COLLEGE OF HEALTH SCIENCE
DEPARTMENT OF NURSING
INTRODUCTION TO THE OPERATING ROOM
TECHNIQUE& PRINCIPLES OF ANESTHESIA
By Worke Yismaw(MSC)
1
Learning objectives
At the end of the course, the trainees will be able to:Describe the three areas of the operation department
and the proper attire for each area
Describe the physical environment of the operating
room and the holding area
Describe the functions/responsibility/of the members of the
operation team
Identify needs experienced by the patient
undergoing surgical procedures
2
Objectives …
Describe basic principles of aseptic techniques used
in the operating room
Discuss the importance of safety in the positioning
of patients
Differentiate between general and regional or local
anesthesia
Discuss techniques for administering local and
regional anesthesia
3
Introduction
4
Definition of ORT
Defn:- An operating room is a particular room where the
surgery and the surgical procedures are conducted
is place/department/& its physical environment where surgical
interventions takes place
is simply the place where invasive procedures are conducted in
collaborated & integrated manner with multidisciplinary health
teams
5
LO1:-ORGANIZATION OF AREAS IN THE
OPERATING ROOM
Learning objectives
At the of these session, the trainees will be able to:Show specific areas within the operating room
Locate and describe the use of furniture and
equipment in the operating room
Identify the role of each member of the operating
room team
Discuss how environmental layout contributes to
aseptic technique
6
Introduction
 Operating room or the theater block is one of the important
special departments of a hospital
 This is where we have to practice a high standard of aseptic
techniques and sterilization of supplies in order to reduce the
events of infection
 This unit is designed as ‘’self contained block ‘’with a series
of rooms leading of a corridor with close doors that separates it
from the general wards
7
Cont’d
 The efficiency of the operating room depends much up on its
physical organization and the organization of its personnel
 An intelligent design in the lay out of the operating room
facilitates the efficient movement of patients and staff and the
economical use of space
 Corridors of the operation theater should never be open b/c
there is a high traffic and bacterial contamination of the air
8
Design of the operating room
Architects follow two principles in planning the physical
layout of the OR suite:
Exclusion of contamination from outside the suite with
sensible traffic patterns within the suite
Separation of clean areas from contaminated areas
within the suite
9
Principles of operation room design
For the operating rooms,there are many different designs
The basic design principles which are common to all operating
rooms must fulfill the following criteria :The design must always be simple and easy to keep it
clean
 wall and floor surfaces should be smooth and made
of nonporous(washable) materials
The floor of the operation theater room must be
smooth for easy cleaning
10
Design…
All electrical socket and conducts must be earthed
Operation room are usually bright and faced north or south so
that they are not exposed to the sun for a long period of time
in order to prevent cross-contamination (the transfer disease
causing microorganisms from one source to another), there
should be separate rooms for clean or sterile instruments and
soiled ones
11
Design…
There should be sufficient space to ensure the safe
transportation of patient and staff
Any cross traffics for people other than the workers of the
unit are strictly avoided
Special laundry facilities should be provided in the operating
unit
The recovery room should be near the operating room, so
that patients can be transported safely and quickly following
surgery
12
Space allocation in OR
The OR suite is divided into three areas that are designated by the
physical activities performed in each area.
A. Unrestricted Area
 Street cloths are permitted
 A corridor on the periphery accommodates traffic from out side,
including patients
 This area isolated by doors from the main corridor and from
other areas of OR suite
 It serves as an out side–to-inside access area
 Traffic, although not limited, is monitored at a central location
unrestricted zone: area in the operating room that interfaces with
other departments;
 includes patient reception area and
13
 holding area
Cont’d…
B. semi restricted area
Traffic is limited to properly attired (dressed) personnel
Body and head covering are required this area includes
peripheral support areas and access corridors to the operating
rooms
The patient may be transferred to a clean inside stretcher on
entry to this area
The patient‘s hair must be covered
semi restricted zone: area in the operating room where scrub attire is
required; may include areas where surgical instruments are
processed
14
Cont’d
C. Restricted Area
Masks are required to supplement surgical attire
Sterile procedures are carried out in this area
The area includes the operation rooms, scrub sink areas and
sub sterile rooms or clean core areas where unwrapped
supplies are sterilized
restricted zone: area in the operating room where scrub attire
and surgical masks are required; includes operating room
and sterile core areas
15
The operating room areas
A. The Supervisor’s office: has direct access to the out side of the
operating room.
The supervisor may need to receive visitors and significant others
who are not dressed in scrub attire
B. Dressing room :-for operating room personnel have a door to the
out side corridors so that personnel may enter there, change into
scrub attire and go directly into the operating room.
C. The Holding Area :-this is the area where the health care givers
properly identify the patient and make sure that all preoperative
cares are carried out and other important data are in the patient’s
chart
16
Cont’d
D. Scrub areas:-are located in several places close the operating
suites. Hot and cold water pipe line supplies, Scrub brushes, caps,
soaps, masks are located at each scrub station .
E. Sterilization Room :-it is adjacent to the operating room
The room is usually equipped with boilers (autoclaves ) for
providing sterile water for solutions and also water for the surgeon
‘s hand and to clean instrument during surgery .
 The room should be wide enough for lying trolleys comfortable, to
reduce humidity, heat and risk of infection and it must be well
ventilated.
17
Cont’d
F. Utility room :-is a room where equipment to be cleaned and
stored . Here a packing room is attached with it and if not available
the utility room must be wide enough for dual purpose that is to
prevent contamination and humidity.
18
Cont’d
G. the sterile supply room:-serves as a supply depot for wrapped
sterile articles. this area should be dusted frequently with a damp
cloth and have storage cabinets with doors to minimize exposure
of the supplies to room air and dust .
H. Supply And Storage Areas :-is a room where sterile equipment
is stored and supplied, here un sterile equipment must not be
mixed and stored .
 for extra equipment and supplies are used to store these extra
instruments and supplies are used to stores these extra instruments
and supplies for each unit .
19
Cont’d
I. The recovery room :-it is an intensively monitored setting that
allows observation, therapeutic intervention and observation of the
patients as they more fully recover form the effect of the surgical
procedure and anesthetics
-It has an access to the out side of the operating room for
transporting patients back to their rooms
20
Cont’d
J. The operating suites ;are rooms where surgery is performed.
 These rooms are wide enough to allow scrub personnel to move
around non sterile equipment with out their contamination.
Green line :- this line is a line where you can not pass before
changing the OR clothes
 In short, operating room block is a self contained unit of the
hospital pertaining to the staff and functioning.
 The operation room technique describes the methods of routine
function of this unit.
21
Bird’s eye view of OR areas/room/
22
OR team members
23
AS the physical design, there is a logical division of duties
among the operating room staff
Operating room team-Operating room and its function
(relation ship)
The sterile team consists of :
-Surgeon
-Assistant Surgeon
- Scrub nurse
The unsterile team includes :
- anesthesia provider (anesthetist) and its assistant
- circulatory/runner nurse
- others, such as students, cleaners and those who may be
needed to set up and operate specialized equipment or
monitoring devices
24
Responsibility
of each member
Sterile team members :
wash (scrub) their hands and arms, put on a sterile gown and
gloves the sterile field is the area of the operating room that
immediately surrounds and is specially prepared for the patient
To establish a sterile field, all items needed for the surgical
procedure are sterilized .After this process, the scrubbed and sterile
team members function within this limited area and handle only
sterile items.
25
Cont’d
Un sterile team members; on the other hand, don’ t enter the sterile
field;
They function outside and around it.
They assume responsibility for maintaining sterile technique
during the surgical procedure, but they handle supplies and
equipment that are not considered sterile.
Following the principles of aseptic technique, they keep the sterile
team supplied, provide direct patient care , and handle other
requirements that may arise during patient care, and handle other
requirements that may arise during the surgical procedure .
26
Cont’d
Responsibilities of the surgeon


The surgeon must have the knowledge, skill, and judgment
required to successfully perform the intended surgical
procedure.
The surgeon‘s responsibilities include, but are not limited to,
the following
- Preoperative diagnosis and care
- Selection and performance of the surgical procedure
- Post operative management of care
27
Cont’d
Responsibilities of the assistant Surgeons
under the direction of the operating surgeon, one or two
assistants help to :

Maintain visibility of the surgical site

Control bleeding

Close wounds and apply dressings
28
Cont’d
Responsibilities of the scrub nurse
The ‘’scrubbed ‘’nurses learn how best to work with each
surgeon and other team members as a smooth working team.
He/she is guided and directed constantly by what the surgeon is
doing
This means that the scrubbed nurse must have a constant
attention to the operation field
Before the operation

Enquire from surgeon about type of incision and instruments
required

Check the cleanliness of the OR

Prepare and check material for operations

Scrub, gown, and glove prior to surgeon
29
Cont’d
Prepare tables with adequate instruments
Help surgeon to drape patient
Check electrical apparatus and equipment
Count swabs, needles, together with circulating nurse before
operating begins
Respect aseptic roles all times
During operation
Anticipate requests from surgeon
Handle instruments in correct way
Maintain order around surgical field and instruments table
30
Cont’d
Keep track and count of swabs together with circulating nurse
Perform final swab check
Apply dressing
After operation
Participate in the safe transfer of patient to trolley
Collect instruments for decontamination
Place needles and blades in the safety box
Clean instruments table
Participate in cleaning and re arrangement of the operating room
31
Cont’d
Between operations :
Decontaminate, clean and dry soiled material
Reset and repack clean equipment
Prepare drapes and towels for sterilization
Check cleanliness and order of the operating room between
operations
Other tasks
Order, check and restock the material
Check that material is in sufficient quantities and is functional
Ensure full cleaning of OR at least on monthly bases
32
Cont’d
The circulatory nurse duties
Before operation
Receive patient on arrival to OR
Check patient’s card, name, consent, type and side of
operation
Enquire from surgeon about any special preparation
check and remove jewels
check patient’s clothes
take patient to operating room and place him or her on table
33
cont’d






check electrical apparatus and equipment
open packs and sets
help scrub team to gown and glove
perform first count together with scrub nurse
Count with swabs, needles together with scrub nurse
Count swabs, needles together with scrub nurse before operating
begins
 Respect asepsis rules at all times
 assist anesthetist if necessary
34
Cont’d
During operation
 Anticipate requests from surgeon
 Insert urinary catheters if necessary (with assistant
 Keep track and count of swabs together with scrub nurse
 Adjust light, diathermy apparatus, suction machine
 Promptly address requests from the scrub team
 Perform final swab check
 Detect and report aseptic mistakes
 Help applying dressing
35
Cont’d
After operation
participate in the safe transfer of patient onto strecher
Collect instruments for decontamination, place needles
and blades in the safety box
Clean instruments table
Participate in cleaning and re arrangement of the
operating room
Be present from beginning until end of operation
36
Cont’d
Between operations
 Decontaminate ,clean and dry soiled material
 Reset and repack clean equipment?
