Chapter second

Intraoperative care
• Intraoperative Care
• • Organization and physical setup of the operation theatre
• Classification
• • OT Design
• o Staffing
• • Members of the OT team
• • Duties and responsibilities of then urse in OT
• • Position and draping for common surgical procedures
• • Instruments, sutures and suture materials, equipment for common
surgical procedures
• • Disinfection and sterilization of equipment
• • Preparation of setsf or common surgical procedures
• • Scrubbing procedures – Gowning ,masking and gloving
• • Monitoring the patient during the procedures
• • Maintenance of the therapeutic environment in OT
• • Assisting in major and minor operation, handling specimen
• • Prevention of accidents and hazards in
• • Anaesthesia - types, methods of administration, effects and stages ,
equipment& drugs
• • Legal aspects
Introduction
• Intraoperative care is the management and monitoring of a
patient during surgery, from entering the operating room
until transfer to recovery, ensuring safety, stability, and
optimal conditions through continuous assessment,
anesthesia management, fluid/medication administration,
and strict sterile techniques by a multidisciplinary
team. Key goals include maintaining vital signs, preventing
infection, ensuring proper positioning, managing blood
loss, and providing analgesia, all coordinated to support
the surgical procedure and promote healing
An Operation Theatre (OT) or Operating Room (OR) is a specialized, sterile hospital
area for surgery, equipped with advanced tools (lights, tables, monitors, anesthesia
machines) and strict hygiene protocols (gowns, masks, air filtration) to ensure patient
safety and prevent infection, allowing precise medical procedures by surgeons and staff
in a controlled environment. Modern OTs maintain aseptic conditions through dedicated
zones, specialized ventilation, and technology to support various complex operations.

Key Features & Components

•Sterile Environment: Maintained through air filtration (HEPA), controlled
temperature/humidity, and strict protocols for staff and equipment to prevent
contamination.
•Specialized Equipment: Includes surgical lights, operating tables,
anesthesia workstations, patient monitors (vital signs), surgical instruments
(scalpels, forceps), and advanced tech like lasers or laparoscopes.
•Zoned Areas: Typically includes pre-operative, operating (sterile core), and
post-operative areas, along with scrub-up stations.
•Medical Gases & Power: Access to essential gases (oxygen, nitrous
oxide) and reliable electricity is crucial.
Purpose
•To provide a safe, controlled, and aseptic setting for performing major and
minor surgical procedures.
•To facilitate precision and efficiency for surgical teams.
•To allow for close monitoring of patients by anesthesiologists, nurses, and
technicians.
Modern Advancements
•Modular OTs: Feature pre-engineered panels, chemical-resistant floors,
and integrated systems for easier installation and cleaning.
•Computer-Assisted Systems: Navigation modules help surgeons with
precise cuts, especially in complex orthopedic or neurosurgery.
• In the OT design and plan, there should be allocation of designated
places for clean areas, sterile areas, disposal areas, and aseptic areas
in the OT based on the requirement of cleanliness and asepsis.
Cleanliness is maintained by positive pressure ventilation rising from
the inner to the outer area.
• • There should be restricted entry of unnecessary people.
• Only healthcare professionals on duty should be allowed to enter the
OT. The health personnel always use only the designated way for
entry and exit in OT.
• • Always try to avoid frequent entry and exits by the healthcare
professionals. Once entered into the OT, the duty staff should leave
the OT after the end of the duty time. If necessary, if they want to
leave the OT for significant patient care, they should follow standard
institute protocol for reentering, such as changing the mask, shoes,
dress, cap, apron, etc.
• The healthcare professional should follow the infection control protocol in
the adjacent corridor. It is beneficial to prevent infection in OT.
• • Assess the pathogen count in all areas of OT. It is minimized in each area
by following standard cleaning areas of OT. Protocol Regularly check the
pathogen count in all
• • Try to restrict the unnecessary items and equipment entry inside the OT.
The necessary equipment should be arranged inside the OT during free
time without the surgery procedure going on inside the OT. It may be C
• allowed in emergencies when new equipment or articles are required for
surgery. However, it is not available in the OT.
• • Do not permit to bring consumables, drugs, and own dress by patient or
attendants.
• • Maintain the appropriate temperature, humidity, air movement, and
positive pressure ventilation by the technical team in the OT.
• • Dispose properly of all the soiled linen biomedical waste items on
time without delay regularly from the OT.
• • Measure the sterilization and cleaning protocol followed by staff as
per the protocol in OT to clean the various areas, articles, and
equipment daily.
• • Keep the surgery tray/trolley in as per the WHO surgical checklist
before starting the surgery.
• • Ensure quality assurance by properly documenting SOP guidelines
and checking the parameters, such as microbial count from various
areas in OT, to prevent infection.
Criteria to be considered for number of OT rooms

• • Types of specialty, experienced, and skillful human resources available in

the hospital
• • Feasible number of surgeries per month, week, or day in the hospital
• • Facilities available in the hospital, such as general or super specialty
services
• • Number of inpatient bed strength and outpatient cases
• • Number of departments available in the hospital
• • Based on the percentage of the number of emergency and invasive
procedures performed in the hospital.
• Well-organized coordination and procedures were established for the
proficient flow of patients, personnel, and supplies.
Factors influencing numbers of OT
Type of hospital
• Type of surgery
• Number of hospital beds
• Hospital policy
• Staff and strength and capacity of sterile supply
• Average number of operations
• Time for OT maintenance
• Turnover rate in OT
• Average length of stay
• Projected emergency surgical cases
Physical activities involved in OT
• Reception of patient
• Supportive services
• Administrative area
• Physical activities
• Housekeeping
• Store keeping
• Repair and maintenance
• Clerical activity
Classification of OT
• The Rao committee suggested one operation theater for 50 surgical
beds in India.
• • In America, one operation theater for 25 surgical beds.
• • In European countries, one operation theater for 50 surgical beds.
Based on sterility Based on Based on timing of surgery
Construction
• Extreme sterile such • Elective OT
CTVS, transplant OT • Modular OT • Emergency OT
• • Antiseptic OT • Non-modular OT
• Infected OT

Based on level of surgery Based on kind of facility Based on allocation of OT

delivered Decentralized OT:
• Minor OT
• Major OT • Outpatient OT Neurosurgery, orthopedic,
• Inpatient OT cardiothoracic and vascular
surgery,
ENT, eye, general surgery,
gyne, renal
• Centralized
OT Design
• • Central corridor plan: i. Racetrack plan, ii. Hotel plan
• • Peripheral corridor
• • Specialty grouping plan
• Central corridor plan: This plan consists of two styles:
• 1. Racetrack plan:
• 2. Hotel plan: ORs are located alongside the central corridor. The clean, sterile, and soiled areas
are divided separately. In this design, all enters and exits are through only one entry (Fig. 2.5).
• Peripheral corridor: The OR entrance is in front of every
• OR from the peripheral corridor, and equipment and articles supplies are reclaimed through a
back entrance from the OR leading to the central-core storage and work areas (Fig. 2.6).
• Specialty grouping plan: The specialty departments OR gather in one place. Each specialty OR has
its standard protocol for entry and exit infection control into the OR, and every OR has its storage
place, solid collecting place, and cleaning area.
Racetrack plan: The forward-
facing front entry door in every
operation room is from the outer
corridor, and materials are
reclaimed from side to side, a
back entry to the room prominent
to the central-core storage and
work areas
Hotel plan:
ORs are located alongside the
central corridor. The clean, sterile,
and soiled areas are divided
separately. In this design, all enters
and exits are through only one entry
Peripheral corridor:
The OR entrance is in front of
every OR from the peripheral
corridor, and equipment and
articles supplies are reclaimed
through a back entrance from the
OR leading to the central-core
storage and work areas
staff flow chart inside the operation theatre
• Before protective area:
• Lobby and guard area
Protective area:

• Entry to the OT complex

• OT front office reception
• Patient trolley are:
For keeping stretcher/trolley
• Trolley/transfer day
• Entry to the main storeroom
• Entry into the preoperative area
• Assistant gowning area
• Entrance to clean passageway for healthcare providers and patients
• Doctor's room cum counseling room
Clean area:

• Pre and postoperative recovery room with attached toilet and small store
• Staff changing rooms with lockers (separate for male and female nurses and one
for general support staff)
• Nursing in-charge changing room with lockers
• Toilet for staff
• Entrance to sterile corridor for patients and healthcare providers
• Storage
• Janitor place
• Trolley space
• Handwashing space
• Pantry equipment preparation space
Sterile area (aseptic area:

• Operation theatre with pass box

• Storage for sterile, lifesaving equipment, consumable articles
• Scrub area
• Handwashing room with OT
• OT in-charge room
• Records room
• Autoclave area/Sterilization/CSSD
• Passage to fire exit
Disposal area:

• Disposal corridor
• Dirty utility area
• Pass box
• Fire exit
• Disposal items leaving from OT by stairs or lift, it is use only for
disposal
Protective Zone

It is situated after the lobby area.

• Entry to protection zone: All healthcare providers should follow the
infection control protocol, e.g., wearing a mask, shoe cap, cap, OT dress
and handwashing.
• Patient entry: The patient has to be changed from the ward's trolley
or wheelchair to the OT trolley. The ward's trolley should not permitted
entry inside the OT. The OT nurse makes sure the ward's trolley has
been changed, and the patient's document and case sheet should be
given to the OT staff.
• OT front office or reception area: The OT front office should be
responsible for the protective area. Assess all the standard protocols,
such as making sure the patient wears an OT gown, cap, mask shoe cap
before transferring the patient from the ward's trolley to the OT trolley,
taking over the patient case sheet from ward staff to OT staff,
documenting the patient entry time into the patient OT in and out
register has to follow before the patient entre into the OT. The
reception staff should pass patient-related information like health
status and other significant information through an intercom, mobile,
telephone, or public address system to patients or family members in
the waiting room.
Clean Zone

It consists of patient and staff dress changing room, OT front office, patient
transfer from ward trolley to OT trolley area, store room, sterilization area,
nursing station, surgeon room, outside the OT, OT staff washroom, recovery
room charting facilities, medication, handwashing facilities, link provision,
bedpan, laboratory. The clean zone is maintained at positive pressure,
slightly higher than the protective zone.

• Pre and post-OT recovery room: If the hospital has 200 beds, they require
four beds for preoperative and four for postoperative recovery rooms. All
beds should be moveable like trolley beds and monitor facilities such as
oxygen supply suction, continuously monitor the patient's physiological
parameters for each bed separately. A recovery room must be available in
the washroom.
Storeroom: In this place, store all consumables like single-use items and
non-consumable like equipment and articles stored for OT use. The OT
staff should follow the infection control protocol to avoid the outside
infection entering the OT. Preferably, all OT items must be covered by a
sheet after being collected from the main store to avoid outside
infection entering the OT.
• Pantry inside clean area: In this place, the OT staff prepare food and
snacks for OT staff whenever necessary.
Sterile Area (Inner or Aseptic Area)

This is an authentic operation room. It consists of a preparation area, sterile

area, scrub area, gowning area, patient induction area, packing area, and
sterilization area.
The healthcare professional should follow the maximum level of sterile and
aseptic practice and wear a head cap, mask, and OT dress.
• Scrub area: This has to be designed with a non-slippery floor and with an
elbow-operated or infrared sensor or foot-operated water taps without
splashing water and conveniently changing direction. It should be fixed 10
cm above the wash basins for hand scrubbing along with sufficient depth and
width scrub washbasin to avoid the outside water spilling and for free
movement of the OT staff. Washbasin peripherally rust-free stainless.
• Autoclave room: All used items should be autoclaved in this area as per the
protocol. There should be a facility available for chemical/plasma sterilization
and also for sterilizing the laparoscope, tubes, etc. All sterilized items should
be stored in this place before being sent to the OT trolley.
• Documentation room: Healthcare professionals will document the patient's
health status in e-health records or OT registers.
• Movement of used equipment and linen from OT to CSSD: All used
equipment should be covered by a lid. Before sending to CSSD, clean the
used item thoroughly as per protocol and pack the cleaned items before
transfer to CSSD with clean cloths. OT solid waste should be packed into a
sealed biomedical waste bag.
,
• Disposal Zone
• This is the place to dispose of biohazard waste. Separate exits for
contaminated/used linen and instruments dirty utility areas, disposal
corridors, and OT dress are mandatory in this area.
Operation Theater Layout

• • Location: OT should be set in a silent environment. It should avoid

noise, contamination, and transmission of outside infection,
sewerage, debris yards, standard toilets, and unnecessary outside
transport. It should permit adequate sunlight. OT should always be
linked with the blood bank, main store, surgery ward, emergency
department, central lab, laundry and CSSD, labor room, etc. If the OT
complex is situated in a multistory building, it should not be located
on the top floor.
• Never keep toilets and washrooms above the OT room to avoid solid
leakage.
• • Room size: It is based on the requirement. It should permit the free
association with a healthcare professional, OT equipment, patient
trolleys, surgery equipment, patient monitoring devices, portable
machines, wheelchairs, etc. OT room size should have sufficient space
for free movement by the healthcare professional.
• OT size preferably 20 × 20 x 10 feet in size and floor space of 400 sq.
feet approx. (Recommended size is 6.5 m x 6.5 m x 3.5 m.) The
standard OT should be rectangular or square in shape.
• The minor OT may be considered for a small space (size of 18 × 18 ×
10 feet with a floor space of 324 sq. feet.) for endoscopy or minor
surgery.
• Specialty OT (cardiac or neurosurgery) should be more spacious (size
of 20 × 30 x 10 feet with 600 sq. feet of floor space).
• Flooring: It should be designed to prevent the passing of static
electricity, without slippery floors, free-reflective, not allowing liquid
or air to pass through even slowly,
• waterproof, stain proof, simply cleanable, with smooth surface and
fireproof. OT floor construction material should tolerate frequent
washing with germicidal! chemical agents and sound absorption.
Floor color should be selected to help to avoid any small items
(needles) falling on the floor. It can be visible easily.
Ventilation: There should not be keep sealing fan or cross-ventilation to
prevent the spread of airborne infection in the surgical wound. OT air flow
should occur from the sterile area to the clean area and from the clean area
to the less clean areas. In OT, following recirculating air condition system
takes some or all of the air, corrects the temperature, and again circulates air
back to the room; another technique is a non-recirculating air conditioning
system, which heats or cools the air as preferred and transports it into the
OT with preferably
20-air exchange per hour. Air is then bushed outside and automatically
removed anesthetic agents in the OT. The filtered air delivery must be 90%
efficient in removing particles more than 0.5 mm. A positive air pressure
system in OT should ensure a positive pressure of 5 cm H,0 from the ceiling
of OT downwards and outwards to push out air from OT.
Temperature: Preferably maintain 18 to 24°C
temperature inside the OT, and it should not change based on the
health professional's convenience but consider the patient's
requirements, mainly older patients, neonatal, and burns patients.
• Humidity: It should maintain relative humidity of
50-60%.
Staffing in OT
50 100 200 300 400 500
No of OT 2 3 4 5 5 5
Nurse 11 13 22 24 24 24
OT technician 4 5 8 9 9 9
Theater 3 3 3 4 4 4
sterile supply
unit
assistance
Sanitation 3 3 3 9 9 9
staff
• Member of the OT Surgical Team (Fig. 2.9)
• • Medical personnel
• • Anesthesiologist
• • Nursing personnel
• • OT technician
• • OT attendants
• • Lab technician
• • OT sweepers or cleaners
 OT staff members
OT INCHARGE

OPERATING STAFF ANESTHRTIC STAFF NURSING STAFF SUPPORTING STAFF

SUPPORTI OT OT LAB
CHIEF ANESTHESI ANESTHRTIC TECHINICAN ATTENDANTS TECHNICIAN
SURGON NG OLOGIST ASSISTANT
SURGON

NURSING SCRUB CIRCULATORY

SUPERVISIOR NURSE NURSE
• • Surgeon: The surgeon should thoroughly go through the medical
history of the patient, verify if the patient has any allergies or
comorbidity, check the preoperative checklist, and consent once
again before starting the surgery. Before starting the surgery, the
surgeon should verify that all surgery-required equipment is available
and in working condition. He or she should explain the outcome and
risk of the surgery to the patient and family members. He or she
should document the surgery procedure, anesthesia used for surgery,
and physiological parameters of the patient after completing the
surgery.
• • Anesthesiologist: Primary responsibility is administering anesthetic
medication based on the surgery and patient condition to prevent
surgery pain and sensations.
• During surgery, continuously monitor the patient's vital and
physiological parameters to regulate anesthetics based on the
parameters. Check the patient's vital signs and recovery stage after
surgery and adjust the pain medicine dose accordingly.
Nursing Personnel and their Responsibilities

• Deputy Nursing Superintendent

• She or he should maintain high standards of patient care and be
responsible for OT administration. Place the indent for OT requirement,
submit the requirement of OT equipment, and supervise the OT staff to
ensure they follow the OT protocol as per institute policy.
• Senior nursing officer: She or he should maintain high standards of patient
care, be responsible for OT management, update everyday activity to
superiors, and plan the surgery arrangement based on surgery. Allot the
duties and accountability to every OT staff, especially scrub and circulatory
nurses, for the smooth running of OT function. Check the OT stock
inventory periodically.
• Communicate significant information among the teammembers and
coordinate with surgeons and anesthetists to prepare the OT list. Report to
the superior for any uneven or practical difficulty in the OT. Initiate the
continuing education program for OT staff and conduct and participate in
research activities.
• Scrub Nurses
• • Before surgery: Works directly with the surgeon within the sterile field.
She or he should arrange and check all equipment available in the trolley
based on surgical procedures. Perform surgical scrubbing, gowning, and
gloving to assist with surgery and always follow the aseptic technique
throughout the surgery. She or he is accountable for sponges, instruments,
and needle counting with the circulator nurse. She or he may receive items
through the circulatory nurse whenever any articles.
• * During surgery: The nurse may be considered to support the
surgeon for gowning and gloving. Start to assist the surgeon
throughout the surgery till the end of the procedure. Perform the
drapes based on the type of surgery. Start with the towel, towel clips,
draw sheet, and then lap sheet. Fix the blade on the knife handle
using a needle holder, and assemble the suction tip and tube. She or
he should supply all required articles to the surgeon in sequence
order and whenever he or she asks for it in the correct technique.
Always maintain an aseptic technique throughout the surgical
procedure.
• End of surgery: Count the used sponge, needle, articles, etc., and
informs the surgeon before closing the surgical incision, help with
suturing, put dressing on the surgical incision site, and remove all the
used instrument and equipment away from the surgery table.
• Circulatory Nurse
• She should manage patient care within the OT and coordinate with the OT team
members. Verify the working condition of all equipment in OT, like the cautery machine,
suction machine, OT table, and OT light.
• • Before surgery: Check all equipment for proper functioning, such as the cautery
machine, suction machine, OR light, and OR table. Make sure that the theater is clean.
The OT table, surgeon chair, and equipment are positioned based on the surgical
procedure. Place a clean sheet, arm board, and a pillow on the OR table. Maintain the OT
temperature and air condition according to protocol. Help the scrub nurse supply sterile
items, count and record the equipment, sponge, and instruments, and arrange a clean
kick bucket or container. Collect necessary stock and equipment.
• • During surgery: The nurse helps the anesthesiologists position the patient, administer
anesthesia, and, whenever necessary, monitor the patient throughout surgery. Keep the
OR light position convenient for performing surgery. Observe any failure in the aseptic
technique. If there are any disruptions, inform the surgeon instantly. Stay in the OR until
the surgery.
• • End of surgery:
• - Document the surgery in the OT register. After surgery, the collected
specimens will sent to the lab with appropriate labels and signs.
• - Help the scrub nurse with patient dressing, removing and disposing
of the drapes, and preparing the patient for transport to the recovery
room.
• - Assist the scrub nurse in taking the instrumentations to the
washroom.
• - Make arrangements for the preparation of theater for the next case.
POSITION AND DRAPING FOR STANDARD
SURGICAL PROCEDURES
• Criteria for Positioning
• • No interference with respiration: Unrestricted diaphragmatic
movement and a patent airway are vital to maintaining respiratory
function, avoiding hypoxia, and helping induction by inhalation.
• • No interference with circulation: Sufficient circulation is essential to
maintain blood pressure, assist venous return, avoid thrombus
formation, and prevent circulatory disturbances.
• No pressure on peripheral nerves: Prolonged pressure on or
stretching peripheral nerves can result in slight sensory and motor
loss due to paralysis.
• Extremities and the body are sound support at all times. Appliances,
restraints, and equipment in contact with skin well padded. The most
frequent injury sites are divisions of the brachial plexus and the ulnar,
radial, peroneal, and facial nerves. To avoid nerve damage or injury,
padded arm boards, chest rolls, and elbow padding should not be too
tight, and avoid using shoulder braces for steep Trendelenburg
positions
• Minimal skin pressure: Weight concentrated over bony prominences
can cause skin pressure ulcers. These areas safeguard from
continuous external pressure against hard surfaces, mainly in thin or
underweight patients.
• • Accessibility of operative site: Operative procedures determine the
patient's position. The surgeon must have adequate exposure to
minimize trauma and operating time.
• • Accessibility for anesthetic administration: The anesthesiologist
must be able to attach monitoring electrodes, administer anesthesia,
observe its effects, and maintain an intravenous lifeline.
• • No undue musculoskeletal discomfort: If the head extends for a
prolonged time, the patient may suffer more pain from a resulting
stiff neck than the operative wound. Proper body position sustained.
• • Individual requirement met: Patients with arthritis deformities may
need special individualized care because of limited range of motion in
joints. A cardiac patient may experience dyspnea when lying flat.
• Preparations for Positioning: Responsibility
• • The circulating nurse should evaluate the suggested position.
• • Request the surgeon for assistance placing patient in an appropriate
position if unsure how to position the patient.
• • Assess for any patient-specific positioning whenever needed.
• • Assemble and test all table attachments and protective pads
anticipated for the surgical procedure and have them immediately
available for use.
• • Evaluate the working parts of the OR bed before bringing the
patient into the room.
• Position for anesthesia induction: Supine position, head extended,
neck flexed. This position aims to visualize oral, haryngeal, and
tracheal spaces. This position may cause roblems like injury to lips,
teeth, jaw dislocations, laryngeal or vocal cords injury, epistaxis, and
pharyngeal wall injury.
• Supine or dorsal position
• Lies flat on his back. The arms might be kept beside the body, on an arm
board, or supported across the chest by lifting the gown, which acts as a
sling. It is an appropriate position for laparotomy and particular
gynecological and orthopedic surgery
• Possible complications
• • Back pain due to support of lumbosacral curvature area
• • Loss of sensation in arm and hand due to over-abduction
• • Arm/elbow hanging or constricted strapping causes radial or ulnar nerve
palsy
• • Constant pressure on the calves causes venous stasis, causing
thrombosis, which can lead to pulmonary embolisms.
• Precautions to prevent injury
• • Head should not hyperextended
• • Make sure that arms did not abduct <90°
• • Ensure the arm board is pad well
• • Hand in the prone position
• Do not overlap arms or hang over the table edge
• Safeguard the patient from mental contact
• • Safeguard the occiput, scapulae, thoracic vertebrae, and olecranon
boney prominences area
• Prone position
• It was lying with the abdomen on the table.
• Arms keep overhead. It has positioned pillows below the shoulders, hips,
and feet. It is the appropriate position for the posterior back, the cervical
spine, the back, the rectal area, and the dorsal extremities
• Possible complications
• • Pain lower neck and upper back due to hyperextension of the head
• Arm restrainers cause radial and ulnar nerve palsy
• • Hypotension is caused due to pressure on the inferior vena cava and the
pooling of blood in the lower limbs
• • Shoulder dislocation throughout arm positioning
• • Brachial plexus injury due to over-extension of arm <90°
• Precaution of potential injury
• • Place a pillow or towel under the shoulders and hip to help chest
expansion and decrease abdominal pressure and venous oozing at
the operation site.
• Do not hyperextended head; place on the side and keep supported.
• Pressure point should be a safeguard with pad (cheek, ear, acromion
process, beast, genitalia, patella, dorsum of feet, toes).
• Trendelenburg position
• The patient is lying in a supine position with knees over the lower
break of the table. Head tilted down to 15° or as per the surgeon's
preferences. Arm kept on the chest or arm board. It is an appropriate
position for laparoscopic surgeries in the pelvic or lower abdominal
region. Using shoulder or knee supports may assist the patient from
sliding
• Possible complications
• • A 30° Trendelenburg position may reason for changes in blood pressure, cerebral
edema, congestion of face and neck
• • A too-steep position may cause cyanosis due to changes on diaphragmatic extension
and lung expansion
• • Shearing of skin may happen during positioning
• Precautions to prevent injury
• • Do not hyperextended head and arm not abducted more than 90°
• • Padded arm board may be used to keep hands supinated
• Arms do not overlap or hang over at the table edge
• Patient is safeguarded from metal contact
• Safeguard bony prominences occiput, scapulae, thoracic vertebrae, olecranon, sacrum
and coccyx and calcaneus
• Reverse Trendelenburg position
• Place the patient supine with arms by sides or on the arm board. The
table tilted to 5 to 10°.
• The head will be lower than the heart level—a sandbag used below
the neck and the shoulder blade for neck extension (russ technique).
The head rings are used to support the head. It is an appropriate
position for head and neck surgery.
• Take care to reduce venous congestion and to prevent stomach
regurgitation during induction of anesthesia
• Possible complications
• • Back pain due to unsupported lumbosacral curvature
• • Loss on sensation in arm and hand due to over abduction of arm
• • Arm/elbow hanging or constricted strapping cause radial or ulnar nerve palsy
• • Pulmonary embolisms is an outcome of venous stasis
• • Cardiovascular overloaded due to quick return
• • Skin cut off due to sliding down Precautions to prevent injury
• • Do not hyperextended head and arm not abducted more than 90°
• Padded arm board may be used to keep hands are supinated
• • Arms not overlap or hang over at the table edge
• • Patient is safeguard from metal contact
• • Foot bracket may use to prevent sliding
• Stop blood pooling by apply anti-embolic stocking
• • Safeguard boney prominences occiput, scapulae, thoracic vertebrae, olecranon, sacrum and coccyx and calcaneus
• •
• Lithotomy position
• Lies in a supine position with buttocks at the lower break of the table.
Lithotomy stirrups placed in a position level with the patient's ischial
spine. Arms kept over the chest or on an arm board. Legs raise
upwards and outwards, and feet keep in knee crutch or candy cane.
This position is appropriate for urology, gynecology, perineal or rectal
operations.
• Severe back pain due to too high straps
• • Calf hold may be caused by peroneal or femoral obturator nerve injury
• • Osteoarthritis or stiff hips caused by rough management
• • Too rapid of let down the legs may reason for hypotension
• • Femoral nerve injury due to excessively flexed thighs
• • Hip dislocation or fractures as an outcome of faulty stirrups
• Nursing precautions
• • Both legs should be elevated at the same time by two people grasping the sole and the other hand
supporting the calf
• • Stirrup bars must be checked and protected before use, and their height must be similar and not suspend
the patient's weight
• • The buttock must be even with the edge of the bed to prevent lumbosacral strain
• • Stop blood pooling by applying anti-embolic stocking
• • Safeguard boney prominences
Lateral or kidney position
• It was lying with one side facing the operative side uppermost. The
legs flexed to 90°, and keep a pillow in the middle of the legs. The
upper arm rested on the raised armrest, and the other flexed on the
table or board. Roll bags are used below the hip/kidney to increase
the exposure of the iliac region —the position maintained by using
sandbags or braces attached to the side of the bed. Head supported
on a pillow. It is an appropriate position for kidney-related surgery
Neurosurgical position
She was lying in a supine position, prone or
lateral-the head placed on the soft ring or a
spiked headrest. The head of the table can be
tilted slightly to help with venous drainage and
decrease CS pressure in the brain
Fracture table position
• The patient is supine, with the pelvis stabilized against the well-
padded vertical perineal post.
• Traction of the operative leg is attained either by a boot-shaped cuff
or devices with limiting straps. The unaffected leg is placed on a well-
padded, raised leg holder —an appropriate position for closed
femoral nailing
Knee-chest position

They are lying in the prone position. Both legs

are abducted and flexed together at right angles.
Knees flexed and hip raised. Head, shoulders, and
chest rest straight on the table. Arms kept above
the head. It is an appropriate position for
sigmoidoscopies and laminectomy procedures
Jack knife position
• The patient's hips are supported on a pillow, and the table is flexed at
a 90° angle, elevating the hips and letting down the head and body. A
straps used over the thigh to avoid shearing and sliding. Soft pads or
rolls support the head, face, shoulders, chest, and feet to avoid bony
pressure—an appropriate position for hemorrhoidectomy or pilonidal
sinus procedures
Trendelenburg (head lowered, feet elevated)
Reverse
Trendelenburg (head lowered, feet elevated
• Used to reduce risk of shock
• • Improves access to pelvis as bowel moves proximally

• Can be used to prevent or relieve patient choking

• • Reduces venous oozing during head and neck surgery
Lateral tilt

Allows surgeons better access to anatomy

• Used in obstetrics to prevent the baby
from pressing on the mother's abdomen,
causing her to faint
Lithotomy

• Obstetrics
• Gynecological surgery
• Perineal surgery
• Urology
Flexion & Extension

• • Flexion and extension can be of individual

segments
• Back surgery
• Kidney surgery
• Gallbladder surgery
• Abdominal surgery
Draping
• In an Operating Theatre (OT), draping is the critical process of
covering a patient and surrounding areas with sterile cloths (drapes)
to create a clean, barrier-focused sterile field around the surgical site,
preventing microorganisms from entering the wound and causing
infection. This involves using specialized drapes (like incise, adhesive,
or towel drapes) to isolate the surgical area from non-sterile parts of
the body, equipment, and the environment, ensuring patient safety
and successful surgery.
Purpose of Draping

• Prevent Infection: Creates a barrier against bacteria and

contaminants.
• Establish Sterile Field: Defines the clean area where only sterile
instruments and personnel can touch.
• Isolate Non-Sterile Areas: Protects unprepared skin and equipment
from contamination
Towels draping
laparotomy sheet
• A laparotomy sheet (or drape) is a large, sterile sheet used in
abdominal surgery to cover the patient and create a sterile field,
often featuring a central opening (fenestration) for the incision site,
isolating it from non-sterile areas to prevent infection and maintain
hygiene, warmth, and privacy during the procedure. Made from
absorbent, fluid-repellent non-woven fabric, these disposable drapes
provide a critical barrier for abdominal operations like C-sections or
hernia repairs, ensuring a clean environment for surgeons.
A stockinette drape
• A stockinette drape is a flexible, tubular fabric, often cotton or a
synthetic blend, used in surgery and orthopedics as a sterile barrier to
cover limbs, collect fluids, and provide a smooth layer under casts or
bandages, preventing skin irritation and maintaining sterility during
procedures like orthopedic surgery. They come in sterile or non-sterile
forms, with some featuring impervious (fluid-blocking) outer layers
for enhanced protection and non-slip grips for better handling.
Ortho pack sheet drapes (orthopedic
drape kits) are specialized, sterile, single-
use fabrics used to cover patients during
orthopedic surgeries, such as hip or
knee replacements. They are designed
to create a microbial barrier, keeping the
patient sterile and protecting healthcare
professionals from blood and fluid
exposure
Principles of Draping

• Isolate: Isolation is accomplished using a drape, usually fabricated from

plastic.
• Barrier: Arrange for a resistant layer.
• Sterile field: Permanent establishment of a sterile arena by sterile
arrangement of the drape and aseptic application method. If the drape used
is not resistant, adding an extra water-resistant layer may be required.
• Sterile surface: If essential, spread over an incise drape to create a sterile
surface. An incise drape can generate a sterile surface since skin cannot be
sterilized.
• Equipment cover: Sterile drapes protection non-sterile equipment recycled
on the sterile field. These aid in safeguarding the patient from the
equipment.
Surgical Drape Characteristics

• Scrape resistance: The material surface should be kept from

roughened during regular use in wet and dry conditions.
• Obstacle properties: It should not permitted for fluid/ water and
infections to enter inside.
• Biocompatibility: It should be without toxic elements.
• Traceability: The capability of a material to adapt to the nature of the
article above which it is placed.
• Electrostatic properties: In a surgical drape, the facility of the material
to accept an electrical change is desirable.
• Non-flammability: The materials should not support open fire.
• Tensile strength: Drape materials should be tough enough to bear the
pressures come across during typical use when wet or dry.
Procedure

• • Take out the outer covering of the draping pack done by an

unscrubbed surgical assistant.
• • Smoothly pull each layer of covering away from the center of the
Preserve hands from touching the inner cover of the sterile pack.
• • Exposed the inner covering of the sterile draping done by a
scrubbed surgical assistant.
• • Take away the fan-folded draping sheets one at a time.
• • Grip the sheets high above the waist to avoid contamination.
• • Place the folded edge of a sterile draping sheet near the incision site
to expose it for surgery done by the scrubbed assistant or a surgeon.
• • Place another sheet on the reverse side, in the same manner to
further outline the incision site.
• • Remain draping with further sterile sheet to shield the whole
surgical zone and safe with surgical clips.
Warnings during Draping of Patient

• Surgical site should be cleaned before draping.

• Scrubbed personnel should be stay in the sterile zone to avoid
contamination.
• In certain operating rooms, draping is done by surgical assistants and
surgeons, together or separately.
• Contaminated draping sheets should be disposed in appropriate bio-
hazard bags.
• Damaged draping always deliberated contaminated; interchange with
a new sterile sheet.
• • Do not try to reposition wrongly positioned drapes.
• Consider it contaminated, and interchange with new sterile sheet.
• • Sterile draping should be opened on a surgical stand or with a
surgical assistant holding the pack in a sterile fields.
Equipment required in OT.

• Anesthesia machine • Laryngoscope

• Stethoscope • Spinal set
• Air condition unit • OR light
• Suction • BP apparatus adult
• OR table
• • Instrument table • BP apparatus pediatric
• • Wheeled stretcher • Suction apparatus
• • Laparotomy set
• • Oxygen unit
DISINFECTION AND STERILIZATION OF
EQUIPMENT
Standard Terms used in Disinfection and Sterilization
• Disinfection: It deactivates the microorganism or infectious agents by
cleaning with an appropriate concentrated disinfectant solution to
prevent infection.
• Antiseptic: It is an element that consists of antimicrobial action. It is
securely smeared to living tissues.
• Bacteriostatic: It is the agent used to stop bacterial growth and to
maintain a clean field. At the same time, it does not kill bacteria.
• Bioburden: The equipment or instrument or any material polluted
with the different types and numbers of possible organisms.
• Chemical indicator: It is chemical contains tool like tape or peel packs
used to monitor sterilization process.
It is designed to react with a specific chemical change to one or more
sterilization cycle parameters.
• Chemo sterilizers kill entire microbiological life, including spores, by
chemical to maintain the sterile field
• Biological indicator: It is a spores contain tool used to test the quality
of sterilization process in OT. It contains a standardized feasible
population of microorganisms of significant resistance to the mode of
sterilization being monitored.
• Decontamination: The sterile instrument handle without proper
protective attire by the healthcare professional. The instrument is
highly possible to contaminate by microorganism during that time.
• Primary Care of Operation Theater and Equipment
• • Significantly decrease in microbial counts.
• • Avoid unnecessary excessive chemical use to clean the floors.
• • Always make sure the floor is clean and dry.
• • Clean operation tables and theater equipment with disinfectant solution
with detergent.
• • Ensure clean the spillage of blood or body fluids by bleaching
powder/chlorine solution (10% available chlorine).
• • Biomedical waste should be disposed of in appropriate waste bags.
• • Never gather biohazard waste in the OT, disposed of whenever possible
as per routine norms.
• • Never dispose of soiled gowns into OT.
• • Remember that only 1% of the microbes present on the floors are
pathogenic.
• • Decontaminate the floor with the vacuum cleaner and wet cleaning
techniques.
• • Keep the mops washed and dry in sunlight when not in use.
• • Simple soap/detergent decreases flora by 80%.
• • Disinfectant lessens flora up to 95%.
• • Always soak needles and instruments in chemical disinfectant for 30
minutes before cleaning
• • Contaminated instruments should kept in a separate disinfectant basin or
any container before being washed and sterilized.
• • Disinfection declines an instrument's viral and bacterial burden but
does not remove debris from the instrument or confer sterility.
• • Always wear thick gloves when cleaning the sharp instruments to
avoid injury.
• • Maximum widely used bleach (sodium hypochlorite solution)
because it is more effective in antiviral disinfectant solution.
General Cleaning

• • Cleaning with detergents and washing with water.

• • Daily washing of walls and ceiling
• • Closed cabinets clean weekly.
• • All furniture, lights, and equipment in OT should be cleaned with Lysol at the
end of the day
• • Weekly steamed lights and other equipment.
• • Clean the floors with warm water and detergent and dry them. It does not
require disinfectant.
• • All furniture, such as OT tables, chairs, monitors, and other non-clinical
equipment, must be wiped to remove all visible dirt and left to dry.
• • OTs all areas should be cleaned with warm water and detergent and dried
weekly.
Level of Disinfection

• • High level: Destroys all the microorganisms excluding spores, prions,

e.g., glutaraldehyde.
• • Intermediate: Destroys mycobacteria, maximum viruses, and
bacteria.
• • Low: Destroys some viruses and bacteria.
• Formaldehyde Fumigation
• Formaldehyde fumigation usually is used to sterilize the
• OT. It is requisite for an area of 1000 cubic feet, 500 mL of 40%
formaldehyde in one liter of water, stove, or hot plate for heating
formalin, and 300 mL of 10% ammonia.
• Formaldehyde deactivates microorganisms by alkylating the amino
acid and sulfhydryl groups of proteins and ring nitrogen atoms of
purine bases. Duration of formaldehyde fumigation, in case of any
construction in OT, 48 hours; in case of inflected cases, 24 hours; for
routine clean cases, 12 hours
• . Then again, 250 mL of formalin and 3000 mL of tap water are put
into a machine (auto mist), and time is set for 2 hours. The mist
circulates for 2 hours inside the closed room.

• Decontamination of Equipment, Instruments and Other Reusable

Items
• • All soiled and blood-strained items should be immersed in 0.5%
chlorine solution for 10 minutes immediately after use, then brushed
vigorously and washed with lukewarm water and detergent to
remove all blood tissue immediately.
• • Cleaning instruments with ultrasonic cleaners are used for cleaning
micro-surgical instruments.
• High-level Disinfectants
• • Chlorine solutions are fast-acting, very effective against HBV, HCV
and HIV/AIDS, inexpensive and readily available.
• Formaldehyde (8%) is a low-cost, active, high-level sterilizer and is
freely available. Its adverse effects are that vapors are very irritating
and possible carcinogens.
• Never dilute with chlorinated water because it produces a dangerous
gas (bis-chloromethyl-ether).
• • Glutaraldehyde is appropriate for disinfecting sharp cutting
instruments, plastic and rubber items, and endoscopes. It is an active
agent against vegetative pathogens in 15 minutes and resistant to
pathogenic spores in three hours. It is highly effective against
bacteria, fungi, and various viruses. Carefully read and follow the
manufacturer's instructions for use.
• • Hydrogen peroxide (H,) is available cheaply and diluted to a 6%
solution. The 3% H,, solutions have been used as antiseptics. The
major disadvantage is that it is highly corrosive.
• • Autoclaving or steam sterilization: All items should be cleaned
thoroughly before packing for autoclave.
• It destroyed all viruses, including HIV for 20 minutes at 121-132°C
autoclave, or if the instruments were in wrapped packs, required 30
minutes. Autoclaving is depending on the use of steam above 100°C.
They recommended temperatures ranging from 121-134°C at
pressures of 15 to 30 psi (Pounds per square inch). Its steam freely
enters all covered materials and destroys all viruses, bacteria, and the
most resistant spores. At the end of the procedure, the outsides of
the instrument packs should not have wet spots, which may indicate
that sterilization has not happened.
• Chemical sterilization or gas: Ethylene oxide (ETO) is commonly used
for re-sterilizing sensitive items like sharp knives, blades, heat-labile
tubes, vitrectomy cutters, cryoprobes, light pipes, laser probes,
diathermy leads, cannulated instruments like endoscopes, etc., and
also non-corrosive and safe for most plastic and polyethylene
materials.
Sterilization Approaches for Articles

• Linen items gowns, caps, masks, drapes - autoclaving.

• Glassware items, syringes - dry heat sterilization, or use disposables from
reputed firms.
• Metal instruments sterilized by autoclaving.
• Plastic instruments sterilized by ethylene oxide sterilization, formalin
chamber.
• An ethylene oxide hot air oven or chemical disinfection sterilizes sharp-
edge instruments.
• Sutures sterilized by autoclaving.
• Diathermy, cautery electrodes by autoclaving.
Microbiological Monitoring
Swabs should be collected from various places, such as:
1. Operation table at the head end, 2. Over headlamp,
3. Four Walls, 4. The floor below the head end of the table,
5. Instrument trolley, 6. AC duct, and 7. The microscope is handled
every two weeks in the OT every two weeks and is cultured on blood
agar.
Air Quality Monitoring
• Settle plate method: Blood agar and Sabourauds dextrose agar (SDA)
are traced, and the lid is kept open for 30 min. Colony counts of
bacteria and fungi are testified.
• Slit sampler method (from given volume): It is effective and
susceptible. A certain amount of air has sucked and count the bacterial
count. If bacterial colony count of more than 10 per plate and fungal
colony of more than one per plate are considered unacceptable
OT ATTIRE

• Each item of OT attire explicitly protects the patient from contamination

and risk of infection. OT attire includes body cover, surgical mask, head
cover, gown, gloves, eye protection, shoes, and shoe covers. Personal
protective equipment (PPE) such as eyewear and other protective items
are worn by personnel as suitable for predictable exposure to blood and
body fluids.
• OT attire (Operating Theatre or Operating Room attire) refers
to specialized, clean, or sterile clothing worn by medical professionals,
including surgeons and nurses, to minimize the risk of infection by acting as
a barrier against bacteria, microorganisms, and bodily fluids. It typically
includes scrub suits, masks, hair covers, shoe covers, and sometimes
protective eyewear.
Principles of OT Attire

Surgical Attire
• Scrub suits
• Cap/hoods
• Shoe covers
• Masks
• Gloves
• Gowns
Principles of use Attire

• All healthcare providers must change to OT attire during

OT duty hours
• Always sensible of the dress wear policy
• If any staining happened in OT attire, OT staff need to change the
attire
• OT staff should not go out of the OT after wearing OT attire
• Concentrations on retaining asepsis
• Protective eyeglasses should be worn when essential
How to don a gown?
• Choice of suitable type and size
• Opening is in the back
• Secure at neck and waist
• If the gown is too small, use two
gowns
• Ties the gown in front first, then
ties in back
How to don a mask?
• Position on nose, mouth, and
chin
• Proper fix the nose piece on
the nose bridge
• Secure on the head with ties
or elastic
• Adjust to fit
How to don a particulate respirator
• Choice a fit-tested respirator
• Position on nose, mouth, and chin
• Properly fix the nose piece on the nose
bridge
• Secure on the head with elastic
• Adjust to fit
• Carry out a fit check:
- Inhale—respirator should collapse
- Exhale-check for leakage around the
face
How to don eye and face protection?

• Place goggles on the eyes and

secure them to the head using the
earpieces or headband
• Place a face shield on the face
and secure it on the brow with a
headband
• Correct to fit securely
Head cap
• Wear a clean head cover daily;
most hospitals use disposable hoods
and caps. Wear it in a manner to
cover the hair fully
• To avoid contamination of the
sterile field by falling hair or dandruff
Shoe cover
• Worn shoe covers in semi-
restricted and restricted areas
• by the OT staff
• Remove the shoe covers when
they become soiled or wet, and
they must be removed when one
leaves the surgical suite
How to don gloves?
Don gloves last
• Choice of appropriate type
and size
• Insert hands into gloves
• Extend gloves over
isolation gown cuffs
How to Safely use PPE?

• • Always gloved hands should be kept away from the face

• • Never touching or altering other PPE
• • If gloves are torn, remove gloves and do hand hygiene before
donning new gloves
• • Restrict to touch surfaces and items
"Contaminated" and "Clean" Areas of PPE

• • Contaminated - outside front

• • PPE outside areas are in contact with body sites, materials, or
environmental surfaces where the infectious organism may exist.
• • Clean - inside, outside back, ties on head and back
• • PPE outside areas are in contact with body sites, materials, or
environmental surfaces where the infectious organism may exist.
Sequence for Removing PPE

• • Gloves
• • Face shield or goggles
• • Gown
• • Mask or respirator
• Where to Remove PPE
• • At the doorway, before leaving the patient room or in
• the anteroom
• • Take out the respirator outside the room after the door has been
closed
• • Safeguard that hand hygiene amenities are accessible at the point
needed, e.g., sink or alcohol-based hand rub
After Removing used Attire.

• Carry out hand hygiene instantly after the removal of PPE.

• • If hands become visibly unclean during PPE removal, wash hands
before ongoing removal PPE
• • Wash hands with soap and water or use an alcohol-based hand rub
• • Ensure hand hygiene amenities are available at the point needed,
e.g., sink or alcohol-based hand rub.
MONITORING THE PATIENT DURING THE
PROCEDURES
• Purposes of Monitoring the Patient during the Surgical Procedure
• • To maintain the typical patient's physiology and homeostasis throughout
anesthesia and surgery.
• • To assess the drugs used for anesthesia reason for any hemodynamic
uncertainty, myocardial depression, hypotension, and arrhythmias.
• • To check if the patient falls into hypo or hyperventilated and develops
hypothermia due to general anesthesia
• • To identify the risk for blood loss lead anemia hypotension and arrange
for the need for blood transfusion.
• Basic Monitors to Start Surgery
There are four essential monitors to start surgery
without these monitors, surgery should not start
surgery.
• 1. ECG
• 2. SpO, arterial O, saturation
• 3. Blood pressure (non-invasive and invasive)
• 4. Capnography
• ECG
• • Check the heart rate, rhythm, ischemic changes, and ST segment analysis.
It monitors throughout surgery, from induction to extubation and recovery.
• • Ensure good contact with the patient skin non-hairy areas, apply gel
adequately, and avoid slipped or loose electrodes.
• • Make sure to fix the cable connection.
• • Make sure to fix the cable to the monitor.
• Sp02
• • It should be monitored during the surgery before induction till after
extubating and recovery.
• • It offered arterial O, saturation-patient oxygenation, heart rate, and
peripheral perfusion status.
• It should be removed last from the patient just before shifting the
patient outside the OT to the recovery room.
• Spo, monitoring should be continuous in the recovery
• room.
• SpO, in average person on room air (0,= 21%) >96%;
• patient under GA (100%)2) = 98-100%.
• • It is unaccepted for O, saturation to be below 96% with 100% O, under GA. <90% show
hypoxemia and <85g) shows severe hypoxemia.
• • Check the improper placement of the pulse oximeter on the patient's finger or slip.
• • Check the patient's movement and shivering.
• • Deprived tissue perfusion results from cold extremities.
• • Warm the patient by keeping a warm, water-filled glove in the patient hand to avoid
hypothermia.
• • Keep the sound of the pulse oximeter on at all times.
• • Human clinical judgment is much superior to the monitor. Observe the patient
constantly, even the patient under monitor.
• • Check the patient's lip and nail color.
Blood Pressure

• • Check throughout surgery to avoid hypo and hypertension.

• • Avoid MAP below 60 mm Hg (to avoid decreased cerebral and renal
perfusion).
• • Avoid diastolic pressure below 50 mm Hg (to avoid coronary perfusion).
• • Check the BP every five minutes and every three minutes instantly after
spinal anesthesia, in conditions of hemo-dynamic uncertainty, during
hypotension anesthesia.
• • Each 10 minutes, e.g., the patient is under local anesthesia.
• • Check that the BP line is fixed correctly and that the BP apparatus works
appropriately.
• • Check any outflow from the damaged cuff.
Capnography.

• • It is used for continuous capnography (CO,) measurement displayed

as a waveform sampled from the patient's airway during ventilation.
• EtCO, is a point on the program. It is the final measurement at the
endpoint of the patient's expiration before inspiration begins again. It
is usually the highest COz measurement during ventilation.
• • Its standard range is 30-35 mm Hg. Commonly lower than arterial
PaCO partial pressure of carbon dioxide in arterial blood), by 5-6 mm
Hg due to dilution by dead space ventilation. It assists in detecting
pulmonary perfusion changes like pulmonary embolism and ETT
misplaced in the esophageal during intubation, disconnection of tube,
kink or leakage, or obstruction of tube.
Patient's System Monitoring

• ETT positioning
• Respiratory system
• CVS and hemodynamic monitoring
• Level of consciousness
• Temperature
• Monitoring after extubating and recovery
Correct Position of ETT
• Once intubation, auscultation must be done in the right and left
infraclavicular, right and left axillary, and epigastrium.
• The anesthetist must continuously auscultate the chest after
intubation for equal air entry and any adventitious sounds like
wheezes, crepitation, and pulmonary edema.
• The anesthetist must always auscultate the chest again after moving
to confirm if there is any disposition of ETT and avoid lip page and
accidental extubation.
Respiratory Monitoring
• Color of the nails, lips, palms, conjunctiva.
• Chest movement of the chest is normal or abnormal.
• If the filter is used, ETT vapors are absent in ventilators with
humidifiers.
• Check airway pressure
• Increased ETCO, Decreased ETCO2
Changes in CO, elimination
• Hyperventilation
Hypoventilation
• Rebreathing • Hypoperfusion
• Partial airway obstruction • Pulmonary embolism
• Laparoscopy → CO, absorption

Changes in CO, production

• Fever
• Thyroid storm • Hypothermia
• Malignant hyperthermia
CVS and Hemodynamic Monitoring

• Check the color of the lips, tongue, and nails. Pallor indicates anemia or
shock.
• Check a peripheral pulse every 10 minutes.
• Capillary refilling time: Refilling should happen within two seconds after
pressure release. It shows poor peripheral perfusion and circulation if it takes
more than five seconds.
• Monitor urine output: Normal urine output is 0.5 to 1 mL/kg/hr; the nurse
must continually observe the baseline urine volume when the catheter is
inserted at the start of surgery. Standard urine output indicates good
hydration and tissue perfusion. Loss of urine output indicates lengthy surgery
of more than 4 hours, major surgery with significant blood loss.
• Check that the IV line is unkinked or detached.
• Palpate the urinary bladder (suprapubic) fullness or ask the surgeon to
palpate it.
• Rise BP that is MAP more than 80 mm Hg show renal perfusion, IV fluid
challenge, and diuretics.
• • Sometimes, Trendelenburg's position (head down) causes reduced urine
output. Reversal of this position results in an immediate flow of urine.
• Monitor ECG to find the function of heat.
• Blood pressure to find out hypo or hypertension, renal perfusion, and
cardiac output.
• Central venous pressure is an indicator of IV volume and proper ventricular
function.
• CNS Monitoring
• • Check the signs of patient awareness, such as movement,
grimacing, facial expression, pupil dilatation, lacrimation, tachycardia,
and hypertension.
• • All the time, sweating is an alarming or warning sign.
• It is caused by awareness, hypoglycemia, hypercapnia, thyroid storm,
thyrotoxic crisis, and fever.
• Temperature Monitoring
• • Avoid hypothermia (less than 36°C) because hypothermia causes
cardiac arrhythmias like ventricular tachycardia, cardiac arrest,
myocardial depression, delayed recovery, late enzymatic drug
metabolism, metabolic acidosis like tissue hypoperfusion leading to
anaerobic glycolysis and lactic acidosis, hyperkalemia and
coagulopathy.
• • Prevent hypothermia by using warm IV fluids intermittently and
switching off air-conditioning, particularly near the end of the
surgery.
Monitoring after Extubation and Recovery

• • Fix the face mask on the patient with a slight chin lift instantly after
extubation.
• • Check that the breathing bag is even breathing with sufficient tidal
volume transmitted to the bag.
• • No transmission to the bag shows respiratory obstruction or apnea.
Try to wake the patient with a painful stimulus or jaw thrust in this
situation.
• • Blood pressure within 20% of baseline.
• • Spo, should be more than 92%, breathing regularly, adequate tidal
volume.
• • Muscle power should be a constant head elevation for five seconds,
good hand grip, and tongue protrusion.
• • Level of consciousness like obeying orders, eyes open, purposeful
movement.
• • The patient must be able to protect his or her airway.
Highlighted Important Points in Monitoring
the Patient in OT
• Typical target values for an adult under general anesthesia:
• - Heart rate: 60 to 90 (>90—tachycardia and <60-bradycardia)
• - Blood pressure: 90/60-140/90. MAP> 60 mm Hg (cerebral and renal
autoregulation)
• - Diastolic BP> 50 mm Hg (coronary perfusion pressure)
• - SpO: >96% on 100% 02
• - EtCO, = 30-35 mm Hg
• • Pay attention to the monitor the whole time.
• • Always keep the monitor's heart rate sound on; if the monitor fails,
the work nurse has to look at the monitor the whole time.
• • Check every five minutes to note the new BP reading.
• Suppose there are any changes in the tone of the pulse oximeter if
there is any irregularity in heart rate and during the use of diathermy.
MAINTENANCE OF THERAPEUTIC ENVIRONMENT
IN OT

• The therapeutic environment is the total of all peripheral

environments and influences disturbing an individualin the illness.
• Rules to Keep up the Therapeutic Environmentin OT
• • In OT, infection control and prevention are followed byan aseptic
technique to avoid surgical site contamination.
• • Always separate the surgical site from the neighboring unsterile
physical environment.
• • Produce and preserve a sterile field in the surgery site safely.
• Essential Components of the Therapeutic Environment
• • Provide suitable comfort, appropriate food, satisfied cleanliness,
and adequate rest
• • Without creating any injury
• • Tailored patient care
• • Approachable, polite, uncomplaining atmosphere
• • Sense of safety, security, and self-worth
• • Divisional activities for patient
Principles of the Therapeutic Environment in OT

• • Before starting the disinfection process, all dirty and organic material
should be removed from instruments and equipment through vacuuming,
dusting, and other general cleaning.
• Select an appropriate disinfection agent to clean; it should not damage the
surface and equipment.
• • Always follow the manufacturer's instructions to use the cleaning and
disinfection solution; based on the instructions should be used.
• • Cleaning and disinfection solutions should be prepared with the required
concentrations and allow adequate time to contact the equipment.
• • Try to use single-use disposal items whenever possible.
• • Kept the doors and windows closed as much as possible.
• Use a trolley to shift the patient into OT constantly.
• • Never allow the patients into the OT with pieces of jewelry. It should be
removed jewelry, and wear an OT gown, cap, mask, and footwear before
entering into OT.
• • Initially, the patient should be kept in a preoperative room and shifted
into OR.
• • The OT nurse should ensure consent has been obtained and confirm the
mentioned surgery site and side of surgery in the case sheet.
• • Always use separate theater shoes that all OT team members should
wear.
• • Always avoid needless movements, talking loudly, commenting, and
laughing.
• • OT dress should be ready for daily use after washing, ironing, and
cleaning.
• • Mobile phones should be switched off or in silent mode.
• • Do not allow the patient's relatives inside OT.
• • Senior nursing staff should be in charge of OT for all activities.
• • OT nurse and assistant should accompany the patient to the
postoperative nurse.
• • Confirm the anesthetist's fitness option before shifting the patient
from inside OT to outside the ot
Factors Affecting the Ideal OT Environment

• • Temperature
• • Moisture
• • Air movement/ventilation
• • Pureness of air
• • Comfortable and pleasant lighting without eye strain
• • Less noise
• • Psycho-social pressure-free atmosphere
Steps to Maintain the Therapeutic
Environment in OT
• • Appropriate preparation of patient
• • Suitable handwashing
• • Perfect surgical hand scrubs
• • Follow universal barrier techniques such as gloves and surgical attire
• Preserving a sterile field
• • Consuming standard surgical technique
• • Continuing a safe environment in the OR
Guideline to Maintain Sterile Fields in OT

• • In the sterile field, always keep sterile items only.

• • Sterile items are opened, dispensed, or transferred without soiling.
• • All the time, considering below the level of draped patient items to
be unsterile.
• • Never permitting sterile personnel to reach across or touch
unsterile areas or vice versa
• • The gown's neckline, shoulder, and back are considered unsterile.
• • The edges of a package containing a sterile item are considered
unsterile.
• • She never kept sterile items near open windows or doors.
• • Always use sterile drapes to create a sterile field.
• • Sterile items are only used within a sterile field.
• • The sterile field should be continuously monitored and sustained.
• • Avoid moisture in the sterile field. If a solution soaks through a
drape, it is covered with another sterile drape.
• • Keep readily available the aseptic technique protocol.
• It should be documented, appraised yearly, and readily available.
RESPONSIBILITIES OF NURSES IN MAJOR AND
MINOR SURGERY
• A scrub nurse belongs to a nursing professional; she/he will help the
surgeons perform surgery and other health care experts in the
operating room.
• Role of Scrub Nurse in OR
• • To arrange and drape sterile surgical fields, instruments, and
supplies.
• • To help surgeons throughout the surgical procedure by supplying
instruments.
• • To preserve the patient's well-being and safety through the surgery.
• Responsibilities of the Scrub Nurse in OT
• Receiving the patient to OT:

• - Introduce yourself and receive individual data, such as medical

history, drug allergies, name, age, etc., from the patient
• - Enquire if the patient requires any more support
• - Orientate the OT surrounding requirements to the patient like toilet,
changing room, etc.
• - Ensure the patient removed all her/his jewelry
Preoperative nursing assessment:

• - Age, any allergies, vital signs, co-morbidity illness

• - Medicine contraindicated like aspirin, heparin, and warfarin.
• - Dietary pattern
• - Physiological condition
• - Mental state
• - Acceptance of anesthesia
• - Personal habits like smoking, alcoholism
• Checklist before scrubbing:

• - Ensure consent has been obtained from the patient

• - Verify the surgical procedure name, side of surgery, site of the
surgery
• - Count instruments, cotton ball, gaze
• - Make sure the functional condition of the equipment and all
supplies
• Scrubbing to assist surgery and assembling
instruments, counting before surgery:
• - Scrubbing-the scrub nurse carries out hand and arm washing with
antibacterial soap and then wears a sterile mask, cap, gown, and
gloves to avoid contamination in her/his body while assisting in
surgery.
• - Always assemble the instruments on a mayo tray and trolley by
opening the inner sterile set.
• - Count the instrument, cotton balls, gaze, etc., whenever using for
surgery, gather the surgical blade, get ready for surgical suture.
Observe patient's safety:

• - Monitor the patient

• - Ensure the patient's safety
• End of procedure:
• - Before closing the surgical wound, complete a second surgical count
of sponges, sharps, instruments
• - Spread over dressing to the wound using non-touch methods and
help take out the drapes.
• - All sharps should be discord in appropriate ways
• - Always shield the soiled instruments before transporting them for
cleaning/autoclaving
• - Verify the documentation after removing the gown and glove
SUTURE

• Suture referred as any filament of material used to put tie the blood
vessels or tissues.

• Classification of Sutures
• • Absorbed/non-absorbable
• • Natural/synthetic
• • Braided/monofilament
Criteria for Selection of Suture

• • Preference or desired of the surgeon

• • Quickness of healing
• • Tissue infection
• • Price tag and readiness
• • Artistic concern
• • Tension desired in wound healing
Absorbed/non-absorbable

• Sutures are classified as absorbable (broken down by body

enzymes/hydrolysis over time, no removal needed) or non-
absorbable (remain permanently or require manual removal).
Absorbable options like Catgut, Vicryl, polyglycoil acid are used for
deep, fast-healing tissues, while non-absorbable materials like Nylon,
Silk, or Polypropylene are used for skin or high-stress, slow-healing
sites
1. Absorbable Sutures
These sutures lose most of their tensile strength within 60 days and
are absorbed by the body.
• Natural Absorbable: Catgut (Plain or Chromic), derived from
sheep/bovine intestines.
• Synthetic Absorbable: Polyglycolic acid (PGA), Polyglactin 910
(Vicryl), Polydioxanone (PDS), Polyglyconate.
• Common Usage: Deep tissues, subcutaneous layers, rapidly
healing tissues (e.g., mouth, gut), and when patient removal is
challenging.
2. Non-absorbable Sutures
These materials are not digested by the body and remain in the tissue
unless removed.
• Natural Non-absorbable: Silk, Cotton, Linen.
• Synthetic Non-absorbable: Polypropylene (Proline), Nylon,
Polyester, Polyethylene (UHMWPE).
• Metallic: Stainless steel wire.
• Common Usage: Skin closures (removed later), vascular grafts,
tendons, ligaments, and fascia, where long-term, high-strength
support is require
Anesthesia
• Anesthesia is a formally organized, short-term loss of sensation or
awareness created for medical purposes.
• It may contain several features of analgesia, paralysis, amnesia, and
unconsciousness. Anesthetized is a patient in the special effects of
anesthetic drugs. Surgery may be major or minor; however,
anesthesia is only significant.
• So, healthcare professionals take care of the patient carefully.
 Types of Anesthesia

• General anesthesia causes adjustable loss of sense with essential

features of the loss of consciousness, loss of sensation, sleep,
amnesia, skeletal muscle relaxation, potentially diminished ventilator,
immovability, and circulatory function, and exclusion of the somatic,
autonomic, and endocrine responses including coughing, gagging,
vomiting, and sympathetic nervous system responses-general
anesthesia administrator through intravenous, inhaled, or rectal.
• Local anesthesia is providing sensory blockade to a particular area.
Classification of Anesthesia

• • Inhalation gas: Nitrous oxide

• • Volatile liquid: Halothane, enflurane, isoflurane, desflurane,
sevoflurane.
• • Intravenous:
• - Inducing agents-thiopentone sodium, methohexi-tone, etomidate.
• - Slower acting drugs-benzodiazepines, diazepam, lorazepam,
midazolam.
Methods of Administering Local Anesthesia

• • Topical application: Aerosolized, nebulized.

• • Local infiltrations Lidocaine by spray; cream, or injection.
• • Regional injection: Peripheral nerve block, IV regional block sinal
anesthesia, and epidural anesthesia.
• • Endotracheal intubation: A tube is placed into the trach after
induction of anesthesia. After placing the Et rube, an amba bag is the,
and air is introduced; the chest must up sting and descent with the
instillation of air and must be able to listen to the breath sounds
Routes of anesthesia drugs administration.
• Anesthesia drugs administration

• Enteral administration
• • Oral
• • Rectal administration
• Parental administration
• • Sublingual
• • Intranasal
• • Intramuscular
• • Intravenous
I - stage of analgesia

• • Starts from the establishment of anesthetic breathing and carries on

up to the loss of awareness
• • Gradually eliminated pain, the patient will be conscious, able to
hear, see, and experience dream-like feelings, reflexes, and breathing
will be regular
• • It is tough to preserve for a lengthy period
• • It will be used for minor procedures only
Il - stage of delirium and excitement
• • This stage starts from loss of consciousness to the commencement
of automatic breathing
• • Absent the eyelash reflex
• • Patient may shout, skirmish, and hold his breath
• • Rises the muscle tone and forcefully closes jaws
• • In this stage, it is possible to have irregular breathing, vomiting,
spontaneous micturition or defection, and laryngospasm
• • In modern anesthesia, these potential problems will not be present
due to pre-anesthetic medication, rapid induction, etc.
Ill - stage of surgical anesthesia

• This stage start from beginning of natural respiration to respiratory

paralysis
• This has been divided into four phases:
• 1. Roving eye balls ends, and eyes become fixed
• 2. Loss of laryngeal and corneal reflexes
• 3. Pupil dilation starts and lost light reflex
• 4. Intercostal paralysis, shallow abdominal respiration, dilated pupil
IV - stage of medullary/ respiratory paralysis
• • Termination of breathing-miscarriage of circulation end result death
• • Extensively dilated pupils
• • Muscles are completely flabby
• • Unnoticeable pulse
• • Very low blood pressure
Regional Anesthesia

• • Drug administrate through spinal/epidural

• • This method is best choice when surgery carried o lower than
umbilicus
• • Delivers analgesia/muscle relaxation
• • Plexus blocks, e.g., brachial plexus
• • IV Bier's block.
Local Anesthesia Drug

• • Lignocaine-rapid/short acting
• • Bupivacaine/levobupivacaine-slow and long action
• • Amethocaine—topical
• • Prilocaine-intravenous
• Advantages
• It will be the substitute for general anesthesia and act in
• an effective way
• • Try to avoid polypharmacy
• • A smaller amount allergic reactions than the general anesthesia
• • Prolonged analgesia
• • The patient will be continue awake
• • The patient will be drunk and feed early
• Disadvantages
• • Restricted scope
• • Greater failure rate
• • Time constraints
• • Anticoagulants and bleeding diathesis
• • Risk of neural injury
• Factors to be Considered Selecting the Anesthesia
• • It depends up on the type of surgery and time duration of the
surgical procedure
• • It will be based on the patient's health status, physiological
parameters, mental health status, and comorbidity illness
• • Postoperative recovery from several types of anesthesia
• • Postoperative pain management
• • Surgeon's preference
• Intravenous Anesthesia
• • It is used only for the induction phase.
• • It helps with quick induction and is not used for maintenance
phases.
• • Complemented with analgesic and muscle relaxants.
• • IV inducing agents-Thiopentone, Methohexitone sodium, propool
and etomidate, Benzodiazepines (slow acting) Diazepam, Lorazepam,
Midazolam.
• Ketamine is dissociative anesthesia.
• • Neurolept analgesia - Fentanyl
Preanesthetic Medication

• It is drugs used before giving an anaesthetic agent to create

anaesthesia harmless and more efficiently, work in the patient.
Purposes of Preanesthetic Medication

• • Antiemitic effect
• • Decrease secrection
• • Relief of anxiety
• • Analgesia decrease acidity and volume gastric juice
• • Amnesia for pre and postoperative events
• Preanesthetic medications: Six "A"s used for preanesthetic condition
• 1. Anxiolytics-used for sedatives, e.g., diazepam or lorazepam,
midazolam, promethazine, etc.
• 2. Amnesia, e.g., lorazepam
• 3. Anticholinergics, e.g., atropine
• 4. Antacids (H, blockers), e.g., ranitidine, famotidine, etc.
• 5. Antiemetics, e.g., metoclopramide, domperidone, etc.
• 6. Analgesia (opioids), e.g., morphine
• Role of Anesthetic Nurse
• • Assesses the patient's risk of receiving anesthesia
• • Assesses the need for appropriate anesthetic during the surgical
procedures
• • Communicates equipment needs to anesthesia technicians or
circulator nurse
• • Knowledge of equipment used by anesthesiologists
• • Assists with setting up equipment, medications, and supplies and
cleaning up in assigned operating rooms.
• • May assist anesthesia provider during induction o anesthesia.
American Society of Anesthesiologists Physical
Status Classification
• • Category 1: Normal, healthy patient
• • Category 2: Patient with mild systemic disease
• • Category 3: Patient with severe systemic disease (e.g., hypertension,
diabetes)
• • Category 4: Patient with severe systemic disease that is life-
threatening
• • Category 5: Patient with high morbidity
• • Category 6: Patient with brain death
Features of Perfect Anesthetic Agents

• • It should be the quick onset of action.

• • It should be a manageable period of action.
• • It should be detectable levels of depth.
• • It should be theoretically easy to do administration.
• • There should be no unfortunate effects on the circulatory status.
• • It should not have a toxic metabolism effect.
• • It should be able to anticipate removal from the body.
• • It should be definite of action.
• • It should be high in the margin of protection and safety level.
• • It should be beneficial for all age groups of patient.
• • It should be less expensive.
• • It should be a speedy beginning.
Factors Influencing the Development of
Postoperative Problems
• • Intraoperative complications
• • Type of anesthetic technique
• • Patient comorbidities and pre-existing diseases
• • Preoperative condition of patient
• • Length and type of surgery
• • Urgency of surgery
• • Poorly controlled pain
• • Other medications administered intraoperatively
• • Changes in fluid status and electrolyte balance
• • Alterations in body temperature
• Complications during the Intraoperative Period
• • Anaphylaxis can be masked by anesthesia-look for hypotension,
tachycardia, bronchospasm, and pulmonary edema.
• • Hypothermia-due to more extended surgery of more than 12 hours.
Body temperature 34.5°C
• • Hypertension-increased body temperature 38°C or above. It is
happening due to inflammatory medications/ cytokines. It is released
in the postoperative period to increase healing.
LEGAL ASPECTS IN OT

• Appreciation for Autonomy

• • Obtained informed written permission from the patient for surgery
(consent)
• • Explain the reality of surgery (truth-telling)
• • Permission for the participation of trainees in the surgical procedure
• • Privacy and confidentiality
• • Valuing the patient's wish
• • Explain the surgical procedure in the patient's language with good
communication skills
• • OT healthcare professionals should respect the right of the
individual to self-determination
••⁠ Create a co-operative relationship
• • Respect the right to refuse by the patient
• • Preserve confidentiality and privacy
Beneficence

• • Surgical skill
• • Capability to implement wide-ranging decision
• • Constant professional progress
• • Research and innovation in surgery
• • Accountable conduct
• • Working equipment and optimal operating conditions
• • Reducing harm (including pain control)
• • Noble communication skills
• Non-maleficence
• • Surgical ability
• • Endless professional expansion
• • Fitness to exercise is a sound decision
• • Identifying the limit of professional proficiency
• • Research and auditing
• • Expose and talk about surgical complications, including errors
• • Good communication skills
Justice

• • Distribution of scarce resources

• • Legal problems
• • Valuing human rights
• • Whistleblowing
Common Types of Health Care Abuse

• • Overcharging for service supplies

• • Providing medically unnecessary services that do not meet
professional standards
• • Billing health care on a higher fee schedule than others
Common Types of Healthcare Fraud

• • Billing for services not furnished

• • Altering claim forms to receive a higher payment
• • Duplicate billing to beneficiaries, private insurers
• • Falsely representing the nature of services provided Soliciting,
offering, or receiving a kickback
• • Billing a person who has health care for services provided to
someone who does not have health care; using another person's
health care card for services; provider waivers of beneficiary payment
of deductible.
Malpractice

• • Unethical conduct or unreasonable lack of skill by a professional,

unskillful performance of duties when professional skills are
obligatory.
• • The patient has to show that the OT's action fell below the standard
of care and injured the patient, e.g., improper transfers; forgetting to
tell the nurse about a patient's complaint like chest pain or heart
attack; causing burn from hot/ice pack; sexual misconduct; improper
instruction of splint; failing to refer the patient to another therapist
more competent to treat the patient.
Preventing Malpractice

• • Chart clearly and consistently

• • Keep up to date
• • Use approved abbreviations only write legibly
• • Follow the communication system between providers to track sent
and received messages
• • Have good policies follow them; document decisions
• • Good customer service and communication
• • Engage in risk management