Hide Notes 

Slide 2: Pocket Guide to the Operating Room
Slide 3: This page has been left intentionally blank.
Slide 4: Pocket Guide to the Operating Room THIRD EDITION Maxine A. Goldman, BS, RN Clinical Nurse IV Formerly, Operating Room Clinical Education Instructor Medical Center of Tarzana Tarzana, California
Slide 5: F. A. Davis Company 1915 Arch Street Philadelphia, PA 19103 www.fadavis.com Copyright © 2008 by F. A. Davis Company Copyright © 2008 by F.A. Davis Company.All rights reserved.This product is protected by copyright. No part of it may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without written permission from the publisher. Printed in the United States of America Last digit indicates print number: 10 9 8 7 6 5 4 3 2 1 Acquisitions Editor: Christa Fratantoro Developmental Editor: Marla Sussman Manager of Content Development: Deborah Thorp Art and Design Manager: Carolyn O’Brien As new scientific information becomes available through basic and clinical research, recommended treatments and drug therapies undergo changes.The author and publisher have done everything possible to make this book accurate, up to date, and in accord with accepted standards at the time of publication. The author(s), editors, and publisher are not responsible for errors or omissions or for consequences from application of the book, and make no warranty, expressed or implied, in regard to the contents of the book. Any practice described in this book should be applied by the reader in accordance with professional standards of care used in regard to the unique circumstances that may apply in each situation. The reader is advised always to check product information (package inserts) for changes and new information regarding dose and contraindications before administering any drug. Caution is especially urged when using new or infrequently ordered drugs. Library of Congress Cataloging-in-Publication Data Goldman, Maxine A., 1947Pocket guide to the operating room / Maxine A. Goldman. — 3rd ed. p. ; cm. Includes bibliographical references and index. ISBN-13: 978-0-8036-1226-6 ISBN-10: 0-8036-1226-5 1. Surgery, Operative—Handbooks, manuals, etc. 2. Surgical instruments and apparatus—Handbooks, manuals, etc. 3. Operating rooms—Equipment and supplies—Handbooks, manuals, etc. I. Title. [DNLM: 1. Surgical Procedures, Operative—methods—Handbooks. 2. Operating Rooms—Handbooks. 3. Surgical Equipment—Handbooks. WO 39 G6193p 2008] RD32.3.G65 2008 617′.91—dc22 2007036130 Authorization to photocopy items for internal or personal use, or the internal or personal use of specific clients, is granted by F. A. Davis Company for users registered with the Copyright Clearance Center (CCC) Transactional Reporting Service, provided that the fee of $.10 per copy is paid directly to CCC, 222 Rosewood Drive, Danvers, MA 01923. For those organizations that have been granted a photocopy license by CCC, a separate system of payment has been arranged. The fee code for users of the Transactional Reporting Service is: 8036-1829/08 $.10.
Slide 6: I dedicate this work to those special registered nurses and surgical technologists who are entrusted daily with the responsibility of the care and safety of patients in the perioperative environment. M.A.G.
Slide 7: This page has been left intentionally blank.
Slide 8: Preface Although the format appears the same as in previous editions, this third edition of Pocket Guide to the Operating Room reflects completely revised and thoroughly researched “state of the art” material that will enable the practitioner to elevate his/her level of perioperative patient care to new standards of excellence. The reader will find approximately 100 new procedures or their modifications in this third edition; previously included procedures have been updated to reflect current knowledge of evolving technology and perioperative patient care measures. Chapters containing the latest information on advanced surgical modalities employing lasers, endoscopy, robotics, microsurgical techniques and instrumentation, the Harmonic® and Plasma® scalpels, the Argon beam coagulator®, and radiofrequency ablation are included and cited throughout the work. New chapters on various dental and orthognathic procedures and intraoperative radiotherapy are presented. New surgical entries and/or approaches to previously described surgeries include total joint replacement surgeries; microneuroendoscopy; prosthetic disc replacement; micro, percutaneous, and endoscopic discectomy; percutaneous vertebrpoplasty and kyphoplasty; and multiple approaches to correct scoliosis.The chapter on pediatric surgery provides comprehensive measures with explanations particularly designed for the care of the child in surgery. My intent is to continue to limit the text’s physical size for convenience while maintaining the concise format of previous editions and describing perioperative care with an emphasis on the intraoperative phase. The most recent principles, standards, recommendations, and/or mandates set forth by the Association of periOperative Registered Nurses (AORN), the Joint Commission (JC) [formerly the Joint Commission on Accreditation of Healthcare Organizations (JCAHO)], the Centers for Disease Control and Prevention (CDC), the Occupational Safety and Health Administration (OSHA), and the North American Nursing Diagnoses Association (NANDA) International have been incorporated into the text. Measures for providing psychological support and physical safety of the patient in the perioperative environment are emphasized in this edition, particularly in the expanded Special Notes section at the end of each surgical entry. The Special Notes also serve to alert the circulator and the scrub person to important information that may not nec-
Slide 9: viii Preface essarily be found elsewhere. This information assists the practitioner with anticipating and predicting the perioperative needs of the patient and the surgical team members. The reader is encouraged in Chapter 1, and throughout conduction of the surgical procedures in Part 4, to assess individual needs unique to the surgical patient by developing a plan of care and by implementing that plan of care according to currently established safe standards. Perioperative practitioners are also encouraged to evaluate the effectiveness of implemented care by examining patient outcomes to maintain a level of excellence.The discussion section for each surgery includes information on the application of “state of the art” technologic modalities and updated surgical techniques. More than 500 surgical procedures are presented in a preestablished, standardized format. Each includes a definition, a discussion, and a description of each procedure, as well as notes on preparation of the patient and safe positioning practices, skin preparation, draping techniques, equipment, instrumentation, supplies, and Special Notes pertinent to patient care for each procedure. In the Special Notes section, the perioperative practitioner is alerted to care measures of particular importance that are preceded by the notation N.B. The conduction of a surgical procedure may appear to differ from institution to institution, between different sections of the country, and according to the preferences of individual surgeons, but the common goal regarding the best outcome for the patient remains the same. As noted in the previous editions, the particular equipment, instruments, and supplies suggested for use are not to be regarded as exclusive. Rather, the suggested surgical items represent those that are basic and commonly used; items can be added or deleted according to preference. Draping techniques, instrument nomenclature, equipment, supplies, etc. will also vary accordingly. Precise details regarding certain items such as suture material have been omitted due to the everincreasing availability of products and brands. In this edition, the bibliography lists references that include pertinent Internet sites. As in previous editions, the text is reflective of the most current drug information with reference to safety precautions and includes anesthetic agents and their administration in their respective chapters. An encyclopedic reference to every surgical procedure has not been attempted. Infrequently performed procedures or those procedures performed only at select surgical facilities, such as organ transplantation surgery, complex cardiac procedures, etc. have been omitted. Incumbent upon the perioperative practitioner is the need to ever expand knowledge on a daily basis, to provide a continuum of safe
Slide 10: Preface ix patient care in the perioperative environment, and to adapt the latest surgical modalities to established basic concepts. I hope the information presented herein will serve as a generally applicable foundation upon which to build. M.A.G.
Slide 11: This page has been left intentionally blank.
Slide 12: Acknowledgments In writing this third edition, I am indeed indebted to many surgeons, anesthesia providers, perioperative nurses, and surgical technologists for sharing their knowledge with me. They offered highly informative insights gained through years of diligent observation and active participation in the conduction of their respective specialties. I wish to thank the many providers of surgical instruments, equipment, prostheses, and pharmaceuticals who have generously supplied detailed product information and resources. I wish to acknowledge and thank my long-term friend and colleague, Patricia Gautreau, RN, BSN, CNOR, director of perioperative services at West Hills Hospital and Medical Center, West Hills, California, who suggested that I write the first edition of this text over twenty years ago. She continues to be a great source of professional encouragement, support, and enlightenment, unsparing in her assistance in obtaining technical information. I also wish to thank Chris Keegan, CST, MS, FAST Professor/Chair Surgical Technology and Surgical Assisting,Vicennces University, Evansville, Indiana, who advised me on the role of the surgical technologist. She initially reviewed and proposed a number of suggestions regarding surgical entries for the text and lent her expertise to the writing of the chapter on dental surgery. I appreciate the considered critique of the 2nd edition of this Pocket Guide by the following Reviewers: • Janet Cadorette, Instructor, Surgical Technology, Tennessee Technical Center at Knoxville, Knoxville,TN • Tracy L. Ray, RNFA, CNOR, ST, Coordinator and Instructor, Surgical Technology, Ozarks Technical Community College, Springfield, MO • Jane Roman, RN, MEd, Chair, Surgical Technology, Bunker Hill Community College, Chelsea, MA, and • Elizabeth Slagle, MS, RN, CST, Director and Associate Professor, Surgical Technology, University of Saint Francis, Fort Wayne, IN. These highly qualified professionals provided encouragement and certain insights to write a future 3rd edition. I very much appreciate the patience and understanding of my editor, Christa Fratantoro, regarding the nature of delays inherent in compiling the text and the support and encouragement I received from her
Slide 13: xii Acknowledgments and the staff at F. A. Davis Company, especially Elizabeth Zygarewicz, Editorial Assistant. I also thank Robert H. Craven, Jr., President, who encouraged me to proceed with the writing of the third edition of this text. I again thank Francine Kubrin, former medical librarian, Valley Presbyterian Hospital, Van Nuys, California, for obtaining many valuable references. I thank Colleen Ward, Marla Sussman, and Linda Kern and her staff at Progressive Publishing Alternatives for their efforts in preparing the manuscript for production. I am also pleased to acknowledge the love, kind encouragement, and unwavering support of my adult children Laurie, Emily, Judith, and David, and that of my dear friends during the preparation of this work. And finally, as always, I wish to thank my husband Harris, my partner in all endeavors, whose knowledge and love sustained me through the completion of this work.
Slide 14: Contents Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .vii Contents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .xiii PART 1: Perioperative Considerations: Preoperative, Intraoperative, and Postoperative Care Including Psychological Support of the Surgical Patient . . . . . . . . . . . . . .1 CHAPTER 1 Perioperative Care of the Patient . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Psychological Support of the Patient in Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1 Surgical Assessment and Preoperative Checklist Chart . . . . . . . . . . . . . . . . . . . . . .3 Authorization for and Consent to Surgery Document . . . . . . . . . . . . . . . . . . . . . . . .6 Authorization for and Consent to Surgical Sterilization Procedure Document . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7 Preoperative Care Plan Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9 Perioperative Record Chart . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .12 CHAPTER 2 Protection of the Patient in Surgery/ Patient Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 Admission Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .18 Procedure for Safely Transferring the Patient to the Operating Table . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .19 Positioning/Surgical Positions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .20 Surgical Positions Drawings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .27 Medication Practices and Guidelines to Avoid Medication Errors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .30 Allergies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .31 Environmental Controls . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .33 Electrosurgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .38 Counting Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .39 Sterilization Modalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .41 Emergency and Disaster Considerations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .47 Legal Rights . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .48 Legal Records . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49 Death in the OR . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .49 CHAPTER 3 Safety Measures for Operating Room Personnel . . . . . . . . . .50 Orientation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50 Surgery Department In-Service Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .50
Slide 15: xiv Contents Body Mechanics/Ergonomic Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51 Fatigue Factors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .51 Radiation Safety . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .52 Infection Control and Prevention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .53 Latex Allergy Precautions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54 Chemical Waste Hazards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .54 Noxious Smoke Hazards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55 Fire Hazards . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .55 PART 2: Anesthesia General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57 CHAPTER 4 Anesthesia Modalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57 General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .57 General Anesthesia, Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .61 Conduction Anesthesia, Overview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .67 Conscious Sedation and Analgesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .71 Postoperative Transfer of the Patient to the PACU . . . . . . . . . . . . . . . . . . . . . . . . . .75 CHAPTER 5 CHAPTER 6 General Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .79 . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .79 Perioperative Considerations Conduction Anesthesia . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .84 Central Nerve Blocks: Spinal, Epidural, and Caudal . . . . . . . . . . . . . . . . . . . . . . . . .84 Regional, Local, Topical Anesthesia Modalities . . . . . . . . . . . . . . . . . . . . . . . . . . . . .87 PART 3: Technical Adjuncts to Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .91 CHAPTER 7 Laser Technology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .91 Types of Lasers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .91 CHAPTER 8 Endoscopy: A Minimal Access Approach . . . . . . . . . . . . . . . . . . . .99 CHAPTER 9 Robotics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .103 CHAPTER 10 Microsurgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .106 CHAPTER 11 Harmonic Scalpel and Plasma Scalpel . . . . . . . . . . . . . . . . . . . .109 Harmonic Scalpel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .109 Plasma Scalpel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .110 CHAPTER 12 CHAPTER 13 Argon Beam Coagulator . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .111 Radiofrequency Ablation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .112 Integumentary and Minimally Invasive Surgery . . . . . . .113 PART 4: Surgical Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .113 CHAPTER 14 Excision (or Destruction) of Skin Lesions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .113 Muscle Biopsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .113 Excision of Subcutaneous Lipoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .114 Incision and Drainage of an Abscess . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .115 Percutaneous Insertion of Catheters . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .115
Slide 16: Contents xv CHAPTER 15 Breast Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .121 Abdominal Extraintestinal Surgery . . . . . . . . . . . . . . . . . . . . . . .132 Breast Biopsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .121 Mastectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .124 CHAPTER 16 Abdominal Laparotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .132 Abdominal Laparoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .136 Abdominal Herniorrhaphy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .142 Laparoscopic Groin Herniorrhaphy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .145 Cholecystectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .148 Laparoscopic Cholecystectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .153 Drainage of Pancreatic Cyst (Pseudocyst) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .157 Pancreaticoduodenectomy (Whipple Procedure) . . . . . . . . . . . . . . . . . . . . . . . . .159 Pancreatectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .162 Drainage of Abscess(es) in the Region of the Liver . . . . . . . . . . . . . . . . . . . . . . .163 Hepatic Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .166 Splenectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .170 Laparoscopic Splenectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .174 CHAPTER 17 Gastrointestinal Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .178 Esophagoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .178 Gastroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .185 Colonoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .185 Sigmoidoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .186 Laparoscopic Esosphagomyotomy for Achalasia (Heller Procedure) . . . . .191 Esophagectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .194 Esophageal Hiatel Herniorrhaphy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .199 Laparoscopic Fundoplication (Nissen Procedure) . . . . . . . . . . . . . . . . . . . . . . . . .202 Vagotomy and Pyloroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .204 Laparoscopic Vagotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .207 Closure of a Perforated Peptic Ulcer . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .210 Laparoscopic Closure of a Perforated Ulcer (With Vagotomy) . . . . . . . . . . . .211 Gastrostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .212 Gastrectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .215 Bariatric Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .218 Laparoscopic Adjustable Gastric Banding and Proximal Gastric Bypass .219 Jejunostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .226 Small-Bowel Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .230 Cutaneous Ileostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .232 Appendectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .234 Laparoscopic Appendectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .236 Colostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .238
Slide 17: xvi Contents Closure of Colostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .242 Right Hemicolectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .244 Transverse Colectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .246 Anterior Resection of the Sigmoid Colon and Rectum . . . . . . . . . . . . . . . . . . . .248 Abdominoperineal Resection of the Rectum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .250 Laparoscopic-Assisted Colon Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .254 Proctocolectomy with Ileal Pouch Anal Anastomosis . . . . . . . . . . . . . . . . . . . . .259 Transanal Endoscopic Microsurgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .262 Hemorrhoidectomy, Anal Fissurectomy, Anal Fistulotomy . . . . . . . . . . . . . . .265 Anal Sphincteroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .268 Thiersch Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .269 Ripstein Procedure (Presacral Rectopexy) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .271 Perineal Resection of the Rectum for Complete Rectal Prolapse (Procidentia) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .272 Pilonidal Cystectomy and Sinusectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .273 CHAPTER 18 Gynecologic and Obstetric Surgery . . . . . . . . . . . . . . . . . . . . . . .277 Dilation of the Cervix and Curettage of the Uterus (D&C) . . . . . . . . . . . . . . . .277 Conization of the Uterine Cervix . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .281 Therapeutic Abortion by Suction Curettage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .285 Marsupialization of Bartholin’s Gland Duct Cyst . . . . . . . . . . . . . . . . . . . . . . . . . .287 Culdoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .289 Vaginal Hysterectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .289 Anterior and/or Posterior Colporrhaphy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .293 Gynecologic Laparoscopy/Pelviscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .295 Uterine Myomectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .299 Total Abdominal Hysterectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .306 Salpingo-Oophorectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .310 Tubal Sterilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .312 Laparoscopic Hysterectomy and Laparoscopic-Assisted Vaginal Hysterectomy With Or Without Salpingo-Oophorectomy . . . . . . . . . . .317 Hysteroscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .322 Surgery for Ectopic Pregnancy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .326 Tuboplasty of the Fallopian Tubes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .332 Cytoreductive Surgery for Ovarian Cancer (“Debulking Procedure”) . . . . .335 Pelvic Exenteration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .339 Radical Vulvectomy With Regional Lymphadenectomy . . . . . . . . . . . . . . . . . .343 Cerclage Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .346 Cesarean Section . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .348 CHAPTER 19 Genitourinary Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .353 Hypospadias Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .353
Slide 18: Contents xvii Epispadias Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .358 Urethroplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .359 Circumcision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .363 Penile Implant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .365 Marshall-Marchetti-Krantz Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .368 Burch Procedure (Retropubic Colposuspension) . . . . . . . . . . . . . . . . . . . . . . . . . .371 Tension-Free Vaginal Tape (TVT) Procedure for Bladder Suspension . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .376 Varicoelectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .379 Hydrocelectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .383 Vasectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .385 Vasovasostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .387 Cutaneous Vasostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .388 Spermatocelectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .389 Orchiectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .389 Cystoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .391 Cystostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .397 Cystectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .399 Transurethral Resection of the Prostate (TURP) and/or Lesions of the Bladder or Bladder Neck (TURB) . . . . . . . . . . . . . . . . . . . . . .402 Prostatectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .406 Nephrectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .412 Upper Tract Urolithotomy (Ureterolithotomy, Pyelolithotomy, Nephrolithotomy) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .416 Percutaneous Nephrostomy and Nephrolithotomy . . . . . . . . . . . . . . . . . . . . . . .420 Cutaneous Ureterostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .423 Ileal Conduit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .425 Adrenalectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .427 Extracorporal Shockwave Lithotripsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .430 Ultrasonic Lithotripsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .434 Electrohydraulic Lithotripsy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .437 Implantation of an Artificial Urinary Sphincter . . . . . . . . . . . . . . . . . . . . . . . . . . .440 CHAPTER 20 Thoracic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .445 Bronchoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .445 Mediastinoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .451 Segmental Resection of the Lung . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .455 Wedge Resection of the Lung . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .459 Pulmonary Lobectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .460 Pneumonectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .461 Decortication of the Lung . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .462
Slide 19: xviii Contents Insertion of Implantable Transvenous Endocardial Pacemaker . . . . . . . . . .463 Insertion of Implantable Cardioverter Defibrillator (ICD) . . . . . . . . . . . . . . . . .467 Correction of Pectus Excavatum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .467 Thymectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .472 Thoracoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .474 Video-Assisted Thoracoscopic (VATS) Wedge Resection of the Lung . . . . .479 Video-Assisted Thoracoscopic (VATS) Pneumonectomy . . . . . . . . . . . . . . . . . .480 Video-Assisted Thoracoscopic (VATS) Esophagogastromyotomy . . . . . . . . .481 CHAPTER 21 Vascular Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .483 Cartoid Endarterectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .483 Abdominal Aortic Procedures (Abdominal Aortic Aneurysmectomy, Abdominal Aortic Endarterectomy) with Aortoiliac Graft . . . . . . . . . . .490 Femoropopliteal Bypass . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .496 Femoral Arterial Thromboembolectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .500 Greater Saphenous Vein Ligation and Stripping . . . . . . . . . . . . . . . . . . . . . . . . . .503 Portosystemic Shunt . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .506 Arteriovenous Shunt or Arterioveneous (Bridge) Fistula . . . . . . . . . . . . . . . . .509 CHAPTER 22 Cardiac Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .512 Cardiac Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .512 Cardiopulmonary Bypass (CPB) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .514 Intra-Aortic Balloon Catherization (IABC) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .516 Aortic Valve Replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .518 Mitral Valve Replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .519 Coronary Artery Bypass Graft (CABG) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .521 Pulmonary Embolectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .523 MAZE Procedure . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .524 Transmyocardial Laser Revascularization Procedure (TMLR) . . . . . . . . . . . . .525 CHAPTER 23 Orthopedic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .535 Open Reduction and Internal Fixation of a Carpal Bone Fracture . . . . . . . .535 Excision of Ganglion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .540 Carpal Tunnel Release . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .541 Endoscopic Carpal Tunnel Release . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .542 Arthroscopy of the Wrist . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .544 Arthroplasty of the Wrist with Prosthetic Replacement of the Carpal Bones . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .548 Open Reduction and Internal Fixation of the Radius and/or Ulna Fractures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .549 Open Reduction and Internal Fixation of an Olecranon Process Fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .552 Transposition of the Ulnar Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .555
Slide 20: Contents xix Arthroscopy of the Elbow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .556 Open Reduction and Internal Fixation of Fractures of the Humerus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .559 Arthroscopy of the Shoulder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .563 Repair of Recurrent Anterior Dislocation of the Shoulder . . . . . . . . . . . . . . . .567 Open Reduction and Internal Fixation of Fracture(s) of the Humeral Head (Including Humeral Head Replacement by Prosthesis) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .570 Arthroplasty of the Shouder with Hemi (Partial) or Total Prosthetic Replacement of the Shoulder Joint . . . . . . . . . . . . . . . . .574 Open Reduction and Internal Fixation of Fractures of the Hip . . . . . . . . . . .581 Prosthetic Replacement of the Femoral Head . . . . . . . . . . . . . . . . . . . . . . . . . . . . .586 Total Hip Arthroplasty with Prosthetic Replacement of the Hip Joint . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .589 Open Reduction and Internal Fixation of Fractures of the Femoral Shaft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .595 Arthrotomy of the Knee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .598 Arthroscopy of the Knee . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .602 Excision of Popliteal (Baker’s) Cyst . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .606 Arthroplasty of the Knee Joint with Unicompartmental or Total Knee Prosthetic Replacement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .608 Open Reduction and Internal Fixation of Fractures of the Tibial Shaft . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .613 Open Reduction and Internal Fixation of Fractures of the Ankle . . . . . . . . .615 Arthroscopy of the Ankle and Foot . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .617 Triple Arthrodesis of the Ankle . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .619 Total Ankle Arthroplasty with Prosthetic Joint Replacement . . . . . . . . . . . .620 Repair of Tendo Calcaneus (Achilles Tendon) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .622 Bunionectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .624 Correction of Hammer Toe Deformity with Interphalangeal Fusion . . . . .626 Metatarsal Head Resection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .627 Procedure for Correction of Scoliosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .628 Amputation of Lower Extremity . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .636 CHAPTER 24 Neurologic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .640 Craniotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .640 Cranioplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .660 Transsphenoidal Hypophysectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .662 Ventricular Shunts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .666 Laminectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .670 Percutaneous Vertebroplasty and Kyphoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . .679
Slide 21: xx Contents Excision of Cervical Intervertebral Disc with Fusion, Anterior Approach . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .681 Cordotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .686 Rhizotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .688 CHAPTER 25 Plastic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .690 Scar Revision . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .690 Skin Grafting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .692 Cleft Lip Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .696 Cleft Palate Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .701 Reduction of a Nasal Fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .704 Reduction of a Mandibular Fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .708 Reduction of a Zygomatic Fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .713 Open Reduction of Orbital Floor Fracture . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .717 Rhinoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .720 Mentoplasty (Genioplasty) Augmentation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .723 Blepharoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .727 Rhytidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .729 Dermabrasion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .732 Otoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .735 Repair of Syndactyly . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .740 Digital Flexor Tendon Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .743 Peripheral Nerve Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .745 Microsurgical Vascular Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .748 Palmar Fasciectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .751 Reduction Mammoplasty/Mammaplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .752 Augmentation Mammoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .757 Abdominoplasty/Abdominal Lipectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .762 Liposuction and Tumescent Liposuction/Suction-Assisted Lipectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .765 CHAPTER 26 Neck Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .771 Thyroidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .771 Parathyroidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .776 Thyroglossal Duct Cystectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .779 Excision of Pharyngoesophageal (Zenker’s) Diverticulum . . . . . . . . . . . . . . . .782 CHAPTER 27 Otorhinolaryngological (ENT) Surgery . . . . . . . . . . . . . . . . . . .785 Myringotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .785 Tympanoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .789 Stapedectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .796 Mastoidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .801 Cochlear Implant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .808
Slide 22: Contents xxi Submucous Resection (SMR) of the Nasal Septum . . . . . . . . . . . . . . . . . . . . . . .811 Functional Endoscopic Sinus Surgery (FESS) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .814 Intranasal Antrostomy/Intranasal Fenestration of the Nasoantral Wall . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .822 Caldwell-Luc Procedure (Radical Drainage of the Maxillary Sinuses) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .824 Nasal Polypectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .825 Drainage of the Frontal Sinus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .827 Tonsillectomy and Adenoidectomy (T & A) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .831 Uvulopalatopharyngoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .837 Laryngoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .840 Tracheostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .843 Excision of Submandibular (Submaxillary) Gland . . . . . . . . . . . . . . . . . . . . . . . .846 Parotidectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .850 Laryngectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .853 Radical Neck Dissection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .857 Excision of Lesions of the Oral Cavity (Partial Glossectomy with Marginal Resection of the Mandible) . . . . . . . . . . . . . . . . . . . . . . . . . . .863 CHAPTER 28 Ophthalmic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .868 General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .868 Excision of Chalazion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .875 Canthotomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .877 Tarsorrhaphy/Canthorrhaphy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .877 Ectropion Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .878 Entropion Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .880 Blepharoptosis Repair/Blepharoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .881 Excision of Eyelid Lesion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .883 Eyelid Laceration Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .884 Lacrimal Duct Probing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .886 Dacryocystorhinostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .888 Correction of Strabismus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .894 Evisceration of the Eye . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .896 Enucleation of the Globe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .899 Orbital Exenteration . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .900 Corneal Transplant/Keratoplasty . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .902 Cataract Extraction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .907 Secondary Lens Implant . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .913 Extraction of an Intraocular Foreign Body . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .915 Trabeculectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .918 Excision of Pterygium . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .922
Slide 23: xxii Contents Repair of Retinal Detachment/Scleral Buckling . . . . . . . . . . . . . . . . . . . . . . . . . . .925 Vitrectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .930 Refractive Keratoplasty Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .933 CHAPTER 29 Dental Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .936 Dental Extraction/Odontectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .936 Dental Restoration with Implants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .941 Arch Bar Application . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .948 Total Temporomandibular Joint (TMJ) Replacement Surgery . . . . . . . . . . . .952 Orthognathic/Maxillofacial Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .957 CHAPTER 30 Radiation Therapy/Radiotherapy Procedures . . . . . . . . . . .963 Introduction to Radiation Therapy Procedures in Surgery . . . . . . . . . . . . . . . .963 Radiation Therapy for Head and Neck Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . .966 Radiation Therapy for Tumors of the Breast . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .969 Radiation Therapy for Gynecologic Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .971 Radiation Therapy for Carcinoma of the Prostate . . . . . . . . . . . . . . . . . . . . . . . . .974 Radiation Therapy for Rectal Tumors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .976 CHAPTER 31 Pediatric Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .978 Pediatric General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .978 Pediatric Tracheostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .989 Branchial Cleft Sinusectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .993 Correction of Congenital Dislocation of the Hip . . . . . . . . . . . . . . . . . . . . . . . . . . .996 Repair of Congenital Diaphragmatic Hernia . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1002 Omphalocele Repair . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1006 Repair of Exstrophy of the Urinary Bladder . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1009 Pediatric Umbilical Herniorrhaphy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1013 Pediatric Inguinal Herniorrhaphy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1015 Repair of Congenital Atresia of the Esophagus . . . . . . . . . . . . . . . . . . . . . . . . . .1017 Insertion of a Pediatric Central Venous Catheter . . . . . . . . . . . . . . . . . . . . . . . .1022 Pediatric Laparoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1025 Pyloromyotomy for Congenital Hypertrophic Pyloric Stenosis . . . . . . . . .1031 Pediatric Gastrostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1035 Pediatric Hepatic Portoenterostomy/Kasai Procedure . . . . . . . . . . . . . . . . . . .1041 Relief of (Pediatric) Intestinal Obstruction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1045 Reduction of Pediatric Intussusception . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1048 Pediatric Colostomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1051 Pediatric Colorectal Resection for Aganglionic Megacolon (Hirschsprung’s Disease) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1054 Repair of Imperforate Anus . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1061 Pediatric Laparoscopic Appendectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1067
Slide 24: Contents xxiii Pediatric Laparoscopic Fundoplication/Nissen Procedure . . . . . . . . . . . . . . .1070 Excision of Wilms’Tumor . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1074 Excision of Sacrococcygeal Teratoma . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1078 Pediatric Thoracoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1081 Pediatric Laparoscopic Splenectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1087 PART 5: Instrument Trays . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1091 CHAPTER 32 General Surgery Instrument Trays . . . . . . . . . . . . . . . . . . . . . . .1093 Major Procedures Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1093 Basic/Minor Procedures Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1094 Limited Procedures Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1095 Thyroid Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1096 Long Instruments Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1097 Biliary Tract Procedures Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1098 Choledochoscopy Tray (“Open” Procedure) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1099 Laparoscopic Cholecystectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1099 Laparoscopic Choledochoscopy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1100 Basic Rigid Sigmoidoscopy Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1100 Gastrointestinal Procedures Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1101 Ano-Rectal Procedures Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1101 CHAPTER 33 Gynecologic and Obstetric Trays . . . . . . . . . . . . . . . . . . . . . . . . . .1103 Dilation and Curettage (D&C) Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1103 Cervical Conization Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1104 Hysteroscopy Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1104 Pelvic Laparoscopy Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1105 Vaginal Hysterectomy Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1106 Abdominal Hysterectomy Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1107 Laparoscopic Hysterectomy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1108 Laparoscopic Tubal Sterilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1109 Cesarean Section Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1110 CHAPTER 34 Genitourinary Trays . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1111 Hypospadias Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1111 Vasectomy Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1111 Vasovasostomy Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1112 Cystoscopy Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1112 Prostatectomy Instrument Trays . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1114 Kidney, Ureter, Bladder Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1117 CHAPTER 35 Thoracic Instrument Trays . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1118 Bronchoscopy Instrument Trays . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1118
Slide 25: xxiv Contents Mediastinoscopy Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1119 Thoracoscopy or Video-Assisted Thoracic Surgery Tray . . . . . . . . . . . . . . . . . .1120 Thoracotomy Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1121 Pacemaker Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1122 CHAPTER 36 Cardiovascular Procedures Instrument Trays . . . . . . . . . .1124 Abdominal and Thoracic Vascular Procedures Tray . . . . . . . . . . . . . . . . . . . . . .1124 Arteriovenous (A-V) and Carotid Artery (C-A) Shunt Instrument Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1125 Peripheral Vascular Procedures Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1127 Cardiac Procedures Instrument Trays . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1128 Open Heart Basic Instrument Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1128 CHAPTER 37 Orthopedic Instruments Trays . . . . . . . . . . . . . . . . . . . . . . . . . . . .1132 Minor Orthopedic Procedures Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1132 Basic Orthopedic Procedures Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1133 Bone-Holding Instruments Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1134 Knee Arthrotomy Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1135 Hip Instruments Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1135 Total Hip Systems Instrument Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1137 CHAPTER 38 Neurosurgical Procedures Instrument Trays . . . . . . . . . . .1139 Craniotomy Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1139 Kerrison Rongeurs and Pituitary Forceps Tray . . . . . . . . . . . . . . . . . . . . . . . . . . .1143 Laminectomy Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1143 CHAPTER 39 CHAPTER 40 Plastic Surgery Instrument Trays . . . . . . . . . . . . . . . . . . . . . . . . .1147 Otorhinolaryngologic (ENT) Instrument Trays . . . . . . . .1153 Basic Plastic Procedures Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1147 Ear Procedures Instrument Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1153 Myringotomy Instruments Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1155 Nasal Procedures Instrument Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1156 Tonsillectomy and Adenoidectomy Instruments Tray . . . . . . . . . . . . . . . . . . .1158 Tracheostomy Instruments Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1159 CHAPTER 41 Ophthalmic Procedures Trays . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1162 Basic Eye Procedures Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1162 Basic Eye Procedures Microscope Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1163 Basic Eye Muscle Procedures Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1164 Eyelid and Conjunctival Procedures Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1165 Dacryocystorhinostomy Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1166 Globe and Orbit Procedures Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1167 Corneal Procedures Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1168 Cataract Extraction and Lens Procedure Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . .1170 Glaucoma Procedures Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1171
Slide 26: Contents xxv Basic Eye Procedures Microscope Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1173 Retinal Procedures Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1174 CHAPTER 42 Dental Instrument Trays . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1176 Dental Instruments for Extractions Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1176 Dental Restoration with Implant Trays . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1178 Temporomandibular Joint (TMJ) Procedures Instrument Tray . . . . . . . . . .1178 Orthognathic/Maxillofacial Procedures Instrument Tray . . . . . . . . . . . . . . . .1179 CHAPTER 43 Pediatric Instrument Trays . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1180 Pediatric Major Procedures Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1180 Pediatric Minor Procedures Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1181 Pediatric Gastrointestinal Procedures Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1182 Pediatric Thoracotomy Tray . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1182 Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1184 Index . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1217
Slide 27: This page has been left intentionally blank.
