Peri-operative Equipment
Chapter 10
Thermoregulatory Devices
These are not in the book

 Hypothermia is a danger to the pt in the OR
 Rooms are kept cool:
 To inhibit bacterial growth
 OR lights are hot and the surgical team is covered from head to toe
 Decreased temperature can:
 Cause post operative wound complications
 Inhibit wound healing
Ways to Control Hypothermia
 The number one way to prevent hypothermia is to raise the room temperature
 Blankets heated in a warming unit
 Bair hugger blankets
 Upper body
 Lower body
 Hyper/hypothermia unit
 Toco lights
 (french fry lights)
Power Tools
Drills and Saws
 Drills and saws are used in orthopedic cases
 Drills are used to insert pins, screws and drill out the intramedullary canals of long bones to insert rods
 Saws are used to cut into bone
 Oscillating – side to side
 Reciprocating – forward and back
Old Hand Powered Tools

Types of Power Used Today
 Nitrogen
 Also called pneumatic
 Electric
 More common today
 Console units
 Plugged directly into the wall outlet
 Battery operated
 Special batteries are charged and then sterilized to be used in the sterile field



Important Notes On Power Tools
 Do not immerse power into water to clean
 Just wipe it and clean out lumens
 Always check to see if the equipment is working before the case begins
 You will have a chance to get another set or the materials manager will have to send off to another facility to get one
 If they cannot get one then the case may have to be cancelled

Laser
Light Amplification by the Stimulated Emission of Radiation

 Light composed of the same wavelength
 The light is collimated
 It does not spread out as they travel away from the source
 As the energy is absorbed into the tissue, heat is generated and the tissue is damage
 Allows for pinpoint precision

 Uses a separate light beam for aiming the laser
!!! Important !!!
 Protective eyewear should be used in all laser cases accept one
 There are different types of eyewear for each laser
 Be sure to choose the right ones or a beam that has been reflected can damage your eyesight
Types of Lasers
 CO2
 Most frequently used
 Uses CO2, helium, and nitrogen gases
 Can be used on light and dark pigmented tissues



 Argon
 There is an argon laser that is used specifically in surgery and it is not in your book
 It is used in conjunction with cautery
 You do not need eyewear for this laser

 Note: if using other argon lasers eyewear is needed

 KTP
 Potassium Titanyl Phosphate
 Uses either a handpiece or a fiber to deliver the energy pulse
 Produces a smaller beam than a CO2 laser
 Used on red or dark tissue such as hemoglobin or melanin


 YAG Lasers
 Nd:YAG or Ho:YAG
 Absorbed by water and hemoglobin
 Uses either a handpiece or fiber
 Fiber can be attached to an endoscope
Indications for Laser Surgery
 Endometriosis
 Varicose veins
 Hemangioma
 Port wine stains




Microscopes
 Used to magnify and light small surgical areas
 Most are draped for the procedure
 Attachments such as cameras and lasers can be attached


 Types of cases that they are used in:
 Ophthalmic
 Microvascular
 Neuro
 Gynecologic microsurgery
 Salpingoplasty
 Excision of condyloma




Draping a Microscope
 Step 1
 Unfold the drape on the sterile field and insert hands into the folds

 Step 2
 Holding drape so it does not drop below waist level, bring it to the microscope

 Step 3
 Slide the drape over the microscope, keeping your hands covered, and making sure that it is inside the drape

 Step 4
 Slide the drape over the headpiece and over the arm, again protecting your hands as you go

Loops
 Magnifying glasses used instead of a microscope
 Lower magnification than a microscope
 These are usually the property of the physician

Video Equipment
Laparoscopy, Arthroscopy

 All surgery that evolves scopes require video equipment
 A tower is used to put all of the equipment on
 All of the equipment is plugged into the tower and then the tower itself is plugged into an outlet
 This minimizes the need to utilize all of the plugs in the room
Basic Equipment
 Monitor
 To view the procedure

 Camera

 Light source
Laparoscopic Equipment
 Insufflator

Arthroscopic Equipment
 Pump

 Shaver
Headlight
 Used to produce a direct light into the incision
Cell Saver
 Used when doing a procedure that it is known that there will be a lot of blood loss
 A separate suction is used during the procedure
 Laps can be gently rinsed and the solution can be suctioned into the machine
 The blood cells are washed and separated and infused back into the pt

Surgical Pharmacology and Anesthesia
Chapter 9
Pharmacology
• Study of drugs and their actions
• Drugs are used for:
– Diagnosis
– Treatment
– Cure
– Prevention of a disease or a condition
Drug Sources
• Drugs derived from five sources:
– Plants
– Animals
– Minerals
– Laboratory
– Biotechnology
Drug Sources
• Drugs derived from five sources:
• Plants:
– In the past most drugs originated from them
– Some are still used today
– Ex.- morphine
• Animals:
– Primary hormones are derived from animal sources (including humans)
– Cows – bovine
– Pigs – porcine
– Ex. Heparin, thrombin, and some forms of estrogen
• Minerals:
– From earth, minerals and mineral salts
– Available in several drug forms
– Ex. Calcium, gold, iron, magnesium, silver, and zinc
• Laboratory Synthesis:
– Majority of the drugs manufactured in labs
– Accomplished in two methods
• Totally from lab chemicals
– Ex – demerol (Meperidine Sulfate)
• Semisynthetic Drugs
– Natural substances are altered
• Biotechnology:
– Known also as Recombinant DNA Technology
– DNA is artificially constructed by introducing foreign DNA into DNA of a specific organism’
• Cells reproduction occurs rapidly
• Provides large amounts
• ex – Hepatitis B vaccine
Key Words
• Pharmacodynamics: the interaction of drug molecules with the target cells.
• Pharmacokinetics: the entire process of the drug within the body. Involves absorption, distribution, biotransformation and excretion
• Pharmacokinetics:
– Absorption: Occurs at the site of administration; the substance is taken into the bloodstream by the capillaries
– Distribution: Is the transport of the drug that occurs once it enters the body. The substance is distributed to the target cells for action or to the liver for biotransformation
Biotransformation – Or metabolism, of the drug that occurs most often in the liver. Other tissue that can be included; intestinal mucosa, lungs, kidneys, and blood plasma.
Excretion – Drugs continue to be effective until the excreted from the body; Most often through the kidneys/urine, can also leave via sweat, feces, saliva, or even exhaled. Some can also leave through breast milk
• Indication: a reason to perform a specific procedure or prescribe a certain drug
• Contraindication: a reason why a specific procedure or drug may be undesirable or improper in a particular situation
Drug Nomenclature
• Three different names are assigned to each drug
Chemical Name
– The precise chemical composition and molecular structure of the drug – name of the drug is the chemical name and is difficult to use
– Example:
– 5-Thia-1-azabicyclo[4.2.0]oct-2-ene-2-carboxylic acid, 3-[[(5-methyl-1,3,4-thiadiazol-2-yl)thio]methyl]-8-oxo-7-[(1H-tetrazol-1-ylacetyl)amino]-, monosodium salt, (6R, 7R)-
Generic Name
– Generic name: nonproprietary name for a drug – shortened version of chemical name
– Example:
– Cefazolin
Trade or Brand Name
• drug named and copyrighted by manufacturer
– Brand name is capitalized and may be followed by the ® symbol
– Example:
– Kefzol®
Route of Administration
• Oral or enteral: by mouth
• Ingest: to swallow
• Buccal: medication placed between cheek and the teeth
• Sublingual: medication placed under the tongue
– Buccal and sublingual are also considered topical
• Topical: drug applied to the skin or mucous membrane
• Inhalation: direct administration via respiratory tract
• Parenteral: by injection
• Dermal: between the layers of the skin
• Subcutaneous (SC or SQ): under the skin into the adipose tissue layer
• Intramuscular (IM): within the muscle
• Intravenous (IV): into the vein
• Intra-articular: within the joint
• Intrathecal: into the subarachnoid space
• Intracardic: into the heart
The Five R’s of Drug Handling
• Right patient
• Right drug
• Right dose
• Right route of administration
• Right time and frequency
Drug Identification
on the Sterile Field
• Labeled immediately
• Never have a solution or medication on the sterile field without labeling it
• Know the policies and procedures of the facility
– Lack of this knowledge will get you into trouble
Transfer of a Medication to the Sterile Field
• Sterile technique must be used
• Circulator, STSR and surgeon usually involved
• Circulator will remove the top of the vial and dispense on to the field
• Circulator will clean the stopper of the vial, hold the vial upside down and STSR inserts a needle with syringe and withdraws the substance
• From an ampule:
– The circulator will clean the neck of the ampule, snap off the top and insert a needle with syringe and withdraw the medication and dispense it into a receptacle
– The circulator will clean the neck of the ampule, snap off the top and the STSR will insert a needle with syringe and withdraw the medication
Types of Medications
Located on the Sterile Field
• Saline/Water for irrigation
• Antibiotic solution for irrigation
• Local
• Heparin
• Radiographic dye
Balanced Anesthesia
• Hypnosis – results from an altered state of consciousness
• Anesthesia – provides freedom of pain via topical, local, regional and general agents
• Amnesia – Amnestic agents provide lack of recall
• Muscle relaxation – neuromuscular blocking agent providing muscle relaxation to the point of paralysis
Phases of General Anesthesia
• Induction
• Maintenance
• Emergence
• Recovery
Cricoid Pressure
• Sellick’s Maneuver – applying direct pressure to the cricoid cartilage causing blocking of the esophagus
• Helps prevent stomach contents from being expelled
• Pressure is not released until permission is given by the anesthesiologist
Laryngospasm and Bronchospasm
• Spasm or rigidity of upper respiratory tract
• Inability of patient to breathe
• Inability of anesthesia provider to move air and waste gases in and out of the lungs
Malignant Hyperthermia
• Potentially fatal
• Genetically transmitted
• Stop anesthetic gases
• Administer 100% 02
• Chilled IV fluids
• Chilled saline lavage of body cavities
• Dantrolene
Anesthetic Agents
• Inhalation agents:
– Oxygen
– Nitrous Oxide
– Waste gases
• Volatile Agents
– These are liquids that are evaporated and then given through inhalation
– Used for induction and maintenance of anesthesia
– Examples:
• Halothane (Fluothane)
• Enflurane (Ethrane)
• IV agents – provides direct delivery to the bloodstream
• Example:
– Propofol (Diprivan)
– Narcotics
– Opiates
Local/regional agents
• Render small areas or whole regions of the body numb
• Examples:
– Lidocaine
– Marcaine
Monitoring Devices
• Electrocardiogram
• Blood pressure monitor
• Temperature monitor
• Pulse oximeter
– This monitors the amount of oxygen in the blood
– Also called the SAO2