 Prepare drapes and towels for sterilization
 Sterilize sets and packs
 Check cleanliness and order of the operating room
Other tasks
 Order ,check and restock the material
 Check that material is it quantities and is functional
 Ensure full cleaning of OR at least on monthly bases
37
Co-operation and economical use of hospital supplies
,equipment and time
The team approach to care should be a coordinated
effort that is performed with the cooperation of all care
givers
Team member should communicate and should have
a shared division of duties to perform specified tasks as
a united body
The failure of any one member to perform his or her
role can seriously impact the success of the entire team
38
cont’d
Performing as a team requires that each member exert
an effort to attain the common goals in a competent
and safe manner.
A. economical use of supplies and hospital equipment
Most of the hospital equipment is being imported
from abroad and it is costly and, therefore economical
and proper usage of it is mandatory
39
Cont’d
As the cost of supplies and equipment increases ,the
OR team members should be conscious of ways to
eliminate wasteful practices
For example, through away disposable items only
avoid throwing away reusable items.
The operation room is one of the most expensive
departments of hospital
40
Cont’d
The following procedures should be observed
Pour just enough antiseptic solution
Follow the procedures for draping
Do not open another packet of sutures for the last
stitch unless absolutely necessary
Supplies should be opened only as needed ,not
routinely ‘’just in case ‘’ they may be needed
Turn off lights when they are not needed
41
Cont’d
B. Time Economy
Time is money; do not waste it. Know the policies
and procedures, and follow them efficiently
Time is an important element in the OR. If time is
wasted between surgical procedures, the day ‘s
schedule is slowed down and later procedures are
delayed, the patient and families become anxious
during these delays
42
Qualities of the Operating Room team
Pre requisites to join operation team
A.
B.
C.
D.
E.
F.
Stamina
Emotional stability
Respect
Stable health
Good Humor
Team spirit
43
LO2:-INFECTION PREVENTION IN THE
OPERATING ROOM
 Learning Objectives
At the end of the session , the trainee will be able to:
1. Demonstrate infection prevention techniques.
2. Minimize the risk of transmitting serious infections
among patients and service providers.
3. Define aseptic technique
4. Define sterile technique.
5. Describe the modes of transmission of microorganisms
from the source to the susceptible host.
44
Introduction
The infection prevention (IP) practice are intended for
the use in all types of health care facilities –from large
urban hospitals to small rural clinics
The recommended infection prevention practices are
based on the following principles :
 consider every person potentially infectious and
susceptible to infection
 washing hands before and after any procedure is the
most practical procedure for preventing cross –
contamination
45
wearing gloves before touching any thing potentially
infectious and wet such as broken skin ,mucous
membrane, body fluids ,body secretions and
execrations ,or soiled instruments and other items –or
before performing invasive procedures
Using antiseptic agents for cleansing the skin or
mucous membrane prior to surgery ,cleaning wounds,
or doing hand rubs or surgical hand scrub
46
cont’d
Process instruments and other items that come in
contact with blood, body fluids, secretions and
excretions
Disposing contaminated materials and contaminated
waste properly
47
General preparation
Hand Hygiene
Is a general term referring to any action of hand cleansing
Proper hand hygiene and the use of protective gloves in the
operating room is a key component in minimizing the
transmission of disease causing microorganisms and
maintaining an infection free environment
Appropriate hand /washing/hygiene must be carried out:
 before coming in direct contact with patients
 Before putting on sterile surgical gloves or examination
gloves
 After any situation in which hands may be contaminated
such as (handling contaminated objects ,including used
instruments; touching mucous membranes, blood, body
fluids ,secretions
 After removing gloves
48
Cont’d
Clothing
In restricted areas, staff are required to wear hospital –laundered
OR clothing (scrubs) made of woven reusable fabric (trousers
,shirt)
Fresh OR cloth attire should be worn each day
Surgical attire should be changed or removed when it becomes
soiled or wet or after a high septic procedure
OR uniforms should be removed and deposited in a designated
container before leaving the OR
Surgical attire must be removed when leaving the operating
room (out side )and fresh ones worn on reentry
49
cont’d
CAPS
Hair (including facial hair) must be completely
covered by a cap that can be laundered by the
hospital
Hair is an important contaminant and major source
of bacteria. caps should be removed before leaving the
OR.
Shoes
Only OR shoes should be worn: they must provide
protection from liquid and sharp items are preferred to
normal shoes
50
Cont…
OR shoes should be removed and deposited in a
designated receptacle before leaving the operating room
Removal of shoes can transfer microorganisms from
shoes to hands ;hands should be washed after shoes
removal
MASKS:
Masks are worn in the restricted area in the presence of
open sterile items or equipment or where contact with
scrubbed personal is possible
Mask should cover the nose and mouth completely
and securely
51
cont…
Masks contain droplets expelled from the mouth and
the throat when talking ,sneezing ,and coughing
Masks also protect from exposure to pathogenic
organisms spread in the environment
Masks should be tied securely at the back of the head
Masks that have been worn are contaminated with
droplets. they should be removed and discarded by
handling only the ties
Handling of the mask after use can transfer
microorganisms from mask to hands :staff should wash
their hands after handling and discarding a used mask
52
Cont’d
Jewelry
All jewelers and watches should be removed or
completely confined with scrub attire. These items can
harbor germs that are not removed during hand
washing and can contaminate the sterile field by
unintentional contact
It is recommended that earrings be removed, but they
can be worn if completely confined under the hair
covering
53
Cont’d
Finger nails and polish
Finger nails should be kept clean and short as less
than 3mm and nail polish avoided
Other personnel protective equipment
Eye wear provide solid side shields (‘’OR goggles ‘’)
Non sterile gloves should be worn when contact
with blood or body fluids is expected and changed
b/n patients
hands should be washed after glove removal
54
Procedure of hand washing /scrubbing
The patient
 Before entering the OR ,the patient must take off
his/her clothes in the receiving area and wear a patient
gown ,a cap, foot covers ,and a clean bed sheet .
Hand washing and surgical hand scrub
 Hand hygiene :- refers to hand washing, antiseptic hand
wash or surgical hand antisepsis = surgical hand
scrub=scrubbing
 Surgical hand antisepsis =surgical hand scrub
=scrubbing up :mechanical hand wash with a broad
spectrum antimicrobial agents and a sterile brush
performed prior to surgery by surgical team to
eliminate as many as transient mos as possible and
55
Hand Hygiene
Surgical hand scrub
The goal of the surgical hand scrub is to remove as
much debris and bacteria as possible from the hands
and arms. the concept of clean and dirty areas is
important to any one attempting a surgical scrub
The scrub begins at the finger tips (considered a clean
area after the scrub) and progress in one direction to
the elbows (considered dirty)
56
Procedure of hand washing /scrubbing cont’d
The surgical scrub brush is only used on nails and not
on skin to avoid some abrasion of the skin
Hands and arms should be held away from the body
(dirty )during the surgical scrub to prevent contact with
scrub attire (dirty)
Hands should be held higher than the elbows to
prevent fluid from running from the elbows (dirty )to
the hands (clean) during the scrub and during drying
.this position also keeps the hands and arms in
prominent view and helps to prevent accidental
contamination by contact with surrounding areas
57
Cont’d
Avoid splashing water, as a wet surgical attire can cause
the transfer of microorganisms from personnel to the
sterile gown worn during surgery
Theoretically as a surgical scrub time ,it is suggested
for two hands that one minute be spent on the nails
two minutes on the fingers ,30 seconds on the palms
,30 seconds on the backs of the hands and a final one
minute spent on the area of forearm and elbow. That
makes at minimum 5 minutes
58
Procedure of hand washing /scrubbing cont…
Equipment
Scrub sink with running water tap
Sterile and reusable nail brushes
1 bar of a soap (the best scrubbing agents are antimicrobial
scrub agents )
Preparation jewellery should be removed
Nails should be short ,clean and healthy
Skin of the scrubbed person should be free from cuts and
abrasions
Hair should be contained with in an appropriate hair
covering
Mask should be in place
Additional personnel protective equipment such as apron
should be in place
59
Procedure of hand washing /scrubbing cont…
Action/steps /
 Open the drum that contains the sterile hand brushes
and check if the soap is ready
 Turn on water tap and wet your hands and forearms.
1. Take soap(1st application )
 wash and rub the lateral side of your left little finger,
then its medial side :then the lateral and medial of
each successive finger ,then wash the back and the
palm of your left hand the process is repeated with the
opposite hand
60
Steps…
 Then rub your left wrist and forearms higher than
your elbows to anion water to drip off the elbows.
2. Take soap ( 2nd application ).
 Brush only your finger nail carefully for at least 1
minute.
