Special Surgical Procedures II
LESSON 1: Eye, Ear, Nose, and Throat (EENT) Surgery
Section I: EYE SURGERY
1-3
1-3. PREPARATION OF THE PATIENT
a. Preoperative Prep. For a successful operation, the physical, spiritual, and emotional needs of the person must be considered. Each member of the staff should endeavor to meet the needs of each patient and help him to cope with his specific problems.
(1) Emotional factors.
(a) The loss of vision or any interference with the use of the eyes, even temporarily, has a severe emotional effect on any person. It means loss of mobility and ability to take care of or protect oneself. This tends frequently to make the patient nervous and sometimes depressed. The patient is often awake during the entire operation. All operating staff members should allay the fears of each patient. The emotional state of the patient is an important factor in a successful recovery.
(b) A quiet environment and a calm, kindly, understanding voice create confidence in the patient. The patent's comfort is further enhanced by pleasant surroundings and freedom from noise and confusion. When a patient is sedated, he is often unable to speak coherently, but is usually conscious of noises, which become exaggerated in his mind.
(2) Drugs which may be given.
(a) To allay anxiety and reduce general muscle tone, the patient is usually given a barbiturate-narcotic drug on call to surgery, as well as any ophthalmic drugs that may be prescribed. This is often followed by topical anesthetic drops upon arrival at surgery (see figure 1-2).
Figure 1-2. Instillation of eye medication.
NOTE: Observe the position of the dropper and the capillary attraction.
(b) Mydriatic drops are used to dilate the pupil with the patient retaining the ability to focus his eye. This is usually 10 percent phenylephrine (Neo-Synephrine®).
(c) Cycloplegic drugs dilate the pupil and prevent focusing of the eye. Commonly used cycloplegics are 1 percent tropicamide (Mydriacyl), 1 percent atropine, and 1 percent cyclopentolate (Cyclogyl®). Atropine has a long-lasting effect.
(d) Miotic drugs cause the pupil of the eye to contract. Commonly used miotics are 1 percent to 4 percent pilocarpine and 0.012 percent to 0.25 percent phospholine iodides®. Miotics improve the ease with which the aqueous fluid escapes from the eye independent of their action on the pupil, thereby resulting in decrease of intraocular pressure. Miotics are used in the treatment of glaucoma. These drugs increase contraction of the sphincter of the iris, thus causing it to become smaller. Phospholine iodide® is usually discontinued before intraocular surgery is performed.
(e) A great number of corticosteroid preparations exist. They are used to prevent the normal inflammatory response to noxious stimuli. Corticosteroids reduce the resistance of the eye to invasion by pathogens; therefore, they are not used in the presence of infection.
(f) Topical antibiotics are often used prophylactically to prevent infection. Antibiotic instillation may be given prior to intraocular surgery to help prevent wound infection. Zinc sulfate, 0.25 percent, is used to reduce redness and swelling and to soothe tissue. It may be ordered in combination with a 0.125 percent preparation of phenylephrine. Zinc also is a necessary cofactor in wound healing. Lubricating drops or ointments such as Methylcellulose, 0.5 percent, are often used to protect the cornea.
(g) Hyperosmotic agents increase the osmolarity of the serum and, by the effect of the induced osmotic pressure gradient, shrink the vitreous body and reduce the intraocular pressure. These drugs are used routinely in the preoperative medication of patients about to undergo ophthalmic surgery, as well as therapeutically in cases of uncontrolled glaucoma. These drugs, given either orally or by injection, induce diuresis, so nursing personnel have urinals and sterile catheters on hand.
b. Admission into the Operating Room. When the patient is admitted to the operating room, the nursing team should:
(1) Make positive identification of the patient by name, dealing with him in a gentle, kind, and professional manner.
(2) Check the patient's name on his wristlet band with the name on the chart.
(3) Prepare the operating table, making sure all the necessary attachments for the table are in proper readiness.
c. Preparation of the Patient's Face.
(1) Preparation of the patient is done under aseptic conditions. Topical anesthetic drops are administered first if the patient is to be given a local anesthetic. A sterile preparation tray containing sterile normal saline solution, irrigation bulbs, basins, cotton, sponges, towels, and antibacterial skin disinfectant should be near the operating table.
(2) Neither the clipping of eyelashes nor shaving of eyebrows is done routinely. When eyelashes are clipped, this is done prior to the skin preparation. A thin film of petrolatum is
smoothed over the cutting surfaces of the curved eyelash scissors so that free lashes will adhere to the blades. This prevents the free eyelashes from falling into the eyes or onto the face.
(3) The preparation includes cleansing the eyelids of both eyes, lid margins, lashes, eyebrows, and surrounding skin with an antibacterial soap or disinfectant. To prevent the agent from entering the patient's ears, they may be temporarily plugged, using cotton pledgets. Care is taken to keep the agent out of the eyes. The preparation area is washed with warm sterile water, using soft-texture gauze or cotton sponges. The operative area is painted with an aqueous nonirritating skin antiseptic.
