Clinical Coach For Effective Perioperative Nursing Care@2009 PDF

Davis’s
CLINICAL
COACH Series
F. A. Davis Company
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Copyright © 2009 by F. A. Davis Company

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Publisher, Nursing: Joanne P. DaCunha, RN, MSN

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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
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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 obtain-
ing this information. If you are a nurse working in the post-anesthesia
care unit (PACU), you will use this information in planning and institut-
ing 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
does not speak English, you will be required to The primary goal
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
COACH require careful screening to determine the
CONSULT appropriateness of both patients and procedures
to keep risk minimal. Examples of procedures
Hospital and ambulatory
performed in offices include the following:
surgery standards do not
apply to medical offices, so • Vasectomy
it is essential to ensure that • Liposuction
minimal safety standards • Arthroscopy
are met, including personnel 23-hour surgery refers to ambulatory surgery
and monitoring, and to
ensure for the availability
followed by up to 23 hours of monitored care by
of emergency resources nurses. This type of scheduling is useful for
and facility for transfer in procedures in which minimal risks exist that
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 pres-
sures. 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 stabiliza-
tion, 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
• More invasive procedures In the interest of patient
safety, the location of where
• More complex procedures a surgery is performed is
• Possible inpatient admission following not nearly as important as
procedure the determination that the
• Immediate access to diagnostic testing patient is appropriate for
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
depending on biopsy results. If the procedure procedure to be performed.
remains limited to a biopsy, the patient can be
Preoperative Assessment and Care 3

discharged to home following the procedure. If
COACH the procedure is extended to include a mastec-
CONSULT tomy, the patient can be admitted following
surgery.
Presurgical screening will
help the surgeon determine
the urgency of the proce-
Timing of Surgery
Elective surgery is surgery to improve a
dure to allow for appropriate
scheduling of the OR. 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 con-
venience. 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 prepa-
ration, 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
• Cholecystectomy for gallstones and repeated episodes of
cholecystitis
• Uterine artery ablation for postmenopausal bleeding from
fibroids
Semi-elective surgery allows for adequate patient preparation, evalua-
tion, 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 in-
clude 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 condi-
tions, as well as surgery and anesthesia, and
includes the following:
• Bleeding COACH
• Infection CONSULT
• Renal failure Surgical procedures are
• Myocardial infarction classified by necessity, by
Salvage surgery is required when car- location of where the
diopulmonary resuscitation is in progress on surgery will be performed,
and by length of stay.
the way to the OR or in the OR itself. Either a
These classifications will
patient’s life or limb is threatened, requiring help you to determine the
immediate surgery for survival. Examples include relative risk of the proce-
the following: dure. For example, a surgery
• Penetrating trauma that is performed on an
emergency basis in an
• Ruptured aneurysm inpatient facility is of higher
• Perforated ulcer risk for perioperative com-
Death is an inevitable outcome unless the plications than a scheduled
patient is brought immediately to the OR. Even surgery at a free-standing
facility where no overnight
with immediate admission to surgery, death
stay is required.
remains a very real risk.

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
A patient who takes
for a total hip replacement may tell you he
aspirin, Coumadin, or or she is doing it so he can play golf again,
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
medication before surgery anesthetics that the patient may have and
to decrease the risk for how those procedures were tolerated. The
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
surgery to make sure clotting
reaction to a medication. Maybe the patient
studies are within normal experienced a spinal headache after an
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 labora-
tory tests need to be 3. Ask about the patient’s family health
ordered. If a patient is taking history. Include any adverse reactions to
medications for glucose anesthesia. Anesthesiologists were first
control, it is important to made aware of a phenomenon, later to be
obtain a fasting preopera-
tive glucose.
known as malignant hyperthermia, when a
patient reported that 10 of his family mem-
bers 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
the risks of arrhythmias An easy way to inquire
about herbal medicine use
• Garlic taken to lower lipids enhances the is to simply ask, “What
effect of warfarin, increasing bleeding herbal or vitamin supple-
• Ginseng taken for energy causes seda- ments do you currently
tion, tachycardia, and hypertension take?”
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
nondrug allergies, too. history of allergic respon-
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. Al- to drugs administered
though you may find asking about drug during anesthesia.
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
When asking about alcohol
7. Ask the patient about tobacco use. In
use, ask the patient to tell people who smoke, 15% of the oxygen bind-
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,
moderate, or heavy drinker Smokers also have a higher incidence of
is usually based on a com- reactive airway disease, which may result
parison to your own drink- in laryngospasm on induction. If you can,
ing. Document the specifics, encourage patients to stop smoking a mini-
for example, glass of wine
nightly with dinner, six-pack
mum of 6 weeks before surgery to decrease
of beer over the weekend. perioperative morbidity.
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
COACH the fetus to anesthetic agents, particularly
CONSULT during the first trimester of pregnancy.
Although it may be difficult Review of Systems
to ask the parents to step
out of the room, tell the
The last component of the interview is the
teen that you need her to review of systems, with its sole purpose to
void before going to sur- determine the presence or absence of disease.
gery and that you will show It is especially important to assess organ sys-
her where the bathroom is.
tems that affect the actions of anesthetics, such
As you walk her to the
bathroom, you can ask as the pulmonary, hepatic, and renal systems,
about the possibility of and organ systems that can be affected by anes-
pregnancy and the date of thetics, such as the central nervous and cardio-
her last period without her vascular systems.
being embarrassed in front
of her parents. Then you
Cardiovascular System
can obtain a urine sample Ask about a history of dysrhythmias, chest pain,
for testing to be sure. 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 pres- CONSULT
sure is well controlled by medications. Patients
are generally encouraged to take their blood As every medication given
for anesthesia has the
pressure medications on the morning of sur- potential to have an impact
gery with a sip of water to keep pressures under on the cardiovascular system
control. Poor preoperative control increases and the surgical procedure
the risks of anesthesia and surgery. Poorly itself places the patient at
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
failure. If a patient has
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
medical evaluation and clearance before sur- of reinfarction is about 6%.
gery. If the hypertension is mild and controlled, If the MI was between 3 and
6 months before a proce-
the 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
surgery should be postponed with immediate within 3 months of the MI,
evaluation and intervention. the risk of reinfarction
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 cough-
ing, 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
COACH the cough is productive. This can be a clue to an
CONSULT upper respiratory infection, which commonly
leads to cancellation of surgery, especially if an
The patient with normal elective procedure. Patients with an upper res-
pulmonary function runs a
6% to 10% risk of develop-
piratory infection are at a greater risk for peri-
ing postoperative pulmonary operative bronchospasm, laryngospasm, decreased
complications. As the risk oxygen saturations, and problems with secre-
increases 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
of surgery to be performed, (ACE) inhibitor medication used to treat hyper-
you must be aggressive in tension. A cough that brings up blood may
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
aggressive in providing
history. If the patient is a current smoker, doc-
postoperative pulmonary ument use with the number of years smoked
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,
One study estimated that including emphysema and chronic bronchitis,
60% of patients with COPD is at risk for pulmonary complications includ-
develop postoperative ing infection, hypoxemia, and hypercarbia.
pulmonary complications
Ask about a history of asthma. If asthma is
when given no special
postoperative respiratory acknowledged, ask if the patient knows his or
care. In the same study, the her normal peak flow values. Peak flow moni-
incidence of postoperative toring is becoming a standard of care for primary
complications dropped to care management of asthma. Known values
22% when antibiotics,
bronchodilators, and chest
will help you and the anesthesia provider to
physical therapy were detect any increase in bronchospasm if a
included in the PACU decline in the peak flow is detected, often
routine. occurring before the patient becomes sympto-
matic. Ask the patient what medications are
used to control the asthma, and if the medica-
tions 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.

Central Nervous System
Ask questions to determine the patient’s ability COACH
to respond to questions, follow commands, and CONSULT
maintain ordered thought patterns. Appropri-
ateness of response and thoughts must be If you don’t identify deficits
preoperatively, when they
determined and any deficits carefully evalu- present after surgery, you
ated. For example, the inability to respond may will be unable to compare
simply be the result of a language barrier that with a baseline. This will
can be readily corrected by the use of a transla- force you to subject the
patient 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 weak-
ness. 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.
Ask about the presence of any neuromuscular COACH
diseases or conditions requiring special atten- CONSULT
tion. For example, a child with mental retarda- Approximately 12 million
tion might benefit by having a parent present people in the United States
for induction of anesthesia. A patient with a his- are affected by renal disease,
tory of cerebral palsy often has an unpredictable so it is important to ask
about renal dysfunction.
response to muscle relaxants, sedatives, anal- This may include renal
gesics, and hypnotics. Parkinson’s disease often insufficiency or renal failure.
causes gait disturbances and increases the risk These patients are at an
of falls. A history of stroke increases the risk of increased risk of infection
and sepsis, bleeding,
cardiac disease.
cardiovascular dysfunction,
Renal System and hyperkalemia. Response
The patient with renal dysfunction is almost to medications is often
always anemic, with an average hematocrit of unpredictable.
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 anesthe-
sia 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 as-
ALERT sessment of electrolytes, fluid status and hydra-
tion, date of last dialysis, frequency and type
The greatest
perioperative risk for the (hemodialysis or peritoneal), and anemia status
patient with renal disease should be determined, to decrease periopera-
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
If you remember the many sites and increasing drug effects. Protein defi-
roles of the hepatocyte, ciencies also contribute to failed wound heal-
you will quickly understand ing. Coagulation factors are produced in the
why the patient with pre- liver, specifically prothrombin, fibrinogen, and
existing liver disease is at
such an increased peri-
factors V, VII, IX, and X. Deficiencies in these
operative risk. Hepatocytes clotting factors increase the risk of bleeding in
contribute to, or are surgery. Alterations in liver function will pro-
responsible for, glucose long the action of drugs that require the liver
homeostasis, fat metabolism,
for metabolism and clearance, including benzo-
protein synthesis, drug and
hormone metabolism, diazepines, lidocaine, and narcotics.
bilirubin formation and Ask about any history of hepatitis, cirrhosis,
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, conges- COACH
tive heart failure, and, rarely, pregnancy. The CONSULT
most significant problem is the transmission of
the infection to health-care workers. Because As a large percentage of
patients presenting for
everyone associated with the surgical procedure surgery are elderly, atten-
will be exposed to blood, saliva, and potentially tion to the musculoskeletal
vomit, attention to universal precautions is system is of particular
mandatory. Acute hepatitis is associated with a importance. Arthritis will
impact positioning, trans-
surgical mortality of 9.5% and a morbidity of
ferring, and ambulation
11.9%. These rates are high enough for many pre-, intra-, and
surgeons to delay elective surgical procedures. postoperatively.
Chronic hepatitis is the most serious form of
hepatitis, often resulting in cirrhosis and liver
failure. Liver function will be greatly compro-
mised. Alcoholism is the most common cause COACH
of cirrhosis. Not only is physiologic functioning CONSULT
of the liver compromised, hepatic blood flow is
Myasthenia gravis is a
reduced, as blood meets increasing resistance chronic, autoimmune
in moving through the portal vein, known as disease that compromises
portal hypertension. The patient will require the neuromuscular junction.
monitoring for bleeding, drug toxicity, and car- It is characterized by muscle
weakness and fatigability
diovascular compromise. and periods of exacerba-
Musculoskeletal System tion and remission. Multiple
Ask about arthritis, focusing on affected joints. sclerosis is a chronic neuro-
Osteoarthritis affects between 40 and 60 million muscular disease caused
by demyelination of
Americans. Rheumatoid arthritis affects 1% of
neurons. It is characterized
all adults in the United States, with 100,000 to by sensory and motor
200,000 new cases diagnosed each year. Arthritis neurological deficits and is
is a chronic inflammatory disease of the joints, episodic in its frequency
and is characterized by pain, swelling, and and severity of exacerba-
tion and remission. Guillain-
impaired mobility. The most common drugs Barré syndrome is an
taken to control the discomfort of arthritis, non- inflammatory disease that
steroidal anti-inflammatory agents (NSAIDs) and may affect all motor,
aspirin, have the potential to increase bleeding sensory, autonomic, and
cranial nerves. It is charac-
due to their effect on platelet function.
terized by ascending,
Scoliosis will affect not only mobility and posi- symmetric muscle weakness,
tioning, but with greater curvatures, will affect particularly of facial and
respiratory functioning as well by compromis- ventilatory muscles.
ing vital capacity and potentially cardiovascular

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 intraopera-
tively 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 post-
operative 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 relax-
ants. In the case of myasthenia gravis, the neurologist will often become
involved not only with weaning, but in restarting and titrating anti-
cholinesterase 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
Both malnutrition and example, midazolam (Versed) is highly pro-
obesity have the potential tein bound. If fewer sites are available for this
to affect surgery and the drug to bind, the patient will experience
selection of anesthetic profound sedation and potentially respiratory
agents and techniques.
The malnourished and
depression. Protein is also necessary for
undernourished patient is wound healing.
at risk for exaggerated Obesity is another risk factor for both anes-
drug effects, whereas the thesia and surgery. The risks are due to the
obese patient is at risk for
associated impairments in respiratory, cardiovas-
delayed drug metabolism
and exaggerated respira- cular, and GI systems. Hypoxemia commonly
tory and cardiovascular accompanies obesity, secondary to the following:
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 postopera-
tive problem.
Obesity is an important predictor of cardiovascular disease, particu-
larly 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 individ-
uals. 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 con-
traindicated 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 stock-
ings 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 his-
tory 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

its “classic” signs of polyuria, polydipsia, and
COACH fatigue, the manifestations of hyperglycemia,
CONSULT glycosuria, and cellular glucose deprivation. It is
considered to be a risk factor for both anesthesia
In the perioperative period, and surgery. Postoperative wound healing may
the major endocrine concern
remains maintenance of
be compromised with poor glucose control,
normoglycemia. This is and the risk of infection is greater than in the
acutely important in the nondiabetic.
diabetic patient. With the Preoperative evaluation of the diabetic
epidemic of obesity in this
patient centers on the determination of the
country, there has been a
consistent and steady rise type of diabetes, medications used in manage-
in the diagnosis of diabetes, ment, and the degree of relative control of
affecting, in some places, glucose values.
as many as one out of The anesthesia provider will determine the
every four individuals.
optimal management strategy for glucose control
on the day of surgery. Ideally these patients will
be scheduled early in the day to avoid pro-
ALERT longed periods of no oral intake. Insulin dose
may be cut in half, or held completely, with
Patients with poor insulin management by sliding scale before,
glucose control have an during, and after surgery. Oral hypoglycemic
increased risk of long-term
agents are generally held on the day of surgery.
complications of hyper-
glycemia, including neu- It should be mentioned to patients that the
ropathy, nephropathy, and stress of surgery may result in transient glucose
retinopathy. Findings of a fluctuations, requiring insulin administration in
history of myocardial patients who normally do not require insulin.
infarction, hypertension,
congestive heart failure,
This is generally temporary.
voiding dysfunction, renal Nausea and vomiting are especially prob-
disease, and neuropathies, lematic in diabetic patients, as diet is an impor-
both autonomic and periph- tant part of glucose regulation. Administration
eral, suggest end-organ
of antiemetic agents is particularly important
damage.
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 bleed-
ing 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 estab-
lish a baseline.

Ask about any recent infections, or if the
patient is currently taking antibiotics. Current COACH
antibiotic use will reduce a white blood cell CONSULT
count, but may not have yet removed the
source of infection. Active infection is usually The hematologic system
consists of red blood cells,
grounds to cancel elective surgery. while blood cells, and
Ask about unexplained bruising as an platelets. Each plays an
indicator of clotting abnormalities. Also ask important role in the peri-
specifically about the use of any medications, operative period. Red cells
carry oxygen, so any defi-
aspirin, NSAIDs, Plavix, and Coumadin, that
ciency, known as anemia,
will directly affect platelets causing bleeding. will compromise oxygena-
These medications are usually stopped in tion. White blood cells
advance of surgery except in very exceptional mobilize with infection, so
circumstances. any elevation seen preop-
eratively requires investiga-
tion as to cause, with likely
Physical Examination cancellation of any elective
surgery. Platelets are required
Prior to admission to the OR, a physical exam- for clotting, so any deficiency,
ination must be performed. This may be done most commonly due to
medications such as aspirin
in advance of the day of surgery, particularly products, nonsteroidal anti-
if the patient requires medical clearance, or inflammatory agents, Plavix,
may be done on the morning of surgery, most or Coumadin, will increase
commonly by the anesthesia provider. As a the risk of bleeding.
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 cardiopul-
monary function by inspection and auscultation.
The assessment will include observation for COACH
overt signs of distress, poor color, and ausculta- CONSULT
tion of heart and lung sounds for abnormalities. After completing the
Any chest or spinal abnormalities will be patient interview, and in
noted, particularly if they are likely to affect advance of the physical
ventilation. The condition of veins or arteries examination, it is a good
habit to end the interview
that might be cannulated will be inspected, and
by asking the patient,
peripheral pulses might be palpated. “Is there anything else you
If regional anesthesia is to be considered, would like to share with me
the site of injection will be assessed to identify or think I should know?”
the ease of landmark identification and the

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 phys-
ical findings, may result in cancellation of elective surgery. The patient’s
height and weight should be obtained and documented. This is particu-
larly 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 Classification (Adapted from

American Society of Anesthesiologists)
PHYSICAL
STATUS DEFINITION EXAMPLE
I Healthy patient with no Patient with no significant

systemic disease past or present medical history
II Mild systemic disease Patient with a history of

without functional limitations well-controlled asthma with prn
albuterol use
III Severe systemic disease Patient with a history of moderate

associated with definite persistent asthma who uses daily
functional limitations steroid and bronchodilator inhalers;
activity limited
IV Severe systemic disease that Patient with poorly controlled asthma

is an ongoing threat to life experiencing acute episode of falling
saturations requiring oral steroid
rescue and frequent nebulizer
treatments
V Patient unlikely to survive for Patient in status asthmaticus,

more than 24 hours with or intubated
without surgery
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 preoper-
ative 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 exami-
nation, 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 labora-
tory 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

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 anesthe-
sia 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 num-
ber 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 pro-
cedures 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 pro-
cedure 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

is being performed in outpatients. The only
COACH modification is that discharge criteria must now
CONSULT reflect home-going status, as opposed to dis-
charge status to an inpatient unit.
To better understand
patient needs about anes-
thesia, consider this: If you
Skill and Requirements of the
have ever faced the need Anesthesia Provider
for surgery since you Some centers limit regional techniques to physi-
became a nurse, you likely cian anesthesiologists, as opposed to nurse anes-
knew exactly which surgeon thetists. An anesthesia provider might have skill
you were going to go to,
which anesthesia provider
and experience in complicated nerve blocks,
you wanted or did not making that an additional option for procedures.
want, and gave specific
instructions such as not Patient Preference and Needs
waking up with an endotra- Many patients fear loss of control with a
cheal tube, wanting some-
thing for nausea, and
general anesthetic, and would prefer a regional
wanting pain medication technique. Others will simply tell the anesthesia
on board when you woke provider to “put me to sleep and wake me when
up. Patients do not want to it’s over.” Although patients may have a prefer-
give up their control either,
ence, the ultimate decision will be up to the
but do not have the ability
to make demands. Help anesthesia provider and will be made for pa-
them to understand that tient safety.
decisions being made are
for their safety, with their
specific individual needs in
Preoperative Teaching
mind. Encourage patientsAnother purpose of preoperative screening is to
to ask questions to their
provide a final opportunity for patient and family
surgeon and anesthesia
provider along the way. 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 COACH
and responsibility of the physician. Providing CONSULT
informed consent mandates providing com-
Obtaining informed con-
plete and sufficient information for a patient or
sent is the responsibility
a patient’s proxy to make an educated decision of the physician. Education
about health care, and usually begins with first of a patient about a proce-
patient contact with a surgeon or surgeon’s office. dure can be delegated to a
Consent for surgery may or may not cover con- nurse. Obtaining the signa-
ture of patient on a consent
sent for anesthesia. form can be delegated to
Informed consent requires providing com- a nurse. You should deter-
plete disclosure of the following: mine and follow hospital
• Working or presumed diagnosis or facility policy.
• Differential diagnosis
• Purpose of proposed intervention/surgery
• Risks of proposed intervention/surgery,
even if the common risks are not serious COACH
and the serious risks are uncommon CONSULT
• Alternative treatments and risks
You can help in the consent
• Risks of not treating process by making sure that
• Short- and long-term costs all of the patient’s ques-
• Short term: pain, length of stay, tions have been answered
recovery time prior to the signing of the
consent form.
• Long term: loss of function, restriction
of activity, scarring.
Threats to informed consent include coercion
and manipulation. Coercion is the application of
COACH
a threat. Manipulation involves deliberate alter-
CONSULT
ing or omission of facts. Persuasion, on the other
hand, is expected and not faulted, as the sur- Patients who do not speak
geon presents the rationale for recommending English as their first lan-
surgery, allowing the patient to make an guage and patients who
are developmentally imma-
informed choice. ture may also be incapable
of understanding.
High-Risk Patients and Informed Consent
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 under-
stand. There are high-risk patients who may be incapable of under-
standing, either because of preexisting conditions such as mental

illness and organic brain syndrome, or induced
COACH conditions, such as a patient who has received
CONSULT premedication or who is in labor or under stress.
Each facility needs a plan to address high-
Failure to obtain informed risk patient situations. As a nurse, you can assist
consent has legal conse-
quences. Performing
in identifying these patients and help to ensure
surgery without informed that consent is truly informed prior to the sign-
consent may be viewed as ing of the surgical consent.
assault and battery. Lack of
informed consent may Advance Health-Care Directives
be viewed as malpractice.
A durable power of attorney for health care
is a legal document that allows an individual
to appoint an agent, also called an attorney-
in-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-
resuscitate order may exist
• Health-care providers
prior to a patient going • Medical treatment
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
after surgery. It is important A living will is a legal document that
for the surgeon to clarify expresses an individual’s decision to choose or
the order with the family or refuse medical decisions and the use of artifi-
person acting as the cial life support systems if patients are unable
health-care proxy to deter-
mine wishes in the event of
to speak for themselves due to physical or men-
an intraoperative or post- tal incapacitation in the event of terminal
operative 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 indi-
place.
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 emp-
tying 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 dis-
ease, 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 anesthe-
sia 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 indi-
cated 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 periph-
eral 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 infec-
tion, particularly of wounds, in the surgical patient. Antibiotics are also
used to prevent bacterial endocarditis in patients with a history of congen-
ital, 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 classi-
fication 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, neuro-
surgery, 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 stock-
ings 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 throm-
boembolism 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
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
Antibiotic prophylaxis mandatory
Box 1–3 Patients at Risk for Thrombus Formation and

Embolism
Older than 40 years of age Malignant disease
Multiple trauma Obesity
Prolonged surgery Heart disease
Prolonged immobilization Infection
Previous thromboembolic disease Pregnancy
Varicose veins 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 perianes-
thesia 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
• 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 responsi-
bilities 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 preoper-
ative clearance, or you may be having this conversation with patients
over the phone when confirming the time of surgery. Some of this infor-
mation 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,
Prior to surgery, remember
unless the patient is a minor child or unable to
to teach your patient the understand your instruction. Confirm who will
following specifics: be accompanying the patient, either as support
• Who or as the needed driver for patients having
• What
ambulatory surgery.
• Why
• When The What
• Where Confirm with the patient the needed things
• 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 sigmoi-
doscopy 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 sched-
Aspiration greatly uled for surgery at 11 a.m. may be asked to be
increases perioperative at the facility by 10 a.m. If laboratory tests need
morbidity and mortality. to be drawn and results obtained before sur-
gery, as might be the case with coagulation
studies, the patient may be asked to be at the
facility even earlier than 10 a.m. If you do not COACH
yet have this information, instruct the patient CONSULT
about when they will be able to find out the
time, and how that will occur. Patients will also The only exception to the
NPO after midnight rule
need to be told when to stop eating and drink- is to allow patients to take
ing before surgery, and what medications they their usual morning med-
can take on the day of surgery. ications on the morning of
The anesthesiologist will usually request or surgery with a sip of water.
When taken with a small
order that the patient have nothing to eat or
amount of water, between
drink, including water, after midnight on the 30 and 60 mL, there is no
day of surgery. These times will be less rigid evidence of an increased
in pediatric patients and infants. By having the risk of aspiration. In fact,
patient NPO, the risk of intraoperative vomit- morbidity may actually
be increased if patients
ing and aspiration is minimized, as is the risk are denied their routine
of postoperative nausea, vomiting, and aspira- medications, particularly
tion. Box 2–1 specifies current NPO evidenced- their antihypertensive
based recommendations. Box 2–2 discusses and antianginal agents.
aspiration.
The Where
Patients should be told where to park and
where to present on arrival to the hospital. Pro- COACH
viding a map in the mail in advance is helpful CONSULT
to patients who may be unfamiliar with the
area and hospital. If you know where the patient Lack of compliance with
NPO requirements will
will be transferred after surgery, you can in- commonly result in cancel-
struct the family. Also tell the family where lation of surgery or a
they can wait for the patient while surgery is in significant delay, which
progress. Most facilities have a surgical waiting compromises the surgical
schedule and makes a lot
room. Families should be told that information
of folks very angry.
will be relayed to the waiting room, and the
Box 2–1 American Society of Anesthesiologists Evidenced-

Based NPO Guidelines
Clear fluids: 2 hours
Breast milk: 4 hours
Infant formula: 6 hours
Nonhuman milk: 6 hours
Light meal: 6 hours

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 commu-

nicate 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, some-
times, 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

Depending on the needs of the anesthesiolo-
gist, additional teaching may be done specific COACH
to the technique. For example, positioning for CONSULT
an epidural or other regional block, or for an
awake intubation. Although not commonly
started in the PACU, if
If the patient is awake during surgery, the your patient is destined to
patient may receive information about progress. remain in the PACU for an
In some cases, for example during an arthroscopy, extended period of time
the patient may even be able to watch the pro- as a result of lack of a bed,
starting incentive spirome-
cedure on a TV screen and to ask questions
try, if ordered, will be
about what is being seen. important (see Fig. 2–3).
The physician will usually
After Surgery write an order for incentive
spirometry to be used at
Teaching after surgery focuses on postoperative
least 10 times every hour
risk reduction and preparing the patient for dis- while the patient is awake.
charge. You will begin by simply explaining to You will need to explain to
the patient the purpose of the recovery room in the patient the purpose
helping the patient move from an anesthetized of incentive spirometry,
and that the goal is not
state in the OR to a more independent one that to simply “get the balls in
will allow for discharge to a surgical floor or to the air,” but to hold the
home. These teaching points, although part of balls in the air for as long
the postoperative care of any patient receiving as possible, even if it only
means getting one of the
general anesthesia, require the nurse to assess
two or three balls up.
readiness to learn and the ability of the patient to Sustaining elevation
understand the teaching and rationale. promotes deep breathing
Prevention of Atelectasis and Pneumonia and deep lung expansion,
One important risk reduction strategy is promo- whereas quick inhalations
will get the balls in the air
tion of optimal ventilation to prevent atelectasis without sustaining lung
and pneumonia. This is important for any patient volumes. After performing
who has received general anesthesia and particu- the exercises 10 times,
larly important for patients who smoke or who the patient should be
encouraged to cough.
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 elimi-
nation 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.

F I G U R E 2 - 3 : Incentive spirometry.
For patients who may be limited to bed, or

COACH who have limited mobility, incentive spirom-
CONSULT etry will be instituted to promote deep breath-
ing, to increase lung volume, and to encourage
Patients may require coughing to clear mucus from the airway.
administration of small
doses of pain medication
Sometimes just the action of using the spirom-
to use the incentive spirometer will cause the patient to cough, particularly
eter 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 ex-
medication can cause
respiratory depression. ercises easier.
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 pro-
gressive and early ambulation. For outpatients, this is usually not a
problem, as they will need to ambulate to the bathroom to void, must

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 trans-
ferred 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 interven-
tions 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 am-
bulation 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.