 The nail brush is discarded
61
Scrubbing cont’d
3.Take soap ( 3rd applications )
 Wash and rub your left hand and writs, then the right
side
 Thoroughly rinse the suds from your hands while
holding them higher than your elbows
 Turn off water tap with elbow
 If any part of the hands pointed up ward and away
from the scrub attire, the sink, add minutes to that area
of the skin to correct the contamination
 With fingers and hands pointed upward and away from
the scrap attire, the scrap person enters the procedure
room pushing the door open with his/her back
62
Scrubbing cont’d
The gown and towels are packed with the towel on top
;approach tem and pick up the hand – towel without
water dripping on the sterile pack or table. open and
take the sterile hand towel and dry each hand and
forearm separately
Begin drying one of your hands while half the towel
63
Scrubbing cont’d
Proceed from the finger tips to above the elbows.
grasp the unused part of the towel with your dry hand
and release the wet half, and repeat the drying process
on your other hand
Try not to bring a wet (unsterile) part of the towel back
to a dry area , drop the towel
Take and put your gown on, and then put the gloves
on left hand first
64
Hand scrubbing
65
Hand scrubbing…
66
hand scrubbing…
67
Gowning and gloving
Gowning
The sterile gown is put on immediately after the
surgical scrub
The scrubbing nurse handles the sterile gowns very
carefully with out on her body and slips into its sleeves
gently over her theater dress
The circulatory nurse assists by pulling the gown over
the shoulders
68
Gowning …
The gown is tied at the back by the circulating nurse
The hands at the wrist are tied by her self so that the cuffs
of the gloves are fitted over them
69
Kinds of gown
70
Gowning ….
71
Gloving
Gloving :
Sterile gloves may be put in two ways
closed gloving technique
 open gloving technique

72
Gloving cont…
closed gloving technique
1. lay the glove palm down over the cuff of the gown
2.The fingers of the glove face to ward you
3. working through the gown sleeve ,grasp the cuff of the
glove and bring it over the open cuff of the sleeve
4. unroll the glove cuff so that it covers the sleeve cuff
5. proceed with the opposite hand ,using the same
technique
6. never allow the bare hand to contact the gown cuff edge
or outside glove
73
74
Gloving cont….
Open gloving technique
1.pick up the glove by its inside cuff with one hand
2.do not touch the glove wrapper with bare hand
3. slide the glove onto the opposite hand
4. leave the cuff down
5. using the practically gloved hand ,slide the fingers into the
outer side of the opposite glove cuff
6. slide the hand into the glove and unroll the cuff
7. do not touch the bare arm as the cuff is unrolled
8.with the gloved hand ,slide the fingers under the out side
edge of the opposite cuff and unroll it gently ,using the
same technique
75
Open gloving technique
76
Operating room hygiene and cleaning
CLEANING
removal of all foreign material (e.g. soil, organic
material )from objects
It is normally accomplished with water ,mechanical
action and detergents
Cleaning must precede disinfection and sterilization
procedures methods
77
Cleaning
1.Daily
Before the procedure of the day
wipe down all equipment and surfaces in the operating
room
furniture ,equipment ,surgical lights must be damp –
dusted with a cloth moistened with a detergent
/disinfectant .special attentions should be given to mop
all the floors of the operating room ,corridors
,sterilization room ,changing rooms allow drying time
78
Cleaning cont….
2.Between Two operations
empty rubbish bins and take dirty linen out
clean the operating table with soap and water or
detol
change the rubber /plastic sheet for each patient
trolleys must be wiped between patients
mop the floor with soap and water apply bleach on
surfaces and floor and allow to air dry
79
Cleaning cont…
3.At the end of the operation list
Empty and wash rubbish bins
Take remaining dirty linen to the laundry
Clean all furniture with soap and water or detol
Clean scrub up area
mop floor with soap and water ,rinse and apply bleach
and allow to air dry
wash operating shoes
Restock the operating room (sutures ,urinary bags
,antiseptics …)
80
Cleaning cont…
4.weekly protocol
wash walls and cupboards and all the things you do not
wash daily
5.Monthly protocol
move the cupboards and wash every where
cleaning and disinfection include:All equipment surfaces
All rooms and corridors
Surgical furniture (OR light over the operating table
need special care )
Anesthetic equipment Sinks, staff toilets ,showers
Floors ,Walls
81
Cleaning cont’d
How to clean
Start the process from cleanest to most dirty from less
contaminated to more contaminated ,
e.g. after operation ,clean the circulating nurse trolley
before the operating table ,and the operating table
before the floor
Proceed from up downwards ,e.g. ,walls before the
floor ,the upper shelf of the trolley before the low shelf
82
Cleaning…
Use the double bucket system to preserve the
deterioration ,contamination ,inactivation of
disinfectant solution ,and lost effectiveness
All cleaning cloth ,floor mops and buckets must be
disinfected ,rinsed and stored dried to prevent their
becoming a source of microbes
83
LO3:- sterilization and disinfection
 Sterilization is the process by w/c all pathogenic and
non pathogenic microorganisms, including spores are
killed.
Method of sterilization
 Sterilization can be achieved with physical or chemical
methods.
 Physical methods generally rely on moist or dry heat.
84
Sterilization
 Chemical methods use gaseous or liquid chemicals
-ethylene oxide gas is used to sterilize items that
are sensitive to heat or moisture. Its effectiveness
depends on four parameters w/c include :
- Concentration of EO gas
- Temperature
- Humidity ,and
- Duration of (gas exposure )
 Gluteraldehyde 2%and formalaldehyde 8% can also be
used a chemical sterilizer
85
Sterilization cont’d
Physical methods :-heat is a dependable physical agent
for the destruction of all forms of microbial life
,including spores. It may be used moist or dry .the
most reliable and commonly used method of
sterilization is steam under pressure.
A . moist heat (steam under pressure )or auto clave
 Basically ,an auto clave consists of a sterilizing chamber
and to exhaust steam, air and condensation from the
chamber.
86
Sterilization…
 3 parameters are important :
Temperature
Time/duration
Pressure( saturation ,humidity).
 The minimum time for the entire cycle in the autoclave
sterilizer is 25 to 30 min at 121to 132 degree Celsius
87
Cont’d
steam sterilization (Gravity): Temperature should be
1210C (2500F); pressure should be 106 kPa (15
lbs/in2); 20 minutes for unwrapped items; 30 minutes
for wrapped items. Or at a higher temperature of
1320C (2700F), pressure should be 30lbs/in2;15
minutes for wrapped items
Allow all items to dry before removing them from the
sterilizer
88
Sterilization con’t
Dry heat
 Dry heat kills micro organisms by oxidation provided
that the articles to be sterilized are exposed to a
temperature of 160C for one hour is ,all organisms and
their spores will be destroyed or 170C (3400 F) for 1
hour (total cycle time—placing instruments in oven,
heating to 170oC, timing for 1 hour, and then cooling—
is from 2– 2.5 hours), or 160 0C (3200F) for 2 hours
(total cycle time is from 3–3.5 hours)
89
Sterilization…
 This method is used for sterilizing sharps, sponges and
bandages
 The major disadvantage of dry heat are that is
penetrate materials slowly and unevenly
NB:-IF you are not sure the time &duration of sterization
it is better follow manufacturer manual
90
Disinfection
 Disinfection :-eliminates pathogenic microorganisms
on inanimate objects ,with the exception of bacterial
spores. This is generally achieved in health care settings
by the use of liquid chemicals or boiling
91
Methods of disinfection
Chemical disinfections
Formaldehyde (37% aqueous ;8% alcohol ) Kills
microorganisms by coagulating protein in the cells
The solution is effective at room temperature
Hydrogen peroxide: interacts with cell membranes
,enzymes ,or nucleic acid to disrupt the life functions
of microorganisms
Alcohol :ethyl or isopropyl , 70% to 95% ,kills mos by
coagulation of cell proteins.
Chlorine compounds: kills mos by oxidation of
enzymes.
92
LO4:- PROCESSING INSTRUMENT
Learning objectives
At the end of the study session, the trainees will be able
to:Identify the steps of processing instrument
The rationale for decontamination before cleaning
How to prepare chlorine solution for decontamination
Some characteristics of chemical sterilization&
Disinfection
93
Introduction
Surgical instruments are expensive and represent a
major investment
Instruments can last for many years if they are handled
or maintained properly
It is the nurses responsibility to care for the proper
handling and maintenance of the instruments
94
Cont’d…
Handle instruments gently
Do not through them in to basins
Keep the sharp surfaces of cutting instruments away
from other metal surfaces that could dull them
Do not soak them in saline solution
When feasible ,wipe blood to cake and dry on the
instrument
95
Definition of terminology
Cleaning :-Process that physically removes all visible
dust, soil, blood or other body fluids from inanimate
objects as well as removing sufficient numbers of
microorganisms to reduce risks for those who touch
the skin or handle the object
Decontamination:- Process that makes inanimate
objects safer to be handled by staff before cleaning
(i.e.,inactivates HBV, HCV and HIV, it reduces the
number of other microorganisms but does not
eliminate them)
96
Terminology…
High-level disinfection (HLD):-Process that eliminates
all microorganisms except some bacterial endospores
from inanimate objects by boiling, steaming or the use
of chemical disinfectants
Sterilization:- Process that eliminates all
microorganisms (bacteria, viruses, fungi and
parasites) including bacterial endospores from
inanimate objects by high-pressure steam
(autoclave), dry heat (oven), chemical sterilants or
radiation
97
Key Steps in Processing Contaminated
Instruments, Gloves and Other
98
Decontamination
Decontamination is one of the highly effective IP
measures that can minimize the risk of transmission of
these viruses to healthcare workers, especially cleaning
and housekeeping staff, when they handle soiled
medical instruments, surgical gloves or other items
These measures are also important steps in breaking
the infection transmission cycle for patients.
Both processes are easy to do and are inexpensive ways
of ensuring that patients and staff are at a lower risk of
becoming infected from contaminated instruments and
99
other inanimate objects
cont’d…
Immediately after use ,all instruments should be
placed in an approved disinfectant such as 0.5%
(Barakina/hypochlorite sodium )chlorine solution for
10 minutes to inactivate most organisms ,including
HBV and HIV
Do not mix soak metal instruments in water for more
than one hour to prevent rusting
Remove instruments from 0.5%chlorine solution after
10 minutes and immediately rinse them with sterile
cool water to remove residual chlorine before being
thoroughly cleaned
100
Chain of infection
101
Cont’d…
Decontamination is the first step in processing soiled
surgical instruments, surgical gloves and other items. It
is important, before cleaning, to decontaminate these
items by placing them in a 0.5%(Barakina/hypochlorite
sodium) chlorine solution for 10 minutes
This step rapidly inactivates HBV, HCV and HIV and
makes the items safer to handle by personnel who
clean them
102
How to make solution for decontamination
A. The formula for making a dilute chlorine solution
from any concentrated hypochlorite solution
Check concentration(% concentrate) of chlorine
solution you use
Determine total parts water needed by this formula:Total parts (TP) water=[%concentrated/%dilute]-1
Mix 1part of concentrated bleach with total parts of
water required
103
Example
Make a dilute solution (0.5%) from 5% concentrated
solution
Step 1 TP = [5%/0.5%]-1 =10-1=9
step2 take 1part of concentrated solution &add
9parts of water
B. The formula for making a dilute solution from a
powder of any percent available chlorine
Formula for making chlorine solutions form dry powders
104
105
Cont’d…
WHO (1989) recommends 0.5% chlorine solution for
decontaminating instruments and surfaces before
cleaning because potable (clean) tap water often is not
available for making the solution. In addition, because
of the potentially high load of microorganisms and/or
other organic material (blood or other body fluids) on
soiled items, using a 0.5% solution for decontamination
provides a wider margin of safety
106
cleaning
Definition:- is a process of physically removing infectious
agents and other organic matters on which they live and
thrive but doesn’t necessarily destroying infectious agents
This is important because dried organic material can entrap
microorganisms, including endospores, in a residue that
protects them against sterilization or disinfection
107
Cleaning …
Cleaning could be done using hand (bar) or powdered
soap is discouraged because the fatty acids in bar soap
react with the minerals in hard water leaving a residue
or scum (insoluble calcium salt), which is difficult to
remove
Using liquid soap is good because it mixes easily with
water than bar or powdered soap
Cleaning is the removal of all visible dust ,soil, and
other foreign material from the instruments
108
Preparing equipment cont…
Purpose
Instruments can be cleansed & drying manually or with
machine
Packing
un packed items ,such as those sterilized in a flash auto
clave must be used immediately any items not to used
immediately must be packed in order to maintain
sterile conditions ,maintains item’s properties and
integrity ,in such away that article can be extracted and
used under aseptic condition :
 in fenestrated drums or boxes (windows open during
autoclaving).
109
Preparing equipment cont…
Wrapped in 2 layers of heavy duty paper :strong,
brown paper, newspaper(auto clave only)
Wrapped in 2 layer of closely woven linen (autoclave
only )
Wrapped in 1 layer of paper and 1 layer of linen :(
autoclave only),advisable if items is to be stored several
weeks ,b/c it is more resistant than paper alone and a
better barrier for germ than linen alone.
110
Cont’d
When fenestrated containers are equipped with a filter
(a layer of heavy duty paper ),the paper should be
checked and renewed regularly .alternatively ,items can
be wrapped in cotton fabric inside the drum.
Small packages and small drums are preferable to
large ones: the steam will circulate better
Swab and drapes should not b e compressed inside
boxes or drums
111
Cont’d
In the pack, items used first ,such as hands towels
,must be placed on top.
Sets :
The weight of instruments and density of metal mass
are more important
The conditions necessary for steam sterilization are
difficult to achieve in heavy heat set
Make sure the instruments are dry
112
Cont’d
Put instruments in rigid containers with vacuum valves
Instruments should be grouped together by style and
classification
Place sharp and delicate instruments on the top of
heavy ones
113
Cont’d
Sealing and labeling :
write contents and date of sterilization
Sterile storage guide line
storage area must be clean and free of dust ,close to
working area
All sterile items should be stored under conditions that
protect them from the extremes of temperature and
humidity
package should be put into storage with out
condensation inside the drums or the box , wet
packages must be resterilized
114
Shelf life
Shelf –life:15 days after the date of sterilization if the
package is closed correctly
The shelf life of an item (how long items can be
considered sterile) after sterilization is event-related
the highest shelves should be at least 45cm below the
ceiling and 25cm above the floor.
Items should be identified:
Expiry date should be checked regularly
Disposable items eliminate a potential source of
contamination but they also must be stored properly
and they are generally expensive
115
Factors affecting shelf-life
Quality of the wrapper or container
Number of times a package is handled before use
Number of people who have handled the package
Whether the package is stored on open or closed
shelves
Condition of storage area( e.g., humidity and
cleanliness)
116
Cont’d
Use of plastic dust cover and method of sealing
Most packages are contaminated as a direct result of
frequent or improper handling or storage
Prevent events that can contaminate sterile packs, and
Protect them by placing the in plastic cover (bags)
117
Monitoring sterilization procedures
Sterilization procedures can be monitored routinely
using a combination of biological, chemical and
mechanical indicators as parameters
Different sterilization processes have different
monitoring requirement
Biological Indicators
Monitoring the sterilization process with reliable
biological indicators at regular intervals is
strongly recommended
118
Biological…
 The biological indicator types and minimum
recommended intervals should be:
steam sterilizers:- A highly resistant but relatively
harmless (nonpathogenic) microorganism called
Bacillus stearothermophilus is used to test steam
sterilizers undertaken weekly
119
Chemical Indicators
Chemical indicators include indicator tape or labels,
which monitor time, temperature and pressure for
steam sterilization, and time and temperature for dryheat sterilization
mechanical Indicators :-Mechanical indicators for
sterilizers provide a visible record of the time,
temperature and pressure for that sterilization cycle
This is usually a printout or graph from the sterilizer,
or it can be a log of time, temperature and pressure
kept by the person responsible for the sterilization
process that day
120
Preparing equipment cont…
Prior to dispensing sterile supplies
Check the outer wrapper or package for tears or holes
and consider it contaminated if they exist
Confirm that an item’s sterility has not been
compromised by handling
Inspect the indicators on the out side of the package to
ensure that the proper sterilization process was
followed
If indicated ,verify manufacture’s label for sterility
/expiry date/
If sterility is in doubt ,do not use the item
Great care is needed in opening package to maintain
sterility
121
method
Summary
Effectiveness
(kill or remove
microorganisms)
EndPoint
Decontamination
Kills HBV and HIV and
some microorganisms
10 minute soak
cleaning(water only)
Up to 50%
Until visibly clean
cleaning (soap and
Rinsing with water)
Up to 80%
Until visibly clean
sterilization
100%
High-pressure steam, dry
heat or chemical for
recommended time
High-level disinfection
95% (does not inactivate
some endospores)
Boiling, steaming or
chemical for 20 minutes
122
LO5:-GENERAL SURGICAL
INSTRUMENTATION
Learning objective
At the end of this study session, the trainee will be to:1.Identify the use and function of each type of
surgical instrument
2.Demonstrate the appropriate methods for passing each
type of instrument
3.Explain the rationale and methods of decontamination
of instruments
123
Introduction
Surgical instrumentation is critical to the surgical
procedure
The performance of the OR team is enhanced
when team members know each instrument by name,
how each item is safely handled, and how each is
used. Preparing the instrument for appropriate
processing will prolong its use in patient care and
decreases the costs for repair and replacement.
124
Classifications of Instruments
As an aid in memorizing instrument names, it is
helpful to know the basic categories of instruments.
They are classified according to their function, and
most fall into one of four groups
A. Cutting and Dissecting
Cutting instruments have sharp edges/points. They are
used to dissect, incise, separate, penetrate, or excise
tissue
125
Cutting &dissecting
This group includes: scissors, knives, biopsy
punches, scalpels (blades), saws, osteotomes, drills and
curettes, needles, chisels, etc
126
Example…
127
Example2
128
Cutting &dissecting
129
Cutting &dissecting
130
Grasping and Clamping
A clamp is an instrument that clasps tissue between its
jaws
Clamps are available for use on nearly every type of
body tissue, from delicate eye muscle to heavy
bone
The most common clamps are the haemostatic
clamps, designed to grasp blood vessels, crushing
clamps, non crushing vascular clamps etc.
131
Grasping and Clamping
Grasping instruments are used to hold and
manipulate structures
Needle holder, thumb forceps, tissue forceps, Alli’s
forceps, bone holders, tenaculi (tenaculm, singular)
etc. are included in this category
132
Parts of a Clamp
As shown in the above figures an instrument has
identifiable parts
The points of the instrument are its tips. The tips
should approximate tightly when the instrument is
closed
The jaws of instrument hold tissue securely. Most
jaws are serrated.
The box lockis the hinge joint of the instrument.
The shankis the area between the box lock and the
finger ring.
133
parts…
134
Example… Different types of blade
holders (scalpel handles)
135
Different types of thumb forceps
136
Different types of clamps
137
C. Exposing and Retracting
Soft tissues, muscles, and other structures should be
pulled aside for exposure of the surgical site
Exposing and retracting instruments are those that
hold tissue or organs away from the area where the
surgeon is working. Retractors, like clamps, are
available for use in all parts of the body
138
Example Retractors
139
Example…
140
Self-Retaining Retractors
 Holding devices with two or more blades can be
inserted to spread the edges of an incision and hold
them apart
141
Example…
142
D. Probing and Dilating
A probe is used to explore a structure or to
locate an obstruction
Probes are used to explore the depth of a wound or to
trace the path of a fistula. Dilators are used to
increase/enlarge the diameter of a lumen, such as the
urethra, uterine cervix, or esophagus.
143
Example…
144
LO6:-RECEIVING AND POSITIONING THE
PATIENT
Learning objective
At the end of the session, the trainee will be able to:1. Mention some of the responsibilities of the OR
team during receiving the surgical patient.
2. Identify the safety hazards associated with moving a
patient from one surface to another.
