INTRAOPERATIVE PHASE

GOALS OF CARE: ASEPSIS, HOMEOSTASIS, SAFE ADMINISTRATION OF

ANESTHESIA & HEMOSTASIS
COMMON SURGICAL SUFFIXES:

Itis --------- inflammation of an organ. Ex: appendicitis

Otomy ---- make a cut into ex: craniotomy
Ostomy --- make a mouth; opening or stoma ex: colostomy
Ectomy---- removal of an organ ex: appendectomy
Rrhaphy -- suturing / stitching; repair of a defect ex: perionarrhaphy
Pexy-------- to sew up in a position ex: orchidopexy
Plasty------ improve by changing a position ex: cheiloplasty
Scopy ------ looking into ex: bronchoscopy

ORGANS PREFIX SURGERY

Stomach gastro gastrectomy
Pylorus pylor pylorrhaphy
Liver hepa hepatitis
Gallbladder cholecyst cholecystectomy
CBD choledoch choledochotomy
Small intestine enter enterostomy
Colon col colectomy
Appendix appendec appendectomy
Urinary bladder cyst cystostomy
Fallopian tube salphingo salphingectomy
Ovary oophor oophorectomy
Pelvis pyel pyelotomy
Kidney nephro nephrectomy
Loin / abdomen lapar laparotomy

Surgical Environment

Physical Layout of the O.R. Suite:

1. Location – operating room is situated that is central to all supporting services
(laboratory, radiology, pathology & central supply room)

2. Principles in Design –
a. Exclusion of contamination from outside the suite with sensible traffic patterns
within
b. Separation of clean areas from contaminated areas within the suite.

3. Exchange Areas -
Surgical Area:
 a. Unrestricted zone – street clothes are allowed
b. Semi-restricted zone – Attire consist of scrub clothes and caps
c. Restricted zone – scrub clothes, shoe covers, caps and masks are worn

4. Peripheral Support Areas –

a. Central Administrative Control
b. Offices
c. Conference Room/Classroom
d. Laboratory / Radiology Services
e. Anesthesia Work & Storage Areas
f. Housekeeping Storage Areas
g. Utility Room
h. General Workroom
i. Storage Room
j. Sterile Supply Room
k. Instrument Room
l. Scrub Room

5. Operating Room – surgical suite is behind double doors (sliding doors).

- Access is limited to authorized personnel.
- External precautions include adhering to principles of surgical asepsis.
- Strict control of the operating room environment is required.
- OR has special air filtration devices to screen out contaminating
particles, dust, and pollutants.
- Temperature, humidity and airflow patterns are controlled.

Infection
Infection – is the product of the entrance, growth, metabolic activities &
pathophysiologic effects of microorganism in living tissues.

Three Stages of infection:

1. Invasion
2. Localization
3. Resolution leading to recovery

Classification of Infection

1. Community-Acquired Infections – are natural disease processes that developed or were

incubating before a patient’s admission to the hospital or
ambulatory care facility.
2. Communicable Disease – Systemic bacterial, viral or fungal infections may be
transmitted from one person to another (HIV, hepatitis &
Tuberculosis)
3. Spontaneous Infections – Localized infections requiring surgical diagnosis and or
treatment for management or that occur as adjuvants to medical
therapy (acute appendicitis, cholecystitis & bowel perforation with
peritonitis)
4. Nosocomial Infections – are hospital-associated or acquired during the course of health
care of the patient.

Types of Nosocomial Infections:

1. Exogenous – infection is acquired from sources outside the body (personnel &
environment)
2. Endogenous – infection develops from sources within the body. (e.g.
abdominal sepsis caused from enteric flora due to
perforation)

Classification of Surgical Wounds

1. Clean Wound
- No inflammation present
- Procedure under ideal O.R. conditions
- No break in sterile technique
- GIT, respiratory, genitourinary & oropharyngeal cavity not entered
Infection rate: 1% to 5%
2. Clean-Contaminated Wound
- No inflammation or infection present
- Minor break in technique occurred
- Primary closure, wound drained
- GIT, respiratory, genitourinary tracts & oropharyngeal cavity entered under
controlled conditions & no spillage & contamination
Infection rate: 8% to 11%
3. Contaminated Wound
- Major break in technique occurred
- Open fresh traumatic of less than 4 hours
- Acute nonpurulent inflammation present
- Gross spillage/contamination from GIT
- Entrance to genitourinary or biliary tracts with infected urine or bile present
Infection rate: 15% to 20%
4. Dirty and Infected Wound
- Organism present in surgical field before procedure
- Perforated viscus
- Old traumatic wound of more than 4 hours
- Existing clinical infection: acute bacterial inflammation encountered, with or
without purulence
Infection rate: 27% to 40%

