Margot R Baida, RN
Nursing care in use of local anesthesia The patient having surgery under local anesthetic is often a source of aggravation and/or anxiety for operating room nurses who have become disassociated with the “awake” patient through their work setting. In addition, many hospitals do not provide a standard routine for local anesthetic cases. Therefore, the professional nurse must establish individual care plans for her patients and become familiar with local anesthetic agents, their effects, and uses. Local anesthetic drugs. Local anesthetics are drugs capable of blocking nerve conduction. This action is reversible, and complete recovery of nerve function occurs. Types of local anesthesia include topical, field block, nerve
Margot R Baida, RN,was a staff nurse in the Neurosensory Center of Methodist Hospital, Texas Medical Center, Houston, when this article was written. She is now inservice instructor at Sam Houston Memorial Hospital, Houston. Baida is a diploma graduate of Mt Carmel School of Nursing, Columbus, Ohio.
block, spinal block, epidural, and paravertebral. During topical anesthesia, the anesthetic agent is generally sprayed directly onto the skin. It acts by decreasing sensation at the contact point. When local anesthetic is injected into the tissue where the incision will be made, thereby injecting the nerves immediately surrounding the area, it is known as a field block. Many nerves may be delineated to anesthetize specific body parts. A nerve block involves injecting a major nerve to anesthetize a specific body part during delicate procedures, such as microsurgery. A larger area of the body, as from the waist to the toes, may be anesthetized by spinal or epidural block by injecting an anesthetic agent into an area of the spinal column. Finally, general surgery in risk patients is sometimes facilitated by use of the paravertebral block, which anesthetizes the abdominal wall and organs by affecting the associated nerves2 Local anesthesia is preferable to general anesthesia for many reasons. Technique is simple, minimal equipment is needed, a nonflammable drug is used, and surgery can be done at lower cost. The patient experiences less nausea and vomiting, lower incidence of pulmonary and embolic complications, fewer disturbances to bodily functions, and less bleeding and bodily secretions. Surgery under local anesthetic is the
AORN Journal, November 1978, Vol28, No 5
855
method of choice when patient cooperation is needed, when surgery is superficial or minor, or when food had been recently ingested. Finally, less postoperative observation and general care are needed.3 Cocaine was the first local anesthetic noted in medical practice, and even today, cocaine and its derivatives are used. The nurse should be familiar with this drug and its safe dosages (Table 1). The operating room nurse also must be aware of the patient’s possible reactions to the local anesthetic. Reactions are classified as systemic, due to local anesthetic; systemic, due to vasoconstrictors; allergic, due to local anesthetics; and local tissue irritation and de~truction.~ Systemic reactions due to local anesthetics may be manifested by hypotension, pallor, clammy skin, sweating, decreased respirations, apnea, twitching of small muscles of the face and extremities, generalized convulsions, drowsiness, incoherent speech, possible coma, and cardiac standstill. Treatment is symptomatic and may include use of Trendelenburg’s position, hyperventilation of the patient, and use of vasopressor drugs, intravenous (IV)fluids, and ultrashort-acting barbiturates and muscle relaxant^.^ In general, reactions due to vasoconstrictors are due to an epinephrine overdose. The patient may appear apprehensive, exhibit tremors, palpitations, tachycardia, restlessness, weakness, tachypnea, hypertension, sweating, fainting, headache, and skin pallor. In extreme overdose, tachycardia leading to pulmonary edema and ventricular fibrillation may occur. Therapy includes administration of oxygen, vasodilators, and barbiturates.6 Allergic reaction to the anesthetic may be indicated by angioneurotic edema, urticaria, pruritis, hypotension, and asthmatic breathing. Antihis-
856
~~~
Table 1
Cocaine and derivatives Type Cocaine Procaine Tetracaine (Pontocaine) Mepivacaine (Carbocaine) Lidocaine (Xylocaine) Butacaine Dibucaine Piperocaine (Metycaine) Cocaine 10% (solution) Cocaine 4% (solution) Cocaine crystals
