inflammation if ⬎14 mm/hr male age 55; ⬎21 mm/hr female age 55 Albumin: Malnutrition if ⬍3.5 g/dL Glucose: Diabetes mellitus/hyperglycemia is ⬎120 mg/dL Hemoglobin A1c: Poor glucose control if ⬎7.5% Oxygen Saturation: Tissue hypoxia if ⬍92% SaO2


Wound Dehiscence ALERT In the event of a wound dehiscence, you will see profuse serosanguineous drainage. Cover the area immediately with a sterile dressing, and notify the surgeon. The patient will likely be returned to the OR for wound closure. The patient will also need an IV for fluid replacement, as large amounts of fluid loss occurs through exposed viscera.

• • • •

Wound dehiscence refers to a separation of wound edges. The most common cause of dehiscence is infection. Secondary causes include failure of wound closure, slipped knots, and broken sutures. Occurring most commonly 7 to 10 days postoperatively, it is seen in 2% of all midline abdominal incisions. Wound dehiscence is associated with a 15% to 30% mortality. Risk factors associated with wound dehiscence include the following: • Advanced age (older than age 65 years) • Emergency surgery • Poor wound closure • Intra-abdominal sepsis • Systemic sepsis

Wound infection Vitamin C deficiency Hypoproteinemia Weak tissue at the wound site

Other Surgical Drains and Tubes In addition to active and passive wound drains, patients may also present with other drains, such as the following: • Urinary catheter • NG tube • Gastrostomy tube • Jejunostomy tube • Tracheostomy tube • Endotracheal tube

Urinary Catheter Urinary catheters are designed for temporary or continuous drainage of the urinary bladder. They are usually inserted in the OR, either using a transurethral or suprapubic approach. They also may have a port for continuous irrigation of the bladder, as seen following transurethral resection of the prostate (TURP).


Nasogastric Tube Gastrointestinal motility is slowed following GI ALERT surgery, with an unpredictable return of funcAn NG tube is not tion. Simultaneously, gastric fluids continue to clamped in the PACU, be produced, but not moved through, causing except for transport. distention. The NG tube, also known as a Salem sump, is designed to decompress the GI system following surgery to prevent vomiting. The NG tube will be inserted in the OR while the patient is anesthetized, unless it was placed preoperatively. It is connected to low, intermittent wall suction and may be clamped at intervals following the immediate surgical period to assess for returning GI function (see Fig. 8–6).

Gastrostomy Tube A gastrostomy tube, also known as a percutaneous gastrostomy tube, PEG, or G-tube, is a feeding tube placed surgically or laparoscopically into the stomach for nutritional support when it appears unlikely that an individual will be able to eat for longer than 7 days. It may become the sole means of delivering caloric support, or it may be used with oral feedings. It may be permanent or temporary. Feedings will not start in the PACU (see Fig. 8–7).

(a)

(b)

F I G U R E 8 - 6 : (a) Nasogastric tubes may be used for drainage of the stomach or feeding. Smaller gauge tubes are preferred for feeding. (b) Weighted nasoenteric tube.


gvjhgjh b cag t olpenytg villi bnb s

F I G U R E 8 - 7 : Percutaneous gastrostomy tube.

Jejunostomy Tube This tube, also known as a J-tube, is a feeding tube placed surgically or laparoscopically into the jejunum for nutritional support when it appears unlikely that an individual will be able to eat for longer than 7 days. It may be permanent or temporary. Feedings will not start in the PACU. Jejunostomy tubes are associated with a lower risk of aspiration and pneumonia than gastrostomy tubes, and the potential for a higher caloric intake.

Tracheostomy Tube A tracheostomy tube, also known as a trach tube, is inserted into the trachea either permanently or temporarily for airway management. It allows for maintenance of the airway, as well as for pulmonary suctioning. It can be used for ventilation and to relieve upper airway obstruction (see Fig. 8–8).

Endotracheal Tube An endotracheal tube (ET tube) is inserted into the trachea through the oral or nasopharynx, a process known as intubation, to provide access for ventilation. It is placed in the OR to deliver general anesthesia or emergently in the event of a respiratory or cardiac arrest. Usually, the patient will be extubated prior to discharge from the PACU, unless the patient is discharged to the ICU (see Fig. 8–9).


(a)

Outer tube with flange

Inner cannula

Obturator

Outer tube with cuff and inflating tube

Cuff

Cannula

Obturator (b)

Tracheostomy tube

Inner cannula

Fenestration

(c)

F I G U R E 8 - 8 : Tracheostomy tubes: (a) Nondisposable tracheostomy equipment. (b) Disposable tracheostomy equipment. (c) Fenestrated tracheostomy equipment.


Murphy eye

One-way valve

Pilot balloon

Inflating tube

15 mm adapter

Cap to one-way valve Inflated cuff

Depth markings

Radiopaque line (a)

(b) F I G U R E 8 - 9 : (a) An endotracheal tube. (b) Placement of an orotracheal tube.


CHAPTER

9

Perioperative Complications

B

ased on your admission and ongoing assessment, deviations from normal may be identified, requiring prompt interventions. As the nurse at the bedside, you will be the first person to recognize signs and symptoms of actual or potential problems and will be able to intervene with appropriate interventions, minimizing risk, morbidity, and mortality.

Pulmonary Complications Pulmonary complications are by far the most common complications in the post-anesthesia ALERT care unit (PACU), and include the complications of obstruction, hypoxemia, and hypovenRemember, monitoring equipment tilation. These complications occur as a result does not replace your of exposure to anesthetic agents, medications astute nursing assessment used for pain management, surgical intervenand prompt, appropriate tion, as well as preexisting disease. As standards responsiveness. of care require ongoing monitoring with pulse oximetry and ECG, these complications can be rapidly detected, preventing serious negative outcomes.

Obstruction Obstruction of the airway may be due to the tongue, laryngeal obstruction, or croup. Each is associated with specific signs and symptoms, as well as risk factors that can help you make a rapid diagnosis, allowing you to intervene immediately. 213

Tongue Obstruction The tongue is the primary cause of the majority of airway obstructions in the post-anesthetic patient. This type of obstruction occurs when the tongue falls back into a position that occludes the pharynx, blocking airflow. Signs and symptoms of a tongue obstruction include the following: • Somnolence (patient will be very sleepy) • Snoring • Use of accessory muscles of ventilation, as evidenced by nasal flaring, intercostal, and suprasternal retractions • Diaphragmatic breathing Patients at risk for a tongue obstruction include patients • Who are obese, have a very large neck, or an unusually short neck • With Down’s syndrome • With poor muscle tone, possibly due to residual anesthetics or respiratory fatigue • With swelling due to pressure from the endotracheal tube or instrumentation, infection, or anaphylaxis Prevention of a tongue obstruction begins in the operating room (OR) with good anesthetic and surgical management. Once admitted to COACH CONSULT the PACU, you can help prevent tongue obstruction by continuously stimulating your patient, If tongue swelling is an performing ongoing assessment with prompt anticipated concern, for interventions, and by having airway equipment example, following a readily available. palatoplasty, the surgeon will often place a long The treatment of a tongue obstruction foltongue stitch in the patient’s lows a step-wise approach to management. If mouth. The tongue stitch is you are successful in relieving the obstruction taped to the outside of the with the first intervention, you will continue to patient’s cheek so that the tongue can be easily monitor the patient until you determine that retracted if it is the source the problem remains resolved. If your initial of obstruction. intervention is unsuccessful, then you should rapidly move onto the next step, in sequence, until the tongue obstruction is relieved. • Step 1: Stimulate the patient to awaken: You can do this by verbal encouragement or tactile stimulation with gentle or more aggressive touch. A sternal rub or trapezius squeeze can frequently provide the stimulation that a very sleepy patient requires to awaken • Step 2: Manual jaw thrust or chin lift: This is the same maneuver learned when you took cardiopulmonary resuscitation 214 Perioperative Complications

(CPR). By placing your hands on each side of the patient’s lower jaw and COACH thrusting forward, you may be able CONSULT to relieve the obstruction. Lifting the An oral airway will be chin, to extend the neck, will also tolerated only in a somnoaccomplish this goal (see Figs. 9–1 lent patient. An awake and 9–2) patient will require placement of a nasal • Step 3: Placement of oral or nasal airway. airway: You may need to insert an oral or a nasal airway to relieve the obstruction. Both of these airways should be readily available, in differing sizes, at the bedside of all PACU patients (see Figs. 9–3 and 9–4) • Step 4: Intubation, with or without mechanical ventilation, or tracheotomy: Both of these interventions will require the presence of an anesthesia provider or surgeon. If you have been unsuccessful in relieving the tongue obstruction by

F I G U R E 9 – 1 : Chin lift.

F I G U R E 9 – 2 : Jaw thrust.

Perioperative Complications 215

(A) F I G U R E 9 – 3 : Inserting an oropharyngeal airway. (a) Insert the airway into the upside-down position (inner curve of the C faces upward toward the nose). (b) Rotate the airway 180º so that the ends of the C turn downward over the back of the tongue. Continue to insert the airway until the front flange is flush with the lips.

(B)

(C) F I G U R E 9 - 4 : Nasopharyngeal airway.

stimulating the patient, repositioning the airway, or placing an artificial airway, you need to promptly notify and involve the anesthesia provider, as these interventions are beyond the scope of nursing practice. Your role at this point will be to assist with the interventions

216 Perioperative Complications

Laryngeal Obstruction Laryngeal obstruction, also known as laryngospasm, is a second type of obstruction that can rapidly progress into respiratory arrest if untreated. This type of obstruction is caused by a partial or complete spasm of the intrinsic or extrinsic muscles of the larynx that obstructs airflow. Reflex closure of the glottis, controlled by the intrinsic muscles, produces an intermittent obstruction. Laryngeal closure, controlled by the extrinsic muscles, produces a complete obstruction of the airway when spasm occurs. Signs and symptoms of laryngeal obstruction include patient agitation due to a “feeling of suffocation.” These patients will present in acute respiratory distress, evidenced by dyspnea, hypoxemia, and hypoventilation. When you auscultate lung fields, you will not hear breath sounds. An incomplete obstruction may present as a crowing sound or stridor. Patients at risk for a laryngeal obstruction include those with an irritable airway. The airway may become irritated preoperatively as a result of asthma, chronic obstructive pulmonary disease (COPD), or smoking; intraoperatively as a result of endotracheal tube placement or difficult intubation; or postoperatively as a result of coughing, bucking on the endotracheal tube, repeated suctioning, or excessive secretions. Prevention begins in the OR with a smooth induction of anesthesia to minimize airway irritation from either anesthetic gas exposure or by manipulation of the airway with placement of the endotracheal tube. Prompt extubation when the patient is spontaneously breathing to prevent straining on the endotracheal tube will further minimize irritation. The surgeon also contributes to prevention by carefully controlling bleeding in the oropharynx. Intraoperative steroids might be administered to a patient who is undergoing airway surgery to help prevent any swelling that might develop as a result of surgical trauma, as may be seen following tonsillectomy. Treatment must be prompt, as hypoxemia ALERT and hypercarbia are immediate consequences. You will begin by administering positive presYou must simultaneously and immediately sure ventilation with an Ambu-bag, mask, and involve the anesthesiologist oxygen. in management of a patient These patients may require administration with laryngeal obstruction of a subparalytic dose of succinylcholine to as any additional intervenrelax the laryngeal muscles and to stop the tion will be beyond the scope of nursing practice. agitative behaviors. As this medication must be administered by an anesthesia provider, you


COACH CONSULT Although the first-line intervention for a patient in laryngospasm is positive pressure ventilation with an Ambu-bag, mask, and oxygen, this is often difficult to accomplish. The patient feels like he or she is being suffocated, and placement of an airway mask over the mouth and nose adds to that feeling. The result is often increased agitation, making ventilation difficult. As a result, it is imperative to involve an anesthesia provider early in the intervention to regain airway control promptly.

COACH CONSULT Racemic epinephrine is used for its vasoconstriction effects, not for bronchodilation. The effects are temporary, and rebound edema may occur. If used to treat croup, the patient will require prolonged observation and, possibly, overnight admission. Racemic epinephrine will also increase heart rate during administration. Cardiac monitoring should be maintained during and immediately following treatment.

must involve them immediately in the care of these patients. Once the muscle relaxant has been given, patients will require assisted ventilation until spontaneous ventilation occurs. Reintubation will ideally be avoided to minimize further airway irritation.

Croup Croup, also called subglottic edema, is a type of airway obstruction most commonly seen in children. Signs and symptoms characteristic of croup include an expiratory stridor and the classic sign: a barking cough. Children at risk for croup are those between 3 months and 4 years of age who have experienced a traumatic intubation, a tight-fitting endotracheal tube, or a position change while intubated during surgery, such as when a child is flipped from supine to prone for back surgery. Other risk factors include a prolonged intubation, or manipulation of the airway as a result of surgery of the head and neck. Prevention of croup, as with laryngeal obstruction, centers on minimizing airway irritation. This requires a smooth intubation with an appropriately sized endotracheal tube, and the cancellation of surgery for any patient with an upper respiratory infection. Treatment requires administration of humidified oxygen, and frequently racemic epinephrine. Racemic epinephrine is given to reduce swelling in tissues of the airway.

Hypoxemia Hypoxemia is defined as a PaO2 of less than 60 mm Hg or an SaO2 (saturation) of less than 90%. Signs and symptoms of hypoxemia are nonspecific, ranging from agitation to somnolence, tachycardia to bradycardia, and hypertension to hypotension. These nonspecific signs may suggest other conditions and interventions, delaying


the required interventions to treat hypoxemia. As a result, pulse oximetry monitoring is a stanCOACH dard of care for any patient receiving anesthesia CONSULT (see Fig. 9–5). Cyanosis is a late sign. Anytime a patient presents There are many possible causes of hypoxwith unexpected signs and emia in the PACU. Each is associated with symptoms that compromise specific risk factors that should enable you to stability, you should always consider the cause to be rapidly make the determination of the cause hypoxemia until proven of hypoxemia, and to intervene appropriately. otherwise. Hypoventilation Hypoventilation is defined as a decrease in respiratory rate that results in decreased alveolar ventilation, increased PaCO2, and ultimately hypoxemia. It is the most common cause of hypoxemia in the immediate postoperative period. It is caused by • A decreased respiratory drive as seen with sedation due to anesthetics or narcotics or by the loss of an unpleasant stimuli to breathe when the endotracheal tube is removed • Poor respiratory muscle tone as seen with inadequate reversal of a muscle relaxant, abdominal surgery causing splinting, obesity, or preexisting neuromuscular diseases, or scoliosis • A combination of both previously mentioned causes as seen with narcotic and muscle relaxant administration to an obese patient undergoing abdominal surgery Patients at risk for hypoventilation include any patient receiving general or IV anesthetics or narcotics—essentially every PACU patient—any patient following abdominal surgery, and any bedridden patient who is unable to maximally expand his or her rib cage in deep breathing. Signs and symptoms of hypoventilation are as nonspecific as those for hypoxemia, with one exception. Agitation, although seen with hypoxemia, is replaced with somnolence. The patient is usually so sleepy that

F I G U R E 9 - 5 : Pulse oximeter.


your suggestion to take deep breaths as the first-line intervention may be unsuccessful, or require frequent repetition. Patients also will present with the nonspecific signs seen in hypoxemia, including tachycardia or bradycardia, hypertension or hypotension, as well as more specific signs such as a low respiratory rate for age, shallow respirations, diminished to absent breath sounds and, if capnography monitoring has been initiated, an elevated end-tidal CO2. An arterial blood gas will demonstrate a PaCo2 ⬎45 mm Hg. Prevention of hypoventilation requires careful administration of additional narcotics after admission into the PACU, as well as ongoing assessment and stimulation of the patient to take deep breaths. Treatment begins with your strong encouragement for the patient to take deep breaths. Ideally, you can verbally stimulate the patient to do this, but a gentle touch or more aggressive sternal rub may be required to get the patient’s attention. As you encourage use of the incentive spirometer, you are helping the patient to take deep breaths to aid in maintaining open alveoli and in decreasing atelectasis. Strong and persistent encouragement to take deep breaths may help avoid the need for airway placement or reintubation. If the patient is excessively sedated, naloxone (Narcan) may COACH be required to reverse depressant effects of narCONSULT cotics. You should elevate the head of the bed, unless contraindicated, to help maximally There are times when expand the chest cavity. In extreme cases, a hypoventilation is due to pain, requiring administrasymptomatic patient will require reintubation tion of narcotics. Narcotics, and mechanical ventilation until level of conhowever, may themselves sciousness and muscle tone sufficiently cause hypoventilation. improve to allow unassisted ventilation. Clinical decision making, Atelectasis based on assessment, is required, along with the Atelectasis is another common cause of postopercareful administration of ative hypoxemia, particularly on the postoperasmall, titrated doses of tive surgical floor. Atelectasis may be the result of narcotics to manage pain bronchial obstruction caused by secretions or without further compromising oxygenation and due to decreased lung volumes. Hypotension and ventilation. Being able to low cardiac output can contribute to decreased make this judgment is an perfusion and atelectasis. In addition to the nonadvanced skill. When in specific signs of hypoxemia, patients will present doubt, consult an experiwith diminished to absent lung sounds. enced PACU nurse or anesthesia provider. Prevention is most important. Implementation of treatment strategies early, before the


patient becomes symptomatic, will help to prevent the development of atelectasis. Treatment includes use of humidified oxygen, encouraging the patient in cascade coughing, deep breathing exercises, and the use of incentive spirometry, as well as promoting increased mobility with early ambulation. Intermittent positive pressure ventilation (IPPV) may also be employed. Aspiration Aspiration is defined as the presence of foreign matter, such as gastric contents, blood, or a foreign body, in the lungs, compromising airflow and gas exchange. Aspiration is a potentially serious airway emergency that can compromise patient safety and stability on induction of or emergence from anesthesia. Aspiration may occur in the OR, PACU, or at any point during transfer. Patients may aspirate foreign matter, such as a tooth or food; blood, or gastric contents. Each type of aspiration produces a distinct clinical picture. The aspiration of gastric contents, also known as chemical pneumonitis, is the most severe form of aspiration. Symptoms include the following: • Bronchospasm: Secondary to reflex airway closure • Hypoxemia: Secondary to a compromised alveolar-capillary membrane • Atelectasis: Secondary to loss of surfactant • Interstitial edema→hemorrhage→adult respiratory distress syndrome (ARDS): Secondary to loss of capillary integrity X-ray changes may not be seen for up to 6 hours post-aspiration Patients at risk for aspiration of gastric contents include trauma patients who have not been NPO and patients with an increased intraabdominal pressure, including patients who are obese, pregnant, or those with a hiatal hernia or intestinal obstruction. The aspiration of blood, due to airway trauma or bleeding due to surgery, may cause airway obstruction, hypoxemia, and hypercarbia. If particles of soft tissue are also aspirated, infection may develop. Patients at risk for this type of aspiration are those who have undergone surgery within the airway, such as patients who have undergone tonsillectomy. The aspiration of a foreign body may occur as a result of the presence of a foreign body, such a piece of plastic, or a dislodged tooth. These patients will present with a cough, airway obstruction, atelectasis, bronchospasm, and ultimately, pneumonia. Patients at risk for this type of aspiration include those with poor dental hygiene, or when care is not exercised in tracking needle caps or other small piece equipment in the OR.


