CONTENTS

1. Surgical Checklists
2. Comprehensive Anaesthetic checklist
3. Orthopaedic Surgery Safety measures
4. Safety tips - An Obstetrician’s View
5. Role of theatre Nurse.
6. Specialty specific safety precautions:

 Neurosurgery
 Ophthalmology
 Otorhinolaryngology
 Vascular Surgery
 Plastic Surgery
 Pediatric Surgery
 Urology
 Surgical Gastroenterology
 Cardiothoracic Surgery
7. Safe transfusion practices.
8. Infection Control – Essential points.
9. Perioperative Diabetes Management.
 COMPREHENSIVE ANAESTHESIA CHECK LIST FOR

CONDUCT OF SAFE ANAESTHESIA

STRICTLY ADHERE TO GUIDELINES, PROTOCOL AND CHECK LIST

ISSUED BY ISA & WHO

PRE OP CHECK UP

 Patient Details
 Pre of assessment
 Optimization
 Fitness for surgery Emergency / Elective
 Necessary investigations
 Pre op instruction and fasting guidelines
 Raising request for blood
- Responsibility of Anaesthetist

 Informed consent for anaesthesia & surgery

 Follow the WHO surgical safety check list protocol
 Intra operating monitoring
 Adverse events register
- Responsibility of Anaesthetist /
Surgeon / OT Staff Nurse

Ensuring NPO status & Blood arrangements

Blood transfusion in the ward
- Responsibility of Surgeon & Staff Nurse

OPERATION THEATER CHECK UP

 Nil per oral

- Staff nurse and Anaeathesist

 OT sterilization
- Staff Nurse
Machine check out:
 Anaesthesia work station check up
 Availability of adequate Oxygen supply
 Defibrillators
 Working Suction with accessories
 Monitors: ECG, Pulseoximeter, NIBP, Temperature & additional monitors if
needed
 Airway gadgets: laryngoscope,McCoy blade, FOB, Bougie, Stylet
 Ambu bag, ET tubes, Masks, Difficult airway Cart

Need for surgical airway in emergency -- Available surgeon should help

- Responsibility of OT Anaesthetist , Anaesthesia technician and
Bio Medical Engineering

Irrigation fluid volume duration, tourniquet duration, heparine time

- Responsibility of Anaesthetist

IMMEDIATE POST OPERATIVE CARE (in Recovery room)

Vitals monitoring
Adequate pain relief
(Note: Drugs through Epidural catheter will be given by an Anaesthesist )

-Responsibility of OT Anaesthetist & Staff Nurse

Post operative elective ventilation
- Anaesthestist will coordinate with surgeon

Post operative ward

Monitoring
Pain relief
- Surgical team & Staff Nurse

Maintaining sterilization of surgical equipment and Operation theatre

- I/C OT Staff nurse

Shifting the surgical patients

- Workers/ Staff nurses / surgical team
Disposal of waste
 Unused drugs loaded syringe - Responsibility of Anaesthetist
 Soiled linen - Staff nurses / Workers
 Body Parts / blood - Staff nurses / Workers
 Best surgical practices - Orthopaedics

Pre-operative protocols: Surgeon – Team leader

The following instructions to be carried out in the pre-operative period for any
orthopaedic procedures

1. Consent:
1.1. All details pertaining to the procedure planned and the average expected outcomes of the
procedure should be included.
1.2. All possible complications with approximate incidence of the same to be indicated.
1.3. Alternative treatment options if any to be added.
1.4. The consent should be takenwritten document and Video consent (if possible) in
sensitive cases with serious issues.
1.5. The consent must be tailor made based on individual patient profile explaining the high
risk/ very high risk/ on table death possibility/ post-operative need for ventilator support
or ICU care any, if needed.
1.6. All pre-existing co-morbidities should be counted in to arrive at the higher-than-average
risk categorization for that individual patient.