Sources of Contamination
1. Skin
2. Hair
3. Nasopharynx
4. Fomites
5. Air
6. Human Error
7. Cross Infection

Environmental / Infection Control

1. Rigorous adherence to the principles of surgical asepsis by OR personnel is the
foundation of preventing surgical site infections.
2. All surgical supplies, any instruments, needles, sutures, dressings, gloves, covers and
solutions that may come in contact with the surgical and exposed tissues must be
sterilized before use.
3. Surgical asepsis requires meticulous cleaning and maintenance of the OR environment.
4. Floors and horizontal surfaces are cleaned frequently with detergent, soap and water or
a detergent germicide.
5. Sterilized equipment is inspected regularly to ensure optimal operation and
performance.

Methods of Sterilization / Disinfection

1. Thermal (physical)
a. Steam under pressure – moist heat
b. Hot air – dry heat
c. Microwaves – nonionizing radiation

2. Chemical
a. Ethylene oxide gas
b. Formaldehyde gas & solution
c. Hydrogen peroxide plasma / vapor
d. Ozone gas
e. Acetic acid solution
f. Glutaraldehyde solution
g. Peracetic acid solution

3. Ionizing radiation (physical)

Disinfectants:
1. Chemicals
a. Alcohol 70% to 90% (ethyl & isopropyl)
b. Chloride compounds
c. Formaldehyde
1. 37% aqueous
2. 8% in alcohol
d. Glutaraldehyde 2%
e. Iodophors
f. Mercurial compounds
2. Physical
a. Boiling water
b. Ultraviolet irradiation

Surgical Scrub

= is the process of removing as many microorganisms as possible from the hands and
arms by mechanical washing and chemical antisepsis before participating in a surgical
procedure.

Purpose:
1. To remove soil, debris, natural skin oils, hand lotions and transient microorganism
from the hands and forearms of sterile team members.
2. To decrease the number of resident microorganisms on skin to an irreducible
minimum.
3. To keep the population of microorganisms during the surgical procedure by
suppression of growth.
4. To reduce the hazard of microbial contamination of the surgical wound by skin flora.

Gowning and Gloving Techniques

Purpose: Sterile gown and gloves are worn to exclude skin as a possible contaminant and
to create a barrier between the sterile and unsterile areas.

General Consideration:
1. The scrub person gowns and gloves self, then may gown and glove the surgeon and
assistant.
2. Gown packages preferably are opened on a separate table from other packages to avoid
any chance of contamination from dripping water.
3. Avoid splashing water on scrub attire during surgical scrub because moisture may
contaminate the sterile gown

Types of gloving technique:

1. Closed Glove Technique – is preferred except when changing a glove during a surgical
or when donning gloves for procedures not requiring gowns.
2. Open Glove Technique – is used for changing a glove or gown and gloves during a
surgical procedure. It is also used when only sterile gloves
are worn in administration of spinal anesthesia, intravenous
cutdown or for suturing lacerations.

Principles of Surgical Asepsis:

1. All materials in contact with the surgical wound and used within the sterile field must
be sterile.
2. Gowns of the surgical / perioperative team are considered sterile in front from chest to
the level of the sterile field / waist level.
3. Sterile drapes are used to create a sterile field.
4. After a sterile package is open, the edges are considered unsterile.
5. Scrubbed persons and sterile item contact only sterile areas, circulating nurses and
unsterile items contact only unsterile areas.
6. Sterile areas / field must be kept in view during movement around the area, at least 1
foot distance from sterile field must be maintained.
7. A tear or puncture of the drape permitting access to an unsterile surface underneath
renders the area unsterile.
8. Items of doubtful sterility are considered unsterile.
9. Sterile fields should be prepared as close as possible to the time of use.
10. The sleeves are considered sterile from 2 inches above the elbow to the stockinette
cuff.
11. Outmost caution and vigilance must be used when handling sterile fluids to prevent
splashing or spillage.
12. Contact with unsterile objects at any point renders a sterile area contaminated.

Surgical Conscience
= awareness, which develops from a knowledge base, of the importance of strict
adherence to principles of aseptic and sterile techniques.

Nursing Responsibilities:
Good health is essential for any in the OR and any preoperative team member
with an infectious disease (e.g. URTI, infected skin lesions, hepatitis, infectious flu, colds
and cough) should not have direct patient contact. Until the infectious process has
resolved, the perioperative team member should not work in the O.R.

