2. Approach to OR

Where to keep hands to maintain sterility in OR?

Chest level & above OR table

Important considerations for the patient in the OR

- Protect bony prominences — Gel pads

- Secure limbs — Tuck w/ sheet, arm boards

- Safety belt!

- Ensure easy access to IVs, central lines, foley

Risk of injuries with patient in supine position in OR

Brachial plexus & ulnar nerve injuries

Positioning of arms with patient in supine position in OR

- Abduct arms ≥90 degrees in neutral position

- Palms facing patient

- Flex forearm — Avoids elbow hypERextension

Injury reduction with patient in supine position in OR

- Pillows under legs

- Gel pad / donut under head

- Arm board / straps with towel as barrier

Important reminders of putting patient into prone position in OR

- Anesthetize, THEN roll over

- Protect airway!

- Neck neutral

Ideal positioning of patient in OR for OB/GYN or pelvic organs

Trendelenburg — Lithotomy

Risk of injuries with patient in lithotomy position in OR

Peroneal, saphenous, lateral femoral cutaneous, obturator, sciatic nerves

Risk of injuries with patient in lateral decubitus position in OR

Brachial plexus, CN roots

Ideal positioning of patient in OR for neurosurgery

Fowlers (head at 45-60 degrees)

Principles of universal protocol for OR (3)

- Pre-procedure verification process

- Marking procedure site

- Time-out PRIOR to incision

**Reduces wrong person, wrong site, wrong produce indidents

When do time-outs take place?

1st — Pre-op to confirm procedure, laterality, consent

2nd — In OR

How long should it take to scrub in?

5 minutes

When is it acceptable to use a waterless hand antiseptic to scrub in?

AFTER an initial surgical scrub w/ water

Steps to scrub in

1. Wet up to elbows

2. Nail pick

3. Wet brush + sponge for each finger, hand, arm to elbow

4. Scoop arms upwards to rinse

5. Keep arms UP

Protocol for skin preparation prior to surgery

- After patient asleep, prior to draping

- Chlorhexidine-alcohol or povidone-iodine

- MUST allow 3 minutes for it to dry

When are ABX administered with surgery?

- ≥1 hour prior to surgery; Repeated in long cases

- Can be continued 24 hours post-op (procedure dependent)

**Knowledge of allergies are important!

Functions of electrosurgery (4)

- Cutting

- Coagulation

- Dessication — Heats tissue to dry out

- Fulguration — Destroys superficial tissue / stops bleeding

Monopolar vs. bipolar electrosurgery

Monopolar (Bovie): — Electrode grounding pad on patient & active electrode on bovie; Machine → Instrument → Out of device → Patient (what we used for breast reduction)

Bipolar: Active & return electrodes in same instrument; Ideal for smaller areas of tissue (what we used outpt)

Differences between surgeon & PA note

PA does a brief-operative note (& everything else); Surgeon does more detailed-operation note

Indication for a Mercedes-Benz incision

Hepatic / liver tranplant

Post-op medication orders

- Pain, anti-emetics

- DVT prophylaxis

- Peptic ulcer prophylaxis

- ABX

- Home medications