Scrub area:

Are placed strategically outside operating rooms. Surgical scrub sinks are generally ceramic or stainless
steel with foot or knee controls. It is helpful to place shelves above the sink to hold scrub brushes and
masks

Operating room

An operating room is the area where surgical procedures are performed under strict sterile techniques.

Conversation of team members should be appropriate an kept to a minimum. Hand signals between the
surgeon and the scrub person are more useful than a verbal request for instruments. However, the
surgeons may request a number 10 or 15 rather than a knife, or a Mayo or metz rather than a scissors.

Strange noises should be explained to the patient eg. Suction a to remove irrigation solution,: the sound
and odor of the electrosurgical unit.

Legend:
CN – circulating Nurse
SN – Scrub Nurse
DIVISION OF DUTIES

• Circulating nurse and scrub nurse plan their duties so that through coordination of their efforts,
the sterile and unsterile parts of the surgical procedure move along simultaneously.
• By the time the scrub nurse starts the surgical scrub until the surgical procedure is completed and
dressing is applied, an invisible line separates the duties of the scrub nurse and the circulating
nurse.
• As a coordinated, systematic effort the scrub nurse and circulating nurse should complete the
preparation of the environment.
• Both should double check the need for the procedure before the patient arrives at the OR.

SETTING UP THE ROOM

• Bothe the CN and SN set up the room and position equipment.

• The duties and activities change when the patient arrives at the room
• CN begins working with the patient, and SN continues readying the room

DUTIES PERFORMED TOGETHER BEFORE PATIENT ARRIVES

• Place a clean sheet, lift sheet, arm board covers and safety straps on the operating bed
• Obtain any specialized equipment that will be needed such as electrosurgical unit
• Gather protective device such as X-ray protective gown/lead gown and eye wear of the correct
optical density as needed
• Position the operating bed under overhead operating spotlight fixture.
• Test the overhead operating light to check the focus and intensity and reposition as much
as possible.
 • Connect and check the suction between the receptacle canister and the wall outlet to be
certain suction functions on a maximum vacuum.
• Line each kick bucket and waste basket with an impervious plastic lines with a cuff turns
over the edge.
• Arrange furniture and those pieces that will be draped to become part of the sterile field at
least 18 inches away from walls or cabinets
• Place the sterile, wrapped drape pack in the instrument table so that when opened , the
wrapper will adequately drape the table and the drape will be in their proper places.
• Select the correct size of gloves and gowns for the team.
• Select the initial sutures to have ready for the surgeon
• Open the instrument set.

BE ALERT TO ANTICIPATE THE NEEDS OF THE STERILE TEAM (CIRCULATING

NURSE)
• Adjust the operating light
• Removing perspiration from brows and keeping the scrub person supplied with sponges,
sutures, warm saline and other necessary items

SPECIMEN:

• Label correctly (name, ID number, type and site of the specimen)

• Requisition includes: name of the surgeon, date, pre and post diagnosis, surgical
procedure, desired test, tissue to be examined including its source labeled as right or Left.
FOR TISSUE SPECIMEN:

• Pathology: should not be allowed to dry out.

- Saline / solution of aqueous formaldehyde (10%) formalin) is commonly used as the
fixative until the specimen is processed further in the laboratory.
• CULTURE – should be segregated or sent to the laboratory immediately.
• SMEAR AND FLUID – should be taken to the laboratory as soon as possible.
- May be placed in a glass slides or drawn into an evacuator tubes
• STONES- are placed in a dry container so they will not dissolve.
• FOREING BODY- should be sent accession according to policy and a record is kept for
legal purposes
- Descriptions are recorded
- May be given to the police, surgeon or patient depending on the legal implications,
policy in the surgeons wishes
• AMPUTATED EXTERMITIES – are wrapped in plastic before sending them to a
refrigerator in the laboratory or morgue.
- Avoid placing in the patients view or field of vision) may cause emotional distress.
- Patient may request that an amputated extremity be sent to a mortuary for preservation
for burial with his or her body after death.
- Must be noted in the requisition sent to the laboratory.
CLOSURE:
- Count sponges, sharps and instrument with the scrub nurse. report to the surgeon
whether correct or incorrect.
AFTER SURGICAL PROCEDURE IS COMPLETE

• CN Assist in securing the dressing over the surgical wound and managing the surgical
drainage system
• SN roll the drapes off the patient and clean the surrounding skin before the outer layer of
dressing is secured with the appropriate type
• SN open the neck and back closures of the surgeons and assistant surgeons gown so
they can remove them without contaminating themselves.

