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This book has been written by C. Paul Wicker and Sara Dalby for perioperative practitioners (students, nurses and ODPs) and junior doctors who work in anaesthetics, surgery and recovery. This Rapid series book covers a wide range of subjects related to perioperative practice and perioperative care, and each chapter is relatively short and concise so that practitioners can read the chapter efficiently and effectively, which will encourage them to learn how to undertake tasks and actions within the operating department. This book will provide practitioners with detailed knowledge and understanding of many aspects of perioperative practice which will support them in their work in clinical practice and enable them to deliver the best possible care to all perioperative patients.
This book will use a structured approach to perioperative care, starting with an introduction to the perioperative environment, anaesthetics, surgery and recovery, and critical care for patients who have serious health problems.
The first section is called ‘Preoperative Preparation’ which covers areas such as roles of theatre practitioners, preoperative assessment checklists, perioperative equipment, medication and several other chapters. This is an important area for junior theatre practitioners so that they know how to prepare the operating room prior to the patient arriving.
The second section is called ‘Anaesthesia’ and is related to anaesthetic procedures, which are very important to patients because, basically, anaesthesia maintains their homeostasis and physiological status during surgical procedures. Chapters include checking anaesthetic equipment, general and local anaesthesia, rapid sequence induction, airway management and so on. The purpose of anaesthesia is to keep the patient unconscious during the surgical procedure, and maintain oxygenation, blood pressure, pulse, and fluid levels throughout the surgery. The use of anaesthetic drugs also helps to prevent postoperative pain and can help prevent problems such as low blood pressure or malignant hyperthermia.
The next three sections are related to surgery – ‘Surgical Specialities’, ‘Surgical Scrub Skills’ and ‘Surgical Assisting’. The first two sections cover many areas of surgery, including all aspects of surgery such as vascular, breast, orthopaedics, laparoscopic and colorectal surgery, as well as skin preparation, electrosurgery, wound healing, dressings, haemostasis and so on. These two sections cover most surgical specialities and also all aspects of actions taken during surgery by both the surgeons and the scrub practitioner. The final section on surgery covers the actions taken by surgical assistants, including legal issues, suture materials, wound closure, camera holding, retraction and so on. This chapter will provide you with detailed information about the role of the surgical assistant, which will help you to understand fully the ability to assist surgeons, for those practitioners who have undertaken appropriate first assistant training.
The sixth section is called ‘Recovery’ and is related to recovery care of patients. Chapters include recovery room design, patient handover, monitoring, assessment, medications, bleeding problems and so on. When the patient enters the recovery room, he or she recovers from the anaesthesia and surgery. Recovery practitioners monitor patients carefully to ensure they don't suffer side effects and do recover from their anaesthesia and surgery safely. Monitoring includes respiration, breathing, blood loss, temperature, blood pressure, pulse and so on. Patients may also need supervising in case of postoperative problems caused by anaesthetic drugs, for example anxiety or delirium.
Postoperative problems include many areas such as postoperative pain, nausea and vomiting, electrolyte imbalance, low fluid balance, low blood pressure, malignant hyperthermia and so on. These problems may be resolved by recovery staff or may need an anaesthetist's or surgeon's actions. The 13 chapters regarding recovery should provide you with a good level of knowledge and skills in regards to caring for postoperative patients.
The final section is about ‘Perioperative Critical Care’ which covers areas such as management of critically ill patients, hypothermia, hyperthermia, deep vein thrombosis, latex allergies, pressure ulcers, diabetes, anaemia, morbidly obese patients and others. Critical care of patients is important and urgent when they are suffering from serious illnesses or conditions, and so these 13 chapters cover many areas which will be of interest to you when you need to deal with these patient conditions.
This Rapid series book on perioperative care will provide theatre practitioners with short, detailed and concise information about many aspects of their role. This will be useful for trained staff and for students and will help to ensure patient safety and effective working.
Enjoy this book and we hope that you like it!
Acknowledgements
Sara Dalby and myself have asked many people to review the chapters to ensure they are written correctly and clearly. This has taken some time to undertake; however, all chapters have been reviewed and updated which has been of great benefit to us both.
The reviewers who have checked over all the chapters which Paul Wicker has written include Africa Bocos (my wife), Rachel Simpson, Ashley Wooding, Helen Lowes, Laura Rowe and Natalie Lockhart. These reviewers are all qualified operating department practitioners, and they have read through the chapters thoroughly in order to ensure they are correct and well written. Some of the chapters were updated which has helped me in ensuring the chapters are read easily and contain the correct information. Paul Wicker gives his best and sincerest thanks to these reviewers for all the work they have done in updating my chapters.