The Surgical Team / Perioperative Team:

1. Patient
2. Circulating Nurse – also known as the “circulator”
Responsibilities:
a. Manages the operating room
b. Protects patient’s safety and health by monitoring the activities of the surgical
team
c. Checks and verifies the consent form
d. Ensure fire safety precautions, cleanliness, proper temperature,
humidity and lighting of the O.R.
e. Monitors safe functioning of the equipments.
f. Coordinates with the surgical / perioperative team and monitors aseptic
practices
g. Documents O.R. surgical activities
3. Scrub Nurse – responsible for scrubbing for the surgery.
 Responsibilities:
a. Setting up sterile tables
b. Preparing sterile sutures, ligatures & special equipments (e.g. Laparoscope)
c. Assisting the surgeon & assistant surgeon, taking care tissue specimens
d. Count all needles, sponges & instruments together with the circulating nurse
4. Surgeon – head of the surgical team
Responsibilities
a. Performs the surgical procedure
5. Registered Nurse First Assistant – practices under the supervision of the surgeon
Responsibilities:
a. Suturing and handling of tissues
b. Providing exposure at the operative field
c. Providing homeostasis
6. Anesthesiologist – is a physician specifically trained in the art and science of
anesthesiology. Anesthetist is a qualified health care professional who administer
anesthetics.
Responsibilities:
a. Interviews and assesses the patient
b. Select & administer appropriate anesthesia
c. Monitors V/S, ECG, ABG & anesthesia levels
7. Post Anesthesia Care Unit (PACU) Nurse – responsible for caring for the patient
until the patient has recovered from the effects of anesthesia.
Responsibilities:
a. Monitors V/S and post-operative complications (bleeding, respiratory distress
etc)
b. Carry out postoperative orders
c. Refer any unusualities to the physician

Anesthesia

= a state of narcosis, analgesia, relaxation and loss of reflexes.

Levels of Sedation and Anesthesia:

1. Minimal sedation – is a drug-induced state wherein patient can respond normally to

verbal command. Cognitive & coordination is impaired but respiratory &
cardiovascular is not affected.

2. Moderate Sedation – a depressed level of consciousness that does not impair the
patient’s ability to maintain patent airway & respond to physical stimulation and
verbal commands, often called “ monitored anesthesia care” (e.g. intravenous
drugs: midazolam & diazepam)

3. Deep sedation – is a drug induced state which a patient cannot be easily aroused but
can respond purposely after repeated stimulation.
 - Difference of deep sedation and anesthesia is that the anesthetized
patient is not arousable.

Types of Anesthesia:

1. General anesthesia – (inhaled or intravenously)

Refers to drug-induced depression of the central nervous system that produces
analgesia, amnesia and unconsciousness.

e.g. volatile liquids – Halothane, Isofluorane, methoxyflurane, enflurane etc.

Gases – Nitrous oxide

e.g. Tranquilizers and Sedative-Hypnotics - Midazolam (versed), Diazepam

(valium), Lorazepam (ativan)
Opioids - Morphine, Meperidine Hcl (demerol)
Neuroleptanalgesics - Fentanyl (sublimaze), Sufentanil (sufenta)
Dissociative Agent – Ketamine (ketalar)
Barbiturates – Thiopental sodium (pentothal), Methohexital Na (brevital)
Nonbarbiturates Hypnotics – Etomidate (amidate), Propofol (Diprivan)

Stages of General Anesthesia:

Stage I Beginning anesthesia –

feeling of warmth, dizziness & detachment may be experienced, unable to move
extremities easily, experiences roaring, ringing & buzzing in the ears.

Stage II Excitement –
characterized by struggling, shouting, laughing, crying, increased pulse and
irregular respirations. Pupils dilate but contract to light.

Stage III Surgical Anesthesia –

patient is unconscious and lies quietly on the table, surgical procedure begins.
Pupils are small but contract when exposed to light. Respirations are regular,
pulse rate normal, skin is pink and slightly flushed.

Stage IV Medullary Depression/Danger –

this stage is reached when too much anesthesia has been administered.
Respiration is shallow, pulse is weak & thready, pupils dilated & non-reactive,
cyanosis develops & without prompt intervention death rapidly follows

2. Regional Anesthesia –
is a form of local anesthesia that suspends sensation and motion in a body region
or part, the patient is awake and continuous monitoring is required.
3. Spinal Anesthesia –
 is a local anesthetic injected into the subarachnoid space at the lumbar level to
block nerves and suspend sensation and motion to the lower extremities, perineum
and lower abdomen.
4. Conduction Blocks – suspend sensation and motion on various groups of nerves.
Types of conduction blocks:
a. Epidural block – anesthetic into space the dura mater
b. Brachial plexus – produces anesthesia on the arm
c. Paravertebral block – produces anesthesia of the chest, abdominal wall &
extremities
d. Transacral (caudal) – anesthesia of the perineum

