What are the specialties with the highest patient loads

Surgical suite

• A controlled environment designed to minimize the spread of infectious organisms and allow a smooth flow of patients, staff, and equipment needed to provide safe patient care.
• The suite is divided into three distinct areas: the unrestricted, semirestricted, and restricted areas.
• Unrestricted area- Where people in street clothes can interact with those in scrub clothing.
• Semirestricted area- Surrounding support areas and corridors. Only authorized staff are allowed access to the semirestricted areas.
• Restricted area- Masks are required to supplement surgical attire. The restricted area can include the ORs, scrub sink areas, and clean core.

Holding area

• Also called preoperative holding area.
• Is a special waiting area inside of or adjacent to the surgical suite.
• The nurse identifies and assesses the patient before transferring the patient to the OR.

Surgical Care Improvement Project (SCIP)

Admission, observation, and discharge (AOD) area

Perioperative nurse

• A registered nurse who implements patient care during the perioperative period based on the nursing process.
• Prepares the OR for patients before they arrive.
• Serves in the role of circulating nurse when not scrubbed, gowned and gloved and remains in the unsterile field.
• Serves in the role of scrub nurse when following the desgnated scrub procedure, is gowned and gloved in sterile attire, and remains in the sterile field.
• Nurse in circulating role collaborates with scrub nurse and records all nursing care.

Surgeons responsibilities

1. Preoperative medical history and physical assessment, including need for surgical intervention, choice of surgical procedure, management or preoperative testing, and discussion of the risks of and alternatives to surgical intervention.
2. Patient safety and management in the OR.
3. Postoperative management of the patient.

Registered nurse first assisstant (RNFA)

• Works in collaboration with the surgeon to produce an optimal surgical outcome for the patient.
• The Association os periOperative Registered Nurses (AORN) states that the perioperative nurse must have formal education for this role and works collaboratively with the surgeon, patient, and surgical team by handling tissue, using instruments, providing exposure to the surgical site, assisting with hemostasis, and suturing.

Anesthesia care provider (ACP)

• One who administers anesthesia and can be an anesthesiologist or a nurse anesthetist.
• ACPs who are anesthesiologists are resposible for administering anesthetic agents to relieve pain and manage vital life functions (e.g., breathing, heart rhythm, blood pressure [BP]) during surgery.

Anesthesiology

• A discipline within the practice of medicine specializing in the following:

1. Medical management of patients who are rendered unconscious and/or insensible to pain and emotional stress during surgical and other medical procedures.
2. Protection of life functions and vital organs under the stress of anesthetic, surgical, or other medical procedures.
3. Management of pain.
4. Management of cardiopulmonary resuscitation.
5. Management of problems in pulmonary care.
6. Management of critically ill patients in secial care units.

Nurse anesthetist

• A registered nurse who has graduated from an accredited nurse anesthesia program (minimally a master's degree program) and successfully competed a national certification examination to become a certified registered nurse anesthetist (CRNA).
• CRNA scope of practice includes, but is not limited to:
1. Performing and documenting a peranesthetic assessment and evaluation.
2. Developing and implementing a plan for delivering anesthesia.
3. Selecting and initiating the planned anesthetic technique.
4. Selecting, obtaining, and administering the anesthesia, adjuvant drugs, and fluids.
5. Selecting, applying, and inserting appropriate noninvasive and invasive monitoring devices.
6. Managing a patient's airway and pulmonary status.
7. Managing emergence and recovery from anesthesia.
8. Releasing or discharging patients from a postanesthesia care area.
9. Ordering, initiating, or modifying pain relief therapy.
10. Responding to emergency situations by providing airway management, administering emergency fluids, and/or administering emergency drugs.
11. Additional responsibilities within the expertise of the individual.

Psychosocial/cultural assessment 

• Jehovah's Witness community may refuse blood transfusions.
• For Muslims, the left hand is considered unclean, so the right hand should be used to give forms, drugs, and treatments.
• Some Native American patients may request that surgically removed body tissue be preserved so that it may be ritually buried.