WHY IS PREVENTION OF ASPIRATION IMPORTANT? As a result of the potentially serious consequences of aspiration, prevention is key. You can help to identify patients at risk. Patients who fail to maintain NPO status should have surgery cancelled. Patients with delayed gastric emptying, such as patients who are elderly, pregnant, or diabetic can be premedicated with histamine antagonists, nonparticulate antacids, or anticholinergics before induction. Use of a rapid sequence induction and immediate placement of a nasogastric (NG) tube intraoperatively can also prevent aspiration. Treatment of aspiration centers on correction of hypoxemia through oxygen administration; removal of foreign material if possible, such as through gentle suctioning of blood A “rapid-sequence” inducfrom the oropharynx; and maintenance of tion begins with preoxyhemodynamic instability. Antibiotics will be genation of the patient, administered only if the potential for infection followed by IV administration of immediate onset is suspected. Steroid use is not evidenced-based, acting agents, cricoid presbut is common practice. sure, and rapid intubation Bronchospasm of the trachea with the goal Bronchospasm is the result of increased of preventing aspiration. bronchial smooth muscle tone resulting in airway closure. Airway edema develops, causing an increase in secretions, further narrowing the airway. The patient will present with wheezing, dyspnea, use of accessory muscles, and tachypnea. If intubated and mechanically ventilated, increased airway resistance and increased peak airway pressures will be noted. Patients at risk include those with a history of asthma or COPD, aspiration, endotracheal intubation, or tracheal or oropharyngeal suctioning causing airway irritation. Bronchospasm also may develop secondary to histamine release and an allergic response caused by various medications, such as morphine used for pain management. Prevention of bronchospasm centers on minimizing airway stimulation with selection of an appropriately sized endotracheal tube. Aspiration should be prevented using interventions previously identified. Treating bronchospasm requires removal of the precipitating cause and the administration of medications to open the alveoli. Bronchodilators are used to open small airways and to decrease airway resistance. Beta-agonists including albuterol, and racemic epinephrine are the COACH CONSULT


first-line agents used. If you are responsible for setting up the nebulizer, now is the time to get COACH everything ready at the bedside. If your facility CONSULT requires a respiratory therapist to administer First-line intervention for the treatment, call him or her for assistance. bronchospasm is always a Anticholinergics, including atropine sulfate or beta-agonist. glycopyrrolate (Robinul), may be given to decrease secretions, and steroids may be given to decrease airway edema. Pulmonary Edema Pulmonary edema is best described as an accumulation of fluid within the alveoli due to an increase in hydrostatic pressure, decrease in interstitial pressure, or an increase in capillary permeability. Increased hydrostatic pressure occurs as a result of fluid overload, left ventricular failure, ischemic heart disease, or mitral valve dysfunction. Decreased interstitial pressure may follow prolonged airway obstruction. Increased capillary permeability may be the result of sepsis, aspiration, transfusion reaction, trauma, anaphylaxis, shock, or disseminated intravascular coagulation (DIC). Signs and symptoms of pulmonary edema include the nonspecific signs of hypoxemia; crackles, also known as rales, on auscultation; and a decrease in pulmonary compliance. Pulmonary edema can be confirmed by the presence of pulmonary infiltrates on chest x-ray. Patients at risk for pulmonary edema include those with a history of congestive heart failure or myocardial infarction, and those who have received large amounts of IV fluid intraoperatively or during resuscitation. Prevention includes the use of cautious fluid administration in the presence of preexisting heart disease, as these patients cannot tolerate excess fluid without decompensating into overt failure. Elderly patients are at particular risk. Treatment focuses on improving oxygenaCOACH tion, as well as treatment of the underlying CONSULT cause. Oxygenation will be improved with Pulmonary edema due oxygen administration via mask or possibly the to an increase in capillary extreme of intubation with mechanical ventilapermeability is commonly tion. Positive end expiratory pressure (PEEP) referred to as ARDS. Think may be added to force the alveoli open. Diuretics of the “A” as being an “ASSAULT” on the airway. are used to pull fluid from vessels and alveoli. Fluid restriction, coupled with strict intake and


output records, will help keep the patient “dry,” and will reduce fluid overload. Pulmonary Embolism Pulmonary embolism is a leading cause of perioperative morbidity and mortality, with two-thirds of all deaths occurring within 30 minutes of an acute event. A pulmonary embolism occurs as a result of the release of a clot or other matter such as fat or air from venous circulation that travels and lodges within the vasculature of the lungs, obstructing blood flow and gas exchange. Signs and symptoms of a pulmonary embolism are acute, and the patient will rapidly become unstable. The patient may complain of acute dyspnea, and will present immediately with tachypnea; tachycardia; hypoxemia, especially ALERT when already on oxygen postoperatively; chest pain; hypotension; hemoptysis; dysrhythmias; It is imperative and signs of congestive heart failure. Although a that you promptly notify definitive diagnosis requires pulmonary angiogthe anesthesiologist any time a patient complains of raphy, a ventilation-perfusion scan may also acute respiratory difficulty prove useful. The biggest problem is that the in the presence of cardiac patient may be too unstable to move to radiolinstability. ogy, requiring symptomatic treatment based on presumed diagnosis. Patients can be considered to be at risk for the development of a pulmonary embolism if three conditions, known as “Virchow’s triad” exist: • Venous stasis • Hypercoagulability • Abnormalities of blood vessel walls These risk factors are further increased in patients who are obese or elderly; in patients with varicose veins, immobility, malignancy, or congestive heart failure; and in patients following pelvic or long-bone surgery. About 90% of pulmonary emboli arise from deep veins in the legs. Treatment is centered on the management of hypoxemia and the correction of hemodynamic instability by following advanced cardiac life support (ACLS) protocols. As pulmonary embolism may be life threatening, prevention of emboli is of particular importance and is achieved by addressing the three risk factors. You can assist in the application of antiembolic stockings (TED hose) and sequential compression devices (SCDs) applied preoperatively to prevent venous stasis (see Figs. 9–6 and 9–7). Early ambulation following surgery also will prevent stasis, thereby reducing hypercoagulability. The risk of hypercoagulability is further reduced by the administration of subcutaneous heparin postoperatively. 224 Perioperative Complications

F I G U R E 9 - 6 : Antiembolism stockings.

F I G U R E 9 - 7 : Sequential compression device.

Pneumothorax A pneumothorax is a disruption in the integrity COACH of the pleural lining causing lung collapse. It CONSULT occurs most commonly as a complication of It is recommended positive pressure ventilation, central line placethat SCD use not be ment, or following a brachial plexus nerve interrupted for more than block. It also may occur in COPD patients who 30 minutes because of the possibility of clot formation rupture a bleb. It is an expected outcome folwhile the device is off, and lowing open lung surgery so these patients will subsequent dislodgment of be admitted to the PACU with the definitive that clot when compression intervention, a chest tube, already in place. is resumed. Signs and symptoms of a pneumothorax will vary depending on the size of the pneumothorax, and may range from a small fall in oxygen saturation and restlessness to chest pain, dyspnea, and decreased breath sounds on affected side. Definitive diagnosis requires a chest x-ray. Perioperative Complications 225

Prevention of a pneumothorax will require use of the lowest possible level of positive pressure ventilation, if required, both intraoperatively and postoperatively. The anesthesiologist will avoid the supraclavicular approach to central line placement and brachial plexus nerve block as another important strategy. Knowing that pneumothorax is a potential complication of positive pressure ventilation, particularly in smokers, and a potential complication to a supraclavicular approach to block or line placement, allows you to assist the anesthesia provider in immediate assessment of symptoms in the presence of either event. Treatment of a pneumothorax will be determined by the size of the pneumothorax and the degree of symptoms. A small pneumothorax (⬍20%) in an otherwise healthy patient may require only oxygen therapy and monitoring. A larger pneumothorax (⬎20%), causing hypoxemia and dyspnea, will require oxygen therapy, chest tube placement, and continued monitoring until resolved.

Cardiovascular Complications Cardiovascular complications include hypotension, hypertension, dysrhythmias, bleeding, and chest pain. Knowing the signs and symptoms of each, as well as patient risk factors, will allow you to rapidly recognize and intervene appropriately, preventing significant morbidity and mortality.

Hypotension Hypotension is defined as a blood pressure less than 20% of a patient’s baseline BP. It is more accurately defined by clinical signs of progressive hypoperfusion, including the following: • Cool and clammy skin • Compensatory tachycardia • Rapid, shallow respirations • Signs of disorientation • Changes in consciousness • Chest pain and dysrhythmias • Oliguria and anuria Cool, clammy skin reflects shunting of blood away from the periphery. It may become difficult to obtain pulse oximetry readings with peripheral clamping. There will be preferential shunting of blood to protect the heart, brain, and kidneys. The heart will respond with a compensatory tachycardia to boost cardiac output and perfusion. The lungs will respond with shallow, rapid respirations to correct the metabolic acidosis that develops with peripheral clamping and decreased perfusion. Without


correction of the underlying cause of hypotension, compensatory measures will fail, and ultimately vital organs will reflect hypoperfusion, specifically: • Brain: Disorientation, nausea, loss of consciousness • Heart: Chest pain, dysrhythmias • Kidney: Oliguria and anuria Interventions must be prompt to prevent permanent damage to vital organs, including cerebral ischemia, cerebral infarction, renal ischemia, bowel infarction, and spinal cord damage. Hypotension may be the result of hypovolemia, myocardial dysfunction, or decreased vascular resistance. Hypovolemia Hypovolemia is the most common cause of hypotension in the PACU. It is most commonly due to unreplaced intraoperative fluid and blood loss. Pay particular attention to the fluid loss and replacement totals when the anesthesia provider gives you report. Treatment centers on fluid replacement beginning with fluid boluses, unless contraindicated by preexisting diseases such as congestive heart failure or COPD. If blood pressure fails to improve, you should consider myocardial dysfunction as the cause of the hypotension. Positive End Expiratory Pressure PEEP is not a true cause of hypovolemia, but it will accentuate low-volume states. PEEP increases intrathoracic pressure, decreasing venous return to the heart, which lowers cardiac output. This cause of hypotension is difficult to correct, as PEEP is used to optimize ventilation and gas exchange, in order to correct hypoxemia. Primary Cardiac Dysfunction Primary cardiac dysfunction may be due to myocardial infarction or ischemia, tamponade, embolism, or dysrhythmias that interfere with cardiac conduction and compromise cardiac output. Tachyarrhythmias prevent optimal ventricular filling. COACH Conduction blocks compromise myocardial CONSULT pump activity lowering cardiac output. The heart Inotropic medications pumps ineffectively. This cause of hypotension increase the force of will require inotropic and chronotropic medicamyocardial contractions. tions or antiarrhythmics to manage. Chronotropic medications Secondary Cardiac Dysfunction increase the rate of contractions. Secondary cardiac dysfunction is due to myocardial sensitivity to the negative inotropic


or negative chronotropic medications. A reduction of dose may improve cardiac function. For example, an epinephrine infusion may increase heart rate so much as to make the patient symptomatic by compromising ventricular filling. A reduction of the dose may improve both blood pressure and filling pressures by slowing heart rate. Low Systemic Vascular Resistance Low systemic vascular resistance is another potential cause of hypotension and occurs as a result of vasodilatation. Vasodilatation may occur secondary to histamine release, as seen with morphine, succinylcholine, or meperidine; or as seen in cases of anaphylaxis due to an antigen-antibody reaction with profound histamine release and increased capillary permeability. This type of COACH reaction may occur as a transfusion reaction or CONSULT as an allergic response to medications. Vasodilatation may also be due to direct Initial fluid boluses will smooth muscle relaxation that occurs with symgenerally be done with pathetic blockade as a result of the administraeither normal saline or lactated Ringer’s, in the tion of local anesthetics; extreme sensitivity to amount of 300 to 500 cc. afterload reducers, such as sodium nitroprusside Care should be taken in and nitroglycerin used to treat hypertension; or monitoring the speed and due to endotoxin release as seen in sepsis. amount of fluid given so as to not overload the patient. Vaso-Vagal Response This includes monitoring of A vaso-vagal response is an emotional response breath sounds and clinical produced by profound grief, fear, or pain. Blood resolution of signs of pressure falls, causing dizziness, but usually hypoperfusion. self-corrects after the patient resumes a horizontal position. Figure 9–8 provides a framework for identifying the causes of hypotension.

Hypertension Hypertension is defined as a blood pressure of greater than 20% above the patient’s preoperative baseline. There are no other symptoms or signs of hypertension, making blood pressure monitoring essential in the PACU. The American Heart Association defines hypertension as a blood pressure of greater than 130/80 mm Hg, and prehypertension as a blood pressure of greater than 120/80. Many patients presenting for surgery are neither diagnosed with preexisting hypertension nor controlled, so their presenting preoperative baseline is used as the standard for the diagnosis of hypertension.


Hypotension resulting from

Myocardial Dysfunction due to

Primary Dysfunction

Secondary Dysfunction

Hypovolemia due to

Decreased Vascular Resistance due to

Unreplaced intraoperative fluid losses Hemorrhage Dehydration PEEP

Medications Sepsis Anaphylaxis Emotional Response Spinal anesthesia Rewarming

Myocardial Infarction Negative Intrathoracic pressure inotropic and Tamponade Venous return Embolism chronotropic Dysrhythmias medications F I G U R E 9 – 8 : Causes of hypotension.

(

)

The most common causes of hypertension in the perioperative period include pain, hypoxemia and hypercarbia, distention, preexisting hypertension, and iatrogenic, or hospital-induced, hypertension. Firstline treatment of hypertension should be directed toward the cause, as opposed to the administration of medications to lower blood pressure directly. Pain Pain stimulates the somatic afferent nerves, causing the release of the catecholamines epinephrine and norepinephrine, which cause vasoconstriction and increased blood pressure (BP). The administration of analgesics decreases sympathetic responsiveness, normalizing BP. Hypoxemia and Hypercarbia Hypoxemia and hypercarbia stimulate the vasomotor area of the medulla, increasing vasomotor tone, causing arteriolar constriction, and increasing BP. Correction of the cause of the hypoxemia or hypercarbia should normalize BP. Distention Distention of the bladder, bowel, or stomach stimulates the afferent fibers of the sympathetic nervous system, increasing catecholamines, which, in turn, increases blood pressure. Catheterization of the bladder and decompression of the bowel and stomach through placement of a NG tube will normalize BP.


Preexisting Hypertension Preexisting hypertension exists in more than 50% of hypertensive patients in the PACU. This may prove problematic if antihypertensive medications usually taken in the morning are not taken on the day of surgery. This risk can be reduced if patients are told to take their antihypertensive medications as usual on the day of surgery with a small amount of water. Iatrogenic Hypertension Iatrogenic hypertension, is also referred to as COACH idiopathic hypertension, meaning that its cause CONSULT was hospital-induced; something done to the patient in the hospital that caused the blood Correction of hypertension pressure to increase. This may include sensitivity requires prompt identification and correction of the to or overdose on vasoconstrictive medications cause. If that is not possible, due to a malfunctioning infusion pump, misuse of antihypertensive programmed infusion pump, or a medication medications will normalize miscalculation. Discontinuation of medications BP (see Table 9–1). and correction of any pump malfunction or misprogramming should normalize BP.

Table 9–1

Antihypertensive Therapy

DRUGS

ROUTE OF ADMINISTRATION

Nitroglycerin (Tridil, Nitrostat, NitroDur, Nitro paste)

Sublingual Dermal Intravenous infusion

Relaxation of vascular smooth muscle Coronary vasodilation Decrease in venous return Decrease in ventricular filling

Intravenous infusion requires infusion pump and arterial line monitoring, glass bottle, and special tubing

Sodium nitroprusside (Nipride)

Intravenous infusion

Direct peripheral vasodilator Afterload reduction

Requires infusion pump and arterial line monitoring; infusate must be protected from light, usually with foil bag


ACTION


Table 9–1

Antihypertensive Therapy—Cont’d

DRUGS Hydralazine (Apresoline)

ROUTE OF ADMINISTRATION Oral

ACTION


Relaxation of vascular smooth muscle Preferential relaxation of arterioles Maintains cardiac output

Labetalol hydrochloride IV bolus (Normodyne, Trandate)

Alpha-blocker— peripheral vasodilation Beta blocker— decreases heart rate

Do not administer if patient is bradycardic (heart rate ⬍ 60 bpm)

Enalapril maleate (Vasotec)

IV bolus

Suppression of reninangiotensinaldosterone system

Avoid with diuretics or volume depletion; onset occurs in 15 minutes; peak of action usually within 1 hour but occasionally up to 4 hours

Nifedipine (Procardia)

Oral Sublingual

Calcium channel Capsule can be blocker pierced for liquid Relaxes coronary to be given sublingually artery smooth muscle Dilates peripheral arteries

Dysrhythmias In the PACU, most dysrhythmias have an identifiable cause and, when treated promptly, are not life threatening. The exception would be in patients following cardiac surgery. Most will resolve upon correction of the cause of the dysrhythmia as opposed to requiring the administration of antiarrhythmic agents. Being able to quickly recognize abnormal ECG rhythms is an important skill for you as a PACU nurse. Common causes of dysrhythmias are summarized in Table 9–2.


Table 9–2

Common Causes of Dysrhythmias in the PACU

CAUSE

CONTRIBUTING FACTORS

RESULT

Hypoxemia

Obstruction, atelectasis, bronchospasm, aspiration, pulmonary edema, pulmonary embolism, pneumothorax

Myocardial ischemia Depression of contractility Atrial dysrhythmias Ventricular dysrhythmias Conduction delays

Hypokalemia

Gastric suctioning Insulin administration Diuretic use

Widening of QRS complex Development of U waves S-T abnormalities PVCs Ventricular tachycardia Ventricular fibrillation

Altered acid-base status

Gastrointestinal losses Hypotension Lactic acidosis

Cardiac excitability PVCs Ventricular tachycardia Ventricular fibrillation

Circulatory instability

Pulmonary or cardiac compromise

Myocardial ischemia Conduction delays

Preexisting heart disease

History of myocardial infarction, especially within last 6 months

Myocardial irritability and ischemia Conduction delays Atrial fibrillation

Hypothermia

Cold operating rooms Surgical exposure Long surgeries

Conduction delays Bradycardia Heart blocks Atrial fibrillation Ventricular fibrillation

Vaso-vagal response

Valsalva maneuver Direct eye, vagus nerve, or carotid sinus pressure

Severe sinus bradycardia

Medications

Residual anesthetics lower arrhythmic thresholds Spinal anesthesia Narcotics Ketamine

Bradycardia Conduction delays Tachycardia with ketamine

Surgical stress and pain

Increased catecholamines

Tachycardia Myocardial irritability Conduction delays


It is important that you can readily recognize arrhythmias as different from normal sinus rhythm on an ECG monitor so that you can promptly intervene with nursing interventions, initiation of standing orders, or involvement of anesthesia personnel. Practicing rhythm identification will help you quickly master this important skill (see Figs. 9–9 through 9–14). Sinus Tachycardia • Description: Fast, regular rhythm, rate ⬎100 bpm in an adult, P waves present • Common causes in PACU: Pain, hypoxemia, hypovolemia • Treatment: Medicate for pain, oxygenate, hydrate Sinus Bradycardia • Description: Slow, regular rhythm, rate ⬍60 bpm in an adult, P waves present • Common causes in PACU: Hypoxemia, hypothermia (especially in children), high spinal anesthetic • Treatment: Improve oxygenation, rewarming. Pharmacologic treatment not required unless accompanied by hypotension or ventricular ectopy present. If indicated, atropine 0.5–1.0 mg IV Premature Ventricular Contractions (PVCs) • Description: Premature depolarization within the ventricles represented by wide (0.12 seconds or greater) and bizarre looking QRS complexes • Common causes in PACU: Hypoxemia, hypokalemia • Treatment: Not generally required unless ⬎6/minute or multifocal; improve oxygenation; consider lidocaine 1.0–1.5 mg/kg

F I G U R E 9 - 9 : Sinus tachycardia.

F I G U R E 9 - 1 0 : Sinus bradycardia.


F I G U R E 9 - 1 1 : PVC.

F I G U R E 9 - 1 2 : Asystole.

IV bolus or procainamide 20 mg/minute until PVCs suppressed; if low potassium (⬍3.5 mEq/L) is confirmed by laboratory testing, potassium replacement may be indicated Asystole • Description: Complete absence of ventricular electrical activity • Common causes in PACU: Rare in PACU; unable to predict risk factors • Treatment: Prompt recognition of arrhythmia with initiation of CPR and ACLS protocols Ventricular Fibrillation • Description: Chaotic electrical activity with no cardiac output • Common causes in PACU: Rare in PACU; unable to predict risk factors • Treatment: Prompt recognition of arrhythmia with initiation of CPR and protocols; immediate defibrillation Ventricular Tachycardia • Description: Rate ⬎100 bpm, regular, absent P waves, bizarre QRS complexes • Common causes in PACU: Rare in PACU; unable to predict risk factors ALERT • Treatment: • If hemodynamically stable, treatment is pharThe treatment for macologic with amiodarone (150 mg over V-fib is always defibrillation. 10 minutes) or lidocaine (1.0–1.5 mg/kg IV)


F I G U R E 9 - 1 3 : Ventricular fibrillation.

F I G U R E 9 - 1 4 : Ventricular tachycardia.

• If unstable, treatment involves cardioversion and either amiodarone or lidocaine as above • If pulseless, treatment is defibrillation

Bleeding Bleeding after surgery always requires evaluation for the underlying cause. It most commonly occurs as a result of a loss of vascular integrity, specifically bleeding at the surgical site. Arterial loss occurs from highflow, high-pressure vessels. Venous bleeds are usually slow bleeds. You will suspect a surgical bleed when you find saturated dressings, drainage systems that fill rapidly, or blood in urine collection bags or following suctioning. Sometimes, however, a bleed may be hidden, such as in an abdominal cavity, and not readily detectable. Your index of suspicion for bleeding should be heightened when you detect falls in blood pressure after surgery that cannot be explained, blood pressure that does not stabilize after fluid intervention, and compromised oxygenation that does not improve with oxygen therapy. A 20% loss in circulating volume in an adult can produce signs of hypovolemic shock, including decreased blood pressure, tachycardia, increased respiratory rate, cool skin, and pallor. If allowed to progress, signs and symptoms will become more severe, and can produce cardiopulmonary collapse. In children, a 10% to 15% loss of circulating volume will produce signs of hypovolemic shock. A 20% to 25% loss of circulating volume will reduce cardiac output by 50%, causing significant compromise.


