DOWN MEMORY LANE

REVIEW AND RECALL



SELECT DEFINITIONS YOU NEED TO KNOW

ANTISEPSIS

A process that destroys most harmful microorganisms on
The surface of Instruments

BACTERICIDAL

Drugs, chemicals, and other agents able to kill bacteria

BACTERIOSTATIC

Agents capable of inhibiting the growth of bacteria but not killing them


CAVITATION

A process in which air pockets are imploded (burst inward),
Releasing energy to dislodge particles of soil or tissue debris
Sticking to instruments. Antiseptics chemicals used for reducing
Contamination of body surfaces

CLEANING

A process that removes organic or inorganic residue or debris by hand cleaning and brushing

CONTAMINATED

Any instrument or body surface that is known to be unsterile.
A sterile instrument comes in contact with non-sterile objects and thus may harbor Microorganisms

DECONTAMINATION

A process of disinfection

DISINFECTION

A process by which most but not all harmful microorganisms are
Destroyed on instrument surfaces

CRITICAL ITEMS

Those items that must be sterile before use in or on a patient; items
That goes into body tissues or the vascular system

STERILIZATION

A process by which all microorganisms are destroyed

ULTRASONIC CLEANER

Equipment that cleans instruments through cavitations

WASHER STERILIZER

Equipment that washes and sterilizes instruments following an
Operative procedure

FOMITE
An item(towel, bedsheet) that is capable of harboring bacteria and transmitting
Disease.

HOST
Organism that provides nutrition for parasites

PATHOGENIC
Disease causing bacteria

STRICT AEROBES
Bacteria that cannot survive without oxygen

STRICT ANAEROBES
Bacteria that cannot survive in the presence of oxygen
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RECYCLED INSRUMENTS AND MEDICAL WASTE

HOW TO DECONTAMINATE SURGICAL INSTRUMENTS?

Washer Steriliser

The washer-sterilizer operates much the same as the steam
sterilizer.
The washer-sterilizer sends large amounts of soapy
water over the instruments.
Steam under pressure and air are then injected into the water, which activates the water significantly.
As the water is drained from the chamber, tissue debris and scum are filtered off and steam fills the entire chamber.
The temperature is then maintained at 270oF for 3 minutes.
Near the completion of the cycle, the steam is released
through the exhaust system.

Ultrasonic Cleaner

Following processing in the washer-sterilizer, all instruments
should be placed in the ultrasonic cleaner.
This process further removes particles and debris through a process called cavitation.
During cavitation, high frequency sound waves are generated
through a water bath in which the instruments are placed along
with a neutral to slightly alkaline detergent.
Cavitation explode inwardly (implosion), and this causes their release from the surface of the instrument.
Following cavitation, instruments are rinsed thoroughly and dried.

WHAT ARE DISPOSAL MEDICAL WASTE?

The operation of a single surgical OT generates a large amount
of medical waste.

Among these are:

* gloves
* gowns
* backtable covers
* patient drapes
* needles and other sharps
* body fluids and secretions
* and other items that must be disposed of.

The types of regulated waste from health care facilities.

* These are radioactive waste, which is regulated by the
Nuclear Regulation Agency
* Hazardous chemical waste, which is regulated by environmental
protection agency
* The third type is potential infective waste, are for
the purpose of this text will be referred to as regulated
medical waste.

CATEGORIES OF MEDICAL WASTE

Sharps (used and unused)

Discarded medical devices that have been used in human
patient care, medical research, or industrial laboratories and
that are capable of pucturing or cutting the skin and thus
transmitting bacterial or virus infections.

This includes:
* needles
* syringes with needles attached
* trocars
* pipettes
* scalpel blades
* blood vials
* broken or unbroken glassware

Cultures and stocks of infectious wastes

Discarded cultures and stocks of infectious agents and associated
microbiologicals should be considered regulated medical waste.

Animal Waste

Discarded material originating from animals inoculated with
infectious agents during research or production of biological or
pharmaceutical testing.

