Intraoperative Considerations

Core Concepts

Anesthesia: the three main categories

• General anesthesia produces a reversible state of unconsciousness, amnesia, and muscle relaxation, with the person's airway managed and breathing supported. It is usually described in three phases: induction (going under), maintenance (keeping the person anesthetized), and emergence (waking up). The anesthesia provider selects and adjusts agents; the nurse supports monitoring and safety.
• Regional anesthesia numbs a large region (for example, a spinal or epidural block) while the person remains awake or lightly sedated — able to talk and breathe, but not feel the surgical area.
• Local anesthesia with sedation (monitored anesthesia care) numbs a small area while sedation keeps the person relaxed. Sedation depth is a spectrum, and the team monitors consciousness and breathing throughout.

Positioning: protection against injury

The surgical position must give the surgeon access while protecting the person. Common positions include supine (back), prone (abdomen), lateral (side), and lithotomy (back with legs elevated and supported). Risks include nerve compression or stretching, pressure injuries, circulatory impairment, and musculoskeletal strain. Protective practices: padding and positioning devices, aligned body parts kept off hard surfaces, guarding eyes and ears, and documenting position and skin findings. Because anesthesia removes the person's ability to shift or report discomfort, the team positions carefully before the case and checks during it.

Asepsis and the sterile field

The sterile field is the microorganism-free zone around the surgical site. Core principles: only sterile items touch the field; sterile persons keep hands and arms above waist level and in front of the body; they never turn their back to the field; the field stays in view at all times; and anything of doubtful sterility is considered contaminated. Skin preparation follows facility policy, and drapes create the barrier around the site. Breaks in technique are acknowledged aloud and corrected immediately — hiding a break is more dangerous than reporting it.

The universal protocol: time-out

Before the incision — after the person is positioned and prepped — the entire team pauses and verbally confirms the correct patient, the correct procedure, the correct site, and the correct position, plus any implants or special considerations. This pause is the time-out. Site marking before surgery (per facility policy, often with the awake person) supports it. The time-out is not a formality: any team member can stop the case if something does not match.

Preventing hypothermia and maintaining normothermia

Anesthesia and a cool OR can lower body temperature. Inadvertent perioperative hypothermia (an unintended drop in core temperature) increases the risk of surgical site infection, bleeding, prolonged recovery, and shivering. Protective measures include warming blankets and devices, warmed intravenous fluids, and limiting unnecessary skin exposure. Temperature is monitored throughout, and the team acts to keep the person warm rather than waiting for the temperature to fall.

Counts: preventing retained items

Sponges, needles, and instruments are counted — usually by the scrub person and circulating nurse together — at defined points: before the procedure, during wound closure, and at skin closure (timing follows facility policy). Counts are documented, and any discrepancy is reported and resolved before the wound is closed if possible. The count protects the person from a retained surgical item — a serious, preventable harm.

Environmental safety

The OR contains hazards that require vigilance: electrosurgery generates heat and can burn; oxygen and alcohol-based preps create fire conditions; sharps carry injury risk; and lasers require eye protection. The team manages these with checklists, safe device use, and verbal communication — for example, letting alcohol-based preps dry and managing oxygen during electrosurgery per policy. Fire response follows a structured sequence (stop the source, remove burning material, care for the person), rehearsed in drills.

Common Confusions