PRECAUTION IN LIFTING AND ROLLING THE UNCONSCIOUS PATIENT

• Protect the IV and urinary drainage bag, secure IV solution bags on an IV pole.
• Cue the lift sheet to support the arms at the sides so the arms do not dangle
• The anesthesia provider guards the head and neck from injury and call the count for the
move.
• Lift or roll the patient gently and slowly to avoid circulatory depression.
Source: Operating Room Technique 11th edition by Berry & kohn’s

There are four stages of general anesthesia, namely: analgesia - stage 1, delirium - stage 2,
surgical anesthesia - stage 3 and respiratory arrest - stage 4. As the patient is increasingly
affected by the anesthetic his anesthesia is said to become 'deeper'.

Local anesthesia patient care Introduced: May 15, 2020

Introduction

Local anesthesia is the administration of pain-blocking medication to a local site to

minimize the potential pain of a procedure. Infiltration of local anesthesia commonly is
used for wound cleaning and repair, abscess drainage, minor skin surgery, IV catheter
insertion, central venous access device entry, and diagnostic and therapeutic procedures,
such as lumbar puncture and thoracentesis.

The use of local anesthesia has advantages over conventional pain management that
uses analgesics because it doesn't alter the patient's level of consciousness and it's
associated with fewer adverse effects. However, local infiltration of anesthesia might not
be appropriate for some wounds, such as those involving a digit, because digits typically
have tight skin and can accept only a limited volume of medication. Although
topical anesthesia may be appropriate in some instances, infiltration of
local anesthesia takes effect more quickly and provides more adequate pain relief.
 Clinical alert: Local anesthetic agents can cause adverse reactions as well as
produce symptoms of local or systemic toxicity. Local adverse effects include
neurovascular symptoms of prolonged anesthesia or paresthesia that may be irreversible.
Systemic toxicity affects the cardiovascular or central nervous system. 1 Recommended
guidelines to decrease the risk of local anesthetic systemic toxicity (LAST) include using
the lowest effective dose of local anesthetic, aspirating the needle before each injection to
avoid introducing the drug directly into a vessel, using incremental injections of anesthetic,
and continually communicating with the patient to monitor for early signs of toxicity. 23

Equipment
• Vital signs monitoring equipment
• Pulse oximeter and probe
• Local anesthetic of practitioner's choice
• Appropriate size syringe and needle for administration
• Gloves
• Antimicrobial skin preparation solution
• Emergency equipment (code cart with emergency medications, defibrillator,
handheld resuscitation bag with mask, intubation equipment)
• Optional: IV catheter insertion supplies, supplemental oxygen, oxygen mask or
nasal cannula, other personal protective equipment, cardiac monitoring equipment,
prescribed medications, lipid emulsion

Preparation of Equipment

Inspect all equipment and supplies. If a product is expired, is defective, or has

compromised integrity, remove it from patient use, label it as expired or defective, and
report the expiration or defect as directed by your facility.

Ensure monitoring equipment and emergency equipment is readily available and

functioning properly.

Implementation
• Verify the practitioner’s order.
• Gather and prepare the necessary equipment and supplies.
• Review the patient's medical record for medication allergies, past medical and
surgical history, age, height, weight, body mass index, current medications, a
history of the present illness, last oral intake, reason for the current procedure,
and information related to previous experiences with anesthesia. 4
• Conduct a preprocedure verification to ensure that all relevant documentation,
related information, and equipment are available and identified to the patient's
identifiers correctly. 56
• Confirm that informed consent has been obtained and the signed consent form is
in the patient's medical record. 7
• Perform hand hygiene. 8910111213
• Confirm the patient’s identity using at least two patient identifiers. 14
• Provide privacy. 15161718