Safe level 250 mg 1000 mg 100 mg 500 mg 500 mg 125 mg 66 mg 800 mg 2% cc 6 cc exact dosage limit unknown
Table taken from “Policy manual,”Methodist Hospital, Texas Medical Center, Houston. ~~~~~~~~~~~~
tamines, epinephrine, oxygen, vasopressors, and occasionally, calcium gluconate are included in treatment.’ Treatment for local tissue irritation and destruction includes moist packs and antibiotics. Of course, at this stage, the patient has been removed from the operating room. A patient having surgery under a local anesthetic must be monitored carefully by the operating room nurse. The nurse must be familiar with anesthetic monitoring devices, such as blood pressure equipment and electrocardiograph, intravenous therapy, oxygen therapy, and related drug therapy. At Methodist Hospital in Houston, recommendations include intravenous therapy of each patient having local anesthetics and routine monitoring of vital signs every 15 minutes, as well as before and after any medication is administered.* Continuous electrocardiograph monitoring is vital. Nursing implications. Foremost consideration in operating room nursing is given to the patient. An individual plan begins with the preoperativelanesthetic
AORN Journal, November 1978, Vol28, No 5
visit. At this time, the nurse gathers important data about the patient’s special needs and problems and answers the patient’s questions if at all possible. The importance of this visit cannot be stressed enough. According to Snow and Thomas, “the value of the preanesthetic visit has shown t o be equivalent to 100 mg of pentobarbital (Nembutal) in its calming effect and is superior in its value to allay anxiety and provide emotional s u p p ~ r t . ”In~ the operating room, the patient’s emotional support frequently includes a familiar face, voice, and hand to hold.1° Before the nurse receives the patient in the operating room, she should take time to check all equipment, making sure everything needed is readily available and functioning. This includes emergency and therapeutic drugs, electrocardiograph equipment, blood pressure apparatus, temperature monitors, oxygen equipment (including airways), intravenous equipment, and small items such as syringes, needles, and alcohol swabs. All necessary equipment should be easily accessible. After an equipment check and subsequent identification of the patient by the surgeon, the nurse familiarizes herself with the patient by talking with him and checking his chart. Next, the nurse starts the IV and connects electrocardiograph equipment as well as blood pressure apparatus. Temperature devices should be applied and oxygen therapy started if indicated. The nurse should not waste time, since t h e lasting effect of preoperative and local anesthetic drugs is limited. After vital care has been established, the nurse positions the patient as necessary for comfort and informs the surgeon that the patient is ready for the procedure. Positioning the patient depends on the orders of the individual physician. The patient’s needs also determine supports used. Many supports
Cocaine: From the Incas to anesthetic Cocaine is derived from the leaves of a mountain shrub known as Erythroxylon coca. It was first used in the early sixteenth century by the Inca Indians in South America. In their society, chewing the coca leaves represented a great honor; priests and worshippers could only enter the temples if they had a coca leaf in their mouths. Later, Spanish conquistadores used the coca leaf to enslave the Incas. The Spanish discovered that coca’s euphoric and appetite-suppressing properties enabled the Incas to work longer and harder without food. During the nineteenth century, European and American scientists took an interest in the effects of coca leaves and experimented with it in wines and elixers. In 1885,John Styth Pernberton of Atlanta marketed t h e French Wine Coca-Ideal Nerve and Tonic Stimulus.The next year he patented the beverage Coca-Cola,which contained an extract from the kola nut and caffeine, as well as coca. In 1918, after a nine-year court battle with the Pure Food and Drug Law, the manufacturers of Coca-Colachanged the content of its beverage. The chief active ingredient in coca leaves, alkaloid cocaine, was isolated in pure form in 1844. From Edward M Brecher, Licit and Illicit Drugs (Boston: Little, Brown and Co, 1972).
