Christy Bowen; Lindsay Draper; Heather Moore

Learning Objectives

By the end of this section, you will be able to:

Identify classifications of surgical procedures
Recognize surgical advancements and trends in today’s health care
Describe the types of anesthesia used in surgical procedures

The perioperative period, which includes the time before, during, and after a surgical procedure, is a busy time for nurses. While each point in the patient’s surgical journey has its own tasks, needs, and expectations, there are some general concepts related to nursing that the nurse must understand to effectively navigate through each period.

Surgical techniques and technology have advanced at a rapid pace over recent decades. Nurses certainly do not need to be experts on surgical techniques, but keeping a finger on the pulse of surgical innovation is key to staying current with the ever-evolving perioperative landscape. This chapter provides an overview of several important surgical concepts, including classifications of surgical procedures, types of anesthesia used in surgery, and some recent advancements and trends to consider.

Surgery can be broadly classified into four main types: emergent, urgent, expedited, and elective. Performed immediately to save a life, limb, or organ, an emergent surgery often requires resuscitation simultaneously with surgery. An urgent surgery is not necessarily immediate but is performed as soon as possible to treat a condition with acute onset or clinical deterioration of life or limb or for organ survival. When a patient is stable, an expedited (scheduled) surgery requires early intervention for a condition that is not an immediate threat to life or limb or to save an organ but can lead to significant complications and impair quality of life if left untreated. Scheduled in advance, an elective surgery is performed to repair injuries or enhance appearance and function.

The types of anesthesia that can be used during surgery also vary. The choice of anesthesia usually depends on the needs of the individual patient, the requirements of the procedure, and the preferences of the surgical team. The most common types of anesthesia include general, monitored anesthesia care (MAC)/moderate sedation, regional, and local. In general anesthesia, a patient receives a potent cocktail of intravenous (IV) and inhalation medications that induce a state of controlled, reversible unconsciousness, amnesia, and analgesia with or without reversible muscle paralysis so the patient does not feel any pain during the surgery. General anesthesia induces amnesia (temporary or permanent loss of memory). In monitored anesthesia care (MAC)/moderate sedation, a state of drowsiness is induced and anxiety is reduced while allowing the patient to respond to basic commands and breathe on their own during surgery. In regional anesthesia, only the area of the body where the surgery is being performed is numbed through spinal or epidural anesthesia; sedation may also be provided. In local anesthesia, only a small, specific area of the body where a procedure will be performed is numbed while allowing the patient to remain fully conscious.

Among the many advancements and trends that are currently taking place in the field of surgery, there are a few in particular that warrant discussion. One surgical advance is the increasing use and refinement of minimally invasive surgery (MIS), a technique that uses one or more small incisions or natural body openings, which causes less pain and scarring. It typically has a shorter recovery time; however, MIS still carries some of the risks of traditional surgery.

Another emerging trend is robotic-assisted surgery, which is performed with a computer-controlled robot that allows surgeons to make more precise movements. This technique can improve accuracy and reduce the risk of complications but also has limitations and risks. Technological advances (e.g., telesurgery, artificial intelligence [AI]) are also reaching the operating room (OR) and have the potential to change surgical case workflows. With telesurgery, surgeons are able to remotely perform surgical procedures from a distance using robotic systems and telecommunication technology. Using artificial intelligence (AI) allows a robot or other computer system to perform tasks that typically require human intelligence.

Classification of Surgery

The world of surgery is a dynamic and multifaceted realm, encompassing a diverse range of procedures aimed at addressing a wide variety of medical conditions. Understanding the nuances of surgical classifications is paramount for healthcare professionals, ensuring precise and tailored patient care.

The surgeon, alongside a multidisciplinary team, considers factors such as patient health, urgency, and the complexity of the procedure when determining the most appropriate surgical approach. Moreover, patient education plays a crucial role in the decision-making process. Transparent communication regarding the nature of the surgery, potential risks, and expected outcomes empowers patients to actively participate in their healthcare journey.

Emergent Surgery

Imagine a scenario in the emergency department in which a patient presents with a life-threatening hemorrhage that requires immediate intervention or a pregnant person presents with fetal distress. These are situations in which the clock ticks relentlessly, where minutes or even seconds can mean the difference between life and death. Emergent surgery is performed without delay to address critical situations. Emergent surgeries require rapid decision-making and seamless collaboration between all members of the perioperative team. In these uncertain situations, nurses must be prepared to respond immediately to get the patient into the operating room (OR) as rapidly as possible. The focus is on immediate stabilization and survival, with little room for delay or meticulous planning. Examples of emergent surgeries include the following:

Trauma surgery: This field encompasses a range of interventions to repair injuries sustained in accidents, violence, or other traumas, often requiring immediate action to prevent further complications and preserve vital functions.
Emergency cesarean delivery: When vaginal delivery is deemed unsafe for the birthing parent or child because of complications (e.g., fetal distress, placental abruption), an emergency cesarean delivery becomes the lifesaving intervention for both birthing parent and child.