When can prophylactic antibiotics be startedprior to surgical incision

Lithotomy position

• Involves the positioning of an individuals feet above or at the same level as the hips (often in stirrups), with the perinium positioned at the edge of an examination table.
• Is used for some types of pelvic organ surgery (e.g., vaginal hysterectomy).

Anesthesia

• Bispectral index monitor allows ACPs to track the level of patient awareness (i.e., awareness monitoring) during the surgery.
• Regional anesthetics (some with indwelling catheters for postoperative pain control) facilitates the transition from inpatient recovery to eary discharge.
• ACPs effectively use a mode of delvery described as monitored anesthesia care (MAC) that facilitates early discharge to home.
• An absolute contraindication of any anesthetic technique or agent is patient refusal.

ASA anesthesia classifications

• General anesthesia
• Regional anesthesia
• Local anesthesia
• MAC
• Local or regional anesthesia with MAC is often used for procedures performed outside of the OR.
• Only registered nurses who receive education and training in MAC and are permitted by institutional protocols and state nurse practice acts can administer this type of anesthesia. It is administered by the nurse under the direct supervision of a physician.

Total intravenous anesthesia (TIVA) and newer inhalation agents

General anesthesia

• Technique of choice for patients who are having surgical procedures that are of significant duration, require skeletal muscle relaxation, require uncomfortable operative positions because of the location of the incision site, or require control of respiration.
• Additional reasons for use include refusal of local or regional techniques; and uncooperative patients secondary to intoxication, lack of maturity, emotional liability, head injury, or inability to remain immobile for any length of time.
• May be induced intravenously or by inhalation
• A balanced technique, using adjunctive drugs to complement the induction, is the most common approach used for general anesthesia.
• Anticipated effects:
• Loss of sensation with loss of consciousness.
• Combination of hypnosis, analgesia, and amnesia.
• Skeletal muscle relaxation.
• Possible impaired ventilatory and cardiovascular function.
• Elimination of coughing, gagging, vomiting, and sympathetic nervous system responsiveness.

Anticipated effects of regional anesthesia

• Loss of sensation to a region of body without loss of consciousness.
• Involves blocking a specific nerve or group of nerves with administration of a local anesthetic.
• Includes spinal, caudal, and epidural anesthesia and IV and peripheral nerve blocks (e.g., interscalene, axillary, infraclavicular/ supraclavicular, popliteal, femoral, sciatic).

Anticipated effects of Local anesthesia

• Loss of sensation without loss of consciousness.
• Induced topically or via infiltration, intracutaneously, or subcutaneously.
• Topical applications may be aerosolized or nebulized.

Anticipated effects of monitored anesthesia care (MAC)

• Similar to general anesthesia, sedatives (e.g., benzodiazepines) and opioids are used but at a lower dosage; does not involve inhalation agents.
• Relieves anxiety, provides analgesia and amnesia.
• Patients remain responsive and breathe without assisstance.
• May be used in conjunction with regional or local anesthesia.
• Often used for minor surgical procedures and diagnostic procedures (e.g., colonoscopy).

Intravenous general anesthetics

• A single dose lasts only a few minutes, which is long enough for a laryngeal mask airway (LMA) or an endotracheal tube to be placed. Once this is done, the ACP introduces the selected inhalation and IV agent(s).
• All medications are delivered intravenously in TIVA, thus eliminating the need for inhalation agents.

Inhalation general anesthetics

• Enter the body through the alveoli in the lungs.
• Ease of administration and rapid excretion by ventilation make them desirable agents.
• One undesirable characteristic is the irritating effect of inhalation agents on the repiratory tract.
• Once the patient has been induced with an IV agent, the choice for delivering inhalation agents is usually through an endotracheal tube or LMA. The endotracheal tube permits control of ventilation and airway protection, both for patency and to prevent aspiration.

Adjuncts to general anesthesia

• Drugs added to an inhalation anesthetic (other than an IV induction agent) are termed adjuncts.
• These agents are added to the anesthetic regimen specifically to achieve unconsciousness, analgesia, amnesia, muscle relaxation, or autonomic nervous system control.
• Adjuncts include opiods, benzodiazepines, neuromuscular blocking agents (muscle relaxants), and antiemetics.
• May have synergistic or antagonistic effects.