Also teach leg exercises to your patient as
COACH another means of preventing clot formation.
CONSULT 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
10 times every hour while
stasis. Patients should be taught to perform the
awake and on bedrest following:
(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
of motion. extension
An additional intervention designed to re-
duce 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 pro-
thrombin 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 develop-
ment 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, dehis-
cence, extended stay, and readmission. One of the most important
strategies for the prevention of infection is hand washing. This is impor-
tant in the PACU, where one nurse may be responsible for more than
one patient and may help repeatedly in the admission and discharge of
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
alcohol-based hand cleansers may substitute. It CONSULT
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
need to start them or to administer a second dressings, drains, and
dose in the PACU. Confirm the order for the an- drainage systems, includ-
ing 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 infec-
induction, before the surgical incision. You can tion in your patient, the
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
antibiotics, stress the importance of taking all of may be spread by body
the antibiotics as ordered, to prevent infection fluids, including hepatitis
and HIV. Patients who will
and to prevent the development of antimicro- be doing any dressing
bial resistance. changes at home should
It is important to teach the patient and family be taught to wash their
the signs of infection, and the need to report hands both before and
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.

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

Promotion of Surgical Success
Although prevention of infection and promotion of wound healing is cer-
tainly 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 plan-
ning 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 ques-
tion, 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

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 discus-
sion 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 informa-
tion. 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 applica-
ble to most patients. Many surgi-centers use patient discharge instruction
sheets so that patients have a record of instructions to refer to after dis-
charge. 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 compre-
hension or to answer questions. Scheduling a follow-up visit can re-
duce misunderstanding and allow an opportunity for the patient to ask
questions.
Demonstration and return demonstration is a useful method of teach-
ing when you need to teach a patient a psychomotor skill, such as chang-
ing 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

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 unpre-
pared 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 com-
fortable 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 medica-
tions 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
agents increases side effects and potential toxicity.
COACH You will need to be familiar with each class of
CONSULT agent, as well as information specific to each agent
used within a particular class. The classes of
General anesthesia is often anesthetic agents include the following:
referred to as “balanced
anesthesia,” as the goal
• Inhalation agents
of the anesthesia provider • Intravenous agents
is to achieve a balance • Propofol
between hypnosis, analge- • Ketamine
sia, and immobility.
• 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 pro-
vide 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
oxide is such a weak keeping cardiac output, stroke volume, heart
analgesic, you should be rate, and blood pressure stable
prepared to administer • Is a weak analgesic
pain medication if this • May be sufficient for minimally invasive
agent is used as the sole
inhalation agent.
procedures, such as dental surgery
• 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,
causing no hepato-renal toxicity. Desflurane is irri-
tating to the airway on
Sevoflurane
induction, causing breath-
Sevoflurane (Ultane) is the agent that comes holding, laryngospasm, and
the closest to the ideal inhalational anesthetic. coughing. This frequently
Known for its cardiovascular stability, sevoflu- requires induction with
rane protects the myocardium by acting as another agent and then a
change to desflurane.
a coronary vasodilator. Mask induction is well
tolerated, causing no airway irritation. It causes
no hepatotoxicity.
Isoflurane
Isoflurane (Forane) used to be considered the ALERT
gold standard of inhalation agents, but has been Sevoflurane has
replaced by desflurane and sevoflurane the potential for causing
because of their speed of induction, stability, renal toxicity with prolonged
and recovery speed. Isoflurane is associated exposure due to its fluoride
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
induction in pediatrics, as induction is rapid Halothane’s nega-
and well tolerated. tive effects clearly outweigh
its usefulness. Halothane
Intravenous Anesthetics • Depresses mucociliary
function for up to 6 hours
Intravenous anesthetics are used for postoperatively, increas-
• Smooth, rapid induction ing the risk of atelectasis
• Maintenance of anesthesia and pneumonia
• Sedation in monitored anesthesia • Is a myocardial depres-
sant, causing a decrease
care
in heart rate and contrac-
tility, as well as dose-
Barbiturates dependent hypotension
Barbiturates are generally used to produce (Continued)
rapid, pleasant sleep induction prior to the
Anesthesia 47
administration of other slower, less pleasant
ALERT—cont’d anesthetic agents. They may be used to sup-
plement regional anesthesia or as the sole
• Causes a slight neuromus- anesthetic for extremely short, minor proce-
cular irritation, producing
dures such as electroconvulsive therapy and
the “halothane shakes”
postoperatively cardioversion.
• Sensitizes the myocardium Sodium Pentothal and Methohexital
to catecholamines Sodium penthothal and methohexital (Brevital)
• Has been associated with are two agents used for induction of anesthesia,
hepatic necrosis and
hepatitis
as they reliably block the wakefulness center
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 hyper-
carbia and hypoxemia. Postoperative drowsiness and sedation is often
severe. They have a low to moderate emetic effect.
Etomidate
Etomidate (Amidate) is an intravenous anes-
COACH thetic used because of its cardiovascular stability
CONSULT for emergency induction of unstable patients. It
When providing care to a
is considered a cerebral protector, as it decreases
patient who has received an cerebral blood flow and oxygen consumption. On
inhalation agent, it is impor- the downside, it causes uncontrolled muscle
tant you remember that movements known as myoclonia, hiccoughs, and
• All inhalation agents are
postoperative nausea and vomiting.
respiratory depressants,
so all patients will require Propofol
oxygen therapy and Propofol (Diprivan) is the newest and most
monitoring with a pulse popular induction agent. This agent produces a
oximeter smooth induction and a rapid recovery, with no
• All patients require
assessment of their
postoperative “barbiturate hangover.” Propofol
airway and ventilatory also has antiemetic effects, and may decrease
status, and you should the need to administer an antiemetic after sur-
encourage deep breathing gery. Interestingly, the agent looks like milk in
• Inhalation agents have no
a syringe.
residual analgesic effects,
so you should also per- Ketamine
form a pain assessment Ketamine is used to provide for dissociative
and manage accordingly anesthesia, causing a trance-like state of uncon-
sciousness as well as amnesia. Given by either
48 Anesthesia
intravenous (IV) or intramuscular (IM) routes,
this agent is a respiratory stimulant, keeping COACH
airway reflexes, such as cough and gag, intact. CONSULT
Patients generally do not require intubation. The
agent also causes cardiovascular stimulation When providing care to a
patient who has received
through excitation of the sympathetic nervous any intravenous anesthetic
system. Blood pressure (BP) peaks 10% to 50% agent, it is important you
above baseline and normalizes within 15 min- remember that
utes, making this a useful agent for patients in • All agents are extremely
short-acting with limited
shock states as organ perfusion improves with
residual effects in the post-
elevation of BP. anesthesia care unit (PACU)
Ketamine produces profound analgesia; it • If administered in the
may be the sole agent used for painful proce- PACU for short proce-
dures such as a closed reduction of fracture. dures, you should monitor
for respiratory depression
The major negative effect of ketamine is with pulse oximetry and
the postoperative agitation seen following its ongoing respiratory
administration. Ketamine is pharmacologically assessment
related to phencyclidine (PCP) and causes emer- • You should allow patients
who have received
gent reactions, including unpleasant dreams,
ketamine to awaken with-
hallucinations, and delirium. These side effects out tactile or auditory
are most commonly seen in patients aged 16 to stimulation
65 years and may be prevented with concomitant • Ketamine will potentiate
benzodiazepine administration. the effects of any addi-
tional narcotics adminis-
tered 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 ben-
zodiazepine. It is used preoperatively, intraop-
eratively, and postoperatively because of its COACH
rapid onset of action, rapid recovery, and CONSULT
amnestic effects.
Midazolam may be administered orally, IM, The renal clearance of
midazolam is 10-times
or IV, and it has the benefit of being water-
faster than diazepam,
soluble, so it does not burn during IV administra- making it the drug of
tion. Of all the currently used benzodiazepines, choice during the
midazolam comes the closest to being the ideal perioperative period.
agent.
Anesthesia 49
Diazepam
COACH Diazepam (Valium) is an older agent, limited pri-
CONSULT marily to oral administration for preoperative
sedation and relaxation. When given orally, the
When dosing midazolam, onset of action is between 30 and 60 minutes.
start with a low dose and
go slow in administration,
Amnestic effects are minimal with oral adminis-
particularly in elderly tration, facilitating preparation of the patient for
patients. 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 intraopera-
ALERT tive and postoperative use because of profound
sedation. Its slow oral onset limits its use as an
Diazepam crosses
the placenta, with adverse
induction agent. The onset, when given IM, is
effects in the newborn, unpredictable, and when given IV, the burning
including hypotonia and during administration further limits its use. The
altered thermoregulation. recovery time is long, and can be further pro-
When administered during
longed in patients with hepatic dysfunction. Res-
the first trimester of preg-
nancy, this agent has piratory depression may be profound when
adverse effects in the given with narcotics.
fetus, causing birth defects. Lorazepam
Lorazepam (Ativan) is rarely used in the periop-
erative setting because of its long duration of
sedation. This agent is 5 to 10 times more potent
COACH than diazepam. It is still used to prevent emer-
CONSULT gent reactions that might be anticipated with
ketamine administration. The drug’s primary
The half-life of diazepam is
age-dependent in adults.
benefit is its profound amnesia, and that it can be
As an example, in a patient administered either IM or IV.
who is 80 years old, the
half-life would be 80 hours, Narcotics
causing profound sedation
Narcotics are used
postoperatively.
• Preoperatively for sedation and analgesia
• Intraoperatively for induction and mainte-
nance of anesthesia as well as to blunt auto-
nomic responses
• Throughout the perioperative period for analgesia
Fentanyl
Fentanyl (Sublimaze) is the most commonly used narcotic in the perioper-
ative 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 mor-
phine, causes no histamine release. Its only When providing care to a
patient who has received
drawback is its potency. any benzodiazepine, it is
Morphine important you remember
Morphine is limited primarily to postop use for that benzodiazepines
pain control. Similar to fentanyl, its onset when • Potentiate the effects of
narcotics, particularly res-
administered 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
of morphine is that the agent causes histamine • Change responsiveness
release, leading to vasodilation; hypotension; to CO2, causing
hypercarbia
pruritus, especially of face and nose; and may • Can cause hemodynamic
cause bronchospasm in asthmatics. In addi- changes, including a
tion to IV use, this agent may be administered decreased BP, increased
IM or via the epidural or intrathecal route as heart rate, and
decreased systemic
Duramorph, which is long-acting, preservative-
vascular resistance
free morphine. • Cause sedation and
Sufentanil amnesia so teaching
Sufentanil (Sufenta) is limited to intraoperative must include written
use, primarily in cardiac surgery, because of its instructions
• Are reversible with
potency; it is 1000 times more potent than flumazenil (Romazicon);
morphine. Although this agent causes no hista- remember that the rever-
mine release, its small margin of safety can sal agent may not last as
rapidly cause profound respiratory depression. long as depressant
effects of benzodi-
Sufentanil may also be administered epidurally
azepine, requiring
or, uncommonly, intranasally. that you continue
Remifentanil monitoring the patient
Remifentanil (Ultiva) is the newest narcotic to for up to 2 hours
be used intraoperatively. With a potency postadministration
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
Alfentanil
COACH Alfentanil (Alfenta) is 25 times more potent
CONSULT than morphine, with a shorter IV onset of
action of 30 to 90 seconds and a much shorter
As the patient is not likely duration of action of 15 minutes. This drug
to remember patient teach-
ing because of the amnestic
is very limited in its use because of this
effects of a benzodiazepine, short duration of effect, and the extreme
you need to include a family severity of nausea and vomiting associated
member when conducting with its use.
the teaching.
Muscle Relaxants
Muscle relaxants are used intraoperatively to
facilitate endotracheal intubation, for skeletal
ALERT muscle relaxation and, when needed, for paral-
ysis for mechanical ventilation. They work by
Fentanyl is 100
times more potent than
interrupting transmission of nerve impulses at
morphine, making dosing the neuromuscular junction. Based on their
extremely important. specific action at the neuromuscular junction,
they are classified as either depolarizing agents
or nondepolarizing agents.
COACH Depolarizing Agents

CONSULT Depolarizing agents work by mimicking the
When providing care to a
action of acetylcholine at the neuromuscular
patient who has received junction. These agents bind to cholinergic
any narcotic, it is important receptor sites on muscle cells causing depolar-
you remember that ization of the cellular membrane. As long as the
narcotics
cell is depolarized, it is incapable of responding
• Cause respiratory depres-
sion, so pulse oximetry to further stimulation by acetylcholine, causing
monitoring is essential; neuromuscular blockade. As depolarization has
you should also encour- occurred, these agents are nonreversible. Nor-
age deep breathing mal muscle activity can only resume as the
• Potentiate benzodi-
azepines, which can
drug is metabolized and cholinergic receptor
increase both sedation and sites opened.
respiratory depression Succinylcholine
• Cause sedation Succinylcholine (Anectine) is the only depolar-
• Cause pruritus due to
izing agent used clinically. It has a rapid
histamine release
• May cause nausea and onset of 30 to 60 seconds and a rapid offset of
vomiting, so you need to 3 to 5 minutes. It is metabolized by an enzyme
protect patient airway in blood called plasma cholinesterase (pseudo-
cholinesterase), making metabolism hepatorenal
52 Anesthesia
independent. Patients with atypical pseudo-
cholinesterase, either deficient or abnormal, COACH
may have prolonged blockade. CONSULT—cont’d
Adverse effects associated with succinyl-
choline have limited its usefulness in the peri- • May cause muscle rigidity
in high doses, affecting
operative setting. The drug causes histamine muscles of ventilation
release, is a trigger agent for malignant hyper- • Are reversible with nalox-
thermia, and causes bradycardia, hyperkalemia, one (Narcan), but reversal
and an increase in intraocular and intracranial of respiratory depression
will also cause loss of
pressure. It is also associated with myalgias, or
analgesic effects
postoperative muscle soreness.
Nondepolarizing Agents
Nondepolarizing agents work by competing
with acetylcholine at the cholinergic receptor
COACH
site to block acetylcholine from reaching the
CONSULT
motor end plate. Neuromuscular transmission
is inhibited, causing a neuromuscular blockade When providing care to a
or paralysis. As long as the cholinergic receptor patient who has received
site is occupied by the nondepolarizing agent, any muscle relaxant, it is
important you remember
the cell cannot respond to acetylcholine. that muscle relaxants will
Return of responsiveness requires either generally be worn off or
time for the agent to be metabolized or the reversed in the operating
administration of a reversal agent that will room prior to PACU admis-
sion unless prolonged
allow acetylcholine levels to rise to the point
mechanical ventilation is
where the competition is shifted in favor of anticipated. To assess
acetylcholine, allowing for return of function. recovery from the use of
Agents differ in their duration of action, muscle relaxants, or follow-
route of elimination, patient stability, and side ing the administration of
agents to reverse relax-
effects. Muscle relaxants like Vecuronium, ation, the patient should
Cisatracurium, and Rocuronium are agents of be assessed for overall
choice for procedures lasting less than 30 minutes muscle strength. You can
and can be redosed for longer procedures. do this by asking the
patient to lift his or her
Agents like pancuronium, pipecuronium, and
head off of the pillow for
doxacurium are agents of choice for procedures a sustained head lift of
lasting longer than 90 minutes (see Table 3–1). longer than 5 seconds, to
demonstrate a strong hand
Reversal Agents grasp, or to follow com-
mands to move their feet
Reversal agents are used to reverse a negative
and legs against resistance.
effect of an agent. It should be noted that
reversal of a negative effect such as respiratory
Anesthesia 53
Table 3–1 Nondepolarizing Neuromuscular Blocking Agents
DURATION ROUTE SIGNIFICANT
AGENT OF ACTION OF ELIMINATION INFORMATION
Vecuronium Intermediate Hepatic CV stability

(Norcuron) No histamine release
Cisatracurium Intermediate Hoffman CV stability

(Tracrium) elimination* Slight histamine release
Rocuronium Intermediate Hepatic Rapid onset

(Zemuron) ↑ pulmonary vascular
resistance
Pancuronium Long Renal ↑ HR

(Pavulon) No histamine release
Pipecuronium Long Renal CV stability

(Arduan) No histamine release
Doxacurium Long Renal Minimal to no histamine

(Nuromax) release
CV stability
* 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

ALERT 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
dependency. be reversed.
Flumazenil
Flumazenil (Romazicon) is a specific benzodi-
azepine antagonist that works directly at benzodiazepine receptor sites to
reverse the sedative, amnestic, muscle relaxant, anticonvulsant, anes-
thetic, 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
54 Anesthesia
will be dependent on the dose of benzodi-
azepine administered, dose of flumazenil, and COACH
time between dosing of the two agents. CONSULT
Naloxone
Naloxone (Narcan) is a specific competitive Naloxone should be titrated
to minimize reversal of
narcotic antagonist that works directly at the desired effects such as anal-
mu (μ) receptor to reverse the respiratory gesia while addressing the
depression and muscle rigidity associated with need to reverse respiratory
narcotic administration. It is usually adminis- depression. Its short dura-
tion of action of less than
tered in titrated doses of 0.1 to 0.4 mg IV. The
45 minutes may mean that
reversal of analgesia causes sympathetic stimu- the duration of action of the
lation, increasing HR and BP, and may cause narcotic may outlast the
the development of dysrhythmias. Extreme effects of naloxone, requir-
caution must be taken in managing pain with ing redosing or IV infusion
of naloxone. Pulse oximetry
narcotics after reversal. monitoring should be con-
Anticholinesterase Agents tinuous, as respiratory
Anticholinesterase agents provide specific depression may reoccur.
reversal for nondepolarizing muscle relaxants.
These agents bind to the enzyme acetyl-
cholinesterase and inactivate it, thereby allowing
levels of acetylcholine to build up. Acetyl- ALERT
choline displaces muscle relaxant, restoring
Anticholinesterase
normal neuromuscular function.
agents cause muscarinic
There are three agents used clinically: side effects of bradycardia,
neostigmine, pyridostigmine, and edrophonium. hypotension, bronchocon-
These agents vary by onset and duration striction, and excessive
of action, metabolism, and side effects (see salivation. To prevent these
untoward effects, the
Table 3–2). There are also studies investigating a agents are always adminis-
new type of reversal agent for nondepolarizing tered with an anticholinergic
muscle relaxants, one that is not dependent agent such as atropine or
upon the inhibition of acetylcholinesterase glycopyrrolate (Robinul).
(see Box 3–1).
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
Table 3–2 Anticholinesterase Agents
ONSET DURATION IMPORTANT
DRUG OF ACTION OF ACTION INFORMATION
Neostigmine 6–8 minutes 60 minutes 50% renal excretion

(Prostigmin) May cause dysrhythmias
Strong muscarinic effects
Pyridostigmine 12–15 minutes 90 minutes 75% renal excretion

(Regonol, Mestinon) Less muscarinic effects
Edrophonium 2–4 minutes 60 minutes 75% renal excretion

(Tensilon) Minimal muscarinic effects
Must be given with
atropine (glycopyrrolate
causes bradycardia because
of delayed onset of action)
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 gener-
ated, 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 anes-
thetics 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 calcu-
late the dose used (see Box 3–3).
ALERT
Systemic Toxicity
Systemic toxicity from local anesthetics is most Epinephrine is
commonly due to accidental intravascular never added to local anes-
injection of the agent selected, as opposed to thetic blocks of the fingers,
nose, penis, or toes because
the administration of an excessive dose. Toxic
the potent vasoconstriction
effects are seen in the CNS and cardiovascular caused by epinephrine can
systems (see Box 3–4). No reversal is possible lead to ischemia, resulting in
and care is supportive until the agent is metab- necrosis.
olized and eliminated.
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 Severe
Lightheadedness Muscle Twitching
Dizziness Tremors
Tinnitus Unconsciousness
Drowsiness Convulsions
Disorientation Respiratory arrest
CARDIOVASCULAR SYSTEM
Mild Severe
↑ PR Interval ↑↑ PR Interval
↑ QRS duration ↑↑ QRS duration
↓ Cardiac output Sinus bradycardia
↓ Blood pressure 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 (hyperten-
sion 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 intuba-
tion to diminish laryngeal reflexes. Two topical anesthetics include the
following:
• EMLA cream or patch: This eutectic mixture of the local anes-
thetics 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 ef-
fect 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 path-
ways 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
Spinal Epidural
Opioid receptors cord CSF space
(at site of dorsal horn)
T8
T9
T10
T11
Epidural catheter
T12
Subarachnoid
space L1
Dura mater L2
L3
L4
Epidural injection
L5 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 avail-
able. 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 infu-
sion. 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 chemorecep-
tor 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 anesthe-
sia provider. Treatment is bladder catheterization.
Hypotension
Hypotension is usually minimal unless an excessive dose of local anes-
thetic 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 anes-
thesia 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 inva-
sive, 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 depres-
sion, or paralysis. This is a rare complication, as the anesthe-
sia 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 vasoconstric-
tion. 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
COACH Spinal anesthesia, also known as intrathecal
CONSULT anesthesia, involves the injection of a local anes-
thetic into the lumbar intrathecal space. The
The importance of labeling
local anesthetic mixes with CSF causing seg-
the epidural catheter cannot
be overemphasized. Some mental anesthesia, determined by dermatome
facilities use labels of a level (see Figs. 3–3 and 3–4). As the onset of the
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
66 Anesthesia
injection of the local anesthetic to allow for fluid administra-
tion. 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 Spinal fluid
Needle Anesthetic solution injected

into spinal fluid
(a)
F I G U R E 3 - 3 : Spinal anesthesia.
Anesthesia 67
C3
C4
T1
T2 C6
T3
T4
T5 C7
T6
T7
T8
T9
T10
C6 T11
T12
L1 C8
C7 S2
C8
L2
L2
L3 L3
L4 L4
L5 L5
S1 S1
F I G U R E 3 - 4 : Dermatome chart.
68 Anesthesia
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
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 antic-
ipation 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 (neo-
Synephrine) titrated to cause vasoconstriction.
Bradycardia
Bradycardia occurs secondary to a blockade of COACH
the cardioaccelerator fibers and venous pooling CONSULT
from the administration of the local anesthetic. Symptoms of bradycardia
If the patient becomes symptomatic or hypoten- producing hypotension
sive, treatment will require the administration of include clammy skin,
atropine to increase heart rate. If not already in agitation, and difficulty
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
When providing care for
catheterization.
patients receiving spinal
anesthesia, it is important Complications of Spinal Anesthesia
that you Complications of spinal anesthesia are due to
• Ensure the IV is secure. both the agents and technique used, and include
Management of any
acute cardiac or respira-
extensive spread of the anesthetic agent as well
tory complication or side as a postdural puncture headache.
effect will require the Extensive Spread of the Anesthetic Agent
administration of fluid or This complication presents as respiratory and
medications through the
cardiovascular compromise, including appre-
IV. You do not want to be
trying to start an IV hension, agitation, nausea and vomiting, arterial
emergently hypotension, respiratory insufficiency, apnea,
• Assess and document the and unconsciousness. It occurs secondary to ros-
return of sensory and tral, or upward, spread of the local anesthetic
motor function of lower
extremities. Use of a
and may be due to dose or patient positioning.
dermatome chart will Treatment centers on improving oxygenation,
facilitate assessment and assisting ventilation, and restoration of blood
documentation pressure.
• Evaluate level of pain
Postdural Puncture Headache
control and administer
additional analgesics as Also known as “spinal headache,” this compli-
needed. You can expect cation may develop secondary to a leak of CSF
that the patient’s pain from the dural puncture site. This headache
level will increase as the becomes worse with standing and is fre-
spinal recedes
• Evaluate for side effects
quently accompanied by nausea, tinnitus, and
and treat as needed. The photophobia. Conservative management will
use of a standardized include bedrest, fluids, and analgesics. More
order sheet can allow invasive treatment may require placement of
for rapid intervention
an epidural blood patch to “seal the leak.”
70 Anesthesia
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 admin-
istration 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 assis-
tants, or registered nurses.
Registered Nurse First Assistant

The Association of Perioperative Registered Nurses describes the regis-
tered 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 circu-
lating 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 main-
tain a safe and comfortable environment for the patient. The circulating
nurse assesses the patient’s condition before, during, and after the oper-
ation to ensure an optimal outcome for the patient.
“Circulating during surgery is a periopera-
tive nursing function. The role of the circulator
COACH may not be delegated to unlicensed assistive
CONSULT personnel (UAP), a licensed practice nurse
The circulating nurse is
(LPN), or a licensed vocational nurse (LVN).”
responsible for patient (www.aorn.org).
safety during the surgical
procedure. The scrub nurse Scrub Nurse
supports the surgeon by
passing instruments during According to AORN, the scrub nurse “works
the operation while also directly with the surgeon within the sterile
maintaining patient safety.
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 prepara-
tion 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 micro-
bial 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, cover-
ing 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 com-
plete, 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 com-
pletion 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
a routine part of an • Repeated before wound closure of each and
emergency procedure in any surgical cavity
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
case with a crash c-section,
If a discrepancy in the count is identified, the
a bleeding aneurysm, or a surgeon is notified immediately, and a recount
patient “crashing from the initiated. If the recount fails to correct the dis-
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 elimi-

nate 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
specific concerns. Unfortunately, priorities may be conflicting at times.
For example, a surgeon may need the patient positioned in a prone posi-
tion 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 complica-
tions 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
ALERT procedures. Modifications of the supine posi-
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
cardiac or respiratory opposite direction)
compromise, the obese • Scultetus (10º–15º Trendelenburg)
patient or a patient with an • Reverse Trendelenburg
intra-abdominal growth, • Sitting (upright)
such as a tumor or devel-
oping fetus, may have
• Lithotomy
supine occlusion of the The scultetus, or Trendelenburg, position
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
shift the patient to the left reverse Trendelenburg position is used to pro-
side and correct caval vide access to the head and neck and to facili-
occlusion. tate the pull of the viscera away from the
diaphragm (see Fig. 4–1).
F I G U R E 4 - 1 : Supine position.
Obese patients and patients with large intra-

abdominal masses may have respiratory diffi- COACH
culties as the weight of abdominal contents CONSULT
forces the diaphragm upward, limiting respira-
tory excursion and reducing functional residual The supine position offers
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 simulta-
neously 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
neurosurgery and exists as a variation of the ALERT
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
head is secured ventrally on the neck by a face of cerebral air embolism.
rest or a skull-fixation frame (see Fig. 4–2).
F I G U R E 4 - 2 : Sitting position.
The sitting position is associated with a number of cardiovascular com-

plications, 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 respira-
tory 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 intu-
bated 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 micro-
bial 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.
ALERT 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
operated clipper with a using depilatory lotions or creams may cause
disposable head or a head localized reactions, also compromising skin
that can be sterilized before integrity.
re-use. Hair removal should After the patient enters the OR, has been
take place outside of the
OR to control shedding.
anesthetized, and positioned appropriately and
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.
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 re-
duce postoperative complications. What follows As all thoracic
here is a list of common surgical procedures. surgeries will involve the
airway or organs of ventila-
Where appropriate, procedures most com- tion, assessment and care
monly performed on children appear in a sepa- of the airway is the overrid-
rate list. A surgical systems listing is used to ing priority.
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
ALERT
to correct congenital anomalies, treat coronary
artery disease, repair damage following myocar- The priorities for
dial infarction, or treat valvular disease or ar- cardiac surgery will focus
rhythmias. Many of these procedures will be on maintaining cardiopul-
monary stability and main-
performed in the cath laboratory by cardiolo- taining oxygen transport.
gists, and not in the OR.
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 arrhyth-
mias, 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 sponta-
neously or after a myocardial infarction
• Thoracic aortic aneurysmectomy: Excision of outpouching
of the ascending arch or descending thoracic aorta by replace-
ment 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,
pulmonary hypertension, and right-sided heart failure. Com-
monly 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 The priorities for
Patients may be scheduled for peripheral vascu- peripheral vascular patients
lar surgery to increase perfusion to an extremity will be to promote circula-
or organ or to circumvent abnormalities in a tory integrity and perfusion
through the assessment of
blood vessel.
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 reestab-
lish 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
The priority for • Vein stripping: Surgical removal of vari-
neurosurgical patients will cose veins in the leg
be on assessment of neu-
rologic functioning by Neurosurgical Patients
establishment of a baseline
Patients may require neurosurgical interven-
before surgery, which will
be compared with assess- tion to
ments done after surgery, • Decrease intracranial pressure
and sometimes during • Repair damage from trauma
surgery. • 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
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 con-
CONSULT nected to the right atrium or to the peritoneal
cavity via placement of a catheter
Neurovascular preservation
remains the overriding
priority for spinal surgical Spinal Surgical Patients
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, disloca-
tions, 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 sur- COACH
gery for the correction of trauma or injury, for CONSULT
diagnosis of injury, for removal or replacement
Primary importance for
of bone destroyed by disease or trauma, or for
orthopedic surgical proce-
repair of structural defects. Surgery may also dures will be placed on
be indicated to realign structures or to remove maintenance of surgical and
dysfunctional or disease structures that cause anatomic alignment, as well
pain or restrict mobility. as on neurovascular assess-
ment of the extremity. If the
surgery involves the spine,
Orthopedic Surgical Procedures neurologic assessment will
• Closed reduction: Method of reducing also be a priority.
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
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. Liga-
ment 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 Patients may be candidates for urologic or renal
CONSULT surgery to repair a congenital finding, correct
problems with voiding, correct problems that
The priority for renal and cause swelling in the urogenital area, or correct
genitourinary surgical
patients will be on urinary
problems that cause changes in urine concen-
output and prevention of tration or output. Surgery may also be indicated
infection. 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 accumula-
tion 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 transperi-
toneally 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 treat-
ment 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