Slide 28: PART 1 PERIOPERATIVE CONSIDERATIONS: Preoperative, Intraoperative, and Postoperative Care Including Psychological Support of the Surgical Patient CHAPTER Perioperative Care of the Patient Psychological Support of the Patient in Surgery When surgery is recommended to an individual, the proposed operation, regardless of its extent, is perceived by the patient to be a “major” procedure. The patient’s emotional support begins with the referring physician who recommends a surgeon qualified to perform the surgery. The surgeon explains the indications for surgery, the course of events prior to and following the surgical procedure, and the medical terminology used. During the discussion, the surgeon, in a supportive manner, will outline a favorable course of events, but will not make any guarantees regarding the outcome of the surgical procedure. In addition, the surgeon must inform the patient of the possibility of poor results and the potential complications or injuries related to the procedure or the anesthetic, including death, even though the likelihood may be remote. The surgeon then clarifies any information pertaining to the surgery until the patient (or legal representative) indicates that he/she understands and is satisfied with the explanation. If there are alternative treatments or therapies, these must be disclosed prior to asking the patient to sign the “informed consent.” The surgeon may comfort the patient by stating that the chosen hospital or surgicenter is an accredited facility that has a capable and dedicated staff and that every measure will be taken to assure a successful outcome. In some facilities, when time permits, a perioperative nurse telephones the patient prior to the day of surgery to verify the patient’s name, date of birth, height and weight, and other personal data, as necessary. He/she answers the patient’s questions and tries to help the patient feel more comfortable about the impending surgical procedure. This initial patient contact optimally is made prior to the date of surgery, but may not take place until immediately before the surgical procedure. The patient usually arrives at the hospital or surgicenter the day before or the day of the scheduled surgery, according to the surgeon’s orders. Following admission to a unit, as time permits, the patient may be offered a perioperative teaching session and/or a teaching video.When- 1
Slide 29: 2 Chapter 1 Perioperative Care of the Patient ever possible, the patient is afforded an opportunity to express anxieties and/or ask questions.The nurse preparing the patient for surgery completes the Surgical Assessment and Preoperative Checklist (Form 1-1). Prior to transporting the patient to the surgical suite, operating room personnel must use at least two sources of identification to verify the identity of the patient.This may include any two of the following methods: 1. ask the patient to state his/her name 2. compare the name on the chart to the patient’s stated name 3. compare the name on the patient’s armband to the name on the chart 4. compare the name on the addressograph plate to the name on the chart. In addition, as a safety measure, personnel should check the front of the chart to obtain a list of the patient’s allergies and current medications. Once the patient arrives in the surgical holding area preoperatively, the circulator, a perioperative practitioner, will implement the Joint Commission (JC) (formerly the Joint Commission on Accreditation of Healthcare Organizations) 2004 Universal Protocol to identify the patient by asking the patient to state his/her name and by using another identifier from the list above. (Note that by asking for the patient’s name, rather than by asking directly, “Are you Mary Jones,” one minimizes the possibility of misidentification.) The patient’s name, date of birth, the name of the admitting doctor or surgeon, and other identifiers on the patient’s hospital armband must match those identifiers on the chart.The patient is asked to state the proposed procedure; the perioperative practitioner records the patient’s response in the patient’s own words on the record. Obtaining and confirming important information from the patient and the patient’s chart helps to ensure the patient’s safety in the operating room. For patients who are unable to communicate effectively (e.g., a young or shy child, a patient with a language barrier, or a patient who is physically or emotionally impaired or otherwise unable to speak coherently or obtunded), the above information is verified with the patient’s legal representative. In the surgical suite, the circulator again asks the patient to state his/ her name. (Note that the patient’s name and identifiers are verified a number of times by different personnel.) The circulator compares the patient’s name and identification number with the armband, chart, and addressograph plate. The procedure to be performed, the appropriately marked site/side (or laterality) of the body as applicable, and the name of the surgeon are reconfirmed with the patient or the patient’s representative.
Slide 30: FORM 1-1 Surgical Assessment and Preoperative Checklist Patient Identification Verification for Patient Safety Use at least two identifiers Ask the patient to state his/her name Compare stated name to the name on chart Compare the name on chart to the name on armband. Compare armband information to addressograph plate Name of anticipated surgical procedure (write in patient’s own words) “ Surgical procedure Consent signed yes no Special consent signed no yes N/A Prep by Skin condition before prep after prep History and physical examination charted Comment no yes Medications on front of chart (include OTC, herbal products) yes no Comment Sensitivities on front of chart no yes Comment ALLERGIES on front of chart yes no Comment Blood or blood products ordered yes no Time available Preoperative instructions given by Skin preparation by Skin condition before prep NPO since (time) Height B/P Site Solution refuses transfusions Initials ” Comment Comment After prep Weight TPR Old charts in OR yes no Comment continued on following page 3
Slide 31: 4 Chapter 1 Perioperative Care of the Patient FORM 1-1 Surgical Assessment and Preoperative Checklist (continued). Drains site Comment Catheter(s) (1) (2) Comment Intravenous line started: by Comment Prostheses: Dental (dentures, bridges, retainers) retained removed disposition Limb type/location retained removed disposition Eye: R retained removed disposition L by by by type N/A type site site solution type by by by by by by Implanted Electronic Devices (IED): Hearing devices: implantable hearing aids, cochlear implant bone conduction aids type signature Cardiac: defibrillator, pacemaker, or ventricular assist devices (VAD) type signature Bone growth stimulator type signature Medication infusion pump type signature Neurologic devices: ventricular shunts, nerve stimulators, brain stimulators type VALUABLES: Eyeglasses removed/disposition Contact lenses R removed/disposition L by signature by Hearing aids R L retained/removed/disposition Jewelry type retained/removed/disposition Shaver/radio type removed/disposition Wallet/money removed/disposition by by by by
Slide 32: Chapter 1 Perioperative Care of the Patient 5 Entries on the Surgical Assessment and Preoperative Checklist (pp. 3–4) are begun on the nursing unit as the information is reviewed with the patient.The circulator is also required to verify the information with the patient and initial each item on the checklist. (Note that every facility has its own policy and procedure.) The patient’s fasting status, prosthetic devices, special physical needs, and drug and substance intolerances, including sensitivities and ALLERGIES, are reviewed by the circulator with the patient or his/her representative and noted in the chart.The patient’s allergies and current medications should be listed on the front of the chart, although this requirement is not mandated in every health-care institution. Documentation of this information is valuable for preventing errors in patient care; it provides an extra measure of patient safety. Laboratory data are reviewed; a current record of the patient’s history and physical examination (dated according to institution policy) are confirmed.Any deviations from the norm, omissions, or discrepancies are to be reported immediately to the anesthesia provider and surgeon. Any valuables or personal property items not previously collected are secured, and their destination is noted on the chart. When the patient enters the operating room, the circulator may offer a warm blanket and/or touch the patient’s hand or shoulder to indicate concern for the individual. When the circulator answers the patient’s questions or directs the questions to the surgeon as appropriate, the patient may feel more secure. Adding to that security, the circulator should inform the patient that he/she acts as the patient’s advocate during surgery, particularly when the patient is anesthetized or otherwise unable to respond. A simple explanation of “patient’s advocate” may contribute significantly to the patient’s confidence in the course of events to follow. Incidentally, operating room personnel must know and implement patient care safety measures when interacting with patients (e.g., protecting the patient’s fingers from injury when the foot of the table is dropped and later raised). The chart is checked once again by the circulator with respect to the Authorization for and Consent to Surgery (Form 1-2), p. 6. This document may include authorization for the administration of blood, blood products, and/or blood transfusions. Additional special consents may be required, i.e., Authorization for and Special Consent to Surgical Sterilization Procedure (Form 1-3), p. 7.This document indicates that the patient will become sterile. The circulator must verify and document in the Perioperative Record that the surgeon has informed the patient and the patient has stated that he/she understands that he/she will no longer be able to procreate. Once the patient data requirements are verified by the circulator, everyone on the surgical team must agree that the patient on the operating table is the correctly named patient, of the named surgeon present,
Slide 33: 6 Chapter 1 Perioperative Care of the Patient FORM 1-2 Authorization for and Consent to Surgery I, do hereby authorize Dr. and his/her assistant (certified to assist in surgery) to perform the following procedure(s) at this hospital (name) on (date) , . I have been informed of the risks, benefits, and alternative treatments to this surgery. I do/do not authorize permission for a blood or blood products transfusion, if necessary, as deemed advisable by my surgeon and/or anesthesia provider. (If consent is withheld, as for religious reasons, document refusal in (Form 1-1) Surgical Assessment and Perioperative Checklist.) I have been informed and understand the purpose of the procedure and the possible complications. I have received no guarantee regarding the consequences or outcome of the aforementioned procedure, including risk of death. I agree to photography (in which I cannot be identified). The photographer and others may be in the operating room for educational purposes. I leave to the discretion of the pathologist the disposition of any specimen(s). I understand that I am responsible for the fees for any specialized services I receive while in surgery, independent from hospital fees. I acknowledge that I read this document, that I fully understand it, and that I am not under the influence of any preoperative or other sedating medication. Patient (or legal representative) Signature date Relationship to patient, if patient is a minor or if patient requires a legal representative Signature date Signature of witness date
Slide 34: Chapter 1 Perioperative Care of the Patient 7 FORM 1-3 Authorization for and Consent to Surgical Sterilization Procedure I, do hereby authorize Dr. and his/her assistant (certified to assist in surgery) to perform the following procedure(s) at this hospital (name) on (date) , My physician has fully explained the hysterectomy/tubal ligation/vasectomy (or other) surgical procedure and appropriate alternatives to me. I was offered the opportunity to ask questions and to refuse to have the procedure. I understand that following the hysterectomy/tubal ligation/vasectomy I will be sterile, that is, not able to have children. I understand that the procedure is to be regarded as irreversible. If I change my mind after the sterilization procedure (e.g., tubal ligation or vasectomy) has been performed, a reversal procedure, if available, may not be successful in restoring my fertility. Following a hysterectomy procedure there is no possibility that I will be able to become pregnant. Signature date Witness date AFFIRMATION OF INFORMED CONSENT BY PHYSICIAN I, in agreement with the Health and Safety Code of the (state), have given the above named patient (or legal representative) information explaining the nature of the procedure: purpose, alternative methods, risks and potential complications, and limitations. After receiving the foregoing information, the patient consents to the treatment and/or procedure described. Signature date Witness date
Slide 35: 8 Chapter 1 Perioperative Care of the Patient with the correct site and side marked for the particular surgery, and that the patient’s position on the table is correct for the procedure to be performed. Should any member of the team notice something amiss, it is his/her obligation to bring it to the attention of the team. Any special equipment, instrumentation, and/or implants must be available in the operating room, ready for use prior to starting the surgery. If blood or blood products have been ordered, their availability should be determined prior to surgery by the circulator.The information above needs to be corroborated by all members of the surgical team during the obligatory “time out” mandated by the JC before the surgery may proceed.Any unresolved discrepancies must be reported to the surgeon, the anesthesia provider, and the surgery supervisor, documented in the Perioperative Record, and reported in an Incident Report. The surgery may not proceed until all discrepancies are resolved. All pertinent issues and events during the patient’s surgery must be documented on the Perioperative Record, p. 12. Documentation on this record provides the legal accounting of the surgery in detail. Any incident that occurs while the patient is in the operating room that has not been documented cannot be considered “fact” in a court of law. Documentation of all that occurs intraoperatively during the patient’s perioperative experience is recorded for medicolegal purposes as well as to provide information. During the induction of anesthesia, the circulator may hold the patient’s hand and/or make eye contact with the patient until the patient is anesthetized; these measures may be continued intermittently throughout the surgical procedure when the patient experiences varying degrees of awareness (e.g., when sedation and analgesia/ conscious sedation are employed). Be aware that the patient may be able to perceive, in varying degrees, what is said during the induction of general anesthesia, and even subsequently, as hearing is the last sense to be lost. It is imperative that all who are in the operating room maintain silence during the induction of anesthesia to prevent distraction. Talking is best kept to a minimum throughout the surgical procedure. The number of people in the operating room should be kept to a minimum to avoid distractions and to avoid the possibility of inadvertent contamination of the sterile field. Postoperatively, the anesthesia provider and the circulator safely transport the patient to the Post Anesthesia Care Unit (PACU), alert to any untoward events. The perioperative RN in the PACU is given orders from the anesthesia provider upon the patient’s arrival. Similarly, the circulator from the operating room gives report to the PACU RN regarding the patient’s condition, pertinent surgery details, and the patient’s immediate needs. The patient’s care is transferred at that time to the perioperative RN in the PACU, who now assumes the role of the patient’s advocate.
Slide 36: Chapter 1 Perioperative Care of the Patient 9 PREOPERATIVE CARE PLAN NURSING FOCUS I: PATIENT APPEARS ANXIOUS DUE TO ANTICIPATED SURGERY/PROCEDURE AND UNFAMILIAR ENVIRONMENT ASSESSMENT ■ Awake ■ Asleep ■ Obtunded ■ Unresponsive/comatose PAIN 1–10 Language: Deficits: Cognitive Status ■ Alert ■ Drowsy ■ Lethargic Comment ■ Oriented ■ Responsive ■ Disoriented/confused Other Factors: Speaks English ■ yes ■ no ■ Hearing ■ Sensory Discuss impairment(s): ■ Alcohol abuse history ■ Drug abuse history Patient speaks another language ■ Mobility ■ Visual ■ Memory CARE PLAN ■ Greet patient by name (with titles), as necessary ■ Encourage patient to express concerns and questions; incorporate them into the care plan ■ Respond to concerns or questions with calm reassurance and accurate facts; defer to surgeon/anesthesia provider when appropriate ■ Orient patients to surroundings and advise them of events as they occur ■ Consider using touch to enhance communication ■ Consider special needs of pediatric and geriatric patients DESIRED OUTCOME Patient is able to speak calmly, cooperate, and follow directions. Outcome met ■ yes ■ no Comment NURSING FOCUS II: PATIENT MAY PERCEIVE BODY IMAGE AS ALTERED/IMPAIRED SELF ESTEEM CARE PLAN ■ Consider developmental age of all patients, ■ Avoid unnecessary exposure of patient’s body especially pediatric or geriatric patients ■ Adhere to policy regarding visitors and photography; keep number of people in the room ■ Answer patient’s questions and explain procedures before doing them to a minimum DESIRED OUTCOME Patient refers to the surgery with positive attitude, acceptance, and understanding. Outcome met ■ yes ■ no Comment NURSING FOCUS III: PREVENT INJURY TO NERVES, JOINTS, AND SKIN INTEGRITY WHEN POSITIONING PATIENT CARE PLAN ■ Smooth sheets under the patient, remove knots on gown ties to maintain smooth surfaces for skin integrity ■ Consider pediatric patient’s size and adjust table, accessories, equipment, and instrumentation accordingly ■ Pad all bony prominences, e.g., the sacrum, particularly in elderly patients with fragile skin; use adequate padding also on elbows and heels to prevent pressure sores; use positioning aides for support, as necessary ■ Use rolls and/or pillows to ease pressure on skin and nerves, to allow for adequate lung expansion, to relieve pressure between breasts and under scrotum, to support the patient in the desired position, and for comfort, as a pillow Patient position Positioning aids Padding used Grounding pad used ■ yes ■ no Control lot number # Location Skin condition before surgery placed under the knees to minimize back strain or a small pillow under the head ■ Use safety belt across the thighs, taking care to be sure it is not so tight that venous return is impaired ■ Position patient so that the body is in good alignment and symmetry; avoid extreme flexion or extension of joints to prevent pain and injury ■ Use supports above and below joints when moving an extremity; the surgeon is responsible for moving or lifting broken extremities ■ Avoid placing patient’s hands at the break in the table, use arm boards as procedure permits; check position of the fingers, especially when raising the foot of the table Type Type After surgery Site DESIRED OUTCOME: Patient shows no signs or symptoms of injury to nerves, joints and skin integrity. Outcome met ■ yes ■ no Comment (NOTE: When patient arrives in PACU or on the floor unit, patient should be examined and asked about PAIN 1–10 or paresthesiae,and the ability to move, i.e., to rule out paralysis) continued on following page
Slide 37: 10 Chapter 1 Perioperative Care of the Patient PREOPERATIVE CARE PLAN (continued) NURSING FOCUS IV: PREVENT PATIENT’S DISCOMFORT ON THE TABLE AND LOSS OF BODY HEAT CARE PLAN ■ Provide comfort measures as appropriate with pillows, pads, and specially warmed blankets as necessary ■ Confer with anesthesia provider and surgeon regarding application of forced-air warming blanket or MUL-T blanket (hypo/hyperthermia blanket or mattress pad) ■ Observe that skin temperature feels warm and that color appears normal ■ Ask patient if room temperature is comfortable; check room temperature and adjust if necessary. Monitor patient’s body temperature ■ Use warm irrigation solutions (noting also that cold or iced solutions may be employed, e.g., for active bleeding) ■ Avoid over-warming patients with fever ■ Increase room temperature, use radiant heat lamps, thermal blankets, and fluid warmers for pediatric patients according to weight ■ Adjust room temperatures for geriatric patients as necessary ■ Incorporate temperature control measures into procedures, e.g., keep patient well covered when inserting Foley catheter DESIRED OUTCOME Patient has warm, dry skin with normal color. Outcome met ■ yes ■ no Comment NURSING FOCUS V: PREVENT IMPAIRMENT OF SKIN INTEGRITY DURING SKIN PREPARATION CARE PLAN solution as necessary, ask surgeon for fur■ Document condition of skin before beginning ther directions and document the finding if skin preparation and following completion of reaction occurs preparation ■ Work carefully to prevent nicks in skin when ■ Work carefully to prevent skin preparation shaving or using clippers; work carefully to solutions from pooling under patient as they avoid moles, papillomata, and skin tags may cause skin irritation and excoriation and ■ Assess skin for reaction to prep solution; the solution could support combustion observe for rash or hives; discontinue using DESIRED OUTCOME Patient’s skin will remain intact and in good condition. Outcome met ■ yes ■ no Comment NURSING FOCUS VI: ASSIST ANESTHESIA PROVIDER DURING INDUCTION AND ASSIST HIM/HER TO CORRECT PATIENT’S FLUID VOLUME LOSS DURING SURGICAL PROCEDURE CARE PLAN ■ Monitor blood loss in suction canisters and in sponges ■ Monitor urine output ■ Communicate with anesthesia provider and/or surgeon regarding total fluid losses and assist with fluid replacement to maintain fluid and electrolyte balances ■ Consider special needs of the pediatric patient by weighing sponges as soon as possible to prevent evaporation of blood or fluid in sponges ■ Utilize blood warmers to prevent shock from cold transfusion and infusion pumps to speed fluid correction. Use warm saline irrigation unless contraindicated DESIRED OUTCOME Alterations in patient’s fluid volume losses due to NPO and intraoperative losses are restored. Outcome met ■ yes ■ no Comment NURSING FOCUS VII: PREVENT INJURY AND RISK TO PATIENT WITH IMPLANTED ELECTRONIC DEVICE WITH SPECIAL PRECAUTIONS TO PREVENT ELECTROMAGNETIC INTERFERENCE (e.g., interference with implanted pacemaker by ESU) CARE PLAN ■ If IED is to be inserted or replaced, check that IED and instrumentation for implantation are in OR ■ Know details regarding IED (by attending inservice education); circulator is notified in advance about the patient with IED ■ Check that appropriate industry representatives are present in OR ■ Verify representative’s credentials; that rep. has taken AORN OR course (or similar course) for understanding and knowledge of asepsis and the sterile field ■ Assure patient you know about IED; that you will take all safety precautions necessary for patient safety ■ Prevent inherent electromagnetic interference and risk to the patient with a pacemaker or similar device ■ Take special care to see that device is not damaged ■ Complete Special Log if IED is inserted DESIRED OUTCOME Patient will leave OR with IED without injury to patient or damage to device. Outcome met ■ yes ■ no Comment
Slide 38: Chapter 1 Perioperative Care of the Patient 11 PREOPERATIVE CARE PLAN (continued) NURSING FOCUS VIII: PREVENT PATIENT DISCOMFORT OR INJURY DURING TRANSFER TO GURNEY AND TRANSPORT TO PACU CARE PLAN ■ Cover patient with warmed blankets following pro- ■ Consider size and weight of the pediatric patient cedure to determine if isolette, crib, or gurney is needed ■ Ensure adequate assistance for transfer from table following procedure to gurney, lock wheels, check side rails are up ■ Circulator accompanies patient to PACU; assist■ Observe safety measures by using good body ing anesthesia provider, as necessary mechanics, bend knees, lift with strength from ■ Circulator will give verbal report to PACU RN to legs provide continuity of care DESIRED OUTCOME Patient is safely transferred to PACU. Outcome met ■ yes ■ no Comment
Slide 39: 12 Chapter 1 Perioperative Care of the Patient PERIOPERATIVE RECORD PREOPERATIVE, INTRAOPERATIVE, AND PACU RECORD [ STAMP PATIENT ADDRESSOGRAPH PLATE ] PREOPERATIVE RECORD : IMPLEMENT JCAHO UNIVERSAL PROTOCOL CORRECT SITE/SIDE SURGERY Patient speaks English If not, other language IDENTIFICATION: Preoperative Assessment and Checklist ASK PATIENT/PARENT/GUARDIAN ■ Patient’s name ■ DOB ■ Age ■ Sex VERIFY ■ I.D. band, chart, and hospital patient numbers match ■ Surgeon(s) names correct ■ Scheduled surgical procedure correct Comment Patient states (in his/her own words) the proposed surgery is “ ” ■ Signed consent(s) in chart Limitations Comment ■ Implanted Electronic Device Specify OR notified Comment ■ Prosthesis or implant in OR as ordered ■ (Industry representative in OR, if requested) ■ Blood/blood products ordered # units available type ■ Radiology exams (X-rays, MRI, CT scan) in OR ■ Endoscopy reports in OR ■ Old records/previous charts in OR ■ Radiology notified in advance, if anticipated SENSITIVE to: (including foods, contrast media, medications, dose related problems with medications, OTCs, herbal, and LATEX) ■ Correct site/side marked ALLERGIC to: (including contrast media, foods, medications, dose related problems with medications, OTCs, herbal, and LATEX) PATIENT RESPONSES MUST CORRESPOND TO THE CHART DATA. ACCURATE RESPONSES ARE REQUIRED FOR UNIVERSAL PROTOCOL. DO NOT PROCEED UNTIL ANY DISCREPANCY IS RESOLVED. DOCUMENT DISCREPANCY AND ITS RESOLUTION. NOTIFY THE OR SUPERVISOR OR PERSON IN CHARGE. Comment Signature
Slide 40: PERIOPERATIVE RECORD (continued) INTRAOPERATIVE RECORD OR # Time IN Time OUT STAMP PATIENT IDENTIFICATION NAME PLATE HERE ■ major SURGEON ASSISTANT ANESTHESIA PROVIDER CIRCULATOR SCRUB PERSON Relief Relief “TIME OUT” OBSERVED Comment SURGERY (include location) Initials ■ minor PREOPERATIVE DIAGNOSIS Chapter 1 TYPE OF ANESTHESIA USED time started Oxygen saturation IV/lines/CVP/arterial/other B/P cuff location PATIENT’S POSITION POSTOPERATIVE DIAGNOSIS time ended Perioperative Care of the Patient time started time ended supports used SURGICAL PROCEDURE PERFORMED Prep solution Skin intact before starting prep Skin intact after starting prep ESU grounding pad site Coagulation setting Skin area before pad Plume evacuator type applied by cutting setting after Comment Comment ESU serial # blend/pure setting Laser type Key obtained by Signature Type of handpiece Laser operation checked by initials Laser test fired by initials • Room warning signs • windows covered • Limit number of people in room • Eye protection for staff and patient • Non-reflective instrumentation and supplies • Operative area surrounded with water or saline dampened sponges, towels or drapes • Special Halon fire extinguisher in room • Laser plume evacuator type filter type • “Standby” mode on and foot pedal to surgeon ■ Room safety protocol observed Comment Signature 13 continued on following page
Slide 41: 14 PERIOPERATIVE RECORD (continued) INTRAOPERATIVE RECORD (continued) Type of Lithotripsy: ESWL with portable lithotripter ■ Compact S ■ Delta II ■ Laser lithotripsy ■ Ultrasonic lithotripsy ■ Electrohydraulic lithotripsy Patient warned before shockwaves start by ■ Stent or catheter in place on patient’s arrival Type Size ■ Stent or catheter inserted Type Size Location ■ IV urography performed ■ Retrograde urography performed Fluoroscopy total time X-ray precautions taken Appearance of patient’s skin at lithotripsy site preprocedure postprocedure Equipment problem encountered Intervention Incident report filed Outcome Heating devices/warming mattress/lamps Comment TED hose Catheters/drains/devices 1) Foley catheter 2) Nasogastric tube 3) Hemovac 4) Other type drain Tourniquet site time inflated Skin condition before tourniquet MEDICATIONS/DOSE/ROUTE 1) 2) type Sequential hose setting INTRAVENOUS FLUIDS type 1) 2) INTAKE IV OUTPUT Urine Nasogastric tube amount amount Other TOTAL INTAKE Other TOTAL OUTPUT Chapter 1 ■ ■ Perioperative Care of the Patient TRANSFUSIONS type (whole, packed RBCs, autologous, cell saver, washed WBC, FFP, Other) Blood ID checked with patient ID Signatures and Bag # type Signatures and Bag # type Signatures and Albumin Plasmanate Blood pump type warmer Comment size PROTHESIS/IMPLANT/GRAFT Type Manufacturer Implanted Electronic Device (IED) Type Manufacturer External Cardiac Pacemaker (temporary) Manufacturer SPECIMENS Source Frozen section source 1) 2) Serial/lot # Serial/lot # Serial/lot # pressure time deflated after Time Given by CULTURES TOTAL # SPECIMENS Aerobic 1) 2) Anaerobic 1) 2)
Slide 42: PERIOPERATIVE RECORD (continued) INTRAOPERATIVE RECORD (continued) COUNTS SPONGE NEEDLES/SHARPS INSTRUMENTS Other type ALL COUNTS CORRECT Comment first first first first ■ yes ■ no second second second second Signatures Circulator Scrub person Relief Circulator Scrub person Chapter 1 If the count is incorrect, TAKE ANOTHER COUNT COUNT CORRECT INCIDENT REPORT filed Comment ■ yes ■ ■ no Perioperative Care of the Patient OPERATIVE NURSING NOTES Integrity and sterility of packaging and indicators have been confirmed. The standards set by AORN for perioperative clinical practice were applied appropriately for this patient throughout the procedure and were within the scope of my practice. I have met the patient’s needs and charted the outcomes in accordance with those as proposed in the patient’s care plan. I verify that there have been no changes in the patient’s condition (other than those inherent in the surgical procedure) during the preceding interval since my preoperative assessments. Other comments 15
Slide 43: 16 Chapter 1 Perioperative Care of the Patient PERIOPERATIVE RECORD (continued) POSTOPERATIVE RECORD Time admitted to Postanesthesia Care Unit (PACU) transported by IDENTIFICATION checked by Report given to PACU RN by OR RN INTRAOPERATIVE TRANSFER DATA Surgery Preop Diagnosis Postop Diagnosis Assistant Surgeon Scrub person Circulator Anesthesia provider Type Anesthesia Nasal or oral airway Comment Oxygen set at l/m Dressings intact Comment Surgical site dry Comment Respirator settings color normal Comment Monitor in sinus rhythm Comment IV in progress from OR site solution Comment, if redness or swelling IV in PACU solution site Comment CVP catheter/intraartial Swan Ganz type/site Comment Skin color normal, warm, dry Comment Foley catheter draining Comment Nasogastric tube draining Comment Other drains type Comment Position on gurney side rails up restraints pressure type/location Level of consciousness Patient able to move lower extremities with Spinal, Epidural, or Caudal L R Transfusions from OR in progress type checked bag # with chart # initials
Slide 44: Chapter 1 Perioperative Care of the Patient 17 PERIOPERATIVE RECORD (continued) POSTOPERATIVE RECORD (continued) Vital signs on arrival (record or graph all the following vital signs on graph) Pulse oximeter Oxygen saturation % v Pulse 15 240 220 200 180 160 140 120 100 80 60 40 20 30 45 15 Respiration 30 45 15 30 45 15 30 v B/P 45 02 Sat. Pain score MEDICATIONS/DOSE/ROUTE time 1) 2) given by INTRAVENOUS FLUIDS type 1) 2) INTAKE IV Other OUTPUT Urine Nasogastric tube TOTAL INTAKE Other TOTAL OUTPUT TRANSFUSIONS Type (whole, packed RBCs, autogous, cell saver washed WBC, FFP, Other) Blood ID checked with patient ID Signatures and Bag # type Signatures and Bag # type Signatures and Albumin Plasmanate PAIN on departure from PACU 1–10 NURSING NOTES: OBSERVATIONS, INTERVENTIONS, DESIRED OUTCOMES MET Time out of PACU Transferred to by Signature(s) Transport via
Slide 45: CHAPTER Protection of the Patient in Surgery/ Patient Safety Admission Procedure The Joint Commission (JC) (formerly the Joint Commission on Accreditation of Healthcare Organizations) mandated in July 2004 that new criteria be used for safely identifying a patient preoperatively.The Universal Protocol should be employed by all health-care facilities under the auspices of the JC.When identifying a patient, the patient is not to be addressed by name, i.e., “Are you Mary White?” Instead, the patient (or the patient’s legal representative) is asked to give the patient’s name.When the patient states his/her name, the potential for misunderstanding is minimized.The patient’s stated name is compared to the name and patient number on the armband, the chart, and the addressograph plate. The patient is asked the name of the surgeon, the type of surgical procedure that he or she anticipates having, the location (site on the body), and the laterality (side) where the procedure will be performed. The location is identified by the patient and corroborated by the perioperative nurse and/or the surgeon. The site is marked with indelible ink. Even when the procedure will be performed on both sides of the body (either left or right but not both sides on the same day), the site for the procedure is marked (boldly), the designated site/side stated on the consent for surgery. Before the surgery begins, before the scalpel is passed to the surgeon, everyone on the surgical team observes a “time out” during which all must verbally agree to the identity of the patient, the surgery to be performed, and the operative site (correctly marked) according to laterality. The following year, in March 2005, the Association of periOperative Registered Nurses (AORN) recommended adding to the “time out” that everyone on the surgical team must agree that the patient is in the “correct position” on the table before the surgery begins.This “time out” requires the active participation of every member of the surgical team. Should any member find something amiss, he/she is obligated to bring it to the attention of the surgical team.The JC, AORN, American Medical Association (AMA), and other professional organizations consider the mandatory protocol for “wrong site/side, wrong procedure, and wrong patient” in addition to noting that the patient is correctly positioned on the operating table necessary to preventing tragic errors. 2
Slide 46: Chapter 2 Protection of the Patient in Surgery/Patient Safety 19 Every health-care facility has a policy regarding the procedure to be followed when preparing a patient for surgery (ascribing to the recommendations by the JC). (Please note that any facility where surgery is performed may be referred to as a hospital, surgicenter, or healthcare facility, and these names are used interchangeably in this text.) Authorization for and Consent to Surgery, p. 6, and any other special consent form, as necessary, i.e., Authorization for and Special Consent to Surgical Sterilization Procedure, p. 7, or any similar record, must be contained in the chart prior to admitting the patient to the surgical suite preoperatively. Other requirements may include a recent history and physical examination report, hematology and blood chemistry reports, urinalysis report, chest x-ray report, EKG, and any other reports that may be required depending on the patient’s age, diagnosis, and medical condition, and the hospital’s policy. Procedure for Safely Transferring the Patient to the Operating Table The patient should be transferred to the operating table by at least two persons to prevent injury to the patient and personnel. One or more persons is necessary to stabilize the gurney (stretcher) as close as possible to the operating table, taking care to lock the wheels. Similarly, at least one person must stand on the opposite side of the operating table (bed) to receive the patient and prevent him/her from falling.When the patient is alert and physically able, he/she is given directions for moving onto the table; however, if the patient is unable to move without assistance, adequate help should be summoned before the transfer is made. Using proper body mechanics is imperative when lifting patients to prevent injury to the musculoskeletal system of the employee(s). Back injuries, in particular, can be avoided when there is adequate help to move the patient safely. Personnel need to lift the patient in unison, bending their knees and using their leg muscles to provide strength during the lifting. Special devices, such as the Davis roller or the Hoyer pad, serve to reduce the weight being lifted, thereby facilitating the lifting and/or moving of a patient. During the transfer, care is taken to protect all catheters and tubings (e.g., Foley catheter, intravenous lines, Swan Gans lines, etc.) from becoming tangled or pulled out. Following the transfer, the restraint (safety) strap is fastened securely across the patient’s thighs (about three inches above the knees). Do not apply the restraint too tightly to avoid tissue ischemia and nerve damage. Once the patient is on the table, correct alignment is required to prevent injuries to the patient’s musculoskeletal system. All bony
