31.3: Intraoperative Phase

Learning Objectives

By the end of this section, you will be able to:

• Explain the roles of the surgical team
• Identify key components of the surgical environment
• Analyze potential intraoperative complications

The intraoperative stage begins as soon as the patient is transferred to the OR and concludes when the patient is transferred to the PACU. This stage is a highly coordinated effort by a multidisciplinary professional team that includes surgeons, anesthesia providers, perioperative nurses, and surgical technologists, with each member playing a unique and equally vital role.

Perioperative nurses are fully aware of their surroundings and understand the space in which they will be working. The OR environment is a carefully controlled and sterile setting that is designed to minimize the risk of infection and optimize patient outcomes. From the specialized equipment, the design and layout of the space, and the intricate protocols and procedures, every aspect of the perioperative space is carefully orchestrated to optimize patient care and team efficiency.

However, even the most well-designed OR with advanced tools and strict protocols cannot make up for the presence of skilled providers who can work together. The surgical team must be vigilant and responsive to potential complications. Effective communication with informed and swift decision-making and a deep understanding of the patient’s unique circumstances are crucial for mitigating risks and addressing any unforeseen challenges that may arise.

The nurse must understand the roles and responsibilities of the surgical team, understand the key components of the surgical environment, and recognize potential intraoperative complications that can occur. Nurses must understand the dynamic and complex nature of surgical care and be equipped with the knowledge necessary to contribute effectively to the surgical team.

Surgical Team and Assigned Roles

Each member of the surgical team contributes to how a surgery unfolds, and it is their actions that will ultimately ensure patient safety and optimal patient outcomes. The RN circulator orchestrates the flow of the OR. They manage supplies and equipment, ensure sterile technique, anticipate the surgeon’s needs, coordinate communication, document the surgery’s progress, and advocate for the patient’s well-being throughout the procedure. The surgeon is trained to perform surgical procedures and bears the ultimate responsibility for the surgery and the actions of the other surgical team members. The skilled experience of the scrub person (e.g., scrub nurse, surgical technologist) allows close collaboration with the surgeon by preparing and organizing surgical instruments, anticipating the surgeon’s next move, and maintaining a sterile field. The anesthesia provider ensures the patient’s comfort and safety throughout the procedure by administering anesthesia and monitoring vital signs. Perioperative first assistants are specifically trained to assist the surgeon directly by retracting and suturing tissues, providing additional instrumentation, and anticipating needs, among other things.

Each member of this surgical team, with their unique skills and expertise, contributes to the harmonious performance of a successful operation. By understanding and appreciating their roles, nurses can better collaborate with the team, ensuring the highest quality of care (Table 31.3).

Surgical Team Role	Responsibilities	Key Points
RN circulator	Assesses and educates preoperative patients Prepares and maintains the sterile operating room (OR) environment Collaborates with the scrub person, anesthesia provider, and surgeon Monitors the sterile field to prevent contamination Ensures an accurate surgical count to prevent retained surgical items (RSIs) Manages the intraoperative “time-out” Tracks surgical progress and provides supplies as needed Collects and processes specimen, applies dressings, and transfers the patient to the postanesthesia care unit	Acts as patient’s primary advocate Orchestrates the flow of the surgical environment Collaborates with the surgical team Acts as a vigilant guardian intraoperatively Tracks progress Ensures transition to postoperative care
Scrub person	Assists the RN circulator in OR setup Assembles and passes instruments and supplies to the surgeon Labels medications and fluids on sterile field Manages specimens on the sterile field	May be an RN or a surgical technologist Scrubs in during surgery
Surgeon	Performs preoperative evaluation, discusses surgical options with the patient, and determines the surgical approach Obtains informed consent Leads surgical team and makes critical decisions during surgery Maintains communication with anesthesia provider and other team members Monitors patient’s recovery and provides follow-up care	Retains ultimate responsibility for surgery Leads a diverse team Ensures clear communication
Anesthesia provider	Conducts preoperative medical history and physical examination Discusses anesthesia options and obtains informed consent Administers anesthesia and monitors vital signs during surgery Provides postoperative pain management orders	May be a physician (anesthesiologist) or certified nurse anesthetist Manages perioperative care Monitors vital signs Ensures postoperative pain management
Perioperative first assistant	Assists surgeon during surgery by handling tissues, retracting, and using instruments Anticipates surgeon’s needs and provides technical support Collaborates with surgeon to plan procedure and may meet patient preoperatively Assists with wound closure, specimen collection, and patient transfer	May be certified surgical first assistant, registered nurse first assistant, surgical physician’s assistant, or perioperative nurse practitioner Anticipates needs of the surgeon Facilitates informed consent (surgeon responsible) Assists with closure and transfer

Table 31.3

Clinical Safety and Procedures (QSEN)

National Patient Safety Goals and Surgery

The Joint Commission established National Patient Safety Goals (NPSGs) to promote patient safety and minimize risks in healthcare settings. There are several NPSGs that the nurse will need to consider that are of particular relevance to surgical care (The Joint Commission, 2024).