2. Pre-operative responsibilities of the team

Surgeon responsibility Duty of Ward Doctor Duty of ward staff nurse

The desired patient
position and devices
needed for the same
must be intimated to the
surgical team including
theatre staff and workers
one day prior
Need for pneumatic
tourniquet and its
availability should be
ensured pre-operatively
Verification of need and
availability of specific
The pre-operative Preparation of patient
medications advised by including betadine bath
anesthetist in the one day prior to surgery,
assessment chart should catheterization if needed
be strictly followed and clipping of hairs
from surgical incision
site has to be planned
The medications that
and documented in the
should be given on the
case sheet.
day of surgery and
medications that should
be stopped on the day of
surgery should be clearly
indicated in the case
sheet
 equipments and implants
for planned procedure
and devising alternate
options if need arises in
case malfunction
The timing of stopping
anticoagulants should be
noted and alternative
medications that should
be initiated has to be
clearly documented. The
timing to initiating the
same after surgery has to
be noted in the case
sheet.

Dosage adjustment for

steroids and other
DMARDS has to be
documented in
concurrence with the
concerned department
and noted in the case
sheet.

The patient must be

reviewed with the
theatre anesthesia team
in case of any difficulty
anticipated in induction
of anesthesia that in
noted in the assessment
chart including GA and
Spinal

3. On the day of surgery- Staff nurse responsibility

3.1. Proper handing over of patient by ward staff to theatre staff with communication of
specific instructions if any
3.2. Verification of the following
3.2.1. Timing of initiation of nil per oral
3.2.2. Completeness of pre-operative checklist
3.2.3. Marking of operative side on the body
3.2.4. Timing and dosage of per-operative antibiotics
3.2.5. Completion of consent forms
4. Intra-operative – Surgeon responsibilities

4.1. Surgeon must be present from the time of induction of anesthesia

4.2. Proper positioning of patient with adequacy for surgical exposure and placement of
image intensifier (C-arm) if needed
4.3. Proper padding of bony prominences and protection of vital structures
4.4. Tourniquet protocol – as noted below
4.5. Verification of catheterization if needed
4.6. Patient monitoring in conjunction with anesthetist
4.7. Assessment of blood loss and need for intra-operative transfusion of blood products
4.8. Informing the anesthetist prior to cementation and ensure patient safety
4.9. Informing the anesthetist in case of unexpected delay in completion of surgery
4.10. Adhering to the WHO patient safety surgical checklist to the dot.

5. Tourniquet protocol

5.1. Surgeon responsibilities

5.1.1. Choosing of appropriate width of tourniquet
5.1.2. Selection of curved or conical tourniquet in case of obese patients
5.1.3. Setting of appropriate pressure
5.1.4. For upper limb
5.1.4.1. Add 50mm of Hg to the systolic pressure
5.1.4.2. Total duration of 60 mins
5.1.5. For lower limb
5.1.5.1. Add 100mm of Hg to systolic pressure
5.1.5.2. Total duration of 90 mins
5.1.6. The maximum duration for any surgery is 120 mins if need arises.

6. Anesthetist responsibility

6.1. Documentation of start time and end time in case sheet

6.2. Must alert the surgeon every 30 mins when the tourniquet is on
6.3. Vitals should be checked and recorded after deflating and removal of tourniquet

7. Intraoperative staff nurse responsibilities

7.1. Ensuring correctness of patient name, diagnosis, procedure, side, and site
7.2. Setting up of trolley with appropriate surgical instruments
7.3. Adhering the surgical team instructions as per plan
7.4. Verifications of counts for gauze, surgical mop pads and instruments
 7.5. Appropriate dressing and ensuring safe shifting of patients with catheters, drains and
monitors in needed
7.6. Adhering to specific shifting instructions if any as advised by surgeon
7.7. Role of circulating nurse
7.7.1. Documentation of Time in/ Time out in case sheet
7.7.2. Handing over of items needed intraoperatively with sterile precautions, including
medications, opening of packed equipments
7.7.3. Verification of proper placement of Diathermy, suctioning apparatus
7.7.4. Monitoring of blood loss and urine output

