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Assessment Type	Quality Improvement Project
Value	30%
Related Unit Outcomes	1,2,3,4,5  ( I have attached all 5 modules below and I want task based on the reading module and majority of the references from the one provided. )
Due Date	9/9/2026
Length	2500 words +/- 10%
Task	Write a 2500-word written assessment about the following quality improvement (QI) project: · Your operating suite currently only has 1 spinal trolley, which is negatively impacting theatre efficiency. · Your operating suite has decided to set up a spinal trolley for each anaesthetic bay, and you have been tasked with setting them up. · Use Quality Improvement principles of Plan-Do-Study-Act. You will need to: Decide what to include on the trolley and why, then justify your decision. Whom will you consult? Outline a plan for implementation, including timeline and phase, roles and responsibilities, staff education and training, and resources required. How will you present this to the anaesthetic nursing team? What evaluation are you going to do after implementation? Explain how you would measure the success of the project, discussing key performance indicators (KPIs), data collection methods, feedback mechanisms, and a sustainability plan. The goal is to demonstrate your ability to apply QI principles to enhance patient safety, clinical outcomes, or workflow efficiency in perioperative care. Reflective Component: Reflect on: · Your role as an anaesthetic nurse in leading the Quality   Improvement project. · Challenges you might face · How does this project contribute to professional development   and patient care? ​ Relevance The Quality Improvement (QI) Project assessment is multifaceted and deeply aligned with both clinical practice and professional development. It equips you with the skills to identify and address real clinical issues, enhancing patient safety and care quality. It fosters critical thinking, evidence-based practice, and leadership by guidance through the process of designing, implementing, and evaluating a practical intervention. Additionally, it prepares you for professional roles in healthcare improvement, promotes teamwork and communication, and aligns with national safety and accreditation standards—making it a vital component of their clinical and professional development. Task instructions Discuss the quality improvement task provided above. Describe the Context: Provide background on the clinical setting and the significance of the issue. Include: · Relevance to anaesthetics and theatre efficiency. · Stakeholders involved (e.g., nurses, surgeons, anaesthetists) · Impact on patient outcomes or workflow · Discuss the proposed intervention: Discuss the proposed   intervention, ensuring the following: Evidence-based Realistic and achievable Focused on improving safety, efficiency, or patient experience Implementation Plan: Outline how the intervention would be introduced, including: Timeline and phases Roles and responsibilities Staff education or training Resources required Evaluation Strategy: Explain how you would measure the success of the project: Key performance indicators (KPIs) Data collection methods Feedback mechanisms Sustainability plan Reflective Component: Reflect on: · Your role as a perioperative nurse in leading QI · Challenges you might face · How this project contributes to professional development and   patient care · Preparation
Preparation	To prepare for completing this assessment, students should: Have completed all the readings and activities from Modules 1-5. Ensure that they are up to date with tutorial attendance and/or watching the recordings, and are monitoring the relevant discussion boards
Presentation	This assessment is to be submitted via the dedicated Turnitin submission point in Learnline Word length: 2500 words +/- 10%, including the in-text citations. The reference list is not included in the word count. Structure: Essay style. Include a title page with assessment number, title of your topic, submission date, full name, and student number.  Font: Calibri or Times New Roman size 12 Line spacing and alignment: double spacing with left-blocking for paragraphs. Indents are NOT required.  Page numbers: number pages in the bottom right-hand corner Referencing: use  CDU APA 7th 2022 edition referencing
Assessment Criteria	The marking rubric is available on Learnline

https://www.ihi.org/resources/Pages/HowtoImprove/default.aspx

https://www.who.int/teams/integrated-health-services/patient-safety/research/safe-surgery

https://www.safetyandquality.gov.au/

https://www.aorn.org/guidelines

https://asq.org/quality-resources/six-sigma

The link below is for a Plan-Do-Study-Act form provided by the Clinical Excellence Commission, NSW to assist with developing a quality improvement project.

https://www.cec.health.nsw.gov.au/__data/assets/pdf_file/0006/599856/Plan-Do-Study-Act-Cycle-Form.PDF

and their website:

https://www.cec.health.nsw.gov.au/

Instructions

2500-word written quality improvement (QI) to set up a spinal trolley for each anaesthetic bay using quality Improvement principles of Plan-Do-Study-Act.

Discussion Points:

• What to include on the trolley justifying your decision.

• Who to consult

• Outline a plan for implementation including timeline and phases, roles and responsibility, staff education and training, resources,

• How will you present this to the anaesthetic nursing team?

• Evaluation after implementation?

How to measure the success of the project?

The goal is to demonstrate your ability to apply QI principles to enhance patient safety, clinical outcomes, or workflow efficiency in perioperative care.

Assessment 3 Quality Improvement Project Task Instructions and Rubric

Quality Improvement

Introduction to Quality Improvement  In Australian Hospital Base

Quality Improvement (QI) in healthcare is a systematic, data-driven approach aimed at enhancing patient safety, clinical outcomes, and operational efficiency. It involves identifying gaps in care, implementing evidence-based interventions, and continuously monitoring results to ensure sustained improvement.

A quality improvement project in the perioperative environment is critical because:

· Patient Safety: Surgical procedures carry inherent risks; QI reduces complications and adverse events.

· Efficiency: Streamlined processes minimize delays and optimize resource use.

· Error Reduction: Standardization and monitoring help prevent mistakes.

· Patient Satisfaction: Improved care quality enhances patient experience.

QI is continuous, meaning interventions are tested, measured, and refined over time rather than being one-time fixes.

Quality Improvement Frameworks and Tools

PDSA Cycle

The Plan-Do-Study-Act cycle is a cornerstone of QI:

· Plan: Identify the problem, set clear objectives, and design interventions.

· Do: Implement changes on a small scale to test feasibility.

· Study: Collect and analyze data to evaluate impact.

· Act: Standardize successful changes or revise the plan for further improvement.

Lean Methodology

Lean focuses on eliminating waste and improving workflow efficiency. In healthcare, waste includes unnecessary steps, delays, excess inventory, and redundant processes.

Common Lean Tools

Value Stream Mapping

· Visualizes the entire process to identify bottlenecks and inefficiencies.

· Example: Mapping the patient journey from admission to surgery to reduce delays.

5S (Sort, Set in Order, Shine, Standardize, Sustain)

· Organizes the workplace for safety and efficiency.

· Example: Standardizing instrument trays in the OR.

Kaizen (Continuous Improvement)

· Encourages small, incremental changes driven by staff.

· Example: Improving OR turnover time through team suggestions.

Standard Work

· Documents best practices for consistency.

· Example: Standard checklist for surgical prep.

Applying 5S in the Operating Room

5S is highly effective in perioperative settings:

Sort (Seiri)

· Goal: Remove unnecessary items from the OR.

· Action: Identify and eliminate unused instruments, expired medications, and redundant tools.

· Example: Remove duplicate surgical trays.

Set in Order (Seiton)

· Goal: Organize essential items for easy access.

· Action: Arrange instruments logically based on workflow; label shelves clearly.

· Example: Place suction and cautery near the surgical field.

Shine (Seiso)

· Goal: Clean and maintain the OR environment.

· Action: Implement daily cleaning routines; inspect instruments for wear.

· Example: Assign responsibility for cleaning anesthesia machines after each case.

Standardize (Seiketsu)

· Goal: Create consistent practices across all ORs.

· Action: Develop setup checklists; use color-coded trays for specialties.

· Example: Standardize instrument layout for laparoscopic procedures.

Sustain (Shitsuke)

· Goal: Maintain improvements over time.

· Action: Conduct audits; provide staff training; display visual reminders.

· Example: Monthly review of OR organization compliance.

Benefits:

· Reduced setup time

· Improved staff communication

· Lower contamination risk

· Enhanced patient safety

Six Sigma

Six Sigma aims to reduce variability and defects using data-driven methods.

Key Six Sigma Tools

DMAIC Framework

· Define: Identify the problem and goals.

· Measure: Collect baseline data.

· Analyze: Determine root causes.

· Improve: Implement targeted solutions.

· Control: Sustain improvements through monitoring.

Root Cause Analysis (Fishbone Diagram)

· Identifies underlying causes of problems.

· Example: Causes of delayed antibiotic administration.

Pareto Chart

· Highlights the most significant issues (80/20 rule).

· Example: Top reasons for OR delays.

Control Charts

· Monitors process stability over time.

· Example: Tracking monthly infection rates.

Why Use Lean and Six Sigma in Perioperative Care?

· High complexity and risk environment.

· Need for standardization and efficiency.

· Direct impact on patient safety and cost reduction.

Steps to Develop a Quality Improvement (QI) Project in the Perioperative Environment

Step 1: Identify the Problem

· What to Do: Review incident reports, audits, and clinical data.

· Engage staff to gather insights on recurring issues.

· Why It Matters: A clearly defined problem ensures focused interventions.

· Example: SSI rates are higher than national benchmarks in your surgical unit.

Step 2: Set SMART Goals

· What to Do: Define goals that are Specific, Measurable, Achievable, Relevant, and Time-bound.

· Why It Matters: SMART goals provide clarity and accountability.

· Example: Reduce SSI rates by 20% within 6 months by improving antibiotic timing and skin prep.

Step 3: Engage Stakeholders

· What to Do: Involve surgeons, anesthetists, nurses, infection control teams, and patients.

· Hold meetings to align roles and responsibilities.

· Why It Matters: Collaboration ensures buy-in and smooth implementation.

· Example: Create a multidisciplinary QI team to oversee the project.

Step 4: Collect Baseline Data

· What to Do: Gather current performance metrics (infection rates, OR turnover times, medication errors).

· Use historical data for comparison.

· Why It Matters: Baseline data helps measure improvement accurately.

· Example: SSI incidence over the past 12 months and compliance with antibiotic protocols.

Step 5: Design and Implement Interventions

· What to Do: Choose evidence-based strategies.

· Start with small-scale changes (pilot testing).

· Why It Matters: Testing minimizes risk and allows refinement.

· Example: Introduce a standardized antibiotic timing protocol and staff education sessions.

Step 6: Measure Outcomes

· What to Do: Compare pre- and post-intervention data.

· Use process and outcome indicators (infection rates, compliance rates).

· Why It Matters: Measurement validates effectiveness and identifies gaps.

· Example: SSI rates decreased from 4% to 2.8% after intervention.

Step 7: Sustain and Spread Improvements

· What to Do: Embed successful changes into policy and standard operating procedures.

· Provide ongoing training and audits.

· Why It Matters: Sustainability prevents regression and spreads best practices.

· Example: Monthly compliance audits and refresher training for OR staff.

Evaluation and Sustainability

· Continuous monitoring with dashboards.

· Feedback loops for staff.

· Regular audits and refresher training.

Module 1

Introduction

Introduction

In this module you will be further develop your knowledge of the concepts of Anaesthetic and recovery room Nursing. This subsequent modules will build upon the concepts introduced here and elaborate some of the ideas introduced here.

In this module we will look at:

· Anaesthetic Across the Lifespan (Peadiatrics, Geriatrics and Maternal)

· Manage a Therapeutic Anaesthetic Environment and Noise Management

· Patient Awareness, Relevant Equipment

  Here are the module outcomes:

1. Analyze the impact of anaesthetic techniques across different age groups to ensure tailored and effective patient care throughout the lifespan.

2. Evaluate strategies for managing the anaesthetic environment and noise levels to enhance patient safety and comfort.

3. Assess the importance of patient awareness and the use of relevant equipment in maintaining a therapeutic environment during anaesthetic procedures.

4. Apply advanced anaesthetic techniques and equipment to improve patient outcomes and manage complex clinical scenarios effectively.

5. Develop and implement person-centered and culturally safe practices in the perioperative environment, particularly during complex emergencies, to support both patients and staff.

Things to do this module:

1. Go through the learning resources, preferably in the order provided

2. Carry out the learning activities, including preparing for the tutorial in the week.

3. Complete activities 

4. Read the provided articles.

5. Read the books recommended from the reading list

Anaesthetic Across the Lifespan (Paediatrics, Geriatrics and Maternal)

Anaesthetics Across the Lifespan

Anaesthesia must always be individualized to the patient. Age, comorbidities, functional capacity, physiology, and psychosocial needs all influence anaesthetic choice and intraoperative management. Although every patient requires tailored care, paediatric and geriatric populations demand additional, highly specific considerations due to their unique anatomical, physiological, and developmental differences.

 

Paediatrics

Paediatrics is one of the most challenging areas of anaesthesia because infants and children display:

· Rapid physiological changes across development

· Unique airway and cardiovascular anatomy

· Higher metabolic demands

· Smaller physiological reserves

· Higher vulnerability to emotional and psychological distress

Even small deviations in airway patency, temperature, fluid balance, or drug dosage can cause rapid deterioration. Paediatric patients are not a homogeneous group. Each developmental stage shows marked differences in anatomy, physiology, behavior, and drug metabolism. Paediatrics is separated into five different age groups:

Age Group	Approximate Range	Key Anaesthetic Considerations
Neonates	Newborn–4 weeks	Immature organ systems, obligate nasal breathing, high oxygen consumption, poor thermoregulation
Infants	4 weeks–1 year	Improving airway tone but still easily collapsible, rapid desaturation, anxiety peaks around 6–9 months
Toddlers	1–3 years	Heightened separation anxiety, strong resistance to unfamiliar environments
Children	3–12 years	Better reasoning and cooperation; still prone to fear and startle
Adolescents	12–18 years	More adult-like physiology; psychosocial sensitivity; autonomy and consent considerations

Each child is different in how they react to the strange operating room environment with all these strangely dressed people. Usually, a guardian or support person accompanies the child to the operating room. However, these support people can be a hindrance sometimes, as their anxiety can make the child anxious as well. Sometimes, a pre-medication is required, especially if the child has developmental problems.

Paediatric anatomy and physiology are different from those of adults. Read about the airway differences on this Australian anaesthetic education website.

https://www.periopconcepts.com/blog/paediatric-airway-anatomy Paediatric Airway Anatomy

Other differences are also in the cardiovascular system, temperature regulation, and fluid management. Read these short sections in Alexander's Care of the Patient in Surgery by Rothrock, chapter 26

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323776806000261?origin=share&title=Alexander's%20Care%20of%20the%20Patient%20in%20Surgery&meta=2023%2C%20Scully%2C%20Susan%20M.&img=https%3A%2F%2Fcdn.clinicalkey.com%2Fck-thumbnails%2FC2019004928X%2Fcov200h.gif

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323776806000261#hl0001393 Cardiovascular status

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323776806000261#hl0001404 Temperature regulation

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323776806000261#hl0001432 Metabolism

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323776806000261#hl0001437 Fluid management

Paediatric anaesthesia depends on the child's age, the developmental age of the child, and the type of surgery the child is having. Induction needs to occur in a quiet OR to reduce any anxiety in the child and support person, as well as reduce any startle that may occur. This is not easy; someone may need to be assertive with the surgical team and other nursing staff in the OR to achieve it. Distractions during induction are also a frequent tool of the anaesthetic team to facilitate the child's cooperation. Each anesthetist uses different distraction methods, but common ones are stories that involve counting items such as dogs or food with someone using the increasing numbers in the story to increase the inhalation anaesthetic agent being delivered.

Read the following small section in Alexander's Care of the Patient in Surgery by Rothrock, chapter 26 on Anaesthetic considerations in paediatrics.

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323776806000261#hl0001878 Anaesthetic considerations in paediatrics

Watch this 9-minute videos on Pediatric anesthesiology OR setup

Watch this 9-minute video on why is anesthesia for children so different?

Watch this 12-minute video on emergency drugs in paediatric anesthesia

The most important tool for paediatric anaesthesia is the paediatric anaesthesia trolley that your hospital should have. Familiarize yourself with this trolley and where everything is.

 Geriatrics

A person is considered geriatric when they are over 65. However, each person ages differently depending on their genetics, lifestyle, and environment. In their preoperative patient assessment, the anesthetist will do a frailty assessment or an assessment of their ability to carry out independent activities of daily living. These assessments are many and varied, but usually involve assessing the patients:

· Cognitive: Is the patient aware of the time, date, and local news? Are they cognitively "with it"?

· Nutrition: Have they lost weight over the last year?

· Muscle strength: Have they lost muscle strength?

· Energy level: How many activities can they do in a day? Are they active or essentially sedentary?

· Physical activities: How far does the patient walk each day? How much exercise do they do? How many stairs can they walk up and still converse with someone? What is their gait like?

· The pace of walking: At what pace does the patient walk?

· Independent Daily Living: Can the patient care for themselves and live independently?

These assessments assess the patient's ability to survive the anaesthetic and (just as importantly) the recovery period.

Other factors with geriatric patients include comorbidities that often present, which complicate the anesthesia, including renal, liver, heart, and lung diseases, as well as Diabetes Mellitus, and previous surgery or injuries. The following links provide specific details about these disease processes and their impact on anesthetics and PACU. Its is important we understand how aging impacts on anaesthesia as surgery on patients older than 65 years is a major part of our work.

Read the following section in Alexander's Care of the Patient in Surgery by Rothrock, chapter 27 on Physiological Changes (in geriatric patients), including Box 27.2 and The Box above, discussing Surgical Pharmacology medication and the older adult.

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323776806000273#hl0000976 Physiological Changes

The risk of postoperative delirium in geriatric patients can occur in the PACU. Read this section, especially Box 27.5 on Risk Factors for Postoperative Delirium in Older Adults

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323776806000273#hl0001197 Psychological Changes

Then, this small section on Determining the Operative Risk

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323776806000273#hl0001238 Determining the Operative Risk

Then, this small section on Anaesthesia Considerations in geriatrics

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780443105234000092#hl0000641 Anaesthesia Considerations

 

Watch this 17-minute video on geriatric anaesthesia:

 

Comorbidities

Common comorbidities in geriatric patients include liver, kidney, heart, and lung diseases and diabetes Mellitus. To begin, please read the following section, Considerations in Berry & Kohn's operating room technique by Hornacky, chapter 24, which provides an overview of the impact of anaesthesia on each of these major organs.

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780443105234000249#hl0001671 Care of anesthetized patient: Considerations

 Heart disease

Cardiac complications after surgery are a significant cause of perioperative morbidity and mortality. Hence, anesthetists do preoperative assessments of an elderly patient's cardiac function that usually involves an ECG; if a cardiologist manages the patient, then contact is made with them, and the planned surgery is discussed, and an echocardiogram may be requested. An echocardiogram is an ultrasound of the heart that examines its ability to pump and empty the ventricles and assess the heart valves and their function. The anaesthetist will also ask the patient about their exercise tolerance, with questions like:

· How far can they walk?

· How many flights of stairs can they walk up?

· Are they independent of ADLs?

The heart's function is expressed by the left ventricular ejection fraction (LVEF), the percentage of blood ejected by the left ventricle, which is normal at 50 to 70%.

The major diseases of the heart that an anesthetist is interested in are ischemic heart disease, hypertension, heart failure, and valve diseases, as well as whether an implantable pacemaker and/or defibrillator is present. All of these diseases can result in reduced Left Ventricular Ejection Fraction. Read this article for further information:

Lees, H., & Charlesworth, M. (2021). Anaesthesia for patients with cardiac disease undergoing non-cardiac surgery. Anaesthesia and Intensive Care Medicine, 22(5), 297–300. https://doi.org/10.1016/j.mpaic.2021.03.008

 

Watch this 6-minute video on the implications of anaesthesia and coronary artery disease.

Lung disease

Lung diseases reduce the capacity of the lungs for the exchange of gases. Some examples of respiratory diseases include asthma, Chronic Obstructive pulmonary disease (COPD), and restrictive lung diseases that limit lung compliance. Restrictive lung diseases reduce the chest expansion and lungs' ability to breathe air and include pulmonary fibrosis, sarcoidosis, and conditions that affect the chest wall or respiratory muscles, such as obesity, scoliosis, and neuromuscular diseases.

Patients with lung diseases need to have a preoperative assessment of their lung capacity and assessment of disease function. The anesthetist will also ask about the patient's exercise tolerance, how far they can walk, climb stairs, and any relevant medications.

Watch this 6-minute video on anaesthesia implications for COPD:

Renal disease

Renal diseases impact the body's ability to excrete wastes and water. During surgery, the patients receive many drugs and intravenous fluids, placing a load on the kidneys. Preoperative blood to get current electrolytes and serum creatinine levels is usually requested, so it is important to ensure the results are available. As with cardiac diseases, with renal disease, the anesthetist may discuss the patient's disease and ability to cope with surgery with the patient's renal physician.

 Read this article on chronic kidney disease and anaesthesia:

Chowdhury, S. R., & McLure, H. A. (2022). Chronic kidney disease and anaesthesia. British Journal Anaesthesia Education, 22(8), 321-328. https://doi.org/10.1016/j.bjae.2022.03.005

 

Liver disease

Liver diseases know how to pack a punch. The liver is involved in albumin, immunoglobulins, clotting factors, C-reactive protein, antithrombin III, bile acids, lymph, metabolism of many basic parts of our food, metabolism of drugs, storage of glycogen, vitamins, and iron. Liver diseases impact all other organs in the body.

Prior to undertaking the surgery, reassessment of the patient's liver disease is essential, as this list of activities of our busy liver could cause an increased risk of hemostasis, infection, impaired wound healing, acute renal failure, and liver decompensation.

Watch this 24-minute video on liver disease and anaesthesia

Read this article on liver disease and anaesthesia. This article is the one discussed in the above video:

Gilbert-Kawai, N., Hogan, B., & Milan, Z. (2022). Perioperative management of patients with liver disease. British Journal of Anaesthesia Education, 22(3), 111–117. https://doi.org/10.1016/j.bjae.2021.11.006

 

Diabetes

Diabetes can impact patients' wound healing, increase the potential for wound infection, and result in hypoglycemia or hyperglycemia. As with the other comorbidities, the anaesthetist will need to do a thorough preoperative assessment of a patient with Diabetes. Immediately, preoperative blood glucose levels need to be taken.

Watch this 26-minute video on Diabetes and anesthetic management. It gives an overview of Diabetes as well to refresh our memories.

https://www.youtube.com/watch?v=0aVsiHZOzhg&t=11s

Management of a Therapeutic Anaesthetic Environment and Noise Management

Management of the Therapeutic Environment in the Operating Room (OR)

The operating room is a complex, highrisk clinical environment, and attention to the environment is essential for patient safety, physiological stability, infection prevention, and effective team communication. Often, the sterile technique and surgical workflow receive the most emphasis, the therapeutic environment, including temperature regulation, noise control, and general housekeeping/organisation, is equally critical, particularly during Induction of anaesthesia and throughout the intraoperative period. A therapeutic environment reduces physiological stress, minimises complications, and enables the anaesthetic team to perform highly technical tasks safely. Let us start by reading the following section on Safety Factors in Berry & Kohn's operating room technique by Hornacky, chapter 24

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780443105234000249#hl0001732  Safety Factors

1. Noise Management in the Operating Room

Importance of a Quiet Environment During Induction

Induction of anaesthesia is one of the most physiologically vulnerable phases of perioperative care. The transition from consciousness to unconsciousness may involve progressive loss of airway tone, variable respiratory effort, and altered protective reflexes. During this time, noise reduction is critical for several reasons:

Patientrelated risks of sudden noise

Unexpected loud sounds can stimulate a startled or stress response that may lead to:

· Laryngospasm: reflexive closure of the vocal cords, obstructing the airway

· Breathholding or apnoea

· Irregular respiratory patterns: complicating inhalational Induction

· Coughing or retching: which increases aspiration risk

· Vomiting: especially in anxious or paediatric patients

Children are susceptible to environmental stressors due to their developmental stage and intensified anxiety responses.

Teamrelated risks

Induction requires concentration, clear communication, and unobstructed access to equipment. Noise can:

· Mask critical verbal cues between anaesthetist and anaesthetic nurse

· Reduce situational awareness

· Increase cognitive load and delay response times

· Contribute to fatigue and error

Challenges in Maintaining Quiet

Induction typically occurs simultaneously with:

· Instrument nurse opening sterile trays

· Circulating nurse counting and documenting equipment

· Surgical team preparing their workspace

· Equipment being moved or opened

The anaesthetic nurse often serves as the advocate for a "quiet induction," reminding the team that this period demands lower sound levels for safety.

Zone Zero in the Anaesthetic Period

Zone Zero is a concept used in perioperative anaesthesia safety to describe the critical period immediately surrounding Induction and securing the airway, during which the anaesthetic team must have undivided attention, controlled conditions, and minimal environmental distractions. It is similar in purpose to aviation's "critical phases of flight," where all unnecessary activities must stop to prevent errors.

