The WHO surgical safety checklist is used universally to improve patient safety and should be completed for every patient, including sign in, time out, and sign out. Risks are minimized through proper preoperative preparation, appropriate antibiotics and VTE prophylaxis, monitoring, positioning to prevent pressure injuries and hypothermia, and strict infection control. The operating theatre is optimized for lighting, ventilation, humidity and temperature. Additional equipment like diathermy and tourniquets require safe usage to prevent complications. Strict asepsis is followed through scrubbing, prepping, draping and limiting personnel movement to minimize infections.

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