Slide 47: 20 Chapter 2 Protection of the Patient in Surgery/Patient Safety prominences and the extremities must be adequately padded to prevent tissue damage (e.g., to nerves and skin). Some hospitals provide a specially trained staff, a lift team, who can be deployed to any area within the facility to assist in moving patients or heavy objects. The cost/ benefit of employing individuals to accomplish heavy lifting safely far outweighs the cost of sick days taken by personnel with back injuries. Preventing Patient Injuries from Falls Appropriate application of the safety belt (restraint) firmly fastened across the patient’s mid-thighs is the single most important measure taken to prevent falls from the OR table. It is fastened firmly, but not excessively as to interfere with the patient’s circulation.The patient is never left unattended in the operating room (OR).The upper extremities may be protected with softly padded restraints that are secured to padded armboards or the table to ensure stabilization of that extremity, but not too tightly as to compromise local circulation. Positioning/Surgical Positions The surgeon determines the position of the patient by considering the particular surgical approach, the physical condition of the patient, the technique used for anesthesia administration, and his/her preference in consultation with the anesthesia provider. Factors such as height, weight, body habitus, age, coexisting disease limitations, and cardiopulmonary status are taken into consideration. The desired patient outcome at the conclusion of the surgery is the avoidance of integumentary, nervous, vascular, and musculoskeletal injuries related to positioning or the change of position. NOTE: Once the anesthesia provider assumes care of the patient, the patient must never be moved without the anesthesia provider’s permission and direction. In all instances, proper body alignment is to be maintained; adequate assistance should be obtained prior to moving or lifting the patient. Positioning aids (devices), when used, must be brought into the OR prior to the admission of the patient to avoid prolonging OR and anesthesia time (for which the patient is charged) while these devices are located. For patients with fractures, severe injuries, significant deformities, or applied devices, it is the surgeon’s responsibility to protect the area involved when the patient is moved. The ultimate position employed may begin with a basic position, appropriately modified to ensure the patient’s safety and to obtain the best exposure of the surgical site. The patient’s physical mobility is assessed to prevent pain and injury by avoiding excessive flexion or extension of the joints, especially in the patient with arthritis, paralysis,
Slide 48: Chapter 2 Protection of the Patient in Surgery/Patient Safety 21 or other physically limiting preexisting conditions. An (oscillating) air mattress may be placed on the table (OR bed) for selected patients (with fragile skin) to protect the skin integrity from injury caused by pressure ischemia.The patient’s body should not hang over the table in any direction; if necessary, a padded extension can be added to the table.The skin must not be in contact with any metal surface, as the exposed area would become a potential grounding site when electrosurgery is employed. Disregard of this measure may result in serious burns (see electrosurgery safety precautions, p. 38).When using unipolar electrosurgery, the pencil must be replaced in the holster when not in use. As previously noted, when positioning the patient, the circulator protects bony areas with padding, pillows, donuts, towel or blanket rolls, etc. Blanket rolls are utilized under the chest to facilitate adequate lung expansion when the patient is prone. In the prone position, extra padding is placed to protect genitalia and breasts.Table accessories, such as shoulder braces, kidney rests, stirrups, and footboards must be well padded to avoid nerve damage and/or tissue ischemia. Care is taken to prevent strain on lower back muscles (e.g., a pillow is placed under the knees) and hyperextension injuries are avoided with proper support of the arms, hands, fingers, neck, and lower extremities, including feet and toes.The circulator and scrub person must ascertain, when applicable, that neither drape sheets nor the Mayo stand are causing undue pressure on the common peroneal nerve (resulting in foot drop) and/or direct pressure on the feet and toes. The following descriptions include the most common patient positions employed in surgery (See Fig. 2-1 A–J, pp. 27–30). Please note that the protective measures as noted above apply to all standard positions and their modifications. Supine/Dorsal Recumbent (see Figure 2-1A, p. 27) In the supine position, the patient lies face up on the padded table with arms tucked in at the sides (using the lift sheet), or extended on (padded) armboards. The body is maintained in proper alignment to prevent straining muscles.The legs may not be crossed to avoid local presure ischemia.When the upper extremities are extended on padded armboards, they are placed at the level of the table to prevent injury to the brachial plexus with padding under the elbows and wrists to prevent pressure injury to soft tissues, for example, the ulnar nerve; the hands are placed with the palms up (in supination).The head may be positioned on a donut or a small pillow; a pillow may also be placed under the knees, and an additional small pillow may be placed at the sacral area to prevent pressure injury to the soft tissue.The elbows and heels are protected with padding (and protective plastic cups, if necessary), as are other bony prominences. The supine position is the most frequently used. It may be employed for procedures on the face (the
Slide 49: 22 Chapter 2 Protection of the Patient in Surgery/Patient Safety head may be stabilized on a donut), the neck (with a small pillow under the neck to provide increased extension, improving access), the abdomen, the upper extremities (a hand table may be needed), and the lower extremities. Trendelenburg (see Figure 2-1B, p. 27) Trendelenburg is a variation of the supine position. The head and the torso are tilted downward (to a 30 - to 45 -angle), permitting gravity to pull the abdominal contents toward the head (cephalad); this allows for better visualization of the pelvic contents during surgery. Softly padded shoulder braces placed over the supraclavicular area may be used to prevent the patient from sliding off the table.This position should be maintained no longer than absolutely necessary. (In Trendelenburg, blood pools in the torso and the head, increasing blood pressure and intracranial pressure.) The knees are positioned over the lower break in the table to permit flexion. The feet are supported on a padded footboard. Trendelenburg may be employed to minimize hypotension produced by acute blood loss or resulting from the effects of an epidural or spinal anesthetic.Trendelenburg increases venous emptying of the lower extremities to reverse hypotension; additional measures are necessary to treat this condition. Trendelenburg is employed for abdominal hysterectomy and other procedures in the pelvic area. Reverse Trendelenburg (see Figure 2-1C, p. 28) Reverse Trendelenburg is a variation of the supine position.The entire table is tilted upward so that the head is higher than the feet. A padded footboard is placed at the end of the table to prevent the patient from sliding off the table.The arms may be secured on a pillow placed on the patient’s lap, extended on padded armboards, or tucked in at the patient’s sides. Do not allow the fingers to be trapped and injured as the foot of the table is dropped and subsequently raised. Neither the drape sheets nor the Mayo stand should place undue pressure on the feet, toes, and common peronal nerve.A sequential compression device with the application of antiembolitic hose or leg wraps is recommended to avoid venous stasis.This position is employed for neck procedures as thyroidectomy, parathyroidectomy, and scalene node biopsy. It is also used to perform laparoscopic procedures as cholecystectomy. Fowler’s/Sitting (see Figure 2-1D, p. 28) Fowler’s position is also a modification of the supine position; the patient appears to be sitting on a chair. The buttocks are positioned over the middle bend (kidney rest) at the table’s edge, and the knees are positioned over the lower break in the table. The head of the table is tilted (angled) upward to as much as a 90 angle; this position supports
Slide 50: Chapter 2 Protection of the Patient in Surgery/Patient Safety 23 the head and torso. The knees are flexed slightly as the legs are placed on a pillow over the lower section of the table, angled downward.The feet are placed on a padded footrest (horizontal to the table). A small pillow may be placed at the patient’s sacrum to prevent back strain; another pillow may be placed under the knees for comfort.The elbows and heels are protected with padding (and protective plastic cups, if necessary).The arms are frequently placed on a pillow on the patient’s lap, secured with softly padded restraints, tucked in at the patient’s sides, or extended on padded armboards.This position is employed for posterior craniotomy, selected shoulder, and ear, nose, and throat (ENT) procedures. A traction device (e.g., Crutchfield tongs) is used to immobilize the head during procedures on the brain and cervical spine. All bony prominences must be protected with padding, donuts, or pillows, etc. A variation of this position is known as semi-Fowler’s position, in which the degree of elevation of the head and torso is less; the patient appears to be sitting on a lounge chair. In the past, this position was used to permit postoperative intraabdominal secretions or septic exudates to pool in the pelvis to facilitate subsequent surgical drainage.This position may be employed for posterior craniotomy. Dorsal Lithotomy (see Figure 2-1E, p. 28) Dorsal lithotomy position is also a modification of the supine position. Stirrup or strap attachments, adjusted to equal height are secured on the table at the middle break.The buttocks are positioned at the edge of the middle break in the table and the sacrum is padded. The lower extremities are simultaneously elevated (preferably by two persons) and the hips and knees are flexed as the feet are placed in one of the many types of padded stirrups or padded straps looped above and below the ankle. After the feet are secured in stirrups or strap attachments, the lower mattress section is removed and the foot of the table is lowered completely. Extreme abduction of the hips is to be avoided; extra care must be used when positioning elderly or arthritic patients (some of whom cannot tolerate this position at all).When the foot of the table is subsequently raised, care is taken to prevent injury to the fingers. This position is employed for obstetric, gynecologic, perineal, anorectal, and urologic procedures. The term “lithotomy” originally referred to the extraction of bladder stones transperineally.A modification of this position employs leg and foot supports (e.g,. Allen stirrups) that permit a less exaggerated elevation of the lower extremities while giving access to both the abdomen and the perineum.Therefore, this position may be employed for low rectal resections without having to change the patient’s position during the procedure. Another variation of this position is Edebohl’s or Simon’s position, in which the knees and hips are
Slide 51: 24 Chapter 2 Protection of the Patient in Surgery/Patient Safety somewhat less flexed for some vaginal surgeries. At the completion of the procedure, after dressings are placed, both lower extremities are disengaged from the stirrups and slowly lowered simultaneously to prevent a dramatic drop in blood pressure, as the foot of the table is raised. Sims’ (Semi-Prone) (see Figure 2-1F, p. 29) In the Sims’ position, the patient is placed on his/her left side with the left thigh and leg extended.The right knee and hip are flexed and supported by a padded table restraint with a pillow placed between the legs to prevent undue pressure. The patient’s body is rotated to lie more prone than supine (pillows or other supports may be employed). The left arm is protected and secured at the patient’s side and the right arm, supported by a pillow-padded Mayo stand, is placed over the patient’s body.The skin of the right buttocks is protected with tincture of benzoin, distracted by wide (e.g., four inch) adhesive tape, and secured to the underside of the table. Care is taken to keep the pillow between the legs out of the operative field. Having the left side dependent is preferred, especially if sigmoidoscopy, colonoscopy, or enemas may be performed; minimizes the angulation of the distal colon. A variation of this position is utilized for a combined abdominosacral resection of a low rectal lesion. In this situation, the patient’s torso is rotated to provide access to the lower abdomen and the sacral area (with appropriate tissue protection using tincture of benzoin applied to sites prior to the application of tape to achieve distraction of the buttocks and pillows to pad and maintain the position). Draping is done to permit access to both sites without having to reposition the patient during the procedure. Sims’ position is employed for procedures requiring access to the vagina, anorectum, and perineum. Fracture Table (see Figure 2-1G, p. 29) Patients who arrive in the surgical suite in discomfort and/or in a traction device (e.g., with an acute fracture) may first be anesthetized in the hospital bed in which he/she arrives. Following the administration of anesthesia, the surgeon, with adequate assistance, protectively transfers the patient to the fracture table.The patient is placed supine with both arms extended on padded armboards, or the arm on the unaffected side may be extended on a padded armboard and the arm on the affected side may be flexed over the chest, supported by a pillowpadded Mayo stand, and secured with tape or a double armboard may be used.The sacral area and genitalia are well padded (as most of these patients are elderly with fragile skin) and supported by a specially designed saddle with a perineal post (that is padded for comfort and covered for hygienic reasons). The lower extremities are secured in
Slide 52: Chapter 2 Protection of the Patient in Surgery/Patient Safety 25 padded stirrups or padded leg supports. Care is taken not to permit the legs to be in contact with the metal part of the stirrups (when positioning) to prevent the skin from being burned inadvertently when electrosurgery is employed. Separate leg extensions can be moved independently in a variety of positions to permit optimal access to the surgical site. Orthopedic procedures on the lower extremities are performed; x-rays are taken intraoperatively to ensure proper positioning of a prosthesis, plate, or rod. The unaffected extremity may be raised and abducted from the field by adjusting the stirrup height and positioning the leg extension. This position is most often employed for insertion of a hip prosthesis and total hip replacement. Prone (see Figure 2-1H, p. 29) The patient, depending on the selected anesthetic, is placed face down in the prone position, with a padded donut to protect the face, or the head is turned to either side with a donut or pillow to protect the face and ear from undue pressure.The hips are positioned over the middle table break to permit flexion, as required. In this position, caudal or hypobaric spinal anesthesia can be induced without having to turn the patient. Epidural anesthetics are usually administered with the patient in a modified lateral mode. When general anesthesia is employed, the patient is supine. Following induction, the airway (including the endotracheal tube) is secured with adhesive tape (the skin is protected with tincture of benzoin) and the patient is turned over to the prone position (at the direction of the anesthesia provider).The head is turned to the side and placed on a well-padded donut that protects the ear and the face. In this position, blanket rolls are placed bilaterally under the chest to facilitate respiratory excursion. Female breasts and male genitalia are well padded to prevent pressure injury. The arms may be tucked in at the sides or extended on padded armboards. If anorectal or sacrococcygeal surgery is performed, the buttocks are distracted with tape secured to the ipsilateral sides of the table, after the skin is protected with tincture of benzoin. A pillow may be placed under the pelvic region to elevate the buttocks and to prevent pressure on the pubis and genitalia. The table is flexed at the hips (more so for procedures requiring the Kraske approach, a modification of the prone position to expose the sacral area; the “jackknife” approach is employed for anorectal and coccygeal surgeries). Adrenalectomy (unilateral or bilateral) and various spinal surgeries may employ the prone position. For some spinal surgeries, a convex curvilinear padded frame is placed anterior to the prone patient to provide additional flexion. Another modification of this position has the patient flexed at the waist over the middle bend of the table; the patient is kneeling with the thighs per-
Slide 53: 26 Chapter 2 Protection of the Patient in Surgery/Patient Safety pendicular to the floor, the legs horizontal (both areas protected by a pillow), and the feet angled downward. A pillow may also be placed in front of and under the knees, and a rolled towel is placed in front of the ankles to prevent undue pressure.When the lower table section is raised subsequently during the procedure, protect the patient’s fingers. This position may be employed for anorectal procedures. Lateral Kidney (see Figure 2-1I, p. 30) After anesthesia is established, the patient is placed in the lateral position (with the affected side up) and the iliac crest positioned over the “kidney” elevator (rest, bend, bar). The head is placed on a padded donut, protecting the face and ear on the unaffected side from undue pressure. Bony prominences, including the shoulder, knee, hip, and ankle are well padded. On the unaffected side, the lower extremity is flexed on the table and the leg on the affected side is extended straight over the leg below secured with wide adhesive tape to the underside of the table (with a pillow padding between the legs); the feet and ankles are well-padded, supported, and held in position secured by softly padded restraints or adhesive tape.The position is maintained by adhesive tape applied to the chest and the legs, secured to the underside of the table. All areas of skin that are taped are protected by an application of tincture of benzoin. Care is taken to avoid compromising circulation with all tape restraints. The arms may be placed on padded double armboards or the dependent arm may be extended on a padded armboard with the upper arm brought over the chest onto a pillow-padded Mayo stand and secured.The head and neck are aligned without tension, under the care of the anesthesia provider to avoid airway problems or undue stress on the brachial plexus. After the kidney elevator is raised and the table flexed, the patient is observed for respiratory and cardiodynamic changes. Potential compromise of venous return from the lower extremities may occur and pulmonary function in the dependent lung may be compromised, as well. Following the completion of the definitive procedure, the elevated kidney rest may be lowered and the table flexion reduced to facilitate wound closure Postoperatively, the patient may experience muscle pain related to the “unnatural” position employed during surgery. This position is primarily employed for procedures on the upper urinary tract (e.g., kidney), and structures in the retroperitoneal space. Lateral Chest/Posterolateral Thoracotomy (see Figure 2-1J, p. 30) After anesthesia is established, the patient is placed on the unaffected side with the head on a padded donut (to protect the face and dependent ear).The arm on the unaffected side is extended on a padded arm-
Slide 54: Chapter 2 Protection of the Patient in Surgery/Patient Safety 27 board while the superior arm on the affected side is bent over the chest, supported by a pillow-padded Mayo stand, and secured. The arm is pulled slightly forward and downward to provide some traction on the scapula. The lower extremity on the unaffected side is flexed on the table, and the extremity on the affected side is extended straight over the dependent leg (with pillow padding between the legs to prevent undue pressure).A padded restraint (e.g., the table strap) is secured over the hips, or the patient’s position may be secured by wide tape (four inch) to the underside of the table, following the application of tincture of benzoin to protect the skin. A small roll is placed under the shoulder and thorax at the posterior axillary line; female breasts and genitalia are protected with padding, as are the feet and ankles and any other pressure points.The shoulders are padded and tincture of benzoin is applied to the skin under the adhesive tape that is secured to the underside of the table. A soft pad may be placed under the unaffected hip to prevent undue strain on the lumbar region and to relieve pressure on the skin. A modification of this is the anterior chest position; the patient position is more supine than lateral. This position is employed for procedures requiring thoracoabdominal access. Padding and support are altered accordingly. The lateral chest position is employed for thoracotomy procedures. Safety strap Heel Pad Pillow under knees Padded arm board Small pillow FIGURE 2-1A. Supine/Dorsal Recumbent Safety strap Shoulder brace Pillow for head Arm wrap Padding for feet FIGURE 2-1B. Trendelenburg
Slide 55: 28 Chapter 2 Protection of the Patient in Surgery/Patient Safety Safety strap Padded foot board Pillow Small soft roll Arm wrap Heel padding FIGURE 2-1C. Reverse Trendelenburg Safety strap Padded foot rest Pillow Heel pad FIGURE 2-1D. Fowler’s/Sitting Buttocks at edge of mattress FIGURE 2-1E. Dorsal Lithotomy
Slide 56: Chapter 2 Protection of the Patient in Surgery/Patient Safety 29 Distraction tape Pillow between legs Pillow Roll under axilla Pad ankle and foot FIGURE 2-1F. Sims’ (Semi-Prone) Padded arm boards Padded Perineal leg holder post Padding and tape Pillow or donut Tape Saddle FIGURE 2-1G. Fracture Table Pillow Donut under face Chest roll Break in table Safety strap FIGURE 2-1H. Prone
Slide 57: 30 Chapter 2 Protection of the Patient in Surgery/Patient Safety Tape Pillow Soft roll under axilla Break in table Padding FIGURE 2-1I. Lateral Kidney Padded arm boards Pillow Small pad or roll Padding ankle and feet Tape FIGURE 2-1J. Lateral Chest/Posterolateral Thoracotomy Medication Practices and Guidelines to Avoid Medication Errors The circulator assumes responsibility for all medications provided to the scrub person and the surgeon. Most medications should be kept in a cool, dry place; some medications require refrigeration.All medications on the sterile field must be in a sterile container, labeled with the name, the strength, and the dosage of the medication.The scrub person identifies all medications on the sterile field by writing with a sterile skinmarking pen on paper labels that have been sterilized.All medications in solution must be transferred to the sterile field in an aseptic manner.The circulator may use a syringe to draw up a medication in solution before transferring it to a sterile cup. Medications in solution can also be transferred to the sterile field using a sterile vial spike, a sterile filter straw, or a sterile catheter; they may not be poured from bottles with stoppers.
Slide 58: Chapter 2 Protection of the Patient in Surgery/Patient Safety 31 A current, reliable medication reference book should always be available in the OR department for use by personnel. Medication errors must be reported and corrected immediately; an Incident Report form should be available for reporting medication errors. Periodic reviews of medication errors should be made to analyze how and why a particular medication error was made and how it can be prevented in the future. “Constraints,” as recommended by AORN, are approaches that should be used to avoid errors when administering medications; examples include minimizing the number of medication calculations required and stocking dose-related bottles of medication whenever possible. In addition, the competency of perioperative personnel who administer medications should be evaluated on a regular basis. To ascertain if a patient is allergic to a requested medication, the patient is asked directly (if possible), and the front of the chart and the preoperative assessment checklist are consulted. Adequate time must be taken to verify that the correct medication is being given, by the correct route, in the correct dosage, and, to the correct patient, as ordered by the surgeon. The protocol for the administration of medication should be checked and rechecked. When a medication is dispensed to the scrub person, the circulator should state the name of the medication, the strength, and its dosage aloud, while showing the labeled bottle to the scrub person for verification. When a medication must be prepared (in solution), calculations should be checked and rechecked by the person dispensing the medication and the calculations should be verified by another licensed professional. Any unused portions of a used (i.e., opened) medication should be discarded at the completion of the procedure. Any unlabeled medications found in the OR are always discarded.When the scrub person and the circulator are relieved, all labeled medications being used are shown to the relief person(s).The relief person(s) is/are required to take note of specific medications and their locations on the sterile field. Medication containers or vials and the items used for medication preparation and delivery during a surgical procedure must remain in the room until the completion of the procedure. During a procedure, the trash is never to be removed from the room before the conclusion of the procedure. AORN guidance statement suggests using the five “rights” when administering medication: 1) the right patient, 2) the right medication, 3) the right dose, 4) the right time, and 5) the right route. Allergies The circulator should speak directly to the patient about any allergic reactions to medications, foods, herbal preparations, and other substances. Check the front of the chart for the list of the patient’s allergies;
Slide 59: 32 Chapter 2 Protection of the Patient in Surgery/Patient Safety listing the patient’s allergies on the front of the chart can be an invaluable safety measure.The patient allergies most frequently encountered in the OR are those to adhesive tape, latex, and iodine (often contained in some skin preparations and contrast dye agents). Patients who are allergic to certain foods are often allergic to certain types of medications. NOTE: Allergic reactions can be serious; they may lead to anaphylactic shock and possibly even death. Be prepared for this emergency situation by knowing the location of the cardiac arrest “crashcart” prior to bringing the patient into the room. Latex Sensitivity and Allergy When identifying patients before surgery, it is imperative that perioperative personnel question the patient regarding all sensitivities and allergic responses to foods, substances, and medications. Individuals who have a food allergy to bananas, avocados, chestnuts, and kiwi fruit are frequently sensitive or allergic to latex. Patients need to be asked specifically about being sensitive or allergic to those fruits listed, in addition to latex, or any product that may contain latex. Knowing in advance that a patient is allergic to latex may literally save that patient’s life. Latex sensitivity and latex allergic reaction vary in intensity from causing an “irritant dermatitis” that results in dry, red and cracked, itching skin to causing a true (delayed) allergic reaction, an “allergic contact dermatitis” within 48 hours of exposure that exhibits similar symptoms, but may not be limited to the point of contact.The most serious reaction is a “true allergic response” (anaphylaxis) that occurs almost immediately and may be characterized by rapidly developing urticaria, facial edema, and a generalized swelling of body tissues (i.e., the larynx and bronchi), followed by respiratory distress secondary to bronchospasm and laryngospasm and hypotensive shock that may result in death. When an “at-risk” person simply touches a balloon or has cutaneous or mucous membrane contact with latex proteins, an allergic response may result. In surgery, the allergic response may be far greater if the patient or the staff member has had repeated contact with products made of latex, as gloves, nasogastric tubes, anesthesia and respiratory support equipment, urinary catheters, enema equipment, etc. Patients, particularly pediatric patients, who have had multiple surgeries (e.g., procedures for spina bifida, staged hypospadias and epispadias, etc.) and have been exposed to latex proteins during previous operative experiences are at the greatest risk for developing an allergic response. Individuals who frequently don latex gloves or work with latex products may also be at great risk for developing an allergic response. Latex allergy may not be evident until the individual has been exposed to latex proteins numerous times. The best method for treating a latex reaction is to prevent it by creating an environment that is “latex safe” or “latex-free.” Corticos-
Slide 60: Chapter 2 Protection of the Patient in Surgery/Patient Safety 33 teroids, antihistamines, and other appropriate medications are used to lessen the severity of an allergic reaction. Medications (including epinephrine, diphenhydramine, steroids, H-2 blockers, inhalants such as albuterol, glucagon, etc.), a variety of latex free airways and tubings, and all equipment necessary to treat anaphalactic shock should be kept on a well-stocked “latex-free crash cart” in the surgical suite. Health care facilities should develop a protocol for treating latex reactions. The Food and Drug Administration (FDA) requires the manufacturers of products and devices containing latex (proteins) to have a warning label stating that use of the product may cause an allergic response. Decision makers in hospitals and health-care facilities need to adopt a policy requiring latex-safe environments for both patients and health-care workers by selecting alternate products for use in the OR, and throughout the facility, making the environment safer for personnel and patients Environmental Controls Preventing Infections In 1996, the Center for Disease Control and Prevention (CDC) issued Standard Precautions directed to health-care facilities and personnel for the purpose of prevention of and transmission of infectious diseases. These guidelines were initially prompted by the HIV AIDS emergence, / but are applicable to all infectious diseases encountered in the health care system. Universal Precautions, previously established, listing measures to safely deal with blood products, bodily fluids (including vaginal secretions and seminal fluid), was incorporated into Standard Precautions. Patients and health-care givers are presumed to be potentially infectious or susceptible to infection. The practice of hand washing, utilization of gloves, masks, facial shields, gowns, cleansing of patient care equipment, environmental control, linen processing, occupational health and bloodborne pathogens, and patient placement considerations are addressed. By observing these measures, the spread of pathogenic microorganisms can be controlled or limited. The discussions that follow are the practice of these measures, as applied to the OR environment. Each OR, including furnishings and equipment, should be cleaned with a germicidal cleaning agent after every procedure. Numerous studies have shown that selected “ritual cleaning” that was done in the past following “contaminated” or “dirty” cases is an obsolete practice as all cases are known to be potentially infectious. Each OR needs to be cleaned in the same manner every time using a germicide. In addition, the entire surgical department, including its corridors, storage rooms, and other auxiliary areas, is cleaned according to an established schedule.
Slide 61: 34 Chapter 2 Protection of the Patient in Surgery/Patient Safety Traffic patterns are developed to minimize intrusion into restricted areas.Airborne contaminants are reduced by air conditioning (utilizing highefficiency particulate air filters) and laminar airflow systems. The barriers created in and around special areas in the department must be observed. Specially laundered or disposable clothing (scrub attire) is worn. Disposable head coverings, masks, protective facial shields, and waterproof fire-retardant gowns and shoe coverings are utilized and replaced (changed) between cases and removed when leaving the department. Probably the greatest single factor in preventing the nosocomial infections is frequent hand washing with an antimicrobial agent. Nosocomial infections are those infections acquired while in the hospital. Hand washing should be performed upon entering the surgical suite before starting work, and it should be the last thing done by each member of the staff when leaving the department. Hand washing is just as important for the circulator as for the scrub person (following a case even if gloves were worn). Hands should be washed after caring for each individual patient, and gloves should be changed after performing each task (even when on the same patient) while working as a circulator (as in handling of soiled sponges and instruments, tissues, or fluids). Gloves are always changed between patients. Following their initial hand washing, individuals who are not working within the sterile field may use a waterless cleansing agent (antimicrobial gel) following their initial scrub upon entering the department. Personnel with cuts and abrasions of the hands or forearms should not scrub. Jewelry such as rings and bracelets is to be removed. Artificial fingernails (which may harbor bacteria and fungi) may not be worn in surgery according to AORN. An appropriate cap (containing all of one’s hair) and a mask (to cover facial hair) should be adjusted before scrubbing, as should eyeglasses. Disposable masks of synthetic materials are preferable to cloth masks that are permeable to the passage of pathogens. Similarly, the mask protects the wearer from inhaling contaminants or particulate matter generated in the operative field. Additionally, facial shields prevent splashing or spattering of blood and other fluids into the eyes, nose, or mouth. Laser-related eye protective measures are addressed in the chapter on lasers, p. 95. Surgical Scrubbing Technique “Scrubbing” refers to a specified length of time (and number of brush strokes) needed to cleanse all anatomical aspects of the nails, fingers, hands, and forearms and the order in which each zone is washed and rinsed prior to donning gown and gloves. Each institution selects a variety of disposable brushes and cleansing agents approved by the Occupational Safety and Health Administration (OSHA). Strict atten-
Slide 62: Chapter 2 Protection of the Patient in Surgery/Patient Safety 35 tion to “scrubbing” technique by those working in the sterile field, in addition to proper skin preparation of the surgical site, and the constant vigilance and attention paid to the implementation of aseptic technique by the entire surgical team will help to reduce the number of contaminants present about the surgical field. Aeseptic Technique Careful attention must be given to the controlled sterilization of instrumentation, instrument trays, and supplies by specifically noting the time and the condition of the sterility indicators and wrappers. The careful, proper opening of individually packaged sterile instruments, instrument trays, and supplies must be observed.All wrapped items are to be unwrapped by holding the package away from one’s body and unwrapping the item starting with the corner that is farthest away and ending with the corner closest to the body. Disposal of waste material and the removal of laundry into specially colored or marked and labeled plastic bags or containers is mandatory to prevent contamination of the environment inside and outside the hospital/health-care facility. Utilizing an enzymatic foaming agent that can be sprayed on instruments following a surgery before removing trays from the OR aids in preventing blood and other contaminants from drying on the instruments. This debris is sometimes overlooked, and it dries inside the lumen of an instrument as well as in other areas (e.g., crevices, joints of instruments, etc.). Enzymatic foaming agents also prevent contaminated spilled liquids from becoming a biohazard.When this foam is not available, instruments should be covered with a sheet and carefully transported to the decontamination area. Spills are to be mopped up using a germicidal agent. Implanted Electrical Devices It is not unusual to encounter patients with an implanted electrical device (IED).The devices include implantable hearing devices, cardiac devices, infusion pumps, neurological devices, brain stimulators, bone stimulators, and gastric devices. Perioperative personnel should be aware that some IEDs are susceptible to electromagnetic interference, causing them to malfunction in the OR when other electrical equipment (e.g., electrosurgical unit) is used. In 2005, AORN stated that perioperative personnel must possess current knowledge regarding the many types of IEDs; this information is often provided by the surgical department through in-service education.When scheduling a patient for surgery, the surgeon must notify the OR if a patient requires insertion or replacement of an IED.The patient’s status regarding an IED should be noted on the patient’s chart in the nursing surgical assessment preoperatively.
