Anesthesia

101

Everything
you need to know

Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
 2.8 1.5
ANCC CONTACT HOURS CONTACT HOURS

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By Laura Palmer, DNP, CRNA, MNEd

Successful patient outcomes from an operative procedure require vigilance,

diligence, and teamwork among the various providers involved with the
surgical procedure. An understanding of the responsibilities and appreciation
for the complexities of each healthcare provider’s role in the operative
process is essential to a harmonious relationship among the perioperative
team to improve the working environment and provide safe patient care.
The information provided in this article is based on commonly observed
practices in the anesthesia community with the caveat that the choices can
vary considerably and are influenced by patient presentation and surgical
requirements.

Provision of anesthesia services

Several regulatory agencies at state and federal levels, along with reimburse-
ment requirements, control who can provide anesthesia services. Providers
are generally limited to physicians, certified registered nurse anesthetists
(CRNAs), and anesthesia assistants (AAs) in a limited number of states. The
practice patterns commonly seen are: anesthesiologists or CRNAs indepen-
dently providing direct anesthesia care, CRNAs and anesthesiologists work-
ing together in the anesthesia care team model, or physicians medically
directing AAs. CRNAs receive direct reimbursement from the Centers
for Medicare and Medicaid Services, but AAs must always work with
anesthesiologists in the medical direction model.1 Although the provider
administering anesthesia can vary by practice setting and geographic
location, the process and goals are comparable.

Types of anesthesia
When anesthesia services are necessary, there are several options to provide
the patient with pain relief, reduce anxiety, and meet the requirements of
the surgical procedure. There are three basic types of anesthesia: general,
regional, and monitored anesthesia care (MAC); sometimes, a combination

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 Anesthesia 101: Everything you need to know
of techniques is appropriate. General anesthesia is
selected when the patient and surgical needs require
complete immobility and unconsciousness. Regional
anesthesia includes spinal and epidural anesthetics
(neuraxial blocks) and peripheral nerve blocks of
various types. These techniques are often appropriate
for surgeries involving the extremities or the lower
abdomen and perineal area. Although a regional
technique can provide complete pain relief to the
operative area, patients are often more comfortable
when sedation is also administered.
Patients can be distracted and fearful of the ambi-
ent noises in an OR combined with the conversa-
tions between the surgical and anesthesia teams. In
addition, despite surgical site anesthesia, the patient
may find the pressure of the drapes on areas not
anesthetized to be uncomfortable. Sensations from
surgical manipulation can extend outside the anes-
thetized area, and although they may not be painful,
they can add to the discomfort.
In select cases, surgery can be performed with
various levels of sedation combined with a local anes-
thetic injected at the operative site by the surgeon.
The term MAC is an anesthesia service description
and includes all levels of sedation from minimal to
deep.2 MAC requires the anesthesia provider to be
capable of converting to general anesthesia (if neces-
sary) in addition to being skilled at advanced airway
management if deep sedation causes airway compro-
mise. The depth of sedation that can be provided by
nonanesthesia providers, usually RNs, is controlled
by regulations, such as state nurse practice acts and
institutional guidelines, and is usually limited to
minimal or moderate sedation where airway com-
promise isn’t expected.
Regional anesthesia can be useful in many cases
for postoperative pain control, sometimes initiated
before the surgery and combined with a general
anesthetic to provide the conditions required to
perform the procedure.
Preoperative management
The anesthesia provider performs a thorough pre-
operative evaluation, which is essential to identify
comorbidities and assess the patient’s current health
status to determine the most appropriate type of
anesthesia. In this preoperative period, the entire
perioperative team should discuss the assessment of
safety risks and the use of checklists, which are rec-
ommended by the World Health Organization, The
22 OR Nurse 2013 July
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Joint Commission, and the FDA Safe Use Initiative.3-5
Risk assessment, such as the prevention of intraoper-
ative fire, rely on the combined vigilance of the OR
staff, surgeon, anesthesia providers, and effective/
open communication with an understanding of each
provider’s responsibility, which can help prevent
disastrous patient outcomes. Presurgical checklists
emphasize verification of the correct patient, correct
procedure, and, if relevant, correct side. These tools
have demonstrated effectiveness, but their routine
implementation in clinical practice isn’t uniform.6
General anesthesia
The goals of general anesthesia are to provide amne-
sia, analgesia, and immobility. Analgesia includes a
blockade of the sympathetic response to noxious
stimuli, specifically surgical stimulation. If needed,
neuromuscular blocking drugs (NMBDs), also known
as muscle relaxants, may be administered to facilitate
surgical access to the operative region. The process
of general anesthesia begins with a phase known as
induction, which is accomplished by two methods.
Injection of an I.V. drug is the common approach in
the adult population and is a rapid process in which
unconsciousness is achieved roughly 1 minute after
administration of the induction medication. All of the
agents used for inductions produce an expected
apnea, and airway management skill is essential. In
the pediatric population, where gaining I.V. access
preoperatively isn’t well-tolerated, a volatile anes-
thetic agent by mask is the preferred approach for
induction. Compared to I.V. induction, an inhalation
induction requires more time to take effect, and the
patient may demonstrate progression through the
various stages of anesthesia not seen with an I.V.
induction.7
Most important is that some patients experience
excitement when progressing from drowsiness to
unconsciousness. This is a critical phase with the
potential for several adverse events, such as thrash-
ing or movement, vomiting, laryngospasm (closure
of the vocal cords obstructing air flow), and dysrhyth-
mias. Although a quiet environment is preferred for
all inductions, minimizing noise with this technique
is especially important because auditory senses are
heightened, and exaggerated responses may occur.
All OR personnel should be vigilant for sudden
movements that could cause the patient to fall
from the OR table, especially in the pediatric envi-
ronment where safety belting is limited in smaller
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 LMA and endotracheal intubation
A. Laryngeal mask airway. B. Intranasal endotracheal intubation. C. Oral endotracheal intubation

