ANCC/AACN CONTACT HOURS
By Patricia Woolson, RN, MSN
Although uncommon, OR personnel must be prepared to handle a cardiac arrest in a timely manner.
A calm yet stern voice booms over the intercom system of the OR, “anesthesia stat to room two, anesthesia stat room two.” As the nurse in the next room, you can’t help but think, what happened? What case is it? Is there enough help? A team of five OR providers grows to nine. Cardiac arrest in the OR is uncommon, excluding trauma and critically ill patients. For most OR personnel, except open-heart surgery staff, cardiac arrest is unplanned and unexpected. Cardiac arrest is the result of severe cardiovascular and/or respiratory insult, which may occur at any time during the perioperative period. Cardiac arrest is the sudden cessation of heart function, resulting in death if the patient isn’t successfully resuscitated in a timely manner.1 Cessation of cardiac action occurs, and the pumping mechanism of the heart ceases to function.2 Cardiac arrest is the endpoint of dysrhythmias, cardiac pump failure, hypoxemia, sepsis, hemorrhage, drug toxicity, and metabolic disturbances.3 According to the American Society of Anesthesiologists (ASA), because of improved patient monitoring and safer anesthetic agents, cardiac arrest during anesthesia is a rare occurrence. Intraoperative cardiac arrest affords each
May/June OR Nurse 2007
patient an immediate response. There’s little or no delay before corrective actions are initiated within the surgical setting.4 According to the American Heart Association, response time is critically important to the patients’ outcome. Prompt initiation of resuscitative actions may delay any further deterioration of neurological or ischemic effects. Etiology Factors that contribute to cardiac arrest during this period include difficult airway management with subsequent hypoxia, and hyperkalemia, hypovolemia, anesthetic effects, adverse drug effects, myocardial
infarction, and exsanguination due to trauma (see Possible causes of cardiac arrest).2 Other factors that may predispose surgical patients to cardiac arrest are critically ill patients, emergency surgery patients, and those with compromised cardiac and respiratory function. The ASA physical status classification is an assessment tool used to determine the patient’s condition at the time of surgery. Patients deemed an ASA III or higher are at greater risk (see ASA physical status classifications).5 Education One of the most critical elements in preparation for a
Possible causes of cardiac arrest2
Below is a list of some of the potential factors that may contribute to cardiac arrest in the OR. Prompt diagnosis and treatment may prevent cardiac arrest, but if it does occur, initiate CPR and follow ACLS or PALS guidelines as appropriate. Possible cause Hypoxia associated with difficult airway management, difficult intubation, obstruction due to trauma Symptoms Hypoxemia: Initially, patient may exhibit tachycardia and tachypnea. Prolonged hypoxemia may result in hypoxia and cardiac dysrhythmia, renal, liver or heart damage, and cardiac arrest may occur. Hypovolemia may result in hypotension, tachycardia, tachypnea, oliguria, shock, or cardiovascular collapse. Dysrhythmias: bradycardia, supraventricular tachycardia, ventricular tachycardia, or ventricular fibrillation, if not successfully treated, results in cardiac arrest. Serum potassium level is greater than 5.5 mEq/L (per facility laboratory standards). Patients with hyperkalemia may exhibit muscle weakness, flaccid paralysis, ECG changes including tall, peaked T-waves and widened QRS complex, and if hyperkalemia is left untreated, may result in cardiac arrest. Intervention Maintain patent airway and increase oxygenation via bag-valve mask, laryngeal mask airway, or possible tracheotomy.
Extreme blood loss
Replace fluid loss and blood volume with crystalloids, colloids, or volume expanders.
Electrolyte imbalance, history of coronary disease, adverse drug reaction to anesthetic agents, acidosis
Administer antiarrhythmics, perform cardioversion or defibrillation as appropriate based on heart rhythm.