• Correct site, correct procedure, correct patient: This goal emphasizes the crucial steps taken to verify the exact surgical site, procedure, and patient identity before the surgery begins. This is often achieved through a “time-out” during which the entire surgical team pauses and confirms all the pertinent details at three points during the surgical process: before induction of anesthesia, before the first incision is made, and before the patient leaves the OR (World Health Organization, n.d.).
• Prevention of wrong-site surgery: Specific protocols and checklists are used to ensure that every surgery is performed on the intended body part, thereby greatly reducing the chances of a surgery being performed on the wrong site or the wrong procedure being done on the wrong patient. The nurse must be aware of the protocols and procedures at their facility that promote a culture of safety, such as marking the surgical site preoperatively and confirming the site several times before the surgery begins.
• Communication: Effective communication between surgeons, anesthesia providers, nurses, and other team members is one of the most essential components of patient safety during surgery. Clear communication ensures that all team members know and understand the surgical plan, are prepared for any potential issues, and are equipped to make necessary adjustments throughout the procedure.
• Safe medication practices: Adhering to safe medication practices, such as accurate medication labeling, proper dosage administration, and heightened vigilance for potential medication interactions, is essential to patient care before, during, and after surgery.
• Infection prevention: Maintaining a sterile environment is one of the most vital features of surgical safety. The NPSGs emphasize the importance of practicing proper hand hygiene, using sterile technique, and administering antibiotics, when appropriate, to minimize the risk of SSIs.

Key Components of the Surgical Environment

The OR is a meticulously controlled environment designed to minimize patient risk during surgical procedures. To keep this environment highly effective, it is important to be conscious of proper practices and protocols for maintaining sterility (state of being free from living microorganisms), mitigating fire hazards, and preventing occupational health risks.

Figure 31.3 The operating room is designed and run in a manner that prioritizes safety and efficiency. (credit: “Clinical Center Operating Room” by National Institutes of Health Clinical Center/Flickr, CC BY 2.0)

Surgical Asepsis and Sterile Technique

Surgical site infections are potentially serious infections that may occur in surgical wounds or around incisions within thirty days of the procedure or within one year in the case of organ or space infections with an implant. These serious infections remain a persistent adversary, jeopardizing patient recovery and adding a significant economic burden. Microorganisms lurk on patient skin, in the air, and on instruments, posing a constant threat to the vulnerable surgical wound. Meticulous adherence to aseptic techniques and rigorous sterilization protocols are crucial to minimizing this risk (Anderson & Sexton, 2024; WHO, n.d.).

The absence of all living microorganisms within any type of invasive procedure is surgical asepsis; this is achieved through rigorous sterilization processes and meticulously maintained through sterile technique. A set of specific practices and procedures employed to maintain sterility of the sterile field (e.g., equipment, instruments, drapes) is sterile technique.

Individual responsibility is paramount in preventing SSIs, which is demonstrated through having a surgical conscience. A surgical conscience is a moral code of integrity that compels a person to speak up when an infraction has or is thought to have occurred, to prevent patient harm (e.g., contamination increasing the risk of an SSI). Possessing a surgical conscience means that any time doubt exists about a product’s sterility or whether a behavior resulted in contamination, the person speaks up and takes appropriate action without fear or concern of embarrassment or criticism, even when no one else is watching. (Holm, 2023, p. 116)

Maintaining a sterile environment requires the following:

• Hand hygiene: The cornerstone of aseptic practice is thorough handwashing and gloving prior to surgery, which is crucial for minimizing microbial transfer.
• Sterile field creation: Designated areas draped with sterile barriers define the sterile field where instruments and supplies are being used and are kept free from contamination.
• Maintaining sterile field integrity: Movements within the sterile field are restricted and controlled to avoid accidental breaches. Instruments are transferred using specific techniques like “no-touch” or hands-free technique methods. This also helps minimize the risk of sharps injuries during surgery.
• Constant vigilance: Continuous awareness of potential contamination risks and immediate corrective actions is essential to maintain sterility throughout the procedure.

Rigorous adherence to sterile technique significantly lowers the risk of SSIs, which can lead to prolonged hospital stays, increased healthcare costs, and even patient death. By minimizing the risk of infections, sterile practices contribute to faster healing times, better surgical results, and overall improved patient safety and satisfaction. This requires constant vigilance, meticulous attention to detail, and unwavering adherence to established protocols.