If you suspect bleeding, notify both the surgeon and the anesthesiologist. If the patient has to be returned to the OR for repair of bleedIn children, a drop ing vessels or for re-exploration to determine in blood pressure if not the cause of bleeding, both the surgeon and caused by bradycardia or anesthesiologist must be included in managehypoxemia is always to be ment. Obtain a hematocrit and hemoglobin and considered due to bleeding until proven otherwise. compare these new values with the patient’s preoperative baseline values. Treatment may involve surgical repair, application of pressure and irrigation, as well as fluid resuscitation or blood administration for symptomatic hypotension (see Table 9–3). Another less common cause of bleeding in the PACU may be the finding of alterations in coagulation. This is a less common cause as patients frequently have clotting function studies done in advance of major surgery with bleeding risks. The prothrombin time will assess the intrinsic pathway of coagulation, monitoring the effects of heparin, while the international normalized ratio/partial thromboplastin time will assess the extrinsic pathway of coagulation, monitoring the effects of Coumadin. Patients will have been asked preoperatively to discontinue medications that can affect clotting, such as aspirin, ibuprofen, vitamin E, and Coumadin, before surgery. During the preoperative physical, completed either in advance of or on the day of surgery, patients will be asked about unexplained bruising or easy bleeding, which may be an indication of alterations in coagulation. That said, if signs and symptoms of bleeding ALERT

Table 9–3

Blood Administration

BLOOD PRODUCT

DESCRIPTION AND INDICATIONS

Whole blood

Provides red blood cells, white blood cells, and plasma (if not frozen, will also contain clotting factors and platelets) Used in hypovolemic shock requiring volume replacement 500 cc volume/bag Goal of treatment is a hematocrit of 35% to 40%

Packed red blood cells

Packed red cells, no plasma Used to correct anemia and improve oxygenation 250 to 300 cc volume—decreased risk of fluid overload Goal of treatment is a hematocrit of 35% to 40%


are present, and if surgical integrity is intact, alterations in coagulation should be considered, and coagulation studies obtained. Alterations in coagulation are difficult to treat, and generally center on volume replacement and supportive interventions. Protamine may be used to reverse heparin, and vitamin K or fresh frozen plasma may be given to reverse effects of Coumadin. Disseminated Intravascular Coagulation Disseminated intravascular coagulation is an acquired bleeding tendency characterized by widespread activation of the coagulation process that occurs as a complication of a surgical, obstetric, infectious, or traumatic event that allows thromboembolic materials to enter circulation. As this process develops over hours and days, this is an unlikely cause of bleeding in PACU patients. You should, however, suspect DIC in any trauma patient who fails to clot.

Chest Pain Complaints of chest pain in the PACU may be life threatening or benign. Patient risk factors such as COACH increased age, obesity, smoking history, and a CONSULT history of cardiac disease further put cardiac The complaint of chest pain origin at the top of the differential list. The origin should always be assumed of chest pain is not always cardiac, and may arise to be of cardiac origin until from pulmonary, gastrointestinal, musculoskeletal, proven otherwise. and other miscellaneous causes. Cardiac Origin Cardiac chest pain may be anginal or pain associated with an acute myocardial infarction. Angina Angina is a sign of myocardial ischemia. It is described as a continuous pain commonly seen in patients with a cardiac history. Anginal pain is not influenced by respirations. It may radiate to shoulder, arm, jaw, and back (see Fig. 9–15). Anginal pain is managed with sublingual nitroglycerin. Acute Myocardial Infarction Pain from acute myocardial infarction (AMI) is severe, lasting longer than 20 minutes. It may radiate to the shoulder, arm, jaw, or back (see Fig. 9–15). It is frequently described as “crushing” or “squeezing,” although women may not report this type of pain or radiating symptoms. A classic difference between anginal pain and pain with AMI is that pain from AMI is accompanied by autonomic symptoms including nausea,


F I G U R E 9 - 1 5 : Common sites for anginal pain. (From Phipps, W., Long, B., Woods, N. (1987). Medical-surgical nursing: concepts and clinical practice (3rd ed.). St. Louis, Mosby-Year Book.)

diaphoresis, pallor, and weakness. ECG and blood pressure changes are common. Although AMI should be suspected in the presence of acute ECG changes, confirmation requires the drawing of cardiac enzymes, specifically troponin I. AMI is managed according to ACLS protocols, and includes oxygen, morphine, aspirin, and inotropic support if indicated. Pulmonary Origin Pain with a pulmonary origin is generally described as unilateral, sharp, and knife-like, with a sudden onset that intensifies with breathing, coughing, and sneezing. Splinting on the affected side may offer some relief. Pleuritic chest pain is a type of pain, not a diagnosis. It is important that you look for other clues to help narrow the cause of the pleuritic chest pain. Pleuritic chest pain caused by pneumonia is preceded with patient report of a previous upper respiratory infection. Pleuritic chest pain caused


by pneumonia will be associated with fever, chills, dyspnea, productive cough, and an increased heart rate. A chest x-ray will confirm the diagnosis with evidence of consolidation. Treatment focuses on maintaining oxygenation, and although most commonly of viral origin, antimicrobial agents to prevent a secondary infection. Pleuritic chest pain due to pulmonary embolism is accompanied by a sudden onset of dyspnea, agitation, increased respiratory rate, increased heart rate, wheezing, and crackles and cardiovascular instability. Evaluation for the risk factors for embolism (Virchow’s triad) will increase your index of suspicion for this diagnosis. Definitive diagnosis requires pulmonary angiogram, although the patient may be too unstable to move to radiology. Treatment in the PACU will center on maintaining oxygenation and cardiovascular support. Pleuritic chest pain due to pneumothorax presents as sharp, severe, unilateral pain with COACH reduced or absent breath sounds. It will be CONSULT accompanied by dyspnea, increased heart rate, If chest pain worsens with and increased blood pressure. CXR provides breathing, think pulmonary definitive diagnosis. Treatment of a symptoorigin. Improvement and matic pneumothorax will require placement of maintenance of oxygenation will be a priority. Even a chest tube. if you are wrong in assumGastrointestinal Origin ing the origin is pulmonary, Pain from a gastrointestinal (GI) origin may be you will never be wrong difficult to differentiate from cardiac origin. in making oxygenation a Common causes include esophageal disorders, number-one priority. including reflux and spasm. This type of chest pain is described as burning, constricting, and squeezing. Lying down worsens the pain. Patients will commonly tell you that they have COACH CONSULT felt this before, either based on what they eat, or if they have not eaten in a while. Treatment As it is difficult to differenrequires the administration of antacids or food. tiate chest pain of cardiac It is difficult to differentiate GI pain from as opposed to GI origin, cardiac pain; look for autonomic signs of pain is considered cardiac until proven otherwise by diaphoresis, nausea, and anxiety. cardiac enzymes. Delaying Musculoskeletal Origin antacid administration is Pain from a musculoskeletal origin is uncomnot life threatening. Missing mon in the PACU unless following trauma a myocardial infarction could be. as cause of admission. This type of pain may be seen following resuscitation efforts such


as CPR, although the patient is likely to be intubated and unable to complain of this type of pain. The most common example of musculoskeletal injury causing chest pain is rib fracture. Diagnosis is confirmed with a CXR. Miscellaneous Causes There are other miscellaneous causes of chest pain that may be seen in the PACU. These include pain from herpes zoster, which presents as pain along a dermatome, and chest pain from anxiety. One clue to anxiety being the source of the chest pain may be patient history, including the use of anti-anxiety medications and psychiatric history. Box 9–1 provides a summary of these and other less common causes of chest pain seen in the PACU.

Box 9–1

Differential Diagnosis of Chest Pain

CARDIOVASCULAR ORIGIN Angina Acute myocardial infarction Aortic dissection Mitral valve prolapse Pericarditis Postpericardiotomy syndrome PULMONARY ORIGIN Pleuritic chest pain Pleural effusion Pneumothorax Pneumonia Pulmonary embolism Pulmonary hypertension GASTROINTESTINAL ORIGIN Reflux esophagitis Esophageal spasm Peptic ulcer disease Pancreatitis MUSCULOSKELETAL ORIGIN Costochondritis Rib fracture MISCELLANEOUS ORIGIN Herpes zoster Anxiety disorder


Complications of Awakening Complications of awakening include emergence delirium and delayed awakening.

Emergence Delirium Emergence delirium is not life threatening, but makes care delivery difficult. The primary ALERT concern is patient and staff safety. The most No sedative agents common cause of emergence delirium is should be administered hypoxemia until proven otherwise. The quick until respiratory adequacy use of a pulse oximeter will confirm or rule out is confirmed. hypoxemia. Treatment is always maintenance of adequate oxygenation. Preexisting disorientation may be the cause of emergence delirium, particularly in the eldALERT erly patient with Alzheimer’s disease, ParkinManagement of son’s disease, or impaired comprehension. emergence delirium Management of this type of agitation is best frequently requires sedation handled by involving the patient’s family, or and restraint to maintain someone well known to the individual. patient and staff safety. Withdrawal psychosis may develop if the Both interventions have the potential to compropatient experiences withdrawal from chronic mise oxygenation and exposure to alcohol, opioids, hallucinogens, or ventilation, in a patient cocaine. The patient may not have revealed use already potentially comproof these substances preoperatively. Treatment mised following anesthesia administration. Contact the requires maintenance of patient and staff safety, anesthesiologist to assist in administration of benzodiazepines, and prn use care. If sedation is ordered, of restraints. extreme caution must be Pain and discomfort, due to surgical pain, taken when administering full bladder, or extreme anxiety may also consedative medication. Ongoing 1:1 monitoring, tribute to postop agitation. Patients may be including ECG and pulse agitated, but are likely to be able to respond to oximetry, is essential. There questions once you get their attention. is no room for error. Toxic psychosis caused by exposure to toxins, including fumes in the OR, might be seen with a malfunctioning laser. OSHA Standards makes this a minimal cause. Medication-induced emergence delirium may be the result of exposure to ketamine, a phencyclidine derivative. Local anesthetics, droperidol


(Inapsine), antibiotics, antiarrhythmics, and benzodiazepines have all been associated with untoward reactions causing agitation. Functional psychosis is a diagnosis of exclusion and is defined as a brief period of paranoia without an identified organic cause. The differential diagnosis and treatment of emergence delirium is summarized in Figure 9–16.

Withdrawal Psychosis

Toxic Psychosis

Respiratory and Circulatory Causes

Emergence Delirium

Rule out hypoxemia Investigate/treat cause Consider sedation Maintain patient safety

Sedation/Restraints

Oxygenation/Ventilation Investigate origin Oxygenation/Ventilation Cardiovascular stability

Functional Psychosis

Sedation/consult

Anesthetic Exposure

Oxygenation/Ventilation

Medications

Eliminate use/sedation/reversal

Altered Thermoregulation

Rewarm/Investigate cause of hyperthermia

Anxiety

Reassurance/Sedation/Reunite with family

Pain

Rule out hypoxemia/medicate/ comfort measures

Visceral Distention

Decompression/catherization

Metabolic Disturbances

Correct acid-base alterations and electrolyte disturbances

F I G U R E 9 - 1 6 : Differential diagnosis and treatment of emergence delirium.


Delayed Awakening Delayed awakening is defined by a patient exceeding the expected time to return to consciousness or baseline, given the medications and doses received. This is usually not a serious complication, but it may delay turnover of PACU beds. The most common cause of delayed awakening is prolonged action of anesthetic drugs. This may occur secondary to alterations in pharmacodynamics and pharmacokinetics due to hepatic or renal dysfunction, age, hypothermia, alcohol or illegal drug use, impaired ventilation, and potentiation of drugs when multiple agents are used in combination. Delayed awakening due to prolonged drug action is most commonly treated by maintaining oxygenation, rewarming if needed, and time. If the patient shows signs of hypoxemia in the presence of delayed awakening, consider reversal of narcotics and benzodiazepines with naloxone or flumazenil. Delayed awakening may also be due to metabolic causes. Consider the patient’s medical history, as well as the surgery they experienced. For example, consider hypoglycemia if delayed awakening is seen in a diabetic patient. Consider dilutional hyponatremia after TURP with increased use of irrigation fluids. Consider hypocalcemia following parathyroid surgery. Consider hypermagnesemia after prolonged administration of magnesium in an OB patient. Treatment centers on replacement of the deficient electrolyte, such as glucose or calcium, or administration of an “antidote,” such as insulin and potassium for hyperglycemia or fluid restriction for dilutional hyponatremia. Although uncommon, neurologic injury is a potential cause of delayed awakening in the PACU, and may occur as a result of cerebrovascular accident (stroke), intracranial hemorrhage, or increased intracranial pressure. This cause of delayed awakening should be considered after careful review of preoperative and intraoperative events and patient history. For example, there is a risk of cerebrovascular accident as a complication of carotid endarterectomy. Intracranial hemorrhage may have occurred preoperatively, leading the patient to be scheduled for an evacuation of a subdural hematoma. Any intracranial surgery can be associated with postoperative swelling, increasing intracranial pressure. Prolonged preoperative or intraoperative hypotension, or the development of life-threatening dysrhythmias, may also cause neurologic injury. Neurologic injury will be confirmed by computed tomography or magnetic resonance imaging. These patients will require a neurology consult. Figure 9–17 summarizes common causes of delayed awakening. Perioperative Complications 243

Prolonged Anesthetic Drug Effects

Assess/confirm adequacy of oxygenation and ventilation

Metabolic Causes

Evaluate electrolytes

Acute Neurologic Injury

Review preoperative and intraoperative events

Consider reversal when possible and practical

Correct any alterations

Neurologic consult

F I G U R E 9 - 1 7 : Delayed awakening.

Complications of Thermoregulation Complications of thermoregulation in the OR include hypothermia and the development of malignant hyperthermia. Hypothermia is a very common finding. Maintaining normal body temperature in the OR is difficult, as there are multiple sources of heat loss. The development of malignant hyperthermia is a rare, life-threatening emergency.

Hypothermia Hypothermia is defined as a core temp of less than 96ºF or 35.5ºC. It occurs when heat loss exceeds heat production. There are four mechanism of heat loss: 1. Radiation: Loss of heat from warm surface such as the body to a cooler environment such as the OR 2. Convection: Loss of heat via air currents, such as in a laminar flow OR 3. Conduction: Loss of heat when warm surface such as a body touches a cooler one such as an OR table 4. Evaporation: Transfer of heat from liquid to a gas through ventilation loss and exposed viscera There are significant consequences associated with hypothermia. These include decreased oxygen availability due to vasoconstriction, coupled with increased oxygen demand due to shivering. Vasoconstricted tissues contribute to metabolic acidosis, which slows metabolic


processes, including drug biotransformation and absorption, glomerular filtration, and GI COACH function. Cardiac rate and rhythm disturCONSULT bances, including bradycardia and PVCs, are Initial signs of hypothermia common, further compromising oxygen delivreflect sympathetic stimulaery and contributing to metabolic acidosis. tion: increased respiratory Hypothermia contributes to decreased clotting. rate, heart rate, cardiac output, blood pressure, Although all patients going into an OR are at peripheral vascular resistrisk for hypothermia, significant hypothermia is ance, and muscle contraca particular risk for those at the extremes of age. tion with shivering. If allowed The elderly patient is at risk because of a lower to progress, the opposite basal metabolic rate and less subcutaneous fat occurs: system shutdown: decreased muscle tone and as insulation. The neonate is at risk because of coordination, decreased an immature thermoregulatory center and the respiratory rate, decreased inability to shiver to generate heat. Preexisting blood pressure, decreased medical conditions such as hypothyroidism, heart rate, decreased renal function, decreased diabetes, and trauma can contribute to slowed reflexes. metabolism. The intoxicated patient is at risk due to vasodilatation, which promotes heat loss and depression of heat regulation. Surgical risk factors include long procedures, large areas of exposure, and use of irrigation solutions. The local anesthetic used in regional anesthesia causes vasodilatation, contributing to heat loss. Any medication that causes vasodilatation, or agents that compromise thermoregulation such as thyroid hormone, phenothiazines, or narcotics, can contribute to hypothermia. Prevention of hypothermia is centered on prevention of heat loss as opposed to heat generation. This includes warming the OR for pediatric and neonate cases to decrease radiant heat loss. Although this is uncomfortable to personnel in the OR, it is the single most important intervention to prevent heat loss. The OR nurse will wrap the patient’s head, because 50% of heat loss occurs through the scalp as scalp vessels cannot vasocontrict. If appropriate to the surgery and required positioning, active rewarming can be started in the OR using forced warm air therapy. The use of this equipment can be continued into the PACU. Prompt covering of the patient in the OR and PACU will also prevent heat loss. Treatment of hypothermia centers on prevention of further heat loss and upon heat generation. Assist in active rewarming by applying blankets, covers, heat lamps, and warm blankets. Fluid and blood warmers can be used, along with heated humidification of administered oxygen.


COACH CONSULT Care must be taken when administering a narcotic to a shivering patient. Narcotics will depress shivering, but will also depress ventilation, which in the immediate postop period may contribute to hypoxemia and hypercarbia.

Although heated humidification of oxygen can be used, it is not particularly effective as a sole intervention. Shivering will help a patient generate heat to improve body temperature; however, shivering also increases oxygen demand and heart rate and may promote instability in a patient with a preexisting cardiopulmonary compromise diagnosis. Small titrated doses of IV narcotics such as meperidine and Stadol have been used to decrease shivering.

Malignant Hyperthermia

Malignant hyperthermia (MH) is a complication that is much less likely to occur in the PACU than in the OR, but it is possible. It is more likely that you will inherit the patient from the OR into the PACU for continued care and stabilization. MH has been referred to as the “anesthesiologist’s nightmare.” It occurs without warning, and may result in the sudden and unexpected death of an otherwise healthy individual. Of those who develop malignant hyperthermia, as many as 15% may die. Others who survive may be left with severe brain damage, failed kidneys, or impaired function of other organs. The defect that causes malignant hyperthermia appears to be in the skeletal muscle and is associated with a biochemical defect of intracellular homeostasis. Before discussing the specific alterations that occur with malignant hyperthermia, it is important to briefly review normal cell physiology and the role of calcium. In cells, calcium plays a central role in the cell’s energy producing functions. In healthy cells, calcium is released from its storage site in the sarcoplasmic reticulum in response to neuronal stimulation. Calcium concentrations increase, triggering phosphorylase, an enzyme, to mediate the breakdown of glycogen into lactic acid, carbon dioxide, and heat, providing energy for intracellular activities. As calcium concentrations continue to increase, another enzyme, myosin ATPase, is activated. It acts on adenosine triphosphate, causing the release of heat and free energy. This energy activates another enzyme, which promotes linking of actin and myosin, causing muscle fibers to contract. When the neuronal signal subsides, cellular membrane channels open and an ionic pump forces calcium back into the sarcoplasmic reticulum. Intracellular calcium levels fall, actin and myosin separate, and the muscle fiber relaxes.


