K George Varghese
CONDITION OF OPERA
CONDITION OF OPERA
CONDITION OF OPERA
CONDITION OF OPERA
CONDITION OF OPERATING SUITETING SUITETING SUITETING SUITETING SUITE
The responsibility of the surgeon to his patient in the operating suite begins before the wielding of the knife. Much can be done to assure the patients comfort by placing him in a quiet atmosphere out of the hospital traffic. The placing of the sedated patient on a trolley in the hallway or just outside the operating room door for more than a few moments is considered cruel and unreasonable. Most properly equipped operating suites will have an anesthesia induction room to protect the patient from such disturbances. Here patients who have been given premedication and are waiting for surgery are kept. The anesthetist once again reviews the patient here, who has already been examined in the pre- aneasthetic clinic on the previous day. There after the patient is wheeled into operation room with the permission of the anesthetist.
MAINT
MAINT
MAINT
MAINT
MAINTAINING AINING AINING AINING AINING THE STERILITY OF THE STERILITY OF THE STERILITY OF THE STERILITY OF THE STERILITY OF THETHETHETHETHE
OPERA
OPERA
OPERA
OPERA
OPERATION TION TION TION TION THEATHEATHEATHEATHEATERTERTERTERTER
The access to operation theater and recovery area is restricted to operation theater personnel only, who are required to don clean scrub dress, cap, mask and shoes. This is to maintain the sterility of the operation theater. The ceiling, walls and floors of the operation rooms are regularly disinfected prior to surgery. This is done by fumigation. Fumigation can be achieved by the use of fumigators. The chemical used is 40 percent formalin.
Fumigator is set for 30 minutes. The parameters and the optimum levels for effective fumigation are as follows: 1. Relative humidity (RH)—play a significant role in fumigation. A minimum of 70 percent is essential. Higher the humidity, better is the disinfection. Water used in the fumigator along with the fumigant (formalin) helps to achieve and maintain the desired RH.
2. Temperature—Evaporation of gaseous fumigant is more at the higher temperature. The use of fumigator makes the temperature factor less important since it allows the formation of mist in the operation theater. 3. Formaldehyde levels in the air—should be ideally 5 ppm or more.The dose of formalin is usually decided by the size of the room. As a general rule, about 180 ml is used for a room of the size 1000 cubic feet (=10 × 10 × 10 feet)
Parameters Optimum levels for effective fumigation Relative humidity Over 70 %
Temperature 30-40 0 C
Formaldehyde levels 5 ppm or more
Following fumigation, ideally swabs are taken and culture done to ensure the sterility of the operation room.
CHANGING ROOM, SEMI STERILE AND
CHANGING ROOM, SEMI STERILE AND
CHANGING ROOM, SEMI STERILE AND
CHANGING ROOM, SEMI STERILE AND
CHANGING ROOM, SEMI STERILE AND
STERILE AREAS
STERILE AREAS
STERILE AREAS
STERILE AREAS
STERILE AREAS
Before the surgeon and theater staff enters the operation room they have to change to the clean scrub suit/theater
dress in the changing room. The scrub suits consists of linen trousers, and short sleeved shirt. Cap, mask and theater shoes are worn at this point. Only then one can proceed to the semi sterile areas like the preanesthetic room and scrub room/area which are included in the restricted areas of the operation suite. Operating room, instrument setting room and recovery rooms are considered to be sterile areas. Theater dress, disposable masks, caps, and theater shoes that are worn by the operating room staff before they enter the theater helps to minimize wound contamination from outside sources. If these garments are worn outside the restricted area of the operating suite they must be replaced with fresh ones to ensure that the surgeon and his assistants are doing everything possible to reduce extraneous contamination.
Masks
Masks
Masks
Masks
Masks
Disposable masks with flexible nosebands are available which follow facial contours and retain high efficiency of filtration. Masks provide protection for the surgeon from aerosols and blood borne infections. Full facial visors offer better protection.
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Ey
Ey
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Eye Protectione Protectione Protectione Protectione Protection
It is advisable to wear eye protection during any procedure which is likely to generate aerosols, droplets of blood or other body fluids. It also protects mucous membrane of the eyes and transmission of blood borne viral infections. Light weight goggles or full cover transparent visors/face shields are available for this purpose.