Surgical Attire and Surgical Zones

Typical surgical attire is part of personal protective equipment (PPE) and includes scrubs, surgical gowns, gloves, masks, head coverings, shoes, and face shields that are worn to prevent personal and environmental contamination. Scrubs are loose-fitting garments made of tightly woven material, designed to prevent shedding of lint. The material may be made of an antimicrobial fabric that may help decrease bacterial contamination of scrubs. Scrub caps cover hair completely; beard coverings are used when necessary. Shoe covers are not required if the shoes are worn only in the surgical suite. If the shoes come from outside the surgical suite, shoe covers are worn that enclose footwear. Impervious shoe covers may be worn if exposure to fluids is anticipated, such as procedures with copious amounts of irrigation (e.g., arthroscopy). Surgical gowns are sterile disposable garments worn over scrubs to provide an additional barrier against contamination. Different levels of sterile and impermeable gowns exist for various procedures and risk levels. Hands should be covered by sterile, single-use gloves. Double gloving is advised when scrubbed in for all procedures because pinpoint holes occur caused by wear and tear during the procedure. Double gloving also may be employed for high-risk procedures, such as intubation. Masks filter microorganisms, while face shields prevent splashes and splatter.

Personal items (e.g., jewelry, stethoscopes, ID badges, lanyards, briefcases) can become contaminated with bacteria so should be cleaned regularly according to facility policy. Scrubbed personnel must not wear rings, watches, bracelets, or necklaces that can fall outside the sterile scrubbed attire.

The OR is segmented into surgical zones, each with distinct functions and attire requirements. This serves to safeguard against the silent threat of infection. This stratification orchestrates a flow of sterility, protecting the vulnerable surgical site from the outside world. The zones are as follows:

• The unrestricted zone is the outer layer of the OR, where nonsterile activities like patient admission and transport occur. Street clothing is allowed, with personnel donning scrubs and shoe covers for basic hygiene before entering the semirestricted zone. The unrestricted zone includes the admissions area, offices, changing areas, break rooms, and supply receiving and storage.
• The semirestricted zone is an intermediate zone between the unrestricted and restricted zones, where personnel are clothed in surgical attire. This area includes the preoperative and postanesthesia care units and medication rooms.
• The restricted zone is the innermost sanctum encompassing the OR suite itself where surgery is performed and includes the actual OR rooms, the scrub sink areas, substerile rooms, central core, and steam sterilization areas. Access is strictly limited to personnel in at least surgical attire plus head covering and mask.

Health Hazards Linked to the Surgical Environment

While the OR evokes images of sterile precision and lifesaving interventions, it also harbors its own share of hidden health hazards. From fire risks, exposure to invisible anesthetic gases, and ergonomic and psychological stresses to surgical smoke, laser risks, and exposure to blood and body fluids, these risks demand proactive management to ensure the well-being of both patients and healthcare personnel.

Fire Risks and Prevention

Understanding and mitigating fire risks in this high-stakes environment is paramount, demanding constant vigilance and proactive measures. Any fire requires three elements: fuel (e.g., surgical drapes, alcohol-based cleaning agents), an oxidizer (e.g., oxygen, nitrous oxide), and an ignition source (e.g., electrosurgical equipment, lasers). All three elements of the fire triangle are readily available in the OR, creating a potentially volatile mix. Electrosurgical units and lasers can generate sparks sufficient to ignite nearby fuel sources. A technique or device to stop bleeding by burning tissue, typically with electricity, is called electrosurgery. Electrosurgery can be monopolar, bipolar, argon-enhanced coagulators, or ultrasonic. Faulty equipment, electrical malfunctions, and static discharge further contribute to the potential ignition sources.

Link to Learning

This algorithm demonstrates the steps required for mitigating fire risks in the OR using a multipronged approach.

Anesthetic Gases

Anesthetic gases and vapors, while essential for surgery and pain management, can pose health risks when personnel are exposed over time. Chronic exposure to an occupational anesthetic gas (OAG) has been linked to reproductive issues, neurological disturbances, and even cancer in some studies (Occupational Safety and Health Administration, 2000). Critical control measures include implementing closed-circuit anesthesia systems designed to minimize the release of gases and vapors into the room, using scavenging devices that help capture and remove gases and vapors that escape the closed system, and promoting proper ventilation.

Ergonomic Stress

Repetitive movements and standing for long periods of time in the OR can take a cumulative toll on perioperative personnel. Musculoskeletal disorders, particularly in the neck, back, and shoulders, are prevalent among surgeons and OR personnel. Ergonomically designed furniture, adjustable equipment, and promoting frequent postural changes are vital for mitigating these risks.

Psychological and Emotional Stress

Witnessing trauma and dealing with patient mortality can take a psychological toll on healthcare personnel in the OR. Compassion fatigue, burnout, and post-traumatic stress disorder (PTSD) are not uncommon experiences. Offering access to mental health resources, fostering a supportive work environment, and implementing resilience training are crucial in safeguarding the well-being of perioperative personnel.