• Explain the procedure to the patient and family (if appropriate) according to their
individual communication and learning needs to increase their understanding, allay
their fears, and enhance cooperation. 19
• Reinforce the practitioner's explanation of the procedure, and answer the patient's
questions. 20212223
• Obtain baseline vital signs, including blood pressure, pulse rate, respiratory rate,
oxygen saturation level by pulse oximetry, pain level, anxiety level, and level of
consciousness. 424
• Screen for and assess the patient’s pain using facility-defined criteria that are
consistent with the patient’s age, condition, and ability to understand. 24
• Perform a complete physical assessment, if not already done.
• Determine whether the patient has appropriate IV access. Obtain IV access if
necessary. (See the "IV catheter insertion" procedure).
• Conduct a time-out immediately before starting the procedure to perform a final
assessment that the correct patient, site, positioning and procedure are identified
and, as applicable, all relevant information and necessary equipment are
available. 2526
• Assist with positioning the patient for local anesthesia administration, as needed.
• Before the anesthetic is injected, tell the patient to expect a transient burning
sensation and local pain. Instruct the patient to report other persistent pain or
sensations because these may indicate irritation or puncture of a nerve root, which
would require repositioning of the needle. 27
 • Instruct the patient to remain still and breathe normally during needle insertion. If
necessary, hold the patient in position to help prevent sudden movement that may
displace the needle. Ensuring that the patient remains still during the procedure
helps to prevent injury to the nerve root.
• Assist as needed during local anesthesia administration while comforting the
patient and answering any questions. 27
• Note the amount of medication injected.
• Assist as needed with positioning the patient for the procedure.
• Monitor the patient's pain level, level of consciousness, and anxiety level
throughout the procedure. 4
• Monitor the patient's vital signs, including pulse rate, blood pressure, oxygen
saturation level by pulse oximetry and respiratory rate throughout the procedure,
as needed. Monitor the patient's heart rate and rhythm, as appropriate. 4
• Administer supplemental oxygen, as needed and ordered.
• Assess the patient for signs and symptoms of LAST, including dizziness, tinnitus,
metallic taste, circumoral numbness, confusion, slurred speech, shivering, tremors,
agitation, seizures, ventricular arrhythmias, hypertension, and tachycardia initially
followed by progressive hypotension and bradycardia, asystole, and respiratory
arrest. 4 Report such changes to the practitioner because early identification and
intervention help lead to better outcomes. 428 Intervene as needed and ordered.
(See Treating LAST.)

TREATING LAST
If a patient develops local anesthetic systemic toxicity (LAST), treatment commonly
includes:

• maintaining a patent airway.

• ventilating the patient with 100% oxygen.
• administering basic or advanced cardiac life support, as needed.
• establishing IV access if needed.
• administering a 20% lipid emulsion based on lean body mass; a bolus first
followed by an infusion.
• suppressing seizures with medication such as a benzodiazepine.
• avoiding use of vasopressin, calcium channel blockers, beta-adrenergic blockers,
or local anesthetics.
 • reducing EPINEPHrine doses, if necessary, to less than 1 mcg/kg.
• avoiding propofol in patients showing signs of cardiovascular instability.
• alerting the nearest facility that has cardiopulmonary bypass capability if not
provided in your facility.
• monitoring the patient for at least 12 hours following LAST because
cardiovascular depression due to local anesthetics can last or recur after initial
treatment. 4

• Calm and reassure the patient as needed.

• Remove and discard your gloves and other personal protective equipment if
worn. 2930
• Perform hand hygiene. 8910111213
• Document procedure. 31323334

Special Considerations
• The use of music or guided imagery may help calm the patient and decrease
discomfort during and after a procedure. 4
• The Joint Commission issued a sentinel event alert related to managing risk during
transition to new International Organization for Standardization tubing standards
that were designed to prevent dangerous tubing misconnections, which can lead
to serious patient injury and death. During the transition, make sure to trace each
tubing and catheter from the patient to its point of origin before connecting or
reconnecting any device or infusion, at any care transition (such as a new setting
or service), and as part of the handoff process; route tubes and catheters with
different purposes in different standardized directions; label the tubing at the distal
and proximal ends (when the patient has different access sites or several bags
hanging); use tubing and equipment only as intended; and store medications for
different delivery routes in separate locations. 35
• Nurses who will be involved with the care of patients undergoing procedures
performed using local anesthesia should receive education about their roles in the
care of these patients as well as the medications used and safe administration
guidelines.

Patient Teaching

Provide the patient with an ongoing explanation regarding the administration of

local anesthesia, including what to expect as the anesthetic takes effect and how it will
feel when it wears off. Tell the patient about the procedure and what is expected during
it. Answer all questions as completely as possible.

Complications

Bruising and other tissue injury, pain, infection, allergic medication reactions, and
toxicities are all potential complications of this procedure. The use of proper sterile
technique and equipment may alleviate many of these issues. Proper assessment of the
patient's medical history may help to identify potential drug allergies.

Documentation

Document the patient's postprocedure assessment, including vital signs, the condition of
the dressing covering the site (if applicable), temperature, level of consciousness, pain
and nausea levels, treatment and effects, dosage and concentration of administered local
medication and the patient's reaction to it, and intake and output. Record and
immediately report to the practitioner signs of allergy or toxicity. Record any adverse
reactions to prescribed medications or local anesthetic, the date and time the practitioner
was notified, prescribed interventions, and the patient's response to those interventions.
Document teaching provided to the patient and family (if applicable), their understanding
of that teaching, and any need for follow-up teaching.

General anesthesia patient care, OR Revised: November 15, 2019

Introduction

Administration of general anesthesia to a patient during complex surgery induces a loss

of consciousness, produces memory loss about the procedure, provides analgesia,
promotes muscle relaxation, diminishes motor response, and suppresses autonomic
reflexes, such as increases in blood pressure and heart rate that can occur during
surgery. 1 As a result, general anesthesia produces a loss of protective airway reflexes
(such as coughing), loss of airway patency and, sometimes, loss of a regular breathing
pattern due to the effects of anesthetics, opioids, or muscle relaxants. To maintain an
open airway and regulate breathing within acceptable parameters, insertion of some form
of breathing tube into the airway is necessary after the patient is unconscious. For
mechanical ventilation, intubation using an endotracheal (ET) tube is most common. A
patient who can maintain spontaneous ventilation while under
general anesthesia requires an ET tube or alternative device, such as a face mask or
laryngeal mask airway.

Agents that induce general anesthesia can be given intravenously or inhaled with oxygen
through a mask and may be given in combination with other agents, such as muscle
relaxants. (See Common agents used to induce general anesthesia.) IV anesthetics are
preferred for anesthesia induction because of their rapid action; however, inhaled or
volatile anesthetics are preferred for anesthesia maintenance because they can be rapidly
adjusted, if necessary, by adjusting the amount of oxygen that's mixed with the
anesthetic. Inhalation induction commonly is selected for children because IV catheter
insertion may be traumatizing to a child who's awake.

COMMON AGENTS USED TO INDUCE GENERAL ANESTHESIA

A variety of agents are used to induce general anesthesia. The table below features
some commonly used agents along with their advantages and disadvantages.
Agent Advantages Disadvantages
Inhalation anesthetics
Enflurane
• Rapid induction onset • Not recommended for use in
patients with kidney failure
• Possibly faster
recovery than other • Risk of malignant hyperthermia 2
agents

Isoflurane
• No liver toxicity • Can induce irregular heart rhythms
• Risk of malignant hyperthermia 2

Nitrous
• Rapid induction and • Used with other drugs to induce
oxide
recovery time 1 surgical anesthesia 3
• Doesn't slow • Not recommended for use in
respirations or blood patients with possible pre-existing
flow to the brain bowel distention, increased middle
ear pressure, pneumothorax,
• Doesn't cause
pneumoperitoneum,
malignant
pneumocephalus, intraocular gas, or
hyperthermia
venous embolism 3
• Increased incidence of nausea and
vomiting 34

Sevoflurane
• Rapid induction onset 3 • Risk of malignant hyperthermia 2
• Rapid recovery 3
• Doesn't irritate the
airway
Desflurane
• Rapid induction • Causes airway irritation 3
onset 13
• Increased incidence of moderate to
• Rapid recovery 3 severe upper airway adverse
reactions in children; not
• Advantageous for recommended as an induction
older patients and
agent 5
those who are
morbidly obese or • Increases heart rate and blood
have sleep apnea 4 pressure; not recommended as the
sole induction agent in patients with
coronary artery disease or other
conditions in which increases in
heart rate and blood pressure are
undesirable 5
• Risk of malignant hyperthermia 25

IV anesthetic
Ketamine
• Rapid acting 13 • Short duration of action 6
• Wide safety margin 6 • May cause dreams, vivid imagery,
hallucinations, and delirium during
• Causes minimal
postoperative recovery 6
cardiopulmonary
depression 13 • Safety and effectiveness not
established in children younger than
age 16 6

Propofol
• Rapid, smooth • Contraindicated in patients with
induction allergies to eggs, egg products, soy
of anesthesia 3 beans, or soy products 7
• Rapid clearance from • Decreases cardiac output and may
the body 7 cause hypotension, cardiac arrest,
and death 7
• May cause pain at the injection site 7

When choosing which anesthetic or combination of anesthetics to use,

the anesthesia care provider reviews the patient's age, weight, medication allergies,
family history of allergies or malignant hyperthermia, medical history, general health, and
any known problems with anesthetic agents in the past. Typically, the anesthesia care
provider uses a combination of inhaled and IV anesthetics, possibly with opioids added
for pain relief and neuromuscular blockers for muscle paralysis.

Operating room (OR) staff members must be knowledgeable about the possible adverse
effects of the anesthetic agents administered, early identification of patient compromise,
and appropriate response for each agent. General anesthesia can be life-threatening; the
nurse must be alert during intubation and extubation and assist the anesthesia care
provider, as needed.

Equipment
• Anesthesia machine
• Breathing circuit appropriate for age and size of patient
• Anesthetic agent
• Monitoring devices for heart rate and rhythm, oxygen saturation, and blood
pressure
• Suction source
• Suction tubing and tip
• Laryngoscope and various sizes and styles of blades
• Intubating stylet
• Carbon dioxide detector
• ET tube or laryngeal mask airway
• Nasal and oral airways
• Gloves
• Stethoscope
• Disinfectant pad
• Oxygen with face mask
• Emergency equipment (code cart with emergency medications, defibrillator,
handheld resuscitation bag with mask, intubation equipment)
• Malignant hyperthermia cart
• Optional: monitoring equipment for arterial and central venous pressure lines,
bispectral index, difficult-airway cart, fiber-optic intubating bronchoscope, gown,
mask and goggles or mask with face shield
 Preparation of Equipment

Thoroughly check and inventory equipment and supplies for general anesthesia before
each operation, and restock items as they're used, particularly emergency and suction
equipment.