are available, such as headrests and immobilizers, pillows, sheets, and sponges. An armboard may be used to give the patient a feeling of having more room. A pillow may be placed under the patient’s knees to relieve back pressure. Sheepskin and other such material may be placed under elbows, heels, or other bony prominences. Extremities should never be allowed to rub, causing friction. Padding or pillows may be used to
AORN Journal, November 1978, Vol28, No 5
867
avoid this. Proper body alignment is imperative to ensure optimum postoperative function of the patient. The patient’s safety is important, and the nurse should have available necessary restraints and grounding pads. Due to preoperative medication, a patient under local anesthetic may have difficulty interpreting voices and sounds accurately. A quiet atmosphere is necessary. The nurse can maintain this quiet atmosphere by reminding those in the room and outside of the room of the patient’s status. If possible, an appropriate sign, such as “Quiet please. Patient is awake.” can be placed on the door to the operating room. Any non-patient instruction should be minimized or eliminated completely. Postoperatively, most local anesthetic patients do not go to the recovery room, but return directly to their rooms. The operating room nurse occasionally intervenes with this process if a complication occurs during the surgical procedure. This may require collaboration with the anesthetist or recovery room nurse. The operating room nurse should realize that nurses on surgical units may not be prepared to handle an emergency brought on by the side effects of a local anesthetic. This being the case, the operating room nurse accompanies the patient to his room and describes possible patient problems as well as his surgical treatment to the nurse on the unit. Postoperative nursing care of the patient having surgery under local anesthesia includes careful monitoring of vital signs, as indicated by the patient’s status, as well as conscientious observation for possible side effects. The nurse should note the time when sensation returns to the affected part of the body. According to Brunner, et al, “An anesthetic cannot be regarded as having ‘worn off’ until all three systems (motor,
858
sensory and autonomic) are no longer affected by the anesthetic.”” Many times, local anesthetic patients have shorter hospital stays than general anesthetic patients, making postoperative visits unfeasible. When a visit is possible, the operating nurse can evaluate his or her care of the local anesthetic patient, which allows for future implementation of care plans.12 Although local anesthetic cases generally constitute a minor part of a hospital’s surgical caseload, it is important to develop a routine for handling patients having local anesthetic. An effective routine takes into consideration the type of anesthetic used, possible reactions and treatments, preoperative visits by the operating room nurse to become familiar with the patient and his needs, and careful monitoring of the patient during the procedure. Establishing such a plan will help alleviate operating room nurses’ anxiety about caring for the patient under local anesthetic and ensure the patient quality nursing care during the intraoperative phase.
a
Notes 1. John C Snow, Charles C Thomas, Anesthesia: In Otolaryngology and Ophthalmology (New York: J B Lippincott, 1972). 2. Lillian Sholtis Brunner, et al, Textbook of Medical-Surgical Nursing, 2nd ed (Philadelphia:J B Lippincott Co, 1970). 3. Snow, Thomas, Anesthesia: In Otolaryngology and Ophthalmology. 4. Ibid. 5. Ibid. 6. Ibid. 7. Ibid. 8. ”Policy manual,” Methodist Hospital, Texas Medical Center, Houston. 9. Snow, Thomas, Anesthesia: In Otolaryngology and Ophthalmology. 10. Gloria M Francis, Barbara Munjas,Promoting Psychological Comfort (Dubuque, Iowa: William C Brown Co, 1968). 11. Brunner, et al, Textbook of Medical-Surgical Nursing. 12. Ibid.
AORN Journal, November 1978, Vol28, No 5
Nursing care in use of local anesthesia The patient having surgery under local anesthetic is often a source of aggravation and/or anxiety for operating room nurses who have become disassociated with the “awake” patient through their work setting. In addition, many hospitals do not provide a standard routine for local anesthetic cases. Therefore, the professional nurse must establish individual care plans for her patients and become familiar with local anesthetic agents, their effects, and uses. Local anesthetic drugs. Local anesthetics are drugs capable of blocking nerve conduction. This action is reversible, and complete recovery of nerve function occurs. Types of local anesthesia include topical, field block, nerve
Margot R Baida, RN,was a staff nurse in the Neurosensory Center of Methodist Hospital, Texas Medical Center, Houston, when this article was written. She is now inservice instructor at Sam Houston Memorial Hospital, Houston. Baida is a diploma graduate of Mt Carmel School of Nursing, Columbus, Ohio.
block, spinal block, epidural, and paravertebral. During topical anesthesia, the anesthetic agent is generally sprayed directly onto the skin. It acts by decreasing sensation at the contact point. When local anesthetic is injected into the tissue where the incision will be made, thereby injecting the nerves immediately surrounding the area, it is known as a field block. Many nerves may be delineated to anesthetize specific body parts. A nerve block involves injecting a major nerve to anesthetize a specific body part during delicate procedures, such as microsurgery. A larger area of the body, as from the waist to the toes, may be anesthetized by spinal or epidural block by injecting an anesthetic agent into an area of the spinal column. Finally, general surgery in risk patients is sometimes facilitated by use of the paravertebral block, which anesthetizes the abdominal wall and organs by affecting the associated nerves2 Local anesthesia is preferable to general anesthesia for many reasons. Technique is simple, minimal equipment is needed, a nonflammable drug is used, and surgery can be done at lower cost. The patient experiences less nausea and vomiting, lower incidence of pulmonary and embolic complications, fewer disturbances to bodily functions, and less bleeding and bodily secretions. Surgery under local anesthetic is the
AORN Journal, November 1978, Vol28, No 5