8. Immediate post op:

8.1.1. Surgeon responsibility
Must meet the patient attenders and explain the surgical events and what
was done intraoperatively. Any alternative procedure done if any with
proper reasoning. Post operative care and follow-up planned

8.1.2. Ward doctor responsibilities

8.1.2.1. Documentation of patient received noted in case sheet
8.1.2.2. Monitoring of vitals including peripheral pulse, blood pressure and
Input/Output chart
8.1.2.3. Monitoring surgical site dressing for soakage
8.1.2.4. Monitoring drain volume and intimating the same to surgeon if need arises
8.1.2.5. Verification of appropriate drugs as per post-op orders from surgeon

8.1.3. Staff nurse responsibilities

8.1.3.1. Appropriate handing over of patient by theatre staff to ward staff
8.1.3.2. Obtaining blood samples and collecting results with time intimation of the
same to surgeon (if noted in the post-operative instructions)
8.1.3.3. Monitoring and administering blood products in needed
8.1.3.4. To maintain appropriate limb position
8.1.3.5. Elevation with pillow
8.1.3.6. Proper padding of prominences
8.1.3.7. Air bed if needed
8.1.3.8. Application of splints if advised
8.1.3.9. Monitoring for red flag sign as follows
8.1.3.9.1. Inadequate pulse volume
8.1.3.9.2. Blanching of extremities
8.1.3.9.3. Increased capillary refill time
8.1.3.9.4. Pain out of proportion
9. Evening rounds

9.1. By Anesthetist: Duty anesthetist should see the patient in the evening and document the
same.

9.2. By Surgical team Doctor:The following parameters must be noted during the evening
rounds
9.2.1. Monitoring of Pulse, BP, Oxygen Saturation
9.2.2. Adequacy of peripheral pulses if the anatomical region is exposed
9.2.3. In case POP is applied to the limb to create a small window to monitor the pulse
or verifying adequacy of capillary refill
9.2.4. Recording of reading of pulse oximeter probe in the operated limb to ensure
adequate flow
9.2.5. Monitoring of input and output parameters
9.2.6. Monitoring of drain volume
9.2.7. Collection of blood reports and document the same
 SAFETY TIPS - OBSTETRICIAN’S VIEW
 Safety is of prime importance in dealing with patients. It plays an important role in
obstetrics since this is a field of great expectations and litigations.

 Since maternal health is an important health indicator , check list for almost all the
procedures in obstetrics and gynaecology have been formulated and printed and it has
been followed for many years .

 Check list for obstetrics ,gynaecology, family planning ,are available in almost all
centres throughout the state.

 Protocols and procedures to be followed during any adverse events and in reporting of
sensitive issues like maternal or infant death are also available

PATIENT SAFETY OBJECTIVES

 Develop a commitment to encourage a culture of patient safety

 Implement recommended safe medication practices

 Reduce the likelihood of surgical errors

 Improve communication with health care providers

 Improve communication with patients

 Establish a partnership with patients to improve safety

CHECK LISTS IN OBSTETRICS

 Check-1:On Admission: Before birth – safe child birth check list

 Check-2:Just Before and during Birth/C-section

 Check-3:Soon- After Birth- safe child birth check list

 Check-4:Consent for a) induction of labour b) PPIUCD

  Check -5:Intrapartum monitoring –Partogram, Vitals monitoring ,Patients shifting
information

 Check-6:Postpartum monitoring

 Check-7:Discharge/referral/LAMA/Death form

 Check-8:Advice on discharge /referral

CHECK LIST IN GYNAECOLOGY

 Consent form for procedure / surgery, High-risk consent

 Pre operative check list

 Surgical safety check list :a)Before induction of anaesthesia - sign in b)Before skin
incision c) Before patient leaves operating room -time out