Surgical Smoke

During surgery, surgical smoke is generated by thermal destruction of tissue via electrosurgical and radio-frequency devices, lasers, ultrasonic scalpels, power tools, and other heat-destructive devices during surgery. Surgical smoke harbors a hidden threat of potentially harmful chemicals (e.g., bioaerosols, hydrogen cyanide, benzene, formaldehyde) and particulate matter (e.g., dead and live cellular material [e.g., blood fragments, viruses]). Nanoparticles, which make up 80 percent of surgical smoke, can transmit viable bacteria and human papillomavirus (HPV) when inhaled, entering the person’s bloodstream and traveling to organs (The Joint Commission, 2020). Patient exposure to surgical smoke is short-term and relatively low-risk. However, daily exposure of surgical personnel to surgical smoke causes multiple health problems. These include headaches, watering of the eyes, upper respiratory tract irritation (e.g., cough, sore throat, sneezing, rhinitis), nausea, drowsiness, dizziness, ocular and visual problems, and also increased pregnancy complications for female scrubbed personnel (The Joint Commission, 2020). This hidden threat underscores the urgency of implementing effective smoke evacuation systems and employing smoke plume management techniques like smoke shields and suction devices to protect both patients and perioperative personnel from the unseen dangers lurking within surgical smoke.

Laser Risks

With their concentrated beams of light for cutting or cauterizing tissue, the laser has revolutionized surgery, enabling minimally invasive procedures with greater precision and reduced blood loss. To avoid danger, lasers must be used while following meticulous safety protocols and with a deep understanding of potential risks in the surgical environment. Laser hazards in the OR include the following:

• Direct tissue damage: Unintentional exposure to the laser beam can cause severe burns to skin, eyes, and internal organs, for both patients and perioperative personnel.
• Fire hazards: Laser contact with drapes, instruments, or flammable materials can spark fires, posing a significant threat in the oxygen-rich surgical environment.
• Eye injuries: Accidental laser reflections off instruments or even patient skin can cause permanent eye damage to anyone not wearing proper eyewear.
• Airborne contaminants: Lasers vaporize tissues during surgery, creating plumes containing potentially harmful particles and chemicals that can be inhaled by the patient and perioperative personnel.

Exposure to Blood and Body Fluids

Blood and body fluids can be vectors for viruses, bacteria, and parasites. Some major threats include the following:

• Hepatitis B virus: This causes liver inflammation and damage, with chronic infection potentially leading to cirrhosis and liver cancer.
• Hepatitis C virus: Although often asymptomatic initially, chronic infection can lead to liver cirrhosis, liver failure, and even increased risk of liver cancer.
• Human immunodeficiency virus (HIV): This can lead to AIDS, significantly weakening the immune system and leaving individuals at-risk for opportunistic infections.

Sharps injuries (e.g., needlesticks, scalpel cuts) and other injuries from contaminated instruments pose a direct route of pathogen transmission. Even without needles, blood and body fluids can splash or become aerosolized, increasing the risk of inhalation or contact with mucous membranes. Broken or damaged skin on healthcare workers can provide another entry point for pathogens. Exposure to blood and body fluids remains a significant occupational hazard in the surgical environment. However, a safer environment can be created for perioperative personnel by prioritizing universal precautions, consistently using proper PPE, implementing guidelines for sharps safety (e.g., exposure control plan, engineering controls, work practice controls, administrative controls, PPE, sharps disposal), and promoting education and training to minimize the threat posed by these silent, infectious agents (Association of periOperative Registered Nurses [AORN], 2021b).

Addressing health hazards in the OR demands a comprehensive approach. Implementing best practices for fire safety minimizing OAG exposure, promoting ergonomic principles, prioritizing mental health support, and adhering to infection control practices are vital for safeguarding the health and well-being of those who safeguard others. By acknowledging and proactively managing these challenges, we can ensure the OR remains a safe environment for both patients and healthcare team members.

Potential Intraoperative Complications

Despite meticulous planning and skilled surgeons and perioperative personnel, the inherent unpredictability of human biology can introduce challenges during surgery. These intraoperative complications, while not the norm, are a reality for which surgeons and patients must prepare. These complications include hemorrhage, anesthesia awareness, aspiration, allergic reactions and anaphylaxis, cardiac arrest, hypoxia, hypothermia, malignant hyperthermia, and positioning injuries.

Hemorrhage

One common operative concern is excessive bleeding, which may turn into hemorrhage. This can be caused by various factors (e.g., traumatic injury requiring surgery, unexpected anatomical variations, intraoperative tissue damage, preexisting medical conditions). To manage bleeding, surgeons employ a range of techniques, including electrosurgery and sutures, working swiftly to maintain stable blood pressure and ensure oxygen delivery to vital organs. Excessive bleeding may be treated with administration of fluid or one or more of a variety of blood products.