855
method of choice when patient cooperation is needed, when surgery is superficial or minor, or when food had been recently ingested. Finally, less postoperative observation and general care are needed.3 Cocaine was the first local anesthetic noted in medical practice, and even today, cocaine and its derivatives are used. The nurse should be familiar with this drug and its safe dosages (Table 1). The operating room nurse also must be aware of the patient’s possible reactions to the local anesthetic. Reactions are classified as systemic, due to local anesthetic; systemic, due to vasoconstrictors; allergic, due to local anesthetics; and local tissue irritation and de~truction.~ Systemic reactions due to local anesthetics may be manifested by hypotension, pallor, clammy skin, sweating, decreased respirations, apnea, twitching of small muscles of the face and extremities, generalized convulsions, drowsiness, incoherent speech, possible coma, and cardiac standstill. Treatment is symptomatic and may include use of Trendelenburg’s position, hyperventilation of the patient, and use of vasopressor drugs, intravenous (IV)fluids, and ultrashort-acting barbiturates and muscle relaxant^.^ In general, reactions due to vasoconstrictors are due to an epinephrine overdose. The patient may appear apprehensive, exhibit tremors, palpitations, tachycardia, restlessness, weakness, tachypnea, hypertension, sweating, fainting, headache, and skin pallor. In extreme overdose, tachycardia leading to pulmonary edema and ventricular fibrillation may occur. Therapy includes administration of oxygen, vasodilators, and barbiturates.6 Allergic reaction to the anesthetic may be indicated by angioneurotic edema, urticaria, pruritis, hypotension, and asthmatic breathing. Antihis-
856
~~~
Table 1
Cocaine and derivatives Type Cocaine Procaine Tetracaine (Pontocaine) Mepivacaine (Carbocaine) Lidocaine (Xylocaine) Butacaine Dibucaine Piperocaine (Metycaine) Cocaine 10% (solution) Cocaine 4% (solution) Cocaine crystals
Safe level 250 mg 1000 mg 100 mg 500 mg 500 mg 125 mg 66 mg 800 mg 2% cc 6 cc exact dosage limit unknown
Table taken from “Policy manual,”Methodist Hospital, Texas Medical Center, Houston. ~~~~~~~~~~~~
tamines, epinephrine, oxygen, vasopressors, and occasionally, calcium gluconate are included in treatment.’ Treatment for local tissue irritation and destruction includes moist packs and antibiotics. Of course, at this stage, the patient has been removed from the operating room. A patient having surgery under a local anesthetic must be monitored carefully by the operating room nurse. The nurse must be familiar with anesthetic monitoring devices, such as blood pressure equipment and electrocardiograph, intravenous therapy, oxygen therapy, and related drug therapy. At Methodist Hospital in Houston, recommendations include intravenous therapy of each patient having local anesthetics and routine monitoring of vital signs every 15 minutes, as well as before and after any medication is administered.* Continuous electrocardiograph monitoring is vital. Nursing implications. Foremost consideration in operating room nursing is given to the patient. An individual plan begins with the preoperativelanesthetic
AORN Journal, November 1978, Vol28, No 5
visit. At this time, the nurse gathers important data about the patient’s special needs and problems and answers the patient’s questions if at all possible. The importance of this visit cannot be stressed enough. According to Snow and Thomas, “the value of the preanesthetic visit has shown t o be equivalent to 100 mg of pentobarbital (Nembutal) in its calming effect and is superior in its value to allay anxiety and provide emotional s u p p ~ r t . ”In~ the operating room, the patient’s emotional support frequently includes a familiar face, voice, and hand to hold.1° Before the nurse receives the patient in the operating room, she should take time to check all equipment, making sure everything needed is readily available and functioning. This includes emergency and therapeutic drugs, electrocardiograph equipment, blood pressure apparatus, temperature monitors, oxygen equipment (including airways), intravenous equipment, and small items such as syringes, needles, and alcohol swabs. All necessary equipment should be easily accessible. After an equipment check and subsequent identification of the patient by the surgeon, the nurse familiarizes herself with the patient by talking with him and checking his chart. Next, the nurse starts the IV and connects electrocardiograph equipment as well as blood pressure apparatus. Temperature devices should be applied and oxygen therapy started if indicated. The nurse should not waste time, since t h e lasting effect of preoperative and local anesthetic drugs is limited. After vital care has been established, the nurse positions the patient as necessary for comfort and informs the surgeon that the patient is ready for the procedure. Positioning the patient depends on the orders of the individual physician. The patient’s needs also determine supports used. Many supports
Cocaine: From the Incas to anesthetic Cocaine is derived from the leaves of a mountain shrub known as Erythroxylon coca. It was first used in the early sixteenth century by the Inca Indians in South America. In their society, chewing the coca leaves represented a great honor; priests and worshippers could only enter the temples if they had a coca leaf in their mouths. Later, Spanish conquistadores used the coca leaf to enslave the Incas. The Spanish discovered that coca’s euphoric and appetite-suppressing properties enabled the Incas to work longer and harder without food. During the nineteenth century, European and American scientists took an interest in the effects of coca leaves and experimented with it in wines and elixers. In 1885,John Styth Pernberton of Atlanta marketed t h e French Wine Coca-Ideal Nerve and Tonic Stimulus.The next year he patented the beverage Coca-Cola,which contained an extract from the kola nut and caffeine, as well as coca. In 1918, after a nine-year court battle with the Pure Food and Drug Law, the manufacturers of Coca-Colachanged the content of its beverage. The chief active ingredient in coca leaves, alkaloid cocaine, was isolated in pure form in 1844. From Edward M Brecher, Licit and Illicit Drugs (Boston: Little, Brown and Co, 1972).
