Perioperative Practice at a Glance 1st Edition by Paul Wicker 1118842154 9781118842157

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ISBN 10: 1118842154

ISBN 13: 9781118842157

Author: Paul Wicker

A highly visual learning consolidator covering everything healthcare practitioners in the surgical and operating departments need to know about care of patients in the perioperative environment.

Perioperative Practice at a Glance 1st Table of contents:

Part 1 Introduction to perioperative practice

1 Preoperative patient preparation

Table 1.1 Normal physiological lab values

Figure 1.1 Checking patient’s wrist band on entry to the operating department

Figure 1.2 Checking patient’s care plan on entry into the operating department

Figure 1.3 Practitioner in reception checks the patient’s notes and confirms status

Preoperative visiting

Preoperative assessment

Preoperative investigations

Reducing postoperative complications

2 Theatre scrubs and personal protective equipment (PPE)

Figure 2.1 A practitioner prepared for cleaning the operating room and protected by personal protective equipment, including hat, gloves, mask, face shield and apron

Theatre scrubs

Headwear

Footwear

Surgical masks

Patient dress

Theatre scrubs outside theatre

3 Preventing the transmission of infection

Figure 3.1 Key elements of standard precautions to help prevent infection in patients

Operating room cleaning

Personal protection while cleaning

Cleaning equipment

Cleaning between cases

Cleaning at the end of cases

Risks to practitioners

Blood-borne viruses

Sharps and splash injuries

MRSA patients

4 Preparing and managing equipment

Figure 4.1 Equipment checklist This is an example of a potential checklist for equipment. The checklist in each operating theatre depends on the surgical speciality and the equipment that is present.

Initial equipment checks

Anaesthetic equipment

Surgical equipment

5 Perioperative patient care

Figure 5.1 Sample of patient care plan

Patient outcomes

Care pathways

6 Surgical Safety Checklist – Part 1

Figure 6.1 Countries where the Safe Surgery Checklist (SSCL) was piloted, resulting in lower incidences of surgery-related deaths and complications

Figure 6.2 Undertaking the SSCL

Figure 6.3 Example of a Safe Surgery Checklist

The Surgical Safety Checklist (Figure 6.3)

Introducing the checklist into the operating department

Adjusting the checklist

7 Surgical Safety Checklist – Part 2

Figure 7.1 Surgical Safety Checklist This document can be updated and amended to conform to hospital rules and regulations within the NHS

SIGN IN

TIME OUT

SIGN OUT

8 Legal and professional accountability

Figure 8.1 Legal and professional accountability

Figure 8.2 The anaesthetic practitioner checks the patients details and discusses the actions to be taken during anaesthesia

Modes of accountability

Legal issues

Defences against negligence

Assault and consent

Hospital requirements

Accountability and professional practice

9 Interprofessional teamworking

Figure 9.1 Better Training Better Care This poster refers to a pilot project entitled ‘Better Training Better Care’, which is being supported by Health Education England. The pilot projects involve using cadaveric workshops to train surgeons and perioperative practitioners, and also to increase collaboration between all the professions in perioperative care

Interprofessional conflicts

Part 2 Anaesthesia

10 Preparing anaesthetic equipment

Figure 10.1 Basic anaesthetic machine, for use in the anaesthetic room

Figure 10.2 Anaesthetic machine, ECG monitor, capnograph, ventilator etc., used during surgery

Figure 10.3 Guedal (oral) airways These devices may be used in association with a face mask or postoperatively until the patient wakes up

Figure 10.4 ET tubes, laryngoscope, oral airways, laryngeal mask airways (LMA)

Figure 10.5 Cuffed tracheostomy tube

Airway tubes

Consumable items

Monitoring devices

Medical gas cylinders

Fluid warmers

11 Checking the anaesthetic machine

Box 11.1 Checking anaesthetic equipment

Figure 11.1 Checklist for anaesthetic equipment

Basic steps for checking an anaesthetic machine

12 Anatomy and physiology of the respiratory and cardiovascular systems

Figure 12.1 Respiratory anatomy

Figure 12.2 Gas exchange in the alveoli

Figure 12.3 Cardiovascular anatomy (external)