Inspect all equipment and supplies; if a product is expired, its integrity is compromised,
or it's defective, remove it from patient use, label it as expired or defective, and report
the expiration or defect as directed by your facility.

Implementation
• Verify that the anesthesia machine has been cleaned and set up with new
tubing. 89
• Make sure that various sizes of nasal and oral airways, intubation tubes, intubation
stylets,
and laryngeal blades are available, as requested by the anesthesia care provider. 10
• Confirm that a properly functioning laryngoscope is available.
• Determine whether the necessary monitoring equipment is available and in
working condition, including a bispectral index monitor, if requested.
• Verify that emergency equipment is readily accessible in case it's needed. 10
• Check the malignant hyperthermia cart to make sure that it contains all of the
necessary supplies. (See the "Malignant hyperthermia patient care, OR" procedure
and see Malignant hyperthermia.)

MALIGNANT HYPERTHERMIA
Malignant hyperthermia is a genetic, hypermetabolic, life-threatening condition
triggered by the administration of certain inhaled anesthetic agents, including enflurane,
isoflurane, sevoflurane, and desflurane. 1112 The depolarizing muscle relaxant
succinylcholine can also precipitate malignant hyperthermia. 1112 A patient can develop
malignant hyperthermia even without having a previous personal history of a reaction.
Typically, signs and symptoms occur in the operating room, but the 1-hour period after
surgery is also critical. 11

Signs of malignant hyperthermia during surgery include: 12

• increased carbon dioxide production (hypercarbia), which may be two to three

times the normal rate
 • generalized muscle rigidity
• severe masseter spasm (causing difficulty opening the mouth or ventilating)
• unexplained tachycardia or arrhythmias (usually ventricular tachycardia or
premature ventricular contractions)
• tachypnea
• generalized flushing and skin that is warm to the touch
• mixed respiratory and metabolic acidosis
• temperature elevation (can increase 2° F [1° C] every few minutes)
• myoglobinuria
• hyperkalemia
• rhabdomyolysis
• cyanosis and skin mottling
• hypoxemia
• coagulopathy
• kidney failure.

Malignant hyperthermia is an emergency that requires immediate treatment measures.

• Review the patient's medical record for allergies, medical history, and information
related to previous surgical procedures and anesthesia. 10
• Confirm that informed consent has been obtained and the signed consent form is
in the patient's medical record. 101314
• Conduct a preprocedure verification to make sure that all relevant documentation,
related information, and equipment are available and correctly identified to the
patient's identifiers. 1516
• Verify that ordered laboratory and imaging studies have been completed and that
the results are in the patient's medical record. Notify the practitioner of any
unexpected results.
• Perform hand hygiene. 171819202122 (See the "Hand antisepsis, OR" procedure.)
• Put on
gloves and, as needed, other personal protective equipment to comply with
standard precautions. 232425
• Confirm the patient's identity using at least two patient identifiers. 26
• Confirm the patient's nothing-by-mouth status before the procedure. Minimum
fasting recommendations include 2 hours for clear liquids, 4 hours for breast milk,
6 hours for infant formula, 6 hours or more for a light meal or nonhuman milk,
and 8 hours or more for fried or fatty foods or meat. If the procedure is an
emergency, collaborate with the practitioner to compare the risks and benefits of
the procedure, considering the amount and type of liquids or solids ingested. 27
• Conduct a preoperative assessment of the patient if not already done. Before
transporting the patient to the OR suite, ask about medical conditions, including
any personal or family history of allergies and any problems related to anesthetics
that could cause adverse reactions with general anesthesia. 10
• Reinforce the practitioner's explanation of the procedure to the patient and family
(if appropriate) according to their individual communication and learning needs,
and answer any questions to increase understanding, allay fears, and enhance
cooperation.
• Confirm patent IV access. 10
• Verify that all necessary equipment and medications are available and that the
equipment is working properly. 10
• Assist the anesthesia care provider with connecting the patient to the appropriate
monitors—blood pressure, electrocardiogram, and pulse oximetry—and invasive
lines, such as central venous pressure and arterial lines. Trace each line from the
patient to its point of origin to make sure that you're connecting it to the proper
port. 2829 Make sure that the alarm limits are set appropriately for the patient's
current condition and that the alarms are turned on, functioning properly, and
audible to staff. 30313233
• If not already done, administer preoperative medications, as ordered, following
safe medication administration practices. 34353637
• Comfort the patient during the anesthesia induction process.
• Assist the anesthesia care provider in preoxygenating the patient with 100%
oxygen using a face mask, if requested.
• Provide cricoid pressure or other assistance during intubation, as requested by
the anesthesia care provider, to help prevent aspiration of gastric contents.
• Make sure that a stethoscope and carbon dioxide monitor are available for
the anesthesia care provider to verify tube placement.
• Obtain the difficult-airway cart and a fiber-optic intubating bronchoscope if
the anesthesia care provider has problems with the airway. (See Difficult-airway
cart.)
 EQUIPMENT