Types of Anesthesia
• Local
– Monitored anesthesia care (MAC)
• Regional
– Nerve plexus block
– Bier block
– Spinal block

PACU
• Post Anesthesia Care Unit
• Once the pt is stable the anesthesia provider and the circulator takes the pt to PACU for complete recovery
Things to Consider
• When the pt is being induced and as they wake up, the OR personnel must keep noise to a minimum
• At the end of the case work quickly, but gently, to apply dressings and cleaning the patient
• Stay sterile until the pt leaves the room
– Especially if the pt is not completely stable

Case Study
• Amber is a 23 yo female, and has been scheduled for an emergency laparoscopic appendectomy. She was admitted to the ER at 2:03 pm and the surgery is expected to be performed at about 4 pm. She states that she has increased her fluid intake the last 2 days due to the fever that she is experiencing and that she had creamy chicken noodle soup for lunch today. She was instructed by the ER staff shortly after her arrival not to eat or drink anything else and they started an IV.
• What type of anesthetic isAmber likely to receive? Why?
• Is Amber likely to receive any premedications? If so , what type and why?
• Amber’s NPO status is known. Are any special precautions necessary prior to her anesthetic?
• What type of medications may be ordered by the surgeon and used within the sterile field intraoperatively?

HEMOSTASIS
Control of Bleeding
History
• Middle Ages
– Gangrene thought to be natural result of wound
– Boiling oil and hot irons
• Ambroise Pare
– Ran short of oil; concocted mixture of egg yolk, oil of roses, turpentine. Observed soldiers had decreased pain and enhanced wound healing
– First to grasp blood vessels with clamp
– First to use ligatures to control bleeding
• End of 19th century anesthesia and asepsis made surgery a viable branch of medicine
• Control of blood loss still a problem
• 1818 first transfusion of blood
• 1886 blood transfused directly from surgical field into trauma patient by femoral injection
• 1901 blood types discovered
• World War I: Plasma first used
• 1936 First blood bank established

Clot Formation
• Injury (incision) occurs
– Blood rushes to the scene to clean out the wound
• Blood vessel constricts
• Platelets clump and adhere to connective tissue at cut end of blood vessels
• Interaction with connective tissue causes platelets to release adenosine diphosphate (ADP), epinephrine, and serotonin
– ADP: Nucleic acid
– Serotonin: Released from platelets; potent vasoconstrictor
• ADP causes other platelets to migrate to area and clump together forming a platelet plug; initial clot
• Reaction of plasma with connective tissue activates clotting factors causing further clotting reactions
• Prothrombin, normally present in blood, reacts with thromboplastin
• Prothrombin is a plasma protein precursor to thrombin
• Vitamin K is very important in formation of prothrombin
• Prothrombin, thromboplastin, and calcium combine to make the enzyme thrombin
• Thrombin causes fibrinogen to change to fibrin
• Fibrinogen: plasma protein
• Fibrin, a protein, is the basic structural material of blood clots and is responsible for semisolid character of the blood clot
• To end the clotting process, fibrin starts to be digested
• Products of fibrin digestion and antithrombins normally present in blood act as anticoagulants

Methods of Achieving Hemostasis
General Information
• 2 types of bleeding
– Gross bleeding: cut or penetrated vessels
– Oozing: denuded or cut surfaces
• Continuous loss of blood from oozing can become serious if uncontrolled
• Incomplete hemostasis can lead to a hematoma formation

Chemical Methods
• Absorbable gelatin (Gelfoam®)
– Powder or compressed-pad form
– Made from purified gelatin solution
– Available in sterile packaging in different sizes of pads
– When placed on area of capillary bleeding, fibrin deposited and the sponge swells
– Can absorb 45 times its own weight in blood
– Absorption takes place 20 to 40 days
– Before handed to surgeon, dipped in warm saline, press against side of basin to eliminate air and excess saline
– May be soaked in thrombin or epinephrine
– Powder form
• Mix with saline to make a paste
• Applied to cancellous bone to control bleeding or to denuded areas of skin or muscle
• Absorbable collagen (Collastat®)
– Hemostatic sponge
– Applied dry to oozing or bleeding site
– Collagen activates coagulation mechanism, especially aggregation of platelets
– Must be kept dry; applied with dry gloves or instruments; sticks to wet surfaces
– Use is contraindicated in presence of infection or areas where blood has pooled
• Microfibrillar collagen (Avitene®)
– Powder-like form
– Bovine source
– Applied dry
– Stimulates adhesion of platelets and deposit of fibrin
• Microfibrillar collagen (continued)
– Functions as hemostatic agent only when applied directly to source of bleeding
– Applied to oozing surfaces including bone and hard to reach areas of bleeding
– Immediate firm pressure applied to Avitene using a sponge
– Excess removed from around the sponge
– Absorbable
• Oxidized Cellulose (Oxycel®, Surgicel®)
– Pad form
– Sutured to, wrapped around, held firmly against bleeding site or laid on oozing surface
– Reacts with blood to quickly form a clot; it increases in size to form a gel and stops bleeding where other methods of control have failed
– Only small amount needed
• Oxidized cellulose (continued)
– Absorbable
– Not used on bone unless it is removed after hemostasis is attained as it interferes with bone growth
– Has some bactericidal properties, but does not serve as substitute for antimicrobial agents
• Oxytocin (Pitocin)
– Hormone produced by pituitary gland
– Prepared synthetically
– Used to induce labor
– Cause contraction of uterus after delivery of placenta
– Systemic agent used to control hemorrhage from uterus, rather than true hemostatic agent
• Epinephrine
– Hormone secreted by adrenal gland
– Prepared synthetically
– Vasoconstrictor used to prolong action of local anesthetic agent and decrease bleeding
– Rapidly dispersed; short duration of action
• Thrombin
– Enzyme extracted from bovine blood
– Accelerates coagulation of blood and controls capillary bleeding
– Unites rapidly with fibrinogen to from clot
– Powder, liquid
– Liquid form: spray, mixed with saline
– Do not allow to enter large vessels
– Topical use only; never injected
– Label on back table
– Mix just before use; loses potency after a few hours
– Do not use on patient allergic to bovine products
• Sclerotherapy
– Caustic sclerosing solution
– Injected into veins to stop or prevent bleeding

Mechanical Methods

External Methods
• Tourniquets
– Rubber band for digits
– Esmarch bandage
– Penrose drain
– Pneumatic tourniquet: single or double cuffed
– Pressure dressings
– Packing
Internal Methods
• Hemostat: Most commonly used method of hemostasis
• Ligating clips (Ligaclip®)
• Ligature or Tie
• Neurosurgical patties (cottonoids)
• Bone wax
Assistive Devices
• Suction
• Drains: Hemovac®, Jackson-Pratt®
– Aid in removal of blood, body fluids, and air to obliterate dead space, enhance healing of tissues, prevent hematoma formation and edema

Thermal Methods
• Hypothermia
– Decreases cellular metabolism thereby decreasing oxygen demand in the tissues
– Decreased need for oxygen decreases bleeding
– Methods of achieving hypothermia
• Hypothermia blanket
• Ice
• Cold solutions
• Electrocautery
• Hemostatic scalpel
– Steel blade seals blood vessels as it cuts through tissue
– #10 or #15 size blade
– Blade fits into reusable handle that contains controls
– STSR hands end of electrical cord to circulator to be plugged in to control unit
– When surgeon activates blade, blade transfers thermal energy to tissues as it cuts
– Can be used to incise skin, soft tissue, and muscle
– Electric current does not pass through tissue eliminating need for grounding pad