Pathological waste

Discarded pathological wastes (eg. human tissues, organs, body
parts) removed during surgery, autopsy or other medical
procedures


Human blood, blood products, body fluids

This category includes discarded free-flowing human blood and
blood products (eg. plasma, serum), any free-flowing body
Secretion containing blood components (egg. pleural, peritoneal,
Amniotic fluid), human excretions (egg. urine, stool)
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THE INSTRUMENT CARE

Preparing the Tools for a Procedure







HOW TO TAKE CARE OF SURGICAL INSTRUMENTS?
Like all other equipment,medical and surgical instruments also
require a regular care and maintenance protocol so that they
retain their useful character and prolong their life.
Instruments that are dirty or rusty are not only a source of
infection, but ultimately break before their expected life span.

CARE OF STAINLESS STEEL:
Stainless steel is the material of choice for most surgical
instruments;it combines a high resistance to corrosion and rust
and has a smooth surface. However the surface of the finest
stainless steel instruments can become pitted and stained, if
great care is not used in washing, cleaning, polishing and
lubrication of these instruments. Rough handling or the use of
abrasives can permanently mark stainless steel.
- So to start with all instruments after use should be cleaned
with a hard brush under running cool water.Very hot water will
cause coagulation of blood and exudate and make subsequent
cleaning more difficult.
- If use of an Ultrasonic cleaning bath using instrument
detergents is available, this will be ideal and insure good
cleaning and continued high polish of the instruments. This
equipment is available only in some hospitals in India.
- After washing,instruments should be dried to avoid water
remaining in any joint and causing corrosion.
- Lubrication using a water-soluble lubricant applied on joints is
recommended and will greatly prolong the useful life of any
instrument if they are to be stored.
- Salt solutions are a major cause of pitting,and instruments
should never be soaked in them, nor should a saline solution be
allowed to dry on an instrument.
- Whenever cleaning or washing instruments, keep all ratchets
unlocked and box joints open and avoid using wire wool or rough
brushes on the surface of instruments.
- Surgical blades and needles, both of which may rust and corrode
more easily than stainless steel instruments and therefore the
rules above apply to them also.
- Serrated surfaces on artery forceps and needle holders can be
effectively cleaned with a small brass wire brush
- Instruments or plastic parts of instruments are washed
with warm soapy water with a soft cloth sterilization may be
by either soaking in antiseptic solutions or autoclaving at a
lower temperature (121 degree C under 151b/in2 for 15 min.)
than is used for steel instruments.Cleaning and polishing
should only be undertaken using recommended cleansers and
polishers. Most plastics are best stored in a dry state rather
than prolonged soaking in antiseptic solutions.

WHAT ARE CRITICAL ITEMS?

Critical items are those that must be sterile. These objects
enter sterile tissue or the vascular system. Examples of
critical items include:

* Surgical instruments
* Cardiac and urinary catheters
* Implants
* Needles

NONCRITICAL ITEMS
This group of items comes in contact with skin. Skin is
effective in protecting the inner tissues of the body against
bacteria and viral invasions. This category includes items :

* Blood pressure cuffs
* Bed linens
* Bedside tables
* Crutches
* Some food utensils
* Bed frames
* Floors
* Walls
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TO PREPARE FOR THE EVENT

An OT Day
HOW TO PREPARE OT?
- All equipment, particularly the operating theatre table and
all storage ledges,within the rooms,should be cleaned with damp
duster.Floors are cleaned before sterile trolleys are prepared.
- Sterile nail brushes,scrub solution gown packs and all items
required in the OT should be checked and replaced if required
- The required number of bottles or flasks of sterile saline or
water for hand-lotion bowls are placed in position.
- Fresh replacements of bandages, strapping, splints and lotions,
etc., should be available before the operation list commences.
- Finally equipment required for the first operation is checked by
the senior operating theatre nurse or the scrub nurse also selects
sterile packs, may prepare instruments and special apparatus for
sterilization.
- Special attention is given to the operation table and
accessories to ensure that these are present and in working
order, are inspected for illumination and focus of lights.
- All electromedical apparatus such as the diathermy and suction
machines or pipeline suction set are switched on and tested.

