OPERATION THEATRE TECHNIQUES

CONTENTS

1) The surgical team2) Prevention of infections in OT3) Hazards in OT4) Equipments of OT5) Drugs used in OT6) Instruments of OT7) Sterilisation of OT8) Designing an ideal OT room complex9) Responsibility of anesthetist10) Admission of patient to theatre11) Positioning of patient12) Care of specimens13) Surgical terminology

THE SURGICAL TEAM

A team of surgical medical staff help the surgeon during operation. Personnels of team depend on type of surgery. Most teams include the following personnels.

1) Surgeon:- A surgeon is as physician who performs surgical operations. Specialities include:- Cardiac surgery, Colon and rectal, dental, transplant surgery.

2) Anesthesiologist:- An anesthesiologist is a physician qualified in anesthesia & perioperativemedicine.

3) Certified registered nurse anesthetist:- (CRNA) A nurse anesthetist is a registered nurse with advanced educational credentials & significant clinical training. A certified registered nurse anesthetist provide care to patients that require anesthesia or pain management before surgeries or specific types of medical procedures.

4) Operating room nurse:- is a registered nurse specialized in perioperative nursing practice.5) Circulating nurse:- Duties of circulating nurse are carried outside the sterile area. Circulating

nurse manages all necessary care inside surgery room, assisting the team in maintaining & creating comfortable & safe environment for the patient & observing the team from a wide perspective.

6) Physician assistant:- A physician assistant is a health care professional who practices medicine as a part of health care team with collaborating physicians & other health care providers.

7) Surgical technician:- is an allied health professional working as a part of team delievering surgical care. They possess knowledge in sterile & aseptic techniques.

8) Residents:- A resident doctor or house officer is a physician who practice medicine under the direct or indirect supervision of attending physician.

9) Medical representative:- A medical representative provides information about medicines & drugs available to those who prescribe medicines.

LAYOUT OF OT

1) Outer zone:- Main access corridor, transfer area, supervisor office or control station, documentation area, preoperative patient holding area, the changing facilities.

2) Clean/semi restricted zone:- Clean corridor, sterile & equipment sterile store, anesthesia & recovery room, rest areas.

3) Restricted zone:- Scrub sinks, operating room.

Staff must change into theatre clothes & shoes before entering the clean/semi restricted area.

The operating theatre (restricted zone) should be restricted to just the personnel involved in actual operation.

4) Sterile field:- Do not allow sterile personnel to reach across unsterile area or to touch unsterile items or vice versa.

INFECTION PREVENTION & CONTROL IN OT

STANDARD PRECAUTIONS:-

1) Hand hygiene2) Personal protective equipments (PPE)3) Aseptic techniques:- Prevention of needle stick injury4) Environmental cleaning5) Instruments reprocessing.6) Waste management

Blood spillage management/blood or body fluid post exposure management.

CDC recommendation for prevention of SSI:-(SSI- SURGICAL SITE INFECTION)

1) Category IA:- Strongly recommended for implementation & supported by well designed experimental, clinical or epidemiological studies.

2) Category IB:- Strongly recommended for implementation & supported by some experimental, clinical or epidemiological studies & strong theoretical rationale.

3) Category II:- Suggested for implementation & supported by suggestive clinical or epidemiological studies or theoretical rationale.

4) No recxommendation:- Unresolved issue. Practice for which insufficient evidence or no consensus regarding efficacy exists.

CDC Recommendation for Surgical site infection:-

1) Preoperative2) Intraoperative3) Postoperative4) Surveillance

Preoperative:-

1) Preparation of patient2) Hand antisepsis for surgical team members3) Management of infected or colonized surgical personnel.4) Antimicrobial prophylaxis.

Preparation of patient:-

1) Identify & treat all infections remote to surgical site before elective operation IA.2) Do not remove hair preoperativerly unless it interfere with operation IA.

3) If needed, remove hair immediately before operation preferably with electric clippers IA.4) Require patients to shower or bathe with an antiseptic agent at least the night before

the operating day IB.5) Thoroughly wash & clean at & around the incision site to remove gross contamination before

performing skin preparation IB.

Hand/Forearm asepsis for surgical team:-

1) Keep nails short & do not wear artificial nails IB.2) Perform preoperative surgical scrub for at least 2-5 min using an appropriate antiseptic IB.3) Dry hands with sterile towels & don a sterile gowns & gloves IB.

Antimicrobial prophylaxis:-

1) Administer a prophylactic antimicrobial agent when indicated IA.2) Administer by the IV route the initial dose not more 1 hour before incision IA.

Intraoperative:-

1) Ventilation system2) Cleaning & disinfection of environmental surfaces3) Microbiological sampling.

Ventilation:-

1) Maintain positive pressure ventilation in the operating room IB.2) Maintain a minimum of 15 air changes per hour with at least 3 fresh air IB.3) Do not use UV radiation in the operating room to prevent SSI IB.4) Keep operating room doors closed except as needed for passage of equipment personnel &

the patient IB.

Cleaning & disinfection of environmental surfaces:-

1) When visible soiling or contamination with blood or other body fluids or surfaces or equipments occurs, use an approved disinfectant to clean the affected area before the next operation IB.

2) Do not perform special closing the operation room after contaminated or dirty operation.

Sterilization of surgical instruments:-

Sterilize all surgical instruments according to guidelines IB.

Surgical attire & drapes:-

1) Wear full PPE IB2) Surgical mask that fully covers the mouth & nose3) Cap or hood to fully cover hair on head & face.4) Sterile gloves.

5) Impermeable sterile gowns.

Change scrub suits when visibly soiled or contaminated with blood or body fluids IB.

Asepsis & surgical technique:-

1) Adhere to principles of asepsis when placing intravascular devices IA.2) If drainage is used, use a closed suction drain, insert it through a separate incision

distant from the operative incision & remove it as soon as possible IB.

Cleaning spills of blood & body fluids:-

Procedures for dealing with small spillages e.g- splashes & droplets.

- Gloves & plastic apron must be worn.- The area should be wiped thoroughly using disposable paper roll/towels- The area should be cleaned using a neutral detergent & warm water.- Recommended concentration of Presept 1 tab in 2.5 water liters to decontaminate surfaces.- Used gloves, apron/towels should be disposed in yellow waste bag.- Wash hands.

Large blood spills in dry areas (such as clinical areas):-

- Where possible, isolate spill area.- The area must be vacated for at least 30 minutes.- Wear protective equipment like disposable gloves, eyewear, mask & plastic apron.- Cover the spill with paper towels.- Place all contaminated items into yellow plastic bagor sharp container for disposal.- Pour (35 tab Presept in 1 water liter) sdolution& allow 10 minutes To react then wipe up.- Decontaminated areas should then be cleaned thoroughly with warm water & neutral

detergent.- Follow this decontamination process with a terminal disinfection.- Discard contaminated materials (absorbent toweling, cleaning cloths, disposable gloves &

plastic apron).- Wash hands.

HAZARDS IN OT:-

Variety of different equipments are used by personnel working in operating room. This entails working in semi-closed environment, coming into contact with dangerous medical tools & substances. It include sharp objects e.g.- scalpels & syringes, anesthetic gases, drugs & sterilizing chemicals. This includes risk & hazards management in operating room.

Classification of hazards:-

A surgical team member could accidentally injure himself or herself during surgical equipment, slips or falls if a wet floor, fall from OT table, injury due to improper positioning, wrong surgery on patient, having identical names & pain due to long hours of standing or handling of patients.

Causes of hazards & safety measures:-

1) Falls/slips causes:-- Wet floor- Wrong theatre shoes- Oil spillages- Empty paper foils & suture wraps- Trailing cables- Unstable theatre shoes

Safety measures include:-

- Proper cleaning- Avoidance of trailing electrical cables- Use of identical theatre shoes- Careful arrangement of operating room equipment & furniture- Dutiful use of kick about & waste buckets.- Faulty shoes & platforms should be removed from circulation & be brought back only

after they have been repaired.2) Trauma causes:-

- Careless handling of sharps- Uncoordinated speed- Falls- Inexperience of careprovider

Safety measures include:-

- Provision & use of disposable bags for disposable sharps.

- Careful handling of sharps.- Extreme care when speed is required.

3) Electrocaution causes:-- Faulty electrical equipment- Poor maintenance culture.- Wrong handling techniques- Unfimiliarity

Safety measures:-

- Prompt & proper maintenance of equipments.- Careful attention to electrical contacts when used on patients.