Should blood and blood product administration become necessary, the RN circulator and anesthesia provider work together to ensure patient safety. Before blood product administration, the nurse confirms that typing and compatibility screening have been performed within the past seventy-two hours. The RN circulator obtains the supplies and equipment necessary for blood administration (e.g., blood tubing with a blood filter, a mechanical blood delivery pump or pressure bag for rapid, emergent blood administration). Blood is administered via an 18-gauge or larger catheter along with normal saline to avoid clot formation. Microdrip tubing is never used because it destroys red blood cells. Nothing else may be administered through the same IV line. The anesthesia provider and RN circulator perform the mandatory two-person verification process for blood product transfusions before blood is administered (Holm, 2023).

Anesthesia Awareness

The experience of consciousness and even pain during surgery with possible recall of events while under general anesthesia is called anesthesia awareness. While estimates vary, this unsettling occurrence affects roughly 1 in 1,000 to 1 in 15,000 patients undergoing general anesthesia. This spectrum of awareness can range from vague sensations and muffled sounds to vivid memories of the surgical process and excruciating pain (Kim et al., 2021).

The precise causes of anesthesia awareness remain complex and multifaceted. Factors like genetics, individual variations in medication metabolism, inadequate medication dosing, and interactions with specific medications can all contribute to this unwanted awakening during general anesthesia. Additionally, certain patient characteristics (e.g., obesity, pregnancy) and certain medical conditions (e.g., lung disease) may increase the risk. The psychological effect of anesthesia awareness can be profound. Patients often grapple with feelings of fear, vulnerability, and betrayal of trust. Vivid memories of the surgery can lead to anxiety, depression, and PTSD, significantly affecting their quality of life.

Anesthesia awareness is rare, and although its cause may not be fully understood, anesthesia providers employ interventions to help prevent its occurrence. Interventions to prevent anesthesia may include addressing the varying anesthetic requirements for different patients, ensuring that sufficient anesthetic medication is administered, and ensuring that the anesthesia machine has undergone appropriate preventive maintenance to help prevent malfunction.

Life-Stage Context

Anesthesia Awareness in Children

Any patient can experience anesthesia awareness, which is the experience of consciousness and even pain during surgery while under general anesthesia. However, it can be particularly challenging when it occurs in children. Although some studies have suggested young patients might be more at risk for experiencing anesthesia awareness, assessing it in children also presents unique challenges because of communication barriers, trauma and stress, and a child’s limited understanding.

Children have unique needs during surgery related to the state of their physical and emotional development. It is crucial for the surgical team to understand that anesthesia awareness may be a possibility in a pediatric patient and take steps to decrease the risk of it occurring.

It is also critical that a child’s accounts of anesthesia awareness not be dismissed, even if it may not have truly occurred. The child’s experience of confusion, disorientation, and fear can still be traumatizing. It is vital that the anesthesia provider and RN circulator report any incidence to the PACU nurse assigned to recover the patient after surgery. When the parent is brought into the PACU to be with the patient, the PACU nurse should carefully, and with sensitivity, explain to the parent the anesthesia awareness incident and help them speak to the anesthesia provider if necessary.

Aspiration

Instructing patients to be NPO (nothing by mouth) before surgery helps reduce the risks associated with vomiting and aspiration during surgery. However, sometimes patients may not have fasted according to instruction, and in emergencies, a patient may not have had the opportunity to fast at all before the procedure. Although antiemetics can help reduce nausea and vomiting during surgery, it is still possible and carries the serious risk of aspiration. The surgical team must be aware of patient- and surgery-related factors that can contribute to the risk of aspiration and be prepared to respond appropriately to keep the patient safe. For instance, the RN circulator must stand beside the head of the patient with gloves on and be prepared to assist the anesthesia provider during induction of anesthesia and intubation. Furthermore, during local or sedation procedures, the nurse should monitor the patient for signs of nausea (e.g., swallowing, sweating) that could precede an episode of vomiting. The nurse may need to turn the patient’s head or suction the patient’s oral cavity to keep the patient safe if intraoperative nausea and vomiting occur. The nurse may also be responsible for documenting the occurrence and the steps taken in response; the event should be communicated during the handover report so that appropriate postoperative follow-up care can be provided.