In malignant hyperthermia, triggering agents such as anesthetic agents somehow interfere with calcium’s reentry into the sarcoplasmic reticulum. Therefore, with continued neuronal stimulation, cells are forced into a state of hypermetabolism. Exposure to anesthetic agents can trigger COACH the development of MH in susceptible individCONSULT uals. Agents identified as “triggers” include all of the “ane” inhalational anesthetics, as well as The trigger agents are the succinylcholine. Intravenous potassium, when “ane” inhalation anesthetgiven rapidly, can also trigger MH. Not all ics: sevoflurane, desflurane, halothane, and isoflurane; patients who receive these drugs develop MH. they are not the “aine” There is a genetic predisposition for the devellocal anesthetics: lidocaine, opment of MH, identified as autosomal domibupivacaine (Marcaine), and nant with variable penetrance. tetracaine. MH has been described in all racial groups, and occurs most commonly in persons between 3 and 30 years of age. Male and female children are affected equally until puberty, after which time MH is predominant in males. The exact incidence of MH is unknown, but has been estimated to be as common as one in 5000 anesthetics, or as rare as one in 65,000 anesthetics. To more specifically identify patients at risk for MH, all patients scheduled for surgery should be asked about a personal or family history of adverse reactions to anesthetic agents. That said, over 50% of persons who develop MH have previously undergone an anesthetic without any complication. Other risk factors for MH include a patient history of Duchenne muscular dystrophy, central core disease, myotonia, or unusual myopathies. Currently there are no readily available tests for MH. The most accurate test, the halothane-caffeine contracture test, involves the biopsy of skeletal muscle from the thigh. This test is usually reserved for families COACH of patients in whom an episode of MH has CONSULT occurred, or for a patient who has had a suspiThe most sensitive means cious reaction to an anesthetic. The test is availof diagnosing MH in the able at only a few centers in the United States OR is an unanticipated and Canada, and access to these centers is doubling or tripling of limited. The biopsy cannot be mailed to a testend-tidal CO2 levels. The ing facility. most specific sign of MH is total body rigidity. Although most cases of MH will present in the OR, cases have been reported in the PACU,


emergency room, dental offices where general anesthesia is administered, and for up to 24 hours after completion of a surgical procedure. Prompt recognition of the diagnostic signs of MH is After body temperature essential for the survival and successful outcome begins to climb, temperafor the patient. ture may increase as much Other common signs of MH reflect significant as 1°C every 5 minutes. hypermetabolism throughout the body, including unexplained tachycardia, tachypnea, cyanosis, respiratory and metabolic acidosis, muscle rigidity, and high fever. As intracellular function becomes increasingly more compromised, potassium, magnesium, phosphate, and myoglobin will begin to leak from cells into the plasma. The increase in potassium causes ventricular arrhythmias, which may be life threatening. Myoglobin blocks the renal tubules, potentially causing acute tubular necrosis (ATN) and renal failure. The chemical imbalance leads to an alteration in coagulation, with decreases in factor VIII and fibrinogen, causing bleeding. Ongoing muscle rigidity produces heat and an increased body temperature. The increase in temperature, potassium, and progressive hypoxemia contribute to central nervous system effects that include coma, areflexia, unresponsiveness, and fixed and dilated pupils. Table 9–4 identifies the diagnostic signs of malignant hyperthermia. COACH CONSULT

Table 9–4

Diagnostic Signs of Malignant Hyperthermia

PHYSICAL SIGNS

LABORATORY SIGNS

Tachycardia

Elevated ETCO2

Tachypnea

Respiratory acidosis

Arrhythmias (PVCs)

Metabolic acidosis

Rigidity

Hypercarbia

Hyperthermia (late sign)

Hypoxemia

Unstable blood pressure

Myoglobinuria (brown urine)

Cyanosis

Elevated CPK (24 hours later)

Dilated pupils

Hyperkalemia


Treatment of MH requires eliminating the cause, as well as management of the symptoms, and will require simultaneous interventions to occur (see Box 9–2). A team approach to care is mandatory, as many tasks will be occurring simultaneously. The anesthesia provider will stop the administration of all triggering anesthetics, and will ventilate the patient with 100% oxygen. This will treat the cause, and help to correct the hypoxemia and respiratory acidosis. The surgeon will work quickly to end the surgery. The anesthesiologist will administer Dantrolene sodium (Dantrolene, Dantrium) to block calcium release from cells to stop the hypermetabolism. The OR nurses will initiate surface cooling and assist in the administration of central cooling with iced IV fluids, and if needed, iced gastric lavage or bladder irrigation. Metabolic acidosis and hyperkalemia will be treated with sodium bicarbonate and diuretics and fluids. The fluids and diuretics also help flush the myoglobin out of the renal tubules, protecting the kidney. Arrhythmias will be treated according to ACLS guidelines. Additional interventions will focus on any additional presenting symptoms.

Box 9–2

ABCs for the Management of Malignant Hyperthermia

PREOPERATIVE A Ask about personal and family past history of malignant hyperthermia or Adverse Anesthesia reactions (unexplained fever or death during anesthesia). Be Aware of clinical signs of MH. B Body temperature monitoring for all patients undergoing general anesthesia for other than brief procedures. C Capnographic monitoring for all patients undergoing general anesthesia. D Dantrolene: Have dantrolene available wherever MH trigger anesthetics are used. INTRAOPERATIVE Primary Survey/Clinical Signs A Awareness: Are you suspecting an MH crisis? Airway: Severe masseter spasm (difficult to open the mouth). B Breathing: Difficult to ventilate and/or intubate due to masseter spasm or severe Body rigidity after succinylcholine. Body temperature high (late sign). C Capnography: Elevation of end tidal CO2 despite proper ventilation and adequate fresh gas flows with properly functioning anesthesia ventilating apparatus. Circulation: Cardiac arrhythmias, tachy/bradycardia, hyper/ hypotension. Continued


Box 9–2

ABCs for the Management of Malignant Hyperthermia —Cont’d

D Drugs: Are you using triggering agents (succinylcholine, potent halogens)? E Exposure/Examine the patient: skin color, perfusion, temperature, urine color, extremities, muscle tone. Emergency Treatment A Ask for Help/Ask for the MH cart and for dantrolene. Agents/Anesthesia: Stop anesthesia triggering agents and the surgery. B Breathing: Hyperventilate with 100% oxygen. C Cooling, if the patient is hot: insert large intravenous bore catheters. Give Cold intravenous fluids 15 cc/kg IV. Irrigate the wound, stomach and bladder with cold saline. Call MH Hotline: 1-800-644-9737 or 1-315-464-7079 D DANTROLENE: Give dantrolene IV, 2.5 mg/kg, and repeat the dose until the signs are controlled. E Check Electrolytes, especially potassium. Secondary Steps A Acidosis? Assess initial and subsequent arterial or venous blood gases. Is there mixed metabolic and respiratory acidosis? B Bicarbonate? 1–2 mEq/kg guided by pH, Base deficit. C Circulation/monitoring: Consider arterial line, central venous catheter, laboratories: arterial/venous blood gases, CBC, Coagulation tests, CK, myoglobin levels. D Dysrhythmias: Generally subside with resolution of the hypermetabolic phase of MH. Arrhythmias can be treated with amiodarone, lidocaine, procainamide, adenosine, or other drugs indicated according to the ACLS protocol. Remember impact of hyperkalemia. Diuresis: Assure diuresis greater than 1 mL/kg/h. E Electrolytes: If hyperkalemic, treat with bicarbonate, glucose/insulin, calcium. F Follow up: A: Arterial and venous blood gases. B: Body temperature (core) avoid hyper/hypothermia. C: End-tidal CO2, CK, Coagulation tests. D: Diuresis (urine output and color). E: Electrolytes. POSTOPERATIVE Postcrisis Problems A Alkalinize urine and diurese, monitor for ARF (acute myoglobinuric renal failure). B Beware hypothermic, hyperkalemic, hypokalemic, hypervolemic overshoot—serial monitoring of filling pressures, fluid balance, electrolytes, temp, K, Ca, coags., and Hct may require recorrection. C Creatine kinase (CK) levels track severity of rhabdomyolysis: if present, beware of renal failure, which may follow marked rhabdomyolysis. Compartment Syndrome is rare, but requires serial monitoring of extremities and abdominal girth or bladder pressures after severe insults. D DIC with coagulopathy, thrombocytopenia, hemolysis, and abnormal bleeding may follow major crises with severe shock and/or severe hyperthermia.


Box 9–2

ABCs for the Management of Malignant Hyperthermia —Cont’d

E Elevated liver functions are often observed 12–36 hours post-MH crisis. F Follow CNS function serially after MH crisis: Magnitude of crisis may or may not correlate with CNS insult. G Good communication and follow-up is essential among medical specialists in the postresuscitation and monitoring phase of the MH crisis for prevention of secondary crisis-related organ insults. Care may be transferred from an anesthesia care provider to a pediatric or adult medical or surgical intensivist, provided good information about the MH crisis and postresuscitation management is maintained. Post-Acute Phase A Aware of recrudescence signs. Ask the relatives about anesthesia problems/ neuromuscular disorders. B Biopsy: Send the patient to a biopsy center for evaluation. C Contact MHAUS for further information/referral of patient. D Dantrolene 1 mg/kg IV q 4–6h and continued for 24–48h after an episode of malignant hyperthermia. Documentation: Submit forms to the national/ international North American MH Registry of MHAUS: www.mhreg.org ANESTHESIA FOR MH-SUSCEPTIBLE PATIENT A Anesthesia machine preparation: Change circuits, disable or remove the vaporizers, flush the machine at a rate of 10 L/min for 20 min. Anesthesia: Use local or regional anesthesia but general anesthesia with nontriggering agents is acceptable. Safe drugs include: barbiturates, benzodiazepines, opioids, nondepolarizing neuromuscular blockers and their reversal drugs, and nitrous oxide. B Body temperature monitoring. C Capnography: Close monitoring for early signs of MH. D Dantrolene available. Discharge, if no problems, after 2.5 hours.

Complications of Positioning Injuries due to positioning may occur to soft tissue and the skeleton, to the eyes, or to nerves. Soft tissue and skeletal injuries are due to excessive and prolonged pressure, especially over bony prominences. The risk of soft tissue injury is increased in debilitated, malnourished, paraplegic, or incontinent patients. Pressure for ⬎2 hours can result in irreversible ischemia. Using the injury grading system for pressure injuries, it is uncommon to see anything greater than Stage One in the PACU. Stages Two and Three may present in the ICU or on the surgical unit (see Box 9-3).


Injury to the eyes is usually due to direct trauma and corneal abrasion, especially when the patient is placed in a prone position in the OR. As injury may cause no obvious signs of All of the complications of external trauma, any complaint of eye pain or positioning are much easier impaired vision in the PACU requires an to prevent than to manage, ophthalmology consult. as many complications result in permanent damInjury to nerves is due to direct stretching of age. Prevention begins in a nerve through improper positioning or to comthe OR with close attention pression of a nerve against bone or OR equipto positioning, padding of ment. This type of injury most commonly affects exposed extremities, and the brachial plexus nerves, ulnar and radial careful eye care. nerves, and the peroneal nerve in the leg. There is an injury grading scale for nerve injuries that can be used to assess injury and to predict prognosis (see Box 9–4). Any complaint of persistent paresthesia or impaired movement should be promptly reported to the surgeon and anesthesia provider. Box 9–5 identifies positioning injuries associated with specific positions used in the OR. COACH CONSULT

Box 9–3

Injury Grading System for Pressure Injuries

STAGE ONE Blanching followed by nonblanching erythema STAGE TWO Induration or edema with breakdown of the dermis STAGE THREE Ulceration extending to subcutaneous tissues and still further into fascia, muscle, and bone

Box 9–4

Injury Grading System for Nerve Injuries

GRADE ONE Neuropraxia: Response to blunt force compression Temporary dysfunction without axonal damage GRADE TWO Axonotnemesis: Destruction of axons occur, although regeneration is possible Eventually function will return GRADE THREE Neurotmesis: Nerve is crushed, avulsed, or severed Return of function impossible unless nerve ends reapproximated


Box 9–5

Positioning Injuries

SUPINE POSITION Pressure alopecia Pressure point compression Nerve injury Backache Postural hypotension LITHOTOMY POSITION Lower back pain Peroneal nerve injury secondary to stirrup use SITTING POSITION Postural hypotension Air embolism Facial edema Airway edema PRONE POSITION Eye abrasion Ear abrasion Neck pain Nerve injury Joint damage LATERAL POSITION Eye abrasion Ear compression Neck pain Nerve injury Atelectasis

Nausea and Vomiting Despite the availability of new anesthetic agents and antiemetics, postoperative nausea and vomiting (PONV) remains a common occurrence in the PACU. Nausea is a subjective feeling associated with an awareness of the urge to vomit. It is due to excitation of the medullary vomiting center, which may be the result of hypoxia, pain, increased intracranial pressure, sensory stimulation, psychological factors, and stimulation of the visceral afferents as triggered by cardiac, GI, and GU diseases. PONV may also be due to stimulation of the chemoreceptor trigger zone, which occurs as a result of motion, such as the movement of the cart from the OR to the PACU or movement of the patient from the cart to a


chair; medications, most commonly narcotics; and metabolic disturbances, which are uncommon in the PACU. Risk factors for PONV may be due to anesthetic factors, patient characteristics, or to the surgical procedure itself. Anesthetic factors contributing to PONV include the following: • Positive pressure ventilation prior to intubation • Longer anesthetic exposure time • Development of hypotension with regional anesthesia • Narcotic-based anesthesia • Etomidate, ketamine Patient characteristics associated with PONV include the following: • Female • Obesity • Nonsmoker • History of postop nausea and vomiting Pediatric surgical procedures associated with an increase in PONV include the following: • Strabismus • Orchiopexy • Tonsillectomy and adenoidectomy • More than 30 minutes of anesthetic exposure Adult surgical procedures associated with an increase in PONV include the following: • GI procedures • Diagnostic laparoscopy • Otologic/ophthalmic surgery Other factors contributing strongly to an increase in PONV include the following: • Pain and anxiety • Premature administration of fluids and food • Motion COACH It is important to note that prevention CONSULT of PONV is easier than treatment. Prevention Evidenced-based practice begins preoperatively by identification of the identifies the four biggest high-risk patient and prophylactic antiemetic predictors of PONV to be administration. Care will be taken by the anesfemale gender, nonsmoker, thesiologist to avoid positive pressure ventilahistory of postoperative tion, which can distend the stomach; to medicate nausea and vomiting, and use of opioids in surgery. for pain; and to ensure adequate fluid replacement. The use of propofol for induction and


maintenance of anesthesia has been shown to decrease PONV. The administration of an NSAID ALERT to decrease pain has also proven effective in Droperidol (Inapdecreasing PONV. In the PACU, you can help to sine) works in a unique prevent PONV by helping the patient with slow manner to antagonize the position changes, remembering to dangle the emetic effects of narcotics. patient first before standing as taught in nursing This agent, given a Black Box warning by the FDA in school. For patients being discharged to home, 2001, requires cautious use leave the IV in place until just before discharge. as the drug can increase the There are a number of antiemetics available QT interval, arrhythmias, for prevention and treatment of PONV. Many and torsade de pointes. times agents with differing mechanisms of action will be used in combination to treat multiple causes of PONV, thereby increasing the effectiveness (see Fig. 9–18 and Box 9–6). Other medications and therapies used for postoperative nausea and vomiting include the use of steroids, acupoint stimulation, and acupressure. Low-dose steroids, for example dexamethasone as a single 5 mg IV dose, are being tried as a prophylactic intervention for postoperative nausea and vomiting. Although steroids do not currently have an established role in prophylaxis, they are being widely used as a result of efficacy, low cost, and lack of significant side effects.

Input to Vomiting Center Substance P-NK1 Receptor Serotonin

Muscarinic receptor

5-HT3 receptor

Cholinergic receptor

Emetic Reflex Center

Dopamine

Histamine

D2 receptor

H1 receptor

F I G U R E 9 - 1 8 : Input to vomiting center.


Box 9–6

Antiemetics: Mechanism of Action

SUBSTANCE P-NK1 ANTAGONIST Aprepitant (Emend) SEROTONIN 5-HT3 ANTAGONIST Dolasetron (Anzemet) Granisetron (Kytril) Ondansetron (Zofran) Palonosetron (Aloxi) Tropisetron (Navoban) ANTICHOLINERGIC Scopolamine (Transderm Sc op) ¯ Trimethobenzamide (Tigan) ANTIDOPAMINE Metoclopramide (Reglan) ANTIHISTAMINE Prochlorperazine (Compazine) Promethazine (Phenergan)

ALERT It is very unlikely that nausea and vomiting will be controlled without controlling pain.

Acupoint stimulation through the use of pressure point bands (Sea Bands) and acupressure have been tried, placing direct pressure on the Neikuan (Neiguan; P6) point on the wrist. Neither have proven efficacious when used as solo therapy.


CHAPTER

10

Special Populations: The Elderly and Pediatric Patient The Elderly Patient Every year the number of elderly individuals in America increases. Today, persons 65 years of age and older comprise almost 15% of the U.S. population, with more than 24% of all surgical procedures being performed in elderly patients. Given that there are clearly differences between someone who is 65 and someone who is 100, the following definitions are used: • 65 to 75 years of age: Young-old • 75 to 85 years of age: Old • Older than 85 years of age: Old-Old The elderly patient presents unique physical, COACH physiologic, and pharmacologic changes that CONSULT influence anesthetic management and preoperative and postoperative care. The risks associThe risks associated with anesthesia and surgery in ated with anesthesia and surgery are increased elderly patients with prein elderly patients; however, it is a myth to think existing medical condithat the increased risks of anesthesia and surtions, are increased 10% to gery are due to age alone. Risks are due to the in30% over the 0.5% of all creased prevalence of age-related, concomitant patients without preexisting medical conditions. disease, and to the decline in basic organ system function independent of disease.

257

The risk factors that serve as the best predictors of postoperative death include the following: • Cardiac failure • Impaired renal function • Angina

Physiologic Changes Associated with Aging When you think about physiologic changes associated with aging, remember that these are normal age-related changes that occur in aging and that they are independent of injury or disease. These changes may, however, be accentuated by injury or disease. For example, although lung volume and function decline approximately 10% with aging, this decline will be much greater in someone who has smoked two packs of cigarettes a day for 40 years.

Cardiovascular Changes • Loss of large artery elasticity, secondary to arteriosclerotic changes in all major vessels: Because of this loss of elasticity, organ perfusion and compensatory regulation in all body systems decrease COACH • Myocardial changes, including an CONSULT increase in myocardial irritability and alterations in the conduction system: As a result of the anatomic Result is an increase in dysrhythmias and changes in the myocardium and in the vessels, cardiac conduction delays reserve and the heart’s • Left ventricular hypertrophy, the effectiveness as a pump increased fibrosis of the endocardial declines. lining due to endocardial thickening and rigidity: Result is an increased systolic blood pressure • Calcification of the valve leafs: Result is COACH progressive valve incompetence CONSULT • Hemodynamic alterations: Cardiac output Circulation time for a declines approximately 1% per year after 20-year-old is 15 to the age of 30. The decrease in cardiac 20 seconds. For an output slows circulation time, which slows 80-year-old, circulation the onset of action of drugs, including time increases to 25 to 30 seconds. inhalation agents.

258 Special Populations: The Elderly and Pediatric Patient

• Heart rate decreases: This is suspected to be due to increased activity of the parasympathetic nervous system. The decrease may also be due to degenerative changes in the conduction system. More than half of elderly patients have significant coronary artery disease, even if symptoms are not noted on physical examination • Orthostatic hypotension: This occurs as blood vessel tone decreases and baroreceptors in the carotid body and aortic arch fail. The heart rate response to hypotension is less in elderly patients. In addition, the elderly patient may be taking medications that contribute to orthostatic hypotension, including antihypertensives, diuretics, and tricyclic antidepressants

Respiratory Changes Anatomic changes that occur with the respiratory system include the following: • ↑ in rib and vertebral calcification, leading to an ↑ in the anterior-posterior (A-P) diameter of the chest • Progressive flattening of the diaphragm • ↑ in chest wall rigidity • ↓ in alveolar surface • ↓ vital capacity • ↑ residual volume increases The result of these changes is that total lung capacity is reduced by 10%, also due to narrowing of the intervertebral discs. Loss of skeletal muscle mass results in wasting of the diaphragm and intercostal muscles. Physiologic changes include the following: • ↓ in pulmonary elasticity and chest wall mobility • Destruction of alveolar septa and expansion of alveolar spaces • ↓ pulmonary compliance • ↑ airway resistance and air-trapping Large airways increase in diameter; small airways decrease in diameter, resulting in increased physiologic dead space. Ventilation-perfusion alterations develop such as • ↓ tidal volume • ↓ vital capacity • ↓ oxygen and carbon dioxide exchange • ↓ aerobic capacity The oxygen content of blood (PaO2) normally decreases with age, reflected by the following equation: PaO2 ⫽ 100 ⫺ (0.4 ⫻ age [years]) ⫽ mm Hg

Special Populations: The Elderly and Pediatric Patient 259

For example: in an 80-year-old adult, as opposed to the normal value of 100 mm Hg: PaO2 = 100 ⫺ (0.4 ⫻ 80) ⫽ 68 mm Hg The addition of narcotics administered for pain and general anesthetics administered for surgical procedures will further blunt these agerelated changes.

Central Nervous System Changes An important central nervous system change associated with aging is the decrease in neuronal density and nerve conduction, secondary to atrophy and loss of peripheral nerve fibers. An average of 50,000 neurons, from an initial pool of 10 billion, are lost daily. Reflexes are slowed. However, perhaps more importantly, there is a decline in sympathetic responsiveness, secondary to a significant decrease in the rate of synthesis of neurotransmitters. Sympathetic stimulation results in • Release of the catecholamines epinephrine and norepinephrine • Heightened physiologic ability of the body to face stressors It is clear that a fall in sympathetic response contributes to a fall in cardiac reserve and responsiveness. Thermoregulation is also compromised. A result of arteriosclerotic changes within the cardiovascular system is a higher incidence of organic brain syndrome, cerebrovascular accidents, and dementia secondary to microemboli. Cerebral blood flow and cerebral metabolic oxygen consumption are decreased. An acute change in mental function is more commonly caused by malnutrition, medication intolerance, depression, or dehydration, as opposed to the results of aging. These acute alterations are usually physiologic in nature and reversible. They should be closely evaluated, and ideally corrected preoperatively.

Gastrointestinal Changes Gastrointestinal changes include a decrease in salivation and peristalsis. As a result, gastric emptying is delayed, and the risk of aspiration increases. Aging causes a decrease in airway reflexes, which may further increase the risk, especially when blunted by drugs. Perhaps the most significant change is a decline in hepatic blood flow, secondary to arteriosclerotic changes in the cardiovascular system and a decrease in microsomal enzyme activity. As a result, first pass drug extraction is reduced, and drugs metabolized and excreted via the liver, such as fentanyl and vecuronium, will remain present and active for a prolonged period of time. There also is a decreased absorption of orally administered drugs and nutrients, particularly ferrous sulfate (iron) and calcium. Malnutrition


is a common finding in elderly patients, and may be due to alterations in taste, activity limitations, knowledge deficits, or finances. Malnutrition has the potential to increase perioperative morbidity and mortality and to compromise postoperative recovery and wound healing.