Blood Replacement
• Homologous – donated by another person
• Autologous – donated by the pt
• Blood types and groups
– A, B, O & AB
– Rh factors – antigenic substance found in the erythrocytes
• Rh positive
• Rh negative
– Hemoloysis – destruction of red blood cells due leading to anemia
• Handling of blood replacement components
– Obtained from blood bank
– Stored between 1 and 6 C
– Confirmation is done
• Autotransfusion
– Reinfusion of patient’s own blood during surgery
– Cell saver

Skin Prep
Purposes

• Remove soil, dirt, and debris
• Remove natural skin oils
• Remove residue from hand lotions
• Remove transient microbes from the skin
• Decrease the number of resident microbes on the skin
• Suppress the growth of microbes during the surgical procedure
• Reduce possibility of contamination of the surgical wound by skin flora
• Remember
– The skin prep is similar to the surgical scrub - using both mechanical and chemical action

General Information
• Hair follicles are a major source of microbes
– Hair follicles harbor microbes in large numbers
• Hair can interfere with wound exposure, closure, and application of the wound dressing
• Hair may prevent adequate contact of electrodes
– EKG
– Electrocautery grounding pad
• Hair that enters a surgical wound can introduce microbes associated with postoperative wound infection
• Hair removal can injure the skin if not performed properly
– Can be cause of greater problems than not removing the hair
– Breaks in the skin, first line of defense, can allow microbes to enter and cause infection
• Shave prep performed according to surgeon’s orders
• Avoid unnecessary exposure of the patient while performing the shave prep
• Shave prep may be performed in
– patient’s ward room
– preoperative holding area
– O.R.
– Some patients may be provided with information preoperatively that will allow the shave prep to be performed in the privacy of their home
Remember
NEVER shave the eyebrows unless specified in the surgeon’s order
– Scalp hair is saved in a bag to be given the patient/family postoperatively
• scalp hair is the property of the patient
• serious violation if lost
• patient may want to have a wig made out of their hair
– Example: neurosurgical procedure for which head is shaved








Electric Clippers
General Information
• Clippers cut hair close to the skin
• Motion of blade is oscillating
• Clipping can be performed immediately before the procedure or up to 24 hours preoperatively
• Cut against the direction of the hair growth
Procedure
• Be sure to lay blade flat against surface of skin
– Angling may cut or gouge the skin
• After use
– Disassemble
• Disposable blade is placed in the sharps container
• Reusable blade is sent to CSS to be cleaned and sterilized
– Wipe handle with disinfectant

Safety Razor
General Information
• Shave prep performed as close as possible to time of skin incision
• Using razor presents more risks than electric clipper
– Easier to make nicks and cuts in skin
– Most patients reminded not to perform shave prep at home with a razor
• Cuts that are not serious and nicks made immediately prior to the surgical incision are considered clean wounds
– Usually not cause for cancellation of procedure
– 30 minute leeway time
• Nicks and cuts that are older than 30 minutes considered contaminated
– Surgeon must be notified immediately
– Procedure may be cancelled
– Risk of SSI greatly increased

Commercial Shave prep Kits

Commercially available
• Contents may include
– 2 towels
– Foam sponges
– Plastic tray
– Safety razor

Procedure
• Place a towel in position to absorb fluid and contain loose hair
• Fill plastic container with warm water
• Wear non-sterile gloves
• Wet the sponge and create a lather
– Sponges may be impregnated with soap solution
• Apply soap to area to be shaved
– Do not perform a dry shave; increases risk of creating cuts and/or nicks
– Keratin absorbs water making hair softer and easier to remove
• Hold the skin taut between thumb and forefinger
• Shave in the direction of hair growth
• If necessary, use the moist sponge to collect loose hair
• Dispose of the razor in the sharps container
• Use second towel dry site
• Dispose of gloves
• If necessary, an adhesive, such as a strip of tape, may be used to remove loose hair from the shaved site and bedding
– Be sure patient is not allergic to tape
– Hair is removed from bedding so it is not transferred to the OR table when patient is transferred
Depilatory
General Information
• Hair removed by chemical means
• Can be used immediately prior to procedure or up to 24 hours preoperatively
• Skin patch test is generally performed to rule out allergy to the depilatory cream
• Do not use around eyes or genitalia
• Safest method for avoiding cuts and nicks
• Skin irritation: number one complication
Procedure
• Thick layer of cream is applied to site with provided applicator or sponge
• Cream remains on skin for approximately 20 minutes
• Cream is washed off with water and the hair is removed with the cream
• Condition of skin should be immediately observed and noted in patient’s chart

Prep Tray
• Assorted types of prep trays with different configurations are available commercially
• Commercial tray may include the following
– Wrapper that will be used to create the sterile field on the prep stand
– Two absorbant towels for blotting the prep solution
– Packets containing pre-measured prep solutions (scrub and paint)
– Two cotton tip applicators (to clean the umbilicus)
– Two to four foam sponges on a stick
– Four to six winged sponges
– Two absorbant towels with barrier to prevent pooling of solution under body parts or along side of patient
– Pair of sterile gloves
• Remember
– Verify patient’s allergy status prior to application of antiseptic prep solution
– Prep tray may be placed warmer to heat solutions (according to facility policy)
– Inform the awake patient that prep will begin and let them know that the solution may be cold
– Extra antiseptic solution(s) may be added to the tray if needed
– As a courtesy, if time permits, the STSR may organize the contents of the prep tray for the circulator

Antiseptic Solutions

Chlorhexidine Gluconate
• Popular commercial name is Hibiclens®
• Effective against gram positive and gram negative microbes
– Damages cell wall
• Rapid acting
– Produces immediate and effective reductions of transient and resident flora
• Long lasting effects
– Maintains reduction of microbes 4-5 hours
• Rarely irritating to skin
– Contraindicated for use on the face
• May cause corneal damage
• Few people allergic

Iodophor
• Iodine mixed with a detergent solution
– Referred to as Povidone-iodine solution
• Popular commercial name is Betadine®
• Effective against gram positive and gram negative microbes
• Some sporicidal activity
• Some residual effect
– Slowly releases iodine
• Higher incidence of persons allergic to solution due to iodine allergy
• Available as scrub and paint solution, and in spray or gel forms

Alcohol
• Ethyl or isopropyl alcohol
– Available 60% to 90% concentrations
– Most common is 70%
• No residual activity
• Denatures the protein to kill the cell
– Cannot be applied to mucous membranes or open wounds
• Nontoxic
• Dries the skin
• Flammable
– Must not be allowed to pool around or under patient
– Must be allowed to dry before draping to prevent build-up of fumes under the drapes if cautery or laser will be used

General Skin Prep Procedure

Procedure
• Position and expose patient
– Be sure edge of blanket and gown are folded back from site in a sufficient manner
• If surgery is unilateral, make sure you check patient chart to ensure correct side or extremity is prepped
• Check preoperative orders
– Surgeon may have written orders concerning the skin prep
• Note the condition of the patient’s skin
– Abnormal skin irritations, abrasions, bruises, or infection should be noted
– Document any conditions in the intraoperative record
– Notify the surgeon before beginning the prep
• Open the sterile prep tray
• Provide adequate lighting
• Don the sterile gloves using the open glove technique
• Organize contents of prep tray
– Open packets of scrub and paint solution
– If needed, have someone else pour additional amounts of solution into the tray
• Apply sterile barrier drapes
• Apply antiseptic solution
– Wing sponges are used to perform the scrub
– Wet the sponges with scrub solution
– Start at the center of the intended incision site
– Use a circular motion and work outward toward the periphery of the skin prep boundaries
– Apply enough pressure and friction to remove dirt, debris, and microbes
– After reaching the skin prep boundary, discard the sponge
– Repeat the scrub process for prescribed amount of time
• Remember
– Never bring a used sponge back to an area that has already been prepped
– Remember to separate the clean from the dirty areas
• Blot the area with an absorbant towel
– To remove the towel, grasp the opposite corners, lift and pull the towel towards self
• Do not “drag” over prepped area
– Repeat if necessary
• Apply “paint” solution
– Sponges on the stick are usually used for this step
– Wet the sponges with the paint solution
– Apply the paint in the same circular fashion as the scrub
• Begin at the intended incision site and work outward
• Remove the barrier drapes that were placed to absorb the runoff solutions
– Do not contaminate prepped area when removing drapes
– May be necessary to move to opposite side or OR table to remove

Important Notes
• Areas of the body suspected to have cancer cells, such as the breast, should not be scrubbed
– Only a gentle paint is applied
– Scrubbing can dislodge cancer cells which can then be picked up by the blood stream or lymph system for transportation to other parts of the body
• Scrub brushes with bristles should not be used
– Bristles can dislodge and fall into surgical wound
– Bristles are abrasive to the skin
• One-step prep kits are commercially available
– Combination scrub and paint solution is stored in the handle
– The end of the applicator is a foam sponge
– Pressing on the sponge releases the solution
– Same principle of using a circular motion applies

