NLE Perioperative & Pain Nursing — Preoperative and Intraoperative NursingStudy Notes

Surgery is categorized along two primary dimensions: urgency and purpose, each affecting preoperative preparation and risk management. **By Urgency:** - **Emergent Surgery**: Life-threatening conditions requiring immediate intervention (within minutes to hours). Examples include ruptured abdominal aortic aneurysm, tension pneumothorax, or massive hemorrhage. The preoperative period is abbreviated; focus is on stabilization and rapid consent. - **Urgent Surgery**: Significant pathology requiring intervention within 24–48 hours. Examples include acute appendicitis, bowel obstruction, or acute cholecystitis. Preoperative workup is compressed but systematic. - **Elective Surgery**: Planned, non-emergent procedures scheduled in advance. Examples include cataract repair, hernia repair, or joint replacement. Full preoperative assessment and patient education are standard. - **Optional Surgery**: Procedures performed at the patient's preference, not medically necessary. Examples include cosmetic surgery or elective weight-loss surgery. The patient has autonomy to defer or decline. **By Purpose:** - **Diagnostic**: Procedures to obtain tissue or imaging (biopsy, laparoscopy, colonoscopy). - **Curative/Ablative**: Removal of diseased structures (appendectomy, mastectomy, nephrectomy). - **Palliative**: Relief of symptoms in terminal or advanced disease (nerve blocks, bypass for pain relief). - **Reconstructive**: Restoring form and function after trauma or disease (plastic and reconstructive surgery). - **Cosmetic**: Aesthetic improvement (face lift, rhinoplasty). **By Risk:** - **Major Surgery**: Involves large incisions, significant tissue trauma, high blood loss risk, or prolonged anesthesia (e.g., open abdominal, thoracic, or vascular surgery). Higher risk of complications. - **Minor Surgery**: Limited tissue trauma, short anesthesia, low blood loss risk (e.g., removal of skin lesion, cyst aspiration). Lower complication risk.

Preoperative assessment is a systematic NCM Level II nursing activity that identifies factors increasing surgical risk and guides interventions to optimize the patient for surgery. The goal is to reduce morbidity and mortality. **Comprehensive History and Physical Examination:** Obtain: - Chief complaint and surgical indication - Past medical history (PMH): chronic diseases, previous surgeries, anesthesia exposure - Past surgical history: previous anesthesia reactions, complications - Medications: prescription, over-the-counter, herbal supplements, and anticoagulants—clarify what will be held or continued - Allergies: medications (especially antibiotics and anesthetics), latex, iodine, foods (for cross-reactivity) - **Family history of malignant hyperthermia or adverse anesthesia reactions**—this is a critical safety screening question - Social history: smoking, alcohol, substance use (affect healing, airway risk, and drug interactions) - Review of systems: cardiopulmonary, gastrointestinal, endocrine, renal, hepatic, neurological - Vital signs and baseline physical exam **Factors Increasing Surgical Risk:** 1. **Age**: Extremes of age (very young, very old) have reduced physiologic reserve. Older adults have: - Decreased cardiac output and increased risk of arrhythmias - Reduced pulmonary function and airway reflexes - Slower drug metabolism (increased anesthetic effect) - Increased bleeding tendency - Higher infection and wound complication risk 2. **Obesity** (BMI ≥ 30 kg/m²): - Increased anesthetic requirement and altered drug distribution - Airway management difficulty; aspiration risk - Impaired wound healing; increased infection (seroma, dehiscence) - Thromboembolic risk (DVT/PE) - Intraoperative positioning challenges; nerve injury risk - Prolonged recovery and pain management complexity 3. **Malnutrition**: - Depleted protein stores impair wound healing and immune function - Vitamin C deficiency impairs collagen synthesis - Delayed wound healing and increased infection risk - Poor muscle tone and delayed ambulation 4. **Chronic Diseases**: - **Cardiovascular disease** (HTN, CAD, CHF, arrhythmia): increased risk of MI, arrhythmia, heart failure, and unstable hemodynamics intraoperatively - **Uncontrolled diabetes**: Hyperglycemia impairs wound healing, increases infection risk, and affects glucose homeostasis under anesthesia; hypoglycemia is a crisis. Requires perioperative glucose monitoring and insulin adjustment - **Renal disease**: Impaired drug clearance, electrolyte abnormalities, bleeding (uremic platelet dysfunction), and fluid overload - **Hepatic disease**: Impaired drug metabolism, coagulopathy, hypoglycemia risk, and encephalopathy - **Respiratory disease** (COPD, asthma, sleep apnea): Airway obstruction, hypoxemia, delayed extubation, and bronchospasm risk 5. **Smoking**: - Impairs oxygenation and CO uptake (carboxyhemoglobin) - Impairs wound healing and increases infection risk - Increases airway irritability and sputum production - Increases thromboembolic risk 6. **Fluid, Electrolyte, and Coagulation Abnormalities**: - Dehydration, hypovolemia: Hemodynamic instability intraoperatively - Hypokalemia, hyponatremia: Arrhythmias and altered anesthetic response - Coagulopathy (INR > 1.5, PTT prolonged, platelet count < 50,000): Bleeding risk; may require correction 7. **Medications**: - **Anticoagulants** (warfarin, DOACs, heparin): Bleeding risk; hold timing per protocol - **Antiplatelets** (aspirin, clopidogrel): Bleeding risk; hold per protocol (often 5–7 days) - **Corticosteroids** (chronic use): Delayed healing, increased infection risk, adrenal suppression (may need stress-dose steroids perioperatively) - **Herbs** (ginkgo, garlic, ginseng, vitamin E): Increased bleeding - **ACE inhibitors, beta-blockers**: Continue or hold per anesthesia protocol - **Oral hypoglycemics, insulin**: Adjust or hold per protocol **Baseline Diagnostics (per institutional protocol and anesthesia guidelines):** - **CBC**: Baseline hemoglobin (assess anemia), WBC (infection risk), platelets (bleeding) - **Electrolytes**: Identify hypokalemia, hyponatremia, or hyperkalemia - **Renal function**: BUN, creatinine (guide fluid management and drug dosing) - **Liver function**: AST, ALT, bilirubin (assess hepatic reserve) - **Coagulation studies**: PT/INR, PTT (assess bleeding risk; correct if abnormal) - **Blood type and crossmatch**: For procedures with anticipated blood loss - **ECG**: Especially for patients > 40 years, cardiac disease, or significant risk factors - **Chest X-ray**: Patients with respiratory disease, cardiac disease, or age > 50 (baseline) - **Pregnancy test**: For reproductive-age females (teratogenic risk) **Managing Chronic Conditions Perioperatively:** - **Diabetes**: Goal is glucose 100–180 mg/dL (180–280 mg/dL on day of surgery per some protocols). Long-acting oral agents (e.g., metformin, glipizide XL) and most oral hypoglycemics are held the morning of surgery. Insulin-dependent patients: short-acting insulin is held; long-acting insulin may be reduced by half or held per protocol; a dextrose IV is started to maintain glucose and prevent hypoglycemia. Glucose is checked intraoperatively and postoperatively. - **Anticoagulants and Antiplatelets**: Warfarin is typically held 3–5 days preoperatively; aspirin and NSAIDs are held 5–7 days. For urgent procedures, fresh frozen plasma or vitamin K may be given. DOACs (dabigatran, apixaban, rivaroxaban) have shorter half-lives but are often held 24–48 hours. Always verify the surgical team's protocol. - **Corticosteroid-Dependent Patients**: Chronic steroid use suppresses the adrenal axis. To prevent an intraoperative adrenal crisis, stress-dose steroids are given (e.g., hydrocortisone 50 mg IV before induction, then 25 mg IV every 8 hours × 24 hours postop, then taper back to baseline). - **Medication Reconciliation**: A core NLE competency. Clarify each hold/continue order with the surgical team. Document clearly on the chart and communicate to all team members.