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Source: Smeltzer SC, Bare BG, Hinkle JL, Cheever KH. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. 12th ed. Philadelphia, PA: Wolters
Kluwer/Lippincott Williams & Wilkins; 2010:450.
patients. Since airway compromise can occur rap-
idly, it’s essential to have additional OR personnel
available.
When general anesthesia is selected, there are
several options for the type of induction and medi-
cation choices. The anesthesia provider must deter-
mine whether endotracheal intubation is required
or if an alternative airway device, such as a laryngeal
mask airway (LMA), can be used (see LMA and
endotracheal intubation). These are reserved for cases
meeting specific requirements, including patients
who have been N.P.O. and without known risk
of aspiration because the LMA is seated proximal
to the glottis and doesn’t seal the airway from
secretions.8
Since the introduction of the LMA into clinical
practice in 1988, there’s been considerable contro-
versy regarding the selection criteria for use of this
device in different clinical situations, often with
opposite viewpoints represented in the literature
and reflected in clinical practice.9 An LMA is usually
chosen for cases in which the torso is supine, since
the LMA doesn’t secure the airway, and some anes-
thesia providers view lateral or prone position as a
risk for dislodgement. Use of the lateral position
does seem to be increasing, however. Other limiting
factors include the length of the case, with less than
a few hours preferred, overall hemodynamic stability
of the patient, and surgery not within the abdominal
or thoracic cavity, which requires airway control and
muscle paralysis.
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&2UDOHQGRWUDFKHDOLQWXEDWLRQ
An advantage to using an LMA is that it elimi-
nates the risks associated with intubation of the tra-
chea, such as trauma and dental damage. Although
anesthesia can be provided in select circumstances
via mask, this method has been largely replaced
by LMAs, which free the provider’s hands for
other tasks.9
The sequence of actions during a standard induc-
tion with intubation usually starts with the adminis-
tration of preoperative sedation, sometimes in the
holding area, and additionally after the patient is
secured on the OR table and monitors are applied.
Midazolam, a water-soluble benzodiazepine, is com-
monly used for sedation because it reduces anxiety
and causes amnesia with minimal cardiovascular
effects. Patients receive oxygen via facemask prior
to receiving an I.V. induction agent.
After determining that the patient is unconscious,
an NMBD is administered. It’s important to note,
that when an endotracheal tube (ETT) is required
for airway management, it’s placed after the patient
is determined to be unconscious from the induction
drug and has received an NMBD. There are two
types of NMBDs, and they’re classified according to
their mechanism of action. Laryngoscopy is a nox-
ious stimuli, and the airway’s innervation is complex
with strong protective reflexes. The resulting hyper-
tension and tachycardia (if undesirable) can be atten-
uated by several methods, including the addition of
opioid analgesics, local anesthesia to the trachea, or
specific cardiovascular drugs, although none are ideal.10
July OR Nurse 2013 23
 Anesthesia 101: Everything you need to know
The patient is ventilated by mask until paralysis is
complete, usually within 1 to 3 minutes, depending
on the NMBD and dose used. Intubation can be
performed by direct visualization of the vocal
cords using a laryngoscope with either a curved
(Macintosh) blade or a straight (Miller) blade, depend-
ing on provider preference. Video laryngoscopy for
intubation is gaining in popularity with both portable
and fixed mount devices available.11 The oral ETT
can be prepared with a stylet to maintain an anatom-
ic curve to facilitate intubation or inserted without a