Contaminated Areas
Stoma
Stoma can be sealed off from surgical site using plastic towel drape
– If use of towel drape not possible use one of the following options
• Gently pack the opening of the stoma with an antiseptic soaked sponge while performing the skin prep
• Cover stoma with an antiseptic soaked sponge; prep the stoma last
• Each repeat of the scrub; use a separate sponge to gently scrub the stoma

Umbilicus
Options
– Prep abdomen to include umbilicus
– Clean umbilicus first
• Use Q-tips® to avoid runoff of dirty solution over clean area
• Umbilicus may be cleansed one last time at end of prep
– If dirt and debris are hardened, soften by squeezing antiseptic solution into the umbilicus
• Perform abdominal prep around the umbilicus
• Thoroughly cleanse umbilicus as last step with separate Q-tips®

Preparation for Skin Graft
Skin Graft
• Two prep sets are required
– One for the recipient site
– One for the donor site
• Donor site scrubbed first
– Site scrubbed with a colorless antiseptic solution such as Hibiclens®
• Surgeons view of graft not obscured
• Recipient Site
– Sponges used to prep recipient site must not come into contact with the donor site
– Excess solution (runoff) from the recipient site must not come into contact with the donor site

Eye Prep
• Remember
– NEVER shave the eyebrows
– Surgeon may order eyelashes to be trimmed
– Do not use chlorhexidine gluconate (Hibiclens®) for facial preps (including the ear)
– Explain procedure to an awake patient
• Procedure
– Eyelids and periorbital area usually cleansed with warm water using Q-tips®
– Start at center of lid and gently work outwards toward brow and cheek
– Repeat as needed
– Flush conjunctival sac with warm saline
• Instruct patient to turn head to side
• Place a sponge or towel to catch the run off
• Use a bulb syringe to gently irrigate the area

Thoracoabdominal Prep
• Patient is in lateral position
• Arm is elevated during the prep
– Prep arm to elbow
• Include axilla, chest, and abdomen in prep
• Extends from neck to down to iliac crest at the level of the pubis
• Extends beyond the anterior and posterior midlines

Breast/Chest Prep
• Remember
– If breast malignancy is suspected, only a paint may be performed
• Patient’s head turned toward nonoperative side
• Arm on operative side may be elevated to expose axilla if necessary
– Finger traps hanging from an IV pole may be used to elevate the arm
• Area includes
– Shoulder on operative side
– Axillary region on operative side if necessary
– Elevated arm up to the elbow if necessary
– Past the midline (sternum) to the opposite shoulder but not including the shoulder
• Breast Biopsy
– Arm not elevated
– Area includes
• Entire breast
• Extends to shoulder on affected side but does not include the shoulder or axillary region
• Extends to midline (sternum)
• 1”-2” below the breast

Shoulder Prep
• Patient will either be in supine or lateral position
• Arm on operative side elevated by grasping the hand
– Patient supine: Elevate arm to also slightly elevate shoulder from the OR table
• Area includes
– Entire circumference of elevated arm
– Axilla
– Entire shoulder to include scapular region
– Anteriorly to the sternum
– Inferiorly to the mid-chest
– Base of neck

Forearm/Hand Prep
• Roll towel is placed under shoulder and axillary region
– If only hand prep, this step is omitted
• Arm elevated by supporting it above the elbow to allow a circumferential scrub
• Extent of prep depends on surgical procedure to be performed
• Area could include
– Entire arm including axilla, or
– Forearm to 3” above the elbow
– Entire hand

Vaginal Prep
• Remember
– If Lugol’s solution will be used during operative procedure, do not use Betadine scrub or paint inside the vagina and on the cervix
• Sponge forceps are needed in order to prep the inside of the vagina
• Patient is in lithotomy position
• Area includes
– Pubis
– External genitalia
– Perineum
– Inner aspect of thighs
– Vagina
– Anus
• Procedure
– Place towel or pad under the buttocks
– Begin at the pubis, scrub downward over the external genitalia, perineum and anus
• Discard the sponge
– Use a new sponge each time, repeat the above step several times
– Use a new sponge, start next to the labia majora and scrub inner 1/3 of thigh
• Do not scrub the circumference
• Use a new sponge for each leg
– Scrub the vagina
• Use circular motion due to the many folds and crevices of the vaginal mucosa
• Variations of the vaginal prep
– Vagina may be prepped last
– Antiseptic soaked sponge on sponge forceps may be inserted into vagina initially; sponge remains while external prep is completed
• Complete the external prep, then prep the vagina
• Reasoning is that residual effect of antiseptic solution will have increased effect inside the vagina if left in contact for a few minutes

Hip Prep
• Patient is in lateral position
• Operative leg is elevated by supporting at the ankle and lower leg
• Area includes
– Inguinal region over to the level of the umbilicus and down the midline to the pubis
– Buttocks extended lateral to table line
– Circumference of upper thigh extended down to knee joint (may extend to include the foot)

Knee Prep
• Patient is in supine position
• Non-affected leg
– Lower portion of table is lowered; leg allowed to hang over lower portion supported by a pillow placed underneath
– Leg is placed in leg holder and positioned to prevent interference with operative side
• Operative leg is elevated by supporting the foot and ankle
• Depending on surgical procedure area includes
– Arthroscopy: Entire circumference of leg from mid-thigh to mid-calf
– Total joint replacement: Entire circumference of leg from groin crease to ankle

Urinary Catheterization

• Catheterization may not be performed without a doctor’s order.
• It is considered an invasive procedure
• Why?
• Strict sterile technique must be maintained!

Indications
• Decompression of the bladder
• To provide better visualization during abdominal procedures
• To prevent trauma during abdominal procedures
• To promote healing following GU procedures
• Drainage of urine
• To prevent the overfilling of the bladder during lengthy procedures
• To measure urinary output
• To obtain a sterile specimen
• To relieve urinary retention
• To treat urinary incontinence
• Irrigation of the bladder
• Control of bleeding
• The balloon can be placed in the bladder neck following TURP to tampenade excised area

Considerations
• In surgical cases the catheter will be following induction of anesthesia
• Insertion of catheter may cause an infection and/or injury to the urethra & bladder
• Use the smallest size to drain the urine without leakage around the edges
• The Foley catheter is the most common style
• The balloon should be filled with water
• Saline breaks down the catheter material
• Air could cause an embolism
• 10cc of water is used to completely fill a 5cc balloon
• To compensate for the water that remains in the infiltration channel
• Urine is drained by gravity
• The catheter is attached to a urinary drainage bag
• It should be placed below the level of the bladder
• The catheter should be secured to the pts thigh to prevent tension and accidental removal
• Always check the patient post op to find out if they have a catheter
• If you move a pt with a catheter and you forget to check, it can be pulled out when you transfer them to the stretcher
Types of Catheters
• Red Rubber (straight) catheter
• For in and out application
• Not for continuous drainage

A. Conical-tip urethral catheters
B. Coudé hollow olive-tip catheter
E. Malecot self-retaining urethral catheter
F. Foley-type balloon catheter
G. Foley-type, three-way balloon catheter

Sizes of Catheters
• Range from 8 fr to 30 fr
• Use 8 fr to 12 fr for pediatrics
• 14 fr to 30 fr for adults
• The most common size used for adults is 16 fr
Procedure for Females
• Pt is placed in the frog-leg position
• If not already in lithotomy
• The catheter kit is placed between the legs and opened
• Apply gloves using the open technique
• Create the sterile field and place the fenestrated drape with the opening over the vulva
• Check the catheters balloon to make sure there are no leaks in the balloon and the valve works correctly
• Place the lubricate on the end of the catheter
• Open and pour the prep solution in to the tray provided
• With non dominant hand separate the labia majora and locate the urethral meatus
• If you remove your hand at any time during the procedure you will have to start over
• Using the disposable forceps with dominant hand pick up a cotton ball and dip into prep solution
• You will need three cotton balls for the whole procedure
• With the first cotton ball, cleanse laterally from clitoris to vaginal opening
• Discard cotton ball
• With the second cotton ball, cleanse the other side
• Discard cotton ball
• With the third cotton ball, cleanse directly down the middle
• Discard cotton ball
• Insert the catheter into the urethral opening approximately half the length of the catheter
• If you miss the urethra and it accidentally inserts into the vagina, another catheter must be used
• Wait until urine flows before you inflate the balloon
• Pull the catheter just until you feel resistance
• Secure the catheter to the pts leg

Electrosurgery
The Electrosurgical Unit - Surgery with Electricity
Introduction
Electrosurgery
Definition and Usage
• Electric current used to cut and/or coagulate tissue
• Used to cut fat, fascia, muscle, and internal organs
• Part of surgeon’s routine armamentarium
• Often referred to as the “Bovie”
Monopolar vs Bipolar
Monopolar Current