Figure 12.4 Cardiovascular anatomy (internal)

Figure 12.5 Cardiovascular blood flow

Figure 12.6 ECG

Respiratory system

Mechanics of breathing

Physiology of gas exchange

Cardiovascular system

The ECG

The coronary circulation

13 Anaesthetic drugs

Figure 13.1 Action of inhalational agents

Figure 13.2 Neuromuscular junction

Figure 13.3 Action of muscle relaxants

Figure 13.4 Action of opioids

Induction agents

Inhalation agents

Muscle relaxants

Analgesics

14 Perioperative fluid management

Figure 14.1 Compartmental distribution of total body water in a 70 kg male

Figure 14.2 Osmosis Osmosis is the movement of fluid across a membrane into an area where there is a high concentration of solutes. Osmotic pressure is pressure that is applied to the chamber with the highest ratio of solutes, in order to prevent fluid moving from the chamber with the lowest level of solutes to the chamber with the highest number of solutes.

Figure 14.3 Crystalloids Samples of crystalloid solutions

Figure 14.4 Colloids Samples of colloid solutions

Figure 14.5 Intravenous cannula inserted in hand ready for anaesthetic drugs or intravenous fluids

Effects of crystalloids

Hartmann’s solution

Normal saline (NS)

5% dextrose

Hypertonic saline (2%, 3% and 7.5%)

Effects of colloids

Blood and blood byproducts

15 Monitoring the patient

Figure 15.1 CARESCAPE Monitor B850 The CARESCAPE Monitor B850 can be used for patients both preoperatively and postoperatively. The monitor is a high-acuity monitor that can help practitioners manage their patients by providing a dependable level of data continuity and integration across care areas

Electrocardiogram (ECG)

Pulse oximeters

Temperature probes

Vapour analyser

Capnography

Non-invasive blood pressure (NIBP) measurement

16 General anaesthesia

Figure 16.1 Anaesthetic drugs cupboard in anaesthetic room

Figure 16.2 Anaesthetic drugs prepared for anaesthetic, including Propofol, muscle relaxants and analgesics

Figure 16.3 Patient anaesthetised in the anaesthetic room

Signs and stages of anaesthesia (Guedel’s signs)

Induction, maintenance and extubation

Administration of anaesthetic agents

Total intravenous anaesthesia (TIVA)

Complications of general anaesthesia

17 Local anaesthesia

Figure 17.1 Local anaesthetic being injected prior to insertion of an intravenous cannula

Figure 17.2 Local anaesthetic injected into a knee

Figure 17.3 EMLA

Clinical use of local anaesthetics

Topical anaesthetics

Infiltrative local anaesthetics

18 Regional anaesthesia

Figure 18.1 Vertebral column anatomy

Figure 18.2 Vertebral column anatomy detail

Figure 18.3 Caudal epidural block

Figure 18.4 Epidural injection

Anatomy of the spine

Effects of local anaesthetics

Spinal technique

Epidural technique

Intravenous regional techniques

Part 3 Surgery

19 Roles of the circulating and scrub team

Figure 19.1 The circulating and scrub team

Figure 19.2 Practitioners cleaning operating room following surgery and preparing for the next patient’s arrival

Circulating practitioners

Scrub practitioners

Before surgery

During surgery

After surgery

20 Basic surgical instruments

Figure 20.1 An array of surgical instruments including: needle holders, retractors, scissors, tissues forceps, curettes, towel clips, bone holders, suction devices etc.