Zone Zero focuses on preventing:

· Hypoxia

· Loss of airway

· Medication errors

· Communication failures

· Startle-induced complications

· Delays in access to emergency equipment

When Does Zone Zero Occur?

Zone Zero typically includes these moments:

Before Induction

· Patient positioning complete

· Monitoring applied

· Airway equipment prepared

· Drugs drawn up and labelled

· Suction functional

During Induction

The most vulnerable period:

· Loss of consciousness

· Loss of airway reflexes

· Risk of apnoea, aspiration, or laryngospasm

Securing the Airway

· Mask ventilation

· Laryngeal mask insertion

· Endotracheal intubation

· Confirmation of ETCO₂

· Securing the tube/device

Transition to Maintenance

· Stabilising vital signs

· Ensuring proper ventilation

· Securing IV lines, positioning, warming

Zone Zero ends when:

· The airway is secured

· Ventilation is stable

· Anaesthesia is in a steady maintenance phase

Zone Zero includes four core principles:

Silence: A quiet environment minimises:

· Startle response in the patient

· Laryngospasm during volatile Induction

· Miscommunication during critical steps

· Distractions that can cause medication or airway errors

This is why the anaesthetic nurse may instruct the surgical team: "Quiet, please — this is Zone Zero."

No NonEssential Tasks

During Zone Zero, the following must not occur:

· The surgical team is setting up loudly

· Instrument tray opening

· Phone calls or pagers are being answered

· Staff walking through the induction area

· Side conversations

Task interruptions during Induction are a major contributor to anaesthesia-related incidents.

All Hands on the Patient

The anaesthetic nurse and anaesthetist must be solely focused on:

· Airway

· Breathing

· Circulation

· Monitoring

· Patient safety

The circulating nurse may assist but should avoid introducing distractions.

Unobstructed Access

During Zone Zero, the anaesthetic area must be:

· Uncluttered

· Free from equipment blocking access

· Fully stocked (airway gear, emergency drugs, suction)

Why Zone Zero Matters

Because Induction is the highestrisk phase of anaesthesia, Zone Zero reduces:

Risk of Airway Events

· Laryngospasm

· Bronchospasm

· Airway obstruction

· Aspiration

· Hypoxia

Risk of Human Error

· Wrong drug/wrong dose

· Wrong patient/wrong site

· Failure to check suction, oxygen flow, or equipment

Risk of Communication Failures

· Missed critical instructions

· Misinterpreted requests

· Delays in handing over airway equipment

The Anaesthetic Nurse's Role in Zone Zero

The anaesthetic nurse acts as guardian of Zone Zero.

Responsibilities include:

Before Zone Zero

· Preparing drugs, airway equipment, IV, and monitoring

· Ensuring the anaesthetic area is tidy and functional

· Performing equipment safety and machine checks

· Advocating for a controlled environment

During Zone Zero

· Enforcing silence and stopping interruptions

· Monitoring vital signs

· Anticipating the anaesthetist's needs

· Preparing for potential emergencies

· Ensuring rapid access to suction, airway devices, and drugs

After Zone Zero

· Documenting the Induction

· Restocking equipment used

Communicating with recovery and surgical teams

2. Temperature Management: Maintaining Patient Normothermia

Maintaining normothermia, core temperature between 36.0°C and 37.5°C, is essential during surgery. Read this short section in Alexander's Care of the Patient in Surgery by Rothrock, chapter 5, Temperature Control https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323776806000054#hl0002035.   Temperature Control

Why Patients Lose Heat in the Operating Room

Patients are at high risk of inadvertent perioperative hypothermia due to:

· Exposure of internal organs to room air

· Evaporative loss from surgical prep solutions

· Infusion of cold IV fluids

· Anaestheticinduced vasodilation

· Reduced metabolic heat production

· Cool ambient room temperatures required for surgical sterility

Consequences of Hypothermia

Hypothermia can cause:

Cardiovascular instability

· Bradycardia

· Hypotension

· Arrhythmias

Coagulation impairment

· Platelet dysfunction

· Slowed clot formation

· Increased intraoperative bleeding

Metabolic and respiratory changes

· Reduced drug metabolism

· Prolonged recovery from anaesthesia

· Increased oxygen consumption in shivering

Infection risk

· Hypothermia reduces immune function and increases surgical site infections (SSIs)

Consequences of Hyperthermia

Although less common, hyperthermia can result in:

· Increased metabolic rate

· Higher oxygen demand

· Increased cardiac output

· Reduced systemic vascular resistance → potential hypotension

· Reduced hepatic and renal perfusion

· Increased seizure susceptibility

Maintaining Normothermia: Nursing Responsibilities

The anaesthetic nurse plays a significant role in temperature control through:

· Preoperative temperature assessment

· Application of warmed blankets

· Use of forced-air warming devices (e.g., Bair Hugger)

· Minimising unnecessary exposure

· Warming IV fluids when appropriate

· Ongoing temperature monitoring throughout the procedure

Temperature monitoring is critical in:

· Children

· Elderly patients

· Patients undergoing long procedures

· Trauma and emergency surgery

· Patients with endocrine or metabolic disorders

3. Housekeeping and Organisation of the Anaesthetic Area

The anaesthetic area must remain clean, organised, and immediately functional because unexpected events, such as airway emergencies, arrhythmias, or anaphylaxis, can occur at any time.

Why Housekeeping Matters

A poorly organised environment increase:

· Risk of contamination

· Trip hazards around cables or equipment

· Delays in locating drugs or airway devices

· Cognitive load on the anaesthetic team

· The risk of errors in drug preparation

Key Housekeeping Responsibilities

A. Cleanliness

· Wipe all surfaces before and after each case

· Clean the anaesthetic machine and nearby surfaces

· Dispose of used items promptly

· Follow standard precautions and infection prevention guidelines

B. Sharps Management

· Dispose of sharps immediately into designated containers

· Do not recap needles

· Keep sharps bins within arm's reach, but away from patient movement

C. Waste Disposal

· Rubbish should never accumulate in the anaesthetic work zone

· Contaminated waste must be placed in appropriate clinical waste bins

· Spills (blood, body fluids, medications) must be cleaned immediately

D. Restocking and Equipment Checks

Restocking is not a courtesy; it is part of patient safety.

The anaesthetic trolley must always contain:

· Correctly sized airway equipment (LMAs, endotracheal tubes, oral airways)

· Emergency drugs (e.g., adrenaline, atropine, metaraminol, anaphylaxis kits)

· IV access supplies

· Drugs for Induction and Maintenance

· Resuscitation/airway adjuncts

· Monitoring equipment (SpO₂, ECG electrodes, BP cuffs)

The goal: every expected item is exactly where the anaesthetic team anticipates it to be, every time.

E. Anaesthetic Machine Checks

Performed at the beginning of each list and after any equipment change:

· Oxygen supply verification

· Circuit leak test

· Vaporiser levels

· Suction availability

· Airway connectivity

· Emergency backup oxygen cylinder

A disorganised environment delays these checks, increasing the risk of missed safety steps.

Postoperative Cognitive Dysfunction

Postoperative cognitive dysfunction can occur in any age group and is a decline in cognitive function after surgery. It is also called postoperative delirium. Due to all the drugs we give to get the patient into an anesthetic state, normal brain function can take a few hours to return to normal with common issues including short-term memory loss, short attention span, amnesia from partial to complete, and depressed conscious state. Postoperative cognitive dysfunction can result in the patient being difficult to manage in the PACU and the ward.

Read the section Postoperative Cognitive Dysfunction in Alexander's Care of the Patient in Surgery by Rothrock, chapter 5

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323776806000054#hl0001689. Postoperative Cognitive Dysfunction

Also, here is an interesting article on Postoperative Cognitive Dysfunction in PACU:

Aldwikat, R. K., Manias, E., Holmes, A., Tomlinson, E., & Nicholson, P. (2022). Validation of Two Screening Tools for Detecting Delirium in Older Patients in the Post-Anaesthetic Care Unit: A Diagnostic Test Accuracy Study. International Journal of Environmental Research and Public Health, 19(23). https://doi.org/10.3390/ijerph192316020

Patient Awareness and Relevant Equipment

Patient Awareness and Reassurance in Anaesthesia

Patient Awareness and Relevant Equipment

Patient awareness under anaesthesia, sometimes called intraoperative awareness or accidental awareness during general anaesthesia (AAGA), refers to situations in which a patient becomes partially or fully conscious during surgery despite receiving a general anaesthetic. Resulting in patients hearing conversations, feeling pressure or movement, or experiencing pain or distress. Awareness is considered an uncommon complication, but if it occur, it can have significant psychological consequences, including anxiety, nightmares, and posttraumatic stress symptoms. Awareness can occur in any setting, but is more likely when lower anaesthetic doses are required for patient safety, such as in trauma, haemodynamic instability, obstetric emergencies, or cardiac surgery. Significantly, awareness varies depending on the type of anaesthetic administered, the depth of anaesthesia, the patient's physiological status, and the use of neuromuscular blockers, which prevent movement but not consciousness.

Perioperative nurses play a critical role in preventing awareness, recognising early signs, and responding appropriately. According to Bull & Foran (2022), perioperative nurses are essential in supporting anaesthetists by ensuring appropriate equipment is available, functioning, and used correctly, and by monitoring for any indicators of inadequate anaesthesia. This includes observing vital signs, noticing unexpected patient movements, reporting equipment alarms promptly, and ensuring accurate and timely documentation. Nurses must also be prepared to provide emotional reassurance postoperatively if a patient reports awareness, and to escalate concerns for formal followup and psychological support.

Relevant Equipment in Preventing Awareness

Preventing awareness relies on reliable, wellmaintained anaesthetic equipment and vigilant monitoring.

1. Anaesthetic Machine

· The anaesthetic machine is a critical component of perioperative care, designed to deliver a safe, controlled mixture of gases and inhalational anaesthetic agents while supporting or fully providing patient ventilation. Primary functions include delivering oxygen, supplying fresh gas flow, and administering volatile anaesthetic agents such as sevoflurane or desflurane through calibrated vaporisers. These vaporisers precisely convert liquid anaesthetic into vapour and mix it with the carrier gas to achieve the desired concentration of inhaled anaesthesia.

· The machine also incorporates essential ventilatory controls, allowing clinicians to maintain appropriate tidal volumes, respiratory rates, airway pressures, and breathing circuit function.

· To ensure patient safety, the anaesthetic machine must undergo comprehensive preuse checks at the start of every list and whenever equipment is changed. These checks verify oxygen supply, confirm correct operation of the vaporisers, test for gas leaks, confirm circuit integrity, assess the function of the ventilator and scavenging system, and ensure that alarms and monitors are active and functioning. Skipping or failing to perform these checks significantly increases the risk of intraoperative complications.

· Faults within the anaesthetic machine, such as empty or incorrectly seated vaporisers, malfunctioning flowmeters, disconnections, or leaks in the breathing circuit, can lead to inadequate delivery of anaesthetic agent, insufficient oxygenation, hypoventilation, or accidental awareness under anaesthesia. For this reason, vigilance during setup and ongoing intraoperative monitoring is essential. The anaesthetic machine is therefore both a lifesupport device and a highrisk piece of equipment that requires structured daily testing, correct operation, and continuous observation to ensure safe, effective delivery of anaesthesia.

Endtidal Monitoring, Capnography and Depth of Anaesthesia

2. Endtidal Anaesthetic Agent Monitoring (ETAA)

Endtidal Anaesthetic Agent Monitoring (ETAA) is a critical component of modern anaesthetic practice that measures the concentration of volatile anaesthetic agent (such as sevoflurane, desflurane, or isoflurane) present in the patient's exhaled breath at the end of expiration. This "endtidal" value reflects the amount of volatile agent reaching the alveoli, which closely correlates with the concentration of anaesthetic delivered to the brain. Because of this relationship, ETAA is considered one of the most reliable indicators of actual anaesthetic depth, offering a direct assessment of the hypnotic effect of inhalational agents.

ETAA plays a significant role in preventing accidental awareness under general anaesthesia (AAGA). Unlike clinical signs alone, such as heart rate or blood pressure, ETAA provides objective, quantifiable evidence of anaesthetic adequacy. If endtidal concentration drops below the minimum alveolar concentration (MAC) required to maintain unconsciousness, ETAA alarms alert clinicians early, allowing prompt correction. This is especially important during periods of high surgical stimulation, equipment malfunction, or unexpected changes in patient physiology.

Because ETAA precisely reflects the amount of volatile anaesthetic delivered to the lungs and, indirectly, to the central nervous system, it provides clinicians with realtime feedback on whether the patient is receiving sufficient anaesthesia. A falling ETAA may indicate insufficient anaesthetic depth due to low fresh gas flow, a malfunctioning vaporiser, circuit disconnections, leaks, or sudden changes in patient ventilation. Conversely, excessively high ETAA alerts clinicians to the risk of oversedation, hypotension, delayed emergence, and drug accumulation, enabling more precise titration of anaesthetic delivery.

3. Capnography

Capnography is a critical monitoring tool in anaesthesia that measures the concentration of carbon dioxide (CO₂) in a patient's exhaled breath and displays the results as both a waveform (capnogram) and a numerical value (endtidal CO₂, or EtCO₂). Its primary purpose is to confirm adequate ventilation and provide early detection of problems affecting the airway, breathing, or the anaesthetic circuit.

A normal capnogram verifies that the patient is moving air through the airway and that the breathing circuit is intact. Because capnography reflects realtime respiratory function, it is susceptible to issues such as circuit disconnections, accidental extubation, airway obstruction, kinked tubing, or ventilator failure. A sudden drop to zero CO₂ is one of the most immediate and reliable signs of a disconnection or major airway problem, often appearing before other vital signs change.

Capnography also helps monitor the quality of ventilation. Rising EtCO₂ values can indicate hypoventilation, increased CO₂ production (e.g., sepsis, malignant hyperthermia), or equipment malfunction. Falling EtCO₂ may signal hyperventilation, low cardiac output, pulmonary embolism, or impending arrest. Because of its sensitivity, capnography enables clinicians to detect deteriorations quickly, long before oxygen saturation begins to fall.

Although capnography does not directly measure anaesthetic agent levels, it indirectly supports adequate anaesthetic delivery by verifying that inhalational agents are being transported effectively through the respiratory circuit. If CO₂ is not being exhaled normally, it suggests that oxygen and volatile anaesthetic gases may not be reaching the lungs reliably or predictably. Therefore, capnography plays a supportive role in ensuring the patient continues to receive a consistent and safe anaesthetic.

4. Depth of Anaesthesia Monitoring (e.g., BIS Monitor, SedLine)

The Bispectral Index (BIS) is a form of processed EEG monitoring used during general anaesthesia to assess the depth of hypnosis. BIS measures raw electrical activity from the cerebral cortex via forehead electrodes and converts it to a numerical value of 0–100. This value helps anaesthetists titrate drugs safely, reduce the risk of accidental awareness under general anaesthesia (AAGA), and avoid excessive anaesthetic depth.

BIS works by analysing EEG signals through several algorithms: bispectral analysis (relationship between EEG wave phases), power spectral analysis (balance of high and lowfrequency activity), burst suppression detection (presence of alternating flat and burst patterns seen in deep anaesthesia or hypothermia), and timedomain analysis (waveform shape and coherence). Together, these analyses produce a continuously updated BIS score.

The BIS scale ranges from 100 (fully awake) to 0 (no EEG activity). A BIS value of 40–60 is the target range for general anaesthesia, as it indicates adequate unconsciousness with a low risk of awareness. Values above 60 may indicate light anaesthesia or potential awareness, especially in paralysed patients. In contrast, values below 40 often reflect deep hypnosis and are associated with risks such as hypotension, delayed emergence, and postoperative cognitive dysfunction.

Clinically, BIS is used to titrate volatile anaesthetic agents (e.g., sevoflurane) and intravenous agents (e.g., propofol in TIVA). It is beneficial in situations where drug levels are not otherwise easy to monitor, such as TIVA cases, trauma, cardiac surgery, haemodynamic instability, obstetric emergencies, and care of elderly or frail patients.

Accurate BIS readings require proper electrode placement, clean/dry skin, good contact, and minimal electrical interference. Several factors can produce false readings. False-high BIS values may occur with facial EMG activity (shivering, muscle tension), electrocautery, poor electrode contact, ketamine, nitrous oxide, or patient movement. False-low BIS values can result from hypotension, hypothermia, hypoglycaemia, cerebral ischaemia, signal dropout, or sedative/opioid effects. Certain drugs, especially ketamine, dexmedetomidine, and neuromuscular blockers, affect BIS values in ways that do not reflect actual unconsciousness.

BIS has limitations. It measures only cortical brain activity, not deeper structures, so some awareness events may not be detectable on the EEG. It is not validated for infants under 1 year old, may be influenced by many medications, and does not guarantee against AAGA. BIS should therefore be used alongside clinical signs, endtidal agent monitoring, and anaesthetic dosing trends rather than as a standalone indicator.

Perioperative nurses play an important role in BIS monitoring. Before induction, they ensure proper device function, correct electrode placement, and adequate signal quality (SQI > 80%). During surgery, they track BIS trends, report sudden changes, troubleshoot electrode issues, and respond to alarms. After surgery, they document BIS use and communicate any concerns regarding anaesthetic depth.

BIS Value	Clinical Meaning
100	Fully awake, normal EEG
80–100	Light sedation, conscious
60–80	Moderate sedation; may respond purposefully
40–60	Target range for general anaesthesia (low probability of awareness)
<40	Deep hypnosis
<20	Burst suppression (very deep anaesthesia or pathology)
0	Flat EEG (no detectable brain activity)

BIS Monitoring in Paediatric Patients

Bispectral Index (BIS) monitoring is a processed EEG method used to estimate the depth of anaesthesia. While BIS is well established in adults, its use in paediatric patients is more challenging because children's brains, especially those under 1 year old, produce EEG patterns that differ significantly from those of adults. BIS algorithms were developed based on adult EEG data, so they often misinterpret immature neurophysiology. Infants have underdeveloped neural networks, rapidly changing synaptic connections, and an EEG dominated by slower frequencies, leading to unreliable or misleading BIS values. As a result, BIS is unreliable in infants under 6 months, inconsistent in children up to 2–3 years, and progressively more accurate after approximately 4–5 years of age.

Although BIS still produces values between 0 and 100, interpreting these numbers in children is not straightforward. Young children may show higher BIS values (60–80) even when deeply anaesthetised, and children under 3 often exhibit greater variability. BIS may also lag behind physiological or anaesthetic changes. Therefore, BIS should always be used as an adjunct, never the sole determinant of anaesthetic depth, especially in younger patients.

Despite its limitations, BIS can be clinically valuable in certain paediatric situations. It is beneficial during Total Intravenous Anaesthesia (TIVA), where interruptions in infusion lines or pump malfunctions can increase the risk of awareness, BIS may help detect insufficient hypnotic depth sooner. It is also helpful when neuromuscular blockade is used, because paralysed children cannot respond to inadequate anaesthetic depth through movement. Other situations where BIS supports decision-making include long cases, haemodynamic instability, burns, trauma, congenital heart disease, and procedures requiring lighter anaesthesia.

However, BIS use in children has several pitfalls. The most significant is the EEG immaturity in infants, which often results in falsely elevated BIS readings. Additional factors that artificially elevate BIS include EMG activity (common in children due to higher muscle tone and facial movement), electrical interference, and drugs such as ketamine, which increases cortical activity. Sevoflurane induction can also produce unpredictable BIS shifts in children. Conversely, falsely low BIS values can be caused by hypotension, hypothermia, hypoglycaemia, cerebral ischaemia, or signal dropout.

Perioperative nurses play a key role in ensuring BIS accuracy and safety. Proper electrode placement is essential: sensors must be applied to clean, dry skin, well adhered, and correctly positioned on small paediatric foreheads to avoid artefacts. Nurses must integrate BIS values with other clinical indicators, including endtidal volatile concentrations, heart rate, blood pressure, patient movement (if not paralysed), anaesthetic dosing, and overall clinical presentation. Sudden increases in BIS may signal pump disconnection, low anaesthetic concentration, heightened surgical stimulation, or inadequate ventilation. Conversely, unexpectedly low BIS values may indicate deep anaesthesia, opioid overdose, hypotension, or hypothermia.

Age	BIS Reliability
< 6 months	Poor — EEG immature, BIS not validated
6–12 months	Variable — BIS often inconsistent
1–2 years	Some correlation but still limited
> 2–3 years	BIS starts to align more closely with adult patterns
> 4–5 years	BIS becomes more dependable

5. Infusion Pumps (e.g., TIVA—Total Intravenous Anaesthesia)

Infusion pumps used for Total Intravenous Anaesthesia (TIVA) deliver continuous IV anaesthetic agents, such as propofol and sometimes remifentanil, in precise, controlled amounts to keep the patient unconscious during surgery. TIVA does not use inhalational agents, therefor, no endtidal gas monitoring to confirm anaesthetic depth, making the pump’s accuracy and uninterrupted function absolutely essential for safety. Even small programming errors, such as incorrect drug concentration, patient weight, or infusion rate, can lead to inadequate anaesthesia, movement, or accidental awareness, while overdosing may cause hypotension or delayed emergence. Any interruption in the infusion, due to pump malfunction, IV dislodgement, occlusion, extravasation, or an empty syringe, can quickly reduce anaesthetic depth, particularly dangerous when the patient is paralysed and unable to move.

Perioperative nurses play a critical role in preventing these complications by verifying pump settings, confirming drug concentration, and ensuring the infusion rate matches the anaesthetist’s plan. They must also check IV-line integrity, monitor for kinks, leaks, or infiltration, and perform regular visual checks of the syringe and tubing. Ongoing monitoring for signs of inadequate depth, such as changes in heart rate, BIS increases, or altered ventilation, is essential, with immediate escalation to the anaesthetist if abnormalities occur.

6. Alarm Systems

Alarm systems on anaesthetic machines, monitors, ventilators, and infusion pumps are essential safety features that alert clinicians to deterioration in the patient's physiological status or technical problems with equipment. These alarms must remain active and audible at all times, as they provide rapid warning of issues such as hypoxia, airway disconnection, ventilator failure, infusion interruption, or dangerous changes in vital signs. Muting, silencing, or ignoring alarms removes a key layer of protection. It significantly increases the risk of delayed recognition of critical events, which can lead to patient harm, including hypoxia, cardiac compromise, or accidental awareness. Keeping alarms functional and responding to them promptly is therefore fundamental to safe anaesthetic practice and patient safety.

Reference

References:

Aldwikat, R. K., Manias, E., Holmes, A., Tomlinson, E., & Nicholson, P. (2022). Validation of Two Screening Tools for Detecting Delirium in Older Patients in the Post-Anaesthetic Care Unit: A Diagnostic Test Accuracy Study. International Journal of Environmental Research and Public Health, 19(23). https://doi.org/10.3390/ijerph192316020

Chowdhury, S. R., & McLure, H. A. (2022). Chronic kidney disease and anaesthesia. British Journal Anaesthesia Education, 22(8), 321-328. https://doi.org/10.1016/j.bjae.2022.03.005

Gilbert-Kawai, N., Hogan, B., & Milan, Z. (2022). Perioperative management of patients with liver disease. British Journal of Anaesthesia Education, 22(3), 111–117. https://doi.org/10.1016/j.bjae.2021.11.006

Lees, H., & Charlesworth, M. (2021). Anaesthesia for patients with cardiac disease undergoing non-cardiac surgery. Anaesthesia and Intensive Care Medicine, 22(5), 297–300. https://doi.org/10.1016/j.mpaic.2021.03.008

Phillips, N., & Hornacky, A. (2020).  Berry & Kohn's Operating Room Technique (14th ed.). Elsevier.

Rothrock, J. C. (2022).  Alexander's Care of the Patient in Surgery (17th ed.). Elsevier.

https://www.periopconcepts.com/blog/paediatric-airway-anatomy

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323776806000261 - hl0001393

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323776806000261 - hl0001404

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323776806000261 - hl0001432

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323776806000261 - hl0001437

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323776806000261 - hl0001878

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323776806000273 - hl0000976

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323776806000273 - hl0001197

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323776806000273 - hl0001238

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780443105234000092 - hl0000641

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780443105234000249 - hl0001675

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780443105234000249 - hl0001732

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323776806000054 - hl0002035

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323776806000054 - hl0001689

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780443105234000249 - hl0001612

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780443105234000249 - hl0001638

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780443105234000432 - hl0000989

https://www.youtube.com/watch?v=0aVsiHZOzhg&t=11s

MODULE 2

Responding to the Deteriorating Patient

Responding to the Deteriorating Patient (Aligned to NSQHS Standard 8)

As an anaesthetic nurse, you play a vital role in early recognition and rapid response to patient deterioration in the operating room. NSQHS Standard 8 emphasises that all staff must be able to identify acute deterioration, respond appropriately, communicate effectively, and ensure escalation occurs without delay. In the OR, your vigilance can prevent serious harm such as cardiac arrest, hypoxia, haemodynamic collapse, or accidental awareness.