Slide 63: 36 Chapter 2 Protection of the Patient in Surgery/Patient Safety If an IED is initially being implanted or replaced, the appropriate industry representative may be present during the surgery. He/she must take the AORN special OR instruction course (or its equivalent) in order to be present in the OR.The industry representative is in the OR to lend his/her expertise and support to the OR team. Documentation should be made in the Intraoperative Record that the industry representative is present in the OR (with the permission of the patient, surgeon, and OR supervisor). Documentation of all the special care measures and precautions taken by the circulator and the team members must be recorded in the Intraoperative Record, as well as the IED ownership log. Before the patient arrives, the circulator needs to review all necessary information regarding the IED. Often a separate log for a particular type of device is kept in the OR; the circulator is responsible for maintaining current information, as the name of the device, type, manufacturer, serial number, and other applicable information to help identify the device. Electrical and Fire Hazards Electrical and fire safety precautions are set forth in hospital policy and are carried out by members of the OR staff.The National Fire Protection Association (NFPA) provides health-care facilities with standards for fire prevention and safety. NFPA recommends that specific types of portable fire extinguishers (labeled according to the source of the fire to be extinguished) should be accessible and in close proximity to the ORs. Health-care facilities provide in-service programs and fire drills for personnel. These programs should address the potential causes of surgical fires, their prevention, and methods for extinguishing a fire in the department. Most facilities request that members of the local fire department teach a fire prevention class; they may also be requested to teach methods for rescue and evacuation of patients. The engineering department determines the safety of equipment before permitting its use in the OR. Inspection of the equipment prior to each use is the responsibility of the person(s) who will participate in using said equipment. Personnel are required to receive instruction for the safe operation of all electrical equipment and then demonstrate their ability to use the equipment safely before putting it to use. All electrical equipment used in the OR must be grounded. A threepronged plug on equipment cords indicates that it is grounded. Electrical cords should be inspected for damage; any electrical equipment in the OR must not be used if it has a damaged cord.When a surgeon asks the circulator to increase the current of an ESU several times, eventually above normal limits, this indicates a malfunction of the unit. It is imperative for the perioperative RN to investigate whenever a red
Slide 64: Chapter 2 Protection of the Patient in Surgery/Patient Safety 37 light suddenly appears on a piece of electrical equipment as it is a warning sign that indicates a problem. That particular ESU or other piece of electrical equipment should be unplugged. If the source of the defect or malfunction cannot readily be determined and corrected, the unit should be replaced and referred to the engineering department. The model number of the replacement equipment should be noted on the intraoperative record along with the reason why the previous unit was replaced, e.g., red warning light remained on. Fires result from a combination of HEAT plus OXYGEN plus FUEL; an inciting source of ignition (e.g., electrical spark) sets off the fire.These three elements create the fire triangle and are replete in an OR. Personnel must be instructed how to prevent fires in the OR, as well as what action is required of each individual should a fire occur. The location of fire extinguishers, the fire alarm, and the code name (e.g., CODE RED) to alert personnel are to be known by everyone in the surgical department and the entire facility. All personnel should receive special instruction regarding their responsibilities in case of fire and may be asked during fire drills to perform those duties. Fire drills are not scheduled; they should be called at least twice a year. Fire drills are to be taken seriously. Flammable anesthetic agents are infrequently employed today; however, there are flammable materials and liquids that may be in use at any time in an OR (e.g., alcohol-based skin preparation solutions). Paper or fabric items, such as gowns, head and shoe coverings, and drapes used in the OR, are made as fire retardant as possible, but they are not fireproof. Flammable liquids should be avoided, but when absolutely necessary, are to be used with great caution when preparing the skin.These solutions must not be permitted to pool under the patient or in the drapes, as they can ignite from a spark when using the electrosurgical unit (ESU) or the laser. Note that the pooling of any solution under the patient or in the drapes is also to be avoided to prevent injury to the skin by excoriation, and to prevent the solution from becoming the fuel for a fire. Neither the ESU nor the laser should be used in the mouth or oropharynx concurrent with the administration of high concentrations of oxygen. When the administration of oxygen is absolutely necessary, the oxygen should be halted transiently when the ESU or laser is employed in these locations to avoid local, tracheal, and pulmonary burn injury. Rapport between surgeon and anesthesia provider is to be maintained in these circumstances. Insulated nonflammable endotracheal tubes or modified metal endotracheal tubes that have been covered with a nonflammable, nonreflective material are employed during laser applications. Towels, drapes, and sponges placed about the surgical site during laser applications are to be premoistened to prevent combustion. For laser safety precautions, see p. 94.
Slide 65: 38 Chapter 2 Protection of the Patient in Surgery/Patient Safety When all factors are considered, careful forethought and vigilance regarding the use of flammable materials in the OR are the best defense in preventing surgical fires that could result in an injury or the death of patients and personnel. Electrosurgery The ESU is commonly employed in the OR for the coagulating or cutting of tissue. In a bipolar ESU, the current flows from the generator (ESU) to an active electrode, one side of the forceps, through the tissue, and returns to the ESU through an inactive electrode, i.e., the other side of the forceps. In the monopolar ESU, the active electrode is usually an electrosurgical “pencil,” and the inactive electrode is the dispersive (grounding) pad. In the monopolar system, when using an adhesive dispersive pad, the pad is placed on the patient’s skin, as close as possible to the surgical site to minimize the pathway of the current through the body. The pad must make direct contact with the skin; shaving the area may be necessary for good contact. It must also be placed as far as possible from ECG leads to prevent interference. All connections must be secure. A variety of ESU dispersal pad (return electrode or ground), Megadyne 2000, utilizes a nonadhesive pad that is large enough to cover an adult torso. It is placed on the operating table under the patient. This reusable pad, covered by a sheath and a linen sheet, does not make direct contact with the patient’s skin; no shaving of the area is required. Safety precautions must always be taken when employing an ESU to prevent burn injury to the patient.These include the following: 1. All connections must be secure. 2. The disposable adhesive pad (the inactive electrode) of the ESU should cover a sufficiently large area of skin, relatively free of hair (which acts as an insulator). 3. The patient’s body should never make direct contact with any metal surfaces when an ESU is being used during the procedure. If the return circuit is faulty, the ground circuit could be completed through the contact area, causing an inadvertent burn injury. 4. Keep the electrosurgical pencil in its holster when not in use to prevent direct skin burns. 5. Although the electrosurgical pad should be placed as close as possible to the operative site, it should be placed as far away as possible from ECG leads to avoid interference with the heart’s electrical field forces. As noted in the section above, repeated requests to increase the current on an ESU should be thoroughly investigated by the circulator.
Slide 66: Chapter 2 Protection of the Patient in Surgery/Patient Safety 39 All connections and the dispersive pad should be checked. If no problem is found, e.g., a frayed cord, the unit may be faulty. Turn off and unplug the ESU. Label the faulty unit, request repair, and obtain another ESU. Be certain that this occurrence and the serial number of the units involved are documented in the patient’s operative record. Special Notes • Drapes, gowns, shoe coverings, head coverings, etc. must be fire retardant. NOTE: These items are not fireproof. • If the patient has an implanted pacemaker, the ESU could cause malfunctioning of the pacemaker.The patient needs to be continuously monitored and observed closely. • When the ESU is in use, the cardiac arrest cart or the “crash” cart, complete with defibrillator and paddles, should be in close proximity to the particular OR. This is of extra concern when the patient being operated on has a pacemaker.The unit should be brought close to that OR before the surgery begins. Documenting that this has been done before surgery began is imperative for medicolegal reasons. • During surgery, the electrosurgical pencil should be kept in a holster when not in use to avoid inadvertently burning the patient with the tip. Counting Procedure Each institution has its own written policy and procedure regarding the counting of sponges (varying types), sharps, and instruments. The following guidelines should be observed when counting all objects potentially subject to inadvertent inclusion within a wound: 1. The scrub person and the circulator count together (aloud) all items on the sterile field as the scrub person touches to each item. 2. The circulator immediately records the number (count) of each type of item. Keeping a record of the count is the legal responsibility of the circulator. 3. If there is any uncertainty regarding any count, it is repeated. 4. As additional items (e.g., sponges or needles) are introduced to the sterile field during the procedure, the scrub person counts the item(s) with the circulator, who adds the item to the count in the record and initials it. 5. Nothing (including laundry, trash, instruments, or sponges) may be removed from an OR while a procedure is in progress
Slide 67: 40 Chapter 2 Protection of the Patient in Surgery/Patient Safety 6. 7. 8. 9. until the final count is acknowledged to be correct. The only exception to this is when a specimen is sent to the laboratory for immediate inspection (e.g., frozen section) and the specimen remains attached to a “counted” item (as by sutures to maintain its orientation); this must be noted and initialed on the intraoperative record. Whenever there is a change of team members, a count is taken. The name of the replacement person(s) is documented on the intraoperative record. When a package containing an incorrect number of items is opened, the items should be passed off the table, bagged, and labeled accordingly. The bag with the incorrect number of sponges is labeled, set aside, and not included in the count.The bag may not be removed from the room. Counts are taken before the procedure begins, before wound closure begins, and when skin closure is initiated. An additional count is taken prior to the closure of an organ with a cavity (e.g., uterus, bladder, or bowel). Incorrect closure counts must be repeated immediately. If the count remains incorrect, the circulator alerts the surgeon, who will inspect the patient’s wound for the missing item. If the item is not located, hospital policy must be followed, i.e., usually to include immediate x-ray examination. Notification of the OR supervisor and an incident report must be filed as part of the chart, the permanent record. Any item inadvertently left in a wound may become a source of infection and result in subsequent litigation. Sponge Counts All sponges, including neurosurgical sponges (cottonoids and patties), soft goods (e.g., umbilical tapes), and loose items are counted. Each type of sponge according to size is counted together and kept separate from all other types or sizes. All sponges used within the wound must be x-ray detectable. X-ray-detectable sponges are never used for dressings, and dressing sponges are never used to dry the wound or surgical field as undetectable sponges could be inadvertently left in the wound (if placed on the sterile field before the final count). Soiled sponges are counted by the scrub person and the circulator together and then bagged in impervious plastic bags according to a predetermined number (usually in sets of 5 or 10).When the counts are taken, the scrub person counts the sponges according to type, beginning with the sponges on the sterile field, proceeding to the sponges on the back table, and following with those off the field. The circulator wears gloves when separating or counting soiled items. The circulator
Slide 68: Chapter 2 Protection of the Patient in Surgery/Patient Safety 41 informs the surgeon of the results of the counts. As noted above, if the sponge count is not correct, the surgeon examines the wound and the count is repeated immediately. If it is still incorrect, hospital policy is to be followed (i.e., usually policy states the incident must be reported to the OR supervisor and an x-ray must be taken). An incident report must be filed in the chart as a part of the permanent record. Sharps Counts All needles, knife blades, electrosurgical tips and all other sharp or edged items (“sharps”) are counted. Needles in multiple-suture packs may be counted according to the number on the package; some hospitals require each package to be opened and each needle counted individually. Used needles, blades, and other sharps should be retained on a magnetic pad to prevent inadvertent loss and to facilitate counting. Dispose of the sharps on the magnetic pad (usually encased in a compact). This compact can be closed and discarded in a specially marked container designated for sharps disposal only following the final count. All parts of any needle (or other sharp item) broken during a procedure must be accounted for in its entirety. If a minor fragment of a broken needle cannot be retrieved without undue trauma to the patient and the surgeon concurs, the fragment is left in situ.The surgeon will describe this event in the operative report. Follow hospital policy regarding the filing of an incident report when a sharps item is broken (e.g., a needle or knife blade) or when all of its parts are not recovered. Closure counts for sharps follow the same protocol as that for sponges. Instrument Counts Instruments are counted before the surgery begins and subsequently following, using the protocol for sponges and sharps. All parts of disassembled or broken instruments must be accounted for in their entirety. Follow the policy noted above if an instrument (or part of an instrument) is lost. Sterilization Modalities All items (e.g., instruments, supplies, and equipment) that come in contact with the sterile field and the wound must be sterile. As soon as possible, following the completion of a surgical procedure, soiled instruments are cleaned in the washer-sterilizer.After terminal decontamination in the washer-sterilizer has been completed, the instruments are cleaned in an ultrasonic cleaner to remove any remaining soilage.When available, an enzymatic foaming agent may be sprayed on the instruments initially in the OR before they are taken to the decontamination area.
Slide 69: 42 Chapter 2 Protection of the Patient in Surgery/Patient Safety The most commonly used methods of sterilization employed in the OR (or central supply) include: 1. Saturated steam under pressure 2. Gas chemical sterilization 3. Liquid chemical sterilization 4. Low-temperature hydrogen peroxide gas plasma sterilization Saturated Steam Under Pressure Sterilization The flash sterilizer is utilized in the OR for urgently needed equipment, unwrapped instruments, and trays. Customarily, the temperature is set at 270 F (132 C) for a 3- or 10-minute cycle. The length of the cycle is determined according to the density of the item(s) to be sterilized. The manufacturer of any item used in the sterile field must provide directions for its sterilization; the recommended temperature and length of exposure time for the sterilization of that particular item must be given. The recording device on the sterilizer should be checked to confirm that the instrument(s) to be sterilized has (have) been exposed to the proper temperature for the desired length of time. Heatsensitive indicators should accompany the instrument(s). Trays with mesh bottoms are recommended for complete exposure to the steam. Wrapped instruments, trays, basins, and other items are usually sterilized in a prevacuum, high-temperature steam sterilizer. Proper packing and wrapping of instruments and trays is mandatory, as is the proper loading of the sterilizer; the Bowie-Dick test is used to verify that there were no air pockets in the sterilizer that would negate the sterilizing process. A heat-sensitive indicator is placed within each wrapped tray (or package), and each package is secured with heatsensitive tape. The packaging of instruments and trays must be unwrapped by holding the item away from the body using aseptic technique when opening. The corner of the wrapper farthest away from the body is unwrapped first, then either of the sides is unwrapped, and lastly the corner closest to the body is unwrapped. By utilizing this technique, one will not contaminate the item by reaching over the sterile field. Gas Chemical Sterilization Ethylene oxide gas is used to sterilize items that are vulnerable to heat and/or moisture. Any item that can withstand sterilization by steam under pressure should not be gas-sterilized. Ethylene oxide sterilization depends on concentration of gas, temperature, humidity, and exposure time.The ethylene oxide sterilizer must be operated exactly according to the manufacturer’s instructions to ensure that the requirements for sterilization are met.The type of item, arrangement of the load, and rate of penetration of the gas influence the amount of
Slide 70: Chapter 2 Protection of the Patient in Surgery/Patient Safety 43 exposure time required. A vacuum that is created within the sterilizer aids gas penetration. Usually cycles of 3 to 7 hours are employed. An ethylene oxide chemically sensitive indicator that is placed inside the wrapped package indicates that the item was exposed to ethylene oxide, but it does not necessarily indicate that sterilization has occurred. Therefore, for sterilization to have occurred, the process must conform completely to manufacturer’s specifications. Inhalation of ethylene oxide is to be avoided, as is direct contact with the sterilized items prior to aeration.The length of aeration time required depends on the composition of the items, the type of wrapper used, the concentration of the ethylene oxide used, the airflow rate, and the temperature during the aeration process.When items are aerated in a mechanical aerator, the air is automatically changed a minimum of four times an hour, depending on the size and composition of the load. The temperature is controlled at 122 F (50 C) to 140 F (60 C) for 8 to 12 hours. If a mechanical aerator is unavailable, items should be aerated in a well-ventilated room at a controlled temperature of 65 F (18 C) to 72 F (22 C) for 7 days. Liquid Chemical Sterilization When items cannot tolerate sterilization by saturated steam under pressure and when the time required for gas sterilization is impractical, liquid chemical sterilization is employed. A 2% activated aqueous glutaraldehyde solution (e.g., Cidex) is the agent often employed when liquid disinfection is desired. Instruments must be completely immersed in the solution for 10 hours to achieve sterilization. Highlevel disinfection is effected if the instrument is submerged for 10 minutes. All items must be thoroughly rinsed in sterile distilled water before use to prevent irritation of the skin and mucous membranes. The glutaraldehyde solution may be reused after testing it for potency, noting that the solution soon loses its potency after it is activated. Frequent testing with a test strip or a kit of reagents (obtained from the manufacturer) is recommended to be certain of its effectiveness. Polyethylene gloves or doubled latex gloves should be worn for skin protection. Directly breathing the fumes is to be avoided; OSHA recommends wearing a monitor for those individuals at risk. Following use, Cidex may be disposed of into most sewer systems. Steris 20™ is a single-use sterilant that employs peracetic acid as the active sterilizing agent. Peracetic acid, a highly biocidal oxidizer, maintains its efficiency even when high levels of organic soil are present. Steris 20 has a low surface tension, which makes it very effective at reaching all instrument surfaces. To sterilize items, they must be completely immersed in Steris 20 for 12 minutes at 50 C. The sterilant is prepackaged in single-use containers where dilution is automatically
Slide 71: 44 Chapter 2 Protection of the Patient in Surgery/Patient Safety prepared within the environmental processing chamber. The sterilized items are rinsed in microfiltered tap water in the processor. The used solution is disposed of in an ordinary drain during the processing cycle, eliminating exposure to chemicals to the operator. After use, the peracetic acid decomposes into acetic acid (vinegar) and oxygen. Low-Temperature Hydrogen Peroxide Gas Plasma Sterilization A hydrogen peroxide gas plasma sterilization system employs 1.8 ml of 58% hydrogen peroxide that is vaporized in a sterilization chamber after a vacuum is created; the vapor is converted into a plasma by means of radio-frequency energy. The resulting plasma consists of highly charged particles and free radicals that sterilize instruments at low temperature in one hour without producing toxic emissions or residues. Its by-products are simply water vapor and oxygen. The plasma particles destroy a wide variety of microorganisms, including bacteria, fungi, viruses, and spores. An indicator of bacterial spores is used to monitor the sterilization process. An FDA-approved commercially available self-contained system, STERRAD®, using cassettes or cartridges of hydrogen peroxide, can be used to sterilize metallic and nonmetallic instruments, fiber-optic cables, endoscopes, microsurgical equipment, glass, ceramic, and electrical equipment in a low-temperature (50 C, 122 F) and lowmoisture environment.As there are no toxic by-products, aeration and cooling post cycle are not necessary, in contrast to ethylene oxide, which is toxic, explosive, carcinogenic, and takes up to 12 hours for effect, and packs must be thoroughly aerated prior to use. However, the hydrogen peroxide gas plasma system is not appropriate for sterilization of cellulose products, as towels, paper, cotton, dressings, organic matter, and similar items that absorb the sterilant, making it incompletely effective. A standard electrical outlet is the only connection for the contained system.The initial cost of these units is high, but its safety features, effectiveness, shorter turn around, and lower operating cost will lead to increasing utilization of the modality. Reuse of “Single-Use” Instruments The reuse of instrument(s) or device(s) intended for “single use” (by the manufacturer) that have been opened but unused remains controversial. The issue regarding the reprocessing and resterilization of instrument(s) or device(s) that have been used is very highly controversial. The FDA has set up rules to regulate the reuse of “single-use” instruments in an effort to help to control rising hospital costs.The manufacturer of “single-use” or disposable instrumentation must follow the FDA’s guidelines precisely. Validation of the process used by the com-
Slide 72: Chapter 2 Protection of the Patient in Surgery/Patient Safety 45 pany should be enclosed in the packaging of the resterilized item. The FDA has a published list of instruments that may be resterilized if the instrument has been opened but not used.They also have a list of instruments that may be resterilized and reused in addition to a list of those instruments or devices that may not be resterilized and reused once they have been used. If there is doubt regarding the sterility of a “reprocessed instrument,” consult the website www.FDA.com and follow the prompts for instrument resterilization or reuse of “single-use” instruments. A hospital may resterilize an item (opened and unused or a used item), or it may be sent out to a third party to be resterilized if it is resterilized according to the guidelines established by the FDA.The FDA mandated in August of 2000 the requirements for resterilization of “single-use” items. AORN’s guidance statement requires the patient’s safety to be of utmost consideration in the acceptance of a reprocessing procedure. Even with the FDA’s ruling, the acceptance of the reprocessing and the resterilization of “single-use” items remains somewhat controversial. This topic is discussed further in the chapter on Endoscopy, p. 102. Safe Use of Pneumatic Tourniquet A pneumatic tourniquet is often employed for surgical procedures on the extremities, particularly during orthopedic procedures. For perioperative personnel unfamiliar with the use of tourniquets, return demonstration is recommended (before permission to apply tourniquets is granted). The tourniquet used in most operating rooms today is comprised of a cuff with pressure sensor, tubing, and an inflation device equipped with a pressure gauge (microprocessor) that is used to regulate pressure and time settings in addition to providing audible and visual feedback (a micro pressure and time settings regulator). The surgeon wraps Webril (or other soft material) around the extremity at the level of tourniquet placement, and the cuff applied. Following skin preparation and draping, the extremity is elevated and abducted, and a sterile rubber bandage (e.g., Esmarch, Ace, or self-adherent Coban) is applied from the tips of the fingers or toes to the level of the tourniquet, proximally, to achieve exsanguination after which the tourniquet is inflated by the circulator or anesthesia provider at the direction of the surgeon.The time of inflation and the pressure employed is recorded (including on the anesthesia record).The tourniquet is inflated for the least amount of time possible. Guidelines for Safe Use of the Pneumatic Tourniquet. An appropriately sized tourniquet should be used.The ends of the tourniquet must overlap by about 3 inches but not more than 6 inches. Do not apply the tourniquet at or near the elbow. For the average adult, tourniquet use should not exceed 1 hour on the upper extremity and 11/2 hours on the
Slide 73: 46 Chapter 2 Protection of the Patient in Surgery/Patient Safety lower extremity. Pressure setting is approximately 250 to 300 mm Hg (up to 6 pounds) on the upper extremity and 350 mm Hg on the lower extremity. Thin adults and children may require less pressure. When tourniquet use is anticipated to exceed these time limits, the tourniquet is deflated at intervals at the discretion of the surgeon to avoid tissue ischemia. The location, placement of, and use of the tourniquet, the pressure setting, and the times at which the tourniquet is inflated and deflated are recorded on the Perioperative Record and initialed by the circulator. In addition, the anesthesia provider records use of the tourniquet. Safe Use of Pulsed Lavage This suction-irrigator for single-patient use pulsed lavage (with cojoined suction and irrigation tubing) is used for controlled, high powered irrigation with or without suction; 1 or 2 irrigation bags may be used. The scrub person attaches tubing with spike adaptor to the pistol grip handle (contains batteries) and passes off the single- or dual-spike tubing to the circulator; one channel of the cojoined tubing (either straight or a “Y”) is connected to the irrigation bag(s), and the other channel of the cojoined tubing is connected to suction (if used). The scrub person inserts the tip of choice (e.g., soft splash shield tip) into the pistol grip handle and primes the unit by squeezing the trigger until irrigation solution exits the tip. The circulator may squeeze the irrigation bag(s) to facilitate priming. Safety Measure Guidelines for Pulsed Lavage Usage. Read manufacturer’s instructions prior to use. Do not use if packaging has been damaged. All persons scrubbed are advised to wear a face shield for protection from splashed irrigation fluid. The pulsed lavage is a “single use” unit and may not be resterilized or reused. Do not submerge handle of the unit. Do not use it close to an oxygen-enriched area. Do not use in presence of flammable anesthetics. Following use, the unit and/or its batteries is disposed of according to hospital regulations regarding the disposal of a biohazard. Safe Use of Powered Saws and Drills Powered saws and drills are employed in various surgical specialties to save intraoperative time, resulting in many tangible and intangible benefits to the patient.The hospital engineering department must be consulted before any new piece of powered equipment may be permitted or used in the OR. Reading the manufacturer’s recommendations for the safe operation of this powered equipment in the operating room is mandatory. Power equipment should be tested prior to use whenever
Slide 74: Chapter 2 Protection of the Patient in Surgery/Patient Safety 47 possible. All attachments must be appropriately secured; attachments previously used must be tested for their sharpness. Size discrepancy of the jigs and templates used with powered equipment must be determined prior to their use and if found, adjustment or use of properly fitting accessories must be employed (before the surgery is begun). Immediately following its use, the rotary section of the instrument must come to complete standstill before it is set aside.When not in use for a substantial interval, the power source (electrical, battery, or air compressor) should be deactivated and the instrument secured. Emergency and Disaster Considerations Operating rooms are required to be equipped with a special emergency signal (usually a flashing red light) to alert others to an emergency; the signal can be operated from within each separate OR. In the event that a patient suffers a cardiopulmonary arrest, the anesthesia provider and surgeon administer cardiopulmonary resuscitation (CPR). In the absence of the anesthesia provider, the surgeon, assisted by nursing personnel, must administer CPR. Health-care providers must be knowledgeable regarding CPR and be prepared to perform it. An emergency cardiopulmonary arrest cart/“crash” cart should be available in the surgery department at all times. Included on this well-stocked cart are in-date emergency drugs, needles and syringes, infusion equipment, a defibrillator with paddles, ventilation devices (e.g., bag-valve-mask/“Ambu”), and monitoring equipment. Nursing personnel responding to the emergency signal should bring the “crash” cart into the room. Documentation of all medications administered to the patient, according to the strength and dosage, and route of administration; the treatments and procedures performed, including the time and the name of the person giving each type of care. Perioperative personnel who care for pediatric patients are required to have pediatric advanced life systems (PALS) skills to assess and assist in the treatment of “at risk” pediatric patients. Hospitals are required to be equipped with an alternative power source, usually an independent generator that is triggered when a power failure occurs. During the time lapse, or should the independent generator not function, high-intensity flashlights (kept in the department) should be located by members of the surgery staff and brought into the individual OR. All team members are required to know the location of these high-intensity flashlights kept in the department for use during the time lapse following a loss of power until the alternate power source begins functioning and during any emergency where the lights are needed.
Slide 75: 48 Chapter 2 Protection of the Patient in Surgery/Patient Safety Malignant Hyperthermia Malignant hyperthermia (MH) is a rare, potentially lethal condition triggered by the use of inhalation anesthetics and depolarizing muscle relaxants (e.g., succinylcholine chloride). This condition requires proper treatment to be initiated immediately; documentation of treatment for MH must be recorded. As soon as MH is suspected, one should call for assistance. Immediate treatment is begun, usually by the anesthesia provider, who administers dantrolene (Dantrium), steroids, and iced intravenous (IV) solutions, the gavage of all open cavities with iced saline, and the cooling of the patient with ice packs. These treatments can significantly reduce mortality. In preparation to meet this emergency situation, OR personnel are required to be informed of the protocol set up by their anesthesia department. Setting up a Malignant Hyperthermia (MH) Protocol and Emergency Treatment Cart in the OR department is highly recommended by the American Association of Anesthesiologists (AAA). Again, documentation must be made of all medications given, IV and pressure lines established, and treatments performed. Additional discussion of this entity is presented in Chapter 4, General Anesthesia, p. 68. Legal Rights The patient’s legal rights and the rights of OR personnel are significantly protected by the documentation recorded in the patient’s Intraoperative Record. The JC requires the Intraoperative Record to include the name of the surgeon, the preoperative diagnosis, the procedure performed, the postoperative diagnosis, the type and number of specimens obtained, and the names of the surgical team members providing intraoperative care. The documentation of important intraoperative information, such as the skin preparation (noting the condition of the skin prior to and following the skin preparation), the results of the counts (e.g., sponges, sharps, and instruments), the placement of catheters, intravenous lines, and wound packing, and the use of equipment (e.g., ESU, the pneumatic tourniquet, etc.), in addition to other notations, is an invaluable tool for verification of actions, observances, and the delivery of specific treatments, and/or medications administered. An example of the suggested format for the Intraoperative Record is on p. 12. Documentation is of major importance, as it is the legal record of the surgical procedure. The circulator should remember that in a court of law, only information that was documented is accepted as a legal fact.
Slide 76: Chapter 2 Protection of the Patient in Surgery/Patient Safety 49 Legal Records In addition to the Intraoperative Record that is maintained by the circulator, the JC mandates that an Anesthesia Record must be maintained for every patient during a surgical procedure. The anesthesia provider documents his/her care in the Anesthesia Record, but in his/her absence, a perioperative RN (in addition to the circulator) assumes this role and is responsible for the Conscious Sedation and Analgesia Record. According to the policy of the hospital, when an anesthesia provider is not present during a surgical procedure, a perioperative RN (specially trained) may provide the patient care to include the monitoring of the patient’s vital signs, administering of treatments, medications, etc. (as directed by the surgeon). Documentation should provide the name of any person giving medications or treatments, including all pertinent times, dosages, and routes of administration, in addition to his/her observations of the patient throughout the surgical procedure. Everything that takes place must be documented. This nursing anesthesia record, complete with full documentation of the events as they occurred in the OR, will legally protect the RN providing conscious sedation and analgesia.The Analgesia and Conscious Sedation Record is on p. 76. Death in the OR Should the death of a patient occur in the OR, individual state law and hospital policy must be adhered to regarding the handling and disposition of the deceased patient. Most often, the scrub person and the circulator prepare the body for departure from the OR by removing all lines, tubings, and devices and by washing the body until it is free of all visible blood and body secretions and excretions. An Incident Report must be recorded by the circulator, and the death must be recorded in the Intraoperative Record, detailing the times, the interventions, and the outcome of events leading to the patient’s death.These documents are part of the patient’s permanent medicolegal record.
Slide 77: CHAPTER Safety Measures for Operating Room Personnel Perioperative personnel are directly involved in patient care. They must become aware of the many potential risks and hazards that exist in today’s surgical environment, not only for the benefit of the patients, but for their own safety as well.Their opportunity and the obligation to observe safe practices in the performance of their roles as health-care providers in an environment in which potentially lethal drugs, noxious gases, and lifethreatening diseases may be encountered is a continuous process. 3 Orientation The orientation programs for the new employees of a health-care facility are designed to familiarize them with the policies and procedures of the facility. Working in a health-care facility is very different from working in any other environment. Housekeeping, engineering, maintenance, security, and other health-care personnel are exposed to potential health hazards.These hazards should be identified by the facility, and procedures to prevent or minimize their transmission of disease and other risks must be learned by the employees. Hospitals are required to inform new employees about numerous other safety measures advised by the facility, e.g., the prevention of fires, the prevention of falls from spilled liquids, and the prevention of creating a biohazard when body fluids are present, in addition to many other important factors that serve to create a hazard for the healthcare worker and the environment inside and outside the facility. Fire drills are held at least twice each year in hospitals; other safety drills, including disaster training, are mandatory. Perioperative employment necessitates a special type of orientation and knowledge for those who work in the OR. Orientation to the OR prepares the employee to deliver safe care to the patient and familiarizes him/her with the techniques and procedures specific to the OR. During this period, AORN recommends that new employees have a mentor or that they work on the buddy system with more experienced personnel. Surgery Department In-Service Education Hospital perioperative departments are required to have in-service education programs for their employees. Most perioperative departments
Slide 78: Chapter 3 Safety Measures for Operating Room Personnel 51 schedule monthly in-service education meetings to provide their staff with information regarding the safest methods to use for delivering care to the surgical patient, information regarding new procedures and the latest techniques, equipment, and instrumentation for use in the department, as well as other matters of concern, including patient safety. Body Mechanics/Ergonomic Safety Personnel must employ good body mechanics, particularly when lifting or moving (unconscious) patients, heavy instrument trays, or equipment, to prevent strains and other injuries to their musculoskeletal systems. Lifting should be done by bending the knees, positioning one’s body under the load, and then straightening the legs, allowing the lower-extremity muscles to do the lifting. A roller (e.g., Davis) can be of significant value in preventing strains when moving unconscious or obese patients; see Procedure for Safely Transferring the Patient to the Operating Table, p. 19. Another moving device that can be of significant value is the Hoyer pad, which is placed on the operating table preoperatively. Following the surgical procedure, a crane-like machine directed by an employee is attached to the Hoyer pad and lifts the patient. In 2002, the Occupational Safety and Health Administration (OSHA) required hospitals and other health-care facilities to reduce the number of ergonomic injuries to health-care personnel. Suggestions enumerated by OSHA can be found on the Web at www.OSHA.gov. Lift teams may be hired by health-care facilities to assist personnel in lifting obese patients or heavy objects. They are very effective in helping to prevent injuries to employees. Fatigue Factors Fatigue is one of the most important factors influencing job performance. Although becoming fatigued can be minimized through working quickly and efficiently, the underlying reason for frequently feeling fatigued must be investigated. In our fast-paced world, one may feel pressured to perform more tasks than he/she can reasonably handle. Often employees with this problem are sleep-deprived because they attempt to perform too many tasks at home as well. Sleep deprivation prevents the body from being restored. It takes longer for someone who is sleep-deprived to complete a task correctly than the individual who has had 7 or 8 hours of sleep. AORN’s statement on safe practices in the OR recommends that an RN should not work in direct patient care for more than 12 con-
Slide 79: 52 Chapter 3 Safety Measures for Operating Room Personnel secutive hours. The association further recommends 8 hours of uninterrupted sleep per night and a workweek (including on-call time) of no longer than 60 hours.The time away from the OR allows the individual adequate time to recuperate. Fatigued staff members are more prone to errors than others who have had adequate rest. Errors in the health-care field, in particular, can result in harm to or death of a patient and/or employee. Sleep deprivation can greatly influence one’s efficiency, job performance (including patient care), and endurance. It would be unethical to work in the OR when one’s judgment is affected. Radiation Safety Operating room personnel may be exposed to radiation during intraoperative x-rays and when radioactive implant procedures are performed. To reduce the deleterious effects of radiation exposure, hospital policy must be strictly followed. Radiation exposure (received by an individual) depends on the amount of radiation, the proximity of the radiation source, the length of time of the exposure, and the frequency of exposure. Personnel should stand as far away from the radiation source as possible when x-ray equipment is in use.Additional protective measures should include, but are not limited to, the following: 1. All nonsterile team members should leave the room (whenever possible) or wear a lead apron. 2. Sterile team members should either stand behind a lead screen or wall or wear a lead apron donned before scrubbing, i.e., in cases using fluoroscopy. 3. Monitoring devices or badges (e.g., dosimeters) should be worn by personnel who may be exposed to radiation; readings should be computed weekly. 4. Pregnant personnel or those who may be pregnant should avoid all cases involving exposure to radiation, as radiation may harm the unborn fetus and possibly the mother’s reproductive capabilities. Personnel holding x-ray cassettes during radiography should wear lead gloves. In addition to wearing a lead apron, special eyewear and thyroid shields were once frequently worn when older equipment was employed; today this is infrequently done. Modern x-ray machines have a direct beam that limits the size of the area exposed.When the beam of the x-ray machine cannot be limited, the patient’s reproductive organs and thyroid gland must be shielded. Female patients must be asked if they are or could be pregnant to prevent x-ray exposure to the fetus.