(4) When toxic chemicals or small particles of foreign matter must be removed, the eyes may be irrigated with tepid sterile normal saline solution. The conjunctival sac is thoroughly flushed, using an irrigating bulb or an Asepto syringe.
d. Draping the Patient. For general eye surgery, the basic draping procedure is as follows:
(1) A large, folded sheet is needed to cover the patient and operating table.
(2) The head is draped with a double-thickness half sheet and two towels or appropriate disposable drapes.
(3) A fenestrated eye sheet, 14 inches square, with a center opening of
2 1/2 x 3 inches, is placed over the operative site. More recently, disposable plastic drapes have been used.
e. Anesthesia. Local anesthesia is frequently preferred and indicated for eye surgery, especially in elderly individuals and in those with circulatory and other systematic diseases. A sedative is given the night before surgery and again two hours prior to surgery.
(1) Anesthesia setup. The operating room staff assembles the sterile local anesthesia setup as ordered by the surgeon before the patient enters the operating room and checks the bottles of drugs to make sure they are the correct medications and of the proper strength.
(2) Needles and syringes.
(a) Subcutaneous injection and infiltration. Two Luer-Lok 2-ml syringes and two 25-gauge needles, 1/2-inch length may be used.
(b) Subconjunctival injection. Two Luer-Lok 2-ml syringes and two 26- or 27-gauge needles, 1-or 1 1/2-inch length.
(c) Retrobulbar injection. Two Luer-Lok 2-or 5-ml syringes or one 10-ml syringe and two 24-gauge needles, 1-or 1 1/2-inch length.
(3) Frequently-used drugs.
(a) Tetracaine hydrochloride (Pontocaine hydrochloride®) in a 2 percent solution may be instilled into the eye before an operation. For local anesthesia in adults, 2 percent lidocaine (Xylocaine®) with epinephrine hydrochloride in a 1:150,000 or 1:200,000 dilution is frequently used.
(b) Hyaluronidase (Wydase®, Alidase) is commonly mixed with the anesthetic solution (75u/10ml). The enzyme increases the diffusion of the anesthetic through the tissue, thereby improving the effectiveness of the anesthetic nerve block. For cataract surgery, an effective retrobulbar injection reduces intraocular pressure by preventing positive muscle contraction, thus becoming a surgical safeguard against vitreous loss. Hyaluronidase is nontoxic and is effective over a wide range of concentrations.
(c) In cataract surgery, alpha chymotrypsin in a 1:5,000 or 1:10,000 solution may be used to dissolve the zonular fibers that suspend the cataract within the eye. To produce eye muscle paralysis in intraocular surgery, tubocurarine chloride or succinylcholine chloride may be administered intravenously by the anesthesiologist.
(d) Epinephrine in a 1:1,000 solution may be applied topically to mucous membranes to decrease bleeding. Epinephrine in a 1:500,000 to 1:200,000 solution may be combined with injectable anesthetics to prolong the duration of anesthesia. Epinephrine in a 1:1,000 solution is not used in local anesthetics because if it were used in such concentrations, the patient could succumb to cardiac arrhythmia.
(4) Methods used for administration of local anesthetics. The three methods of administration are instillation of eye drops, infiltration, and block or regional anesthesia.
(a) Instillation of eye drops. With the patient's face, tilted upward, the first drop is placed in the lower cul-de-sac, and the following drops (number depends on the type of operation to be performed) may be placed from above, with the patient looking downward and the upper lid raised. However, the natural blinking of the lids distributes the drug evenly on the eye surface, regardless of where the drop is placed. When a toxic drug is instilled, the inner corner of the eyelids should be dried of excessive fluid with a tissue or clean cotton ball after the instillation of each drop, thereby minimizing systemic absorption of the drug. The tip of the applicator must not touch the patient's skin or any part of the eye.
(b) Infiltration method. The surgeon injects the anesthetic solution beneath the skin, beneath the conjunctiva, or into Tenon's capsule, depending on the type of surgery. Retrobulbar injection is usually performed 10 to 15 minutes before surgery to produce a temporary paralysis of the extraocular muscles.
(c) Block or regional anesthesia. The solution is injected into the base of the eyelids at the level of the orbital margins or behind the eyeball to block the ciliary ganglion and nerves. For eyelid repairs, the solution is introduced through the lower lid. For operations on the lacrimal apparatus, the anesthetic is injected at the level of the anterior ethmoidal foramen in order to anesthetize the internal and external nasal nerves. In the Van Lint block method, procaine solution is injected into the orbicular muscle and reaches the ends of the facial nerve.
(5) General anesthesia. A general anesthetic, with or without intravenous injection of thiopental sodium (Pentothal Sodium®) is used when a patient is unable to cooperate because of youth, dementia, or nervousness, or because the solutions of 20 percent mannitol (Osmitrol®) or 5 percent glucose in water are given intravenously during surgery. A sedative is given the night before surgery, and a drying agent (atropine or scopolamine) and an analgesic are given 1 to 1 1/2 hours prior to surgery. The patient must not eat or drink anything for 6 hours prior to induction.