Sara Dalby also asked several reviewers to look at all the chapters she has written in regards to surgery to ensure the chapters are accurate and concise. Sara would like to thank all these reviewers for their help and assistance, and their knowledge and skills in reading the chapters and updating them.
These people include:
Jill Mordaunt, Practice Education Manager
Jennie Grainger, Registrar General Surgery with Specialist Interest in Coloproctology
Elizabeth Clark, Consultant Anaesthetist
Kaylie Hughes, Speciality Registrar Urology
Tim Gilbert, Core Surgical Trainee General Surgery
Dave Ormesher, Speciality Registrar Vascular Surgery
Laura Ormesher, Speciality Registrar Obstetrics and Gynaecology
Claire Morris, Speciality Leader Orthopaedics and Trauma
Zoe Panayi, Senior House Officer General Surgery
Elizabeth Kane, Core Surgical Trainee General Surgery
Helen Bermingham, Core Surgical Trainee General Surgery
Andrew McAvoy, Speciality Registrar Colorectal Surgery
Kristen Daniels, Physician Assistant Plastic Surgery
Photos have kindly been provided by Aintree University Hospital, Liverpool Womens Hospital, and from the Cadaveric Workshop at University of South Manchester.
Finally, we would also want to thank Karen Moore and James Watson for their help in developing our book from John Wiley & Sons Limited, and for their help and support in getting this book published.
Kind regards to all.
Paul Wicker
Sara Dalby
Abbreviations
AAA
abdominal aortic aneurysm
AAGBI
Association of Anaesthetists of Great Britain and Ireland
ABG
arterial blood gas
ACL
anterior cruciate ligament (knee)
ACS
acute coronary syndrome
AF
atrial fibrillation
ARDS
adult respiratory distress syndrome
ARF
acute renal failure, acute rheumatic fever
AV
arteriovenous or arterial-venous
AVR
aortic valve replacement
BMD
bone mass density
BMI
body mass index
BMR
basic metabolic rate
BNF
British National Formulary
BP
blood pressure
C
centigrade, Celsius
C/S
caesarean section
CABG
coronary artery bypass graft
CAD
coronary artery disease
CBD
common bile duct
CBF
cerebral blood flow
CEA
carotid endarterectomy (vascular surgery)
CF
cystic fibrosis
CHD
congenital heart disease
CHF
chronic heart failure
CNS
central nervous system
CO2
carbon dioxide
COPD
chronic obstructive pulmonary disease
CPAP
continuous positive airway pressure
CPR
cardiopulmonary resuscitation
CT
computed tomography
CV
cardiovascular
CVC
central venous catheter
CVD
cardiovascular disease
CXR
chest x-ray
DCU
Day Case Unit
DoH
Department of Health
DIC
disseminated intravascular coagulation
DL
direct laryngoscopy
DOB
date of birth
DVT
deep vein thrombosis
ECF
extracellular fluid
ECG
electrocardiogram; electrocardiography
ECT
electroconvulsive therapy
EEG
electroencephalography
ET
endotracheal
ETT
endotracheal tube
F
Fahrenheit
FEF
forced expiratory flow
fem-fem
femoral-to-femoral bypass (vascular surgery)
fem-pop
femoro-popliteal bypass (vascular surgery)
FFP
fresh frozen plasma
GA
general anaesthesia
GU
genitourinary
H&P
history and physical examination
H2O
water
HA
haemolytic anaemia
HAV
hepatitis A virus
Hb
haemoglobin
HBV
hepatitis B virus
HCPC
Health and Care Professions Council
HCV
hepatitis C virus
HR
heart rate
I&D
incision and drainage
ICF
intracellular fluid
ICP
intracranial pressure
IHD
ischaemic heart disease
IM
intramuscular
IP
inpatient
IPPV
intermittent positive pressure ventilation
ISF
interstitial fluid
IV
intravenous
IVC
inferior vena cava
IVF
in vitro fertilization
IVIG
intravenous immune globulin
K
potassium
kg
kilogram
L
litre
LIH
left inguinal hernia
LMA
laryngeal mask airway
LV
left ventricular
MD
muscular dystrophy
MH
malignant hyperthermia
MI
myocardial infarction
ML
millilitre
mol
mole
MS
multiple sclerosis
MVR
mitral valve replacement
NG
nasogastric
NICE
National Institute for Health and Care Excellence
NM
neuromuscular
NPSA
National Patient Safety Agency
NSAID
nonsteroidal anti-inflammatory drug
O2
oxygen
ODP
operating department practice, operating department practitioner
OPD
outpatient department
P
pulse
Pa
Pascal
PaCO2
arterial carbon dioxide partial pressure (measured from a blood gas sample)
PACU
post-anaesthesia care unit
PAH
pulmonary arterial hypertension
PaO2
arterial oxygen partial pressure (measured from a blood gas sample)
PAP
pulmonary artery pressure
PAWCP
pulmonary artery wedge capillary pressure
pCO2
partial pressure of carbon dioxide
PE
pulmonary embolism
PEEP
positive end expiratory pressure
PKD
polycystic kidney disease
PNS
peripheral nervous system
pO2
partial pressure of oxygen
PONV
postoperative nausea and vomiting
RA
right atrium
RBC
red blood cell
RCT
randomised controlled trial
RHD
rheumatic heart disease
RSI
rapid sequence induction
SaO2
saturation level of arterial oxyhaemoglobin
SBO
small bowel obstruction
SIRS
