16. Introduction to the Operating Room | Clinicians Pocket Reference, 11th Edition

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Introduction to the Operating Room: Introduction

Prepare before you get to the OR by knowing the patient thoroughly and having a basic understanding of what is planned. Avoid stereotyping the nurses as "cranky," the surgeons as "egotistical," and the medical students as "clueless" by learning the OR routine. Be alert, attentive, and, above all, patient. Don't be afraid to admit to the scrub nurse and the circulating nurse that you're new in the OR. They are usually happy to help you follow correct procedures.

Sterile Technique

The members of the OR team include the surgeons, anesthesia staff, and the nursing staff. Members of the surgical team are the surgeon, surgical assistants, students, and scrub nurse or technician responsible for the instruments, gowning the surgical team, and maintaining a sterile field. The circulating nurse acts as a go-between between the sterile and nonsterile areas.

Sterile areas include the front of the gown to the waist, gloved hands and arms to the shoulder, draped part of the patient down to the tabletop, covered part of the Mayo stand (the small table where the most commonly used instruments are kept), and the top of the back table where additional instruments are kept. The sides of the back table are not considered sterile, and anything that falls below the level of the patient table is considered contaminated.

Entering the OR

In the OR everything is geared toward maintaining a sterile field. Use of sterile technique begins in the locker room. Change into scrub clothing. Remove your T-shirt, tuck the scrub shirt into the pants, and tuck the ties of the scrub pants inside the pants. In some hospitals scrub clothes are allowed on the wards, provided they are covered by a coat or other form of gown; check your hospital's requirements. If you wear scrub clothing out of the OR, be sure that it is not bloodstained.

Pass into the surgical anteroom to get your mask, cap, and shoe covers. The mask should cover your entire nose and mouth. Full hoods are necessary for men with beards. The cap must cover all of your hair. Because of universal precautions, protective eyewear is required while you are at the operative field. If you wear regular glasses, use a mask with adhesive at the bridge of the nose to prevent fogging. Tape the glasses to your forehead if you think they may be loose enough to fall onto the table during the operation. Do not wear nail polish, and remove any loose jewelry, watches, and rings before scrubbing. Make sure that shoelaces are tucked inside the shoe covers.

At most hospitals you do not have to wear the mask in the hallway of the OR suite, but you do have to wear everything else. The mask must be worn in the OR itself, near the scrub sinks, and in the substerile room between ORs.

Find the OR where your patient's procedure is taking place, and assist in transport, if necessary. Introduce yourself to the intern or resident and nurse, and try to get an idea of when to begin scrubbing (usually when the first surgeon starts to scrub). If you have a pager or cell phone, follow local OR procedures, and remove the pager or cell phone if you are going to scrub into the case. If the electronic device is allowed, keep it in the room, identifying it with your name and informing the circulating nurse about its presence.

Surgical Hand Scrub

The purpose of the surgical scrub is to decrease the bacterial flora of the skin by mechanical cleansing of the arms and hands before the operation. Key points to remember: (1) If contamination occurs during the scrub, start over, and (2) In emergency situations exceptions are made to the time allowed for scrubbing (as in obstetrics, when the baby is brought out from the delivery room and the student is still scrubbing!). Properly position your cap and mask before starting the scrub.

Povidone Iodine (Betadine) Hand Scrub

Scrubbing technique depends somewhat on local policies. Some ORs require a timed scrub in which you determine the duration of scrubbing by watching the clock. Other ORs use an "anatomic" scrub in which the duration of scrubbing is determined by counting strokes. Some ORs use brush-free or waterless scrubs.

Timed Scrub

1. Perform a general prewash with surgical soap and water up to 2 in (5 cm) above the elbows.

2. Aseptically open one brush and place it on the ledge above the sink for the second half of the scrub. Open another brush, and begin the scrub with povidone iodine. Use the nail cleaner to clean under all fingernails.

3. Scrub both arms during the first 5 min. Start at the fingertips and end 2 in (5 cm) above the elbows; pay close attention to the fingernails and interdigital spaces. Discard the brush and rinse from fingertips to elbows.

4. Take the second brush and repeat step 3. Always start at the fingertips and work up to the elbows.

5. Always allow water to drip off the elbows by keeping the hands above the level of the elbows.

6. Move into the OR to dry your hands and arms (back into the room to push the door open).

7. Scrubbing times:

a. Ten minutes at the start of the day or with no previous scrub within the last 12 h and on all orthopedic cases

b. Five minutes with a previous scrub or between cases if you have not been out of the OR working with other patients

Chlorhexidine (Hibiclens) 6-Min Hand Scrub (Timed)

1. Wet your hands and forearms to the elbows with water.

2. Dispense about 5 mL of chlorhexidine into your cupped hands and spread it over both hands and arms to the elbows.

3. Scrub vigorously for 3 min without adding water. Use a sponge or brush for scrubbing, and pay particular attention to fingernails, cuticles, and interdigital spaces.