Informed consent is a foundational ethical and legal requirement that protects patient autonomy, self-determination, and the right to make medical decisions. Under RA 9173 (Philippine Nursing Act of 2002) and Philippine bioethics frameworks, informed consent is mandatory for all elective procedures. **Components of Valid Informed Consent:** 1. **Disclosure**: The surgeon explains the procedure, its purpose, benefits, material risks (including serious or common complications), and alternatives (including non-surgical options). 2. **Comprehension**: The patient understands the information at a level appropriate to their literacy and language. 3. **Voluntary**: The consent is free of coercion, undue influence, or duress. 4. **Competence**: The patient is mentally capable of making the decision (alert, oriented, no cognitive impairment, not under the influence of sedatives). 5. **Authorization**: The patient (or legal surrogate) provides written signature on the consent form. **Obtaining Consent: Surgeon's Responsibility** The **surgeon (physician performing the procedure)**, not the nurse, is legally responsible for obtaining informed consent and explaining the procedure, risks, benefits, and alternatives. This is a core physician responsibility that cannot be delegated. **The Nurse's Pivotal Consent Role:** The nurse's role in informed consent is **not to explain the procedure** (which invites liability if explanations differ from the surgeon's) but to: 1. **Witness the signature** on the consent form. 2. **Verify that the consent is signed voluntarily**, without pressure or coercion. 3. **Confirm the patient appears to understand** the procedure and risks (ask: "Do you have any questions about what the doctor explained?" or "Can you tell me what procedure you are having?"). 4. **Ensure the form is complete**: signed by the patient or legal surrogate, dated, and witnessed; includes the procedure name and site; and is in the medical record before sedation. 5. **Notify the surgeon immediately** if the patient expresses: - Misunderstanding or confusion about the procedure, risks, or alternatives - New questions or concerns - Desire to withdraw consent or request additional time to decide - Language or literacy barriers requiring interpreter or simplified materials **Critical Timing and Competence:** - Consent must be signed **before premedication with sedatives or analgesics**. A consent signed after sedation is **invalid** and unenforceable because the patient was not competent (alert, oriented). - If a patient is premedicated before the nurse verifies consent, the nurse must alert the surgical team immediately. **Special Consent Situations:** 1. **Minors (Age < 18 years or < 21 in some jurisdictions)**: - A legal parent or guardian (not a minor sibling) signs consent. - Exceptions: Emancipated minors, minors seeking reproductive or STI care (per provincial law), or life-threatening emergency. 2. **Patients Unable to Provide Consent** (unconscious, severely cognitively impaired, or legally incompetent): - A legal surrogate (spouse, adult child, parent, or court-appointed guardian) signs. - Order of surrogate authority varies by jurisdiction; check Philippine Family Code and institutional policy. 3. **Life-Threatening Emergency Without Available Surrogate**: - **Implied consent**: The law presumes a reasonable person would consent to life-saving treatment. The procedure may proceed without written consent if documented as an emergency. - Obtain surrogate consent as soon as possible after stabilization. 4. **Refusal of Treatment or Specific Interventions**: - A competent patient has the right to refuse treatment or specific interventions (e.g., blood transfusion in Jehovah's Witnesses). - The nurse documents the refusal clearly, notifies the surgeon and anesthesia team, and discusses alternatives and risks of refusal. - A separate "refusal of treatment" form may be signed. **Consent and Latex Allergy:** If the patient reports a latex allergy, this is documented prominently, and the surgeon discusses whether a latex-free environment is feasible. Allergy is part of the consent discussion because it affects surgical planning. **Documentation:** The nurse documents: - Time and date consent was verified - Whether the form was complete and signed - Patient's apparent understanding (quotes are helpful: "Patient stated, 'The doctor explained I'm having my appendix removed because it's inflamed, and there are risks of infection and bleeding'") - Any patient concerns or questions, and whether the surgeon was notified - Signature and name/credentials of witnessing nurse

Preoperative preparation is a systematic NCM Level II nursing process that readies the patient physically and psychologically for surgery. NPO (nothing by mouth) status is a cornerstone safety intervention. **NPO Status and Aspiration Prevention:** The patient is kept NPO before surgery to reduce the risk of **aspiration of gastric contents** during anesthesia induction and maintenance. When the patient is unconscious under general anesthesia, airway reflexes (gag, cough) are abolished, and passive regurgitation of gastric contents can occur. If aspirated, the gastric acid and particulate matter damage the lungs (chemical pneumonitis or "Mendelson syndrome"), causing respiratory distress, hypoxemia, and potential death. **Standard NPO Guidelines** (per American Society of Anesthesiologists; institutional protocols may vary): - **Solid foods and milk**: NPO for approximately 6–8 hours - **Clear liquids** (water, black coffee, apple juice, clear broth): NPO for approximately 2 hours - **Infant feeding**: Breast milk 4 hours, formula 6 hours **Key NPO Management Actions:** 1. **Verify and maintain NPO status**: Ask the patient directly, check the chart for the NPO order, and post NPO signs above the bed and on the chart. 2. **Remove water pitcher and cup** from the bedside; instruct patient, family, and visitors not to offer food or drink. 3. **Report any intake** (food, drink, even gum or mints) immediately to the surgeon and anesthesia team; NPO violation may necessitate procedure delay (risk of aspiration). 4. **Clarify routine medications**: - Many cardiac, antihypertensive, and antiseizure medications are taken with a small sip of water (typically ≤ 30 mL) per anesthesia protocol. - Oral hypoglycemics and metformin are usually held. - Insulin is held; a dextrose IV is started intraoperatively. - Verify the surgical team's specific NPO and medication orders. 5. **Communicate NPO status** at shift handoff and to all team members. **Preoperative Checklist and Physical Preparation:** A comprehensive preoperative checklist ensures all preparatory steps are completed and documented. Below are the essential items: 1. **Patient Identification and Verification** (critical for preventing wrong-site, wrong-patient surgery): - Verify identity using **two identifiers** (name and date of birth, or name and medical record number; not room number). - Check that the identification band is secure and legible. - Confirm the **correct surgical procedure and site**. - **Mark the surgical site** with an indelible pen; the surgeon (or per institutional protocol, the surgeon with the patient) marks the incision site. This is a WHO Surgical Safety Checklist step. 2. **Consent and Documentation**: - Verify the **signed informed consent form is on the chart**. - Confirm laboratory results (CBC, electrolytes, coagulation, blood type, pregnancy test, ECG, imaging) are available and reviewed by the surgical team. - Note any **abnormal lab values** and whether the surgeon has addressed them. 3. **Vital Signs**: - Obtain **baseline blood pressure, heart rate, respiratory rate, temperature, and oxygen saturation**. - Report any abnormalities (e.g., fever, tachycardia, hypotension) to the surgical and anesthesia teams. 4. **Bladder Emptying**: - Have the patient **void** (urinate) before premedication to empty the bladder. A full bladder increases risk of bladder injury during abdominal surgery and discomfort in recovery. If the patient cannot void, a catheter may be inserted per order. 5. **Removal of Personal Items and Valuables**: - Instruct the patient to remove all jewelry (including body piercings), watches, and valuables. These are locked in a safe or given to family to prevent loss or intraoperative injury. - Document items and their disposition in the chart. 6. **Removal of Prostheses and Dental Appliances**: - **Dentures, removable bridges**: Remove and place in a labeled container with the patient's name. Dentures can be aspirated or damaged intraoperatively. - **Contact lenses**: Remove and store safely; the anesthetized patient cannot protect their eyes. - **Hearing aids**: Remove; they may be damaged or lost. - **Prosthetic limbs or eyes**: Remove and store securely. - **Hairpins, wigs, and hairpieces**: Remove to access the head during anesthesia and allow assessment of scalp. 7. **Nail Polish, Makeup, and Nail Bed Assessment**: - **Remove nail polish** from at least one finger on each hand (ideally the index or middle finger). Under general anesthesia, the anesthesia provider needs to see the **nail beds to assess peripheral perfusion and oxygenation status**. Nail beds normally pink turn pale or cyanotic if oxygenation is compromised. Nail polish obscures this critical assessment. - **Remove makeup**: This allows assessment of the patient's color and any skin changes; makeup can enter the eyes or respiratory tract. 8. **Hair Removal** (if ordered): - Hair is **clipped (not shaved)** if it interferes with the surgical site. Shaving causes microabrasions that increase infection risk; clipping is safer. Clipping is done immediately before surgery (in the OR if not done preoperatively). - Instruct the patient not to shave the surgical area themselves; risk of cuts. 9. **Skin Preparation**: - The patient is instructed to shower or bathe with an antimicrobial soap the evening before or the morning of surgery (per protocol) to reduce skin flora. - Some institutions use preoperative chlorhexidine or povidone-iodine wipes. 10. **Dressing**: - Have the patient change into a hospital gown after hygiene, void, and verify NPO. - Ensure the gown is on correctly and the patient is warm and comfortable. 11. **Application of Identification Band**: - Ensure the **identification band is secure and legible** with name, date of birth, medical record number, and allergies (especially latex, drug allergies). 12. **Preoperative Medications**: - Administer medications as ordered by the anesthesia team. Common preoperative medications include: - **Sedatives** (e.g., midazolam): Reduce anxiety and promote relaxation. - **Analgesics** (e.g., fentanyl): Provide analgesia and reduce pain response to anesthesia. - **Anticholinergics** (e.g., glycopyrrolate): Reduce salivation and protect airway. - **Prophylactic antibiotics**: Given 60 minutes before incision (120 minutes for vancomycin, clindamycin) to reduce surgical site infection (SSI). - **Antiemetics** (e.g., ondansetron): Prevent postoperative nausea and vomiting. - **Proton pump inhibitors** (e.g., omeprazole): Reduce gastric acid and aspiration risk. - Document time, drug, dose, route, and patient response. - **Warn the patient** that medications will make him/her drowsy; side rails should be raised and the call bell placed within reach. 13. **Dentures and Last Void Verification**: - Confirm dentures have been removed and stored. - Confirm the patient has voided or has a catheter. - Ensure NPO status is maintained. 14. **Chart Completion**: - Ensure all charting is complete, legible, and signed. The preoperative checklist serves as a legal document. **Preoperative Teaching:** Effective preoperative teaching, conducted ideally 1–2 days before surgery when the patient is less anxious, reduces postoperative complications and anxiety. Teaching should be documented and reinforced on admission. **Teaching Topics:** 1. **What to Expect**: - A tour of the preoperative holding area, OR, and recovery room. - Explain the sequence: preoperative preparation, transfer to OR, induction, procedure, recovery. 2. **Breathing and Oxygenation**: - **Deep breathing and coughing**: Teach the patient to take deep breaths (in through the nose, out through the mouth) 5–10 times, hold, and cough forcefully. This expands collapsed alveoli, mobilizes secretions, and prevents atelectasis and pneumonia. - **Incentive spirometry**: Teach use of the spirometer to encourage deep breathing; goal is to use it every 1–2 hours postoperatively. 3. **Pain Management**: - Explain that pain is expected after surgery but is manageable. - Teach **splinting of the incision**: Hold a pillow against the incision, hug it, or press it while coughing or moving to reduce pain and protect the incision. This increases patient comfort and mobility. - Discuss pain medication options: PCA (patient-controlled analgesia), IM injections, or oral medication; reassure the patient that requesting pain relief is appropriate and will not create addiction. 4. **Leg Exercises and Early Ambulation**: - Teach ankle pumps (plantarflex and dorsiflex the foot 10–20 times each): Calf muscle contraction promotes venous return and reduces DVT risk. - Teach leg raises (lift the leg while lying flat): Strengthens legs for early ambulation. - Teach hip and knee flexion/extension: Promotes circulation. - Explain that early ambulation (within 4–24 hours postop, per surgeon's order) prevents blood clots, atelectasis, and stiffness. 5. **Drain and Tube Management**: - If drains or tubes (NG tube, urinary catheter, chest tube) are anticipated, show the patient examples, explain their purpose (e.g., NG tube removes gastric fluid to prevent distention; chest tube drains air/fluid after thoracic surgery; catheter collects urine while catheterized), and reassure them. 6. **Turning and Positioning**: - Teach the patient to turn in bed every 2 hours postoperatively to prevent pressure injury and promote circulation. 7. **Psychological Preparation**: - Allow time for questions and concerns. - Validate fears and anxiety. - Provide spiritual support if desired (offer chaplain or pastoral care; respect religious practices and restrictions). - Use simple, clear language; avoid medical jargon. - Provide written materials in the patient's language. **Preoperative Teaching Effectiveness:** Research shows preoperative teaching reduces postoperative pain perception, reduces use of analgesics, shortens hospital stay, reduces anxiety, and improves patient satisfaction.