HOW TO PREPARE AN INSTRUMENT TROLLEY?
- Instrument trolley should be prepared immediately before an
operation.
- It is a bad practice to prepare all trolleys required for a
list in the morning,for even if they are covered carefully,it
is impossible to guarantee sterility when required later.
- All metal surfaces of trolleys and tables which are to be used
for setting out sterile instruments and apparatus should first
be covered with a sterile water-proof material before the
application of sterile drapes.
- If the instrument trays have been placed on the trolleys
aseptically,the instruments are laid out by a nurse wearing
sterile gown and gloves.
- It is a bad practice for an" unscrubbed"person to complete
this arrangement using Cheatle forceps, because of the great
risk of contamination occurring when ungloved hands are moved
to and fro over the sterile trolley.
THERE IS NO PLACE IN A MODERN OPERATING ROOM FOR USE OF UNSTERILE
FORCEPS STORED HALF SUBMERGED IN A CONTAINER OF DISINFECTANT.
- Prepared sterile packs containing all the necessary equipment
relevant to a listed operation, and incorporating trolley
drapes which fall into position as the pack is opened, will
shorten the time taken for preparation and cut down bacterial
contamination in the O.T.
WHAT ARE THE DUTIES OF THE SCRUB NURSE?
- The nurse or operating department assistant (ODA) acting as
scrub nurse, scrubs up puts on sterile gown, and sterile gloves
on the hands like the rest of the surgical team
- When scrubbing up to carry out surgical hand disinfection, care
must be taken to ensure that all parts of the hands and
forearms are cleaned thoroughly, special attention being given
to the nails and between the fingers.
- It is important that no person should scrub unless free from
upper respiratory infection and skin lesions.
- Cuts and abrasions or infected pimples can endanger the patient
by increasing the possibility of post-operative infection.
- She/he anticipates and provides all instruments required by the
surgeon.
- Keeps count of them and all swabs used.

WHAT ARE YOUR DUTIES AS CIRCULATING NURSES?
- In addition to the scrub nurse,one or two nurses or ODAS are
on duty to act as circulators.One stays in the operating
theatre, watching the scrub nurse and ready to bring anything
she requires.
- The main duties of the second circulating nurse are to see
that the instruments and trolleys are READY for the NEXT CASE,
and she should help in PLACING the PATIENT on the operation
table if a porter or technician is not available.
- She anticipates and gives to the scrub nurse articles from
sterile bags or packs, she REPLACES sterile gowns and gloves
used up on the sterile trolley reserved for the purpose.
- The first circulating nurse also TIES up the gowns, being
careful to avoid touching any part of the gown other than
the tapes.
- She should identify the patient by the identity tag and case
notes before he/she enters the OT.
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DRESS CODES AND TABLE POSITIONS

ENTRY RULES & POSITIONS



Some more positions


HOW DO YOU GET THE LATERAL POSITION OF EXTENSION?
This is used for operations on the kidney and chest, but may be
modified slightly for operations on the hip.
For the former operations the patient is positioned over the kidney bridge which is raised to extend this region.
Alternatively if an operation which incorporates a `break back' is used, extension is achieved by positioning the patient over the division in the centre section before adjusting the angle of the table top. Fig 8

HOW TO GET THE PRONE CRANIAL POSITION?
This position is used for cerebella operations and high cervical
laminectomy.
Some reverse Trendelenburg tilt is used and a padded strap placed round the thighs and the table top for additional security.
The shoulders and thorax are supported by shoulder supports in conjunction with small pillows. Fig. 9

HOW TO GET PATENT IN SITTING CRANIAL POSITION?
This is a position for cerebella cranial operations and high
cervical laminectomy and is an alternative to that described.
The patient is sitting and stabilised by the cranial support.
The hands are placed in the lap and the body immobilised by
securing the arms with body supports which are attached to the
operation table at each side.
These have been omitted in the illustration in order to show the position of the arms. fig 10

