Transfer to OR table

ORP should assess the patient’s condition before transfer. If able the patient should be allowed to move onto the operating table (OT) with minimal assistance, but most trauma patients require help to transfer. No matter how this is organized ORP must make sure that the transfer is managed safely. The OT and patient trolley must be positioned properly with the brakes fully applied to both before the transfer begins. Adequate staff and moving aids, for example sliding devices, must be available to move the patient safely. Patients should be kept suitably covered to maintain their dignity and keep them warm. Before being moved the patient must be informed about the transfer, which should be carried out in a smooth and well-coordinated manner. Care must be taken of any intravenous or arterial lines, catheters, chest drains, and so on and the injured limb should be adequately supported.

Preoperative checklist

The most important duty of the perioperative team is to protect the patient from harm. Therefore, ORP must make certain that all required documents/orders/tests are present and complete and that a series of checks are performed in accordance with hospital policy before the patient is anesthetized.

Preoperative checklist

This should include but need not be limited to:

Patients should be treated as individuals. Although these preoperative checks are important in safeguarding every patient, additional information is sometimes relevant to the perioperative team. For example, a patient’s injuries or mobility limitations may affect the manner in which the patient is moved and positioned, and the possibility of a patient being pregnant will have implications for radiological imaging and the possible effect of anesthesia.

Provision must be made for patients with particular needs, such as the disabled, those with sight or hearing impairments or special needs, and those who need an interpreter. Caregivers may need to accompany these patients right up to the induction of anesthesia to help with communication and transfer, and be available again for the postoperative care.

Pediatric patients need special consideration and should always have a parent or caregiver with them until induction of anesthesia or at an appropriate stage of the child’s care. The child should be allowed to bring a personal item, such as a toy for comfort. ORP should greet both the parent and child in a friendly and professional manner and, as part of the preoperative check, ensure that the consent form has been completed correctly and where necessary signed by the parent/guardian in the appropriate place. Parents may become emotional and need sympathetic support and reassurance from ORP.

Preoperative verification for correct site surgery

Verification that the correct patient has arrived and is listed for the correct intended surgery or procedure on the correct operative site is an ongoing process that must be performed whenever the patient’s care is transferred.

The risk of operating on the wrong site must be managed effectively. Procedures and protocols to promote correct site surgery should be available in all areas where surgery takes place.

The possibility of operating on the wrong site is an ever present danger. Preoperative marking of the operative site is important in promoting correct site surgery and ORP performing the preoperative checks must verify that the correct site is marked. Remember, anesthetized patients cannot speak for themselves and depend on the perioperative team to ensure that the right procedure is performed on the correct operative site.

The operative site should be marked with an indelible marker pen at or near the incision site with an arrow that will remain visible following the application of skin preparation, although plaster casts or other splints sometimes make this difficult. Marking of the operative site should take place preoperatively, ideally on the ward, and before the patient receives any premedication. Marking should be checked by the surgeon before the patient arrives in the OR.

At each transfer of the patient marking must be checked with the documentation to confirm the correct site.

Consent

The consent form documents the patients’ agreement to the proposed surgery being performed and is confirmed with patients on their arrival to the OR. To give consent the patient should be given relevant information regarding the surgery and be able to understand that information and make an informed decision.

There may be instances when patients are unable to give consent themselves; for example, when a patient is unconscious or does not have the mental capacity to understand the information given. As a principle, no adult can consent for another adult and it is the responsibility of the surgeon who is proposing the surgery to assess the patient’s capacity to give or withhold consent. Although the next of kin and family members should be consulted and involved in any decisions whenever possible, the final decision to proceed with surgery rests with surgeons who should always act in what they believe is in the best interests of patients who do not possess the capacity to make that decision for themselves.

The consent process can be complex and must comply with legislation relevant to each country. For example, the age at which children can be considered competent to give consent for themselves can vary from country to country, so ORP must have the knowledge and awareness of legislation that governs patient consent within their country.

