In order to better understand the role of the anesthesia technician (AT) as a member of the perioperative team and the flow of patients through the operating room (OR), it is useful to understand the overall surgical experience from the patient’s point of view. This chapter provides a description of the different phases of care a patient passes through while undergoing a surgical procedure. It provides an introduction to the perioperative setting, the work of the AT, and the role of the AT in the OR team.
There are many steps to safely coordinate a patient’s perioperative care. After the determination that a surgical intervention is appropriate, a provider reviews the planned procedure to make sure that the patient understands the risks, benefits, and alternatives. This is called informed consent: the concept is reviewed in more detail in Chapter 65, Legal and Regulatory Issues. The surgical team will verify this consent on the day of surgery.
On occasion, surgeons may have patients with severe medical conditions or special anesthesia considerations consult an anesthesiologist before surgery is scheduled. The patient may also be referred to a specialist consultant in another field for a specific coexisting problem, for example to a cardiologist. Once the decision for surgery is made and the appropriate preoperative evaluations are ordered, the surgical procedure is scheduled.
The timing will depend upon the following:
There is often a presurgical visit prior to the day of surgery. This can be done either with a primary care practitioner (PCP) or at a hospital-based preoperative medicine clinic supervised by internists or anesthesiologists. At this time, the history and physical, including a full review of systems, is updated, and education is given to patients to prepare them for the day of surgery and their recovery. Patients receive information regarding what needs to be brought with them the day of the surgery, what to avoid (including instructions regarding fasting prior to surgery, usually for at least 8 hours), what to expect after surgery, whether or not medications should be continued, and when they should plan on arriving at the hospital or outpatient surgical facility.
The patient may also go through additional testing depending on the patient’s medical condition and the scheduled surgery. This may include additional lab work, imaging studies, cardiac testing, or referral to a specialist consultant. The American Society of Anesthesiologists (ASA) recommends that any testing be done for specific indications, not routinely; for many healthy patients, no tests are necessary. The preoperative medical clinic may adjust medications to optimize patients’ health before surgery or may delay surgery if patients are not in optimal health (e.g., if a patient is in active heart failure, or needs to be treated for recently worsened asthma).
On the day of surgery, patients coming from home are asked to arrive 1-2 hours prior to their scheduled surgery time. Upon arrival, the patient will complete any outstanding admission paperwork prior to being directed to the preoperative (pre-op) holding area. Family members can often remain with the patient.
In the pre-op area, patients will be asked to change into a hospital gown and wear a cap to cover their hair. They will also be asked to remove any items such as jewelry, hearing aids, contact lenses, glasses, and dentures, which are marked for return to the patient after surgery. An identification bracelet or name band will be created and secured to the patient. The accuracy of the information on the name band is essential for safety as the surgical patient moves through various phases of care. Depending on institutional policy, an additional band may be placed to alert all medical personnel of allergies or any special precautions (e.g., fall risk).
A pre-op nurse will complete the preoperative assessment, which includes taking vitals, measuring height and weight, and completing a physical examination. An intravenous (IV) line is placed to keep the patient hydrated and also serve as an access point for administering medications. The nurse will also confirm that the paperwork and the surgical consent form are correct and have been signed by the patient and the provider.
In many cases, the patient may briefly meet with the surgeon. The surgeon will answer any last-minute questions, update the history and physical assessment, and “mark” the surgical site on the patient. Marking the surgical site in cooperation with the patient is required to reduce the risk of wrong-site surgery. This may also be done by a representative of the surgeon, such as a physician assistant (PA) or surgical resident.
In addition to meeting the surgeon, the patient will meet some of the other members of the perioperative team. For every procedure, there is a circulating nurse. The circulating nurse is responsible for all of the care interventions and coordination outside of the sterile field in the OR. Prior to the procedure, the circulating nurse greets the patient and family, confirms that the consent is correct, and completes any remaining preoperative assessment.