RULES YOU OBSERVE IN OT?
No one should enter the operating rooms without first washing his
hands and changing into clean OT clothing and footwear such as
theatre rubber shoes, sandals or slipper.
The main objective is to prevent entry of street bacterial contamination into the operating rooms.
This rule must apply even when there are no operations in progress.
- Personnel preparing to assist at operations cover their hair
and wear masks in addition to wearing suitable clothing and
footwear.
Visitors and other staff are similarly attired.
- Cotton, poplin or polyester cotton are the most commonly used
materials for theatre clothing; Blue, grey colour or white for
scrub suits, and green colour or white for operating gowns.
- The hair should be completely covered with a closely fitting
caps.
- The most efficient mask is one made from synthetic fibres or
fibre glass, linen masks can be used in case these are not
available.
- These masks, which should be moulded to fit the facial outline
snugly when worn, actually filter the air rather than deflect
as with the paper or cloth masks.
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NEED TO KNOW

TABLE MANNERS





Who Should Know?
It is essential that all members of the theatre staff familiarize
Themselves with the operation table and its accessories which
must be easily available and ready for immediate use.
To insure this, passing on of this information is a part of the introductory briefing of all new staff.
- The whole apparatus must be maintained in good working order
and checked before each operation list.
Careful and correct positioning of the patient is very important.
- It is essential to provide good access for surgery.
- And also to take into account patient safety.
- Anesthesia technique requirements.
- Monitoring and position of i.v. lines.
- The table top rubber mattress must provide insulation and
Prevent harm to the patient due to pressure, especially on
Nerves and bony prominences.
Most of the following positions are demonstrated on an general
purpose operation table which incorporates the majority of the
features described already.

What are the Positions?
In Supine or Dorsal Recumbent Position (Fig.2)
In this position the patient lies on his back and is used for MOST operations, including those on the
- Eye
- Ear
- Face
- Chest
- Abdomen
- Legs or Feet
- And with modifications is suitable for operations on the breast
and arms or hands, which may be placed across the chest or
extended on an arm table.

WHAT IS BREAST AND AXILLA POSITION?
This is the position for operations on the breast and axilla. It
is a modified supine position, either with both arms extended and
secured on arm tables, or one arm secured by the side of the
patient and the other on the affected side abducted and
supported by a nurse (Fig 3).

WHAT IS NECK POSITION?
This position is used for operations on the neck, especially
Thyroidectomy, and tracheotomy.
The patient is placed in the supine position with a pillow or sandbag under the shoulder blades, and the head is held by a nurse or assistant with the neck well extended, a padded horse-shoe provides a good support for the head in such operations.

WHAT IS SUPINE HIP POSITION?
This is used mainly for nailing a femoral neck fracture, but is
suitable for osteotomy, slipped femoral epiphysis,etc.
The patient is in a supine position, with his pelvis supported by a
supplementary table top which is translucent to X-rays and
incorporates a slot for introducing anterior position film
cassettes under the pelvis fig 4.

WHAT IS THE TRENDELENBURG POSITION (HEAD DOWN)?
This position, a modification of supine, is used for intrapelvic
operations. Fig 5.
- The object being to allow the intestines to displace away from
the pelvic cavity by gravity towards the upper abdomen.
- They may also be packed off readily to leave easier access to
the pelvic organs.