3. Describe the effects of positioning on the patient’s
body systems
145
Introduction
The patient is the reason for the existence of the health
care team
She or he looks to the operating room team to fulfill
her or his diverse needs during the pre-, intra-, and
postoperative phases of care. The patient is always the
focus of attention, not just when she or he is under
the operating room (OR) spotlight
146
Cont’d
Receiving the Surgical Patient
Positioning the Patient
Each operative position represents an agreement
between the surgeon and the anesthesia provider
to the patient
The surgeon requires an accessible, stable
operative area
147
Cont’d…
Patient positioning is determined by the procedure
to be performed, with consideration given to the
surgeon’s choice of surgical approach and the
technique of anesthetic administration
Factors such as age, height, weight,
cardiopulmonary status, and preexisting disease
(e.g., arthritis) also influence positioning and should
be incorporated into the plan of care
148
Timing of Patient Positioning and Anesthetic
Administration
The following states the time at which the patient is
positioned and/or anesthetized
 After transfer from the stretcher to the
operating bed, in supine position
 The patient may either be anesthetized in this
position
 If the patient is having a procedure performed
while in a face down (prone) position and under
general anesthesia, he/she is anesthetized and
intubated on the transport stretcher
149
Cont’d…
 A minimum of four people are required to
place the patient safely in the prone position on
the operating bed
150
Factors influencing time of pt position
Several factors influence the time at which the
patient is positioned. Some of these include:
• The site of the surgical procedure
• The age and size of the patient
• The technique of anesthetic administration and
• If the patient is conscious, has pain on moving
151
Modifications for individual patient
needs
As with every thing else, the patients individual needs
are met during positioning
Anomalies and physical defects are considered
Whether pt is conscious or un conscious avoid un
necessary exposure
The pt position should be observed objectively before
skin preparation & draping to see that it adheres to
physiologic principles
152
Cont’d
Protective devices, positioning aids & padded areas
should be reassessed before draping because they
could have shifted during the skin preparation
procedure or during insertion of catheter
Careful observation of patient protection & positioning
facilitates the expected out come
153
Safety Measures
Injuries to the back, arms, or shoulders as a result
of lifting patients or moving equipment are
common to the staff working in the OR
Several principles of body mechanics (using the
body as a machine) should be observed to
minimize physical injury
154
Safety measures
Some of these principles include, but are not limited
to, the following:Keep the body as close as possible to the person or
equipment to be lifted
Lift with the large muscle groups of the legs and
abdominal muscles, not the back
Lift with a slow, even motion, keeping pressure off the
lumbar (lower back) area
Bend forward with hip flexion and hand support
155
Equipment for Positioning
The following are list of special equipment for
positioning a surgical patient:
• Shoulder Bridge (Thyroid Elevator)
• Safety Belt (Thigh Strap
Anesthesia Screen
• Lift Sheet (Draw Sheet)
• Armboard, double Armboard
• Wrist or Arm Strap
156
Equipments…
• Kidney Rests
• Body (Hip) Restraint Strap
• Metal Footboard
• Headrests
• Pressure-minimizing Mattress
• Operating Bed
• Shoulder Braces or Supports
• Body Rests and Braces
157
Surgical Positioning
The position in which the patient is placed on the
operating bed/table depends on the surgical procedure
to be performed as well as on the physical condition of
the patient
Positioning on the operating table
158
Common positioning
A. Supine:- cholecystectomy
bowel and bladder surgery
and some gynecological
procedures
B. Trendelenburg
eg;-used for surgery on the
lower abdomen & the
pelvis to obtain good
C. lithotomy:-Nearly all
perineal, rectal, and
vaginal surgical
procedures require this position
159
Common positioning
D. Modified sim’s/kidney
E. Prone position
F. Reverse trendelenburg
position
Eg;-soft roll under
shoulders for thyroid,
neck, or shoulder
procedures
160
summary
1.List the preliminary considerations during positioning?
2. Mention at least three most commonly used
operative positions?
161
Lo7:-PREPARATION AND DRAPING OF
THE SURGICAL SITE
Learning objectives
At end the this session, the trainees will be able to:1. Explain potential problems of inadequate
preparation of the surgical site
2. Discuss the implications of chemical and
mechanical actions of prepping the patient.
3. Show how a patient is draped using sterile technique
162
Introduction
The surgeon, assistants for the surgeon, the scrub
nurse, as well as the patient, must have a preoperative
surgical scrub
The patient must also be covered with sterile linen
leaving the incision site open
While the solutions used for the patient’s skin
preparation may vary in different hospitals, basic
principles remain the same. Likewise, draping
materials vary somewhat, but draping principles are
universal
163
Skin preparation
Skin preparation (skin prep) begins before the patient
arrives in the operating room (OR)
It is the removal of as many microorganisms as
possible from the operative site and surrounding
areas before operation
It is done by trimming, mechanical washing, and
chemical disinfection
164
Purpose
The purpose of skin preparation is to render the
surgical site as free as possible from transient and
resident microorganisms, dirt, and skin oil so that the
incision can be made through the skin with minimal
danger of infection from this source
165
The Trim Preparation
Hair readily supports the growth of
microorganisms and therefore, the skin at and around
the incision site is trimmed immediately prior to
surgery
Procedure for Trimming
1. Explain the procedure to the patient
2. Assemble needed supplies before beginning
3. Be sure to have good lighting
166
Cont’d
4. Trim the hair to its minimum size
5. Talk with the patient as you work as this helps to reduce
anxiety or embarrassment
6. Wash the trimmed area thoroughly
167
The Scrub Preparation
Procedure
1. Expose the site and adjust light. Check the trim prep.
2. Don (wear) sterile gloves
3. Place sterile towels at the periphery of the scrub area
4. Starting at the incision site, begin washing in a circular
motion.
5. Repeat the process
6. Dry the prep area using the same technique with dry
sponges
168
Cont’d
7. Antiseptic paint is usually applied immediately
after the scrub.
8. Scrub and paint solutions should be chemically
similar.
169
Skin preparation for Specific Anatomic Areas
Eye
1. Never shave/trim the eyebrows; the eyelashes may be
trimmed
2. Use soft cotton balls
3. Irrigate from the inner to the outer canthus
4. Use nonirritating antiseptic agents
5. The conjunctival sac is flushed with nontoxic
agent (normal saline)
6. The ear on the affected side should be plugged with
cotton
170
Preparation…
Ear
• Clean folds with cotton tipped applicators
• Prevent pooling of solution in the ear canal
Face
o Has several unclean areas (the mouth, nose, and
hairline)
o Difficult to avoid contaminating the prep when the
usual technique is employed
171
Cont’d
 Prep from the center outwards (from hairline)
 Return to the incision site using clean sponges
and prep that area last.
 Braid, cap or held back the hair with clips prior to the
prep.
172
Vagina
• Begin a few centimeters from the vulva
• Extend the prep outwards to include the thighs and
lower abdomen
• Sponge sticks are used to prep the vagina itself
• To complete the prep wash the vulva and anus and
passing the soapy sponge downward
• Discard the sponge after it passes the anus
• Repeat several times, always starting with a new
sponge
173
Drapes and Draping
Drapes:-are pieces of cloth used to cover areas in
order to provide sterile field, protective barrier
against contamination and moisture
Draping:-is the process of covering the patient and
surrounding areas with sterile linen, leaving only a
minimum area of skin exposed at the site of incision.
174
Purpose of Draping
 To create and maintain an adequate sterile field
during the operative procedure
Points Concerning Drapes
When packaged for sterilization, drapes must be
properly folded and arranged
They must be free from holes
175
Basic Principles of Draping
Provide a wide cuff for the hand
Drapes are nearly always unfolded at the field to avoid
moving them around
Once placed, drapes should not be moved
When linen drapes are used, provide adequate
barriers against moisture and contamination
176
Making drapes
177
Draping Rules
1. Handle drapes as little as possible
2. Never flourish drapes
3.If a drape becomes contaminated or has a hole in
it, discard it.
4. Never allow gloved hands to come into contact with
the patient’s prepared skin during the draping process
5.Whenever draping, always provide a cuff for the gloved
hand
178
Cont’d
6.Never allow a drape to extend outside the sterile area,
unless it is to remain there.
7.Do not allow the drapes to touch the floor or
become tangled in floor equipment
8. Plan ahead
179
surgical nomenclature/surgical
languages/
 Surgery is usually performed in order to accomplish
one of three objectives--to alleviate pain, to cure by
removing diseased organs, or to repair or reconstruct a
part
 The surgicalprocedures themselves may be classified
as follows:
1) Palliative. A surgical procedure that is intended to
relieve pain rather than cure the disease.
2) Curative. A surgical procedure in which the diseased
organ is removed.
180
Terms Pertaining To Operative Procedures
a. Classification of Operations. Surgical operations can
be classified according to the type of procedure, as
follows:
1) Incision
7)Destruction
2) Excision
8) Suturing
3) Amputation
9) Manipulation
4) Introduction
5) Endoscopy
6) Repair.
181
Cont’d
3) Plastic. A surgical procedure in which the part is repaired or
reconstructed.
4) Diagnostic. A surgical procedure for the purpose of
diagnosing
182
Incision procedures
 Incision is a cutting into, a formation of an opening.
The suffixes commonly used for operations classified
as incisions are:
1) -(o)tomy--to cut into.
2) -(o)stomy--to provide with an opening.
3) -centesis--puncture or perforation.
183
Otomy Procedures
 Otomy procedures, with examples, include the
following:
1) Exploratory operation.
Laparotomy--cutting into the peritoneal cavity for
exploratory purposes.
2) Removal of foreign bodies.
(a) Accidental.
Sclerotomy--removal of a foreign body from the eye
184
(b) Therapeutic.
Arthrotomy--removal of a surgical nail, pin, screw, and
so forth, from a joint.
(c) Pathological.
Nephrolithotomy--removal of kidney stones.
(3) Division of a structure.
Myotomy--cutting or dissection of a muscle; also
neurotomy, tenotomy.
(4) Decompression.
Craniotomy--cutting into the skull for relief of
pressure on the brain
185
Ostomy Procedures
c. Ostomy procedures, with examples, include the
following:
1) Surgical creation of an artificial passageway.
Gastrostomy--an artificial passageway through the
abdominal wall to the stomach.
2) Formation of an artificial opening.
Colostomy--formation of an opening in the abdominal
wall for exteriorization of the colon
186
EXCISION PROCEDURES
a. Excision is the cutting out of a part. The suffixes used
to denote excision are as follows:
1) --ectomy--to cut out or excise. Excisions are divided
into two types--partial or subtotal excision and
complete or total excisions.