stylet depending on provider choice and patient
presentation. The ETT is secured after verification
of tube placement by continuous capnography (end-
tidal CO2 [ETCO2] monitoring), clinical signs, and
auscultation of breath sounds. A volatile inhalation
agent or a combination of I.V. medications may be
used to maintain anesthesia. Additionally, nitrous
oxide (N2O) can be included for maintenance; how-
ever, the use of this agent has stirred controversy for
several reasons, including increased risk of postopera-
tive nausea and vomiting (PONV), potential cellular
toxicity, effect on embryonic development, and
absorption into air-filled cavities.11 The introduction
Structures of the larynx
Anterior view
Epiglottis
Greater horn of hyoid bone
Lesser horn of hyoid bone
Thyrohyoid membrane
Median thyrohyoid ligament
Oblique line
Median cricothyroid ligament
Inferior horn of thyroid cartilage
Cricothyroid muscle
(straight and oblique)
Trachea
Source: The Anatomical Chart Company
24 OR Nurse 2013 July
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of more potent and safe volatile agents provides a
viable alternative.
In a patient determined to be at risk for aspira-
tion during induction (for example, obese patients,
those with a history of gastric reflux, or patients
who haven’t been NPO), the induction technique
known as rapid sequence induction (RSI) is often
utilized. Although availability of suction equipment
is required for all inductions, a second suction is
recommended as backup should regurgitation
occur, equipment fail, or the suction become
clogged by particulate matter.
The noticeable difference between an RSI and
a standard induction is that cricoid pressure is
initiated on induction and continues until the ETT
placement is verified. The cricoid cartilage is the
only tracheal structure that forms a complete ring,
which can compress the esophagus located poste-
rior and mechanically block fluid from migrating
into the oropharynx and airway, causing aspira-
tion pneumonia (see Structures of the larynx). In
addition, the I.V. induction agent is followed
immediately by the NMBD, and there’s no manual
ventilation, as this process may force air through
the esophagus and into the
stomach, increasing the risk of
regurgitation.11
NMBD choices are limited to
agents in doses that will pro-
duce intubating conditions in
1 minute, such as succinylcho-
line or rocuronium. This apneic
Hyoid bone period isn’t always well-tolerat-
Superior horn of thyroid cartilage ed despite adequate preoxygen-
Lateral thyrohyoid ligament ation, and if desaturation occurs,
the technique can be modified
to include gentle ventilation
Superior thyroid notch with cricoid pressure to main-
tain oxygenation at safe levels.11
Inferior thyroid notch
When an LMA is used for
general anesthesia, the induction
is simplified. After sedation and
preoxygenation, an I.V. induction
Cricoid cartilage (arch)
agent is administered. No NMBD
is needed for LMA placement,
and after the patient is uncon-
scious, the LMA is inserted. The
patient usually receives a volatile
inhalation agent titrated to main-
tain anesthetic depth appropriate
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for the surgery; however, a propofol infusion
can also be used.
I.V. induction agents
Historically, the drug most associated with I.V.
induction was thiopental sodium, an ultrashort-
acting thiobarbiturate. In recent years, thiopental
sodium use began to rapidly decline in favor of
newer agents, and in January 2011, the sole manu-
facturer permanently ceased production of the drug
in the United States.12
Currently, propofol is the I.V. induction agent
routinely used. The drug is known for several
desirable attributes, such as a rapid return to a
clear mental state for recovery, and providing a
pleasant overall anesthetic experience. It doesn’t
simply reduce the incidence of PONV; it has
antiemetic properties.11 In addition to producing
unconsciousness with the common induction, pro-