HOW IS THE GALL-BLADDER AND LIVER POSITION ARANGED?
This is another modified supine position which is used for
operations on the gall-bladder or liver.The patient is
positioned over the back elevator which is raised to produce
extension; and thereby push the gall-bladder towards the anterior
abdominal wall. Fig.6

HOW TO ARRANGE FOR LITHOTOMY POSITION?
This is used for operations on the external genital organs,
perineum and anal region. The buttocks project well over the
edge of the table at the junction of the centre and foot section
which is lowered or removed.The legs are flexed at the hips and
knees, and raised with the feet supported in webbing slings
suspended from the lithotomy poles. A douching funnel may be
fitted below the perineal area to collect blood.
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THE WORK TABLE

2 What are the requirements of the O.T. TABLE?

The modern operation table is a mechanical apparatus capable of
Adjustment to give a variety of positions for a patient
undergoing surgery.
- Most tables are designed to provide suitable positions for a
wide range of general surgical operations.
- It can be adapted for specialised procedures by the addition
Of accessories (neurosurgery, orthopedics).
- The introduction of complex operative procedures has required
The manufacture of more sophisticated operation with the table
Base unit positioned in the centre of the theatre on to which
Is fitted a removable top.
- This facilitates the transport of the operated patient.
An operation table which offers power operation,
Interchangeability of table top for ease of patient transport is
Illustrated. Fig. 1A, and 1B
The table must have the following functions:
* Can be tilted downwards at the head and foot ends.
* Can be tilted from side to side.
* Can be elevated or lowered as a whole.
* Can be broken at hip level for gynaecological operation (e.g.
vaginal hysterectomy), renal surgery, and certain orthopaedic
operations.
* Can have the head and foot ends of the table removed to allow
for other attachments, eg. the application of a neurosurgical
frame.

What are the Accessory Equipments?
Most operating tables should have the following accessory
equipment or attachments:
* A rubber mattress placed on top of the table to prevent the
patient's body touching any metal part of the table in all
positions.
- The mattress is divided into head, body and leg sections,
which may be attached together to prevent slipping.
* A non-slip mattress designed to prevent movement of the patient
in tilted positions.
* An anaesthetic screen - a metal frame, the base of which slides
under the mattress.The top of the frame allows for the
operative drape to be placed over it, thus separating the
sterile operative area from the anaesthetic area.
* A head rest frame - a horseshoe shaped metal frame which is rubber
padded. It attaches to the operating table to stabilize the
patient's head during neurosurgical operations.
* Acrylic plates - transparent plastic bridges which may be placed
on the operating table under the mattress. X-rays can be taken
during an operation by slipping a X-ray plate under the plastic bridge.
* A kidney bridge - a bridge under the mattress at waist level which,
when elevated, arches the middle of the body for easy exposure
of the right or left kidney.
* An arm rest - used to support the patient's arm for intravenous
therapy,blood pressure monitoring or hand operations.It may
also be used to extend the arm for a radical mastectomy,thus
exposing the axilla for access to the axillary lymph nodes.
* An armslide supports the unused arm and preventing it from
falling over the edge of the table.
* Leg stirrups are usually marked left and right.They are used to
stabilise the patient's legs in the lithotomy position,eg.for
a dilation and curettage operation.
* The laminectomy bridge is an arched frame over which the patient
is placed face down.It allows for extension of the
vertabrae and exposure of the lamina.
* A hand table may be attached to the operating table to allow for
a wide working field during operations on the hand or arm.
* Sandbags assist in stabilizing a limb, eg. they may be placed
under a patient's knee for support during a menisectomy
operation.
In a thyroidectomy, the neck may be extended slightly backwards and the head stabilized in a round rubber ring.
A sandbag may be placed on either side of the head for
stability.
* Pillows to provide cushioning and protection for a patient's body
and limbs.
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CRITICAL LOCUS REQUIRMENTS

THE OT COMPLEX MANAGEMENT
THE OT PLAN AND DESIGN

Where should it be located?
All operating theatres should be centralized in one operating
Area rather than spread in the hospital.
this has been shown to be the most economic approach;
-For good engineering and
-Focused nurse’s services,
-Use of equipment and
-Training of staff.

How is it designed?

Present trends in hospital design favor the low-rise building,
Two/three floors high.
With an internal courtyard. This enables maximum use of natural light and ventilation.
The operating department should be constructed separate from general traffic and air movement in the rest of the hospital.