2) --exeresis--to strip out.
187
LO8:-SUTURE MATERIALS AND SUTURES
Learning objectives
 After completion of this chapter, the learner will be able to:
1.Define suture and suture materials.
2.Discuss the difference between absorbable and non
absorbable sutures.
3.Identify the different suture materials.
4.Prepare suture materials properly.
5.Identify the different parts of a needle.
6.List down the types of needles.
7.Mention the types of sutures.
188
8.1 Introduction
Suture Materials
The noun suture is used for any strand of material
used for ligating or approximating tissue; it is also
synonymous with stitch. The verb to suture denotes
the act of sewing by bringing tissues together and
holding them until healing has taken place.
189
Types of Suture Materials
Surgical suture materials are classified as either
 Absorbable or non absorbable;
 Natural or synthetic;
 Monofilament or multifilament;
 With or without needle;
 By size
190
Suture materials cont….
Suture are also described by their physical characteristics:
Tensile strength :-the weight (breaking strength )
necessary to break the material
Knot strength : the force necessary to cause a knot to
slip
Elasticity:-inherent ability to regain original form and
length after being stretched
Memory:-capacity of a suture to return to its former
shape after deformed, as when tied; high memory
yields less knot security
191
Suture materials cont…
Absorbable /non –absorbable
A/ absorbable suture materials
Absorbable suture is evenly absorbed by the body as a
result of the enzymatic action of body fluids and does
not require removal
Absorbable sutures come in polyfilament (braided)
and monofilament (unbraided) sutures
Each have various half-lives and strengths. The length
of time needed by absorption depends upon the
specific type of suture as well as the condition of the
tissue
192
Cont’d
Absorption takes place in from 3 days to 3 months
Absorption time is variable and important to consider
I. Quick absorption: e.g. plain catgut (5-7 days, some
times less in case of infection).
II. Medium absorption: e.g. chromic catgut (2-3 weeks).
III. Slow absorption :e.g. vicryl (polyglactic acid ),dexon
, ercedex , ligedex(polyglycolic acid ):2-3 months
;PDS(polydioxanone ):up to 3 months ;they handle
and tie better than cat gut
193
Cont’d
Advantages: does not remain in the tissues
Disadvantages: must retain its strength until the tissues
have healed ,or the suture line /anastomosis will break
down.
 Eg:-Plain catgut: subcutaneous fat; mucous surface of
mouth or vagina, circumcision.
Chromic catgut: 2nd choice for bowel anastomosis, uterus
peritoneum, abdominal wall.
Slow absorption suture materials: 1st choice for bowel
anastomosis, uterus, peritoneum, abdominal wall Catgut
has been withdrawn in many countries b/c it is based on
cow product, susceptible of transmitting bovine
encephalitis
194
Plain catgut cxz
195
Vicryl rapide
196
monocryl
197
Coated vicryl
198
polydioxanone
199
Suture …
B/ Non –absorbable
Not absorbed by the tissues:this material will remain
in the tissues or will have to be removed
E.g. Nylon (polyamide), prolene (poly propylene),
polyethylene, polyester, silk, cotton.
Advantages: retain their strength for a long time, induce
little tissue reaction when synthetic.
Disadvantages: they are foreign bodies and can cause
inflammatory reaction in the tissues or work their way
to the surface when natural (stitch granuloma); not to
be used for the urinary or biliary tract (can induce the
formation of stones).
200
Suture…
Examples of use:
Nylon ,prolene ,polyethylene ,polyester :skin,
abdominal wall ,hernia repair (repair stitch )
Prolene :vascular anastomosis
Silk :skin
Cotton :not used any more
201
silk
202
Nylon
203
polyester
204
prolene
205
Stainless steel
206
Suture materials
Natural /synthetic
Natural suture materials :e.g. catgut (from sheep gut ) ,silk
, cotton
Advantage :cheap
Disadvantage :more irritant
Synthetic suture materials :Nylon ,polyester ,vicryl
,dexon
Advantage :less irritant (inert )
Disadvantage : more expensive
207
Cont’d
Monofilament /braided
 Monofilament :e.g. Nylon .prolene
Advantages : glides easily ,less reactive
Disadvantage: slippery ,requires multiple knots
 Multiple filament (braided) :poly ester ,vicryl .
Advantages : safe knotting ,easy handling
Disadvantage: more reactive (Non absorbable)
208
Suture materials cont…
With /with out needle
 With out needle (spool or roll )used as ties (ligatures )
To make a knot ,you need your finger ,a threading
forceps , a long forceps ;average length 150 cm.
 With eye –needle ,through w/c the suture material is
passed . the head of the needle is relatively large
,making a bigger hole than the thread it self .they save
money b/c they are sterilized ,and spooled threads are
less expensive.
Advantages :cheaper
Disadvantage: more traumatic ,time consuming
209
Suture materials cont…
With a traumatic needle ( fixed suture material )
Advantages :less traumatic ,quicker to use
Disadvantage :expensive
 The suture is fused into the end of an eyeless needle.
 the thread and the needle form a unit , they have almost
the same diameter .
 a traumatic sutures are essential in circumstances in
which there may be leakages ,in particular in digestive or
vascular anastomosis
210
Suture materials…
Caliber (diameter ) : two classifications are used :
The old system and
The new metric (decimal system
The following are the equivalent for the sutures most
frequently used ,from finer to thicker :
5-0 the finest and 1 the largest are the commonly
available sizes
the more zeros ,the finer the gauge.
Finer materials
Advantage :less traumatic to the tissues ;more cosmetic
(skin in particular on the face )
Disadvantages :less strong
211
Gauges/size
212
213
Suture …
Strong materials
Advantage :less likely to rupture .
Disadvantage :take longer to absorb ,more traumatic
,not cosmetic
 Examples of use :
Nylon 2/0 or 3/0 :for general skin closure
Chromic catgut : 2/0 or 3/0 for tying small
bleeding points
2/0 for peritoneum
214
Suture materials cont…
Types of Needles
 The main characteristics are :
- The point:-round ,triangular ,taper cut
(triangular point ,round body).
- The shape: straight or curved
- The length
A/ Straight or curved
 Straight: for superficial sutures (held by hand );their use
is discouraged as stab injuries may happen easily
 Curved (held by needle holder ): curvature of the
needle varies.
215
Suture…
B/ Rounded -bodied or cutting
Rounded –bodied
Advantages :less traumatic ,used for most tissues .
Disadvantages :will not go through tough tissues
or skin.
Cutting needle (triangular in shape )
Advantages :goes easily through tissues ,mostly
used for the skin
Disadvantage: cuts through the tissues ,not for
fragile tissues (mucosa)
216
Common types of stitch
The known suture is used for any strand of material
used for ligating or approximating tissue; it is also
synonym to stitch
The verb to suture denotes the act of sewing by
bringing tissues together and holding them until healing
has taking place
If the material is tied around a blood vessel to occlude
the lumen ,it is could a ligature or tie
A suture attached to a needle for a single stitch for
homeostasis is referred to as stick tie or suture ligature
217
Method of suturing
There are two basic method s of suturing and various
ways to utilize the two techniques
The suture is either running utilizing a single
continuous suture, or else it is interrupted
Interrupted = sutures are placed separately and tied
separately.
 Simple interrupted. Each individual stitch is placed,
tied ,and in succession from one suture.
218
Method of suturing …
Simple continuous ( running ).this suture can be used to
close multiple layers with one suture. The suture is not
cut until the full length is incorporated in to the tissue.
219
Method of suturing…
A.Continuous running/locking; also known as a blanket
stitch. A single is passed in and out of the tissue layers
and looped through the free end before the needle is
passed through the tissue for another stitch , the new
stitch locks the previous stitch in place
B.Everting sutures .these interrupted(individual stitches)
or continuous (running stitch ) sutures are used for skin
edges.
220
Continuous running
suturing
Interrupted suturing
221
Method of suturing…
1. Horizontal mattress. Stitches are placed parallel to
wound edges. Each single bite takes the place the place
of tow interrupted stitches.
2.Vertical mattress. This suture uses deep and superficial
bites ,with each stitch crossing the wound at right angles
.it works well for deep wounds. Edges approximate
well.
3. Inverting sutures. these sutures are commonly used
for two layer anastomosis of hallow internal organs,
such as the bowel and stomach .
222
Mattress type of suturing
223
Method of suturing…
Placing two layers prevents passing suture through the
lumen of the organ and creating a path for infection
A purse-string suture – is used to approximate the end
of a lumen, such as a hernia sac or appendicle stump.
The suture is passed around the lumen & tied in
purse-string fashion
stitches can be either interrupted or continuous
224
LO9:SURGICAL CONSCIENCE AND ETHICS
Learning Objectives
After completing this session, the learner will be able to:
1. Discuss surgical Conscience.
2. List areas in operating room work that are affected by
surgical conscience and ethics.
3. State situations that can undermine surgical
conscience.
225
Objectives…
4. Describe the role of law in relation to surgical
interventions.
5. Mention some of the areas of criminal responsibilities.
6. List six areas of negligence in the healthcare facilities
226
Surgical Conscience
A surgical conscience may simply be stated as a
surgical Golden Rule: Do unto the patient as you
would have others do unto you.
The caregiver should consider each patient as himself
or herself or a loved one.
Surgical conscience involves a concept of selfinspection coupled with moral obligation.
In short, a surgical conscience is the inner voice for
conscientious practice of asepsis and sterile technique
at all times.
227
Cont’d
The team member who wanted his/her patient to have
the best possible care practices surgical ethics.
 Respect for the patient's religious beliefs must be
observed
 Respect the patient as an individual
 Fears and pain should be treated strongly
 Patient needs care and attention
 Respect for the patient's right to privacy
228
Cont’d
The patient must not be discussed outside the surgical
department
The patient's condition is a private matter between
himself and his caregivers; it is not a topic for public
discussion or opinion
229
Areas affected by surgical conscience
1. Protection of the patient
 Electrical hazards
 Moving and positioning
 Environmental protection
 Protection from psychological insult
 Anxiety and fear
 Unnecessary time spent
230
2. Aseptic Technique
A second major area affected by surgical conscience is
the practice of good aseptic technique. When ever we
break the aseptic technique, the individuals are a risk of
infection.