DIFFICULT-AIRWAY CART
The items on a difficult-airway cart help the anesthesia care provider intubate patients
who have conditions that make intubation difficult, such as obesity, loose teeth, or an
inability to open the mouth adequately or move the neck or chin.

A difficult-airway cart should include:

• laryngeal mask airways

• McCoy laryngoscope, which has a hinged tip on its blade that allows a better
view of the patient's larynx
• fiber-optic bronchoscope and light source
• video laryngoscope 38
• laryngoscope with various blades and handles (adult and pediatric)
• extra batteries for laryngoscope
• endotracheal tubes (various sizes, cuffed and uncuffed)
• oral and nasal airways of various sizes
• intubating stylets
• McGill forceps 38
• suction tubing with flexible and Yankauer tips.

• Conduct a time-out immediately before starting the procedure to ensure that the
correct patient, site, positioning, and procedure are identified and, as applicable,
that all relevant information and necessary equipment are available. 1639
• Assist the anesthesia care provider, as needed during the procedure, including
observing the patient for signs of adverse effects.
• Protect the patient from injury throughout the procedure, especially during
positioning and transfers.
• When the procedure is complete, assist the anesthesia care provider with
extubation.
• Provide a nasal or oral airway and secure the airway, if necessary.
• Remove and discard your gloves and other personal protective equipment if
worn. 2325
• Perform hand hygiene. 171819202122
• Clean and disinfect your stethoscope using a disinfectant pad. 4041
• Perform hand hygiene. 171819202122
• Document the procedure. 42434445

Special Considerations
• The Joint Commission issued a sentinel event alert concerning medical device
alarm safety because alarm-related events have been associated with permanent
loss of function and death. Among the major contributing factors were improper
alarm settings, inappropriately turned-off alarms, and alarm signals not audible to
staff. Make sure that alarm limits are appropriately set and that alarms are turned
on, functioning properly, and audible to staff. Follow facility guidelines for
preventing alarm fatigue. 32
• Depending on the patient's level of anxiety and medical conditions as well as the
procedure, the patient may receive premedication. Most medications given before
general anesthesia are anxiolytics or analgesics. Patients in severe pain before
surgery may receive morphine or fentanyl. Patients with a history of bronchospasm
or heavy airway secretions receive anticholinergics, which block impulses from the
parasympathetic nervous system.
• During and after intubation, coordinate patient movement with
the anesthesia care provider.
• A bispectral index helps the anesthesia care provider measure the anesthetized
patient's level of consciousness. The device gives a reading from 100 for fully
awake to 0 for no brain activity.
• The entire surgical team must be aware that, although the patient is unconscious,
hearing is the last sense to fade.
• The circulating nurse is responsible for preventing possible injury, such as pressure
injury formation, to the patient during a long procedure. Proper positioning
equipment and padding, such as gel pads, help secure the patient and protect
bony prominences.
• The Joint Commission issued a sentinel event alert related to managing risk during
transition to new International Organization for Standardization tubing standards
that were designed to prevent dangerous tubing misconnections, which can lead
to serious patient injury and death. During the transition, make sure to trace each
tubing and catheter from the patient to its point of origin before connecting or
reconnecting any device or infusion, at any care transition (such as to a new setting
 or service), and as part of the hand-off process. In addition, route tubes and
catheters with different purposes in different, standardized directions; label tubing
at both the distal and proximal ends when the patient has different access sites or
several bags hanging; use tubing and equipment only as intended; and store
medications for different delivery routes in separate locations. 29

Complications

Even in the best situation, general anesthesia can cause some complications. Patients
waking from general anesthesia commonly vomit, shiver, and become restless.

Although serious complications during general anesthesia are uncommon, they can
include malignant hyperthermia, myocardial infarction, stroke, renal problems, brain
damage, and even death. The risk of complications depends in part on the patient's age,
sex, weight, allergies, general health, and history of smoking and alcohol and drug use.