 Pre induction assessment

 Operation notes

 Intraoperative nursing record

 Transfusion report

 Post operative check list

 Vitals monitoring

CHECK LISTS IN FAMILY PLANNING

Medical record and checklist for female/male sterilisation

 Eligibility

 Medical history

 Physical examination

 Local examination

 Laboratory investigations

ETHICS TO BE FOLLOWED TOWARDS PATIENTS BY DOCTORS

 Empathy

 Attitude towards the patients

 Effective communication- with healthcare providers / patients

Communication with healthcare providers

Listen to the patient , talk politely

Communication failure is the root cause occupying almost two third of the events.

Training , team work and communication techniques is increasingly being recognized as

a cornerstone of robust patient safety programme. One communication tool is SBAR-

Situation,Background, Assessment and Recommendation or request.

Miscommunication occurs mainly during patient handoffs . Accurate information

about patients care treatment and services current condition , and any recent or

anticipated changes should be communicated.

Communication with patients

Communication should be complete clear concise and timely relationship is essential

for delivery of high quality, safe patient care.

Open communication and transparency in health care will increase trust , improve

patient satisfaction and may decrease liability exposure.

 Discuss labour and delivery issues in the third trimester when the patient has time to

make informed decisions about her care.

 Patients who are well informed are less likely to misunderstand medical interventions and

interpret them as errors in care

 Informed consent wherever necessary

 Confidentiality especially in family planning procedures like abortion

  Meticulous filling of check lists even during emergencies leaving no blanks.

 Information should be available to any obstetric provider who might be covering labour

and delivery

 Terminating patient relationships for high risk mothers in PHCs

 Respectful maternity care

 Information about the patients to be given to the attenders periodically during labour

 Attending to their basic needs

 Implement recommended safe medication practices – improve legibility of handwriting

and avoid use of non standard abbreviations ,check for drug allergies and sensitivities

 Reduce the likelihood of surgical errors- speak up program

 Advice during discharge and periodical follow up

 Mentoring of doctors in primary health centres and CEMONC centres and offering them

guidance and support

 Documentation must reflect all the test results and should be reviewed by the provider

and communicated to the patient. Ensure that there is a test tracking system for notifying

the staff when the result is not received. Document the non compliance or refusal with the

patient reason and include a notation that risks are explained to the patient.

 Empower your staff with knowledge and practical drills which gives them opportunity to

practice life saving skills

 Repeated choreographing emergency events makes everyone more comfortable with the

process when the actual event occurs example., PPH drill Eclampsia drill

CONCLUSION
  To err is human

 Building a safer health system emphasizing on patient safety is of prime importance

 Institutions should promote error reporting and identify potential hidden problems , as
well as to motivate health care workers and to collaborate with them to resolve system
failures.

 Obstetricians and gynaecologists should continuously incorporate elements of safety into

their practices and also encourage others to these practices

ROLE OF THEATRE NURSE

- Intraoperative nursing involves caring for patients from the time the patient enters the
operating room through the procedure and until the patient is transferred to the post
anaesthesia care unit (PACU)

- Intraoperative care is patient care during an operation and relating to that operation. Activities
such as monitoring the patients vitals, blood oxygenation levels, fluid therapy, medications,
transfusions, anaesthesia, radiography and retrieving samples for lab tests

- General surgery

 Instrument table arrangement according to the surgery

 Suture materials
 Pad counting
 Gauze counting needles counting
 Surgical instruments counting
 Operation side marking

- Orthopedic surgery
  Lead apron
 Plate , screw size and cautery
 Drill checking, Diathermy checking
 Pad counting
 Gauze counting needles counting
 Surgical instruments counting
 Operation side marking

-Vascular Surgery

 Tourniquet applying minutes

 Time Duration checking
 Microscopic arrangements
 Diathermy
 Operation side marking

-Neurosurgery

 Table arrangements
 Preparing and positioning
 Debakey instruments
 Diathermy
 Pad counting
 Gauze counting needles counting
 Operation side marking

