Intraoperative Case Management, Anticipation, Routines, & Counts ST230 Concorde Career College

Objectives:  Outline basic intraoperative routines and describe appropriate responses to variations in the routine.  Define the term anticipation and implement critical thinking activities that allow surgical team members to predict the needs of the patient and other surgical team members.  Identify and respond to verbal and nonverbal communication techniques utilized in the surgical environment.

Objectives: Define the term hemostasis and describe the principles that relate to hemostasis. List and describe the methods utilized to maintain and achieve hemostasis. Explain the principles related to exposure of the surgical site and explain the techniques utilized when retracting tissue.

Intraoperative routines Anticipation/critical thinking Verbal/nonverbal communication

Memorize this routine! Clamp (one side of tissue/blood vessel) Clamp (the other side) Cut (with appropriate tissue scissors) Tie (with appropriate suture material) Cut (with suture scissors) Tie (with same suture material) Cut (with suture scissors)

Anticipation IS critical thinking 1. Identify the goal or problem 2. Gather and evaluate as much information as possible. (Using the A POSitive CARE Approach) 3. Generate one or more responses and consider the implications. (A response may be a series of actions) 4. Implement the best response 5. Assess the results of the action taken and make adjustments, if necessary

Communication Verbal “Metzenbaum scissors, please” Nonverbal

Hemostasis Maintenance of the normal blood level within the body by prevention or stoppage of bleeding. Failure to maintain hemostasis may result in death.

Method of Achieving Hemostasis Mechanical Thermal Pharmaceutical

Mechanical Hemostasis  Direct pressure (e.g., pack with sponges)  Instrumentation (clamping/occluding)  Suture (tie or ligature)  Pledgets  Hemostatic clip  Tourniquet

Thermal Hemostasis Heat Cold Electrosurgical unit Laser

Pharmaceutical Hemostasis  Vasoconstrictors (e.g., epinephrine)  Absorbable gelatin  Collagen  Oxidized cellulose  Silver nitrate  Topical thrombin

Exposure Plan ahead to be sure that you have the necessary instrumentation Review regional anatomy to reduce the risk of injury to nearby structures Protect underlying structures Ideally, the surgeon or surgical assistant will place/position the retractor(s) Apply only the necessary amount of tension to the retractor Be sure to avoid leaning on the patient

Halstead's principles Basic principles of surgical technique regarding tissue handling, vascular occlusion etc. If followed, the soft tissue surgical success rate is greatly improved Strict asepsis during preparation and surgery. Good hemostasis to improve conditions for the procedure and limit infection and deadspace Minimize tissue trauma Use good Surgical judgment ensuring elimination of deadspace and adequate removal of material Minimize surgery time through knowledge of anatomy and technique Correct use of instruments and materials used

Counting Click Here to Review AST RSOP

What is the importance of counting instruments, sponges, sharps, and incidental items?

What is meant by the term incidental items?

How many counts are needed for each procedure? When are the counts performed? Are there any exceptions?

Who is responsible for counting? How?

What is the counting procedure?

What happens if additional items are added to the field during the procedure (after the initial count)?

What if… The count is incorrect?