are available, such as headrests and immobilizers, pillows, sheets, and sponges. An armboard may be used to give the patient a feeling of having more room. A pillow may be placed under the patient’s knees to relieve back pressure. Sheepskin and other such material may be placed under elbows, heels, or other bony prominences. Extremities should never be allowed to rub, causing friction. Padding or pillows may be used to
AORN Journal, November 1978, Vol28, No 5
867
avoid this. Proper body alignment is imperative to ensure optimum postoperative function of the patient. The patient’s safety is important, and the nurse should have available necessary restraints and grounding pads. Due to preoperative medication, a patient under local anesthetic may have difficulty interpreting voices and sounds accurately. A quiet atmosphere is necessary. The nurse can maintain this quiet atmosphere by reminding those in the room and outside of the room of the patient’s status. If possible, an appropriate sign, such as “Quiet please. Patient is awake.” can be placed on the door to the operating room. Any non-patient instruction should be minimized or eliminated completely. Postoperatively, most local anesthetic patients do not go to the recovery room, but return directly to their rooms. The operating room nurse occasionally intervenes with this process if a complication occurs during the surgical procedure. This may require collaboration with the anesthetist or recovery room nurse. The operating room nurse should realize that nurses on surgical units may not be prepared to handle an emergency brought on by the side effects of a local anesthetic. This being the case, the operating room nurse accompanies the patient to his room and describes possible patient problems as well as his surgical treatment to the nurse on the unit. Postoperative nursing care of the patient having surgery under local anesthesia includes careful monitoring of vital signs, as indicated by the patient’s status, as well as conscientious observation for possible side effects. The nurse should note the time when sensation returns to the affected part of the body. According to Brunner, et al, “An anesthetic cannot be regarded as having ‘worn off’ until all three systems (motor,
858
sensory and autonomic) are no longer affected by the anesthetic.”” Many times, local anesthetic patients have shorter hospital stays than general anesthetic patients, making postoperative visits unfeasible. When a visit is possible, the operating nurse can evaluate his or her care of the local anesthetic patient, which allows for future implementation of care plans.12 Although local anesthetic cases generally constitute a minor part of a hospital’s surgical caseload, it is important to develop a routine for handling patients having local anesthetic. An effective routine takes into consideration the type of anesthetic used, possible reactions and treatments, preoperative visits by the operating room nurse to become familiar with the patient and his needs, and careful monitoring of the patient during the procedure. Establishing such a plan will help alleviate operating room nurses’ anxiety about caring for the patient under local anesthetic and ensure the patient quality nursing care during the intraoperative phase.
a
Notes 1. John C Snow, Charles C Thomas, Anesthesia: In Otolaryngology and Ophthalmology (New York: J B Lippincott, 1972). 2. Lillian Sholtis Brunner, et al, Textbook of Medical-Surgical Nursing, 2nd ed (Philadelphia:J B Lippincott Co, 1970). 3. Snow, Thomas, Anesthesia: In Otolaryngology and Ophthalmology. 4. Ibid. 5. Ibid. 6. Ibid. 7. Ibid. 8. ”Policy manual,” Methodist Hospital, Texas Medical Center, Houston. 9. Snow, Thomas, Anesthesia: In Otolaryngology and Ophthalmology. 10. Gloria M Francis, Barbara Munjas,Promoting Psychological Comfort (Dubuque, Iowa: William C Brown Co, 1968). 11. Brunner, et al, Textbook of Medical-Surgical Nursing. 12. Ibid.
AORN Journal, November 1978, Vol28, No 5