Post-operative nursing care

Post-operative care Promotes patient recovery after surgery by managing pain, supporting
oxygenation and cardiovascular stability, maintaining fluid balance, providing wound care,
monitoring bowel function. Assisting with mobility and preventing complications.
Immediate - on receiving
Precautionary -before receiving
Postop-period of stay

PRECAUTIONARY

 Proper postop bed - after Carbolization and with clean sheet, bed cover, Macintosh,
blanket.
 Dressing material well sterilised in trays.
 Instruments to be auto claved and kept ready.
 Ventilators, monitors, ECG machine to be ready for use.
 Central supply, oxygen, suction to be properly checked standby Cylinders and suction
apparatus to be kept ready.
 Emergency trays with drugs with correct expiry date.
 Power supply back up to is verified.

ON RECEIVING - ALL TO BE DOCUMENTED

 Level of conscious
 Vital sign /any oozing from the site of Surgery.
 IV fluids to be connected.
 Drain tubes, catheters to be connected properly.
 If on ET, to be connected on ventilator.
 Patient on ventilators, suction to be done hourly
 For oxygenated patients - 6 to 8 L per minute to be continued till further medical Officer
advise.
 Level of consciousness, half hourly pulse, hourly BP, intake output chart to be
maintained properly.
 I/O chart, positive or negative balance to be checked, to avoid overload of fluid.
 Paediatric cases fluid as per calculation drops per minute to be regulated.
  Support drugs like dopa, to be regulated with drops per minute per the prescription.
 Antibiotics to be given to prevent infection.
 Sedated to be given as per doctor’s advice.
 IV fluids to be given as per the order.
 Drain amount to be checked.
 Position changing to prevent bedsore
 Any problem to be informed to the medical officer immediately.
 Dressing changed days, the antibiotic Days to be noted in chart.
 Early ambulation to prevent DVT
 On 9th or 11th day of POD suture removal to be done
 Time of Discharge - counsel the patient for post op follow up.
 Discharge summary to be handed over properly and advise for review to be given

SAFE NEUROSURGERY PRACTICES IN OT

“Surgical knowledge of value is built up more on the mistakes than on the successes of past
experience.”
Harvey Williams Cushing

Human error:

Inherent part of human commonly due to fatigue, distractions, responsibilities to other patients
with more urgent conditions, imperfect communication in the operating room. If systems are in
place that make it impossible for human error to reach the patient and cause harm, patient safety
will be markedly improved.
Medical errors / Adverse event:
Any act of omission or commission resulting in deviation from a perfect course for the patient.
An adverse medical error is different from expected complication.

Incidence in Spine neurosurgery:

The incidence of wrong-level lumbar surgery was estimated to be 4.5 per 10,000 operations, 6.8
for cervical discectomies per 10,000 operations.
Check list Incharge – Neurosurgeon.
Scrubbing etiquettes:
First scrub of the day must always be a full five-minute scrub
Subsequent ones can be an abbreviated three-minute scrub
Be respectful if any staff member points out a breech in sterility and start all over again.
If you accidentally touch anything non-sterile at any point, you have to start all over again.
Practice proper way of wearing gloves
Check list Incharge – Staff Nurse
Wrong side surgery:Incidence is 2.2 per 10,000 craniotomies.
Risk factors of Wrong-sided procedures
Incorrect patient positioning or preparation of the operative site
Erroneous information provided by the patient or their family
Missing or improper patient consent
Failure to use site markings
Neurosurgeon exhaustion
Several neurosurgeons involved in one case
Multiple procedures on the same patient
Unusual time limits, emergent procedures
Unusual patient anatomy
Overall poor operative team communication
Remedy:
Open discussion between the surgical team about the case, verifying the surgical procedure to be
performed, marking the surgical site in advance, adopting a series of neurosurgical checklists,
using the latest technology in the field or keeping an error record. In wrong side surgery even an
incision without the craniotomy represents a serious mistake and should be avoided.

