Acute care handbook for physical therapists (fourth edition) chapter 20 anesthesia perioperative considerations for the physical therapist

Acute care handbook for physical therapists (fourth edition) chapter 20 anesthesia perioperative considerations for the physical therapist Acute care handbook for physical therapists (fourth edition) chapter 20 anesthesia perioperative considerations for the physical therapist Acute care handbook for physical therapists (fourth edition) chapter 20 anesthesia perioperative considerations for the physical therapist Acute care handbook for physical therapists (fourth edition) chapter 20 anesthesia perioperative considerations for the physical therapist Acute care handbook for physical therapists (fourth edition) chapter 20 anesthesia perioperative considerations for the physical therapist

Anesthesia: Perioperative Considerations for

the Physical Therapist

CHAPTER

20

Michele P West

CHAPTER OBJECTIVES

The objectives of this chapter are the following:

1 Describe the types of anesthesia and the perioperative physiological effects of anesthesia on the body

2 List the potential complications that can occur with anesthesia by body system

3 Provide an introduction to the basic operative body positions and discuss the potential for complications related to OR positioning

4 Discuss the physical therapy considerations related to postoperative effects of anesthesia on the patient

PREFERRED PRACTICE PATTERNS

The acute care setting is multifactorial in nature and applies to many body systems For this reason, specific practice patterns are not delineated in this chapter Please refer to Appendix

A for a complete list of the preferred practice patterns in order to best delineate the most applicable practice pattern for a given diagnosis

The physical therapist should have a general understanding of the types of anesthesia and the physiological impact that anesthesia can have on a patient in the perioperative phase: that is, before (preoperative), during (intraoperative), and after (postoperative) surgery This includes

an understanding of the intraoperative effects, postoperative recovery phases, and potential complications of anesthesia Insight into these factors allows the physical therapist to intervene

as safely as possible, prioritize the plan of care, modify interventions and treatment parameters, and more accurately predict length of stay, discharge disposition, and physical therapy goals Surgery may be classified by urgency (elective, required, urgent, or emergent) and by purpose (diagnostic, explorative, reconstructive, transplant, curative, or palliative) The surgi-cal classification determines the preoperative preparations, operative setting, and type of anesthesia.1

Types of Anesthesia

There are two types of anesthesia: general and regional General anesthesia is a reversible state of unconsciousness consisting of four components (amnesia, analgesia, inhibition of noxious reflexes, and skeletal muscle relaxation) and is achieved by the use of intravenous and inhalation anesthetics, analgesics, and muscle relaxants.2 Regional anesthesia is used for site-specific surgical procedures of the upper or lower extremity or lower abdomen and is achieved

by spinal (subarachnoid), epidural (thoracic or lumbar), or peripheral nerve blocks.2 Local anesthesia is considered a subset of regional anesthesia and involves the topical or direct appli-cation of an anesthetic to the skin or mucosa and the injection of a local anesthetic to a superficial site.1

CHAPTER OUTLINE

Types of Anesthesia

Intraoperative Effects of

Anesthesia

Postoperative Effects of

Anesthesia

Immediate Postoperative Phase

Postsurgical Complications

Operative Positioning

Physical Therapy Considerations

The administration of anesthesia to a patient for a brief

diagnostic or surgical procedure has transitioned from the

oper-ating room (OR) to other inpatient and outpatient settings.3

Procedural sedation (formerly conscious sedation) is

character-ized by the patient’s ability to maintain a patent airway

without intervention, spontaneously ventilate, maintain

cardio-vascular function, and respond purposely to verbal or tactile

stimulation.2

Intraoperative Effects of Anesthesia

The major intraoperative effects of general anesthesia include

the following4:

A Neurological effects Decreased cortical and autonomic

function

B Metabolic effects Hypothermia or malignant

hyperthermia (in patients with a genetic

predisposition)

C Cardiovascular effects The potential for arrhythmia,

hypotension, hypertension, decreased myocardial

contractility, and decreased peripheral vascular

resistance.5

D Respiratory effects.6

1 Anesthesia has multiple effects on the lung, including

decreased or altered:

a Arterial oxygenation

b Response to hypercarbia or hypoxia

c Vasomotor tone and airway reflex

d Respiratory pattern

e Minute ventilation

f Functional residual capacity

2 The shape and motion of the chest are altered

because of decreased muscle tone, which causes

the following:

a Decreased anteroposterior diameter

b Increased lateral diameter

c Increased cephalad position of the diaphragm

3 Other factors that affect respiratory function and increase

the risk of postoperative pulmonary complications (e.g.,

atelectasis, pneumonia, lung collapse) include the

following7:

a Underlying pulmonary disease such as chronic

obstructive pulmonary disease (COPD)

b Incisional pain, especially if there is a thoracic or

upper abdominal incision

c Smoking history

d Obesity

e Obstructive sleep apnea

f Advanced age

g The need for large intravenous fluid administration

intraoperatively

h Prolonged operative time (more than 180

minutes)

i Emergency surgery

Postoperative Effects of Anesthesia

Immediate Postoperative Phase

In the immediate postoperative phase, the patient is transported from the OR to a postanesthesia care unit (PACU) (after general anesthesia) or to an ambulatory surgery recovery room (after regional anesthesia); both are located near the OR for continuous nursing care The recovery period after surgery is characterized

as a time of physiological alteration as a result of the operative procedure and the effects of anesthesia.3 During this initial postoperative phase, the priorities of care are to assess emergence from anesthesia and the status of the surgical site, to determine the patient’s physiological status and vital sign trends, and to identify actual or potential postsurgical problems.8

Discharge from the PACU is often now dependent on clinical criteria rather than time-based criteria Specific discharge crite-ria and/or the use of scoring systems varies among institutions; however, the general criteria for discharge from the PACU includes stable vital signs with normothermia, adequate respira-tory function, return to baseline level of consciousness, return

of motor function, satisfactory pain control, satisfactory man-agement of nausea and vomiting, and control of surgical wound bleeding/drainage.1

The criteria for discharge from the ambulatory recovery room are similar to those for the PACU and include recovery from sedation or nerve block

Postsurgical Complications

During the days to weeks of the postsurgical phase, the patient

is monitored for the proper function and return of all of the major body systems The prompt prevention and recognition of potential or actual postsurgical complications is the cornerstone

of high-quality care by all health care providers, including physical therapists The development of postsurgical com-plication(s) in the immediate or secondary phase may be expected or unexpected and determines further medical-surgical management and treatment parameters The most common postoperative complications include the following9:

A Neurological complications

1 Delayed arousal, altered consciousness, agitation, or

delirium

2 Cerebral edema, seizure, or stroke

3 Peripheral muscle weakness or altered sensation

B Cardiovascular and hematological complications

1 Hypotension, cardiogenic shock, or both

2 Hypertension

3 Dysrhythmia

4 Myocardial ischemia and/or infarction

5 Hemorrhage

6 Deep vein thrombosis

7 Pulmonary embolism

C Respiratory complications

1 Airway obstruction

2 Hypoxemia or hypercapnia

and/or surgical injury or for back or joint pain related to joint stiffness from immobility or connective tissue injury

Physical Therapy Considerations

• Typically there is a brief written operative note and a more detailed operative report that is dictated by the attending surgeon in the chart The brief note is similar to a procedure note and may be helpful to confirm the date and time of surgery as well as the name of surgery performed The full operative report specifically states the patient position during surgery, the exact surgical technique used, specimens that were taken, estimated blood loss, unexpected findings, and/

or complications

• A review of the anesthesiologist’s notes can provide informa-tion about the patient’s surgical procedure(s) and type of anesthesia, intraoperative hemodynamic and vital sign status including electrocardiographic changes, unexpected anes-thetic effects, operative time, and medications given intraoperatively

• The physical therapist should monitor vital signs such as heart rate, blood pressure, oxygen saturation, and respiratory rate when intervening with the patient because of the altered

or potentially altered physiology of multiple body systems after general anesthesia

• Careful examination of sensation and motor control in the lower extremity after a local or regional anesthetic (e.g., after knee arthroplasty) is important to prevent falls, especially when the patient is not fully aware of the impairment

• Nausea and vomiting are among the most common patient complaints after anesthesia and may continue for days after surgery Nausea and vomiting may make the patient reluc-tant to mobilize out of bed The physical therapist may need

to consider the timing of the physical therapy session relative

to these symptoms as well as antiemetic medication use, mealtimes, and rest between patient position changes or other activities in the day

• Be aware that blood sugar levels may be elevated in the diabetic or nondiabetic patient postoperatively and that hyperglycemia can be caused by medications (e.g., cortico-steroids), stress, acute pain, blood loss, and lengthy surgical procedures.12 Check for the current blood glucose levels as you would other vital signs

• Document the development and/or resolution of any postop-erative complications or changes in the physical therapy evaluation and/or treatment notes Discuss the relevance and impact of these changes on the patient’s performance in the assessment of your note

3 Atelectasis, pneumonia, or both

4 Aspiration of gastric contents

5 Hypoventilation

6 Pulmonary edema, acute lung injury, acute respiratory

distress syndrome (ARDS)

