Care in the

operating room
 Patient preparation
Both the operating surgeon and the anesthetist should see the patient
prior to surgery. The patient’s identity and the proposed surgery should
be confirmed. After explaining the risks and benefits to the patient, valid
consent for surgery should be obtained. There should be an opportunity
for questions, and the patient should have adequate time to make their
decision. Any changes in the patient’s condition since listing for surgery
should be noted, and a check made for any contraindications to elective
surgery, e.g. intercurrent illness or remote site infection. In procedures
that may cause neurovascular complications, the preoperative
neurovascular status should be assessed and documented. Check that all
relevant results and imaging are available, and that the side or area to be
operated on is marked with an arrow at or near to the incision site.
 Theatre team preparation
Preoperative planning should
cover all aspects of the surgical
process. Close communication
and coordination between
preoperative departments and
operating theatres allows
timely preparation and
improves efficiency and safety
in the operating theatre.
Antibiotics

To prevent surgical site infection, patients should receive appropriate

antibiotics, using local guidelines, less than an hour before surgical
incision. Antibiotic prophylaxis should be given to patients before clean
surgery involving insertion of a prosthesis or implant, clean-
contaminated surgery or contaminated surgery. Antibiotic prophylaxis
should not be used routinely for clean, non-prosthetic surgery.
Prophylactic antibiotics should be discontinued within 24 hours of
surgery.
Venous thromboembolism
All patients should be risk-assessed preoperatively for venous
thromboembolism (VTE). Patients should not be allowed to become
dehydrated perioperatively. In theatre, mechanical and pharmacological VTE
prophylaxis can be used.
Mechanical methods include:
• anti-embolism graduated compression stockings;
• foot impulse devices;
• intermittent pneumatic compression devices.
The choice of pharmacological VTE agents depends on local policies and
individual patient factors, including comorbidities (such as renal failure).
Regional anesthesia (spinal or epidural) carries a lower risk of VTE than
general anesthesia. If used, plan the timing of pharmacological VTE
prophylaxis to minimise the risk of spinal hematoma.
Operating theatre environment
Ventilation
The aim of the air flow system is to prevent airborne microorganisms
entering the surgical wound. After filtration, air is introduced at ceiling
height and exhausted near the floor with at least 20 air changes per
hour. The operating theatre is maintained at positive pressure relative
to surroundings. Keeping doors closed and limiting the movement of
personnel in and out of theatre will reduce the risk of surgical site
infection. Laminar air flow provides 100–300 air changes per hour and
is used in some centers for surgery involving implants, e.g. joint
replacements, to avoid airborne infection.
 Humidity and temperature
Theatre temperature should be
acceptable for the patient and
theatre staff. Ideal working
temperatures for surgeons are 19–
20°C, but patients may develop
hypothermia below 21°C.
Temperatures of 20–24°C are
acceptable with a relative humidity
of 50–60 per cent to protect
against electrostatic charges.
Patient transfer and positioning

Both transfer and positioning

should be performed carefully under
the supervision of the anesthetist and
surgeon. These precautions are
essential under general anesthesia as
the patient will be immobile and
unable to communicate problems;
the patient receiving local or regional
anesthesia should also feel
comfortable.
Transfer

Patient transfer is coordinated

by the anesthetist, who protects
airway devices and other
connections during the move. A
variety of manual handling aids are
used (sliding boards and low-
friction sliding sheets) to reduce
risks to staff and patient; universal
precautions should be maintained
by everyone
Positioning

The plan for intraoperative positioning should be communicated to

the entire team as it may require specific accessories, such as arm
supports, to be available; aesthetic management may also be affected.
Stability of the patient on the table should be ensured using straps
and/or solid supports, particularly where anything other than supine
positioning is anticipated.
Pressure and stretch injuries resulting from poor positioning are
common. High-risk groups include the elderly, the cachectic or the
obese. High-risk areas should be checked and padded prior to starting
surgery. During lengthy operations, movement of non-involved limbs
may be necessary to relieve pressure
 In addition, in order to avoid electrical injury, no part of the patient
should be in contact with any metal other than the diathermy plate. If
radiological imaging is to be used intraoperatively, the patient could be
protected with lead shielding and a radiolucent table used.
Finally, the awake patient should be comfortable. A pillow under the
knees often relieves the aching low back pain associated with lying
supine.
Diathermy
If monopolar diathermy is to be used, the diathermy dispersal electrode
must be applied to an appropriate site, which should be:
• clean and dry, free of hair;
• situated over well-perfused muscle mass, avoiding bony prominences,
scar tissue, areas distal to tourniquets and implanted metalwork;
• as close to the operative site as feasible;
• checked at the end of surgery for injury.
The patient should not be in contact with any earthed metal appliance.
Special consideration must be given to the risks of monopolar diathermy
if the patient has implanted devices which may be affected by the
current (including pacemakers, implantable defibrillators, cochlear
implants and spinal cord stimulators).
 Tourniquets
A tourniquet may be used to improve visibility at surgery and to reduce blood
loss.
Application of tourniquet
Appropriate size should be selected;
Apply as proximally as possible;
Apply padding to site without creases;
Apply tightly enough to avoid slippage, but not so tightly as to impede
exsanguination;
Exsanguinate the limb prior to inflating the tourniquet using elevation, an
Esmarch bandage or a roll cylinder;
When the tourniquet is inflated, the time must be noted;
When the tourniquet is removed, the site should be inspected for damage and
the limb for return of circulation. This should be recorded in the notes (with
the time);
Temperature control
Patients undergoing anesthesia and surgery lose heat rapidly from
radiation to the environment, latent heat of evaporation from exposed
wet organs in body cavities or from cleaning fluids applied to the body
surface, exposure to cold intravenous fluids and anesthetic gases. The
patient’s ability to compensate for these losses is also impaired
(reduced metabolic heat production, limited vasoconstriction and the
loss of behavioural responses).
The measures which will limit the development of intraoperative
hypothermia include the use of forced air warming blankets, warmed
intravenous and irrigation fluids, increasing the operating room
ambient temperature and minimising exposure of the patient.
Hair removal