4) Radiation safety measures:- Lead should be tested routinely by radiology department every 6 months.- Radiation exposure: - This should be monitored with film badges or pocket dosimeters,

these must be checked monthly by radiation protection officers.5) Burns safety measures:-

- Ensure that all equipment including cables, surgical instrumentation & patient plates are fully insulated & that any faulty equipment is removed immediately &reported as per hospital policy.

- Always ensure that electro-surgical equipments are kept within an insulated container throughout the procedure.

6) Heat stroke causes:-- Faulty ventilation devices.- Overcrowding- Presence of heat generating equipment within the operative room.

Safety measures include:-

- Repair & maintenance of faulty ventilation devices.- Avoid qvercrowding of operating room (OR).- Maintain normal operating room temperature of 16-20 deg C.

7) Infection causes:-- Contracting of HIV & AIDS virus through needle stick, splashing of blood contact to the eyes.- Hepatitis A & B & other organism.- Failure to maintain aseptic technique.- Poor ventilation.- Unreliable cleaning & decontamination.- Dirty operation room attire.- Use of non-theatre equipment.

8) Infection safety measures:-- Proper maintenance of aseptic technique.- Careful handling of infected & contaminated causes.

- Standard precautions.- Reliable routine cleaning programme.- Proper ventilation.- Adequate decontamination & sterilization of appropriate equipments/objects.- Personal & patient hygiene.- Identification/separation of high risk patients.- Utilize safe zone during each surgical procedure.- Dispose of sharps in sharps container immediately after use.- Use of PPE.- For eye/face exposures: - Use an eye wash & rinse for about 15 minutes.- For a needle stick: - Wash with soap/water or betadine if available.- Report exposures immediately to hospital PEP committees for proper evaluation &

recommendation.- Employers must ensure that the appropriate protective equipmentsis available & that

employees are trained to wear & use it.

Air pollution causes:-

- Leaking of ambient gases (gaseous mixture mainly nitrogen & oxygen)- Septic cases.

Safety measures include:

- Gas cylinders should be checked for leakages every morning.- Closed circuit anesthetic administration should be encouraged to reduce the theater level

of composed gases.- Check corrugated tubes for leakages & recent gas leakage from other sources to reduce

the theater level of ambient gases.- Avoid sparks or active fire outbreak.- Avoid overcrowding in operating room.- Empty waste bucket promptly.- Provide a different theater for septic cases.- Execute an efficient cleaning to prevent rodent infestation.- Noise should be reduced to minimum.

Fire outbreaks/sparks causes:-

- Lack of training for the fire precaution & fighting.- Naked flames in the theatre.- Excessive heat.- Lack of fire prevention inbuilt in operating room.

Safety measures:-

3 basic elements of surgical fire constitute fire triangles which are:-

1) Ignition source:- Electrosurgical equipment, surgical laser, electro cautery, fiber optics light source & defibrillators.

2) Oxidisers include- Oxygen enriched atmosphere nitrous oxide, medical air.

Fuels include operating theatre materials like mattresses, sheets, gowns, drapes & dressings.

Oxygen Heat

Fuel(Oil)

Ways of minimizing ignition risks:-

During electro surgery the pencil should be placed in quiver or holster when it is not in active use & the active electrodes should be activated only when the tip is under the surgeon’s direct vision.

Elimination of fuels:-

- Avoid the use of flammable gases e.g.- Ether or cyclopropane gases.- Provision of a good ventilation system to diffuse the concentration of flammable gas,

vapor or liquid.- Safe keeping of flammable items.

Ways of eliminating sparks:-

- Ensuring that the theatre floor most especially, around the operation & anesthetic rooms is spark resistant.

- Theatre flooring should be of terrazzo/marble laid upon a metal mesh to conduct currents away.

- Patients on whom diathermy machine is used must be adequately guarded.- Avoid creating frictions on two metallic surfaces.- Stools, buckets, trolleys, equipment stands etc should have antistatic properties.- Shoe covers or shoes worn must have soles & heels impregnated with non

conducive properties.- All electrical cords must be rubber coated.- Avoid naked flames as this literally set up an ignition, very hot objects like lights & sources

of heat etc should be least one meter away from anesthetic machine or any flammable agent or item.

- There must be no smoking.- The position of extinguishers in the theatres should be well marked & the fire routes

& assembly points should be known by all personnel.- Regular fire drills should be done to improve on awareness.

Ways of minimizing oxidizing risks:-

- During oropharyngeal surgery, suctioning of potential breathing gas leak should be done as a means of scavenging gases from oropharynx of an intubated patient.

- Wet gauze should be used with uncuffed tracheal tubes to minimise leakages of gases into the oropharynx of all guaze, sponges &pledgets& their strings should be kept moist throughout the procedure to render them ignition resistant.

Ways of minimizing fuel risks:-

During skin preparation, the surgeon should avoid pooling or wicking of flammable liquid preps (spirit containing). The flammable liquid preparations should be allowed to dry fully before draping.

Classes of fire extinguishers:-

1) Class A fire:- This comprises of solids such as carbonaceous materials like paper wood 7 their derivatives. It should be extinguished with water.

2) Class B fire:- This involves liquids & liquefiable solids e.g. oil, fat, petroleum products, parading waxetc. they should be extinguished with sodium bicarbonate powder, carbon dioxide, incombustible sheet or foam materials.

3) Class C fire:- This involves propane, butane, methane i.e. liquefied gases, theyare extinguished withwater or their containers.

4) Class D fire: - This involves metals. Water must not be used instead CO2, dry sand should be utilized.

Responding to surgical fire during surgery:-

- If fire occur in operating room during a surgical procedure, the first concern is the safety of the patient & personnel.

- To prevent explosion, the burning article is removed immediately from the proximityofoxygen source & the anesthetic machine or outlet of piped in gases.

- The fire on the field is smothered with wet towels & burning drapes are removed from the patient.

- The shut off valves for piped in gases are turned off & electrical power cords are unplugged.

Injury during surgery:-

A penetrating injury (e.g. needle stick) or a splash (e.g. into the eye mucus membrane) with fluids, contaminated with blood o body fluids must not be ignored if exposure to blood or body fluids occurs.

The following procedures should be performed:-

- Stop activity immediately, & step back from the point of contamination.- Cleanse the puncture site or flush the eye with cool water.- Flush out the puncture site with alcohol or iodine preparation.- Report the incident according to security policy & procedure seek medical attention

promptly.- Follow the particular protocol established by the facility for follow up.

Safety measures in preventing chemical hazards:-

Improper handling of chemicals can result in injury to health care workers & patients:-

- All chemical containers must have proper labeling indicating contents, safe use & associated hazards. This also applies to secondary containers.

- Potential hazards associated with the use of chemicals, in the practice setting should be identified & the safe practices should be established.

- Injuries may result from exposure to any portion of the body, including the integumentary or respiratory system.

- Perioperative staff can protect themselves by helping containers & basins tightly covered.

Causes of deaths on OT table:-

- Preoperativepatient’s condition.- Inexperienced personnel.- Lack of monitoring devices.- Cardiac arrest.- Respiratory arrest.- Imbalanced anesthesia- Severe hemorrhage.- Prolonged anesthesia.- Lack or resuscitative equipments.- Lack of resuscitative drugs.- Discourage operation on patients at risk of moridity

Safety measures:-

- Good induction technique- Provision of good monitoring devices/resuscitative drugs &equipments.- Identify high risk patients.- Supervision of less competent hands.- Prevention of undue blood loss & provision for fluid level maintenance.- Avoidance of unduly prolonged anesthesia & surgery time.

Risk management:-

It consist of 4 related elements:-

1) Administration2) Prevention3) Correction4) Documentation

Administration:-

- Regulation, recommendations, guidelines & laws should be enforced to prevent disastrous consequences of occupational hazards.

- Policies & procedures should be written, reviewed periodically & updated as appropriate.- Protective attires & safety equipments should be made available to employees as

appropriate.- Monitoring devices should be used in all hazardous location as recommended by regulatory

agencies.- Employees health services should be provided for immunization & in the event of injury.

Prevention:-

- Regular in-service training programs should be conducted to keep employees informed about hazards & safeguard measures.

- Employees should be taught how to use & care for new equipments before it’s been put to use.

- Employee must know the location & use of emergency equipments such as fire extinguishers & shut off valves.

- Employee must wear PPE as appropriate.- Routine preventive maintenance should be provided for all potentially hazardous

equipments.

Correction:-

- Faulty or malfunctioning equipments should be taking out of services with immediate effect to prevent harm to the patients & users.

- Any form of injury should be reported, with medical attention sought for, as soon aspossible.