COACH CONSULT A low serum albumin is the best indicator of proteincalorie malnutrition.

Renal Changes Anatomic changes within the renal system include the following: • ↓ bladder capacity • ↓ muscle tone • Weakening of sphincters This is particularly true in elderly women who have had multiple pregnancies and deliveries. More importantly, renal blood flow caused by arteriosclerotic changes in the cardiovascular system reduces the glomerular filtration rate. Glomerular filtration decreases by 1% to 1.5% per year after the age of 30. There is a 1 mL/min/year decline in creatinine clearance after the age of 40. The following formula estimates creatinine clearance based on age using serum creatinine measurements: (140 ⫺ age) ⫻ wt (kg) Creatinine clearance = 72 ⫻ serum creatinine Maximum urine concentrating capability at age 80 is about 70% of the values found at age 30. As a result, there is decreased renal metabolism and clearance of medications and metabolites, including antibiotics and digoxin. Table 10–1 illustrates differences seen in drug half-lives between the young and old, due to age-related changes in renal metabolism.

Table 10–1 Elimination Half-Lives DRUG

YOUNG

OLD

Fentanyl

250 minutes

925 minutes

Vecuronium

16 minutes

45 minutes

Midazolam

2.8 hours

4.3 hours

Diazepam

24 hours

72 hours


In addition, the response time to correct fluid and electrolyte imbalances increases, placing the elderly patient at risk for fluid overload. Urine concentrating ability also is reduced. The inability to conserve sodium may result in hyponatremia. As many as 20% of elderly patients have been found to have sodium values below the normal limit of the reference range, 128 to 147 mmol/L. A decrease in renin activity and plasma aldosterone may result in hyperkalemia.

Orthopedic Changes The most significant change within the skeletal system is osteoporosis— a decline in the bone matrix that provides skeletal support. In osteoporosis, bone resorption of calcium exceeds the rate of bone formation. Therefore, the elderly patient is at risk for • Pathologic fractures • Skeletal deformities • Bone and joint pain In fact, repair of hip fractures, known as hip stabilization, is one of the five most commonly performed surgeries in elderly individuals. Osteoarthritis also may be a significant finding in elderly patients, making intraoperative positioning a challenge. Osteoarthritis of the cervical spine may make positioning for intubation more difficult.

Endocrine Changes With increasing age, there is progressive impairment in the body’s ability to metabolize glucose, resulting in glucose intolerance. This is due to many factors, including decreased insulin synthesis and secretion, insulin resistance, impaired glucose utilization, and changes in body composi-tion, diet, and activity. In the older patient, this can more easily lead to a hyperosmolar, nonketotic state. Pancreatic function declines, and the incidence of adult onset diabetes increases with age, becoming greatest between 60 and 70 years of age. Plasma renin concentration and activity decline by 30% to 50%, decreasing the plasma concentration of aldosterone and increasing the risk of hyperkalemia. Subclinical hypothyroidism has also been noted. Hypoalbuminemia is the most common cause of hypocalemia.

Metabolic Changes The overall basal metabolic rate declines at the rate of 1% per year after the age of 30. As a result, time for the metabolism and excretion of drugs increases. Coupled with dermatologic changes, elderly individuals


have more exaggerated intraoperative heat loss and response to decreased temperature.

Changes in Body Composition The decrease in subcutaneous fat is an anatomic change with important physiologic seCOACH quelae. Temperature regulation and maintenance CONSULT are compromised, adding to the elderly patient’s risk of hypothermia. Although the amount There is a decline in skin of subcutaneous fat declines, overall body fat pigmentation in elderly individuals, making pallor an increases, especially in women. unreliable indicator of In addition, the decline in the number and anemia and respiratory or efficacy of sweat glands compromises the elderly cardiac distress. patient’s ability to lose heat when hyperthermic. With aging, the epidermis begins to atrophy, and collagen is lost. As a result, the elderly patient is at an increased risk for skin breakdown and decubitus ulcers. Careful intraoperative and postoperative positioning is essential. Good skin care requires caution in the use of adhesive tape and its removal.

Sensory Changes Sensory changes resulting from a reduction in afferent innervation cause alterations in all forms of perception, including vision, hearing, and sensation. Visual acuity and peripheral vision decrease. Auditory changes center in a decreased sensitivity to sound, particularly high-pitched tones. The sense of smell and taste are altered, which may contribute to poor nutritional intake. There also is a decrease in tactile sensation and response to pain. Figure 10–1 summarizes the physiologic changes associated with aging.

Pharmacokinetic and Pharmacodynamic Changes of Aging Physiologic changes occur during aging that affect both the pharmacokinetic and pharmacodynamic variables in the elderly patient. Pharmacokinetic variables determine the relationship between the dose of a drug administered and its concentration delivered to the site of action, and include the following: • Changes in vascular volume • Plasma protein binding


Respiratory tidal volume vital capacity residual volume lung capacity compliance

Renal bladder capacity renal blood flow glomerular filtration

Endocrine glucose intolerance aldosterone hypocalcemia hypothyroidism Metabolic basal metabolic rate risk for hypothermia

Central nervous system neuronal density reflexes sympathetic response Cardiovascular myocardial irritability dysrhythmias blocks L ventricular hypertrophy systolic blood pressure cardiac output circulation time

Gastrointestinal gastric emptying hepatic blood flow drug absorption

Orthopedic osteoporosis risk of fractures Body composition subcutaneous fat overall body fat sweat glands skin pigmentation Sensory visual acuity sensitivity to sound response to pain changes in taste and smell

F I G U R E 1 0 - 1 : Physiologic changes associated with aging.


• Percentage of body mass that is lipid or lean • Efficiency of metabolism and elimination of drugs Pharmacodynamic variables determine the relationship between the concentration of the drug at the site of action and the intensity of the effect produced, and include an increased sensitivity to administered agents. The changes due to aging that are of the greatest concern are the pharmacokinetic variables.

Vascular Volume With aging, there is a 20% to 30% decrease in vascular volume. Therefore, medications are injected into a smaller circulating volume, increasing the volume of distribution and causing a higher than expected plasma drug concentration.

Protein Binding All anesthetic agents bind to plasma proteins to some extent. The portion of the drug that is bound cannot cross central nervous system membranes. Only the portion that is “free” or unbound in plasma is capable of crossing membranes in the central nervous system and of exerting a clinical effect. In the elderly, protein binding is less effective, due in part to a 10% decline in serum albumin as well as any additional decreases due to malnutrition. As a result, with an increase in free drug, there will be an exaggerated pharmacologic effect of drugs given.

Changes in Body Composition With aging, there is a loss of skeletal muscle, or lean body mass. The percentage of weight that is lipid increases, especially with women. As a result, there is an increase in body fat and lipid storage sites and an increased reservoir for the deposition of lipid-soluble drugs, such as midazolam and diazepam. The result will be an increase in • Time for the elimination of drugs • Residual plasma concentration of drugs • Drug effects

Renal and Hepatic Function The major effect of aging on drug action is in clearance. Renal blood flow declines, which, coupled with a loss of glomeruli, results in decreased excretion of drugs and their metabolites. Plasma concentration of drugs, therefore, decreases more slowly.


ALERT Care should be taken with initial drug dosing. Drug doses are generally reduced when administered to an elderly patient. Monitor drug effects closely. Start low and go slow with medications.

Hepatic blood flow decreases with age, reducing first pass drug clearance, the result of which is higher remaining blood levels of administered agents. Phase I oxidative metabolic processes of the liver decrease with age. Therefore, drugs such as benzodiazepines, where initial degradation is oxidative, have a prolonged action.

Pathophysiologic Conditions in the Elderly

In addition to age-related changes that occur with normal aging, there are a number of illnesses and diseases that are seen more frequently in the elderly (see Box 10–1). In addition to the hazards associated with these diseases, the medications used in the management of these diseases, as well as alterations in hepatorenal dysfunction, may further contribute to perioperative complications. It has been estimated that the average elderly person is on five medications per day. Each medication is capable of causing independent side effects. For example: furosemide (Lasix) used as a diuretic for hypertension may result in hypokalemia. Beta blockers slow the heart rate. In combination, drug effects are magnified and the potential for adverse drug interactions increases substantially. Furosemide (Lasix), as a diuretic, promotes fluid loss. Fluid loss can lead to orthostatic hypotension. Beta blockers, used as antihypertensive, antianginal agents, slow the heart rate and may also cause orthostatic changes. Orthostatic changes increase the risk for falls and injury.

Box 10–1

Common Pathophysiologic Conditions in the Elderly

Alzheimer’s disease Anemia Arteriosclerosis Arthritis Cataract COPD Congestive heart failure Diabetes

Glaucoma Hypertension Malignancy Osteoporosis Parkinson’s disease Prostate cancer Spinal stenosis Stroke


In addition, many elderly patients see multiple providers, such as an internist, cardiologist, urologist, or psychiatrist, and each may be writing medication prescriptions without the other’s knowledge. Over-the-counter medications, as well as herbal supplements, also have the potential to alter underlying disease states and increase the potential for adverse reactions when combined with prescription drugs. Box 10–2 lists the most common classes of medications, with examples, prescribed to patients older than age 65.

COACH CONSULT Encourage patients to use one pharmacy for all medications. That way, potential drug interactions can be detected quickly by the pharmacist, regardless of the prescriber.

Preoperative Assessment for the Elderly Patient The American Society of Anesthesiologists classifies the physical status of patients based on preexisting medical conditions, not age. Overall physical status, activity level, operative site, and preexisting cardiopulmonary disease appear to be the only preoperative factors that have consistent predictive value in identifying the high-risk surgical patient. The primary purposes of a preoperative assessment are to • Obtain a precise preoperative baseline • Plan optimal anesthetic care • Anticipate postoperative actual or potential problems Given the normal physiologic changes that occur with aging, and the pathophysiologic changes associated with disease or injury, it becomes of major importance to conduct a preoperative assessment. This is particularly important if the patient is to be scheduled as an outpatient, or

Box 10–2

Most Common Classes of Medications Prescribed to the Elderly

Antiarrhythmics: Lanoxin (digoxin) and Imdur (isosorbide) Antihyperlipidemics: Lipitor (atorvastatin) and Zocor (simvastatin) Antihypertensives: Norvasc (amlodipine) and Toprol XL (metoprolol) Antiplatelet: Plavix (clopidogrel) and Coumadin (warfarin) Antireflux: Nexium (esomeprazole) and Pepcid (famotidine) Hormonal protection: Actonel (resendronate) and Fosamax (alendronate) Sleep and pain medications: Ambien (zolpidem) and Neurontin (gabapentin)


ALERT When asking about medication use, ask about prescription, overthe-counter, and herbal medications. It is also important to ask about errors in omission, overdosing, and underdosing. This is important. Just because the prescription bottle says the medication should be taken twice daily for hypertension, the patient, feeling fine, may decrease the medication to once a day, or may have stopped taking the medication altogether because of a perceived lack of need or cost of the medications. Not only does this increase the potential for poor control of hypertension, but if hospitalized after surgery and started back on twice a day medication enforced by the nursing staff, the patient may experience side effects of being exposed to a medication that he or she has either not been taking or has been taking in a reduced dose.

day-of-surgery admission. A complete physical examination, targeted to systems and patient history, should be obtained and documented prior to the day of surgery. The need for routine preoperative laboratory tests remains controversial, and therefore should be dictated by physical examination and the presence of disease. Medications used in the management of disease also should be considered when determining the need for laboratory testing. Lack of information may also influence decision making. For example, many patients do not seek routine physical examinations, and, as a result, may be unaware of hypertension, diabetes, or cardiac abnormalities. As a result, many providers will order a preoperative glucose, blood pressure, and ECG in patients older than 65 years.

Anesthetic Options for the Elderly Patient

The elderly patient is a potential candidate for general, regional, and intravenous sedation anesthesia. Each technique and medication will offer specific advantages and disadvantages. The anesthesia provider, in consultation with the patient and the surgeon, and in consideration of the procedure to be performed, will select the safest anesthetic technique best suited for the patient. General anesthesia is often the technique of choice for the elderly patient because of the smooth induction and generally rapid recovery. Minimal alveolar concentration decreases at the rate of 4% per year after the age of 40, which will result in a decreased anesthetic requirement. An 80-year-old will require 25% less agent than a young adult. In addition, hepatorenal function declines with aging, delaying drug metabolism and drug clearance. Intravenous anesthetics used for general anesthesia and for IV sedation, including barbiturates, benzodiazepines, propofol, and narcotics, must be given in reduced doses.


General anesthesia compromises thermoregulation, which is already compromised as a result of normal age-related changes. Hypothermia is a frequent finding in the postanesthesia care unit (PACU). Ideally, the operating room (OR) nurses will attempt to minimize heat loss as much as possible, even if their sole intervention, owing to the site of surgery and length of procedure, is wrapping the patient’s head. Although patients are frequently asked to remove dentures prior to going to surgery, some anesthesia providers will ask that dentures remain in place to facilitate the use of an anesthetic mask. That said, if the dentures become loose, they can obstruct the airway and potentially contribute to aspiration. If removed in the OR after induction, they are at risk of being lost. Regional anesthesia may prove beneficial to the elderly patient because it is associated with minimal physiologic alterations. There is a decreased incidence of cardiopulmonary complications, and of postoperative confusion. Recovery is more rapid, as anesthesia is limited to the site of surgery. Finally, regional anesthesia may provide for postoperative analgesia, decreasing the need for additional narcotics in the PACU. Regional anesthesia does have the limitations of the time required to do the block, the prolonged duration of action, and potential difficulties in placement due to spinal stenosis. Hypotension associated with spinal anesthesia may be problematic, especially for the elderly patient who is already at risk secondary to decreased catecholamines, baroreceptor failure, and decreased myocardial reserve. Small doses of ephedrine may be effective in correcting the hypotension. It will also be important to maintain adequate filling pressures and volume status in these patients. Epidural anesthesia will result in less hypotension. As a result of anatomic changes in the intervertebral foramina, the epidural spread of the injectate is increased in the elderly patient. Therefore, the dose of the anesthetic is decreased by 25% to 50%. Other regional techniques that may be used with the elderly patient include caudal anesthesia for anorectal procedures, intravenous regional anesthesia (Bier block), brachial plexus blocks, and field blocks or other forms of local anesthesia.

IV Sedation As previously mentioned, intravenous agents must be given in reduced doses for both induction and maintenance of anesthesia. The elderly patient will be more sensitive to both the desired and undesirable side Special Populations: The Elderly and Pediatric Patient 269

effects of all intravenous medications, as well as having a decreased clearance of these agents.

Ambulatory Surgery as an Anesthetic Option Ambulatory surgery is often a desirable option for the elderly patient. It offers the advantages of minimizing separation from family, friends, and a known environment, allowing for a more rapid return to familiar surroundings, with less disruption in routines, diet, sleep, and medications. Exposure to medications is reduced, as is exposure to hospital-acquired infections. The type of surgery and the physiologic status of the patient will influence the decision as to whether ambulatory surgery is an appropriate option. A good candidate for ambulatory surgery is one who is reasonably active, with no acute symptoms of cardiopulmonary disease or dementia. Although you as a nurse will have little say as to whether the patient is scheduled as an inpatient or outpatient, you can help the decisionmaking process by making an assessment of the quality of home care and the availability of assistive personnel. You can make a recommendation for home nursing care if you see a particular need.

Most Common Surgical Procedures in Elderly Patients The most common surgical procedures performed on elderly patients include the following: • Cataract extraction • Prostatectomy • Herniorrhaphy • Cholecystectomy • Hip stabilization

Postoperative Priorities for the Elderly Patient The goal of providing care to any patient in the PACU is the reduction of morbidity and mortality associated with surgery and anesthesia. For the elderly patient, this will become increasingly important in consideration of all of the physiologic changes associated with aging. Ventilation, cardiovascular stability, fluid balance, activity stir-up routine, and comfort will be your priorities of care. For each goal, try to think of specific activities that you can use to achieve it. If in doubt, refer to Chapter 6, PACU Assessment and Care, and Chapter 9, Perioperative Complications. 270 Special Populations: The Elderly and Pediatric Patient

Ventilation • Promote optimal gas exchange • Prevent respiratory infections • Monitor compromised function

Cardiovascular Stability • Detect myocardial compromise • Promote cardiovascular stability

Fluid Balance • Correct preoperative dehydration • Prevent fluid overload • Monitor urine output

Activity Stir-Up Routine • • • •

Promote neurologic assessment Promote thermoregulation Optimize gas exchange Reorientation

Comfort • • • •

Reposition without injury Maintain skin integrity Rewarming as needed Pain management without adverse effects

The Pediatric Patient The pediatric patient has unique needs requiring specialized PACU care. It should be remembered that children are not just miniature adults. Each pediatric patient has unique needs, both physiologic and developmental, based on age. Being aware of these differences will help you to provide optimal care to each individual patient. Pediatric patients are generally defined by age, as there are unique needs across the 18 years that separates the newborn from the adolescent: • Neonate: Newborn within the first month of life • Premature infant: Neonate born prior to 40 weeks’ gestational age • Infant: 1 to 12 months of age • Toddler: 1 to 3 years of age • Preschooler: 3 to 6 years of age • School-age child: 6 to 12 years of age • Adolescent: 12 to 18 years of age Special Populations: The Elderly and Pediatric Patient 271

Physiologic Differences Between Pediatric Patients and Adult Patients There are unique physiologic differences between pediatric patients and adults that affect preanesthesia, intraoperative, and postoperative management. Being familiar with these differences will help you to anticipate special needs and to react accordingly.

Cardiovascular System Mean heart rate for the newborn is 120 beats/minute. It increases to a mean of 160 beats/minute by 1 month of age. Mean systolic blood pressure at birth is 65 mm Hg, increasing to 95 mm Hg by 6 weeks of age. At rest, cardiac output is about 2 to 3 times that of the adult, which is likely explained by the increased metabolic rate and increased oxygen consumption of children (see Tables 10–2 and 10–3). The myocardium of the neonate and infant is less compliant that that in the adult, causing a decreased stroke volume. As a result, pediatric patients

Table 10–2

Normal Pediatric Heart Rates

AGE

MEAN (BEATS/MINUTE)

RANGE (BEATS/MINUTE)

Newborn

120

100 to 150

1 to 7 days

135

100 to 175

7 to 30 days

160

115 to 190

1 to 3 months

140

125 to 190

3 to 6 months

140

110 to 180

6 to 12 months

140

110 to 175

1 to 3 years

125

95 to 160

3 to 5 years

100

65 to 130

5 to 8 years

80

70 to 115

8 to 12 years

80

55 to 105

12 to 16 years

75

55 to 100


Table 10–3 AGE

Normal Pediatric Blood Pressures SYSTOLIC (mm Hg)

DIASTOLIC (mm Hg)

MEAN (mm Hg)

Newborn

65

45

52

6 weeks

95

55

69

1 year

95

60

72

2 years

100

65

77

9 years

105

70

82

12 years

115

75

83

depend on heart rate and adequate circulating blood volume to maintain cardiac output. In addition, the infant and neonate have immature sympathetic nervous systems, which only allow limited catecholamine stores, decreasing myocardial reserve. It is important to remember that many anesthetic agents are associated with myocardial depression. Neonates, in particular, are especially sensitive to negative inotropes.

Respiratory System

COACH CONSULT Although the sympathetic nervous system is underdeveloped, the parasympathetic nervous system is mature at birth. As a result, vagal bradycardia occurs during stress, such as during intubation. Therefore, children are usually premedicated with an anticholinergic agent such as atropine, with the goal of preventing vagal bradycardia.

Anatomically, the infant has a disproportionately large head and, at times, a seemingly nonexistent neck. The infant’s tongue is large, and the glottis is high and narrow, making laryngoscopy and intubation more difficult and increasing the potential for tongue obstruction. The infant also tends to have an increased antero-posterior diameter of the chest and may appear barrelchested. For the first few months of life, infants are obligate (no choice in the matter) nose breathers. As the trachea is narrower in the pediatric patient, particularly at the level of the cricoid cartilage, an uncuffed endotracheal tube is used to prevent tracheal tissue trauma. Selection of an endotracheal tube of


appropriate size is also important in decreasing airway irritation (see Table 10–4). The child’s breathing patterns are generally diaphragmatic, and periods of apnea may occur in the very young, especially in the premature infant. As the child matures, the functional work of the intercostal muscles improves, decreasing the work of breathing. It should be remembered that the pediatric patient has a high basal metabolic rate, creating a high demand for oxygen—approximately 7mL/kg/minute, versus the adult’s need of 3.9 mL/kg/minute. Although COACH tidal volumes in the infant are the same as CONSULT for the adult (1 mL/kg), oxygen demand is three Protective responses to times greater, requiring a respiratory rate approxihypercarbia (↑CO2) and mately three times greater than that of the hypoxemia (↓O2) are normal adult, 40 to 60 breaths per minute as limited in the neonate compared with 12 to 16 breaths per minute (see and infant. Unlike the adult, where respiratory comproTable 10–5). mise is usually compensated for by tachycardia, in the neonate and infant, bradycardia is always a sign of hypoxemia until proved otherwise.

Table 10–4

Nervous System No other system shows greater development throughout infancy and childhood that the central nervous system (CNS), as evidenced by an increase in motor, sensory, and intellectual functioning with maturation.

Pediatric Endotracheal Tube Sizes

AGE

SIZE AND TYPE OF ENDOTRACHEAL TUBE

Premature infant

2.5 to 3.0 uncuffed

0 to 6 months

3.0 to 3.5 uncuffed

6 to 12 months

3.5 to 4.0 uncuffed

12 to 18 months

4.0 to 4.5 uncuffed

2 to 4 years

4.5 to 5.5 uncuffed

4 to 6 years

5.5 to 6.5 (⬍6.0 uncuffed; ⬎6.0 cuffed)

6+ years

6.5 to 7.5 cuffed


Table 10–5

Normal Pediatric Respiratory Rates

AGE

RESPIRATORY RATE (BREATHS/MINUTE)

Newborn

40

1 week

30

1 year

24

3 years

22

5 years

20

8 years

18

12 years

16

15 years

14

21 years

12

Unlike the CNS, the autonomic nervous system is fairly well developed in the newborn and infant. The parasympathetic components are fully developed at birth. The sympathetic components are not fully developed until 4 to 6 months of age.

Gastrointestinal System For the first month of life, the liver is immature. This results in delayed drug metabolism of any drug dependent on hepatic excretion. After 1 month of age, hepatic function assumes adult levels of functioning. Of major importance, children have an increased level of salivation, which may irritate the airway, increasing the risk of laryngospasm. For this reason, an anticholinergic (antisialagogue) is usually given preoperatively to dry secretions. Atropine and glycopyrrolate (Robinul) are the agents most commonly used.

Genitourinary System In the first few months of life, there is a decrease in the glomerular filtration rate and creatinine clearance slowing the metabolism of any drug requiring renal biotransformation. There also is a decreased ability to


COACH CONSULT The normal urine output is ideally 1 mL/kg/hour, equal to that of the adult.

COACH CONSULT As infants and small children often wake up agitated, protection from falls is imperative.

COACH CONSULT A fall of 2°C in environmental temperature may lead to a twofold increase in oxygen consumption for the infant and neonate.

clear fluid and sodium loads, making fluid overload and hypernatremia potential hazards of fluid administration.

Skeletal System Infants have a relatively immature skeletal system. Bone epiphyses, or growth plates, are not yet fused, and cranial fontanelles remain open.

Integumentary System The infant’s skin is extremely sensitive and requires care when placing electrocardiogram (ECG) leads, tape, and automatic blood pressure cuffs. In addition, infants have little subcutaneous fat and a relatively large surface area. Therefore, profound heat loss may occur in even a short period of time. Neonates, in particular, are at risk, because compensatory heat generation is achieved by nonshivering thermogenesis through the metabolism of brown fat. Use of this mechanism increases oxygen demand and may contribute to metabolic acidosis. Hypothermia markedly increases oxygen consumption.

Developmental Issues Related To Surgery and Hospitalization

For pediatric patients, hospitalization evokes feelings of separation, loss of control, and fear of injury and pain. Clearly the response of the patient will vary with the patient’s level of intellectual and verbal functioning, and will also be greatly influenced by the response of the parent or caregiver to the situation. The infant who is too young to understand may react only to feelings of separation from a parent, and respond by crying and be difficult to comfort. A toddler may react with physical aggression and being uncooperative. After 6 years of age, children are more used to separation and are able to understand instructions and explanations. Adolescents also understand separation and explanations, but are more likely to have questions related to surgical outcome, pain, and what will happen next.


These age-related differences will influence preoperative teaching and preoperative preparation. In the OR, the technique used for induction will be dependent upon the child’s ability to understand and cooperate as well as anatomic differences related to age. For example, telling a child that you will be helping him or her to sleep may need an explanation that surgical sleep is different from nighttime sleep or “putting a pet to sleep.” Some children will happily play “spaceman” and breathe from a face mask. Others may benefit from the use of a scented mask. The IV may be started before induction or after induction, depending on the ability of the child to cooperate. See Table 10–6 for age considerations for postoperative care. Postoperatively, age and developmental level are important considerations in providing patient comfort, pain control, and postoperative teaching. Table 10–6

Age Considerations for Postoperative Care

STAGE

APPROXIMATE AGE (YEARS)

PREDOMINANT FEAR

HELPFUL NURSING STRATEGIES

Infancy

0 to 1

Separation

Provide warm blankets Pacifier or bottle if appropriate Hold or rock child Reunite with caregiver

Toddler

1 to 3

Separation, viewed as permanent

Call child by name parents use Have favorite toy Reunite with caregiver quickly

Preschool

3 to 6

Separation, viewed as rejection

Allow child to make choices Have favorite toy Provide simple instructions Reunite with caregiver quickly

Schoolaged

6 to 12

Loss of control

Cover child for privacy Allow child to make choices Provide explanations for actions and experiences


Preoperative Assessment for the Pediatric Patient

COACH CONSULT Ideally, the preoperative assessment should occur in the presence of family members, although some adolescents may prefer to be interviewed privately, particularly when asking questions about drug and alcohol use, smoking, and possible pregnancy.

Table 10–7

Although most pediatric patients have few, if any, chronic or acute medical problems, it is still important to obtain a preoperative history, physical examination, and where appropriate, laboratory tests. Use of a systems approach will facilitate data collection. See Table 10–7 for a review of systems and their anesthetic implications.

Review of Systems: Anesthetic Implications

SYSTEM Respiratory

QUESTIONS TO ASK: DOES YOUR CHILD HAVE (A HISTORY OF)... Asthma? Hospitalization for asthma? A recent cold? Seasonal allergies? Current cough? Croup? Apnea . . . use an apnea monitor at home?

ANESTHETIC IMPLICATIONS Irritable airway: Potential for bronchospasm and laryngospasm

Atelectasis: Infiltrate Subglottic narrowing Postop risk of apnea

Cardiovascular

Heart murmur? Diagnosed congenital problem? Exercise intolerance? History of rheumatic fever?

Possible septal defect Possible shunt; renal disease CHF Possible valve disease

Neurologic

Seizures? Swallowing difficulties?

Medication interactions Possible aspiration; hiatal hernia

Gastrointestinal/ Hepatic

Vomiting/diarrhea? Malabsorption? Reflux?

Possible dehydration; infections Evaluate for anemia Potential for aspiration


Table 10–7

Review of Systems: Anesthetic Implications —Cont’d

SYSTEM

QUESTIONS TO ASK: DOES YOUR CHILD HAVE (A HISTORY OF)...

ANESTHETIC IMPLICATIONS

Genitourinary

Frequent infections?

Evaluate renal function

Endocrine/ metabolic

Growth delays

Consider endocrinopathies

Hematologic

Anemia? Easy bruising? Sickle cell disease?

Obtain hematocrit/hemoglobin Potential coagulopathy Need to maximize warmth and oxygenation; avoid acidosis

Allergies

Medication allergies?

Plan to avoid; select alternative

Dental

Loose teeth? Multiple cavities?

Potential for aspiration Consider need for endocarditis prophylaxis

Social

Nickname? Any special concerns or fears?

Eases establishing relationship Allows opportunity to address

Preoperative Medications for the Pediatric Patient Patients are rarely premedicated as a matter of routine. Instead, the individual patient is assessed, and determination of need is based on that assessment. Age, maturity, personality, and past medical and surgical history will influence the need for preoperative medication. Possible choices for premedication include the following: • Anticholinergics • Example: atropine • Purposes: • Minimize cholinergic effects of medications such as succinylcholine • Offset possible bradycardia seen with intubation • Decrease or dry secretions


• Sedatives • Examples: benzodiazepines (midazolam), barbiturates (methohexital), opioids (meperidine) • Purposes: • Decrease apprehension • Promote sleep • Smooth induction • Decrease anesthetic requirements • Decrease pain • Antiemetics • Example: Metoclopramide • Purposes: • Lower gastric pH • Reduces postoperative nausea and vomiting The route of administration will be influenced by age, need for speed, and patient cooperation. Oral medications are often easily accepted by children, but have a delayed onset of action. Intravenous and intramuscular medications require a needle stick, but onset of action is more predictable. Rectal administration requires cooperation, and onset is unpredictable.

Pharmacologic Differences in the Pediatric Patient Although the drugs selected to provide anesthesia for children are not different from those used for adults, the delivery of the drugs, and obviously the doses, will be different because of age-related differences in uptake, extravascular fluid volume, and receptor maturity. There also is less protein binding, a larger volume of distribution, a smaller proportion of fat and muscle stores, and relatively immature renal and hepatic function.

Anesthetic Options for the Pediatric Patient The pediatric patient is a potential candidate for general or regional anesthesia. IV sedation anesthesia is rarely an option, as most pediatric patients will not cooperate or tolerate this type of anesthesia. In fact, for many pediatric patients, induction must be mask-induced, and the IV started after the patient is asleep. Each technique and each medication will offer specific advantages and disadvantages. The anesthesia provider, in consultation with the patient and the surgeon, and in consideration of the procedure to be performed, will select the safest anesthetic technique best suited for the patient.


General Anesthesia with Inhalation Agents General anesthesia using inhalational anesthetics is the technique of choice for the pediatric patient, as it provides a rapid onset of anesthesia with a smooth induction. The rapid onset is due to the rapid respiratory rate, increased cardiac index, and greater blood flow to vessel rich tissues of the heart, liver, and kidneys seen in the pediatric patient. Inhalation anesthetics are well tolerated by infants and school-agers, but are likely met with resistance by toddlers as mask induction is required. Inhalation anesthesia is associated with a higher risk of hypotension and bradycardia on induction due to its rapid uptake.

General Anesthesia with Intravenous Agents IV anesthetics are associated with a higher risk of respiratory depression and apnea in infants. The immature blood-brain barrier increases sensitivity to opioids and barbiturates. The pediatric patient has an increased sensitivity to nondepolarizing muscle relaxants. Decreased renal clearance requires dosage reductions.

Regional Anesthesia Regional anesthesia may be used as an adjunct to general anesthesia. It may be the sole anesthetic in the cooperative, older patient. Its use is highly dependent on patient cooperation, and is often done while the child is asleep for postoperative pain management. Examples include the following: • Axillary block for hand surgery • Ilioinguinal/iliohypogastric block following herniorrhaphy • Penile ring block following circumcision • Caudal anesthesia for perineal surgery • Spinal anesthesia (L4–L5, or L5–S1) procedures below the diaphragm

Postoperative Priorities for the Pediatric Patient In addition to recovering from anesthesia and surgery, pediatric patients have unique needs and concerns specific to their physiologic and psychologic level of functioning. Concerns lie in the areas of • Altered ventilation • Hypothermia • Fluid balance


• Emergence • Comfort

Alterations in Ventilation Goals include the following: • Promoting oxygenation because of high oxygen demand and anesthetic depression • Monitoring for compromised function Infant Apnea The effect of opioids and other respiratory depressants on the immature respiratory center of the infant may result in infant apnea. This is especially problematic in infants with a history of prematurity, respiratory distress, or bronchopulmonary dysplasia. Hypothermia may also contribute to apnea. Prevention and Treatment • Oxygen administration • Stimulation • Pulse oximetry monitoring • Consideration of overnight monitoring for high-risk infants • Airway support if needed Postextubation Croup Postextubation croup is signified by a hoarse, barking cough seen in children after extubation due to intubation trauma, tight-fitting endotracheal tube, prolonged intubation, coughing with the endotracheal tube, surgery on the head and neck, or movement of the tube during positioning. Prevention ALERT Begins in the OR with careful, controlled intubation If racemic epinephrine is administered, • Administration of cool, humidified initiate ECG monitoring oxygen as medication causes Treatment tachycardia. • Racemic epinephrine • Continued monitoring Obstruction Obstruction most commonly occurs owing to the tongue obstructing the oropharynx in a deeply anesthetized patient. Prevention • Transport in and maintenance of lateral decubitus (side-lying; tonsillar) position until fully awake


Treatment • Stimulation • Jaw thrust or chin lift • Oral or nasal airway placement • Manual ventilation with an Ambu-bag • Intubation

Hypothermia Hypothermia is a special risk factor for the pediatric patient as a result of a large head size compared with body size. Infants in particular have little subcutaneous fat, decreased catecholamine stores, and an increased need for oxygen. The goal for a patient with hypothermia is to maintain or restore normothermia to prevent: • Apnea • Bradycardia • Hypotension • Metabolic acidosis Prevention • Warming the OR • Keeping patient covered Treatment • Active rewarming postoperatively • Continuous temperature monitoring

Fluid Balance Goals for the patient with a fluid balance deficiency include the following: • Meeting normal physiologic needs • Restoring deficits by replacing losses Potential for Fluid Overload Infants and younger children are at increased risk for fluid overload due to alterations in renal clearance ability and a decreased ability to handle fluid and sodium loads. Prevention • Careful fluid administration with volumetric controller • Monitoring of intake and output Treatment • Careful fluid administration with volumetric controller • Protecting and maintaining the IV line • Fluid replacement on a mL/mL replacement basis


Emergence The goal for the patient with emergence is maintenance of safety with return to baseline neurologic status. Emergence Delirium About 15% of young children and adolescents will present with emergence delirium without known risk factors. Prevention • Allow patient to wake spontaneously without stimulation Treatment • Evaluate for hypoxemia and treat if needed with improved oxygenation • Maintain patient safety by holding child, padded and/or elevated side rails

Comfort Goals include the following: • Prevent or minimize separation • Minimize loss of control • Minimize pain Pain and anxiety may be related to the pain of separation or the pain from surgery. For example, infants will be unable to understand separation. Young children will awaken in an unfamiliar room with unfamiliar personnel. And, unfortunately, there still exists a belief that pediatric patients do not have pain, COACH which has repeatedly been shown to be untrue. CONSULT Prevention • Allow parent or caregiver to remain with The pediatric patient is not child as much as possible just a miniature adult. • Have parent present upon awakening These patients require specialized care and knowl• Use of regional anesthesia for postoperative edge. Not only are physiopain control logic differences important • Anticipatory use of pain medication considerations, develop• Nonpharmacologic comfort measures mental needs of the infant, toddler, school-aged, and Treatment adolescent require atten• Reunite patient and caregiver tion pre-, intra-, and • Administer pain medication postoperatively. • Reorientation if age appropriate


CHAPTER

11

Special Populations: The Pregnant, Diabetic, and Obese Surgical Patient

P

regnant, diabetic, and obese patients are frequently seen in the perioperative setting. Each presents special concerns. Knowing their unique considerations will help you to provide for their special needs and, thereby, improve outcomes.

The Pregnant Patient The pregnant woman may undergo surgery for nonobstetric reasons during pregnancy, surgery for delivery, or surgery to terminate a pregnancy. The physiologic changes that are seen with pregnancy impact pre-, intra-, and postoperative care.

Physiologic Changes During Pregnancy The pregnant patient undergoes physiologic changes that affect preoperative, intraoperative, postoperative, and postanesthetic care. Cardiovascular System The cardiovascular changes that occur during pregnancy are protective for anticipated blood loss during delivery, to meet the increased physiologic demands of the fetus, and to meet increased maternal demand for oxygen. See Table 11–1 for cardiovascular changes that occur during pregnancy. Although both plasma volume and red cell volume increase during pregnancy, they are disproportionate in their increase. This difference explains the physiologic anemia seen in pregnancy. Despite this expected finding, a hemoglobin of less than 11 g/dL or a hematocrit of less than 33% is considered abnormal, and is usually due to maternal iron deficiency. 285

Table 11–1

Cardiovascular Changes in Pregnancy

SPECIFIC CHANGE

% OR Torr INCREASE

Blood volume

35%

Plasma volume

45%

Red blood cell volume

20%

Cardiac output

40%

Heart rate

15%

Total peripheral resistance

15%

Mean arterial pressure

15 torr

Systolic blood pressure

0 to 15 torr

Diastolic blood pressure

10 to 20 torr

Stroke volume

30%

Aorto-caval compression may occur as a result of the enlarging uterus, particularly when the woman is positioned flat. This will be particularly true after the 20th week of pregA normal vaginal delivery nancy. The uterus compresses the vena cava, is associated with a 500 to reducing blood flow to the right atrium, while 600 cc blood loss. A also reducing uterine blood flow and cardiac cesarean delivery may have an 800 to 1000 cc blood output. This is also referred to as supine hypotenloss. sive syndrome. The goal of treatment is to displace the uterus from the vena cava by having the woman avoid the supine position. A left lateral position is preferred, and can be maintained with placement of a wedge pillow or blanket roll under the woman’s right side (see Fig. 11–1). Respiratory System Ventilatory changes begin in the first trimester and continue until delivery. All of the changes are in response to increased maternal oxygen consumption, which occurs as a result of the increased maternal and fetal requirements for oxygen and the increased work of breathing against the enlarging uterus. Changes include: COACH CONSULT

286 Special Populations: The Pregnant, Diabetic, and Obese Surgical Patient

(A)

(B) F I G U R E 1 1 - 1 : (A) aortocaval compression; (B) aortocaval decompression with left lateral tilt.

ALERT • Minute ventilation increases by 50% due to increased tidal volume and respiratory rate • Blood oxygen levels (PaO2) increase by 5 to 10 mm Hg • Carbon dioxide (PaO2) levels decrease to approximately 32 mm Hg • Functional residual capacity reduced 15% to 20% at term

The feeling of shortness of breath may be a normal finding in a pregnant patient. Hypoxemia is not normal. The demands of surgery and anesthetic exposure make hypoxemia a potential risk, requiring pulse oximetry monitoring and oxygen therapy.

Special Populations: The Pregnant, Diabetic, and Obese Surgical Patient 287

• 60% to 70% of women will complain of shortness of breath with enlarging uterus • Capillary engorgement of nasal and oral mucosa Central Nervous System Central nervous system changes center around an increased responsiveness to the effects of anesthetic agents. Inhalational anesthetic requirements are reduced by 40%, although the mechanism for why is unclear. Less local anesthesia is required to achieve spinal and epidural levels of anesthesia. This may be related to the acid-base changes in the CSF or to hormonal changes seen in pregnancy. The increased pressure of the enlarging uterus causes epidural veins to become engorged, increasing the potential for an intravascular injection during a lumbar or epidural caudal block. Renal System Renal blood flow and glomerular filtration increase by 50% to 60% in pregnancy, beginning in the first trimester. As a result: • Creatinine clearance increases • BUN and creatinine levels fall by 40% It is also important to note that maternal progesterone increases sharply in pregnancy. COACH Progesterone is a smooth muscle relaxant that CONSULT causes dilation of the renal calyces, pelves, and ureters. Ureteral dilatation occurs as the uterus For a pregnant woman, a enlarges. As a result, urinary stasis may be normal BUN is 8 or 9 mg/dL. A normal creatinine is a problem, predisposing the woman to uri0.46 mg/dL. It is important nary tract infections and an increased risk of to note that accepted pyelonephritis. Both the stasis and the pressure normal BUN, 15 mg/dL; of the uterus contribute to urinary frequency, creatinine, 1.0 mg/dL; particularly in the last trimester. and creatinine clearance, 100 mL/min; values of the Aldosterone levels increase in pregnancy, nonpregnant patient are causing retention of sodium and water. Glycoindicative of abnormal suria of as much as 1 to 10 g/day occurs because renal function in pregnant tubular reabsorption of glucose is less than the women near term. increase in glomerular filtration of glucose. Proteinuria of as much as 300 mg/day is also not uncommon. Neither is indicative of pathology. Gastrointestinal System The changes in the gastrointestinal system are due to the enlarging uterus and to hormonal changes due to pregnancy. The enlarging uterus causes: • Increased gastroesophageal reflux (heartburn) • Increased regurgitation


• Increased risk of aspiration • Decreased gastric emptying COACH The increase in progesterone causes relaxCONSULT ation of smooth muscles, resulting in: As a result of delayed • Decreased gastric emptying gastric emptying, the • Increased constipation pregnant patient is always Hematologic System considered to be a “full stomach” patient, and Although no change is seen in the platelet at risk for aspiration on count during pregnancy, pregnancy itself is a induction and intubation. condition of hypercoagulability. All coagulation Reglan (metoclopramide) factors, with the exception of factors XI and may be given prior to a XIII, are increased, which predispose the pregprocedure to increase gastric emptying and to nant woman to thromboembolic events. The increase gastric pH. risk of deep venous thrombosis and pulmonary embolism are greatest just after delivery. The physiologic alterations associated with pregnancy are summarized in Figure 11–2.