This guide explains what to look for, how to assess, how to act, and when to escalate, in line with the principles of NSQHS Standard 8.

1. Recognising Early Signs of Deterioration

(NSQHS Standard 8: Early Recognition of Deterioration)

Patients often show subtle but important warning signs before they collapse. These may appear in vital signs, ventilation parameters, consciousness level, or behaviour.

Respiratory signs (often the earliest indicator)

Respiratory changes are often the earliest and most sensitive indicators that a patient is becoming unstable, and anaesthetic nurses must recognise them promptly. An increasing or decreasing respiratory rate is usually the first abnormality and signals that the patient is either working harder to breathe or losing respiratory drive. Dropping oxygen saturations indicate that oxygen is not effectively transferred into the bloodstream, often due to airway obstruction, hypoventilation, or poor ventilationperfusion matching. Shallow or irregular breaths suggest inadequate tidal volume, fatigue, sedation effects, or impaired respiratory control. Increased use of accessory muscles, such as visible neck muscle activity, chest wall retractions, or nasal flaring, means the patient is struggling to maintain adequate ventilation and may soon tire. Sudden coughing, wheezing, or absent breath sounds suggest airway irritation, bronchospasm, partial or complete obstruction, or equipment malfunction. Finally, abnormal endtidal CO₂ (ETCO₂) trends or waveform changes are critical early warning signs: rising ETCO₂ suggests hypoventilation or obstruction, falling ETCO₂ may indicate hyperventilation or reduced cardiac output, and a sudden drop to zero almost always signals circuit disconnection, accidental extubation, or ventilator failure. Together, these respiratory signs provide the earliest clues that immediate assessment and intervention are needed to prevent further deterioration.

Circulatory signs

Circulatory changes are key indicators that a patient may be becoming unstable, and anaesthetic nurses must recognise them early to prevent further decline. Tachycardia often signals pain, anxiety, hypovolaemia, bleeding, hypoxia, or early shock, while bradycardia may indicate severe hypoxia, vagal stimulation, high anaesthetic depth, or impending cardiac arrest. Hypotension or sudden blood pressure changes suggest that the heart is not maintaining adequate perfusion, commonly seen with blood loss, anaesthetic overdose, sepsis, or anaphylaxis. The skin provides important clues: cool, clammy, pale, or mottled skin reflects poor Circulation and reduced peripheral perfusion. Weak pulses or delayed capillary refill show that tissues are not receiving enough oxygenated blood and may indicate shock or low cardiac output. Unexpected bleeding or rapid blood loss, whether visible in the surgical field, drains, or on the patient, can quickly lead to hypovolaemia, hypotension, and cardiovascular collapse. Together, these circulatory signs demand immediate assessment, rapid intervention, and early escalation to prevent further deterioration.

Neurological Signs

Neurological changes are important signs that a patient may be deteriorating, and they often reflect reduced cerebral perfusion, altered sedation depth, hypoxia, or emerging complications such as stroke, hypoglycaemia, or anaesthetic imbalance. New restlessness or agitation may be an early signal of hypoxia, inadequate anaesthesia, pain, or rising carbon dioxide levels, while reduced responsiveness indicates worsening neurological status or excessive anaesthetic depth. Delays in answering questions or altered behaviour suggest early neurological decline and require immediate reassessment of oxygenation, haemodynamics, and sedation. Pupillary changes, such as unequal pupils, poor reactivity, or dilation, can be signs of serious issues, including hypoxia, brain injury, or drug effects. Additionally, unexpected movement in a patient who is not paralysed may indicate inadequate anaesthesia or emerging awareness, especially critical during surgery. Together, these neurological signs require prompt recognition, rapid ABCDE assessment, escalation to the anaesthetist, and immediate intervention to prevent further deterioration.

Other indicators

In addition to respiratory, circulatory, and neurological changes, several other important warning signs can indicate early patient deterioration in the operating room. Low urine output is often one of the earliest markers of reduced kidney perfusion and can signal hypovolaemia, shock, or poor cardiac output. It reflects the body’s attempt to conserve fluid when blood flow is inadequate. A sudden change in surgical field bleeding, such as unexpectedly heavy bleeding, poor visibility, or rapid blood loss, may indicate vascular injury, coagulopathy, or hemodynamic instability and can quickly lead to hypovolaemic shock if not recognised early. Monitor alarms must never be ignored; they are designed to alert staff to critical changes, such as falling oxygen saturation, capnography abnormalities, arrhythmias, hypotension, disconnections, or ventilator issues. Even a short delay in responding can lead to rapid deterioration. Finally, a nurse’s intuition that “something is not right” is a vital indicator. Experienced clinicians often detect subtle behavioral, color, or pattern changes before numerical values shift. Trusting and acting on clinical intuition is an important part of early recognition in line with NSQHS Standard 8.

NSQHS Standard 8 requires staff to recognise early clinical deterioration and respond promptly.

2. Use the ABCDE Approach

(NSQHS: Systematic, Structured Assessment)

The ABCDE method keeps you systematic and focused on lifethreatening issues first.

A — Airway

Look/listen for:

· Snoring, gurgling

· Stridor

· Vomit, blood, or secretions

· Difficult ventilation smell (resistance, leaks)

What you do:

· Reposition airway (chin lift/jaw thrust)

· Suction

· Prepare OPA/NPA

· Assist the anaesthetist with intubation or airway rescue

B — Breathing

Assess:

· Chest rise

· Respiratory rate and depth

· SpO₂

· ETCO₂ waveform (key for anaesthetic nurses)

What you do:

· Increase oxygen delivery

· Check breathing circuit connections

· Assist with ventilation

· Troubleshoot obstruction, bronchospasm, or disconnection

C — Circulation

Monitor:

· Heart rate & ECG

· Blood pressure

· Capnography trends (low ETCO₂ can indicate reduced perfusion)

· IV patency and access

· Bleeding

What you do:

· Ensure IV lines are patent

· Prepare fluids or emergency medications

· Alert the anaesthetist to rapid changes

D — Disability (Neurological)

Look for:

· Changes in consciousness

· BIS increases (if used)

· Unexpected patient movement

· Pupillary changes

What you do:

· Check medications affecting sedation

· Report sudden changes immediately

· Prepare for more profound anaesthesia if needed

E — Exposure/Environment

Check:

· Surgical field for bleeding

· Skin color, temperature

· Lines, drains, circuits

· Heat loss

What you do:

· Prevent hypothermia

· Correct circuit or device problems

· Keep environment tidy to prevent delays

3. Escalation of Care — Act Early

(NSQHS: Rapid Response Systems)

Never wait for collapse — early escalation prevents harm.

Escalate when you see:

· RR < 8 or > 30

· SpO₂ < 92% despite oxygen

· SBP < 90 or rapidly falling

· HR < 40 or > 130

· Sudden ETCO₂ drop (possible disconnection)

· New unresponsiveness

· Seizure-like activity

· Suspected anaphylaxis

Whom to call in the OR

· The anaesthetist (immediate)

· Senior anaesthetic nurse

· Nurse Unit Manager / Team leader

· MET/RRT if patient is unstable

· Surgeon for surgical source (bleeding, trauma)

Use ISBAR for clear communication.

· Identify

· Situation

· Background

· Assessment (ABCDE)

· Recommendation

NSQHS Standard 8 emphasises structured communication to prevent misunderstandings.

4. Immediate Actions for Anaesthetic Nurses

(NSQHS: Timely, Appropriate Intervention)

Airway & Breathing

· Increase oxygen delivery

· Assist with manual ventilation

· Reconnect or troubleshoot leaks/disconnections

· Prepare emergency airway equipment

Circulation

· Check IV lines for patency

· Prepare fluids and emergency medications

· Assist in treating hypotension, bradycardia, or arrhythmias

Monitoring

· Check ETCO₂ changes

· Monitor ECG rhythm

· Recheck blood pressure

· Respond immediately to alarms (never mute)

Anticipate deterioration

Ask:

· “What could happen next?”

· “Do I need extra help?”

· “Is the airway safe?”

5. Monitoring & Documentation

(NSQHS: Accurate, Timely Documentation)

Reassess frequently

· In unstable patients: every 1–5 minutes

· After every intervention

· Look for trends, not oneoff numbers

Document:

· Vital signs

· What changed

· Actions you took & when

· Who you notified

· The patient’s response

Good documentation = good communication + patient safety.

6. Common Causes of Deterioration in the Operating Room

(NSQHS: Identify & Manage Risk)

· Airway obstruction

· Anaesthetic overdose or underdose

· Hypoventilation or ventilator failure

· Surgical bleeding or hypovolaemia

· Anaphylaxis

· Sepsis

· Malignant hyperthermia

· Cardiac arrhythmias

· Equipment failure

Knowing these helps anticipate problems early.

Skills of an Effective Anaesthetic Nurse (Aligned to NSQHS)

Goals of Care

Goals of Care in the Perioperative Setting

Goals of care are the agreedupon aims and priorities that guide the clinical management of a patient throughout their perioperative journey. These are goals for the health care team that ensure that every member works toward safe, effective, patientcentred outcomes. The goals incorporate clinical needs, safety requirements, procedural considerations, and the patient's personal preferences, ensuring that care is both appropriate and aligned with what matters most to the individual.

These goals of care start in the preoperative setting, where nurses and anaesthetists assess patient risk, prepare equipment, confirm consent, evaluate comorbidities, and identify issues that may impact anaesthesia or surgery. The focus is on optimising patient stability, reducing anxiety, preventing complications, and ensuring the operating room is safe and ready.

Intraoperative goals of care are redirected to maintaining physiological stability, ensuring sterility, preventing deterioration, and enabling the surgical plan to proceed smoothly. Anaesthetic nurses concentrate on airway management, ventilation, haemodynamic monitoring, depth of anaesthesia, and responding to changes in vital signs. Scrub and scout nurses focus on maintaining a sterile field, managing instruments and equipment, monitoring bleeding within the surgical field, and alerting the team to changes such as excessive blood loss or unexpected patient movement.

Throughout the procedure, communication and teamwork are essential goals of care. The use of structured communication tools, such as ISBAR, ensures that changes in patient condition are shared quickly and clearly. All staff must be prepared to escalate concerns immediately, in line with NSQHS Standard 8: Recognising and Responding to Acute Deterioration, which emphasises early detection, rapid action, and multidisciplinary collaboration.

Finally, postoperative goals include safe transfer to PACU, effective handover, management of pain and nausea, ongoing monitoring, and ensuring the patient's dignity and comfort as they recover. Documentation remains a key requirement, supporting continuity of care and ensuring that interventions, changes, and decisions are recorded accurately.

Goals of Care for the Anaesthetic Nurse in the Perioperative Setting

Anaesthetic nurses provide specialised care that supports safe anaesthesia delivery and optimises patient outcomes before, during, and after surgery. Their goals of care can be divided into preoperative, intraoperative, and immediate postoperative responsibilities, each centred around safety, monitoring, communication, and patient advocacy.

1. Preoperative Goals of Care

A. Patient Assessment and Optimisation

· Conduct thorough preoperative checks, including allergies, fasting status, medications, airway risks, comorbidities, and relevant pathology.

· Identify red flags such as uncontrolled hypertension, hypovolaemia, infection, or airway abnormalities.

· Assess anxiety, provide reassurance, and support patient comfort.

B. Preparation of the Environment and Equipment

· Ensure the anaesthetic machine is thoroughly checked (oxygen supply, vaporisers, breathing circuits, leak tests).

· Prepare monitoring equipment (ECG, pulse oximetry, NIBP, capnography, BIS if needed).

· Prepare IV access equipment, airway adjuncts, emergency airway cart, suction, and resuscitation drugs.

· Anticipate additional equipment based on the procedure: warming devices, regional anaesthesia kits, TIVA infusion pumps, and rapid infusion devices.

C. Communication & Safety

· Participate in the surgical team timeout (WHO checklist).

· Clarify the anaesthetic plan with the anaesthetist.

· Advocate for patient needs and highlight identified risks to the team.

2. Intraoperative Goals of Care

A. Maintain Airway, Breathing, and Circulation

· Assist with airway management: preoxygenation, laryngoscopy, intubation, LMA insertion.

· Continuously monitor vital signs, including SpO₂, ETCO₂, ECG, BP, and temperature.

· Detect early signs of deterioration (hypoxia, hypotension, tachycardia, bronchospasm).

B. Ensure Adequate Anaesthetic Delivery

· Prepare and administer IV induction agents under anaesthetist guidance.

· Monitor depth of anaesthesia (clinical signs, ETAA, BIS).

· Prevent awareness by ensuring continuous anaesthetic delivery and responding to equipment alerts.

C. Manage Intraoperative Risks

· Prevent hypothermia with active warming.

· Monitor fluid balance and assist with IV fluid or transfusion therapy.

· Recognise and respond rapidly to emergencies (anaphylaxis, MH, airway obstruction, arrhythmias).

D. Documentation & Communication

· Document vital signs, drugs given, and interventions performed.

· Communicate changes promptly to the surgical and nursing team.

· Ensure traceability of controlled drugs and anaesthetic agents.

3. Postoperative Goals of Care

A. Safe Transfer to PACU

· Ensure patient is stable for transfer (airway patent, breathing adequate, haemodynamics stable).

· Provide a structured clinical handover using ISBAR.

· Continue to monitor early recovery parameters until PACU staff assume care.

B. Patient Comfort and Recovery

· Manage pain, nausea, shivering, and anxiety.

· Reinforce postoperative instructions and care plan with PACU nurse.

C. Quality and Safety

· Ensure all equipment is cleaned, restocked, and ready for the following case.

· Reflect on issues to improve future practice.

Goals of Care for the Scrub/Scout Nurse in the Perioperative Setting

Scrub and scout nurses work as an integrated team to maintain sterility, assist the surgical team, and support safe operative flow. Their goals of care focus on asepsis, equipment management, patient advocacy, and situational awareness.

Summary

· Anaesthetic nurses focus on physiological stability, anaesthetic delivery, monitoring, airway management, emergency response, and safe recovery.

· Scrub/scout nurses focus on surgical sterility, instrumentation, equipment, counting, environmental safety, communication, and early recognition of deterioration from the surgical field perspective.

Together, all perioperative nurses work to:

· Keep the patient safe

· Recognise and respond early to deterioration

· Maintain a sterile and controlled environment

· Support the surgical and anaesthetic team

· Uphold NSQHS Standard 8 and all other safety standards

· Advocate for the patient at every stage of the perioperative journey

ANAESTHETIC NURSE — Goals of Care

Domain	Goal of Care
Patient Assessment	Identify risks (airway, allergies, comorbidities), assess anxiety, confirm fasting & consent.
Preparation	Check anaesthetic machine, airway equipment, suction, monitoring (ECG, SpO₂, ETCO₂, NIBP, temp), IV access equipment, emergency drugs.
Safety	Maintain airway, breathing, circulation; prevent hypoxia, hypotension, awareness; maintain normothermia; recognise early deterioration.
Anaesthetic Delivery	Assist induction (IV or gas), maintain depth of anaesthesia (ETAA, BIS, clinical signs), monitor ventilation.
Intraoperative Monitoring	Continuous observation of vitals, capnography, oxygenation, haemodynamics, medications given and effects.
Emergency Response	Respond to anaphylaxis, MH, airway obstruction, cardiac instability; activate MET/RRT if needed.
Communication	Use ISBAR for concerns; coordinate with surgeon & scrub/scout; share vital sign changes promptly.
Documentation	Record drugs, vitals, events, interventions; prepare postoperative handover for PACU.
Patient Advocacy	Ensure comfort, dignity, safety; anticipate needs based on procedure & risk

Code Blue and Emergency Equipment Management

SCRUB & SCOUT NURSE ROLE DURING CODE BLUE

Scrub/scout nurses ensure the environment is safe, accessible, and ready for advanced interventions.

1. Hazard Reduction & Scene Clearing

Removing hazards

Scrub nurses are responsible for:

· Retracting drapes

· Clearing retractors, sharp instruments, and diathermy

· Moving Mayo stands

· Clearing poles, lines, and instruments from the chest area

CPR requires sternal access and avoidance of injury to rescuers. [ACN01883 A...VE 2024 FA | PDF]

2. Patient Repositioning

If the patient is not supine, effective CPR cannot occur.

Scrub/scout nurses assist in:

· Coordinating the team to logroll

· Securing lines and tubes

· Protecting the surgical site

· Minimising delays in compressions

Supine repositioning must happen within seconds, ideally without compromising sterility or team safety.

3. Supporting Surgical Management

If bleeding is the cause

You assist by:

· Passing haemostatic agents

· Preparing diathermy tips

· Managing suction lines

· Ensuring visibility for the surgeon

If a surgical emergency intervention is required

· Thoracotomy

· Control of significant vessel injury

· Packing for massive haemorrhage

You prepare trays and instruments instantly.

4. Equipment Anticipation

Scrub/scout nurses prepare or bring:

· Suction

· Additional IV cannulas

· Pressure infusers

· Emergency airway equipment

· Rapid transfusion lines

· Defibrillator pads, if not already applied

Your anticipatory actions directly reduce delays in the arrest response.

5. Communication & Coordination

You help coordinate:

· Blood bank

· Pathology

· Porters

· Additional staff

· Documentation support

You maintain closedloop communication to prevent misunderstandings.

6. Documentation Support

If not assisting physically:

· Timestamp events

· Record drugs

· Note rhythms

· Assist the scribe or take over documentation

Highquality documentation helps guide management and satisfies legal requirements.

7. Handling Sterility

Sterility is important, but resuscitation takes priority.

Scrub nurses judge when:

· They should descrub to assist safely

· They should rescrub after ROSC for surgical closure

8. Debriefing

Scrub nurses provide critical insights on:

· Equipment issues

· Ergonomic barriers

· Safety improvements

ANAESTHETIC & RECOVERY NURSE ROLE DURING CODE BLUE

The anaesthetic/recovery nurse role is one of the most critical in the entire perioperative arrest response. Below is a complete expansion of each point.

1. Early Recognition & Escalation

Recognising perioperative cardiac arrest indicators

The top four indicators in anaesthetised patients differ from ward patients because they are continuously monitored and often pharmacologically suppressed:

· Impalpable pulse: Most reliable sign, because chest movement and breathing are often controlled or masked by drapes. [ACN01883 A...VE 2024 FA | PDF]

· Severe hypotension: A rapid drop in mean arterial pressure suggests loss of forward flow.

· Severe bradycardia: Particularly dangerous under anaesthesia, may precede asystole.

· Abrupt drop in ETCO₂: A sudden ETCO₂ fall indicates immediate loss of pulmonary blood flow, often the earliest sign. [ACN01883 A...VE 2024 FA | PDF]

Escalation

· The anaesthetic/recovery nurse is often the first to recognise these changes because they directly monitor the patient.

· They activate Code Blue immediately ("Cardiac arrest, Theatre X") while continuing the assessment.

· Quick escalation is essential: early recognition and early CPR improve survival. [ACN01883 A...VE 2024 FA | PDF]

2. Airway Management Responsibilities

Airway confirmation

· Under anaesthesia, airway patency cannot be assumed; equipment may fail, or the tube may migrate.

· The nurse checks:

· Chest rises and falls.

· Bilateral breath sounds

· Capnography waveform quality

· If airway obstruction is suspected, they troubleshoot suction, reposition the head, or prepare for advanced management.

If no advanced airway is present

· The anaesthetic nurse prepares:

· Oropharyngeal airway

· Laryngeal mask airway (LMA)

· Endotracheal intubation equipment

· Intubation must not interrupt compressions for longer than 5 seconds. [ACN01883 A...VE 2024 FA | PDF]

The Vortex Approach During Difficult Intubation

The Vortex Approach is a simple visual and cognitive framework used during difficult or failed airway situations. It helps teams stay calm, coordinated, and focused on achieving oxygenation, not just intubation.

It highlights that there are three nonsurgical airway lifelines:

· Facemask ventilation

· Supraglottic airway (SGA)

· Endotracheal intubation (ETT)

You can attempt each of these as many times as needed, but progress only counts if oxygenation is achieved (visible chest rise, improving SpO₂).

If oxygenation cannot be achieved with any of the three lifelines, even after optimisation steps such as repositioning, suction, adjuncts, or changing operator, the team has entered:

The Red Zone → "Can't Intubate, Can't Oxygenate" (CICO)

At this point, the Vortex approach directs clinicians to perform emergency frontofneck access (eFONA) without delay.

The Vortex Approach

· Keeps the team structured and reduces panic

· Encourages rapid cycling through airway options

· Reinforces optimisation (position, technique, adjuncts)

· Promotes a shared mental model

· Prevents prolonged, repeated, unsuccessful attempts

Supports timely decisionmaking for a surgical airway

3. Ventilation Management

Ventilation with a secure airway

· Deliver 1 breath every 6 seconds (10/min).

· No pause in compressions. [ACN01883 A...VE 2024 FA | PDF]

· The anaesthetic nurse synchronises breaths with the chest recoil phase to optimise venous return.

ETCO₂ Monitoring

· ETCO₂ provides realtime feedback on:

· CPR quality

· Tube position

· Perfusion status

· Impending ROSC

· ETCO₂ >20 mmHg = effective compressions.

· Sudden rise = likely ROSC.

· Sudden fall = tube dislodgement, massive PE, or failing compressions. [ACN01883 A...VE 2024 FA | PDF]

4. Circulatory Support: Lines & Drugs

Securing IV (Intravenous) or IO (Intraosseous) access

If existing lines fail, the nurse rapidly initiates largebore access or prepares IO equipment.

Task	IV Access Equipment	IO Access Equipment
Basic access	Gloves, tourniquet, alcohol swabs, IV cannula	IO needle, IO drill/driver
Local anaesthetic	Optional lignocaine	Lidocaine (for conscious patients)
Site prep	Dressing pack, sterile field	Antiseptic swabs, dressing pack
Confirmation	Saline flush	Saline flush (vigorous)
Flow support	Roller clamp, IV tubing, fluid bag	Pressure bag often required
Securement	Transparent dressing, tape	IO stabiliser, securement device

Drug preparation

· Anaesthetic/recovery nurses are often the ones preparing and administering:

· Adrenaline 1 mg (timed every 3–5 min depending on algorithm).

· Amiodarone for refractory VF/VT.

· Fluids for suspected hypovolaemia (20 mL/kg if indicated). [ACN01883 A...VE 2024 FA | PDF]

Close monitoring

The nurse tracks drug dosing times, monitors for ROSC indicators, and helps synchronize rhythm checks.

5. Rhythm Recognition Support

Applying multifunction pads

· They place pads in anterior–lateral or anterior–posterior positions while CPR continues.

Assisting with rhythm checks using COACHED

· C — Continue compressions

· O — Oxygen away

· A — All others clear

· C — Charge defibrillator

· H — Hands off

· E — Evaluate rhythm

· D — Defibrillate or dump

This ensures defibrillation is safe and rapid with minimal pauses (<5 seconds). [ACN01883 A...VE 2024 FA | PDF]

6. Communication & Leadership

Closedloop communication

Essential phrases such as:

· "Adrenaline 1 mg given now."

· "Twominute cycle complete."

Anticipation

Anaesthetic nurses are experts in:

· Knowing what the anaesthetist needs before they ask

· Predicting reversible causes

· Preemptively preparing airway equipment, drugs, or blood products

7. Management of Reversible Causes in OT

The OT environment has unique reversible causes:

· Surgical bleeding → hypovolaemia

· Anaphylaxis → drugs, latex, and antibiotics are common in OT

· Pneumothorax → barotrauma from ventilation

· Air embolism → common risk in neurosurgery, CVC insertion

· High spinal block → bradycardia and hypotension

The anaesthetic nurse assists by:

· Identifying trends

· Preparing treatment

· Communicating early

[ACN01883 A...VE 2024 FA | PDF]

8. PostEvent Responsibilities

· Document airway events, drugs, times, and rhythms.

· Assist with patient stabilisation or transfer.

· Participate in a formal debriefing to improve quality.

BASIC LIFE SUPPORT (BLS): DRSABCD

According to the ACCCN ALS Manual, each step of the DRSABCD approach should be completed within 30 seconds, except for CPR, which is continuous. [ACN01883 A...VE 2024 FA | PDF]

D – Danger

Before touching the patient, assess and manage risks to:

· Yourself – e.g., sharps, spills, electricity, oxygen, fire risk.

