Intraoperative Radiography DMI online ed.

Working in OR requires : Super awareness of sterile environment! Skill in use of portable machine and c-arm Skill in working OR table Using radiation protection appropriately Knowledge of anatomic landmarks- whether you can see them or not! Ability to work with surgery staff under high pressure circumstances

Mobile Image Intensifier Commonly referred to as? C-arm Is it sterile? No! Unless----

Portable X-ray Unit Sterile? No! Unless covered with sterile plastic covers after portable brought into OR (X-ray machine should be cleaned prior to entering each OR!)

OR table Learn how to work control box Sterile? No! Unless- Covered with sterile drapes!

Radiation Protection Shield patient if possible! If it doesn’t interfere with exam The mobile unit should not be used as shield by you YOU must provide Lead aprons for all personnel! Monitoring badges should be worn by all personnel You are responsible for making sure all personnel who can or want to leave room prior to making an exposure are given a loud clear warning and have a chance to get out

Fluroscopy When using the c-arm, the radiation source is generally under pt, so where should shielding should be placed? Under the pt! between source and pt Must be done before pt is put on table

If you are not sure, consider it sterile!

During surgery Technologist works under direction of surgeon not a radiologist Who will appear to hate you! You must be able to perform accurately and quickly! “Repeat” is no longer in your vocabulary! Remember: it’s a high stress situation for all –but success or failure rests on surgeon’s shoulders

Check your ego at the door! You no longer have a name - you are “X-ray” Only person lower than you is guy who cleans OR- at least they know his name! (Jose) Expect some abuse! Good part -if you screw up, they won’t recognize you outside OR!

You must be able to read minds! When running c-arm, when Dr. wants fluoro, he expects you to understand that: – “X-ray” – “now” – “OK” – “uh huh” – “ready” – grunt – mumble – Or maybe just a glance at monitor Mean: hit the fluoro pedal- even when used interchangeably God help you if you fluoro when he didn’t want it!!!

3 Areas of OR Unrestricted Semi-restricted Restricted

Unrestricted areas of OR Provides outside to inside access No traffic restrictions Street clothes permitted

Semi-restricted areas of OR Provides access from unrestricted area of OR to restricted area Authorized personnel only Pts and staff Proper OR attire required Scrubs, head and shoe covers

Examples of Semi-restricted area Hallways within OR rooms Instrument and supply processing area Non-sterile supply areas and utility rooms

Restricted Areas Where surgical procedures are carried out Proper OR attire and mask must be worn Examples: Scrub sink areas Sterile supply rooms Operating suites

The Surgical Suite Restricted area! Scrub clothes must be worn, and covered with robe if leaving department Know Who is sterile and who isn’t! Know What equipment is sterile and what isn’t! No items should be touched without permission of circulating nurse or person in charge!

Operating Room Attire Clean, fresh attire, surgical “scrubs,” donned at beginning of each shift Are they sterile? no Change as necessary Should soiled scrubs be worn outside OR suite? no!

What the surgery team wears!

Masks worn at all times in OR! Are they sterile? No!

Operating Room Attire Caps Worn in all areas of OR to contain hair Hoods available to cover any facial hair not contained by mask Are they sterile? No!

Surgical Shoe Covers Purpose: Top prevent you from tracking in contaminants To prevent contaminants from soiling your shoes Are they sterile? NO!

Operating Room Attire for Techs Gloves Worn to protect tech from body fluids –sterile? No! Radiation badge Proper ID

Lead attire

Person with known transmittable infection should not be permitted in OR suite! o Cold o Acute infection o Open cold sore o Sore throat o Carrier of transmittable conditions Pathogens fall into two broad categories: Blood and body fluid borne Airborne

Universal Precautions The practice in medicine of avoiding contact with patients' bodily fluids, by means of wearing of nonporous articles such as medical gloves, goggles, and face shields to prevent exposure to pathogens of potential portals of entry for infection (nose, mouth, mucous surfaces, conjunctival membranes, abrasions and lacerations on skin, etc.) Initially developed in 1987 by the Centers for Disease Control and Prevention in US Surgical gloves now worn when performing simple procedures such as drawing blood from veins and conducting intra-oral exam OSHA (Occupational Safety and Health Administration) standards include procedures for cleaning and disposing of used surgical equipment, needles, and laundry, and for disposal of contaminated waste