While in the preoperative holding area, the patient will also meet the anesthesia provider. The anesthesia provider reviews the patient’s medical history and inquires if there is a family history of anesthetic complications. Part of the pre-op evaluation includes evaluating the patient’s airway, physical examination, and reviewing all labs, diagnostic imaging, and any other tests relevant to the procedure. The anesthesia provider typically has a preliminary anesthetic plan based upon initial information, but makes a more definitive plan, including the type of anesthesia, after evaluating the patient. The type of anesthetic may include local, regional, general, monitored anesthesia care, or a combination of these. Any special monitoring or vascular access will also be planned. The anesthesia provider obtains informed consent for anesthesia and all related procedures independently of the surgical consent.
If a regional block is indicated, the primary anesthesia provider or the regional block team may place the block in the pre-op holding area before the patient goes to the OR, often with the assistance of an AT or a registered nurse (RN).
In preparation for a surgical case, the anesthesia provider and the AT will make sure all necessary equipment, medications, monitors, and supplies for the procedure are readily available. This is particularly important if special equipment or supplies will be needed based upon the anesthesia plan, including if the technician will be required to assist the provider with any procedures. Communication between the anesthesia provider and the AT is essential to ensure a safe and efficient care.
When the OR is ready for the patient, a member of the perioperative team will transport the patient to the room. At this point, adult patients typically separate from family members, who wait in the surgical waiting room, or may be available by phone or a paging system. Anesthesia providers often give medications for anxiety relief when leaving the pre-op area. Pediatric patients may also separate from parents after receiving oral sedation; in other cases, parents may accompany unsedated children to the OR and separate after anesthesia induction (see Chapter 48, Pediatric Anesthesia).
There are three phases of anesthesia: induction, maintenance, and emergence. Once in the OR, ASA standard monitors are placed (see Chapter 31). The anesthesia provider will induce anesthesia with IV or inhalation anesthetic agents. The patient’s airway may require intubation or the use of other devices to ensure safe airway management. A member of the team (like an AT or RN) stands by to assist during this critical time of induction.
Invasive lines, such as arterial lines or central lines, are usually placed after the patient is asleep with the assistance of an AT. In some cases, due to the patient’s medical status, venous access or monitoring lines may be placed while the patient is still awake.
The next phase of the anesthetic is referred to as maintenance. The anesthesia provider will administer anesthetic gases, additional pain medications, and drugs to keep muscles paralyzed, as necessary for the procedure. The anesthesia provider continuously monitors the patient’s vital signs during the procedure. The level of awareness is also monitored through measurement of vital signs and the reaction to surgical stimulation, through agent monitoring, or through brain wave monitors. During the operative procedure, the anesthesia provider will assess the need for transfusion of blood products or other fluids. Lab tests drawn and reviewed during the procedure will aid in this evaluation. In addition to maintaining the anesthetic, the anesthesia provider will monitor the patient’s respiratory status and in many cases will ventilate the patient with a mechanical ventilator (or anesthesia machine).
The final stage of the anesthetic is awakening the patient from anesthesia. This process is referred to as “emergence.” Once the surgical case is coming to an end, the anesthesia provider will slowly reduce the anesthetic medications or may give an IV reversal agent to assist with the waking-up process. When full strength and awareness in the patient is observed, the anesthesia provider will remove the breathing tube or device. When the patient is stable, the team will transfer the patient to the postanesthesia recovery room (PACU) or directly to the intensive care unit (ICU).
At any point during the surgery, the AT may be asked to come to the OR to assist with a procedure; bring additional medications, equipment, or supplies; or help troubleshoot an equipment problem. In addition, the AT may be called to assist the anesthesia provider during medical emergencies.
The postanesthesia care unit (PACU) is an area that monitors and supports patients as they recover from the immediate effects of anesthesia and surgery. Patients’ vital signs are continually monitored, and pain medication and antinausea drugs are administered as needed. Pain medication can be given in the form of oral medication, suppository, or IV or through a patient-controlled analgesia (PCA) pump. In some cases, a nerve block will be performed in the PACU to assist with pain that cannot be controlled with other measures. In some facilities, it is convenient to flex the pre-op holding area and the PACU in the same physical location, as they surge in patient use at different times of the day, require similar layout and equipment, and should be near the ORs.