• Most frequently used type of cautery
• Requires a grounding pad
• Pencil-style handpiece is used
• May be activated with a foot control or hand switch
Bipolar Current
Used for minor procedures; plastic procedures; delicate procedures such as ophthalmic and neurosurgery
• Does not require a grounding pad
• Various types of forceps are used (one tip is the active electrode and the opposing tip is inactive)
• Foot pedal is used to activate
Flow of Current
Monopolar
current flows from the
1. Generator or electrosurgical unit (ESU) to the
2. Active electrode (cautery tip) through the
3. Patient’s tissue to the
4. Dispersive electrode (grounding pad) and back to the
5. ESU
Bipolar current flows from the
1. Generator or electrosurgical unit (ESU) to the
2. Active tip of the forceps through the
3. Patient’s tissue to the
4. Opposing forceps tip and back to the
5. ESU
Types of Monopolar Current
Coagulate
• Coagulate capillary and other small bleeding vessels
Cut
• Cut adipose tissue, fascia, internal organs
Blend
• Combination of cutting and coagulating current
• Not a strong coagulating current
• Effective on capillary bleeding
Monopolar Handpiece
• Handpiece (with cord attached) and tip are single-use disposable items
• Distal end of cord is passed to the circulator to be connected to the generator
• Coagulating current is activated with the distal handpiece button
• Cutting current is activated with the proximal handpiece button

Tip of handpiece is
• Removable to facilitate use of various styles (blade, needle, loop, etc)
• Considered a “sharp” and must be handled and disposed as such
• A countable item in some facilities
Types of tips
• Blade - most frequently used; available in regular and long (for use in deep body cavities) lengths
• Ball - ball shape on end of tip; frequently used in throat procedures such as T&A
• Needle - ends in a sharp point; used in minor procedures, plastic, and delicate procedures
Cleaning of Tip
• To keep charred tissue from building up on cautery tip preventing effective flow of current
• Clean the tip using moist sponge or cautery scrapper
– Cautery scrapper: small square abrasive pad with adhesive backing placed on sterile field
• Knife blade NOT recommended, but is often used
Grounding Pad and Placement
• Technical names - inactive or dispersive electrode
• Single-use disposable item
• Available in various sizes ranging from adult to infant
• Prelubricated with conducting gel
• Position patient; then place the pad
• Place pad as close as possible to the operative site
• Do not remove and reposition pad
– Loss of conducting gel
– New pad must be placed
• Pad should cover as large of area as possible
• Extremity - place on area of largest circumference
• Do not place on area with excessive scar tissue
• Do not place over area with excessive hair
– May have to shave the area
• Do not place over bony prominences
• Do not place over or near metal implants
• Do not allow skin prep fluids to pool around or under the pad
• Place on clean, dry skin
• Pad must uniformly adhere to patient’s skin
– No tunneling effect or air pockets
– Edges cannot curl up
• No part of the patient’s body can touch a metal surface such as OR table
– Electric current is attracted to metal
– Current will seek the path of least resistance to complete the circuit
– Body part touching metal will be severely burned
• Awake patient
– Warn patient of placement due to cold and sticky nature of conducting gel so that the patient is not startled
Principles Associated with
Cauterizing Tissue
• ESU produces “buzzing” sound when activated
• Surgeon may ask the assistant to “buzz” a clamp or forceps to coagulate tissue within
– Surgeon holds tissue or vessel with forceps or clamp
– Assistant touches instrument with electrocautery (“Bovie”) tip
– Current travels down instrument to cauterize tissue or vessel
Precautions when “buzzing”
• Do not activate cautery prior to application to instrument to avoid “arcing” of current
• Place cautery tip below fingers of surgeon
– Current can penetrate surgical gloves and cause pin point 3rd degree burn
• Be sure that the instrument grasping the tissue is not touching other tissue
• Be sure that the instrument grasping the tissue is not touching other metal instruments such as a retractor








Documentation
Documentation
Circulator records all information on patient’s intraoperative record
• Location of grounding pad
• Condition of patient’s skin pre- and postoperatively
• Power settings for cutting and coagulating currents
• ESU hospital identification number
Safety Principles

• Initial skin incision is be made with the scalpel
– Bovie will char and scar the skin
• Keep handpiece protected when not in use to prevent accidental activation
– Place in plastic protective holster that can be attached to the drapes
– Keep out of team member’s way to avoid leaning on it

General safety rule
• Start with lowest power settings of current that accomplish the job
• Adjust the current at the surgeon’s request

Clue to equipment malfunction
• Surgeon has repeated request for more power
Avoid inhaling plume (smoke)
• Not yet proven; could be harmful
• Could contain bits of vaporized tissue that could be mutagenic and/or carcinogenic
• Plume is irritating to the respiratory tract
• Oxygen and Nitrous Oxide Used
– Do not use cautery in the mouth, around the head, or in pleural cavity in the presence of oxygen and nitrous oxide
– Nitrous oxide supports combustion
• Metal jewelry removed from patient
• Only moist sponges used in presence of ESU
• ECG Electrodes
– Place electrodes as far away from operative site as possible
– Place grounding pad as far away from ECG electrodes as possible
– Electrical current can be attracted to ECG electrodes and cause severe burns
• ESU can disrupt the operation of implanted cardiac pacemaker
• Alcohol used for skin prep
– Alcohol must be allowed to dry before draping the patient
– If not allowed to dry, fumes can build up under the drapes and possibly ignite when cautery is used
Reasons for Malfunction of ESU

• Improper placement of grounding pad
• Less that full contact of grounding pad with skin surface
• ESU machine malfunction
• Frayed cord

Physical Environment and Safety Standards
By Javier Espinales, CST
Physical Environment and Safety Standards
• Objectives:
• 1. Identify and describe hazards to the patient in the operative department.
• 2. Identify support services that work with the OR team in the care of the patient.
• 3. Discuss the type of air-handling system required in the OR and the temperature and humidity required to maintain a sterile field.
• 4. Identify cleaning procedures, traffic patterns, and routines in the operative environment.
Physical Environment and Safety Standards
• 5. Identify the design types of the OR.
• 6. Identify hospital departments that relate to surgical services.
• 7. Discuss the working environment of the OR.
• 8. Identify the physical components of the OR.
Physical Design of the OR Suites
• Location – Usually in an area near critical care and supporting departments.
• Principles in design.
– Exclusion of contamination from outside the suite.
– Separation from clean and contaminated areas.
Areas of the Operating Room
• Central Core Race Track Plan
• Central Core Peripheral Corridor
• Central Core Hotel Plan
• Central Core Cluster Combination
Physical Design of the OR Suites
• Ventilation System
– Should provide clean air and remove airborne contamination
– Air exchange should be 20 air changes per hour
– HEPA filters capable of removing bacteria
Physical Design of the OR Suites
• Vestibular/Exchange Area
– Unrestricted Area
– Semirestricted Area
– Restricted Area
Peripheral Support Areas
• Preoperative Check-in Unit
• Preoperative Holding Area
• Induction Room
• Post Anesthesia Care Unit (PACU)
• Dressing Rooms and Lounges
• Control Desk
Peripheral Support Areas
• Anesthesia Work Room
• Housekeeping
• General workroom
• Storage
• Sterile Supply Room
• Instrument Room
Peripheral Support Areas
• Laboratory Dept
• Radiology Dept
• Pathology Dept
• Environmental Services
• Central Sterile Supply and Processing
Operating Room
• Usually 20’ x 20’ x 10’
• Larger rooms 20’ x 30’ x 10
– Larger pieces of equipment; Microscopes, C-arms,
Video equipment.
Operating Room
• Substerile Room
– Saves time and steps
– It allows better care of equipment
– Usually contains a warmer, Flash/washer sterilizer
Operating Room
• Inside the room
– Temperature and Humidity
• Temp between 65 F and 75 F
• Humidity between 50% and 55%
– Floors - most common seamless vinyl
– Walls and Ceilings
Physical Components of the OR
• Equipment
• Electrical outlets
• Suction outlets
• Gas outlets
• Lights
• Viewing box
Standard OR Furniture
• O.R. Table
Standard OR Furniture

