operating room - etiquettes

1. Care in the operating room
By Dr. Masoom & Dr. Jason
Moderator : Dr. Pradeep Saxena

2. Learning Objectives
• How to prepare a patient for theatre
• The importance of the WHO checklist and its
components
• How to reduce intraoperative risks of positioning,
venous thromboembolism, infection and
hypothermia, by using appropriate monitoring
and equipment.
• The operating theatre environment and how to
behave in it, including scrubbing up, the role of
the assistant and how to write an operation note.

3. Preoperative Preparation
• Before theatre
■ Patient must be seen by anaesthetist and
operating surgeon preoperatively
■ Communicate early with theatre team
regarding specific requirements
■ Arrange theatre list appropriately for the
case-mix and resources available

4. IN THEATRE
• WHO Surgical Safety Checklist: UK process
■ Step 1: Prelist briefing
■ Step 2: Sign in
■ Step 3: Time out
■ Step 4: Sign out
■ Step 5: Postlist debriefing

5. Prelist briefing
• A short meeting before the start of the
operating list
• Introduction between team members
• Share information about potential safety
problems and highlight concerns about
specific patients to ensure smooth running of
the list

7. Antibiotics
• To be given within an hour of surgical incision
to prevent surgical site infections
• Discontinued within 24 hours of surgery
• Cephalosporins are commonly given
• Can be given in clean cases involving
prosthesis/implant

8. Venous thromboembolism
• Risk assessment should be done preoperatively
• Optimum hydration to be maintained
• Mechanical and pharmacological VTE prophylaxis can
be used
• Mechanical methods include:
• • anti-embolism graduated compression stockings;
• • foot impulse devices;
• • intermittent pneumatic compression devices

9. Monitoring
• The most important ‘monitor’ is the presence
of a trained, dedicated individual to observe
the patient throughout anaesthesia

10. Operating theatre environment
Ventilation
Aim: prevent airborne microorganisms entering the
surgical wound
• Filtered air is introduced at ceiling height and
exhausted at the floor (min 20 air changes/hour)
• Maintain positive pressure relative to surroundings
• Keep doors closed and limit the movement of
personnel in and out of theatre
• Laminar air flow provides 100–300 air changes per
hour

11. Operating theatre environment
Humidity and temperature
• Ideal working temperatures for surgeons are
19–20°C
• Patients may develop hypothermia below
21°C
• Temperatures of 20–24°C are acceptable with
a relative humidity of 50–60 per cent to
protect against electrostatic charges

12. Patient transfer and positioning
• Under the supervision of the anaesthetist and surgeon
• Transfer
Coordinated by the anaesthetist, who protects airway devices
and other connections during the move
Sliding boards and low friction sliding sheets are helpful
• Positioning
The plan for intraoperative positioning should be
communicated to the entire team
Stability of the patient on the table should be ensured using
straps/solid supports

13. Patient transfer

14. Positioning

15. Pressure areas which must be given
special consideration
• The skin over bony prominences
• Nerves in superficial courses, e.g. common peroneal
nerve.
• Nerves at risk of stretch injury, e.g. brachial plexus
• To avoid electrical injury, no part of the patient
should be in contact with any metal other than the
diathermy plate

16. Equipments
• Diathermy
In monopolar, the electrode plate site should be:
• clean and dry, free of hair
• situated over well-perfused muscle mass,
avoiding bony prominences, scar tissue, areas
distal to tourniquets and implanted metal work
• as close to the operative site as feasible
• checked at the end of surgery for injury

17. Equipments
Tourniquets
• used to improve visibility at surgery and to
reduce blood loss

18. Equipments
Precautions while using tourniquets:
• Avoided in high risk patients
• Proper padding and taping of tourniquet
• Cuff pressure to be minimum
• Use of tourniquet clock : reminded every 1 hr
and not to exceed >1.5hr in total

19. Time out
Performed immediately before the surgical procedure
starts:
• Team introductions
• Verbal confirmation of the patient’s identity
• Operative site and procedure to be performed
• Discussion of anticipated critical events by the surgeon,
anaesthetist and nursing team
• Confirmation of antibiotic prophylaxis
• Review of essential imaging

20. Temperature control
• Patients undergoing anaesthesia and surgery lose
heat rapidly from radiation
• Measures to limit the development of
intraoperative hypothermia :
Warming blankets
Warmed intravenous and irrigation fluids,
Increasing the operating room ambient
temperature and
Minimising exposure of the patient