- Unsafe conditions should be reported.

Documentation:-

- Record all information about equipment in the theatre.- A well planned orientation program for newly employed staff or students in the

operating room should be organized.- Incident report regarding injuries to health caregiver & patients should be filled in line

with the facility procedures.

EQUIPMENTS IN OPERATION THEATRE

1) Operating table:- Multi-purposed side controlled table.

2) Monitors:- Monitor displays different output parameters of the patient which help the patient in diagnosing.

ECG monitor:- An electrocardiogram records the electrical signals in heart. It's a common test used to detect heart problems and monitor the heart's status in many situations.Electrocardiograms — also called ECGs or EKGs — are often done in a doctor's office, a clinic or a hospital room. And they've become standard equipment in operating rooms and ambulances.

An ECG is a noninvasive, painless test with quick results. During an ECG, sensors (electrodes) that can detect the electrical activity of heart are attached to chest and sometimes limbs. These sensors are usually left on for just a few minutes.

-

Other monitors:-

- Pulse oximetry:- an oximeter that measures the proportion of oxygenated haemoglobin in the blood in pulsating vessels, especially the capillaries of the finger or ear.

-

- Blood glucose monitor:- A blood glucose meter is a small, portable machine that's used to measure how much glucose (a type of sugar) is in the blood (also known as the blood glucose level). People with diabetes often use a blood glucose meter to help them manage their condition.

3) Anesthetic machine:- Assissts patients breathing during surgery.

4) Heart lung machine:- A machine that temporarily takes over the function of heart and lungs, especially during heart surgery.

5) Surgical ceiling light:- Surgical light is a medical device intended to assisst medical personnel during a surgical procedure by illuminating a local area or cavity of the patient.

Equipments used in OT:-

- Adhesive tape (Elastoplast)- ADK drain- B.P. blade- Bandage- Catgut plain with needle- assorted numbers- Chromic catgut with needle- assorted numbers- Cotton- Crape bandage- A.D. syringe 2cc/3cc/5cc/10cc/50cc.- Epidural set.- Foley’s catheter- Assorted sizres.- Gloves- assorted sizes.- Gypsona- Readymade plaster roll.- Safety cannula – assorted sizes- Melecot catheter- Mersilk- 1/0, 1.- Proline- 1/0, 2/0, 1.

- Readymade adhesive traction kit- Adult/child.- Ryle’s tube- assorted sizes.- Skeletal traction kit.- Spinal needle- assorted sizes.- Trochar & canula.- T- tube- assorted sizes.- Urobag- Vicryl- assorted numbers.

OT Instruments:-

OPERATING ROOM MEDICATIONS:-

1) Anectine:- Neuromuscular blocker. Adjunct to anesthesia to induce skeletal muscle relaxation. Facilitates intubation.

2) Aminophylline:- Bronchodilator. Relaxes smooth muscle of bronchial airway. Treatment of bronchospasms.

3) Atropine:- Anticholinergic. Decreases secretions & block cardiac vagal reflexes.4) Cocaine:- Local anesthetic. Used for oral cavity & nasal procedures.5) Dantrium:- Dantolene sodium. Treatment for malignant hyperthermia.6) Diprivan:- Short acting anesthetic given IV for induction & maintainence of general anesthesia.

Also used for sedation.7) Dopamine:- Adrenergic. Improves perfusion to vital organs. Increase cardiac output.8) Dobutrex:- Adrenergic. Increases cardiac output, adjunct in cardiac surgery.9) Decadron:- Dexamethasone. Corticosteroid (decreases inflammation).10) Dilantin:- Phenytoin. Anticonvulsant. Treatment of seizures.11) Epinephrine:- Bronchodilator. Treatment for anaphylaxis. Increases heart rate, blood pressure

etc. Used in an arrest.12) Fentanyl:- Narcotic analgesic. Adjunct to general anesthesia.13) Flourexcein:- Bright yelloe dye if viewed under cobalt blue illumination.14) Garamycin:- Aminoglycoside for GI/GUsurgery prophylaxis.15) Glucagons:- Treatment of hypoglycaemia. Increases blood glucose. Also increases smooth

muscle relaxation in bowel surgery.16) Hypague:- Dye used to visulaise under X-ray (e.g.- Cholangiograms)17) Hyskon:- Visual media for hysteroscopy.18) Isoflurance:- Inhalation anestyhetic19) Isuprel:- Treatment for bradycardia.20) Indigo carmine:- Blue dye used in urologic surgery cases.21) Ketamine:- General anesthetic.22) Kantrex:- Aminoglycoside. Pre-op bowel sterilization. Intraperitoneal irrigation.23) Lugol’s solution:- Strong iodine solution. Cell dye for colon biopsy & gynaecologic

surgery. Preperation for thyroid surgery.24) Mannitol:- Irrigation solution for TURP ( Transurethreal resection of prostate).25) Marcaine:- Bupivacaine (Sensorcaine). Local anesthetic.26) Monsels:- Ferric subsulphate. Tpopical cautery for gynaecologic surgery.27) Morphine:- Narcotic analgesic, fast acting.28) Nesacaine:- Chloroprocaine, local anesthetic.29) Neomycin sulphate:- Aminoglycoside. Suppression of intestinal bacteria.30) Nipride:- Antihypertensive. Produces controlled immidiate hypotension during anesthesia.

Nitroprusside sodium.31) Neosporin:- Antibiotic ointment. Neomycin+Polymixin+Bacitracin.32) Neosynephrine:- Phenylephrine. Adrenergic vasoconstriction for maintainence of blood pressure

during decreased blood pressure, spinal & inhalational anesthesia.

33) Oxycel:- Hemostatic agent.34) Polymyxin:- Anti-infective irrigations. B-sulphate.35) Pronestyl:- Procainamide HCl. Antiarrythmic for atrial fibrillation, atrial tachycardia.36) Paparvarine;- Vasodilator- Cerebral & peripheral ischemia treatment.37) Pitressin:- Pituitary hormone. ADH effect controls bleeding abdomen. Surgery & esophageal

varices.38) Pitocin:- Labor induction & decrease post partum bleeding, incomplete or inevitable abortion.39) Neostigmine:- Cholinergic. Antidotefor skeletal muscle relaxants.40) Sodium bicarbonate:- Alkalinizers (antacid). Treatment for cardiac arrest.41) Solucortef:- Steroid- decrease inflammation. Hydrocortisone.42) Solumedrol:- Steroid. Methyl prednisone.43) Surgicel:- Oxidised cellulose. Absorbable hemostat.44) Thrombin:- Hemostats- control bleeding.45) Taradol:- Ketorolac. Non narcotic analgesic. Injectable NSAID.46) Tridil:- Nitroglycerin. Antiarrythmic vasodilator. Decreases blood pressure.47) Vibramycin:- Doxycycline.48) Wydase:- Hyaluronidase. Enzyme that increases absorption & dispersion of injected drugs.49) Xylocaine:- Lidocaine. Antiarrythmic.50) Versed:- Midazolam. Sedative. Pre op.51) Zemuron:- Rocuronium. Neuromuscular blocking intubation.

STERILIZATION OF OPERATION THEATRE

Sterilization:- Sterilization is absolute, removes microbes & spores too. To achieve steri lization is expensive, non sustainable, many times not needed.

Disinfection:- An effective disinfection reduces the infections drastically.

Basic care of Operation Theatre:-

1) Reduction of microbial contents is important.2) Very rarely, the microbes reach the operation site.3) Paying great attention to floors using unnecessary, too may chemicals not necessary.4) Keep the floor clean & dry.5) Most important component of bacteria is water. A dry areas causes natural death except spores.

Frequent cleaning of walls & operation theatre is not needed:-

1) Frequent cleaning has little effect.2) Do not disturb these areas unnecessarily.

3) Floors get contaminated, quickly depend on number of persons present in the theatre/movements.

Do not disturb the roof:-

1) Do not disturb unnecessarily.2) Do not use ceiling fans they cause aerosol spread.3) Clean only when remodelling or accumulated good amount of dust.

Care of specimens:-

1) Do remember only 1% of the microbes present on the floors are pathogenic. On many occasionS. aureus isolates as prominent pathogen.

2) Floors should be decontaminated with vaccum cleaner & wet cleaning techniques.3) Keep the mops dry when not in use.4) Use only vaccum cleaners.5) Don’t broom as it increases the bacterail floora in the environment.

Cleaning of floor:-

1) A simple detergent reduces flora by 80%.2) Addition of disinfectant reduces to 95%.3) In busy hospitals count raises in 2 hours.