Allergic Reaction and Anaphylaxis

Allergic reactions in the surgical environment can range from mild discomfort to life-threatening emergencies (e.g., anaphylaxis) posing a significant challenge for both patients and healthcare professionals. Surgical allergies encompass a range of reactions, triggered by various substances encountered during surgery. These can include the following:

• Anesthetic medications: Certain medications used for general anesthesia (e.g., neuromuscular blockers, muscle relaxants) can trigger allergic responses.
• Latex: Gloves, drapes, and other equipment and supplies made of latex can cause itchy rashes, wheezing, and even anaphylaxis in sensitized individuals. Many perioperative departments in the United States have put together a latex-free cart to be used for patients with diagnosed latex allergies. However, to avoid this risk in patients with undiagnosed latex allergies, many perioperative departments have removed all latex products to completely eliminate this surgical risk.
• Antibiotics: Preoperative and intraoperative antibiotics are crucial for infection prevention, but some individuals may have allergic reactions to specific types of antibiotics.
• Iodine: Some contrast agents contain iodine, as does povidone iodine 10 percent, a common skin preparation solution. Historically, practitioners have believed that patients with an allergy to shellfish (which normally harbor iodine) should not be exposed to iodine to minimize the risk of an iodine reaction. However, recent evidence indicates that a seafood allergy actually may be related to fish protein, not iodine (AORN, 2021a).
• Blood products: Transfusions used during surgery might trigger allergic reactions in some patients, especially those with preexisting sensitivities.

Real RN Stories

A Lesson about Latex

Nurse: Celia, RN
Clinical setting: Operating room at a community hospital
Years in practice: 12
Facility location: Outside Orlando, Florida

I tell this story to all the new nurses on the surgical floor because I truly believe it could save a life. Or, if not a life, then a lot of itching. A few years ago, I was on a pretty routine case—a 17-year-old with ovarian torsion who was having a laparoscopy. During the preoperative assessment, the patient had denied allergies, but her mother had piped up and said, “Well, kiwi makes her mouth itchy, so she won’t eat them anymore.” I noted it in the chart and didn’t think too much about it—oral allergy syndrome is pretty common, especially with fruit.

But throughout the process of getting her prepped, she just seemed to be getting more and more uncomfortable. She was in a lot of pain but had some medications in the ED before she came to us. The anesthesia provider thought she’d feel better when the sedative kicked in. She’d never had surgery before, not even stitches for a bumped knee as a kid, so she was very nervous.

It wasn’t until we wheeled her into the OR and were scrubbed in that things took a turn, though. By then, she’d had a lot of gloved hands on her body—around her mouth, on her abdomen. I was focused on the checklist and time-out, so I didn’t see the redness at first. As the surgery got going and the anesthesia provider was monitoring her vital signs, we noticed her heart rate accelerating a little. I looked her over and noticed that what might have started out as faint redness on her abdomen was spreading and looking more like welts and hives. Just as I was about to speak up, the anesthesia provider did, because he’d noticed that her nose had started to run a bit, and her eyes were tearing.

The anesthesia provider clicked into her chart just as the surgeon asked, “What does her chart say about allergies?” “None known,” I offered, “Well, except her mother says kiwi makes her mouth tingle.” I knew almost as soon as I’d said it that I must have missed something, because the anesthesia provider immediately said, “Kiwi is highly cross-reactive with latex. She’s having an allergic reaction to the gloves, I’d bet on it!”

Well, we got lucky. The reaction was pretty mild and easy to control when everyone’s gloves were changed out. The patient had a successful procedure and uneventful recovery. But I made a big note in her chart that she had very likely had a latex allergy and ensured that the PACU nurse was aware of the allergic response and was prepared to include it in the patient’s discharge teaching to include suggesting seeking out latex allergy testing. And like I said, it’s the first tidbit I give to new nurses!

Cardiac Arrest

Cardiac arrest is sudden cessation of heartbeat and cardiac function, caused by an electrical disturbance or a lethal rhythm resulting in the loss of effective circulation. Causes of cardiac arrest that occurs perioperatively include myocardial infarction, dysrhythmias, anaphylaxis, malignant hyperthermia (MH), respiratory arrest, and massive blood loss. In most facilities, the RN circulator is required to have Basic Life Support, Advanced Cardiac Life Support, and/or Pediatric Advanced Life Support certification. If a cardiac arrest occurs, the RN circulator calls for assistance, requests the code cart, and directs another team member to begin compressions. Compressions circulate the blood until someone arrives with the defibrillator. Defibrillation stuns the heart and briefly terminates its electrical activity. This is the most likely intervention that will resuscitate the patient because it allows the normal intrinsic heart pacemakers to resume electrical control of the heart.

Roles in the OR are assigned depending on who and the number of people who arrive to help. Often, the ACLS-trained anesthesia provider assumes the role of team leader. However, if the patient requires airway or cardiac intervention (e.g., intubation, medications) immediately, another person may take over as leader. As soon as the defibrillator is brought to the room, the nurse applies the defibrillator pads and prepares to deliver a shock when instructed to do so by the team leader. Two other roles are to administer medications and document medication administration and other events with times and the patient’s responses. Another nurse continues the role of RN circulator by providing supplies and maintaining the counts if surgery continues during resuscitation (Holm, 2023).