pofol can be used for maintenance of anesthesia
and sedation, and is usually administered by con-
tinuous infusion. Propofol can cause burning on
injection, and anesthesia providers can minimize
the discomfort by using a large forearm or antecu-
bital vein for drug administration, mixing lido-
caine with the drug or pretreating the patient with
a small bolus of lidocaine to anesthetize the vein.
Despite its many advantages, propofol can
decrease BP primarily as the result of significant
vasodilation and concurrent myocardial depres-
sion. Those most susceptible to the hypotensive
effects of propofol include older adults, hypovo-
lemic patients, and those with impaired compen-
satory mechanisms; therefore, an alternative
induction agent is usually chosen.11
Etomidate is the I.V. induction agent most often
used for patients with myocardial contractility
impairment where propofol would likely cause an
undesirable and dangerous drop in BP. The induc-
tion dose of etomidate has a similar onset profile
as propofol, with unconsciousness produced in
about 1 minute, but has minimal cardiovascular
effects. Although it may seem reasonable to use
etomidate routinely for healthy patients, the many
adverse reactions associated with etomidate pre-
clude this choice for most anesthesia providers.
These adverse reactions include a dose-dependent
adrenocortical suppression, myoclonus, pain on
injection, and an increase in PONV.11 Unlike
propofol, which can be administered throughout
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the case, etomidate is usually used only as an
induction agent.
There are two other I.V. agents that can be used
in selected circumstances when propofol or etomi-
date are not appropriate choices for induction.
Ketamine is most often reserved for patients with-
out ischemic cardiovascular disease who are hypo-
volemic and hypotensive. It’s usually used for the
trauma patient with substantial blood loss and in
need of emergent surgical intervention. Ketamine
is unique in that it doesn’t induce unconsciousness
by depressing central nervous system activity but is
a phencyclidine derivative, causing dissociative
anesthesia, which interrupts normal synaptic path-
ways, disrupting perception and reaction to stimuli.
Ketamine causes sympathetic stimulation, which
increases endogenous catecholamines, helping to
maintain BP in the compromised patient. In addi-
tion, ketamine can provide bronchodilation and
is the only induction agent with analgesic proper-
ties.11 Ketamine can also be administered I.M.
in select circumstances where I.V. access is
problematic. Hallucinations and perceptive distor-
tions can limit the routine use of this agent.
Methohexital is an ultrashort acting oxybarbitu-
rate, and although similar in many ways to thiopental
sodium, it doesn’t reduce the seizure threshold like
other barbiturates. This has led to the specific use of
methohexital for induction of anesthesia for electro-
convulsive therapy where the therapeutic effect of the
treatment may be related to the associated seizure.13
Although methohexital can be used for routine
induction of anesthesia or sedation, it’s largely been
replaced by propofol.
Inhaled anesthetics
The current inhalation agents and techniques in
clinical practice have evolved from the early days
of the discovery of the pain relieving properties of
substances, such as ether, chloroform, and N2O.
N2O is a gas that is delivered by a specific flowme-
ter on the anesthesia gas machine (AGM). The
concentration of oxygen delivered to a patient
should always exceed room air (21%), and for
safety reasons, levels of 25% to 30% oxygen are
usually the minimum provided. Therefore, N2O
concentrations rarely exceed 70%, and most
anesthesia providers often do not exceed 50%.
N2O isn’t a potent agent and can only be used to
supplement other agents during general anesthesia.
July OR Nurse 2013 25
 Anesthesia 101: Everything you need to know

