ENVIRONMENT OF OPERATION THEATER
The environment of operation theater must be free from any microorganism. It should provide safe and comfortable environment for the patient as well theater personnel.
- It should be away from the other areas.
- The floor should have a smooth surface for easy washing and cleaning.
- Any wire running across the floor should be avoided.
- It should be in noise free place.
- Movement in the operation theater must be kept minimum.
- To maintain the sterilization of operation theater, it should be kept closed.
FUMIGATION OF OPERATION THEATER
Fumigation is a process of disinfection by exposure to the fumes of vaporized germicides.
Formalin (Formaldehyde) is commonly used agent to sterilize the OT and wards. It is very irritant to eye, mucus membrane and skin. That's why it is neutralized with the ammonia. The exposure period is 3 to 6 hours. After fumigation all the doors must be kept closed. Then it is used for the operation. Our main aim is to give a sterilized environment to the patient. By this process all the articles which we use in OT are also sterilized by this method.
OPERATION THEATER SET UP
- Floor of OT should be mopped up with 1% hypochlorite solution.
- OT should be near to surgical wards and the main lifts or ramp.
- It should be within easy access of the trauma and emergency ward and radiology department.
- OT should have a double door entrance and double door exit into the clean corridor.
- There should be a separate store for OT to keep sutures, dressings, needles and other articles used in surgery.
- There should be a separate space to keep the dirty drapes, linen, instruments and waste products at the end of the procedure.
- All the doors should be well sealed for proper fumigation of OT.
- OT must have an adequate power points, emergency electricity, piped gases, etc
- Cardiac resuscitation equipment (DC, shock, defibrillator) must be readily available.
- The temperature should range between 19°C and 22°C with humidity of 45 to 55%.
- OT table should be adjustable with all the working parts and compatible to C-arm.
- Cushion of OT table should be easy to clean and in good repair.
- There should be ceiling light and should be adjustable, sealed and cleaned with a facility of light handles so that surgeon and scrub team can adjust it.
Scrub Room
- This room opens into the OT with two doors one leading to OT and one to the corridor.
- Sink with taps can be manipulated with the elbow and soap holders can be manipulated by foot pedals or by elbow.
- There must be brushes for cleaning finger nails.
- Removal of personal clothing-remove your own clothes and wear gowns or OT dress in changing room.
Masks and Caps
Purpose of masks: Masks are usually used to prevent the spread of respiratory microorganism. The oropharynx is also a source of bacteria (about 36 bacteria are emitted for 100 spoken words). The use of mask has been shown to decrease the number of bacteria. These are also important for staff protection to avoid cross infection.
Mouth and nose should be covered with the masks. Tie the strings at the back of the head. It should be worn before scrubbing and it should be worn in the scrub room before entry to the OT. Masks should be discarded when it is damp or wet. It should be so thin to take breathing comfortably. Before wearing the masks and caps (sterilized) wash the hand thoroughly. Head cap should also be worn to prevent falling of hair, dust from the head. Female staff should wear scarf to cover all the scalp hairs.
Scrubbing
- After wearing the cap and mask, scrub the hands and forearm up to the elbow.
- Brushes should be used for cleaning fingernails.
- Nails should be short to avoid microorganism to reside there.
- Remove all jewellery, e.g. rings, rings with stone.
- Scrub-up time—5 minutes for first case and 2 minutes for next are with chlorhexidine soap or povidone-iodine soap (scrub) is essential. The technique should include thorough washing of the hands to the elbow with removal of the hands to the elbow with removal of the soap in the direction hand to elbow. Repeat the procedure for thorough cleanliness. Wash interdigital spaces thoroughly and each finger separately.
- Drying is again essential. Dry the forearm and hands with sterilized towel again in the direction hand to elbow then discard the towel.
Gowning (To Wear Gown)
- Design of the gown should be with long sleeves long skirt and high neck to cover all the clothes of wearer.
- Hold the gown at the inside of gown's neck and open the knot, and unfold the gown not allow the gown to touch floor or other equipments in the OT.
- Now slide your hands down in the sleeves of gown.
- Ask the assistant/nurse to tie the strings after overlapping the gown at the back as much as possible.
Gloves (Gloving)
Gloves are already folded at its sleeves. For the first glove of left hand, hold the left hand glove with right hand by its folded cuff, do not touch outside of the glove. Slide your left hand in the gloves and wear it to cover up to sleeve of gown by keeping the cuff folded. Now wear the right hand glove, use left hand (worn glove) hold the right hand glove by inserting the gloved finger under the folded cuff, do not touch outer side of folded glove, slide over the hand and unfold it without touching inner side of a glove. Now unfold the left glove cuff by using inner side of folded cuff and pull over the sleeve of gown.
