Intraoperative managment
After the preoperative assessment, the patient is usually brought back to the procedure room; although at times the preoperative assessment may be performed with the patient in the procedure room. The interoperative management starts with the anesthesia provider attaching the monitoring devices to the patients. This is very key for the anesthesia provider as these monitors provide a way to detect and treat problems before any harm may come to the patient.
| Intraoperative monitors |
|---|
| EKG |
| Pulse oximetry |
| Capnography |
| Temperature monitoring |
| Blood pressure |
| Other monitors as needed (arterial waveform, pulmonary artery catheter, LVAD) |
The first thing the anesthesia provider usually does is secure the intravenous access (either via an existing IV or by placing a new IV). This is usually necessary for the sedation, but more importantly is the life-line by which the patient can be resuscitated. Patients with difficult IV access may require more time or additional equipment, such as an ultrasound, for line placement. In rare occassions it may be necessary to place a central line for access.
The next thing the anesthesia provider will do is to manage the airway. The intubation or placement of a breathing device is a critical moment in the patient's anesthetic as there is a period of time where the patient is not able to breathe on their own and there is no secured way for them to be ventilated. This is a time when the anesthesia providers will be extremely focused on making sure that the airway is secured. There are two phases to this process normally, ventilation and intubation. Typical equipment can include a laryngoscope, but the anesthesia provider may request a video laryngoscope (glidescope/cmac), fiberoptic bronchoscopy cart (fiberoptic bronch cart), bougie (rubber intubating stylette). The anesthesia provider may also ask for assistance with ventilation (ie squeezing the bag), it is common to keep the pressure below 20cm of water as this is the opening pressure of the lower esophageal sphincter. They may also ask for cricoid pressure, which displaces the larynx more posteriorly to provide slightly improved visualization of the airway if done correctly, although it may distort the view entirely if done incorrectly.
Positioning the patient is of key importance to the anesthesia provider as they need to be able to rescue an airway if it becomes compromised during the procedure. Also many of these monitors that have been applied as well as any IVs or other lines will need to be managed during any repositioning of the patients. The anesthesia provider almost always manages the airway (or head) of the patient as this is the most critical lifeline. OR culture dictates that one should warn the anesthesia provider before any movement of the patient as lines or devices attached to the patients (including the airway device) can get dislodged.
After giving the sedation medication or inducing general anesthesia, the provider will usually indicate that it is "ok" to proceed. Based on the anesthetic, patient and procedure, there may be different amounts of time from the "start" of anesthesia before the patient can tolerate the start of the procedure, so it is always wise to ask or wait for the anesthesia provider to indicate that starting the procedure is permitted.
During the case, the anesthesia provider will continually monitor the vital signs and assess the adequacy of ventilation of the patient. Most cases are uneventful, but it is important to understand that when a crisis happens that the anesthesia provider will likely make strong vocal suggestions as to the course of action. Commonly, the procedure may need to be halted or aborted in order to resuscitate the patient, additional medications or equipment may need to be secured from the pharmacy, additional expert clinical staff may be needed to help. In the operating room environment, much of this safety is built-in and closeby to the anesthesia provider, but in the non-OR environment, help may be far away and the healthcare providers in the room may need to assist in helping the patient. It is important to know where the emergency equipment is kept (including the emergency airway equipment), to be able to assist in the case of an emergency.
At the end of the case, the anesthesia provider will try to decrease the sedation level to provide a smooth and quick emergence from the anesthetic. Accurate communication is key at this point, as if the anesthesia provider does not know that the case is about to end, they may be unprepared and the emergence may take longer than it needed to. On the other hand, if the provider is told the case is going to end in 5 minutes, they may have lightened the patient to near emergence by that point, so the patient may not be adequately sedated for an additional 10 minutes that was needed to finish the procedure. The key is an open and honest communication in the team regarding the situation and projected needs.