4. Rinse thoroughly with running water.

5. Dispense another 5 mL of chlorhexidine into your cupped hands.

6. Wash for an additional 3 min. There is no need to use a brush or sponge at this point. Rinse thoroughly. Move into the OR back first to dry your hands.

Anatomic Scrub

1. Perform a general prewash with surgical soap and water, up to 2 in (5 cm) above the elbows.

2. Use disposable brushes if available. Aseptically open one brush and place it on the ledge above the sink for the second half of the scrub. Open another brush and begin the scrub. Use the nail cleaner to clean under all fingernails.

3. Scrub each surface vigorously 10 times. Start with each finger (each of which has four surfaces), proceeding to the hand, the forearm, and the arm above the elbow. After finishing one extremity, scrub the other from fingers to above the elbow. Be sure to include all parts of your hand, especially the interdigital spaces.

4. Rinse both arms and rescrub each extremity, this time not going above the elbow. The method is the same as that for step 3: 10 times on each surface from fingers to elbow.

5. Rinse thoroughly and proceed into the OR.

Waterless Surgical Scrub (Handrub)

1. Most waterless surgical hand rubs are alcohol based (usually > 60% ethyl alcohol with chlorhexidine). The CDC recommends that surgical staff prewash with nonantimicrobial soap and dry hands and arms completely before using an alcohol-based product, such as Avagard or Triseptin.

2. For the first scrub of the day, make sure your hands are visibly clear of any soiling (the same is true for subsequent scrubs), and clean the nails with the provided cleaner.

3. Apply the product to clean, dry hands. Dispense one pump (2 mL) into the palm of one hand. Dip the fingertips of the other hand into the hand prep and work under the fingernails. Spread the remaining hand prep over the hand and up to just above the elbow.

4. Dispense one pump (2 mL) and repeat the procedure with the other hand.

5. Dispense the final pump (2 mL) of hand prep into either hand and reapply it to all aspects of both hands up to the wrists. Allow the prep to air dry; do not use towels. Air dry completely before gowning and gloving.

Preparing the Patient

Most ORs have instituted a time-out policy whereby all attention is directed at reading the surgical permit aloud and clearly identifying the patient, operation, and site of procedure to reduce medical errors. The patient prep technique can vary but involves mechanically cleansing the patient's skin in the region of the surgical site to reduce bacterial flora. Ask the resident to guide you through the procedure; it is always better to prep a wider area than you think necessary. For example, for midline laparotomy, prep the patient from nipples to pubis and from the flank at table level on one side to the flank at table level on the other side.

Materials

Small prep table containing gloves, towels, povidone iodine or other scrub soap (optional), povidone iodine or other paint solution, 4 x 4 gauze squares or sponges, ring forceps (optional)

Technique

1. Prep the patient before putting on the sterile gown. Using sterile technique, put on a pair of gloves, and scrub the area designated with the soap solution. At many centers, wound scrubbing is no longer routine and is used only in specific conditions, such as contaminated wounds.

2. Cover the area with a towel, and then gently pat the area dry if the wound was scrubbed. Gently peel off the towel from one side, being careful not to allow the towel to fall back on the prepped area.

3. Use 4 x 4s to paint the exposed area with the povidone iodine or other solution, using the proposed incision site as the center. Move circumferentially away from the incision site. Never bring the 4 x 4s back to the center after they have painted peripheral areas. Paint in a series of concentric circles.

4. After the prep, remove the gloves using sterile technique and put on your gown.

Gowning and Gloving

1. If you have just completed the hand scrub, back into the room to push the door open; keep your hands above your elbows.

2. Ask the scrub nurse for a towel. Do not be impatient; the scrub nurse is often very busy. Stick out one hand, palm up and well away from the body. The nurse drapes the towel over your hand.

3. Bend at the waist to maintain sterility of the towel. It should never touch your clothing.

4. With one half of the towel, dry one arm, beginning at the fingers; change hands and dry the other arm with the other half of the towel. Never go back to the forearm or hands after drying your elbows.

5. Drop the towel in the hamper. Again, remember to keep your hands above your elbows. Ask for a gown and hold your arms out straight. The scrub nurse places the gown on you, and the circulator ties the back.

6. The nurse holds out a right glove with the palm toward you. Push your hand through the glove. Gloves come in several sizes small (5 6 ), medium (7 7 ), and large (8 8 ) and materials: standard latex gloves, hypoallergenic (powder free), reinforced (orthopedic), and latex free. Ask the resident or scrub nurse for guidance on the type of glove to request. It is good form to ask the circulating nurse to open your gloves before you actually begin to scrub.

7. Repeat the procedure with the left glove. It is easier if you use two fingers of your gloved right hand to help hold the left glove open.

8. Visually inspect the gloves for holes. Double gloving is becoming commonplace because of increased awareness of universal precautions and may be mandatory depending on the procedure being performed.

9. Give the scrub nurse the long string of your front gown-tie. Hold the other string yourself and turn around in place. Tie the strings.

