Authors: Jennifer O'Neill MSN AGACNP-BC, Elizabeth Helwig MSN AGACNP-BC
Spinal anesthesia is a common regional anesthesia used in ambulatory and hospital settings. Spinal anesthesia has been shown to reduce postoperative pain and morbidity in certain populations. Understanding the physiological changes during spinal anesthesia can help predict and manage side effects including hypotension, bradycardia, decreased expiration, nausea, vomiting, and urinary retention. This article describes the physiological effects of spinal anesthesia in a body systems approach, describes how to assess the spinal level, and presents common side effects seen postoperatively and how to successfully manage and treat these patients.

This module includes patient care priorities for the obstetrical patient.

Authors: Barbara A. Alliod MSN APN ACNP-BC CCNS-BC CPAN, Rebecca A. Ash MSN APN CPNP-AC
More patients suffering with Duchenne muscular dystrophy (DMD) and Becker muscular dystrophy (BMD) are presenting to perianesthesia settings for emergent and nonemergent treatment and care. A group of collaborative health care providers at Rush University Medical Center in Chicago developed a multidisciplinary DMD/BMD Task Force to study this disorder and create a set of guidelines to aid those engaging in the planning, execution of care, and recovery of this unique population in the perianesthesia setting. Attention to detail, well-executed preplanning, meticulous awareness of the patient, and prearranged implementation and intervention has proven to offset potential problems and complications and is the key to a successful perianesthesia period.

Authors: Debbie Smith BSN RN TNS, Jackie Murauski MSN APN CCRN CPAN
Pulmonary embolism (PE) is a complication that can occur at any time during the perioperative period. The patient undergoing surgery to repair a hip fracture is at a high risk of developing a PE due to venous thrombosis, tissue, or fat emboli. The signs and symptoms of a PE are often nonspecific and can be obscured in the patient receiving or recovering from general anesthesia. This case study describes the presentation, diagnosis, and treatment of a patient experiencing a pulmonary embolism in the postanesthesia care unit (PACU) after surgery to repair a hip fracture.

Authors: Nikki Lucci DNAP CRNA, Cole McConnell BSN, Chuck Biddle PhD CRNA
Dysphagia is the disruption of the normal swallowing process; its epidemiology is a national health care concern. Dysphagia affects as many as nine million Americans. Understanding normal swallowing mechanics and how they may be disrupted is a vital patient safety goal in rendering care during the perianesthetic period. The diversity of patients and perianesthetic conditions that may cause or exacerbate existing dysphagia requires that a heightened index of suspicion be maintained. In this continuing education article for perianesthetic nurses, we review normal swallowing, pathophysiologic perturbations in the swallowing process, and drug-related impairments.

Authors: Barbara J. Duffy MSNA CRNA, Tito D. Tubog DNAP CRNAA
Perioperative peripheral nerve injury is a serious yet preventable perioperative complication. Since the inception of the American Association of Anesthesiologists Closed Claim Project, the incidence of peripheral nerve injury has remained constant with an overall reported prevalence rate of 15% to 16%. To date, the most frequent nerve injuries are ulnar nerve neuropathy and brachial plexus injury. This article will review the clinical presentation, pathophysiology, causative and risks factors, and preventive measures for the two most common nerve injuries. Knowledge of the anatomical structures and components of peripheral nerves prone to injuries during surgery can assist in defining precautionary actions in the perioperative setting. Positioning techniques in the operating room, early recognition of neuropathies, and use of a perioperative tool in the postoperative setting are keys to reduce significant clinical complication.

Authors: Kyle Nelson RN BSN, Chris Nicholls RN BSN, Virginia C. Muckler DNP CRNA CHSE
Perioperative management of pediatric patients demands knowledge of the relevant ways in which pediatric physiology and physiological regulation differs from the adult. This article will outline some of these most pertinent differences, and also present current recommendations for perioperative management.

Author: Catherine Hebert MSN RN GCNS-BC
Delirium is a pervasive and dangerous syndrome for older adults in the perianesthesia setting, occurring in up to 60% of surgical cases. The American Geriatrics Society performed a systematic review to develop recommendations for the prevention and management of postoperative delirium in older adults. The recommendations emphasize nonpharmacologic interventions with a strong focus on reducing the use of psychoactive medication. Perianesthesia nurses can serve as leaders in translating these recommendations into evidence-based practice at the bedside for older adults.

Authors: Cheryl A. Allen BSN RN-BC, Julius R. Ivester Jr. MD
Ketamine, an anesthetic agent, is gaining attention as an analgesic for the management of acute and chronic pain conditions. Perianesthesia nurses may expect to see ketamine's use increase as more anecdotal and evidence-based experience is gained with its use for pain management. Unlike opioids, ketamine supports respirations while supporting hemodynamic function; moreover, the agent has potential for decreasing opioid-induced hyperalgesia. Ongoing clinical evidence continues to support ketamine's use for analgesia, thus it may be argued that the current Food and Drug Administration classification for ketamine as an anesthetic agent is outdated, and patients would be better served by a reclassification of this medication to include its use for analgesic purposes. This continuing education article provides an overview of ketamine, its side effects, and the possible adverse reactions so perianesthesia nurses may be prepared to care for postsurgical patients who receive ketamine for analgesic purposes.

Author: Jacque A. Crosson MSN RN CPAN
Continued advancements in perioperative care and anesthesia technology have improved surgical outcomes and accelerated the patient's ability to resume preoperative activities. With the current emphasis on decreased utilization of expensive hospital resources, a shorter length of stay while maintaining patient satisfaction is encouraged for maximum reimbursement. Through the implementation of evidence-based protocols that standardize care and promote patient medical optimization, the surgical stress response, complications, and time spent in the hospital can be reduced. Enhanced recovery after surgery uses a multidisciplinary and multimodal evidence-based approach to maximize patient recovery. Perianesthesia nurses are critical to its success and have an obligation to understand and participate in the process to optimize patient outcomes. After completing this educational article, the reader will be able to recognize the importance of the perianesthesia nurse in implementing an enhanced recovery after surgery program; review the patient benefits of enhanced recovery; and describe the impact of multimodal pain management on patient length of stay and patient mobility.