Hyperkalemia related to chronic kidney disease, metabolic acidosis, adverse drug reaction to ACE inhibitors, succinylcholine, potassium supplement or potassium-sparing diuretic therapy
Treatment determined by patient’s condition. Stop any administration of potassium; may need to administer loop diuretics, and regular insulin I.V. with hypertonic dextrose to move potassium ions into the cells. Calcium chloride or calcium gluconate can be used to reduce myocardial effects of hyperkalemia and prevent ventricular fibrillation.
OR Nurse2007 May/June
cardiac arrest in the OR is staff education. As nursing professionals, we need consistent, ongoing education. Perioperative educators must continue to pursue avenues to enhance the staff’s knowledge base in a variety of clinical situations, including cardiac arrest. Perioperative nurses and nonlicensed OR personnel should be trained in basic life support (BLS). Advanced cardiac life support (ACLS) training is encouraged. ACLS concentrates on the intricacies of managing cardiac arrest as it relates to identification and control of dysrhythmias, medication administration, and use of adjunctive equipment and monitoring. In ORs that care for pediatric patients, pediatric advanced life support (PALS) is also encouraged. PALS training incorporates all the elements of ACLS but with a pediatric focus. Minimally, nurses should attend these classes every 2 years, however some facilities support a yearly refresher course. As professionals, the standard of practice indicates that nurses must assume responsibility for their ongoing education. Education related to emergency situations includes staff participation in ACLS and PALS programs. Nurses need to stay current in standards of practice and stay abreast of advances in emergency care technique. The ideal follow-up to BLS and ACLS training is to conduct “mock codes.” Mock codes allow the staff to become proficient in emergency procedures. Educators and clinical nurse specialists present scenarios for the staff to actively demonstrate their response in an emergency situation. The educator or observer notes the timeliness of staff response, the order of events, the process of assessing factors, which may adversely affect the patient, and the staff’s ability to articulate the process. Validation of competence for each staff member should be completed during a mock code. The importance of each of the following must also be addressed: • repositioning the patient before compressions can be attempted • closing or packing the wound (with patient in different positions) before resuscitative efforts can be initiated • transferring the patient to a stretcher or bed with different incision types • disconnecting any equipment attached to the patient • removing all instrumentation (such as retractors) that could interfere with CPR • preventing fire in the OR by securing lasers and electrosurgical units and removal of oxygen source from the patient prior to defibrillation.
ASA physical status classifications5
During the preanesthesia visit, the anesthesiologist completes the anesthesia evaluation and assigns the patient a numerical value according to the ASA Physical Status Classification. This classification system is used to determine the patient’s condition at the time of surgery. The higher the number, the greater the patient’s risk under anesthesia. ASA Indicator 1 2 Definitions Normal healthy patient Patient with mild systemic disease (type 2 diabetes, wellcontrolled asthma, hypertension) Patient with severe systemic disease that’s limiting but not incapacitating Patient with incapacitating disease that’s a constant threat to life Patient not expected to survive without surgery Patient declared brain dead who is undergoing organ removal for organ donation
Whether mock codes are practiced monthly or quarterly, staff should be prepared for a cardiac arrest situation. Other learning opportunities include scavenger hunt exercises with the emergency carts (crash cart, malignant hyperthermia cart, and PALS cart) and demonstration of ability to appropriately operate the defibrillator. The objective is to learn not only what’s on the cart but where it’s located. AORN’s standards and recommended practices indicate that education is an integral part of maintaining patient safety.6 Educators must consistently address the needs of the staff regarding performance of CPR, emergency medication administration and other adverse events. Other educational considerations include understanding equipment and alternate positioning. The following operating tables or positions need to be reviewed: • prone position