Hypoxia

A state in which the body’s tissues are deprived of adequate oxygen is known as hypoxia. It can pose a significant challenge during surgery, with potentially devastating consequences if left unrecognized. Hypoxia in the surgical setting can manifest in various ways, depending on its cause and severity. Some potential presentations include the following:

• Decreased alertness and responsiveness: Patients might appear drowsy, confused, or disoriented.
• Rapid or shallow breathing: The body attempts to compensate for the oxygen deficit by increasing respiratory rate.
• Changes in vital signs: Heart rate and blood pressure may rise initially, followed by a drop in severe cases.
• Skin discoloration: Bluish or grayish skin tone, particularly around the lips and nail beds, can indicate a critical lack of oxygen.

Preventing hypoxia is fundamental in safeguarding patients in the OR. Strategies include the following:

• Preoperative assessment: Preoperative nurses can help by identifying patients at risk based on medical history and respiratory function tests.
• Optimizing oxygenation: After identifying the risk of hypoxia, the preoperative nurse can initiate oxygen therapy and introduce incentive spirometer use preoperatively. This helps ensure adequate preoperative oxygen levels and facilitates use postoperatively in the PACU.
• Standardized protocols: Nurses in all perioperative settings should understand and implement airway management guidelines, monitoring for and responding to hypoxic events.
• Continuous training: Regularly educating on hypoxia recognition and management is particularly important for perioperative personnel.

Hypothermia

A drop in core body temperature below 96.8°F (36°C), or hypothermia, can have significant consequences during surgery and potentially affect patient outcomes. Hypothermia in the surgical setting is not merely an issue of discomfort. Hypothermia triggers a cascade of physiological changes that can affect vital functions. In an attempt to conserve heat, the body constricts blood vessels, reducing blood flow to vital organs. The body’s involuntary attempt to generate heat through muscle contractions (shivering) can increase oxygen demand and metabolic rate. Low temperature can disrupt the heart’s electrical rhythm, leading to irregular heartbeats and potentially jeopardizing blood circulation. Additionally, impaired blood flow and reduced oxygen delivery to tissues can hinder wound healing and increase the risk of infection.

Several factors can contribute to hypothermia in the OR:

• Exposure: Cold OR temperatures, inadequate patient warming, and open surgical sites can lead to significant heat loss.
• Anesthesia: Certain anesthetic medications can cause vasodilation, lower the cold threshold in the hypothalamus, and suppress the body’s shivering response and temperature regulation.
• Fluid administration: Large volumes of cool IV fluids can rapidly cool the body core.
• Underlying medical conditions: Patients with preexisting conditions like thyroid disorders or malnutrition may be more susceptible to hypothermia.

Actions to prevent hypothermia that the perioperative team can implement include passive insulation and active warming methods. Passive insulation includes blankets, drapes, and surgical garments. Active warming methods include forced-air warming devices; water-circulating devices; conductive/resistive warming; radiant warming; and using warmed anesthesia gases, IV fluids, insufflation gases, and irrigation fluids. Some of these measures should be implemented by the preoperative nurse as prewarming actions.

Malignant Hyperthermia

A rare, inherited, hypermetabolic disorder of skeletal muscles called malignant hyperthermia (MH) can be fatal if not identified and treated quickly. It is triggered by certain anesthetic medications, most commonly inhalant medications and muscle relaxants. During the preoperative assessment, the RN circulator should ask the patient if they or any immediate family member has ever had a problem with anesthesia. A family or personal history of a “bad reaction to anesthesia” or statements such as “my uncle died in surgery, but no one knows why” indicate the need for further questioning by the anesthesia provider. Another indication of MH susceptibility is a history of a muscular or neuromuscular disorder (e.g., muscular dystrophy).

The MH reaction presents with a cascade of symptoms, including masseter muscle rigidity, hyperkalemia, and muscle breakdown (rhabdomyolysis). This results in a hypermetabolic reaction during which body heat can reach beyond life-sustaining temperatures (e.g., 106°F [41.1°C]), which can quickly lead to organ damage and death if not recognized and treated immediately. The first action if MH is suspected is for the anesthesia provider to discontinue the triggering agent. The scrubbed team should rapidly finish surgery or pack the surgical wound. Meanwhile, other perioperative team members should quickly obtain the MH cart and begin reconstituting dantrolene sodium (e.g., Dantrium, Ryanodex), the specific antidote for MH. Other team members institute prompt cooling measures: administer cold IV fluids; pack the patient’s neck and head, groin, axilla, and any open cavities with ice; change the forced-air blanket to cool air; and provide supportive care, which is crucial for successful MH management. Patient stabilization is demonstrated by a decrease in end-tidal carbon dioxide (CO₂), muscle rigidity, and heart rate.