Check list Incharge : Neurosurgeon.

Incorrect positioning:
Perioperative nerve injury - Brachial plexus injury, Ulnar, Radial or Median neuropathy
Postoperative visual loss - most common causes of postoperative visual loss .
Remedy:
Meticulous care in patient positioning and adequate padding to pressure points.
Check list incharge: Neurosurgeon and Anaesthesiologist.

Organizational Factors
Adequate personnel
Substitution of usual team members with new members restricted to 10 to 15% every 6 months.
Nurses substituted 6th hrly, to prevent fatigue and error arising as a result of the fatigue
Surgeons - compulsory break of at least 10 minutes , 3 hourly.
Anaesthetist to remind the surgeon of their turn to rest and the surgeon compulsorily take food
every 6th hourly.
Check list inbcharge: Anaesthesiologist.
Per – operative period:
Side of surgery and route of surgery must be checked and acknowledged by all members of the
team
Spine surgery, level at which the surgery is being done must be checked by C arm and must be
acknowledged by all members of the team
Expectant blood loss must have adequate blood, a central line, arterial line.
Check list Incharge: Neurosurgeon and Anaesthesiologist.
Patient Factors:
Obesity
Anatomical variation
Disease severity
Comorbidity
Hardware attachments to patients post surgery:
Lumbar CSF drains, EVDs, Throat and nasal packs and Drain tubes must be mentioned in the
operative notes if retained after surgery.Clear instructions in case sheets and while handing over
should be given about the pressure requirements, position of the hardware, abnormal situation
that can arise regarding volume of drain, when to alert and intervene.
While removing the same, the tip must be noted and recorded in the case sheet
Tip of any of these is missing, necessary action taken
Check list Incharge: Neirosurgeon.
Tissue removed:
Pathological or any tissue removed should be sent to Pathological examinatioin in Proper
preservative.
Checklist Incharge: Staff nurse
Bone Flap:
When Bone flap is removed, it is to be mentioned in the case sheet and how it is preserved in
Abdomen,freezer or discarded need also to be mentioned. A clearly written label saying “NO
BONE” need to be pasted.
Check list incharge: Neurosurgeon
Transfer:
Adequate care
Spinal cases can be shifted in a spinal board
Check list Incharge: Neurosurgeon and Anaesthesiologist.
Post operative:
DT if kept , fully compressed or partially compressed or dependent drain is to be written and
also clearly communicated to the ward duty doctors and staff nurses.
Pupillary size and reaction
GCS must be assessed and recorded again after shifting to the ward.
Patients not extubated in the theatre should be electively ventilated, managed and extubated
accordingly
Pupil chart, GCS chart, BP chart, pulse rate chart, temperature chart, I/O chart, DI,DT,Flap bulge
must all be maintained in the post operative ICU
Focal neurological deficits
Post operative Imaging
Check list Incharge: Neurosurgeon
Equipments and Gadgets:
High speed drills, Craniotomes,Operating microscopes, neuroendoscopes, ultrasounds, C-arms,
neuronavigation, cavitron ultrasonic surgical aspirators.
Always have a bacvkup with Conventional methoids should be kept ready incase of failure of the
equipments, instruments and devices.
Check list Incharge: Staff nurse.
Improve Measurement of Error and Adverse Events:
Create a Culture of Safety:
AEs are viewed as valuable participants in a learning process as opposed to being viewed as
inadequate workers.
Embrace a Systems Approach- principles:
Human error is an unavoidable and inherent aspect of human work
Faulty systems allow human error to cause harm to the patient
Systems can be designed that prevent or detect human error before a patient is harmed.
Things to do:
1.Good breakfast before entering OT
2.Punctuality
3. meticulously following the Check list.
4.Scrubbing etiquettes
5.Veracity
6. Do no harm
&. Allk relevant documents concerned with patient to be available in OT with relevant Image
displayed .
Thing avoided in OT
1. Mobile phone
2. Disruptive behaviour
3. Priority Conflicts
4. Insufficient communication

Prevention :
Focus on having an open discussion between the surgical team about the case, marking the site,
adopting a series of neurosurgical checklists, using the latest technology in the field or simply
keeping an error record.
Most preventable adverse effects and errors are not simply the result of
human errors but are the result of defective systems that allow errors to occur
and/or go undetected.

