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Operating theatre preparation for cardiothoracic surgical procedures
Teresa Hardcastle and Bibleraj Gnanasekaran
Introduction
Most cardiothoracic operating theatres worldwide commence surgery at around 7.30am, due to the length and complexity of the surgical procedures required. All equipment should be checked and ready to use (prior to the patient arriving in the anaesthetic room and the operating theatre) by the anaesthetic practitioner and the scrub team. Before starting the operating list, all members of the team who will be present for the procedures meet to discuss each patient in depth. The team includes anaesthetists, surgeons, registrars, surgical care practitioners, the anaesthetic practitioner, the scrub team, perfusionists and students.
This meeting is known as the team brief and it is part of the ‘Five Steps to Safer Surgery’ and has been mandatory in all operating theatre departments in the United Kingdom since 2010 (WHO 2009). The aim of this briefing is for each member of staff to introduce themselves and their role and most importantly to discuss each patient individually, their comorbidities, and the anaesthetic and surgical equipment requirements for each procedure. This briefing has been shown to improve team working, communication and patient safety (Hardcastle 2013).
Most operating theatres in the UK are built with an anaesthetic room, where the patient is anaesthetised and prepared for surgery before entering the operating theatre. One of the fundamental responsibilities of the anaesthetic practitioner is to prepare the anaesthetic room and operating theatre for surgery, while the scrub team prepare the appropriate instrumentation and equipment required for the surgical procedures. This involves:
• Ensuring that the operating theatre temperature and humidity are set within normal limits
• Ensuring that the operating theatre ventilation is working
• Checking the operating theatre lights
• Checking the anaesthetic machines
• Preparing airway equipment and adjuncts
• Preparing patient monitoring equipment
• Preparing intravenous, arterial and central venous monitoring equipment
• Checking and making available a variety of drugs required by the anaesthetist
• Checking the operating theatre table and preparing specialist patient positioning equipment
• Checking and preparing specialist equipment such as transoesophageal probe, machine, and heart and lung machine.
Temperature and humidity
The operating theatre temperature and humidity are both controlled by the air conditioning system. The normal temperature of the operating theatre is ideally set at 20–23° Centigrade or Celsius (Phillips 2016, p. 183). The environment should be comfortable for staff to work in but also needs to take into consideration the requirements of the patient. The humidity should be controlled, between 50 and 60%, to inhibit the growth of micro-organisms (Al-Benna 2012, p. 320). A high level of humidity creates an uncomfortable environment for staff to work in, whereas humidity that is too low can increase the risk of an explosion due to a static charge of electricity.
Ventilation
The ventilation system delivers filtered air under positive pressure. This can be visually checked on a central control panel within the operating theatre. The ventilation system is one important factor in reducing the incidence of surgical site infection. The air flow should be delivered in a downward directional flow towards floor and exhaust panels (Spry 2015). There are two types of ventilation system available: plenum and laminar. Plenum ventilation produces, on average, 20 air changes every hour (Humphreys 2012, p.71).
Laminar ventilation, also known as ‘Ultra Clean’, is commonly used in modern operating theatres, especially orthopaedic theatres. Laminar ventilation delivers highly filtered positive air using special filters (known as high-efficiency particulate air filters) that remove airborne particles. Air changes can range from 400 to 600 every hour (Kotcher-Fuller 2013, p. 58).
Lighting
The operating theatre has various lighting sources. These range from ceiling fixtures to the overhead, ceiling-mounted main surgical light. The operating theatre light should be ‘shadow less, produce the blue-white colour of daylight, produce minimum heat and be freely adjustable to any position or angle with either a vertical or horizontal range of motion’ (Phillips 2017, p.188).
Good operating lighting is essential for good surgical access. The operating lights must therefore be checked prior to use. They need to be in good condition and all in working order. If any lights fail, this should be reported immediately to the medical engineering department of the local trust or organisation.
As patients are commonly anaesthetised in an anaesthetic room, anaesthetic machines can be found both in the anaesthetic room and the operating theatre. It is one of the anaesthetic practitioner’s roles to check both machines prior to their use and at the start of each operating list, following the safety guidelines (AAGBI 2012). This is a joint responsibility with the anaesthetist. The anaesthetist is also responsible for checking the anaesthetic machine prior to its use (AAGBI 2012).
These checks ensure that all aspects of the anaesthetic machine are functioning safely, including:
• Medical gas supply and delivery
• Breathing systems
• Vaporisers
• Ventilators
• Suction apparatus
• Scavenging system to collect waste gases.
The appropriate volumes must also be set on ventilators and all audible alarm systems on the anaesthetic machines must be tested. A record of these checks is then kept with each anaesthetic machine. These vital checks help ensure the safety of patients when they are at their most vulnerable during anaesthesia (see Figure 3.1).
Figure 3.1: The anaesthetic machine in the theatre setting
A full range of standard airway equipment should be checked and made available at the start of every operating list (Royal College of Anaesthetists 2018). The anaesthetic practitioner will therefore prepare the following:
• A selection of different size face masks (see Figure 3.2) to ensure a close fit to the face and prevent gas leak.
• Oropharyngeal airways size 2, 3 and 4. When inserted lies over the tongue to prevent it from covering the epiglottis (see Figure 3.2).
• A variety of laryngoscopes with appropriately sized blades to aid visualisation of the vocal cords on direct laryngoscopy. Popular are the Macintosh, Miller and the McCoy blade which has a hinged tip to lift the epiglottis to improve the view of the larynx. Choice of laryngoscope blade used is usually the anaesthetist’s preference (see Figure 3.2).
• Supraglottic airway devices, Laryngeal Mask Airways size 3 to 5 (see Figure 3.3). The LMA was first developed by Archie Brain in 1981 and was used for spontaneous breathing as an alternative to bag, mask ventilation. They are designed to sit over the opening in the larynx. They have subsequently been used for Positive Pressure Ventilation (Gwinnutt & Gwinnutt, 2017). Modifications have been made to the original design, for example the development of the proseal and igel® LMAs. They were first manufactured as reusable but now are available as disposable items. The choice of LMA will depend on anaesthetist’s preference, and availability. It is not routine for an LMA to be used in cardiac or thoracic anaesthesia. However, LMAs are a valuable airway adjunct in the case of a difficult airway or in an emergency situation (Difficult Airway Society 2015).
• The size of the required LMA will depend on gender and weight of the patient.
• Endotracheal tubes size 7.0 to 9.0mm with an inflatable cuff will also need to be readily available (see Figure 3.4).
• These sizes are available in 0.5mm ranges – for example, 7.5mm.
• The actual size of tube required for the patient will depend on gender and weight. Commonly 7.5–8mm for a female and 8.5–9mm for a male.
• The length of the ETT will require cutting depending on the gender and weight of the patient. Commonly 21cm for a female and 22cm for a male.
• For thoracic surgery, double lumen endotracheal tubes to facilitate one lung ventilation. The lung to be ventilated will depend on the site of operation and they are available in a variety of sizes.
• Equipment for the management of anticipated or unexpected airway difficulties such as bougies and stylets.
Other equipment that should also be checked in accordance with departmental policies and made available in the ‘difficult airway trolley’. The trolley will contain a range of airway devices – for example, flexible intubating laryngoscopes, intubating LMAs, Aintree catheters and surgical cricothyroidotomy kits to use in the event of an anticipated or unanticipated airway difficulty (see Figure 3.5).
The resuscitation equipment and defibrillator must also be available and checked, in accordance with departmental policies, in the event of an emergency (AAGBI 2015).
Figure 3.2: Different sizes of face masks, laryngeal blades, airways and eye pads
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