N2O diffuses quickly into air-filled spaces, caus- N2O is also associated with PONV, especially in at-
ing dramatic increases in pressure or volume risk populations, which include those with a history
depending on the ability of the surrounding struc- of PONV or motion sickness, women, nonsmokers,
tures to distend and the concentration of the agent. and younger patients.14
The other inhalation agents are classified as vola-
tile and chemically halogenated, often with fluorine,
How NMBDs work and delivered through the AGM circuit by agent-
Depolarizing NMBD specific vaporizers. Several agents, such as halothane
Succinylcholine, the only NMBD in this category, and enflurane, are no longer used, leaving the fol-
mimics the action of acetylcholine and binds to lowing three agents in current anesthesia practice:
the cholinergic receptor sites on skeletal muscle
isoflurane, sevoflurane, and desflurane. Although
cells. This causes the cells to depolarize, leading to
there are subtle differences, the selection is based
muscle relaxation.
largely on provider preference. Inhalation anesthet-
Succinylcholine
ics are widely used for induction in the pediatric
population and maintenance of anesthesia in adults
either alone or in combination with I.V. agents to
meet the required goals of general anesthesia.
Cholinergic
receptor site Neuromuscular blocking drugs
Paralysis is routinely used to provide optimal condi-
tions for intubation in general anesthesia, but main-
taining skeletal muscle paralysis throughout the case
Initiation of
muscle largely depends on surgical requirements. There
response
are two categories of NMBDs determined by their
mechanism of action: depolarizing and nondepolariz-
ing NMBDs (see How NMBDs work). The depolariz-
ing agent, succinylcholine, works by depolarizing
Nondepolarizing NMBDs
the neuromuscular junction (NMJ), and, in essence,
Nondepolarizing NMBDs compete with acetylcho-
behaves as a long-acting acetylcholine, the neu-
line at the cholinergic receptor sites on skeletal
muscle cells. This competition prevents acetyl-
rotransmitter responsible for activation of muscle
choline from reaching the motor endplates, thus, fibers. Succinylcholine causes an unsynchronized
disrupting nerve impulse transmission at the motor contraction of skeletal muscles visible as twitching,
endplate, resulting in neuromuscular blockade. referred to as fasciculations. This is the only drug in
the depolarizing NMBD category and has many
Nondepolarizing adverse reactions. The most serious of these include
neuromuscular
blocker dysrhythmias, massive fatal hyperkalemia in muscle
wasting diseases, and prolonged paralysis in patients
who demonstrate genetic defects in the enzyme
needed to metabolize the drug (pseudocholinester-
Cholinergic
ase deficiency).11 Despite the many adverse
Acetylcholine
receptor site reactions of the drug, it’s the only NMBD that
has both rapid onset and rapid recovery, so it’s
still used in current anesthesia practice. Since this
drug causes total body paralysis lasting a minimum
of 5 minutes and there’s no reversal agent, airway
management is critical.
The nondepolarizing category of NMBDs compete
with acetylcholine at receptors necessary for normal
Source: Surgical Care Made Incredibly Visual. Philadelphia, PA:
Lippincott Williams & Wilkins; 2007:32.
muscle contraction at the NMJ. There’ve been
several drugs in this category that aren’t used as