Slide 80: Chapter 3 Safety Measures for Operating Room Personnel 53 Infection Control and Prevention The Centers for Disease Control and Prevention (CDC) mandates that one should consider body secretions and excretions of all individuals as contaminated. It is impossible to determine whether a patient or healthcare worker has a contagious disease due to the latency (conversion time period) of serological tests for various communicable diseases, such as human immunodeficiency virus (HIV), acquired immunodeficiency syndrome (AIDS), strains of hepatitis, and many other diseases; therefore, standard precautions must be observed at all times during patient care. AIDS, hepatitis (several strains), pyogenic infections, and numerous other blood-borne infections can be transmitted via puncture wounds. Hospital procedure must be followed regarding the disposal of “sharps” (needles and edged implements) to help to control the transmission of blood-borne diseases. In the OR (in the sterile field) a needle magnet is available encased in a flat plastic compact, the lid of which can be used for counting needles and sharps and for containing them. Following a surgical procedure, the compact is closed for its safe disposal (including its contents).A designated rigid plastic container is used for the disposal of sharps (knife blades and needles) and for plastic syringes; an attached device separates the hub and shaft of the needle while breaking the syringe tip prior to its disposal. Some syringes are made for use specifically without needles (in particular situations/setups). Biologically engineered sharps or needleless systems offer the safety protection recommended by OSHA. Some of these devices include: 1. 2. 3. 4. Syringes with a sliding sheath that shields needles after use. Needles that retract back into the syringe after use. A jet injection system without needles. An intravenous delivery system that uses a catheter port to house the needle in a protective covering. 5. A delivery system that uses plastic capillary tubes. Sharps must be handled responsibly in all situations.The scrub person must always pass the handle of the knife to the surgeon while holding the knife by the shaft. It is safest if suture is mounted just before use, again, passing the handle to the surgeon. A “no-passing” technique can be employed. It requires both the scrub person and the surgeon to agree on a neutral zone where the sharps will be placed. A magnetic pad may be used to prevent the sharps (and all instruments) in the neutral zone from falling.The scrub person places the sharps object on the pad in the same direction it would be passed.The sharps object is used and returned to the same place by the surgeon. In this way, the “nopassing” technique limits the potential for either person being stuck by
Slide 81: 54 Chapter 3 Safety Measures for Operating Room Personnel sharps. All personnel should wear gloves when performing patient-care tasks, i.e., when catheterizing a patient, when starting intravenous fluids, and when handling potentially contaminated articles, such as soiled sponges, instruments, intravenous lines, blood transfusion sets and blood pouches, and any other items soiled by body secretions or excretions that might provide the source of infection through a break in the skin. Some authorities advocate double gloving when virulent infections are present or suspect. Similarly, during endoscopy procedures or procedures in which drills or saws are employed, and when one is involved in any surgery where he or she may be spattered or sprayed by potentially contaminated tissue fragments, saliva, or irrigation fluids, it is necessary for scrubbed personnel to wear a protective facial shield. Latex Allergy Precautions In the surgical suite, health-care personnel and patients who are sensitive to latex are not only sensitive to the latex in latex gloves, but they may also be sensitive to the powder found in various types of latex gloves. The powder containing latex proteins is released into the air when latex gloves are handled. A “sensitivity” response has the appearance of varying degrees of irritant dermatitis, i.e., red, itchy, irritated, and/or broken skin. Most often, mild reactions merely require the individual to change into gloves that do not contain latex. Latex allergy and its serious systemic effects, the prevention of an allergic response to latex products, the medications and equipment needed for a latex allergy cart, and the precautions necessary for a latex safe environment are discussed on p. 32. Chemical Waste Hazards The National Institute of Occupational Safety and Health (NIOSH) has established guidelines regarding the unsafe levels of waste (anesthetic) gases in the operating room. The harmful effects of these gases are leaked to health-care personnel during surgery and may cause harmful effects as a decrease in mental performance, audiovisual ability, and manual dexterity. Exposure to anesthetic chemicals may result in an increased risk of abortion in female employees and developmental defects in an unborn fetus. Fire, explosion, and the toxicity of compressed gases are additional potential hazards of these chemical wastes. The control of waste gases in the OR is accomplished with an efficient scavenger system, a well-designed anesthetic system that includes securely fitting patient masks, tubings, and connectors, and an efficient room air-dilution ventilation conditioning system.A similar ventilation
Slide 82: Chapter 3 Safety Measures for Operating Room Personnel 55 air conditioning system should also be provided for the PACU, due to the unit’s close proximity to the surgical suite. Well-maintained scavenging systems, air-conditioning systems using high-efficiency particulate air filters that do not recirculate the air, and anesthetic gas leak detectors help to minimize the exposure of personnel and patients to hazardous waste gases in the operating room. Fires, explosions, and the toxicity of compressed gases are sources of potential chemical hazards. Cylinders containing compressed gases must be secured. Care must be taken to never drop a canister or allow one cylinder to forcefully strike another. The skin may be exposed to harmful chemical liquids that are used in the OR; they include methyl methacrylate (an acrylic “cement” molded to replace sections of bone or used to secure some types of prostheses) and paracetic acid (used as a cold sterilant). OSHA recommends that hospitals advise surgical personnel to mix the cement in a closed unit and to follow manufacturers’ recommendations for safe handling, storage, and disposal of chemical wastes. Noxious Smoke Hazards A plume of noxious smoke results from the burning of patient tissues (and vaporization of potentially infectious lesions such as papilloma virus lesions and various secretions) when the electrosurgical unit or the laser is used during surgical procedures to cut, or coagulate tissue. The plume pollutes the air in the immediate vicinity unless a plume evacuator is employed to suck up the smoke into a suction apparatus or the wall suction unit.The masks made of man-made materials worn by personnel function to filter the air are more efficient than cotton cloth masks that are easily made damp (from the wearer). The high-particulate air-filtering action of the air conditioning systems found in modern ORs can be very effective in removing smoke from the air.The concern regarding plume smoke is that it may be carcinogenic or contain infectious particles. Fire Hazards Obviously, the best way to deal with fires in the OR is to prevent them. All employees need to be responsible for learning about how fires occur in the OR and how, in the delivery of care to patients, steps can be taken to minimize the risk of fire. Employees in the department are responsible for attending fire drills and learning fire evacuation plans. In 2005, the Joint Commission (JC) (formerly the Joint Commission on Accreditation of Healthcare Organizations) issued a “Sentinel
Slide 83: 56 Chapter 3 Safety Measures for Operating Room Personnel Alert” on fires in surgical facilities to alert the health-care worker to the ever-present danger fires pose to patients and employees. Innumerable items found in the OR are flammable; they support combustion. A fire requires fuel (which includes anything flammable), oxygen, heat, and a source of ignition. The fuel might be the paper drapes, clothing, or paper from packaging, all of which have been treated to become “nonflammable” (i.e., less flammable) but not truly fireproof. Chemical agents, preparation fluids, and substances like methyl methacrylate glue are found in the OR; these substances all support combustion. Some anesthetic gases and liquids also support combustion.The OR is an “oxygen–rich” environment because oxygen escapes from the anesthesia delivery tubing system. Gases arrive via this route as well. Liquids, particularly solutions used to prepare the skin, are often highly flammable. Manufactured preparation solutions that are flammable are not recommended for use in the OR. However, there are times when a surgeon will request that a combustible solution be used, even though he/she is aware of its dangerous properties, because the particular solution does the best preparation (in a particular situation). Never allow flammable solutions to pool under a patient.To prevent skin excoriation and a flammable reaction, dry all prep solution puddles. One should know the location of all fire-fighting equipment in the OR. Knowledge of the methods for rescue and evacuation of patients should be practiced so that the execution of those skills will be automatic should they ever be needed.
Slide 84: PART 2 Anesthesia General Information CHAPTER Anesthesia Modalities General Information Anesthesia is defined as the absence of sensation. A physician (anesthesiologist), or certified registered nurse anesthetist (CRNA), administers anesthesia in the operating room (OR). Surgeons also may administer local or regional anesthesia to their own patients. In this guide, the term anesthesia provider refers to the anesthesiologist or CRNA. Using an anesthesia preoperative evaluation form, the anesthesia provider interviews the surgical patient prior to his/her arrival in the OR. He/she identifies the patient and discusses the patient’s medical, surgical, and anesthesia history as well as a drug/medication history. He/she reviews the patient’s lab work and diagnostic studies and the history and physical examination report made by the surgeon, and then the anesthesia provider performs a pertinent physical examination of the patient. If the patient has had previous surgery, the anesthesia provider asks the patient if he/she had an unusual response to anesthesia or if there has been any familial history of unusual responses to anesthesia. The anesthesia provider explains a “plan of anesthesia,” including risks, benefits, and alternatives to the particular type of anesthesia modality (if any alternative methods are permissible), to the patient.The patient is given the opportunity to ask relevant questions about alternative methods of anesthesia. The anesthesia provider follows through with the agreed plan for anesthesia. The anesthesia provider then verifies the site and side of the procedure with the patient and with the chart, as well as the position on the table that the patient will assume for the administration of the anesthetic. After the patient is brought to the surgical suite, the circulator, identifies and admits the surgical patient to the OR by using at least two identifiers, e.g., the patient’s chart and hospital armband.The circulator must implement the Universal Protocol for Preventing Wrong Site, Wrong Side, Wrong Procedure, and Wrong Person Surgery mandated by the Joint Commission (JC) (formerly the Joint Commission on 4
Slide 85: 58 Chapter 4 Anesthesia Modalities Accreditation of Healthcare Organizations). In addition, he/she reviews the patient’s chart thoroughly, noting that there is a current written history and physical examination, a complete blood count (CBC), urinalysis (UA), and possibly an electrocardiogram (EKG) report and other reports depending on the patient’s age, physical condition, and diagnosis. He/she verifies the chart information with the patient (or the patient’s legal representative) and ascertains whether the patient has any sensitivities or allergies to foods, medications, latex, or other allergens.The importance of documenting and relaying information (to the surgeon and anesthesia provider) regarding patient allergies and current medications is vital; for latex allergy safety, see Chapter 2, p. 32. When an anesthesia provider is not present during a patient’s surgery, a perioperative RN, in addition to the circulator, will start intravenous fluids (IV) and monitor the patient’s vital signs, blood pressure (B/P), and EKG (ECG); and apply a pulse oximeter to the patient’s finger to monitor the patient’s pulse and oxygen saturation. He/she monitors all aspects of the patient’s physical condition and also oversees the care of the anesthesia equipment used for the patient during the surgical procedure (such as a mask and anesthesia circuit delivery system for oxygen).The perioperative RN, who stands in for the anesthesia provider, must document an initial assessment and medications given (with the route, dose, time, and response); monitor and chart the vital signs, including temperature, pulse, and respirations (TPR), oxygen saturation, and method of oxygen administered (e.g., nasal catheter, mask, etc and flow rate in liters per minute); and record nursing observations and interventions, and whether the desired or expected outcomes were met. Remember, documentation of nursing interventions is the proof necessary for medicolegal consideration in a court of law.The importance of documenting all that transpires during a surgical procedure cannot be exaggerated. The techniques of anesthesia administration utilized in the OR include: 1. General anesthesia.The patient is made unconscious. 2. Conduction anesthesia. Anatomical sites are anesthetized by infiltration or topical application of various anesthetic agents. A peripheral nerve block may be produced by injecting an agent about nerve(s) supplying sensation to the operative site, or a block may be placed at a central level. Local anesthesia and topical anesthesia are established by employing anesthetic agents immediately about the area to be treated. Conduction anesthesia may be supplemented by varying degrees of general anesthesia or sedation.
Slide 86: Chapter 4 Anesthesia Modalities 59 The American Society of Anesthesiologists (ASA) recommends the following standards for basic intraoperative monitoring: 1. An anesthesia provider must be present throughout the administration of all general and most conduction anesthetics. 2. During the administration of the anesthetic, vital signs and EKG are to be continually monitored and evaluated. 3. Oxygen saturation is determined by use of an oxygen analyzer, pulse oximeter, and observing skin and nailbed color. 4. The patient’s temperature can be evaluated with a forehead tape strip or transesophageal or urinary bladder temperature probe. Breathing efficiency may be evaluated by observing chest excursions and by using respirometry. During general anesthesia the monitoring of the carbon dioxide content of expired gas is accomplished by use of tidal carbon dioxide monitors (ETCO2). A “disconnect” alarm; indicators for various volatile agents; and monitors and gauges for measuring invasive arterial pressure, pulmonary artery (PA) pressure, and central venous pressure (CVP) are immediately available. Bispectral Index System (BIS) can be employed to monitor the effect of general anesthesia via electroencephalogram (EEG) patterns to better titrate the amount and level of anesthesia with respect to awareness, but it is not universally utilized for this purpose. BIS also can be used during neurosurgery to detect early signs of brain ischemia. The choice of an anesthetic technique is influenced by the feasibility of the particular modality of anesthesia, position to be assumed, extent of the surgical procedure, medical status, prior history of exposure to anesthetics, surgeon’s preference, patient’s preference (when not contraindicated), and anticipated need for particular postoperative analgesia (e.g., with an indwelling epidural catheter). The anesthesia provider will classify the patient’s physical status according to the guidelines of the ASA into six categories (P1–6, 1–6, I–VI), where P1 is a healthy patient and P6 describes a brain-dead patient maintained on life support to permit harvesting of donor organs according to accepted ethical protocols. Prior to the administration of anesthesia, premedication, as a single drug or a combination of various drugs, is often given.The purpose of the premedication is to allay anxiety, to help the patient relax, and to diminish secretions. Premedication is administered by intramuscular injection about 30 to 60 minutes before surgery, prior to the patient’s arrival in the OR suite, or by the anesthesia provider, intravenously, immediately prior to induction of anesthesia, or not at all. Similarly, when surgery must be performed in an emergent situation, premedication may be given intravenously or may be omitted. These
Slide 87: 60 Chapter 4 Anesthesia Modalities drugs are selected according to the patient’s general condition and the extent and nature of the surgery to be performed. Outpatients or surgicenter patients are given less premedication or none at all. Specialized equipment is required to deliver anesthesia. For general inhalation anesthesia, an anesthesia machine delivers an anesthetic gas mixture to the patient at a specific rate and concentration as determined by the anesthesia provider.The most simplistic machine consists of a cart with attached key-coded tanks of nitrous oxide (or other agents) and oxygen with flow meters and pressure gauges. Usually, expired “air” from the patient passes through a carbon dioxide absorbing tank or cartridge. Currently, a sophisticated machine that is able to store and deliver several compressed gaseous and highly volatile liquid anesthetic agents is employed in the OR. In addition, the compact anesthesia cart contains a variety of monitoring devices, an oxygen depletion alarm, and special equipment that includes masks, laryngoscopes with interchangeable blades, McGill forceps, endotracheal tubes, and obturators, as well as a source of suction and anesthesia circuits.An additional cart of drawers is required for drugs and supplies. Equipment and prepackaged kits for various procedures (e.g., insertion of arterial and central venous pressure catheters) must be stored nearby. A variety of intravenous fluids, administration sets, and stands for these items should be located nearby in the surgical suite. One role of the circulator with respect to the administration of anesthesia is to provide an “extra hand” for the anesthesia provider, particularly during the induction of anesthesia. In some institutions, an anesthesia technician may perform this role. The circulator is responsible for maintaining the patient’s immediate safety, helping to allay the patient’s anxiety, and being attentive to the special needs of the patient. Some patients’ fear can elicit psychological distress; the circulator may extend a caring gesture, such as holding the patient’s hand during induction. Even after the patient is anesthetized, the circulator assumes the role of the patient’s advocate, as a diligent observer and administrator of the total care of the patient in surgery. As a perioperative practitioner, he/she identifies the needs of the patient in a preoperative care plan that is written for the individual patient and that is implemented preoperatively, intraoperatively, and postoperatively. The information gathered is used to implement a plan of care that is “tailor made” to address the needs of the individual patient while taking into consideration the potential problems that might be incurred, their possible solutions, and desired patient outcomes. Special consideration is made for the patient who cannot move by himself/herself, for the patient with a “bad” back or “stiff ” joints, for one who is hearing impaired, or for one with any other physical or mental impairment.
Slide 88: Chapter 4 Anesthesia Modalities 61 Following surgery, the circulator accompanies the anesthesia provider to transport the patient to the postanesthesia care unit (PACU). The anesthesia provider reports the patient’s immediate needs and condition and gives orders to the PACU practitioner. The circulator gives additional information according to his/her observations of the patient during the course of the surgery performed. This documented report is vital for providing for the patient’s safety and continuity of care. General Anesthesia, Overview For the administration of general anesthesia, the patient is initially in the supine position.An intravenous line is inserted, if not already present, an automatic B/P cuff is applied, and the oxygen sensor (pulse oximeter) and EKG monitoring electrodes are placed. Oxygen may be administered by mask for a few minutes. A minimal test dose of intravenous agent or muscle relaxant may be given to observe any untoward reaction. Induction is usually begun by injecting a rapidly acting intravenous agent, e.g., thiopental (Pentothal), propofol (Diprovan), or methohexital (Brevital). (For children, a nonmalodorous inhalation agent, such as sevoflurane [Ultane], can be given by mask, and as consciousness is lost, intravenous lines are placed and other anesthetic measures are introduced.) As the patient loses consciousness, oxygen and gaseous agents are gradually introduced by mask. For cases of lesser duration or when profound muscle relaxation is not required, maintenance can be achieved with an intravenous agent alone or with an inhalation agent administered by facemask and oral airway or by utilizing a laryngeal mask airway. If an endotracheal tube is to be inserted (transnasally, transorally, or via tracheostomy), a fast-acting muscle relaxant, e.g., succinylcholine chloride (Anectine), may be used in adults, or an intermediately fast-acting curare-like drug, e.g., rocuronium (Zemuron), atracurium (Tracrium), or vecuronium (Norcuron), is used in children. In adults and some children, following the administration of the muscle relaxant, the endotracheal tube is inserted under direct vision with the aid of a laryngoscope (and McGill forceps, as needed). Several milliliters of a 4% lidocaine solution may be instilled into the larynx prior to placing the endotracheal tube that has been lubricated with anesthetic ointment. The tube cuff is inflated, except in infants and small children, and the tube is secured with tape (hypoallergenic tape for children and adults who are sensitive to adhesives). For the duration of the procedure, muscle relaxation is maintained with any of the several curare-like drugs.
Slide 89: 62 Chapter 4 Anesthesia Modalities Additional monitoring devices may be applied, and the patient’s position changed as necessary, with the permission of the anesthesia provider. (In situations such as clinical emergency or when gastric emptying is not assured [trauma, intestinal obstruction, obstetrical labor, etc.], a “crash” insertion of an endotracheal tube may be required, even in the conscious patient, by employing rapid-acting muscle relaxants and by pressure exerted transiently on the cricoid cartilage to avoid pulmonary aspiration of potentially regurgitated gastric contents.) A working suctioning device that must be checked before starting anesthesia should be immediately available; suction apparatus should be checked on the anesthesia equipment, and the circulator is responsible for checking the room suction. Changes in the position of the patient as directed by the anesthesia provider may also be made to permit the anesthetic to “settle” in the desired area following a central block. The circulator assists the anesthesia provider in any way necessary, such as by helping the patient to maintain a position, displaying easy access to the equipment, giving additional premeasured drugs as directed by the anesthesia provider, and manipulating the cricoid cartilage, at the instruction of the anesthesia provider. A wide variety of drugs and inhalation agents is described in Table 4-1, p. 63. To supplement the anesthetic agents, numerous additional drugs may be administered intravenously to “balance” the anesthesia. These drugs include various narcotics (e.g., morphine, meperidine, fentanyl, remifentanil, alfentanil, and sufentanil), amnestics (e.g., midazolam), and neuroleptics (e.g., haloperidol). Muscle relaxants, as referred to above, are regarded as depolarizing agents (e.g., succinylcholine) or nondepolarizing agents (e.g., the curare-like drugs). Succinylcholine (Anectine) and mivacurium (Mivacron) are short-acting with rapid onset and recovery; intermediate-acting muscle relaxants include vecuronium (Norcuron), atracurium (Tracrium), cisatracurium (Nimbex), and rocuronium (Zemuron).The longer-acting muscle relaxants include pancuronium (Pavulon) and lesser used d-tubocuarine, doxacurium, pipecuronium, metocurine, and gallamine. Shorter-acting agents often need not be reversed; however, neostigmine (Prostigmin) or edrophonium (Enlon and Enlon Plus containing atropine) can be used to effect reversal of the longer-acting agents as necessitated by the patient’s response, dosage, postoperative respiratory status, etc. If cholinesterase deficiency is encountered, prolonged respiratory support (hours to days) will be needed. The anesthesia provider must be familiar with all of these agents (and others), although frequently utilizing only a select few in daily practice. Antiemetics in common use include chlorpromazine (Compazine), promethazine (Phenergan), metochlopramide (Reglan), hydroxyzine
Slide 90: Chapter 4 Anesthesia Modalities 63 TABLE 4-1 General Anesthetics Agent Thiopental (Pentothal) Route of Administration Form intravenous stable liquid Comments rapid induction; short duration; respiratory depressant; can cause laryngospasm and hypotension (opiate or additional agent required for adequate pain control) induction: 3–4 mg/kg maintenance: 50–100 mg/q 10–12 min ultra-short-acting; rapid induction; rapid recovery; may cause hiccoughs; can be administered rectally (pediatrics) induction: 1–1.5 mg/kg maintenance: 20–40 mg/q 4–7 min pediatric rectal induction via 14Fr catheter 7 cm into rectum as 10% solution 20–25 mg/kg rapid induction; short duration; can be used for continuous infusion with clear-headed rapid recovery; used for endoscopy; may cause respiratory depression, transient hypotension; some pain on injection; some anti-emetic effect; common usage induction: 1–2.5 mg/kg maintenance: 50–150 mcg/ kg/min (with nitrous oxide or opiate) sedation: 25–75 mcg/kg/min short-acting anesthetic, long-acting analgesic; used for pediatric and burn wound procedures; trauma cases; may cause emergence hallucinations if given in larger dosages (especially in adults) continued on following page Methohexital (Brevital) intravenous stable liquid Propofol (Diprovan) intravenous stable liquid Ketamine (Ketaject, Ketalar) intravenous; intramuscular stable liquid
Slide 91: 64 Chapter 4 Anesthesia Modalities TABLE 4-1 General Anesthetics (continued) Agent Route of Administration Form Comments induction: 0.5–2.0 mg/kg; 4–6 mg/kg IM maintenance: 0.5–1.0 mg/ min (with nitrous oxide) sedation: 0.2–0.8 mg/kg q 3 min; 2–4 mg/kg IM (pediatric usage) Etomidate intravenous (Amidate, Hypnomidate) stable liquid induction used for unstable cardiac patients; some nausea; local pain on injection; debatable cause of steroid depression; may be used for sedation in critically ill patients and with fentanyl for percutaneous angioplasty induction: 0.2–0.6 mg/kg maintenance: 0.010 mg/ kg/min sedation: 0.005–0.010 mg/ kg/min commonly used; employed with other agents to potentiate their action to produce deeper anesthesia slow, smooth induction; maintenance; for pediatric and burn patients as well as adults; bradycardia; may cause ventricular arrhythmia if epinephrine given; hepatotoxic in some recipients (check prior history); nonmalodorous rapid induction; maintenance; rapid recovery; may cause hypotension; associated with seizures in children; less often used maintenance; good relaxation; rapid recovery; malodorous; increased postoperative nausea Nitrous oxide inhalation compressed gas Halothane (Fluothane) inhalation volatile liquid Enflurane (Ethrane) inhalation volatile liquid Desflurane (Suprane) inhalation volatile liquid
Slide 92: Chapter 4 Anesthesia Modalities 65 TABLE 4-1 General Anesthetics (continued) Agent Isoflurane (Forane) Route of Administration Form inhalation volatile liquid Comments maintenance; good relaxation; cardiovascular stability; useful for cardiac patients rapid induction (useful for mask induction in children); rapid recovery; good relaxation; may cause emergence delirium in children Sevoflurane inhalation (Ultane) volatile liquid (Vistaril), ondansetron (Zofran), dolasetron (Anzemet), and granisetron (Kytril). These agents can be used for premedication as well as for antiemetics. (Droperidol, employed commonly until recently, has limited use due to an incidence of ventricular arrhythmias.) Malignant Hyperthermia Malignant hyperthermia (MH) is a rare hypermetabolic, highly lethal state triggered by exposure to halogenated inhalation anesthetics (e.g., halothane, enflourane, desflurane, and isoflurane) and depolarizing muscle relaxants (e.g., succinylcholine). There is a predisposition to this syndrome; various myopathies (e.g., muscular dystrophy) present a high risk. MH usually develops during the administration of an anesthetic, not necessarily on the first exposure, and it can also present in the postoperative period.The major pathophysiological event is the release of an abnormally large amount of an intracellular calcium ion that leads to inordinate muscle contraction (often manifested initially in the masseter muscle). There is tachycardia with dysrhythmias, increased end-tidal carbon dioxide levels, and muscle cell breakdown (rhabdomyolysis) with production of myoglobinemia. Myoglobinuria can lead to renal failure, and there is respiratory and metabolic acidosis. Hyperkalemia results, with an increased creatine phosphokinase (CPK) and a progressive rise in core body temperature (even to over 110 F [43 C]). Untreated or suboptimally treated MH results in cardiac and renal failure. Intravascular coagulopathy, muscle necrosis due to hypoxia, and neurologic sequelae also related to hypoxia result in coma and death (occurring in 80% to 90% of the cases). Suspicion of and prompt recognition of MH when any of the clinical findings occur must be treated well before actual temperature ele-
Slide 93: 66 Chapter 4 Anesthesia Modalities vation presents. Immediate institution of treatment can significantly reduce mortality. A protocol for treatment has been proposed and promulgated by the Malignant Hyperthermia Association of the United States (MHAUS). MHAUS is a nonprofit entity with a 24-hour hotline; it also provides educational material. The MHAUS chart (Figure 4-1, p. 68–69) is clear for establishing guidelines for treatment of MH. As soon as this syndrome is suspect, the anesthetic and/or depolarizing relaxant should be discontinued and positive pressure oxygenation begun. If the surgical procedure has been started and cannot be aborted, safe “nontriggering” agents can be used, such as nitrous oxide, opiates, and various intravenous anesthetics (e.g., thiopental, propofol, and ketamine), and most local anesthetics can be used to complete the surgery expeditiously. Treatment is begun as soon as this entity is suspected.The surgeon is notified. Succinylcholine and volatile agents are discontinued. The circulator should obtain Dantrolene and immediately call for assistance. Hyperventilate patient with 100% oxygen at 10 l/min. Dantrolene sodium (Dantrium) 2 to 3 mg/kg reconstituted with 60 ml of sterile (nonpreservative) water (containing 3 g of mannitol) is given as an IV bolus and repeated every 5–10 minutes to a limit of 10 mg/kg (up to 30 mg/kg) or until the manifestations subside, and it is then administered 1mg/kg every 4 to 6 hours for 24 to 72 hours. This agent is effective (within minutes) due to its prevention of the calcium ions from being released into the muscle cells, thus interfering with the excessive contractions. Simultaneously, multiple laboratory parameters related to the entities noted above must be checked serially, as well as blood gases. Dysrhythmias are treated (e.g., by procainamide or other antiarrhythmia drugs, noting that calcium channel blocking agents are not to be used). Sodium bicarbonate is given; hyperkalemia is treated with insulin and calcium. Additional mannitol and furosemide are administered to prevent an accumulation of myoglobin in the renal tubules and to maintain adequate urine flow. A CVP line should be established. Cooling measures are begun with an intravenous infusion of iced saline 15 ml/kg every 15 minutes 3. Gastric and/or transrectal iced lavage must be initiated; external ice packs and/or a hypothermia blanket are indicated (while monitoring the core body temperature so as not to produce hypothermia). Any electrolyte, blood gas, coagulation factor, or other abnormality is corrected. On occasion, partial cardiopulmonary bypass may be required as a life-saving measure (to assist with cooling and providing
Slide 94: Chapter 4 Anesthesia Modalities 67 adequate oxygenation). Patients are kept in the intensive care unit (ICU) and are closely monitored using the numerous parameters noted above that are necessary for survival. Anesthesia providers must be familiar with all of the aspects of MH and must establish a protocol to be followed in the surgical department.The OR staff should be instructed regarding the protocol that requires a coordinated effort to assure the patient’s survival. An MH treatment cart stocked with the various agents listed above, including additional IV fluids and fluid administration equipment, defibrillators, and other items, must be available in the department. Whereas MH can occur de novo, all candidates for anesthesia should be questioned regarding any family history of this problem. Elevation of CPK should trigger further investigation. When there is any increased likelihood of MH, prophylaxis with dantrolene may be begun preoperatively and avoidance of the “triggering” types of anesthetic agents should be observed. It is to be noted that each patient who suffers this problem will present with an individual spectrum of what has been described. The discussion above by no means addresses the entire subject of MH. Please refer to the Emergency Therapy for Malignant Hyperthermia chart on pages 68–69. Conduction Anesthesia, Overview Nerve Blocks The term central block refers to spinal, epidural, or caudal anesthesia.Appropriate supplies for their administration are available in most hospitals in disposable prepackaged trays. Additional drugs may be requested. If a longer procedure is contemplated or postoperative central analgesia is to be utilized, the anesthesia provider places a catheter to deliver increments of an anesthetic agent, as in continuous epidural or continuous caudal anesthesia. Postoperatively, morphine (Duramorph) specially prepared for this purpose may be similarly injected for pain relief. For these blocks, the anesthesia provider positions the patient with an established intravenous line; the circulator helps the patient maintain this position while the block is administered. When an anesthetic catheter is placed, it must be secured with tape.The patient may then be placed in a temporary position to allow the block to take effect or moved to the position of surgery at the direction of the anesthesia provider. When the patient is positioned prone (and slightly flexed), a hypobaric spinal anesthetic can be accomplished; sterile water is added to the anesthetic mixture, causing the anesthetic to rise to the site of the injection (as employed sterile water is for anorectal surgery).
Slide 95: 68 Emergency Therapy for Malignant Hyperthermia DIAGNOSIS Signs of MH: • Increased ETCO2 • Trunk or total body rigidity • Masseter spasm or trismus • Tachycardia/tachypnea • Acidosis • Increased temperature (may be late sign) Sudden/Unexpected Cardiac Arrest in Young Patients • Presume hyperkalemia and initiate treatment (see #6) • Measure CK, myoglobin, ABGs, until normalized • Consider dantrolene • Usually secondary to occult myopathy (e.g., muscular dystrophy) • Resuscitation may be difficult and prolonged MH Hotline 1-800-MH-HYPER (1-800-644-9737) Outside the US: 1-315-464-7079 Chapter 4 Anesthesia Modalities Trismus or Masseter Spasm with Succinylcholine • Early sign of MH in many patients • If limb muscle rigidity, begin treatment with dantrolene • For emergent procedures, continue with nontriggering agents; consider dantrolene • Follow CK and urine myoglobin for 36 hours at least. Check CK immediately and at 6-hour intervals until returning to normal. Observe for cola-colored urine. If present, test for myoglobin. • Observe in PACU or ICU for at least 12 hours ACUTE PHASE TREATMENT GET HELP. GET DANTROLENE — 1. Notify Surgeon • Discontinue volatile agents and succinylcholine. • Hyperventilate with 100% oxygen at flows of 10 L/min or more. • Halt the procedure as soon as possible; if emergent, use nontriggers. (The circle system and CO2 absorbent need not be changed.) 5. Dysrhythmias usually respond to treatment of acidosis and hyperkalemia. • Use standard drug therapy except calcium channel blockers, which may cause hyperkalemia or cardiac arrest in the presence of dantrolene.