Balancing the nurse’s role as a member of the care team with their responsibilities to the patient during this time-intensive process can be challenging. However, it is integral that the nurse participates in clear, effective, transparent communication with the team, the patient, and the family members. One responsibility of the nurse is to provide support to the patient’s loved ones during this confusing and uncertain period, if at all possible. With compassion and clarity, the nurse can guide a patient’s family through the whirlwind they are experiencing. If critical patient care precludes the nurse from providing this support, the nurse should call for administrative nursing support.

Urgent Surgery

An urgent surgery is when an acute condition has occurred, or there is clinical deterioration of life or limb, or organ survival is at risk. Typically, urgent surgery occurs within hours of the decision to operate, and if resuscitation was required, it has been performed and resolved. Examples of urgent surgery include wound debridement plus fixation of a fracture or an exploratory laparotomy (a surgical procedure where a large incision is made in the abdomen to expose the abdominal cavity) for bowel perforation or other injuries.

Real RN Stories

Every Second Counts

Nurse: Cheri, BSN
Clinical setting: Emergency department
Years in practice: 4
Facility location: New York City

A few weeks ago, I was working in the emergency department (ED) when a teenager was brought in after a motor vehicle accident (MVA). Trying to obtain the pertinent details about the MVA from the emergency medical services (EMS) team was difficult because the patient was screaming as they rolled him in on the stretcher. His leg was visibly deformed and obviously fractured. I also observed the patient appeared to be in excruciating pain, terrified, and possibly in shock. Trying to listen as EMS gave me the information I needed while simultaneously assessing the patient was challenging. In those hectic moments, I recalled my father’s advice to “stay cool as a cucumber.” In the ED, you see a lot of life-and-death situations, but there are also moments when you know that even if a patient survives a trauma, their life may never be the same again.

I didn’t know if the surgical team would be able to save the teenager’s leg, but I knew that my job was to get him stable enough for them to try. I quickly assessed him and got IV fluids started, then made sure we communicated to the OR that an orthopedic surgical consult was urgently needed and that we were prepping the patient for transfer to the OR. I knew those minutes would feel agonizingly slow for the young man. I tried to reassure him, but I could see the fear in his eyes and wasn’t sure he was processing what I was saying.

When we transferred him to the OR and provided the patient handover, I knew it was up to others to do their work at that point. I felt grateful for my team, but knew I had to let go of the urge to keep helping and accept not knowing what was going to happen next. As I headed back to the ER, I tried to keep positive thoughts about the patient in my mind. Later, I did find out that he survived, and his leg was saved, though his recovery was going to be very long and challenging. Although it was the skilled work of the surgeon and surgical team that ultimately led to that positive outcome, I know the part I played in caring for the patient also mattered.

Surgery to perform an appendectomy for appendicitis is an interesting case because traditionally it was considered an emergent procedure. An appendectomy involves surgically removing an appendix. The goal is to remove the appendix before it ruptures and spills infectious material into the abdominal cavity, potentially leading to life-threatening peritonitis. While complicated cases can certainly be emergent, there is some disagreement about whether all cases of appendicitis require immediate surgery. Some research suggests that delaying surgery for up to twenty-four hours may not adversely affect the outcome of either adult or pediatric patients with appendicitis (van Dijk et al., 2018). Considering appendicitis as urgent rather than emergent allows for more efficient identification of a surgeon, anesthesia provider, perioperative personnel, and available OR time (Salem, n.d.).

Expedited (Scheduled) Surgery

Not all surgeries are performed in the face of immediate danger. Some address chronic or progressive conditions that, while not life-threatening in the immediate term, can lead to significant complications and impair quality of life if left untreated. The goal of expedited surgery is to prevent future harm and improve long-term well-being. Examples of expedited surgeries include the following:

Tumor removal: Excising cancerous or precancerous growths to prevent their spread and improve patient survival.
Joint reconstruction: Repairing joints damaged by injury may offer temporary relief and stabilization until a more definitive treatment (like replacement) can be undertaken.
Open-heart surgery: Repairing damaged heart valves or bypassing blocked coronary arteries to improve blood flow and address cardiovascular issues.

Expedited surgeries are often scheduled in advance, allowing for careful planning, preoperative optimization of the patient’s health, and detailed discussions of potential risks and benefits. These procedures, while not as time sensitive as emergent or urgent cases, still play a vital role in preventing future health problems and improving long-term quality of life.

Elective Surgery

Beyond lifesaving interventions requiring emergent or urgent surgery and addressing pressing medical needs requiring expedited interventions, surgery also offers options for repairing injuries or enhancing appearance and function, allowing individuals to make informed choices about their well-being. An elective surgery is one chosen by a patient to improve their quality of life, address cosmetic concerns, or manage specific health conditions that are not immediately life threatening. Elective surgery is planned and scheduled in advance of routine admission to a hospital or surgery center. The timing of the elective surgery is determined to suit the patient and also the availability of perioperative personnel and an appropriate surgical facility. Examples of elective surgery include the following:

Elective orthopedic surgery: Repairing sports injuries, correcting deformities, or relieving chronic pain can improve mobility, function, and quality of life.
Joint replacement: Replacing damaged or diseased joints with artificial implants can restore mobility, alleviate pain, and improve function.
Cosmetic surgery: Procedures (e.g., breast augmentation, liposuction, facial rejuvenation) can help individuals achieve desired aesthetic enhancements and boost self-confidence.
Weight-loss surgery: Gastric bypass or other procedures can address obesity and its associated health risks, leading to improved physical and mental well-being.

Elective surgeries are often personal decisions, requiring careful consideration of potential benefits and risks, long-term implications, and recovery time. These procedures, while not essential for survival, can significantly enhance a patient’s physical and emotional well-being, contributing to a better quality of life.

Surgical Advancements and Trends

In recent years, the field of surgery has experienced a remarkable transformation propelled by a convergence of cutting-edge technologies and pioneering research. These advancements are revolutionizing traditional surgical practices, offering new avenues of treatment, and significantly enhancing the capabilities of healthcare professionals in the OR.

Minimally invasive techniques are at the forefront of innovation in surgery. The shift toward procedures that use smaller incisions, specialized instruments, and advanced imaging technologies has not only reduced the physical impact on patients but has also led to quicker recovery times and decreased postoperative discomfort.

Robotic Surgery

Minimally invasive surgery (a technique that uses fewer and smaller incisions than traditional open procedures) and robotic-assisted surgery (a procedure performed with robotic systems controlled by surgeons) offer many benefits for both patients and surgeons (Figure 31.2). The advantages of robotic-assisted surgery include the following:

Enhanced dexterity: Imagine nimble fingers navigating tight spaces with unmatched precision. Robotic arms transcend human limitations, providing tremor-free movements and 7-degree freedom (the number of independent movements the robot can make), mimicking the natural dexterity of the human wrist. This translates to precise dissection and manipulation of delicate tissues. Surgeons can access and operate on hard-to-reach areas, minimizing collateral damage and preserving healthy structures.
Intricate suturing and reconstruction: Robotic arms provide unmatched needle control, enabling meticulous closure and faster healing.
Magnified vision: Robotic systems boast high-definition cameras with three-dimensional (3-D) capabilities, offering surgeons a panoramic view of the surgical field where even the tiniest nerve is brought into sharp focus. With the aid of robotics, surgeons can identify anatomical landmarks clearly, minimizing the risk of complications and enhancing surgical decision-making.

Image of medical personnel watching a robotic arm perform surgery.

Figure 31.2 Robotic-assisted surgery has not replaced the human operating room team, but the innovation has given surgeons new techniques for many common procedures. (credit: “Keesler MDG Airmen perform first robotic surgery in AF” by Senior Airman Jenay Randolph/Air Education and Training Command, Public Domain)

Common robotic-assisted procedures include laparoscopic prostatectomies, hysterectomies, and mitral valve repairs. For instance, a robotic-assisted laparoscopic prostatectomy is a minimally invasive approach for prostate cancer removal. It offers shorter operative times, increased precision, reduced pain, less scarring, shorter hospital stays, reduced blood loss, and faster recovery compared to traditional open surgery (Chuchulo & Ali, 2023).

That said, there are also very real challenges associated with robotic surgery, including the cost to implement and maintain the systems, the need for specialized training for all team members, a “learning curve” for surgeons to gain experience, and the potential for technical issues that could compromise the efficiency of a procedure or even put patient safety at risk (Chuchulo & Ali, 2023).

Telesurgery

Robot-assisted remote surgery, or telesurgery, uses advanced robotic technology that allows surgeons to operate on patients from a remote location in real time. This empowers surgeons to provide specialized care to underserved areas, overcome geographical barriers, and potentially reduce healthcare disparities. During telesurgery, the surgeon works in a control room equipped with high-definition 3-D screens and haptic interfaces that provide real-time feedback to the surgeon. Haptic interfaces are a type of human-computer interaction technology that is created by using force feedback, or the application of forces or vibrations to the user’s skin, via movement of a limb or the head to simulate bodily tactile sensations and movements, which can mimic the feel of touching natural objects. The surgeon operates a “slave robot” (a robotic system that is directly controlled by the surgeon, often from a console) that mimics the surgeon’s movements with precise dexterity.

Telesurgery is already making strides in various specialties. It is used for brain surgery, where remote neurosurgeons have performed tumor resections and stroke interventions, potentially improving access to specialized care for patients in remote locations. Other examples of common telesurgeries include laparoscopic cholecystectomies, joint replacements, and fracture repairs (Patel et al., 2024).

Real RN Stories

Like Science Fiction

Nurse: Liliana, BSN
Clinical setting: Surgery
Years in practice: 8
Facility location: A teaching hospital in Boston, Massachusetts

I’ll admit it, I was very uncertain about the first telesurgery case I worked. Maybe even more than uncertain—nervous. Really nervous! I mean, it sounded like science fiction, and when you actually see it happening . . . well, it kind of looks like science fiction too. But it’s a modern marvel, and not so much science fiction as a balance of science and art. It takes a really special kind of surgeon to do remote procedures. They need to be able to communicate like they’re in Mission Control and also need to have a real knack for technical problem-solving—doing all this while not being in the room with the team or the patient.

And I think on that first case, it was that realization that really helped me see my role more clearly. It’s always my job to be there for the patient, but in a telesurgery setup, it is even more important. It’s not enough to be present, you have to have “presence.” And that feels even more crucial when you’re one of the only people who is physically in the OR with the patient.

During that first case, the patient was also nervous, and I needed to make sure that I didn’t let my jitters affect the patient at all. The truth was, the surgeon on the case was one of the best in the country, and the fact that this patient could be treated by that surgeon despite the distance was incredible. I could never have fathomed that even ten years ago this was not possible. But your mind starts to run with all the what-ifs. What if the internet goes out? Or the connection intermittently goes in and out? Or the computer decides to do an update and restart right after the first incision? Now, rationally, I understood there were safeties in place for telesurgery just like there would be for an in-person surgery. But since I’d never seen it play out in anything other than a simulation lab, my mind was running wild. However, our on-site surgeon had done so many of the procedures at that point that he remained calm and composed. I think his demeanor helped me feel a little more assured—and it definitely helped me reassure the patient when they groggily asked me if it was time for “lift off.”

The procedure itself was . . . well, actually almost routine. The voice of the specialist surgeon miles away came through the speakers as though they were in the room with us. The image on the video wasn’t quite high definition (HD); however, it was on the higher end of video calls I’ve been on, that’s for sure.

And whether the voice was coming from across the room or across the country, it didn’t really change my job. I was still monitoring the patient, communicating with the team, and thinking through my tasks with the same focus that I have every time I’m in the OR.

When it was over, I almost forgot it had been anything new! But when the patient woke up in recovery and made a groggy reference to Star Trek, I was happy to report to them that the mission had been a success.

In many ways, the role of perioperative nurses in telesurgery is no different from that in any other surgery. The RN circulator (a registered nurse whose primary responsibilities include managing the overall environment of the OR to ensure it remains safe, sterile, and efficient) must have cognitive awareness during any procedure; however, it is particularly essential when the surgeon is not physically in the room. Cognitive awareness may be defined as an increased level of attention that results in a “positive presence” by being consciously aware of all the components of an interaction. It is more than hearing what the surgeon is saying. Rather, the nurse learns to anticipate what the surgeon is thinking in order to determine what the surgeon needs in the moment and help the surgeon achieve the desired result even though the surgeon is not physically in the room.

Despite its immense potential, telesurgery presents risks and challenges that need to be addressed. For example, any delays in the transmission of data within communication networks, limited touch-based (haptic) feedback, and potential robot malfunctions can be catastrophic for the patient. Delays in data transmission could affect real-time control, and technical glitches or poor connectivity could adversely affect communication. Regulatory requirements may vary between regions, and there could be risks to security and patient privacy. Legal and ethical concerns also need to be addressed, which would include the liability related to remote surgeries. Additionally, implementing and maintaining telesurgery infrastructure requires costly investments, necessitating cost-effective solutions, and resource allocation strategies.

Artificial Intelligence

Robotic surgery and telesurgery have become far safer and more practical because of advances in AI. These computer systems are trained with algorithms designed to perform tasks that require human intelligence. The effect of AI is multifaceted, encompassing various aspects of surgical care. Examples include the following:

Preoperative planning: There are AI algorithms that can analyze medical images and patient data to predict potential complications, optimize surgical planning, and even suggest the most suitable surgical approach. Certain AI algorithms can analyze patient data to predict individual responses to surgery, allowing surgeons to provide more personalized surgical techniques and optimize treatment plans. For instance, AI has been used with great success in detecting and identifying tumors. This is because AI can analyze medical images to detect cancer cells with higher accuracy than human eyes, potentially leading to earlier diagnoses and better treatment options.
Intraoperative assistance: There are AI-powered systems that can provide real-time feedback during surgery, guiding surgeons by highlighting critical structures, identifying anomalies, and even predicting potential bleeding risks.
Postoperative care: Some AI algorithms can analyze surgical data to monitor patient recovery, predict potential complications, and suggest personalized care plans.

Although the field is constantly evolving and much remains unknown or theoretical, we do have some clear indications of the overarching pros and cons of using AI in health care. From a clinical standpoint, the possible benefits of using AI in medical settings such as the OR include the following:

Increased accuracy: Artificial intelligence can help surgeons make more accurate incisions and reduce the risk of complications.
Improved efficiency: Artificial intelligence can help automate tasks, freeing up surgeons to focus on more complex aspects of the procedure.
Reduced risk of human error: Artificial intelligence can help to prevent human errors, acting as a “safety check” against human factors like fatigue and inattention.
Better patient outcomes: The combination of increased accuracy and precision, efficiency, and safety could ultimately improve surgical outcomes for patients.

However, there are also some potential risks and challenges associated with the use of AI in surgery:

Reliability: Artificial intelligence algorithms must be thoroughly validated for accuracy, and large language models must be fine-tuned with appropriate, accurate, relevant datasets.
Lack of human intuition: Artificial intelligence cannot exercise the nuanced judgment of experienced surgeons in challenging situations that are not “textbook” or that require “in the heat of the moment” decisions.
Data bias: Artificial intelligence algorithms can be biased based on the data on which they are trained (e.g., garbage in, garbage out).
Security: It may be difficult to protect patient data or even proprietary data from cybersecurity threats introduced by AI.
Integration: Integrating AI seamlessly into existing workflows presents unique challenges and high up-front costs as well as the costs for maintaining the systems to keep up with a quickly evolving industry.
Regulation: It is necessary to establish clear regulations for AI broadly across all industries, particularly in health care.

Healthcare professionals must ensure that AI is ethically, responsibly, and effectively developed to balance the gains with the risks. Artificial intelligence must ensure that patient safety and privacy remain the priority, and patient outcomes are the ultimate guiding force behind implementing new technology.

Multi-Angle Rear-Viewing Endoscopic TooL

Developed by researchers at NASA’s Jet Propulsion Laboratory, the Multi-Angle Rear-Viewing Endoscopic tooL (MARVEL) is a thin, flexible endoscope equipped with a unique single-lens system and complementary multi-band-pass filters. This innovative combination allows the endoscope system to achieve 3-D imaging without the bulky need for dual cameras. This offers several key advantages (Shearn et al., 2012):

Enhanced visualization: Unlike traditional endoscopes that offer a limited field of view, MARVEL can bend and rotate its tip, providing surgeons with a panoramic view of hidden anatomical structures, especially in confined spaces like the brain or spine. This improved view reduces the risk of accidental damage to critical structures and improves surgical precision.
Minimized tissue trauma: The small diameter and flexible nature of MARVEL minimize tissue disruption during surgery. This leads to faster recovery time, less pain, and potentially fewer complications for patients.
Improved access: Compared to traditional endoscopes, MARVEL can navigate through complex anatomical pathways with greater ease, reaching previously inaccessible areas and expanding the possibilities for minimally invasive procedures.

Practitioners in several surgical specialties are exploring MARVEL’s versatility and potential advantages. For example, neurosurgeons are using MARVEL for brain tumor resections, aneurysm clipping, and other delicate procedures, gaining improved access to deep and narrow brain regions. The tool’s maneuverability is proving valuable for minimally invasive spinal surgeries, allowing surgeons to see and access spinal structures with minimal tissue disruption. In the area of otolaryngology, MARVEL’s ability to reach hidden areas in the ear, nose, and throat makes it ideal for sinus surgery, tumor removal, and other endoscopic procedures.

Although MARVEL is a promising new technology with a number of potential benefits for surgeons and patients, there are also some potential risks and challenges that must be considered:

High cost: The expense of acquiring and maintaining MARVEL can be financially prohibitive for many facilities.
Steep learning curve: A substantial amount of training and expertise is required to use MARVEL skillfully, and it can be time-consuming to put in the time and effort to learn how to use it.
Image quality constraints: While MARVEL provides better visualization, the actual clarity and detail of the images it produces may fall short when compared to the high-quality images generated by traditional endoscopic equipment.
Seamless integration: Incorporating MARVEL into established surgical workflows could hinder widespread adoption.
Patient acceptance: Some patients may be hesitant or even unwilling to consent to undergoing procedures with new technology like MARVEL.
Regulatory oversight: Currently, there is a lack of comprehensive regulations for new tools like MARVEL. Frameworks need to be developed to ensure that the technology is safe and effective.

Even if they do not yet have the technology at every facility, nurses should be familiar with MARVEL and its potential benefits and have a clear understanding of how it differs from traditional endoscopes. Having a baseline understanding of MARVEL will help nurses provide optimal preoperative care, facilitate efficient intraoperative surgical workflow, and provide excellent postoperative care and patient education.

3-D Printing

From printing custom implants to creating lifelike anatomical models for use in surgical planning, 3-D printing or a manufacturing process that creates 3-D objects from digital files, is becoming more common in surgical practice because it offers several key benefits (Sun, 2018). For example, anatomical models printed from patient data allow surgeons to visualize complex structures, practice surgical approaches, and identify potential challenges before entering the OR. This improved planning leads to reduced surgical time, enhanced surgical precision, and real advancements in personalized implants and surgical tools.

Certain applications for 3-D printing in surgery seem especially promising. These include the following:

Orthopedic surgery: Custom-printed implants for joint replacements or bone fractures ensure a perfect fit, leading to faster healing, improved function, and reduced risk of complications.
Craniofacial surgery: Reconstructive surgery can benefit from patient-specific implants that restore facial features and functionality, improving both physical appearance and self-esteem.
Vascular surgery: In vascular surgery, 3-D-printed stents and other vascular implants can be customized to the specific needs of each patient’s blood vessels, enhancing the success and safety of these procedures.