COACH
Patients may have plastic surgery to reconstruct CONSULT
a congenital or acquired deformity or for cos-
metic reasons to enhance appearance. Surgery Surgical priorities for the
may be to skin, face, thorax, or abdomen. patient undergoing plastic
or reconstructive surgery
will focus on optimizing
Plastic and Reconstructive Surgical appearance and prevention
Procedures of infection.
• Skin graft: Use of donor skin to cover
a wound. Skin may be taken from pa-
tient 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 trans-
ferred 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 malfor-
mation 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 pro-
cedure to eliminate need for second surgery
• Craniofacial surgery: Correction of congenital malformations
of the face and skull. Usually requires several surgeries involv-
ing a team approach to repair
Ophthalmic Surgical Patients
Patients scheduled for ophthalmic surgery may COACH
be undergoing procedures to CONSULT
• Correct congenital abnormalities
Priorities for ophthalmic
• Repair damage
surgical patients will focus
• Correct pathophysiologic conditions on patient education, and
• Provide cosmetic reconstruction prevention of problems
Surgeries are most commonly performed on such as coughing, nausea,
pediatric and geriatric patients, and most will and vomiting, which may
increase intraocular
be performed on an ambulatory basis. pressure, compromising
surgical integrity.
Ophthalmic Surgical Procedures
• 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 Indications for ear, nose, and throat (ENT) sur-
CONSULT gery include reconstruction, need to remove
diseased or damaged tissue, promote healing by
Despite the fact that ENT
surgery may involve three decreasing or removing infection, and need to
anatomically distinct areas, maximize the airway.
almost all of the surgeries
are performed in or through Ear Surgery
the airway, making airway
• Tympanoplasty: Reconstruction of a
maintenance a number one
priority. damaged tympanic membrane
• Mastoidectomy: Removal of diseased bone
of the mastoid. Simple mastoidectomy
involves removal of only diseased bone.
COACH Modified radical mastoidectomy involves
CONSULT removal of diseased bone, some of the
ossicles, and the ear wall canal. Radical
Ear surgery is also known
mastoidectomy involves removal of dis-
as otologic surgery.
eased bone, all of the ossicles, and the
ear wall canal
• Stapedectomy: Removal of the stapes with subsequent replace-
ment 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 inflam-
matory and anatomic defects of the sinuses to restore mucocil-
iary 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 place-
ment of tympanostomy tubes to facilitate drainage
Neck and Throat Surgery

• Thyroidectomy: Removal of the thyroid gland for hyperthy-
roidism 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 proce-
dures to
• Establish a diagnosis
• Correct pathophysiologic conditions, includ-
COACH ing obesity
CONSULT • Correct congenital malformations
The major priority for the
Surgery may involve the esophagus, stom-
gastrointestinal surgical ach, biliary or hepatic systems, small and large
patient will be prevention intestines, and the rectum or anus.
of infection and protection of
the airway by prevention of Gastrointestinal Surgical Procedures
aspiration and vomiting, as
well as ensuring a means
• Esophagectomy: Removal of the esophagus,
for elimination. usually for carcinoma
• Esophagogastrectomy: Removal of cancer-
ous portion of esophagus and stomach

• Hiatal hernia repair: Restoration of the cardioesophageal junc-
tion 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 attach-
ment 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

• 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, thera-
peutic 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 gastrec-
tomy 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: Proce-
dure to enlarge pyloric sphincter to
correct pyloric stenosis in the newborn ALERT
Gynecologic Surgical Patients The priority for
Patients scheduled for gynecologic surgery may gynecologic surgical
undergo diagnostic procedures, procedures to patients will be on the
prevention of infection and
remove growths or organs, or procedures to cor- attention to detail so that
rect anatomic deviations of pathology. Surgery the bladder or bowel is not
may also be scheduled to prevent or terminate inadvertently perforated.
pregnancy, or for assisted delivery (c-section).

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 con-
tents. 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 preg-
nancy 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 instru-
ments back for cleaning and resterilization. Documentation will be com-
pleted, 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 nondis-
posable, must be able to be cleaned, disinfected, and sterilized.
Cleaning refers to the removal of surface contaminants through phys-
ical scrubbing, commonly with soap and water, and occasionally ultra-
sound 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 germi-
cidal 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 com-
monly 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 abnor-
malities. In the surgical patient, IV access is necessary for the adminis-
tration 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 compart- 2. Anti-diuretic hormone (ADH)
ments by using the rule
of thirds: TBW is two-thirds
3. Sympathetic nervous system
ICF and one-third ECF. Of Decreased blood flow to the kidney in
the ECF, two thirds is ISF hypovolemia activates the renin-angiotensin-
and one-third is plasma. aldosterone system. The kidney releases renin,
causing activation of angiotensin I and its con-
version 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 hypo-
volemia, 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 reabsorp-
tion and increased arterial pressure and increased perfusion.
The sympathetic nervous system, in conjunction with the cardiovas-
cular system, responds to changes in fluid volume, which directly affects
arterial blood pressure and urinary output. Increased blood volume in-
creases 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 circu-
lating 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 deter-
mining 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 in-
travascular and interstitial compartments.
Common crystalloids include the following*:
• D5W COACH
• D5LR CONSULT
• Lactated Ringer’s Fluid losses from the lungs
• D5NaCl 0.45% and skin are referred to as
• D5NaCl 0.9% insensible losses, as they
• 0.9% NaCl are fluid losses that cannot
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
Crystalloids are generally used daily, with approximately
• As maintenance fluids to compensate 600 mL through the skin,
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 resem-
bles 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
POTAS- MAGNE- BICAR- OSMO-
SOLUTION SODIUM SIUM CALCIUM SIUM CHLORIDE BONATE LALITY
ECF 142 4 5 3 103 27 270–300
Lactated 130 4 3 — 109 28 273

Ringer’s
0.9% NaCl 154 — — — 154 — 308
D5 45% 77 — — — 77 — 407
NaCl
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

Colloids
Colloids are natural or synthetic solutions that COACH
maintain colloid osmotic pressure within the CONSULT
intravascular space, helping to maintain circu-
The 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 crystal-
• Albumin 25% loids in the resuscitation
• Hetastarch 6% of patients in shock and the
development of pulmonary
• Dextran 40 edema associated with
• Dextran 70 fluid resuscitation. Colloids
Albumin is obtained from pooled human are more osmotically active
plasma, pasteurized and chemically stabilized. than crystalloids, and draw
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 vol-
composed primarily of amylopectin. This solu- ume to maintain blood
tion produces a 6% solution with an osmolality pressure and perfusion.
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 crys-
talloids in comparison to colloids.
Table 5–3 Crystalloids vs Colloids: Advantages and

Disadvantages
ADVANTAGES DISADVANTAGES
Crystalloids Inexpensive Dilution of plasma proteins

Restores urinary flow Reduces colloidal oncotic pressure
Restores third space losses Peripheral edema
Pulmonary edema
Transient effect
Continued

Table 5–3 Crystalloids vs Colloids: Advantages and
Disadvantages—Cont’d
ADVANTAGES DISADVANTAGES
Colloids Sustained increase in plasma Expensive

volume Coagulopathy (Dextran >
Smaller volume for resuscitation Hetastarch)
Less peripheral edema Anaphylactic reaction (Dextran)
Remains intravascular Decreased calcium (Albumin)
More rapid resuscitation 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 calcu-
lated according to the following formula:
Serum Na⫹⫹ ⫺ 140
Water deficit ⫽ 0.6 ⫻ Weight (kg) ⫻
140
Water deficit refers to the amount of fluid required to replace insensi-
ble 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, ongo-
ing 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 identi-
fied 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 ortho-
static 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, includ-
ing 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 decom-
pensation
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 oxy-
genation, such as a decreased saturation. Peripheral edema will compro-
mise myocardial function as the heart has to pump against an increased
afterload with a decreased preload. The patient may present with bound-
ing pulses, increased blood pressure until the point of failure, and then
decreased pressure, widening pulse pressure, and increased weight gain.
Edema
COACH Edema is an accumulation of fluids within tis-
CONSULT
sues caused by
You can assess for edema • An increase in hydrostatic pressure due to
in peripheral tissues by venous obstruction
looking for and palpating • Sodium and water retention
for dependent edema,
• Decreased plasma oncotic pressure through
particularly in the ankles.
In the lungs, pulmonary the loss of plasma proteins
edema will manifest as • Increased capillary permeability associated
crackles, hypoxemia, and with inflammation
decreased saturation. Third • Lymphatic obstruction
spacing of fluids, fluid that
is neither intracellular nor
Fluid status can also be evaluated using
extracellular, but lodged laboratory studies for concentration status,
in tissues, will not be seen including the following:
until the third postopera- • Serum sodium concentration
tive day, and may be a
• ⬍135 mEq/L hemodiluted, volume overload
cause of hypotension.
• ⬎145 mEq/L hemoconcentrated, volume
depletion
• Serum osmolality
• ⬍270 mOsm/L hemodiluted, volume overload
• ⬎300 mOsm/L hemoconcentrated, volume depletion

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 elec-
trolyte alterations seen in the PACU are more likely to be a conse-
quence 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, magne-
sium, 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 concentra-
tion 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 under-
gone 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 noncon-
ductive 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 develop-
ing 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

normal saline IV fluids. Serial serum sodium levels will confirm restora-
tion 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 con-
tribute 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 preopera-
tive 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 suc-
tioning, 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 aber-
rant 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 sched-
uled dialysis. Although a hyperkalemic cardioplegic solution is used in
cardiac bypass surgery, most of these patients develop hypokalemia

following surgery, due to either increased cate-
ALERT cholamines causing potassium to move intra-
cellularly or the administration of a loop diuretic
IV potassium will such as furosemide. Unexplained hyperkalemia
never be administered
detected in preoperative laboratory testing is
via IV push, no matter how
low the serum potassium grounds for cancellation of surgery pending
may be. Potassium must be medical evaluation to determine cause, which
diluted, usually 20 mEq or is most commonly renal disease.
40 mEq in a minimum of
100 or 250 cc of IV fluid,
and administered over
Chloride
an hour, using an infusion Chloride is the major anion of ECF. Normal
pump. This is done to pre- values range from 95 to 108 mEq/L. Chloride
vent inadvertent rapid levels are regulated by renal and extrarenal
administration, which couldmechanisms. Chloride will be reabsorbed or
produce cardiac arrest.
Cardiac monitoring should
excreted along with sodium. Like sodium, a
be maintained during potas-change in the serum chloride level may be due
to a change in dilution or absolute concentra-
sium replacement. It is also
important to assess renal tion. Any alteration in sodium will result in an
function prior to the admin-
abnormality of chloride. The regulation of
istration of IV potassium
supplements. As potassium chloride is dependent upon the regulation of
is regulated through the sodium, with reabsorption or excretion by
kidneys, a reduced dose the kidneys, as needed to maintain serum
will be given in patients with
concentrations.
renal insufficiency to pre-
vent hyperkalemia from
Chloride has the following roles:
developing. • 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 accompa-
nying 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. Hyper-
chloremia 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 cal-
cium 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 hyperparathy-
roidism. Although PTH levels are usually high-normal, or high preced-
ing 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 supple-
mental 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 magne-
sium 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 magne-
sium 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
COACH • Facilitate sodium-potassium transport across
CONSULT cell membranes
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
the upper GI system and to vomiting, diarrhea, gastric suctioning, and
will cause hypomagnesemia loop diuretics. Inadequate absorption seen
to occur more rapidly. with malnutrition and malabsorption syn-
dromes 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 hypo-
magnesemia, occurring due to GI loss, malabsorption, and increased
renal elimination.
As magnesium is required for cardiac and skeletal muscle contractil-
ity, 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 mon-
itored for signs of impending hypomagnesemia. Treatment for hypomag-
nesemia 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 vasodila-
tion 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 reduc-
tion 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
failure or those with glomerular filtration rates In symptomatic hypermag-
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,
antacids. Any patient with diagnosed renal dis- intravenous calcium
ease will have laboratory tests drawn prior gluconate will be given
as a temporary measure.
to surgery, and any abnormalities corrected.
Calcium gluconate antago-
Correction begins with the elimination of any nizes the toxic effects of
offending medications. If severe, the goal will magnesium by electrically
be to promote the excretion of magnesium opposing magnesium at
through the kidneys through fluid administra- the sites of action.
tion 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 phos-
phate 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 alter-
ations 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 con-
comitant 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 perioper-
ative 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 phos-
phorus, cellular destruction due to chemotherapy or trauma, and osteo-
porosis, in which low serum calcium levels cause phosphorus to be
pulled from bone. Treatment can include the administration of medica-
tions 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 acid-
bicarbonate buffer system. The body requires a narrow steady pH
for optimal cellular and organ system functioning. The carbonic acid-
bicarbonate system buffers almost 90% of biochemical reactions in the
body, maintaining a pH of 7.35 to 7.45. Understanding the role of bicar-
bonate, 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.

Measurement of pH requires obtaining a
blood gas, usually arterial, to allow for assess- COACH
ment of oxygenation as well as acid-base status. CONSULT
Acid-Base Alterations Remember, pH reflects the

The condition called respiratory acidosis occurs amount of acid or base in a
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
the blood increases, making the blood too pH between 7.1 and 14 is
acidic. In the PACU, respiratory depression basic, or alkaline. In the
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
well as preexisting medical conditions such as 7.35 or greater than 7.45
asthma, emphysema, or in patients who alters enzymatic activity
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 correc-
tion 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
that results when excessive amounts of acidic overall acid-base balance.
substances are released into the blood. In the The PCO2 reflects the respi-
ratory control of pH. The
perioperative period, this is uncommon, but PO2 level reflects adequacy
may be due to hyperglycemia, prolonged hy- of oxygenation. The HCO3
potension or cardiac arrest, or septicemia. The reflects the renal control
normal body response to this condition is in- mechanisms. Normal ranges
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
7.45, and an HCO3 of less than 22. Treatment • HCO3: 22–26 mEq/L
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. Treat-
ment 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. Com-
passionate 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 mecha-
nisms 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 con-
tinually 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 con-
served 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 elimi-
nate carbon dioxide, making it less available to bind with water to make
carbonic acid. If serum pH is too alkaline, the lungs respond with shal-
low, 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 The kidneys are capable of neutralizing more
CONSULT acid and more base than either the chemical
buffer systems or the respiratory control mech-
Compensation is a term
anisms. Renal control focuses on bicarbonate
used to indicate the
attempt of the body to reabsorption, bicarbonate production and ex-
normalize pH by using the cretion, and hydrogen ion excretion. If the
system not affected by dis- serum pH is too acidic, the kidneys will reab-
ease, medications, or other sorb additional bicarbonate within the proxi-
physiologic stressors, to
stand in place of deficien-
mal renal tubule and will excrete hydrogen
cies within the opposite ions. If the serum pH is too alkaline, the kid-
system. For example, if the neys will respond by excreting additional bicar-
lungs are not adequately bonate in the form of ammonium (NH4), which
maintaining oxygenation
is a base. Renal control mechanisms, although
and effective ventilation,
the renal control mecha- very effective in normalizing pH, engage a
nisms will respond to slower process than either the chemical buffer
normalize pH. If the body, systems or respiratory control mechanisms,
as evidenced by the accu- and can take many hours, up to 3 days, to be
mulation of acids or the
depletion of bicarbonate,
fully effective. pH will be normalized, but PCO2
fails to control pH through and HCO3 levels will reflect the attempt of the
renal regulation, the lungs lungs and kidneys to compensate for the alter-
will alter the pattern of res- ations in pH. After the underlying problem
piration to compensate for
causing the imbalance is corrected, these
the failure of the kidneys. If
abnormalities are seen in levels will normalize.
either PCO2 or HCO3, yet
the pH is normal, compen-
sation has fully occurred.

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

• Restlessness
• Agitation
• Confusion
• Coma
• Muscle twitches or seizures
• 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

• Confusion
• Impaired motor/sensory function
• 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,
you can then obtain report from the anesthesia The immediate PACU
provider in preparation for continued care. admission assessment is
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
is a Standard of Care for the American Society in-depth postsurgical and
post-anesthetic assessment
of Anesthesiologists and the American Society
can be initiated.
of Perianesthesia Nurses. The purpose is to pro-
mote 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 cholecystec-
tomy. 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 some-
thing 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

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 Neurologic
Cardiac rate Responsiveness to stimuli
Cardiac rhythm Moves all extremities
Blood pressure Follows commands
Temperature Orientation
Skin condition
Respiratory
Renal Rate
Intake and output Rhythm
IV lines/infusions Breath sounds
Irrigation Pulse oximetry
Drains/catheters Airways
Oxygen delivery system
F I G U R E 6 - 1 : PACU major body systems assessment.

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 per-
fect, 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

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 evi-
denced 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

interfere with the functioning of the inter-
COACH costals and diaphragmatic muscles required for
CONSULT inspiration.
The surgical procedure may compromise the
Your nursing interventions patient’s ability to oxygenate and to take deep
will be directed toward the
maintenance of ventilation
breaths. Any surgery that enters the thoracic
and perfusion and toward cavity will cause pain with inspiration. A chest
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 place-
ment of an artificial airway. The postoperative, post-anesthetic complica-
tions of obstruction, hypoxemia, and hypoventilation are detailed in
Chapter 9: Perioperative Complications.
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 depres-
sants. 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 dimin-
ished 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 distur- CONSULT
bances of potassium, will affect myocardial con-
tractility. Secondary to hypoxemia, hypokalemia Your nursing interventions
will be directed toward
is the most common cause of postoperative maintenance of cardiac
ventricular ectopy. output and elimination of
The surgical procedure itself may compro- the cause.
mise cardiac output. A cardiac tamponade
following a valve or bypass procedure will inter-
fere with myocardial contractility. Baroreceptor stimulation after a
carotid endarterectomy may cause hypertension.
Actions taken may be independent, such as encouraging deep breath-
ing, 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
When you make a judgment that your patient COACH
is experiencing physical pain or psychologic CONSULT
discomfort, evidenced by complaints of pain,
Separation from family
nausea, and vomiting, or behavioral or physio- members 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
• Fear of the unknown CONSULT
• Anxiety about the outcome of surgery
Your nursing interventions
• Body image changes as a result of
surgery increasing patient comfort
Physical discomfort or pain may be the result and eliminating the cause
of surgical manipulation, positioning, shivering, of pain.
or the presence of binders, casts, tight dressings,
or invasive lines. Pain may also be the result of in-
adequate 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 post-
operative, 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 diag-
nosis 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, includ-
ing 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
COACH anesthesia disoriented or delirious. Viscous dis-
CONSULT tention, including gastric and bladder disten-
tion, may contribute to postoperative agitation
Your nursing interventions
and uncooperativeness.
restoration of appropriate Interventions may be independent, includ-
neurologic functioning and ing reorientation, use of touch, and continued
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 postopera-
tive, 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

is most certainly due to intraoperative events,
such as surgical exposure, use of IV or irriga- COACH
tion fluids, and the amount of time spent in a CONSULT
cold OR. The pediatric and geriatric patient
will be more susceptible to heat loss. Your priority when caring
for a patient who is
Nursing interventions may be independent, hypothermic centers on
including application of warm blankets or rewarming and the preven-
rewarming devices or collaborative with the tion of further heat loss.
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 atten- CONSULT
tion and which problem can wait. For example,
if a patient is admitted demonstrating signs Actual problems take
of being unable to maintain an airway inde- priority over potential
problems. 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, ther-
priority over rewarming. moregulation, and delayed
As you provide care to the patient, you also awakening.
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, cardiovas-
cular stability, awakening, and pain control, you can prepare your
patient for discharge. Discharge may be to the surgical floor, to an ambu-
latory 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.

Assessment of the Thoracic Surgical
ALERT Patient
Inspection will be the first physical assessment
If your patient is skill you will use to evaluate the patient who
not breathing, stop your
assessment and begin
has experienced thoracic surgery. Your observa-
resuscitation. tions 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 breath-
ing 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, hypox-
emia, hypoventilation, or secretions. Bradypnea may be secondary to
anesthetic and narcotic administration, or secretions. Epidural anes-
thesia 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, irreg-
ular, 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?
A patient who is recovering
If the patient has a chest tube, is it mediasti-
from a pneumonectomy nal or pleural? A mediastinal tube is designed
requires a wound drainage for wound drainage and is usually attached to
system. A patient recover- low, continuous wall suction. A pleural tube is
ing from a lobectomy or
designed to reinflate the lung or to drain a
segmentectomy requires
placement of a pleural wound, and will also be attached to low, contin-
chest tube to promote lung uous wall suction.
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 re-
expanded. 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 evalua-
tion of air and fluid and to promote reexpansion of the lung.
Some systems are also equipped to be
utilized as an autotransfusion system
See Figure 6–2 for a representation of a pleural COACH
drainage system. CONSULT
Hemorrhage is a potential early complica-
When turning a patient
tion following thoracotomy. When monitoring who is recovering from
chest tube drainage, output should be measured lobectomy or segmentec-
every 15 minutes. If drainage exceeds 100 tomy, the operative side
mL/hour, if fresh bleeding is noted, or if a sud- should remain in the
uppermost 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
The positioning of the patient is important. patient should be posi-
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 tho- lung, keeping any drainage
racic surgical patient. Palpation will be used to dependent.
identify any area of tenderness or observed
abnormalities. Swelling or bulges can be pal-
pated to assess consistency and pain. The chest
tube insertion site should be palpated for crepi- COACH
CONSULT
tus, also known as subcutaneous emphysema,
which is caused by the presence of air trapped Crepitus will feel like “Rice
in subcutaneous tissue. Krispies” under the skin.

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 tis-
sue replaces air-containing tissue. Hyperresonance is heard over hyperin-
flated, emphysematous lung tissue when air is trapped in distal alveoli.
Auscultation of breath sounds is part of the post-anesthetic and post-
thoracic 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 noncon- COACH
tinuous, lessen with coughing, and CONSULT
are usually heard during early or late
inspiration If you are unfamiliar with
the sound of crackles, rub
• Rhonchi: Low-pitched, continuous the hair next to your ear
snoring sounds usually heard on with your fingers. The
expiration as air moves through narrow sound of crackles is very
airways. Rhonchi may be heard in similar to this sound.
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 recover-
ing 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 labora-
tory, 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 coopera-
tion 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

postoperative period. The patient should also
COACH have arterial blood pressure monitoring initiated
CONSULT 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 vasocon-
secondary to the adminis-
tration of intraoperative
stricted. If the patient has a pulmonary artery
diuretics, should alert you catheter in place, it too should be connected,
to the possible need for calibrated, and monitored.
potassium replacement, so The chest tubes (usually mediastinal, occa-
be prepared to obtain
sionally pleural) should be connected to
admission laboratory tests,
including a potassium suction immediately in case bleeding should
level. start. The sternal dressing and leg dressings, if
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 initi-
ated 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 car-
diopulmonary 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 intraop-
eratively, which may compromise gas exchange
• Coagulation studies—prothrombin time (PT), partial thrombo-
plastin 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.
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 adminis- COACH
tration of anesthetics. Patients may need to be CONSULT
intubated and ventilated for an extended period
of time, well into the evening, and extubated Chest tube outputs of
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
Assess and monitor hemoglobin levels. Hemo- should notify the surgeon.
globin may have fallen as a result of hemor-
rhage, hemodilution, or lysis of red blood cells
on bypass. An evaluation of coagulation function
is mandatory. With significant postoperative COACH
bleeding, the cause may be loss of surgical in- CONSULT
tegrity or alterations in coagulation.
Think of preload and after-
Maintenance of oxygen transport is dependent load this way: Preload is
on an adequate cardiac output. Maintenance of the amount of blood that
cardiac output is dependent on stroke volume enters the heart that must
and heart rate. Stroke volume is dependent be moved through the
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
ventricle during diastole. The degree of preload. Afterload reflects
stretch depends on the volume of blood the tone of peripheral
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
force of contraction required to empty blood, afterload is low. If
the ventricle (Starling’s law) the vessels are clamped
down, making the left
• Afterload: The degree of pressure
ventricle work hard, after-
opposing 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 dis-
ruptions in the conduction system and may be seen in patients recover-
ing from valve surgery or in those having experienced an intraoperative
myocardial infarction. Beta blockers may also cause bradycardia. Tachy-
cardia 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
COACH upon preload. Right ventricular preload is meas-
CONSULT ured by central venous pressure (CVP). Left
ventricular preload is measured by the pul-
Cardiac tamponade is a monary artery occlusion pressure, or “wedge
surgical emergency. The
patient must be returned
pressure.” Preload will be decreased as a result
to the OR immediately to of fluid shifts, positive end expiratory pressure, or
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
in the intensive care unit if is aimed at improving circulating volume with-
no OR is immediately avail- out compromising overall myocardial function,
able. Although not the and may include fluids, inotropic medications, or
ideal, it is considered a life- other vasoactive medications.
saving maneuver when no
other options are available.
The exception to this clinical picture is car-
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. Treat-
ment 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
In cases of increased SVR, the myocardium must empty against resist-
ance, 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 in-
clude rewarming and the use of vasodilators,
If the dysrhythmia
including morphine, nitroglycerin, and sodium
is life threatening,
advanced cardiac life- nitroprusside (Nipride).
support protocols should Finally, treatment will be directed toward
be instituted. correction of dysrhythmias. Dysrhythmias
are usually transient; they may be caused by
underlying disease, electrolyte imbalance, cardiac manipulation, hypox-
emia, hypothermia, or acid-base disturbances. Treatment will be directed
toward correction of the underlying cause. See Chapter 9 for identifica-
tion 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 dress-
ing, 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 com-
pared 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 loca-
tion 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
affected extremity. Pain is an indicator of possi- COACH
ble circulatory impairment. CONSULT
If the surgery involved the cerebral circula-
If 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
the section on care of the neurosurgical patient.) with a Doppler. If absent
Vital signs should be monitored in all vascu- to Doppler, the vascular
surgeon should be notified
lar surgical patients. Hypertension in these immediately.
patients may cause hemorrhage, hematoma

Temporal
Right Subclavian Carotid

Left Subclavian
Aortic arch
Coronary
Celiac
Abdominal
aorta Superior mesenteric
Renal
Brachial Inferior mesenteric
Common iliac
Radial Internal iliac
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 nitroprus-
side 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

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 noti-
fied immediately of any changes in pulses, in color, skin temperature,
or vital signs.
Postoperative bleeding should be evaluated carefully. Hematoma for-
mation may compromise vascular integrity. In the carotid endarterec-
tomy patient, hematoma formation may com-
promise the airway. Excessive bleeding may
indicate loss of vascular integrity along a su- COACH
ture line, requiring return to the OR, or it may CONSULT
indicate alterations in coagulation, secondary
If the patient is recovering
to intraoperative anticoagulation with heparin. from a carotid endarterec-
You should obtain a coagulation profile: PT, tomy, neurologic function-
PTT, INR. Alterations may be treated with pro- ing should be evaluated
tamine sulfate. and documented. Acute
changes should be promptly
reported to the surgeon.
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 COACH
assessment has been made preoperatively and CONSULT
documented in the patient’s chart to provide
you with a baseline for comparison. Decorticate posturing,
The neurologic assessment begins with an flexion of the arms across
the chest, and decerebrate
evaluation of the patient’s level of conscious- posturing, extension of
ness. The anesthesia team will try to bring the arms, are signs of neuro-
patient to the PACU as awake as possible to allow logic deterioration (see
for a more complete and accurate evaluation. Figs. 6–4A and B).
You should first assess the patient’s response to

(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 pres-
sure. Before determining true unresponsiveness, fluid and electrolyte
balance should be checked and alterations corrected, normothermia
restored, anesthetics metabolized or reversed, and adequacy of oxygena-
tion 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 cere-
brospinal fluid (CSF). Normally, brain tissue compromises 78% of in-
tracranial 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 in-
tracranial 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

Table 6–4 Manifestations of Increased Intracranial Pressure
DIMENSION CLINICAL SIGNS CAUSE
Level of Decreased level of consciousness Impaired cerebral blood flow

consciousness Changes in affect
Changes in attention
Coma
Vital signs Increased systolic blood pressure Increasing pressure on pons, medulla,
Widening pulse pressure* hypothalamus, and thalamus
Bradycardia*
Full, bounding pulse
Irregular respiratory pattern*
Changes in temperature
Ocular signs Dilatation of ipsilateral pupil Compression of oculomotor nerve

Sluggish to no response to light (cranial nerve III)
Inability to move eye upward
Ptosis of eyelid
Blurred vision
Diplopia
Changes in extraocular eye Compression of optic nerve (II),
movements trochlear nerve (IV), and abducens
nerve (VI)
Motor function Contralateral hemiparesis or General increases in intracranial

hemiplegia pressure
Pain response
Posturing
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 respira-
tory 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.