PREOPERATIVE PREPARATION OF PATIENT
- Preoperative bath: Preoperative bath should be given to every patient (if possible)—it definitely reduce the incidence of infection.
- Preoperative hospital stay: A short preoperative hospital stay is also important, it reduces the chance of infection (hospital acquired infection). As well as acclimatize the patient. Long preoperative stay should be avoided.
- Shaving: The trauma of shaving undoubtedly results in lacerations to the skin that can increase the infection rate. It is preferably to do just before the operation (chances of infection are less). It is preferable to use either clipper or ideally depilation cream but it is expensive.
- Transport: There should be a separate trolley for OT and ward. One should be for inside use and one should be of outside use.
- Remove the personal clothing: Preferably it is good to change the clothing of patient and ask to wear sterilize gown or OT patients dress.
- Jewellary: Jewellary, rings and all the other ornaments worn in legs, toes should be removed and should be handed over to patients close relatives.
- Check the check list before you receive the patient in OT from ward sister.
- Finger nails should be cleaned and free from any nail polish for applying pulse oxymeter electrode and for color watching of nail bed.
- Patient bladder must be empty before operation theater entry or put a Foley catheter.
THE PATIENT IN THE OT
Position of the Patient
- Patient's trolley (if shifted by trolley) should be positioned close to the OT table and height should be adjusted.
- Transfer the patient very carefully preferably by using ‘patient slide’ to avoid lifting at an awkward angle.
- Patient's leg should be supported to avoid undue pressure on the calf.
- Optimum position is achieved for surgeons in such height so that surgeon's hand movements should be free over the patient.
- The airway and IV drip lines should be protected.
- Head should be well protected to avoid hyperextension of neck.
- If strips are used, must be securely anchored to the table.
- Make a required position that must be appropriate according to the site which surgery is to be performed.
Protection of Nerves
- This is especially important for a thin patient, chances of nerve compression are more because of less fat.
- In the Lloyd Davis Stirrups-protect the lateral peroneal nerve. These must be well padded so that there is no direct contact with metal.
- If the arms are placed on an arm board, protect the ulnar nerve at the elbow.
- In case of breast operation when arm is placed above the head, shoulder is supported posteriorly to prevent traction on brachial plexus.
- In patients with neck problem—patient should wear a protective cervical collar.
- If patient is having lumber disk problem when Lithotomy position is required, position should be carefully considered.
- In case of thyroid surgery, tracheostomy in which hyperextension of cervical spine is required—head must be supported.
- In case of major orthopedic surgery or pelvic surgery to prevent DVT (deep vein thrombosis)—calves should be well protected against pressure by whatever means is chosen—stockings or pneumatic compression. For this subcutaneous heparin is also used additionally.
Painting and Scrubbing the Operative Site
- The skin of the operation site should be thoroughly scrubbed with povidone iodine detergent. This will clean and degrease the skin and removes all the microbes. It must be dried off completely.
- The area like axilla, umbilicus, perineum should be cleaned completely with extra care as these are the site of harboring microbes. Vagina and perineal area should be cleaned with chlorhexidine and cetrimide solution.
- Area must be dried off completely otherwise there is danger of burn with the use of electrosurgery (diathermy).
Drapping of the Patient
Drapping of the patient should be adequate. Cover all the area except the endotracheal tube side and the site of incision according to operation.
During Procedure
- All the instruments should be kept in an order to avoid unnecessary time to find them.
- Instruments must be handled in such a way as to avoid injury to the patient and staff.
- Instruments should not be left on drapes where they can directly injure the patient.
- Contaminated instruments, swabs, pads should be discarded.
- Before starting the procedure counting of instruments, pads, swabs, needle is must.
- Before closure of body cavities, incised organ or joints spaces-count all the articles.
- Nothing should be removed from OT until the incision is closed and till scrub nurse tells that all is correct.
- Particular care should be taken when there is a changeover of staff (in case of prolonged procedure or fatigue of staff) change over nurse must know each and all about the extent of surgery and all the equipments and articles being used and their count.
- Staff in the OT including surgeons should be in good health with no upper respiratory tract infection and there should not be any septic lesions.
- Talking and movements during procedure should be minimum.
- Assistant should not lean on patients as this may cause compression of chest/abdomen and may cause damage, bruising or neuropraxia.
- Use of tourniquet, if used the pressure and time should be checked and noted when it was applied.
- Anesthetist or OT assistant (circulator) should remind the surgeon about the “tourniquet” time.