· Your team – crowded space, trip hazards, unstable environment.

· The patient – e.g., repositioning to avoid further harm.

Failure to check for danger may lead to rescuer injury, halting resuscitation altogether.

R – Response

Use a combination of:

· Voice stimulation ("Can you hear me?")

· Physical stimulation (shoulder squeeze, trapezius squeeze)

A patient who responds:

· It is not in cardiac arrest

· Should be repositioned into the recovery position and monitored

No response → proceed immediately to the next step.

S – Send for Help

Immediately:

· Activate the Code Blue system/emergency response team.

· Direct a bystander: "YOU—call for help and bring the defibrillator."

BLS emphasises early activation of the emergency response system to shorten the time to defibrillation. [ACN01883 A...VE 2024 FA | PDF]

A – Airway

Open and transparent the airway:

· Head tilt–chin lift if no spinal concern

· Jaw thrust if spinal injury suspected

· Remove visible obstruction with suction or finger sweep

· Avoid overextending the neck of children or frail older adults

Airway obstruction is a leading cause of inhospital cardiac arrest, making this step essential. [ACN01883 A...VE 2024 FA | PDF]

B – Breathing

Assess for normal breathing for no more than 10 seconds:

· Look (chest rise)

· Listen (breath sounds)

· Feel (air on your cheek)

Abnormal breathing includes:

· Gasping

· Agonal breaths

· Shallow, inconsistent breaths

If abnormal → begin CPR.

C – Compressions

Start highquality CPR:

· Rate: 100–120/min

· Depth: ≥5 cm in adults

· Ratio: 30 compressions: 2 breaths

· Full recoil between compressions

· Minimal interruption (<5 seconds for rhythm checks)

Rescuer fatigue occurs quickly; change the compressor every 2 minutes. [ACN01883 A...VE 2024 FA | PDF]

D – Defibrillation

Use an AED/SAED/defibrillator as soon as available.

· Attach pads while CPR continues.

· Follow prompts.

· Deliver shock if indicated (VF or pulseless VT).

· Resume CPR immediately without checking for a pulse.

Early defibrillation is the single most effective intervention for shockable rhythms.

ADVANCED LIFE SUPPORT (ALS ALGORITHM)

ALS builds on BLS by adding rhythm recognition, advanced airway, vascular access, and drug therapy. [ACN01883 A...VE 2024 FA | PDF]

1.Rhythm Classification: Shockable vs NonShockable

Shockable Rhythms

· Ventricular Fibrillation (VF): Electrical activity is completely disorganised, preventing any meaningful heart contraction. A defibrillator/monitor shows a chaotic, disorganised, wavy line with no identifiable QRS complexes, no P waves, and no consistent pattern. The baseline looks “scribbly” and erratic.

· Pulseless Ventricular Tachycardia (pVT): There is fast, organised ventricular activity, but it produces no cardiac output. ECG shows a regular, widecomplex tachycardia with a rate typically >100 bpm, and the complexes are broad and repetitive. The patient has no pulse.

Immediate defibrillation.

NonShockable Rhythms

· Asystole: The ECG shows a flat or nearly flat line—no P waves, no QRS complexes, nothing but minimal baseline artifact. There is no electrical activity in the heart.

· Pulseless Electrical Activity (PEA): There is electrical activity that should produce output, but the heart is not pumping effectively. A monitor displays what looks like a normal or nearnormal rhythm, for example, organised narrowcomplex QRS complexes, or even bradycardia—but the patient has no pulse.

Highquality CPR and Adrenaline.

Additional ECG Patterns

Condition	Key ECG Features	Rate	Rhythm	P Wave	PR Interval	QRS Complex	Notes
Atrial Fibrillation (AF)	Irregular baseline, no distinct P waves	Atrial: 350–600 bpm Ventricular: 120–200 bpm	Irregularly irregular	Absent or erratic	Not measurable	Normal	May cause emboli; anticoagulation often needed
Atrial Flutter	Sawtooth P waves	Atrial: 250–400 bpm	Regular or irregular	Sawtooth	Variable	Normal	May need cardioversion or rate control
Ventricular Fibrillation (VF)	Chaotic, irregular waves	Rapid, ineffective	Chaotic	Absent	Absent	Wide, irregular	Medical emergency; CPR & defibrillation required
STEMI	ST elevation in specific leads	Varies	Varies	Present	Normal or prolonged	May be wide	Indicates full-thickness infarction
NSTEMI	ST depression or T wave inversion	Varies	Varies	Present	Normal	Normal	Subendocardial infarction; no ST elevation
1st Degree AV Block	Prolonged PR interval (>0.20s)	Normal	Regular	Present	Prolonged	Normal	Often asymptomatic
2nd Degree AV Block Type I (Mobitz I / Wenckebach)	Progressive PR lengthening then dropped QRS	Atrial: Regular Ventricular: Irregular	Irregular	Present	Progressively longer	Normal	May need atropine or pacing
2nd Degree AV Block Type II (Mobitz II)	Sudden dropped QRS without PR change	Atrial: Regular Ventricular: Irregular	Regular	Present	Constant	Normal or wide	Risk of progression to complete block
3rd Degree AV Block (Complete)	No relation between P and QRS	Atrial: Regular Ventricular: Regular but slow	Independent	Variable	Variable	Normal or wide	Requires pacemaker

2. Drug Timing in ALS

Adrenaline

· Shockable rhythms: after the 2nd shock, then every 2 cycles (~4 min)

· Nonshockable rhythms: immediately, then every 2 cycles

Adrenaline increases coronary and cerebral perfusion pressure via vasoconstriction.

Amiodarone

Amiodarone is the first-line antiarrhythmic recommended when VF or pulseless VT persists after defibrillation attempts.

Dose and Timing

· 300 mg IV/IO → given after the 3rd shock

· 150 mg IV/IO → given after the 5th shock if VF/pVT continues

These doses come from the Advanced Life Support (ALS) cardiac arrest algorithm.

Why Amiodarone

· It stabilises cardiac electrical activity.

· It works by prolonging the action potential and refractory period in cardiac cells, which helps suppress lifethreatening ventricular arrhythmias.

It helps “quiet” the chaotic ventricular activity, so defibrillation has a better chance to work.

Other Drugs (when indicated)

These medications are NOT routine—they are used only when a reversible cause is identified (focused on the Hs & Ts).

Magnesium

· Torsades de Pointes (polymorphic VT due to prolonged QT)

· Magnesium helps stabilise the myocardium and corrects the abnormal repolarisation that drives torsades.

Calcium

· Severe hyperkalaemia

· Calciumchannel blocker overdose

· Calcium works to stabilise cardiac membranes, improving contractility and reducing the risk of fatal arrhythmias.

Sodium Bicarbonate

· Tricyclic antidepressant (TCA) overdose

· lifethreatening metabolic acidosis (not routine)

· It helps reverse sodiumchannel blockade caused by TCAs and corrects severe acidosis.

Glucose

· Hypoglycaemia during cardiac arrest or periarrest states

· The brain requires glucose; critically low glucose can cause unresponsiveness or worsen recovery outcomes.

Drug	Use	Why
Amiodarone	Refractory VF/pVT	Prolongs action potential, stabilises electrical activity
Magnesium	Torsades de Pointes	Corrects abnormal repolarisation in prolonged QT
Calcium	Hyperkalaemia, CCB overdose	Stabilises cardiac membranes
Sodium bicarbonate	TCA overdose	Reverses sodiumchannel blockade; alkalinises blood
Glucose	Hypoglycaemia	Prevents brain injury, restores metabolic function

REVERSIBLE CAUSES (4H & 4T)

These must be corrected for ROSC. [ACN01883 A...VE 2024 FA | PDF]

4 x H

1. Hypoxia

· Cause: airway obstruction, respiratory failure

· Clues: low SpO₂, cyanosis

· Treatment: oxygenation, airway management

2. Hypovolaemia

· Cause: bleeding, fluid loss

· Clues: hypotension, tachycardia, poor cap refill

· Treatment: fluids, blood products, haemorrhage control

3. Hypo/Hyperkalaemia or metabolic

· Clues: ECG changes

· Treatment:

· Hypokalaemia → K⁺ replacement

· Hyperkalaemia → calcium, insulin/glucose, salbutamol

4. Hypothermia

· Clues: cold, slow vitals

· Treatment: rewarming, modified ALS

4 x T

1. Tension Pneumothorax

· Clues: unilateral breath sounds, distended neck veins

· Treatment: needle decompression

2. Tamponade

· Clues: JVD, muffled heart sounds

· Treatment: pericardiocentesis

3. Toxins

· Clues: ingestion history, altered mental state

· Treatment: antidotes, supportive care

4. Thrombosis

· Includes:

· Pulmonary embolism

· Coronary thrombosis

· Treatment: thrombolysis or PCI

SPECIAL CIRCUMSTANCES

1. Trauma

· Prioritise reversible causes: bleeding, airway obstruction, pneumothorax, tamponade

· CPR may be ineffective until the causes are corrected

· Minimal role for Adrenaline initially

2. Cardiac Surgery

· Stacked shocks (up to 3) before starting CPR

· Early re-sternotomy (repeat opening of the sternum) (<10 min): It is performed as an emergency, lifesaving procedure when a patient arrests after cardiac surgery and the cause is thought to be tamponade (blood compressing the heart) or severe bleeding, where external chest compressions are ineffective.

· Avoid Adrenaline due to graft rupture risk

3. Pregnancy

· Manual uterine displacement

· Left uterine tilt

· Consider perimortem Caesarean after 4 min of unsuccessful resus if >24 weeks

4. Hypothermia

· <30°C:

· Max 3 shocks

· Withhold drugs until rewarming

· <35°C:

· Double drug intervals

5. Drowning

· Primary issue: hypoxia

· Emphasise ventilation first

· Early airway management

· Avoid compression-only CPR

Electrical Therapies: Defibrillation, Cardioversion and Pacing

ELECTRICAL THERAPIES

In the OR, electrical therapies happen in a highrisk, hightech, teamdense environment where:

· The patient is often anaesthetised,

· Their chest may be inaccessible due to drapes, positioning, equipment, or sterility,

· There may be metal instruments, fluids, diathermy, and multiple lines in use,

· The anaesthetist is the team leader for resuscitation.

1. DEFIBRILLATION IN THE OPERATING ROOM

The most urgent of all electrical therapies.

Common OR Situations That Require Defibrillation

· VF/pulseless VT during anaesthesia induction (e.g., hypoxia, hyperkalaemia, druginduced arrhythmia).

· Electrolyte shifts (massive transfusion, TURP syndrome, insufflation issues).

· Cardiac arrest during highrisk surgery (cardiac, thoracic, vascular, laparoscopic).

· Local anaesthetic toxicity (LAST) leading to VF/pVT.

ORSpecific Considerations

1. Remove surgical field hazards

Before shocking:

· Surgeon must stop operating immediately.

· Metal instruments must be removed from patient’s chest if possible.

· Diathermy/electrocautery must be turned OFF.

· Wet drapes should be dried if they are contacting staff.

2. Pad placement challenges

Drapes, positioning, and equipment often block standard pad placement.

In the OR, you may need:

· Anterior–posterior placement

· Lateral placement

· Pads placed early during highrisk cases (“prophylactic paddling”)

Many anaesthetists preplace pads on:

· highrisk cardiac patients

· patients receiving regional blocks with potential LAST

· major abdominal/thoracic cases

3. “Hands-off” during chest compressions

Drapes, microscopes, and tables may obstruct access.

Staff must coordinate quickly to make space.

4. Oxygen safety

Remove oxygen-rich drapes from the shock path.

The bag-mask circuit often lies across the chest—this MUST be moved.

2. CARDIOVERSION IN THE OPERATING ROOM

Cardioversion is more common than people realise in the OR.

Why arrhythmias occur in theatre

· Anaesthetic drugs altering conduction

· Hypoxia / hypercarbia

· Surgical stimulation

· Fluid shifts

· Electrolyte abnormalities

· High sympathetic tone during emergence

· Cardiac or thoracic surgery

· Laparoscopy (pneumoperitoneum)

These can trigger:

· Unstable AF

· Unstable SVT

· VT with a pulse

In all of these, synchronised cardioversion may be required.

ORSpecific Considerations

1. The patient is usually already sedated

Unlike in ED or wards, cardioversion in the OR rarely needs additional sedation because:

· The patient is anaesthetised

· The airway is secure

This makes cardioversion faster and safer in theatre.

2. Anaesthetist controls timing with surgical team

Before shocking:

· Surgeon stops

· Diathermy is turned off

· Team steps back

· Circulator announces “CLEAR”

3. ECG tracing must be stable

Surgical movement can distort ECG readings.

If synchronisation markers don’t appear clearly, the shock could desynchronise and become defibrillation, increasing risk of VF.

4. Energy settings tailored to rhythm

Examples:

· SVT → 50–100 J

· AF → 100–200 J

· VT with pulse → 100–150 J

These are typically biphasic in modern OR defibrillators.

3. PACING IN THE OPERATING ROOM

Used when the heart is too slow to maintain perfusion.

Common OR Causes of Bradycardia

· High vagal tone during intubation, peritoneal stretch, or ocular surgery

· Regional blocks (spinal, epidural, interscalene)

· Anaesthetic drugs (propofol, opioids, volatile agents)

· Inferior MI presenting during surgery

· Electrolyte shifts

· Hypoxia

Some can rapidly progress to asystole.

ORSpecific Pacing Considerations

1. Transcutaneous pacing is usually first line

Pads may already be applied pre-emptively for:

· Highrisk cardiac cases

· Severe bradycardia on arrival

· Potential LAST incidents

· Major trauma under anaesthesia

Because the patient is anaesthetised, discomfort is usually a non-issue.

2. Capture is easier to confirm

With:

· Invasive BP lines

· Continuous capnography

· Anaesthetic depth monitors

You can see whether pacing improves perfusion instantly.

3. Transvenous pacing may be required

This is done in OR if:

· The patient is already opened (cardiac surgery)

· Bradyarrhythmia persists despite TCP

· The surgical team has pacing wires ready (e.g., epicardial pacing post-cardiac surgery)

Therapy	OR Trigger	Pulse?	Key Challenges	What You Do
Defibrillation	VF/pVT arrest, drug toxicity, severe electrolyte disturbances	No	Drapes, metal instruments, oxygen, positioning	Stop surgery → clear area → shock immediately
Cardioversion	Unstable AF/SVT/VT during surgery	Yes	ECG artefact, synchronisation issues	SYNC ON → timed shock → coordinate with team
Pacing	Symptomatic bradycardia or complete heart block	Yes (low)	Pad placement under drapes, confirming capture	Set rate & mA → achieve capture → treat reversible causes

Capnography and Other End-Tidal Devices, ABG Interpretation and CPR Pharmacology

1. Capnography & EndTidal CO₂ (ETCO₂)

What it is

Capnography measures the amount of carbon dioxide (CO₂) a patient breathes out at the end of exhalation — this is called EndTidal CO₂ (ETCO₂).

It gives realtime information about:

· Ventilation (movement of air in/out)

· Perfusion (blood flow to the lungs)

· Metabolism (how much CO₂ the body produces)

This makes ETCO₂ a powerful early-warning tool.

Normal ETCO₂

· 35–45 mmHg

Clinical importance

ETCO₂ helps you detect:

· Respiratory depression

· Airway obstruction

· Cardiac arrest quality

· ROSC (Return of Spontaneous Circulation)

· Tube placement (ETCO₂ confirms correct ETT position)

The waveform

The capnogram has 4 phases. Students mainly need to recognise abnormal patterns:

· Shark-fin shape → asthma/COPD/bronchospasm

· ETCO₂ suddenly drops to zero → apnea, cardiac arrest, dislodged tube

· Gradual decline → hypotension, decreased perfusion

· Sudden jump in ETCO₂ → usually ROSC

2. Arterial Blood Gas (ABG) Interpretation

Step-by-step approach

Step 1: Look at pH

· < 7.35 = acidosis

· 7.45 = alkalosis

Step 2: Look at CO₂ (Respiratory)

· High CO₂ = respiratory acidosis

· Low CO₂ = respiratory alkalosis

CO₂ acts like an acid.

Step 3: Look at HCO₃⁻ (Metabolic)

· Low HCO₃⁻ = metabolic acidosis

· High HCO₃⁻ = metabolic alkalosis

Bicarbonate acts like a base.

Step 4: Compensation

· Lungs compensate quickly (minutes)

· Kidneys compensate slowly (hours–days)

What “Compensation” Means in ABGs

Compensation is the body’s attempt to restore normal pH when either the lungs or kidneys are causing an acid–base problem.

· Think of pH as the priority.

· The body will do whatever it can to push pH back toward 7.35–7.45.

There are two systems:

a. Lungs (fast)

· Can change CO₂ levels within minutes.

· CO₂ acts like an acid.

· Breathe faster → blow off CO₂ → pH goes up (more alkaline)

· Breathe slower → retain CO₂ → pH goes down (more acidic)

b. Kidneys (slow)

· Adjust HCO₃⁻ (bicarbonate) over hours to days.

· HCO₃⁻ acts like a base.

· Retain HCO₃⁻ → pH goes up

· Excrete HCO₃⁻ → pH goes down

The Three Levels of Compensation

· Uncompensated “The pH is off, and no one is helping yet.”

The pH is abnormal AND the system that’s supposed to help hasn’t started correcting.

Example: pH 7.25 (acidic)

CO₂ 60 (acidic → respiratory problem)

HCO₃⁻ 24 (normal)

The lungs are causing an acidic problem because CO₂ is building up. The kidneys haven’t stepped in yet to fix it. So, the patient is stuck in pure respiratory acidosis

· Partially Compensated “The pH is still off, but the other system is trying to help.”

The pH is still abnormal BUT the other system is trying to help.

Example: pH 7.30 (still acidic)

CO₂ 60 (acidic)

HCO₃⁻ 30 (alkaline → kidneys trying to help)

The lungs are still keeping too much CO₂ (acid). But now the kidneys notice the problem and start adding extra bicarbonate (base) to fight the excess acid. They are helping, but not enough yet.

So, the pH is better, but still abnormal.

· Fully Compensated “The pH is back to normal because the helper system has done enough.”

The pH is back in the normal range, even though CO₂ or HCO₃⁻ is still abnormal.

Example:  pH 7.38 (normal, but leaning acidic)

CO₂ 60 (acidic)

HCO₃⁻ 34 (alkaline)

The lungs are still holding onto CO₂ (acid), so the respiratory problem is still there. But the kidneys have worked hard and long enough to add enough bicarbonate (base) to neutralise the acid. So even though CO₂ and HCO₃⁻ are both abnormal, the pH looks normal again. This means the body has fully compensated.

You know it’s compensated because:

· pH is normal

· CO₂ and HCO₃⁻ are both abnormal but moving in opposite directions

One is the problem → the other is the compensation.

Status	pH	Problem	The Other System	Example
Uncompensated	Abnormal	Abnormal	Normal	pH 7.25 / CO₂ 60 / HCO₃⁻ 24
Partially Compensated	Abnormal	Abnormal	Abnormal (same direction)	pH 7.30 / CO₂ 60 / HCO₃⁻ 30
Fully Compensated	Normal	Abnormal	Abnormal (opposite direction)	pH 7.38 / CO₂ 60 / HCO₃⁻ 34

3. CPR Pharmacology (ALS Drugs)

These are the medication actions nursing students must know during cardiac arrest.

Adrenaline (epinephrine)

· 1 mg every 3–5 minutes

· Used for: asystole, PEA, and shockable rhythms after 2nd shock

· Purpose: Squeezes blood vessels → improves perfusion to heart & brain during compressions

Amiodarone

· 300 mg after 3rd shock, then 150 mg

· For shockrefractory VF or pulseless VT

· Purpose : stabilises electrical activity

Lidocaine (alternative)

· If amiodarone unavailable

· Also treats VF/pVT

Magnesium Sulphate

· 1–2 g

· Used for Torsades de Pointes

Sodium Bicarbonate

Only indicated for:

· Hyperkalaemia

· TCA overdose

· Severe metabolic acidosis

Not for routine use in arrest.

Calcium (CaCl₂ or Ca gluconate)

Used for:

· Hyperkalaemia

· Hypocalcaemia

· Calcium channel blocker overdose

ACN01883 ACCCN_Adult Manual INTERACTIVE 2024 FA.pdf

Recognizing and Managing Anaesthetic Complications

Emergency (ColorCoded Category)	First 60 Seconds	Anaesthetic Nurse Responsibilities	Scrub Nurse Responsibilities	Scout Nurse Responsibilities	Recovery Nurse Responsibilities
1. AIRWAY EMERGENCIES Difficult intubation, laryngospasm	• Call for help • 100% O₂ • Hand ventilate • Insert OPA/NPA • Suction airway • Clear access to head of bed	Recognise early signs. Prepare airway devices (bougie, VL, LMA, ETTs, cric kit). Apply airway maneuvers (jaw thrust, CPAP). Prep Suxamethonium, propofol, adrenaline, salbutamol. Assist RSI.	Pause surgery. Move Mayo stand. Preserve sterility. Prepare tracheostomy equipment if needed.	Retrieve airway trolley, LMAs, fiberoptic scope. Call airway team. Clear room and head of bed.	Recognise early obstruction. Insert adjuncts. BVM support. Escalate for stridor/no chest rise.
2. HAEMORRHAGE & SHOCK Surgical bleeding, trauma, obstetric hemorrhage	• Call for help • 100% O₂ • Activate MTP • Rapid IV access • IV fluids warm • Identify bleeding source	Recognise shock (↓BP, ↑HR). Start MTP. Prepare rapid infuser/Level 1. Prepare vasopressors. Serial ABGs/Hb.	Communicate blood loss. Pass haemostatic tools quickly. Assist with conversion to open surgery.	Retrieve blood products, warm fluids. Contact blood bank. Call senior staff.	Recognise shock early. Escalate immediately. Prepare return to theatre. Vital signs q2 min.
3. CARDIAC ARREST & ARRHYTHMIAS	• Call Code Blue • Start CPR • Apply defib pads • Ensure airway/ventilation • Identify rhythm	Set up CPR board + defib pads. Prepare adrenaline, amiodarone, atropine. Assist airway. Record drug/rhythm times.	Clear chest area fast. Remove drapes safely. Prepare for emergency thoracotomy.	Call Code Blue. Retrieve crash trolley + pacing kit. Manage crowd/room.	First responder CPR. Apply pads. Assist with airway + drugs.
4. ANAPHYLAXIS Antibiotics, NMBAs,	• 100% O₂ • Adrenaline immediately • Stop trigger • Lay patient flat • Large fluid bolus • Call for help	Recognise: bronchospasm, hypotension, swelling, rash. Give adrenaline + fluids. Prepare salbutamol, antihistamines, steroids.	Stop surgery unless lifesaving. Note swelling. Suction if vomiting.	Bring anaphylaxis kit. Call emergency team. Document LOT numbers.	Monitor for biphasic reaction. High-flow O₂. Support airway/fluids. Prepare adrenaline infusion.
5. MALIGNANT HYPERTHERMIA Volatile agent or Suxamethonium	• Stop volatile • Hyperventilate 100% O₂ • Call MH protocol • Mix dantrolene • Apply cooling	Recognise early signs (↑ETCO₂, rigidity). Stop volatiles. Give dantrolene. Cooling measures. Manage ABG/K⁺.	Maintain sterility. Assist with line insertion. Prepare rapid closure.	Retrieve MH trolley + ice. Call ICU + consultant. Coordinate resupply of cooling equipment.	Continue cooling. Monitor K⁺, CK, creatinine. Strict UO. Prep repeated dantrolene doses + ICU.
6. NEUROLOGICAL EMERGENCIES	• Maintain airway/O₂ • Protect from harm • Call medical review • GCS + pupils • Prepare midazolam	Draw up midazolam/propofol. Support airway. Ventilate to ↓ICP. Prepare mannitol/hypertonic saline.	Notify surgeon of swelling. Prepare craniotomy tools. Provide suction/diathermy.	Retrieve seizure kit + neuromonitoring. Call neurosurgery. Prep OR for emergency conversion.	Monitor GCS/pupils. Protect patient. Escalate decreased LOC.
7. LOCAL ANAESTHETIC SYSTEMIC TOXICITY (LAST)	• Stop LA immediately • Prepare lipid rescue • Support airway • Treat seizures early • Call for help	Recognise early signs. Start lipid infusion. Prepare anti-seizure meds. Manage airway/ventilation.	Stop LA administration. Preserve sterility. Communicate dose/volume used.	Bring lipid rescue kit. Call emergency team. Retrieves defib/airway kit.	Monitor for arrhythmias/seizures. Support airway. Prepare ICU transfer.