When patients are stable, they are either discharged (referred to as “ambulatory” or “outpatients”) or transferred to a surgical ward in the hospital or an ICU (inpatients). An ambulatory patient is a patient who comes in for a procedure and leaves the facility the same day. An inpatient is a patient who was either already a patient in the hospital or a patient who was coming in for surgery and expected to stay in the hospital. Ambulatory (literally, “walking”) patients must leave with another person.
Patients undergoing surgical procedures are at their most vulnerable. When anesthetized, they are powerless to make decisions on their own behalf, to protect their bodies from injury, or perhaps even to maintain their vital functions like breathing or circulation of blood. All members of the perioperative team, including the AT, are tasked with the responsibility for ensuring patient safety: everything from meticulous hand hygiene to assisting in the placement of a complex invasive line.
To understand the perioperative team dynamic, it is important to understand the various roles.
There are two common pathways to becoming an anesthesia provider: the anesthesiologist and the certified registered nurse anesthetist (CRNA). An anesthesiologist is a physician (both MD and DO are medical degrees) who has attended both college and 4 years of medical school, followed by 1 year of internship and 3 years of anesthesia residency. A CRNA has attended nursing school (for at least a bachelor’s degree); worked as a nurse in a hospital, typically with at least 2 years of ICU experience; and then attended at least 2 years of nurse anesthetist school. There are a few variations on these pathways and degrees, including a relatively newer certification as an anesthesia assistant (AA), but these are the two primary paths.
The model for anesthesia provider coverage varies based on the organization and region. In some organizations, there may be an anesthesiologist practicing alone in each surgical suite. In other institutions, the anesthesia providers function as a care team, with an anesthesiologist supervising multiple CRNAs simultaneously. In academic settings, anesthesia residents train under the supervision of an attending anesthesiologist. In these cases, the anesthesiologist may be supervising two residents simultaneously. In a care team, the anesthesiologist discusses and formulates the anesthetic plan along with the CRNA or resident. The physician anesthesiologist is then present for induction, emergence, critical portions of the procedure, and is immediately available for consultation if help is needed. Depending on state scope of practice laws, CRNAs may practice independently in some institutions.
Surgical attendings are physicians (MDs or DOs) who have completed training in general surgery, a surgical subspecialty, or both. Surgical residents rotate through multiple specialties as part of their training program, becoming increasingly more independent in their practice. After residency, some surgical attendings specialize further by completing fellowship programs.
While some institutions have surgical residents to assist attending surgeons, other organizations utilize specialty trained PAs or nurse practitioners (NPs). Additionally, surgical technicians and surgical RNs can complete training programs and become Certified Surgical First Assist (CSFA) and Registered Nurse First Assist (RNFA), respectively. Surgical assistants are responsible for helping the surgeon, from retracting tissue or limbs during the procedure to closing or suturing a patient’s fascia or skin closed at the end of a procedure.
The circulator is a nurse who has training specific to his or her responsibilities during procedures, often through a Perioperative RN Internship Program. The circulator is responsible for all of the care interventions and coordination outside of the sterile field in the OR. The circulator supplies any needs of the sterile field while assuring that it remains uncontaminated. Some (not all) perioperative nurses are also trained to “scrub in” to the sterile field and assist with surgical instruments.
For all surgical procedures, there is a person “scrubbed in” to assist at the surgical field. A perioperative nurse or a surgical technologist may perform the scrub role. They are responsible for adherence to proper sterile technique, in addition to managing the sterile instruments and supplies and responding to dynamic patient needs.
In addition to the primary perioperative team, there are many other supporting roles. To provide intraoperative diagnostic imaging, radiology technologists operate various imaging equipment (fluoroscopy, x-ray, computed tomography [CT], etc.). OR aides help transport equipment, supplies, specimens, products and various other items. Some units have dedicated Environmental Services Technologists (housekeeping) to help in cleaning and “turning over” surgical suites. Sterile Processing is an entire hospital department immediately adjacent to the OR that cleans, disinfects, and sterilizes reusable instruments and endoscopes. Representatives of specialty equipment also routinely visit ORs to support or instruct personnel in equipment or surgical implant use; visitors must always clearly identify themselves, but are important to teams as equipment (e.g., surgical robotics) becomes more and more complex and as its pace of change accelerates.
