Introduction to operating room

Basic introduction to operating room.

1. INTRODUCTION TO THE OPERATING ROOM SYED AHMEDUDDIN IMRAN (BSc, REEGT, CNIM) SENIOR NEUROPHYSIOLOGY TECHNOLOGIST NEUROPHYSIOLOGY DEPARTMENT KING FAISAL SPECIALIST HOSPITAL & RESEARCH CENTER RIYADH, KINGDOM OF SAUDI ARABIA

2. INTRODUCTION TO OPERATING ROOM Can be an intimidating environment for nonsurgical personnel. Lack of OR knowledge, unfamiliarity with aseptic techniques and sterile field and minimal training contribute to anxiety. Familiarity with the personnel, instrumentation and environment of OR can help make NIOM successful.

3. ASEPTIC TECHNIQUE Refers to practices used to minimize the patient’s exposure of pathogens, usually one undergoing a surgical procedure. Involves not only cleaning surgical instruments but also routines followed by surgeons and OR personnel to minimize the spread of microorganisms.

4. STERILIZATION METHODS Is a process by which objects are cleansed of living organism. Differentiate sterilization from disinfection. Disinfection reduces number of viable organism, whereas sterilization kills all organism. Three methods of sterilization are available. ( i ) Thermal (ii) Chemical (iii) Radiation

5. ( i )THERMAL STERILIZA TION Heat is a reliable method of sterilization. Also referred to as autoclaves. This process causes denaturation and coagulation of enzymes and protein system of microorganism. All living organism are killed with steam at a temperature of 115 degree centigrade for 15 min. Electrodes, stimulators and other objects used in NIOM should be thermally sterilized.

6. (ii) CHEMICAL STERILIZATION Includes ethylene oxide gas, hydrogen peroxide, formaldehyde and formaldehyde gas. Interfere with metabolism of organism, lead to cell death. Extensively used by commercial companies to prolong the shelf life of their products. NIOM equipment like electrodes should not be chemically sterilize.

7. (iii) RADIATION STERILIZATION Mostly used for commercial sterilization. Kills microorganism by forcefully dislodging electrons from ions and disrupting their DNA. Is very expensive and exposure of healthcare personnel must be monitored clos ely. Not needed for NIOM equipment.

8. OPERATING ROOM ATTIRE Effective barrier against the spread of organism to the patient. To maintain the integrity of sterile environment, street clothes are not allowed. OR attire should not be worn outside the OR. Head cover, shoe cover and mask should u se.

9. STERILE FIELD Includes patient, personnel wearing sterile attire, furniture covered with sterile drapes and items within sterile fields. NIOM staff must be able to follow sterile technique and learn to transfer objects such as electrodes, stimulators in a sterile manner.

10. PERSONNEL Many different people are likely to be encountered by the NIOM team. Includes surgical team, Medical students, Anesthesia team, Nursing team, Allied heath personnel as radiology technician, perfusionist .

11. EQUIPMENT A variety of different machines can be found in the operating room. NIOM must know their function and effect on the monitoring. Many machines produce artifacts.

12. ( i ) Electrocautery Functions : Used to electrically cut skin and to burn bleeding blood vessels closed. Effect on monitoring: Very large artifact, cannot be averaged through. Need to “pause” the monitoring.

13. (ii)Cardiopulmonary Bypass Machine Function: Used for aortic surgeries. (EEG, SEPs or MEP). Perfusionist used to administer anesthesia through it. NIOM tech should be aware and make note. Effect on monitoring: Can produce artifact that makes interpretation difficult.

14. (iii) Microscope Function: Much used in neurosurgeries for delicate surgeries. Connected to a monitor, displays what the surgeon is seeing through. Effects on monitoring: No artifacts noted.

15. (iv) Cavitron Ultrasonic Surgical Aspiration (CUSA) Function: Uses sound waves to break the tissue, usually tumors. Effects on monitoring: Can produce artifact that makes it difficult to average evoked potentials ( Eps ).

16. (v) Anesthesia Equipment Function: Includes monitoring equipment, gas delivery devices, a documentation station, storage area and variety of other anesthetic tools. Effects on monitoring: Does not produce artifacts. Technologist should learn to identify anesthetic parameters, blood pressure and temperature .

17. C-Arm Function: It is based on X-ray technology and can be used flexibly in OR. Effects on monitoring: Has no effect on the monitoring.