Anesthesia is the controlled, reversible suppression of consciousness and sensation to allow painless surgery. The anesthesia provider (anesthesiologist or nurse anesthetist) selects the type and agents based on the procedure, patient risk, and institutional protocols. **General Anesthesia:** General anesthesia produces a triad of effects: 1. **Loss of consciousness** (hypnosis) 2. **Analgesia** (pain relief) 3. **Muscle relaxation** (to facilitate airway management and surgical access) 4. (Some add amnesia as a fourth component) General anesthesia is achieved with a combination of: - **Induction agents** (IV): Propofol, sodium thiopental, etomidate, ketamine—produce rapid unconsciousness - **Inhalational agents** (maintenance): Isoflurane, sevoflurane, desflurane—maintain anesthesia - **Opioids** (IV): Fentanyl, remifentanil—provide intraoperative analgesia - **Neuromuscular blockers** (paralytics, IV): Succinylcholine (depolarizing), rocuronium, vecuronium (non-depolarizing)—cause muscle relaxation to enable intubation and ventilation **Airway Management in General Anesthesia:** The airway is secured to prevent aspiration and ensure ventilation: - **Endotracheal (ET) tube**: A cuffed tube placed through the mouth into the trachea; most common for major surgery and procedures lasting > 30 minutes. Allows complete airway control and mechanical ventilation. - **Laryngeal mask airway (LMA)**: A supraglottic device with a cuff that sits over the larynx; used for shorter procedures and patients with difficult airways. Does not protect fully against aspiration. - **Bag-mask ventilation**: Manual ventilation used during induction and emergence if intubation is delayed or refused. **Complications of General Anesthesia:** 1. **Airway complications**: - Difficulty with intubation (due to anatomic features, obesity, cervical spine pathology) - Aspiration of gastric contents (prevented by NPO, cricoid pressure, rapid sequence intubation) - Airway obstruction post-extubation (laryngeal edema, sore throat) 2. **Respiratory complications**: - Hypoventilation, hypoxemia - Atelectasis (collapsed alveoli) - Bronchospasm (especially in asthmatics or COPD) - Delayed emergence (prolonged sedation) 3. **Cardiovascular complications**: - Hypotension (from anesthetic agents, blood loss, anesthesia-induced vasodilation) - Hypertension (from catecholamine release, inadequate anesthesia, pain) - Arrhythmias (from anesthetic agents, electrolyte abnormality, myocardial ischemia) - Myocardial infarction (especially in patients with CAD) 4. **Thermoregulation**: - **Intraoperative hypothermia**: General anesthesia impairs thermoregulation; the patient loses heat through radiation, convection, and evaporation. Hypothermia increases cardiac arrhythmias, increases infection risk, and impairs drug metabolism and coagulation. Prevent with warming blankets, warm IV fluids, and limited body exposure. 5. **Other complications**: - Postoperative nausea and vomiting (PONV): 30–40% incidence; managed with antiemetics - Malignant hyperthermia (discussed below) - Emergence delirium: Agitation, confusion upon waking; common in children and males **Malignant Hyperthermia (MH): A Life-Threatening Pharmacogenetic Emergency** Malignant hyperthermia is a rare but potentially fatal hypermetabolic crisis triggered by exposure to certain anesthetic agents in genetically susceptible individuals. The incidence is approximately 1 in 10,000 to 1 in 100,000 general anesthetics. **Genetics:** - Autosomal dominant inheritance; mutations in the ryanodine receptor (RYR1) or skeletal muscle calcium-ATPase (CACNA1S) gene - A positive family history is the key screening question **Triggering Agents:** - **Succinylcholine** (depolarizing neuromuscular blocker): Most common trigger - **Volatile inhalational agents** (sevoflurane, isoflurane, desflurane): Potent triggers - Safe agents: IV induction agents, opioids, benzodiazepines, non-depolarizing paralytics (rocuronium, vecuronium) **Pathophysiology:** Trigger agents cause uncontrolled intracellular calcium release in skeletal muscle, leading to sustained contraction (rhabdomyolysis), hypermetabolism, heat production, and lactic acidosis. **Clinical Presentation (Signs and Symptoms):** **Early Signs** (may appear within minutes of induction): - **Masseter muscle rigidity** or generalized muscle rigidity ("wooden" muscles) - **Unexplained tachycardia** (heart rate > 120 bpm)—a sensitive early sign - **Elevated end-tidal CO2 (ETCO2)** on capnography (rising steadily despite hyperventilation)—another sensitive early sign - **Jaw clenching** (difficult to open the mouth) - **Spontaneous contractions** or visible muscle fasciculations **Late Signs** (occur if episode continues): - **Very high, rapidly rising core temperature** (may rise 1–2°C every 5 minutes); this is a LATE sign and should not be awaited - Severe muscle rigidity - **Dark-colored (cola-colored) urine** (myoglobinuria from muscle breakdown) - **Hyperkalemia** (from rhabdomyolysis; can cause cardiac arrhythmias and arrest) - **Metabolic and respiratory acidosis** - **Cardiac arrhythmias** (from hyperkalemia, acidosis, hyperthermia) - **Disseminated intravascular coagulation (DIC)** - **Acute renal failure** (from myoglobinuria) - **Death** (if not recognized and treated rapidly) **Management of Malignant Hyperthermia (Time-Critical):** 1. **Immediate actions** (within minutes): - **STOP the trigger agent immediately**: Disconnect the vaporizer; switch to an IV anesthetic (propofol); notify the anesthesia provider. - **Hyperventilate** with 100% oxygen to increase CO2 elimination and reduce acidosis. - **Activate the MH protocol**: Alert OR staff; get dantrolene sodium and ice. 2. **Administer dantrolene sodium** (the specific antidote): - Dose: **2.5 mg/kg IV bolus, repeated every 5 minutes as needed, maximum 10 mg/kg** - Dantrolene blocks intracellular calcium release in skeletal muscle, stopping the hypermetabolic cascade - Onset: 5–10 minutes (first dose) - If initial signs resolve (rigidity decreases, HR normalizes, ETCO2 drops), continue with 1 mg/kg dantrolene every 4–6 hours for 24 hours postop to prevent recrudescence (delayed second episode) 3. **Cooling measures**: - Apply ice packs to groin, axillae, and head - Infuse **cold normal saline IV** - Irrigate body cavities with cold saline if core temp remains > 39°C - Goal: Cool to 38–38.5°C - Monitor core temperature continuously 4. **Correct metabolic derangements**: - **Hyperkalemia**: Treat with calcium chloride (stabilizes myocardium), insulin + dextrose, and sodium bicarbonate to shift potassium intracellularly. Avoid succinylcholine, which worsens hyperkalemia. - **Acidosis**: Sodium bicarbonate IV to correct metabolic acidosis; hyperventilation corrects respiratory acidosis - **Coagulopathy/DIC**: Fresh frozen plasma, platelets as needed 5. **Monitor urine output and prevent acute renal failure**: - Maintain urine output > 200 mL/hour with aggressive IV hydration (normal saline, then D5W with electrolyte management) - Monitor urine color; dark/cola-colored urine indicates myoglobinuria - Consider **mannitol** or **furosemide** to diurese myoglobin - Insert Foley catheter to monitor urine output - Check CK, myoglobin, BUN, creatinine, electrolytes, coagulation studies frequently 6. **Arrange ICU admission** for continuous monitoring of cardiac rhythm, core temperature, renal function, and acid-base status **Prevention of Malignant Hyperthermia:** - **Screening**: Ask all preoperative patients (and relatives) about family history of adverse anesthesia reactions, unexplained perioperative deaths, or MH diagnosis - **Testing**: Patients with family history or suspected MH can undergo **caffeine halothane contracture test (CHCT)** or **genetic testing** to confirm susceptibility - **Anesthetic planning**: In susceptible patients, use **MH-safe anesthesia**: propofol or etomidate for induction, opioids for analgesia, non-depolarizing paralytics (not succinylcholine), and volatile agents are avoided. Nitrous oxide and benzodiazepines are safe. - **OR preparation**: Dantrolene must be available (mixed, drawn, labeled) and staff must be trained in MH protocol - **Vigilance**: Capnography and core temperature monitoring are standard in all ORs and allow early detection of MH (rising ETCO2 is often the first sign) **Regional Anesthesia:** Regional anesthesia blocks sensation in a specific region while the patient remains conscious (or sedated) and can maintain their own airway and respiratory drive. Risks are lower than general anesthesia for some patients, but the patient may be anxious. Opioids and benzodiazepines are often given for sedation and comfort. **Spinal (Subarachnoid) Anesthesia:** - **Technique**: Local anesthetic (usually bupivacaine or lidocaine) is injected into the **subarachnoid space (CSF)** at L3–L4 or L4–L5. Anesthetic diffuses through CSF and blocks spinal nerve roots. - **Onset**: 5–15 minutes; rapid, dense block - **Duration**: Varies; lidocaine 30–60 min, bupivacaine 60–90 min (longer if opioids are added intrathecally) - **Level of block**: Depends on baricity, volume, and position; typically T10–S5 (lower body) - **Uses**: Lower extremity, pelvic, abdominal, and urological procedures - **Advantages**: No airway manipulation, maintains protective airway reflexes, reduced postoperative nausea, faster recovery - **Disadvantages**: Limited to lower body; sympathetic block causes vasodilation **Complications of Spinal Anesthesia:** 1. **Hypotension and bradycardia**: From sympathetic blockade (vasodilation, decreased cardiac preload). Treat with IV fluids, elevation of legs, ephedrine or phenylephrine IV. 2. **High spinal block**: If the anesthetic rises to thoracic or cervical level, it blocks intercostal and phrenic nerves, causing hypoventilation and apnea. Requires bag-mask ventilation and possible intubation. Prevent by careful positioning and appropriate drug dosing. 3. **Post-dural puncture headache (PDPH, spinal headache)**: - Occurs in 5–15% of spinal anesthetics (higher in younger patients, females, larger needles) - Caused by CSF leakage through the dura puncture, leading to decreased CSF pressure and traction on meninges - Onset: Typically 24–48 hours postop - Characteristics: **Postural** headache (worse when upright, better supine); often accompanied by neck stiffness, tinnitus, auditory symptoms, and photophobia - Prevention: Use small-gauge spinal needles (25–29 gauge) and pencil-point needle designs (less traumatic than cutting needles) - Management: - **Conservative**: Bed rest, hydration (IV or oral), analgesics, caffeine (500 mg IV or oral acts as a vasoconstrictor) - **Epidural blood patch (EBP)**: If headache is severe or persists > 7 days: 10–20 mL of patient's own blood is injected into the epidural space at or below the puncture level, creating a clot that seals the dura. Effective in > 90%. Risk: transient back pain, radiculopathy - **Nursing care**: Keep patient flat (or nearly flat) for the first 24 hours postoperatively; encourage fluids; manage pain; explain the condition to reduce anxiety **Epidural Anesthesia:** - **Technique**: Local anesthetic is injected into the **epidural space** (outside the dura, surrounding CSF). Anesthetic diffuses through tissues to block spinal nerves. - **Onset**: 10–20 minutes (slower than spinal); block develops from site of injection upward and downward - **Duration**: Depends on agent; can be prolonged with continuous catheter - **Uses**: Lower extremity, pelvic, abdominal, thoracic, and upper extremity procedures; also used for labor analgesia and postoperative analgesia (continuous epidural infusion) - **Advantages**: Slower onset allows patient adjustment; can be prolonged with a catheter; maintains more hemodynamic stability than spinal; allows titration of level - **Disadvantages**: Slower onset; slightly less dense block; risk of intravascular injection if catheter is placed inadvertently in a blood vessel; risk of epidural hematoma (especially with anticoagulation) **Complications of Epidural Anesthesia:** - **Inadvertent dural puncture**: If the epidural needle goes too far and punctures the dura, the patient may experience a "wet tap" (CSF seen in the needle hub) and risk spinal anesthesia effects or PDPH - **Intravascular injection**: If the catheter is in a blood vessel, local anesthetic enters the bloodstream, causing toxicity (seizures, arrhythmias, cardiac arrest). Prevent by aspirating before injection, injecting a test dose, and incremental dosing with frequent reassessment. - **High epidural block**: Similar to high spinal; hypoventilation, apnea, cardiovascular collapse if cervical levels blocked - **Hypotension and bradycardia**: From sympathetic blockade; manage with fluids and vasopressors - **Epidural hematoma** (rare but serious): Especially in anticoagulated patients; presents with progressive motor and sensory loss; requires urgent MRI and surgery **Peripheral Nerve Blocks:** - Local anesthetic is injected around a specific nerve or plexus (e.g., brachial plexus, femoral nerve, interscalene block for shoulder surgery) - **Advantages**: Excellent analgesia with minimal systemic effects; patient remains conscious; preserved airway reflexes - **Disadvantages**: Limited to the specific area innervated; may fail partially - **Risk of nerve injury**: Improper needle placement or injection can damage the nerve; permanent neuropathy is rare (< 1%) but possible **Local Anesthesia:** - Local anesthetic (lidocaine, bupivacaine) is infiltrated into tissues at the surgical site - **Uses**: Minor procedures (laceration repair, small biopsy, dental work) - **Onset and duration**: Varies by agent; lidocaine 5–15 min, bupivacaine 15–20 min - **Advantages**: No systemic effects; patient awake; rapid recovery - **Disadvantages**: Limited to small areas; patient may be anxious; does not allow airway manipulation - **Toxicity**: If too much anesthetic is absorbed systemically, local anesthetic toxicity occurs (seizures, arrhythmias, cardiac arrest); **lipid emulsion (Intralipid®) is the treatment** for local anesthetic toxicity **Monitored Anesthesia Care (MAC) / Conscious Sedation:** MAC or moderate (conscious) sedation involves sedation and analgesia while the patient maintains their **own airway, respiratory drive, and response to stimuli** (responds to commands or tactile stimulation). It is used for shorter procedures (endoscopy, minor surgery) or in patients for whom general anesthesia is risky. **Agents used**: - **Benzodiazepines** (midazolam): Anxiolysis, sedation, amnesia - **Opioids** (fentanyl): Analgesia - **Propofol**: Deep sedation **Monitoring Requirements**: - **Continuous pulse oximetry**: Maintain SpO2 > 94% - **Continuous capnography**: Detect hypoventilation early (rising CO2) - **Cardiac monitor**: Detect arrhythmias - **Blood pressure**: Measure every 5–15 minutes - **Depth of sedation**: Assess responsiveness regularly - **Oxygen delivery**: Supplemental O2 to prevent hypoxemia **Reversal Agents** (must be immediately available): - **Flumazenil**: Benzodiazepine antagonist; reverses midazolam. Dose: 0.2 mg IV, repeat every 1 minute up to 1 mg. Risk: seizure in benzodiazepine-dependent patients; short half-life (requires repeat dosing) - **Naloxone (Narcan)**: Opioid antagonist; reverses fentanyl and other opioids. Dose: 0.4–2 mg IV every 2–3 minutes as needed. Risk: acute withdrawal, worsens pain **Nursing Role in Anesthesia Management:** 1. **Preoperative**: Assess anesthesia risk, communicate risk factors (especially MH history, airway concerns, allergies), ensure NPO status, confirm informed consent 2. **Intraoperative**: Assist with IV access, monitor vital signs per protocol, maintain safety, assist with patient positioning, monitor consciousness in MAC, communicate changes to anesthesia provider 3. **Postoperative**: Assess level of consciousness, pain, respiratory status; treat side effects (nausea, shivering, pain); manage drains and dressings; prevent complications