D Renal complications

1 Acute renal failure/acute kidney injury (ARF/AKI)

2 Urine retention

3 Urinary infection

E Gastrointestinal complications

1 Nausea and vomiting

2 Hiccups

3 Abdominal distention

4 Paralytic ileus or obstruction

F Integumentary complications

1 Wound infection

2 Wound dehiscence, evisceration, or both

3 Hematoma or seroma

G Other complications

1 Fever

2 Sepsis

3 Hyperglycemia

4 Fluid overload or deficit

5 Electrolyte imbalance

6 Acid-base disorders

Operative Positioning

Occasionally, a patient may experience postoperative

pressure-induced nerve or skin damage as a result of operative

position-ing, especially during a lengthy procedure The physiological

effects of anesthesia such as hypothermia, hypotension, and

pharmacologically blocked pain and pressure receptors make a

patient vulnerable to pressure injuries.10 When combined with

risk factors such as advanced age; poor skin integrity; altered

nutrition; diabetes; peripheral vascular disease; or the presence

of cancer or neurological or cardiac disease, the incidence of

pressure injury increases.10 Judicious proper operative

position-ing with pads, limb holders, and drawsheets can prevent or

minimize these injuries

Standard operative positions include supine (dorsal

decubi-tus), prone (ventral decubitus, low or full jackknife), side-lying

(left or right lateral decubitus, jackknife, or flexed lateral),

seated, and lithotomy (standard, low, or exaggerated) (Figure

20-1).11

The physical therapist may be consulted in the postoperative

phase to evaluate for extremity weakness related to neuropathy

from stretch, compression, ischemia, metabolic derangement,

FIGURE 20-1

A, Supine position Patient is placed on back with arms at sides or extended to 90 degrees and head in

align-ment with body Legs are uncrossed, with a safety strap placed above knees B, Prone position Patient is usually

anesthetized while supine, and then turned Arms are placed at sides, with rolls beneath axillae to facilitate

respiration C, Jackknife position Patient is usually anesthetized while supine, and then turned Knees are flexed slightly to reduce lumbosacral stress D, Lithotomy position Patient is on back, and foot section of

operating table is removed or lowered to 90-degree angle Buttocks are moved to table’s edge Feet are sus-pended in straps to flex knees Legs are placed into or removed from the stirrups simultaneously to avoid hip injuries

A

B

C

D

6 Hedenstierna G: Respiratory physiology In Miller RD et al, editors: Miller’s anesthesia, ed 7, Philadelphia, 2009, Churchill Livingstone, pp 361-391.

7 Lane JL: Postoperative respiratory insufficiency In Atlee RL, editor: Complications of anesthesia, ed 2, Philadelphia, 2006, Saunders, pp 877-880.

8 Barnes D: Perianesthesia management In Urden LD, Stacy KM, Lough ME, editors: Critical care nursing, ed 6, St Louis, 2010, Mosby, p 260.

9 Nicholau D: Postanesthesia recovery In Miller RD, Pardo MC, editors: Basics of anesthesia, ed 6, Philadelphia, 2011, Saunders,

pp 631-647.

10 Primiano M, Ffiend M, McClure C et al: Pressure ulcer prevalence and risk factors during prolonged surgical procedures, AORN J 94(6):555-566, 2011.

11 O’Connell MP: Positioning impact on the surgical patient, Nurs Clin North Am 41:173-192, 2006.

12 Rutan L, Sommers K: Hyperglycemia as a risk factor in the perioperative patient, AORN J 95(3):352-361, 2012.

1 Moe KL: Perioperative nursing In Craven RF et al, editors:

Fundamentals of nursing: human health and function, ed 7,

Philadelphia, 2013, Wolters Kluwer Lippincott Williams &

Wilkins, pp 534-563.

2 Sherwood E, Williams CG, Prough DS: Anesthesiology

principles, pain management, and conscious sedation In

Townsend CM et al, editors: Sabiston textbook of surgery, ed 19,

Philadelphia, 2012, Saunders, pp 389-417.

3 Neumeyer L, Vargo D: Principles of preoperative and

operative surgery In Townsend CM et al, editors: Sabiston

textbook of surgery, ed 19, Philadelphia, 2012, Saunders,

p 237.

4 Wadlund DL: Prevention, recognition, and management of

nursing complications in the intraoperative and postoperative

surgical patient, Nurs Clin North Am 41:151-171, 2006.

5 Wilson RS: Anesthesia for thoracic surgery In Baue AE,

Geha AS, Hammond GL et al, editors: Glenn’s thoracic and

cardiovascular surgery, ed 96, Stamford, CT, 1996, Appleton &

Lange, p 23.