F I G U R E 6 - 5 : Pupil assessment scale.
Sensorimotor function also should be as-

COACH sessed. Ask your patient to smile, frown, and to
CONSULT 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 pres-
sure is death, secondary to
feet. Equality of the right and left sides should
cerebral herniation. Clinical be evaluated.
manifestations of increas- Formal assessment of cranial nerve func-
ing 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,
ocular signs, motor func- the tests for their assessment.
tion, headache, and vomit- Figure 6–6 illustrates the progression of
ing. Report any and all of events resulting from uncontrolled increases in
these signs immediately. ICP. Treatment of increased ICP is both prophy-
lactic and therapeutic. Prophylactic treatment
may include elevating the head of the bed 30
degrees unless contraindicated by the surgery,
COACH hyperventilating the patient if intubated to
CONSULT keep the CO2 level less than 35 mm Hg, utiliz-
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.
When you plant, you put early increases in ICP. Therapeutic interven-
something down into the tions may include aggressive application of pre-
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

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 Assess facial response to touch

Motor Assess patient’s ability to clench jaw
VI Abducens Motor Assess lateral deviation of eye
VII Facial Sensory Check taste on anterior two-thirds of tongue*

Motor 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 Check taste on posterior tongue*

Motor Ask patient to swallow. Check gag reflex
X Vagus Sensory Ask patient to speak

Motor 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 preopera-
tive, or baseline, assessment, as well as the assessment immediately pre-
ceding the current one. Documentation should be kept current. Any
acute changes or signs of increased ICP should be reported immediately
to the neurosurgeon.

Increased cerebral Increased cerebrospinal Cerebral
blood flow fluid 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

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 bleed-
ing 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 prostatec-
tomy patients, you should verify the solution and rate of infusion and
maintain accurate output records, calculating urine output from irriga-
tion output. The output catheters should be assessed for patency. Out-
put also may occur via an ostomy outlet, as seen with patients under-
going 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 postoper-
ative 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 irriga-
tion 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 solu-
tions 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 postoper-
ative 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,
If the patient uses the ambulatory surgical patients will be required
bathroom to void, as to void before discharge.
opposed to a urinal, ask Ice packs may be ordered to decrease
the patient not to flush
swelling. Likewise, after procedures like hydro-
the toilet so that you can
assess the output for celectomy, varicocelectomy, or spermatocelec-
bleeding or clots. tomy, a scrotal support may be ordered to prevent
edema and to decrease discomfort.

You should recognize that patients may
experience embarrassment from the procedure COACH
and the continued assessments required post- CONSULT
operatively. Care should be provided profes-
sionally and directly, maintaining patient Although IV narcotics
are most commonly used
privacy at all times. for pain management in
If the patient is post-renal transplant, either patients following renal
living related or cadaveric, it is important that and genitourinary surgical
you follow institutional protocols and/or postop- procedures, you may see
an order for belladonna
erative orders specific to IV fluids and rate of
and opium (B&O) supposi-
administration, laboratory tests to be obtained, tories. B&O suppositories
criteria for fluid replacement, intake and output work well to control blad-
monitoring, and pain control. Care of the patient der spasms that may
post-transplant is commonly not only specific to be experienced after
transurethral surgery in
the institution, but to the surgeon who performs which the catheter is left
the operation. 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 mobil-
ity. 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 pos-
sibility 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 anes-
thetic 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 no-
tify 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 follow-
ing 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 dis-
COACH charge.
CONSULT The surgeon may order elevation of the
Carefully review the chart
extremity to minimize or prevent swelling. If
for specific positioning the extremity is casted with a plaster cast that
considerations that may be may still be damp to touch, pillows or blan-
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 exter-
nal 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 devi-
ations 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 auto-
transfusion 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 postop-
erative patients, it is important that you be aware of its potential occur-
rence. 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 compart-
ments 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
• Pallor COACH
• Paralysis CONSULT
• Pulselessness You should remember that
Treatment of compartment syndrome pulseless is an extremely
involves prompt recognition of symptoms. Non- poor prognostic sign, and
surgical intervention may include cast removal is indicative of severe
compromise.
or splitting of the cast. Surgical intervention

will be decompression via a fasciotomy, in which the compartment is ex-
cised to release pressure.
Assessment of the Plastic and Reconstructive Surgical Patient

It is important to remember that plastic or reconstructive surgical proce-
dures may involve skin and the face, thorax, or abdomen. Despite the
anatomic variations, PACU care has some clear similarities for any pa-
tient 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 avail-
able 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 suc-
tion. 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 oxygena-
tion will be a priority in any patient undergoing
COACH surgery in or around the airway. You will mon-
CONSULT itor respiratory effort and adequacy continu-
Your major nursing priority ously. Airway protection equipment such as
should mirror the surgeon’s airways, suction, and Ambu-bag should be im-
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 tech-
niques 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

circulation of the flap via an opening in the surgical dressing. Infants
following cleft lip, cleft palate, or pharyngeal flap repair will require care-
ful 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 COACH
ophthalmic surgery is rooted in skills of inspec- CONSULT
tion. On admission to the PACU, the patient will
If the patient is a pediatric
often be wearing an eye patch, covered with a
patient, care will be needed
metal or rigid plastic shield. Make sure the to protect the dressing
dressing is secure. Take care not to dislodge the from inquisitive fingers and
dressing when applying the oxygen mask or frustrated personalities.
when repositioning the patient.
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, nau-
sea, 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 anes-
thetic 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.

Dressing care has already been addressed. However, the effects of de-
creased vision secondary to the surgery and the eye patch must be con-
sidered. Visual impairment may contribute to disorientation and postop-
erative 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
discomfort is expected and by the surgeon. For these types of surgery, the
may be treated with anal- surgeon will often inject air or an expandable
gesics. Severe eye pain may gas behind the retina. The patient will be posi-
be indicative of increased tioned so that the air, when it rises, will hold the
IOP or hemorrhage. The
ophthalmologist should be
retina against the choroid blood supply. Patients
notified immediately in may even arrive in the PACU face down. It will
either case. be important to consult the surgeon or postoper-
ative 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 dis-
coloration 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

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 pro-
motes sinus drainage. In addition, this position promotes respiratory
excursion.
If the patient has an artificial airway in place,
including an endotracheal tube, tracheostomy COACH
tube, or nasal airway, placement of the airway CONSULT
should always be confirmed by repeated auscul-
Watch closely for any signs
tation of breath sounds. A chest x-ray examina- of airway obstruction,
tion may be performed to confirm placement of including snoring, increased
an endotracheal tube. respiratory effort, absent
Confirm whether the surgeon has ordered breath sounds, and falling
oxygen saturation. If you
additional airway equipment to be kept at the suspect obstruction, inter-
bedside in case of emergency. A reintubation ventions will include stimu-
tray and a tracheostomy set should also be read- lating your patient to take
ily available. deep breaths, and opening
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
vascular and, as a result, bleeding may become COACH
CONSULT
a problem postoperatively. If wound drainage
devices are in place, their patency should be If the patient has a new
evaluated and the adequacy of suction main- tracheostomy, a spare
tained. If the wound has packing in place, as tracheal airway is usually
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
cover dressings may need to be changed or be kept at the bedside.
reinforced. The packing should be left in place.

If the patient is bleeding into the mouth or
COACH oropharynx, suctioning may be required. Suc-
CONSULT tioning 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
soft catheter, reminding
must be maintained to prevent infection.
the patient to self-suction Secretions may be problematic after ENT
gently. surgery. Normally, 20 to 50 ml of saliva are pro-
duced 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 sur-
gery. Steroids may be ordered to decrease inflammation. Steroids are
commonly ordered after tonsillectomy, radial neck dissection, or maxil-
lary 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. Pre-
vention 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 speci-
fied 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.

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 anes-
thesia 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. Know-
ing the patient’s baseline skill level, language and communication skills,
and level of caregiver dependence will be an important part of preoper-
ative 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 COACH
in the mouth. The mouth and oropharynx CONSULT
should be inspected for bleeding. Bleeding can
Remember, these patients
result in laryngospasm and, if blood is swal-
could not tolerate a proce-
lowed, in nausea and vomiting. dure in the dentist’s office,
so you will need to be par-
Assessment of the Gastrointestinal Surgical ticularly attentive to their
Patient unique needs. Involving
their primary caregiver
Inspection will be the first physical assessment will aid efforts to decrease
skill used to evaluate the patient who has postoperative agitation
undergone gastrointestinal (GI) surgery. The and to promote patient
surgical site dressing will be evaluated for loca- comfort.
tion, 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 reposi-
tioning or irrigating the NG tube. The tube may lie in close proximity to
an anastomosis, or suture line. Repositioning the tube could cause perfo-
ration 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 inci-
sions are extremely painful, and can cause the patient to limit respiratory
excursion, causing hypoventilation. Hypoventilation will predispose the
patient to atelectasis and pneumonia. Pain man-
agement 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
repositioned, it is helpful anesthetics may be injected along the incision
to post a sign over the line. Epidural analgesia and patient-controlled
patient’s bed stating “NO analgesia are popular pain control interven-
REPOSITIONING OF NG tions in these patients.
TUBE.” Although you
might not post this sign in
To prevent thrombus formation and the
the PACU, because you will development of pulmonary embolism, antiem-
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
unit, and is often written as will be especially true for long surgical proce-
a postoperative surgical dures on high-risk patients, such as patients who
order by the surgeon. are obese. Encouraging the patient to perform
active range of motion exercises will promote

venous return. Subcutaneous heparin will fur-
ther decrease the risk of clot formation. This COACH
drug may be started in the OR or in the PACU. CONSULT
Fluid status should be evaluated, consider-
ing intraoperative fluid intake, output, and Loss of intravascular
volume, known as “third-
blood loss. Accurate intake and output records spacing,” is not usually
are important, and will assist in the manage- seen until the third
ment of fluid status once, and if, third-spacing postop day.
develops,
Assessment of the Gynecologic Surgical

Patient
COACH
Inspection will be the first skill used to assess
CONSULT
the patient who is recovering from gynecologic
surgery. The surgical site should be inspected, Occasionally, the urine in
and the condition of dressings noted. A diag- the drainage bag may
nostic laparoscopy patient may have only two contain methylene blue
dye. This dye is injected
abdominal band-aids, whereas a patient follow- into the bladder intraoper-
ing an abdominal hysterectomy may have a atively to observe for any
large suprapubic dressing. The presence of movement of dye into the
drains should be noted, and an assessment of surgical field. If dye is
detected in the surgical
the type and amount of output recorded. A
field, a bladder perforation
drain should alert you to the fact that drainage will be suspected. This
is expected. Drains are also used to decrease observation and subse-
swelling. A urinary catheter may have been quent repair will be done
placed to promote bladder emptying and to in the OR.
monitor urine output more closely on an
hour-by-hour basis.
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

bed will promote respiratory excursion. High
COACH humidity oxygen will promote gas exchange.
CONSULT Antiembolism stockings such as TED hose,
with or without sequential compression devices,
It should be noted that may have been applied in the OR, especially for
generalizations for surgical
care are just that, gener-
high-risk patients and those patients who were
alizations. Care of the sur- positioned in the lithotomy position. Subcuta-
gical patient is often very neous heparin may be ordered to further prevent
specialized, particularly for clot formation postoperatively.
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.

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 com-
ponent 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
• Patient’s physiologic and psychologic COACH
make-up CONSULT
• Preoperative pharmacologic and psy-
Patients who have under-
chologic preparation of the patient gone abdominal and
• Anesthetic management before, intrathoracic surgery
during, and after surgery generally experience the
• Presence of postoperative most postoperative pain.
Posterolateral incisions
complications tend to be more painful
• Quality of postoperative nursing care than anterolateral ones.
Specific contributing factors to postoperative Surgery on the joints, back,
pain may be found in Table 7–1. and anorectal areas also
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 classi-
fied 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 postopera-
tive 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 throm-
boembolic 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 increas-
ing 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 self-
report. Pain medication and the institution of other relief measures may
Pain Management 173

be withheld if the report of pain is not accom-
COACH panied by behavioral or physiologic signs of
CONSULT distress.
If the patient does confirm Behavioral Indicators

the existence of pain, it is
Behavioral indicators of pain include crying,
important to ask two more
questions: moaning, or grimacing. Pain may also be sus-
1. Where is your pain? Do pected when the patient demonstrates guard-
not assume that a post- ing by pulling back from touch to protect an
operative patient is area, restlessness, and frequent repositioning.
experiencing pain at
the surgical site. For
These behavioral indicators of pain can assist
example, it would be the post-anesthesia care unit (PACU) nurse in
improper to assume that determining the reality of pain, particularly in
a patient who had a the preverbal or nonverbal patient.
total hip replacement
and is complaining of
Physiologic Indicators
pain is experiencing pain
at the surgical site. The Physiologic indicators of pain include manifes-
pain may in fact be tations of sympathetic stimulation, including
myocardial, due to a tachycardia, hypertension, tachypnea, dilated
dysrhythmia and immi- pupils, and increased muscular tone. It has
nent infarction.
2. Can you describe your
been recommended by clinical practice guide-
pain? A patient may lines to utilize physiologic measures only as
describe postsurgical adjuncts to the patient’s self-report and not as
incisional pain as sharp sole indicators of pain. This is because physio-
and burning, but a report
logic indicators are neither sensitive to nor spe-
of crushing pain that lim-
its the ability to take a cific as indicators of pain. For example, the signs
deep breath describes of tachycardia, hypotension, and tachypnea can
very different pain. 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.
ALERT
Restlessness may
Pain Assessment Tools
be indicative of hypoxemia,A number of useful pain assessment tools have
so careful evaluation must
be made.
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 1 2 3 4 5 6 7 8 9 10
No Moderate Worst
pain pain pain
F I G U R E 7 - 2 A : 0 to 10 numeric pain intensity scale.
Pain Management 175

10 WORST PAIN
5 MODERATE PAIN
F I G U R E 7 - 2 B : 0 to 10 vertical numeric pain inten-

sity 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 assess-
ment 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 MILD MODERATE SEVERE VERY WORST
PAIN PAIN PAIN PAIN SEVERE POSSIBLE
PAIN PAIN
NONE ANNOYING 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 28–31 ⱕ 28 wks

6/7th wks 6/7th wks
Behavioral state Active/ Quiet/ Active/ Quiet/

Awake Awake Sleep Sleep
Heart rate 0–4 beats/ 5–14 beats/ 15–25 beats/ 25 beats/

minute minute minute minute
increase increase increase increase or ⬎
02 Sats 0%–2.4% 2.5%–4.9% 5%–7.4% 7.5% or ⬎

decrease decrease decrease 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 inten-
sity 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
–2 –1 0 1 2
Crying No cry with Moans or cries Appropriate crying Irritable or crying High-pitched or
Irritability painful stimuli with painful stimuli Not irritable at intervals silent-continuous cry
Consolable Inconsolable
Behavior state No arousal to Arouses minimally Appropriate for Restless, Arching, kicking
any stimuli to stimuli gestational age squirming Constantly awake
No spontaneous Little spontaneous Awakens or arouses minimally/
movement movement frequently no movement (not
sedated)
Facial expression Mouth is lax Minimal expression Relaxed Any pain Any pain expression
No expression with stimuli Appropriate expression continual
intermittent
Pain Management 179
Extremities tone No grasp reflex Weak grasp Relaxed hands Intermittent Continual clenched
Flaccid tone reflex and feet clenched toes, toes, fists, or finger
Decreased muscle Normal tone fists, or finger splay
tone splay Body is tense
Body is not tense
Continued
180 Pain Management
Table 7–4 N-PASS Scale—Cont’d

ASSESSMENT
CRITERIA SEDATION NORMAL PAIN/AGITATION
–2 –1 0 1 2
Vital signs: HR, No variability ⬍10% variability Within baseline 10%–20% from ⬎20% from baseline
RR, BP, SaO2 with stimuli from baseline or normal for baseline SaO2 ⱕ75% with
Hypoventilation with stimuli gestational age SaO2 76%–85% stimulation—slow
or apnea with stimulation— recovery
quick recovery Out of sync with vent
Premature Pain ⫹3 if ⬍28 weeks

Assessment 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/ Frowning/ Clenched Full cry

smiling grimacing teeth expression
Body movement Calm, relaxed Restless/ Moderate Thrashing,

fidgeting agitation or flailing,
moderate incessant
mobility agitation, or
strong
voluntary
immobility
Sleep Sleeping Restless while Sleeps Sleeping for

quietly with asleep intermittently prolonged
easy (sleep/awake) periods of
respirations time
interrupted
by jerky
movements
or unable to
sleep
Verbal/vocal No cry Whimpering, Pain crying Screaming,

complaining high-pitched
cry
Consolability Neutral Easy to Not easy to Inconsolable

console console
Response to Moves easily Winces when Cries out High-pitched

movement/ touched/ when touched/ cry or scream
touch moved moved 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 Occasional grimace Frequent to constant

expression or smile or frown, withdrawn, frown, clenched jaw,
disinterested quivering chin
Legs Normal position Uneasy, restless, Kicking, or legs

or relaxed tense drawn up
Activity Lying quietly, Squirming, shifting Arched, rigid, or

normal position, back and forth, jerking
moves easily tense
Cry No cry (awake Moans or whimpers, Crying steadily,

or asleep) occasional screams or sobs,
complaint frequent complaints
Consolability Content, relaxed Reassured by occa- Difficult to console

sional touching, hug- or comfort
ging, or being talked
to, distractible
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 SCORING
0 1 2
Face No particular Occasional grimace Consistent grimace or

expression or smile or frown; withdrawn, frown; clenched jaw,
disinterested; frequent/constant
appears sad or quivering chin;
worried 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 SCORING
0 1 2
Legs Normal position or Uneasy, restless, Kicking, or legs drawn

relaxed; usual tone tense; occasional up; marked increase in
and motion to tremors spasticity, constant
limbs tremors or jerking
Does your child move his/her arms/legs in a manner that indicates pain? Describe.
Activity Lying quietly, Squirming, shifting Arched, rigid, or jerking;

normal position, back and forth, severe agitation; head
moves easily. tense or guarded banging; shivering
Regular, rhythmic movements; mildly (not rigors); breath
respirations agitated (e.g. head holding, gasping or
back and forth, sharp intake of breaths,
aggression); severe splinting
shallow, splinting
respirations;
intermittent sighs
Are there other bodily movements/activities that indicate pain in your child? Describe.
Cry No cry Moans or whimpers, Crying steadily,

occasional complaint; screams or sobs,
occasional verbal frequent complaints;
outburst or grunt 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 Difficult to console or

occasional touching, comfort; pushing away
hugging, or being caregiver, resisting care
talked to, distractible 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 1 2 3 4 5
No hurt Hurts little Hurts little Hurts even Hurts whole Hurts
bit more more lot worst
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 Score
Breathing Normal Occasional Noisy labored

Independent of labored breathing
vocalization breathing Long period
Short period of of hyperven-
hyperventilation tilation
Cheyne-Stokes
respirations
Negative None Occasional Repeated

vocalization moan or groan troubled
Low level speech calling out
with a negative Loud moaning
or disapproving or groaning
quality Crying
Facial expression Smiling, or Sad; frightened; Facial

inexpressive frown grimacing
Continued
184 Pain Management

Table 7–8 PAINAD Scale—Cont’d
0 1 2 Score
Body language Relaxed Tense Rigid

Distressed Fists clenched
pacing Knees
Fidgeting pulled up
Pulling or
pushing away
Striking out
Consolability No need to Distracted or Unable to

console reassured by console,
voice or touch 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 represen-
tative on the team.
As soon as the need for pain management has been determined, it is
necessary to determine the most appropriate intervention, whether phar-
macologic or nonpharmacologic. If the choice is pharmacologic, the deci-
sion 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 man-
age pain, including nonsteroidal anti-inflammatory agents, opioids, and
local anesthetics. Each has specific indications and limitations.
Pain Management 185

NSAIDs (Nonsteroidal Anti-inflammatory Drugs)
Pharmacologic management of mild to moderate pain should begin, un-
less 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, includ-
ing 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,
Only acetaminophen
ketorolac (Toradol), is limited to 5-day
(Tylenol) does not affect maximum use due to concerns about renal
platelet function. As a toxicity
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 alter-
ations 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 com-
monly in the PACU by the nurse or by the patient using a regulated, pro-
grammed 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 levor-
phanol (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 antag-
onists at others. The action of the mixed agonist-antagonists is deter-
mined 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 agonist-
antagonists 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.
Pain Management 187

nalbuphine (Nubain), and buprenorphine (Buprenex). In the PACU, their
use is limited, although they can be used in the management of moder-
ate 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 discom-
fort 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, orthope-
dic, 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 preopera-
tive 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 Neck
Interscalene plexus block Superficial cervical plexus block
Local infiltration Infiltration
Arm Chest
Brachial block Intercostal blocks
Local infiltration Epidural
Cryothermy
Groin (hernia) Abdomen

Ilioinguinal Upper intercostal blocks
Iliohypogastric blocks Wound perfusion
Epidural
Hand
Brachial block Lower wound
Elbow block perfusion
Epidural
Fingers
Digital block
Loin (nephrectomy)
Wrist block
Epidural
Anterior thigh (skin graft) Intercostal block
Lateral femoral cutaneous Paravertebral somatic block
Anogenital
Caudal
Varicose vein strip Epidural
Femoral nerve block Penile block
Knee
Femoral block
Epidural
Toes Local infiltration
Digital block
Ankle block 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 postoper-
COACH ative pain relief. The exception might be in
CONSULT labor and delivery for cesarean delivery, where
the catheter is used as the primary anesthetic.
The test dose uses a com- Anticipating that the ideal approach to pain
bination of a local anes-
thetic and epinephrine to
management is prevention, not treatment, the
assess for correct place- anesthesiologist will begin the epidural infusion
ment. 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
intrathecal as opposed to to starting the infusion. This is done in recogni-
epidural placement. tion of the fact that it frequently takes 2 hours
Epinephrine is used to to infuse enough medication to provide ade-
assess for the development quate analgesia. By beginning the infusion pre-
of tachycardia and an
increase in blood pressure.
operatively or intraoperatively, the patient may
which is indicative of awaken in the PACU relatively pain free.
intravascular injection, as An alternative approach is for the bolus to be
opposed to epidural place- given 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
the administration of anes- nurse will likely have to supplement the epidural
thetic agents, to allow infusion with small, titrated doses of narcotic
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
effects due to the adminis-
advantage of excellent pain control, they offer a
tration of any anesthesia. If number of physiologic benefits, including the
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
prior to use. extremities
• 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 postop-
erative period is the potential for untoward side effects, particularly respi-
ratory 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
190 Pain Management

morphine permit rostral or upward ascension of
the drug, producing a higher incidence of side COACH
effects, most notably respiratory depression. CONSULT
Fentanyl is lipophilic, and moves preferentially
into the spinal cord. To avoid this problem, it may Infusions must always be
delivered via an infusion
be preferable to use lipophilic drugs such as fen- pump because epidural
tanyl, rather than the more hydrophilic narcotics infusions need to be
such as morphine, to decrease the risk of side delivered under pressure in
effects. The use of pulse oximetry monitoring a controlled manner. A
Buretrol volume control
will also be helpful in monitoring for signs of
chamber should also be
respiratory depression, evidenced by a falling utilized to limit available
oxygen saturation level. Box 7–2 offers a checklist infusion to no more than
of items that should be confirmed when manag- 20 mL, as a safety precau-
ing postoperative epidural anesthesia. tion in the event of a pump
failure.
Other potential side effects include the
following:
• Pruritus without rash
• Paresthesia
Box 7–2 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
Pain Management 191