Preinduction phase of anesthesia

• Description: Time period starting with preoperative medication, initiation of IV/arterial access, application of monitiors (e.g., ECG).
• ACP role:
• Preanesthetic assessment.
• Determination of final anesthetic care plan.
• Application and monitoring of IV/arterial access.
• Confirmation of antibiotic prophylaxis
• Role of perioperative nurse related to anesthesia:
• Completion of preoperative assessment.
• Check and confirm operative permits.
• Complete "time-out" for patient identification and confirmation of correct procedure and site.
• Anticipated classes of drugs to be used:
• Benzodiazepines
• Opioids
• Antibiotics
• Aspiration prophylaxis:
• H2-receptor blockers (e.g., ranitidine [Zantac]).
• Gastric motility agents (e.g., metoclopramide [Reglan])
• Anticholinergics (e.g., scopolamine [Transderm-Scop])

Induction phase of general anesthesia

• Description: Initiation of medications that render patient unconscious, airway secured with airway assist devices.
• ACP role:
• Administration of appropriate drugs.
• Securing airway.
• Appropriate positioning for surgical procedure.
• Role of perioperative nurse related to anesthesia:
• Assist with application of monitors (noninvasive and invasive).
• Assist with airway management.
• Anticipated classes of drugs to be used:
• Benzodiazepines
• Opioids
• Barbiturates
• Hypnotics
• Volatile gases

Maintenance phase of general anesthesia

• Description: Time period during which surgical procedure id performed; patient remains in an unconscious state with measures to ensure safety of airway.
• ACP role:
• Monitor physiologic status of patient.
• Administer medications and titrate fluids as appropriate.
• Role of perioperative nurse related to anesthesia:
• Adjust patient position as necessary.
• monitor patient safety.
• Anticipated classes of drugs to be used:
• Benzodiazepines
• Opioids
• Barbiturates
• Hypnotics
• Volatile gases

Emergence phase of general anesthesia

• Description: Time period during which surgical procedure is completed; patient is prepared for return to consciousness and removal of airway asisst devices.
• ACP role:
• Reversal of residual neuromuscular blocking agents.
• Assessment for return of all protective reflexes.
• Removal of airway asisst devices.
• Assessment of pain and appropriate assignment of recovery.
• Role of perioperative nurse related to anesthesia:
• Asisst in placement of dressing.
• Protection of patient during full return of reflexes.
• Prepare patient for movement to PACU.
• Anticipated classes of drugs to be used:
• Reversal agents:
• Anticholinergics
• Anticholinesterases
• Sympathomimetics
• Opioid antagonists (prn)
• Benzodiazepine antagonists (prn)
• Supplemental opioids (prn)
• Antiemetics (prn)

Dissociative anesthesia

• Interrupts associative brain pathways while blocking sensory pathways.
• Patient may appear catatonic, is amnesic, and experiences profound analgesia that lasts into the postoperative period.
• Ketamine (Ketalar) is a commonly administered dissociative anesthetic.
• A potent analgesic and amnesic.
• Is used in asthmatic patients undergoing surgery because it promotes bronchodilation and in trauma patients requiring surgery because it increases heart rate and helps maintain cardiac output.
• May cause hallucinations and nightmares, greatly limiting its usefulness.

Local anesthesia

• Interrupts the generation of nerve impulses by altering the flow of sodium into nerve cells through cell membranes.
• Volume and concentration of the local anesthetic agent will, in accelerating fashion, first block autonomic, then somatic sensory, and, last, somatic motor impulses.
• The result is autonomic nervous system blockade, anesthesia, and skeletal muscle flaccidity or paralysis.
• Local anesthetics are topical, opthalmic, nebulized, or injectable.