How to plan?
Movement of patients is made easier if at the time of planning
The requirement of the operating department surgical wards and
Intensive care unit (ICU)
Accidents and emergency departments (AED)
Radio diagnostic (X-ray) departments are all considered.
The laboratory facilities should also be close by.

How to Design and Control Environmental?
The term operating suite is sometimes used to designate the room used for surgery.
This room is usually 400sq ft with minimum of 20 feet distance from cabinets and wall shelfs.
Special surgery suits cardiac, orthopedic neurosurgery and minimal invasive surgery and requires 600 sq ft. of space.
The support areas (changing rooms, scrub and utility
Rooms) are separate.
All operating suites are similar in design.

They are roomy enough to allow scrubbed staff to move around
Sterile equipment without the risk of contamination.
The design is such that dust is not trapped in areas that would be difficult to clean.
The surface vinyl material is free of joints and crevices.

The operating suite, is designed to insure maximum patient safety

* The floors, ceilings, and other surfaces are smooth, non-
Porous, and made of fireproof materials.
* The smooth surfaces allow thorough cleaning and prevent the
trapping of biologic material that could cause cross
Contamination
* All surface materials are made to withstand frequent washings
And cleaning with strong disinfectants
The ventilation system in the surgical suite has filters to
Prevent the contamination of the clean environment by
Air-borne bacteria.
The entry of air is thru high up vents
* The current requirements is, 15 exchanges of air per
Hour, 3 of which must be fresh air.
• Clean air exchange is possible if there is a positive pressure within the suite.
• This air is derived directly from the outside to avoid circulating air that might be contaminated By passage through other areas of the hospital
* The humidity is also controlled to minimize static
Electricity and consequent ignition of any flammable
Solutions or objects used in the operating room.
* The ideal humidity level to achieve minimal static and also
Reduce bacterial growth is 30% to 55%.
The air temperature
Is maintained at 200C to 240C (680F to 750F).
* Emergency signal. The O.T.Management committee should
Consider installing an alarm system in case of a life
Threatening emergency. The activation of this alarm will
Save valuable time to mobiles. The emergency designate staff
And direct them to the site of the emergency.

A CRITICAL HOSPITAL LOCUS

THE RESOURCE FOR OTMANAGE

Tryseffcare is a Metaphor, with emphasis on self, as a motivator, and care providing the path to good performance and achieving your personal development goals


The hospital scene is fast changing in India, it is
estimated that over 15 thousand hospitals and nursing homes already exist, and this number is fast increasing.
This makes a demand on the training requirement of manpower in position.
This could in part be met by making available self learning hand books, or electronic media, to improve absorption capacity for high technology in use in modern Operating Theatres.

The health care outlet (public private hospital/nursing homes) have needs, for upgrading knowledge and skill of staff in place (Nurses & nurse assistant),.and new entrants to these cadres.

This involves areas of high levels of new technology in use in the OT complex. Advanced technique used by surgeons in the operating room complex need to be accessible.
Nurses and thru them other staff (OR assistants and theatre orderlies) need to acquire a commensurate learning abilities to remain efficient, provide quality service and meet the needs of their personal development goals.
The most cost effective means to improve absorption abilities of nurses and staff in position and new ,staff employed is to provide access to inexpensive self learning handbooks in surgical specialties and to introduce them to new required instruments used in modern procedures in these specialties.@

The instruments are illustrated for ease of recognition for organizing sets for procedures
The procedures are outlined in a standard format including;
• objectives of the procedure
• position of the patient during the procedure
• Anesthesia required for the procedure
• Steps of the procedures
• Instruments required (sets and special instruments)

The hand book also covers the important subject of infection control in the OT. Management of the OT complex,
Information on ligature, and
Suture material.
Defibrillators,
Ultrasonic equipment,
Lasers,
Diathermy,
Cryoprobes
.All this information imparts management and nursing skills to the OT staffThis information can be of use trainers as a training guide.

@A Complete Hospital Manual of Instruments and Procedures 2005 Jaypee ISBN81-8061-546-4