May/June OR Nurse 2007
• fracture tables • beach-chair position • Jackson table. Competency validation in positional equipment should be performed at least annually. Evidence-based practice Nursing research states that 84% (54/64) of patients exhibit at least one behavioral change and/or have a new complaint in the 8 hours preceding cardiac arrest.7 This study also noted that physiological abnormalities are present in as many as 90% (58/64) of the patients in the 8 hours preceding an adverse event (AE). These behavioral and physiological abnormalities are respiratory and/or circulatory dysfunction; identified changes were tachypnea, bradypnea, hypoxemia, tachycardia, bradycardia, hypotension, and hypertension.6 During the preoperative interview, the circulating nurse should assess the patient and ask questions regarding these indicators: • headache • heart palpitations • increased heart rate • shortness of breath • indigestion • chest discomfort • edema • dizziness Additional “red flags” are any history of difficult intubation, malignant hyperthermia, past anesthesia problems, or history of cardiac disease. The circulating nurse has so little time with patients that every interaction is a valuable opportunity to elicit information. Communication with the surgical team is essential to address any changes the patient may have recently experienced. Staff responsibilities Organization and preparation may contribute to a patient’s favorable outcome. Staff member’s uncertainty of the appropriate procedure will bring chaos to an already critical situation. The surgical team must be familiar with their responsibilities as this will impact their performance during the code. Every member of the surgical team must be prepared to respond quickly and efficiently. Roles and responsibilities include2: Code director. This is usually the anesthesia provider’s responsibility, but if an arrest takes place during a local case, the surgeon would assume this
role. This individual runs the code and directs code activity. During this time, personnel are directed to retrieve necessary equipment and/or medications. As resuscitative interventions are implemented, all surgical team members are expected to participate. Circulating nurse. Activates the call for the code according to facility guidelines. The circulator performs the following actions according to the level of activity and assistance available in the surgical suite: • records time of arrest • retrieves the crash cart if alone, otherwise first-line medications are available in the anesthesiologist's cart • assists in repositioning the patient and the OR table to facilitate CPR. May direct others to remove equipment from the room if it interferes with successful resuscitation. • notifies the OR manager/charge nurse of emergency and requests assistance, including but not limited to anesthesiologists, intensivist, pharmacist, anesthesia technicians, RNs, and PACU personnel • controls traffic in the room (directs visitors/ students from the room) • maintains the accuracy of the instrument, sponge and needle counts with specific attention to wound closure if in progress • assists in maintaining the integrity of the sterile field. It’s important to note that resuscitative efforts are paramount to the security of the sterile field • delegates tasks to other personnel as necessary • documents all activities in the room (time, dose, and frequency of all medications administered, route, and who administered them) in order of occurrence • performs compressions as needed until support personnel are available • follows facility guidelines for family notification if CPR attempts are unsuccessful, care of the body, specimen care and documentation of the death and disposition of the body. Scrub person. Maintains personal sterility and the sterile field. In the event of noncardiac surgery (where the chest isn’t open), prepares for packing of the surgical wound with saline-soaked sponges and covers with sterile drape. The scrub person also performs the following: • assists in repositioning the patient for initiation of CPR • gives total attention to surgical field and surgeon’s needs related to bleeding, suctioning, and/or wound closure • assists as required in the event the circulator is otherwise occupied.