Slide 96: 2. Dantrolene 2.5 mg/kg rapidly IV through large-bore IV, if possible To convert kg to lbs for amt of dantrolene, give patients 1 mg/lb (2.5 mg/kg approximates 1 mg/lb). • Repeat until there is control of the signs of MH. • Sometimes more than 10 mg/kg (up to 30 mg/kg) is necessary. • Dissolve the 20 mg in each vial with at least 60 ml sterile preservativefree water for injection. Prewarming (not to exceed 38ºC) the sterile water will speed solublization of dantrolene. • The crystals also contain NaOH for a pH of 9; each 20 mg bottle has 3 gm mannitol for isotonicity. 3. Bicarbonate for metabolic acidosis. • 1-2 mEq/kg if blood gas values are not yet available. 4. Cool the patient with core temperature > 39ºC. Lavage open body cavities, stomach, bladder, or rectum. Apply ice to surface. Infuse cold saline intravenously. Stop cooling if temp < 38ºC and falling to prevent drift < 36ºC. 6. Hyperkalemia - Treat with hyperventilation, bicarbonate, glucose/insulin, calcium. • Bicarbonate 1-2 mEq/kg IV. • For pediatric, 0.1 units insulin/kg and 1 ml/kg 50% glucose or for adult, 10 units regular insulin IV and 50 ml 50% glucose. • Calcium chloride 10 mg/kg or calcium gluconate 10-50 mg/kg for life-threatening hyperkalemia. • Check glucose levels hourly. 7. Follow ETCO2, electrolytes, blood gases, CK, core temperature, urine output and color, coagulation studies. If CK and/or K+ rise more than transiently or urine output falls to less than 0.5 ml/kg/hr, induce diuresis to >1 ml/kg/hr urine to avoid myoglobinuria-induced renal failure. • Venous blood gas (e.g., femoral vein) values may document hypermetabolism better than arterial values. • Central venous or PA monitoring as needed and record minute ventilation. • Place Foley catheter and monitor urine output. Chapter 4 POST ACUTE PHASE A. Observe the patient in an ICU for at least 24 hours, due to the risk of recrudescence. B. Dantrolene 1 mg/kg q4-6 hours or .25 mg/kg/hr by infusion for at least 24 hours. Further doses may be indicated. C. Follow vitals and labs as above (see #7) • Frequent ABG • CK every 6 hours D. Follow urine myoglobin and institute therapy to prevent myoglobin precipitation in renal tubules and the subsequent development of Acute Renal Failure. Follow standard intensive care therapy for acute rhabdomyolysis and myoglobinuria (urine output > 200 ml/h, alkalinization of urine with Na-bicarbonate infusion with careful attention to both urine and serum pH values, etc.). E. Counsel the patient and family regarding MH and further precautions; refer them to MHAUS. Fill out and send in the Adverse Metabolic Reaction to Anesthesia (AMRA) form (www.mhreg.org) and send a letter to the patient and her/his physician. Refer patient to the nearest Biopsy Center for follow up. Non-Emergency Information MHAUS 11 East State Street, PO Box 1069 Sherburne, NY 13460-1069 Phone 1-800-986-4287 (607-674-7901) Fax 607-674-7910 E-mail info@mhaus.org Website www.mhaus.org Anesthesia Modalities CAUTION: This protocol may not apply to all patients; alter for specific needs. FIGURE 4-1. Wall chart distributed by the Malignant Hyperthermia Association of the United States (MHAUS), which describes the protocol for managing hyperthermia crisis. (Reprinted with permission from the Malignant Hyperthermia Association of the United States, Sherburne, NY.) 69
Slide 97: 70 Chapter 4 Anesthesia Modalities In an isobaric spinal block, spinal fluid is mixed with the agent(s), with minimal migration of the anesthetic within the intrathecal space. Similarly, for hyperbaric spinal, 10% dextrose is added so that by positioning the patient, the anesthetic will (being heavier than spinal fluid) gravitate accordingly (i.e., in sitting position, a “saddle” block for pelvic procedures or on the dependant side, such as for a unilateral inguinal herniorrhaphy). A vasoconstrictor (e.g., ephedrine) can be added to the anesthetic mix to provide a longer effect. A central block can be supplemented by a variety of narcotics, amnestics, and intravenous anesthetic agents; oxygen and inhalation anesthetics may be administered by mask as well. To control postoperative pain, a catheter may be left (or newly placed) in the epidural space (or at caudal, thoracic, and, less often, cervical levels) for continuous or intermittent bolus infusion of narcotic and/or low-dosage local anesthetic. Similarly, a single dose of a narcotic (e.g., morphine) may be given and the catheter removed. When these modalities are employed, most hospitals require the concurrent use of an apnea monitor in addition to a postoperative protocol regarding the use of additional analgesics, antiemetics, and certain other medications prescribed by an attending anesthesia provider until 8 to 24 hours after the catheter is removed. There are numerous types of regional blocks and agents used to affect anesthesia (Table 4-2 p. 72). Often, the surgeon will administer these anesthetics. Examples include brachial plexus blocks, retrograde intravenous blocks (e.g., Bier for surgery upon the extremities, most often for upper extremity or ankle level in the lower extremity), pudendal blocks (for gynecologic surgery), perianal blocks (for anorectal surgery), inter-costal nerve blocks (for segmental thoracic pain), and “field” blocks (for inguinal hernia repair). These blocks may be supplemented with various systemic agents, as described under central nerve blocks earlier. Etidocaine (Duranest), benzocaine (Americaine), chloroprocaine (Nesacaine), and procaine (Novocaine) currently have minimal usage in the OR. Alternative dosages of these agents are employed for pediatric surgeries. Numerous ancillary drugs, including tranquilizers, narcotics, and amnestic agents, likewise, have not been specifically listed, as use of these agents varies widely between anesthesia providers, surgeons, and institutions. Local Anesthesia Local anesthesia is frequently used for lesser procedures, e.g., plastic, ophthalmic, and anorectal procedures. The surgeon administers the anesthetic by the infiltration of the agent or the diluted agent (and by utilizing a “tumescent” degree of dilution, such as for liposuction).
Slide 98: Chapter 4 Anesthesia Modalities 71 With few exceptions, an intravenous line is inserted. When “anesthesia standby” is requested, the anesthesia provider will monitor the patient and administer supplemental sedation or even general anesthesia, should it be required. When an anesthesia provider is not present, a perioperative RN, in addition to the circulator, will insert an intravenous line (in accordance with hospital policy); place EKG electrodes and pulse oximeter; and monitor the patient’s vital signs, B/P, and other parameters, as applicable. At the direction of the surgeon, the perioperative RN may administer various drugs parenterally, including narcotics (e.g., morphine, meperidine, fentanyl [Sublimaze], or sufentanil [Sufenta]), sedatives (e.g., diazepam [Valium] or hydroxyzine [Vistaril]), and agents that have an amnestic effect (e.g., midazolam [Versed]). Upon completion of the procedure, drugs to reverse the effects of the aforementioned agents may be required, such as naloxone (Narcan) or flumazenil (Mazicon). The perioperative RN completes the Conscious Sedation and Analgesia Record (p. 76), which includes the documentation of the time at the beginning and at the termination of the procedure, the patient’s vital signs and B/P at appropriate intervals, and the times and dosage of anesthetic agents or any other drugs administered. Topical Anesthesia Topical anesthesia is the direct application of an anesthetic agent such as a liquid solution, eye drops, jelly, ointment, and/or spray to the site of the surgery; see Table 4-2, p. 72. Local or general anesthesia may be required to supplement these anesthetics. Table 4-2 lists only several of the more commonly employed agents for adult patients.Again, numerous other agents can be utilized, and stated dosages must be altered for pediatric patients. In addition, a wide array of ancillary agents, including tranquilizers, narcotics, and amnestic agents, have not been listed because their use varies widely among anesthesia providers and institutions. Special considerations in the administration of pediatric anesthesia can be found on p. 984. Conscious Sedation and Analgesia The perioperative RN is not intended to take the place of an anesthesia provider.The American Association of Nurse Anesthetists (AANA) suggests that health care facilities consider professional nursing standards and scope of practice of the RN, not in the capacity of an anesthesia provider who is qualified to administer conscious sedation and analgesia.
Slide 99: 72 Chapter 4 Anesthesia Modalities “Sedation and analgesia” describes a modality that allows patients to tolerate unpleasant procedures while maintaining adequate cardiorespiratory function and the ability to respond purposefully to verbal commands and tactile stimulation, states the American Society of Anesthesiologists (ASA) Task Force. The Task Force believes that “conscious sedation,” a term in common usage, is imprecise terminology and that “sedation and analgesia” more accurately describes this state.When a patient is able to respond only to painful stimulation, a greater degree of sedation exists. Procedures in which sedation and analgesia are employed include those in which regional or local anesthetics are used. TABLE 4-2 Commonly Used Conduction Anesthetics* Agent Lidocaine (Xylocaine ) Bupivacaine (Marcaine, Sensorcaine) Tetracaine (Pontocaine) Route of Administration spinal** spinal** Concentration/ Dose 5%/100 mg 0.75%/15– 22.5 mg 0.5%–1.0%/ 5–12 mg Comments rapid onset; shorter acting longer acting; longer analgesia after return of sensation rapid onset; longer acting with higher dosage and/or added ephedrine or epinephrine** rapid onset; shorter duration longer acting; obstetrics; postoperative analgesia (including obstetrics) as infusion via catheter; cardiac arrest in higher dosage reported as per bupivacaine but less toxic as per bupivacaine rapid onset; doublecuffed tourniquet required spinal** Lidocaine (Xylocaine) Bupivacaine (Marcaine, Sensorcaine) epidural/** caudal epidural/** caudal 1.0%–2.0%/ 500 mg 0.25–0.7.5%/ 150 mg Ropivacaine (Naropin) Mepivacaine (Polocaine) Lidocaine (Xylocaine) epidural/** caudal epidural/** caudal regional nerve block/ retrograde (Bier) intravenous block 0.5%–0.75%/ 75–200 mg 1.5%–2.0%/ 150–400 mg 1.0%–2.0%/ 500 mg; 5%/40– 60 ml (200– 300 mg)
Slide 100: Chapter 4 Anesthesia Modalities 73 TABLE 4-2 Commonly Used Conduction Anesthetics* (continued) Agent Bupivacaine (Marcaine, Sensorcaine) Ropivacaine (Naropin) Mepivacaine (Polocaine) Lidocaine (Xylocaine) Bupivacaine (Marcaine, Sensorcaine) Ropivacaine (Naropin) Mepivacaine (Polocaine) Lidocaine (Xylocaine) Route of Administration regional nerve block regional nerve block regional nerve block local local Concentration/ Dose 0.25%–0.5% Comments long acting 0.5%–0.75%/ 75–300 mg 1%–2%/50– 400 mg 0.5%–2%/ 500 mg 0.25%–0.5%/ 225 mg 0.5%/5– 200 mg 1.0%/400 mg 2% or 4% 2%/15–30 ml; 4%/15 ml 4% or 5% long acting long acting commonly used long acting local local topical liquid ointment; gel topical cream long acting long acting low toxicity; short acting; intra-tracheally cystoscopy; other endoscopies on intact skin or mucous membranes; not for open wounds or ophthalmic use; superficial skin procedures; to lessen pain of subsequent puncture (children); may take 5–40 min to be effective; occlusive dressing for skin use as per lidocaine 4%–5% cream; occlusive (EMLA) Lidocaine (LMX 4; LMX 5) Lidocaine/ Prilocaine topical cream 2.5%/2.5% dressing use (25 mg/ for skin (up 25 mg/g) 1–2 hr) before 1–2 g/10 cm2 procedure continued on following page
Slide 101: 74 Chapter 4 Anesthesia Modalities TABLE 4-2 Commonly Used Conduction Anesthetics* (continued) Agent Cocaine Route of Administration topical liquid Concentration/ Dose Comments 2%-10% high potency; rapid (4% common)/ absorption through 200 mg mucous membranes; ENT procedures 0.5%–1.0% 0.5%–1.0% rapid onset; ophthalmic use mucous membranes (anorectal) Tetracaine (Pontocaine) topical liquid ointment; cream *All conduction anesthetic agents, when administered in greater than recommended dosages or if accidentally given intravenously (or by idiosyncratic reaction), may cause extreme agitation, convulsions, cardiac arrest, and death. Resuscitative equipment and drugs must be immediately available whenever these agents are employed. The dosages of agents listed in this table are approximate, modified by the patient’s weight, height, duration of the procedure (with incremental doses), and cardiac arrhythmias. ** Vasoconstrictors such as ephedrine and epinephrine can be added to an anesthetic agent to prolong the effect of the block. A diffusing agent such as hyaluronidase (Wydase) may be added to local anesthetics to hasten the onset of the anesthetic effect. This table lists only several of the most commonly used anesthetic agents in the dosages used primarily for adult patients. There are four levels of sedation and analgesia described by the JC. They are: 1. minimal sedation and analgesia (the patient responds normally) 2. moderate sedation (conscious sedation) 3. deep sedation (the patient is not easily aroused but maintains respiration), and 4. anesthesia in which the patient requires assisted ventilation. Patients can easily slip from moderate sedation to deeper levels of sedation, the deeper levels necessitating the assistance of a skilled anesthesia provider. The JC (last revised, 2003), has set forth qualifications for the nonanesthesia provider, the perioperative RN who administers conscious sedation and analgesia in a health-care facility. The competency of the perioperative RN should be periodically evaluated and documented.The RN must have knowledge of anatomy and physiology, pharmacology, EKG arrhythmias, and complications related to sedation and analgesia. See Analgesia and Conscious Sedation Record, p. 76. The perioperative RN who administers conscious sedation and analgesia must continually assess the patient’s physical status and behavioral changes. He/she is required to know about oxygen saturation and the use of the pulse oximeter and to understand the indications for oxygen sup-
Slide 102: Chapter 4 Anesthesia Modalities 75 plementation and its administration. He/she must be able to recognize signs and symptoms of drug toxicity and hypersensitivity to medications and anesthetic agents resulting in anxiety, sweating, pallor, nausea, vomiting, urticaria, tachycardia, laryngeal swelling, severe hypotension, convulsions, and shock. It is mandatory that he/she be familiar with the treatment for these conditions and know when to request assistance in an urgent manner. Similarly, he/she must be able to assess, diagnose, and intervene during the procedure to manage the airway and to request the intervention of an anesthesia provider. The perioperative RN administers agents, e.g., meperidine (Demerol) and midazolam (Versed), as ordered by the anesthesia provider or surgeon for sedation and analgesia only; anesthetics are not to be given by the perioperative RN who is not a qualified anesthesia provider. He/she who provides conscious sedation and analgesia is to have no other responsibilities during the procedure. Frequent monitoring and documentation of the patient’s physiologic status (vital signs, B/P, and oxygen saturation) and the charting of medications according to the time administered are required. An emergency cart or “crash cart” must be readily available, and an anesthesia provider is required to be present (in the facility) to handle emergencies and complications and, in some facilities, to discharge the patient. Postoperative Transfer of the Patient to the PACU Upon completion of the surgical procedure and placement of dressings, the circulator accompanies the anesthesia provider or RN provider of conscious sedation and the patient to the recovery room. The patient is repositioned (as necessary) for movement onto the gurney (or special bed or frame); intravascular lines, urinary catheter, and splinted extremities are protected. The security of the airway is the responsibility of the anesthesia provider. The patient may never be moved until the anesthesia provider is ready. When the patient has been expeditiously transported to the recovery room, the anesthesia and perioperative records, special appliances, and equipment are given to the PACU provider. The circulator also reports to the PACU provider any significant intraoperative events, as a severe fluctuation in cardiovascular or pulmonary functions, any untoward reaction to drugs, or the need for multiple transfusions or special medications. The patient’s chart may be temporarily retained by the surgeon to complete the operative note, postoperative orders, or dictation. If the chart is not immediately available, the circulator will advise the PACU
Slide 103: 76 Chapter 4 Anesthesia Modalities ANALGESIA AND CONSCIOUS SEDATION RECORD PROCEDURE SURGEON TIME CONSCIOUS SEDATION STARTED PROCEDURE STARTED PROCEDURE ENDED CONSCIOUS SEDATION ENDED ANALGESIA AND CONSCIOUS SEDATION ADMINISTERED BY: RN signature PREOPERATIVE PHYSIOLOGICAL ASSESSMENT Preprocedure Respiration: Deep breathes and coughs freely Dyspnic or limited Cyanotic Skin color: Skin moisture: Skin temperature: PREOPERATIVE Behavior, mental ■ Conscious ■ Drowsy ■ Confused ■ Unconscious ■ Oriented x __ ■ Agitated POSTOPERATIVE Behavior Speech VITAL SIGNS RECORD Time Temp. B/P | | | | | | | | Pulse | | | | | | | | Respirations | | | | O2 Sat. ■ normal ■ normal ■ normal ■ pale ■ dry ■ warm ■ flushed ■ moist ■ cool DATE | Postprocedure | | | ■ jaundiced ■ diaphoretic ■ cold status ■ Cooperative ■ Uncooperative ■ Combative ■ Anxious ■ Other Speech ■ Coherent ■ Incoherent ■ Silent ■ Slurred ■ Crying POSITION Aids for positioning (e.g., pillows, rolls, donut) Skin condition: preprocedure Does patient’s skin appear free from injury postprocedure?
Slide 104: Chapter 4 Anesthesia Modalities 77 ANALGESIA AND CONSCIOUS SEDATION RECORD IV INSERTED (site) BY SOLUTION #1 B/P CUFF PLACED (site) OXYGEN BY MASK ANGIOCATHETER # #2 PULSE OXIMETER BY CANNULA #3 yes ■ l/m no ■ NURSING FOCUS: OBSERVATIONS/INTERVENTIONS/OUTCOME Continuous Assessment is made of the patient’s condition PRE, INTRA, AND POSTPROCEDURE: Note anxiety, degree of alertness during procedure, ability to follow commands while receiving conscious sedation, etc. Use the suggested PERIOPERATIVE PATIENT CARE PLAN, p _____, as applicable. DOCUMENT ALL OBSERVATIONS AND CARE INTERVENTIONS for continuity of care and for medicolegal purposes. NURSING FOCUS I: PATIENT APPEARS ANXIOUS DUE TO ANTICIPATED SURGERY/ PROCEDURE AND UNFAMILIAR ENVIRONMENT List nursing interventions e.g., Orient patients to surroundings and advise them of perioperative events as they occur Explain to the patient that you will act as his/her advocate. Presence near patient during anesthetic injections suggests you want to provide comfort and emotional support. Explain the sequence of perioperative events before starting a procedure, as insertion of an IV. DESIRED OUTCOME: Patient is able to speak calmly, cooperates, and follows directions. Outcome met ■ no ■ yes Comment Outcome met; patient stated he/she felt minimal discomfort and did not appear to be in distress. MEDICATION ROUTE DOSE TIME RESPONSE Midazolam IV Fentanyl IV Demerol IV Romazicon IV Narcan IV Signature
Slide 105: 78 Chapter 4 Anesthesia Modalities provider of any postoperative orders made to him/her requiring immediate attention, as the application of an ice pack or the connection of drainage systems to a suction source. If significant nausea occurs, the anesthesia provider may administer an antiemetic, e.g., ondansetron (Zofran) or dolasetron (Anzamet). The circulator will remain with the patient until the transfer to the PACU is completed.
Slide 106: CHAPTER General Anesthesia Perioperative Considerations Definition General anesthesia is the administration of agents by intravenous injection or inhalation that renders the patient unconscious or obtunded. 5 Discussion This anesthetic method is commonly employed. The depth and duration of anesthesia are regulated according to the type of anesthetic employed and the amount of the agent(s) administered. In addition to numerous intravenous and inhalation anesthetics, a large number of other agents, including muscle relaxants, tranquilizers, and narcotics, are employed. Rarely is a single drug used, although for limited procedures, a single agent (e.g., ketamine) may be employed. Intramuscular injection and rectal instillation of a primary agent are rarely used. During all general anesthetics, the patient must be well oxygenated and the patency of the airway maintained. The anesthesia provider must also maintain the patient’s cardiovascular system and other vital functions. For more information on general anesthesia, see Chapter 4. Preparation of the Patient The patient is supine, with the safety strap in place across the thighs (about 3 inches above the knees). Care is taken not to compromise circulation by securing the restraint too tightly. The head support, a donut, pillow, or headframe is adjusted or removed at the discretion of the anesthesia provider. For procedures performed in the supine or lithotomy position that are of short duration, i.e., those in which profound muscle relaxation is not usually required, patency of the airway is managed with a mask and oral (or nasal) airway or by means of a laryngeal mask airway (LMA). Following induction, the insertion of an endotracheal tube will be required if the patient’s position is to be other than supine or lithotomy, for a prolonged procedure in the supine position, for surgeries that affect respiration, or when profound muscular relaxation is needed. A variety of types and sizes of endotracheal tubes is available. Most often the endotracheal tube is placed transorally, but it may also be inserted transnasally or via an established tracheostomy.
Slide 107: 80 Chapter 5 General Anesthesia NEVER move the patient without the anesthesia provider’s permission. Prior to any position change, the anesthesia provider must indicate that the patient’s airway is secure and that he/she will control the airway and protect the head and neck as the patient is repositioned. The patient’s eyes are protected by the instillation of ophthalmic ointment and/or by taping the lids closed. For details on positions, see pp. 20–27; the position diagrams are on pp. 27–30, or refer to the specific surgical procedure. Draping No draping is required. Equipment and Supplies The anesthesia equipment and supplies necessary to care for and monitor the patient in surgery are selected by the anesthesia provider to meet the needs of the individual patient. Factors considered include whether the patient is a child or an adult, the patient’s age, stature (physical size), physical condition, and state of health. The following should be available for general anesthesia and maintenance: Suction sou e, preferably a separate unit (in addition to the one on anesthesia cart) Laryngoscope and blades Suction catheters and suction tips, e.g., Yankauer (disposable, as requested) McGill forceps (or similar) to facilitate endotracheal tube or nasogastric tube (and other transesophageal probe) insertion Face mask, head strap, variety of endotracheal tubes (with obturators), oral and nasal airways, connectors for masks or endotracheal tubes, sterile anesthetic lubricant (for the endotracheal tube and obturator), syringe (to inflate the tube cuff), tongue blades, topical anesthetic for instillation into the larynx, e.g., local tracheal anesthesia (LTA) kit Anesthesia breathing circuit (disposable) Stethoscopes, standard and esophageal Monitoring devices for blood pressure and pulse, electrocardiogram (EKG), oxygen and carbon dioxide monitors, oxygen alarm, pulse oximeter, and EEG (as appropriate) Intravenous (IV) line(s), central venous pressure line (CVP), intraarterial line and the specific tray containing the items needed for insertion of the line and appropriate gauges Ether screen, IV standards, and drape clips
Slide 108: Chapter 5 General Anesthesia 81 Padded armboards and shoulder supports, pillows, headrest or headframe, and chest rolls Nasogastric tube (NG tube), if requested BIS (bispectral index system) attachments and monitor (if requested) Special Notes These Special Notes are in regard to the administration of a general anesthetic. Prior to the surgical procedure, the circulator must use the Universal Protocol mandated by the Joint Commission (JC) (formerly the Joint Commission on Accreditation of Healthcare Organizations) to identify the patient, “time out” must be observed by the OR team, etc. Apply Special Notes from Abdominal Extraintestinal Surgery, p. 151, as applicable. • The circulator should be familiar with the anesthesia equipment (the name, function, and assembly of each piece of equipment) and know its location. This is invaluable in saving time and is potentially lifesaving as well. • The circulator should check the working order of the room suctions prior to bringing the patient into the room. In the event that the suction on the anesthesia cart does not function properly, the room suctions must be substituted immediately. • The circulator should confirm that the compressed oxygen cylinder contains more than 250 psi of oxygen to avoid needing to replace the oxygen tank before the surgery is completed. When cylinder pressure is below 250 psi or if a long procedure is anticipated, the cylinder should be replaced before the patient is brought into the room. • The circulator is required to know the location of the emergency “crash” cart (supplied with medications, syringes, supplies, defibrillator paddles, etc.); if the patient suffers a cardiac or respiratory arrest additional assistance should be summoned immediately. • Prior to bringing the patient into the room, the circulator should obtain pillows, pads, rolls, etc. necessary for positioning the patient for the correct surgical procedure. • Positioning aids may be needed during endotracheal intubation (e.g., shoulder roll to support the scapulae, shoulders, and posterior neck of an obese patient); the circulator should bring the necessary aids into the room prior to the patient’s arrival to save time.
Slide 109: 82 Chapter 5 General Anesthesia • The circulator must know the location of the anesthesia “Emergency Airway Cart”; it should be positioned immediately outside the room whenever a difficult intubation is anticipated or when there is concern regarding the patient’s medical status. • The circulator must know what emergency equipment (by name) is on the Emergency Airway Cart; knowing the names, parts, and assembly of each piece of equipment is vital. • When the circulator brings the patient into the OR, he/she can help to allay or minimize the patient’s anxiety by directly addressing the patient’s concerns and questions with knowledgeable information when appropriate and by referring questions to the surgeon as necessary. • The circulator may want to explain to the patient that he/she will act as the patient’s advocate (i.e., that he/she will act or speak on the patient’s behalf), particularly while the patient is anesthetized. • Conversation and movement in the room should be kept to a minimum during the induction of anesthesia, particularly endotracheal intubation. The induction and administration of anesthesia is facilitated by a quiet atmosphere. Remember that hearing is the last sense to be lost and that movement can be distracting. • The circulator needs to be prepared to assist the anesthesia provider at all times during the surgery, particularly prior to, and during, induction. • The circulator should stand at or near the head of the table during endotracheal intubation to assist the anesthesia provider by manipulating the cricoid cartilage (thereby providing better visualization of the glottis) and by injecting premeasured intravenous drugs, as directed by the anesthesia provider. • Following the induction of anesthesia (and placement and securing of an endotracheal tube when utilized), the circulator reaffirms with the surgeon and the anesthesia provider regarding the patient’s position for the anticipated surgical procedure. Perioperative personnel should never move or reposition the patient until directed to do so by the anesthesia provider. • Care must be taken to protect the patient to avoid injuries as the result of burns, neurological damage, pressure sores, or other traumas that cannot be perceived by the anesthetized
Slide 110: Chapter 5 General Anesthesia 83 patient. Use adequate cushioning for all bony prominences to prevent excessive pressure injuries to the skin, nerves, and soft tissues that would eventually lead to tissue necrosis. • When the patient’s medical status is compromised and minimizing anesthesia time is desirable, the surgical area may be prepared and draped prior to the induction of the anesthetic.
Slide 111: CHAPTER Conduction Anesthesia Central Nerve Blocks: Spinal, Epidural, and Caudal Definition Central nerve blocks are achieved by injecting anesthetic solutions intrathecally into the subarachnoid space, into the epidural space, or into the caudal canal (an extension of the epidural space). 6 Discussion Conduction anesthetics are often employed when surgical procedures are performed on the lower abdomen and lower extremities.The composition and concentration of the anesthetic solution used determines the duration of the block.The patient’s position immediately after the injection of the anesthetic solution influences the level and distribution of the block.These anesthetics may be supplemented by varying depths of general anesthesia and/or sedation. Preparation of the Patient The patient’s position during the administration of the anesthetic is determined by the type of anesthetic block being administered, the surgical procedure to be performed, the patient’s physical condition, the preference and ability of the anesthesia provider to administer the particular block, and the preference of the surgeon. The physician selects the type of anesthesia that he/she considers safest for the patient. During the administration of the anesthetic block, the patient may be placed in a sitting, lateral, or prone position. Sitting: with the back arched and feet supported on a stool (spinal or epidural) Lateral: with the knees, hips, back, and neck flexed (spinal or epidural) Prone: with the body flexed at the waist (caudal or hypobaric spinal) Following the injection of the anesthetic agent (after an interval determined by anesthesia provider), the patient is placed in the selected operative position or the patient remains in the same position, as appropriate (e.g., patient remains in the prone position after caudal or hypobaric spinal is administered for anorectal surgery).The circulator or other available personnel helps to support the patient in the required position necessary to administer the block.
Slide 112: Chapter 6 Conduction Anesthesia 85 For prolonged procedures and/or postoperative analgesia, “continuous epidural” or “caudal” anesthesia is established at the time of the initial needle placement by inserting a catheter into the appropriate space (epidural space or caudal canal) for the nerve block. Increments of anesthetic solution may then be administered via the catheter. Skin Preparation and Draping Prior to administering the anesthetic, the anesthesia provider usually preps the skin and drapes the patient. The supplies for the skin prep and draping are often included in a prepackaged disposable tray.When the circulator preps the skin, the prep begins at the site of injection, extending for an appropriately wide margin circumferentially. The anesthesia provider then drapes the patient. Equipment Stool/lift (for patient’s feet, sitting position) Sitting stool (for anesthesia provider) Supplies Appropriate sterile disposable prepackaged tray, according to type of block to be administered (e.g., spinal, epidural, or caudal) Additional anesthetic agents, needles, catheters, tubing, etc. (as requested) Special Notes These Special Notes are in regard to the administration of the anesthetic, not a surgical procedure. For a surgical procedure, the circulator must use the Universal Protocol mandated by the Joint Commission (JC) (formerly the Joint Commission on Accreditation of Healthcare Organizations) to identify the patient, “time out” must be observed by the OR team, etc.Apply Special Notes from Abdominal Extraintestinal Surgery, p. 151, as applicable. • The circulator may want to explain to the patient that he/she will act as the patient’s advocate (i.e., that he/she will act or speak on the patient’s behalf) particularly while the patient is anesthetized. • The circulator should be familiar with the anesthetic agents, supplies, equipment, and trays required to perform each type of anesthetic block. • The circulator should know the location of necessary additional anesthesia supplies not included in the prepackaged anesthetic
Slide 113: 86 Chapter 6 Conduction Anesthesia • • • • • • • • • tray to save valuable time. The patient is charged for all time spent in the OR. The circulator may be requested to make preparations for starting an intravenous line (the anesthesia provider usually inserts the line) or the circulator may be asked to insert the intravenous line. The circulator or scrub person assists the anesthesia provider by helping the patient to assume and maintain the position required during administration of the block. The circulator (in addition to the anesthesia provider) must closely observe the patient for signs of respiratory distress caused by the sedation or by the inadvertent administration of a “high” spinal resulting in the depression or paralysis of the respiratory muscles. In this situation, the patient would require immediate endotracheal intubation and ventilatory assistance, as he or she would be paralysed (physically unable to breathe). The circulator must know the location of the anesthesia “Emergency Airway Cart”; it should be positioned immediately outside the room in case of respiratory distress or when there is concern regarding the patient’s medical status. The circulator must know what emergency equipment (by name) is on the Emergency Airway Cart; knowing the names, parts, and assembly of each piece of equipment is vital to patient safety during an emergency. The circulator should check the working order of the room suctions prior to bringing the patient into the room. Room suctions must be ready for use at all times. In the event that the suction on the anesthesia cart does not function properly, the room suctions must be substituted immediately. The circulator is required to know the location of the emergency “crash” cart supplied with medications, syringes, supplies, defibrillator paddles, etc. in case of cardiac or respiratory arrest, assistance must be obtained immediately. Special care must be taken to protect the patient to avoid injuries as the result of burns, neurological damage, pressure sores, or other traumas that cannot be perceived by the “unfeeling” anesthetized patient. Use adequate cushioning for all bony prominences to prevent excessive pressure injuries to the skin, nerves, and soft tissues that would eventually lead to tissue necrosis. The circulator should determine what equipment is needed to administer the nerve block and to perform the surgery before
Slide 114: Chapter 6 Conduction Anesthesia 87 • • • • • • bringing the patient into the OR; the electrical equipment must be in working order before it is brought into the room. In order to avoid postspinal headache, patients must be instructed preoperatively and reminded postoperatively to remain on bedrest without raising their heads for 24 to 48 hours.A good deal of fluids via an appropriate route (oral, intravenous, or both), as ordered, should be given until the possibility of headache has passed. Special needles with a trocar tip and side port are available for intrathecal injection (e.g., Whitacre needle) to minimize the leakage of spinal fluid. For persistent leakage, an epidural puncture is made at approximately the level of the prior spinal puncture and a “patch” of autologous blood is injected to facilitate closure of the leak. Adhesive, hypoallergenic plastic, or paper tape is used to secure intravenous and pressure lines, the anesthetic catheter, and all other tubes or lines.The circulator should ask the patient about and check the patient’s chart regarding tape allergies. Do not dispose of any items on the disposable anesthetic tray until the anesthesia provider indicates that the appropriate information needed for the anesthetic record has been obtained.The tray may be disposed of in the room only.The room trash is not removed until the surgical procedure is completed. The patient, although often sedated, may be alert enough to hear, as hearing is the last sense to be lost.Therefore, discussion of the diagnosis, other medical information, and idle conversation should be limited accordingly. Perioperative personnel should employ all measures necessary to ensure the patient’s privacy. Regional, Local, Topical Analgesia Modalities Definition An anesthetic agent may be applied by injection about the peripheral nerve trunk, by injection adjacent to or directly into the surgical site, or by application directly to the surface to be treated. Discussion Regional nerve block (e.g., brachial plexus block or ankle block) is achieved by depositing an anesthetic agent immediately adjacent to a
Slide 115: 88 Chapter 6 Conduction Anesthesia larger peripheral nerve(s).This anesthetic is used primarily for surgery on the extremities. Intercostal nerve block is administered for local pain control, such as for a patient with a fractured rib or herpes zoster. A field block is used for limited abdominal surgery (e.g., gastrostomy or inguinal herniorrhaphy). Local anesthesia refers to the injection of the anesthetic agent into, or immediately adjacent, to the site of surgery, anesthetizing smaller nerves directly. In topical anesthesia, the anesthetic agent (cream, gel, or liquid) is absorbed through the tissues (usually mucous membrane) to anesthetize the area immediately beneath where it is being applied (i.e., ophthalmic or gingival) or the agent is applied to the tissue overlying a larger nerve trunk that courses close to the surface (e.g., glossopharyngeal nerve block).These anesthetic modalities (local or topical) may be administered by the surgeon (without the presence of an anesthesia provider); however, when the patient is medically fragile, or when general anesthesia or deep sedation is employed, an anesthesia provider is required.When the patient receives “conscious sedation,” a perioperative registered nurse (RN), in addition to the circulator, is required to monitor the patient. Hyaluronidase (Wydase™ ) may be added to an injectable agent to promote more rapid spread and resolution of the local edema related to the injection. Epinephrine (adrenalin) added to the anesthetic solution will prolong the effect of the anesthetic solution. Preparation of the Patient The patient is positioned to expose the site of the proposed injection or application. In local or topical anesthesia, this site is often identical to the site of the surgery; whereas in regional anesthesia, the site of injection may be remote from that of surgery. Skin Preparation Regional: Skin preparation is done before the block is established, most often by the person performing the block (anesthesia provider or surgeon).The circulator may be requested to prep the skin; the prep begins at the site of injection, extending for an appropriately wide margin circumferentially. Local: Skin preparation for the injection and the surgery are usually the same. Topical: Usually none is required, but an occlusive dressing is recommended for the transdermal application of EMLA™ or LMX™ (anesthetic agents in a cream formula).