Environmental cleaning of operation theatres:-

1) Do not waste chemicals.2) Only remove the dust with cloth wetted with clean water.3) Don’t use chemicals/disinfectants as a habit.4) Use only when contaminated with blood or body fluids.

Handling of air in operation theatre:-

1) Negative air pressure vented to the operation theatre.2) Environmental cleaning should be twice daily.

Environmental cleaning of hospitals should be chlorinated compounds:-

Disinfectants Purpose1. Sodium hypochlorite Contaminated with blood or body fluids2. Bleaching powder 9 grams per litre Toilets, bathrooms.

Environmental cleaning of instruments & equipments in OT:-

- Disinfectant:- Alcohol 70% used in cleaning metal surfaces & trolleys. However expensive for hospitals in developing countries.

- Fumigation:- To sterilize the operation theatre formaldehyde gas (bactericidal, sporicidal & viricidal) is widely employed as is is cheaper for steilization of huge areas like operation theatres.

Formaldehyde kills the microbes by alkylating the amino acids & sulfydral group of protiens & prine bases.

Inspite of the gas being hazardous continues to be used in several developing countries.

Fumigation usually involves the following phases- First the area to be fumigated is usually covered to create a sealed environment, next the fumigant is released into the space to be fumigated, then the space is held for a set period while the fumigant gas percolates through the space & acts on & kills any infestation in the product, next the space is ventilated so that the poisonous gases are allowed to escape from the space & render it safe for humans to enter.

Procedure of fumigation:-

1) Thoroughly clean windows, doors, floor, walls & all washable equipments with soap & water.2) Close windows & ventilators tightly. If any openings found, seal it with cellophane tape or

other material.3) Switch of all light, A/C & other electronic items.

Personal care during fumigation:-

1) Adequate care must be taken by wearing cap, mask, foot cover, spectacle.2) Formaldehyde is irritant to eye & nose & it has been recognised as a potential carcinogen.

So the fulmigating employee must be provided with the personal protective equipments.

Creating the formaldehyde gas:-

Electric boiler fumigation method:- For each 1000 Cu. feet of the volume of operation theatre 500 ml of formaldehyde (40% solution) added in 1000 ml of water in an electric boiler, leave the room & seal the door. After 45 minutes (variable depending to volume presents in the boils apparatus) switch off the boiler withoput entering into the room.

Methods of fumigation:-

1) In principle, we have to generate formaldehyde gas .2) Can be done by most easier way to mix the needed quantity of formalin to water & heating

at lower temperaturesat 80 deg C to 90 deg C.Can be done also with addition of formalin to potassium permangnate.

Adding potassium permangnate to formaldehyde:-

- Potassium permangnate method:- For every 1000 cu. feet add 450 gm of potassium permangnate (KmnO4) to 500 ml of formaldehyde (40% solution). Take about 5-8 bowels ( heat resistant : place it in various locations)with equally divided parts of formaldehyde & add equally divided KmnO4 to each bowel. This will cause auto boiling & generate fume.

- After the initiation of formaldehyde vapor, immidiately leave the room & seal it atleast 48 hours.

Fumigation to be neutralized:-

- Neutralize residual formalin gas with ammonia by exposing 250 ml of ammonia per literof formaldehyde used.

- Place the ammonia solution in the center of the room & leave it for 3 hours to neutralize theformalin vapor.

An example :-

- Operation theatre Volume = LXBXH= 20X15X10=3000 cu feet.- Formaldehyde required for fumigation = 500 ml for 1000 cu feet.- =So 1500 ml of formaldehyde required.- Ammonia required for neutralization = 150 ml of 10% ammonia for 500 ml of formaldehyde.- = So 450 ml of 10% ammonia required.

Need for newer chemical agents in hospital use:-

1) A need for non aldehyde based chemicals is growing concern.2) Need for qicker sterilization methods with ever increasing work loads.3) Need for non toxic safe agents.

Care of self & surroundings:-

- Theatre dress (includes head cap, mask, apron, chapel should be made available for all persons who are entering into the operation theatre (surgeons, anasthetist, microbiologist team , theatre assisstants & helper)

- Surroundings should be clean & free from garbage, open drainage, bushes, shrubs, wastes.Do not keep any material which are not necessary for operation theatre procedures.

- Operation theatre should be cleaned & fumigated as the prevailing conditions of work load.- Depends on septic cases handled in the theatre.

Safety of air conditioning & water cooling systems:-

- Legionaires disease is associated with air conditioning system.- Chlorination/Heating of water may prove better alternatives.

Between procedures in the operation theatres:-

- Clean operation tables, theatre equipment with disinfectant solution with detergent.- In case of spoilage of blood/body fluids decontaminate with bleaching powder/chlorine

solution (10% available chlorine).- Always discard wastes in prescribed plastic bags- don’t accumulate biohazard waste in the

operation theatres.- Don’t discard soiled gowns in operation theatre.

At the end of the day in operation theatre:-

- Clean all the table top sinks, door handles with detergent/lowlevel of disinfectant.- Clean the floors with detergents mixed with warm water.- Finally mop with disinfectant like Phenol in the concentration of 1:10.- Low concentration of Phenol serve as perfume & not as disinfectant.

INFECTION CONTROL PROGRAMS:-

1) Monitoring of hospital associated infections.2) Training of health care workers.3) Investigations of outbreaks.4) Any technical lapses.5) Monitoring of staff health.6) Education of universal precautions.7) Advise on isolation of infectious patients.8) Waste disposal9) Safety use of anticbiotics/antibiotic policy.

ROLE OF MICROBIOLOGY DEPARTMENT:-

- Identifies the pathogens.- Monitoring of antibiotic therapy.

- Education of specimen collection & transportation.- Information on antibiogram pattern.- Data on hospital infection.- Surveillance of the hospital environment.- Counselling of the hospital staff.

SLIT SAMPLER:-

- Very effective/ highly sensitive.- Fixed volume of air is sucked & bacterial counts are made.

SURVEILLANCE OF OPERATION THEATRE

EXAMINATION OF AIR:-

- Estimations are done for detection of bacteria carrying particles in air.- Factors influence number of persons present, body movements, disturbances of clothing.

METHODS OF AIR SURVEILLANCE:-

- Settle plate method.- Slit sampler method (from given volume)- Counts vary from many settle plate method.- Record position- Time- Duration

Plates with media as blood agar exposed for specified period & incubated in the incubator for 24 hours at 37 deg C.

HOW MANY BACTERIA ARE PATHOGENIC:-

- Counts vary on number of personal present in the given area.- Behaviour of persons.- Depend on nature of procedures, type of operations.- Varying ranges.- But only 1% are pathogenic.- Presence of S. aureus makes difference.

SURVEILLANCE FOR ANAEROBIC SPORES:-

- The age old tradition of detection of anaerobic spores of Cl. tetani & other gas gangrene producing spores in the operation theatre & closing the theatres is losing relevance with changing understanding & newer concepts.

- Routine & regular testing for anaerobic spores is not essential except when there was suspected case of tetnus or gas gangrene attributed to operating in particular operation theatre.

IDEAL TO SURVEY FOR ANAEROBES:-

- It is ideal to survey the operation theatres for anaerobes when operating in newly constructed or after remodelling & structural alterations are done.

- In these circumstances surveillance will increase safety of the theatres.

DO WE NEED SURVEILLANCE REGULARLY:-

- Bactteriological surveillance testing at regular intervals is not warranted.- But warranted when modification of operation theatres is done.- In any unforeseen in crease of incidence of infection from any particular operation theatre.

FACTORS WHICH INFLUENCE SAFETY IN HOSPITAL ENVIRONMENT:-

- Operation theatre- Discipline:-1) Only people absolutely needed for an assigned work should be present.2) People present in theatre should make minimal movements in & out of theatres, which

will greatly reduce bacterial count.3) Air borne contamination is usually affected by type of surgery, quality of air which in fact

depends on rate of air exchange.

Every body partners in infection control:-

- All persons including the least cadre of employers are partners in infection control regulations. 4 prompt disposal of theatre waste out of theatre is of top priority. Any spillage of body fluids including blood on the floors is highly hazardous & prompts the rapid multiplication of nosocomial pathogens in particular Pseudomonas spp.

The Following precautions have greatly reduced the rates of infection:-

- Every hospital must constitute infection control committee to monitor the events in the hospital, on all matters related to control of infections.

- The entry of unnecessary personnel to be restricted to operation theatre as every one contributes to infection.