OR Nurse2007 May/June
Surgeon. Closes wound if needed, assists in resuscitative activity (performs compressions, assists in repositioning patient), and leads code in non-anesthesia case. Administers medications as needed. OR manager/charge nurse. Assigns personnel to assist the surgical team (extra circulator, personnel to handle supplies or lab work) as needed. Notifies the ICU and house supervisor of potential admission. Also responsible for: • revising schedule as situation dictates • monitoring and assessing emergency procedure and staff performance • supporting the team as required • supporting the surgical team in a cardiac arrest event. Physician assistants, residents, and registered nurse first assistants (RNFAs). These individuals should assist as directed by the code leader/ anesthesiologist and assist the circulator as needed. Appropriate documentation during an emergency event is crucial. Information noted during adverse events must be complete, concise, and factual. Code forms are maintained on the crash cart to facilitate easy access. Documentation during a cardiac arrest must include several critical elements. This data is determined by the institution and staff need to be familiar with its content. The information recorded is time sensitive and minimally includes: • patient label/identification per facility • time of arrest • name of all surgical team members or participants • diagnosis • presence of endotracheal (ET) tube, or tracheostomy tube and type of ventilation • start of compressions • condition of patient before arrest • insertion of any peripheral or central lines • medications administered • fluids administered • lab studies performed • time of defibrillation • other information per facility policy. Note also whether the patient was repositioned to accommodate effective resuscitative efforts. The circulating nurse must indicate if, for any reason, resuscitative efforts were delayed due to wound closure, table and patient repositioning, or any detachment from surgical equipment. A patient’s condition and disposition at the conclusion of the code must be recorded. In the case of successful CPR, an ICU bed must be requested to facilitate
safe transfer. Notify the family of the delay and document the notification. Also advise them that the physician will be out to speak with the family as soon as possible. The physician must speak to the family in private and allow them the opportunity to ask questions. It’s important that all nursing personnel be familiar with their institution’s code policy and guidelines. A copy of the code form must be forwarded to the nurse manager and risk management representative for review, depending on the facility policy. Additionally, a post-code debriefing may be conducted to evaluate the performance of the team. The patient’s record may be reviewed by the risk management department to ensure elements documented are clear and concise. Do not resuscitate (DNR) Advance directives were developed to ensure a patient’s ability to participate in the decisions affecting her healthcare. As an amendment to the Omnibus Reconciliation Act in 1990, the Patient SelfDetermination Act became effective in December 1991.8 This act gives the patient the ability to preserve her dignity in end-of-life decisions. It also addresses the fact that Medicare and Medicaid providers are required to give an adult patient’s information concerning advance directives. These decisions focused on CPR, intubation, defibrillation and medication administration and are components of what’s commonly referred to as DNR orders. DNR orders represent the patient’s request for treatment limitations. Once DNR orders have been identified and confirmed with the patient, the chart is flagged to alert the OR team. Preoperatively, patients should have a discussion with the surgeon to determine how the DNR will affect them in surgery.9 The anesthesia provider will specifically review resuscitation procedures as they relate to providing anesthesia, and any impact on the postoperative period related to surgical complications. The surgeon and anesthesia provider will discuss all of these areas to ensure agreement on the intervention. The circulator and scrub person need to be informed of the patient’s DNR status before the patient is taken to the surgical suite. The circulator must check the record to confirm that the DNR order form is signed and the appropriate checks and balances are completed. Automatic suspension of DNR orders undermines the patient’s ability to participate in this process.10
May/June OR Nurse 2007
