THEY ARE IN CHARGE SCRUB TECH & CIRCULATING NURSE Every OR has a “scrub tech” and a “circulating nurse” They are responsible for ensuring that the surgery proceeds safely ◦They enforce sterile technique ◦They enforce “time-out” procedures ◦They document EVERYTHING in their intra- operative notes Who preps the patient Who inserts/removes the foley Who scrubs in the case
YOU CAN HELP WITH THIS! The scrub tech and circulating nurse have a LOT of jobs before and after the case ◦Setting up the OR ◦Documentation Because of this, it is a courtesy for the surgical team to move, position, and prep the patient ◦This includes the attending, resident and student
TAKE INITIATIVE Don’t expect the resident to tell you everything you have to do DON’T CONTAMINATE THE STERILE TABLE Note the location of the sterile table DO NOT TOUCH IT Do not let any objects fall on the sterile table Of note, if you are doing a robotic surgery, the robot is also sterile
RESPECT THE AUTHORITY OF THE SCRUB TECH AND CIRCULATING NURSE Introduce yourself to them Be respectful Do what they say
STEP 1: MOVE THE PATIENT FROM THE CART TO THE O.R. BED Remove their bottom gown (unsnap and untie) The cart and the table must be locked The patient must be protected on both sides by either a railing or a person If the railing is down, there must be a bed or a human being there to protect the patient from falls
The patient will transfer themselves from the cart to the bed ◦They must stay on their back You can then remove the cart from the room ◦Take it into the hallway
STEP 2: PUT ON THE SCDs Put these on patient’s legs Don’t forget to turn the machine on SCDs PREVENT DVTs!!!
STEP 3: POSITION THE STIRRUPS ON THE O.R. BED For gyne surgeries, the patient is usually in lithotomy position ◦Their legs are raised and flexed in stirrups
You should position the stirrups on the O.R. bed ◦Pre-operatively, the stirrups are usually hanging on a rack
Place the positioning clamp on the bed Insert the stirrups into the clamp WATCH THIS VIDEO: scroll ahead and watch 5:30 to 8:00 ◦http://www.allenmedical.com/allenStirrups.php
STEP 4: AFTER THE PATIENT IS ASLEEP, POSITION THE PATIENT IN DORSAL LITHOTOMY
SAFETY FIRST Important points about lithotomy position: ◦Hips flexed 80-100° from the trunk ◦Legs ABducted 30-45° from the midline ◦The lowest part of the bed (“femoral”) is lowered ◦The legs are raised simultaneously to avoid torsion of the lumbar spine ◦Position the hands to avoid entrapment when moving the legs and the bottom of the bed
In dorsal lithotomy, the bottom portion of the bed is lowered The end of the bed must be removed The mattress must be removed
Students should help with this Our beds have an extension at the bottom that needs to be removed. Remove the mattress before this part of the bed is lowered.
SMALL POINTS, BUT CRUCIAL! Make sure the fingers are protected
STEP 5: HELP THE RESIDENT PREP THE PATIENT AS NEEDED See powerpoint on surgical prep
STEP 6: GIVE THE SCRUB NURSE YOUR GLOVES You might also do this before the patient is asleep Open the gloves in sterile fashion STEP 7: GIVE THE CIRCULATING NURSE YOUR ID AND PAGER They need your ID in order to document everyone who scrubbed into the surgery
REVIEW THIS TECHNIQUE! AFTER ALL OF THIS, YOU CAN GO SCRUB IN
It is dangerous for the patient to wake up in lithotomy position ◦If the patient thrashes around, she risks hip fracture The most important priority after surgery is to lower her legs to supine Remember the steps: ◦Replace the end of the bed ◦Replace the mattress Lower the legs in unison This should happen quickly!
In general: You should never be standing around doing nothing in the OR! There are always helpful jobs to do. Keep thinking, “What happens next” and do it! After this, you can remove the stirrups, go get the cart from the hallway, etc
In the OR Adverse effects of positioning: a review
Increased preload increased cardiac output Increased cerebral venous and intracranial pressure The abdominal viscera displaces the diaphragm cephalad, reducing lung volume compliance decreased tidal volume If a large abdominal mass is present, venous return from the heart can be compromised The normal lordotic curve of the back is lost, which can possibly exacerbate lower back pain Adverse effects: Trendelenburg Position
Adverse effects: Lithotomy Position Common peroneal nerve (78% of all nerve injuries in lithotomy position) ◦Occurs when the lateral fibular head is compressed against the stirrups Femoral nerve injury ◦From exaggerated hip flexion or abduction
Sources: ◦Miller’s Anesthesia, 7 th ed. Miller et al. 2009 Churchill Livingstone, an imprint of Elsevier. ◦Lentz: Comprehensive Gynecology, 6 th ed. Lentz et al. 2012 Mosby, an imprint of Elsevier. ◦Allen Medical Systems. http://www.allenmedical.com/