systemic inflammatory response syndrome
SOB
shortness of breath
SpO2
oxygen saturation measured by a pulse oximeter
SVA
supraventricular arrhythmia
SVT
supraventricular tachycardia
T
temperature
TAH
total abdominal hysterectomy
TB
tuberculosis
TBI
traumatic brain injury
TGA
transient global amnesia
TIA
transient ischaemic attack
TIMI
thrombolysis in myocardial infarction
TIVA
total intravenous anaesthesia
TURP
transurethral resection of prostate
TVR
tricuspid valve replacement
TVV
tricuspid valve valvuloplasty (valve repair)
UA
urinalysis
UE
upper extremity
UFH
unfractionated heparin
UO
urine output
URI
upper respiratory infection
UTI
urinary tract infection
VCO2
carbon dioxide production
VF
ventricular fibrillation
VHD
valvular heart disease
VO2
oxygen consumption
VS
vital signs
VT
ventricular tachycardia
WB
whole blood
WBC
white blood cell
Section 1 Preoperative Preparation
Paul Wicker
Chapter 1 The Role of the Anaesthetic Practitioner
An anaesthetic practitioner is an essential member of the operating department team working alongside anaesthetists, surgeons, practitioners and healthcare support workers to ensure that anaesthesia for the patient is as safe and effective as possible. Anaesthetic practitioners provide high standards of patient care and skilled support alongside the other members of the perioperative team during the perioperative phases before, during and after surgery (Fynes et al. 2014). It is also essential that they continue with updates and attend current in-house training to maintain their skills and knowledge.
The role of the anaesthetic practitioner has nationally agreed standards and levels of practice, implemented by the Royal College of Anaesthetists (RCA 2006). An anaesthetic practitioner's roles are also covered by the College of Operating Department Practitioners and the Health Care Professions Council. Hospital regulations manage these standards appropriately and are implemented within a nationally recognised framework (Fynes et al. 2014).
The roles and responsibilities of anaesthetic practitioners include working by themselves to prepare equipment and providing care for the patient, as well as offering support to the anaesthetist during all stages of anaesthesia (Fynes et al. 2014). The main roles and responsibilities of the anaesthetic practitioner include:
To deliver psychological and emotional support to the patient
To check the anaesthetic machine
To prepare the anaesthetic equipment
To support the patient throughout the stages of anaesthesia
To support the anaesthetist during anaesthesia
To understand responsibility and accountability for the patient during anaesthesia, including patient documentation, for example the consent form and the World Health Organization (WHO) Surgical Safety Checklist.
Preanaesthetic phase
The anaesthetic practitioner assists the patient before surgery and provides individualised care. This will include supporting the patient by reducing anxiety, placing blood pressure cuffs, connecting electrocardiograph (ECG) electrodes and pulse oximeters, and preparing IV fluids and anaesthetic drugs (NHS Modernisation Agency 2005). The practitioner will also communicate effectively within the team to pass on problems, issues or any past adverse events, such as when catheterising patients and when preparing and assisting in the safe insertion of invasive physiological monitoring such as central venous pressure (CVP) lines and arterial lines.
The anaesthetic practitioner is also able to support the patient if he or she has any concerns. For example, most patients fear anaesthesia, because of fearing the risk of waking up too early or not waking up following surgical procedures. Many patients ask, ‘Will I wake up alright after surgery?’ and then become anxious if they don't receive a reply. One of the main roles is therefore to provide psychological support, which is something that practitioners can do on a face-to-face basis. This may include discussing problems, offering reassurance to the patient to let them know they are monitored safely, ensuring the patient is comfortable, talking to the patient and reassuring the patient throughout their time in theatre (Fynes et al. 2014).
The anaesthetic practitioner will also undertake roles which will also involve many clinical skills, such as preparing a wide range of specialist equipment and drugs (Copley 2006). This includes:
Testing anaesthetic machines
Preparing anaesthetic equipment (AAGBI 2012)
Preparing intravenous equipment
Making devices available to safely secure the patient's airway during anaesthesia
Ensuring drugs such as propofol, local anaesthetics, anaesthetic gases and so on are available
Knowledge of the different operating tables, including positioning equipment, clamps and pressure-relieving devices.