231
Situations that undermine surgical conscience
Every professional in the medical field should be on
the lookout for apathtic and its causes since it greatly
reduces the quality of patient care and safety.
 Peer Apathy
 Stress, fatigue, poor Health
 Personal problems
 Staff relations
232
The Legal Aspects of surgery
 Every country has laws that regulate the activities of
healthcare providers including surgeons.
These laws limit the practice of medicine/nursing to
holders of a license granted only after extensive training
and rigorous examinations.
These laws, called medical practice acts, nursing
practice acts, etc.
233
Criminal Responsibilities
 Exceeding the Scope of Practice
 Patient Property
 Hospital Property
 Negligence
234
Common Areas of Negligence
A. Side Rails and Supports
B. Burns
C. Patient Identification
D. Loss of Items within the patient
E. Medications and solutions
F. Explosion
G. Abandonment of the patient
H. Specimen
235
Cont’d
I. Surgical consent
J. Defamation
236
LO10:-Principles of Anesthesia
After completing session, the learner will be able to:
1.Differentiate between local and general anesthesia.
2.Mention the routes of administering local anesthesia.
3.Identify three methods of administering general
anesthesia.
4.Manage the adverse effects of local anesthesia.
5.List two agents used as local anesthesia.
6.Identify the stages of general anesthesia.
7.Mention two agents used for general anesthesia
237
Introductions
Anesthesiology is the branch of medicine that is
concerned with the administration of medication or
anesthetic agent to relieve pain and support physiologic
function during a surgical procedure
anesthesiology as the practice of medicine dealing with
the management of procedures for rendering a patient
insensible to pain during surgical procedures, and with
the support of life functions under the stress of
anesthetic and surgical manipulations
238
Definition
The word anesthesia derived from Greek word
“anisthesis”, which literally means “not sensation”
Anesthesia, the absence of sensation, may be produced
in a specific body area or systemically. When the
agent given causes unconsciousness, the anesthetic
is termed general (general anesthesia) when an agent
is directed into a specific area to cause analgesia, the
absence of pain, it is called conductive or local or
regional
239
Types of Anesthesia
 General anesthesia
 Local anesthesia
 Regional anesthesia
 Spinal anesthesia
240
Local anesthesia
 The agent used during local anesthesia acts on a
single nerve, a group of nerves or on superficial
nerve endings.
 During all types of local/regional anesthesia
including local infiltration, nerve block, topical,
epidural and spinal, the patient remains conscious
241
The anesthetic travels quickly to the brain and the
following symptoms may be observed:
Stimulation: patient may become very talkative or
anxious, signs of tachycardia thready pulse,
convulsion.
Depression: patient may appear sleepy and
unresponsive, bradycardia, hypo tension
Other signs: patient may develop cyanosis, sweating
feel cold, act restless (signs of shock). Fainting,
itching, nausea or sudden headache may also occur.
242
General anesthesia
 Definition:-“An altered state physiologic state
characterized by reversible loss of consciousness,
analgesia of the entire body, amnesia, and some degree
of muscle relaxation.
243
Cont…
It is a type of anesthesia which causes
- unconsciousness,
- provides analgesia and
- muscle relaxation.
Depending on the type and amount of agent used , the
patient may be slightly or not at all responsive to stimuli
There are four stages of general anesthesia, these are
induction,
excitement,
relaxation and danger.
244
Stages of General anesthesia
Induction - is the beginning of administration of the agent
 Lasts until the patient is unconscious.
 Pt retains sense of hearing until the last moment.
 Warmth, dizziness , & feeling of detachment. Ringing,
roaring or buzzing in the ears. Still conscious but may
sense inability to move the extremities easily
245
Excitement
Struggling, shouting ,talking, singing, laughing or
crying – (avoided if given smoothly & quickly)
Pupils dilate ( but contract if exposed to light) PR
rapid & RR irregular. Restraining the patient may be
possible
The pt become delirious and sensitive to
external stimuli
 involuntary muscle activity& struggle
 pt is physiologically unstable
246
Cont…
Relaxation – it is the level in which surgery is performed
safely
The pt is relaxed , unconscious of pain and
physiologically stable
 Breathing is steady or automatic
This phase ends at its deepest level with respiratory
paralysis
Danger – begins when the amount of agent causes severe
depression of CNS that pt immediate danger of cardio
pulmonary arrest
247
Anaesthetic Agents & Adjuncts
 Gaseous Inhalation Anesthetic
Volatile Inhalation Anesthetics
Non‐Depolarizing Muscle Relaxants(NDMRs)
Depolarizing Muscle Relaxant
NDMR Reversal Agents
Intravenous Anesthetic Induction Agents
248
Gaseous Inhalation Anaesthetic
 Nitrous Oxide (N2O)
 weak anesthetic effects
◦Non irritating to the respiratory system
◦Minimal cardiovascular effects
◦Odorless!
◦100% O2 important
◦Can cause nausea
◦Called “ Laughing gas”
249
Volatile Gas Inhalation Anesthetics
 Volatile Gas Inhalation Anesthetics
◦ Liquids that evaporate at room temperature
◦ Names end in –ane
◦ Central Nervous System (CNS) effects within minute
◦ No Analgesic
◦ Increased risk of aspiration
250
Cont’d
 Volatile Gas Inhalation Anesthetics Volatile Gas Inhalation
Anesthetics
 Examples
Isoflurane
◦ Not used for induction
◦ Maintenance
◦ Post‐operative shivering
Sevoflurane
 ◦ Induction & maintenance
251
Cont’d
◦ Newest agent –Preferred for pediatric inductions
◦ non irritating, less pungent
◦ Works quickly
◦ Less side effects
Halothane
◦ decline in use since 2000 for paediatrics
Desflurane
252
I.V. Induction Agents
Quick onset, short duration, rapid offset
Immediate effects
CNS depression
Spontaneous ventilation stopped
Loss of laryngeal reflexes
Increased risk for aspiration
Respiratory effects
Increased risk of upper airway obstruction due to
relaxation of soft tissue muscle surrounding airway
253
Examples
Thiopental (pentothal)
Ultra short‐acting
No analgesic effects
Prolonged drowsiness in patients with liver disease
Propofol
No analgesic effect
Painful on injection
Rapid and alert emergence
Used in children > 3 yrs
254
Cont’d…
Ketamine
rapid acting
Intense analgesic properties
Patient appears to be awake
Amnesia
Minimal respiratory depression Minimal respiratory
depression
 Airway reflexes should remain normal with proper
dosing
255
IV Opioids
 Analgesic or anesthetic induction agent
 Reduces need for large doses of general anesthesia
 Side effects
 Drug examples
 Fentanyl
 Remifentanyl
 Morphine
256
Morphine ‐Side Effects
•True allergic reactions are rare
•Too much morphine
o Hypotension
causes
◦Respiratory depression
◦Apnea
◦Bradycardia
Naloxone
◦Morphine antidote
◦Shorter half‐life than
morphine
o Bradycardia
o Sedation/drowsiness
o Pruritis
o Facial flushing
o Increased sweating
o Nausea & vomiting
o Hyper‐excitability
257
Muscle Relaxants
Can provide good muscle relaxation while needing
less general anesthesia
Affect skeletal muscle
Ventilator support required
Classified into:
◦Depolarizing
◦Non‐depolarizing
258
Non‐Depolarizing Muscle Relaxants
(NDMR)
Block the depolarizing effect of acetylcholine at the
neuromuscular junction
◦ Results in neuromuscular paralysis
Onset of paralysis 1‐2 minutes
Main side effects are changes in heart rate and blood
pressure
259
Cont’d…
Paralysis from fine to gross motor
Examples:
◦ Rocuronium
◦ Pancuronium
◦ Vecuronium
260
Cont’d…
 Non‐Depolarizing Muscle Relaxants (NDMR)
 Undesired effects can occur in:
◦eyes (miosis)
◦heart (bradycardia)
◦lungs (bronchospasm)
◦GI tract (increased peristalsis)
◦Secretory glands (increased secretions)
261
Additional medications for NDMR side effects
Atropine
◦Used to prevent bradycardia associated with intubation
Glycopyrrolate
◦To decrease the amount of oral secretions
◦Can cause post‐op sore throat due to drying
◦Increases heart rate
Neostigmine
◦NDMR reversal agent
◦children more sensitive
◦more rapid effect
262
Depolarizing Muscle Relaxants
Succinylcholine
◦only drug of this type in general use
Acts similar to acetylcholine at the neuromuscular
junction
Quick on‐set
◦Good for rapid sequence inductions
Ultra short‐acting
263
Methods of administering
Inhalation
The anesthesia machine is used to administer both
compressed gas anesthetics and volatile liquids that are
vaporized with in the machine before administration.
since the anesthesia provider controls all gases that enter
the patient’s lungs ,the machine also conveys oxygen in
the proper proportion
The vapor is administered to the patient through a tube
or a mask.
264
cont…
The inhalation anesthetic may also be administered
through a laryngeal mask
The endotracheal technique for administering
anesthetic consists of introducing a soft rubber or
plastic endotracheal tube into the trachea, usually by
means of a laryngoscope
The endotracheal tube may be inserted through either
the nose or mouth
265
cont…
Intravenous
General anesthesia can also be produced by the
intravenous injection of various substances, such as
barbiturates, benzodiazepines, non barbiturate
hypnotics, dissociative agents, and opioid agents
These medications may be administered for induction
(initiation) or maintenance of anesthesia
They are often used along with inhalation anesthetics
but may be used alone
They can also be used to produce moderate sedation.
266
cont…
An advantage of intravenous anesthesia is that the
onset of anesthesia is pleasant; there is none of the
buzzing, roaring, or dizziness known to follow
administration of an inhalation anesthetic
For this reason, induction of anesthesia usually begins
with an intravenous agent and is often preferred by
patients who have experienced various methods
The duration of action is brief, and the patient
awakens with little nausea or vomiting
267
Methods cont…
 Intravenous anesthetic agents are nonexplosive, they
require little equipment, and they are easy to
administer.