Nonobstetric Surgery During Pregnancy Ideally, all surgeries should be postponed until after delivery. If surgery cannot be avoided, it ideally should be delayed until after the first trimester, the period of time when the most fetal development occurs. Avoiding exposure of the fetus to anesthesia and surgery will help to decrease the anesthetic and surgical risks during pregnancy. Despite these ideals, 1% to 2% of all pregnant women will require anesthesia for surgery unrelated to delivery. Common urgent conditions that will require surgical intervention include: • Trauma • Appendicitis • Intestinal obstruction There are five anesthesia-related goals when providing care to pregnant patients. 1. Protection of the mother 2. Maintenance of uterine blood flow 3. Maintenance of fetal oxygenation 4. Avoidance of teratogenic drugs 5. Prevention of preterm labor Protection of the mother includes maintaining maternal oxygenation and perfusion. Uterine blood flow will be secure if maternal perfusion is adequate. Fetal monitoring will detect signs of fetal distress secondary to Special Populations: The Pregnant, Diabetic, and Obese Surgical Patient 289

Central nervous system 40% decrease in inhalation agent requirements 40% reduction in local anesthetic for spinal/epidural Increased neurosensitivity to local anesthetic Respiratory 40% tidal volume 15% respiratory rate 20% oxygen consumption PaO2 PaCO2 30% in compliance 35% in resistance

Cardiac 35% blood volume 40% cardiac output stroke volume 30% 15% heart rate 15% peripheral vascular resistance

Renal glomerular filtration rate renal blood flow creatinine clearance BUN and creatinine

Coagulation factors coagulation factors except XI and XIII

Gastrointestinal reflux gastric emptying gastric pH

Reproductive uterine blood flow size/weight pressure

F I G U R E 1 1 - 2 : Physiologic changes of pregnancy.


hypoxemia. Decelerations in heart rate, bradycardia, or persistent tachycardia are signs of fetal distress. If detected, the priority becomes improving uteroplacental perfusion and fetal oxygenation. This may be accomplished through left lateral displacement of the uterus, increasing maternal oxygen concentration, and determining if changes in maternal ventilation are required. Maternal circulating volume is augmented through the administration of fluid or through pharmacologic intervention aimed at increasing maternal perfusion pressures. Ideally, fetal exposure to anesthetic agents is avoided during the first trimester, when the potential for teratogenicity is highest. To be labeled a teratogen, a substance known to have the potential to produce a defect, a drug must be given in the appropriate dosage, at a particular developmental stage of the embryo, and to an individual with a specific genetic susceptibility to that teratogen. Nitrous oxide and benzodiazepines are avoided in the first trimester because of their teratogenic effects. Ibuprofen is a low-risk drug early in pregnancy, but high-risk in the last trimester close to term, as it can cause premature closure of the ductus arteriosus. As it is unethical to perform research exposing pregnant women to drugs to examine their effects, all data about teratogenicity of anesthetic agents during pregnancy is anecdotal rather than being based on evidence. The U.S. Food and Drug Administration (FDA) created a Pregnancy Classification for Drugs to help identify risk (see Table 11-2). The major problem with this classification system is that only 40% of currently available agents have a designated pregnancy classification. Most anesthetic agents do not have ratings. Even with a classification of C, albuterol remains the drug of choice for the acute management of bronchospasm, in which a threat to the ability to oxygenate outweighs any potential threat to the fetus. In addition, the categorization does not help providers examine risk specific to fertility, pregnancy, and lactation. The FDA is currently working on such a system, with supporting evidence provided for practitioners to make informed decisions. Pregnant surgical patients have a 12% spontaneous abortion rate in the first trimester, dropping to less than 5% in the second trimester. The risk of exposing a woman to the potential of preterm labor is greater than the risk of fetal anomalies due to anesthetic exposure. Of women who have surgery while pregnant, slightly more than 8% will develop preterm labor. If the anticipated due date is weeks away, it may be necessary


Table 11–2

DRUG CATEGORY

U.S. Food and Drug Administration Classification for Drug Safety DEFINITION

EXAMPLES

A

Drugs that have been found safe in controlled studies on pregnant women

Prenatal vitamins Folic acid Oxygen

B

Drugs that either have animal studies showing no fetal damage but have no human studies, or show adverse effects in animals but not in human studies

Acetaminophen Ketamine Ondansetron (Zofran) Propofol Sevoflurane

C

Drugs that have either no animal or human studies or have studies that show adverse effects on the fetus with no available data on human subjects

Fentanyl Albuterol Isoflurane Doxacurium

D

Drugs that show positive evidence of human fetal risk but have benefits that may outweigh the risks

ACE-Inhibitors Benzodiazepines (Midazolam)

X

Drugs with proven risks to the fetus that outweigh the benefits and should not be used under any circumstances

Warfarin Thalidomide HMG CoA reductase inhibitors (“Statins”)

to start tocolytic therapy to stop contractions. Agents that may be used include ritodrine (Yutopar), terbutaline (Brethine), and magnesium sulfate (MgSO4). See Table 11–3 for more on the pharmacologic management of preterm labor. ALERT Preterm labor places the fetus at risk for the development of intrapartum death, neonatal respiratory failure, and intraventricular hemorrhage.

Anesthetic Options for Nonobstetric Surgery During Pregnancy

Most pregnant patients presenting for surgery are relatively young, generally healthy patients and, as a result, may be candidates for either general anesthesia or regional anesthesia. The choice will most likely be dependent upon the


Table 11–3

Medications Used for Preterm Labor

DRUG

USUAL DOSE

Betaadrenergic agents Ritodrine (Yutopar) Terbutaline (Brethine)

Magnesium sulfate (MgSO4)

MAXIMUM DOSE

0.5 to 0.1 mg/min 0.01 mg/min

0.35 mg/min 0.08 mg/min

4 g IV bolus followed by infusion of 2 g/hr with goal of serum magnesium level of 5.0 to 7.0 mg/100 mL

Magnesium level of 7.0 mg/ 100 mL

MATERNAL EFFECTS

FETAL EFFECTS

Hypotension Tachycardia Chest pain and tightness Arrhythmias Nervousness Headache Hyperglycemia Pulmonary edema

Tachycardia Hyperglycemia ↑ free fatty acids

Pulmonary edema Chest pain and tightness Maternal weakness Nausea and vomiting Blurred vision Flushing ↓ deep tendon reflexes Cardiac failure ↑ sensitivity to muscle relaxants

Hypotonia Drowsiness ↓ gastric motility Hypocalcemia

location of the surgical site, degree of urgency, and trimester of pregnancy. Each is associated with distinct advantages and disadvantages. General Anesthesia • Advantages: Inhalation agents may prevent uterine contractions and preterm labor • Disadvantages: General anesthesia is associated with a risk of aspiration due to intubation, spontaneous abortion, and fetal exposure to agents Regional Anesthesia • Advantages: Regional anesthesia does not increase the risk of spontaneous abortion. This technique is nonteratogenic and avoids airway manipulation. It is the technique of choice when the type of surgery will permit • Disadvantage: This technique may not be possible because of the nature of the surgery


COACH CONSULT

PACU Assessment of the Pregnant Patient Following Nonobstetric Surgery

Postoperative priorities will focus on three areas: 1. Postsurgical assessment (see chapter 6) 2. Postanesthetic assessment (see chapter 6) 3. Assessment and maintenance of maternal and fetal well-being Maintenance of cardiac output is important. To prevent supine hypotension, the patient should be positioned in a left lateral tilt position. Heart rate and rhythm will be monitored for signs of distress, most commonly tachycardia due to pain or hypoxemia or bradycardia due to hypothermia or hypoxemia. Oxygen will be applied to promote maternal and fetal oxygenation. Fetal heart tones should be monitored continuously if possible. While most post-anesthetic care units (PACUs) do not keep a fetal COACH monitor in the unit, a consult should be made CONSULT to the obstetric unit for both a fetal monitor and the assistance of a nurse skilled in fetal moniMaintaining a stable toring. These patients are frequently admitted maternal heart rate, blood to the OB unit for postoperative surgical care pressure, and oxygenation will help to ensure fetal and to facilitate continued fetal monitoring. well-being. Uterine contraction monitoring should also be continued in the PACU, using a tocodynometer. Again, if not readily available in the PACU or OR, one should be obtained from the OB unit. Evidence of uterine contraction should be reported to the surgeon and obstetrician managing the patient. Regardless of technique, fetal heart rate monitoring should be done continuously during surgery after the 18th week of gestation. This will allow for rapid detection of abnormalities in maternal oxygenation and uterine perfusion. It has been argued that monitoring prior to 18 weeks is not necessary because a cesarean delivery would not be performed, because the fetus prior to 18 weeks is not viable outside of the uterus.

Obstetric Surgery during Pregnancy Surgical procedures during pregnancy include delivery via cesarean section or termination of pregnancy via abortion or ectopic pregnancy. As the necessity for fetal protection is different for each type of surgery, each is discussed separately. Cesarean Section Delivery by cesarean section has become increasingly more common, and may be as high as 25% of all deliveries. In high-risk centers, where a 294 Special Populations: The Pregnant, Diabetic, and Obese Surgical Patient

disproportionate number of mothers are preeclamptic–eclamptic or have diabetes, Rh isoimALERT munization, a history of prematurity, multiple It is important to fetuses, or other high-risk conditions, the rate protect the mother and of cesarean delivery may be even higher. fetus from x-rays in the A cesarean section delivery is performed to PACU. X-rays are frequently prevent or treat fetal or maternal jeopardy. taken in the PACU for orthopedic cases. Lead Common indications for cesarean section delivaprons may be used to eries include cephalopelvic disproportion (CPDshield the mother from the fetal size vs. maternal pelvis size), failure to x-ray, although ideally, the progress, malpresentation of the fetus or breech, mother should be moved away from the x-ray unit to hemorrhage, placenta previa, prolapsed cord, a more distant part of the pre-eclampsia-eclampsia, and fetal distress. PACU. Box 11–1 identifies the most common indications for cesarean delivery. Anesthetic Options for Cesarean Delivery The choice of anesthetic for cesarean delivery depends on the reason for the surgery, the degree of urgency, the desire of the patient, and the judgment of the anesthesia provider and obstetrician. There is no one ideal method. The only ideal is that the anesthetic choice be the safest and most comfortable for the mother, least depressant for the fetus, and provide an optimal working condition for the obstetrician. It should be noted, that in an emergency, it is possible to perform a cesarean section delivery under a local anesthetic, but this is hardly ideal.

Box 11–1

Indications for Cesarean Delivery

MATERNAL FACTORS • Obstructive lesion in lower genital tract • Anal involvement with inflammatory bowel disease • Active genital herpes • Infection with human immunodeficiency virus • Contraindications to labor, such as previous section delivery or cerclage in place FETAL FACTORS • Malpresentation or breech • Congenital abnormalities • Nonreassuring fetal heart rate MATERNAL-FETAL FACTORS • Abnormal lie of the placenta (previa, accreta) • Abnormal labor (failure to progress; cephalopelvic disproportion)


Regional Anesthesia Advantages of regional anesthesia include: • Awake mother • Little to no risk of maternal aspiration • No neonatal drug depression Spinal anesthesia produces rapid and reliable profound analgesia. Epidural anesthesia can be used for labor and delivery, carries less risk for maternal hypertension than spinal anesthesia, and has a more controllable anesthetic level than spinal anesthesia. Epidural and spinal anesthesia are commonly combined to allow for rapid onset and reliability of the spinal anesthetic with the ability and flexibility to reinforce, or raise, the anesthetic level with an epidural catheter. General Anesthesia Advantages for general anesthesia include: • Rapid induction with less maternal hypotension and circulatory instability • Better control of the airway and ventilation • Better for mother who wants to be “asleep” or who fears needles • Useful for mothers with pre-existing conditions that limit use of regional techniques, including infection, coagulopathies, and neurologic or lumbar disease Risks for general anesthesia include: • Maternal aspiration • Fetal exposure to the anesthetic agents • Potential for supine hypotensive syndrome • Potential for a failed intubation If general anesthesia is required, the anesthesiologist will work to minimize risk. The risk of aspiration may be minimized with meticulous rapid intubation technique and cricoid pressure. Using a nonparticulate antacid (Bicitra) prior to induction will raise gastric pH and minimize destruction of lung tissue if aspiration does occur. Fetal anesthetic exposure is minimized through rapid delivery of the fetus. Maternal hypotension is prevented with left lateral uterine displacement through positioning with a wedge pillow and adequate hydration. All anesthesia providers will have alternative plans for management of the airway in the case of a failed intubation.

PACU Assessment Following Cesarean Section During the first 2 hours after delivery, the mother will begin the physiologic return to the nonpregnant state. Aggressive nursing care and attention to detail will help to prevent postdelivery complications.


Assessment of bleeding is a priority. Hemorrhage, characterized by a blood loss of 500 mL ALERT or more, is a serious complication after delivery Bleeding caused and is associated with increased maternal by uterine atony will morbidity. The PACU nurse should immedirequire uterine massage ately assess the uterine fundus to note position and, if unsuccessful, and consistency. Immediately after delivery, administration of oxytocin (Pitocin) to stimulate uterine the uterus should be located approximately contractions. Uterine atony 2 cm below the umbilicus. The uterus should be means loss of uterine tone, firm to palpation. which can become a cause Almost all patients recovering from a of profuse bleeding. If uterine atony is discovered cesarean section will have an indwelling or suspected, the obstetriurinary catheter in place. Drainage color should cian should be notified be assessed. If the urine turns bloody, bladder immediately, while mainperforation should be suspected and the obstetaining uterine massage. trician notified. The PACU nurse should also observe and document the presence and amount of lochia. Lochia is the vaginal discharge, consisting of blood, tissue, and mucus, that appears immediately following childbirth. Lochia rubra, a distinctly bloody vaginal discharge, is expected, with moderate flow. A flow rate of greater than 100 mL, estimated by a saturated perineal pad, is considered excessive and should be monitored at frequent intervals. The PACU nurse should also check under the woman’s buttocks for bleeding, as vaginal bleeding may pool in a distended vagina and flow downward. If excessive bleeding is noted, uterine tone should be assessed for atony. Incisional pain and the incisional dressing should be assessed. Uterine contractions following delivery, either spontaneous or as the result of the administration of oxytocin, will also contribute to postoperative pain. Analgesic therapy may be indicated. Patient-controlled analgesia is a popular method of pain control following cesarean delivery. Although a concern for some mothers, the transfer of narcotic via breast milk to the fetus is negligible in usual doses. If an epidural or spinal anesthetic was used for delivery, the PACU nurse will monitor for signs of regression and resolution of the block. It is possible that the epidural catheter may be maintained for post-delivery pain control. Assuming stability of vital signs and no evidence of bleeding, the woman will usually be discharged from the PACU after an average of two hours.


Termination of Pregnancy Surgery to terminate a pregnancy may be scheduled following a spontaneous abortion (miscarriage), or as a therapeutic or elective abortion. A spontaneous abortion is also referred to as an incomplete miscarriage, with retained products of conception. A therapeutic abortion may be scheduled in the case of an ectopic, or outside of the uterus, pregnancy. An elective abortion is the decision of a woman to end a pregnancy. Regardless of the type of abortion, many women undergoing this procedure have strong emotional reactions, including loss, sadness, grief, and sometimes anger and relief. If the abortion is performed in the second trimester in response to the diagnosis of fetal abnormalities from genetic testing, the intensity of the emotions may be profound. The ability of the surgical and recovery team to attend to these needs is just as important as attention to the surgical and anesthetic needs of the patient. Anesthetic Options for Pregnancy Termination The most common anesthetic technique for termination of pregnancy is the administration of local anesthesia via a paracervical block, with IV sedation and analgesia. Epidural, spinal, and general anesthesia may be used. Complications seen during this type of surgery are directly related to the week of gestation and the skill of the surgeon. PACU Care Following Termination of Pregnancy Normally, a termination occurs during the first trimester of pregnancy. The woman admitted to the PACU will demonstrate some of the physiologic changes normally seen in pregnancy, but without the intensity or severity of changes that occur in the second or third trimester. As with any surgery, vital signs should be monitored. Uterine tone should be assessed, and as a perineal pad is placed, an assessment made of vaginal bleeding. To encourage uterine contractions and to decrease vaginal bleeding, IV oxytocin is commonly administered. The PACU nurse should check the chart to determine maternal blood type. If typing has not been done, it needs to be done prior to discharge. If the mother is Rh-negative, and the father of the baby or baby is Rh-positive, RhoGAM must be administered to prevent the formation of maternal antibodies to the Rh-positive factor. As the blood type of the father is rarely known, and in cases of termination of pregnancy where blood-typing of the baby is not done, all Rh-negative mothers will be given RhoGAM within 72 hours of delivery via IM injection. As most of these women will be discharged to home following their procedure, RhoGAM is commonly given in the PACU prior to discharge.


In addition to discharge instructions related to anesthesia and surgery, it is important to provide the women with information about bereavement counseling and, possibly, birth control.

Pre-eclampsia–Eclampsia Pre-eclampsia, formerly called toxemia of pregnancy, is a disorder that manifests after the 20th week of pregnancy, most commonly after the 24th week. It is characterized by a triad of diagnostic indicators: • Hypertension: Systolic blood pressure ⬎140 mm Hg or diastolic ⬎90mm Hg • Generalized edema: Not limited to the ankles and feet • Proteinuria: ⬎0.3 g/L in a 24-hour collection Although not part of the triad, hyper-reflexia is often also present. The symptoms usually disappear within 48 hours of delivery. See Figure 11–3 for more pathophysiologic changes that occur in pre-eclampsia–eclampsia. Pre-eclampsia becomes eclampsia when accompanied by a grand mal seizure not related to another cerebral condition. It occurs when the symptoms of pre-eclampsia, particularly the hypertension and proteinuria, worsen (see Box 11–2). Pre-eclampsia occurs in 5% to 7% of all pregnancies, and occurs most often in unmarried, primigravida (first pregnancy). It is also higher in patients on Medicaid as opposed to private insurance. Although eclampsia occurs in greater frequency in younger women, the morbidity and mortality of the disease increase with age and parity. The cause of pre-eclampsia–eclampsia is unknown, although theories of immunology, genetics, and decreased uterine blood flow have been cited. The development of HELLP syndrome—Hemolysis, Elevated Liver enzymes, and Low Platelets—is also a sign of the increasing severity of the disease, and is associated with a high fetal and maternal mortality. The definitive treatment is delivery of the fetus and the placenta. If too early in gestation for fetal viability, the goal is to control the disease processes and to continue the pregnancy as long as the uterine environment is adequate to support growth and maturation of the fetus without endangering the mother. Treatment goals will include the following: • Maintaining and improving circulation • Improving intravascular volume • Correcting acid-base abnormalities • Decreasing central nervous system hyperactivity In cases of severe hypertension and eclampsia, and the development of HELLP syndrome, the mother will be stabilized and the fetus delivered


Respiratory hypoxia/hypercarbia airway/laryngeal edema pulmonary edema left shift of oxyhemoglobin curve cyanosis

Renal renal blood flow proteinuria glomerular filtration creatinine clearance oliguria acute renal failure

Reproductive uteroplacental perfusion intrauterine growth retardation hyperactivity placenta decompensation fetal prematurity

Central nervous system cerebral edema ICP CNS irritability hyper-reflexia headache seizures Cardiovascular cardiac output blood pressure plasma volume vasoconstriction

Gastrointestinal epigastric pain (due to hepatic swelling) nausea and vomiting

Systemic generalized edema

Lab values serum albumin renin aldosterone catecholamines thrombocytopenia bleeding time fibrin split products F I G U R E 1 1 - 3 : Pathophysiologic changes in pre-eclampsia–eclampsia.


Box 11–2

Diagnostic Indicators of Eclampsia

Systolic blood pressure (⬎160 torr) Diastolic blood pressure (⬎110 torr) Mean arterial pressure (⬎120 torr) Proteinuria (⬎5 g/24 hr) Oliguria (⬍500 mL/24 hr)

Pulmonary edema Cyanosis Visual disturbances Headache Epigastric pain

as soon as possible to prevent maternal demise. Allowing continued fetal development under these circumstances is associated with high fetal mortality and many maternal complications.

The Diabetic Patient

COACH CONSULT Women with pre-eclampsia –eclampsia are rarely cared for in the PACU. Most have been previously admitted to the OB floor for monitoring, with deliveries occurring emergently in OB.

Diabetes affects 6% of all Americans younger than the age of 50 years, and 10% to 15% of those older than age 50. It is suspected that an equal number are undiagnosed. Diabetes will affect surgery and anesthesia for the following reasons: • Sheer number of patients with diabetes • Estimate that 50% of all diabetics will require surgery • Complications of diabetes requiring surgery Common surgical procedures seen in increased frequency in diabetic patients include cataract extraction/lens implant, vascular bypass grafts for intermittent claudication, coronary artery bypass grafts, amputation secondary to infection, kidney transplant secondary to renal failure, and bariatric surgery for obesity. The overriding goal of perioperative management is to achieve an outcome in patients with diabetes equal to that of patients without diabetes. Diabetes, per se, does not increase the risks of surgery. The secondary end organ consequences of poorly controlled, long-standing diabetes increases the risk. Perioperative risks include the following: • Increased perioperative myocardial infarction (may be silent) • Cardiac arrest secondary to autonomic neuropathy • Chronic renal failure secondary to diabetic nephropathy • Stroke and limb ischemia secondary to peripheral vascular disease • Postoperative wound infection secondary to hyperglycemia • Dehydration secondary to hyperglycemia Special Populations: The Pregnant, Diabetic, and Obese Surgical Patient 301

COACH CONSULT Recognizing that end organ compromise is the biggest predictor of risk and that it is also the result of poor glycemic control, the maintenance of good (tight) glycemic control would be the overriding goal of diabetic management.