- A thorough washing with warm water & good detergent & carbonization can bring overall improvement than mere fumigation.

STERILIZATION & DISINFECTION POLICIES:-

- Create your own infection control team which suits your hospital.- Infection control team decides the policies.- Educate the staff on methods & policies in hospital safety & hygiene.- Educate the staff on few useful options, many theoretical ideas confuse.

DESIGNING AN IDEAL OT ROOM COMPLEX:-

An operation theatre complex is the ‘heart’ of major surgical hospital. An opearting theatre, operating room, surgery suite or a surgery centre is a room within a hospital within which surgical & other operations are carried out.

PURPOSE OF OPERATION THEATRE COMPLEX:-

OT complexes are designed & built to carry out investigative, diagnostic, therapeutic & palliative procedures of varying degrees of invasiveness. Many such set ups are customized to the requirements based on size of hospital, patient turnover & may be speciality specific. The aim is to provide the maximum benefit for maximum number of arriving to the operation theatre. Both the present as well as future needs should be kept in mind while planning.

DIFFERENT ZONES OF OT COMPLEX:-

The location & flow of patients, the staff & materials form the three broad groups to be considered during all stages of design.

Four zones can be described in OT complex, based on varying degrees of cleanliness, in which the bacteriological count progressively dimnishes from the outer to inner zones (operating area) & is maintained by a differential decreasing positive pressure ventilation gradient from the inner zone to the outer zone.

1) Protective zone:- It includes:-- Change rooms for all medical & paramedical staff with conviniences.- Transfer bay for patient, material & equipments.- Rooms for administrative staff.- Stores & records.- Pre & post operative rooms.- ICU & PACU(Post anesthesia care unit)- Sterile stores.

2) Clean zone:- Connects protective zone to aseptic zone & has other areas also like:-- Stores & cleaner room.- Equipment store room.- Maintenance wokshop.- Kitchenette (Pantry)- Firefighting device room- Emergency exists- Service room for staf- Close circuit TV control area

3) Aseptic zone:- Includes operation rooms (sterile)- Includes operation rooms (sterile)

4) Disposal zone:- Disposal areas from each operating room & corridor leads to disposal zone.

Subareas (excluding OT place)

1) Pre-operative check in area (reception):- This is important with respect to maintaining privacy, for changing from street clothes to gown & to provide lockers & lavatories for staff.

2) Holding area:- This area is planned for IV insertion, preparation, catheter/gastric tube insertion, preparation, connection of monitors & shall have oxygen & suction lines. Facility for CPR should be available in this area.

3) Induction room (Anesthetic room):- It should have all facilities as in OT, but there is controversy as to its need. One for each OT is required, ideally each is duplicate of the other in each floor. The anesthetic room will provide a more tranquil atmosphere to the patient than the OT. It should provide space for anesthetic trolleys & equipment & should be located with direct access to circulation corridors & ready access to the operating room. It will also allow cleaning, testing & storing of anesthesia equipment. It should contain work benches, sink. It should have sufficient power outlets & medical gas panels for testing of equipment.

4) Post anesthesia care unit (PACU):- Preferably adjacent to recovery room. These should containa medication station, hand washing station, nurse station, storage space for stretchers, supplies & monitors/equipment & gas, suction outlets & ventilator. Additionally 80 sq. feet (7.43 sq. m) for each patient bed, clearence of 5 ft (1.5 m) between patient bed sides & adjacent walls should be planned.

5) Staff room:- Men & women change dress from street cloth to OT attire, lockers & lavatory are essential, rest room TV etc. are desible.

6) Sanitory facility for staff:- One wash basin & one western closet (WC) should be provided for 8- 10 persons. Showers & their number is a matter of local decision. Inclusion of toilet facilities in changing room is not acceptable, they should be located in an adjacent space.

7) The anesthesia gas /cylinder manifold room/storage area:- A definite area to be designated. It should be in a cool, clean room that is conducted for fire resistant materials. Conducive flooring must be present but is not required if non inflammable gases are stored. Adequate ventilation to allow leaking gases to escape, safety labels & separate places for empty & full cylinders to be allocated.

8) Offices- For staff nurse & anesthesia staff:- The office should allow access to bot unrestricted & semi-restricted areas as frequent communication with public is needed.

9) Rest rooms:- Pleasant & quiet rest for staff should be arranged either as one large room for all grades of staff or as separate rooms, both have merits. Comfortable chairs, one writing table, a book case may etc be arranged.

10) Laboratory:- Small lab with refrigerator for pathologist to be arranged.11) Seminar room:- Since staff cannot leave an OT complex easily, it is better to have a seminar

room within the OT complex. Interdepartmental discussions, teaching & training session for staff (with audio-visual aids) may be conducted here.

12) Store room:- This is designed to store large but less frequently used equipment in OT. There should be storage space for special equipment after cleaning.

13) Theatre sterile supply unit:- (TSSU) Within this area, followinhg are desirable- Temperature between 18-22 deg C, humidity of 40-50% is the aim.- Air conditioning with 10-12, air exchanges per hour.- Storage of sterile drapes, sponges, gloves, gowns & other items ready to use.- Option to store in from one side & remove from other side.- Proper inventory to prevent running out of stock.

14) Scrub room:- This is planned to be built within the resticted area. Elbow operated or infrared sensor operated taps/water source is ideal. It is essential to have non slippery flooding in this area.

TYPES OF OT COMPLEXES:-

There are 3 main categories of operating theatres:-

1) The single theatre suit with OT, scrub-up & gowning, anesthesia room, trolley preperation, utility & exit bay pMlus staff change & limited ancillary accomodation.

2) The twin theatre suits with facilities similar to 1, but with duplicated ancillary accomodation immidiate to each OT, sometimes sharing a small post anesthesia recovery area.

3) OT complexes of three or more Ots with ancillary accomodation inluding post anesthesia recovery, reception, porter’s desk, sterile store & staff change.

PRINCIPLES TO BE TAKEN INTO CONSIDERATION WHILE PLANNING AN OT (PHYSICAL/ ARCHITECTURE):-

1) Location:- Low rise buildings limited to two or three storey’s high are preffered because of maximum advantage of natural light & ventilation as appropraite can be delievered. The OT should be separate from general’ traffic’ & air movement of rest of the hospital, OT surgical wards , intensive care units (ICU), accident & emergency department (A&E), radiological department (X-ray)should be closely related & access is also required to sterilizing & disinfecting unit (SDU) & laboratory facilities. The location of the operation complex in a multi storey building is planned for the first floor, connecting to surgical & other wards on the same floor. Adequate electric lift is planned for vertical movement from casualty on the ground fllor & ENT, orthopaedics, ophthalmology & other wads on the floor above.

2) Zone wise distribution of the area, so as to avoid criss cross movements of men & machines.3) Adequate & appropriate spaceallotted as per utility of the area.4) Provision for emergency exit.5) Provision for ventilation & temperature control, keeping in mind the need for laminar

flow, HEPA filter air conditioner etc.6) Operation rooms:- The number & size can be as per requirement but recommended size is 6.5

mX6.5 mX3.5m. Glass windows can be planned on one side only.Doors:- Main door to the OT complex has to be of adequate width (1.2 to 1.5 m). The doors ofeach OT should be spring loaded flap type, but sliding doors are preffered as no air currents are generated. All fittings in OT should be flush type & made of steel.

The surface/ flooring must be slip resistant, strong & impervious with minimum joints(e.g.- mosaic with copper plates for antistatic effect) or jointless conducive tiles/terazzo, linoleum etc. The recommended minimum conductivityis 1 m ohm & maximum 10 m ohms.

Presently the need for antistatic flooring has dimnished as flammab;le anesthetic agents are no longer in use.Walls:- Laminated polyester or smooth paint provides seamless wall, tiles can break & epoxy paint can chip out. Collusion corners to be covered with steel or alluminium plates, colour of paint should allow reflection of light & yet soothing to eyes. Light color (light blue or green) washable paint will be ideal. A semi matt wall surface reflects less light than a highly gloss finish & is less tiring to the eyes of OT team.Operation table:- One operation table per OTElectric point:- Adequate electric points on the wall (at 1.5 m height from the floor)X-ray illuminators:- There should be X- ray film illuminators preferably recessed.Scrub area:- To be planned per atleast for 2-3 persons in each OT.

7) There has to be preperation room in clean zone.8) Corridors not less than 2.85 m width for easy movement of men, stretcher & machines.9) Separate corridors for uses other than going into OT.10) Rooms for different persons working in OT & for different purpose (It should be as per zone

& size)11) Gas & suction (control, supply & emergency stock) for all Ots & areas where patients are

retained. Oxygen, gas & suction pipe to be connected with central facility & stand by local facility should also be availabble.