Slide 116: Chapter 6 Conduction Anesthesia 89 Supplies Skin preparation tray, often located inside the regional or local tray Needles and syringes (regional or local) Medicine cup (for anesthetic agent) Sponges Anesthetic agent(s) Special Notes • See Special Notes from Central nerve blocks above and apply, as applicable. • When the surgical site is anesthetized using a regional, local, or topical anesthetic agent, equipment for administration of general anesthesia and performing resuscitative measures must be immediately available. • A perioperative RN may insert an intravenous line, according to hospital policy. • In the absence of an anesthesia provider, a perioperative RN (in addition to the circulator) is needed to monitor and record the patient’s vital signs and blood pressure, monitor the intravenous line, and record any other important information on the Analgesia and Conscious Sedation Record. • Determine the type of anesthesia chosen for the patient and the supplies that will be needed; the items should be in the operating room prior to bringing the patient into the room. • Be aware of special items needed to administer selected anesthetic blocks (e.g., Bier block [retrograde intravenous], requires two tourniquets [or a double-cuff tourniquet]), in addition to the medication cup, anesthetic agent (as requested), paper labels, sterile marking pen, needles, and syringes. • Although the patient receiving regional, local, or topical anesthetic is often sedated, he/she may be alert enough to hear; discussion of the diagnosis, other medical information, and idle conversation should be limited accordingly. • Perioperative personnel must always observe measures necessary to maintain the patient’s privacy.
Slide 117: This page has been left intentionally blank.
Slide 118: PART 3 Technical Adjuncts to Surgery CHAPTER Laser Technology Types of Lasers Definition The laser (an acronym for light amplification by stimulated emission of radiation) is an energy source derived from light. 7 Discussion The laser emits light energy produced by stimulating the electrons of various media (solid, liquid, tunable dye, or gas) with electricity (or xenon flash lamp or another laser) to reach a high-energy (excitement) state, releasing this energy in the form of photons.The photons collide within the laser chamber between mirrors, creating more energy that then escapes in a controlled manner as the laser beam.This beam is collimated (parallel), maintaining a constant diameter for great distances (unlike an ordinary light beam, which expands). This beam is monochromatic and of a single optical frequency, and the energy particles, photons, travel in a coordinated fashion with the light waves in phase with each other, i.e., coherently.These properties allow the laser light beam to travel over great distances with extremely concentrated energy that focuses the light into a tiny spot, the focal point. Each individually stimulated substance emits energy of a different wavelength, which influences the absorption of this energy in a selective manner.The laser does not produce ionizing radiation and is not hazardous in that sense, as are radioactive substances or x-rays. Body tissues are affected by the laser beam as the light energy is converted to heat (or acoustical energy).The result is the vaporization, fragmentation, cutting, or coagulation (or “welding”) of these tissues.The level of the laser power setting, the wattage, the duration of the contact time with the target tissues, the use of continuous or pulsed mode, the cooling action of the local blood flow pigmentation, translucency of the target, and adjacent tissues determine the effect of the laser beam on tissues. Several lasers of different wavelengths measured in nanometers (nm) and with different clinical capabilities are commonly used in the operating room.
Slide 119: 92 Chapter 7 Laser Technology The CO2 (carbon dioxide) 10,600-nm laser is used in a noncontact mode for cutting and vaporization of tissues (and welding of certain tissues, for example, vascular anastamoses). This laser may be excited by electricity or radiowaves.The source of CO2 (and accompanying gases helium and nitrogen) can be from a replaceable tank or a sealed source employing a catalytic reaction to reclaim the gases. Previously, because of its longer wavelength, the CO2 laser beam could not be transmitted through lengthy fiber delivery systems. However, a hollow tubular articulated arm within which are specially positioned mirrors that permit adaptation of the laser beam via a microscope or handpiece with a lens system to focus the beam is in use. Another variant is a flexible hollow wave guide lined with reflective metal ribbons and a dielectric (electrically nonconducting) coating that extends the CO2 laser’s ability to treat previously inaccessible areas, but with loss of laser energy. The Nd:YAG (neodymium yttrium aluminum garnet) 1064-nm laser can pass through clear fluid, targeting darker tissues beyond, or it can be transmitted by a flexible probe (fiber) through an endoscope for the destruction of gastrointestinal, urinary, and respiratory tract lesions.With the use of a sapphire tip, the Nd:YAG laser can be used in a contact mode. The argon 488-nm (blue) to 515-nm (green) laser composes blue-green laser energy that is absorbed by melanin and hemoglobin and is used in ophthalmology (e.g., photo coagulation of retinal vessels and bleeding points), in plastic surgery to ablate hemangiomata, and in various dermatologic applications. The KTP (potassium titanyl phosphate) 532-nm laser is a variant of the Nd:YAG wherein the beam is passed through a potassium titanyl phosphate crystal, doubling its frequency (halving its wavelength), giving this laser properties similar to the argon laser but with increased tissue-destructive capability. The Ho:YAG (holmium) 2100-nm laser with penetration to 0.4 to 0.6 mm is absorbed by water (as is CO2 laser energy) and can be applied directly or via a fiber. It can be used for acoustical effect to shatter biliary or urinary tract calculi. The Er:YAG (erbium) 2940-nm laser is absorbed by water with shallow tissue penetration, making it useful for local ablation and skin resurfacing. Tunable dye lasers refer to laser energy derived from various dyes exposed to intense light (e.g., the argon laser), the wavelength (400 to 1000 nm) modified by a tuning crystal. Included in this modality are pulsed dye lasers of various frequencies, depending on the particular liquid dye medium and a pulsed light source. For example, this laser (with a frequency of 504 nm), as conducted through a fine (0.2-mm) quartz fiber, can be passed through a ureteroscope immediately adjacent to or
Slide 120: Chapter 7 Laser Technology 93 in direct application to a calculus, causing it to shatter. A 530-nm wavelength yellow dye laser will also disrupt urinary tract calculi. A flashlamp pumped pulse dye (FLPPD) laser depends on a dye activated by a flashlamp and tuned to 400 to 1000 nm by changing the dye and the use of prisms to treat dermatologic conditions involving specific pigments. Candela lasers (585 nm and 510 nm) are used for urologic purposes or can be used to ablate colored skin lesions as hemangiomata and are often used in outpatient settings for a variety of cosmetic purposes as pigmented lesion ablation, reduction of fine varicose veins, and tattoo removal. An additional application is photodynamic therapy, which involves the systemic injection of a photosensitive dye (e.g., modified porphyrin as 5-aminolaevulinic acid [5ALA], porfirmer sodium [Photofrin], meso tetra hydroxyphenyl chlorin [m-THPC, Foscan]), which are selectively retained by malignant (and other) tissues. These tissues (e.g., urinary bladder, breast, retina, and maxillary sinus) are exposed to a laser light of appropriate wavelength (range, 400 to 1000 nm) to produce a photochemical reaction, resulting in tumor destruction. Thus, a tunable dye laser adjusted (tuned) by prism to emit, for example, red light (argon laser energy source for rhodamine B laser 630 nm) produces the photochemical effect in conjunction with the administration of hematoporphyrin to ablate certain superficial lesions, as carcinoma in situ, pigmented skin lesions, and transitional cell bladder tumors, and to restore a lumen in cases of obstructive esophageal and lung malignancies. Via image guidance technique, a needle through which a laser fiber is introduced interstitially can be used to destroy liver metastases, pancreatic tumors, and breast tumors, benign and malignant. Photodynamic therapy is also employed to reopen arterial stenosis after angioplasty. Pulsation and wattage can be adjusted to minimize adjacent tissue damage (e.g., Q-switched lasers with which very brief but frequent pulses attain a high level of target destruction, sparing surrounding tissues). The ruby laser (694 nm) is used for tattoo removal. The excimer (excited dimeric medium) laser utilizes an inert gas-halide system (including argon-fluoride 193 nm, krypton-fluoride 248 nm, xenon-chloride 308 nm, and xenon-fluoride 351 nm), which can be incorporated in a fine catheter that includes a video system and irrigating mechanism used to open occluded coronary arteries (pulsed 308 nm) by direct contact destruction of intimal plaque. An additional excimer laser use is in optical contouring of the cornea.These gases are toxic so that appropriate apparatus housing structures and exhaust systems are inherent in their use.
Slide 121: 94 Chapter 7 Laser Technology The Diode laser, 750 to 950 nm (or gallium arsenide, 840 to 910 nm), has been introduced in a compact system for photocoagulation in ophthalmologic use, delivered directly by fiber or introduced through a slit lamp.The diode laser also may be used for urological applications. Delivery fibers with a rotary mirror (metallic) to orient the beam are available, as are units that can deliver a selection of lasers of different wavelengths. As CO2 and Nd:YAG laser beams are colorless, an accompanying neon-helium beam that emits a red light is used for “aiming.” Adapted to use with the operating microscope, the laser is invaluable in microlaryngeal and ophthalmologic procedures. Many laser procedures can be performed in outpatient surgery or special-procedure units (e.g., eye laboratories) with reduced operating room and anesthesia time. There are many advantages to using any one of the many types of lasers. In general, they include the following: Less blood loss, as most small blood vessels are sealed Working in a relatively dry field, which facilitates visibility Minimal tissue trauma, with reduced injury to adjacent structures Faster wound healing, with less pain and edema (due to sealing of nerve endings and lymphatics) Decreased chance of malignant cells being spread through the lymphatics Decreased scarring due to precision Decreased stenosis due to decreased scarring in the lumen of structures Faster recovery time in most cases Treatment of areas otherwise inaccessible via catheters and endoscopes Safety Precautions Any time a laser procedure is performed, a scrub person, a circulator, and a laser safety officer should be present.The laser safety officer may be a registered nurse or a surgical technologist (ST).All laser team members need continuing in-service education regarding their expanded responsibilities. Strict safety precautions must be enforced. Signs posted on all of the entrance doors must warn of laser use with the words “DANGER, Laser in use; Special Eyewear Required.” Windows must be appropriately covered. All equipment must be checked prior to the procedure, including but not limited to testing the beam focus, electrical connections, and suction apparatus. Only personnel trained in laser safety and technique should participate. A master key enabling operation of the laser must be obtained
Slide 122: Chapter 7 Laser Technology 95 and then returned at the completion of the procedure; the key should be kept in a locked box. A “sign-out” log is suggested for the key. The pedal (when used) is identified as it is placed in front of the operating surgeon to avoid accidental activation. The laser is set at “standby” or “stop” mode during significant interruptions in its use. Eye protection for patients and all personnel in the room is mandatory for most lasers, except when the conditions of minimum permissible exposure exist (i.e., when optical injury from “scatter” is not a danger). Flammable prep solutions and other flammable liquids should not be used in the area where the laser is used. A large amount of water or saline, a Halon fire extinguisher, and a fire blanket must be in the room in case of fire. All dry materials in or near the operative field must be dampened with saline or water. Nonflammable endotracheal tubes must be used, or traditional tubes should be wrapped with commercially available tape prepared specifically for this purpose.The cuff should be inflated with saline; the tube is wrapped in wet sponges around the lips. All instrumentation should be ebonized, or in the case of large retractors being used, covered with wet towels. Everything around the impact site, excluding the target site, must be moistened; the sterile field must be monitored for strike-through wetness contamination. Special surgical masks should be worn when the laser is in use to filter out microscopic particulate matter that has hazardous potential concerning the respiratory tract. A smoke evacuator must be used, held close to the target to evacuate the plume with its toxic by-products and odor. Small amounts of plume can be evacuated with the in-line room suction. An individual smoke evacuator with charcoal and ultra-low penetration air filters is recommended when there is a large amount of plume. Smoke evacuation filters must be changed according to manufacturer’s instructions. Disposal of “used” evacuation filters is controversial regarding whether they should be considered general waste or medical waste. Treating the used filter as a “biohazard” will eliminate the possibility of its contamination of the environment. According to standards set by the American National Standards Institute (ANSI), maximal permissible exposure, as determined by wavelength, power, exposure time, and pulsed versus continuous laser energy, must be observed to avoid skin injury.A nominal hazard zone can be calculated regarding wherein the operating room laser hazard to eye,
Slide 123: 96 Chapter 7 Laser Technology skin, and fire considerations exists. For practical considerations, appropriate maximal protection should be employed for all procedures. Ordinary eyeglasses and contact lenses are inadequate for protection. Lens filters for endoscopes are necessary to avoid scatter.When using the CO2 laser, clear glasses with side wings are worn by everyone in the room, including the patient, if he or she is awake. Under general anesthesia, the patient’s eyes are taped shut and covered with wet pads and the face is covered with a wet towel. If the area to be operated is on the face, wet towels are placed about the site.All flammable materials near the area of laser use should be covered with wet towels.The Nd:YAG laser requires blue-green safety goggles, and the argon laser requires orange goggles. Fire is a realistic potential hazard, particularly when the CO2 laser is used in or near the airway (as in laryngeal procedures). Only nonflammable anesthetics are permitted. Conventional endotracheal tubes must be wrapped with a specific laser-retardant protective (wrap) tape.A polyvinyl chloride (PVC) tube is highly flammable and should never be employed when the laser is used in the oropharanyx or in procedures about the head. Insulated silicone endotracheal tubes are available. The cuff of the endotracheal tube should be filled with saline. The protocol for an endotracheal tube fire must be rehearsed to minimize fire’s untoward effects. The first thing to do in cases where the endotracheal tube has caught fire is to remove the endotracheal tube and turn off the flow of oxygen from the tank. Water or saline should always be available in abundance. Having fire extinguishers readily available is a must.A technique of jet ventilation, employing a rigid laryngoscope through which a thin needle-like metal catheter delivers calibrated amounts of anesthetic agent into the trachea, can be used in microlaryngoscopy as a means to avoid fire hazard. (see Box 7–1). All employees in the surgical suite must receive safety education regarding laser use to prevent injuries.A variety of instruments to protect the tissue surrounding the laser target have been devised (e.g., Donnez “backstop”), some with plume suction incorporated. Similarly, nonreflective instruments (with anodized or ebonized finishes) that defocus and disperse the laser energy are used. Larger instruments and BOX 7-1 In Case of Laser-Induced Fire Involving the Endotracheal Tube 1) 2) 3) 4) Remove the endotracheal tube Pinch or shut off the supply of oxygen Assist the anesthesia provider in the reintubation of the patient Open the oxygen supply NOTE: As the mucous membranes will become edematous very rapidly, reintubation of the patient is of great importance.
Slide 124: Chapter 7 Laser Technology 97 retractors are covered with wet towels or pads during laser use to protect against scatter of laser energy if a beam is accidentally misdirected. If mirrors are needed to reflect a laser beam to an otherwise directly inaccessible site, the reflecting surface is to be stainless steel or rhodium rather than glass, which may shatter. Wet towels or sponges must be used to surround the operating field, but precautions are taken to prevent strike-through contamination. A saline-filled irrigating syringe should be available to cool local tissues or extinguish a flash fire around the operative field. Special fire extinguishers, e.g., Halon (halogenated hydrocarbon), can be used for a flash fire in any portion of the laser system apparatus without significant damage to the expensive and delicate components.The solution used for skin preparation must not contain combustible agents (i.e., no alcohol or ether). As noted previously, the laser should be in the “standby” mode when not in use. Only the operating surgeon should control the laser activation switch or pedal. Other controls (such as for the electrosurgical unit [ESU]) may be delegated to the assistant. When a laser fiber is passed through a scope or tube (catheter), the laser must not be activated until the laser tip is beyond the tip of the scope or tube to avoid heating the tube and inadvertently burning the patient. A satisfactory smoke evacuator to remove noxious smoke (plume) is necessary. Plume smoke evacuate filters should be changed as recommended by the manufacturer with appropriate “hazardous waste” technique (as some viable microorganisms may be contained in the plume). Laser masks filter out particles of a finer size (1–2 microns) than do ordinary masks (5 microns). During endoscopic procedures, smoke evacuation is important to eliminate the noxious plume and also to maintain visibility.The plume may contain carbonized microscopic particulate matter that, when inhaled on repetitive exposure, may lead to respiratory distress, hyperplasia of bronchial tissue, bacterial or viral diseases, and possibly even cancer. The smoke evacuator should have an in-line filter when room suction is used. When large amounts of plume are to be evacuated, an individual smoke evacuator that has a charcoal filtration system and ultra-low penetration air (ULPA) filter is required. In the presence of pneumoperitoneum during laparoscopy, smoke evacuation done too rapidly is to be avoided. Special suction devices with high-flow CO2 insufflators are available to counter the loss of intraabdominal pressure during the evacuation of the plume. When lasers are employed, movement by the patient is limited by restraints, if the patient is awake; for delicate microscopic surgery, general anesthesia with muscle paralysis is necessary. The circulator assists the laser officer to enforce all precautions, to support the patient, to explain the need for wetting sponges and drapes, and to explain the need for protective eyewear. He/she documents use of
Slide 125: 98 Chapter 7 Laser Technology the laser in the Intraoperative Record, the medicolegal record of the procedure.The scrub person keeps the immediate field surrounded by wet sponges, towels, and drapes while guarding against strike-through contamination, assists in suctioning the plume, and anticipates the need for special instruments or supplies.The laser officer, working in conjunction with the surgeon, tests the laser equipment to assure that it is functioning properly. The laser officer also maintains all rules, regulations, and precautions regarding the use of the laser by all personnel. He/she maintains an individual patient record in the laser log book for each patient. Care and Competency Standards for Use of Lasers Care and competency standards for use of the lasers (various types) have been established, with ongoing revisions by several agencies, including the Food and Drug Administration (FDA), National Institute of Occupational Safety and Health (NIOSH), Occupational Safety and Health Administration (OSHA), American Society for Laser Medicine and Surgery (ASLMS),Association of periOperative Registered Nurses (AORN), and the American National Standards Institute (ANSI). The Joint Commission (JC) (formerly the Joint Commission on Accreditation of Healthcare Organizations) mandates that physicians employing the laser must be credentialed and that all operating room personnel (including orderlies and housekeepers, as applicable) must be instructed in laser safety. All employees involved in laser use must receive hands-on training. Quality maintenance of the expensive equipment is essential. Documentation of laser procedures becomes part of the patient’s intraoperative record.The data must include type of procedure, type of laser, duration of use, wattage settings, and verification that the safety protocol was observed. [A significant proportion of laser equipment is not owned by the hospital or surgicenter, but is rented; a certified technician may accompany the equipment and assist in its use.]
Slide 126: CHAPTER Endoscopy: A Minimal Access Approach Endoscopy refers to the direct visualization of a body cavity or tissue space through an illuminated tubular instrument inserted via a natural body orifice or a minimal incision to view, diagnose, or treat a wide variety of conditions. When appropriate, the surgeon chooses an endoscopic approach for a given surgical procedure. In making this determination, the surgeon must consider his/her clinical judgment and endoscopic experience. Advantages of the endoscopic approach versus open surgery may include: out-patient treatment versus a hospital stay smaller incision; less-invasive, less-traumatic procedure precise control of a laser beam (via instrument channel) unobstructed view of the operative site minimal trauma to tissues as retraction is obviated or lessened less postoperative pain faster healing, shorter recovery, and faster return to usual activities • potential for a decrease in overall cost of treatment • • • • • • • Diagnostic capabilities, including assessment of metastatic disease, infertility, endometriosis, sepsis, extent of trauma, etc. may be achieved. Biopsies, fluid samples, and cultures may be taken. Disadvantages include expensive instrumentation and equipment, need for special training with updating for the surgeon and surgical team, possible equipment failure, and potential complications requiring that an open procedure be performed. The basic tenet of endoscopy is that the definitive portions of the procedure be accomplished in identical fashion to that of an “open” procedure. If, for any reason, the inability to safely expose and visualize structures due to hemorrhage, inflammation and sepsis, dense adhesions, obesity, or excessive anesthesia time ensues, or consequent surgical injury is sustained, the urgency of the situation dictates, or there is equipment failure, the procedure must promptly be converted to the traditional approach. In certain instances, endoscopic surgery may be performed in conjunction with an additional lesser formal incision (e.g., “laparoscopic-assisted” colon resection). 8
Slide 127: 100 Chapter 8 Endoscopy: A Minimal Access Approach Endoscopes may be rigid or flexible and all perform a similar task, i.e., provide the ability to see within a body cavity (or tissue space). Their shape and size is determined by the part of the body to be viewed.There are some scopes made of plastic that are disposable, e.g., otoscopes and sigmoidoscopes.The rigid endoscopes are usually metal and permit the surgeon a straight-ahead or angulated view, e.g., otoscope, nasal sinus scope, laryngoscope, thorascope, mediastinoscope, esophagogastroscope, laparoscope, arthroscope, hysteroscope, cystoscope, anoscope, proctosigmoidoscope, and trans-anal microsurgical scope. Flexible endoscopes provide the ability to survey the entire operative field. Advantages such as intense illumination, magnification, and the ability to see “around” corners gives the surgeon better visualization of the operative field. A fiber-optic light source is used with a direct lens-viewing system or a video camera that displays the images on a television monitor. In many surgical specialties, flexible endoscopes have supplanted rigid endoscopes in many applications (or by the surgeon’s preference). Some of these flexible endoscopes include the mediastinascope, bronchoscope, angioscope, choledochoscope, cystonephrostoscope, ureteroscope, hysteroscope, esophagogastroduodenoscope, and colonoscope. Incandescent bulbs have been replaced by fiber-optic bundles that produce an evenly distributed, nonglaring, high-intensity, “cool” light that remains cool inside the patient’s body. Electricity furnishes the power for the lighting systems. The scrub person attaches one end of the power cable to the instrument with the light, and the other end of the power cable is handed to the circulator, who inserts it into the light source.The drape sheet covering the patient’s body should be very carefully wrapped around the power cable and secured so that the cable does not hang down or slide off the sterile field and become contaminated. The fibers in the power cable are extremely fragile and must be handled with extreme care.The cable should never be bent, folded, or handled roughly, as the fibers in this very expensive component will break. The lamps are 175 to 300 watts and have a use life of 250 to 700 hours. They require changing the bulb at a moment’s notice. Care should be taken when replacing a lamp (bulb) in use, as it will be “hot.” Lamp-life status monitors are often incorporated into the light source units to anticipate the need to change the lamp. Imaging is by lens systems or by a miniaturized video camera chip charged-coupled device (CCD) that is transmitted to a video monitor displayed near the operating table. Other recording modalities, such as videotape, distant broadcasting, and still image photos, are also available. Use of the additional modalities should be readily available, preferably with the necessary equipment placed compactly on multi-
Slide 128: Chapter 8 Endoscopy: A Minimal Access Approach 101 leveled carts. Angulated viewing (e.g., 0 , 25 , 30 , 50 , 70 , 90 , and 120 ) may be employed accordingly to provide optimal visualization of a particular site. Dual cameras are available so that two images can be seen on separate monitors (or split screen). The light source needs to be “balanced” so that white light is achieved in most instances.The current technologies provide a variety of settings for light and monitor adjustment. The light cable must be of sufficient length to go from the sterile field (if present) to the visualization system. Numerous connectors (couplers) are available, permitting various viewing permutations. The monitors must exceed camera specifications and also must be compatible to receive the three varieties of camera signal: composite, S-video comprised of Y (brightness) and C (chroma/color) components, and RGB (red, green, blue) color components.To prevent fogging, commercial solutions and pads (e.g., FRED®, ELVIS®) are made; special lenses, scope warmers, CO2 insufflator warmers, and simply “touching” the scope end to adjacent tissues are effective. Instrumentation for endoscopic surgery is generally similar to that used for traditional surgery but is smaller with respect to the working end and often controlled by pistol grip or palm grip activation, with capability of locking, rotating, and angle changing. Dissectors, graspers, various shaped scissors, needle holders and suture passers, clip applicators, staplers, sponging devices, irrigator/aspirator/coagulator devices, specimen bags, expandable fans or balloon retractors, and a host of specialty-oriented products are available. Many of these implements have insulated shafts so that electrosurgical modalities (cutting or coagulation) can safely be performed with the primary function (e.g., graspers and scissors). Adapted laser devices, argon beam coagulator, harmonic scalpel, and other sophisticated dissectors (e.g., hydrodissectors), cutting, and coagulating modalities can be employed. The ability to use multiple instruments depends on the placement of additional access ports when the site permits. Numerous trocars with cannula devices used in abdominal surgery must have pneumatic sealing valves and lumen reducers (permitting the passage of smaller-diameter instruments) in order to prevent deflation of the induced pneumoperitoneum. Cannulae may have expandable tips to effect larger bore access; some have “grippers” (screw-like coarse threads) to avoid dislodgement. Many of the cannulae are radiolucent to permit radiographic studies (e.g., cholangiogram) without undue interference. Cannulae for use other than in the abdomen usually do not require valves. Various suture-tying and knot-passage techniques have been devised to minimize the tedious effort to tie knots with instruments alone; special kits and suture passers, some with pretied knots, are available, such as the Laparomed® applier, Surgitie®, and Surgiwhip®.
Slide 129: 102 Chapter 8 Endoscopy: A Minimal Access Approach There also are techniques where the actual knot is tied extracorporeally and placed with the suture-passer device. To facilitate some procedures, both laparoscopic and open (but through a smaller incision than would ordinarily be used) techniques are employed.This is referred to as laparoscopic-assisted surgery.After initial evaluation and dissection is performed laparoscopically, the secondary incision is made.The wound is protected, and by using a modified sleeve device, through which a hand can be inserted (“handport”), larger specimens are retrieved and anastomoses and suture tying are performed. Pneumoperitoneum, required for laparoscopic procedures, will be discussed in the laparoscopic procedures, Chapter 16. Instrument processing for endoscopic surgical devices is similar to processing for devices used in standard procedures; however, as many of the instruments are miniaturized and more fragile, meticulous care must be exercised to carefully remove all debris (e.g., enzymatic and ultrasound cleaning); light cables must be handled with great care so as to not shorten their use life by fracturing delicate fibers. The usual “cold” sterilization techniques using glutaraldehyde and peracetic acid solutions, ethylene oxide, or hydrogen peroxide gas plasma are used for instruments containing heat-sensitive elements (e.g., lenses and fibers). Cutting instruments such as scissors and trocar tips, when reused, require sharpening. There is a huge inventory of “single-use” or disposable instrumentation available; however, many of these expensive items are well made and can be reused if Food and Drug Administration-approved commercial reprocessing is performed, certifying the reuse of single-use instruments. Some hospitals are certified to perform reprocessing. Stapling devices are not recycled. In addition to the special care given to the instrumentation, the electronic equipment, CO2 insufflator, monitors, and other related devices, equipment, and supplies must be cared for by specially trained personnel. Innovative techniques and the introduction of new instrumentation are ongoing. Robotics (see Chapter 9) are used to control the light/camera in certain applications and also have been adapted (some highly miniaturized) to the performance of intricate surgical maneuvers, controlled when applicable from sites remote to the procedure, by means of televised connections. Virtually every surgical specialty employs endoscopic procedures. Special training courses (often included in surgical residency programs) for physicians and in-service programs for the perioperative RN and surgical technologist (ST) accredited for credentialing have accompanied the new technology. Surgical discretion, experience, and availability of all aspects necessary for the success of the procedure must dictate the propriety of the endoscopic modality for each individual patient.