The intraoperative period spans from when the patient enters the operating room until they leave it. The intraoperative nursing team ensures patient safety, maintains the sterile environment, and advocates for the anesthetized, vulnerable patient. The surgical team includes the surgeon, anesthesia provider (anesthesiologist or nurse anesthetist), **scrub nurse** (or surgical technologist), and **circulating nurse** (the registered nurse coordinating care outside the sterile field). **The Circulating Nurse's Role and Responsibilities:** The circulating nurse is the **registered nurse (RN)** who coordinates the OR and is responsible for: 1. **Patient safety and advocacy**: Ensuring correct patient, procedure, and site; protecting the unconscious patient; preventing infection and injury 2. **Maintaining the environment**: Temperature, humidity, lighting, equipment function, traffic control 3. **Documenting**: Surgical counts, patient care, medications, drains, implants, specimens, and intraoperative events 4. **Communication**: Between the surgical team and other departments; reporting abnormalities 5. **Coordination**: With scrub team, anesthesia, and outside OR (lab, imaging, supply) **The Scrub Nurse's Role:** The scrub nurse (registered nurse or surgical technologist) works **within the sterile field** and is responsible for: 1. Creating and maintaining the sterile field 2. Passing instruments and supplies to the surgeon and assistants 3. Counting sponges, instruments, and sharps 4. Managing specimens 5. Protecting the sterile field from contamination **Surgical Safety: The WHO Surgical Safety Checklist and Time-Out** The WHO Surgical Safety Checklist, adopted by many institutions including Philippine hospitals, is a three-phase protocol that reduces surgical errors and complications: **Phase 1: Sign-In (Before Anesthesia)** - The circulating nurse or anesthesia provider verifies: - Patient identity (name, DOB) matches the wristband and chart - Consent form is signed and on the chart - NPO status is confirmed - Site marking is present (if applicable) - Relevant imaging is in the OR - Patient is allergic to anything - Difficult airway risk is assessed **Phase 2: Time-Out (Before Skin Incision)** - **The entire surgical team pauses**; the circulating nurse reads aloud: - Patient name and DOB (confirm with patient if awake, or wristband) - Procedure name and site ("Right knee arthroscopy") - Surgeon name - Expected blood loss and critical steps - Anticipated complications - All team members (surgeon, anesthesia, scrub nurse, circulating nurse) **verbally confirm** they agree on the correct patient, procedure, and site - Any discrepancies are resolved before proceeding - This is a critical error-prevention measure **Phase 3: Sign-Out (Before Patient Leaves OR)** - The scrub and circulating nurses confirm aloud: - Sponge and instrument counts are correct (or documented as intentionally incorrect, e.g., a packing left in a large cavity) - Specimen label matches patient ID - Equipment problems are reported - Any concerns are noted **Preventing Wrong-Site, Wrong-Patient, Wrong-Procedure Surgery:** 1. **Two-identifier verification**: Match name and DOB (or MRN) with the chart, wristband, and consent form 2. **Surgical site marking**: The **surgeon marks the incision site with an indelible pen** (best practice: in consultation with the patient if awake). This is done preoperatively or immediately before surgery. The mark should be at the incision site or in close proximity, not on the opposite side. 3. **Time-out verification**: The entire team pauses and verifies correct patient, procedure, and site before incision 4. **Documentation and communication**: All team members are clear on the procedure and site; no assumptions 5. **Vigilance**: Any discrepancy triggers a STOP and clarification **Surgical Counts: Preventing Retained Foreign Objects** Retained surgical items (sponges, instruments, sharps/needles) are a serious complication that can cause infection, obstruction, perforation, and litigation. Counting protocols prevent this. **Count Timing:** 1. **Initial (baseline) count**: Before the procedure begins. All sponges, instruments, and sharps are counted and recorded on the surgical count sheet. The scrub nurse and circulating nurse both verify the count. 2. **Intermediate count**: Before closing a body cavity (e.g., peritoneum before closing the abdomen, pleura before closing the chest). The count is verified; if incorrect, the surgeon is notified and the cavity is inspected. 3. **Final count**: After all instruments are removed from the field but **before skin closure**. Sponges, instruments, and sharps are recounted. If the count is **incorrect**, the surgeon is notified immediately: - The wound is **NOT closed** - An **X-ray or imaging** (CT) may be taken to locate the missing item - The surgical field is inspected (the scrub nurse retraces steps) - The wound is irrigated or packed - Once the item is located or accounted for, closure proceeds **Count Components:** - **Sponges**: Gauze sponges of various sizes, laparotomy pads - **Instruments**: Forceps, clamps, retractors, scissors, etc. - **Sharps/Needles**: Suture needles, hypodermic needles - **Other items**: Towel clips, counted if used **Special Situations:** - **Intentional incorrect count**: If the surgeon deliberately leaves an item (e.g., a packing in a large abdominal cavity to control bleeding), this is **documented explicitly** on the count sheet (e.g., "1 lap pad intentionally left in abdomen per surgeon order") and communicated to the recovery nurse so a post-op image can verify removal - **Cesarean section**: Some institutions have specific count protocols - **Trauma/emergency surgery**: If patient is unstable, counts may be abbreviated or deferred; document the reason **Maintaining Surgical Asepsis and the Sterile Field:** Surgical asepsis (sterile technique) is the practice of preventing microbial contamination during surgery. Contamination risks infection, which prolongs hospitalization, increases mortality, and incurs costs (especially surgical site infection, SSI). **Operating Room Zones and Dress Code:** The OR is divided into three zones: 1. **Unrestricted Zone** (outside the OR) - Street clothes are permitted - Access to hallways and general hospital areas 2. **Semi-Restricted Zone** (corridors and areas adjacent to the OR) - **Scrub attire** (OR pajamas, shirt