• Diabetic control disrupted by acute stress response • Airway compromise secondary to obesity • Altered drug metabolism secondary to obesity and altered renal function

Role of Insulin

The role of insulin is to facilitate the uptake of glucose into the cells, for use in cellular metabolism. Without insulin, glucose remains extracellularly, causing hyperglycemia. Cells are incapable of utilizing glucose as an energy source, and must rely on the utilization of fats for energy. The burning of fats for energy produces lactic acid, causing ketosis. The cause of diabetes is unknown, but is suspected to be a combination of genetics and lifestyle, including obesity and inactivity. In type 1 diabetes, also known as Juvenile Onset Diabetes Mellitus and ketosis-prone diabetes, the beta cells of the pancreas no longer produce insulin. Type 1 diabetes is characterized as a disease of altered glucose metabolism and hyperglycemia due to an absolute lack of insulin. Insulin administration is required to sustain life. In type 2 diabetes, also known as Adult Onset Diabetes and ketosisresistant diabetes, the beta cells of the pancreas still produce insulin, however the insulin produced is either deficient in production, secretion, or uptake. Many of these patients are in fact hyperinsulinemic, but the insulin produced is ineffective for cellular uptake. These patients may require insulin, but are frequently and more commonly managed with the use of oral hypoglycemic agents designed to facilitate insulin production, release, or cellular uptake.

Medical Management of the Diabetic Patient Management of diabetes will include the following: • Insulin or oral hypoglycemic agents • Diet with carbohydrate control • Exercise to facilitate the uptake of glucose by cells • Serum glucose monitoring • Regular medical assessment and care

Metabolic Response to Anesthesia and Surgery Surgery elicits a stress response, proportional to the amount of tissue trauma. The result is an increase in cortisol and catecholamines. The 302 Special Populations: The Pregnant, Diabetic, and Obese Surgical Patient

effect of the increased hormones will be insulin hyposecretion, insulin resistance, and increased protein catabolism. Anesthesia further suppresses insulin secretion and alters glucose metabolism, with resultant hyperglycemia and ketogenesis.

Perioperative Priorities for the Diabetic Patient As the overriding goal of management in the perioperative patient is to achieve an outcome in patients with diabetes equal to that of patients without diabetes, the major strategy will be the attempt to mimic normal metabolism by avoiding: • Hypoglycemia • Excessive hyperglycemia • Electrolyte alterations • Protein and fat catabolism (ketosis) It will also be important to be aware of and to manage any comorbidities, including coronary artery disease, vascular disease, and renal disease. Developing a Perioperative Management Plan Having a management plan specific to diabetic patient management will be important in maintaining glucose stability. Preoperatively, the history should include the following: COACH • Type of diabetes and current treatment CONSULT • Diagnosed end-organ comorbidities • Symptoms of ischemic cardiac, renal, The easiest way to assess for autonomic neuropathy or vascular disease is to obtain orthostatic • Previous hospitalizations due to diabetes blood pressures. Failure • Previous surgeries and diabetic response to self correct for position The preoperative physical examination changes is indicative of should include the following: autonomic neuropathy. • Complete cardiac evaluation, including EKG • Sensory and peripheral circulation assessment COACH • Assessment for autonomic neuropathy CONSULT Preoperative laboratory tests should include The target level for a HgbA1C the following: is less than 7%. Greater • Fasting serum glucose than 7% is indicative of • HgbA1C poor glucose control over • Blood urea nitrogen and creatinine the preceding 3-month period (see Table 11–4). • Screening for microalbuminuria/ proteinuria Special Populations: The Pregnant, Diabetic, and Obese Surgical Patient 303

COACH CONSULT

Day of Surgery Management of the Type 1 Diabetic Patient

Ideally, patients with type 1 diabetes will be scheduled as first cases of the day to prevent The evidence supports prolonged NPO. The key in management holding all doses of regular will be to balance energy intake (calories) insulin on the day of surgery, with insulin requirements, pre-, intra-, and and for patients to take half of their Hagedorn or postoperatively. There is significant controLente dose. Regular insulin versy about the use of patient-administered peaks within 3 to 4 hours insulin on the morning of surgery. Some of administration and, in surgeons will ask patients to take half the NPO patient, could result in a precipitous fall of their scheduled dose. Others will ask in glucose levels. patients to take their usual dose, and others still will ask patients to hold their morning dose. An IV should be started on the patient’s arrival to the preoperative holding area with a D5-containing solution. This will provide any needed

Table 11–4

Comparing HgbA1C to Blood Glucose Levels

HgbA1C

BLOOD GLUCOSE LEVEL (mg/dL)

4%

60

5%

90

6%

120

7%

150

8%

180

9%

210

10%

240

11%

270

12%

300

13%

330


glucose, preventing hypoglycemia. A preoperative glucose level should be obtained, with hyperglycemia covered by use of a sliding scale of regular insulin administered. In minor surgery, the standard of care for glucose monitoring is every 2 hours. In major surgery, monitoring is hourly. Perioperative Insulin Regimens Sliding Scale SQ • Most common and familiar • Acknowledges 2- to 4-hour peak effect of regular insulin • Unpredictable absorption of SQ in hypothermia patients • Will result in ups and downs of glucose control Continuous IV Regimen D10 ⫹ regular insulin ⫹ potassium solution (GIK solution) • Closely mimics steady state physiology with administration of 5 to 10 g glucose, 1 to 2 units of insulin, and 100 to 125 cc/ fluid/hour to match glucose production, insulin secretion, and replacement of loss • Infusion mix may have to be recalculated and changed with each glucose measurement IV Bolus at Regular Intervals • Additional insulin if needed via sliding scale • 20-minute peak in regular insulin does not mimic normal physiology. causing extremes in measurements Sliding Scale IV Continuous • Most elemental and physiologic of all regimens • Dextrose IV with insulin IV via separate lines titrated to serum glucose levels • Care must be taken to avoid accidental overdose • Other medications may precipitate if mixed in insulin line (insulin line should be a dedicated line) Postoperatively, insulin should be restarted per the presurgical routine, assuming diet has been resumed. The “sick-day” plan for insulin administration should be followed, reducing the dose, for postoperative nausea and vomiting and reduced caloric intake.

Day of Surgery Management of the Type 2 Diabetic Patient Evidence of poor preoperative control, including an elevated HgbA1C, and hospitalizations for diabetic management or its complications, are evidence of increased perioperative morbidity and mortality. Research supports switching the patient from oral medications to insulin to


achieve glycemic control, even for type 2 diabetics who are not currently using insulin. Elective surgical cases in poorly controlled patients should be seriously evaluated for risk-benefit. These patients should maintain a preoperative fast, recommended to be 12 hours, as opposed to the usual 8 hours. This is because of the common finding of gastroparesis, also known as delayed gastric emptying. Oral agents will also be stopped, with the timing dependent upon the class of agents: • Long acting agents (Diabinese) should be stopped 3 days before surgery • Diabeta (Glyburide) and Glucotrol (Glipizide) can be stopped on the day of surgery • Thiazolidinediones/Metformin are stopped the night before surgery An IV should be started on arrival to the preoperative holding area with a D5.45 solution. This solution provides glucose, thereby preventing hypoglycemia and protein catabolism. Lactate solutions are avoided, as lactate converts to glucose in fasting states, leading to hyperglycemia. Glucose monitoring should occur prior to induction, with use of a sliding scale as needed to maintain glycemic control (see Table 11–5). The frequency of glucose monitoring will be dependent upon the type of surgery, stress of the procedure, and the patient’s response to the process. Postoperatively, oral medications can be restarted at half dose as oral intake is restarted, with a return to full dose on the second day following surgery. If hospitalized, the patient may require use of insulin as opposed to oral agents until a normal diet is resumed and surgical stress minimized. If postoperative renal failure should develop as a postsurgical complication, metformin should NOT be restarted. COACH CONSULT Complications in the PACU for All If postoperative congestive heart failure develops as a postoperative complication, thiazolidinediones should not be restarted. These agents have been associated with fluid retention, peripheral and pulmonary edema.

Diabetic Patients Hypoglycemia and hyperglycemia are the two potential complications that may present in the postsurgical diabetic patient. Hypoglycemia is defined as a serum glucose level of less than 70 mg/dL. Symptoms of hypoglycemia may include headache, sweating, dizziness, impaired vision, tachycardia, feelings of hunger, shaking, irritability, anxiety, weakness,


Table 11–5

Sliding Scale for Patients with Type II Diabetes*

Serum glucose 150–200 mg/dL

2 units SQ


4 units SQ


6 units SQ


8 units SQ

Serum glucose ⬎ 350 mg/dL

10 units SQ

*Regular insulin only

and fatigue. It should be noted that many of these symptoms are difficult to separate from the feelings of any patient following anesthesia and surgery, making the monitoring of serum glucose levels imperative. Treatment will center on the administration of IV glucose, usually in the form of D10IV and continued glucose monitoring. An oral glucose solution, such as juice, might be used in the awake, ambulatory patient. Hyperglycemia, evidenced by a serum glucose of ⬎200 mg/dL, may be accompanied by symptoms of extreme thirst, frequent urination, hunger, blurred vision, drowsiness, and nausea. Treatment will include administration of insulin via sliding scale, continued hydration, and continued glucose monitoring.

The Obese Patient Obesity is now at epidemic proportions in the United States, not only for adults, but for children as well. It is considered the number-one nutritional disorder in the world. The obese patient may present for surgery specifically for weight loss or may present for surgery impacted by their obesity. The National Institute of Health recommends the use of Body Mass Index (BMI) to classify the degree of obesity. It can be calculated two different ways: 1. BMI ⫽ weight (kg) ⫼ height (m)2 2. Nonmetric calculation of BMI ⫽ weight in pounds ⫼ (height in inches ⫻ height in inches) ⫻ 703 The result of the calculation gives you the patient’s BMI number: • 25 to 29.9 is considered overweight • 30 to 35 is considered obese • ⬎35 is considered morbid obesity


Risks of Obesity Independent of surgical and anesthetic risks, the obese patient is at risk for comorbidities that have the potential to affect lifestyle, function, and overall health. These risk factors include the following: Cholecystitis Congestive heart failure Coronary artery disease Degenerative joint disease Diabetes mellitus Disc disease Endometrial cancer Gastroesophageal reflux disease Gout Hyperlipidemia Hypertension Hypertrophic cardiomyopathy Hypoventilation Increased mortality Infertility Intermittent claudication Low back pain Obstructive sleep apnea Osteoarthritis Stress incontinence Stroke Thromboembolism Presurgical assessment will, therefore, center on not only assessment of weight, but of pre-existing comorbidities and signs and complications of coexisting diseases.

Causes of Obesity No one theory explains the pathophysiology of obesity. There is consensus that all causes are multidimensional, and include the following: • Genetic factors • Cultural values and constraints • Metabolic influences and abnormalities • Social factors • Psychologic factors • Medication induced (e.g., steroids) • Sedentary lifestyle

Perioperative Assessment In addition to weight and measurement of BMI, the patient should be assessed for the presence of coexisting diseases that can affect anesthetic and surgical management. This assessment should include a cardiac evaluation, including echocardiogram and stress testing. Blood pressure assessment should be made using a large, appropriately sized cuff. Pulmonary function testing should include arterial blood gases and spirometry assessment. This will be particularly important if the patient has been identified with obstructive sleep apnea. The patient should be asked specifically about exercise intolerance and ability,


dyspnea, and use of continuous positive airway pressure (CPAP) or bi-level positive airway pressure. If diabetic, fasting glucose assessment and measurement of HgbA1C should be obtained to assess glycemic control. The presence of pre-existing cardiac and renal disease should be assessed, along with signs of autonomic dysfunction.

Risk Management

COACH CONSULT To prevent embarrassment for the patient and inconvenience for the staff, many centers have established an “early warning” system to alert staff to the scheduling of an obese and, particularly, morbidly obese patient. This will allow staff to prepare, in advance, appropriately sized gowns, TED hose, blood pressure cuffs, chairs, carts, operating room (OR) tables, moving equipment, surgical equipment, bedside commode, and surgical inpatient bed. For example, the standard inpatient hospital bed is 35-inches wide, whereas a “baribed” (bariatric bed) may be as wide as 60 inches.

The obese patient is at risk for complications due to weight, including risk of thromboembolism and aspiration. Intraoperative risks include complications of positioning, airway difficulties, and difficult surgical access. Postoperative complications include pulmonary and wound infection. Thromboembolism Prophylaxis The obese patient is at risk for thromboembolism due to obesity and the venous relaxation that occurs under the influence of anesthesia. Thromboembolism prophylaxis will include the use of sequential compression devices and TED compression hose, as well as the administration of low molecular weight heparin. There is some controversy about the appropriate dosing of heparin, based on actual vs ideal body weight. Unless contraindicated by the surgery, clinical evidence supports placement of the patient in a steep Trendelenburg position to help to decrease the risk of deep venous thrombosis. Prevention of thromboembolus is important to prevent the development of a postoperative pulmonary embolism, which can be fatal. Aspiration Prophylaxis As a result of the increased risk of gastroesophageal reflux disease, antacid prophylaxis is indicated prior to induction with metoclopramide (Reglan), which will increase gastric pH and increase gastric emptying as well. Intraoperative Risks The obese patient is at an increased risk for nerve palsies and paralysis due to improper positioning. It will be the responsibility of all OR staff to ensure safety in positioning and appropriate padding of extremities to prevent compression.


Management of the airway will be a major concern for the anesthesiologist. Excessive soft tissue in the airway may compromise the ability to visualize the trachea, making intubation difficult. It may be difficult to position the head and neck into proper position for intubation because of arthritis and excessive tissue. Preoxygenation will help to prevent the rapid desaturation that may occur during intubation, particularly in those patients with a history of sleep apnea and CPAP use. Obstructive sleep apnea is an important predictor of airway problems during and after intubation. Higher ventilator pressures will be required as a result of the weight of the chest. Drugs and gases administered that are absorbed by fatty tissue require increased doses and will result in unpredictable offloading and recovery. The anesthesiologist may elect to perform an awake intubation to maintain control of the airway. This will require appropriate equipment at the bedside. Regional anesthesia may seem an attractive alternative to intubation; however, success of this technique may be limited by the inability to identify landmarks for blocks. Obesity presents mechanical problems for the surgeon in terms of exposure of the surgical site, retraction of tissue, excessive blood loss, and surgical access. For example, the use of the laparoscope will be affected by the thickness and mass of the anterior abdominal wall and the distance between the lowest rib and the top of the hips. The thicker the abdominal wall, the more restricted the movement of the laparoscope and the more force required to move the scope. Joint replacements may be refused because of weight and a poor likelihood for postoperative success. Positioning in a lateral or prone position is avoided unless mandatory for the surgery because of the difficulty in maintaining adequate ventilation. Moving an unconscious patient from OR table to cart or bed is always of concern, but increasingly so with the obese patient. Injury to both the patient and to members of the health-care team is possible. Some centers have created “lift teams” with trained personnel and special transfer boards to facilitate transfer of obese patients. Frequently, these patients will be placed directly onto a hospital bed, as opposed to a PACU cart after surgery, for comfort, ease of positioning, and postoperative care. Postoperative Risks The risk of pneumonia following surgery is increased for the obese patient, especially when postsurgical bedrest is required. Incentive spirometry should be started as soon as possible to prevent atelectasis and to promote lung expansion.


The risk of postoperative wound infection also is increased as a result of the size and depth of the wound required for surgical access. These patients are at increased risk for nosocomial infections. Detection of infection may be difficult, as x-rays do not penetrate well, and extremely large patients may not fit into computed tomography or magnetic resonance imaging scanners.


CHAPTER

12

Tools Common Causes of Acid-Base Imbalance IMBALANCE

CAUSES

Respiratory acidosis

Asphyxia Respiratory depression Central nervous system depression

Respiratory alkalosis

Hyperventilation Anxiety Diabetic ketoacidosis

Metabolic acidosis

Diarrhea Renal failure Salicylate overdose (aspirin)

Metabolic alkalosis

Hypercalcemia Alkaline overdose (antacid)

313

Anatomical Landmarks Anterior View with Landmarks

Clavicle

1

Manubrium of sternum Body of sternum

2 3 4 5

Costal cartilage

6

Diaphragm

7 8

Co

Xiphoid process

stal angle

9 10

A

11

Left Lateral View with Landmarks

Scapula Clavicle

1 2

Body of sternum

3 4 5 6 7

Costal cartilage

8 9 10

C 314 Tools

Structure of the Heart Aortic arch

Left pulmonary arteries

Right pulmonary arteries

Left atrium

Superior vena cava Right pulmonary veins

Left pulmonary veins

Pulmonary semilunar valve

Aortic semilunar valve

Right atrium

Mitral (AV) valve

Tricuspid (AV) valve

Left ventricle

Inferior vena cava

Epicardium Right ventricle

Myocardium Interventricular septum Thoracic aorta

Abdominal Organs and Structures

Liver

Spleen Stomach

Gallbladder

Transverse colon

Small intestine Descending colon Ascending colon Appendix Urinary bladder

Tools 315

Internal Female Genitalia FaFallopian tube Ovary

Peritoneal cavity

Rectum

Uterus Bladder Symphysis pubis

Posterior fornix of vagina

Urethra

Cervix Anterior fornix of vagina

Clitoris Labia majora

Labia minora

Vagina

Anus

Internal Male Genitalia Urinary bladder

Rectum Ampulla of ductus deferens

Ductus deferens

Seminal vesicle

Urethra Corpus cavernosum

Prostate

Corpus spongiosum

Anus

Anus

Glans penis

Testicle Scrotum

316 Tools

Bulbourethral gland Epididymis

Cross-section of Musculoskeletal System

Bones

Muscles

Bones

Muscles

Cranium

Cranium Facial muscles

Maxilla Mandible

Sternocleidomastoid

Acromion Trapezoids process Pectoralis major Vertebrae:

Clavicle Scapula

Deltoid Ribs

Trapezoids

Deltoid

Cervical Triceps brachii Latissimus dorsi

Thoracic

Biceps Lumbar brachii Rectus abdominis

Humerus Iliac crest

Extensor carpi radialis

Brachioradialis

Radius

Sacrum Rectus femoris

Ulna

Carpals Metacarpals Phalanges

Femur

Gluteus maximus

Ischium

Biceps femoris

Sartorius Vastus medialis

Patella

Fibula

Fibula

Tibia

Tibia

Gastrocnemius

Achilles tendon

Tarsals Metatarsals Phalanges

Calcaneus

Anterior

Posterior

Tools 317

Lobes of the Brain Lateral fissure

Central fissure

Broca’s area

Emotion Behavior Intellect Motor Speech

Mot or c orte x Som cort atosen ex sory

Frontal lobe

Hearing Smell Taste

Parietal lobe

Sensation

Speech comprehension

Wernicke’s area Transverse fissure

Visual perception Coordination Equilibrium Balance

Occipital lobe Cerebellum

Temporal lobe

318 Tools

Origin of Cranial Nerves Ophthalmic division Maxillary division I Olfactory

Mandibular division

IV Trochlear V Trigeminal VI Abducens

II Optic III Oculomotor

VII Facial

VIII Acoustic Vestibular nerve Cochlear nerve IX Glossopharyngeal

X Vagus

XI Spinal accessory XII Hypoglossal

Sensory nerves Motor nerves

Tools 319

General Chemistry Note: Reference ranges vary according to brand of laboratory assay materials used. Check normal reference ranges from your facility’s laboratory when evaluating results. LAB

CONVENTIONAL

SI UNITS

Albumin

3.5–5.0 g/100 mL

35–50 g/L

13–39 U/L, infants and adolescents up to 104 U/L

217–650 nmol · sec–1/L, up to 1.26 μmol/L

Ammonia

12–55 μmol/L

12–55 μmol/L

Amylase

4–25 units/mL

4–25 arb. unit

Anion gap

8–16 mEq/L

8–16 mmol/L

AST, SGOT

Male: 8–46 U/L

0.14–0.78 μkat/L

Female: 7–34 U/L

0.12–0.58 μkat/L

Bilirubin, direct

up to 0.4 mg/100 mL

Up to 7 μmol/L

Bilirubin, total

up to 1.0 mg/100 mL

Up to 17 μmol/L

BUN

8–25 mg/100 mL

2.9–8.9 mmol/L

Calcitonin

Male: 0–14 pg/mL

0–4.1 pmol/L

Female: 0–28 pg/mL

0–8.2 pmol/L

8.5–10.5 mg/100 mL

2.1–2.6 mmol/L

4.25–5.25 mg/dL

1.1–1.3 mmol/L

24–30 mEq/L

24–30 mmol/L

100–106 mEq/L

100–106 mmol/L

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