26 OR Nurse 2013 July www.ORNurseJournal.com

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often anymore because of adverse reactions or pro-
duction has been discontinued. The nondepolarizing
NMBDs currently used include the following:
rocuronium, vecuronium, cisatracurium, and, to a
lesser extent, pancuronium. These drugs can be used
for skeletal muscle relaxation during intubation, admin-
istered after intubation with succinylcholine when mus-
cle relaxation is necessary, or given in a very small
dose prior to succinylcholine to mitigate the undesir-
able fasciculations. It’s important to note that NMBDs
have no anesthetic properties and aren’t the primary
mechanism to provide immobility. Sufficient anesthetic
depth is essential to prevent awareness during general
anesthesia. Peripheral nerve stimulators measure ade-
quacy of muscle paralysis and determine when addi-
tional medication is necessary.
Nondepolarizing NMBDs can be reversed with
anticholinesterase drugs, usually neostigmine. These
drugs block acetylcholinesterase, the enzyme respon-
sible for metabolizing acetylcholine, and allow acetyl-
choline to build up, increasing competition for the
NMJ receptor and allowing normal muscle function
to return. These medications must be administered
with an anticholinergic, often glycopyrrolate, to block
the undesirable effects (bradycardia, bronchoconstric-
tion, and excessive salivation) caused by increased
levels of acetylcholine at other sites in the body—
especially the cardiac muscarinic receptors—which
can result in profound bradycardia.
Pain medications
Opioids are by far the primary drugs used for pain
control under anesthesia. Fentanyl is a synthetic
opioid that demonstrates cardiac stability even in
high doses and is widely used in current practice.
Other synthetic or naturally occurring opioids can
be used depending on provider preference, includ-
ing sufentanil, hydromorphone, or morphine.
Remifentanil is the most recent opioid introduced
to anesthesia. Commonly administered in an infu-
sion, it has a different pathway of metabolism,
which provides intense analgesia with a very quick
recovery; however, it may require an additional
medication to provide pain control into the post-
operative period.11
Other pain medications include ketorolac, a non-
steroidal anti-inflammatory medication that can be
included when the potential risk for bleeding doesn’t
compromise the surgical recovery and the patient
has no conditions that increase the risk of bleeding,
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such as peptic ulcer disease. Ketorolac shouldn’t be
used in patients that have severely impaired kidney
function. The most recent addition to the pain medi-
cation choices is I.V. acetaminophen, FDA approved
in November 2010.15
Maintenance and emergence
After induction, the maintenance phase can include
many options, both inhalation and I.V. drugs to
continue to meet the goals for general anesthesia.
Dexmedetomidine, a selective alpha2–adrenergic
agonist found to have sedation properties, is gaining
popularity as a supplement to general anesthesia and
procedural sedation. PONV is controlled or prevent-
ed by the use of a variety of antiemetics and adjunc-
tive medications. Antibiotics are administered as per
the Surgical Care Improvement Project protocols
and surgeon preference.
After surgery, emergence from anesthesia is
accomplished by discontinuing inhaled anesthetics
and infusions as well as a reversal of muscle relax-
ation as indicated unless postoperative management
requires controlled ventilation. The anesthesia pro-
vider will assess for readiness for extubation or
removal of an LMA based on specific criteria.
Regional anesthesia
Regional anesthesia for surgical interventions is a
complex subject with considerable variations in the
types and techniques used. For a spinal anesthesia,
the patient is positioned lateral (or sitting), and the
anesthesia provider inserts a needle through the spi-
nal structures and punctures the dura, confirmed by
the presence of cerebrospinal fluid (CSF). A small
dose of local anesthetic is injected, which provides a
dense motor, sensory, and autonomic block, and
is often used for surgeries below the umbilicus.
Epidural anesthesia differs in that the dura is not
punctured. Instead, medication (local anesthetic with
or without an opioid) is injected into the epidural
space, which is the potential space between the
ligamentum flavum and the dura (see Injection sites for
spinal and epidural anesthesia). A catheter may also be
inserted into the epidural space to allow for continu-
ous infusion of a local anesthetic agent. Pain relief
can be obtained without significant impairment of
motor function depending on the medication and
dose; therefore, epidurals are widely used in obstet-