Electrosurgery (Diathermy)
Better term is diathermy than electrocautery. In diathermy high frequency alternating current is passed through the body tissue that liberates heat.
In Monopolar—current passes through the patient and complete the circuit through the patient's plate of diathermy. In this there is single point in the hand.
In Bipolar—the two blades of the forceps are in hand and tissue is grasped between the blades.
Coagulation and cutting of tissue depends on the power setting, size of electrode, time and tissue type.
Precautions
- Staff must know the details of diathermy.
- Power should be checked before using.
- It should not be used when ether is used.
- Patient's plate must be accurately placed, it should not touch the metal objects such as parts of OT table and IV stand, etc.
- Conductor, e.g. wrapped with wet cloth or jelly is used over the plate which is in contact with the patient.
- Diathermy and its parts (accessories) foot pedals, plugs leads and sockets should be checked regularly that all are OK.
- Mode of diathermy monopolar, bipolar or under water cutting should be checked and selected before to use and correct setting to be used should be checked.
- Skin is checked after removal of plate.
If it is not working then look for:
- Its connection
- Faulty electrodes
- Contact of plate
- If there is pacemaker—use of diathermy may affect the pacemaker.
- It is always safer to use a “Bipolar” circuit when possible.
For Endosurgery
- Insulation of the instruments should be checked regularly.
- Always use in a low power setting. Use low voltage.
- Use intermittent rather than continuous.
- Do not use when electrode is in contact with other metallic instruments.
When Image Intensifier Television (IITV) is Used
- All staff should wear a good quality of lead apron.
- Pregnant staff must not be in OT.
- Sterility must not be compromised.
Specimens
- Specimen removed in operation should be kept in a separate bowl.
- It should always be shown to the patient's relative.
- It is a duty of attending staff to keep in 10% formalin solution in a container, seal it and label it.
Care of Instruments after Operation
- All the washable instruments must be rinsed with cold water (hot water cause blood to clot) and washed thoroughly under running water with brush mainly at the ratchet or joints of instruments.
- All the plug points rechecked for their disconnection.
- Delicate instruments like camera, light cord, diathermy wire, electrodes, scope should be handed over very first to other responsible assistant. He/she will clean, dry and will keep in the respective place.
Care of Linen
- Soiled linen should not be placed or thrown on the floor.
- Linen soiled with urine, stool should be washed with cold water and remove all the stain.
- If stains are not removed by cold water then use stain remover.
- Blood stains are removed by rinsing in cold water, because blood contains protein. Heat (hot water) coagulates the protein, so never use hot water to remove blood stains.
- If blood is dry, apply hydrogen peroxide and wash with cold water.
- When dye stains the linen—wet the cloth and bleaches them in sunlight, chlorine water.
Care of OT Table Mattress and Pillows
- OT table mattresses should be covered with Macintosh to prevent staining after the procedure. Macintosh is washed thoroughly.
- Similarly pillow which is used during the procedure for positioning can be of plastic cover otherwise small Macintosh can be used as a protection against staining by discharge and expirations.
- If table is stained by blood, should be washed immediately after the procedure, and clean with 1% hypochlorite solution.
TRANSFER OF THE PATIENT TO RECOVERY ROOM
- Recovery room is usually designed very close to the OT.
- In this room—adequate monitoring equipments are necessary like— suction machine, oxygen with mask, all emergency medicine, pulse oxymetry, etc.
Management of Patients in Recovery Room
- The patient airway should be regularly checked.
- Monitor oxygen saturation more than 95%.
- Breathing should be normal.
- Temperature should be normal.
- Pulse, BP, and respiration rate should be regularly recorded in chart.
- Pain relief is mandatory.
- Check the pressure areas.
- IV cannula should be at hand and fit well.
- Any medicine given should be recorded with time.
- If central venous line is present this should be handled in a strict aseptic way and clearly labeled.
- All tubes and catheter should be cared and should be properly fixed.
- Before sending the patient in ward, patient must be fully awake with all the verbal response.
- Pulse, BP, respiration and temperature should be normal.
- The effect of muscle relaxants must be completely reversed. Patient should be able to cough, lift the head and protrude the tongue.
- Dressing (incision site) should be rechecked and if there is bleeding, inform the doctor and redress it after achieving homeostasis.
- Anti-emetic drugs should be given if needed.
- Take a green signal from anesthetist before sending to ward.
- Urine output, amount of drain, nasogastric aspiration should be recorded.
TRANSFER OF THE PATIENT TO THE WARD
- If any special instructions should be told to the ward staff.
- All postoperative instructions record must be complete.
- All the OT notes including anesthetic record must be complete.
- Patient should be comfortable and well positioned on the trolley.