Documentation

Record your assessment findings, the time of the patient's last food and fluid intake, and
the response to your question about allergy status. Describe the protective measures you
used to prevent injury during transfer and positioning. Document any medications you
administered, including the medication strength, dose, route of administration, and date
and time of administration. 46 If the patient develops complications, describe the signs
and symptoms, date and time you notified the practitioner, prescribed interventions, and
the patient's response to those interventions. Document teaching you provided to the
patient, the patient's understanding of that teaching, and any need for follow-up teaching.

Local anesthesia patient care, ORRevised: November 15, 2019

Introduction

Local anesthesia provides a regional loss of sensation for a patient during a surgical
procedure in an operating room (OR). It can be used in conjunction with other forms of
anesthesia for pain control, or it can be used alone for a patient who doesn't require a
general anesthetic. The type of anesthetic and method of administration used vary,
depending on the location and type of surgical procedure. Common methods of
administration include infiltration, digital ring block, and peripheral nerve conduction
block.

Local anesthesia, which is safer than general or systemic anesthesia, is used whenever
possible, especially in patients who are at risk for complications with the use of other
types of anesthesia. Although local anesthesia has several advantages, such as the
patient avoiding the adverse effects of general anesthesia and recovering more quickly,
it isn't suitable for use in all patients. Anxious, uncooperative patients and patients who
can't lie still for the duration of the procedure might not be able to tolerate surgery using
a local anesthetic alone. During the preoperative assessment, the perioperative nurse
should assess the patient for issues that may interfere with the effectiveness of the use
of this type of anesthesia and discuss the care plan with the surgeon.

When used properly, local anesthetics have few major adverse effects. However, the use
of high doses may have toxic effects on the patient's respiratory and cardiovascular
systems if they're absorbed through the bloodstream into the rest of the body. Other
factors, including the patient's age, medical condition, and concomitant medication use,
may increase this risk. The perioperative nurse must be able to recognize the signs and
symptoms of local anesthetic systemic toxicity (LAST) and to understand the necessary
treatment protocol. 1

The perioperative nurse should evaluate the patient's medical history and physical
condition thoroughly before administering local anesthesia. In addition, the perioperative
nurse should ensure that emergency equipment is readily available during all procedures
involving the use of local anesthesia.

Equipment
• Vital signs monitoring equipment
• Pulse oximeter and probe
• Local anesthetic of surgeon's choice
• Syringes and needles for administration
• Gloves
• Emergency equipment (code cart with emergency medications, defibrillator,
handheld resuscitation bag with mask, intubation equipment)
• Optional: IV catheter insertion supplies, antimicrobial skin preparation solution,
preoperative medications (if ordered), supplemental oxygen, oxygen mask or nasal
cannula, other personal protective equipment, cardiac monitoring equipment,
prescribed medications, lipid emulsion

Preparation of Equipment

Inspect all equipment and supplies; if a product is expired, its integrity is compromised,
or it's defective, remove it from patient use, label it as expired or defective, and report
the expiration or defect as directed by your facility. Ensure that all monitoring equipment
is functioning properly and that emergency equipment is easily accessible.
 Implementation
• Gather and prepare the necessary equipment.
• Review the patient's medical record for medication allergies, past medical and
surgical history, age, height, weight, body mass index, current medications,
baseline cardiac and respiratory status, a history of the present illness, last oral
intake, reason for the current surgical procedure, and information related to
previous experiences with anesthesia. 1
• Conduct a preprocedure verification to ensure that all relevant documentation,
related information, and equipment are available and identified to the patient's
identifiers correctly. 23
• Confirm that informed consent has been obtained and the signed consent form is
in the patient's medical record. 4567
• Perform hand hygiene. 8910111213 (See the "Hand antisepsis, OR" procedure.)
• Put on gloves and other personal protective equipment, as needed, to comply with
standard precautions. 141516
• Confirm the patient's identity using at least two patient identifiers. 17
• Assess the patient's understanding of the procedure and the patient's emotional
state; answer any questions according to the patient's communication and learning
needs to help increase understanding, allay fears, and enhance cooperation. 11819
• Perform a preoperative nursing assessment, if not already done. 1
• Obtain the patient's baseline pulse rate, blood pressure, respiratory rate, oxygen
saturation level by pulse oximetry, pain level, anxiety level, and level of
consciousness (LOC). 12021
• Determine whether the patient has patent IV access. Obtain IV access if necessary.
(See the "IV catheter insertion" procedure.)
• If not already administered, administer preoperative medications, as ordered,
following safe medication administration practices. 22232425262728
• Assist with positioning the patient for local anesthesia administration.
• Secure all necessary safety straps.
• Conduct a time-out immediately before starting the procedure to perform a final
assessment that the correct patient, site, positioning and procedure are identified
and, as applicable, all relevant information and necessary equipment are
available. 329
• Be prepared to assist with skin preparation, if necessary. 30
 • Before the anesthetic is injected, tell the patient to expect a transient burning
sensation and local pain. Instruct the patient to report other persistent pain or
sensations because these may indicate irritation or puncture of a nerve root, which
would require repositioning of the needle. 22
• Instruct the patient to remain still and breathe normally during needle insertion. If
necessary, hold the patient in position firmly to help prevent sudden movement
that may displace the needle. Ensuring that the patient remains still during the
procedure helps to prevent injury to the nerve root.
• Assist as needed during anesthesia administration while comforting the patient
and answering any questions. 22
• Note the amount of anesthetic injected.
• After anesthetic administration, assist with positioning the patient as appropriate
for the surgical procedure.
• Protect the patient from injury throughout the surgical procedure because the
patient won't have normal sensation at the anesthetic site and may also undergo
additional anesthesia, such as monitored anesthesia care.
• Monitor the patient's pain level, anxiety level, and LOC throughout the procedure. 1
• Monitor the patient's heart rhythm and rate, pulse rate, blood pressure, respiratory
rate, and oxygen saturation level by pulse oximetry throughout the procedure as
needed and determined by the patient's condition. 1
• Administer supplemental oxygen as needed and ordered.
• Assess the patient for signs and symptoms of LAST, including dizziness, tinnitus,
metallic taste, circumoral numbness, confusion, slurred speech, shivering, tremors,
agitation, seizures, ventricular arrhythmias, hypertension and tachycardia initially
followed by progressive hypotension and bradycardia, asystole, and respiratory
arrest. 1 Report such changes to the anesthesia care provider because early
identification and intervention help lead to better outcomes. 1 Intervene as needed
and ordered. (See Treating LAST.)