Intravenous dantrolene sodium is continued for at least twenty-four hours and titrated to alleviate symptoms. The surgeon and anesthesia provider inform the patient and family members of the event and counsel first-degree family members to undergo genetic testing for MH susceptibility. While rare, MH awareness and appropriate OR protocols remain critical for ensuring patient safety during surgery.

Clinical Judgment Measurement Model

A Patient Experiencing Malignant Hyperthermia

Malignant hyperthermia is a rare, potentially life-threatening genetic predisposition to uncontrolled muscle breakdown (hypermetabolism) typically triggered by certain anesthetic medications, most commonly inhalant medications and muscle relaxants. This crisis can quickly cause organ damage and death if steps are not swiftly taken to correct it. The nurse can use the Clinical Judgment Measurement Model framework to assess for and respond to cases of MH.

1. Recognize cues: Identify the key signs and symptoms of MH (e.g., masseter muscle rigidity, metabolic acidosis, and extremely high temperature [e.g., 106°F {41.1°C}]).
2. Analyze cues: Interpret clinical data, including muscle contractions while under general anesthesia, rapidly elevating temperature, and patient and family history (e.g., problems with anesthesia; family member died during surgery, but the cause is not remembered; a history of a muscular or neuromuscular disorder), to assess the severity of the condition and potential for complications.
3. Prioritize hypotheses: Determine the most immediate threats to patient health, such as the unsustainably high temperature. By prioritizing, the nurse can focus on providing immediate care interventions to prevent life-threatening complications and death.
4. Generate solutions: Develop a treatment plan: The RN circulator should immediately notify the charge nurse to obtain additional support while the anesthesia provider stops the flow of the triggering agent, the surgeon and scrubbed team stop surgery if at all possible (e.g., close or pack the wound), the RN circulator assigns another nurse to reconstitute and administer dantrolene sodium according to the anesthesia provider’s orders, and other team members institute rapid cooling actions (e.g., providing the anesthesia provider cold IV fluids, pack the patient in ice).
5. Take action: Clearly communicate the plan and implement steps until the patient is stabilized. The nurse provides a handover report to the receiving PACU nurse of the patient’s need for additional or higher-level care. The surgeon and anesthesia provider notify the patient’s family members about the event and counsel them regarding genetic testing for MH susceptibility.
6. Evaluate outcomes: The PACU nurse takes over monitoring the patient’s response to treatment, adjusting the plan as necessary based on the possibility of symptom reoccurrence.
7. Reflect on the process: Reflect on your clinical decision-making process, outcomes, and what could be improved if you encounter the situation again in the future. Think about the appropriateness and effectiveness of the interventions and the timeliness of the response.

Positioning Injuries

Positioning injuries are unintended complications that arise from patient positioning during surgery, which could lead to nerve damage, pressure sores, or compartment syndrome. The human body is a complex network of nerves, blood vessels, bones, muscles, and soft tissue, all susceptible to pressure and strain. During surgery, prolonged or improper positioning can compress these structures, leading to the following:

• Nerve damage: Nerve compression can cause tingling, numbness, weakness, and even paralysis in the affected area. Common sites of nerve injury include the arms, legs, and head.
• Pressure sores: Prolonged pressure on bony prominences like the heels, elbows, and back can disrupt blood flow and lead to tissue breakdown, forming painful and potentially infected sores.
• Compartment syndrome: In severe cases, prolonged pressure can lead to compartment syndrome, a life-threatening condition where blood flow is so restricted that tissue damage and even muscle death can occur.

Recognizing the potential for positioning injuries is crucial to preventing them. A proactive approach includes identifying patients at risk via a thorough physical examination and medical history review, selecting the most appropriate surgical position based on the procedure and patient factors, regularly checking for signs of pressure, and repositioning the patient as needed throughout the surgery.

The nurse will take steps to prevent positioning injuries, such as the following:

• Carefully padding and supporting bony prominences with positioning devices (e.g., gel pads) to distribute pressure evenly.
• Assessing skin integrity regularly and monitoring for signs of pressure, discoloration, or impaired circulation during long procedures as well as during the postoperative and recovery period.
• Repositioning the patient at regular intervals, adjusting positioning devices, and relieving pressure points as often and as much as possible.
• Ensuring adequate padding and support for the head, neck, and extremities as much as possible to maintain proper body alignment and avoid nerve compression given the positional requirements of the surgical procedure.
• Communicating concerns about positioning or potential pressure points to the surgical team as soon as possible and collaborating to identify solutions that ensure patient comfort and safety. Documenting steps taken to prevent or mitigate pressure injury should also be detailed and thorough to assist with recovery care planning.