Slide 130: CHAPTER Robotics 9 Robotics is an emerging modality in the surgical armamentarium. Robots have been developed to perform relatively simple tasks, such as controlling an endoscopic camera, but also to perform intricate surgical maneuvers, even beyond the capability of a surgeon’s hand. Robotic systems respond to manual or voice-activated commands to maneuver mechanical arms or an endoscopic camera.As manual manipulation of endoscopic instruments can be affected by fatigue-induced tremor of the surgeon, some delicate procedures such as endoscopic anastomosis may be difficult, and in other situations, visualization may be suboptimal or positional application of instruments may be limited. The master/slave robotic application can improve dexterity with large control movements translated into micromotions that enhance manipulation and decrease any tremor effect, allowing the surgeon to be more comfortable (ergonomic improvement). In regard to surgeon fatigue and reproducibility, robots work (i.e., with the ability to perform technically precise maneuvers repetitively) with no discernable difference between the first or last time the maneuver is performed.Visualization and hand-eye coordination perception have been improved in current robotics over former systems, and the “fulcrum”effect (i.e., the need to move an instrument in the opposite direction as on the monitor image) has been eliminated.The surgeon can now view the field in 3D using natural hand-eye coordination with the adaptation of “all-around”vision. He/she can zoom in and out of the surgical field as well.There has been an improved feeling of dexterity, resulting in the surgeon feeling as though the manipulations done during laparoscopic procedures are being performed in “open” surgery.There has been improved access using smaller incisions for many procedures, such as laparoscopic cholecystectomy, laparoscopic radical prostatectomy and other pelvic procedures, thoracoscopic-assisted cardiotomy, and others. Clinical trials are being performed for coronary artery bypass graft (CABG) surgery and repair of atrial-septal defects, as well as many other surgeries. Heart surgeries that once could only be performed via sternal splitting incision are being done through mini-incisions. It has been predicted that soon many surgeries will be performed utilizing as few as three 1-cm incisions. Pain and bleeding are reduced, and the patient has a faster recovery when procedures are performed using this technology. The robotic modality can permit the surgeon to operate in comfort from workstations (with video display, utilizing a control panel) about 5 feet from the operating table. The robot may be operated by
Slide 131: 104 Chapter 9 Robotics controls that are moved synchronously with the surgeon’s hand movements; other robots may be in the form of mechanical arms or cameras that move according to voice activation. Procedures utilizing robotic systems require governmental (Food and Drug Administration) approval. Most systems permit the surgeon to perceive that he/she is closer to the operative field than human vision would allow, resulting in the extremely precise excision of malignancies and other lesions, thus, perhaps, affording a better potential for cure. With respect to the EndoWrist® (da Vinci System), surgeons have 7 of freedom and 90 articulation. Surgical maneuvers can be performed by a miniaturized robotic “hand” inserted into the depth of a wound that can perform minimally invasive heart valve (e.g., mitral valve) and CABG procedures. Other procedures being performed include the Nissen fundoplication for gastroesophageal reflux disease, gastric bypass surgery for obesity, esophageal surgery, thymectomy for myasthenia gravis, and insertion of endocardial pacemaker leads for biventricular resynchronization, to name just a few. Surgery can be performed from a remote site. (In 2001, a procedure in Strasbourg, France was controlled by a surgeon in New York City.) There are some negatives regarding the use of robotics, including evolving technology requiring the constant upgrading of equipment and the high cost of the electronics and compatible instruments.As the systems are cumbersome in an already crowded operating room, increasing the size of suites and/or downsizing robotic systems will be required; newly built facilities suspend the necessary equipment from the ceiling (or conceal it in ceiling compartments). A problem with long-distance operations is the time delay. In these cases of remote-control surgery, there is about a 1-second “real-time” delay in current application (to which the surgeon must adapt). A telerobotic remote surgical facility has been set up to service hospitals in rural Canada (controlled by surgeons in Hamilton). Remote control battlefield surgery can be done, but it is not yet a practical measure. Complex transmission and reception video networking is required for remote-control application. Historically, in 1985, the Puma 560™ system was capable of performing neurological surgical biopsies, and in 1988, it could perform transurethral resection of the prostate (TURP). The Probot™ system also could perform TURP, and a Robodoc™ system was used to machine the femur in hip arthroplasty. Updated systems such as AESOP™ (automated endoscopic system for optimal positioning, Computer Motion, Inc.) respond to voice commands to manipulate an endoscopic camera. ARTEMIS™ provides two arms to be controlled by the surgeon from a console. The da Vinci™ system (Stanford Research Institute/Green Telepresence Surgery is mounted on a cart
Slide 132: Chapter 9 Robotics 105 and has dual light sources and computer chip telecameras that can produce a 3D image, a master remote control console for the surgeon, and four instrument arms (one of which controls the camera and light source) attended directly on the operative field by the assistant surgeon, who passes the instrumentation manipulated by the robotic wrist, and provides exposure, foot pedals for electrosurgical unit control and camera focus, and grips to control the arms.The Zeus™ system (Computer Motion, Inc.) is mounted on the operating table with three arms, using straight and jointed instruments, and includes the AESOP camera control.The Socrates™ “telestrator,” a remote site control of AESOP, has been introduced. A system for colonoscopy has been used that applies “inch-worm” advancement of the scope with suction. Current applications include endoscopic camera control and femoral preparation in hip arthroplasty, as noted. Multiple procedures have been performed in general surgery utilizing robotics, including cholecystectomy, Nissen fundoplication, right hemicolectomy, sigmoid colectomy, gastroplasty and bypass in bariatric surgery, Heller myotomy, esophagectomy, intrarectal procedures, inguinal herniorrhaphy, and adrenalectomy. In urology, radical prostatectomy with superior potency outcomes is being performed in many centers; nephrectomy, ureteral repair, varicocelectomy, and renal transplantation are being performed robotically. In gynecology, robotics has greatly enhanced tubal reanastomosis. In orthopedics, total hip arthroplasty (femoral preparation and acetabular cup replacement), total knee arthroplasty, and spinal surgery can be performed with robotics enhancement. Robotics are also used in neurological surgery image-guided procedures and in lumbar sympathectomy and in ENT for laryngeal surgery. Cardiac surgery, internal mammary artery harvest, CABG, total endoscopic coronary artery bypass (TECAB), mitral valve repair, and closed chest off-pump procedures are all enhanced by robotics. In pediatrics, microanastomoses, as for biliary and esophageal atresia, are being performed with increasing frequency employing robotic technology. At present, the practicality and availability of the modality is not a reality for many hospital centers. Research is ongoing. Issues regarding malpractice insurance, credentialing and training, and interstate licensing (for telesurgery) are being addressed. Magnetic resonance imaging (MRI) and 3D models created prior to performing robotic neurosurgical procedures are in practice. Increasing tactile perception between surgeon and robot has been further improved. Economic constraints and improved patient care must be balanced. Potentially, robotics could lower the cost of health care some time in the future.When that happens, in addition to cost efficiency over conventional surgery, the benefits of the enhanced precision afforded by robotics that cause minimal trauma to the patient will be undeniable.
Slide 133: CHAPTER Microsurgery Microsurgery employs magnification, fine instrumentation, fine suture material, and minimal tissue manipulation for precision procedures on diminutive structures.These techniques are applicable in many surgical fields as procedures to enhance fertility, fertilization, microlaryngeal and otoscopic surgery, intracranial neurological surgery, construction of musculocutaneous flaps, and anastomoses of small-caliber arteries, veins, nerves, and tendons. In ophthalmology, procedures performed with a slit lamp are regarded as a modality of microsurgery. Although these procedures are otherwise similar to most surgical procedures, intense practice sessions for the surgeon and training for the perioperative personnel are required. The procedures are often tedious, with special attention required of the anesthesia provider (e.g., to prevent sudden patient movement, especially when anesthesia other than general is employed). More than the usual care of the delicate instruments is necessary. The technique for handling microsurgical instruments, tissue, and suture material requires that meticulous attention be paid to detail; working in the microsurgical field requires techniques that are often precise, time consuming, and complex. Both the circulator and, particularly, the scrub person need to know what their responsibilities are (which varies according to the type of procedure) during a microsurgical procedure. The scrub person needs to develop skills to assure his/her movements are smooth and not at all jerky; the slightest movements are exaggerated under magnification. It is important that the surgeon, the assistant surgeon, and the scrub person refrain from drinking caffeinated beverages the day of surgery. Care must also be employed to avoid obstructing the operative field in the exchange of instruments. For the circulator, being prepared for dealing with problems involving the operating microscope (e.g., having extra lamps available) and knowing how to solve them is a valuable asset. Surgeons and support personnel must be familiar with all aspects of use of the operating microscope, including special drapes, foot controls, beam splitters, laser adapters, eyepiece protectors, and filters. The surgeon’s and assistant surgeon’s chairs must be stable, as must be the support of the patient’s operative site. Attention to padding, e.g., donut, pillow, foam, gel, an egg-crate mattress, and well-padded armboards, is vital. When used, a hand table must be padded as well. Paying attention during the long pro- 10
Slide 134: Chapter 10 Microsurgery 107 cedures by the scrub person is mandatory; this is more easily accomplished when the operative field is displayed on a television monitor. The operating microscope is composed of two or more lens systems in a compound binocular instrument of magnifying equipment that provides stereoscopic viewing. There are a variety of objective lenses and interchangeable eyepieces that combine to present different magnifications according to the working distance required. Both the scrub person and the circulator need to know and understand how the parts of the microscope work.As the scrub person drapes the microscope, the circulator often needs to assist with pulling the distal ends of the drape cover over the scope. The microscope is electrically powered (as light waves provide the illumination); the cord requires a grounded three-prong plug. When lesser magnification (e.g., up to five times) is needed, loupes may be used; most often the microscope is set for 16- to 40times power with a working focal length of 40 cm. Commonly used fine instruments employ spring-locking mechanisms rather than ratchets (to minimize jarring) and include jeweler’s forceps (straight and curved), microscissors, microirrigators, microvascular clamps and needle holders, probes, microbipolar coagulation forceps, and sutures of varying composition (9–0, 10–0, 11–0, 12–0). Blue tinged titanium steel instruments are lightweight and produce less glare in the microscopic operative field and are preferable to antiglare-finished stainless steel. Micro power drills and small lint-free sponges are used. During surgery, the scrub person protects instrument tips and keeps the instruments free of tissue debris and secretions. Microsurgery in the field of orthopedic trauma includes reimplantation/replantation of amputated digits and more proximal levels of the extremities. Accidental amputation involving varying levels of the extremities may be associated with more significant life-threatening injuries, which take precedence over digital or limb salvage. Multiple factors influence the reattachment of severed portions of the extremities, including: • • • • • • interval from time of injury age of patient severity of injury additional injuries to the amputated part site, level, multiplicity of amputations, and bilaterality (if present) general medical status and associated injuries A reattached member should be expected to regain at least 30% of normal function. Rehabilitation potential, occupation, intelligence, and the patient’s economic situation must be considered prior to performing these extensive surgical undertakings. Larger amputations require reim-
Slide 135: 108 Chapter 10 Microsurgery plantation/replantation within 4 to 6 hours after injury; smaller members (such as digits) can be preserved longer in iced saline solution. When surgery is completed, the concept of tension-free repairs of softtissue structures may require shortening of the involved bone after complete inspection. Debridement of nonviable tissues and cleansing of the wound are also performed. K (Kirshner) wires are employed for smaller bones (e.g., digits), and other rods or pins are used for larger bones. Nerve and tendon repair may be done initially, if time, with respect to the patient’s general condition, permits and the local tissues are not severely crushed or questionably viable.Arterial and venous repair must be done at the initial procedure. Common to all reimplantations, including, for example, transfer of a great toe to replace a thumb, are techniques of vascular and nerve repair.These will be described in their respective chapters; see individual procedures for further information.
Slide 136: CHAPTER Harmonic Scalpel and Plasma Scalpel Harmonic Scalpel The Harmonic Scalpel® and LaparoSonic Cutting Shears (LCS) employ ultrasonic energy to affect cutting and coagulation of tissues. Using the piezoelectric principle, mechanical effect, e.g., vibration, is produced by stimulating a reactive substance (certain crystals or discs) with electricity (and vice versa in that mechanical energy imparted to an appropriate crystal will generate an electrical force). A single-use titanium blade or cutting forceps is made to vibrate (at its working end) at 55,500 Hz (cycles per second), which produces heat in the local tissues. This causes a cutting effect by denaturing the proteins into a coagulum that also provides hemostasis, but without smoke and at a lower temperature, usually 176 F (80 C) [with range of 122 F to 212 F (50 C to 100 C)], than an electrosurgical unit, which vaporizes water and other tissue substances at 302 to 752 F (150 C to 400 C) resulting in smoke and eschar formation. There is less lateral thermal injury to surrounding tissue with the ultrasound energy, making it safer to use closer to vital structures than using electrosurgery.The surgeon controls precision cutting and coagulation by adjusting the power level, blade edge, tissue traction, and blade pressure. As there is no electrical effect on tissue, no electrodispersive pad is necessary for its use.The harmonic scalpel unit consists of a hand piece (blade or shears), cable, generator, and footswitch. Advantages for using the harmonic scalpel over electrosurgery are: • • • • • • • no noxious smoke plume is produced greater precision near vital structures minimal, if any, lateral thermal tissue damage minimal charring and desiccation reduces the need for ligatures fewer instrument changes during procedure does not produce the eschar of electrosurgery (bleeding can reoccur if an eschar is disrupted) 11 This modality has many applications in traditional surgery, such as for tonsillectomy, hemorrhoidectomy, and a wide variety of laparoscopic and thoracoscopic procedures, etc.
Slide 137: 110 Chapter 11 Harmonic Scalpel and Plasma Scalpel Plasma Scalpel The plasma scalpel passes a visible stream of inert noncombustible argon or helium (hot) gas through an electric arc that ionizes the gas into a high thermal state. The single-use applicator, acting like a tiny “blowtorch,” lightly cauterizes as it cuts through tissue. The plasma scalpel is a large surgical pencil that simultaneously cuts and coagulates tissue, effecting hemostasis of blood vessels up to 4 mm, making it is especially useful in areas of greater vascularity. A smaller amount of inflammatory response is generated with the plasma scalpel than with an electrosurgical blade. It can be used with the same efficacy and low complication rate as the CO2 laser.The visible beam permits control, and unlike the argon beam coagulator (p. 111), there is no electrical effect to the tissues so that an electrodispersive pad is not needed. Advantages of the plasma scalpel over electrosurgery are thought to be: • • • • better precision less scarring faster healing reduced operating room time
Slide 138: CHAPTER Argon Beam Coagulator The argon beam coagulator allows a jet of argon gas to carry electrons from a unipolar electrode through space to impact on tissue in a grounded patient, delivering electrosurgical energy in a way similar to a standard unipolar electrosurgical unit (ESU). However, inherent in the argon beam coagulator is a no-touch technique, and the stream of argon gas, as it conducts the electrical energy, simultaneously has a “blast” effect on the target tissues, momentarily blowing away blood, fluid, and debris for more efficient coagulation. The flow of gas (i.e., 4 l/min), power (40 to 50 W), and spot diameter of the beam can be adjusted.The coagulation effect is good on solid organ surfaces such as the spleen, liver, and myometrium and broad oozing surfaces such as in enterolysis. Smoke is minimal as argon gas surrounds the target site. In a laparoscopic adaptation, 5- and 10-mm diameter (disposable) probes are employed. Excess gas must be evacuated to prevent it from creating an increase in intraperitoneal pressure (rare cases of fatal gas embolism have been reported). A suction irrigation probe, therefore, is placed near the argon beam coagulator probe when it is activated. Additional safety precautions include: • purging the electrode and argon tank gas line of air • limiting the flow of gas to 4 l/min • placing the electrode tip no more than several millimeters from the target tissue • being certain that the laparoscopic insufflator has functioning audible and visual over-pressurization alarms • following manufacturer’s recommendations and other established procedures to prevent gas embolism during laparoscopic surgery [Doppler ultrasonography, awareness of decreasing end-tidal carbon dioxide, and electrocardiographic signs of gas embolism can detect these changes (i.e., indicating gas embolism) early on to permit therapeutic measures in due time.] The argon beam coagulator has been used to obliterate endometrial implants and ovarian cancer metastatic implants and to perform presacral neurectomy through laparotomy or laparoscopy. Whereas the electrical generator is less costly than a laser, the electrode tips are relatively expensive, requiring frequent replacement; however, the efficacy of the argon beam coagulator, with its potential for a reduction of operating room time and its efficient achievement of (otherwise tedious) hemostasis, may negate these expenses. 12
Slide 139: CHAPTER Radiofrequency Ablation Radiofrequency (RF) energy is a form of electromagnetic wave energy occurring in nature, but in medical usage, directed from a generator. The energy is transformed to heat at the target tissue level, causing local cell death. RF energy is “nonionizing,” as opposed to x-ray or gammaray emission. It is applied via a catheter inserted in approximation to the target area via guided needle technique. Local anesthesia is administered to the patient in a radiology suite to ablate liver and lung metastases (without the need for the procedure to be performed in an operating room). RF may be employed to destroy local nerve endings, such as for (painful) facet syndrome, and by cardiologists to ablate cardiac foci causing arrhythmias. Intraoperative uses include treatment for benign prostatic hypertrophy, varicose veins, osteoid osteoma, sleep apnea, endometrial ablation for dysfunctional uterine bleeding, and prevention of pregnancy. When used in the uterus, the goal of therapy is to create endometrial fibrosis or stenosis of the uterine cavity.The system does not depend upon a distensive medium (as for hysteroscopy) and is less expensive than laser equipment.The endometrial tissues are heated to 144 F to 149 F (62 C to 65 C) for approximately 15 minutes. Uterine blood flow, thermal nonconductivity of the myometrium, and geometrically proportional “falloff ” of the heating effect combine to protect surrounding organs. The cervix is dilated to Hegar size 10, and the uterus is sounded.A probe (the length appropriate to avoid heating the endocervical canal) is selected.The probe is then passed into the uterine cavity through an insulated vaginal sleeve (which also affords protection to the bladder).Thermal monitoring probes and a special grounding belt are employed. Care is taken to be certain that the patient is not in contact with any metal surfaces (to avoid an accidental burn). During the procedure, the thermal probe may be rotated to achieve more uniform tissue destruction. 13
Slide 140: PART 4 Surgical Procedures CHAPTER Integumentary and Minimally Invasive Surgery Excision (or Destruction) of Skin Lesions Definition Excision or ablation of epidermal, dermal, and subcutaneous lesions. 14 Discussion Numerous small benign skin lesions, including nevi, papillomata, cysts, warts, indolent ulcers, and unsightly scars, and minimally invasive malignant skin lesions, such as squamous cell carcinoma, basal cell carcinoma, and malignant melanoma, can be excised, often employing local anesthetics. Usually, these patients are treated in same-day surgery or outpatient surgery facilities. Procedure Following the skin prep, the outline of the lesion is marked prior to infiltrating the area with a local anesthetic. An elliptical incision is made about the lesion oriented to the skin lines (Langer’s lines). Primary closure is achieved by undermining the wound edges to facilitate tension-free approximation.After hemostasis is achieved, the wound is closed.When there are numerous lesions, after excisions of representative specimens, e.g., condylomata, and the remaining lesions do not require histological examination, the electrosurgery unit (ESU) or laser of choice (e.g., CO2 laser) may be used. Muscle Biopsy Definition Excision of a representative section of muscle tissue for histological study. Discussion Various neuromuscular diseases, such as muscular dystrophies, myotonia, and myositis, may require a muscle biopsy for definitive diagnosis
Slide 141: 114 Chapter 14 Integumentary and Minimally Invasive Surgery after clinical assessment, electromyography, and biochemical studies have been performed. Various vascular diseases, such as inflammatory arteritis and giant cell arteritis, require similar tissue sampling for definitive diagnosis (e.g., temporal artery biopsy). Sectioning of the temporal artery may be therapeutic for some patients when the symptoms related are restricted to the local area. Procedure Following skin preparation, a local anesthetic is administered. An incision is made at the selected site (e.g., forearm, calf, or temporal artery) and continued through the muscle tissue layers (epimysium and perimysium) or other investing connective tissue to expose the tissue to be sampled. After an appropriate specimen is excised and hemostasis is achieved, the wound is closed. Excision of Subcutaneous Lipoma Definition The surgical removal of a fatty tumor. Discussion A lipoma is usually a benign fatty tumor presenting subcutaneously, most often over the trunk, neck, and extremities. Superficial lipomata are primarily removed for cosmetic or nuisance tactile symptoms. A lipoma may be encapsulated with attached nutrient vessels or amorphous with fibrous tissue of increased vascularity, which can cause discomfort. Lipomata occur singly, multiply, or as part of a condition called lipomatosis. The excised tissue should be submitted for histological study to ensure that no malignant component (such as liposarcoma) is present. Procedure Following skin preparation, depending on the size and number of lesions, appropriate anesthesia is instituted. An incision is made following the skin lines over the prominence of the lesion.The incision can be smaller than the lesion in many instances; after the superficial fascia is incised and local enveloping tissues are dissected about the lipoma (and if the lesion is mobile and discrete), manual pressure can cause this soft lesion to protrude so that its vascular attachment can easily be cross clamped and divided, facilitating the removal of the lesion. Hemostasis is assured and the wound closed.When the lipoma is amorphous, i.e., without discrete margins, dissection is more tedious and a wound drain may be needed.
Slide 142: Chapter 14 Integumentary and Minimally Invasive Surgery 115 Incision and Drainage of an Abscess Definition Surgical release of septic fluid from a confined tissue space (compartment) in the body. Discussion An abscess is a collection of fluid and inflamed or necrotic tissue, usually related to a bacterial infection in a confined tissue space.The fluid is comprised of leukocytes, serum, and local tissue exudates that cannot be locally absorbed, accumulating under pressure and spreading towards the tissue planes of least resistance. In superficial or even those presentations of deeper origin, the abscess “points” to the skin producing the classical signs of inflammation, swelling, heat, redness, and tenderness. Once an abscess develops, prompt drainage is required. This may occur spontaneously when pressure necrosis destroys the overlying skin, releasing the septic fluid, to relieve the symptoms and avoid dissection of additional areas. On occasion, the abscess contents are “sterile.” Any abscess, whether from a deep (e.g., ruptured viscus) or a superficial (e.g., puncture wound) source, must be drained. Rarely will antibiotics alone reverse the process without accompanying drainage. Abscesses affecting certain structures must be treated according to special anatomical considerations (e.g., acute tenosynovitis). Procedure After skin preparation, choice of anesthetic is influenced by the local consideration and the patient’s tolerance to pain.The prominence of the inflammatory swelling is incised, obviously necrotic tissue is excised, and, often, an ellipse of skin about the incision is excised to prevent premature closure of the wound.The depth of the wound is cleansed (may be irrigated with antibiotic agent of choice), and the wound is packed loosely with gauze stripping to facilitate drainage. If the origin of the abscess is deep, a drain may be inserted.These wounds are not closed; dressings or a fluid-collecting pouch is applied. Percutaneous Insertion of Catheters Definition Introduction of a cannula into a deeper structure via the skin.
Slide 143: 116 Chapter 14 Integumentary and Minimally Invasive Surgery Discussion Vascular access via internal jugular or subclavian vein or radial, brachial, or femoral artery is achieved by means of a catheter introduced through a needle puncture (guided by anatomical landmarks). A “cut-down” (small incision) may be used to facilitate catheter placement. In addition to vascular cannulation, hollow organs or ducts (e.g., biliary system) or an abscessed cavity may be accessed. A needle threaded with a guidewire is introduced under fluoroscopy or scan (CT, ultrasound, etc.) to provide passageway for dilators that enlarge the tract.An endoscope, cannula, or tube (e.g., feeding tube) may then be safely placed in the channel leading to the targeted structure.These latter procedures are often performed in the radiology suite; for examples of this type of cannulazation, see percutaneous gastrostomy (p. 212), jejunostomy (p. 226), and nephrostomy (p. 420). Procedure After skin preparation, local anesthesia is injected at the puncture site to ease the passage of a larger bore-introducing needle through which the catheter will be passed. Following verification of the position of the catheter by evidence of blood return or presence of specific fluids, the catheter is attached to an intravenous line, arterial strain gauge, fluid collecting apparatus, etc.The catheter is anchored to the skin by means of suture or tape (check the chart for patient sensitivities and allergies when choosing tape). The following directions for Skin Preparation, Equipment, Draping, etc., are to be modified according to the location of the operative site for any of the aforementioned procedures. Some suggestions are offered here as guidelines. Preparation of the Patient The patient is positioned to permit optimal access to the operative site, as determined by the surgeon (and the anesthesia provider, when necessary); see pp. 20–27 for position descriptions. Bony prominences and all areas vulnerable to skin and neurovascular trauma or pressure are padded.The patient’s physical limitations (e.g., arthritis) must be taken into consideration when positioning the patient.The patient’s circulation should not be compromised by placing the restraints too tightly or by crossed legs. An electrosurgical dispersive pad is applied to a skin area relatively free of hair (the area may need to be shaved).The pad should be placed on the body as close as possible to location of the procedure. Skin Preparation Begin at the intended site of incision, cleansing the skin outwardly for an adequate margin (or as directed by the surgeon). If the site is a drain-
Slide 144: Chapter 14 Integumentary and Minimally Invasive Surgery 117 ing abscess, leave a sponge saturated with prep solution on the abscess while cleansing outwardly with another sponge. Cleanse immediately around the abscess last, working inward. Remove the sponge covering the abscess when the prep has been completed. Draping The operative field is draped with folded towels around the perimeter of the intended incision. An optional sterile adhesive plastic drape may be placed. For a single operative site, a fenestrated sheet may be used, e.g., a laparotomy sheet; when multiple incision sites are anticipated, use individual drape sheets. Equipment Electrosurgical unit Suction Instrumentation Limited procedures tray Small sharp self-retaining retractor, e.g.,Weitlaner Supplies Small basin Steridrape (plastic skin drape), optional Local anesthetic and medicine cup Needles, #22 and #25 and Luer-lok syringes Sterile marking pen and labels Blades, (1) #10 and (1) #15; #11 blade, optional Suction tubing, as needed Electrosurgical pencil Culture tubes, two for abscess, one aerobic and one anerobic Cannula for percutaneous insertion; cannula may be contained in a prepackaged kit Small drain, e.g., 1/4-inch Penrose (with sterile safety pin), optional Gauze (plain or iodoform) for packing the wound, as needed Bulb syringe, optional General Special Notes • These detailed General Special Notes will not be restated following every surgery, as they were presented previously in Chapter 1, but they are included here (in this first chapter of surgical procedures) as a reminder. These reminders should be taken into consideration for all surgical procedures, e.g., always
Slide 145: 118 Chapter 14 Integumentary and Minimally Invasive Surgery follow Universal Protocol as mandated by the Joint Commission (JC) (formerly the Joint Commission on Accreditation of Healthcare Organizations) for identifying the correct patient, the correct procedure, and the correct site and side (laterality). • Always ascertain that a signed Authorization and Consent for Surgery is contained in the chart before bringing the patient into the room. • Before every surgery begins, an official “time out” must be taken. It is a safety measure to ensure the correct patient is on the table to have the correct surgery (site and laterality); all members of the team must participate. • Time out is required and must be documented on the Perioperative Record for medicolegal reasons. Special Notes • See the suggested Patient Care Plan, p. 9. The circulator adapts care to meet the patient’s needs in order to implement nursing interventions that result in optimal desired outcomes for the patient.Adjust the plan of care with the Special Notes to ensure that all reasonable considerations have been taken into account. • Advise the patient that you will act as his/her advocate. • Provide emotional support by maintaining eye contact when conversing with the patient and by holding the patient’s hand during the injection of the (local) anesthetic. • Prevent musculoskeletal injuries to personnel and the patient by employing ergodynamic measures when positioning or moving the patient, as necessary. • Ascertain that accessory equipment (when used) has been properly secured onto the table to ensure patient safety. • Provide emotional support to the patient regarding feelings of altered body image and allow the patient the opportunity to express his/her feelings. • Regarding physical exposure of the patient, keep the patient well covered; exposing only the immediate area for the procedure. • Employ reassuring measures to help the patient cope with fears and anxiety of the unfamiliar environment (e.g., answer questions in a knowledgeable manner). • Take appropriate measures to maintain patient’s body temperature (e.g., offer a warm blanket, raise room temperature, apply forced-air warming blanket for long procedures).
Slide 146: Chapter 14 Integumentary and Minimally Invasive Surgery 119 • Assess hemodynamic factors, e.g., keep patient’s legs uncrossed, apply antiembolitic hose before positioning patient, if requested. • Check chart for patient sensitivities and allergies, including to latex products (e.g., gloves, drains, or elasticized dressings). • These procedures are usually performed using a local anesthetic. Medication safety precautions are always observed; see Medication Guidelines and Practices to Avoid Medication Errors, pp. 30–31. • The circulator confirms selection of the local anesthetic agent and its strength with the scrub person and surgeon aloud. • All medicine containers in use must be labeled according to agent and strength and remain in the room until the conclusion of the procedure. • In integumentary and minimally invasive procedures,Wydase™ (hyaluronidase) may be requested by the surgeon to facilitate dispersion of the anesthetic agent and to minimize related localized associated swelling. • For muscle biopsy, an elastic bandage (e.g., Elastoplast™ tape) may be used to create a pressure dressing. • When an abscess is drained, culture tubes are needed for aerobic and anaerobic cultures; requisitions for culture and sensitivity are prepared in advance by the circulator. Cultures are dispatched to the laboratory as soon as possible (to prevent their drying out). • Antimicrobial agents may be requested for wound irrigation (such as in drainage of abscess). • A Penrose drain with a gauze wick (for fluid absorption) may be referred to as a “cigarette drain.” • A Penrose drain, if used, should be moistened with saline before passing it to the surgeon. • If a drain is placed, it is usually sutured to the skin; a sterile safety pin also may be attached to the exposed portion. (A cut rubber band may be used in a smaller wound.) • Gauze strips may be used to drain the wound. • Electrosurgery is often employed; see safety precautions, p. 38. • A laser may be employed; see safety precautions, p. 94. • When the surgeon closes the skin, he may use one of the following methods to minimize scarring: 1. interrupted or continuous subcuticular nonabsorbable sutures (e.g., nylon) on a cutting needle, 2. continuous subcuticular absorbable suture (e.g., plain gut, Vicryl™) placed just under the epithelium,
Slide 147: 120 Chapter 14 Integumentary and Minimally Invasive Surgery 3. liquid skin sealant that forms a clear, plastic-like protective barrier when it dries, or 4. semipermeable, microporous closure tapes (e.g., Steristrips™). Apply tapes to dry skin or skin prepared with tincture of benzoin or Mastisol®; remove half of the backing on the tape strips along perforations to facilitate their application.
Slide 148: CHAPTER Breast Surgery Breast Biopsy Definition Removal of tissue from the breast to determine the nature of a breast lesion. 15 Discussion When the lesion is not palpable, prior to the biopsy procedure, the patient is taken to the radiology department, where needles are inserted into the breast under imaging techniques to localize the lesion. Alternatively, a specimen can be obtained for examination utilizing a stereotactic-guided needle; this biopsy may obviate the need for open surgical biopsy. A frozen section can be performed on the specimen immediately, if indicated. Procedure The incision may be made over the lesion; however, most often the incision is made circumareolar, if it is at all possible to reach the lesion. The lesion is grasped and dissected free.The specimen may be sent for a frozen section. After hemostasis is obtained, a drain may be inserted. Subcuticular tissue is approximated. Skin is closed with fine subcuticular suture or fine interrupted skin stitches.A stitch secures the salinemoistened drain; a safety pin is attached to the drain to prevent its retraction into the wound. Preparation of the Patient Patient is supine with the arm on the affected side extended on a padded armboard; the other arm may be padded and tucked in at the patient’s side using the draw sheet. Antiembolitic hose may be put on the legs, particularly if a long procedure is anticipated. A pillow may be placed under the head, as well as an additional small pad placed under the lumbar spine and/or a pillow placed under the knees to avoid straining back muscles, to prevent pressure damage to tissue, and for comfort. Apply electrosurgical dispersive pad. When local anesthesia is to be administered by the surgeon and the presence of an anesthesia provider is not required, a perioperative registered nurse (RN), in addition to the circulator, will monitor the patient’s vital signs, etc.; for the perioperative RN’s monitoring duties, see p. 58, and for the Analgesia and Conscious Sedation Record, see p. 76.
Slide 149: 122 Chapter 15 Breast Surgery Skin Preparation Use a gentle circular motion beginning at the site of incision and extending from neckline to lower ribs, including a wide margin beyond the midline and under the arm, down to the table on the affected side. For lesions in the upper outer quadrant, include the axilla. The scrub is performed with a “gentle touch,” as cancer cells could (theoretically) be dislodged from the specimen into the bloodstream if vigorous scrubbing were done. Draping Four folded towels and a laparotomy sheet Equipment Electrosurgical unit (ESU) Instrumentation Basic/minor procedures tray Supplies Antiembolitic hose, as requested Basin set Local anesthetic, as requested, and medicine cup Disposable needles and syringe (to administer local anesthesia) Paper labels and marking pen (to label local medication) Blades, (2) #15 and (1) #10, if specimen is likely to be “large” Electrosurgical pencil and cord Abrasive electrosurgical cleaner (adhesive-backed) Needle magnet or counter Small drain (e.g., 1/4-inch Penrose) and safety pin Special Notes • The circulator, using Universal Protocol, must confirm the side and site of the lesion with the patient and the chart. (The site should have been marked preoperatively with an indelible pen.) • See the suggested Patient Care Plan, p. 9.The circulator adapts care to meet the individual patient’s needs by implementing the nursing interventions that result in optimal desired outcomes. Use the Special Notes to augment the plan of care to ensure that all reasonable considerations have been taken into account. • Before every surgery begins, an official “time out” must be taken.This safety measure ensures the correct patient will have the correct surgery (site and laterality); all members of the team
Slide 150: Chapter 15 Breast Surgery 123 • • • • • • • • • • • • • must participate. Time out must be documented on the Perioperative Record for patient safety and medicolegal reasons. The circulator should provide measures of emotional support to the patient, e.g., maintain eye contact with the patient and hold the patient’s hand during the administration of anesthesia, etc. The circulator conveys to the patient that he/she will act as the patient’s advocate. The patient may have fear and anxiety regarding the surgery and the unfamiliar environment; answer questions in a knowledgeable manner whenever possible or refer questions to the surgeon. The circulator can provide emotional support regarding feelings of altered body image by allowing the patient an opportunity to express his/her feelings. Take appropriate measures to maintain patient’s body temperature (e.g., offer warm blanket, raise room temperature, or apply forcedair warming blanket when a long procedure is anticipated). In regard to local anesthetic, label all medications according to name and strength, and keep all containers in room until procedure ends; use precautions to avoid medication errors (see pp. 30–31). Keep the patient adequately covered to avoid overexposure of areas not involved in the procedure. Check chart for patient sensitivities and allergies, including to latex products, e.g., gloves, drains (such as Penrose), or elasticized dressings (such as pressure bandages). Assess hemodynamic factors, e.g., keep the patient’s legs uncrossed and apply antiembolitic hose before positioning the patient, if requested. Exercise all precautions in handling excised tissue to avoid misidentification of biopsies when multiple specimens are taken. Each specimen must have the exact location (from which the specimen was taken) indicated on the request form. The surgeon may indicate the orientation of the specimen with a suture; the circulator needs to indicate this on the request form along with the surgeon’s explanation. The circulator is responsible for sending the specimen to the laboratory immediately for “frozen section.” Do not put the specimen in formalin or other fixative. The circulator must notify the pathologist if the patient is awake; this should be indicated in an obvious area on the request form in large letters, e.g., PATIENT AWAKE.