A major role of the AT is to support the anesthesia provider. Additionally, ATs work closely and partner with all other members of the surgical team. The scope and responsibilities of the AT may vary based on the institution and region. Some of these include partnering with the perioperative team, anesthesia machine checkout, room turnover, supply, and resource covering multiple areas.
A large part of the AT’s time is dedicated to direct assistance of the anesthesia provider. This may include assisting with regional blocks, transporting patients, placement of monitoring equipment, airway management, invasive line placement, use of ultrasound devices, and troubleshooting equipment. All of these will be covered individually in later chapters.
The AT is in and out of the surgical suites before, during, and after the procedure. ATs are an integral part of keeping the patient safe, responding to emergency situations, assisting with delivery and checking of blood products, and facilitating lab draws and point-of-care testing. They may assist the intra-op team with lateral transfers and patient positioning, paying special attention to the head, airway, and lines. The AT is an essential part of the transport team for critically ill patients between OR, imaging suites, and intensive care unit.
The anesthesia machine checkout is the full inspection of the anesthesia machine according to the manufacturer’s recommended procedure. This complete workup needs to be performed every morning by the AT and/or the anesthesia care provider. See Chapter 25 for details on the anesthesia machine checkout, As an AT, you will become experienced at solving machine problems (see Chapter 29), and as your knowledge expands, you will be called upon for your expertise with monitors, ventilators, and many other technical aspects of anesthesia delivery systems.
Room turnover is the term used to describe the time after one patient has left the OR or procedure room while the room is being cleaned and prepped for the next case. Room turnovers must be efficient both for the anesthesia provider (who will be busy with the patients in the recovery and preoperative areas) and for the AT. The AT’s responsibilities may include
Resource planning is a significant part of the job of an AT. It deals with analyzing available resources and making certain that the anesthesia team is fully prepared for the day’s cases as well as for emergencies or unanticipated needs (see Chapter 64, Resource Planning).
The AT should be involved on a daily basis in making sure adequate supplies are available. This may entail direct ordering or communication of needs to a purchasing department. It is important that there be a process in place that ensures products are continually checked for expiration dates.
Nondisposable devices used by anesthesia need to be cleaned between uses. The level of cleaning required depends on the device and its use. Critical items are ones that come in contact with the bloodstream or sterile body tissues, like surgical instruments. These must be sterilized between use. Sterilization kills all microbial life. Semicritical items are ones that come in contact with mucous membranes or nonintact skin, like esophageal temperature probes. Semicritical items must have high-level disinfection between uses. Lastly, noncritical items are ones that are exposed to blood and infectious material or come in contact with intact skin, like a blood pressure cuff. Noncritical items require low-level disinfection between uses. Depending on the institution, the AT may be required to complete the cleaning or the contaminated items may be sent to a Sterile Processing Department (SPD) (AORN, 2017) (see Chapter 47, Anesthesia Supply and Equipment Contamination, Sanitation, and Waste Management for a full discussion).
ATs work in all areas where the anesthesia team is needed. These can include holding areas, ORs, PACUs, emergency department (ED), block rooms, obstetrics rooms, magnetic resonance imaging (MRI)/CT scan rooms, nuclear medicine suites, interventional radiology suites (IR), cardiac procedure suites, gastrointestinal (GI) procedure areas, special procedure rooms, ICUs, and many more. With advances in modern-day medicine and technology, the areas covered by the anesthesia team are constantly growing; therefore, the areas covered by the AT are also growing. Chapter 50 provides an overview of the special challenges associated with providing care in these areas.
This chapter provides an overview of the surgical experience of the patient, and of the AT as a member of the surgical team. The AT has an important role in the care of surgical patients, completing tasks systematically in order to ensure safety in a collaborative environment. Though there are many tasks that anyone new to the team is required to learn, the critical function of the AT is to understand the principles and reasoning behind their practice and be able to speak up for safety when deviations are noticed.