and pants) is required - **Head cap** covering all hair is required - Shoes may be street shoes or OR shoes - No street clothes 3. **Restricted Zone** (the OR suite itself) - **Full scrub attire**: OR pajamas, head cap, **surgical mask** (covering nose and mouth) - **Sterile gloves** for sterile team members (surgeon, scrub nurse) - **Eye protection** may be worn - Surgical gown and drape for sterile team - Hair, beard, mustache must be fully covered by cap; no hair visible - No body jewelry except plain wedding band - Shoes with closed toe - No movement in or out of the OR without need **Principles of Surgical Asepsis:** 1. **Sterile items touch only sterile items**; non-sterile items touch non-sterile items - Sterile instruments are placed on sterile drapes or fields - Sterile solutions are poured into sterile containers - Non-sterile items (external drapes, floor, equipment) are not touched by sterile items 2. **Sterile team members (those who are gowned and gloved) are considered sterile only in specific areas**: - **Sterile areas**: The front of the body from chest to waist, the arms from shoulders to elbows (gloved hands are the most sterile part) - **Non-sterile areas**: The back of the body, the sides of the torso, areas below the waist, the back of the arms - Team members face each other when passing sterile items; they never turn their backs to the sterile field 3. **Edges of sterile packages are not sterile**: - The **outer 2.5 cm (1 inch) border** of any sterile drape or package is considered contaminated once opened - Sterile items from a package are removed from the **center**, not the edges - If an item touches the border, it is considered contaminated 4. **Anything below the level of the sterile field or out of sight is not sterile**: - Items dropped on the floor are contaminated - Items held below the waist are not sterile - If you cannot see it, it is contaminated 5. **Movement in the OR is controlled to minimize air currents and microbial shedding**: - Movement is kept to a minimum - OR doors are kept closed except for necessary entry and exit - The circulating nurse monitors the sterile field and calls out any breaks 6. **Gloving and gowning**: - Sterile gloves are donned after hand hygiene and draping (or before, depending on procedure) - The sterile gown is donned by a sterile (already-gloved) team member or by reaching into the gown carefully - If a glove tears or a gown is torn or touched by a non-sterile item, it must be changed immediately **Signs of Sterile Field Compromise:** - Moisture or rain on drapes (moisture transfers organisms) - A non-sterile person's body or clothing touching the sterile field - A sterile person's back or sides facing the field - A sterile person sitting down (areas below waist become non-sterile) - A non-sterile item (instrument, package, solution) touching the sterile field - Items protruding from sterile packages **Action on Contamination:** If a sterile field is contaminated, the affected area (or entire field, depending on extent) must be considered non-sterile and replaced if possible. Communication is immediate: "The field is contaminated; we need a new [drape/instruments]."**Preventing Latex Allergy Reactions:** Latex allergy is an immediate hypersensitivity to latex (rubber) proteins. Reactions range from mild (contact dermatitis) to life-threatening (anaphylaxis). **Types of Reactions:** 1. **Contact dermatitis** (delayed type IV): Rash, itching at contact sites; onset hours to days 2. **IgE-mediated allergy** (type I): Urticaria, angioedema, respiratory symptoms (wheezing, stridor), hypotension, anaphylaxis; onset minutes to hours **Risk Groups:** - Healthcare workers (frequent latex glove exposure) - Patients with latex allergy history - Patients with multiple surgeries (sensitization from repeated exposure) - Patients with spina bifida or urogenital anomalies (high exposure during procedures) **Preparation for Latex-Allergic Patients:** 1. **Identification**: Ask during preoperative assessment: "Are you allergic to latex or rubber?" Document prominently on the chart, ID band, and care team communication. 2. **Latex-Free OR Preparation**: - Remove all latex products: latex gloves, catheters, drains, IV tubing, tape, bandages, stethoscope tubing - Stock the OR with latex-free alternatives: nitrile gloves, non-latex catheters, non-latex IV tubing, synthetic drapes - Clean the OR with damp cloths or appropriate disinfectant (latex particles are airborne; dampening reduces airborne contamination) - Post "LATEX-FREE" signage at the OR entrance - Brief all team members (surgical, anesthesia, nursing, custodial) of the allergy 3. **Medications and Supplies**: - Check all medications and supplies for latex rubber stoppers in vials or bottles; order latex-free alternatives if needed - Verify anesthesia equipment is latex-free (ET tubes, LMA, IV tubing, stopcock) 4. **Perioperative Medications**: - Consider premedication with antihistamines (diphenhydramine) and corticosteroids (methylprednisolone) to reduce allergy severity if exposure occurs - Have **epinephrine and emergency airway equipment** at bedside - Have **antihistamines, corticosteroids, and vasopressors** immediately available 5. **Anaphylaxis Management** (if it occurs): - **STOP the procedure** immediately - **Notify all team members** of anaphylaxis - **Administer epinephrine** 0.3–0.5 mg IM (or 0.1 mg IV if IV access is available) immediately - **Maintain airway**, oxygen, IV access; give fluids - **Antihistamines** (diphenhydramine 25–50 mg IV) - **Corticosteroids** (methylprednisolone 125 mg IV or dexamethasone 10 mg IV) - **Transfer to ICU** for monitoring **Patient Positioning in the OR:** Intraoperative positioning is critical for surgical access, but improper positioning causes complications. The anesthetized patient cannot feel discomfort or reposition; the surgical team's positioning choices can cause nerve injury, pressure injury, compartment syndrome, or rhabdomyolysis. **Goals of Positioning:** 1. **Surgical access**: Position allows the surgeon optimal visualization and reach 2. **Patient safety**: Maintain alignment, prevent injury, preserve circulation and ventilation 3. **Comfort and dignity**: Minimize unnecessary exposure; cover non-surgical areas **Positioning Principles:** 1. **Maintain correct body alignment**: - Spine: Keep neutral; avoid twisting or hyperextension (especially cervical spine) - Joints: Maintain in physiologic position (slight flexion); avoid hyperextension or hyperflexion - Head: Neutral; avoid extreme rotation 2. **Pad bony prominences and pressure points** to prevent pressure injury and nerve compression: - Occiput (back of head) - Ears - Shoulders - Elbows - Sacrum - Heels - Knees - Ankles - Pressure-relieving pads, pillows, gel pads, or foam are used under these areas 3. **Secure the patient with safety straps and restraints** to prevent falls: - Safety straps are placed across the torso (above the knees) and secured to the table - Restraints are padded to prevent skin injury - Straps are snug but not constrictive; allow one finger to fit under the strap 4. **Avoid overextension of joints**: - Shoulder abduction should not exceed 90° - Hip flexion/abduction should maintain alignment - Knees should be slightly flexed - Wrists should be neutral or slightly extended, not hyperextended 5. **Protect from falls and shifts**: - Side rails are raised when the patient is positioned - Movement of the table is announced