Hair Co
Hair Co
Hair Co
Hair Co
Hair Covvvvvererererer
Long hair must be tied up. All hair must be completely covered by a close fitting cap. Similarly beard and mustache also should be completely covered.
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Operating theater personnel should wear clean, comfortable, antislip and antistatic shoes. Sole of the footwear should be hard enough to protect the feet from sharps injury.
The importance of excluding personnel with even a small, innocuous septic lesion in sterile areas cannot be
overemphasized. Sneezing and coughing and those with respiratory infection are not permitted in operation room.
SCR
SCR
SCR
SCR
SCRUBBING AND DONNING STERILE GOUBBING AND DONNING STERILE GOUBBING AND DONNING STERILE GOUBBING AND DONNING STERILE GOUBBING AND DONNING STERILE GOWNWNWNWNWN
AND GLO
AND GLO
AND GLO
AND GLO
AND GLOVESVESVESVESVES
Hand scrubbing is the single most important method of controlling infection in the hospital environment. Investigations have revealed that about one quarter of rubber gloves used in oral surgery are perforated during use. Hence, it is obvious that the wearing of gloves does not diminish the importance of cleaning the hands by scrubbing.
1. Before scrubbing make sure that the finger nails are cut short and all nail polish removed. Wrist watches, rings, bracelets and bangles are also removed. Any adjustments of the cap, mask and protective eye wear/ glasses required should be done before starting the scrubbing.
2. The hands and forearms are scrubbed up to the elbows with brush and soap (or povidone iodine scrub) in running water according to prescribed plan. In many hospitals the recommended scrub technique is posted directly over the scrub sinks. Recommended time for scrub is 5 to 10 minutes. Two minute scrub between operations is acceptable. During the scrubbing, fingernails and webs of fingers should be given more attention. The hands are cleaned along with the forearms and the scrubbing is progressed towards the elbow, extending two inches above the elbow. 3. After scrubbing both the arms, the brush and the soap
are discarded and the arms are rinsed of excess soap. This rinse should be done with the arms elevated above the elbow height to enable the water to drain from the fingertips progressing down the arms and the elbows.
4. The hands are then dried with a sterile hand towel handed over to the surgeon by the scrub nurse. The technique of drying begins at the finger tips of one hand and progresses down the arm. Then, with the opposite side of the towel, the other arm is dried in a similar manner.
5. Application of hand gels/disinfectants—There are certain propriety preparations available to be applied to the hand after scrubbing and drying (e.g. Sterillium).
FIGURES 10.1A TO F: Steps in apron wearing
They help to give protection against hepatits B and HIV for about five hours in case of injury during surgical procedure. These gels should be completely dry before donning the gloves.
6. Wearing a sterile apron (gown)—The surgeon can now wear the sterile surgical gown with the help of an assistant (see the Figs 10.1A to 10.1F on
apron wearing).
a. Pick up the gown by holding its inner surface. b. Insert the right arm into the sleeve without touching
the out side of the gown. c. Then insert the left arm.
d. An assistant who is not scrubbed- up secures the gown ties at the surgeon’s back. The surgeon’s back as well as the gown below the level of the waist are considered unsterile.
7. Wearing sterile gloves—The surgeon is either helped into his gloves by a properly gowned and gloved surgical assistant or he wears the gloves himself
(see Figs. 10.2A to E). This is done in a such a
manner that only the interior of the gloves is touched by his/her bare hands. (The exterior and not the interior of the rubber glove is considered sterile)
a. The glove powder or the dusting agent provided is applied to the hand prior to wearing the gloves to facilitate the smooth passage of the palm into the gloves.
b. Pick out the left glove by grasping its folded cuff with the right hand.
c. Draw the left glove on to the hand without touching its outer surface.
d. Pick up the right glove by inserting the gloved left hand under its folded cuff.
e. Draw the right glove on to the hand turning the cuff on to the sleeve of the gown.
f. Turn the cuff of the left glove on to the sleeve of the gown.
8. The surgeon should take extreme care, so that the gown and gloves should not touch any area or objects that is not sterile. The backs of those who are gowned are considered unsterile, and also those areas below the waist. Hence one must be careful to keep the arms above the waist, when not operating. The mask and the cap are not sterile, hence also should not be touched with gloved hand.
Certain operation theater lights have handles that are detachable and are sterilizable. These can be adjusted
FIGURES 10.2A TO E: Steps in wearing gloves by the surgeon. Other lights must be adjusted by the
operating room personnel.