• Mayo Stand
Standard OR Furniture
• Back table
Standard OR Furniture
• Ring stand
Standard OR Furniture
• Kick buckets
• Linen hamper
Hazards in the OR
• Safe environment
– Equipment must be properly handled and operated properly.
– ST’s must be educated and trained on safety measures.
– Surgical team must have knowledge of the possible hazards and how to keep everyone safe.
Hazards in the OR
• Physical: noise, ionizing radiation, electricity, injury to body, fire, explosion
• Biologic: laser/electrosurgical plume, pathogens , latex sensitivity, sharps injury
• Chemical: disinfecting agents, waste anesthetic gas, vapors and fumes
Physical Hazards
• Surgical Lights – non glare
• Noise in the OR
• Proper posture and body mechanics
• Electrical hazards
• Radiation
Fire Hazards
• Fire/explosion can result from:
– Source of ignition
• Spark from metal hitting metal
– Oxygen
– Flammable materials
• Gas, vapor, liquid (ethyl alcohol)
Biological Hazards
• Universal precautions – defined in 1985
• Standard precautions – defined in 1996
• Causes
– Needles in needle holders
– Suturing
– Manual tissue retraction
– Needle on the field
Biological Hazards
– Dropping needle/blade on a foot
– Reaching for falling items
– Placing sharps into sharps containers
Biological Hazards
• Preventions for possible sticks
– Have a sharps management plan
– Neutral zone
– Appropriately place sharps containers
– Never recapped needles
– Sharps on the mayo stand should be kept in a central area.
– Load needles prior to use
Biological Hazards
• Hazardous waste disposal
– Infectious waste disposed in a red bags
• Follow local policy
• Management for exposure
– Needle stick squeeze wound, then clean
– Exposure to oral or nasal flushed with water
– Eyes flushed with water or saline
Biological Hazards
• Laser plume
– Use a smoke evacuator or use the suction tip to the regular suction canister.
• Latex allergy
– To patient and staff
– Two types
• External and systemic
Chemical Hazards
• Waste Anesthetic Gases
• Methyl Methacrylate – Bone cement, liquid and power components.
• Formalin
• EtO
• Glutaraldehyde

Special Populations
By Tracey Carpenter
Pediatric Patients
• Ages between birth and 12 years of age
– Neonates- the first 28 days of life
– Infant- 1 to 18 months
– Toddler- 18 to 30 months
– Preschooler- 30 months to 5 years
– School Age- 6 to 12 years
Communication
• Fearful of separation from family and
• Unfamiliar surroundings
– Unknown people all covered up
– Can only see eyes
• Lack of understanding and communicative skills

Calming Fears
• Allow child to bring a favorite toy with them
• Don’t have too many people in the room
• Stay quiet and calm
– Why
• Anesthesia and circulator are only ones to interact with pt
– Accept if child becomes combative
– Restrain only to prevent the child from hurting themselves
Intra-operative Considerations
• Temperature
– Less fat, poor thermal insulation
– Monitored either with skin or rectal thermometers
• Shock
– Septic shock
• due to infection
– Hypovolemic
• due to dehydration and bleeding
Birth Trauma
• *Cord compression
• Broken clavicle
• Facial paralysis
• *Placental abruption
Obese Patients
• 100 lbs or more over ideal weight
• Increased morbidity and mortality due to:

Considerations
• Transportation
– Some must be transported on their hospital bed into the OR
– Sometimes two OR beds must be used
– Sometimes (seldom) the operation must be done on the hospital bed
– Extra personnel needed to transport for saftey
Respect
• Pts are usually self conscious
• Keep negative comments to yourself
• Keep exposure to a minimum
Anesthesia Complications
• May need a cut down for venous access
• Difficult intubation due to lack of movement in the neck
• Poor ventilation
• Need for more anesthetic agents
Intra-operative Considerations
• Need for longer instrumentation
• Longer surgical time due to lack of exposure
• As with all surgical procedures counts must be accurate
– There is more of a chance that something could be left behind in deep incisions
Post-operative Considerations
• Longer healing time
– Adipose tissue in the obese has decreased blood supply
• Increased likelihood of wound infection
• Wound dehiscence
• Pulmonary embolism
• Post operative asphyxia due to sleep apnea
• Leaks at anastomosis sites……

Geriatrics
• The term geriatric is taken from the Greek word yeros, which means old.
• People over the age of 65 are considered elderly
• Elderly people may maintain their functional capabilities throughout their life time.
• The main influence on aging depend on their genetic, environment, and lifestyle
Geriatrics
• Gerontology - is the study of all aspects in aging to include, physiologic, psychologic, economic, and sociologic problems and consideration of the aging person.
• Life expectancy has increased with major advancements in the study of the disease process, prevention and treatment
Geriatrics
• The US Dept. of Health and Human Services indicate that a person born in;
– 1954 expect to live to 68 years of age
– 1988 expect to live to 74 years of age
– By 2030, 1 in 10 will be older than 85 years of age with only 41% of the population below the age of 35
– The median age will be 40 y/o
– With the increase life expectancy and decrease in mortality the largest patient population will be geriatrics
Geriatrics
• As the life expectancy increase so does the rate of comorbidity.
• Comorbidity – the existence of two or more disease process in a single pt
– ie a pt with coronary artery disease, may also have osteoporosis, may also be hypertensive and be diabetic.
• Comorbidity is also a major consideration in the attainment of expected outcome.
Geriatrics
• Aging is viewed from many perspectives, some positive & some negative
• The positive aspects are;
– Maturity & wealth of knowledge
• The negative aspects are:
– Debilitation
– Pervading weakness & dependence at the end of their life
Geriatrics
• Major organ systems affected by the aging process:
– Central Nervous System
– Musculoskeletal System
– Cardiovascular System
• Other systems include:
– Gastrointestinal Endocrine
– Genitourinary Integumentary
Geriatric Surgery
• The surgical team needs to be aware of the physical, psychological, and social status of the geriatric pt.
Surgical Considerations
• Ease with bruising or laceration
• Loss of mobility in joints
• Ease of fx’s and strains
• Lack of ability to tolerate episodes of hypoxia
• Potential lack of understanding
Geriatric Surgery
• The normal changes of the aging process present the surgical team with a wide variety of needs
– Protecting the pt’s skin and joints
– Temperature loss
– Fluid dynamics
– Cardiovascular response
Geriatric Surgery
• Questions to ask yourself
– Is the room temp OK?
– Is there sufficient padding on the OR bed?
– How is the pt’s skin condition?
– How flexible is the pt?
– What is the mental status of the pt?
– What specific complications are most likely with this pt’s?
Trauma
• #1 health care issue in the world
• About 160,000 Americans die each year from trauma
• Difficult to diagnose and treat because most trauma victims have multiple types of injuries
• When working with a trauma team the ST must be ready to do almost every type of surgery
Trauma Centers
• Level I
– Meets all needs required for trauma patients on a 24 hour basis
• Level II
– Can treat seriously ill and injured pts but not to the extent of Level I
• Level III & IV
– Usually a community or rural hospital. Trauma pts are stabilized and transported to a Level I
Types of Trauma

Blunt
&
Penetrating

Blunt Trauma
• Skin is usually unbroken
• Injury to the underlying tissues and organs
• Makes diagnosis difficult
• Examples include:
– Car accidents, falls, battery and sports injuries
Penetrating Trauma
• When a foreign object passes through tissue
• The most common are bullets and knives
• Extent of injury depends on the size and type of foreign object and how many tissues and/or organs that are affected
Penetrating objects
• Should never be removed in the until in the operating room
• The object acts as a tampenade for bleeding
• If it is removed before in an area that can take care of this then the patient may die from subsequent bleeding
Questions?

Standards
of Conduct
Chapter 2
Legal Aspects of Health Care
• Laws, standards, and guidelines
• Patient is an autonomous individual
• Concepts related to legal aspects of medicine
Traditional Principles
Doctrine of Borrowed Servant
• The one controlling or directing the employee has greater responsibility than the one paying the employee
• Surgeon is liable for any negligent act committed in their presence
• Captain of the Ship doctrine
Doctrine of Personal Liability
• Each person is responsible for his or her own tortuous conduct
• Others may be liable as well
• Physicians assure the medical professional will take responsibility for an action
Intentional Torts
• Assualt
– an act that causes another person to fear that they will be touched in an offensive manner w/o consent
• Battery
– the actual act of harmful contact w/o consent
• Defamation
– slander (oral) or libel (written) - reputation or good name
Intentional Torts
• False Imprisonment
– Illegal detention w/o consent
• Intentional Infliction of Emotional Distress
– Disparaging remarks
• Invasion of Privacy
– Disclosure of private information
Unintentional Torts
• Individuals make mistakes
• Most common type of patient indiscretions by OR personnel include
– Negligence: breach of duty
– Malpractice: wrongful conduct
Errors That Can Occur
• Patient misidentification
• Incorrect procedure
• Foreign bodies left in patient
• Patient burns
• Falls or positioning errors
• Improper handling of specimen
• Incorrect drugs or administration
Errors (continued)
• Harm secondary to use of defective equipment/instruments
• Loss of or damage to patient’s property
• Harm secondary to a major break in sterile technique
• Exceeding authority or accepted functions
• Abandonment of a patient
Consent for Surgery
• Permission being given for an action
• Granting party must have authority
• Voluntary and informed act
• Nonconsensual touching = battery