Figure 20.2 Instrument trays being set up for gynaecological surgery

Types of instruments

Cutting and dissecting

Grasping and holding

Clamping and occluding

Exposing and retracting

Suturing and stapling

Suctioning and aspirating

Microinstrumentation

Powered surgical instruments

21 Surgical scrubbing

Figure 21.1 Scrub procedures

Figure 21.2 Using scrub solution to wash hands and arms

Figure 21.3 Rinsing hands and arms at end of scrubbing

Figure 21.4 Drying hands and arms carefully to prevent contamination

Figure 21.5 Donning gloves and gown ready for surgery

Surgical scrub procedure

Side effects of surgical scrubbing

22 Surgical positioning

Figure 22.1 Patient positioning

Equipment requirements for positioning

Surgical positions

23 Maintaining the sterile field

Figure 23.1 Sterile and unsterile members of the team and the sterile field

Sterile procedures

Preparing a sterile tray

Surgical draping

24 Sterilisation and disinfection

Figure 24.1 Procedures for disinfection and sterilisation

Figure 24.2 Sterile instruments which are stored safely within two coverings to keep them sterile.

Methods of sterilisation

Physical agents

Chemical agents

Mechanical agents

25 Swab and instrument counts

Figure 25.1 Practitioners completing the swab board following counting of swabs and instruments Swab boards vary between hospitals although practitioners are always trained how to complete the boards according to hospital guidelines, rules and regulations.

Figure 25.2 Counting instruments following surgery, using an instrument count sheet

Rationale behind the swab and instrument count

Principles of the swab and instrument count

Checking swabs and other items

Checking instruments

26 Working with electrosurgery

Figure 26.1 Monopolar electrosurgery

Figure 26.2 Bipolar electrosurgery

Figure 26.3 Surgical effects of electrosurgery

Figure 26.4 Electrosurgery used to cut tissues The tip of the pencil is very thin which allows careful cutting of tissues and avoiding damage to other tissues.

How does electrosurgery work?

The three surgical effects of electrosurgery (Figure 26.3)

Monopolar electrosurgery (Figure 26.1)

Bipolar electrosurgery (Figure 26.2)

The return electrode

Safety checks

Hazards of electrosurgery

Conclusion

27 Tourniquet management

Figure 27.1 Attaching the velband

Figure 27.2 Wrapping the tourniquet

Figure 27.3 Fixing the tourniquet in place, and securing it

Figure 27.4 Applying an Eschmarch bandage

Figure 27.5 Applying the Rys-Davies Exsanguinator to remove blood from the arm. Following this the machine is switched on and the tourniquet inflates

Figure 27.6 Applying an Eschmarch bandage

Figure 27.7 Tourniquet machine

Applying the tourniquet

Pneumatic tourniquets

Side effects

28 Wounds and dressings

Figure 28.1 Applying Opsite © dressing to small wounds that have been sutured

Figure 28.2 Covering an open wound with melolin dressings

Figure 28.3 Wrapping soffban © wool around dressings to hold them in place

Figure 28.4 Applying a crepe bandage to the open leg wound to secure all dressings

Modes of healing

Types of dressings

Bandages

Complications

Part 4 Recovery

29 Introducing the recovery room

Figure 29.1 Patient being looked after in recovery by a recovery practitioner

Caring for the postoperative patient

Patients who have undergone spinal anaesthesia

Patients who have undergone general anaesthesia

Discharge from the recovery room

30 Patient handover

Figure 30.1 Patient handover in the recovery room following surgery

Admission into the recovery unit

Initial assessment

Documentation

Discharge

31 Postoperative patient care – Part 1

Figure 31.1 Entering recovery

Figure 31.2 Patient feeling unwell

Figure 31.3 Checking the patient’s notes and surgical procedure

Box 31.1 Respiratory status

Box 31.2 Cardiovascular status

Respiratory status (Box 31.1)

Cardiovascular status (Box 31.2)

32 Postoperative patient care – Part 2

Figure 32.1 Example of a postoperative patient care plan

Temperature status

General patient care

33 Monitoring in recovery

Figure 33.1 Checking the patient’s temperature postoperatively to check for any problems related to hypothermia or hyperthermia

Figure 33.2 Complex selection of monitoring devices used to care for patients safely.