Anaesthesia
There are three parts to anaesthesia:
Induction: This is when the patient goes to sleep using anaesthetic drugs.
Maintenance: This is maintaining the anaesthetic during surgery.
Reversal: This is wakening the patient up by stopping the administration of drugs and anaesthetic gases, or by using specialist drugs to revive the patient (Goodman & Spry 2014).
Responsibility of the practitioner for the care of the patient throughout the stages of anaesthesia is vitally important (Fynes et al. 2014). The practitioner is responsible for ensuring the patient is positioned correctly to maintain safety and comfort, to ensure pressure areas are supported, and also to provide maximum access during the operative procedure. The practitioner also needs to follow legal and ethical considerations, and ensure that they are following the Health and Care Professions Council (HCPC) regulations and guidelines.
Checking the anaesthetic machine
Making sure the anaesthetic machine is working correctly is an essential part of the anaesthetic practitioner's role, in collaboration with the anaesthetist. Knowing ‘how’ it works is of course equally important (Goodman & Spry 2014). During induction of anaesthesia, the patient is at one of the most vulnerable points in his or her perioperative care. Equipment error can therefore put the patient at high risk of harm, for example through airway obstruction, circulatory problems, reduced blood oxygenation or even death, because of errors such as flow reversal though the back bar on the anaesthetic machine (Smith et al. 2007).
Practitioners should check the anaesthetic machines by using the Association of Anaesthetists of Great Britain and Northern Ireland checklist (AAGBI 2012) and the manufacturer's manual as guides to ensure the machine is safe to use. There is a joint responsibility between the anaesthetist and anaesthetic assistant for ensuring the correct functioning of anaesthetic equipment before patient use. Often, the anaesthetic assistant will assemble and check the equipment in preparation for the anaesthetist, who then ensures that he or she has the correct equipment for the anaesthetic procedure. The assistant's role is therefore to support the anaesthetist, check the equipment and ensure the patient's safety (Wicker & Smith 2008).
Errors during anaesthesia have often been associated with lack of proper equipment checks. However, checking an anaesthetic machine using a checklist can lead to a reduction of incidents. Patient safety can be increased by the use of the checklist for checking new anaesthetic machines which can highlight faults during their manufacture. For example, wrong assembly of the anaesthetic machine can lead to errors such as high dosages of volatile agents. The use of a checklist also needs to be carried out when equipment is returned from servicing – it cannot be guaranteed that a serviced or brand-new anaesthetic machine is working perfectly. A thorough check will therefore ensure the equipment has been returned in a working condition and is ready for use. However, it is not the ultimate responsibility of the anaesthetic practitioner to ensure the anaesthetic machine is in perfect working order; it is the anaesthetist who carries the main responsibility. Nonetheless, practitioners have a duty of care to identify and report any faults and are also responsible for their actions, including recordkeeping of anaesthetic machine checks (Fynes et al. 2014).
Monitoring responsibilities
The anaesthetic practitioner's responsibility is to attach two ECG electrodes to the patient's upper left and right-sided chest, and one ECG electrode to the lower left side of the chest, before anaesthesia so heart rate and rhythm are monitored by the ECG monitor during induction of anaesthesia. There are many other areas to monitor, and three of the most important are blood pressure, oxygen saturation and temperature.
Non-invasive blood pressure (NIBP) measurement
Pulse oximeters
A pulse oximeter measures the patient's oxygen saturation in their blood. Normal oxygen saturation is between 95 and 100%; anything less than 95% is seen as causing problems for the patient. Patients with chronic obstructive pulmonary disease (COPD) may also suffer from hypoxia. The pulse oximeter is normally attached to a finger, but it can also be attached to an earlobe or toe. The light source in the probe passes through the tissue, and the patient's oxygen concentration is measured via the absorption of the light, then recorded on the monitoring screen (O'Neill 2010). The light is detected by light sensors and is altered by the levels of oxyhaemoglobin and deoxyhaemoglobin. The pulse oximeter should be regularly checked to ensure that it is correctly placed on the extremity and also that circulation at that point is not impaired. Constantly observing the patient's oxygen levels is essential during anaesthesia, and using a pulse oximeter is one of the most important monitors used during anaesthesia as it can help to identify patient problems associated with low oxygen levels (Valdez-Lowe et al. 2009).
Conclusion
Anaesthetic practitioners have the potential to contribute to team working, and this results in enhancing patient care and patient access, improving operating room capacity and reducing cancellations and waiting times. Practitioners can also enhance the learning experiences of anaesthetic trainees and other junior anaesthetic practitioners.