Local Anesthetics Agents:

1. Lidocaine (xylocaine) – topical or injection

Advantages: Rapid, longer duration of action compared with procaine & free from
local irritative effect
2. Bupivacaine (sensoracaine) – infiltration, peripheral nerve block & epidural
Advantages: Duration is 2-3 times longer than lidocaine or mepivacaine
3. Procaine (novocaine) – subcutaneously, intramuscular, intravenously & spinal
Advantages: low toxicity & inexpensive
4. Tetracaine (pontocaine) – topical, infiltration & nerve block
Advantages: low toxicity & inexpensive
5. Etidocaine (duranest) – infiltration & nerve block
Advantages: Longer action than lidocaine

POSITIONS DURING SURGERY

1. Dorsal recumbent – flat on the back, used for most abdominal surgeries.
ex: hernia repair, mastectomy, bowel resection
2. Trendelenberg position - the head & body are lowered, used for surgery on the
lower abdomen and pelvis.
3. Lithotomy position – patient positioned at the back with the legs and thighs flexed used
for perineal, rectal and vaginal surgical procedures.
ex: D&C, vaginal repair, APR
4. Sims or lateral position – patient positioned on the nonoperative side, used for renal
surgery.

SURGICAL INCISIONS:

• BUTTERFLY = for craniotomy

• LIMBAL = for eye surgeries
• HALSTEAD/ ELLIPTICAL = for breast surgeries
• Mc BURNEYS = for appendectomy
• LUMBOTOMY/ TRANSVERSE = for kidney surgeries
• VERTICAL = for upper gastrectomy
• PARAMEDIAN = if ®UQ = gall bladder; if (L)UQ =spleen
 • INGUINAL/ GRIDVION = hernio, hydrocele repair
• THORACO-ABDOMINAL = esophago-gastrectomy
• PFANNESTIEL or BIKINI = for CS, Pelvic sx
• COLLARLINE = thyroid & parathyroid surgery
• POSTERIOR AURAL = mastoidectomy
• CANNINE FOSSA = caldwell-luc
• GIBSON = ureterolithotomy

Preparation on the Operative Site

-Skin preparation (skin prep) begins before the patient arrives in the OR.
Purpose:
- is to render the surgical site as free as possible from transient and resident
microorganisms, dirt, and skin oil so the incision can be made through the
skin with minimal danger of infection from this source.

Draping - is the procedure of covering the patient and surrounding areas with a
sterile barrier to create and maintain an adequate sterile field.

Intraoperative Complications

1. Nausea and Vomiting – if it occur turn patient to sides, the head of the table is lowered
and a basin is provided to collect vomitus.
- Suction saliva and vomited gastric contents.
- Administration of anti-emetics.
2. Anaphylaxis – is a life threatening acute allergic reaction that causes vasodilation,
hypotension and bronchial constriction.
- Carefully observe the patient for changes in V/S and symptoms of
anaphylaxis.
3. Hypoxia & other Respiratory Complications – inadequate ventilation, occlusion of the
airway, inadvertent intubation of the esophagus and hypoxia are
potential problems of general anesthesia.
- Peripheral perfusion & pulse oximetry are monitored continuously.
- Vigilant assessment of the patient’s oxygenation status is a primary
function of the anesthesiologist or anesthetist or the circulating
nurse.
4. Hypothermia – body temperature below 36.6
- caused by low temperature in OR, infusion of cold fluids, inhalation of
cold gases, open body wounds, decreased muscle activity and
advanced age.
5. Malignant Hyperthermia – is an inherited muscle disorder chemically induced by
anesthetic agent.
 - Susceptible people include those with strong and bulky muscles, a
history of muscle cramps or muscle weakness and unexplained
temperature elevation.

Clinical Manifestation:
1. Tachycardia >150 beats/min. (earliest sign)
2. Hypotension
3. Decreased cardiac output
4. Oliguria
5. Body temperature >40 Celsius (late sign)
6. Cardiac arrest

Medical Management:
1. Discontinuing the anesthesia and surgery
2. Administration of Dantrolene sodium (muscle relaxant) and Sodium Bicarbonate
3. Decrease body temperature
4. Correct electrolyte imbalance
5. Disseminated Intravascular Coagulopathy - is a life-threatening condition
characterized by thrombus formation and depletion of select coagulation proteins.

Nursing Management:
- Identify patients at risk; recognize the signs & symptoms have appropriate
medications and equipment available.