rics for labor. Postdural puncture headache is an
adverse reaction of spinal anesthesia and is related to
July OR Nurse 2013 27
 Anesthesia 101: Everything you need to know
the loss of CSF when the dura is entered. Since the
introducer needle used for an epidural is a larger
diameter than a spinal needle, inadvertent dural
puncture (during epidural anesthesia) increases the
likelihood of a significant postdural puncture head-
ache. The definitive treatment of the headache is an
epidural blood patch, injecting the patient’s blood
into the epidural space, and relief of symptoms can
be immediate. A much larger volume of local anes-
thetic is required for epidural anesthesia compared to
a spinal. A test dose (small amount of local anesthetic
with epinephrine) is used to assess for inadvertent
dural puncture or intravascular injection (noted by a
rise in heart rate). A large volume of local anesthetic
injected intravascularly can cause toxicity symptoms,
such as seizure. A subarachoid injection could result
in a total spinal and serious hemodynamic instability.
Multiple types of peripheral nerve blocks—axillary,
interscalene, I.V. regional, or ankle—can be adminis-
Injection sites for spinal and
epidural anesthesia
Skin
Spinal cord
Dura
Ligamentum flavum
Interspinous ligaments
Epidural
Spinal
Epidural space
Subarachnoid space
Sacral hiatus
A
Source: Smeltzer SC, Bare BG, Hinkle JL, Cheever KH. Brunner
& Suddarth’s Textbook of Medical-Surgical Nursing. 12th ed.
Philadelphia, PA: Wolters Kluwer/Lippincott Williams & Wilkins;
2010:453.
28 OR Nurse 2013 July
Copyright © 2013 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
tered to facilitate surgical intervention or provide
postoperative pain relief. The use of ultrasound
technology to guide regional nerve blocks is increas-
ing in popularity. The use of ultrasound-guided
regional anesthesia provides identification of land-
mark anatomic, vascular, and neural structures not
appreciated by conventional techniques, such as
palpation, loss of resistance, or the use of a nerve
stimulator. In addition, the needle tip can be con-
stantly visualized and the spread of local anesthetic
appreciated. This has shown to improve the success
rate of regional anesthesia administration.16
Other considerations
Hemodynamic stability must be maintained, and
careful assessment of blood loss and fluid manage-
ment is essential. Invasive operative procedures often
cause significant compartmental fluid shifts combined
with blood loss, requiring considerable volumes of
crystalloid solutions, colloids, and blood replacement.
Monitoring devices used during anesthesia follow
standards established by the professional organiza-
tions for both physicians and CRNAs and include
the following: cardiac rhythm monitoring, BP at least
every 5 minutes, and pulse oximetry monitoring for
all cases. If an airway management device is inserted,
such as an LMA or ETT, ETCO2 monitoring is also
required. Many other monitors are used depending
on the anesthetic technique and condition of the
patient. The bispectral index monitor is a more
recent technology that was introduced to anesthesia
practice after FDA approval in 1997. Although con-
sciousness monitoring has been advocated for pre-
vention of awareness and assessment of anesthetic
depth, there’s ongoing controversy regarding the
reliability and clinical utility of these devices leading
to variable acceptance in clinical practice.17
Positioning an anesthetized patient for surgery
can be challenging and requires cooperation of the
entire perioperative team to prevent injuries to both
patient and provider. Position changes should be
coordinated by the anesthesia provider to maintain
hemodynamic stability, airway control, and to pre-
vent neck injuries in the flaccid patient.
Moving forward
Anesthesia providers offer a wide range of periopera-
tive services and utilize complex management
modalities requiring substantial knowledge, critical
thinking, and clinical expertise. Considering the anes-
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thesia provider’s scope of practice and the diversity
of techniques and agents, this article was intended
simply as an overview. Appreciation for the roles and
responsibilities of all team members involved in the
surgical procedure can improve cooperation, create a
cohesive and supportive work environment, and pro-
mote positive patient outcomes and satisfaction. OR
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Laura Palmer is an Assistant Professor and Assistant Director at the
University of Pittsburgh Nurse Anesthesia Program, School of Nursing,
Pittsburgh, Pa.
The author and planners have disclosed that they have no financial
relationships related to this article.
DOI-10.1097/01.ORN.0000431584.22992.aa

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