12) Provision for adequate & continuous water supply. Besides normal supply of available water at the rate of 400 liters per bed per day, a separate reserve emergency over head tank should be provided for operation theatre. Elbow taps have to be 10 cm. above wash basins.

13) Proper drainage sytem.14) Pre-operative area with reception with separate designated area for pediatric patients is

desirable.15) Adequate illumination with shadow less lamps of 70,000-12,000 lumens intensity, for assessing

patient colour & tissue visibility (discussed under “lighting”)16) The safety in working place is essential, & fire extinguishers have to be planned in

appropriate zone.17) Provision for expansion of the OT complex should be borne in mind during planning stages itself.

Recommended on the number of OTs required:-

It is observed that out of all surgical beds, of the hospital, 50% of patients are expected to undergo surgery. Thus for 100 beds, with average length of stay of 10 days for each patient, 10 operations per day can be performed.

In general, multiuse Ots, instead of multiple Ots offer advantages of efficient man power untilization, economical maintainence & better training of supporting staff.

Thus in a 300 bedded hospital (with 150 surgical beds), one OT complex with 3 Ots for general surgery, gynaecology, orthopaedics/ENT, one for endoscopy & one for septic. OT will be required with 8 hours a day working duration.

Ventilation:- Ventilation should be on the principle that the direction of air flow is from operation theatre towards the main enterance. There should be no interchange air movement between one OT & another. Efficient ventilation will control temperature & humidityin OT, dilute the contamination by micro-organisms & anesthetic agents.

There are two types of air-conditioning systems:- re-circulating & no re-circulating. Non re- circulating systems heat/cool the air as desired & convey it into the operating room with ideally 20 air exchange per hour. Air is then exhausted to outside. Anesthetic agents in the OT air are also automatically removed. These are thus ideal but not expensive.

The circulating system takes some or all of the air, adjusts the temperature & circulates air back to the room. The broad recommendations include:-

- 20-30 air exchanges/hour for re-circulated air.- Only upto 80% recirculation of air to prevent build up of anesthetic & other gases.- Ultraclean laminar air flow:- The filtered air delievery must be 90% efficient in

removing particles more than 0.5 mm.- Positive air pressure system in OT:- It should ensure a positive pressure of 5 cm of

H2O from ceiling of OT downwards & outwards, to push out air from OT.

- Relative humidity of 40-60% to be maintained.- Temperature between 20-24 deg C. Temperature should not be adjusted for the comfort of

OT personnel but for the requirement of patient, especially in pediatrics, geriatric, burns, neonatal cases etc.

PENDANT SERVICES:-

Two ceiling pendants for pipeline services should be designed, one for surgical team & one for anesthetist. Anesthetic pendant should be retractable & have linited lateral movement & provide a shelf for monitoring equipment. It should have oxygen, nitrous oxide, for bar pressure, medical compressed air, medical vaccum, scavenging terminal outlets & atleast four electric sockets.

PIPED GASES IN THE OT:-

1) Automatic/semi-automatic fall safe manifold room to be designed.2) Two outlets for oxyge, suction & one for N2O are a manimum in each OT.3) Pipeline supply system should be able to cut off from mainline if the problem occurs anywhere

along the delievery hosing/tubing.

SCAVENGING:- The method of scavenging should be decided during planning stage of OT. US & International standards are available for scavenging but it is ideal to plan the type of system. (active/passive) & no. & location of scavenging beforehand.

ELECTRICAL:-

All electrical equipments in the OT need proper grounding:-

In the past, isolated power systems were preffered when explosive agents are being used. They have the advantage of a transformer using grounded electricity & there is no risk to the patient or machines if a machine gets faulty.

The grounded systems as used at homes offer protection from macro shock but devices may lose power without warning. Life support systems, if in use could be disturbed.

Following criteria are ideal with respect to electicity in OT complex:-

1) Use of circuit breakers/interrupters is desirable if there is an overlaod or ground fault.2) Power line of 220 volts.3) Suspended ceiling outlets should have loking plugs to avoid accidental disconnection.4) Insulation around ceiling electrical power sources should withstand frequent bendings &

flexings. They should not develop cracks & should not damage wires. Wires inside rigid or retractable ceiling service column can help to some extent.

5) Wall outlets to be installed 1.5 m above ground.6) Use of explosion proof plugs.

7) Multiple outlets from different electrical line sources should be available.8) Electrical load calculation should be based on, equipments likely to be used &

appropriate current carrying capacity cords to be used.9) Emergency power:- OT electrical networks need to be connected to the emergency generators

with automatic two way changeover facility.

LIGHTING:- Some natural daylight is preffered by staff. Where possible, high level windows which give a visual appreciation of the outside world can be considered in the OT.

1) General lighting:- Color corrected flourescent lamps (recessed or surface ceiling mounted) to produce even illumination of atleast 500 lux at working height, with minimal glare are preffered. Means of dimnished may be needed during endoscopies. To minimize eye fatigue, the ratio of intensity of genearl room lighting to that at the surgical site should not exceed 1:5, preferably 1:3. This contrast should be maintained in corridors & scrub areas, as well as in the room itself, so that the surgeon becomes accustomed to the light before entering the sterile field. Color & hue of the lights also shopuld be consistent.

2) About 2000 lux light is needed to assess the aptients color.3) White & glistening /shiny body tissues need less light than dark & dull tissues.4) Operating area:- Overhead light gives adequate illumination both at depth as well as surface

of body.5) About 10-12 inch of focus of light gives adequate illumination both at depth as well as surface of

body.6) Lights should be freely movable both in horizontal & vertical ranges. Pendant systems are

preffered. OT light should produce blue white color of daylighr at spectral energy range of 50,000 K(35000-67000 kelvin acceptable) produce less heat & hence preffered. OT light should not produce more than 25000 mw/sq. cm. of radiant energy. Elimination of heat by dichroic reflectors (cold mirrors) with heat absorbing reflectors or filters should be available along with luminaire.

7) An auxillary light for a second8) Halogen lights produce less heat & hence preffered. OT light should not produce more than

25000 mw/sq. cm of radiant energy. Elimination of heat by dichroic reflectors (cold mirrors) with heat absorbing reflectors or filters should be avaliable along with the luminaire.

9) An auxillary light for a second surgical site is also beneficial.10) UPS of adequate capacity to be installed after considering OT light, anesthesia nmachine,

monitors, cautery etc until the backup generator takes over.11) In endoscopic Ots, a reduced lighting is sometimes recommended. A grazing light over the

floor can be helpful.

Anesthesia equipment & monitoring needs:-

At least one anesthesiologist should be in the team involved in planning an OT. It is imperative that certain mandatory considerations with respect to the anesthetic equipment U& monitors be

planned during the planning & design stage itself. Personal, practice & cost preferences may influence the plans.

Communications:- Telephones, intercom & code warning signals are desirable inside the OT. One phone per OT & one exclusively for use of anesthesia personnel is desirable. Intercom to connect to control desk, pathology & other Ots as well as use of paging recievers (bleeps) is also ideal. A code signal, when activated, signals an emergency state such as cardiac arrest or need for immidiate assistance.

Catering:- Basic services such as preparation of beverages & some snacks, use of vending machines may be planned, augmented by provision of hot & cold meals from main hospital kitchen.

Cleaning:- The construction materials selected for the OT complex should aim to minimize maintainence & cleaning costs.

Data management:- Customize network connections should be put in place on a conduit should be planned. A well designed system can provide automated records, materials management, laboratory tracking etc. The software of OT management are costrly & hospitals are generally slow to adopt to changes. Customized OT software can needs.

Operating theatre satellite pharmacy:- Access to the OT areas & outside should be possible. It should have a laminar flow hood, a refrigerator, space for drug storage locked containers for contolled substances computer, desk area for paper work & pharmaceutical literature. Special kits foe specific surgeries may also be arranged. The pharmacy may openfor 1 to 24 hours based on need but it is desirable that an after hour system is planned.

Statutory regulations:- The design & planning of an OT complex will need compliance with mandatory regulations related to local administration such as Municipal corporation, government, pollution control boards, fire safety department, water supply & drainage etc.