 A disadvantage of an intravenous anesthetic such as
thiopental is its powerful respiratory depressant effect.
268
Methods…
Regional anesthesia: is a reversible loss of sensation after
a local anesthetic has been injected to block nerve fibers.
E.g. Spinal anesthesia
Local anesthesia: is usually employed for minor
procedures in which the surgical site is infiltrated with a
local anesthetic such as lidocine
In spinal anesthesia ,a spinal needle is inserted in to a
lower lumbar space with the patient in a sitting position
.then a local anesthetic (usually lidocine or bupivacaine) is
injected in to the cerebrospinal fluid CSF of the
subarachinoid space.
269
Complications of anesthesia
 Potential intra operative complications include
 nausea and vomiting,
 anaphylaxis,
 hypoxia, hypothermia, malignant hyperthermia, and
disseminated intravascular coagulopathy.
270
Laryngospasm
Closure of the vocal cords
Larynx closes the glottis by contracting
Prevent substances from entering the lungs
Complete obstruction Æhypoxia , no audible air entry,
bradycardia
“Approx 25‐30% of elective healthy pediatric patients
less than 1year desaturate to < 90% during induction
or venous cannulation”
271
272
Factors aggravating
 Laryngospasm Triggers:
◦Secretions
◦Suctioning
◦Awake anesthesia
◦Artificial airway or tracheal tube
◦Attempted laryngoscopy
◦Extubation
◦Other causes
273
Mild Episode sign&symptoms
◦Airway obstruction
◦Paradoxical abdominal movement
◦Intercostal muscle retractions
◦Characteristic crowing noise
274
bronchospasm
 Causes of Bronchospasm
 Anesthesia in a poorly controlled asthmatic
 Bronchial intubation
 Irritation of carina
◦ by tracheal tube and or aspiration of gastric contents
o
Use of irritant volatile anesthetic drugs
Intubation without use of a relaxant at an inadequate
depth of anesthesia
275
Signs & Symptoms of Bronchospasm
 Signs & Symptoms of Hypoxia
 Increased inflation pressures
 Expiratory wheeze
Treatment
 Remove stimulus if possible
 Deepening of anesthesia
 Nebulized bronchodilator treatment
◦ such as salbutamol
276
Anaphylaxis
The incidence during anesthesia is estimated to be 1 in 5000
to 1 in 25, 000 anesthetic administrations
Common Causes of Anaphylaxis Common Causes of
Anaphylaxis
Anesthetic drugs:
◦ IV anesthetics (propofol)
◦ Muscle relaxants (succinylcholine, “iums”)
◦ Opiods
◦ Local Anesthetics
277
Cont’d
Latex
Other:
◦ Surgical prep
◦ Intra‐operative medications
◦ Unknown
278
 Clinical Manifestations
 Treatment
 Uticaria* ‐ may not be
 Discontinue suspected
noticed if drapes on Facial
agent
and laryngeal edema
 May need to conclude
 Laryngospasm
operation
 Bronchospasm*
 Anesthesia will ensure
 Tachycardia
that the airway and
 Hypotension*
ventilation are maintained
 *Key signs under general  Epinephrine
anesthesia*
 IV fluids to restore
intravascular volume
279
Cont’d
 Give diphenhydramine
 B2 agonist (salbutamol) for bronchospasm
 Hydrocortisone
280
LO11:-HAZARDS IN THE OPERATING
THEATER
Learning Objectives
After the completion of this session, the learner will
be able to:
1.Identify the main dangers in the operating room.
2.Explain the factors that increase the hazards in the
OR.
3.Differentiate between physical and chemical hazards.
4.Discuss malignant hyperthermia.
5.Define anaphylactic reaction.
281
Introduction
Historically, the operating room (OR) has been a
place full of hazards for both the patient and the care
giver. The primary dangers include, but are not
limited to fire, chemical exposure to anesthetic
agents and direct exposure to biologic materials.
282
11.1 Environmental Hazards
The perioperative environment poses many hazards
for both patients and personnel. The potential for
physical injury from electric shock, burns, fire,
explosion, exposure to blood-borne pathogens, and
inhalation of toxic substances is ever present
283
Injuries can be caused by:
 Using faulty equipment
 Using equipment improperly
 Exposing oneself or others to toxic or irritating
agents,
 Or Coming into contact with harmful agents
284
Hazards in the OR environment can be classified as
follows:
•Physical: including back injury, fall, noise pollution,
irradiation, electricity and fire
•Chemical: including anesthetic gases, toxic fumes
from gases and liquids, cytotoxic drugs and cleaning
agents
•Biologic: including the patient (as a host for or
source of pathogenic microorganisms), infectious
waste, cuts or needle-stick injuries, surgical plume
and latex sensitivity
285
Regulation of Hazards
1.Elimination
of substances
286
1.Elimination of sources of ignition
A. Electrostatic Spark
B. Precautions To Be Observed By Personnel
a. The hair must be covered completely
b. Materials that accumulate static (wool, nylon,
rayon, sharkskin, silk, or plastics) must not be worn
c. Conductive shoes should be worn
d. No woolen blankets are permitted in the OR
e. Personnel should avoid any unnecessary motion
in the area near the patient's head and the
anesthesia equipment
287
C. Precautions Observed in Construction of the
Suite and Equipment
1) Conductive flooring, usually ceramic or vinyl plastic
tile, is installed
2) Furniture is made of metal with the leg tips or
casters made of either metal or conductive rubber to
provide a conductive path to the floor
3) Carbon-permeated rubber mattresses, pillows, and
sheeting should be used
4) An instrument (ohmmeter) is used to measure the
electric resistance of personnel and equipment
288
Cont’d
5. All plugs, sockets, and switches must be explosionproofed for use in anesthetizing locations
6.Only electrical equipment that has been designed for use
in hazardous locations may be used
7. The electric cautery is to be used with extreme care
8. The use of photoflash and photoflood bulbs should be
prohibited
9. Anesthesia machines or oxygen cylinders are never to be
completely covered
289
Cont’d
10.Anesthesia equipment must be kept in good repair
and must be leak proof
11. Oil or grease is never to be used on any part of the
anesthesia machine or oxygen valve
12. The humidity of the OR should be kept at 55 to 60
percent to lessen the accumulation of static charges
290
2.Elimination or Control of Sources of
Heat
1) No smoking should be permitted in hazardous area.
2) Open flames such as lighted matches or alcohol
lamps may be used in some operative procedures but
only after their use has been cleared by the anesthetist.
3) Electric hot plates should never be used in the same
room or area where flammable agents are stored or
used.
291
3.ELIMINATION OF HIGH OXYGEN
CONCENTRATION
1. Ventilating or Air-Conditioning Systems
2. Oxygen Cylinders. Oxygen cylinders must be
operated properly
4.FIRE EXTINGUISHERS
292
Catastrophic Events in the operating Room
Unanticipated intraoperative events occasionally
occur. Although some might be anticipated (e.g.,
cardiac arrest in an unstable patient, massive blood
loss during trauma surgery), others may occur
without warning, demanding immediate
intervention by all members of the OR team. Two
such events are anaphylactic reactions and malignant
hyperthermia
293
Anaphylactic Reactions
Anaphylaxis is the most severe form of an allergic
reaction, manifesting with life-threatening pulmonary
and circulatory complications. The initial clinical
manifestations of anaphylaxis may be masked by
anesthesia
294
Cont’d
Anesthesia Care Providers (ACPs) administer an
array of drugs to patients, such as anesthetics,
antibiotics, blood products and plasma expanders,
and since any parenterally administered material can
theoretically produce an allergic response, vigilance
and rapid intervention are essential
295
Cont’d
An anaphylactic reaction causes hypotension,
tachycardia, bronchospasm and possibly
pulmonary edema. Antibiotics and latex are
responsible for many perioperative allergic
reactions
296
Malignant Hyperthermia
Malignant hyperthermia (MH) is a rare metabolic
disease characterized by hyperthermia with rigidity
of skeletal muscles that can result in death. It occurs
in affected people exposed to certain anesthetic
agents
When it does occur, it is usually during general
anesthesia, but it may manifest in the recovery
period as well
297
Cont’d
The fundamental defect is hypermetabolism of
skeletal muscle resulting from altered control of
intracellular calcium, leading to muscle contracture,
hyperthermia, hypoxemia, lactic acidosis, and
hemodynamic and cardiac alterations
298
summary
1.List four primary dangers for both the patient and the
care giver in the operating room.
2.In order to minimize the potential hazards in the OR,
what knowledges are expected from the OR team?
3.Identify the three hazard classifications that could
happen in the OR environment?
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Pathophysiology of Pain
 The sensory experience of pain depends on the
interaction between the nervous system and the
environment
 PAIN TRANSMISSION
The nerve mechanisms and structures involved in the
transmission of pain perceptions to and from the area
of the brain that interprets pain are nociceptors, or
pain receptors, and chemical mediators
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Cont’d
 Chemical mediators(algogenic like Histamine,
bradykinin, acetylcholine,serotonin, and substance P
301
post operative Control of pain
 Why control of pain?
Importance: Psychological reasons/humanity/
 social reasons
 Biological reasons
pain
autonomic activation
increased
adrenergic activity
Arterial vasoconstriction
reduced wound perfusion
decreased tissue
oxygenation
delayed wound healing
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Pain management
 Pharmacologic pain mgt
 Three general categories of analgesic agents are
1. opioids, Eg:-morphine, codeine
2. NSAIDs, and
3.
Eg :-diclofenac, ibuprofen
local anesthetics. Eg:- ELMA cream
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Non-pharmacological pain mgt
 Cutaneous Stimulation and Massage
 Including rubbing the skin and using heat and cold
Ice and Heat Therapies
Ice should be applied to an area for no
longer than 20 minutes at a time
 Distraction
 Guided Imagery
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THANK
YOU!!
THE
END
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