Checklist for elective intraocular surgery

 Random blood sugar <= 200 mg %

 Blood pressure <150/90 mmHg

 Physician clearance in cases with systemic disease

 Pre op topical antibiotics

 Written informed consent in patient’s language

 No contact procedures / syringing on day of surgery

 Microscope must

 Sterilized gloves for every case

 Disposable adhesive drape to isolate lashes

 Betadine on skin and periorbital area for three minutes

 Betadine in conjunctival sac for 1 minute

 Note batch number of irrigating fluid

 Document all findings (Pre op, operative and post op )

 Instruments autoclaved

 NO chemical sterilization
  Maximum use of disposables

 In case of doubt of infection – Talk to Patient, Institute prompt appropriate

treatment, seek help from higher authorities

SAFE SURGICAL PROTOCOLS - ENT

Pre-Operative Checklist
• Blood Grouping and Typing is mandatory as bleeding is a common problem in ENT

surgeries.

• Evaluation of Coagulation profile for all cases undergoing surgery is mandatory.

• In cases of tracheostomy for obstructive laryngeal stridor caused by malignancy, X-ray of the

soft tissue neck lateral should be taken compulsorily to determine the sub glottic air column.

If there is opacification in the subglottic region, cardiothoracic opinion should be obtained

immediately.

• Preliminary willingness for tracheostomy for all cases undergoing extensive surgeries of the

oral cavity, oropharynx and larynx and Laryngopharyngeal.

• Indirect Laryngoscopy/Video Laryngoscopy and evaluation of the vocal cord structure and

mobility with documentation of the same in the case sheet is necessary for all cases

undergoing Laryngeal and Thyroid Surgery.

• Polysomnography and Drug Induced Sleep Evaluation (DISE) is essential for all cases

undergoing surgery for Obstructive Sleep Apnoea Syndrome (OSAS).

• CT scan of the Para Nasal Sinuses is essential for all cases undergoing Endoscopic Sinus

Surgery.

• Xray Mastoid Law’s view/CT Temporal Bone is essential for all cases undergoing mastoid

surgeries.
• The complication of facial paralysis should be explained to the patient and pre operative

consent obtained before undergoing mastoidectomy.

• Chances of Sensorineural Hearing Loss should be explained in cases undergoing

stapedectomy surgery for otosclerosis.

• Pre operative Audiogram should be done supplemented by speech audiometry in all ear cases

requiring micro ear surgeries.

• Lignocaine test dose should be mandatorily given in all cases as most cases are done under

local anaesthesia.

• OAE and BERA is compulsory for all cases of congenital Hearing loss Children.

• Meningococcal and Pneumococcal Vaccine is mandatory for all children undergoing cochlear

implant Surgery

Intraoperative Checklist• The side of the Ear/Nose and Sinus and the Vocal Cord to be
operated should be checked

before starting the surgery.

• Throat packing is done by the anaesthetist and it has to be removed by the anaesthetist by the

end of the surgery.

• Nasal Packing is done by the ENT surgeon and should have a count on the number of packs

used.

• Any missed pack in the Nose or Nasopharynx will lead to aspiration- Responsibility of the

Surgeon.

• Always check the following equipments like the micromotor drilling system, Endoscope,

Light source and monitor, nerve monitoring equipments, diathermy and coblator before

starting the surgery.

• Amount of adrenaline used for packing and infiltration should be given in permitted levels

after clearance from the anaesthetist.