USUAL AREAS OF DEFICIENCIES IN OTs(EXISTING OTs):-

1) No reception area2) No separate rooms for

- Surgeons- Anesthesiologist- Jr. Doctor- OT attendents

3) Not enough number of change for different class of people.4) Inappropriate size & type of doors etc .5) Lack of laminar flow & mandatory air exchange systems in OT.6) Lack of standard OT protocol.7) No separate central sterile supply department (CSSD).8) Waiting area- Recovery

- Not well equipped- Lack of amenities

THE AUTHORITY FOR STANDARDIZATION:-

Reccomendations are available in various surgical, anesthesia & nursing manuals with regard to the planning & establishment of operation theatres/complexes. The hospital can get accredited by the Joint Commission of accreditation of health care organizations (JCAHO), a professionally sponsored program that stimulates a high quality of patient care in health care facilities. There is also an accreditation option that is available for ambulatory surgery centers (Accreditation association for ambulatory health care- AAAH). The department of health & social security (DHSS) in UK has publications containing information on planning for new health buildings & for upgrading existing buildings.

CONCLUSION:- In the present era of evidence based medicine, it becomes imperative to give maximum importance to planning an operation theatre complex. Within the limitations of finance & space, the best results can be obtained & anesthesiologist with multiple roles inside the operation theatre complex, should be consulted in the process. Efforts should be made to conform to standards laid down by local bodies & international agencies, as health care facilities in India are now catering to more & more international clientele. However new OTs & hospitals that are being established that cannot be expected to fulfill all theoretical requirements as new ideas are constantly being developed. By the time they are incorporated into buildings, fresh ones take their place on the drawing board.

THE DUTIES OF ANESTHESIOLOGIST DURING SURGERY:-

An anesthesiologist is a physician who, after completing medical school, served a four year residency to specialize in anesthesiology. Some anesthesiologists choose a subspeciality such as pediatric anesthesia & spend another year completing a fellowship. One duty of an anesthesiologist during surgery is to sedate the patient, but that is only part of her responsibility.

1) Administer anesthetics:- Before surgery, anesthesiologists review the patient’s medical history to determine any issues that might be encountered during the procedure. Based on thepatient’s history & the procedure to be performed, anesthesiologists decide on the best method to sedate the patient. When patient arrives in the operating room, the anesthesiologist administyers the anesthetic in one of three forms- a regional anesthetic, which numbs a specific portion of the body, a local, which blocks sensations in a smaller area, or a general anesthetic, which renders the patient unconscious. As procedures progress, anesthesiologists may need to make adjustments to ensure that patients remain comfortable.

2) Monitors patient:- Anesthesiologists have the primary responsibility for monitoring the patient’s vital signs during surgery. In addition to basic measurements such as pulse, bloodpressure & temperature, anesthesiologists also measure the patient’s respiration. If the patientis under general anesthetic, the anesthesiologist measures the volume the patient inhales & carbon dioxide level exhaled. During some procedures, the anesthesiologist must also monitor the volume of blood being pumped by the heart, nerve functions or the blood pressure inside the patient’s lungs. If the procedure requires the use of special monitors, such as arterial

catheters, the anesthesiologist is typically responsible for placing them. Anesthesiologists also ensure that patients remain in the proper position, such as keepingthe patient’s head alligned during neck surgery.

3) Controls intravenous fluids:- During surgery,patients typically receive intavenous fluids to help control dehydration & to allow the administration of medications through the drip. Anesthesiologists are in the control of IV. Should the patient require blood transfusion, whether as a result of an unexpected occurrence during surgery or through prior planning, the anesthesiologist is also in charge of transfusion.

4) Handles medical emergencies:- As physicians, aneshesiologists are trained to treat the whole patient, not just the patient’s pain issues. Whenever a patient experiences a condition such as heart arrythmia, low blood pressure, hemorrhaging or breathing difficulties, the anesthesiologist reacts to the problem & take the corrective steps necessary. This may involve adjusting the anesthetic, administering additional drugs or taking other actions to safeguard the patient’s health.

ADMISSION OF PATIENT TO THE OPERATION THEATRE:-

All patients arriving to theatremust have completed a checklist before admitted to the OT department.

1) Patient’s weight, temperature, respiration rate, blood pressure, pulse rate, blood sugar, fasting status & fluid intake must be recorded as required.

2) Allergies must be recorded.3) Medication chart & IV prescription sheet must accompany the patient.4) Cannula site must be documented.5) Bladder/catheter emptied.6) Loose teeth, caps, crowns & braces must be recorded.7) Jewellery must not be worn.8) Patient must be clean for theatre to reduce risk of intraoperative infection. Hair must be clean

& free from lice.9) Nail varnish must be removed.10) Theatre gown must be worn.11) X-rays must be present.12) Blood results must be present in the chart if it is required for surgery.13) Recent or current infections e.g.- Rotavirus, chest infections etc.14) Parents present, contact number, patient’s property & patient comforter must be recorded.15) The consent form must be signed & validation of correct site & side of surgery made with the

patient or patient’s guardian prior to admission to OT suite by the competent medical person.16) The surgical site for surgery must be marked on the patient & verification of marked site to

be made verbally with the nurse/ patient & parents & guardian.

POSITIONING PATIENT DURING SURGERY:-

Surgical positioning is the practice a patient in particular physical position during surgery. The goal in selecting & adjusting a particular surgical position is to maintain the aptient’s safety while allowing access to the surgical site.

Positioning normallyoccurs after administration of anesthesia. In addition to considerations related to the location of surgical site, the selection of a surgical position is made after considering relevant physical & psychological factors, sucha s-

- Body alignment- Circulation- Respiratory constraints- Musculatory system to prevent stress on the patient.

Physical traits of patient must also be considered including- Size- Age- Weight- Physical condition- Allergies- Type of anesthesia used

Changing positions:- If the patient has been immobilized, it amy be important to change the patient’s position periodically to prevent blood pooling, to stimulate circulation & to relieve pressue on the tissues. The patient should not be placed in unnatural positions for an extended period of time. After anesthesia, thevpatient’s inability to reach to movements may damage these muscle gropusby, for example, moving both legs simultaneously.

Risk to extremities:-

1) The most common nerve injuries during surgery occur in the upper & lower extremities.2) Injuries to the nerves in the arm or shoulder can result in numbness, tingling &

decreased sensory or muscular use of the arm, wrist or hand.3) Many operating room injuries could be solved by simply restraining the arms & legs.4) Other causesof nerve or muscular damage to the extremities is caused by pressure on the

body by surgical team leaning on patient’s arms & legs. The patient’s arms can be protected from theses risks by using an arm sled.

5) Seperation of sternum during heart procedure can also cause the first rib to put pressure on the nerves in the shoulder.

6) The lithotomy position is also known to cause stress on the lower extremities.

Positions:-

1) Supine position:- The most common surgical position. The patient lies with back flat on operating room bed.

2)

3) Trehelenburg position:- Same as supine position but the upper torso is lowered.

4) Reverse trehelenburg position:- Same as supine but the upper torso is raised & legs are lowered.

5) Fracture table position:- For hip fracture surgery. Upper torso is in supine position with unaffected leg raised. Affected leg is extended with no lower support. The leg is strapped at the ankle & there is padding in the groin to keep pressure on the leg & hip.

6) Lithotomy position:- Used for gynaecological, anal & urological procedures. Upper torso is placed in the supine position, legs are raised & secured, arma are extended.

7) Fowler’s position:- Begins with patient in supine position. Upper torso is slowly raised to a 90 degree position.

8) Semi fowler’s position:- Lower torso is in supine position & upper torso is bent at a nearly 85 degree position. The patient’s head is secured by a restraint.

9) Prone position:- Patient lies with stomach on the bed. Abdomen can be raised off the bed.

10) Jackknife position:- Also called the kraske position. Patient’s abdomen lies flat on the bed. The bed is scissored so the hip is lifted & the legs & head are low.

11) Knee- chest position:- Similar to the jackknife except the legs are bent at the knee at a 90 degree angle.

12) Lateral position:- Also called the side-lying position, it is like the jackknife except the patient is on his or her side. Other positions are lateral chest & lateral kidney.

13) Lloyd davies position:- It is a medical term reffering to a common position for surgical procedures involving the pelvis & lower abdomen. The majority of colorectal & pelvic surgery is conducted with the patient in Lloyd Davies position.

14) Kidney position:- The kidney position is much like the lateral position except the patient’s abdomen is placed over a lift in the operating table that bends the body to allow access to retroperitoneal space. A kidney rest is placed under the patient at the location of the lift.

15) Sim’s position:- The sim’s position is a variation of the left lateral position. The patient is usually awake & helps with the positioning. The patient will role to his or her left side. Keeping the left leg straight, the patient wil slide the left hip back & bend the right leg. This position allows access to the anus.