Consent for Surgery
• Express
– Direct verbal or written statement granting permission for treatment
• Implied
– Manifested by action or inaction of silence that assumes consent has been authorized
Written Informed Consent
• Physician’s responsibility:
– Information must be given in understandable language
– There can be no coercion or intimidation of the patient
– The proposed surgical procedure or treatment must be explained
– Potential complications must be explained
Written Informed Consent
• Potential risks and benefits must be explained
• Alternative therapies and their risks and benefits must be explained
Written Informed Consent
• A proper consent form should contained the following:
– Patient’s legal name
– Surgeon’s name
– Procedure to be performed
– Patient’s legal signature
– Signature of witness(es)
– Date and time of signatures
Who Can Give Informed Consent
• Competent adult
• Parent or legal guardian of a minor
• Guardian in case of physical inability or legal incompetence
• Temporary guardian
• Hospital administrator
• Courts
Consents
• Witnesses for a consent signature
– Physician/surgeon
– Registered nurse
– Other hospital employee
• Once given a consent can be taken away
Documentation
• Placing information into a patient’s medical record (chart)
• Combined account of interaction between the patient and health care providers
Documentation
• Hospitals are mandated to report certain items to other authorities:
– Disease of the neonate
– Child abuse
– Elder abuse
– Communicable diseases
– Births and deaths
Documentation
• Any suspicious deaths
• Any known criminal acts
• Professional misconduct
• Incident reports
Additional Information
• Advanced directives
– Rights of self-determination
• Ethical and moral issues
– Concepts of right and wrong
• Bioethics
– Study of ethical implications of biological research and applications in medicine
Patient’s Bill of Rights
• Adopted by American Hospital Association 1972 and revised in Oct 1992
• Requires collaboration between
– Patients
– Physicians
– Other health care professionals
• Establishes patient as consumer of health care
Patient’s Bill of Rights
• Hospital must respect the pt’s rights and role in health care decision making
• Hospital must be sensitive to culture, racial, linguistic, religious, age, gender, and other differences including disability
Ethics
• Surgical technologists will be exposed to many issues that may create discomfort
• Decide what type of situations you cannot participate in and act upon your decision
• Respect other viewpoints
Ethics
• Elective sterilization
• Fertilization procedures
• Elective abortion
• Human experimentation
• Animal experimentation
• Organ donation/transplantation
• Quality vs. quantity of life
• Substance abuse
• Gender reassignment
• HIV and AIDS pts
• Newborns w/severe disability
• Good Samaritan law
• Assisted suicide
• Genetic engineering
• Refusal of treatment
• Termination of care & right to die
Surgical Conscience
• Personal moral authority to accept responsibility
• Committed to maintaining confidentiality
• Nondiscriminatory treatment
• Personal values, feelings, and principles are secondary
Surgical Conscience
• Basis
– If you or someone else in the case breaks sterile technique, admit it or acknowledge it
– If someone says that you have broken sterile technique, take them at their word
– Above all: do not argue, do not give excuses

The Surgical Patient
By Javier Espinales, CST
The STSR and the Surgical Patient
 The ST’s contact with the patient occurs preoperatively, intraoperatively and postoperatively.
 No matter what role the ST is playing you must be aware of the pt, other team members, surrounding environment, and care and safety issues.
The STSR and the Surgical Patient
 Every health care employee is morally obligated.
 No one is excused.
Physical, Psychological, Social, and Spiritual needs of the PT
 For a pt to go through surgical intervention, the physical, psychological, social and spiritual are major events for them.
 The pt may presume good care – but the pt inner self may haunt them before and after surgery.
Physical, Psychological, Social, and Spiritual needs of the PT
 The pt has a life before surgery and the question remains after.
 The health care professional needs to care for the pt well being or they need to find another profession.
Causes for Surgical Intervention
 All surgical pt’s have one thing in common – they rather not be there.
 Most have surgery due to trauma, disease, genetic factor that can only be corrected by surgery.
Prioritizing Needs
 Maslow’s Hierarchy
– Physiological Needs
– Safety Needs
– Love and Belonging Needs
– Esteem Needs
– Self-actualization
Prioritizing Needs
 Guidelines and Constraints
– The OR team must recognize the pt’s physical needs but the team has to also understand that the pt has certain rights to refuse surgery.
What can an ST do?
 Help establish an environment that communicates care and concern.
– Discuss with the circulator if there are any issues with the pt that you need to know.
– Plan simple actions for the pt
– Introduce yourself professionally
– If the pt ask what you do, explain in simple language.
Cultural and Religious Influences
 Every culture has different beliefs.
 You must be aware that different pts react differently due to their beliefs.
Patients Bill of Rights
 American Hospital Association – adopted the Patients Bill of rights in 1972.
 These assumptions are for the protection of the patient.
 The bill was later reinforced with The Patient Self-Determination Act of 1990
– It says that each patient has the right under state law to make decisions concerning his/her care, including the right to refuse treatment.
Consent for Surgery
 JCAHO’s definition – A person who receives health services from a health care provider and who gives consent for the provider to provide those services.
 To perform surgery without consent is liable to be charged with battery.
Consent for Surgery
 Consent
 Battery
 Expressed
 Implied
 Informed Consent
Principles of Documentation
 Surgical records that will also go into the pt’s record
– Informed consent, surgical procedure
– Anesthetic procedure – response to anesthesia and post anesthetic care
 As far as the OR Nurse
– Pt’s condition before, during and after the case
Principles of Documentation
– Time of initiation and termination of case
– Proper counts, implants, drains, dressings and so on
– Specimen/lab report
Principles of Documentation
 Mandated reportable items to proper authority
– Disease of Neonate
– Child Abuse
– Elder Abuse
– Communicable disease
– Births and Deaths
Principles of Documentation
– Any suspicious death
– Any known criminal acts
– Professional misconduct
– Incident reports
Legal and Ethical Considerations
 AST Code of Ethics
Legal and Ethical Considerations
 Bioethical Situations
– Elective Sterilizations
– Fertilization Procedures
– Abortion
– Human Experimentation
– HIV and Other Infections
Legal and Ethical Considerations
– Animal Experimentation
– Organ donation/transplant
– Quality of life
– Euthanasia
– Right to Die
– Death and Dying
Legal and Ethical Considerations
 Possible mistakes in the OR
– PT mis-ID
– Performing incorrect procedures
– Foreign bodies left in the pt
– Burns by ESU
– Falls or positioning mistakes
Etc, etc.

Health Care Facilities
Javier Espinales, CST
Health Care Facilities
• Traditionally hospitals provided all the care
• Since the 1990’s you now have facilities;
– Wellness care and education
– Home health care
– Follow up care
Health Care Facilities
• All surgeries use to be in one building
• There were few specialty hospitals
• You now have ;
– Traditional OR’s
– Free standing ambulatory
– Surgical facilities
– Free standing specialty centers
– Dr’s offices and clinics
– L&D units
Health Care Facilities
• Several types of hospitals;
– Nonprofit (Not-for-profit)
– Proprietary (For profit)
– Tax supported
Health Care Facilities
• Nonprofit (Not-for-profit) – acute-care hospitals – nontaxable
• Owned by
– Community
– Church
– Other organization
• Profits put back into maintenance and improvements
• Can be supported by tax revenues
Health Care Facilities
• Proprietary (for profit) – investor-owned hospitals
– Owned and operated individual or corporation
– Profits returned to investors
– Profits are taxable
Health Care Facilities
• Surgeries can be performed in more than one setting in the hospital
– Traditional OR’s
– Outpatient surgery
– L&D
– Pediatric surgery
Health Care Facilities
• Free standing ambulatory surgical facility – separate from a hospital
• HMO – Health Maintenance Organization
– Insurer
– Provider of medical services
• Clinics – for specific procedures
• Vets provide surgical services
Hospital Organization
Hospital Organization
• Surgeon’s
– Medical doctors
– Doctors of Osteopathy
– Podiatry
• Board certified in their specialty
Hospital Organization
– RN’s
• GN – Graduate Nurses
• LPN/PVN – Licensed practical /vocational nurses
• ADN - Associate Degree Nurse
• BSN – Bachelor’s Science Nursing
• Master’s and PhD’s
• CNOR
• CRNFA
Hospital Organization
• Anesthesia staff
– Anesthesiologists – MD’s/DO
– Anesthetists – nurses CRNA
– Anesthesiologist assistant – AA
– Anesthesia technician
• PA’s – Physician Assistants – role usually as a surgical assistant
Hospital Organization
• Other personnel working in the OR
– X-ray tech
– Perfussionist
– Cell saver tech
– Bioelectrical tech
– Lab tech
– Ortho tech
– Ophthalmic tech
– Dental tech
Hospital Departments and Interdepartmental Communication
• Direct Patient Care Departments
– Nursing Care Units
– Diagnostic Imaging
– Medical Laboratory
– Pharmacy
– Physical/Occupational Therapy
Hospital Departments and Interdepartmental Communication
• Indirect Patient Care Department
– Administration
– Maintenance
– Biomedical
– Housekeeping
– Food Service
– Purchasing/Central Services
– Medical Records
Financial Considerations and Reimbursement
• Surgery is expensive
• Some surgeons provide free care
• Insurances – designate contractual relationship and mutual benefit that exist when one party or entity agrees to pay another for a specific loss or condition.
Financial Considerations and Reimbursement
• Most health care coverage are provided by HMO’s or PPO’s (Preferred Provider Organization)
– All seek to control cost through contractual arrangements
– Limit payments to agreed-on amounts
Financial Considerations and Reimbursement
• Medicare – administered by the Fed. Gov. Through the Centers for Medicare and Medicaid Services (CMS)
– Reimbursements to hospitals and physicians
– 65 y/o & older qualify
– People eligible for Social Security disability payments for at least 2 years
– Certain workers & families who require kidney dialysis or transplantation
Financial Considerations and Reimbursement
• Medicaid is a government assistance funded jointly by Fed. Gov. and State Gov.