Respiratory monitoring

Cardiovascular monitoring

Neuromuscular monitoring

Psychological monitoring

Temperature monitoring

Pain monitoring

Monitoring nausea and vomiting

Fluid monitoring

Urine output and voiding

Drainage and bleeding

34 Maintaining the airway

Figure 34.1 Oral airway and face mask

Figure 34.2 Tracheostomy

Figure 34.3 Nasopharyngeal airway

Figure 34.4 Endotracheal tube

Physiology of the airway

Circulation

Monitoring of the airway

Postoperative airway complications

Discharge criteria

35 Common postoperative problems

Table 35.1 Postoperative complications The prevalence of postoperative complications in a research study into postoperative patients who had undergone cardiac surgery (Lobo et al. 2008), which showed that the patient population had an overall major complication rate of 38.3% and 90-day mortality rate of 20.3%

Allergy

Haemorrhage

Septic shock

Intravascular catheters

Urinary complications

Wound dehiscence

Other issues

36 Managing postoperative pain

Figure 36.1 A pain rating scale

Figure 36.2 A PCAM® syringe pump which monitors the patients use of pain killers. The patient administers the pain killer by pressing the button attached to the black cable

Concept of pain

Effects of pain

Pain physiology

Managing pain

Systemic opioids

Nonsteroidal anti-inflammatory drugs (NSAIDS)

Regional techniques

Non-pharmacologic techniques

37 Managing postoperative nausea and vomiting

Figure 37.1 Physiology of vomiting

Figure 37.2 Act of vomiting

Physiology of vomiting

Risk factors

Prevention of vomiting

Anti-emetic therapy

Conclusion

Part 5 Perioperative emergencies

38 Caring for the critically ill

Box 38.1 Principal recommendations for caring for the critically ill

Figure 38.1 A recovery practitioner caring for a high-risk patient following major surgery

Critical risk areas

Improvements in patient care

High-risk patients in recovery

Conclusion

39 Airway problems

Figure 39.1 Insertion of oral airway The airway is first inserted upside down, and then reversed to insert into the trachea

Figure 39.2 Ventilation using a mask and bag Two practitioners make ventilation more effective and easier to control

Assessing the airway

Airway control

Tracheostomy

40 Rapid sequence induction

Box 40.1 Sedation

Box 40.2 Neuromuscular blocking (NMB) agents

Figure 40.1 Patient undergoing rapid sequence induction The anaesthetist is inserting the endotracheal tube while the practitioner is applying cricoid pressure to prevent gastric re ux from the stomach into the lungs

Preparation (T(time) − 10 minutes)

Preoxygenation (T − 5 minutes)

Pretreatment (T − 3 minutes)

Paralysis with induction (zero)

Placement of endotracheal tube (T + 30 seconds)

Postintubation management

41 Bleeding problems

Figure 41.1 The management of critical bleeding in surgical patients

Managing rapid blood loss in surgery

Managing rapid blood loss in recovery

42 Malignant hyperthermia

Box 42.1 EMHG guidelines: Recognising an MH crisis

Box 42.2 EMHG guidelines: Managing an MH crisis

Diagnosis

Symptoms

Prevention

Expected duration

Treatment (Box 42.2)

43 Cardiovascular problems

Figure 43.1a Cardiovascular system

Figure 43.1b Ischaemic heart attack

Figure 43.2 Replacement of blocked coronary arteries using blood vessels from arms or legs

Preoperative evaluation

Hypertension

Arrhythmias

Aortic stenosis

Congestive heart failure

44 Electrosurgical burns

Figure 44.1 Diathermy burns Forearm and hand – 50 days after the surgery

Figure 44.2 Diathermy burns Atrophy and contracture of the forearm and hand

Figure 44.3 An electrosurgical burn This 38-year-old patient underwent a circumcision. Instead of using bipolar electrosurgery, the surgeon used monopolar electrosurgery. As the current returned up the penis towards the return electrode, the vessels in the penis became coagulated, leading to necrosis. After two weeks the penis was amputated. This event occurred about 9 years ago. Bipolar electrosurgery would have prevented this from occurring, as the current would only have passed through the tissues held between the tines of the bipolar forceps

Thermal burns

Explosion and fire

45 Venous thromboembolism

Figure 45.1 Action of intermittent pneumatic compression (IPC) on blood vessels

Figure 45.2 Action of IPC on blood and lymphatic supplies

Physiology of DVT

Treatment options

Mechanical prophylaxis

Intermittent compression devices (ICD)