Regional anesthesia (or block)

• Using a local anesthetic is always injected and involves a central nerve (e.g., spinal) or group of nerves (e.g., plexus) that innervate a site remote to the point of injection.
• Regional blocks are now used as preoperative analgesia, intraoperatively to manage surgical pain, and postoperatively to control pain.
• Indwelling catheters that deliver local anesthetic via a pump to the surgical site may be implanted before patient emergence in order to deliver continuous pain relief up to 72 hours postoperatively.
• Many patients report "allerigies to local anesthetics. Although true allergies to local anesthetics occur, they are rare. Allergies are likely to be a result of additives or preservatives in the preparation.
• Two classes of local anesthetics are esters and amides. highly unlikely that an individual is allergic to both.

Spinal anesthesia

• Spinal anesthesia and epidural anesthesia are also types of regional anesthesia.
• Spinal involves the injection of a local anesthetic into the cerebrospinal fluid found in the subarachnoid space, usually below the level of L2. The local anesthetic mixes with cerebrospinal fluid and, depending on the exten of its spread, varius levels of anesthesia are achieved.
• Because the local anesthetic is administered directly into the cerebrospinal fluid, a spinal anesthetic produces an autonomic, sensory, and motor blockade.
• Patents experience vasodilation and may become hypotensive as a result of the autonomic block, feel no pain as a result of the sensory block, and are unable to move as a result of the motor block.

Epidural anesthesia (block)

• Involves injection of a local anesthetic into the epidural (extradural) space via a thoracic or lumbar approach. The anesthetic agent does not enter the cerebrospinal fluid but works by binding to nerve roots as they enter and exit the spinal cord.
• By using a low concentration of local anesthetic, sensory pathways are blocked but motor fibers remain intact. In higher doses, both sensory and motor fibers are blocked.
• May be used as the sole anesthetic for a surgical procedure, or a catheter may be placed to allow for intraoperative use with continued use into the postoperative period to provide analgesia.
• Onset of spinal anesthesia is more rapid than epidural anesthesia.
• Patient must be closely observed for signs of autonomic nervous system blockade, including hypotension, bradycardia, nausea, and vomiting.
• There is less autonomic nervous system blockade with epidural anesthesia than with spinal anesthesia.
• If "too high" a block is achieved, patient may experience inadequate breathing and apnea.
• Other complications of spinal or epidural anesthesia include postdural puncture headache, back pain, isolated nerve injury, and meningitis.

Anaphylactic reactions

• Cause hypotension, tachycardia, bronchospasm, and possibly pulmonary edema.
• Antibiotics and latex are responsible for many perioperative allergic reactions.

Malignant hyperthermia (MH)

• A rare disorder characterized by hyperthermia with rigidity of skeletal muscles that can result in death.
• Succinylcholine (Anectine), especially when given with volatile inhalation agents, appears to be the primary trigger of the disorder.
• Is usually during general anesthesia, but may manifest in the recovery period as well.
• Is an autosomal dominant trait but is variable in its genetic manifestation, so predictions based on family history are important but not reliable.
• The fundamental defect is hypermetabolism of skeletal muscle resulting from altered control of intacellular calcium. This leads to muscle contracture, hyperthermia, lactic acidosis, and hemodynamic and cardiac alterations.
• Tachycardia, tachypnea, hypercarbia, and ventricular dysrhythmias are generally seen but are nonspecific to MH.
• MH is generally diagnosed after all other causes of the hypermetabolism are ruled out. The rise in body temperature is not an early sign of MH.
• MH can result in cardiac arrest and death. 
• The definitive treatment of MH is prompt administration of Dantrolene (Dantrium). Dantrolene slows metabolism, reduces muscle contraction, and mediates the catabolic processes associated with MH.

New and future considerations

• The use of hypothermia, or the deliberate lowering of body temperature, decreases metabolism. This, in turn, reduces both the demand for oxygen and anesthetic requirements. Neurosurgery and selected trauma surgery benefit from this approach.
• Transesophageal echocardiography (TEE) is used intraoperatively to assess ventricular function and competency of heart valves and to recognize venous air embolism.
• TEE is less invasive, inexpensive, and associated with few complications. It is quickly replacing the use of pulmonary artery catheter during surgery to assess hemodynamics.
• Ultrasonic guided regional anesthesia refers to the technique of visualizing a nerve or plexus of nerves using ultrasound to place a regional block with more accuracy.

Telesurgery