Death in the Operating Room

DEATH IN THE OPERATING ROOM

When a patient dies in the operating room, it is never treated like a standard ward death.

It is automatically considered a reportable death because it occurred during a medical procedure that was not reasonably expected to result in death [coronersco...qld.gov.au]. This activates legal, clinical, procedural, and governance obligations that all perioperative staff must follow with absolute precision.

ANAESTHETIC & RECOVERY NURSE RESPONSIBILITIES

The anaesthetic nurse is the custodian of the patient's airway, ventilation, physiological monitoring, drug administration, and documentation. During an intraoperative death, their role becomes central because they hold all realtime information about the patient's physiological status before and during the arrest.

A. Confirming Cessation of Life (Supporting the Anaesthetist)

Although the medical practitioner declares death, the anaesthetic nurse must:

1. Assist with final physiological assessment

· Confirm absence of cardiac activity on the monitor

· Confirm no spontaneous respirations once ventilation is ceased

· Assist with auscultation if requested

· Relay final drug doses, fluids, and interventions

2. Do NOT turn off or clear monitoring equipment

This is critical because:

· The coroner may require the data

· It forms part of the medical record, legally protected under hospital governance guidelines [catalogue.nla.gov.au]

The anaesthetic nurse should save all data, print rhythm strips, and keep equipment as-is until authorized.

B. Airway & Line Preservation (Coronial Requirement)

Coronial law requires that all tubes and lines remain in situ because removing them may compromise forensic evidence or hinder the determination of the cause of death.

[coronersco...qld.gov.au]

The anaesthetic nurse must therefore ensure:

Tubes & Lines to Keep in Situ

· Endotracheal tube

· Laryngeal mask (if present)

· IV cannulas (capped but not removed)

· Central lines

· Arterial lines

· Urinary catheter (spigotted)

· Temperature probes, oesophageal probes

· NG/OG tubes

· Pacing wires

You must not remove, cut, or adjust these devices except to cap or secure them.

C. Documentation (Extensive Detail Required)

The anaesthetic nurse completes critical documentation, including:

1. Anaesthetic Record

· Induction time

· All drugs: dose, route, time

· All infusions and blood products

· Ventilation parameters

· Airway events

· Interpretation of physiological trends

· Arrest timeline and interventions

2. Observation charts and machine logs

Coroner's guidelines require accurate clinical data.

The WA Review of Death guidelines emphasize retention of all relevant documentation and strict governance of records. [catalogue.nla.gov.au]

D. Notifications & Escalations

The anaesthetic nurse must ensure:

· Nurse in Charge / NUM notified immediately

· After-hours supervisor notified (if applicable)

· The Bed Manager informed

· Patient Safety / Quality Unit alerted if required by the hospital

Hospitals legally require this because healthcarerelated deaths must undergo governance review. [catalogue.nla.gov.au]

E. Family Support Role

While the doctor is responsible for informing the family, the anaesthetic nurse often:

· Provides compassionate presence

· Assists family viewing if allowed

· Coordinates with social work/pastoral care

· Ensures cultural and spiritual considerations are followed

Note:

Do not wash, remove devices, or prepare the body unless instructed and permitted by coronial legislation.

F. Handover for Body Transfer

· Cover body respectfully

· Maintain the airway tube in the neutral position

· Ensure all equipment remains intact

· Assist in safe transfer to the mortuary gurney

· Ensure the body is labelled according to protocol & coroner requirements

SCRUB/SCOUT NURSE RESPONSIBILITIES

The scrub/scout nurse plays a different but equally essential role, focusing on environment, sterile field, equipment preservation, documentation, and evidentiary integrity.

ACORN standards expect that scrub/scout nurses maintain environmental control, equipment traceability, and accurate documentation throughout perioperative care.

Their role description reinforces responsibility for instruments, counts, and continuity of sterile practice. [coroners.nsw.gov.au] [ACN01883 A...024 FA.pdf | PDF]

A. Ceasing the Procedure & Maintaining the Sterile Field

When death is declared:

· The scrub nurse must stop the instrumental activity immediately

· Instruments must remain on the sterile field

· NOTHING should be packed into the body

· Wound should be covered with a waterproof dressing only

· (Your provided guidelines emphasize this)

Why:

The surgical field becomes a potential forensic site. Removing anything may violate coronial requirements.

B. Instrument & Count Management

Contrary to standard case closure:

· Do not perform normal pack counts

· Do not remove instruments

· Do not send specimens unless specifically directed

Instead, the scrub/scout nurse must:

· Ensure the final count is documented cognitively (not performed physically)

· Keep the tray intact

These items may be inspected if the coroner suspects retained items or procedural issues.

C. Preservation of the Operative Environment (Evidence)

Scrub/scout nurses must ensure:

· Used instruments remain precisely as they were

· Surgical implants or devices used (e.g., diathermy, staplers) remain available

· The sterility of the field is maintained until it is cleared

· All packaging and opened materials remain on site

This aligns with coroner investigative processes for hospital deaths.

[health.wa.gov.au]

D. Documentation

Scrub/scout nurses must DOCUMENT:

· Time of events

· Instruments opened

· Implants used

· Specimens collected

· Any equipment malfunctions

· Any unexpected events during the procedure

Documentation must be objective and factual.

Per clinical governance guidelines, documentation becomes part of the legal record for coronial review.

[catalogue.nla.gov.au]

E. Communication & Coordination

The scrub/scout nurse ensures:

· Theatre NUM notified

· Theatre list coordinator informed

· Mortuary contact is initiated according to protocol

· "Death in OR Box" is retrieved (forms, checklists, coronial kit)

Because perioperative teams must meet national standards of safe, coordinated care, ACORN emphasises clear communication and structured teamwork [coroners.nsw.gov.au]

F. Respectful Care of the Deceased

Scrub/scout nurses:

· Clean the external body only if permitted

· Apply a fresh sterile dressing

· Cover the patient respectfully

· Remove extraneous blood from drapes if allowed

· Ensure dignity is preserved

If death is coronial:

· Do not reposition body parts not required for dignity

· Maintain natural body posture to preserve evidence

CORONIAL REPORTING: SHARED RESPONSIBILITY

Under Australian coroner legislation, a death must be reported if it:

· Occurred during a healthcare procedure not expected to result in death

· Occurred in unusual or suspicious circumstances

· Occurred while under mental health involuntary treatment

· [coronersco...qld.gov.au]

Both nursing roles support medical staff in:

· Preserving evidence

· Completing clinical documentation

· Filing internal incident reports

· Following statutory requirements

HOSPITAL GOVERNANCE OBLIGATIONS

Hospitals must:

· Conduct a clinical incident review (mandatory)

· Conduct a mortality review under governance frameworks

· Ensure documentation integrity

· Report to the coroner based on strict criteria

· [catalogue.nla.gov.au]

Nurses must follow:

· Local "Death in OR" protocols

· NSQHS governance requirements (supported by ACORN standards)

· [coroners.nsw.gov.au]

THE "DEATH IN OR BOX": CRITICAL FOR BOTH ROLES

Typically includes:

· OR-specific death protocol

· Coronial death form

· Body tag and mortuary transfer documentation

· Checklist for maintaining lines/tubes

· Communication tree

· Pastoral care/cultural liaison contacts

Both the anaesthetic and scrub/scout nurse must know:

· Where it is stored

· How to use its contents quickly

Comparison Table: Roles in an OR Death

Category	Anaesthetic / Recovery Nurse Responsibilities	Scrub / Scout Nurse Responsibilities
Immediate Clinical Response	• Assist anaesthetist with verification of absence of vital signs. • Continue or cease resuscitation as directed. • Manage airway, ventilation equipment, monitoring devices. • Document anaesthetic monitoring trends preceding death.	• Maintain sterile field if resuscitation began during surgery (until instructed otherwise). • Assist surgeons with equipment needed for resuscitation. • Secure and account for all instruments, sharps, and swabs.
Confirmation of Death	• Support anaesthetist (who often leads death verification in theatre). • Record exact time lifesustaining measures stop.	• Record final instrument count and ensure no retained items (even in a death situation).
Communication	• Notify perioperative manager and assist anaesthetist in communicating to family (depending on hospital policy). • Liaise with recovery area to cancel bed/prepare for deceased transfer.	• Notify and coordinate with surgeons and circulating staff. • Communicate equipment-related issues that may need documenting for incident review.
Documentation	• Complete anaesthetic record with detailed timeline: vitals, interventions, drugs, events leading to death. • Document cessation of resuscitation. • Contribute to clinical incident reporting.	• Complete intraoperative nurse’s notes (swab/instrument counts, events during surgery). • Document equipment issues, intraoperative complications, and team actions. • Assist with incident reporting from the surgical team’s perspective.
Handling the Body	• Remove or keep devices as instructed (e.g., lines, tubes left in situ if coroner involved). • Assist with respectful preparation for transfer.	• Ensure surgical site is left intact (no closure or removal of devices if coroner’s case). • Help maintain dignity and prepare patient for transfer to mortuary.
Legal/Coronial Requirements	• Ensure anaesthetic chart accuracy for coronial review. • Support completion of coroner-required observations regarding anaesthesia, medications, and airway management.	• Ensure surgical count documentation is complete (critical in coronial cases). • Provide detailed account of intraoperative sequence of events relevant to surgery.
Family Support	• May provide preliminary support if policies allow, usually alongside anaesthetist.	• Usually, no direct role with families unless part of broader perioperative team communication.

Coroner Documentation Process (Australiafocused but applicable internationally)

In many countries (including all Australian states/territories), a coroner must be notified when a death occurs in a theatre, especially if:

· It was unexpected or unexplained

· Related to anaesthetic complications

· Occurred during, immediately after, or due to a medical procedure

· Involved trauma or negligence concerns

1. Immediate Notification

· The senior surgeon or anaesthetist notifies:

· The coroner (usually through a mandated hospital process)

· Hospital executive/manager

· Police (depending on jurisdiction)

· Nurses assist by preparing accurate documentation to accompany the report.

2. Preservation of Evidence

Coronial rules require that nothing be removed from the patient unless permitted:

· Lines, drains, tubes, ETT, and catheters stay in place

· All dressings, wounds, and surgical sites remain untouched

· The anaesthetic and surgical equipment used may be sequestered for examination

Nurses play a key role in ensuring this is adhered to.

3. Completion of Documentation

Nurses must ensure:

Anaesthetic Nurse Documentation

· Full anaesthetic record: monitoring values, interventions, drugs, timing.

· Timeline accurate to minutes or seconds.

· Copies of:

· Medication sheets

· Airway management notes

· Resuscitation documentation

Scrub/Scout Nurse Documentation

· Instrument/sponge/sharp counts.

· Equipment issues or faults.

· Intraoperative notes, including:

· Complications

· Sequence of events

· Staff present and timing of role changes

4. Incident Reporting

A clinical incident report (e.g., via RiskMan/SafetyLearning/Safety1st) is completed by relevant nursing staff.

5. Transfer to Mortuary

· The body is transferred with all lines and devices in situ.

· Accompanied by:

· Identification paperwork

· Coroner notification forms

· Relevant clinical documentation packages

· Nurses ensure the body is handled respectfully.

6. Coroner Investigation

May include:

· Review of charts, equipment, and medications.

· Staff statements (including nurses).

· Post-mortem examination.

· Timeline reconstruction.

Nurses must provide a factual, objective statement if requested.

References

References:

Phillips, N., & Hornacky, A. (2020).  Berry & Kohn's Operating Room Technique (14th ed.). Elsevier.

Rothrock, J. C. (2022).  Alexander's Care of the Patient in Surgery (17th ed.). Elsevier.

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780702076428000263#hl0001052

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780443105234000249#hl0002368

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780729544412000251#hl0004948

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780729544467000358#hl0001587

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323810340000593#hl0001501

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https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780443105234000432#hl0000563

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323776806000236#hl0000578

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323776806000261#hl0001383

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323776714000218#hl0003059

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323776806000285#hl0001235

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780443105234000432#hl0000563

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323776806000236#hl0000578

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323776806000261#hl0001383

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323776714000218#hl0003059

MODULE 3

Complications and Emergency Management in Anaesthesia

Anaesthetic Complications and Emergency Management

Respiratory Complications:

Airway Injuries

Lips, Tongue, and Gums: Injuries can occur during intubation, especially in patients with difficult airways. Which can lead to bleeding, swelling, and pain postoperatively.

· Emergency Management:

· Look for signs of bleeding, swelling, and airway obstruction.

· Secure the airway, provide suction, and administer anti-inflammatory medications if needed.

Teeth: Loose teeth can be dislodged and aspirated, potentially causing airway obstruction

· Emergency Management:

· Identify missing or loose teeth during preoperative assessment.

· Remove loose teeth if possible and use a bite block to protect teeth during intubation.

Glottic Structures : Damage to the vocal cords, epiglottis, and surrounding cartilage during intubation can result in hoarseness, stridor, or even airway obstruction

· Emergency Management:

· Monitor for hoarseness, stridor, and difficulty breathing.

· Administer humidified oxygen steroids and consider reintubation if airway obstruction is severe.

Bronchospasm/Laryngospasm

Bronchospasm: Constriction of the bronchi, often in patients with reactive airways, leading to hypoxia. It can be triggered by airway manipulation, aspiration, or allergic reactions.

· Emergency Management:

· Wheezing, increased airway pressures, and desaturation.

· Administer bronchodilators (e.g., salbutamol), steroids, and deepen anaesthesia. Consider using magnesium sulfate for severe cases.

Laryngospasm: Involuntary spasm of the vocal cords, causing airway obstruction. This is more common in children and can be triggered by secretions, blood, or stimulation of the larynx.

· Emergency Management:

· Stridor, paradoxical chest movements, and desaturation.

· Remove the stimulus, apply 100% oxygen, provide positive pressure ventilation, and administer a muscle relaxant like suxamethonium if necessary.

Aspiration

Gastric Contents: Inhalation of stomach contents into the lungs can lead to chemical pneumonitis or aspiration pneumonia. This is particularly risky in non-fasted, pregnant, or obese patients.

· Emergency Management:

· Sudden desaturation, coughing, and wheezing.

· Suction the airway, provide 100% oxygen, and consider bronchoscopy if large particles are aspirated. Administer antibiotics if infection is suspected.

Pulmonary Complications

Pneumothorax: Air in the pleural space, potentially from barotrauma due to high ventilation pressures.

· Emergency Management:

· Decreased breath sounds, hypotension, and hypoxia.

· Perform needle decompression or chest tube insertion.

Pulmonary Edema: Fluid accumulation in the lungs, often due to heart failure, fluid overload, or negative pressure pulmonary edema from laryngospasm.

· Emergency Management:

· Crackles, pink frothy sputum, and hypoxia.

· Provide diuretics, oxygen, and positive pressure ventilation.

Pulmonary Embolism: Blood clots in the pulmonary arteries can be life-threatening.

· Emergency Management:

· Sudden onset of dyspnea, chest pain, and hypoxia.

· Administer anticoagulants and consider thrombolysis.

Cardiovascular Complications

Hypotension: Blood loss, vasodilation from anesthetic agents, or myocardial depression. It can lead to inadequate perfusion of vital organs.

· Emergency Management:

· Low blood pressure readings, tachycardia, and signs of poor perfusion.

· Administer fluids, vasopressors (e.g., phenylephrine, ephedrine), and inotropes (e.g., dopamine, dobutamine) to maintain adequate blood pressure and perfusion.

Hypertension:

Pain, inadequate anaesthesia, or pre-existing hypertension. It can increase the risk of bleeding and myocardial ischemia.

Adjusting anesthetic depth, providing analgesics, and administering antihypertensive medications.

· Emergency Management:

· Elevated blood pressure readings, signs of end-organ damage (e.g., chest pain, headache).

· Administer antihypertensive medications (e.g., beta-blockers, calcium channel blockers), adjust anesthetic depth, and provide analgesics.

Arrhythmias:

Types: Bradycardia (slow heart rate), tachycardia (fast heart rate), and other irregular heart rhythms.

Causes: Electrolyte imbalances, hypoxia, or direct effects of anesthetic drugs. These can compromise cardiac output and perfusion.

· Emergency Management:

· Irregular heart rhythms on ECG, hemodynamic instability.

· Identify and treat underlying causes (e.g., electrolyte imbalances, hypoxia), use antiarrhythmic drugs (e.g., amiodarone, lidocaine), and consider electrical cardioversion for unstable arrhythmias.

Neurological Complications

Postoperative Cognitive Dysfunction (POCD)

· Memory loss, confusion, and cognitive decline are more common in elderly patients. It can affect daily functioning and quality of life. It can be temporary or long-lasting, with some patients experiencing symptoms for months.

· Emergency Management:

· Cognitive changes, memory loss, confusion.

· Provide supportive care, optimize the postoperative environment, and consider neuropsychological evaluation.

Peripheral Nerve Injuries

· Improper positioning during surgery leads to nerve compression or stretch. This can result in sensory and motor deficits.

· The ulnar nerve (elbow), brachial plexus (shoulder), and peroneal nerve (knee) are commonly affected.

· Emergency Management:

· Sensory and motor deficits in the affected area.

· Reposition the patient, provide physical therapy, and consider nerve conduction studies.

Gastrointestinal Complications

Postoperative Nausea and Vomiting (PONV):

Female gender, non-smoker, history of motion sickness or PONV. It can lead to dehydration, electrolyte imbalances, and delayed recovery.

· Emergency Management:

· Nausea, vomiting, and dehydration.

· Administer antiemetics (e.g., ondansetron, dexamethasone), provide hydration, and minimize opioid use.

Ileus:

Abdominal distension, pain, and absence of bowel movements. It can prolong hospital stays and increase the risk of complications.

· Emergency Management:

· Abdominal distension, pain, and absence of bowel sounds.

· Insert a nasogastric tube for decompression, provide fluids, and encourage early mobilization.

Genitourinary Complications

Acute Kidney Injury (AKI):

Hypotension, nephrotoxic drugs, or pre-existing renal disease. It can lead to fluid and electrolyte imbalances and the need for dialysis.

· Emergency Management:

· Decreased urine output, elevated creatinine, and electrolyte imbalances.

· Optimize hemodynamics, avoid nephrotoxic drugs, and consider renal replacement therapy if necessary.

Urinary Retention:

Older age, male gender, and certain medications. It can cause discomfort, bladder distension, and urinary tract infections.

· Emergency Management:

· Inability to void, bladder distension.

· Perform bladder catheterization and monitor urine output.

Hypothermia

Exposure to a cold operating room environment and infusion of cold fluids.

Recognition:

· Shivering, cold skin, bradycardia, hypotension, altered mental status, and decreased urine output.

· Continuous core temperature monitoring using esophageal, bladder, or rectal probes.

Initial Interventions:

· Active Warming: Use forced-air warming blankets, warmed intravenous fluids, and heated humidification for respiratory gases.

· Passive Warming: Cover the patient with blankets and increase the ambient temperature of the operating room.

Advanced Interventions:

· Warm Fluids: Administer warmed intravenous fluids (37-40°C) to prevent further heat loss.

· Respiratory Warming: Use heated humidification for ventilated patients or a high-flow nasal cannula with warmed, humidified oxygen.

Understanding these complications and their management is crucial for ensuring patient safety during anesthesia. 

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780702076428000263#hl0001052 Maternal Collapse -Introduction and next section

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780443105234000249#hl0002368 Local and regional Anaesthesia Complications - up to and including Treatment of Adverse Reactions

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780729544412000251#hl0004948 Local Anaesthetic System Toxicity (LAST)

Reflection Questions: (Note that reflective learning activities are not compulsory but will improve your understanding of the subject).

1. How can I improve my preoperative assessment to better identify patients at risk for anaesthetic complications?

2. What strategies can I implement to enhance my recognition and prompt management of respiratory and cardiovascular emergencies during anaesthesia?

3. How effective are my current protocols for preventing and managing postoperative cognitive dysfunction and peripheral nerve injuries?

4. What measures can I take to minimize the risk of hypothermia and its associated complications during surgery?

5. How can I optimize my use of monitoring and supportive care to improve patient outcomes in the event of anaesthetic emergencies?

Recognizing and Responding to Acute Deterioration Adverse Effects and Anaphylaxis in the Recovery Unit

Recognising and Responding to Acute Deterioration, Adverse Reactions, and Anaphylaxis in the PACU

The PostAnaesthesia Care Unit (PACU) is a highrisk clinical environment. Patients are emerging from anaesthesia, physiologically unstable, and vulnerable to acute deterioration, adverse drug reactions (ADRs), and lifethreatening anaphylaxis. Nurses are often the first clinicians to recognise subtle changes; your vigilance is critical.

This section integrates your content on ADRs, reaction classifications, and PACU emergency response, linking them to NSQHS Standard 9: Recognising and Responding to Acute Deterioration.

1. Understanding Adverse Drug Reactions (ADRs)

Definition

An Adverse Drug Reaction (ADR) is an unintentional, harmful, or undesirable effect experienced at normal therapeutic doses.

They threaten patient safety and may lead to acute deterioration if not recognised early.

Clinical importance in the PACU

· Patients are exposed to multiple medications:

· anaesthetics, analgesics, sedatives, antiemetics, antibiotics, neuromuscular blockers.

· Physiological instability makes ADRs more dangerous.

· Nurses observe patients continuously, early recognition prevents escalation.

Example

A patient on ceftriaxone develops a rash and facial swelling within 24 hours. The nurse recognises this as a possible allergic reaction and escalates care, preventing progression into anaphylaxis.

2. Classification of ADRs and Their Relevance in PACU Emergencies

Understanding ADR categories helps nurses anticipate, recognise, and respond effectively.

Type A Reactions – “Augmented”

Predictable, doserelated, common.

Examples relevant in PACU:

· Opioids → respiratory depression

· Propofol → hypotension

· Gentamicin accumulation → nephrotoxicity (postop patients with renal impairment)

Mechanism: Drug accumulates, interacts with another drug, or the patient has increased sensitivity.

Type B Reactions – “Bizarre”

Unpredictable, not doserelated, often immunemediated.

These are most linked to acute emergencies such as anaphylaxis.

Examples:

· Penicillin → anaphylaxis

· Primaquine → haemolysis in G6PD deficiency

· Chloramphenicol → bone marrow suppression

Type C, D, and E Reactions

Less common in PACU but important for broader patient safety.

· Type C (Chronic): Longterm steroid use → adrenal suppression

· Type D (Delayed): Chemotherapy → secondary cancers

· Type E (Endofuse): Withdrawal from benzodiazepines → seizures

While PACU nurses rarely encounter these directly, understanding them helps with handover, medication reconciliation, and postoperative education.

3. Allergic Reactions and Anaphylaxis

Spectrum of allergic responses:

· Mild → rash, itching

· Moderate → angioedema, wheeze

· Severe → anaphylaxis

Anaphylaxis Characteristics

· Rapid onset (minutes)

· Triggers: IV antibiotics, neuromuscular blockers, latex, chlorhexidine, contrast

· Symptoms:

· Hives, rash

· Facial/lip swelling

· Stridor, bronchospasm

· Hypotension

· Cardiovascular collapse

Emergency Management

· Immediate adrenaline (IM or IV depending on severity)

· Highflow oxygen

· IV fluids

· Antihistamines & corticosteroids (after adrenaline)

· Prepare for airway management

· Call MET / Code Blue

· Document & report (ADR alert, allergy bands)

Anaphylaxis represents a Type B ADR and is one of the most dangerous emergencies in the PACU.

4. Contributing Factors to ADRs and Acute Deterioration

Genetic factors

Influence drug metabolism and immune responses:

· G6PD deficiency → haemolysis

· Genetic enzyme variations → altered drug metabolism

Host factors

· Age (elderly, paediatrics)

· Renal or liver impairment

· Sepsis

· Medical comorbidities

Environmental factors

· Fooddrug interactions

· Grapefruit juice → increased drug levels

· Vitamin K foods → warfarin interaction

5. Recognising Acute Deterioration in the PACU (NSQHS Standard 9)

To prevent preventable deaths, nurses must identify early warning signs through:

A. Vital Signs Monitoring

Frequent assessment of:

· Heart rate and rhythm

· Blood pressure

· Respiratory rate

· Oxygen saturation

· Temperature

· Pain

· Level of consciousness (AVPU or GCS)

B. Clinical Signs

· Respiratory distress

· Cyanosis

· Reduced urine output

· Delirium or agitation

· Hypotension or hypertension

· New-onset arrhythmias

· Skin changes (rash, flushing, swelling)

C. Use of Technology

· ECG monitoring

· Pulse oximetry

· Capnography

· MEWS (Modified Early Warning Score)

6. Responding to Acute Deterioration

Escalation Protocols

· Activate MET or Rapid Response

· Use SBAR to communicate

· Document all assessments and interventions

· Follow facility-specific NSQHS Standard 9 guidelines

Immediate Interventions

· Oxygen therapy

· IV fluids

· Medication reversal agents (naloxone, flumazenil)

· Treat underlying cause (e.g., bronchodilators, antiarrhythmics)

Advanced Interventions

· Defibrillation

· Intubation

· Critical care transfer

7. Bringing It All Together: ADRs, Anaphylaxis, and Acute Deterioration

In the PACU, deterioration often results from:

A. ADRs

· Opioid respiratory depression

· Hypotension from anaesthetic agents

· Oversedation from benzodiazepines

B. Allergic Reactions & Anaphylaxis

· Rapid progression → airway obstruction, hypotension, collapse

C. Surgeryrelated complications

· Bleeding

· Shock

· Sepsis

· Cardiovascular instability

Nurses must be able to link the symptom, cause, and correct response quickly to prevent irreversible harm.