When the patient is discharged to the surgi-
COACH cal floor, a pulse oximeter should be in place to
CONSULT continue monitoring. In addition, naloxone
(Narcan) should be readily available at the bed-
If the epidural infusion side, along with a syringe, for administration in
seems to be inadequate in
controlling a patient’s pain,
the event of apnea or respiratory depression.
the anesthesia provider may Many centers have standing orders for the ad-
bolus the catheter with the ministration of naloxone to allow the nurse to
epidural infusion and administer the medication without delays that
reassess the patient in 30 to
may occur while trying to notify the physician.
60 minutes. If analgesia
remains inadequate, a test
dose of local anesthetic and Nonpharmacologic Interventions
epinephrine, usually Pain management in the PACU will certainly
2% lidocaine and 1:200,000 center on the use of pharmacologic interven-
epinephrine, will be injected
through the catheter to
tions. That said, there will be times when non-
confirm placement. The test pharmacologic interventions may be more
dose will generally yield one appropriate or used as adjuncts to medica-
of three results. (1) If a bilat- tions. For example, a 6-month-old infant who
eral sensory block occurs in
underwent a herniorrhaphy in which the local
a few segmental der-
matomes, correct place- anesthetic bupivacaine had been injected into
ment of the epidural is the wound for pain control would benefit
confirmed. In this case, greatly from being reunited with his or her
insufficient volume of the parents or another primary caregiver, as
infusion mixture is the likely
cause of inadequate analge-
parental support is a powerful adjunct to pain
sia and may be corrected control. The application of warm blankets to
by increasing the rate of the control shivering is another adjunct. The use
infusion. (2) A unilateral sen- of music therapy has been shown to reduce
sory block indicates that the
postoperative pain and anxiety. Patients who
catheter tip has advanced
too far into the epidural are already skilled in relaxation and biofeed-
space, with a lateral migra- back will benefit from using these tools to
tion into the neural fora- help control pain.
men. The condition may be
corrected by withdrawing
the catheter 1 to 2 cm and
Evaluation of Pain Management
repeating the test dose.The final step in the pain management process
is the evaluation of the effectiveness of inter-
This is usually done by the
anesthesia provider or pain
ventions in controlling or reducing pain. The
management nurse.
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
192 Pain Management

with postmedication pain scores. A score of
zero, or no pain, is not necessarily the goal of COACH
pain management. The goal is to reduce the CONSULT—cont’d
pain to a level tolerable for the patient, with no
adverse side effects or patient compromise. (3) The complete absence
of any sensory block indi-
After evaluation, the nurse may decide to cates that the catheter is no
administer additional pain medication, to con- longer in the epidural
tinue to monitor the patient, or to discharge the space. The catheter should
patient to home or a surgical floor, assuming all be removed and replaced,
or the patient may be
other discharge criteria have been met.
switched to an alternative
form of postoperative pain
Challenges in Pain Management control, such as patient-
One of the biggest challenges in pain manage- controlled analgesia.
ment is attempting to control acute surgical pain
in the patient who chronically uses opioids in the
management of a chronic pain condition. These
patients may be taking high doses of opioids to COACH
control baseline pain, and now an acute pain CONSULT
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
already taking 140 mg extended release mor- the interest of patient
phine (Kadian) BID, using 2-mg doses of mor- safety, to order the pulse
oximeter and to confirm
phine IV for postoperative pain management
that it is in place before
may be grossly ineffective, particularly on post- discharging the patient to
operative day two when the effects of the last the surgical floor. The
dose of extended release morphine have expired, PACU nurse maintains
unless the morphine has been restarted. If the 1:1 or 1:2 staffing ratios,
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.
morphine, pain control will be problematic on Sending the naloxone and
day one, 4 hours after the last dose of the usual syringe also will be helpful.
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 med-
ication. 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.
Pain Management 193

Dosing Conversion Tables
COACH There are numerous dosing conversion tables
CONSULT available in textbooks and on the Internet allow-
ing calculation of dosing when converting one
Rarely will nonpharmaco-
narcotic to another; for example, oral morphine
logic interventions be used
in place of medications to to parenteral (injectable) fentanyl or oral
control pain. The exception methadone to injectable hydromorphone (Di-
might be following extuba- laudid). The problem is that these tables do not
tion or the administration take into account that patients will restart their
of naloxone or other rever-
sal agent for respiratory
oral medications once they are able to tolerate
depression, when the oral fluids and food, and that the nature of the
administration of opioids acute surgical pain is intense immediately fol-
would further depress ven- lowing surgery, improving over time. Also,
tilation and compromise
these tables will indicate the need for very high
patient safety. Once respi-
ratory adequacy has been dose narcotic administration in the immediate
confirmed, pain medica- postoperative period, which can be done safely
tions can be judiciously in the PACU with 1:1 or 1:2 staffing and monitor-
administered, with pulse ing, but is less safe when done on the postoper-
oximetry monitoring in
place.
ative 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
COACH staffing ratios and closer monitoring.
CONSULT
When Patients Are Not Opiate-naive
Patient-controlled analge- High-dose narcotic administration in the pa-
sia remains one of the tient chronically using opioids is not uncom-
most effective strategies in
the management of acute
mon, and it is important to remember that
pain in the chronic pain these patients are NOT opiate-naive, meaning
patient, as it allows the they will have a high tolerance for narcotics.
patient to have some con- Doses that would cause concern in the opiate-
trol over medication use,
naive patient following surgery will have little
something that patients
are very used to doing in to no effect on the patient who is opioid
the management of their dependent. The administration of these high
chronic pain. 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.
194 Pain Management

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 sur-
gical recovery is infection. As a nurse, your role will be to prevent infec-
tion 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 essen-
tial, 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 contam-
ination. 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 precau-
tions 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. Character-
istics 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 activa-
tion of the coagulation cascade and the subsequent release of clotting fac-
tors. 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 cellu-
lar 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 deposi-
tion, granulation tissue formation, epithelialization to cover the wound,
and wound contraction.
Wound Assessment and Care 197

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 heal-
ing. See Figure 8–1 for all the stages of wound healing.
Injury to tissue
Inflammatory phase
Hemostasis Occur Inflammation

simultaneously
Severed vessels Release of bradykinin,

constrict histamine, serotonin,
prostaglandins
Platelet and fibrin Vasodilation and

clots form 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
for further surgical procedures. The CONSULT
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 granu- wound closure as bacterial
lation. See Figure 8–2 for examples of contamination increases
wound healing by primary, second- sharply after the 8th day.
ary, 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
(b) Secondary intention
Wound gaping and irregular Granulation occurring Epithelium fills in scar
(c) Tertiary intention
Wound not sutured Granulation partially fills Granulating tissue sutured

in wound together
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 Nonadhesive
portion portion
F I G U R E 8 - 3 : Montgomery straps.
Types of Surgical Dressings

Most surgical dressings are made of gauze and ALERT
secured with tape. Paper tape can be used for
patients allergic or sensitive to adhesive tape. Original surgical
dressings should not be
Large wounds that require frequent changing removed unless ordered.
or irrigation may require securing with Mont-
gomery straps (see Fig. 8–3).
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, how-
ever, when you must remove the dressing as a result of excessive bleed-
ing, malfunction of a drain, or prolonged stay in
the PACU. Assessment begins with observation
and ends with documentation.
When assessing, make sure to assess the COACH
wound’s location, as well as its: CONSULT
• Size: At presentation; it should dimin- Well approximated implies
ish with healing edges that are clean and
• Edges: Should be well-approximated tightly closed together.
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
ALERT 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
other signs of infection, • Serous: Clear to straw-colored, watery
including purulent drainage, • Serosanguineous: Thin, watery, pale red
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
If the wound is pink or red, • General condition of patient: Look espe-
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 documen-
tation is complete. Box 8–1 is an example of a wound assessment checklist.
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 oth-
ers 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
• Remove fluid that causes swelling ALERT
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 postopera-
• Using suction may cause tissue trauma tive order to not reposition
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 con-
nected 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 reser-
voir that must be compressed to establish suction. May be
used for autotransfusion (see Fig. 8–4)

F I G U R E 8 - 4 : Hemovac drain.
Passive Drains
• Penrose: Soft flat tube of latex or silicon
placed when drainage is expected. Usually
COACH free drains to gauze, but can be inserted into a
CONSULT collection bag to measure output. Frequently
secured with a sterile safety pin to prevent
You can expect 300 to
500 cc of drainage from a
dislodgement or migration into the wound
T-tube for the first 24 hours (see Fig. 8–5)
following surgery. Output • T-tube: Placed to drain bile from common
of ⬎500 cc should be bile duct following surgical exploration, to
reported to the surgeon.
relieve blockage of bile duct, or to bypass an
After 4 days, drainage will
decrease to ⬍200 cc/day. 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

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 under-
lying 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 Complications
COACH Delaying Healing
CONSULT
Delayed healing can be caused by local causes,
Prophylactic antibiotics may such as infection, tissue hypoxia, and repeated
be given in the OR prior to trauma; and systemic causes such as diabetes
incision to decrease risk of
postop infection. It is impor-
mellitus, malnutrition, and immunosuppres-
tant to verify the antibiotic sion; advanced age; and abnormal laboratory
was administered, and to values reflective of disease.
continue any antibiotics
ordered postoperatively.
Local Causes Delaying Wound
Healing
Infection is the most common cause of
delayed healing. It interferes with new granu-
COACH lation tissue and tissue growth factors delay-
CONSULT ing collagen deposition. The risk of wound
Wound healing requires tis- infection is higher in hospitalized patients in
sue O2 levels of greater than comparison with patients discharged to home.
40 mm Hg. One of the Staph. aureus is the most commonly cultured
biggest detriments to organism, followed by the gram-negative
wound healing is smoking,
as it causes vasoconstriction
bacilli.
and localized tissue hypox- Tissue hypoxia leading to tissue necrosis is
emia. Encouraging a patient another cause of delayed healing. An inade-
to stop smoking is important quate blood supply, due to hypotension, arterial
in the perioperative period.
occlusion, vasoconstriction, or hypothermia will
slow the production of collagen and will inhibit
the migration of fibroblasts, increasing the risk
of infection.
COACH
CONSULT Repeated trauma due to poor surgical opposi-
tion or excessive mobility of the wound can also
Protection of the wound is lead to poor wound closure and an increased
essential to promote heal- risk of infection.
ing. This will be particularly
important if a regional anes-
thetic or block is used, with Systemic Causes Delaying Wound
residual anesthesia blocking Healing
sensation of excess pres- Diabetes mellitus, particularly when poorly
sure, thereby increasing the
controlled, blocks neutrophil and macrophage
risk of unintentional injury.
function, increasing the risk of infection. Glyco-
sylation of red blood cells, seen with poor
control, leads to hypoxia and ischemia.

Malnutrition, particularly protein-calorie
malnutrition (PCM), decreases fibroblast prolif- COACH
eration and neovascularization, increasing the CONSULT
risk of infection. Vitamin C is required for colla-
gen synthesis. Knowing a patient’s hemo-
globin A1c value will pro-
Immunodepression, immunodeficiency, and vide you with information
immunosuppression due to chemotherapy, about his or her level of
radiation, malignancy, or HIV, and use of im- glucose control. Poor
munosuppressive medications such as steroids, glucose control leads to
increased glycosylation of
NSAIDs, and aspirin will delay healing and
red blood cells. The target
increase the risk of infection. Steroids suppress hemoglobin A1c is less
inflammation, blunting healing, whereas NSAIDs than 7%, reflecting good
and aspirin interfere with platelet aggregation glucose control over time.
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 concomi- COACH
tant diseases increases. CONSULT
Abnormal laboratory tests indicative of sys- The best indicator of malnu-
temic disease also may provide a reason for trition is the serum albumin
impaired wound healing or may provide evi- level. A serum albumin of
dence of underlying infection not previously 3.5 to 5 g/dL (35 to 50 g/L)
is considered normal. A
detected. Box 8–2 identifies laboratory tests
serum albumin of less than
that should be checked in the event of 3.5 g/dL (35 g/L) is diagnos-
delayed wound healing, along with the under- tic of protein calorie malnu-
lying condition that may be interfering with trition, which may be present,
healing. even with a normal body
weight.
Box 8–2 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
Wound dehiscence refers to a separation of
In the event of a wound edges. The most common cause of de-
wound dehiscence, you will hiscence is infection. Secondary causes include
see profuse serosan-
failure of wound closure, slipped knots, and
guineous drainage. Cover
the area immediately with a broken sutures. Occurring most commonly 7 to
sterile dressing, and notify 10 days postoperatively, it is seen in 2% of all
the surgeon. The patient midline abdominal incisions. Wound dehiscence
will likely be returned to the is associated with a 15% to 30% mortality.
OR for wound closure. The
patient will also need an IV
Risk factors associated with wound dehis-
for fluid replacement, as cence include the following:
large amounts of fluid loss • Advanced age (older than age 65 years)
occurs through exposed • Emergency surgery
viscera.
• 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 con-
tinuous irrigation of the bladder, as seen following transurethral resec-
tion of the prostate (TURP).

Nasogastric Tube
Gastrointestinal motility is slowed following GI ALERT
surgery, with an unpredictable return of func-
tion. Simultaneously, gastric fluids continue to An NG tube is not
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 feed-
ings. 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
olpenytg t
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 emer-
gently 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).

Outer tube Inner Obturator
(a) with flange cannula
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 Pilot Inflating 15 mm
valve balloon tube adapter
Cap to
one-way
valve
Inflated Depth
cuff 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 inter-
vene 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 complica-
tions of obstruction, hypoxemia, and hypoven- Remember,
tilation. These complications occur as a result monitoring equipment
of exposure to anesthetic agents, medications does not replace your
astute nursing assessment
used for pain management, surgical interven-
and 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 obstruc-
tion, 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 air-
flow. 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
COACH and surgical management. Once admitted to
CONSULT the PACU, you can help prevent tongue obstruc-
tion by continuously stimulating your patient,
If tongue swelling is an
anticipated concern, for
performing ongoing assessment with prompt
example, following a interventions, and by having airway equipment
palatoplasty, the surgeon readily available.
will often place a long The treatment of a tongue obstruction fol-
tongue stitch in the patient’s
lows a step-wise approach to management. If
mouth. The tongue stitch is
taped to the outside of the you are successful in relieving the obstruction
patient’s cheek so that the with the first intervention, you will continue to
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
chin, to extend the neck, will also An oral airway will be
tolerated only in a somno-
accomplish this goal (see Figs. 9–1 lent patient. An awake
and 9–2) patient will require
• Step 3: Placement of oral or nasal placement of a nasal
airway: You may need to insert an oral airway.
or a nasal airway to relieve the obstruc-
tion. 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

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 res-
piratory 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 irri-
table 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 pre-
vent 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 adminis-
tered 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 pres- You must simulta-
sure ventilation with an Ambu-bag, mask, and neously and immediately
oxygen. involve the anesthesiologist
in management of a patient
These patients may require administration
with laryngeal obstruction
of a subparalytic dose of succinylcholine to as any additional interven-
relax the laryngeal muscles and to stop the tion will be beyond the
agitative behaviors. As this medication must be scope of nursing practice.
administered by an anesthesia provider, you

must involve them immediately in the care of
COACH these patients. Once the muscle relaxant has
CONSULT been given, patients will require assisted venti-
lation until spontaneous ventilation occurs.
Although the first-line Reintubation will ideally be avoided to minimize
intervention for a patient
in laryngospasm is positive
further airway irritation.
pressure ventilation with
an Ambu-bag, mask, and Croup
oxygen, this is often difficult Croup, also called subglottic edema, is a type of
to accomplish. The patient
feels like he or she is being
airway obstruction most commonly seen in
suffocated, and placement children. Signs and symptoms characteristic of
of an airway mask over the croup include an expiratory stridor and the
mouth and nose adds to classic sign: a barking cough. Children at risk
that feeling. The result is
for croup are those between 3 months and
often increased agitation,
making ventilation difficult. 4 years of age who have experienced a trau-
As a result, it is imperative matic intubation, a tight-fitting endotracheal
to involve an anesthesia tube, or a position change while intubated dur-
provider early in the inter- ing surgery, such as when a child is flipped
vention to regain airway
control promptly.
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
COACH obstruction, centers on minimizing airway irrita-
CONSULT tion. This requires a smooth intubation with an
appropriately sized endotracheal tube, and the
Racemic epinephrine is
cancellation of surgery for any patient with an
used for its vasoconstriction
effects, not for bronchodi- upper respiratory infection.
lation. The effects are Treatment requires administration of humid-
temporary, and rebound ified oxygen, and frequently racemic epineph-
edema may occur. If used rine. Racemic epinephrine is given to reduce
to treat croup, the patient
will require prolonged
swelling in tissues of the airway.
observation and, possibly,
overnight admission. Hypoxemia
Racemic epinephrine will Hypoxemia is defined as a PaO2 of less than
also increase heart rate 60 mm Hg or an SaO2 (saturation) of less than
during administration.
Cardiac monitoring should
90%. Signs and symptoms of hypoxemia are non-
be maintained during and specific, ranging from agitation to somnolence,
immediately following tachycardia to bradycardia, and hypertension to
treatment. hypotension. These nonspecific signs may sug-
gest other conditions and interventions, delaying

the required interventions to treat hypoxemia.
As a result, pulse oximetry monitoring is a stan- COACH
dard of care for any patient receiving anesthesia CONSULT
(see Fig. 9–5). Cyanosis is a late sign.
There are many possible causes of hypox- Anytime a patient presents
with 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
rapidly make the determination of the cause consider the cause to be
of hypoxemia, and to intervene appropriately. hypoxemia until proven
otherwise.
Hypoventilation
Hypoventilation is defined as a decrease in respi-
ratory rate that results in decreased alveolar ventila-
tion, 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 anes-
thetics 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 gen-
eral 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 hypox-
emia, 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 addi-
tional narcotics after admission into the PACU, as well as ongoing assess-
ment 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 per-
sistent 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 nar-
CONSULT cotics. You should elevate the head of the bed,
There are times when
unless contraindicated, to help maximally
hypoventilation is due to expand the chest cavity. In extreme cases, a
pain, requiring administra- symptomatic patient will require reintubation
tion of narcotics. Narcotics, and mechanical ventilation until level of con-
however, may themselves
sciousness and muscle tone sufficiently
cause hypoventilation.
Clinical decision making, improve to allow unassisted ventilation.
based on assessment, is Atelectasis
required, along with the Atelectasis is another common cause of postoper-
careful administration of ative hypoxemia, particularly on the postopera-
small, titrated doses of
narcotics to manage pain
tive surgical floor. Atelectasis may be the result of
without further compromis- bronchial obstruction caused by secretions or
ing 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 non-
advanced skill. When in
doubt, consult an experi- specific signs of hypoxemia, patients will present
enced PACU nurse or with diminished to absent lung sounds.
anesthesia provider. Prevention is most important. Implementa-
tion 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 emer-
gence 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 aspi-
ration 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 intra-
abdominal 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 sur-
gery, may cause airway obstruction, hypoxemia, and hypercarbia. If par-
ticles 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 induc-
tion. Use of a rapid sequence induction and immediate placement of
a nasogastric (NG) tube intraoperatively can also prevent aspiration.
Treatment of aspiration centers on correc-

COACH tion of hypoxemia through oxygen administra-
CONSULT tion; removal of foreign material if possible,
such as through gentle suctioning of blood
A “rapid-sequence” induc- from the oropharynx; and maintenance of
tion begins with preoxy-
genation of the patient,
hemodynamic instability. Antibiotics will be
followed by IV administra- administered only if the potential for infection
tion of immediate onset is suspected. Steroid use is not evidenced-based,
acting agents, cricoid pres- but is common practice.
sure, and rapid intubation
Bronchospasm
of the trachea with the goal
of preventing aspiration. Bronchospasm is the result of increased
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, aspi-
ration, 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 medica-
tions, such as morphine used for pain management.
Prevention of bronchospasm centers on minimizing airway stimula-
tion 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. Bronchodila-
tors are used to open small airways and to decrease airway resistance.
Beta-agonists including albuterol, and racemic epinephrine are the

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
the treatment, call him or her for assistance. First-line intervention for
bronchospasm is always a
Anticholinergics, including atropine sulfate or beta-agonist.
glycopyrrolate (Robinul), may be given to de-
crease 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, aspira-
tion, 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 oxygena- COACH
tion, as well as treatment of the underlying CONSULT
cause. Oxygenation will be improved with
oxygen administration via mask or possibly the Pulmonary edema due
to an increase in capillary
extreme of intubation with mechanical ventila-
permeability 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
are used to pull fluid from vessels and alveoli. “ASSAULT” on the airway.
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 trav-
els 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 pa-
tient 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
that you promptly notify
and signs of congestive heart failure. Although a
the anesthesiologist any definitive diagnosis requires pulmonary angiog-
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 radiol-
instability.
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 con-
gestive 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 cor-
rection of hemodynamic instability by following advanced cardiac life
support (ACLS) protocols. As pulmonary embolism may be life threaten-
ing, 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.

F I G U R E 9 - 6 : Antiembolism
stockings.
F I G U R E 9 - 7 : Sequential com-
pression 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
positive pressure ventilation, central line place- It is recommended
that 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
rupture a bleb. It is an expected outcome fol- possibility of clot formation
lowing open lung surgery so these patients will while the device is off, and
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 pneumotho-
rax, and may range from a small fall in oxygen saturation and restless-
ness to chest pain, dyspnea, and decreased breath sounds on affected
side. Definitive diagnosis requires a chest x-ray.

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 immedi-
ate 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 ther-
apy 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, dys-
rhythmias, 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 meas-
ures 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 diffi-
cult 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 out-
put. Tachyarrhythmias prevent optimal ven-
tricular filling. COACH
Conduction blocks compromise myocardial CONSULT
pump activity lowering cardiac output. The heart
pumps ineffectively. This cause of hypotension Inotropic medications
increase the force of
will require inotropic and chronotropic medica-
myocardial contractions.
tions or antiarrhythmics to manage. Chronotropic medications
Secondary Cardiac Dysfunction increase the rate of
Secondary cardiac dysfunction is due to contractions.
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 pres-
sure 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 second-
ary 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.
Initial fluid boluses will
Vasodilatation may also be due to direct
generally be done with smooth muscle relaxation that occurs with sym-
either normal saline or pathetic blockade as a result of the administra-
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
monitoring the speed and and nitroglycerin used to treat hypertension; or
amount of fluid given so as due to endotoxin release as seen in sepsis.
to not overload the patient. Vaso-Vagal Response
This includes monitoring of A vaso-vagal response is an emotional response
breath sounds and clinical
resolution of signs of
produced by profound grief, fear, or pain. Blood
hypoperfusion. pressure falls, causing dizziness, but usually
self-corrects after the patient resumes a hori-
zontal 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 Hypovolemia Decreased Vascular

due to due to Resistance due to
Primary Secondary Unreplaced Medications

Dysfunction Dysfunction intraoperative fluid losses Sepsis
Hemorrhage Anaphylaxis
Dehydration Emotional Response
Myocardial Infarction Negative PEEP Spinal anesthesia
Tamponade
Embolism
inotropic and
chronotropic
(Intrathoracic pressure
Venous return ) Rewarming
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. First-
line 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 vasocon-
striction and increased blood pressure (BP). The administration of anal-
gesics 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 nor-
malize 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 anti-
hypertensive 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
Correction of hypertension
patient in the hospital that caused the blood
requires prompt identifica- pressure to increase. This may include sensitivity
tion and correction of the to or overdose on vasoconstrictive medications
cause. If that is not possible, due to a malfunctioning infusion pump, mis-
use of antihypertensive
programmed infusion pump, or a medication
medications will normalize
BP (see Table 9–1). miscalculation. Discontinuation of medications
and correction of any pump malfunction or
misprogramming should normalize BP.
Table 9–1 Antihypertensive Therapy

ROUTE OF IMPORTANT
DRUGS ADMINISTRATION ACTION INFORMATION
Nitroglycerin (Tridil, Sublingual Relaxation of Intravenous infusion

Nitrostat, Nitro- Dermal vascular smooth requires infusion pump
Dur, Nitro paste) Intravenous infusion muscle and arterial line
Coronary vasodi- monitoring, glass bottle,
lation and special tubing
Decrease in
venous return
Decrease in
ventricular filling
Sodium nitroprusside Intravenous infusion Direct peripheral Requires infusion pump

(Nipride) vasodilator and arterial line moni-
Afterload toring; infusate must be
reduction protected from light,
usually with foil bag

Table 9–1 Antihypertensive Therapy—Cont’d
ROUTE OF IMPORTANT
DRUGS ADMINISTRATION ACTION INFORMATION
Hydralazine Oral Relaxation of

(Apresoline) vascular smooth
muscle Prefer-
ential relaxation
of arterioles
Maintains cardiac
output
Labetalol hydrochloride IV bolus Alpha-blocker— Do not administer if

(Normodyne, Trandate) peripheral patient is bradycardic
vasodilation (heart rate ⬍ 60 bpm)
Beta blocker—
decreases heart
rate
Enalapril maleate IV bolus Suppression Avoid with diuretics

(Vasotec) of renin- or volume depletion;
angiotensin- onset occurs in
aldosterone 15 minutes; peak of
system action usually within
1 hour but occasionally
up to 4 hours
Nifedipine (Procardia) Oral Calcium channel Capsule can be

Sublingual 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 administra-
tion of antiarrhythmic agents. Being able to quickly recognize abnor-
mal 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, Myocardial ischemia

bronchospasm, aspiration, Depression of contractility
pulmonary edema, Atrial dysrhythmias
pulmonary embolism, Ventricular dysrhythmias
pneumothorax Conduction delays
Hypokalemia Gastric suctioning Widening of QRS complex

Insulin administration Development of U waves
Diuretic use S-T abnormalities
PVCs
Ventricular tachycardia
Ventricular fibrillation
Altered acid-base Gastrointestinal losses Cardiac excitability

status Hypotension PVCs
Lactic acidosis Ventricular tachycardia
Circulatory instability Pulmonary or cardiac Myocardial ischemia

compromise Conduction delays
Preexisting heart History of myocardial Myocardial irritability and

disease infarction, especially within ischemia
last 6 months Conduction delays
Atrial fibrillation
Hypothermia Cold operating rooms Conduction delays

Surgical exposure Bradycardia
Long surgeries Heart blocks
Atrial fibrillation
Vaso-vagal response Valsalva maneuver Severe sinus bradycardia

Direct eye, vagus nerve,
or carotid sinus pressure
Medications Residual anesthetics lower Bradycardia

arrhythmic thresholds Conduction delays
Spinal anesthesia Tachycardia with ketamine
Narcotics
Ketamine
Surgical stress and Increased catecholamines Tachycardia

pain 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 in-
volvement 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 look-
ing QRS complexes
• Common causes in PACU: Hypoxemia, hypokalemia
• Treatment: Not generally required unless ⬎6/minute or multi-
focal; 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 test-
ing, 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 phar-
The treatment for
V-fib is always defibrillation. macologic with amiodarone (150 mg over
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 high-
flow, 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 car-
diopulmonary collapse. In children, a 10% to 15% loss of circulating vol-
ume 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
ALERT surgeon and the anesthesiologist. If the patient
has to be returned to the OR for repair of bleed-
In 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
hypoxemia is always to be anesthesiologist must be included in manage-
considered due to bleeding ment. Obtain a hematocrit and hemoglobin and
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 medica-
tions 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
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 replace-
ment 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 bleed-
ing 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 continu-
ous 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 breath-
ing, 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 oxygena-
tion, 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. Evalua-
tion for the risk factors for embolism (Virchow’s triad) will increase your
index of suspicion for this diagnosis. Definitive diagnosis requires pul-
monary 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 sympto- origin. Improvement and
matic pneumothorax will require placement of maintenance of oxygena-
a chest tube. tion will be a priority. Even
Gastrointestinal Origin if you are wrong in assum-
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
felt this before, either based on what they eat, CONSULT
or if they have not eaten in a while. Treatment
As it is difficult to differen-
requires 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
diaphoresis, nausea, and anxiety. until proven otherwise by
cardiac enzymes. Delaying
Musculoskeletal Origin
antacid administration is
Pain from a musculoskeletal origin is uncom- not life threatening. Missing
mon in the PACU unless following trauma a myocardial infarction
as cause of admission. This type of pain may could be.
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
common cause of emergence delirium is No sedative agents
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 eld- ALERT
erly patient with Alzheimer’s disease, Parkin-
son’s disease, or impaired comprehension. Management of
Management of this type of agitation is best emergence delirium
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
patient experiences withdrawal from chronic the potential to compro-
mise oxygenation and
exposure to alcohol, opioids, hallucinogens, or
ventilation, in a patient
cocaine. The patient may not have revealed use already potentially compro-
of these substances preoperatively. Treatment mised following anesthesia
requires maintenance of patient and staff safety, administration. Contact the
administration of benzodiazepines, and prn use anesthesiologist to assist in
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 con- sedative medication.
tribute to postop agitation. Patients may be Ongoing 1:1 monitoring,
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 mini-
mal 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
Sedation/Restraints
Psychosis
Toxic Psychosis Oxygenation/Ventilation

Investigate origin
Respiratory and
Oxygenation/Ventilation
Circulatory Causes
Cardiovascular stability
Functional
Sedation/consult
Psychosis
Emergence
Delirium Anesthetic
Oxygenation/Ventilation
Exposure
Rule out hypoxemia Medications Eliminate use/sedation/reversal

Investigate/treat cause
Consider sedation
Maintain patient safety Altered
Rewarm/Investigate cause of
Thermoregulation
hyperthermia
Anxiety Reassurance/Sedation/Reunite
with family
Pain Rule out hypoxemia/medicate/

comfort measures
Visceral
Decompression/catherization
Distention
Metabolic Correct acid-base alterations

Disturbances 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 alter-
ations 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 awak-
ening, 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 admin-
istration 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 pres-
sure. 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 post-
operative swelling, increasing intracranial pressure. Prolonged preoperative
or intraoperative hypotension, or the development of life-threatening dys-
rhythmias, 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.

