Anesthesia awareness; formalin handling; standing orders; witnessing consents

AORN Journal,  Jan, 2005  by Byron L. Burlingame

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QUESTION: We have been told that we need to address patient awareness during general anesthesia in response to the Oct 6, 2004, Joint Commission on Accreditation of Hearthcare Organizations (JCAHO) sentinel event alert. This seems like an issue for anesthesia care providers and not something that perioperative nurses can or should address. What can perioperative staff members do to help prevent awareness in patients under anesthesia?

ANSWER: Perioperative RNs can assist in preventing awareness in patients under anesthesia by becoming informed about the issue, implementing appropriate interventions throughout the perioperative period, and helping increase other staff members' sensitivities to the issue. Anesthesia awareness is the postoperative recollection of noises; conversation; pain; feelings, such as those experienced during the intubation process or by cold instruments being inserted into the surgical site; or other events that occurred during the time the patient was under anesthesia. (1-3,4) (p421) Although patients are unable to communicate their level of awareness because of induced paralysis or intubation, they may be aware of their surroundings? The rate of awareness is approximately 0.1% to 0.2% (3) (ie, 20,000 to 40,000 cases per year). (5) Awareness can be caused by four basic situations:

* a light level of anesthesia,

* patient-related factors creating the need for an unusually high dose of anesthetic agents,

* mechanical problems with anesthesia equipment, or

* anesthesia care provider error resulting in an inadequate dose of anesthetic agent being delivered. (1)

Anesthesia awareness has been documented to occur more frequently during cesarean sections, surgery resulting from trauma, and cardiac surgery. (1)

When interviewing patients preoperatively, perioperative nurses should assess patients for previous incidents of anesthesia awareness. If a history of awareness is discovered, the preoperative nurse should notify the anesthesia care provider and all other perioperative team members immediately of the potential risk for anesthesia awareness. (1)

Intraoperatively, conversation should be kept to a minimum (6) and should relate to the care of the patient as much as possible. All OR team members should refrain from making inappropriate comments or jokes or discussing other patients or unrelated topics because patients may recall all or parts of the conversation. (1) The circulating nurse should monitor traffic entering and leaving the room and keep it to a minimum. Conversations and other environmental noises should be reduced whenever possible.

If a patient mentions a recall situation postoperatively, the RN caring for that patient should notify the anesthesia care provider as soon as possible. The nurse should support the patient by taking the time to listen to and understand the patient's concerns. The anesthesia care provider should explain what has happened and answer the patient's or family members' questions. During the discharge process, the patient should be instructed to inform all future anesthesia care providers about his or her potential for anesthesia awareness. (1)

The surgeon also should be informed of the event. The surgeon or primary care physician may request a psychological consult because some incidents of anesthesia awareness have been reported to lead to posttraumatic stress disorder. (3) A health care facility risk management staff member also should be made aware of the event. A facility representative, such as the anesthesia care provider, risk manager, nursing staff member, or other designated professional, should follow up with the patient daily during the period of hospitalization and for a period of time after the patient is discharged. The length of time for follow-up will vary with the response of individual patients. (1)

Facility policies and procedures should be developed to address care of patients who experience anesthesia awareness. The facility policy and procedure should include staff member education to recognize and manage patients who experience anesthesia awareness. The organizational quality improvement process should include reviewing anesthesia awareness incidents. Brain activity monitoring devices should be considered and evaluated for purchase by the facility. This consideration should be documented for accrediting agency review.

Perioperative nurses should listen to and believe any patient who states he or she had an anesthesia awareness event. Perioperative nurses should be involved actively in patient care and take all possible measures to make the experience less frightening.

QUESTION: How should formalin be handled in the OR? Is it acceptable to prefill specimen containers? If not, is it acceptable to store the formalin in the clean core area in a larger receptacle containing a large quantity of formalin?

ANSWER: Caution should be used when dispensing and using formalin in the surgical suite. Formalin can be absorbed through the skin and nasal passages, splashed in the eyes, and ingested. (7) Formalin is a potential carcinogen that may be fatal if inhaled or absorbed through the skin. Irritation or burns to areas such as skin, eyes, mucous membranes, upper respiratory tract; allergic reactions; coughing; chest pain; or pulmonary edema may result from exposure. (8)