Sterile Technique
This is the difference between asepsis and sterility
Asepsis is the absence of pathogenic organisms
Sterility is the absence of virtually all organisms
These scissors are used for tissue dissection and should not be used to cut sutures
Metzenbaum scissors
Who is responsible for performing surgical counts?
Two periop nursing professionals—one must be an RN
The scrub nurse is involved in all counts, and is responsible for directing the count
According to the ASA guidelines for NPO status, clear liquids should be stopped this far ahead of surgery
2 hours
This is when you can expect succinylcholine to be used as the muscle relaxant
Emergency intubation—laryngospasm, anaphylaxis
Rapid Sequence Induction (RSI)—for patients at high risk of aspiration
These factors can impact the shelf-life of a sterilized item
Shelf-life is event-related—items are sterile unless packages are damaged, or compromised. Event-related elements include:
Storage conditions—temperature, humidity, moisture
Handling—transport, frequency
Package integrity—rips, tears or other damage to packaging
Note: Time is not a factor
This type of retractor has a curved blade with a rounded off end; it is used when operating on deep tissue
Deaver retractor
For any items added to the field after the initial count is complete, this is the process to follow
The circulating nurse counts the additional item(s) with the scrub nurse
The circulating nurse, who counted, add the item(s) to the count sheet
Initial all additions—above and to the right of the item
This is the key difference between Monitored Anesthesia Care (MAC) and Local Anesthesia
Personnel present and responsible for patient monitoring
For Local Anesthesia, there is no anesthesia care provider present; patient is monitored by the perioperative nurse
For MAC, the anesthesia care provider is responsible for administering medications and monitoring the patient
For patients who will be transferred to PACU intubated, these are workflow modifications you may need to consider
Call ahead to get ventilator setup—10-15min heads up required
Ask anesthesiologist if transport monitor is required
Ambu-bag for transport with full tank of O2
Additional personnel will be needed to help with transport
Specific to in-house sterilized items, this is how you assess sterility of an item
Check package integrity before and after opening—tapes or locks in place, no holes or damage to packaging, no moisture or obvious contamination
External indicator—present and has changed colour
Internal indicator—present and has changed colour
Instruments and miscellaneous items are counted in the quantities you have—sponges are counted according to this
By units of issue—in other words, by the number in each package
If an error is made on the count sheet—this is the process for making corrections
Single strike through the error; write the word error and your initials above and to the right of the item
After settling the patient on the OR bed and applying the safety strap, this should be your first priority
Apply monitors—start with pulse oximeter, then everything else on that side, then walk around the bed to apply rest of monitors
This is the reversal agent for non-depolarizing muscle relaxants
Neostigmine for all non-depolarizing muscle relaxants
Note: Suggamadex is rocuronium-specific
When establishing the sterile field, this is the first thing that you should open
Gown for the scrub nurse; then continue opening around the semi-circle in a sequential manner
True or False: Surgical clips are counted
False—the clip rack (aka bar/cartridge) is counted, but not the actual clips
These are the times that a count will be completed for every surgical procedure (unless it's on the exceptions list)
Initial count—to establish baseline
Final count—at end of procedure or skin closure
This is when cricoid pressure can be released
After ETT placement is confirmed and the balloon is inflated (and you've confirmed it's okay to release)
At the direction of the anesthesiologist
In the event of active vomiting
If initial attempts at intubation with a traditional laryngoscope and stylet are unsuccessful, what could you offer to retrieve for the anesthesiologist?
Offer Glidescope or McGrath (video laryngoscope) along with disposable cover—this is usually the next step
These are some principles of sterile technique you should follow as the circulating nurse
Hand hygiene
If in doubt, consider items contaminated
Communicate actual or potential contamination to the team
When moving around the sterile field: (1) maintain distance (at least one foot) from the sterile field at all times, (2) always face the sterile field when passing by, (3) do not pass between two sterile fields, (4) do not reach or lean over the sterile field
Open packages in a controlled manner—do not flip items; maintain control of package edges
Traffic control—keep movement, door opening, and talking to a minimum; limit the number of people in an OR
These are the three types of needles that are counted
Sutures—suture needle with thread attached (aka Atraloc at LGH)
Free needles—suture needle without thread attached
Injection needles
These are the counts required for a caesarean section
Initial Count—SSMI (Full Surgical Count)
Closure of Uterus—SSM (Partial Surgical Count)
Closure of Peritoneum—SSMI (Full Surgical Count)
Closure of Skin—SSM (Partial Surgical Count)
The acronym LOSTSEMMS refers to the basic equipment required for safe, basic intubation with an endotracheal tube. What does LOSTSEMMS stand for?
Laryngoscope—traditional or video
Oral airway—for assistance with ventilation
Suction—to clear secretions
Tubing (circuit)—includes the gas sample line for capnography
Syringe—to inflate the cuff on the ETT; may substitute cufflator
Endotracheal tube
Mask—for preoxygenation and ventilation
Magill forceps—to help direct the ETT
Stylet
In collaboration with the anesthesiologist, this information should be included as part of your handover to PACU
Patient identification—2 identifiers
Age and weight
Allergy status
Type of anesthesia
Surgical procedure performed—including issues or complications
Skin and pressure injury risk assessment
Ins and outs—including EBL
Drains and packing
Concerns or items for follow-up—pending bloodwork, hearing or sight deficits (and location of assistive devices), settings or status of medical devices (SCDs, NPWT)