Prolonged Anesthetic Assess/confirm Consider reversal
Drug Effects adequacy of when possible
oxygenation and practical
and ventilation
Metabolic Causes Evaluate electrolytes Correct any

alterations
Acute Neurologic Review preoperative Neurologic consult

Injury and intraoperative
events
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 mecha-
nism 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 ven-
tilation 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. Vasocon-
stricted tissues contribute to metabolic acidosis, which slows metabolic

processes, including drug biotransformation
and absorption, glomerular filtration, and GI COACH
function. Cardiac rate and rhythm distur- CONSULT
bances, including bradycardia and PVCs, are
common, further compromising oxygen deliv- Initial signs of hypothermia
reflect sympathetic stimula-
ery and contributing to metabolic acidosis. tion: increased respiratory
Hypothermia contributes to decreased clotting. rate, heart rate, cardiac
Although all patients going into an OR are at output, blood pressure,
risk for hypothermia, significant hypothermia is peripheral vascular resist-
ance, and muscle contrac-
a 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:
as insulation. The neonate is at risk because of decreased muscle tone and
an immature thermoregulatory center and the coordination, decreased
respiratory rate, decreased
inability to shiver to generate heat. Preexisting blood pressure, decreased
medical conditions such as hypothyroidism, heart rate, decreased renal
diabetes, and trauma can contribute to slowed function, decreased
metabolism. The intoxicated patient is at risk reflexes.
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 anes-
thesia 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 uncom-
fortable to personnel in the OR, it is the single most important interven-
tion 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 blan-
kets, covers, heat lamps, and warm blankets. Fluid and blood warmers
can be used, along with heated humidification of administered oxygen.

Although heated humidification of oxygen can
COACH be used, it is not particularly effective as a sole
CONSULT intervention. Shivering will help a patient gen-
erate heat to improve body temperature; how-
Care must be taken when ever, shivering also increases oxygen demand
administering a narcotic to a
shivering patient. Narcotics
and heart rate and may promote instability in
will depress shivering, but a patient with a preexisting cardiopulmonary
will also depress ventilation, compromise diagnosis. Small titrated doses of
which in the immediate IV narcotics such as meperidine and Stadol
postop period may con-
have been used to decrease shivering.
tribute to hypoxemia and
hypercarbia.
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 pos-
sible. 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 indi-
vidual. 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 intracellu-
lar 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 medi-
ate 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 sarcoplas-
mic 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
the development of MH in susceptible individ- COACH
uals. Agents identified as “triggers” include all CONSULT
of the “ane” inhalational anesthetics, as well as The trigger agents are the
succinylcholine. Intravenous potassium, when “ane” inhalation anesthet-
given rapidly, can also trigger MH. Not all ics: sevoflurane, desflurane,
patients who receive these drugs develop MH. halothane, and isoflurane;
they are not the “aine”
There is a genetic predisposition for the devel-
local anesthetics: lidocaine,
opment of MH, identified as autosomal domi- bupivacaine (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, in-
volves 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 suspi-
cious reaction to an anesthetic. The test is avail- The most sensitive means
able at only a few centers in the United States of diagnosing MH in the
OR is an unanticipated
and Canada, and access to these centers is
doubling or tripling of
limited. The biopsy cannot be mailed to a test- end-tidal CO2 levels. The
ing facility. most specific sign of MH
Although most cases of MH will present in is total body rigidity.
the OR, cases have been reported in the PACU,

emergency room, dental offices where general
COACH anesthesia is administered, and for up to 24 hours
CONSULT 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, tempera-
ture may increase as much
for the patient.
as 1°C every 5 minutes. Other common signs of MH reflect significant
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, potas-
sium, 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 fail-
ure. 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 temper-
ature. 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.
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 manage-
ment 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 hyper-
kalemia 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 blad-
der 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, pro-
cainamide, 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 over-
shoot—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. Com-
partment 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 manage-
ment 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
COACH trauma and corneal abrasion, especially when
CONSULT 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
to prevent than to manage,
impaired vision in the PACU requires an
as many complications ophthalmology consult.
result in permanent dam- Injury to nerves is due to direct stretching of
age. Prevention begins in a nerve through improper positioning or to com-
the OR with close attention
pression of a nerve against bone or OR equip-
to positioning, padding of
exposed extremities, and ment. This type of injury most commonly affects
careful eye care. the brachial plexus nerves, ulnar and radial
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 identi-
fies positioning injuries associated with specific positions used in the OR.
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, postop-
erative 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 cen-
ter, which may be the result of hypoxia, pain, increased intracranial pres-
sure, 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 distur-
bances, which are uncommon in the PACU.
Risk factors for PONV may be due to anesthetic factors, patient char-
acteristics, or to the surgical procedure itself. Anesthetic factors con-
tributing 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
• Strabismus
• Orchiopexy
• Tonsillectomy and adenoidectomy
• More than 30 minutes of anesthetic exposure
Adult surgical procedures associated with an increase in PONV
• 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
CONSULT It is important to note that prevention
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 anes-
female gender, nonsmoker,
history of postoperative thesiologist to avoid positive pressure ventila-
nausea and vomiting, and tion, which can distend the stomach; to medicate
use of opioids in surgery. for pain; and to ensure adequate fluid replace-
ment. 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
decreasing PONV. In the PACU, you can help to Droperidol (Inap-
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
school. For patients being discharged to home, Box warning by the FDA in
leave the IV in place until just before discharge. 2001, requires cautious use
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 mul-
tiple 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 estab-
lished 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 ōp)
Trimethobenzamide (Tigan)
ANTIDOPAMINE
Metoclopramide (Reglan)
ANTIHISTAMINE
Prochlorperazine (Compazine)
Promethazine (Phenergan)
Acupoint stimulation through the use of

ALERT pressure point bands (Sea Bands) and acupres-
sure have been tried, placing direct pressure on
It is very unlikely the Neikuan (Neiguan; P6) point on the wrist.
that nausea and vomiting
will be controlled without
Neither have proven efficacious when used as
controlling pain. 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. popu-
lation, 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,
physiologic, and pharmacologic changes that COACH
CONSULT
influence anesthetic management and preoper-
ative and postoperative care. The risks associ- The risks associated with
ated with anesthesia and surgery are increased anesthesia and surgery in
in elderly patients; however, it is a myth to think elderly patients with pre-
existing medical condi-
that the increased risks of anesthesia and sur-
tions, are increased 10% to
gery are due to age alone. Risks are due to the in- 30% over the 0.5% of all
creased prevalence of age-related, concomitant patients without preexist-
disease, and to the decline in basic organ system ing medical conditions.
function independent of disease.
257
The risk factors that serve as the best predictors of postoperative death
• Cardiac failure
• Impaired renal function
• Angina
Physiologic Changes Associated with Aging

When you think about physiologic changes associated with aging, remem-
ber 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 arterioscle-
rotic 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
As a result of the anatomic alterations in the conduction system:
changes in the myocardium Result is an increase in dysrhythmias and
and in the vessels, cardiac conduction delays
reserve and the heart’s
• Left ventricular hypertrophy, the
effectiveness as a pump
declines. increased fibrosis of the endocardial
lining due to endocardial thickening
and rigidity: Result is an increased systolic
blood pressure
COACH • Calcification of the valve leafs: Result is
CONSULT progressive valve incompetence
• 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
80-year-old, circulation output slows circulation time, which slows
time increases to 25 to the onset of action of drugs, including
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 medica-
tions that contribute to orthostatic hypotension, including anti-
hypertensives, 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 diame-
ter, 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 age-
related 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 at-
rophy 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 sympa-
thetic 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 intoler-
ance, 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 activ-
ity. 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 COACH
limitations, knowledge deficits, or finances. Mal- CONSULT
nutrition has the potential to increase periopera-
tive morbidity and mortality and to compromise A low serum albumin is the
best indicator of protein-
postoperative recovery and wound healing. calorie 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, includ-
ing 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 im-
balances 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 ref-
erence 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 cer-
vical spine may make positioning for intubation more difficult.
Endocrine Changes
With increasing age, there is progressive impairment in the body’s abil-
ity 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 de-
creased temperature.
Changes in Body Composition

The decrease in subcutaneous fat is an
anatomic change with important physiologic se-
quelae. Temperature regulation and maintenance COACH
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 indi-
increases, especially in women. viduals, making pallor an
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 atro-
phy, and collagen is lost. As a result, the elderly patient is at an
increased risk for skin breakdown and decubitus ulcers. Careful intraop-
erative 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 pharmacoki-
netic and pharmacodynamic variables in the elderly patient. Pharmacoki-
netic variables determine the relationship between the dose of a drug
administered and its concentration delivered to the site of action, and
• Changes in vascular volume
• Plasma protein binding

Central nervous system
neuronal density
reflexes
sympathetic response
Respiratory
tidal volume
Cardiovascular
vital capacity
myocardial irritability
residual volume
dysrhythmias blocks
lung capacity
L ventricular hypertrophy
compliance
systolic blood pressure
cardiac output
circulation time
Renal
bladder capacity
renal blood flow Gastrointestinal
glomerular filtration gastric emptying
hepatic blood flow
drug absorption
Endocrine Orthopedic
glucose intolerance osteoporosis
aldosterone risk of fractures
hypocalcemia
hypothyroidism Body composition
subcutaneous fat
Metabolic overall body fat
basal metabolic rate sweat glands
risk for hypothermia 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 phar-
macokinetic variables.
Vascular Volume
With aging, there is a 20% to 30% decrease in vascular volume. There-
fore, medications are injected into a smaller circulating volume, increas-
ing 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 mem-
branes. Only the portion that is “free” or unbound in plasma is capable of
crossing membranes in the central nervous system and of exerting a clin-
ical 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 per-
centage 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.

Hepatic blood flow decreases with age,
ALERT reducing first pass drug clearance, the result of
which is higher remaining blood levels of
Care should be administered agents. Phase I oxidative meta-
taken with initial drug
bolic processes of the liver decrease with
dosing. Drug doses are
generally reduced when age. Therefore, drugs such as benzodiazepines,
administered to an elderly where initial degradation is oxidative, have a
patient. Monitor drug prolonged action.
effects closely. Start
low and go slow with
medications.
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 medica-
tions used in the management of these diseases, as well as alter-
ations in hepatorenal dysfunction, may further contribute to perioperative
complications.
It has been estimated that the average elderly person is on five medica-
tions 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 combina-
tion, drug effects are magnified and the potential for adverse drug interac-
tions 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 Glaucoma
Anemia Hypertension
Arteriosclerosis Malignancy
Arthritis Osteoporosis
Cataract Parkinson’s disease
COPD Prostate cancer
Congestive heart failure Spinal stenosis
Diabetes Stroke

In addition, many elderly patients see mul-
tiple providers, such as an internist, cardiolo- COACH
gist, urologist, or psychiatrist, and each may CONSULT
be writing medication prescriptions without
the other’s knowledge. Over-the-counter med- Encourage patients to use
one pharmacy for all med-
ications, as well as herbal supplements, also ications. That way, poten-
have the potential to alter underlying disease tial drug interactions can
states and increase the potential for adverse be detected quickly by the
reactions when combined with prescription pharmacist, regardless of
the prescriber.
drugs. Box 10–2 lists the most common classes
of medications, with examples, prescribed to
patients older than age 65.
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 cardiopul-
monary disease appear to be the only preoperative factors that have con-
sistent 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 par-
ticularly 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)

day-of-surgery admission. A complete physical
ALERT examination, targeted to systems and patient
history, should be obtained and documented
When asking prior to the day of surgery.
about medication use, ask
The need for routine preoperative laboratory
about prescription, over-
the-counter, and herbal tests remains controversial, and therefore should
medications. It is also be dictated by physical examination and the pres-
important to ask about ence of disease. Medications used in the manage-
errors in omission, over- ment of disease also should be considered when
dosing, and underdosing.
This is important. Just
determining the need for laboratory testing. Lack
because the prescription of information may also influence decision mak-
bottle says the medication ing. For example, many patients do not seek
should be taken twice daily routine physical examinations, and, as a result,
for hypertension, the
may be unaware of hypertension, diabetes, or
patient, feeling fine, may
decrease the medication to cardiac abnormalities. As a result, many providers
once a day, or may have will order a preoperative glucose, blood pressure,
stopped taking the med- and ECG in patients older than 65 years.
ication altogether because
of a perceived lack of need
or cost of the medications.
Anesthetic Options
Not only does this increase
for the Elderly Patient
the potential for poor con-
The elderly patient is a potential candidate for
trol of hypertension, but if
general, regional, and intravenous sedation
hospitalized after surgery
and started back on twiceanesthesia. Each technique and medication will
a day medication enforcedoffer specific advantages and disadvantages.
by the nursing staff, theThe anesthesia provider, in consultation with
patient may experience
side effects of being
the patient and the surgeon, and in considera-
exposed to a medication tion of the procedure to be performed, will
select the safest anesthetic technique best
that he or she has either not
been taking or has been suited for the patient.
taking in a reduced dose.
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 require-
ment. An 80-year-old will require 25% less agent than a young adult. In
addition, hepatorenal function declines with aging, delaying drug metab-
olism and drug clearance.
Intravenous anesthetics used for general anesthesia and for IV seda-
tion, 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 confu-
sion. 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 myocar-
dial reserve. Small doses of ephedrine may be effective in correcting the
hypotension. It will also be important to maintain adequate filling pres-
sures 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

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 sur-
roundings, 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 appro-
priate 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 decision-
making 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
• 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 consid-
eration of all of the physiologic changes associated with aging. Ventila-
tion, 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.

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

Physiologic Differences Between Pediatric
Patients and Adult Patients
There are unique physiologic differences between pediatric patients and
adults that affect preanesthesia, intraoperative, and postoperative man-
agement. Being familiar with these differences will help you to anticipate
special needs and to react accordingly.
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 pres-
sure 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 con-
sumption 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 Normal Pediatric Blood Pressures
AGE 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 COACH
addition, the infant and neonate have imma- CONSULT
ture sympathetic nervous systems, which only
Although the sympathetic
allow limited catecholamine stores, decreasing
nervous system is underde-
myocardial reserve. It is important to remem- veloped, the parasympa-
ber that many anesthetic agents are associated thetic nervous system is
with myocardial depression. Neonates, in par- mature at birth. As a result,
ticular, are especially sensitive to negative vagal bradycardia occurs
during stress, such as during
inotropes. intubation. Therefore,
children are usually premed-
Respiratory System icated with an anticholiner-
Anatomically, the infant has a disproportion- gic agent such as atropine,
ately large head and, at times, a seemingly non- with the goal of preventing
vagal bradycardia.
existent neck. The infant’s tongue is large, and
the glottis is high and narrow, making laryn-
goscopy and intubation more difficult and increas-
ing the potential for tongue obstruction. The infant also tends to have an
increased antero-posterior diameter of the chest and may appear barrel-
chested. 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 peri-
ods of apnea may occur in the very young, especially in the premature
infant. As the child matures, the functional work of the intercostal mus-
cles 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
COACH the adult’s need of 3.9 mL/kg/minute. Although
CONSULT tidal volumes in the infant are the same as
for the adult (1 mL/kg), oxygen demand is three
Protective responses to times greater, requiring a respiratory rate approxi-
hypercarbia (↑CO2) and
mately three times greater than that of the
hypoxemia (↓O2) are
limited in the neonate normal adult, 40 to 60 breaths per minute as
and infant. Unlike the adult, compared with 12 to 16 breaths per minute (see
where respiratory compro- Table 10–5).
mise is usually compen-
sated for by tachycardia,
in the neonate and infant,
Nervous System
bradycardia is always a No other system shows greater development
sign of hypoxemia until throughout infancy and childhood that the cen-
proved otherwise. tral nervous system (CNS), as evidenced by an
increase in motor, sensory, and intellectual
functioning with maturation.
Table 10–4 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
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 devel-
oped 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.
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 preoper-
atively 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 fil-
tration rate and creatinine clearance slowing the metabolism of any drug
requiring renal biotransformation. There also is a decreased ability to

clear fluid and sodium loads, making fluid over-
COACH load and hypernatremia potential hazards of
CONSULT fluid administration.
The normal urine output is Skeletal System

ideally 1 mL/kg/hour, equal
Infants have a relatively immature skeletal sys-
to that of the adult.
tem. Bone epiphyses, or growth plates, are not
yet fused, and cranial fontanelles remain open.
Integumentary System
COACH The infant’s skin is extremely sensitive and
CONSULT
requires care when placing electrocardiogram
As infants and small chil- (ECG) leads, tape, and automatic blood pressure
dren often wake up agi- cuffs. In addition, infants have little subcuta-
tated, protection from falls neous fat and a relatively large surface area.
is imperative.
Therefore, profound heat loss may occur in even
a short period of time. Neonates, in particular,
are at risk, because compensatory heat genera-
tion is achieved by nonshivering thermogenesis
COACH through the metabolism of brown fat. Use of this
CONSULT mechanism increases oxygen demand and may
contribute to metabolic acidosis. Hypothermia
A fall of 2°C in environ-
mental temperature may
markedly increases oxygen consumption.
lead to a twofold increase
in oxygen consumption for
Developmental Issues
the infant and neonate. Related To Surgery
and Hospitalization
For pediatric patients, hospitalization evokes feel-
ings 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 feel-
ings of separation from a parent, and respond by crying and be diffi-
cult 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 induc-
tion will be dependent upon the child’s ability to understand and cooper-
ate 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 explana-
tion 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 abil-
ity of the child to cooperate. See Table 10–6 for age considerations for
postoperative care.
Postoperatively, age and developmental level are important considera-
tions in providing patient comfort, pain control, and postoperative teaching.
Table 10–6 Age Considerations for Postoperative Care

APPROXIMATE PREDOMINANT HELPFUL NURSING
STAGE AGE (YEARS) FEAR 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, Call child by name

viewed as parents use
permanent Have favorite toy
quickly
Preschool 3 to 6 Separation, Allow child to make

viewed as choices
rejection Have favorite toy
Provide simple
instructions
quickly
School- 6 to 12 Loss of Cover child for privacy

aged control Allow child to make
choices
Provide explanations
for actions and experiences

Preoperative Assessment
COACH for the Pediatric Patient
CONSULT
Although most pediatric patients have few, if
Ideally, the preoperative any, chronic or acute medical problems, it is
assessment should occur in still important to obtain a preoperative history,
the presence of family
members, although some
physical examination, and where appropriate,
adolescents may prefer to laboratory tests. Use of a systems approach
be interviewed privately, will facilitate data collection. See Table 10–7
particularly when asking for a review of systems and their anesthetic
questions about drug and
implications.
alcohol use, smoking, and
possible pregnancy.
Table 10–7 Review of Systems: Anesthetic Implications

QUESTIONS TO ASK:
DOES YOUR CHILD
SYSTEM HAVE (A HISTORY OF)... ANESTHETIC IMPLICATIONS
Respiratory Asthma? Hospitalization Irritable airway: Potential for

for asthma? bronchospasm and
A recent cold? laryngospasm
Seasonal allergies?
Current cough?
Croup? Atelectasis: Infiltrate
Apnea . . . use an apnea Subglottic narrowing
monitor at home? Postop risk of apnea
Cardiovascular Heart murmur? Possible septal defect

Diagnosed congenital Possible shunt; renal disease
problem? CHF
Exercise intolerance? Possible valve disease
History of rheumatic fever?
Neurologic Seizures? Medication interactions

Swallowing difficulties? Possible aspiration; hiatal
hernia
Gastrointestinal/ Vomiting/diarrhea? Possible dehydration;

Hepatic Malabsorption? infections
Reflux? Evaluate for anemia
Potential for aspiration

Table 10–7 Review of Systems: Anesthetic Implications
—Cont’d
QUESTIONS TO ASK:
DOES YOUR CHILD
SYSTEM HAVE (A HISTORY OF)... ANESTHETIC IMPLICATIONS
Genitourinary Frequent infections? Evaluate renal function
Endocrine/ Growth delays Consider endocrinopathies

metabolic
Hematologic Anemia? Obtain hematocrit/hemoglobin

Easy bruising? Potential coagulopathy
Sickle cell disease? Need to maximize warmth and
oxygenation; avoid acidosis
Allergies Medication allergies? Plan to avoid; select alternative
Dental Loose teeth? Potential for aspiration

Multiple cavities? Consider need for endocarditis
prophylaxis
Social Nickname? Eases establishing relationship

Any special concerns Allows opportunity to address
or fears?
Preoperative Medications for the Pediatric Patient

Patients are rarely premedicated as a matter of routine. Instead, the individ-
ual patient is assessed, and determination of need is based on that assess-
ment. 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 suc-
cinylcholine
• 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 chil-
dren, 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 dif-
ferent 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 pro-
tein 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 anes-
thesia. 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 sensi-
tivity to opioids and barbiturates. The pediatric patient has an increased
sensitivity to nondepolarizing muscle relaxants. Decreased renal clear-
ance 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 psycho-
logic 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 espe-
cially problematic in infants with a history of prematurity, respiratory
distress, or bronchopulmonary dysplasia. Hypothermia may also con-
tribute 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 endotra-
cheal 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
If racemic epi- intubation
nephrine 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 nor-
mothermia 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 emer-
gence 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
just a miniature adult. child as much as possible
These patients require • Have parent present upon awakening
specialized care and knowl- • Use of regional anesthesia for postoperative
edge. Not only are physio- pain control
logic differences important
considerations, develop-
• Anticipatory use of pain medication
mental needs of the infant, • Nonpharmacologic comfort measures
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 preg-
nancy. 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 preoper-
ative, intraoperative, postoperative, and postanesthetic care.
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

COACH result of the enlarging uterus, particularly
CONSULT when the woman is positioned flat. This will be
particularly true after the 20th week of preg-
A normal vaginal delivery
nancy. The uterus compresses the vena cava,
is associated with a 500 to
600 cc blood loss. A reducing blood flow to the right atrium, while
cesarean delivery may have also reducing uterine blood flow and cardiac
an 800 to 1000 cc blood output. This is also referred to as supine hypoten-
loss. sive syndrome. The goal of treatment is to dis-
place the uterus from the vena cava by having
the woman avoid the supine position. A left
lateral position is preferred, and can be main-
tained 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 con-
sumption, 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:
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
The feeling of
• Minute ventilation increases by 50% shortness of breath may be
due to increased tidal volume and a normal finding in a preg-
respiratory rate nant patient. Hypoxemia is
• Blood oxygen levels (PaO2) increase by not normal. The demands
of surgery and anesthetic
5 to 10 mm Hg
exposure make hypoxemia
• Carbon dioxide (PaO2) levels decrease a potential risk, requiring
to approximately 32 mm Hg pulse oximetry monitoring
• Functional residual capacity reduced and oxygen therapy.
15% to 20% at term
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
For a pregnant woman, a
ureters. Ureteral dilatation occurs as the uterus
normal BUN is 8 or 9 mg/dL. enlarges. As a result, urinary stasis may be
A normal creatinine is a problem, predisposing the woman to uri-
0.46 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;
creatinine, 1.0 mg/dL; of the uterus contribute to urinary frequency,
and creatinine clearance, particularly in the last trimester.
100 mL/min; values of the Aldosterone levels increase in pregnancy,
nonpregnant patient are causing retention of sodium and water. Glyco-
indicative of abnormal
renal function in pregnant
suria of as much as 1 to 10 g/day occurs because
women near term. tubular reabsorption of glucose is less than the
increase in glomerular filtration of glucose.
Proteinuria of as much as 300 mg/day is also not
uncommon. Neither is indicative of pathology.
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 relax- CONSULT
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
Although no change is seen in the platelet stomach” patient, and
count during pregnancy, pregnancy itself is a at risk for aspiration on
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 preg- procedure to increase
nant woman to thromboembolic events. The gastric emptying and to
increase gastric pH.
risk of deep venous thrombosis and pulmonary
embolism are greatest just after delivery.
The physiologic alterations associated with preg-
nancy 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 preg-
nant 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
40% decrease in inhalation agent requirements
40% reduction in local anesthetic for spinal/epidural
Increased neurosensitivity to local anesthetic
Cardiac
Respiratory 35% blood volume
40% tidal volume 40% cardiac output
15% respiratory rate 30% stroke volume
20% oxygen consumption 15% heart rate
PaO2 15% peripheral vascular
PaCO2 resistance
30% in compliance
35% in resistance
Renal
glomerular filtration rate
renal blood flow
creatinine clearance
BUN and creatinine Gastrointestinal
reflux
gastric emptying
gastric pH
Coagulation factors Reproductive

coagulation factors uterine blood flow
except XI and XIII size/weight
pressure
F I G U R E 1 1 - 2 : Physiologic changes of pregnancy.
hypoxemia. Decelerations in heart rate, bradycardia, or persistent tachycar-
dia 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 adminis-
tration 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 develop-
mental 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 evi-
dence 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 U.S. Food and Drug Administration Classification
for Drug Safety
DRUG
CATEGORY DEFINITION EXAMPLES
A Drugs that have been found Prenatal vitamins

safe in controlled studies on Folic acid
pregnant women Oxygen
B Drugs that either have animal Acetaminophen

studies showing no fetal damage Ketamine
but have no human studies, or Ondansetron (Zofran)
show adverse effects in animals Propofol
but not in human studies Sevoflurane
C Drugs that have either no animal Fentanyl

or human studies or have studies Albuterol
that show adverse effects on the Isoflurane
fetus with no available data on Doxacurium
human subjects
D Drugs that show positive evidence ACE-Inhibitors

of human fetal risk but have benefits Benzodiazepines
that may outweigh the risks (Midazolam)
X Drugs with proven risks to the Warfarin

fetus that outweigh the benefits Thalidomide
and should not be used under HMG CoA reductase
any circumstances 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
Anesthetic Options for Nonobstetric
Preterm labor Surgery During Pregnancy
places the fetus at risk
Most pregnant patients presenting for surgery
for the development of
intrapartum death, neonatal are relatively young, generally healthy patients
respiratory failure, and intra- and, as a result, may be candidates for either
ventricular hemorrhage. general anesthesia or regional anesthesia. The
choice will most likely be dependent upon the
Table 11–3 Medications Used for Preterm Labor
MAXIMUM MATERNAL FETAL
DRUG USUAL DOSE DOSE EFFECTS EFFECTS
Beta- Hypotension Tachycardia

adrenergic Tachycardia Hyperglycemia
agents Chest pain and ↑ free fatty acids
Ritodrine 0.5 to 0.1 0.35 mg/min tightness
(Yutopar) mg/min 0.08 mg/min Arrhythmias
Terbutaline 0.01 mg/min Nervousness
(Brethine) Headache
Hyperglycemia
Pulmonary edema
Magnesium 4 g IV bolus Magnesium Pulmonary edema Hypotonia