10. The nurse may offer you a damp sponge to clean the powder off the gloves (powder is implicated in some postoperative complications, eg, adhesions); however, most gloves are powder free.

11. Wait patiently; stay out of the way, and keep your hands above your waist. Hold them together to prevent yourself from accidentally dropping them or touching your mask. This is one of the most difficult things to remember. Be attentive. The only sterile area is the front of your body from chest to waist and hands to shoulders. Your back is not sterile, nor is your body below the waist. Do not cross your arms.

Draping the Patient

Draping the patient is usually done by the surgeon and assistants. Watch how they do it, and consider helping in a future procedure. It is more difficult to keep sterile than it looks.

Finding Your Place

As a student, stand where the senior surgeon indicates. The first thing to remember is that once you are scrubbed, you must not touch anything that is not sterile. Put your hands on the sterile field and do not move about unnecessarily. If you need to move around someone else, pass back to back. When passing by a sterile field, try to face it. When passing a nonsterile field, pass it with your back toward it. If you are observing an operation and are not scrubbed in, do not go between two sterile fields, and stay about 1 ft (30 cm) away from all sterile fields to avoid contamination (and condemnation!). When not scrubbed in, keep your hands behind your back, being careful not to back into the instrument table.

When scrubbed, do not drop your hands below your waist or table level. Do not grab at anything that falls off the side of the table it is considered contaminated. If something falls, inform the circulating nurse. Do not reach for anything on the scrub nurse's small instrument stand (the Mayo stand); ask for the instrument to be given to you.

If someone tells you that you have contaminated a glove, light handle, or anything else, do not move and do not complain or disagree. Remember that the focus of the OR is maintaining a sterile field, so if anyone says, "You're contaminated," accept the statement, and change gloves, gown, or whatever is needed. If a glove alone is contaminated, hold the hand out away from the sterile field, fingers extended and palms up, and a circulating nurse will pull the glove off. The same is true if a needle sticks you or if a glove tears. Tell the surgeon and scrub nurse and change gloves. For a skin break event such as a needle stick, follow local infectious disease policies.

If you have to change your gown, step away from the table. The circulator will remove first the gown and then the gloves. This procedure prevents the contaminated inside of the gown from passing over the hands. Regown and reglove without scrubbing again.

Always be aware of "sharps" on the field. When passing a potentially injurious instrument, alert the other members of the team aware that you are passing a sharp (eg, "needle back," "knife back"). Learn the names and functions of the common instruments. A knowledgeable student is more likely to actively participate in the operation.

At the end of the operation (once the dressing is on the wound), remove the gown and gloves but not the mask, cap, or shoe covers. To protect yourself, remove the gown first, and remove your own gloves last. This system keeps your hands clean of blood or fluids that got onto your gown during the procedure.

In accordance with the OSHA Bloodborne Pathogens Standard, wash your hands with soap and water after the surgical procedure. Assist in the transfer of the patient to the recovery room. Write postop orders and a brief operative note immediately (see Chapter 2 on how to write postop notes and orders). It is good form to offer to write the postop note and orders if you are comfortable with the process. Because of regulations that affect attending physicians at teaching hospitals, the attending may be required to write the note personally. At the very least, the attending of record annotates an "attestation" to your note saying that the surgeon was "personally present during the critical portions of the procedure."

Universal Precautions

All operating room personnel are at risk of infection with blood-borne infectious agents (eg, HIV, hepatitis). To reduce the incidence of such transmission, the CDC has developed a set of guidelines called universal precautions. The underlying principle is that because patients cannot be routinely tested for HIV and are rarely tested preoperatively for transmissible diseases such as hepatitis, the safest policy is to treat all patients as though they have an infection. This approach ensures evenhanded treatment of all patients and the safest work environment for those exposed to the blood of others.

Minimizing the risks to all who are in the OR requires constant vigilance. Movements must be coordinated among surgeon, assistant, and technician. Never use your fingers to pick up needles; pick them up only with another instrument. DO not use your fingers and hands as retractors. Two people should never be holding the same sharp instrument. Placing a sharp instrument down or handing it to another member of the team is always preceded by a verbal warning that notifies the recipient that a sharp object is about to be passed. Protective eyewear must be worn by all members of the operating team.

The practice of double gloving is often reserved for operations in which the patient is known to carry a transmissible agent. This technique reduces the incidence of blood skin contact, especially in light of the extraordinarily high incidence of unrecognized glove perforations. Until puncture-resistant gloves are developed, double gloving is the best approach.

Latex Allergy

People with medical conditions or occupations heavily exposed to products containing natural rubber latex may became sensitized to it and develop allergic reactions (~7% of health care workers). Some conditions, such as spina bifida and cerebral palsy, predispose patients to an 18 40% incidence of allergy. Reactions vary from mild rash and itching to anaphylaxis and death. Latex products are found in a wide array of products, from gloves and drapes, to IV tubing and syringes. Some patients have documented latex allergy. Hospitals have latex allergy protocols, and hospitals maintain an inventory of latex-free products that should be used in these cases.