Precautions

46 Latex allergy

Figure 46.1 Some of the tissues affected following an allergic reaction The early phase of the allergic reaction typically occurs within minutes, or even seconds, following allergen exposure and is also commonly referred to as the immediate allergic reaction or Type I allergic reaction. The reaction is caused by the release of histamine and mast cell granule proteins by a process called degranulation, as well as the production of leukotrienes, prostaglandins and cytokines, by mast cells following the crosslinking of allergenspecific IgE molecules bound to mast cell FcεRI receptors. These mediators affect nerve cells, causing itching, smooth muscle cells causing contraction (leading to the airway narrowing seen in allergic asthma), goblet cells causing mucus production, and endothelial cells causing vasodilatation and oedema

Reducing problems with latex

Dangers of latex

Treatment for severe allergic reaction

Managing the perioperative environment

Postoperative management

Part 6 Advanced surgical practice

47 Assisting the surgeon

Figure 47.1 A patient undergoing wound closure following a fasciotomy due to trauma damage to his leg The surgical care practitioner is assisting the surgeon by attaching loops to the skin to help close the wound. The wound will not close completely because of the expanded leg muscles

Surgical First Assistant

Roles and responsibilities

Surgical Care Practitioner

Roles and responsibilities

48 Shaving, marking, prepping and draping

Figure 48.1 Shaving the patient prior to surgery

Figure 48.2 Disposal of swabs and instruments following prepping of skin

Figure 48.3 Common draping for major abdominal cases

Figure 48.4 Draping the patient’s leg using a drape with a central hole for the leg to go through

Figure 48.5 Draping the patient by covering their top, bottom and side – here the leg is being wrapped by a drape

Figure 48.6 Marking the patient

Shaving

Skin marking

Skin preparation

Draping

49 Retraction of tissues

Figure 49.1 (a) Deavers retractors, (b) Langenbecks retractors, (c) rake retractor, (d) Balfour self-retaining retractor and (e) Travers self-retaining retractor

Figure 49.2 (a) Transanal surgical retractor, for hip surgery, (b) table-mounted Omni-flex® retractor for hip surgery

Figure 49.3 Retraction of tissues using a self-retaining retractor and a Hohmann’s retractor

Figure 49.4 Curved Travers retractor

Figure 49.5 Gelpi self-retaining retractor

Holding retractors

Managing retractors

Hand-held retractors

Self-retaining retractors

Table-mounted retractors

50 Suture techniques and materials

Figure 50.1 Methods for releasing clips attached to suture materials

Figure 50.2 Examples of suture techniques

Figure 50.3 Suturing a damaged blood vessel and ligating other blood vessels in close proximity

Assisting the surgeon

Suture techniques

Suture materials

51 Haemostatic techniques

Figure 51.1 Coagulation of blood The coagulation of blood is dependent on the actions of enzymes and activity by blood cells. The end result, following the activation of coagulation by thrombin, is the formation of a blood clot that acts as a plug to stop further bleeding. During the healing phase, as the vessel repairs itself, the clot starts dissolving in a phase known as fibrinolysis During this phase the clots dissolve, releasing fibrin fragments.

Figure 51.2 Use of diathermy to stop bleeding

Assisting with haemostasis

Minor bleeding

Major bleeding

Haemostatic agents

52 Laparoscopic surgery

Figure 52.1 Laparoscopic surgery – placement of equipment for optimum viewing

Figure 52.2 Laparoscopic surgery in gynaecology

Figure 52.3 Laparoscopic cholecystectomy

Figure 52.4 Laparoscopic colorectal surgery

Before surgery

During surgery

Training and development

53 Orthopaedic surgery

Figure 53.1 Arthroscopy

Figure 53.2 Hip replacement

Figure 53.3 Knee-replacement surgery

Figure 53.4 Tibial surgery requiring insertion of nail

Specific factors in orthopaedic surgery

Arthroscopic knee surgery

Elective joint replacement

Trauma orthopaedics

54 Cardiac surgery

Figure 54.1 Aortic valve replacement

Figure 54.2 Mechanical bicuspid aortic valve

Figure 54.3 Aortic valve from a pig (porcine bioprosthesis

Role of the surgeon’s assistant

55 Things to do after surgery

Figure 55.1 Surgeon and assistant shaking hands after successfully completing surgery