18. Surgical Table Function: Electrically powered device. In addition to moving up and down, turn in various direction to help optimize patient positioning. Effects on monitoring: Produce artifacts which can make averaging EPs difficult. If unplugging the bed, eliminate the artifacts .

19. Surgical Drill Function: Many procedures involving the skull and other bones require the use of drill by the surgeon. Commonly seen in retro mastoid craniotomies, such as CPA surgeries. Effects on monitoring: Significant artifact is produced. Best to pause averaging.

20. PREPARATION Prepare prior to the procedure day. Thorough planning reduces anxiety during the surgery and ensure best possible monitoring.

21. Preoperative Studies Are EP or EEG studies. Primary reason for a preoperative study is verification of responses that can be monitored. If any abnormality exist, the surgeon is notified prior to surgery. Also allows greater degree of confidence in baseline response in the OR.

22. Contraindications to NIOM Cardiac pacemakers Cranial implants (DBS) Other implants like cochlear implant Skull fractures or recent craniotomy

23. Supplies Supplies Applications A variety of tapes To attach surface and needle electrodes Conductive gel To use for disc electrode conduction Exfoliant To prepare the skin prior to application of electrodes Alcohol preps To disinfect skin before placing needles Skin marking pen Head and muscles marking Collodion For gluing surface electrodes to head Acetone / Collodion remover To remove collodion 1-inch gauze Used with collodion to reinforce the attachment of electrodes Conductive paste To use for disc electrode conduction Cotton applicator tips To apply exfoliant Syringes To hold and apply collodion and conductive gel Tape measure To measure head Air dryer To dry collodion Cotton balls Used with acetone to remove collodion Blunt-tip applicator Used with syringe to apply conductive gel into electrode hole

24. Setup The type of monitoring is needed when the type and site of surgery is known. Access to the patient should be coordinated with surgical team, anesthesia team and the circulating nurse. If using surface electrodes, it is often easier to apply in the preoperative holding area rather than in OR. For the patient comfort, needle electrodes are placed after the patient has been anesthetized .

25. Setup It is important to place the electrode securely, since it will be difficult to access them once the patient is prepped and draped. The wires should be guided along the patient’s body, toward the NIOM machine. They should be secured along the operating table and not left to dangle. The setup is extremely important, it will determine the integrity of waveforms and the ease with which the technologist can monitor the case.

26. Anesthetic Considerations The monitoring technologist should have frequent, open and clear communication with anesthesia team prior to and during the case. Neuromuscular blocking agents and Inhalation agents should not be considered. Consideration should be given to TIVA technique, as with propofol and opioids .

27. SAFETY Safety is most important in the operating room. The monitoring technologist must be not only concerned with the safety of the patient but also with his or her own safety and other personnel in the OR. Attention to the issued listed below can help ensure safety for all.

28. ( i ) Cords and Cables The electrode wires need to be neatly secured along the side of the bed so that the staff will not trip over them. All of these should be run along the floor to the monitoring computer. Some “no trip” operating room supplies are available to cover these cords for safety.

29. (ii) Grounding The patient will have an electrical ground through the electrocautery system. An additional ground will be necessary for NIOM if the monitoring equipment requires it as a system reference .

30. (iii) Infection control NIOM team should always practice universal precautions. If needle electrodes are being used, the skin should be prepped with alcohol skin prep. Needle electrodes are for single use only and should be disposed of in a sharp container. Surface electrodes may be reused and should be cleaned and disinfected using the laboratory protocols.

31. (iv) Personal Protective Equipment During x-rays those taken with C-arm, the technologist should either exit the room or wear lead protection covering. Gloves should always be worn when handling patient , as this is fundamental to universal precautions.

32. Disinfecting Equipment and Supplies Upon completion of surgery, cables, head boxes, stimulating boxes and amplifiers should be wiped down with disinfecting solution and stored neatly on the NIOM machine. Any pencils, tape measurement or other tools that touched the patient or may have been cross contaminated should be disinfected also. Any reusable electrodes should be scrubbed and then soaked in a disinfectant. Disposable supplies should be disposed of properly.

33. CONCLUSION Performing NIOM is not simply performing clinical EP or EEG studies in the operating room. It requires a different knowledge and mind set. The operating room can be an exhausted environment for new NIOM staff. Beginners should learn the etiquettes and policies of their operating room. They must know who the other members of the operating team are and their roles.

34. CONCLUSION There are many pieces of equipments in the room, and the technologist must know which one will cause problem with NIOM. Attention to detail in setup, performing the NIOM, and afterwards will help the NIOM team provide the safe and effective service.

35. THANKS