8. Why Recognition Matters

Timely identification prevents:

· Respiratory arrest

· Cardiac arrest

· Organ failure

· Longterm disability

· Death

Early action improves:

· Recovery

· Safety

· Patient outcomes

· Team efficiency

· Compliance with NSQHS standards

Recognizing and responding to acute deterioration, Adverse effects and Anaphylaxis in the PACU

The table below, summarize how to recognize and respond to acute deterioration, adverse effects, and anaphylaxis according to the NSQHS standard 9. Please familiarize yourself with the protocols and standards in your facility on acute deterioration, adverse effects and anaphylaxis. We make use of the MEWS (Modified Early Warning Score.

Category	Recognizing	Responding
Acute Deterioration	· Monitoring Vital Signs: Monitor heart rate & rhythm, blood pressure, respiratory rate, oxygen saturation, and temperature. · Clinical Signs: Look for respiratory distress, altered mental status, and changes in urine output. · Using Technology: Utilize monitoring equipment like ECGs, pulse oximeters, and capnography.	· Escalation Protocols: Follow established protocols, know the chain of command. · Rapid Response Teams: Activate RRT or MET when necessary. · Communication: Use SBAR for clear communication. · Interventions: Administer appropriate interventions like oxygen therapy, fluid resuscitation, or medications. · Documentation: Document all observations and interventions accurately.
Adverse Effects	· Monitoring Vital Signs: Continuously monitor heart rate, blood pressure, respiratory rate, oxygen saturation, and temperature. · Observing Clinical Signs: Look for respiratory distress, changes in mental status, and signs of pain or discomfort. · Using Technology: Utilize monitoring equipment like ECGs, pulse oximeters, and capnography.	· Immediate Interventions: Administer oxygen, provide medications for pain or nausea. · Escalation Protocols: Follow established protocols, notify senior staff. · Advanced Interventions: Be prepared for intubation or defibrillation. · Communication: Use SBAR for clear communication. · Documentation: Document all observations and interventions accurately.
Anaphylaxis	· Monitoring Vital Signs: Look for hypotension, tachycardia, and increased respiratory rate. · Observing Clinical Signs: Look for hives, itching, swelling, shortness of breath, wheezing, nausea, vomiting, dizziness. · Using Technology: Utilize pulse oximeters and capnography.	· Immediate Interventions: Administer epinephrine, position patient supine with legs elevated. · Supportive Measures: Administer high-flow oxygen, establish IV access. · Advanced Interventions: Administer antihistamines, corticosteroids, prepare for advanced airway management. · Escalation Protocols: Activate rapid response team, continuously monitor patient. · Communication: Use SBAR for clear communication. · Documentation: Document all observations and interventions accurately.

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780729544511000798?origin=share&title=Lewis%E2%80%99s%20Medical-Surgical%20Nursing%206th%20Australia%20and%20New%20Zealand%20edition&meta=2024%2C%20Hambrecht%2C%20Ken&img=https%3A%2F%2Fcdn.clinicalkey.com%2Fck-thumbnails%2FC20210023981%2Fcov200h.gif

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780729544757000250#hl0002347

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323936255000029#hl0001018

https://www.allergy.org.au/images/ASCIA_HP_Guidelines_Acute_Management_Anaphylaxis_2024.pdf

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323091145000268#hl0004102

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323793155000317#hl0000562

Reflection Questions: (Note that reflective learning activities are not compulsory but will improve your understanding of the subject).

Acute Deterioration:

· How do I ensure that I am consistently monitoring vital signs and clinical indicators to detect early signs of acute deterioration in my patients?

· Can I recall a recent situation where I had to escalate care for a deteriorating patient? What steps did I take, and what could I have done differently to improve the outcome?

Adverse Effects:

· What protocols do I follow to identify and manage adverse effects in the anaesthetic and recovery setting? How confident am I in my ability to implement these protocols effectively?

· Reflect on a time when a patient experienced an adverse effect under your care. How did you respond, and what did you learn from that experience that could enhance your future practice?

Anaphylaxis:

· How prepared am I to recognize the signs and symptoms of anaphylaxis quickly? What steps do I take to ensure I am ready to administer immediate interventions, such as epinephrine

Managing Complex Cases and Anaesthetic Emergencies

Managing Complex Surgical Cases

No matter how small, every surgery deserves our full attention and care to keep our patients safe and well. We cannot afford to slack off, even with routine procedures. I remember a colleague telling me about a routine appendectomy that suddenly got complicated because of an unexpected twist in the anatomy. Their quick thinking and vigilance made all the difference in keeping the patient safe.

Certain surgical cases, for example, cardiac, thoracic, paediatric, pregnancy-related, trauma, etc., come with higher risks and complexities. These need advanced monitoring, specialized approaches, careful observation, and tailored care. We can ensure our patients get the best outcomes by staying sharp and prepared.

Type of Surgery	Examples	Anesthetic Considerations	Emergency Management	Pain Control	Anesthetic Approach	Risks Involved
Cardiac	- Coronary Artery Bypass Grafting (CABG) - Valve Replacement - Heart Transplant	- Preoperative assessment of cardiac function and comorbidities - Use of general anesthesia with advanced monitoring (e.g., TOE (Transoesophageal Echocardiogram), arterial lines) - Hemodynamic stability	- Immediate access to cardiopulmonary bypass - Management of arrhythmias and cardiac arrest - Rapid blood transfusion protocols	- Multimodal analgesia - Regional techniques (e.g., thoracic epidural) - Opioids and NSAIDs	- General Anesthesia - Regional Anesthesia (e.g., thoracic epidural)	- Bleeding - Infection - Stroke - Heart attack - Arrhythmias - Organ damage
Thoracic	- Lobectomy - Pneumonectomy - Esophagectomy	- Airway management for one-lung ventilation - Monitoring of pulmonary function - Use of general anesthesia with possible regional blocks	- Management of pneumothorax and bleeding - Rapid re-expansion of collapsed lung - Emergency thoracotomy if needed	- Epidural analgesia - Intercostal nerve blocks - Opioids and NSAIDs	- General Anesthesia - Regional Anesthesia (e.g., epidural, intercostal nerve blocks)	- Bleeding - Infection - Lung collapse - Blood clots - Respiratory complications
Neurosurgical	- Craniotomy - Spinal Fusion - Aneurysm Clipping	- Monitoring of intracranial pressure - Use of general anesthesia with neurophysiological monitoring - Management of brain swelling	- Management of intracranial hemorrhage - Rapid control of seizures - Emergency craniotomy if needed	- Scalp nerve blocks - Opioids and acetaminophen - NSAIDs (if not contraindicated)	- General Anesthesia - Regional Anesthesia (e.g., scalp nerve blocks)	- Infection - Bleeding - Blood clots - Neurological damage - Seizures - Stroke
Transplant	- Kidney Transplant - Liver Transplant - Lung Transplant	- Preoperative optimization of organ function - Use of general anesthesia with invasive monitoring - Immunosuppressive considerations	- Management of graft rejection - Rapid control of bleeding - Immediate postoperative ICU care	- Epidural analgesia - Opioids and acetaminophen - NSAIDs	- General Anesthesia - Regional Anesthesia (e.g., epidural)	- Organ rejection - Infection - Bleeding - Blood clots - Organ failure
Paediatric	- Congenital Heart Defect Repair - Gastroschisis Repair - Tumor Resection	- Tailored anesthetic approach based on age and weight - Use of general anesthesia with careful dosing - Monitoring of fluid and electrolyte balance	- Management of congenital anomalies - Rapid control of airway emergencies - Immediate access to pediatric ICU	- Regional techniques (e.g., caudal blocks) - Opioids and acetaminophen - NSAIDs	- General Anesthesia - Regional Anesthesia (e.g., caudal blocks)	- Infection - Bleeding - Anesthesia complications - Respiratory issues - Delayed recovery
Pregnant Women	- Caesarean Section - Placenta Accreta Surgery - EXIT Procedure (Ex Utero Intrapartum Treatment)	- Avoidance of teratogenic drugs - Use of regional anesthesia when possible - Monitoring of fetal well-being	- Management of obstetric emergencies (e.g., hemorrhage) - Rapid control of preeclampsia - Immediate access to neonatal care	- Epidural analgesia - Opioids and acetaminophen - NSAIDs (if safe for pregnancy)	- Regional Anesthesia (e.g., epidural) - General Anesthesia (if necessary)	- Preterm delivery - Infection - Bleeding - Anesthesia complications - Fetal distress
Patients with Multiple Comorbidities	- Major Abdominal Surgery - Orthopedic Surgery - Vascular Surgery	- Comprehensive preoperative assessment - Use of general anesthesia with careful monitoring - Management of drug interactions	- Management of exacerbation of comorbid conditions - Rapid control of bleeding and infection - Immediate postoperative ICU care	- Multimodal analgesia - Regional techniques - Opioids and NSAIDs	- General Anesthesia - Regional Anesthesia (depending on surgery)	- Infection - Bleeding - Organ failure - Anesthesia complications - Prolonged recovery
Substance Abuse Patients	- Elective Spine Surgery - Orthopedic Surgery - Abdominal Surgery	- Management of altered drug metabolism - Use of general anesthesia with careful dosing - Monitoring for withdrawal symptoms	- Management of acute withdrawal - Rapid control of overdose symptoms - Immediate access to ICU care	- Multimodal analgesia - Regional techniques - Opioids (with caution) and NSAIDs	- General Anesthesia - Regional Anesthesia (if feasible)	- Increased bleeding - Infection - Respiratory complications - Withdrawal symptoms - Relapse risk
Trauma Patients	- Exploratory Laparotomy - Damage Control Surgery - Thoracotomy	- Rapid assessment and stabilization - Use of general anesthesia with invasive monitoring - Management of airway and bleeding	- Management of hemorrhagic shock - Rapid control of airway and breathing - Immediate access to trauma ICU	- Regional techniques (if feasible) - Opioids and acetaminophen - NSAIDs	- General Anesthesia - Regional Anesthesia (if feasible)	- Bleeding - Infection - Shock - Nerve and organ damage

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323776806000285#hl0001235 Anaesthetic Implications (with Trauma surgery)

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780443105234000432#hl0000563 Intraoperative Monitoring and Cardiopulmonary Bypass

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323776806000236#hl0000578 Chest Drain Systems

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323776806000261#hl0001383 Paediatric Surgery - Airway and Pulmonary Status

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323776714000218#hl0003059 Surgery During Pregnancy, Appendicitis, and Cholelethiasis

Reflection Questions: (Note that reflective learning activities are not compulsory but will improve your understanding of the subject).

1. How thoroughly did I assess the patient's medical history and risk factors before administering anaesthesia? Reflect on the preoperative evaluation. Were there any overlooked conditions or risk factors that could have influenced the anaesthetic plan?

2. What protocols did I follow to ensure patient safety during the anaesthetic emergency? Consider the steps taken during the emergency. Were the protocols followed effectively? What improvements could be made?

3. How did I communicate with the surgical team and other healthcare professionals during the emergency? Think about the clarity and efficiency of communication. Was everyone informed and coordinated? How could communication be enhanced?

4. In what ways did I manage the patient's physiological and psychological responses during the emergency? Reflect on the interventions used to stabilize the patient. Did you address both physical and emotional needs adequately?

5. What did I learn from this experience that can improve my management of future anaesthetic emergencies? Identify key lessons and areas for improvement. How can these insights be applied to enhance patient care in future emergencies?

References

References

Hatfield, A. (2023). The complete recovery room book (5th ed.). Oxford University Press.

Phillips, N., & Hornacky, A. (2020). Berry & Kohn's Operating Room Technique (14th ed.). Elsevier.

Rothrock, J. C. (2022). Alexander's Care of the Patient in Surgery (17th ed.). Elsevier.

https://www.acorn.org.au/client_images/2451502.pdf

https://resources.wfsahq.org/atotw/postanaesthesia-care-unit-discharge-criteria-and-considerations-for-the-paediatric-patient/#h2-0

https://publications.aap.org/pediatrics/article/143/6/e20191000/37173/Guidelines-for-Monitoring-and-Management-of?autologincheck=redirected

https://aneskey.com/pediatric-postanesthesia-care-unit/

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323776806000133#hl0000636

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780729544511000713#hl0002357

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323776806000145#hl0001103

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323642958000369#hl0002510

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323776806000273#hl0001700

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B978032377680600025X#hl0003966

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B978032377680600011X#hl0001733

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323776806000236#hl0000695

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323776806000182#hl0002205

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323776806000261#hl0001948

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323776806000169#hl0000971

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323776806000224#hl0000873

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780323776806000194#hl0001565

MODULE 4

Advanced Anaesthetic Techniques and Equipment

Advanced Anaesthetic Techniques and Equipment

Understanding Hypothermia, Induced Hypotension, Bier’s Block, IABP, ECMO, and Cell Saver

These advanced techniques are often used in specialised surgical environments to protect vital organs, optimise surgical conditions, and support critically unstable patients. They require skilled clinicians, meticulous monitoring, and a deep understanding of physiology, pharmacology, and perioperative risks.

Use of hypothermia

Hypothermia is used in some surgical specialties to reduce the patient's metabolic rate and, therefore, their oxygen requirements. Hypothermia needs to be done with a heart-lung bypass if the patient's temperature is being taken below 29◦C.

Hypothermia is used in highrisk surgical specialities, including:

Cardiac surgery

· Protects the myocardium from ischemic damage

· Facilitates heart–lung bypass procedures

Neurosurgery / Intracranial procedures

· Reduces cerebral blood flow

· Lowers intracranial pressure

· Protects against cerebral ischemia

Organ transplantation

· Preserves organs by slowing metabolism

· Ice may be used around isolated organs during transplant procedures

Hypothermia can be taken to different temperatures:

· Light: between 32 and 37◦C

· Moderate: between 26 and 32◦C

· Deep: between 20 and 26◦C

· Profound: below 20◦C

In cardiac surgery, hypothermia is achieved with the heater-cooler unit part of the heart-lung bypass machine. Light hypothermia can be achieved by lowering the operating room temperature. Otherwise, hypothermia is achieved by several means:

· Lowering the temperature of the operating room

· Placing ice around the patient's body.

· During organ transplants, ice can be placed around organs in the body.

Normothermia is achieved by slowly rewarming the patient with the heater-cooler unit and forced air patient warmers. Rewarming needs to be done slowly and in a manner that prevents shivering, as shivering intensely increases oxygen requirements and can result in circulatory collapse from sudden vasodilation.

Hypothermia primarily affects the myocardium of the heart, increasing the risk of ventricular fibrillation and heart block. Other potential complications of hypothermia can include embolism, microcirculation stasis, tissue damage, and metabolic acidosis.

From Berry & Kohn's operating room technique by Hornacky, chapter 24.

 Induced hypotension

Induced hypotension is used in some surgeries where lowering arterial blood pressure can shorten the surgical operating time, reduce the risk of hemorrhage, reduce the need for transfusion, and facilitate visibility at the surgical site. However, the lowered arterial blood pressure must be balanced against the need for adequate oxygenated blood flow to vital organs. So, the lowered arterial pressure duration is usually restricted to a particular part of the surgery. Induced hypotension may be indicated in the following situations:

· Surgical procedures expecting blood loss

· Intracranial surgery especially that where control of vessel haemorrhage may be difficult.

· Surgery on the head, neck, face, and upper thorax, such as carotid endarterectomy and ascending aortic aneurysms.

· Surgical procedures where blood transfusion needs to be avoided.

Read the following sections: Attaining Hypotension and Precautions in Using Hypotension in Berry & Kohn's Operating Room Technique by Hornacky, chapter 24.

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780443105234000249#hl0001564 Attaining Hypotension

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780443105234000249#hl0001638 Precautions in the Use of Hypotension

From Berry & Kohn's operating room technique by Hornacky, chapter 24.

 Biers Block

A Biers block is a type of local anesthesia used on the upper extremities and arms for procedures that last less than 30 minutes.

· A double tourniquet cuff is applied to the surgical arm but not inflated, and an IV catheter is inserted into the surgical arm.

· The tourniquet cuff is then covered with a plastic drape to isolate it from the surgical prep solution.

· The patient is prepped and elevated, and the arm is exsanguinated using an Esmarch bandage.

· The proximal cuff is then inflated, and the Esmarch bandage can be removed but kept in the sterile field.

· Local anaesthetic is injected into the arm using the IV.

· When the local anaesthetic takes effect, the distal tourniquet cuff is inflated and the proximal cuff deflated.

· The surgery can then occur. The patient experiences less discomfort and pain from the tourniquet cuff as the cuff is inside the LA zone.

· At the end of the surgery, the distal cuff is released.

On the release of the distal cuff, the patient can experience symptoms from the remains of the LA and any metabolic wastes entering the systemic system.

From Berry & Kohn's operating room technique by Hornacky, chapter 24.

 Intra-aortic Balloon Pump

An intra-aortic balloon pump (IABP) is a device that assists the left ventricle when the patient is in acute cardiac failure. A long catheter with a balloon is inserted into the aorta via the femoral artery, with the tip sitting just below the left subclavian take-off point and ending just above the renal arteries. The balloon inflates in diastole and deflates for systole, thereby creating a sucking-type effect that assists the left ventricle in systole.

Read the following section on the intra-aortic balloon pump in Alexanders Care of  Patient in Surgery by Rothrock, chapter 25.

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B978032377680600025X#hl0005213

From Rothrock Alexanders Care of Patient in Surgery, chapter 25.

 Extra Corporeal Membranous Oxygenation or ECMO

ECMO is when a patient's heart and lungs are in acute failure and expected to recover. ECMO involves large bore catheters inserted in the femoral artery and veins, and the patient's blood is oxygenated and returned to the patient. This resuscitative procedure requires the patient to be high-level heparinized.

Watch this 20-minute video on VV vs. VA ECMO:

https://youtu.be/hSyQ25UJ-FA?si=82iqOjSQRh0PfmlF

Cell Saver

A cell saver (intraoperative cell salvage (ICS) system) is a medical device used during surgery to collect, process, and reinfuse a patient’s blood that is lost during the procedure. This technique is part of blood conservation strategies and is especially useful in surgeries with high expected blood loss. A device that collects blood lost during surgery filters and washes it to remove contaminants and then returns the cleaned red blood cells to the patient, reducing the need for donor blood transfusions.

Indications:	Contraindications:	Risks:	Special Precautions:
· Surgeries with expected high blood loss · Cardiac, orthopedic, vascular, and trauma surgeries · Placenta Previa and Caesarean Section surgery · Jehovah's Witnesses or patients refusing allogeneic blood transfusions	· Infection or sepsis · Malignancy in the surgical field · Amnio fluid in Caeserean Sections procedures. So in this surgery the Cell Saver use isn't started until after amnio fluid is all removed and usually after baby has left the surgical field. · Contaminated surgical fields (e.g., bowel perforation)	· Air embolism · Hemolysis due to improper suction or processing · Coagulopathy if excessive blood is salvaged without replacement of clotting factors · Contamination if aseptic technique is breached	· Ensure machine setup and calibration before surgery · Confirm patient suitability and consent - Monitor blood loss and coordinate with surgical team · Document volumes collected and reinfused · Maintain sterile technique throughout · Many Operating Suites that use Cell Saver devices will allocate a 2nd anaesthetic nurse just to look after it and monitor it.

Watch this 2-minute video on the cel saver:

Additional Advanced Anaesthetic Techniques & Equipment to Consider Adding

1. Total Intravenous Anaesthesia (TIVA)

TIVA involves maintaining anaesthesia using IV agents only, without inhalational gases.

Clinical Importance

· Avoids volatile anaesthetic exposure

· Reduces postoperative nausea and vomiting (PONV)

· Useful for patients at risk of malignant hyperthermia

· Enables smoother wakeups and rapid recovery

Key equipment

· Targetcontrolled infusion (TCI) pumps

· BIS (Bispectral Index) monitoring for depth of anaesthesia

2. Depth of Anaesthesia Monitoring

Advanced monitors help prevent awareness and overdosing.

Examples

· BIS (Bispectral Index)

· Entropy monitoring

· MACBrain monitoring (emerging)

Clinical importance

· Reduces risk of intraoperative awareness

· Helps titrate TIVA

· Minimises drug use → improved haemodynamic stability

3. Neuromuscular Transmission Monitoring

Used to monitor the effect of neuromuscular blocking agents.

Techniques

· TrainofFour (TOF) monitoring

· Double burst stimulation

· Posttetanic count

Clinical Importance

· Prevents residual paralysis

· Ensures safe extubation

· Reduces respiratory complications in PACU

4. Regional Anaesthesia with Ultrasound Guidance (USRA)

This is an essential modern anaesthetic skill.

Examples of advanced regional blocks

· Interscalene block

· TAP block

· Sciatic/femoral nerve blocks

· ESP (Erector Spinae Plane) block

· Paravertebral block for thoracic surgery

Benefits

· Reduced opioid use

· Better analgesia

· Faster recovery

· Improved mobilisation

5. HighFlow Nasal Oxygen (HFNO) & Apnoeic Oxygenation

Now widely used in difficult airway management.

Uses

· Extends safe apnoea time during intubation

· Supports oxygenation in obese or critically ill patients

6. Advanced Airway Devices

Modern anaesthesia includes a wide range of advanced tools:

Examples

· Video laryngoscopes (Glide Scope, CMAC)

· Fiberoptic bronchoscopes

· Supraglottic devices (2ndgeneration LMAs)

· Jet ventilation

Why they're advanced

They improve success in difficult airway scenarios, trauma, or cervical spine precautions.

7. Rapid Sequence Induction (RSI) – Updated Practices

Technically not “new,” but contemporary RSI now involves:

· Modified cricoid pressure recommendations

· Preoxygenation with HFNO

· Rocuronium + sugammadex reversal

· Use of video laryngoscopy as first line

8. Sugammadex Reversal (for Rocuronium/Vecuronium)

A major breakthrough in anaesthesia.

Advantages

· Rapid full reversal of paralysis

· Increased airway safety

· Improved conditions for “can’t intubate, can’t oxygenate” scenarios

· Essential in emergency Csections

9. GoalDirected Fluid Therapy (GDFT)

Uses advanced haemodynamic monitoring to optimise perfusion.

Equipment

· Esophageal Doppler

· Flo Trac

· LiDCO Haemodynamic monitor

· PiCCO cardiac monitor

Benefits

· Reduces fluid overload

· Improves surgical outcomes

· Reduces postoperative complications

10. Cardiopulmonary Bypass (CPB) Advancements

Beyond basic bypass, modern cardiac theatres may use:

Examples

· Minibypass systems

· Heparincoated circuits

· Pulsatile perfusion technology

· Integrated heatercooler safety controls

11. CRRT (Continuous Renal Replacement Therapy) in Theatre

Used for patients with:

· Severe sepsis

· Fluid overload

· Renal failure

Allows finetuned fluid and electrolyte management during long or complex procedures.

12. Transesophageal Echocardiography (TOE/TEE)

An essential skill in cardiac and major vascular surgery.

Applications

· Visualising cardiac chambers and valves

· Detecting emboli

· Guiding fluid and inotrope therapy

· Monitoring response to surgical repair

13. Anaesthesia for Robotic Surgery

Increasingly common in colorectal, urology, and gynaecology.

Special considerations

· Extreme Trendelenburg position

· Restricted access to the airway

· Increased airway pressure

· Requires specialised ventilatory management

14. Jet Ventilation & HFJV

Used for:

· ENT surgery

· Airway reconstruction

· Tracheal stenosis

Provides ventilation without obstructing surgical view.

15. Inhaled Nitric Oxide (iNO)

Used in:

· Pulmonary hypertension

· Right heart failure

· Severe ARDS

Acts as a selective pulmonary vasodilator.