CARE OF SPECIMENS:-

Perioperative staff should have knowledge in the care & handling of specimens, the safety issues involved & the potential for adverse events in order for optimal patient outcomes & to minimize risks.

Procedure:- Gather the appropriate equipment & supplies according to the surgical procedure. Coordinate & communicate with allied departments. E.g. Core lab for fresh/frozed specimens.

For all procedures where a specimen is to be taken, the perioperative staff shall:-

Identify the correct patient information:-

- The patient’s name, UR number & DOB on the hospital identification label is checked & the specimen container is correctly labeled.

Identify the specimen correctly:-

- Immidiately upon removal from the ptient’s body the instrument nurse shall confirm with surgeon/procedure list the name of the specimen, identification markers & any fixative solution required, that is communicated to the circulating nurse.

Confirm the identification & labelling of the patient’s specimen:-

- The instrument nurse shall verbally confirm with the circulating nurse, the name of the specimen, identifying markers of fixative solutions required.

Label the specimen container prior to placement of the specimen.- The circulating nurse will place a patient UR label on the container not on the loid &

record the date, time, consultant & description of the specimen on the label. No abbreviations should be used.

- The circulating nurse shall read back the specimen label recorded on the container & allow the instrument nurse the oppuntunity to view/check the label prior to collection of the specimen.

To maintain the integrity of the specimen in the fixative, the specimen must be completely covered & surrounded by the fixative.

Specimen types:-

1) Blood gas specimens:- Ensure lids are screwed on firmly.2) Blood gas specimens:- Ensure that the needle has been removed, that any air bubbles have

been expelled & that the syringe is properly sealed with a stopper.3) Capillary acid base specimens:- (CABS) Ensure that there are no air bubbles & that the ends

of capillary are completelysealed. Place the capillary in CABS holder (obtainable from specimen reception, laboratory services).

4) Small specimen containers:-(Sputum/random urine/faceces):- Ensure that lids are on firmly.5) Swabs:- Ensure lids are on firmly.6) Glass slides accompanying swabs:- Ensure slides are placed in a slide carrier before placing in

the specimen transport bag.7) Blood culture bottles:- NO special requirements.8) Cerebrospinal fluid:- (CSF) Ensure lids are screwed on firmly.

The following specimens must be delivered by hand:-

- Items heavier than 1.1 Kg (this does not include carrier weight)- 24 hour/timed urine collections.- Histology specimens- Cytology specimens:- e.g.- Fine needle aspitration, pap smears etc.

SURGICAL TERMINOLOGY:-

1) Cleisis:- Closure, occlusion.2) Desis:- Fusion.3) Lysis:- Freeing of, reduction of.4) Oma:- Tumor or neoplasm.5) Orrhaphy:- Surgical repair of.6) Pexy:- Fix or suture into place.7) Plasty:- Restorative or reconstruction procedure.8) Chole:- Gall.9) Cholecyst:- Gall bladder.10) Colpo:- Vagina.11) Lamin:- Posterior vertebral arch.12) Os:- Opening or mouth, bone.13) Pyelo:- Renal, pelvis.14) Spermato:- Semen.15) Splanchno:- Viscera.16) Teno:- Tendon.17) Thrachel:- Neck of uterus.18) Vas:- Vessel or duct.19) Cecectomy:- Excision of cecum.20) Coccygectomy:- Excision of coccyx.21) Glomectomy:- Excision of glomus (i.e. carotid body)22) Hemicolectomy:- Excision of half of the colon.23) Hemorrhoidectomy:- Excision of hemorrhoids.24) Hydrocelectomy:- Excision of hydrocele.25) Hypophysectomy:- Excision of pituitary gland.26) Mastoidectomy:- Excision of muscle tumor.27) Salpingo-oopherectomy:- Excision of fallopian tube & ovary.28) Sequestrectomy:- Excision of nectrotic bone.29) Stapedectomy:- Excision of stapes.30) Sympathectomy:- Excision of sympathetic nerve.31) Thromboendarterectomy:- Excision of a clot.32) Choledochotomy:- To cut into common into bile duct.33) Chlolelithotomy:- to cut into the gall bladder to remove stone.34) Chordotomy:- to cut into spinal cord.35) Colpotomy:- to cut into the vagina.36) Commissurotomy:- to cut into the cusps of heart valve.37) Craniotomy:- to cut into the vulva, surgical incision into the perineum to prevent tears during

childbirth.38) Laprotomy:- to cut into a duct/organ to remove a stone.39) Lithotomy:- To cut into a duct/organ to remove stone.

40) Myringotomy:- to cut into the tympanic membrane.41) Osteotomy:- to cut into the bone.42) Pyelolithotomy:- to cut into the kidney to remove stones.43) Pyloromyotomy:- to cut into the muscle of the pylorus of the stomach.44) Scalenotomy:- to cut into the scaleni muscles.45) Sphincterotomy:- to cut into sphincter muscle.46) Vagotomy:- to cut into the vagus nerve.47) Valvulotomy:- to cut into heart valve.48) Herniaplasty:- Restorative/reconstructive procedure to repair hernia.49) Pyloroplasty:- Restorative/reconstructive procedure to pylorus/stomach.50) Tuboplasty:- Restorative/reconstructive procedure to fallopian tubes.51) Tympanoplasty:- Restorative/reconstructive procedure to middle ear.52) Z-plasty:- Restorative/reconstructive procedure to skin.53) Herniorrhaphy:- Surgical repair of hernia.54) Perineorrhaphy:- Surgical repair of perineum.55) Tenorrhaphy:- Surgical repair of tendon.56) Ostomy:- to make & leave an opening or form a connection between.57) Antrostomy:- Operation to make a nasoantral window (sinus surgery)58) Duodenoduodenostomy:- Operation to form a connection between a ureter & sigmoid colon.59) Ureterosigmoidostomy:- Operation to form a connection between a ureter & the sigmoid colon.60) Oscopy:- Examination of an organ by viewing through endoscope.61) Colonoscopy:- Endoscopic exam of the colon from ileocecal valve to anus.62) Colonoscopy:- Examination of avgina & cervix using a microscope.63) Culdoscopy:- Endoscopic examination of cul-de-sac to retro-uterine space.64) Cystoscopy:- Endoscopic examination of urinary bladder.65) Laproscopy:- Endoscopic examination of abdominal & pelvic organs.66) Mediastinoscopy:- Endoscopic examination of mediastinal spaces in the chest cavity.67) Peritoneoscopy:- Endoscopic examination of peritoneum.68) Proctoscopy:- Endoscopic examination of anus.69) Sigmoidoscopy:- Endoscopic examination of sigmoid colon & rectum.70) Abdominoperineal resection:- Removal of rectum.71) Amputation:- Removal of a portion of the arm or leg, excision of other appendage such

as uterine cervix.72) Anastomosis:- Surgical joining of two organs or surfaces such as blood vessels or intestine.73) Anthrodesis:- Surgical fusion of a joint.74) Arthodesis, triple:- Surgical fusion of 3 joints of ankle.75) Biopsy:- Removal of tissue for diagnostic purposes.76) Bypass graft:- Surgical creation of a diversion for the bloodstream by suturing a graft to blood

vessel so that blood bypasses an obstructed or weakened portion of the vessel.77) Cesarean section:- Abdominal delivery of infant via incision of uterus.78) Cauterization or conization:- Use of electric current to destroy or remove tissue.79) Circumcision:- Excision of foreskin of penis.

80) Closure of colostomy:- Closure of opening previously made in colon to empty bowel content outside abdomen.

81) D&C/D&E:- Dilatation & curettage/evacuation, operation to dilate uterine cervix & scrape lining of uterus or empty contents of uterus.

82) Decompression:- Surgical relief of pressure, such as intracranial.83) Disarticulation:- Amputation of an arm or leg at a joint.84) Enucleation:- Removal of an eyeball.85) Evisceration:- Removal of viscera or internal organs, removal of contents of eyeball.86) Palliative operation:- An operation done to relieve symptoms rather than cure.87) Pelvic exenteration:- Radial removal of contents of pelvis.88) Portacaval shunt:- Surgical creation of anastomosis between portal & caval veins.89) Skin graft:- Transfer of skin from one site to another to improve function or appearance.90) Splenorenal shunt:- Surgical creation of anastomosis between splenic & renal veins.91) T&A (Tonsillectomy & adenoidectomy):- Excision of tonsils & adenoids.92) Vein ligation & stripping:- Tying off & removing a major blood vessel for treatment of

varicose veins.