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

CHAPTER 20 Anesthesia: Perioperative Considerations for the Physical Therapist Michele P West CHAPTER OUTLINE CHAPTER OBJECTIVES Types of Anesthesia Intraoperative Effects of Anesthesia Postoperative Effects of Anesthesia Immediate Postoperative Phase Postsurgical Complications Operative Positioning Physical Therapy Considerations The objectives of this chapter are the following: Describe the types of anesthesia and the perioperative physiological effects of anesthesia on the body List the potential complications that can occur with anesthesia by body system Provide an introduction to the basic operative body positions and discuss the potential for complications related to OR positioning 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 surgical 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 sitespecific 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 application of an anesthetic to the skin or mucosa and the injection of a local anesthetic to a superficial site.1 451 452 CHAPTER 20    Anesthesia: Perioperative Considerations for the Physical Therapist The administration of anesthesia to a patient for a brief diagnostic or surgical procedure has transitioned from the operating room (OR) to other inpatient and outpatient settings.3 Procedural sedation (formerly conscious sedation) is characterized by the patient’s ability to maintain a patent airway without intervention, spontaneously ventilate, maintain cardiovascular 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 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 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 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 criteria 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 respiratory function, return to baseline level of consciousness, return of motor function, satisfactory pain control, satisfactory management 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 Delayed arousal, altered consciousness, agitation, or delirium Cerebral edema, seizure, or stroke Peripheral muscle weakness or altered sensation B Cardiovascular and hematological complications Hypotension, cardiogenic shock, or both Hypertension Dysrhythmia Myocardial ischemia and/or infarction Hemorrhage Deep vein thrombosis Pulmonary embolism C Respiratory complications Airway obstruction Hypoxemia or hypercapnia CHAPTER 20    Anesthesia: Perioperative Considerations for the Physical Therapist Atelectasis, pneumonia, or both Aspiration of gastric contents Hypoventilation Pulmonary edema, acute lung injury, acute respiratory distress syndrome (ARDS) D Renal complications Acute renal failure/acute kidney injury (ARF/AKI) Urine retention Urinary infection E Gastrointestinal complications Nausea and vomiting Hiccups Abdominal distention Paralytic ileus or obstruction F Integumentary complications Wound infection Wound dehiscence, evisceration, or both Hematoma or seroma G Other complications Fever Sepsis Hyperglycemia Fluid overload or deficit Electrolyte imbalance Acid-base disorders Operative Positioning Occasionally, a patient may experience postoperative pressureinduced nerve or skin damage as a result of operative positioning, 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 positioning with pads, limb holders, and drawsheets can prevent or minimize these injuries Standard operative positions include supine (dorsal decubitus), 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, 453 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 information about the patient’s surgical procedure(s) and type of anesthesia, intraoperative hemodynamic and vital sign status including electrocardiographic changes, unexpected anesthetic 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 reluctant 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., corticosteroids), 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 postoperative 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 454 CHAPTER 20    Anesthesia: Perioperative Considerations for the Physical Therapist A B C D FIGURE 20-1  A, Supine position Patient is placed on back with arms at sides or extended to 90 degrees and head in alignment 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 suspended in straps to flex knees Legs are placed into or removed from the stirrups simultaneously to avoid hip injuries CHAPTER 20    Anesthesia: Perioperative Considerations for the Physical Therapist 455 References 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 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 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 Wadlund DL: Prevention, recognition, and management of nursing complications in the intraoperative and postoperative surgical patient, Nurs Clin North Am 41:151-171, 2006 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 Hedenstierna G: Respiratory physiology In Miller RD et al, editors: Miller’s anesthesia, ed 7, Philadelphia, 2009, Churchill Livingstone, pp 361-391 Lane JL: Postoperative respiratory insufficiency In Atlee RL, editor: Complications of anesthesia, ed 2, Philadelphia, 2006, Saunders, pp 877-880 Barnes D: Perianesthesia management In Urden LD, Stacy KM, Lough ME, editors: Critical care nursing, ed 6, St Louis, 2010, Mosby, p 260 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  ...452 CHAPTER 20    Anesthesia: Perioperative Considerations for the Physical Therapist The administration of anesthesia to a patient for a brief diagnostic or surgical... hypercapnia CHAPTER 20    Anesthesia: Perioperative Considerations for the Physical Therapist Atelectasis, pneumonia, or both Aspiration of gastric contents Hypoventilation Pulmonary edema, acute. .. 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 454 CHAPTER 20    Anesthesia: