Gas Insufflation

  • Mitigate the risk for injury associated with gas insufflation:

    • - set the insufflation flow rate according to the surgeon's specification and the manufacturer's instructions for use

    • - elevate the insufflator above the level of the surgical cavity, if possible

    • - flush the insufflator and insufflation tubing with the selected gas before the tubing is connected to the cannula

    • - use a hydrophobic filter between the insufflator and tubing

    • - turn on endoscopic gas insufflator alarms to a volume sufficiently audible to be heard above competing noise

    • - have a second full cylinder readily available for immediate replacement of the empty cylinder

    • - maintain insufflation pressure at the lowest level necessary to achieve pneumoperitoneum within the surgeon's specifications

  • Know how to detect and implement interventions to manage a gas embolism:

    • - discontinue insufflation gas

    • - discontinue anesthetic agents and hyperventilate with 100% oxygen

    • - place the patient in either Trendelenburg or left lateral position

    • - infuse large amounts of IV fluids

    • - administer inotropes, vasopressors, and vasodilators specific to pulmonary circulation

    • - perform cardiopulmonary resuscitation

Use of carbon dioxide, the gas most commonly used for creating pneumoperitoneum, is considered safe but can cause metabolic, hemodynamic, and cardiovascular adverse effects. In the event of a gas embolism, the RN circulator should assist with immediate treatment to prevent the embolus from blocking circulation to vital organs.

Irrigation and Distention Media

  • Select the irrigation or distention fluid in consultation with the surgeon based on procedure type, patient assessment, and instruments to be used.

  • Monitor the amount of fluid dispensed and collected during the procedure.

  • Contain fluids used for irrigation or as distention media to help monitor input and output.

  • Report fluid deficit to the anesthesia professional and surgeon at regular intervals throughout the procedure.

  • Monitor the patient for physiologic changes, including:

    • - core temperature

    • - laboratory test results

    • - potential fluid retention in the abdomen, face, and neck

Complications from fluid intravasation or extravasation are rare but can be life threatening. Fluid extravasation can lead to edema in surrounding tissue, abdominal distention, or intraabdominal compartment syndrome. Fluid intravasation can lead to hyponatremia, hypervolemia, and cardiovascular and pulmonary complications.

Computer-Assisted Surgical Procedures

  • Position the patient in a manner that will facilitate use of computer-assisted equipment.

  • Follow the manufacturer's instructions for use of all equipment.

  • Notify the surgeon if the patient is moved after registration in computer-assisted navigation or after the robotic arms have been docked.

  • Participate in education and competency verification activities related to computer-assisted robotic procedures.

The computer-assisted robotic system is complex, necessitating coordination by the team members to reduce the risk for error and potential for injury.

Intraoperative MRI Procedures

  • Post signs denoting the presence of a magnetic resonance imagining (MRI) scanner prominently outside the OR suite.

  • Undergo and pass an MRI safety screening before entering the scanner room.

  • Use MRI-safe equipment in all procedures.

  • Confirm that MRI-incompatible equipment has been moved outside the 5 gauss line (where the magnetic force is the strongest).

  • In the event of a cardiopulmonary arrest, move the patient out of the MRI area to prevent an MRI-incompatible device from entering the scanner room.

  • Participate in education and competency verification activities related to managing a hybrid OR with MRI equipment.

The magnetic field can cause metal implants in the body to heat up or induce current, causing burns or twisting of implant wires or malfunction of the implant. Patients and personnel with cardiac devices, stents, filters, grafts, cochlear implants, pumps, nerve stimulators, or metal foreign bodies should be screened for MRI safety.