Fig. 5.2 Equipment for intravenous access. Sterile occlusive dressing, tape, alcohol swab, iv cannula, iv tubing, disposable gloves, tourniquet and intravenous fluid. 1 = iv spike, 2 = roller clamp, 3 = injection port, 4 = luer lock end.
Intravenous Preparation:
Every patient having a surgical procedure will require intravenous access. If available, pre-warmed fluids can be used. For adult patients, a litre of Normal Saline or Ringer’s Lactate with standard intravenous tubing can be prepared. If the patient is having a procedure where a blood transfusion may be required, special tubing with a blood filter and warmer should be prepared.
Preparing a standard intravenous infusion:
1 Hang the intravenous bag on an IV pole.
2 Close the roller clamp on the tubing to control the flow of fluid. Remove the seal over the IV tubing “spike”, and take care not to touch the spike as it is sterile and will come in contact with the intravenous fluid.
3 Grasp the IV bag port at the base.
4 Insert the tubing spike into the bag port with a pushing and upward twisting motion until the spike is in the port up to its hilt.
5 Squeeze and release the drip chamber until it is ½ filled with liquid.
6 Open the roller clamp, and flush the air out of the tubing.
Patient Safety:
To ensure the correct procedure is performed on the correct side and on the correct patient, a number of safety checks must be completed. The patient’s identity must be confirmed both verbally and against their identifying arm bracelet. The patient’s procedure, consent, and signature must also be confirmed.
Once inside the operating room, a “Preoperative Pause” is conducted by the OR team. The team members verbally identify themselves and their role—if this has not been done previously in the day, and the patient’s identity is again verified. The indications for antibiotic administration are reviewed and administered, when appropriate, if this has not already been done. This is followed by a discussion of the proposed procedure, sterility of equipment, known allergies, and any problems anticipated by the anesthesia, surgical, and nursing teams. To communicate this vital information effectively, everyone in the OR must pay close attention to minimize the risk of error. At the completion of surgery, a “Debriefing Pause” is conducted to point out any deviations from the planned procedure that may have occurred.
Hand Hygiene:
Every year, thousands of Canadians die from infections acquired while being treated in our hospitals.2 One in nine patients in our hospitals will acquire an infection while being treated for a different medical condition. Proper hand hygiene by health care providers is one of the most effective ways to prevent infections associated with health care. Proper hand hygiene involves the use of an alcohol-based solution or soap and water. The four essential moments for hand hygiene are:
1. Before initial contact with a patient and the patient’s environment,
2. Before aseptic techniques,
3. After body fluid exposure, and
4. After contact with a patient and the patient’s environment.
Ensure proper hand hygiene before and after interacting with the patient. After proper hand hygiene, the use of disposable gloves is recommended when performing airway and intravenous access tasks. Sterile gloves should be used after proper hand hygiene when performing sterile techniques (e.g., spinal, epidural anesthesia, arterial line insertion).
Monitoring Procedures:
Once the patient has been safely transferred to the OR table, appropriate monitors should be applied and intravenous access established.
Monitors
Initial basic monitoring for all patients includes:
1 A noninvasive blood pressure (NIBP) cuff,
2 An electrocardiogram (ECG), and
3 A pulse oximeter probe to measure oxygen saturation (SPO2).
The NIBP cuff is typically placed on the patient’s upper arm opposite that used for intravenous access. The ECG electrodes are color coded and should be placed on flat, hairless sections of the patient’s torso far enough away from the surgical prep area.
Fig. 5.3 ECG lead placement. Left image: three lead ECG configuration with white (right arm), black (left arm) and red (left leg) lead placement. Right image: five lead ECG configuration adds a green (right leg), and a brown lead in the V5 position.
ECG Monitoring:
A three-lead system that includes electrodes for the right arm (RA), left arm (LA), and left leg (LL) is commonly used for healthy patients undergoing minor or moderate-risk surgical procedures. A five-lead system is commonly used for patients who have risk factors for cardiac disease, advanced age, and / or significant comorbid conditions and are undergoing moderate to high-risk surgical procedures. The pulse oximeter probe is typically placed on a digit of the patient’s hand on the same side as the intravenous access. See Chapter 10 for a discussion on intraoperative monitors.
The saying “white is right and smoke over fire” is a simple saying to recall the positioning of the while, black and red electrodes in a simple three-lead system.
Intravenous Access:
Needlestick injuries to health care workers (HCWs) and the risk of transmission of infections to HCWs remains a serious problem in the operative setting.3,4 The use of safety needles has been shown to decrease the incidence of needlestick injuries. Many hospitals now use intravenous catheters that have incorporated safety features to minimize the risk of a needlestick injury. The BD InsyteTM intravenous catheter safety system uses a spring-loaded mechanism activated by a safety button to retract the needle into a safety chamber once the intravenous catheter is placed in the vein. To further limit needlestick injuries, it is recommended that all needles be disposed of in a designated ‘sharps’ container, and HCWs should refrain from recapping needles. Newer versions of intravenous insertion cannulas incorporate a membrane in the hub to prevent blood spillage when the needle is retracted (e.g., BD Insyte™ AutoguardTM Blood Control).
Fig. 5.4 BD Autoguard 20 ga. intravenous safety catheter. Depressing the white button activates the spring loaded needle retraction system. Note the needle is approximately 2 mm longer than the catheter.
Fig. 5.5 Venous anatomy of the upper limb.
Placement of the Intravenous:
Many operating rooms are configured such that the anesthesiologist is closest to the patients left side. As such, the patient’s