Supplement, not replace routine infection-control procedures, such as handwashing and use of surgical gloves Does not eliminate need for other categories of disease-specific isolation measures, such as isolation procedures used for open pulmonary tuberculosis and "enteric" procedures used for cases of infectious diarrhea At first regarded use of universal precautions as actually or potentially stigmatizing—tending to label patients as "contaminated" but this attitude has been overcome by careful explanation and educational material Universal precautions are intended to :

Aseptic Vs Sterile Aseptic : Free from pathogenic (disease causing) microorganisms Sterile: Free from all living microorganisms

Nosocomial infections Infections resulting from of treatment in a hospital or a healthcare service unit Infections are considered nosocomial if they first appear: 48 hours or more after hospital admission or within 30 days after discharge

Nosocomial infections (cont’d) In US, Centers for Disease Control and Prevention estimates 1.7 million hospital-associated infections, cause or contribute to 99,000 deaths each year Commonly transmitted when hospital officials become complacent and do not practice correct hygiene regularly Increased use of outpatient treatment means people hospitalized are more ill and have more weakened immune systems than may have been true in past

Radiographers or other non-sterile personnel must maintain a safe margin from any sterile field- What is worse than contaminating a sterile field? - not reporting it!

What is the sterile corridor? Area between instrument table and draped pt not non-sterile Must not be entered by any non-sterile personnel! Notify immediately Notify proper personnel immediately if a sterile field is contaminated!!

What parts of sterile gown are considered sterile? On sleeves- elbow to cuffs On body- shoulder to level of sterile field

Logistical Problems Getting c-arm or portable through jungle of equipment and people Getting cassette under pt without breaking sterile field Centering CR to pt and to cassette when you can’t see or touch either one! Grid cut off! When x-ray is performed table top, covered with sterile cloth- you can’t see body part! Watch out for your lead apron hitting field

Loading A Cassette in Sterile Cover 2 person job! Tech OR staff

Retrieving IR in Sterile Field Why must Radiographer be wearing gloves? in case IR cover is contaminated with blood or body fluids Surgical tech or nurse gives covered IR to radiographer OK to contaminate cover now, but not person handing you cassette! Cover and gloves are disposed of properly before handling uncovered IR

After the exposure: Hot foot it up department and develop image STAT and return with image to OR ASAP Remember: Longer time pt. spends under anesthesia the greater risk to patient Prolonged exposure unnecessarily adds to the risk of infection Longer time spent in the OR for pt, the greater the cost to pt! Longer time you take, the angrier the Dr.s will be with you!

Cardiac Surgery Anything pertaining to heart and related major blood vessels Most common procedures: – pacemaker and automatic internal cardiac defibrillator insertions (C-arm) – Coronary artery bypass grafts Post-op CXR generally required after above mentioned procedures

Cholangiogram

Neurosurgery Laminectomies – Requires x-table lateral projections Shunt placements Transphenoidal cases – Requires C-arm or skull films

Cross-Table Lateral Cervical Spine

Oncology Catheter placements Usually by C-arm Requires a post-op CXR Brachytherapy localization Requires two views at right angle to each other Cesium Implant

Orthopedic Surgery ORIF stands for? Open reduction internal fixation May require C-arm or plain film radiography Closed reduction is what? No surgical incision- just manipulation C-arm or plain films

Joint Replacement

Orthopedic Surgery

Pain Management Requires C-arm to locate injection site for facet block Usually in: – Lumbar spine or – SI joint or – Cervical spine

Vascular Surgery Utilizes both plain film and mobile fluoroscopy AV fistulas, AV grafts are most common procedures What is an AV fistula? abnormal connection or passageway between artery and vein)

Urology Suite Retrograde Pyelograms (contrast flows from bladder up to kidney) IVU’s Kidney & gallstone extractions Percutaneous Nephrolithotomy (removal stones from kidney by small puncture wound ( up to about 1 cm) through skin)

Summation of Important Things To Remember in OR! Upon entering OR, alert all staff of your presence and purpose Be aware of sterile fields and personnel Enlist aid of circulating nurse to move equipment out of way Any cassettes placed in sterile field must be covered first by a sterile member of the team Allow team to clear room prior to making the exposure Do it right the first time!!!