sulfate followed by level of Chest pain and Drowsiness
(MgSO4) infusion of 7.0 mg/ tightness ↓ gastric motility
2 g/hr with 100 mL Maternal weakness Hypocalcemia
goal of serum Nausea and vomiting
magnesium Blurred vision
level of Flushing
5.0 to 7.0 ↓ deep tendon reflexes
mg/100 mL Cardiac failure
↑ sensitivity to muscle
relaxants
location of the surgical site, degree of urgency, and trimester of preg-

nancy. 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
PACU Assessment of the Pregnant
COACH Patient Following Nonobstetric
CONSULT Surgery
Postoperative priorities will focus on three areas:
Regardless of technique,
1. Postsurgical assessment (see chapter 6)
fetal heart rate monitoring
should be done continuously2. Postanesthetic assessment (see chapter 6)
3. Assessment and maintenance of maternal
during surgery after the 18th
week of gestation. This will and fetal well-being
allow for rapid detection Maintenance of cardiac output is impor-
of abnormalities in maternal
oxygenation and uterine
tant. To prevent supine hypotension, the
perfusion. It has been patient should be positioned in a left lateral
tilt position. Heart rate and rhythm will be
argued that monitoring prior
to 18 weeks is not necessary
monitored for signs of distress, most com-
because a cesarean delivery
monly tachycardia due to pain or hypoxemia
would not be performed,
because the fetus prior to or bradycardia due to hypothermia or hypox-
18 weeks is not viable emia. Oxygen will be applied to promote mater-
outside of the uterus. nal and fetal oxygenation.
Fetal heart tones should be monitored con-
tinuously if possible. While most post-anes-
thetic 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 moni-
Maintaining a stable
maternal heart rate, blood toring. These patients are frequently admitted
pressure, and oxygenation to the OB unit for postoperative surgical care
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 con-
traction should be reported to the surgeon and obstetrician managing the
patient.
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
disproportionate number of mothers are pre-
eclamptic–eclamptic or have diabetes, Rh isoim- ALERT
munization, a history of prematurity, multiple
fetuses, or other high-risk conditions, the rate It is important to
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
Common indications for cesarean section deliv- orthopedic cases. Lead
eries include cephalopelvic disproportion (CPD- aprons may be used to
shield 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
hemorrhage, placenta previa, prolapsed cord, away from the x-ray unit to
pre-eclampsia-eclampsia, and fetal distress. a more distant part of the
PACU.
Box 11–1 identifies the most common indica-
tions 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 judg-
ment 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 pro-
vide 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 con-
trollable 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 flex-
ibility 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 mini-
mize 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 physio-
logic return to the nonpregnant state. Aggressive nursing care and atten-
tion to detail will help to prevent postdelivery complications.
Assessment of bleeding is a priority. Hemor-
rhage, characterized by a blood loss of 500 mL ALERT
or more, is a serious complication after delivery
and is associated with increased maternal Bleeding caused
by uterine atony will
morbidity. The PACU nurse should immedi-
require uterine massage
ately assess the uterine fundus to note position and, if unsuccessful,
and consistency. Immediately after delivery, administration of oxytocin
the uterus should be located approximately (Pitocin) to stimulate uterine
2 cm below the umbilicus. The uterus should be contractions. Uterine atony
means loss of uterine tone,
firm to palpation. which can become a cause
Almost all patients recovering from a of profuse bleeding. If
cesarean section will have an indwelling uterine atony is discovered
urinary catheter in place. Drainage color should or suspected, the obstetri-
cian should be notified
be assessed. If the urine turns bloody, bladder
immediately, while main-
perforation should be suspected and the obste- taining uterine massage.
trician notified.
The PACU nurse should also observe and
document the presence and amount of lochia. Lochia is the vaginal dis-
charge, 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, esti-
mated 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 miscar-
riage, 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 proce-
dure 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 physio-
logic 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 dis-
charge. 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 bereave-
ment 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 protein-
uria, 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 environ-
ment 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
cerebral edema
ICP
Respiratory CNS irritability
hypoxia/hypercarbia hyper-reflexia
airway/laryngeal edema headache
pulmonary edema seizures
left shift of oxyhemoglobin curve Cardiovascular
cyanosis cardiac output
blood pressure
plasma volume
Renal vasoconstriction
renal blood flow
proteinuria
glomerular filtration
creatinine clearance Gastrointestinal
oliguria epigastric pain (due to
acute renal failure hepatic swelling)
nausea and vomiting
Reproductive
uteroplacental perfusion
intrauterine growth retardation Systemic
hyperactivity generalized edema
placenta decompensation
fetal prematurity
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) Pulmonary edema
Diastolic blood pressure (⬎110 torr) Cyanosis
Mean arterial pressure (⬎120 torr) Visual disturbances
Proteinuria (⬎5 g/24 hr) Headache
Oliguria (⬍500 mL/24 hr) Epigastric pain
as soon as possible to prevent maternal demise.

Allowing continued fetal development under COACH
these circumstances is associated with high fetal CONSULT
mortality and many maternal complications.
Women with pre-eclampsia
The Diabetic Patient –eclampsia are rarely cared
for in the PACU. Most have
Diabetes affects 6% of all Americans younger been previously admitted
to the OB floor for monitor-
than the age of 50 years, and 10% to 15% of
ing, with deliveries occurring
those older than age 50. It is suspected that an emergently in OB.
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 out-
come 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
• Diabetic control disrupted by acute stress
COACH response
CONSULT • Airway compromise secondary to obesity
• Altered drug metabolism secondary to
Recognizing that end
obesity and altered renal function
organ compromise is the
biggest predictor of risk
and that it is also the result Role of Insulin
The role of insulin is to facilitate the uptake
of poor glycemic control, the
maintenance of good (tight) of glucose into the cells, for use in cellular
glycemic control would be
metabolism. Without insulin, glucose remains
the overriding goal of
diabetic management. 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 ketosis-
resistant 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 produc-
tion, 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
effect of the increased hormones will be insulin hyposecretion, insulin
resistance, and increased protein catabolism. Anesthesia further sup-
presses 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 comorbidi-
ties, 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 main-
taining glucose stability. Preoperatively, the his-
tory should include the following:
• Type of diabetes and current treatment COACH
CONSULT
• Diagnosed end-organ comorbidities
• Symptoms of ischemic cardiac, renal, The easiest way to assess
or vascular disease for autonomic neuropathy
• Previous hospitalizations due to diabetes is to obtain orthostatic
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 following: The target level for a HgbA1C
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
• Screening for microalbuminuria/ period (see Table 11–4).
proteinuria
Day of Surgery Management of
COACH the Type 1 Diabetic Patient
CONSULT 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
insulin on the day of surgery, will be to balance energy intake (calories)
and for patients to take with insulin requirements, pre-, intra-, and
half of their Hagedorn or postoperatively. There is significant contro-
Lente dose. Regular insulin versy about the use of patient-administered
peaks within 3 to 4 hours
of administration and, in
insulin on the morning of surgery. Some
the NPO patient, could surgeons will ask patients to take half
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 reg-
ular 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 rou-
tine, 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 com-
mon 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 pre-
venting 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 depend-
ent 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, met-
formin should NOT be restarted.
COACH
CONSULT Complications in the PACU for All
Diabetic Patients
If postoperative congestive
heart failure develops as Hypoglycemia and hyperglycemia are the two
a postoperative complica- potential complications that may present in the
tion, thiazolidinediones postsurgical diabetic patient.
should not be restarted. Hypoglycemia is defined as a serum glucose
These agents have been
associated with fluid
level of less than 70 mg/dL. Symptoms of hypo-
retention, peripheral glycemia may include headache, sweating, dizzi-
and pulmonary edema. ness, 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
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 con-
tinued 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 specifi-
cally 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 consen-
sus 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 anes-
thetic 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 COACH
airway pressure. If diabetic, fasting glucose CONSULT
assessment and measurement of HgbA1C
should be obtained to assess glycemic con- To prevent embarrassment
for the patient and incon-
trol. The presence of pre-existing cardiac and venience for the staff, many
renal disease should be assessed, along with centers have established an
signs of autonomic dysfunction. “early warning” system to
alert staff to the scheduling
Risk Management of an obese and, particu-
larly, morbidly obese
The obese patient is at risk for complica- patient. This will allow staff
tions due to weight, including risk of throm- to prepare, in advance,
boembolism and aspiration. Intraoperative risks appropriately sized gowns,
include complications of positioning, airway TED hose, blood pressure
cuffs, chairs, carts, operat-
difficulties, and difficult surgical access. Postop-
ing room (OR) tables,
erative complications include pulmonary and moving equipment, surgical
wound infection. equipment, bedside
Thromboembolism Prophylaxis commode, and surgical
The obese patient is at risk for thromboem- inpatient bed. For example,
the standard inpatient
bolism due to obesity and the venous relaxation hospital bed is 35-inches
that occurs under the influence of anesthesia. wide, whereas a “baribed”
Thromboembolism prophylaxis will include (bariatric bed) may be
the use of sequential compression devices and as wide as 60 inches.
TED compression hose, as well as the adminis-
tration 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, clini-
cal evidence supports placement of the patient in a steep Trendelenburg
position to help to decrease the risk of deep venous thrombosis. Preven-
tion 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 anesthesiol-
ogist. 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 unpre-
dictable 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 2
of sternum
3
Body of
sternum 4
Costal 5
cartilage
6
Diaphragm 7
Xiphoid process Co
stal angle 9
10
A 11
Left Lateral View with Landmarks
Scapula
Clavicle
Body of 2
sternum
3
7
Costal
cartilage 8
10
314 Tools
Structure of the Heart
Aortic arch
Left pulmonary
Right pulmonary arteries arteries
Superior vena cava Left atrium
Right pulmonary veins Left pulmonary

veins
Pulmonary semilunar valve
Aortic
Right atrium semilunar valve
Tricuspid (AV) valve Mitral (AV)

valve
Left
ventricle
Inferior vena cava
Epicardium
Right
ventricle
Myocardium
Interventricular septum
Thoracic aorta
Abdominal Organs and Structures
Spleen
Liver
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
Urethra fornix of
vagina
Cervix
Clitoris Anterior
fornix of
vagina
Labia Labia
majora minora Vagina Anus
Internal Male Genitalia

Urinary bladder Rectum
Ampulla
Ductus of ductus
deferens deferens
Seminal
Urethra vesicle
Corpus
cavernosum Prostate
Corpus
spongiosum Anus
Glans Anus
penis
Testicle Bulbourethral
Scrotum gland
Epididymis
316 Tools
Cross-section of Musculoskeletal System
Bones Muscles Bones Muscles
Cranium Cranium
Facial
Maxilla muscles
Mandible Sternocleidomastoid
Acromion Trapezoids
Clavicle Trapezoids process
Pectoralis
Scapula major Deltoid
Vertebrae:
Cervical
Deltoid Triceps
Ribs Thoracic
brachii
Biceps Lumbar Latiss-
brachii imus
Humerus Rectus dorsi
Iliac abdominis Exten-
crest Brachio- sor
radialis carpi
Radius
radialis
Sacrum
Rectus
Ulna
femoris
Carpals
Metacarpals Gluteus
Femur Phalanges Ischium maximus
Sartorius Biceps
Patella Vastus femoris
medialis
Fibula Fibula
Gastrocnemius
Tibia Tibia
Achilles
Tarsals tendon
Metatarsals
Phalanges Calcaneus
Anterior Posterior
Tools 317
Lobes of the Brain
Lateral fissure Central fissure

Frontal lobe
Parietal lobe
sory
x
orte
cort atosen
Emotion
or c
Broca’s area Behavior Sensation Wernicke’s
ex
Mot
Intellect
Som
area
Motor Speech
Speech Hearing comprehension Transverse
Smell fissure
Taste
Visual
perception
Coordination Occipital lobe
Equilibrium
Balance
Cerebellum
Temporal lobe
318 Tools
Origin of Cranial Nerves
Ophthalmic
division
Maxillary
division
Mandibular
I Olfactory division
IV Trochlear
V Trigeminal
II Optic VI Abducens
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
Alkaline 13–39 U/L, infants and 217–650 nmol · sec–1/L,

phosphatase adolescents up to 104 U/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
Calcium (Ca++) 8.5–10.5 mg/100 mL 2.1–2.6 mmol/L
Calcium (ionized) 4.25–5.25 mg/dL 1.1–1.3 mmol/L
Carbon dioxide (CO2) 24–30 mEq/L 24–30 mmol/L

-
Chloride (Cl ) 100–106 mEq/L 100–106 mmol/L
Cholesterol <200 mg/dL <5.18 mmol/L
Cortisol (AM) 5–25 μg/100 mL 0.14–0.69 μmol/L
(PM) <10 μg/100 mL 0–0.28 μmol/L
320 Tools
General Chemistry—Cont’d
Creatine Male: 0.2–0.5 mg/dL 15–40 μmol/L
Female: 0.3–0.9 mg/dL 25–70 μmol/L
Creatine kinase (CK) Male: 17–148 U/L 283–2467 nmol · sec–1/L
Female: 10–79 U/L 167–1317 nmol · sec–1/L
Creatinine 0.6–1.5 mg/100 mL 53–133 μmol/L
Ferritin 10–410 ng/dL 10–410 μg/dL
Folate 2.0–9.0 ng/mL 4.5–20.4 nmol/L
Glucose 70–110 mg/100 mL 3.9–5.6 mmol/L
Iron (Fe) 50–150 μg/100 mL 9.0–26.9 μmol/L
Iron binding capacity 250–410 μg/100 mL 44.8–73.4 μmol/L

(IBC)
Lactic acid 0.6–1.8 mEq/L 0.6–1.8 mmol/L
LDH (lactic 45–90 U/L 750–1500 nmol · sec–1/L

dehydrogenase)
Lipase 2 units/mL or less Up to 2 arb. unit
Magnesium (Mg++) 1.5–2.0 mEq/L 0.8–1.3 mmol/L
Osmolality 280–296 mOsm/kg water 280–296 mmol/kg
Phosphorus 3.0–4.5 mg/100 mL 1.0–1.5 mmol/L
Potassium (K+) 3.5–5.0 mEq/L 3.5–5.0 mmol/L
Protein, total 6.0–8.4 g/100 mL 60–84 g/L
PSA <4.0 ng/mL <4 μg/L
Pyruvate 0–0.11 mEq/L 0–0.11 mmol/L
Continued
Tools 321
General Chemistry—Cont’d
Sodium (Na+) 135–145 mEq/L 135–145 mmol/L
T3 75–195 ng/100 mL 1.16–3.00 nmol/L
T4, free Male: 0.8–1.8 ng/dL 10–23 pmol/L
Female: 0.8–1.8 ng/dL 10–23 pmol/L
T4, total 4–12 μg/100 mL 52–154 nmol/L
Thyroglobulin 3–42 μ/mL 3–42 μg/L
Triglycerides 40–150 mg/100 mL 0.4–1.5 g/L
TSH 0.5–5.0 μU/mL 0.5–5.0 arb. unit
Urea nitrogen 8–25 mg/100 mL 2.9–8.9 mmol/L
Uric acid 3.0–7.0 mg/100 mL 0.18–0.42 mmol/L
322 Tools
Hematology (ABC, CBC, Blood Counts)
Blood volume 8.5–9.0% of body weight in kg 80–85 mL/kg
Red blood cell (RBC) Male: 4.6–6.2 million/mm3 4.6–6.2 ⫻ 1012/L
Female: 4.2–5.9 million/mm3 4.2–5.9 ⫻ 1012/L
Hemoglobin (Hgb) Male: 13–18 g/100 ml Male: 8.1–11.2 mmol/L
Female: 12–16 g/100 ml Female: 7.4–9.9 mmol/L
Hematocrit (Hct) Male: 45%–52% Male: 0.45–0.52
Female: 37%–48% Female: 0.37–0.48
9
Leukocytes (WBC) 4,300–10,800/mm3 4.3–10.8 ⫻ 10 /L
• Bands 0–5% 0.03–0.08
• Basophils 0–1% 0–0.01
• Eosinophils 1%–4% 0.01–0.04
• Lymphocytes 25%–40% 0.25–0.40
• B-Lymphocytes 10%–20% 0.10–0.20
• T-Lymphocytes 60%–80% 0.60–0.80
• Monocytes 2%–8% 0.02–0.08
• Neutrophils 54%–75% 0.54–0.075
9
Platelets 150,000–350,000/mm3 150–350 ⫻ 10 /L
Erythrocyte Male: 1–13 mm/hr Male: 1–13 mm/hr

sedimentation
rate (ESR) Female: 1–20 mm/hr Female: 1–20 mm/hr
Tools 323
Lipids (Cholesterol)
Total less than 200 mg/dL less than 5.20 mmol/L
HDL 30–75 mg/dL 0.80–2.05 mmol/L
LDL less than 130 mg/dL 1.55–4.65 mmol/L
Triglycerides 40–150 mg/100 mL 0.4–1.5 g/L
Cardiac Enzyme Markers

ENZYME CONVENTIONAL SI UNITS
Troponin-I 0–.1 ng/mL 0–0.1 μg/L
Troponin-T ⬍0.18 ng/mL ⬍0.18 μg/L
CPK ⬍150 U/L ⬍150 U/L
CPK-MB 0–5 ng/mL 0–5 μg/L
SGOT 1–36 U/L 1–36 U/L
LDH 70–180 U/L 70–180 U/L
Myoglobin Male: 10–95 ng/mL 10–95 μg/L
Female: 10–65 ng/mL 10–65 μg/L
Progression→ Onset Peak Duration
Troponin-I 3–6 hrs 12–24 hrs 4–6 days
Troponin-T 3–5 hrs 24 hrs 10–15 days
CPK 4–6 hrs 10–24 hrs 3–4 days
CPK-MB 4–6 hrs 14–20 hrs 2–3 days
SGOT 12–18 hrs 12–48 hrs 3–4 days
LDH 3–6 days 3–6 days 7–10 days
Myoglobin 2–4 hrs 6–10 hrs 12–36 hrs
324 Tools
Coagulation
ACT 90–130 sec 90–130 sec
PTT (activated) 21–35 sec 21–35 sec
Bleeding time 3–7 min 3–7 min
Fibrinogen 160–450 mg/dL 1.6–4.5 g/L
INR Target therapeutic: 2–3 Target therapeutic: 2–3
Plasminogen 62%–130% 0.62–1.30
6
Platelets 150,000–300,000/mm3 ⫻ 10 /L
PT 10–12 sec 10–12 sec

(prothrombin time)
PTT (partial 30–45 sec 30–45 sec

thromboplastin
time)
Thrombin time 11–15 sec 11–15 sec
Metric Conversions
Weight Temperature Height
lbs kg °F °C cm in ft/in
300 136.4 212 100 boil 142 56 4’ 8”

275 125.0 107 42.2 145 57 4’ 9”
250 113.6 106 41.6 147 58 4’ 10”
225 102.3 105 40.6 150 59 4’ 11”
210 95.5 104 40.0 152 60 5’ 0”
200 90.9 103 39.4 155 61 5’ 1”
190 86.4 102 38.9 157 62 5’ 2”
180 81.8 101 38.3 160 63 5’ 3”
170 77.3 100 37.8 163 64 5’ 4”
160 72.7 99 37.2 165 65 5’ 5”
Continued
Tools 325
Metric Conversions—Cont’d
Weight Temperature Height
lbs kg °F °C cm in ft/in
150 68.2 98.6 37.0 168 66 5’ 6”

140 63.6 98 36.7 170 67 5’ 7”
130 59.1 97 36.1 173 68 5’ 8”
120 54.5 96 35.6 175 69 5’ 9”
110 50.0 95 35.0 178 70 5 ‘10”
100 45.5 94 34.4 180 71 5 ‘11”
90 40.9 93 34.0 183 72 6’ 0”
80 36.4 92 33.3 185 73 6’ 1”
70 31.8 91 32.8 188 74 6’ 2”
60 27.3 90 32.1 191 75 6’ 3”
50 22.7 32 0 freeze 193 76 6’ 4”
40 18.2 196 77 6’ 5”
30 13.6
20 9.1
10 4.5
5 2.3
2.2 1
2 0.9
1 0.45
lb ⫽ kg ⫻ 2.2 or kg ⫽ lb ⫻ 0.45
°F ⫽ (°C ⫻ 1.8) ⫹ 32 or °C ⫽ (°F ⫺ 32) ⫻ 0.556
Inches ⫽ cm ⫻ 0.394 or cm ⫽ inches ⫻ 2.54
326 Tools
Body Mass Index
Basic English-to-Spanish Translation

ENGLISH PHRASE PRONUNCIATION SPANISH PHRASE
Introductions—Greetings
Hello oh-lah Hola
Good morning bweh-nohs dee-ahs Buenos días
Good afternoon bweh-nohs tahr-dehs Buenos tardes
Good evening bweh-nahs noh-chehs Buenas noches
My name is meh yah-moh Me llamo
I am a nurse soy lah oon en-fehr-meh-ra Soy la enfermera
What is your name? koh-moh seh yah-mah oo-sted? ¿ Cómo se llama usted?
Continued
Tools 327
Basic English-to-Spanish Translation—Cont’d
How are you? koh-moh eh-stah oo-stehd? ¿Como esta usted?
Very well mwee b’yehn Muy bien
Thank you grah-s’yahs Gracias
Yes, No see, noh Sí, No
Please pohr fah-vohr Por favor
You’re welcome deh nah-dah De nada
Assessment—Areas of the Body
Head kah-beh-sah Cabeza
Eye oh-hoh Ojo
Ear oh-ee-doh Oído
Nose nah-reez Nariz
Throat gahr-gahn-tah Garganta
Neck kweh-yoh Cuello
Chest, Heart peh-choh, kah-rah-sohn Pecho, corazón
Back eh-spahl-dah Espalda
Abdomen ahb-doh-mehn Abdomen
Stomach eh-stoh-mah-goh Estómago
Rectum rehk-toh Recto
Penis peh-neh Pene
Vagina vah-hee-nah Vagina
Arm, Hand brah-soh, mah-noh Brazo, Mano
Leg, Foot p’yehr-nah, p’yeh Pierna, Pie
328 Tools
Assessment—History
Do you have... T’yeh-neh oo-stehd... ¿Tiene usted...
• Difficulty breathing? di-fi-kul-thad pa-ra res-pi-rar ¿Dificultad para

respirar?
• Chest pain? doh-lorh hen lh peh-chow ¿Dolor en el pecho?
• Abdominal pain? doh-lorh ab-do-minl ¿Dolor abdominal?
• Diabetes? dee-ah-beh-tehs ¿Diabetes?
Are you... ehs-tah ¿Esta...
• Dizzy? ma:r-eh-a-dho(dha) ¿Mareado(a)?
• Nauseated? cone now-she-as ¿Con nauseas?
• Pregnant? ¿ehm-bah-rah-sah-dah? ¿Embarazada?
Are you allergic to ¿ehs ah-lehr-hee-koh ¿Es alergico a alguna

any medications? ah ahl-goo-nah meh- medicina?
dee-see-nah?
Assessment—Pain
Do you have pain? T’yeh-neh oo-stehd doh-lorh? ¿Tiene usted dolor?
Where does it hurt? dohn-deh leh dweh-leh? ¿Donde le duele?
Is the pain... es oon doh-lor... ¿Es un dolor...
• Dull? Leh-veh ¿Leve?
• Aching? kons-tan-teh ¿constante?
• Crushing? ah-plahs-tahn-teh? ¿Aplastante?
• Sharp? ah-goo-doh? ¿Agudo?
• Stabbing? ah-poo-neo-lawn-teh ¿Apuñalante?
• Burning? Ahr-d’yen-teh? ¿Ardiente?
Continued
Tools 329
ENGLISH PHRASE PRONONCIATION SPANISH PHRASE
Does it hurt when Leh dweh-leh kwahn- ¿Le duele cuando le

I press here? doh ah-pree-eh-toh aprieto aqui?
ah-kee?
Does it hurt to C’yen-teh oo-sted ¿Siente usted dolor

breathe deeply? doh-lor kwahn-doh cuando respira
reh-spee-rah pro-foon- profundamente?
dah-men-teh?
Does it move L- doh-lor zeh moo- ¿El dolor se mueve a

to another area? eh-veh a oh-thra ah-ri-ah otra area?
Is the pain better C yen-teh al-goo-nah ¿Siente alguna mejoria?

now? me-horr-ee-ah
330 Tools
Frequently Used Phone Numbers
Blood bank:
Central supply:
CT/MRI:
Dialysis:
Dietary:
EKG:
Emergency:
Family waiting:
Housekeeping:
Intensive Care Unit:
Lab:
Operating Room:
Pharmacy:
Respiratory therapy:
Security:
Transport:
X-ray:
Tools 331
Notes
332 Tools
ILLUSTRATION CREDITS
Figures in Chapter 2, Chapter 5, and Chapter 8, and figures 3–2, 3–3, 4–1, 4–3,
4–4, 6–7, 6–8, 9–1, 9–2, 9–3, 9–4, 9–5, 9–6, 9–7, and 12–10 are from Wilkinson,
J. M., & Van Leuven, K. (2008). Fundamentals of nursing. Philadelphia: FA Davis.
Figures 3–4, 4–2, 6–3, 7–4, 12–1, 12–2, 12–3, 12–4, 12–5, 12–6, 12–7, 12–8, and
12–9 are from Dillon, P. M. (2007). Nursing health assessment: A critical thinking,
case studies approach (2nd ed.). Philadelphia: FA Davis.
Figure 6–2 is courtesy of Atrium Medical Corporation.
Figures 6–4 and 6–5 are from Myers, E. (2006). RN notes: Nurse’s clinical pocket
guide (2nd ed.). Philadelphia: FA Davis.
Figure 7–5 is adapted from Pither, C., & Hartrick, C. (1985). Postoperative pain.
In P. Raj (Ed.), Handbook of regional anesthesia. Chicago: Churchill–Livingstone.
Figures 9–9, 9–10, 9–11, 9–12, 9–13, and 9–14 are from Myers, E., & Hopkins,
T. (2007). LPN notes (2nd ed.). Philadelphia: FA Davis.
Figure 9–15 is adapted from Phipps, W., Long, B., & Woods, N. (1987). Medical
surgical nursing: Concepts and clinical practice (3rd ed.). St. Louis: Mosby
Year Book.
Tools 333
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Chapter 10: Special Populations: The Elderly and Pediatric Patient

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Index
Page numbers followed by “b” denote boxes, “f” denote figures, and “t” denote
tables.
Abdominal organs/structures, 315f