However, the integration of 3-D printing in surgical settings is not without its potential downsides and risks, such as the following:

Financial and economic investment: The initial setup costs and materials can be expensive, and printing complex structures can be time-consuming.
Safety and suitability: Ensuring the safety and biocompatibility of printed materials as well as making sure that printed models accurately represent an individual patient’s anatomy are critical areas of challenge that must be addressed.
Regulations and standards: There also need to be clear, evidence-based guidelines for the approval of 3-D-printed medical devices. This may prove difficult because advancements in materials for improved biocompatibility remain ongoing challenges in a field that is changing quickly.

Ongoing research and development are essential for advancing 3-D-printed materials that offer enhanced biocompatibility and open new possibilities for patient-specific treatment.

Types of Anesthesia

Modern surgery requires not only surgical precision but also sophisticated pain management with anesthesia. The variety of anesthesia types each offer a unique blend of unconsciousness, pain relief, and controlled depth of anesthesia. These include general anesthesia, monitored anesthesia care (MAC)/moderate sedation, regional anesthesia, and local anesthesia (Table 31.1). The choice of anesthesia is a delicate decision, tailored to the specific needs of the surgery, the patient’s health, and the medical team. In addition to the type of surgery being performed, anesthesia providers (e.g., anesthesiologists, certified nurse anesthetists [CRNAs]) carefully evaluate each patient, considering factors such as age, medical history (including bleeding risk), and anxiety levels, to determine the most appropriate approach for a safe and comfortable surgical experience.

Factors to Consider	General Anesthesia	Monitored Anesthesia Care (MAC)/Moderate Sedation	Regional Anesthesia	Local Anesthesia
Pros	Complete unconsciousness: The patient is completely unaware and feels no pain during the procedure, nor will they remember anything about it afterward. Muscle relaxation: Inducing muscle relaxation is necessary for the surgery to be performed to prevent involuntary movements and muscle contractions that could interfere with the surgical procedure and/or cause injury. Controlled: Anesthesia providers can precisely control the depth of anesthesia, allowing them to keep a patient unconscious until the procedure is over and bring the patient out of sedation.	Less disruptive: It allows patients to remain conscious but relaxed. Quick recovery: The recovery time is shorter compared to general anesthesia. Versatile: It is suitable for various procedures and diagnostic tests.	Selective numbing: It numbs a large region while allowing the patient to remain conscious. Reduced systemic effects: It limits effects to a specific region, reducing overall systemic impact. Postoperative pain control: It provides extended postoperative pain relief. Types: Spinal anesthesia: a one-time injection of numbing medication. Epidural anesthesia: injected through a catheter placed in the epidural space. Nerve blocks target specific limbs or areas: offer precise pain control with no effect on consciousness unless sedation is added.	Minimal systemic effects: It acts only on the specific area where it is administered. Quick recovery: Patients can often resume normal activities shortly after the procedure. Fewer side effects: It is typically associated with fewer systemic side effects.
Cons	Recovery time: The patient needs to fully regain consciousness after general anesthesia, which can prolong recovery time. Potential side effects: Nausea, vomiting, and respiratory issues can be side effects of anesthesia medications and protocols. Postoperative disorientation: Some patients may experience confusion or disorientation after waking up from general anesthesia, while others have different reactions, such as tearfulness or agitation.	Limited depth: It may not provide enough depth of anesthesia for more complex or painful procedures that require a patient to be unconscious. Potential respiratory depression: Some patients may experience reduced breathing rate with sedation. Patient cooperation: It requires patient cooperation because the patient will remain conscious during the procedure.	Potential complications: There are risks associated with nerve blocks or epidurals (e.g., hypotension, bleeding, infection, potential respiratory complications, paralysis). Limited area of effectiveness: It may not cover all areas for certain complex surgeries. Monitoring challenges: It requires careful monitoring of the patient’s neurological status.	Limited area: It is effective only in a specific localized area. Discomfort during administration: It may cause temporary discomfort (e.g., burning, stinging) during injection. Not suitable for all procedures: It is not suitable for more extensive or deeper surgeries.
Duration and recovery	These vary based on surgery type and medications used. Typically, this stage lasts for the duration of surgery, and the patient will emerge or “wake up” gradually as the medications wear off.	Effects are typically short lived, lasting only for the procedure and not lingering for long, although drowsiness may last for a while afterward.	Spinal: This takes effect almost immediately and may last up to two hours. Epidural: This takes ten to twenty minutes to provide relief but lasts as long as necessary by repeated injections through the catheter. Nerve blocks: Pain relief can vary from a few hours, to a few days, to several weeks, months, or even years.	Duration is generally limited to the time needed for the procedure. Recovery is rapid, and effects wear off relatively quickly.
Effectiveness and safety monitoring	Basic anesthetic monitoring includes (1) oxygenation (e.g., pulse oximetry), (2) ventilation (e.g., capnography, partial pressure of carbon dioxide in exhaled air over time), (3) circulatory function (e.g., heart rate, blood pressure, electrocardiogram), and (4) temperature. Depth of anesthesia is assessed by patient response to stimuli (e.g., nociception). Continual observation of respiratory parameters and end-tidal CO₂ levels is necessary.	Consciousness level and responsiveness to verbal stimuli (e.g., asking their name) are assessed. Continuous respiratory rate and oxygen saturation monitoring is performed. Vital signs (e.g., blood pressure, heart rate, pulse oximetry) are evaluated.	Neurological function in the targeted region is assessed. Vital signs (e.g., blood pressure, heart rate) are continuously monitored. Patient comfort and pain levels are evaluated.	Pain control and absence of sensation in localized area are assessed. The patient’s comfort level during the procedure is observed.
Potential side effects and management	Nausea and vomiting: Antiemetic medications and essential oil aromatherapy (Fearrington et al., 2019) may be used. Temporary cognitive changes: These typically resolve within a few days with supportive care and reassurance. Respiratory issues: Respiratory function and mechanical ventilation are closely monitored, if necessary. Sore throat: Over-the-counter throat lozenges may be recommended.	Respiratory depression: Breathing issues may occur, particularly in higher doses, requiring continuous monitoring of vital signs; supplemental oxygen may be provided if needed. Drowsiness: Patients may feel excessively sleepy, requiring observation until the effects wear off. Hypotension: Decreased blood pressure may require fluid administration or vasoactive medications.	Hypotension or bradycardia: These are possible effects of spinal or epidural anesthesia due to sympathetic blockade requiring administration of fluids and medications to support blood pressure and heart rate. Nerve damage or irritation: These are rare but potential complications, especially with nerve blocks, caused by needle/catheter placement; they require close monitoring for any signs of neurological issues.	Localized pain or discomfort: Topical anesthetics may be applied. The patient may require reassurance during local administration and during the procedure. Allergic reactions: Immediate treatment of allergic reactions is necessary; alternative anesthetics may have to be used. Local anesthetic systemic toxicity: Prompt recognition and treatment is necessary; supportive care is administered.