This may be necessary over the operative field to facilitate exposure

(for incision, suturing and dressing application) or the diathermy plate
site (to maximise plate contact with skin). Surgical site infections may
be reduced if hair is clipped rather than shaved; there is a lack of
evidence to determine whether the timing or location of hair removal
affects the incidence of wound infection.
Glycemic control

The blood glucose needs careful monitoring and controlling

in the diabetic patient. Hyperglycemia perioperatively may
increase the incidence of postoperative wound infection. If
unrecognised, hypoglycemia may lead to seizures and death.
 Asepsis and universal precautions
Cross-infection between patients or between staff member and patient
(in either direction) is potentially disastrous and every effort must be
made to minimise this risk. In addition to some of the specific areas
considered below, universal precautions should be taken in every case
involving exposure to body fluids. These include the following:
• protective non-porous gloves, eyewear, mask, apron for staff;
• safe sharps handling techniques and adequate provision of sharps bins;
• staff vaccination for hepatitis B;
• staff with infected wounds or active dermatitis should not work in
theatre
 Scrubbing up
The risk of transfer of microbes between staff
and patients is minimised by meticulous
‘scrubbing up’;
Standard scrub solutions include:
• 2 per cent chlorhexidine (effective for more
than 4 hours, potent against Gram-positive
and -negative organisms, some viruses, less
effective against the tubercle bacillus);
• 7.5 per cent povidone-iodine (duration of
effect shorter, highly bactericidal, fungicidal
and viricidal; some effect against spores and
good anti-tubercle effect);
• alcohols (highly effective against all but
spores and inexpensive).
 Movement in theatre
Scrubbed personnel should:
• keep their hands and arms on the operating table where possible;
• keep their hands away from their faces;
• touch only sterile items or areas;
• watch the sterile fields to avoid contamination;
• not lean over unsterile fields;
• pass each other back-to-back or front-to-front.

Unscrubbed personnel should:

• touch only unsterile items or areas;
• face and observe a sterile area when passing it to be sure that they do not touch it;
• avoid walking between the patient and trays;
• minimise activity near the sterile field.
Prepping and draping the patient
Pre-prep’ may be indicated where there is visible debris to be removed;
it consists of washing the skin with soapy disinfectant, then water or
saline, then surgical disinfectant. Patients undergoing elective surgery
may instead shower on the day of surgery with a soapy disinfectant.
Skin preparation should include the surgical site and a wide area
around it, starting from the incision site and working away from it.
Contaminated areas (groin, perineum, axilla) should be covered last.
Two coats are usually used and the solutions are similar to those used
for scrubbing up. Care should be taken to avoid using excessive
amounts of prep solution. This leads to pooling which can cause a
chemical burn or ignite in the presence of a spark.
 Draping aims to create a protective
zone around the operative site to
avoid contamination of items used
for the procedure. Both disposable
and reusable drapes are suitable, and
should be handled only by scrubbed
personnel. They should be sited to
allow full access to the incision (or
any possible extension). Once in
place, they should not be disturbed.
Skin immediately around the incision
site may also be covered with a self-
adhesive transparent drape.
Diathermy and suction equipment
are attached to the drape.
 Role of the assistant
Surgical assistants are frequently surgeons in training. They are
therefore in theatre to help the senior surgeon and to learn as much as
possible.
Preparation. Assistants should review the anatomy and the operation
before surgery so that they can anticipate and understand the actions of
the senior surgeon. They should start scrubbing first, having checked that
the patient is ready for theatre.
Training. Trainees should write important steps of proposed operation in
brief on a board in the operating theatre.
At surgery. The assistant should try to provide the surgeon with the best
access possible by placing and holding retractors and showing the surgeon
the field where they are working.
 ‘Sign out’
Before any personnel leave
theatre, the WHO ‘sign out’ checks
should be completed. These
include checking that the
procedure has been recorded, that
instrument and swab counts are
correct, that there have been no
equipment problems requiring
further action and the key
concerns for recovery recorded for
the staff taking over care of the
patient