Association of periOperative Registered Nurses | AORN



ADMINISTRATIVE APPROVAL

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Purpose

To provide guidance to perioperative personnel for creating an environment that reduces the risk for injury to patients and perioperative team members during minimally invasive surgical procedures. The expected outcome is that the patient is free from signs and symptoms of injury or complications from minimally invasive surgery (MIS).

Policy

It is the policy of [insert name of facility] that when a patient undergoes a minimally invasive surgical procedure, the perioperative team is competent in the use of the appropriate equipment and instrumentation and in mitigating potential risks or complications to the patient and/or perioperative personnel related to MIS.

Procedure Interventions

• The risk of injury to patients and the perioperative team during MIS and computer-assisted procedures will be reduced.

o Only personnel who have appropriate credentials and have met required qualifications will be allowed to operate devices or specific equipment (eg, radiologic equipment, magnetic resonance imaging [MRI] equipment, insufflators) used during MIS or computer-assisted procedures.

o Loaned equipment to be used in MIS procedures will have written documentation to validate compliance with biomedical criteria and decontamination procedures.

o Minimally invasive surgery and computer-assisted equipment will be validated for proper functioning immediately before being used for patient care.

o The perioperative team will be prepared to convert any endoscopic procedure to an open surgical procedure.

o Minimally invasive surgery equipment will have appropriate alarm and monitoring systems.

Fluid Management

• The risk of injury to patients associated with fluid used for irrigation and distention media will be reduced. Personnel will

o monitor the amount of fluid dispensed and collected during the procedure;

o report fluid deficit to the anesthesia professional and surgeon at regular intervals throughout the procedure;

o monitor the patient for adverse reactions when medications are added to fluids for irrigation or distention media;

o select distention media based on the properties of the gas or fluid media, the procedure, and the patient’s history;

o monitor the patient for signs/symptoms of hypervolemia and/or hyponatremia when using hypotonic solutions; and

o collect the fluid administered to the patient in a closed container system.

• If an automated fluid management system is used, personnel will

o verify the fluid pump settings with the surgeon before administration;

o continually monitor the settings throughout the procedure;

o monitor pump pressures, inflow volumes, and outflow volumes of fluids used during the procedure; and

o verify alarms on the pump are audible above other competing noise.

Electrosurgery

• Precautions will be taken when using energy-generating devices during MIS. Personnel will

o verify the properties of the distention media to minimize risks related to use of energy-generating devices,

o use only nonflammable insufflation gas (eg, CO2),

o use nonelectrolyte distention fluids when using monopolar electrosurgery,

o use electrolyte distention fluids when using bipolar electrosurgery,

o use conductive trocars, and

o use the lowest power setting that achieves the desired result.

Equipment

• Minimally invasive surgery and computer-assisted equipment will be used in a manner that minimizes the potential for injuries. Personnel will

o verify alarms on the equipment are audible above other competing noise;

o elevate the insufflator above the level of surgical cavity;

o flush the insufflator and insufflation tubing with gas before connecting the tubing to the cannula (eg, Veress needle);

o filter carbon dioxide insufflators with a single-use, hydrophobic filter compatible with the insufflator and impervious to fluids;

o monitor insufflator pressures throughout the procedure; and

o confirm that endoscopic CO2 insufflators are equipped with alarms that cannot be deactivated.

• The risk of injury to patients and perioperative personnel associated with intraoperative MRI will be reduced. Personnel will

o undergo safety training before any team member is assigned to work in the environment;

o use only magnetic resonance imaging-compatible equipment; and

o display signs denoting zones and the presence of an MRI scanner in a prominent location outside the MRI suite and on the door leading to the scanner room.

• An MRI technician will be assigned to every procedure requiring MRI imaging.

• Patients and personnel will be screened for cardiac devices, stents, filters, grafts, cochlear implants, pumps, nerve stimulators, or metal foreign bodies.

• The patient will be moved out of zone IV after initiation of cardiopulmonary resuscitation to prevent an MRI-incompatible device from entering the room.

• All people who respond to an emergency situation will be trained in MRI safety.

Documentation

• The perioperative RN will document the care of patients undergoing MIS and computer-assisted procedures throughout the continuum of care.

o Data collected during MIS or computer-assisted procedures will be monitored and retrieved before the video systems are shut down.

o Video equipment will be checked for adequate memory and retrieval capabilities throughout the procedure and for documentation.

o Intraoperative documentation for MIS procedures will include

• the distention media used;

• the amount of distention media used;

• the flow rate used to deliver the distention media;

• any equipment used to deliver the distention media, including the equipment identification number;

• the quantity of fluid returned, if applicable;

• any fluid deficit;

• any medication added to the distention fluid; and

• relevant information about the equipment that was used (eg, insufflation, electrosurgery, positioning).

Competency

Perioperative personnel participating in minimally invasive surgical procedures will receive education and complete competency verification activities on the principles and processes for safe patient care and use of equipment during minimally invasive surgery.

Quality

Perioperative personnel will participate in quality assurance and performance improvement activities related to safe patient care and use of equipment during minimally invasive surgery.

Glossary

Automated fluid management system: Mechanical medical devices designed to calculate the amount of fluid dispensed to the patient compared to the amount returned to the system; alarms alert the user to fluid deficit to prompt corrective action.

Computer-assisted technologies: Robotic, interventional radiology, voice-recognition software, or other computer technologies used to enhance MIS.

Hybrid OR: An OR designed with numerous imaging technologies (eg, 3D angiography, computed tomography, magnetic resonance imaging (MRI), positron-emission tomography, intravascular ultrasound) to support surgical procedures that require multiple care providers with varied expertise to provide patient care in one location.

Hyponatremia: An abnormally low concentration of sodium ions in circulating blood.

Hypervolemia: An excessive volume of fluid in the vascular space.

Insufflation: The act of blowing gas into a body cavity or the state of being distended with gas for the purpose of visual examination.

Minimally invasive surgery: Surgical procedures performed through one or more small incisions using endoscopic instruments, radiographic and magnetic resonance imaging, computer-assisted devices, robotics, and other emerging technologies.

Pneumoperitoneum: The presence of air or gas within the peritoneal cavity of the abdomen often induced for diagnostic purposes.

References

Guideline for minimally invasive surgery. In: Guidelines for Perioperative Practice. Denver, CO: AORN, Inc; 2017.

Petersen C, ed. Radiation injury. In: Perioperative Nursing Data Set. 3rd ed. Denver, CO: AORN, Inc; 2011:196-198.

Petersen C, ed. Positioning injury. In: Perioperative Nursing Data Set. 3rd ed. Denver, CO: AORN, Inc; 2011:178-184.

Petersen C, ed. Fluid, electrolyte, and acid-base balance. In: Perioperative Nursing Data Set. 3rd ed. Denver, CO: AORN, Inc; 2011:284-293.

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