Table 31.1 Summary of Types of Anesthesia

General Anesthesia

For major and complex procedures, general anesthesia takes center stage. This potent cocktail of IV and inhalation medications induces a state of controlled unconsciousness, amnesia (a temporary or permanent loss of memory), and analgesia (pain relief so the patient does not respond to painful stimuli, with or without reversible muscle paralysis). The process of intubation involves inserting an endotracheal tube into the mouth or nose and into the trachea to maintain an open airway, support breathing and ventilation, and provide oxygen delivery. This, in addition to monitoring vital signs, remains paramount throughout the procedure. General anesthesia offers complete pain relief, keeping the patient unarousable to painful stimuli during surgery, which provides optimal surgical conditions. However, general anesthesia has potential side effects (e.g., postoperative nausea and vomiting, temporary cognitive changes after surgery) (American Society of Anesthesiologists, n.d.).

Monitored Anesthesia Care/Moderate Sedation

For shorter and less-invasive procedures, a patient may not need to be completely unconscious. Monitored anesthesia care (MAC)/moderate sedation induces a state of drowsiness and reduces anxiety while allowing patients to respond to basic commands and breathe on their own. This approach offers a balance between pain relief and awareness, making it ideal for procedures like endoscopies and biopsies. However, some patients may still experience some discomfort or remember fragments of the procedure (American Society of Anesthesiologists, n.d.).

Life-Stage Context

Age-Related Anesthesia Considerations

Some considerations for the use of anesthesia are based on the patient’s life stage, from newborn infants to the oldest patients who need surgery.

Infants and Young Children

Underdeveloped organ systems: Reduced metabolism and medication clearance in infants can lead to prolonged medication effects and unexpected responses to anesthesia. Weight-based dosing of anesthetic medications in children can help ensure that the safest, most effective therapeutic doses of anesthetic agents and pain medication are given while minimizing risks and medication side effects.
Thermoregulation challenges: Infants are more susceptible to hypothermia during surgery, requiring careful temperature monitoring and warming techniques to prevent complications.
Potential for airway obstruction: Careful attention to airway management is crucial for infants and babies who have smaller and more pliable airways.

Pregnancy

Fetal safety: The type and timing of anesthesia could affect the developing fetus. Careful medication selection and monitoring are essential to minimize risks to both the pregnant patient and the unborn baby.
Physiological changes: Pregnancy alters the pregnant patient’s cardiovascular, respiratory, and gastrointestinal systems, which requires special attention throughout anesthesia management.
Pain management: Balancing pain relief for the pregnant patient as well as the safety of the unborn baby is a priority. Regional anesthesia is often preferred, when possible, to reduce fetal risk.

Older Adults (65 years old and older)

Cardiovascular changes: Decreased cardiac reserve makes older adults more vulnerable to hypotension and arrhythmias. Careful titration of anesthetic agents, close monitoring, and consistent fluid management are essential.
Respiratory decline: Reduced lung function and oxygenation capacity in old age can contribute to a higher risk of hypoxia and postoperative respiratory complications. Preoperative optimization of lung function and careful oxygen management are important for older adults who will be undergoing surgery.
Neurological considerations: Older patients may have preexisting cognitive changes or conditions and, therefore, can be more sensitive to the effects of anesthetic medications. Lower doses with titration to effect and careful monitoring can mitigate the risk of emergence delirium (also known as postoperative delirium) and cognitive dysfunction in older surgical patients (Ramroop et al., 2019).
Altered drug metabolism: Decreased kidney and liver function are common in older adult populations and can prolong the effects of medications and increase the risk of toxicity. Dosage adjustments may be needed to help prevent these risks.
Polypharmacy: Older adults are more likely to be on multiple medications to manage chronic diseases, many of which may interact with anesthetic medications. Preoperative medication reconciliation is essential, particularly if a medication may need to be held for a specified time period before a procedure to help avoid interactions or altered effects.