16. Advanced OpioidFree Anaesthesia (OFA)

Uses agents such as:

· Ketamine

· Dexmedetomidine

· Lidocaine infusions

· Magnesium

· Regional blocks

Reduces opioidrelated complications and improves recovery.

17. Anaesthesia in MRI & Hybrid Theatres

Requires:

· MRIsafe ventilators

· Nonmagnetic monitoring equipment

· Specialised training in remote airway management

18. Enhanced Recovery After Surgery (ERAS) Protocols

Not a device, but an advanced anaesthetic strategy integrating:

· Optimised fluids

· Minimal opioids

· Regional techniques

· Early mobilisation

· Preemptive analgesia

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780443105272000144#hl0004929. Hypovolemia

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780729544467000218#hl0001550 Autotransfusion

https://www.clinicalkey.com/student/nursing/content/book/3-s2.0-B9780729544467000371#hl0001885. Use of Cell Salvage for Obstetric Haemorrhage

Reflection Questions: (Note that reflective learning activities are not compulsory but will improve your understanding of the subject).

Use of Hypothermia

1. What are the primary benefits of using hypothermia in cardiac and intracranial surgeries?

2. How does the depth of hypothermia (light, moderate, deep, profound) influence the surgical outcomes and potential complications?

Induced Hypotension

1. What are the main advantages of using induced hypotension during surgeries, and how does it improve surgical outcomes?

2. How can the balance between lowering arterial blood pressure and maintaining adequate oxygenated blood flow to vital organs be achieved?

Biers Block

1. What are the key steps involved in performing a Biers block, and how does each step contribute to the effectiveness of the procedure?

2. How does the use of a double tourniquet cuff enhance patient comfort during a Biers block?

Intra-aortic Balloon Pump (IABP)

1. How does the intra-aortic balloon pump assist the left ventricle during acute cardiac failure?

2. What are the key considerations for the placement and operation of the IABP catheter?

Extra Corporeal Membranous Oxygenation (ECMO)

1. What are the primary indications for using ECMO in patients with acute heart and lung failure?

2. How does ECMO support the patient's cardiovascular and respiratory systems, and what are the key components of the ECMO circuit?

Cell saver

1. How does the use of a cell saver influence your approach to patient blood management, and what ethical considerations arise when offering this option to patients with specific beliefs or medical conditions?

2. Reflecting on a recent case where a cell saver was used (or could have been used), what went well, what challenges did you encounter, and how might you improve your practice in future similar scenarios?

Anaesthetic Machine, Anaesthetic Gasses and Medical Waste Management

Anaesthetic Machine

An anaesthetic machine is essential for the safe delivery of anaesthesia. These machines are very complex pieces of equipment with 3 main purposes: delivery of volatile anaesthetic agents, haemodynamic monitoring of patient during surgery, and respiratory management. The anaesthetic machines have four main areas: 2 screens one with haemodynamic data and the other with respiratory data, gas delivery management to deliver the volatile anaesthetic agents mixed with oxygen and air, ventilator, and storage under the work area.

The anaesthetic machine is connected to the hospital piped supply of medical air, nitrous oxide, and oxygen each with colour coded hoses black, purple and white respectively. The anaesthetic gases are delivered to the machine through different coloured tubing, as well as different connectors so the tubing cannot be accidentally connected to the wrong gas supply at the pendant. The anaesthetic circuit consists of corrugated plastic tubing, and a reservoir bag to supply the anaesthetic gases to the patient. The reservoir bag accommodates variations in respiratory drive and demand as well as enabling manual compression of the bag to deliver a manual breath to the patient.

The anaesthetic machine has many fail-safe alarms to prevent delivery a mix of gases that would deliver a hypoxic mixture and also reduce human error or mechanical failure. These alarms as well as many other checks, must be checked at the start of every day by the anaesthetic nurse to ensure the machine is safe to use. These daily checks prevent serious incidents occurring.

These complex machines require annual maintenance and care from specifically trained biomedical technicians.

Watch the following video on anaesthesia machine check. This is a short video only 9-minutes long and I think the model of machine is a bit old, but it's still the checks.

Also read this ANZCA protocal document on the daily checks that need to be done. This link will get you to the web address, then search for the below document.   https://www.anzca.edu.au/safety-and-advocacy/standards-of-practice/professional-documents

ANZCA 2014 Checking Anaesthetic Delivery Systems.

 

Anaesthetic Gasses

The use of inhalation anaesthetic agents is a controllable method of delivering an anaesthetic agent, and relies on the patients respiratory and cardiac function to absorb and then deliver the anaesthetic agent around the body. The anaesthetic gasses include nitrous oxide, servoflurane, isoflurane, desflurane , enflurane, and halothane. The advantages, disadvantages, and uses of each of these gasses is provided in the table below.

 

Inhalational Agent	Uses	Advantages	Disadvantages	Taste
Nitrous oxide	Used in adjunct to other IV anaesthetic drugs as it lacks potency. Used with narcotics, opiods, & barbiturates.	Avoids excessive depth of anaesthesia Minimal nausea & vomiting Rapid uptake and elimination Minimal physiological change	Poor relaxation Excitement Laryngospasm Bowel distention Potent cerebral vasodilator Not to be used in pregnant patients Is combustible Not to be used in laparoscopy cases	Pleasant fruit like odour
Servoflurane (Yellow label)	Very commonly used.	Rapid induction and emergence. Can be used in paediatrics & adults. Rapidly eliminated by lungs. Causes less cerebral irritation so can be used if raised intracranial pressure.	Can cause glycosuria & proteinuria when used in long cases.
Isoflurane (Purple label)	Closer to ideal than other inhalation agents and very commonly used.	Potent muscle relaxant & protects cardiac muscle from dysrhythmias. Less cardiac depression Heart rhythm is very stable. BP drops with induction by returns to normal during surgery. Low organ toxicity. Depresses bronchoconstriction, so can be used in asthmatics & COPD patients	Potentiates commonly use muscle relaxants. Expensive. Profound respiratory depressant. Can cause vasodilation so can drop BP. Needs a special vaporizer just for this agent
Desflurane (Blue label)	Used for maintenance in adults and maybe children.	Faster uptake and elimination than Halothane and Isoflurane. Rapid emergence & recovery. Produces few urinary metabolites. Inhalation of choice in bariatric surgery. Reduces dosage of neuromuscular blockade.	Not used for induction in children due to potential for coughing & laryngospasm. Elevates Heart rate so if used in patients with cardiovascular disease then needs to be combined with IV opioids or benzodiazepines	Pungent odour – may be irritating.
Enflurane. (orange label)	Not commonly used	Rapid induction and recovery with minimal aftereffects No stimulation of saliva Cardiac rhythm and rate remain stable Muscle relaxation is produced but may need small doses of muscle relaxant	Respiration and blood pressure are depressed Contraindicated in severe renal disease Is absorbed by rubber	Pungent odour
Halothane (red label)	Rarely used	Smooth muscle action	Toxic to liver Profound hypothermia Delayed elimination Profound uterine relaxant Reduces myocardial oxygen consumption more than it depresses cardiac function

  From Alexander’s Care of the Patient in Surgery by Rothrock, chapter 24

 

Medical Waste Management

Appropriate disposal of the anaesthetic gases is essential. Anaesthetic gases exhausted into the OR long term can cause occupational health issues with OR health professionals including decreased fertility, spontaneous abortion, teratogenicity, and carcinogenicity. So instead, the expired anaesthetic gases are removed from the OR using a gas scavenge system. Gas scavenges systems comprise 4 components: relief valve, conducting tubing, receiving system, and a disposal system with 2 main systems: active or passive. The expired anaesthetic gases leave the breathing circuit of the anaesthetic machine via an exhaust valve venting the gases into the gas scavenge line that is yellow coloured line. The gas scavenge line, the conducting tubing, transfers the expired gases to the receiving and disposal systems in another part of the hospital. The receiving systems can be open or closed: an open system the reservoir is a structure that is open to the atmosphere, a closed system is often a distensible bag with pressure relief valves. The disposal system needs to facilitate easy disposal of the expired gases and provide little to no resistance to the outflow of gases and does this with either an active or passive system. Passive systems exhaust the expired gases through the piping to outside the hospital and the atmosphere, the piping should be wide and short to provide as little resistance as possible. Passive systems can be filtered as well, sometimes using charcoal filters. An active system is often associated with open system using the central suction system in the hospital and are the most common form.

Reflection Questions: (Note that reflective learning activities are not compulsory but will improve your understanding of the subject).

Anaesthetic Machine

1. How do the fail-safe alarms and daily checks on an anaesthetic machine contribute to patient safety during surgery?

2. What are the key considerations for ensuring the correct connection of gas supply hoses to the anaesthetic machine, and how can errors be prevented?

Anaesthetic Gases

1. What are the advantages and disadvantages of using different inhalation anaesthetic agents, and how do these factors influence the choice of agent for specific surgeries?

2. How does the use of multi-modal anaesthesia, combining inhalation agents with other analgesics, enhance patient outcomes and reduce potential side effects?

Medical Waste Management

1. What are the potential occupational health risks associated with long-term exposure to anaesthetic gases, and how does the gas scavenging system mitigate these risks?

2. How do active and passive gas scavenging systems differ in their operation, and what are the advantages and disadvantages of each system?

Responding to Exposure

Responding to Exposure

Please refer to your hospital Material Safety Data Sheets for specific details in this. An exposure to these anaesthetic gases has usually occurred during refilling of the specific dispersal containers on the anaesthetic machine. Small spills evaporate quickly at room temperature in the OR and even disappear before the health professional has had time to clean up the spill. However, if a larger spill has occurred such as dropping one of the bottles, then specific actions need to be taken. If the spill occurs in the operating room, then the spill can be suctioned up. If the spill occurs somewhere else, then absorbent hazmat need to be used with the used mats placed in sealed bags and labelled and then handed over to a hazard waste disposal firm. However, the health professional needs to wear appropriate respirator masks and PPE such as disposable gloves, ventilate the area, and remove all people from the OR until the clean-up has been finished. 

https://www.acorn.org.au/client_images/2452854.pdf

Reflection Questions: (Note that reflective learning activities are not compulsory but will improve your understanding of the subject).

1. What are the immediate steps a health professional should take when a large spill of anaesthetic gas occurs in the OR, and why is it important to follow these steps?

2. How does the use of appropriate PPE and ventilation contribute to the safety of health professionals and patients during the cleanup of an anaesthetic gas spill?

Neuraxial Anaesthesia

NEURAXIAL ANAESTHESIA

Neuraxial anaesthesia is one of the most powerful, versatile, and physiologically complex forms of anaesthesia. It requires understanding of spinal anatomy, autonomic physiology, pharmacology, haemodynamics, and careful perioperative assessment.

Neuraxial techniques include:

1. Spinal (subarachnoid) anaesthesia

2. Epidural anaesthesia

3. Combined Spinal, Epidural (CSE)

4. Caudal anaesthesia (a specialised variation)

These techniques produce temporary sensory, motor, and autonomic blockade by depositing local anaesthetic (and sometimes opioids) around the spinal cord and nerve roots.

Advanced Spinal Anatomy and Physiology

To understand neuraxial anaesthesia deeply, it helps to visualise the layers penetrated:

1. Skin

2. Subcutaneous fat

3. Supraspinous ligament

4. Interspinous ligament

5. Ligamentum flavum

6. Epidural space

7. Dura mater

8. Arachnoid mater

9. Subarachnoid space (with CSF )

The Three Meningeal Spaces

· Epidural space – fat, venous plexus, nerve roots

· Subdural space – potential “false” space

· Subarachnoid space – CSF + spinal nerves → true target for spinal

Spinal cord ends at:

· L1/L2 in adults

· L3 in children

Therefore, neuraxial techniques occur at L3–L4 or L4–L5 to avoid cord injury.

Pharmacological Mechanism of Action

Neuraxial anaesthesia causes a threepart block:

Sensory block

Loss of pain, temperature, and touch via blockade of sensory nerve fibers.

Motor block

Weakness/paralysis of muscles below block level.

Sympathetic block

The earliest and most clinically important effect:

· Vasodilation

· Hypotension

· Reduced venous return

· Potential bradycardia (T1–T4 block)

Why sympathetic block spreads most extensively

Autonomic fibers are:

· Small

· Unmyelinated

· Highly sensitive to local anaesthetic

Meaning neuraxial anaesthesia affects blood pressure and perfusion long before movement or pain perception change.

1. Spinal (Subarachnoid) Anaesthesia

Definition

Spinal anaesthesia is produced by injecting local anaesthetic directly into the subarachnoid space, where cerebrospinal fluid (CSF) surrounds the spinal cord and nerve roots. The needle penetrates the dura and arachnoid mater.

Anatomy Targeted

· Subarachnoid space (contains CSF and nerve roots)

· Injection typically at L3–L4 or L4–L5, below the termination of the spinal cord

Characteristics

· Rapid onset (1–5 minutes)

· Dense sensory + motor block

· Profound sympathetic block → hypotension

· Limited duration (depends on drug type)

Indications

· Caesarean section

· Hip/knee arthroplasty

· TURP (urology)

· Hernia repair

· Perineal/rectal surgery

· Lower limb trauma

Advantages

· Fast, reliable block

· Excellent muscle relaxation

· Small drug dose required

· Minimal equipment

Pharmacology

Common agents:

· Hyperbaric bupivacaine (most common)

· Ropivacaine

· Lidocaine (rare now due to transient neurological symptoms)

Adjuncts:

· Fentanyl → rapid onset analgesia

· Morphine → longacting spinal analgesia (12–24 hours)

· Clonidine or dexmedetomidine → prolongs block

Determinants of block height

· Baricity (density relative to CSF)

· Patient position after injection

· Dose & volume

· Pregnancy (epidural veins engorged → higher block)

· Speed of injection

Physiological Effects

· Profound vasodilation → preload ↓ → BP ↓

· Reduction of systemic vascular resistance

· Risk of high spinal if spread excessive

· Urinary retention from sacral block

2. Epidural Anaesthesia

Definition

Epidural anaesthesia is produced by injecting local anaesthetic into the epidural space, a fatfilled area outside the dura mater. A catheter can be left in place for continuous or intermittent dosing.

Anatomy Targeted

· Epidural space (outside dura)

· Injection at lumbar, thoracic, or cervical levels depending on surgery

Characteristics

· Gradual onset (10–30 minutes)

· Ability to titrate block level

· Can provide analgesia or full anaesthesia

· Useful for long surgeries or labour

Indications

· Labour analgesia

· Major abdominal surgery

· Thoracic surgery (for pain control)

· Vascular lower limb surgery

· Chronic pain therapy

· Rib fractures (epidural analgesia)

Advantages

· Tailored titration

· Segmental anaesthesia

· Better haemodynamic stability

· Extended postoperative analgesia

Complications

· Accidental dural puncture → PDPH

· Epidural hematoma

· Epidural abscess

· Failed block

· Hypotension (less abrupt than spinal)

· Intravascular injection → LAST

Epidural anaesthesia involves placing a catheter in the epidural space for:

· Continuous infusion

· Patientcontrolled analgesia

· Titrated surgical anaesthesia

Key Concepts

The "Epidural Test Dose"

Small dose of lidocaine + epinephrine used to check accidental:

· Intrathecal injection (rapid block)

· Intravascular injection (tachycardia)

Epidural infusions

Use:

· Lowdose local anaesthetic + opioid

· Provides analgesia without full motor block

· Ideal for labor or thoracotomy pain

3. Combined Spinal–Epidural (CSE) Anaesthesia

Definition

A hybrid technique combining:

· Spinal injection for rapid onset

· Epidural catheter for prolongation and titration

Performed using a “needlethroughneedle” approach.

Anatomy Targeted

· Spinal injection into subarachnoid space

· Epidural catheter into epidural space

Characteristics

· Speed of spinal anaesthesia

· Flexibility and duration of an epidural

· Excellent for prolonged or staged procedures

Indications

· Obstetrics (labour and Caesarean sections)

· Orthopedic surgeries (hip/knee replacement)

· Highrisk patients needing controlled haemodynamics

· Surgeries where initial rapid block plus long-lasting analgesia is desired

Advantages

· Rapid, reliable block

· Can extend block duration

· Fine control over anaesthetic depth

· Less total amount of local anaesthetic required

Disadvantages

· More complex procedure

· Higher technical skill required

· Risk of catheter misplacement

· Potential for excessive block height if not monitored carefully

Complications

· Same risks as spinal + epidural

· Catheter migration

· High block if epidural dose accidentally enters subarachnoid space

4. Caudal Anaesthesia

Definition

A form of epidural anaesthesia delivered via the sacral hiatus, injecting local anaesthetic into the caudal epidural space.

Most common in paediatric anaesthesia, but also used in adults for chronic pain or certain perineal procedures.

Anatomy Targeted

· Sacral epidural space accessed below the sacrococcygeal ligament

Characteristics

· Good for lower sacral nerve roots

· Predictable spread in infants and young children

· Provides analgesia for perineal and rectal surgeries

Indications

Paediatrics

· Inguinal hernia repair

· Hypospadias repair

· Orchiopexy

· Circumcision

· Lower limb procedures

Adults

· Chronic pain therapy

· Anorectal surgery

· Obstetric analgesia (rare; epidural preferred)

Advantages

· Easy landmarks in children

· Lower risk of dural puncture

· Good for postoperative pain

· Useful when lumbar access is difficult

Disadvantages

· Less reliable in adults (anatomical variation)

· Limited block height

· Larger drug volumes required

· Risk of intravascular injection into sacral venous plexus

Complications

· Intravascular injection

· Inadequate block

· Local anaesthetic systemic toxicity (LAST)

· Infection

Technique	Injection Site	Onset	Duration	Typical Use	Key Advantages
Spinal	Subarachnoid (CSF)	Rapid	Fixed	Csection, lower limb	Dense block, small dose
Epidural	Epidural space	Slow	Adjustable	Labour, abdominal surgery	Titration, prolonged analgesia
CSE	Both spaces	Rapid + flexible	Extended	Obstetrics, ortho	Best of both techniques
Caudal	Sacral epidural	Moderate	Limited	Paediatrics, perineal	Safe, good for children

Complications

Hypotension

From sympathetic block → venous pooling → decreased preload

Most common and dangerous early complication

Management:

· Rapid IV fluids

· Vasopressors (phenylephrine, ephedrine)

· Left uterine displacement in pregnancy

· Oxygen

High Spinal / Total Spinal

Block ascends to:

· Cervical level → respiratory arrest

· Brainstem → loss of consciousness

Causes:

· Excessive spinal drug dose

· Accidental intrathecal injection of epidural dose

Management:

· Immediate airway support, ventilation

· Vasopressors

· Call for help

PostDural Puncture Headache (PDPH)

From CSF leak after dural puncture.

Features:

· Posturedependent headache

· Neck stiffness

· Photophobia

· Relief when lying flat

Treatment:

· Fluids & caffeine

· Epidural blood patch (gold standard)

Epidural Haematoma

A rare but surgical emergency.

Risk:

· Anticoagulation

· Coagulopathy

· Traumatic insertion

Signs:

· Severe back pain

· Neurological deficits

· Urinary retention

Requires urgent MRI and surgical decompression within 6–8 hours.

Local Anaesthetic Systemic Toxicity (LAST)

From inadvertent intravascular injection.

Symptoms:

· Tinnitus

· Circumoral numbness

· Seizures

· Arrhythmias

Treatment:

· Lipid emulsion therapy

· Seizure control

· ACLS as needed

Nursing Responsibilities

Preprocedure

· Check consent

· Coagulation status (platelets, anticoagulants)

· Baseline vitals

· IV access

· Hydration status

· Assist with positioning

During Procedure

· Maintain sterile field

· Monitor haemodynamics

· Provide reassurance

· Support positioning (curved spine, “angry cat” position)

Postprocedure Monitoring

· Sensory block level

· Motor block level

· Vital signs every 5–15 min

· Signs of high spinal

· Urinary retention

· Epidural catheter site

· Pain control effectiveness

Recognising Red Flags

· Sudden hypotension

· Inadequate ventilation

· Severe headache

· New neurological deficits

· Unexplained tachycardia or arrhythmias

Neuraxial Anaesthesia in Obstetrics

Pregnant patients are physiologically unique:

· Engorged epidural veins → increased risks

· Higher cephalad spread of spinal anaesthetic

· Aortocaval compression → worsen hypotension

· High-risk of PONV

· Faster onset of block

Csections require high/fast block; labor requires titratable analgesia.

Protocol	Details	Patient Safety Measures
Admission to the PACU	· Transferred by an anesthesia care team member who provides continuous monitoring and support during transport. · Re-evaluation of the patient's condition and a detailed verbal report to the PACU nurse, including preoperative condition, surgical procedure, and anesthesia used.	· Continuous monitoring to ensure patient stability during transfer. · Detailed and accurate handover to prevent errors.
Monitoring and Evaluation	· Continuous monitoring of heart rate, blood pressure, respiratory rate, oxygen saturation (using pulse oximetry), and temperature. · Regular assessment using standardized scales such as the Glasgow Coma Scale. · Regular assessment using pain scales (e.g., Numeric Rating Scale, Visual Analog Scale) and management accordingly. · Monitoring for adequate ventilation and oxygenation, including observing respiratory rate, depth, and effort, and using capnography if necessary.	Continuous monitoring for early detection of complications and appropriate actions. Use standardized scales for consistent and accurate assessment. Capnography enhanced monitoring of respiratory function.
Care and Management	· Pain Management as needed to manage pain effectively. · Nausea and vomiting management of postoperative nausea and vomiting (PONV) with antiemetic medications such as ondansetron or metoclopramide. · Administration of intravenous fluids to maintain hydration and electrolyte balance, tailored to the patient's needs. · Inspection of surgical sites for signs of bleeding, infection, or other complications, and checking and changing dressings as needed.	· Proper pain management prevents complications from unmanaged pain. · Antiemetic medications reduce risk of aspiration. · Fluid management prevents dehydration and electrolyte imbalances. · Wound care, early detection and management of complications.
Discharge Criteria	· Patients must have stable vital signs within acceptable ranges before discharge. · Pain should be adequately managed with oral medications if possible. · Patients should be awake, alert, and oriented, or at their baseline mental status. · Patients should be able to move safely, either independently or with assistance, depending on their baseline mobility. · Discharge decisions are often guided by standardized protocols that ensure all necessary criteria are met.	· Stable vital signs ensure patient is ready for discharge. · Pain control prevents complications from unmanaged pain. · Alertness ensures patient can safely transition to the next phase of care. · Standardized protocols ensure consistent and safe discharge process.
Special Considerations for Adults	· Patients with significant comorbidities or those who underwent complex surgeries may need extended monitoring and care. This includes patients with cardiovascular, respiratory, or renal conditions.	· Extended monitoring for high-risk patients reduces risk for patients with significant comorbidities.
Documentation and Communication	· Detailed records of the patient's recovery process, including vital signs, medications administered, pain scores, and any interventions performed. · Effective communication during handover is critical. The PACU nurse provides a comprehensive report to the receiving nurse or healthcare provider when the patient is transferred to the next phase of care.	· Accurate records ensure continuity of care and prevents errors. · Effective handover reduces risk of miscommunication and errors during patient transfer.

Reference

References:

Lahvic, N., & Liu, M. (2019). Waste gas scavenging system. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK544254/

MacKenzie, M. (2008). Anaesthetic Gas Scavenging. World Anaesthesia, 154-155.

Phillips, N., & Hornacky, A. (2020).  Berry & Kohn's Operating Room Technique (14th ed.). Elsevier.

Rothrock, J. C. (2022).  Alexander's Care of the Patient in Surgery (17th ed.). Elsevier.

Rothrock, J. (2023). Alexander’s Care of the Patient in Surgery (17th ed.). Mosby.

https://www.acorn.org.au/client_images/2452854.pdf

https://www.anzca.edu.au/safety-and-advocacy/standards-of-practice/professional-documents

MODULE 5

Post-anaesthetic Care Unit (PACU) Protocols

Post-anaesthesia Care Unit (PACU) Protocols

The PACU is a critical area where patients are monitored and cared for immediately after anesthesia. Protocols vary from facility to facility, but they should have similarities in patient safety. Please familiarize yourself with your facilities' PACU protocols.