Emergency arrival in OR

Patients with polytrauma need urgent treatment and may arrive in the OR with little notice. Saving life and limb is the highest priority and in emergency situations it may not be possible to obtain all the usual information and perform the routine safety checks. For example, life-saving surgery should not be delayed because the limb is not marked. As much information as possible should be gathered to safeguard the patient from further harm, such as allergy details and any existing medical conditions that may affect immediate care. Every effort should be made to establish the identity of unconscious patients especially if there is more than one casualty involved. ORP should be prepared to manage anxious and distraught relatives who may also arrive in the operating department.

Infection control

ORP caring for patients arriving in the OR must be aware of infection control policies to minimize the risk of transmission of infection to staff and among patients. They should apply standard infection control precautions to all patients with whom they come into contact.

WHO Surgical Safety Checklist

Concern for patient safety is a global issue and ORP should be aware of the Surgical Safety Checklist developed by the World Health Organization (WHO) in its goal to improve the safety of surgical care worldwide. Three phases of an operation are identified with a series of checks in each phase that have been proven to reduce the likelihood of serious, avoidable harm to the patient while at the same time promoting better communication and teamwork within the perioperative team. The team should confirm that the “sign in” (phase 1) checklist is completed before the induction of anesthesia.

Anesthesia

This section can only present an overview of challenges that confront anesthetists while caring for orthopaedic patients undergoing surgery. Patient acuity, airway management, length and type of surgery, and sometimes the surgeon’s anesthetic preference determine the choice of anesthetic to be administered for a procedure or surgical intervention. Understanding anesthetic choices, airway management, and necessary circulatory support are primary concerns of the intraoperative orthopaedic team. Also, an awareness of the general anxiety of patients undergoing anesthesia and surgery should result in actions that lessen patients’ apprehensions. For example, allowing patients to express their fears or concerns, remaining with the patient during the induction of anesthesia, and if possible assuring a quiet OR with lights dimmed are all valuable actions to minimize anxiety and fear during induction. ORP who are capable of evaluating and anticipating the needs of the anesthetist will facilitate optimal intraoperative care of the patient.

Patient acuity

There is considerable variation between the anesthetic needs of an otherwise healthy patient undergoing a minor procedure and a polytrauma patient with comorbidity health issues. The American Society of Anesthesiologists (ASA) standard monitoring for all patients includes pulse oximetry, noninvasive blood pressure cuff, electrocardiogram (EKG), and temperature control. When more extensive monitoring is indicated, it may include arterial and/or central venous pressures, pulmonary artery pressure, and transesophageal echocardiography. The need for more extensive monitoring devices depends on a history of serious cardiovascular or pulmonary disease, the severity of the patient’s injuries, the type and duration of the surgical procedure, and the patient’s position. A preoperative discussion with the anesthetist and surgical team regarding these issues facilitate patient care.

Airway management

Proper assessment of a patient’s airway and nil per oral (NPO) status before any surgical intervention is imperative to ensure patient safety. Does the patient present with a normal or difficult airway? When it is obvious that the patient has a difficult airway, such as with an unstable neck injury, or when cervical collar/halo traction is in place, planning for the additional equipment required for fiber optic intubation should be a part of preoperative room preparation. However, an unexpected difficult airway may present at any time and require rapid access to specialized intubation equipment. Even in otherwise uneventful tracheal intubations, the anesthetist may need the assistance of ORP to provide downward or lateral pressure on the larynx to facilitate intubation.

Nil per oral status must be ascertained to prevent the possibility of pulmonary aspiration of gastric contents. When a patient has a history of bowel obstruction, an esophageal or gastric hemorrhage, recent ingestion of a meal, a profound history of uncontrollable gastroesophageal reflux, or has an acute trauma, special techniques are needed to accomplish endotracheal intubation safely. These include establishment of a reliable intravenous cannula, application of all necessary monitors, and preoxygenation before the start of anesthesia. ORP may then be asked to apply cricoid pressure during the induction of anesthesia (Fig 1.1-1). The cricoid pressure should be applied as firmly as possible with two fingers, pressing directly posterior (toward the spine). This should be maintained until the anesthetist indicates that the pressure can be released.

Special tracheal tubes may be necessary for some types of orthopaedic surgery. For example, it is advisable to use a wire-reinforced tube when surgery is to be performed on a patient in the prone position or where the head is turned sharply to the side opposite the operative site, such as anterior cervical laminectomies, upper shoulder, or clavicular surgery. This type of tube does not kink if bent at a right angle.