Regional Anesthesia

When the surgical procedure is on a specific region of the body, regional anesthesia may be the best anesthetic option. This approach blocks nerve signals in targeted areas, leaving patients awake and aware during the procedure. Spinal and epidural anesthesia provide partial or complete analgesia by numbing the lower body. Nerve blocks target specific limbs or areas, offering precise pain control with no effect on consciousness unless sedation is added. Regional anesthesia often leads to faster recovery times and fewer side effects compared to general anesthesia but may not be suitable for all procedures or patients with certain medical conditions. Common uses for regional anesthesia include orthopedic surgeries, procedures on extremities, labor and delivery, and some abdominal surgeries (American Society of Anesthesiologists, n.d.).

Patient Conversations

Teaching the Patient about Regional Anesthesia

Scenario: The nurse midwife is preparing an obstetrical patient in labor who will be receiving regional anesthesia for pain relief.

Nurse Midwife: Hi, Kayla. How are you feeling?

Patient: Hurts . . . a lot.

Nurse Midwife: We are about to start your epidural to help with the pain. I’d like to talk to you about what to expect, is that okay?

Patient: Yes . . . please.

Nurse Midwife: An epidural is a kind of regional anesthesia. It’s not like the general anesthesia that puts you to sleep before a surgery; it just numbs part of your body to help with pain relief.

Patient: So, it won’t . . . knock me out?

Nurse Midwife: Nope, you’ll be completely awake. When the anesthesia provider comes in, we will have you sit up or lie on your side and they will use a needle to put a tube into your lower back at the bottom of your spine. It might pinch a little, but they usually put a little numbing medicine in your skin first to help it hurt less.

Patient: Does the needle stay in my back?

Nurse Midwife: No, the needle is just used to poke through your skin. Then they put in a flexible tube called a catheter. They remove the needle but leave the catheter in place. The catheter allows the anesthesia provider to put in numbing medicine. It will probably take about twenty minutes for the medicine to take effect.

Patient: Will I be totally numb?

Nurse Midwife: No, the medicine will only numb you from about the waist down. While you will be numb, it is normal to still feel some pressure as the baby moves down the birth canal. You can still move your legs a bit, but you won’t feel them like you normally would.

Patient: Will I still be able to push?

Nurse Midwife: Yes, the muscles you use to push will still work, even with the epidural.

Patient: Is it safe?

Nurse Midwife: Epidurals are safe; however, all treatments have risks, so I’m glad you asked. We will watch you and your baby closely to make sure that things like heart rate and blood pressure are what we want them to be. Some people take longer to get feeling back than others. It is very important that you remain in your bed. Your legs will be numb so you would fall down. Please ring your bell, it’s right here, if you need anything.

Another possible risk is that sometime people get headaches from having the epidural placed. There is also a risk of more serious complications, like blood clots and nerve damage, but these are rare, and we will be monitoring you closely for any signs of a problem. We will help you manage any of these side effects if they happen, and we’ll make sure that adjustments are made if necessary.

Patient: What if I end up needing a C-section.

Nurse Midwife: Well, if you need a C-section, you’ll be one step closer to being ready, since the epidural will already be done. If that happens, we’ll talk more about what next steps will take place.

Patient: When does it come out? The tube, I mean.

Nurse Midwife: After delivery, the catheter can be removed. You’ll probably start to notice feeling coming back within a couple of hours, but like I said, it might take a little longer or shorter time. You might have some back pain, and it might feel a little weird to try to pee at first, but this will get better as the numbness goes away.

Patient: Thanks . . . so, can we get started?

Nurse Midwife: Yes, the anesthesia provider should be here any minute now.

Local Anesthesia

Local anesthesia is a technique that temporarily numbs only a small, specific area of the body. It is administered either topically or via injection near the site of the procedure. This form of anesthesia is commonly used for minor surgical procedures, dental work, skin biopsies, or wound repairs. Although it is not as complex as other forms of anesthesia, there are still potential downsides and risks to consider along with the benefits (American Society of Anesthesiologists, n.d.). Side effects may occur if too much local anesthesia is administered or if the medication is inadvertently injected into a vein instead of tissue. This reaction is called local anesthetic systemic toxicity. The patient may experience ringing in the ears, headache, dizziness, confusion, twitching, heart rhythm and blood pressure disturbances, metallic taste in your mouth, or rarely have a seizure. It is also possible to have an allergic reaction to an anesthetic, which is also rare.

31.1 Surgical Concepts