It must be remembered that, in addition to protecting the patient from outside contamination, the surgeon and his staff also are protecting themselves from potentially infected material such as blood, pus, saliva, and other possibly contaminated body fluids. Recognition of this fact is particularly important in light of the rapidly rising rate of hepatitis carriers.
HANDLING OF STERILE INSTR
HANDLING OF STERILE INSTR
HANDLING OF STERILE INSTR
HANDLING OF STERILE INSTR
HANDLING OF STERILE INSTRUMENTSUMENTSUMENTSUMENTSUMENTS
Once the instruments have been sterilized they must neither be handled nor laid down on a nonsterile surface. The top of an operating trolley is thoroughly cleaned by application of alcoholic chlorhexidine solution and dried. Using two sterile Cheatle forceps this is covered first with a sterile waterproof towel and then with a sterile towel. The risk of contamination should a wet instrument be placed upon an ordinary towel during surgery makes the use of waterproof towel essential. The dry instruments are laid out with their handles pointing towards the operator in the order in which they will be used. The use of wet instruments should be avoided, especially when gloves are not being worn, because bacteria from
operator’s hands may be carried in fluid which runs down the handles, on to the blades and into the wound. If there is a delay before the operation is commenced, the trolley top should be protected from contamination by covering it with a sterile towel applied with sterile Cheatle forceps.
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Patient Patient Patient Patient Positioning on Operatient Positioning on Operositioning on Operositioning on Operating ositioning on Operating Tating ating ating TTTTababababablelelelele
The patient undergoing surgery on the head and neck usually is positioned best with his head and back elevated, his hips and knees flexed, and his feet on a level just above the knees. This position provides better venous drainage in the legs, reduces venous pressure in the head and neck, and permits more physiological cardiopulmo- nary function, since the weight of the viscera is not on the diaphragm. Pressure points on the heels, elbows, and hands must be avoided at the risk of peripheral nerve injury and stasis damage to the skin.
The surgeon should discuss with the anesthetist before hand the type of procedure planned, the severity of bleeding anticipated, approximate duration of the procedure and any complication expected. This will greatly help the anesthetist regarding the selection of drugs for induction and maintenance of general anesthesia. Requirement for hypotensive anesthesia or permission
to use adrenalin saline injection to reduce bleeding also be intimated to the anesthetist well in advance. For intra oral procedures request the anesthetist for nasotracheal intubation, so that endotrachaeal tube will not interfere with procedure inside the mouth. For extra oral procedures, orotracheal intubation is sufficient. In those cases where there is restricted mouth opening, the cause for the restriction should be discussed with the anesthetist. When the restriction is due to muscle spasm, it will generally be improved after the administration of muscle relaxant. For cases due to other reasons, like temporomandibular joint ankylosis, the anesthetist will have to plan for fiber optic laryngoscopy or blind nasal intubation.
No drug should be injected by the surgeon during surgery without the permission of the anesthetist.
Induction of Anesthsia and Intubation (Fig. 10.3
Induction of Anesthsia and Intubation (Fig. 10.3
Induction of Anesthsia and Intubation (Fig. 10.3
Induction of Anesthsia and Intubation (Fig. 10.3
Induction of Anesthsia and Intubation (Fig. 10.3
and 10.4A to E)
and 10.4A to E)
and 10.4A to E)
and 10.4A to E)
and 10.4A to E)
Once the patient is properly positioned, the anesthetist starts the IV line(if not already placed). All necessary monitoring devises (BP apparatus, pulse oximeter, ECG monitor or multichannel monitors) are connected. This is followed by the induction of general anesthesia with short acting muscle relaxants and ultra short acting
FIGURE 10.3: Tray setup for endotracheal intubation
FIGURES 10.4A TO E: Steps in endotra- cheal intubation (ETT), (A) Pre-oxygena- tion, (B) Induction, (C) Introduc-tion of ET tube, (D) Inflating cuff of ET tube, (E) Inserting throat pack
barbiturares. Once both has taken its effect, endotracheal intubation is done by the anesthtist and the endotracheal tube is connected to the anesthesia machine (Boyles machine). The anesthtist then auscultates to make sure that the endotracheal tube is within the bronchus and both the lungs are equally ventilated. This step is crucial to make sure that the tube is not in the pharynx and there is one lung anesthesia, since the former can result in the death of the patient and the latter can lead to collapse of the unventilated lung. Once the correct
position of the endotracheal tube is ascertained, the cuff of the tube is inflated to obtain an adequate seal at the laryngeal opening.