Both the AORN and American Nurses Association recommend that advance directives should be discussed with all adult patients as part of any nursing assessment.10, 11 AORN states that nurses have a responsibility to uphold the rights of the patient.10 Further-more, as a patient advocate, the perioperative nurse has a moral responsibility to the patient. If a nurse is unable to provide for the wishes of the patient, then that nurse must attempt to find another nurse willing to provide care to that patient.10 All surgical personnel must be knowledgeable about the DNR procedure. This information should be reviewed during orientation and periodically throughout employment. The nurse’s role Early identification of a potential risk for cardiac arrest, understanding the roles of the personnel involved, and providing for the patient’s safety is essential. The knowledge and skills acquired by perioperative nursing staff are used to implement the nursing process as it relates to a variety of situations. Safe, effective, and efficient care in emergency situations depends on the ongoing education programs provided. Knowing the expectations of the roles involved and equipment used will provide optimal resuscitative efforts. All staff need to consider the “what ifs” to be prepared for adverse events. OR
REFERENCES 1. American Heart Association. Cardiac Arrest. AHA Recommendation. 2007. Available at: http://www.americanheart.org/presenter. jhtml?identifier=4481. Accessed April 2, 2007. 2. Phillips N. Berry & Kohn’s Operating Room Technique. St. Louis, MO. Mosby; 2004. 3. Fink MP, Abraham E, Vincent JL, Kochanek JL. Textbook of Critical Care. Philadelphia, PA: Elsevier Saunders; 2005. 4. Gabrielli A, Robicsek SA. New Concepts in ACLS. ASA Newsletter. 2006;70(4). Available at: http://www.asahq.org/Newsletters/ 2006/04-06/gabrielli04_06.html. Accessed April 2, 2007. 5. American Society of Anesthesiologists. ASA physical status classification. Available at: http://www.asahq.org/clinical/physicalstatus. htm. Accessed February 20, 2007. 6. Association of Perioperative Nurses. Standards, recommended practices and guidelines. Denver, CO; 2007. 7. Considine J, Botti M. Who, when and where? Identification of patients of an in-hospital adverse event, implications for nursing practice. A research paper. Int J Nurs Pract. 2004;10:21-31. 8. Patient self-determination act. Ascension Health. Available at: http://www.ascensionhealth.org/ethics/public/issues/ patient_self.asp. Accessed February 20, 2007. 9. American College of Surgeons, Statement of the College;[ST-19] Statement on Advance Directives by Patients: “Do Not Resuscitate” in the Operating Room. Retrieved January 10, 2007. Available at: http://www.facs.org/fellows_info/statements/st-19.html. Accessed April 2, 2007. 10. Association of Perioperative Nurses. Position statement: perioperative care of patients with do-not-resuscitate (DNR) orders. Denver, CO; 2005. 11. American Nurses Association. Ethics and human rights position statement. Available at: http://www.nursingworld.org/readroom/ position/ethics/etsdet.htm. Accessed February 20, 2007.
Patricia Woolson is an education consultant, perioperative services, Sinai Hospital of Baltimore, Md. The author has disclosed that she has no significant relationship with or financial interest in any commercial companies that pertain to this educational activity.
Earn CE credit online:
Go to http://www.nursingcenter.com/CE/ORnurse and receive a certificate within minutes.
Responding to cardiac arrest
TEST INSTRUCTIONS • To take the test online, go to our secure Web site at http://www.nursingcenter.com/ORnurse. • On the print form, record your answers in the test answer section of the CE enrollment form on page 37 . Each question has only one correct answer. You may make copies of these forms. • Complete the registration information and course evaluation. Mail the completed form and registration fee of $19.95 to: Lippincott Williams & Wilkins, CE Group, 2710 Yorktowne Blvd., Brick, NJ 08723. We will mail your certificate in 4 to 6 weeks. For faster service, include a fax number and we will fax your certificate within 2 business days of receiving your enrollment form. • You will receive your CE certificate of earned contact hours and an answer key to review your results.There is no minimum passing grade. • Registration deadline is June 30, 2009. DISCOUNTS and CUSTOMER SERVICE • Send two or more tests in any nursing journal published by Lippincott Williams & Wilkins together and deduct $0.95 from the price of each test. • We also offer CE accounts for hospitals and other health care facilities on nursingcenter.com. Call 1-800-787-8985 for details. PROVIDER ACCREDITATION Lippincott Williams & Wilkins, publisher of OR Nurse 2007 journal, will award 2.0 contact hours for this continuing nursing education activity. Lippincott Williams & Wilkins is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center’s Commission on Accreditation. Lippincott Williams & Wilkins is also an approved provider of continuing nursing education by the American Association of Critical-Care Nurses #00012278 (CERP category A), District of Columbia, Florida #FBN2454, and Iowa #75. LWW home study activities are classified for Texas nursing continuing education requirements as Type 1. This activity is also provider approved by the California Board of Registered Nursing, Provider Number CEP 11749 for 2.0 contact hours. Your certificate is valid in all states.
OR Nurse2007 May/June