1. Which role on the perioperative team does not require a medical or nursing degree?
A) Anesthesia provider
B) Surgical attending
C) Surgical first assistant
D) Circulating nurse
E) CRNA
Answer: C
The surgical first assistant role can be performed by a person with a variety of backgrounds: some are surgical residents; some are specially certified surgical technologists, specially certified RNs, NPs, or PAs. Anesthesia providers are either physicians or nurses. CRNA stands for Certified Registered Nurse Anesthetist. Surgical attending is another term for surgeon and is a physician.
2. Family members
A) Must stay in the surgical waiting area during surgery so that the surgical team can reach them
B) Cannot come into the OR, because it is a sterile environment
C) Can expect to be welcome in the preoperative area, but to separate at some point as the patient goes to the OR
D) Are required to sign the patient out of the hospital
Answer: C
Family members are present when the patient arrives but in general do not come to the OR. They can, under special circumstances, such as with pediatric patients. Family members must be available for contact by the surgical team, but this can be in the waiting room or by phone or pager. Ambulatory patients must be accompanied by another person when they leave the hospital (i.e., they cannot leave alone immediately after anesthesia) but they do not have to be accompanied by a family member.
3. The anesthesia technician
A) Should replenish depleted supplies in between cases
B) Is responsible for disposal of medications between cases
C) Should perform a complete machine checkout between cases
D) Should verify that the ventilator is working between cases
E) All of the above
Answer: A
Turnover between cases is brief and efficient. As you will learn in Chapter 25, a complete anesthesia machine checkout is performed once every 24 hours. This includes verification that the ventilator is working. Between cases, verification that there is no leak in the new circuit is an adequate safety test (even if the automatic ventilator does not work, the anesthesia provider can ventilate the patient safely by hand). The anesthesia provider is responsible for disposal of partially used medications.
4. You have just arrived in a new hospital where you will be working as an anesthesia technician. You should begin to learn your way around. Which of the following locations are you unlikely to visit frequently in the course of your work?
A) ICU
B) Emergency room
C) MRI
D) Labor and delivery
E) General surgery postoperative ward
Answer: E
General surgery postoperative ward. Anesthesia procedures are performed in all these places, including frequent emergency intubations, resuscitations, and transfers to the OR in the ICU and the emergency room. Your patients will go to the general surgery postoperative ward after you care for them in the PACU, and will occasionally require emergency intubation, but it will be the least frequent place where anesthesia care is provided.
5. Prior to surgery, the patient should
A) Have nothing to eat for at least 6 hours
B) See a cardiologist if he or she has a heart problem
C) Have laboratory testing and an EKG if having major surgery
D) Have a complete history, physical, and review of systems, and any testing that is indicated
E) Be evaluated and cleared by a medical doctor or anesthesiologist before surgery is scheduled
Answer: D
Patients should be fully evaluated with a history, physical, and review of systems, and testing if it is indicated. The ASA does not recommend any testing without a specific indication; “major surgery” is not, by itself, an indication for an EKG though it may be a reasonable indication for baseline evaluation of electrolytes, kidney function, and blood counts. A heart problem may be fairly minor and easily managed by the anesthesiologist or primary care doctor, or the patient may recently have seen the cardiologist; not all heart problems or all surgeries require a visit to a cardiologist. Very few patients are so ill that they need assessment before surgery is scheduled. The ASA in general recommends that patients have nothing to eat or drink for 8 hours before surgery, and many anesthesia providers still recommend that patients be instructed “nothing after midnight” to avoid confusion.
6. Place in the correct order:
A) Assessment, induction, maintenance, emergence, recovery, discharge
B) Induction, emergence, assessment, discharge
C) Assessment, discharge, emergence, maintenance, recovery
D) Induction, assessment, maintenance, recovery, emergence, discharge
E) Maintenance, induction, assessment, emergence, discharge, recovery
Answer: A
A full asses
sment happens in the preoperative area. Induction is the beginning of anesthesia, which transitions into the maintenance phase during which surgery occurs. After surgery is complete, the patient is allowed to emerge from anesthesia. The patient goes to the PACU for recovery: when recovery is complete, he or she is discharged.
AORN Guidelines for Perioperative Practice. (2017). Guideline for High-Level Disinfection. 801–814.