21. Hair removal
• Necessary over the operative field to facilitate
exposure
• infections may be reduced if hair is clipped rather than
shaved
• Wound infection rate is 1% if done immediately before
surgery
• Rises to 5% if done 12 hours prior
• Clipping and depilatory creams have infection rate of
<1%

22. Glycaemic control
• Hyperglycaemia perioperatively may increase
the incidence of postoperative wound
infection
• Unrecognised hypoglycaemia may lead to
seizures and death
• Diabetic patients need more strict monitoring
• OHA are stopped on day of surgery and
patient started on insulin if reqd

23. Infection control
Asepsis and universal precautions:
Universal precautions should be taken in every case involving
exposure to body fluids :
• protective non-porous gloves, eyewear, mask, apron for staff
• safe sharps handling techniques and adequate provision of
sharps bins
• staff vaccination for hepatitis B
• staff with infected wounds or active dermatitis should not
work in theatre

24. Scrubbing up
■ Hat, mask and eye protection should be
worn and jewelry should be removed prior
to scrubbing
■ Nails and deep skin creases are cleaned
for 1–2 minutes using a brush
■ Hands and forearms are washed
systematically three times, the hands
being held above the level of the elbows
throughout
■ Hands and arms are dried from distal to
proximal using a sterile towel

25. Scrubbing up
■ The folded gown is lifted away from the trolley
and allowed to unfold (inside facing the wearer),
while the top is held
■ Arms are inserted into the armholes
simultaneously
The gown is secured by an unscrubbed staff
member
■ Gloves are put on using a one- or two-person
technique:
from this point on, hands remain above waist
level at all times.

29. Scrubbing
Standard scrubbing solution:
• 2 per cent chlorhexidine: effective for 4 hrs
• 7.5 per cent povidone-iodine
• Alcohols (70% isopropranolol)

30. Prepping and draping the patient
• Skin preparation should include the surgical site and
a wide area around it.
• Draping aims to create a protective zone around the
operative site to avoid contamination of items used
for the procedure
• Diathermy and suction equipment are attached to
the drape

31. Prepping and draping the patient

32. Role of the assistant
• Preparation: Assistants should review the
anatomy and the operation before surgery.
They should start scrubbing first, having
checked that the patient is ready for theatre.
• Training: Trainees should write important
steps of proposed operation in brief on a
board in the operating theatre.

33. Role of the assistant
• At surgery. The assistant should try to provide
the surgeon with the best access possible and
showing the surgeon the field where they are
working.
• After surgery. The assistant should help transfer
the patient safely off the table and may write the
operative note.
• They should keep a log of all operations attended
and what they have learnt from each case.

34. Summary
• In theatre
■ The WHO checklist is a universal tool to improve
patient safety and should be completed for every patient
coming to theatre
■ Risks to the patient are minimised by appropriate
antibiotic and venous thromboembolism (VTE)
prophylaxis, monitoring, careful positioning,
temperature, glycaemic and infection control
■ The operating theatre environment should be
optimised with regard to lighting, ventilation, humidity
and temperature

35. Summary
• ■ Additional equipment, such as diathermy
and tourniquets, should be used while
recognising their potential complications.
■ Theatre etiquette including scrubbing,
prepping and draping and personnel
movement is designed to minimise cross
infection.

36. Sign out
• These include checking that the procedure
has been recorded
• Instrument and swab counts
• Specimen labelling
• No equipment problems requiring further
action and
• Key concerns for recovery recorded for the
staff taking over care of the patient

37. • ■ The ‘sign out’ process and postlist briefing
complete the WHO checklist
■ The operation note should be completed at
the time of surgery and contain full patient,
personnel and operative information
■ Clear postoperative instructions are vital

38. Writing the operation note
The following information should be included:
• Patient details (name, date of birth, hospital number,
address, ward)
• Date and start/finish times of the operation
• Location of the operation
• Name of the operation
• Surgeon, assistant and anaesthetist
• Anaesthetic type
• Patient position and set up

39. Writing the operation note
• If applicable, tourniquet use (location and time), antibiotics
given, catheterisation, skin prep used and draping method
• Operative information:
– incision and approach
– findings
– procedure (illustrate if appropriate)
– complications or untoward events
– implants used
– closure and suture material used
– dressing

40. Postoperative instructions
• Observations and frequency
• Possible complications and required action
• Specific treatment, e.g. intravenous fluids
• Time line for normal recovery (when to
mobilise, when to resume oral intake,
physiotherapy, dressing changes, etc.)
• Discharge and follow-up details

41. THANK YOU