Back Matter

References and further reading

1 Preoperative patient preparation

References

Further reading

Websites

Videos

2 Theatre scrubs and personal protective equipment

References

Further reading

Websites

Videos

3 Preventing the transmission of infection

References

Further reading

Websites

Videos

4 Preparing and managing equipment

References

Further reading

Websites

Videos

5 Perioperative patient care

References

Further reading

Websites

Videos

6–7 Surgical safety checklist

References

Further reading

Websites

Videos

8 Legal and professional accountability

References

Further reading

Websites

Videos

9 Interprofessional teamworking

References

Further reading

Websites

Videos

10 Preparing anaesthetic equipment

References

Further reading

Websites

Videos

11 Checking the anaesthetic machine

References

Further reading

Websites

Videos

12 Anatomy and physiology of the respiratory and cardiovascular systems

References

Further reading

Websites

Videos

13 Anaesthetic drugs

References

Further reading

Websites

Videos

14 Perioperative fluid management

References

Further reading

Websites

Videos

15 Monitoring the patient

References

Further reading

Websites

Videos

16 General anaesthesia

References

Further reading

Websites

Videos

17 Local anaesthesia

References

Further reading

Websites

Videos

18 Regional anaesthesia

References

Further reading

Websites

Videos

19 Roles of the circulating and scrub team

References

Further reading

Websites

Videos

20 Basic surgical instruments

References

Further reading

Websites

Videos

21 Surgical scrubbing

References

Further reading

Websites

Videos

22 Surgical positioning

References

Further reading

Websites

Videos

23 Maintaining the sterile field

References

Further reading

Websites

Videos

24 Sterilisation and disinfection

References

Further reading

Websites

Videos

25 Swab and instrument counts

References

Further reading

Websites

Videos

26 Working with electrosurgery

References

Further reading

Websites

Videos

27 Tourniquet management

References

Further reading

Websites

Videos

28 Wounds and dressings

References

Further reading

Websites

Videos

29 Introducing the recovery room

References

Further reading

Websites

Videos

30 Patient handover

References

Further reading

Websites

Videos

31 Postoperative patient care – Part 1

References

Further reading

Websites

Videos

32 Postoperative patient care – Part 2

References

Further reading

Websites

Videos

33 Monitoring in recovery

References

Further reading

Websites

Videos

34 Maintaining the airway

References

Further reading

Websites

Videos

35 Common postoperative problems

References

Further reading

Web sites

Videos

36 Managing postoperative pain

References

Further reading

Websites

Videos

37 Managing postoperative nausea and vomiting

References

Further reading

Websites

Videos

38 Caring for the critically Ill

References

Further reading

Websites

Videos

39 Airway problems

References

Further reading

Websites

Videos

40 Rapid sequence induction

References

Further reading

Websites

Videos

41 Bleeding problems

References

Further reading

Websites

Videos

42 Malignant hyperthermia

References

Further reading

Websites

Videos

43 Cardiovascular problems

References

Further reading

Website

Videos

44 Electrosurgical burns

References

Further reading

Websites

Videos

45 Venous thromboembolism

References

Further reading

Websites

Videos

46 Latex allergy

References

Further reading

Websites

Videos

47 Assisting the surgeon

References

Further reading

Websites

Videos

48 Shaving, marking, prepping and draping

References

Further reading

Websites

Videos

49 Retraction of tissues

References

Further reading

Websites

Videos

50 Suture techniques and materials

References

Further reading

Websites

Videos

51 Haemostatic techniques

References

Further reading

Websites

Videos

52 Laparoscopic surgery

References

Further reading

Websites

Videos

53 Orthopaedic surgery

References

Further reading

Websites

Videos

54 Cardiac surgery

References

Further reading

Websites

Videos

55 Things to do after surgery

References

Further reading

Websites

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