If Ryle’s tube feeding is desired after surgery, the Ryle’s tube is inserted at this stage. This is because passing the Ryle’s tube through the most patent nose before surgery can jeopardise the passage of nasoendotracheal tube (when it is absolutely indicated) through the less patent adjacent nostril.
After the patient has been anesthetized and intubated either nasoendotracheally or oroendotracheally, or if the anesthesia is being administered through tracheostomy tube, it is desirable to insert-some form of moistened sterile gauze pack (throat pack) into the oropharynx to screen it from the oral cavity. Most endotracheal tubes are cuffed so that they will prevent the passage of blood, water, or other secretions into the trachea around the endotracheal tube. For various reasons, however, the cuff may not provide a complete seal. During lengthy procedures, it is wise to deflate the cuff periodically to prevent possible pressure against the tracheal mucosa. The throat pack should be placed carefully and gently so that unnecessary irritation to the oral and pharyngeal mucosa is avoided. The pack so placed functions as a protective screen, preventing foreign bodies from passing into the pharynx. The surgeon should inform the anesthetist in advance the approximate duration of the surgery, so that the anesthetist can plan accordingly regarding the administration of muscle relaxants and the anesthetic agents. Early planning will ensure a fast and smooth recovery from an anesthesia.
SURGICAL SITE PREP
SURGICAL SITE PREP
SURGICAL SITE PREP
SURGICAL SITE PREP
SURGICAL SITE PREPARAARAARAARATION AND DRAPINGARATION AND DRAPINGTION AND DRAPINGTION AND DRAPINGTION AND DRAPING
THE PA
THE PA
THE PA
THE PA
THE PATIENT (FIGS 10.5A TIENT (FIGS 10.5A TIENT (FIGS 10.5A TIENT (FIGS 10.5A TIENT (FIGS 10.5A TTTTTO F)O F)O F)O F)O F)
Complete sterilization of the skin or oral cavity cannot be accomplished. However, the bacterial count can be reduced significantly. Shaving of hair-bearing skin should be done as near to the time of surgery as possible to prevent bacterial colonization of the unavoidable abrasions caused by shaving. Subsequently the operative site can be cleansed vigorously with a suitable detergent. At the present time the iodophors or povidone-iodine preparations are popular for cleansing. Studies have
shown that povidone-iodine mouthwash reduced bacteremia during exodontics. Of the patients treated with the iodine preparation, 28 percent had bacteremia as compared to 56 percent of the group receiving placebos. The properly performed intraoral preparation supplemented with appropriate prophylactic antibiotics for patients susceptible to endocarditis is recommended highly. The routine preoperative preparation of the oral cavity, with either a suitable mouthwash for the patient under local anesthesia or with a physical scrubbing and application of one of the iodophors for patients under general anesthesia, is to be highly recommended prior to the extraction of teeth and other intraoral surgical procedures.
Cleansing of the surgical site(skin) in the extraoral region is done using povidone iodine (Betadine)solution (Fig. 10.5A). The cleaning should begin in the center of the site to be prepared and move outward concentrically away from the site of operation. This avoids contamination of the already cleaned area.
Prior to draping, with the patient under general anesthesia, the eyelids should be closed carefully so that no eyelashes are turned under, and the lids should be taped shut with paper tape to protect the cornea and the sclera. Methylcellulose (artificial tears or Liquifilm) drops or an ophthalmic ointment of low allergenicity may be placed in the conjunctival fold as an additional measure. The eyes are then covered with sterile ophthalmic pads or some form of metallic eye shields such as the Fox eye shield that is taped from the supraorbital rim to malar eminence. It is important that female patients be requested to remove all eye makeup the evening prior to surgery.
The patient is now ready to be draped with sterile sheets and towels appropriate to the indicated surgical procedure (Fig. 10.5A to F). The recent availability of sterile, disposable, transparent or semitransparent plastic drapes with large or small apertures has provided new sophistication in draping the patient for intraoral or extraoral procedures.
Once the patient is prepared and draped, only those personnel, who have scrubbed, gowned and gloved should work at the surgical site.