to all team members - The patient's position is stabilized before draping 6. **Monitor respiration and circulation**: - Chest is not compressed; respiratory excursion should be visible - Abdomen is not compressed - Limbs are not compressed against the body or table - Pulse checks are performed distal to any pressure points (e.g., distal to an arm abductor) **Common Surgical Positions:** 1. **Supine (horizontal back-lying)**: - **Uses**: Most surgeries (abdominal, cardiac, vascular, orthopedic, general surgery) - **Risks**: Low (relatively neutral position) - **Precautions**: Pad occiput, shoulders, sacrum, heels; keep arms at sides or abducted < 90°; neutral spine 2. **Prone (horizontal face-down)**: - **Uses**: Spinal surgery, posterior thoracic surgery, rectal surgery - **Risks**: HIGH. Airway management difficult (ET tube must be very secure); increased ICP; reduced respiration; potential for rhabdomyolysis from pressure; brachial plexus injury - **Precautions**: Secure airway very well; pad face, forehead, cheeks (use a head rest that allows free breathing), ears, knees, anterior pelvis (use bolsters under chest and pelvis to keep abdominal contents free of compression), toes; arms at sides or at 90° (not abducted > 90° to prevent brachial plexus injury); avoid hyperextension of lumbar spine; monitor SpO2 and ETCO2 carefully; suction airway frequently; do NOT have one person do total repositioning; use the "logroll" technique with multiple staff 3. **Lateral (horizontal side-lying)**: - **Uses**: Thoracic, kidney, hip, retroperitoneal surgery - **Risks**: Pressure injury to dependent side (shoulder, hip, ankle); brachial plexus injury if upper arm is abducted > 90°; impaired ventilation (dependent lung may collapse) - **Precautions**: Pad dependent shoulder, hip, ankle; use axillary roll (small pillow) under axilla to prevent brachial plexus compression; support upper leg with pillow; keep dependent arm in neutral position; pad non-dependent arm; use gel pads on pressure points; monitor that dependent lung is not compromised 4. **Lithotomy (supine, hips and knees flexed, legs elevated in stirrups)**: - **Uses**: Gynecologic, urologic, rectal, perineal surgery - **Risks**: VERY HIGH. Hip flexion increases ICP and reduces venous return; foot and leg ischemia if straps are too tight; rhabdomyolysis from pressure and muscle exertion; hip and knee joint damage from hyperflexion; saphenous nerve injury; compartment syndrome - **Precautions**: Gentle, coordinated positioning (lift both legs simultaneously to avoid asymmetric stress); pad stirrups with blankets or gel pads; stirrups should support the entire length of the leg; height of stirrups should be symmetric; straps are snug but not constrictive; knees are slightly flexed (not hyperextended); feet and calves are not in direct contact with hard stirrup surfaces; monitor calf and foot for swelling, color, and temperature; ask about patient's hip and leg mobility before positioning (some patients cannot tolerate lithotomy due to arthritis or body habitus); remove from lithotomy gently and symmetrically at end of surgery 5. **Trendelenburg (supine, head end tilted downward)**: - **Uses**: Lower abdominal or pelvic surgery; cardiac surgery; to improve venous return - **Risks**: Increased ICP; facial edema; airway swelling; aspiration risk; impaired ventilation (abdominal contents push up on diaphragm); discomfort (patient feels inverted) - **Precautions**: Moderate angle (< 30°); limit duration; ensure airway is secure and elevated slightly (ET tube must be very secure); monitor SpO2 and ETCO2; have suction available; pad the back of the head and neck; use shoulder braces if available (to prevent sliding); reverse-Trendelenburg may be used for upper abdominal surgery (head elevated) 6. **Jackknife (prone, hips flexed, buttocks elevated)**: - **Uses**: Rectal, anal, lower spinal surgery - **Risks**: Very high ICP; abdominal compression; respiratory impairment; hip flexor strain; sacral plexus injury - **Precautions**: Careful gentle positioning; avoid excessive hip flexion; ensure airway is patent and secure; monitor ventilation; pad bony prominences; limit duration **Thermoregulation Intraoperatively:** General anesthesia impairs the body's thermoregulation, and patients often develop **intraoperative hypothermia** (core temperature < 36°C). Hypothermia increases cardiac complications, impairs drug metabolism, slows emergence from anesthesia, increases infection risk, and impairs coagulation. **Causes of Hypothermia:** - Large exposed body surface area - Prolonged procedure - Cold operating room temperature - Cold IV fluids - Evaporation of prep solutions from skin - Infusion of blood products or room-temperature fluids **Prevention:** 1. **Maintain OR temperature** at approximately 21–23°C (warmer is sometimes used for neonates and small children) 2. **Warm IV fluids** to body temperature using inline warmers or fluid warmers 3. **Use warm blankets** and forced-air warming devices (Bair Hugger®) over non-surgical areas 4. **Minimize body exposure** during draping; uncover only the surgical site 5. **Use reflective blankets** or plastic drapes to reduce heat loss 6. **Warm blood products** before transfusion 7. **Increase room humidity** (reduces evaporative heat loss) **Monitoring Core Temperature:** - Core temperature is monitored via esophageal, tympanic, nasopharyngeal, or bladder probe - Goal: Maintain core temperature > 36°C intraoperatively - At end of surgery, continue warming measures into recovery to reach 37–37.5°C **Intraoperative Skin Integrity and Safety:** 1. **Pressure injury prevention** (addressed above in positioning) 2. **Prep solution injury**: Povidone-iodine and chlorhexidine prep solutions can cause chemical burns if pooled under the patient. Solutions should not be allowed to dry on skin; prep areas are dried after application. 3. **Electrocautery burn**: Electrocautery (Bovie) generates heat. Return electrode pads are placed on large muscle mass (usually on thigh or buttock) to safely complete the circuit. Improper pad placement or wet skin under the pad can cause burn. Pad placement is verified; skin is dry before pad application. 4. **Eye protection**: Eyes are taped or protected with lubricating ointment and shields during surgery to prevent corneal abrasion and drying. 5. **Fluid and blood loss monitoring**: The anesthesia team monitors blood loss and replaces with IV fluids and blood products. The circulating nurse measures blood in sponges and suction and calculates blood loss. **Communication and Documentation:** The circulating nurse documents intraoperatively: - **Time in and time out** - **Patient vitals** at regular intervals - **Medications** given (antibiotics, analgesics, reversal agents, epinephrine, etc.), with time and dose - **Blood loss** estimate - **Drains** placed (type, location, drain bottle/container number) - **Urinary output** (if catheterized) - **Specimens** obtained (type, container, fixative, label) - **Implants** used (type, lot number, size, manufacturer) - **Sponge, instrument, and sharps counts** (initial, intermediate, final; "correct" or "incorrect"; any X-rays) - **Intraoperative events** (positioning changes, equipment issues, breaks in sterile field, anesthetic complications) - **Tourniquet time** (if used) - **Intraoperative notes** regarding any concerns or unusual findings Clear, accurate documentation ensures continuity of care and provides a legal record.