Laryngoscopy

A laryngoscope is used to aid with visualisation of the vocal cords to allow direct placement of the ETT.

This process is known as intubation. The laryngoscope is traditionally a left-handed instrument and has Table 8.4 Preparation for endotracheal intubation

Equipment Rationale

The correctly sized ETT (have one smaller

and one larger size available) Patients are ventilated through an ETT. The tube size needs to be correct to prevent trauma to the trachea and to prevent any leakage of gas from around the cuff

Syringe to inflate the pilot cuff Required to inflate the cuff

Variety of laryngoscope blades A laryngoscope is used to aid visualisation of the vocal cords

Lubricating gel (for the ETT) A water-based gel on the ETT may be necessary in circumstances in which insertion is difficult Oropharyngeal airways (various sizes) Prevent the tongue from falling to the back of the

pharynx and causing an obstruction

Nasopharyngeal airways (various sizes) Prevent the tongue from falling to the back of the pharynx and causing an obstruction

Magill forceps Help with insertion of the ETT between the vocal cords

Bougie (gum elastic or single-use disposable) Used to railroad an ETT when the view at laryngoscopy is suboptimal

Stylette Inserted inside an ETT before insertion to change the

shape of the tube

Table 8.5 Preparation for insertion of an LMA

Equipment Rationale

A suitably sized LMA To prevent any trauma to the soft tissue and teeth To minimise leakage around the cuff

Lubricating gel A water-based gel on the ETT may be necessary in circumstances where insertion is difficult

Syringe for inflating the cuff Required to inflate the cuff

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an atomically shaped blade. It is inserted down the right-hand side of the tongue, displacing it to the left. Once the epiglottis has been elevated, the vocal cords should be in view and the ETT is passed between them.

The role of anaesthetic nurse is to provide assistance to the anaesthetist. In order to provide skilled assistance, the nurse must possess an in-depth knowledge and understanding of anaesthesia to antici- pate the needs of both the anaesthetist and the patient.

The third element of the triad – analgesia – is required to prevent the patient’s sympathetic nervous system responding to the painful stimulus. This is often overcome by administering opioid analgesia on induction. However, the amount of drug and the speed at which it is metabolised may not be adequate to prevent a response to surgical stimuli. The use of intravenous paracetamol is on the increase, and this is often given in the anaesthetic room on induction. An opiate is routinely adminis- tered in theatre, whether this be incremental doses of morphine or a continuous infusion of remifen- tanil. Remifentanil is administered by continuous infusion as part of the total intravenous anaesthesia technique, whereby a continuous infusion of propofol is delivered via a syringe pump in tandem with the remifentanil.

The anaesthetist (or patient or surgeon) may decide against the use of a general anaesthetic. There may be a number of reasons for this including:

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patient choice;

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the patient’s medical family history (e.g. a history of malignant hyperpyrexia or suxamethonium apnoea);

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physiological conditions;

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known problems with a difficult airway.

Alternative techniques include regional anaesthesia. This technique will use one of the following:

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a spinal anaesthetic;

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an epidural anaesthetic;

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combined epidural and spinal anaesthesia.

Although spinal and epidural anaesthetics have their differences (Table 8.6), they also have a number of similarities, including:

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the position of the patient:

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sitting – the anaesthetic practitioner will need a stool (without wheels) for the patient to rest their feet on;

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lateral – the anaesthetic practitioner must consider whether help is required to hold the patient in position;

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preparation of the patient:

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basic monitoring;

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intravenous access with infusion of a crystalloid (or colloid if necessary);

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a means of delivering oxygen via a face mask (or nasal specs/sponge);

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location of the anatomical points;

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aseptic cleaning of the spinal area identified;

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preparation of equipment ¬– using an aseptic non-touch technique (ANTT);

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preparation of the anaesthetic practitioner – again;

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with the anaesthetic practitioner using an aseptic technique with a mask, gown and gloves.

Visit www.wileyfundamentalseries.com/medicalnursing and read Reflective Question 8.3 to think more about this topic.

If patients are non-ambulant, this poses significant health and safety risks to both themselves and the theatre personnel. This risk has been reduced over the last decade or so, with the trend towards ambulatory (day case) surgery enabling a shift towards more patients receiving treatment on specialist operating trolleys, thus reducing the need for staff to employ manual handling techniques. Even for

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those patients not requiring a transfer from trolley to table, however, positioning for optimal surgical access may be required. Most of the risk posed here is to theatre personnel, and predictably this risk is higher where the risk is unforeseen, for example with the presentation of a morbidly obese patient. The minimum number of theatre personnel required to move or position an adult patient is four, based on European Manual Handling directives indicating that male staff should move a maximum load of 25 kg and female staff a 15 kg maximum. Careless positioning of the surgical patient can cause considerable harm. Even the most basic surgical position – supine – carries risks. Risks can, however, be reduced by positioning the patient as far as possible in alignment and by continuous monitoring of at-risk areas.

Assessment of infection risk takes into account the site of the surgery (e.g. bowel), existing bacterial activity and the tissue that will be breached (bone infection, for example, being very difficult to manage). Contact infection is managed by the creation of a ‘sterile field’. This is discussed in the next section. An additional infection risk may be present via reusable equipment that has been inadequately disinfected. Examples of this are operating tables, suction units and diathermy machines – particularly where staff members handle diathermy pedals that are in regular contact with the floor. Gel pads and operating table supports can also have similar contact with a soiled theatre floor and must be disin- fected carefully between patients.

Electrosurgical units, audiovisual stacker systems, suction units, anaesthetic machines, warming units and light source equipment all present the risk of trailing cables. This risk is usually managed via ceiling- mounted booms or pods containing electrical and gas supply socket systems.

Where specimens are taken for pathology examination, a risk of misdiagnosis exists. The biggest risk is error in labelling specimens. This should not occur if labelling takes place in real time, checking takes place and the specimen is despatched as soon as documentation has been completed.

Table 8.6 Spinal and epidural anaesthesia

Property Spinal Epidural

Anatomical differences Inserted below L3/4 or L4/5 Most commonly performed in the lumbar region

Inserted through the dura mater into the subarachnoid space

Sits in the epidural space

Type of needle Uses a small-gauge needle, usually 25 G or 27 G, either a Whitacre or Sprotte type

Tuohy needle (16–18 G)

Has an introducer and a

stylette to aid insertion Uses a loss-of-resistance syringe filled with either air or saline

Drugs used Heavy bupivacaine (8%

glucose), which makes it a hyperbaric solution

Bupivacaine 0.25–0.75%

Type of surgery Lower limb or lower abdominal surgery, e.g. lower segment caesarean section

Often used as postoperative pain relief in surgery involving the upper or lower gastrointestinal tract, e.g.

oesophagectomy

Onset of anaesthesia Rapid onset Slow onset: 20–30 minutes

Duration of anaesthesia Lasts 2–2.5 hours Can be set up as a continuous infusion

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The soiled theatre floor presents multiple risks that include the spread of infection via carelessly discarded equipment coming into contact with used irrigation, skin preparation and bodily fluids (usually blood). There is also a slip hazard relating to these items. Management of these risks involves mopping between cases, but this poses an additional slip risk as it takes place at a time when multiple staff are preparing the operating room for the next case. Good and timely communication is essential in this instance.