• Provide for low-income persons who can not afford medical insurance

• Surgical Technologist and other staff personnel must control cost
Organization Related to Hospitals, Health Care, and Surgical Services
• Governmental
– Dept. of Health and Human Services (DHHS)
• Public Health Services (PHS)
• Centers for Medicaid & Medicare Services formally known as Health Care Financing Administration (HCFA)
• Social Security Administration (SSA)
• World Health Organization (WHO) UN division
Organization Related to Hospitals, Health Care, and Surgical Services
– Various state, county, and city department groups

• Private Volunteer Agencies
– American Cancer Society
– American Diabetes Association
– American Heart Association
– American Red Cross
Organization Related to Hospitals, Health Care, and Surgical Services
• Accrediting Agencies
– Joint Commission on Accreditation of Healthcare Organizations (JCAHO) – An independent, nonprofit national organization
Organization Related to Hospitals, Health Care, and Surgical Services
• Professional Associations
– American College of Surgeons (ACS) – dedicated to improvement of surgical care by elevating standards of surgical education and pratices
– Association of Surgical Technologist (AST)
– Association of Operating Room Nurses (AORN)

Personal and Professional Relationships
Tracey Carpenter

 The calling
 JCAHO (Joint Commission of Accredited Hospitals Association) calls the surgical technologist an educated and trained individual in health care services.
 “The goal of a surgical technology program is not to get someone a job but to make one a surgical technologist.”
Surgical Technologist’s Lifestyle
 Little of the population know about us.
 Great knowledge about the human body.
 Involved in surgical procedures that the world thinks is either gross or miraculous.
 Our world is alien to non health care workers.
Surgical Technologist’s Lifestyle
 Weight of moral, legal, and professional obligations is ours to bear.
 Psychological events and outcomes.
 Excellence is always expected.
Surgical Technologist’s Lifestyle
 Duty and Obligation is our standard
 Accountability extends beyond the OR and interacts with one’s personal life.
Surgical Technologist’s Lifestyle
 Family inconvenience due to call.
 Social life put on hold due to call.
 Greater obligation for the care of your body from communicable disease.
 Details of personal information you cannot share with family and friends.
Surgical Technologist’s Lifestyle
 Many people don’t want to know about our exciting world.
 Isolation from the population may result due to the nature of the OR.
Surgical Technologist as a Professional
 Professional relations begin with competency and commitment at the workplace.
 “Enhancing the profession to ensure quality patient care.”
Surgical Technologist as a Professional
 Certification
 CAAHEP Accredited Schools
 LCC-ST
 CST – CST/CFA
 Specialty Practice and Employment
Surgical Technologist as a Professional
 Desirable Attributes for Success
 Care and Empathy
 Comprehend and convey
 Respect for Others
 Accept people as they are
 Emotional Self-Control
 Honesty and Ethical Behavior
 Admits error
Surgical Technologist as a Professional
 Desirable Attributes for Success (cont.)
 Manual Dexterity
 Organizational Skills
 Concentration
 Constant focused attention
 Possible short and long term problems
 Stress Hunger (hypoglycemia)
 Illness Lack of sleep
 Exhaustion Substance abuse
 Lack of interest or burnout
Surgical Technologist as a Professional
 Desirable Attributes for Success (cont.)
 Problem-Solving Skills
 Prioritizes activities
 Calmly seeks solution to any and all problems
 Uses time wisely
 Assesses own ability
 Demonstrates flexibility
 Selects the best alternative to achieve positive results
 Analyzes results and accepts feedback
Surgical Technologist as a Professional
 Sense of Humor
 “Humor when expressed appropriately, can create ease and relaxation.”
Surgical Technologist as a Professional
 Scope of Practice and State Jurisdiction
 Written hospital policy
 State nursing practice acts
 State medical boards
 State business and professional codes
 Dept of Health and Human Services
 JCAHO
Surgical Technologist as a Professional
 Unlicensed Surgical Technologist may not practice nursing.
 Activities that require nursing assessment and judgment
 Physical, psychological, and social assessment that require nursing judgment, referral, or intervention
 Design a nursing plan involving care and evaluation
 Administration of medication by any route
Surgical Technologist as a Professional
 Role of the Surgical Technologist
 STSR
 Assisting Circulator
 Circulator
 Preoperative
 Intraoperative
 Postoperative
Surgical Technologist as a Professional
 Continuing education is important to the ST for two reasons:
 Continued personal development and improved patient safety.
 Continuing certification requires demonstration of continuing education.
 Community service is another feature of professional responsibility.
Surgical Technologist as a Professional
 The Surgical Technologist as a Preceptor
Homework
 Read Chapter 2
 Key Terms – workbook
 Due by next class

History of Surgery
Tracey Carpenter
Introduction
• The ability to perform surgery depends on:
– Anatomical information
– Control of pain
– Control of infections
• We have been studying the human body for over 6000 year

• Advances were made in three areas contributing to the progression in the field of surgery.
– Anatomical and physiological knowledge
– Factors affecting the understanding of microbiology
– Development in anesthesia

• Advances in medical science were not linear
• Some were philosophical and others were practical

• Practical issues also influenced medical science.
– Type of experience in anatomical dissection
• – actual vs literary
– Level of chemical knowledge for physiology
Time Line
• 4000 BC Cuneiform Tablets from Nineveh are the earliest found documentation to give anatomical descriptions
• 2500 BC Imhotep wrote an early book on surgery
• 2000 BC
– Code of Hammurabi – medical practice
– Moses – Desert rule of cleanliness
Time Line
• 1500 BC Vedas (Hindu) – Correlated sweet smell of urine with a specific disease
• 1000 BC
– Homer – Provides us a view of military medicine through his writings

• 500 BC Aristotle – Established early scientific mindset
• Herophilos – Father of anatomy; Developed the Doctrine of the Pulse
• Nei Ching – Chinese writing on acupuncture

• Year Zero
– Celsus – Described the signs of inflammation
– Galen – First great anatomist; went unchallenged for 1500 years
• 500 AD – Alexander describe the pump like action of the heart
Historical Fact
• 1200 – 1300
– Surgeons and barbers belong to the same guild, until 1540 when the barbers agreed to confine their practice to dentistry.
– The combined groups were dissolved in 1745 and by 1899 the Royal College of Surgeons of London were chartered.
Time Line
• 1400 AD – Linacre - translated Galen (from year zero) from Greek to Latin
• 1500 AD – Pare - Greatest Surgeon of the 16th century.
– Ligated arteries after amputations
– Cauterized with hot irons and oil
Time Line – cont.
• 1500 AD (cont.)
– Versalius – Father of modern anatomy.
• Challenged Galen openly and correctly
• Performed dissections himself on human cadavers
• Created illustrations for permanent records

• 1850 AD –
– Pasteur – Father of Microbiology
• Pasteurization
– Lister – Developed antiseptic surgical technique
– Billroth – Responsible for advances in surgical procedures, ie Gastrectomy
Time Line
• Halsted – Developed meticulous wound closure
– He also developed the practice of using sterilized rubber gloves for surgical procedures
• Roentgen – Developed the X-ray machine
• 1900 – Cushing – Father of neurosurgery
Time Line
• Lord Berkeley George Moynihan (1865 – 1936)
“Surgery has been made safe for the patient; we must now make the patient safe for surgery.”
• Surgery can not be considered safe all the time
• Patient outcome are not always predictable

• “Surgery as we know today is a 20th century phenomenon
Time Line
• 1950
– Cooley –
• Perfected the heart-lung machine.
• Performed 1st heart transplant
• 1st total artificial heart implant
– Debakey – Developed 1st ventricular assist pump
Time Line
• 1980 – Technological revolution began. Endoscopic surgery becomes routine.
• 1990 – Computers age changes surgery.
– Stereotactic surgery
– Virtual reality
– Robotic surgery
Modern Surgery
• Surgery combines the total care of an illness with an intervention (invasive or noninvasive) aspect of treatment.
– Surgical specialization
– Sophisticated diagnostic and imagining techniques
– Minimally invasive equipment
– Collaboration of caregivers and industry
Surgical Categories
• Emergent
• Urgent
• Elective
• Optional
Surgical Specialties
• General Surgery
• OB/GYN
• Orthopedics
• Cardiothoracic
• Peripheral Vascular
• Neurosurgery
• Genitourinary
• Oral & Maxillofacial
• Plastic & Reconstructive
Homework
• Chapter 1
– Read the chapter
– Workbook - Key Terms
• Due by next class