TREATING LAST
If the patient develops local anesthetic systemic toxicity (LAST), treatment commonly
includes:

• maintaining a patent airway.

• ventilating the patient with 100% oxygen.
• administering basic or advanced cardiac life support, as needed.
• establishing IV access if needed.
• administering a 20% lipid emulsion based on lean body mass; a bolus first
followed by an infusion.
• suppressing seizures with medication such as a benzodiazepine.
• avoiding use of vasopressin, calcium channel blockers, beta blockers, or local
anesthetics.
• reducing EPINEPHrine doses, if necessary, to less than 1 mcg/kg.
• avoiding propofol in patients showing signs of cardiovascular instability.
• alerting the nearest facility that has cardiopulmonary bypass capability if not
provided in your facility.
• monitoring the patient for at least 12 hours following LAST because
cardiovascular depression due to local anesthetics can last or recur after initial
treatment. 1

• Calm and reassure the patient as needed.

• Remove and discard your gloves and other personal protective equipment if
worn. 1416
• Perform hand hygiene. 8910111213
• Document the procedure. 31323334

Special Considerations
• Assess whether the patient has a chronic condition (such as a persistent cough)
and, if so, whether it will affect the procedure if it's performed under local
anesthesia.
• The use of music or guided imagery may help to calm the patient during surgery
and to decrease the discomfort associated with local anesthetic administration. 1
• Nurses who will be involved with the care of patients undergoing procedures
performed using local anesthesia should receive education about their roles in
the care of these patients as well as the medications used and safe administration
guidelines.
• Pediatric patients and adult patients who are extremely anxious may benefit from
pretreatment of the injection site area with a topical anesthetic.

Complications
Bruising and other tissue injury, pain, infection, allergic medication reactions, and
toxicities are all potential complications of this procedure. The use of proper sterile
technique and equipment may alleviate many of these issues. Proper assessment of the
patient's medical history may help to identify potential drug allergies.

LAST may occur as serum levels of the local anesthetic increase, presenting as neurologic
and cardiovascular complications. Severe cases of LAST may lead to respiratory or cardiac
arrest. 1

Nerve laceration may occur during regional block administration of a local anesthetic.
Signs and symptoms of nerve laceration include paresthesia, shooting or sharp stinging
sensations, and excessive pain during needle insertion.

Documentation

Document preoperative assessment findings, including potential risk factors, such as

medication allergies, and baseline pulse rate, blood pressure, respiratory rate, oxygen
saturation level, pain level, anxiety level, and LOC. 1 Intraoperatively and postoperatively,
record assessment findings including pain level, anxiety level, LOC, and any other
monitoring parameters obtained. 1 Also document the name, percentage, and amount of
any local anesthetic administered, who administered it, and the patient's reaction to the
anesthesia. Record any signs of drug allergy, adverse reactions, or toxicity, the name of
the practitioner and the date and time the practitioner was notified, prescribed
interventions, and the patient's response to those interventions. Communicate this
information to the postanesthesia care unit nurse. Document any teaching provided to
the patient and family (if applicable), their understanding of that teaching, and any need
for follow-up teaching.