The table below focusing on adult patients in the Post-anaesthesia Care Unit (PACU):

Paediatric patients' protocols in the PACU: Admission to the PACU · Transferred by an experienced pediatric anesthesia care team member who provides continuous monitoring and support during transport. · Re-evaluation of the child's condition and a detailed verbal report to the PACU nurse, including preoperative condition, surgical procedure, and anesthesia used. · Continuous monitoring ensures stability during transfer. · A detailed handover of accurate patient information transfer to prevent errors. Monitoring and Evaluation · Continuous monitoring of heart rate, respiratory rate, oxygen saturation (using pulse oximetry), and temperature. · Blood pressure is usually only taken a few times and stopped once child is awake, then taken only if child's condition indicates. You'll need to check with your hospital for its usual procedure. · Level of consciousness assessment using age-appropriate scales. · Regular pain assessment using pediatric pain scales (e.g., FLACC scale, Wong-Baker FACES scale) and management accordingly. · Monitoring for adequate ventilation and oxygenation, including observing respiratory rate, depth, and effort, and using capnography if necessary. · Continuous monitoring for early detection of complications. · Using standardized scales to ensure consistent and accurate assessment. · Capnography enhanced monitoring of respiratory function. Care and Management · Administration pain medication like opioids, non-opioid analgesics, or regional anesthesia techniques to manage pain effectively. · Management of postoperative nausea and vomiting (PONV) with antiemetic medications such as ondansetron or metoclopramide. · Administration of intravenous fluids to maintain hydration and electrolyte balance, tailored to the child's needs. · Inspection of surgical sites for signs of bleeding, infection, or other complications, and checking and changing dressings as needed. · Appropriate pain management prevents complications from unmanaged pain. · Antiemetic medications reduce the risk of aspiration. · Fluid management will prevent dehydration and electrolyte imbalances. · Wound care early detection and management of complications. Discharge Criteria · Children must have stable vital signs within acceptable ranges before discharge. · Pain should be adequately managed with oral medications if possible. · Children should be awake, alert, and oriented, or at their baseline mental status. · Children should be able to move safely, either independently or with assistance, depending on their baseline mobility. · Discharge decisions are often guided by standardized protocols that ensure all necessary criteria are met. · Stable vital signs ensure child is ready for discharge. · Adequate pain control will prevent complications from unmanaged pain. · Alert level of consciousness ensures child can safely transition to the next phase of care. · A standardized protocol will ensure consistent and a safe discharge process. Special Considerations for Pediatric Patients · Pediatric patients require special attention due to their unique physiological responses to anesthesia. Pediatric-specific protocols include age-appropriate pain assessment tools and dosing guidelines for medications. · Pediatric protocols ensure safe and appropriate care for children. Documentation and Communication · Accurate and detailed documentation of the child's recovery process, including vital signs, medications administered, pain scores, and any interventions performed. · Accurate documentation will ensure continuity of care and prevents errors. · Some states in Australia have Paediatric Observations charts for specific age ranges as normal blood pressure and heart rate rate for a child aged less than 1 year old is quite different to that of a teenager. So check with your hospital and see how it deals with age specific physiological differences. · Effective handover communication is critical. The PACU nurse provides a comprehensive report to the receiving nurse or healthcare provider when the child is transferred to the next phase of care. · Effective handover will reduce the risk of miscommunication and errors during patient transfer. These safety measures are designed to ensure that pediatric patients receive comprehensive and safe care during their recovery from anesthesia, minimizing the risk of complications and promoting a smooth transition to the next phase of their recovery. https://www.acorn.org.au/client_images/2451502.pdf https://resources.wfsahq.org/atotw/postanaesthesia-care-unit-discharge-criteria-and-considerations-for-the-paediatric-patient/#h2-0 https://publications.aap.org/pediatrics/article/143/6/e20191000/37173/Guidelines-for-Monitoring-and-Management-of?autologincheck=redirected https://aneskey.com/pediatric-postanesthesia-care-unit/ Reflection Questions: (Note that reflective learning activities are not compulsory but will improve your understanding of the subject). 1. How do age-appropriate pain assessment tools and dosing guidelines for medications ensure safe and effective pain management for pediatric patients in the PACU? 2. What specific challenges do healthcare providers face when monitoring vital signs and respiratory function in pediatric patients, and how are these challenges addressed in the PACU? 3. How does the presence of a specialized pediatric anesthesia care team during patient transfer and initial assessment enhance the safety and comfort of pediatric patients in the PACU? 4. In what ways do pediatric-specific protocols for managing postoperative nausea and vomiting (PONV) differ from those for adults, and why are these differences important? 5. How do detailed documentation and effective handoff communication practices ensure continuity of care and prevent errors in the management of pediatric patients in the PACU?

0-Golden Rules of Recovery

The 20-Golden Rules of the PACU (Hatfield, 2023).

Introduction to the 20 Golden Rules of Recovery

Recovering from surgery or anesthesia is a big deal and needs a lot of care and attention. The "20 Golden Rules of Recovery" help healthcare professionals ensure that patients are safe, comfortable, and recovering. When patients enter the PACU, it is all about closely monitoring them. The 20 Golden Rules of Recovery is a guideline for managing your patient during recovery. 

1. The confused, restless, agitated patient is hypoxic until proven otherwise

· Principle: Hypoxia is a common cause of agitation and confusion post-surgery.

· Application: Always check oxygen saturation levels first.

· Case Study: A patient becomes agitated shortly after surgery. Saturation levels are checked, and he appears to be desaturated. Administering oxygen stabilizes the patient.

2. Never leave the patient alone for any reason

· Principle: Continuous monitoring is essential.

· Application: Ensure a nurse is always present.

· Case Study: A nurse steps out of the PACU for a few minutes, and the patient experiences a sudden vasovagal, delaying intervention.

3. Blood pressure does not necessarily fall in haemorrhagic shock

· Principle: Shock can occur without a drop in blood pressure.

· Application: Look for other signs of shock.

· Case Study: A patient shows signs of shock but has normal blood pressure. Further investigation reveals internal bleeding.

4. Never ignore a tachycardia – find the cause

· Principle: Tachycardia can indicate underlying issues.

· Application: Investigate the causes of possible and address them as needed.

· Case Study: A patient's elevated heart rate could be due to pain from a surgical complication, e.g., bleeding causing swelling.

5. Post-op hypertension is dangerous

· Principle: High blood pressure post-surgery can lead to complications.

· Application: Monitor and manage blood pressure.

· Case Study: A patient's blood pressure spikes, and antihypertensive medication is administered.

6. Do not use a painful stimulus to rouse a patient

· Principle: Gentle methods are more humane.

· Application: Use verbal and light physical prompts.

· Case Study: A patient is gently woken by calling their name and tapping their shoulder.

7. Noisy breathing is obstructed breathing, but not all obstructed breathing is noisy

· Principle: Check for airway obstruction.

· Application: Reposition the patient's head if needed.

· Case Study: A patient's tongue falls back, causing noisy breathing, which is corrected by repositioning.

8. Nurse a comatose patient on their side – in the coma position, unless intubated

· Principle: Prevent aspiration and maintain the airway.

· Application: Position comatose patients on their side.

· Case Study: A comatose patient is positioned on their side to ensure airway patency.

9. Let the patient remove their own airway

· Principle: Reduce the risk of injury.

· Application: Wait until the patient is awake enough.

· Case Study: A patient removes their airway device themselves once awake. It is unlikely that the patient will leave the hospital still intubated.

10. The patient must be able to lift their head from the pillow, cough, and take deep breaths before discharge

· Principle: Ensure sufficient muscle strength and respiratory function.

· Application: Test these abilities before discharge.

· Case Study: A patient successfully lifts their head, coughs, and takes deep breaths before discharge. This assesses the patient's orientation and alertness.

11. Treat the patient, not the monitor

· Principle: Clinical assessment is crucial.

· Application: Verify monitor readings with patient assessment.

· Case Study: A monitor shows low oxygen saturation, but the patient appears comfortable. The monitor's connection is checked and corrected.

12. Pain prevention is easier than pain relief

· Principle: Preemptive pain management is more effective.

· Application: Administer pain medication before the patient wakes up.

· Case Study: Pain medication is given before the patient wakes, improving pain control.

13. Opioids do not cause a fall in blood pressure in a stable patient

· Principle: Opioids are safe for stable patients.

· Application: Monitor blood pressure when administering opioids.

· Case Study: A stable patient receives an opioid, and their blood pressure remains steady.

14. Cuddle a crying child/baby

· Principle: Comforting measures stabilize vital signs.

· Application: Hold and soothe young patients.

· Case Study: A crying child is comforted, leading to stabilized vital signs.

15. Warmblood with an inline warmer

· Principle: Prevent hypothermia during transfusions.

· Application: Use an inline warmer for blood transfusions.

· Case Study: Blood is warmed before transfusion, maintaining the patient's body temperature and preventing transfusion-associated hypothermia.

16. Hypothermia is insidious and common

· Principle: Monitor and prevent hypothermia.

· Application: Use warming blankets and monitor temperature.

· Case Study: The operating room is usually cold, and an exposed patient can easily get hypothermia. The patient's temperature is closely monitored, and warming blankets are used to prevent hypothermia.

17. When giving drugs to the elderly, start with half the dose and administer twice as slowly

· Principle: Elderly patients are more sensitive to medications.

· Application: Administer lower doses slowly.

· Case Study: An elderly patient receives a sedative at half the dose, administered slowly to avoid adverse reactions. The elderly patient has a slower metabolism, and therefore, overdose or adverse reactions are more likely to occur.

18. If you do not know the pharmacology of a drug, do not administer it

· Principle: Ensure medication safety.

· Application: Consult a pharmacist or reference guide.

· Case Study: A nurse encounters an unfamiliar medication and consults a pharmacist before administration.

19. Thrombophlebitis is a sin; do not leave an IV in

· Principle: Prevent IV-related complications.

· Application: Remove IVs promptly if signs of thrombophlebitis appear.

· Case Study: An IV is removed and replaced at the first sign of redness and swelling.

20. If confused, refer to Rule No. 1

Reflection Questions: (Note that reflective learning activities are not compulsory but will improve your understanding of the subject).

1. How do the 20 Golden Rules of Recovery enhance patient safety and comfort in the PACU? Reflect on specific rules that directly impact patient well-being and how they contribute to a safer recovery environment.

2. Which of the 20 Golden Rules do you find most challenging to implement, and why? Consider any obstacles or difficulties you face in adhering to certain guidelines and how you might overcome them.

3. How do these rules support effective communication and teamwork among healthcare providers in the PACU? Think about how the rules facilitate collaboration and ensure that all team members are on the same page regarding patient care.

4. In what ways can the 20 Golden Rules of Recovery be adapted to meet the unique needs of different patients? Reflect on how you can tailor these guidelines to accommodate individual patient conditions, preferences, and recovery trajectories.

5. How do you measure the success of implementing the 20 Golden Rules of Recovery in your practice? Consider the metrics or indicators you use to evaluate the effectiveness of these rules in improving patient outcomes and overall care quality.

Head-and-Neck Anaesthetics

Head and Neck Anaesthesia

Principles and Application in ENT, Thyroid, Ophthalmic, and Maxillofacial Surgery

1. Overview of Head and Neck Anaesthesia

Head and neck anaesthesia involves the perioperative management of patients undergoing surgery to the ear, nose, throat, thyroid, eye, face, jaws, and upper airway. These regions contain structures essential for breathing, swallowing, speech, and airway protection, making anaesthetic and nursing management uniquely complex and high risk.

Unlike many other surgical specialties, head and neck procedures often directly affect:

· Breathing

· Swallowing

· Voice production

· Airway reflexes

These effects may occur due to the underlying disease, airway manipulation, or surgical intervention, and may manifest immediately or hours after surgery.

2. Key Characteristics of Head and Neck Surgery (With Nursing Implications)

Characteristic	Clinical Example	Nursing Implications
Shared airway	Microlaryngoscopy	Prepare suction, anticipate ventilation changes
Distorted anatomy	Oral cancer + radiotherapy	Early airway escalation, difficultairway alerts
High bleeding risk	Functional endoscopic sinus surgery (FESS)	Aspiration precautions, frequent airway checks
Nerve preservation	Thyroidectomy (RLN monitoring)	Postop voice and swallow assessment
Delayed airway compromise	Neck haematoma	Frequent neck and airway surveillance

Key insight for nurses:

Head and neck patients may appear stable initially and deteriorate later—ongoing vigilance is essential.

3. Why Head and Neck Anaesthesia Is Unique

Head and neck surgery carries a disproportionately high anaesthetic and nursing risk due to the convergence of three factors:

1. Airway vulnerability

2. Bleeding risk

3. Neurological consequences

Even minor complications can escalate rapidly into lifethreatening emergencies.

Nursing Perspective

· Subtle changes in voice, breathing, swelling, anxiety, or agitation often precede vitalsign abnormalities

· Nurses are often the first clinicians to detect deterioration

· Standard postoperative observation frequencies may be insufficient

4. Preoperative Assessment

Nursing Interventions and Responsibilities

A. Airway Assessment Support

While formal airway assessment is performed by anaesthetists, nurses play a critical observational and escalation role.

Nursing Observations

· Hoarseness or voice weakness

· Stridor or noisy breathing

· Dyspnoea at rest or lying flat

· Difficulty swallowing saliva

· Anxiety related to breathing

Targeted Nursing Questions

· “Do you get short of breath when lying flat?”

· “Has your voice changed recently?”

Clinical Example

A patient awaiting thyroidectomy reports sleeping upright due to breathlessness → nurse escalates → awake intubation planned → airway crisis avoided.

B. Systemic and Functional Assessment

Nursing documentation should include:

· Baseline speech, facial movement, swallowing

· Oxygen saturation trends and respiratory effort

· Nutritional status and weight loss

· Medication compliance (e.g. antithyroid drugs, βblockers)

5. Anaesthetic Goals and Nursing Alignment

Anaesthetic Goal	Nursing Interventions
Secure airway	Continuous respiratory, voice, and anxiety monitoring
Minimise bleeding	Inspect wounds, drains, neck contours
Preserve nerve function	Postop neurological and voice assessments
Smooth emergence	Calm environment, pain and nausea control
Early recognition	Timely documentation and escalation

6. Airway Management – The Central Theme

Head and neck patients have the highest incidence of anticipated difficult airway in elective surgery.

Contributors to Difficult Airway

· Tumours or mass lesions

· Radiotherapyinduced fibrosis

· Postsurgical anatomical distortion

· Oedema or infection

· Restricted mouth opening or neck movement

Common Airway Strategies

· Awake fibreoptic intubation

· Awake videolaryngoscopy

· Elective tracheostomy (selected cases)

· Highflow nasal oxygen (e.g. THRIVE)

Example

A patient undergoing subtotal glossectomy requires awake fibreoptic nasal intubation with planned postoperative ventilation.

Nursing Red Flags

· Stridor

· Increased work of breathing

· Sudden agitation or anxiety

· Voice changes

Golden nursing rule:

The patient tells you they can’t breathe before the monitor shows desaturation.

7. Regional Anaesthesia in Head and Neck Surgery

Purpose

Regional blocks provide targeted analgesia, reduce opioid requirements, and may facilitate awake airway management.

Major Nerves Involved

· Trigeminal nerve (CN V)

· Facial nerve (CN VII)

· Glossopharyngeal nerve (CN IX)

· Vagus nerve (CN X)

· Cervical plexus (C2–C4)

Nursing Responsibilities

· Monitor block effectiveness and symmetry

· Observe for local anaesthetic systemic toxicity (LAST)

· Reassure patients during awake procedures

· Maintain positioning and comfort

8. Anaesthesia for ENT Surgery

A. Ear Surgery (Tympanoplasty, Mastoidectomy)

Procedure: Repair of middle or inner ear structures.

Nursing Care

· Prevent pressure injury from head rotation

· Monitor vertigo and nausea postoperatively

· Protect surgical ear from trauma

B. Nasal & Sinus Surgery (FESS, Septoplasty)

Procedure: Endoscopic restoration of sinus drainage.

Major Risks

· Heavy bleeding

· Aspiration

Nursing Management

· Semiupright positioning

· Continuous airway observation

· Confirm throat pack removal

· Aggressive antiemetic prophylaxis

C. Laryngeal and Airway Surgery

Procedure: Surgery on vocal cords or airway structures.

Complications

· Laryngospasm

· Airway oedema

· Airway fire (laser surgery)

Nursing Actions

· Continuous respiratory monitoring

· Emergency airway equipment immediately available

· Immediate escalation for stridor or distress

9. Anaesthesia for Thyroid Surgery

What Is Done

Partial or total removal of the thyroid gland.

Key Risks

· Recurrent laryngeal nerve injury → hoarse voice

· Hypocalcaemia → tingling, cramps

· Neck haematoma → airway obstruction

Nursing Interventions (Critical Section)

Immediate PostOp

· Airway assessment: look, listen, feel

· Inspect neck for swelling, tightness, bruising

· Assess voice and swallowing

· Monitor calciumrelated symptoms

Neck haematoma is a surgical airway emergency

· Call for help immediately

· Stay with the patient

· Remove dressings if airway is compromised

10. Thyroid Storm – Nursing Recognition and Management

What It Is

A lifethreatening hypermetabolic crisis caused by uncontrolled thyrotoxicosis, often precipitated by surgery or anaesthesia.

Early Warning Signs

· Sudden tachycardia or atrial fibrillation

· Hyperthermia

· Agitation or confusion

· Profuse sweating

· Vomiting or diarrhoea

Nursing Actions

· Activate emergency response

· Commence cooling measures

· Administer oxygen

· Establish IV access

· Continuous ECG monitoring

· Prepare for ICU transfer

Elective surgery must never proceed until the patient is euthyroid.

11. Ophthalmic Surgery Anaesthesia

Common Procedures

· Cataract surgery

· Glaucoma surgery

· Vitrectomy

Usually performed under local or regional anaesthesia.

Nursing Care

· Verify correct eye and consent

· Assist with block positioning

· Monitor for oculocardiac reflex (bradycardia)

· Reassure awake patients

· Provide eye protection and education

12. SubTenon Block

What It Is A bluntcannula block delivering local anaesthetic into the episcleral space for globe analgesia and akinesia.

Nursing Considerations

· Check anticoagulation status

· Monitor for:

· Chemosis

· Increasing pain

· Visual disturbance

· Escalate severe pain or visual loss immediately

13. Maxillofacial Surgery

Why It Is an Extreme Airway Specialty

The airway may be:

· Distorted by trauma or tumour

· Actively bleeding

· Needed intraoperatively

· Inaccessible after fixation

Common Procedures

· Trauma: Mandibular or Le Fort fractures

· Orthognathic surgery: BSSO, Le Fort I osteotomy

· Cancer surgery with reconstruction

Airway Strategies

Strategy	Typical Indication
Awake fibreoptic intubation	Anticipated difficult airway
Awake videolaryngoscopy	Partial mouth opening
Nasal intubation	Orthognathic surgery
Submental intubation	Selected trauma
Elective tracheostomy	Major resections
Surgical airway	Failed airway

Nursing Interventions

· Ensure wire cutters/scissors at bedside (IMF patients)

· Maintain suction readiness

· Strict airway observation

· Tracheostomy care if present

Clinical Example

PostBSSO patient with IMF vomits → nurse cuts wires immediately → aspiration prevented.

14. Postoperative Care and Complication Management

Nursing Priorities

1. Airway patency (always first)

2. Bleeding surveillance

3. Neurological assessment

4. Pain and nausea management

5. Nutrition and hydration

Enhanced Monitoring Required For

· Thyroid surgery

· Major ENT cancer surgery

· Maxillofacial reconstruction

15. Key TakeHome Messages for Nurses

· Head and neck patients are airwaycompromised by default

· Subtle changes save lives

· Nurses are central to early detection and escalation

· Escalation is good practice, not failure

· Safe extubation and recovery are shared responsibilities

· Interdisciplinary communication prevents catastrophe

Managing Pain Crisis

Management of Pain and Pain Crisis

Pain is "an unpleasant sensory and emotional experience associated with or resembling that associated with actual or potential tissue damage" (International Association for the Study of Pain). Experiencing pain is a very personal experience with other factors also affecting the experience of pain, including social, psychological, and biological. Management of a patient's pain is one of the significant roles of the PACU nurse. Pain can be acute or chronic; however, in PACU, it is the acute pain we are treating, but we need to acknowledge that a patient may also experience chronic pain in PACU. We must respect a patient when they say they are in pain. Remember, you can also use the pain rating scales mentioned in semester 1, such as the numeric scale, the behavior rating scale, or the Wong-Baker scale, to assess a patient's pain.

Pain management in hospital is usually multi-modal, including:

· Regular IV or IM administration of analgesia

· Regular oral analgesics such as NSAIDs and paracetemol

· Patient-controlled analgesia (PCA) is when the analgesic agent is delivered via an intravenous pump that the patient controls when they need a dose.

· The spinal anaesthetic used reduces the amount of postoperative analgesia required.

· Epidural analgesia

(Alexander's Care of the Patient in Surgery by Rothrock, chapter 5)

Watch this 35-minute video on pain physiology:

Then, this 7-minute video on the Pain Gate Theory:

Analgesic agents

Many types of analgesia agents are available to the anesthetist, and most anesthetists have their "favorite" recipe of drugs that they prescribe. It is important to remember that it's multi-modal delivery. So, if administering an opioid, then see if the patient has an NSAID or paracetamol as well. Do not hesitate to ask the anaesthetist for more variety if you think the patient can benefit.

Watch this 5-minute video on analgesia use in pain. This video explains the multi-modal method of analgesia delivery :

Then, this 3-minute video on NSAIDs:

Additional measures

As pain is an emotion that the patient experiences, we need to appreciate that other factors can enhance or reduce a patient's pain:

Positioning:

If a limb has been operated on, it needs to be elevated and placed in a comfortable anatomical position.

For legs, 1 or 2 pillows are used for elevation with the knee and foot higher than the hip.

For arms, pillows or folded blankets work well, and keeping the fingers higher than the elbow is important.

· For shoulders, the affected arm needs some support behind the upper arm, with the lower arm elevated on the patient's chest.

Noise:

· Noise is distressing for a patient in pain and can exacerbate the situation. So, keep the noise in PACU to a minimum.

A calming, reassuring manner of treatment:

· The nurse caring for the patient must be calm and reassuring. The nurse needs to understand and accept the patient's pain, inform the patient how the pain relief will be delivered, and provide a realistic timeline for when the pain relief should have an effect.

Warm or cold:

· Has the patient rewarmed after their Surgery? A warm blanket is reassuring and relaxing for most patients and can help calm a patient while waiting for pain relief to have an effect.

Postoperative cognitive Dysfunction:

· If a patient is delirious post-operatively, then after assessing their oxygenation levels – as hypoxia is a common cause of postoperative confusion – then assess the patient for pain.

· Colleagues:  You can also ask PACU colleagues about a patient's treatment for pain, even if it's just reassurance that you're on the right track.

Pain crisis

Sometimes, we care for a patient in PACU who is having a "pain crisis" where they are in so much pain that the patient is nearly hysterical.

Anaesthetic review:

· Firstly, get the patient reviewed by the anaesthetist; do not leave the patient so get another nurse to seek the review. It is important to stay on the patient's side and continually reassure them.

· Speak calmly and reassuringly to the patient.

· Tell the patient every step you are taking. It is essential to keep them informed.

Analgesia administration:

· It is very important to administer the analgesia regularly when the patient is in a Pain Crisis. If prescribed for every 5 minutes, then you MUST administer it that frequently to get the patient out of the pain crisis.

· Administer all available analgesic agents that the anaesthetist recommends after the review.

Clinical judgment:

· When the patient is this hysterical, they will be unable to respond to any questions, so you will have to use your clinical judgment.

Additional measures:

· Assess the patient to see if any of the additional measures are relevant.

Hydration:

· Ensure the patient's IV therapy is running as per orders

Oxygenation:

· Oxygenation: Keep supplemental oxygen going. They are unlikely to tolerate a facemask, but nasal prongs will be tolerated. Another trick is to use a facemask but place it on the patient's chest, with the open part of the mask facing the patient's face.

Additional viewing

Dr. Matt and Dr. Mike's YouTube channel also has a video all-encompassing the pain, including pain pathways, physiology, and analgesia. It is 1 hour and 4 minutes long but worth watching.

Reflection Questions: (Note that reflective learning activities are not compulsory but will improve your understanding of the subject).

Management of Pain

1. How can the use of multi-modal pain management strategies improve patient outcomes in the PACU?

2. What role do psychological and social factors play in a patient's experience of pain, and how can PACU nurses address these factors?

Pain Crisis

1. What immediate actions should a PACU nurse take when a patient is experiencing a pain crisis, and why is it important to stay with the patient?

2. How can effective communication and a calm, reassuring manner help in managing a patient's pain crisis in the PACU?

References

References:

Phillips, N., & Hornacky, A. (2020). Berry & Kohn's Operating Room Technique (14th ed.). Elsevier.

Rothrock, J. C. (2022). Alexander's Care of the Patient in Surgery (17th ed.). Elsevier.

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