Abortion, 298–299
Acid, definition of, 124
Acid-base balance, 124–125
alterations in, 125–126
causes for, 313t
carbonic acid-bicarbonate buffer system, 126–127
phosphate buffer system, 127
protein buffer system, 127
renal control mechanisms, 128
respiratory control mechanisms, 127
Advance health-care directives, 24
Afterload, 147
Age, advanced. See also Elderly patients
body composition changes, 263
cardiovascular changes, 258–259
central nervous system changes, 260
endocrine changes, 262
gastrointestinal changes, 260–261
metabolic changes, 262–263
orthopedic changes, 262
pathophysiologic changes, 266–267, 266f
pharmacokinetic/pharmacodynamic changes, 263, 265–266
physiologic changes, 264f
preoperative assessment, 267–268
renal changes, 261–262
respiratory changes, 259–260
sensory changes, 263
wound healing and, 207
Airway(s)
maintenance of, in ear/nose/throat surgical patients, 164–165
management in obese patient, 310
nasopharyngeal, 216f
obstruction, 213
oropharyngeal, 216f
placement in tongue obstruction, 215
Albumin, 108, 111
serum levels, as indicator of malnutrition, 207
343
Aldrete scoring system, 134, 134t–135t
Alfentanil (Alfenta), 52
Alkalosis
metabolic, 126
respiratory, 126
Ambulation, patient instruction in, 36–37
Ambulatory surgery, 2
for the elderly patient, 270
Anatomical landmarks, thoracic, 314f
Anesthesia provider, 74
Anesthesia report, 131–132
Anesthesia/anesthetics, 45–71
for cesarean delivery, 295–296
for elderly patient, 268–270
factors in selecting, 20–22
fetal exposure to, 291
general, 45–55
classes of, 46
objectives/ideal characteristics of, 45
metabolic responses to, in diabetic patient,
302–303
for nonobstetric surgery during pregnancy,
292–293
for pediatric patients, 280–281
regional, 71
review of systems for, 278t–279t
regional techniques, 55–71
for termination of pregnancy, 298
Anesthesiologist assistants (AAs), 74
Angina, 237
common sites for pain of, 237f
Antibiotic prophylaxis
preoperative, 26
wound classification and, 27b
Anticholinergics, preoperative, 25–26, 279
Anticholinesterase agents, 55, 56t
Anticoagulants, 38
Anti-diuretic hormone (ADH), 108
Antiembolic stockings (TED hose), 26, 31, 32f, 37, 168, 170, 225f
Antiemetics, 255
mechanism of action, 256b
preoperative, 26, 280
Antihypertensive therapy, 230t–231t
Aorto-caval compression/decompression, 286, 287f
Apnea, infant, 282
Arterial system, peripheral, 150
Aspiration, prophylaxis in obese patient, 309
Asthma, 10
Asystole, 234, 234f
344 Index
Atelectasis, 220–221
patient teaching in prevention of, 35–37
Awakening, complications of, 241–244
Barbiturates, 47–49
Base, definition of, 124
Belladonna/opium (B&O) suppositories, 159
Benzodiazepines, 49–50
preoperative, 25
reversal agents, 54–55
Bicarbonate, 124
Bier block, 61f
Bleeding/blood loss, 235–237
in cesarean vs. vaginal delivery, 286
post-cesarean assessment of, 297
Blood gases, arterial, 125, 220
Blood patch, 65
Blood products, description/indications, 236t
Body composition, age-associated changes, 263
Body fluids
anatomy of, 107–108
insensible losses of, 109
regulation of, 108
Body mass index (BMI), 307, 327t
Bradycardia, 147
sinus, 233, 233f
in spinal anesthesia, 69
Brain, lobes of, 318f
Breathing patterns, ineffective, 135–136
Bronchospasm, 222–223
Buffer systems, 126–127
Calcium, 119–120
Carbonic acid-bicarbonate buffer system, 126
Cardiac output, alterations in, 136–137
Cardiac tamponade, 148
Cardiovascular complications, 226–240
dysrhythmias, 231–235
hypertension, 228–230
hypotension, 64, 69, 226–227
causes of, 229f
iatrogenic, 230
preexisting, 230
hypovolemia, 108, 113–114, 227
low systemic vascular resistance, 228
primary cardiac dysfunction, 227
secondary cardiac dysfunction, 227–228
vaso-vagal response, 228
Index 345
Cardiovascular system
age-associated changes, 258–259
assessment in patient interview, 8–9
pediatric, 272–273
pregnancy-related changes, 285–286, 286t
Catheters
epidural, placement of, 63f
urinary, 208
suprapubic, 158f
types of, 157f
Caudal anesthesia, 71
Central nervous system (CNS)
age-associated changes, 260
brain, lobes of, 318f
in patient interview, 11
pregnancy-related changes, 288
Certified Registered Nurse Anesthetist (CRNA), 74
Cesarean section, 294–295
anesthetic options for, 295–296
blood loss in, 286
indications for, 295b
PACU assessment following, 296–297
Cetacaine spray, 59
Checklists
preop, 28b
for preop laboratory tests, 19b–20b
wound assessment, 202b
Chest tubes, 146, 147
Cheyne-Stokes respirations, 153
Chin thrust, 214–215, 215f
Chloride, 118–119
Chronic obstructive pulmonary disease (COPD), 10
Chvostek’s sign, 121b, 122
Circulating nurse, 74
role during surgery, 83
Cocaine, 58–59
Colloids, crystalloids vs., advantages/disadvantaged of,
111t–112t
Comfort
goal for pediatric patient, 284
Compartment syndrome, 161–162
Contractility, cardiac, 147
Crackles (rales), 143
Cranial nerves
assessment of, 154, 155t
origins of, 319f
CRIES scale, 176–177, 178f
346 Index
Croup (subglottic edema), 218
postextubation, in pediatric patient, 282
Crystalloids, 109–110
colloids vs., advantages/disadvantages of, 111t–112t
purpose/osmolality of, 110t
Cyclodextrin-mediated reversal, 56b
Davol drain, 203

Deep breathing, patient instruction in, 35–36
Delayed awakening, 243, 244f
Demonstration, in perioperative patient teaching, 43
Depolarizing agents, 52–53
Dermatomes, 68f
Descriptive pain intensity scale, 176, 177f
Desflurane (Suprane), 47
Dextran 40, 111
Diabetes/diabetic patient, 15–16, 301–302
complications in PACU for, 306–307
medical management of, 302
metabolic responses to anesthesia/surgery,
302–303
perioperative priorities for, 303
type 1, day of surgery management of, 303–305
type 2, day of surgery management of, 305–306
Diazepam (Valium), 50
Disseminated intravascular coagulation (DIC), 237
Do-not-resuscitate orders, 24
Drains, surgical, 202–203, 208
nursing management of, 204–205
types of, 203–204, 204f, 205f
Dressings, surgical, 199–201
Durable power of attorney for health care, 24
Dysrhythmias, 148–149, 232–235
causes of, 232
common causes of, 232t
Eclampsia, 299, 301

diagnostic indicators of, 301b
pathophysiologic changes, 301f
Edema, 114
in ear/nose/throat surgical patients, 164–165
pulmonary, 223–224, 239
subglottic, 218
Elderly patients. See also Age, advanced
anesthetic options for, 268–270
definitions of, 257
most common surgical procedures in, 270
postoperative priorities for, 270–271
Index 347
Elective surgery, 4
Electrolytes, 115–124
bicarbonate, 124
calcium, 119–120
chloride, 118–119
magnesium, 120, 122–211
normal values, 115t
phosphate, 123–124
potassium, 117–118
sodium, 116–117
Elimination half-lives, 261t
Embolism. See Thrombus/embolism
Emergence delirium, 241–242
differential diagnosis of, 242f
in pediatric patient, 284
Emergency surgery, 5
EMLA cream/patch, 59
Endarterectomy, carotid, 151
Endocrine system
age-associated changes, 262
in patient interview, 15–16
Endotracheal tubes (ET tube), 211, 212f
pediatric, 274t
English-to-Spanish translations, 327t–330t
Epidural anesthesia, 61, 63f
advantages/disadvantages of, 62b
care for patient receiving, 66b
complications of, 64–65
in elderly patients, 269
postoperative, 188, 190–192
items to confirm when managing, 191b
side effects of, 62, 64
Epidural hematoma, secondary to epidural anesthesia, 65
Epinephrine, in local anesthetics, 57
Equipment, cleaning/disinfection/sterilization of, 105–106
Etomidate (Amidate), 48
Extension, abnormal, in neurosurgical patient, 152f
Extracellular fluid (ECF), 107
buffer system of, 126–127
comparison with commercial fluids, 110t
Fentanyl (Sublimaze), 50–51

Fibrinogen, 108
FLACC Postoperative Pain Tool, 178
behavioral scale, 182t
for children with cognitive impairment, 182t–183t
Flexion, abnormal, in neurosurgical patient, 152f
Fluid balance
control mechanisms, 108
in pediatric patient, 283–284
348 Index
Fluid therapy
choice of fluid, 109–112
objectives of, 109
in perioperative period, 112–113
rate calculation, 112
Flumazenil (Romazicon), 54–55
Friction rub, 143
Gastrointestinal system
organs/structures, 315f
pediatric, 275
pregnancy-related changes, 288–289
Gastrostomy tubes (PEG, G-tube), 209, 210f
Genitalia, internal, 316f
Genitourinary system, pediatric, 275–276
Globulins, 108
Glucose, blood levels
comparison to HgbA1c, 304t
sliding scale for insulin for type 2 diabetics, 307t
H2 antagonists, preoperative, 25
Hair removal, 81–82
Halothane, 47–346
Hand washing, 39, 40f
surgical scrub, 75–76
Headache, postdural puncture, 64–65, 70
Heart, structure of, 315f
Heart rates, pediatric, 272t
HELLP syndrome, 299
Hematologic system, in patient interview, 16–17
Hematological system, pregnancy-related changes, 289
Hematoma, epidural, secondary to epidural anesthesia, 65
Hemoglobin A1c, 207
comparison to blood glucose levels, 304t
Hemovac drain, 203, 204f
Hepatic function, age-associated changes, 266
Hepatic system, in patient interview, 12–13
Hepatocytes, 12
Hetastarch, 111
High-risk patients
informed consent and, 23–24
for thrombus/embolism, 27b
Hypercalcemia, 120
Hyperchloremia, 119
Hyperkalemia, 117–118
Hypermagnesemia, 123
Hypernatremia, 117
Index 349
Hyperphosphatemia, 124
Hypertension, 228–230
antihypertensive therapy, 230t–231t
Hyperthermia. See Malignant hyperthermia
Hypocalcemia, 119–120
testing for, 121b
Hypochloremia, 118–119
Hypokalemia, 117
Hypomagnesemia, 120, 122
Hyponatremia, 116
Hypophosphatemia, 123–124
Hypotension, 226–227
arterial, in spinal anesthesia, 69
causes of, 229f
in epidural anesthesia, 64
iatrogenic, 230
preexisting, 230
Hypothermia, 136, 244–148
Hypoventilation, 219–220
Hypovolemia, 108, 113–114, 227
Hypovolemic shock, 235
signs of, 114
Hypoxemia, 136, 218–219
in neonate/infant, 274
Hypoxia, tissue, wound healing and, 206
Immunosuppression, wound healing and, 207

Incentive spirometry, 35, 36, 36f
Infection
patient teaching to prevent, 38–39
risk in obese patient, 311
signs of, 39, 202
Informed consent, in high-risk patients, 23–24
Inhalation agents, 46–47
care of patient receiving, 48
malignant hyperthermia and, 247
for pediatric patients, 281
Inpatient surgery (hospital-based), 3–4
Insulin, 302
perioperative regimens, 305
serum glucose and, sliding scale for type 2 diabetics, 307t
Integumentary system
functions of, 195
pediatric, 276
Intention. See Wound healing
Intraoperative considerations, 73–106
after procedure, 105–106
350 Index
patient positioning, 77–81
skin preparation/surgical draping, 81–82
sponge/sharp/instrument counts, 76
surgical procedures, 83–105
surgical scrub, 75–76
surgical team, 73–75
surgical time-out, 76–77
Interstitial fluid (ISF), 107
Intracellular fluid (ICF), 107
buffer system of, 127
Intracranial pressure (ICP), increased, 152–153
manifestations of, 153t
progression of, 156f
treatment of, 154
Intrathecal anesthesia. See Spinal anesthesia
Intravascular injection, secondary to epidural anesthesia, 65
Intravenous anesthetics, 47–53
for elderly patients, 269–270
Isoflurane (Forane), 47
IV regional block (Bier block), 61f
Jackson-Pratt drain, 203

Jaw thrust, 214–215, 215f
Jejunostomy tubes (J-tube), 210
Kussmaul respirations, 127
Labor, preterm
medications used for, 293t
in nonobstetric surgery during pregnancy,
291–292
Laboratory tests
cardiac enzyme markers, 324t
for cardiac surgical patients, 146
coagulation, 325t
in event of delayed wound healing, 207
general chemistry values, 320t–322t
hematology values, 323t
lipid values, 324t
preoperative, 19
checklist for ordering, 19b–20b
Language
as barrier to patient teaching, 44
English-to-Spanish translations, 327t–330t
Laryngeal obstruction (laryngospasm), 216–218
Lateral position, 80–81
Lecture format, in perioperative patient teaching, 41–42
Lidocaine, 59–60
Index 351
Liposuction, 163
Lithotomy position, 79
Living wills, 24
Local/regional anesthetics. See also Epidural anesthesia; Spinal anesthesia
caudal anesthesia, 71
classification of, 56–57
cocaine, 58–59
dosage calculation of, 58b
in elderly patients, 269
IV regional block, 61, 61f
local infiltration, 59–60
peripheral nerve blocks, 60
pharmacologic properties of, 58t
for postoperative pain control, 188
possible regional blocks for, 189f
systemic toxicity, 57, 59b
topical use of, 59
Lochia, 297
Lorazepam (Ativan), 50
Magnesium, 120
Magnesium sulfate, administering, 122b
Malignant hyperthermia (MH), 246–249
diagnostic signs of, 248t
management of, 249b–251b
Malnutrition, wound healing and, 207
Medical Doctor Anesthesiologist (MDA), 74
Medical office surgery, 2
Medications
asking about, in patient interview, 6–8, 17
elimination half-lives in young vs. old, 261t
most commonly prescribed to the elderly, 267b
in pregnancy, classification of, 292t
preoperative, 24–26
for preterm labor, 293t
Meperidine (Demerol), indications for using, 187b
Metabolic acidosis, 125
Metabolic alkalosis, 126
Metabolism/metabolic rate
pediatric, 274
responses to anesthesia/surgery, in diabetic patient, 302–303
Methohexital (Brevital), 48
Metric conversions, 325t–326t
Midazolam (Versed), 49
Mixed agonist-antagonists, 187–188
Montgomery straps, 201f
Morphine, 51
352 Index
Muscle relaxants, 52
depolarizing agents, 52–53
nondepolarizing agents, 53, 54t
reversal agents, 53–55
cyclodextrin-mediated reversal, 56b
Musculoskeletal system
cross-section of, 317f
Myasthenia gravis, 13
Myocardial infarction, acute (AMI), 237–238
Naloxone (Narcan), 55
Narcotics
as cause of hypoventilation, 220
perioperative, 50–52
reversal agents, 55
Nasogastric (NG) tubes, 209, 209f
postsurgical confirmation of placement, 168
potential for anastomotic leak with, 203
Nausea/vomiting, postoperative (PONV), 253–256
in diabetic patients, 16
in ear/nose/throat surgical patients, 164–165, 166
input to vomiting center, 255f
Neonatal, Pain, Agitation, and Sedation Scale (N-PASS), 177–178, 179t–180t
Nerve block, peripheral, 60
Nerve function, tests of, 160b
Nerve injuries, grading system for, 252b
Neuromuscular blocking agents
depolarizing, 52–53
nondepolarizing, 53, 54t
Nitrous oxide, 46
Nondepolarizing agents, 53, 54t
reversal agents, 55
NPO guidelines, 33b
NSAIDS (nonsteroidal anti-inflammatory drugs), 186
Numeric pain intensity scare, 175f, 176f
Obesity/obese patients, 307

airway management, 310
causes of, 308
increased risks from, 15
perioperative assessment of, 308–309
positioning of, 79, 309
postoperative risks for, 310–311
risks of, 308
Opiate agonists, 186–187
Opioids, 186
Index 353
Organon (Sugammadex), 56b
Orotracheal tubes, 212f
Orthopedics, age-associated changes, 262
Oxygenation, signs of inadequate, 129b
Pain
assessment of, 173–174
tools for, 174–185
chest, 237
cardiac origin, 237–238
differential diagnosis of, 240b
gastrointestinal origin, 239
musculoskeletal origin, 239–240
pulmonary origin, 238–239
hypertension and, 229
post-cesarean assessment of, 297
postoperative, causes of, 172t
types of, 171–172
Pain Assessment in Advanced Dementia (PAINAD) Scale, 178, 184t–185t
Pain management, 171–195
challenges in, 193–195
effects of untreated pain, 172–173
evaluation of, 192–193
nonpharmacologic interventions, 192
pharmacologic interventions, 185–192
Patient interview
history taking, 6–8
systems review, 8–17
Patient positioning, 77–81
of obese patient, 309
Patient teaching
barriers to, 43–44
postoperative, 35–37
preoperative, 29–34
setting objectives for, 41
strategies, 41–43
during surgery, 34–35
Patients. See also Diabetes/diabetic patient; Elderly patients;
High-risk patients; Obesity/obese patients; Pediatric patients
cardiac surgical, 85
nursing priorities, 146–149
condition of, in wound assessment, 202
dental surgical, assessment/nursing priorities, 167
354 Index
ear/nose/throat surgical, 98
assessment of, 164
gastrointestinal surgical, 100
assessment of, 167
gynecologic surgical, 103
assessment of, 169
neurosurgical, 88
ophthalmic surgical, 97
assessment of, 163
orthopedic surgical, 91
peripheral vascular, 87
nursing priorities, 151
plastic/reconstructive surgical, 95
renal/genitourinary, 92
skin preparation/draping, 81–82
spinal surgical, 90
thoracic surgical, 84
assessment of, 140–141, 143–144
nursing interventions, 144t–145t
nursing priorities, 144
Pediatric patients
age considerations for postoperative care of, 277t
anesthetics, review of systems for, 278t–279t
cardiac surgical procedures, 86–87
cardiovascular system, 272–273
classification of, 271
developmental issues related to surgery/hospitalization, 276–277
gastrointestinal surgical procedures, 103
gastrointestinal system, 275
genitourinary system, 275–276
integumentary system, 276
nervous system, 274–275
Index 355
neurosurgical procedures, 88–90
normal blood pressures, 273t
normal heart rates, 272t
normal respiratory rates, 275t
ophthalmic surgical procedures, 98
otologic surgical procedures, 99
pharmacologic differences in, 280
plastic surgical procedures, 96
postoperative priorities for, 281–284
preoperative medications for, 279–280
renal/genitourinary surgical procedures, 95
respiratory system, 273–274
skeletal system, 276
Penrose drain, 204, 205f
Perioperative complications, 213–256
of awakening, 241–244
cardiovascular, 226–240
in diabetic patients, 306–307
nausea/vomiting, 253–256
of positioning, 251–252
pulmonary, 213–226
of thermoregulation, 244–251
Peripheral arterial system, 150f
Peripheral nerve blocks, 60
Pharmacokinetics/pharmacodynamics, age-associated changes, 263
Phosphate, 123–124
Phosphate buffer system, 127
Physical examination, preoperative, 17–18
Physical status
anesthetics and, 21
classification, 18t
determination of, 18
Plasma proteins, 108
Plasma volume (PV), 107
Pleural drainage systems, 141, 142f
Pneumonia
risk in obese patient, 310
Pneumothorax, 225–226
chest pain of, 239
Positioning. See Patient positioning
Post-anesthetic assessment/care, 129–170
after termination of pregnancy, 298–299
anesthesia report, 131–132
in elderly patients, priorities for, 270–271
pediatric
age considerations for, 277t
priorities in, 281–284
post-cesarean delivery, 296–297
of pregnant patient after nonobstetric surgery, 294
356 Index
priority setting, 139
surgical-specific care, 139–170
Post-anesthetic care unit (PACU), 129
assessment
approaches to, 132–134
major body systems, 133f
care plan, 135–139
sample report, 132b
scoring systems, 134–135
Potassium, 117–118
Pre-eclampsia, 299
pathophysiologic changes, 301f
Pregnancy
cardiovascular system, 285–286
central nervous system, 288
gastrointestinal system, 288–289
hematological system, 289
nonobstetric surgery during, 289, 291
obstetric surgery during, 294
cesarean section, 294–297
physiological changes of, 290f
renal system, 288
respiratory system, 286–287
termination of, 298–299
Pregnancy Classification for Drugs, 291, 292t
Preload, 147
Premature Infant Pain Profile, 176, 177f
Premature ventricular contractions (PVCs),
233–234, 234f
Preoperative assessment, of pediatric patients, 278
Preoperative assessment/care, 1–28
anesthesia selection, 20–22
of diabetic patient, 303
of elderly patient, 267–268
laboratory testing, 19
legal concerns, 22–24
medications, 24–26
asking about, in patient interview, 6–8
patient interview, 6–17
physical examination, 17–18
physical status determination, 18
presurgical assessment, 1–5
sending patient to OR, 28
surgical scheduling, 2–4
teaching, 22
timing of surgery, 4–5
Pressure injuries, grading system for, 252b
Prone position, 80–81
Propofol (Diprivan), 48
Index 357
Protein buffer system, 127
Pruritus, in epidural anesthesia, 64
Pulmonary complications, 213–226
airway obstruction, 213
aspiration, 221–222
atelectasis, 220–221
bronchospasm, 222–223
croup, 218
hypoventilation, 219–220
hypoxemia, 136, 218–219, 274
laryngeal obstruction, 216–218
pneumothorax, 225–226, 239
pulmonary edema, 222–224, 239
pulmonary embolism, 224
tongue obstruction, 214–216
Pulmonary edema, 222–224
Pulmonary embolism, 224, 239
Pulse oximeter, 219f
Pupil assessment, 153, 154f
Range of motion exercises, foot/leg, 38, 38f

Registered nurse first assistant (RNFA), 73
Remifentanil (Ultiva), 51
Renal system
pregnancy-related changes, 288
Renin-angiotensin-aldosterone system, 108
Respiratory alkalosis, 126
Respiratory depression, in epidural anesthesia, 62, 64
Respiratory rates, pediatric, 275t
Respiratory system
pregnancy-related changes, 286–287
Reversal agents, 53–55
anticholinesterases, 56t
Riley Infant Pain Scale, 178, 181t, 191t
Rhonchi, 143
Salem sump. See Nasogastric (NG) tubes

Salvage surgery, 5
Same-day admission surgery, 3
Scoliosis, 13–14
Scrub nurse, 74–75
role during surgery, 82
358 Index
Scultetus (Trendelenburg) position, 78–79
Sedatives, preoperative, 280
Seizures, in neurosurgical patients, 154–155
Semi-elective surgery, 4
Sensory system, age-associated changes, 263
Sequential compression device, 225f
Sevoflurane (Ultane), 47
Sitting position, 79–80, 80f
Skeletal system. See also Musculoskeletal system
pediatric, 276
Skin preparation, 81–82
Sodium, 116–117
Sodium pentothal, 48
Spinal anesthesia (intrathecal anesthesia),
66–67, 67f
side effects of, 69–70
Splinting, to promote deep breathing, 36, 37f
Sterilization, 106
Stroke volume, 147, 148
Subarachnoid puncture (wet tap), secondary to epidural anesthesia, 64
Succinylcholine (Anectine), 52–53
Sufentanil (Sufenta), 51
Supine position, 78–79, 79f
Surgeon, 73
Surgery
classification by degree of contamination, 195–197
scheduling, 2–4
timing of, 4–5
Surgical draping, 82
Surgical procedures
cardiac, 85–87
descriptors for, 83
ear, 98–99
gastrointestinal, 100–103
gynecologic, 104–105
neck/throat, 99–100
neurosurgical, 88–90
ophthalmic, 97–98
orthopedic, 91–92
peripheral vascular, 87–88
plastic/reconstructive, 95–96
renal/genitourinary, 93–95
spinal, 90
thoracic, 84–85
Surgical scrub, 75–76
Surgical team, 73–75
Surgical time-out, 76–77
Index 359
Sympathetic nervous system, in regulation of fluid balance, 108
Systemic vascular resistance (SVR), 148
low, 228
Tachycardia, 147
sinus, 233, 233f
ventricular, 234, 235f
Teaching, preoperative, 22
TED hose. See Antiembolic stockings
Thermoregulation
hypothermia, 244–246
malignant hyperthermia, 246–249
diagnostic signs of, 248t
management of, 249b–251b
Thought processes, alterations in, 138
Thrombus/embolism
patients at risk for, 27b
prevention in gastrointestinal surgical patient, 168–169
prophylaxis in obese patient, 311
Tissue perfusion, signs of inadequate, 130b
Tobacco, 8
Tongue obstruction, 214–216
in pediatric patient, 282–283
Total body water (TBW), 107
Total spinal, secondary to epidural anesthesia, 65
Tracheostomy tubes, 210, 211f
Transcellular fluid, 107
Translations, English-to-Spanish, 327t–330t
Trendelenburg (scultetus) position, 78–79
Trousseau’s sign, 121b, 122
23-hour surgery, 2–3
Urgent surgery, 4–5

Urinary retention
Vaso-vagal response, 228

Ventilation, signs of inadequate, 130b
Ventricular fibrillation, 234, 235f
Verbal rating scale, for pain assessment, 175
Virchow’s triad, 239
Visual analog scale, for pain assessment, 175, 175f
Volume status, postoperative, evaluation, 113–114
Wheezes, 143
Wong Baker FACES Pain Rating Scale, 178, 184f
360 Index
Wound assessment, 201–202
checklist, 202b
Wound healing (intention)
classification of wounds by, 199
complications delaying, 206–207
by levels of intention, 200f
prevention of infection to prevent, 38–39
process of, 197–198, 198f
Wounds
antibiotic prophylaxis and classification of, 27b
dehiscence, 208
surgical, classification by degree of contamination, 195–197
Written information, in perioperative patient teaching, 42
Index 361

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Copyright © 2009 by F. A. Davis Company

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

Library of Congress Cataloging-in-Publication Data

Michelle M. Byrne, RN, PhD, CNOR

Shirley P. Clarke, RN, BSN, MS

Sydney Fulbright, RN, MSN, CNOR. PhD Candidate

Sandra Galura, MSN, RN, CCRN, CPAN

Deborah B. Hadley, RN, MSN, CNOR

Janet C. Kinkade, RN, MSN

Genelle Leifso, RN, MSN, CPN(C)

Martha Olson, RN, BSN, MS

Julie Osness-Thorson, RN, MSN, CNOR

Martin Phillips, RN, BSN, CNOR, RNFA

Carla E. Randall, RN, PhD

Patricia A. Shaner-Christy, RN, BSN, CNOR

Marilyn Smith Stoner, RN, PhD, CHPN

Rose Utley, RN, PhD

Steven W. Wherrey, CST

2 Preoperative Assessment and Care

Preoperative Assessment and Care 3

4 Preoperative Assessment and Care

Preoperative Assessment and Care 5

6 Preoperative Assessment and Care

Preoperative Assessment and Care 7

8 Preoperative Assessment and Care

Preoperative Assessment and Care 9

10 Preoperative Assessment and Care

Preoperative Assessment and Care 11

12 Preoperative Assessment and Care

Preoperative Assessment and Care 13

14 Preoperative Assessment and Care

Preoperative Assessment and Care 15

16 Preoperative Assessment and Care

Preoperative Assessment and Care 17

Determination of Physical Status

Table 1–1 Physical Status Classiﬁcation (Adapted from

I Healthy patient with no Patient with no signiﬁcant

II Mild systemic disease Patient with a history of

III Severe systemic disease Patient with a history of moderate

IV Severe systemic disease that Patient with poorly controlled asthma

V Patient unlikely to survive for Patient in status asthmaticus,

VI Brain dead patient awaiting

18 Preoperative Assessment and Care

Box 1–1 Checklist for Ordering Preoperative Laboratory

Preoperative Assessment and Care 19

Factors in Selecting the Type of Anesthesia

20 Preoperative Assessment and Care

Age of the Patient

Physical Status of the Patient

Type of Surgery to be Performed

Preference of the Surgeon

Inpatient versus Outpatient Status

Preoperative Assessment and Care 21

22 Preoperative Assessment and Care

Preoperative Assessment and Care 23

24 Preoperative Assessment and Care

Preoperative Assessment and Care 25

26 Preoperative Assessment and Care

Box 1–3 Patients at Risk for Thrombus Formation and

Preoperative Assessment and Care 27