Post Operative

• Post operative monitoring of the vitals (Pulse Rate, Temperature, Blood Pressure and Oxygen

Saturation) in the post operative ward to be done by the ENT surgeon and the staff nurse.

• Antibiotic Laced ribbon gauze packing to be removed in the first or second post op day.

• Tracheostomy care to be given by the ENT surgeon. Frequent deflation and inflation hourly

for 5 mins, toileting of the tracheostomy tube and changing of the moist gauze to be done.

Discharge Check List:

• A legible discharge summary with advice should be given to the patient. The advice contains

medical treatment, review date and warning signs and symptoms of any complications.

VASCULAR SURGERY OPEN PROCEDURES

Preoperative check list – General

 Patient identity
 High risk written informed consent
 Planning session completed
 Side and site marked

Test doses given:

 Antibiotics, xylocaine
 Preparation of parts
 Dentures
 Blood components

Required investigations
  BT, CT, PT INR , Serology
 Ventilator availability
 Icu bed availability

Pre-operative check list – Special

Medications to be
 Continued
 Stopped: anticoagulants
 Last dose of heparin
 Vein mapping

Availability of
 Grafts, shunt
 Suture materials
 Perfusion cannula

Per op check list

 Right patient
 Right procedure
 Right side or site
 Diathermy connection
 Defibrillator availability
 Antibiotics administered

Pneumatic torniquet
 Pressure
 Time
  Removed

Heparin
 Time
 Dose
 Reversal: protamine
 Needle count verified
 Swab count verified
 Gauze count verified

Post op check list

 Post operative orders written

 Specimen: HPE/ culture labelled and sent
 Procedure and outcome explained to patient and relative
 Body parts disposed properly
 Vitals monitoring
 Ventilatory settings
 Status of limb/pulse status
 Bleeding from surgical site
 Neurological status

VASCULAR SURGERY ENDOVASCULR

PROCEDURES
PREOPERATIVE CHECK LIST – GENERAL
 Patient identity
 High risk written informed consent
 Planning session completed
 Test doses: antibiotics, xylocaine
 Allergic to medication, contrast
Medications to be
 Continued: antiplatelets
 Stopped: anticoagulants
 Last dose of heparin
 Preparation of parts
Required investigations:
 PT INR , serology, creatinine
 Bladder catheterised
 Hard wares availability
 Pre op optimization for renal failure executed
Per op check list
 Right patient
 Right procedure
 Right side/site
 Antibiotics administered
Heparin
 Time
 Dose
 Dosimetry
 Radiation exposure time
 Amount of contrast
 Intact tip of catheters and wires
 Compression bandage to puncture site
Post operative check list
 Post operative orders written
 Procedure and outcome explained to patient and relatives
 Vitals monitoring
 Puncture site bleeding / hematoma
 Limb status / pulse status
 Urine output
 Relevant investigations sent
 Any allergic reactions

SAFE PLASTIC SURGERY - PROTOCOLS AND CHECKLIST

Pre operative
 • Observation
• Diagnose before you treat
• Consult other specialist
• Honourably postpone
• Competent assisting team
• Competent nursing team
• Competent anaesthesia team
• ICU care
Pre operative - Specialised instruments
• Loupe / microscope
• Tourniquet
• Vascular clamps
• Bipolar/ Diathermy
• Micromotor drill
• Suture materials
• Tumescent
• Rhinoplasty set
• Nerve stimulator

Pre operative - Counselling

• Surgical options
• Procedure to be done
• Donor site requirements
• Complications
• Repeat surgeries in failure
• Overall outcome

Per operative
• Specialised instruments - separate table
• Tourniquet and tumescent
• Know your limit
 • Point of return and no return
• Before shifting verify specialised instruments

Post operative
• General post op care
• Positioning
• Periodic monitoring
• Involve other specialists

Emergency protocol
• Life threatening - No plastic surgery , Except airway, bleeding
• Stable life, limb threatening - Plastic intervention
• Stable life and limb - Honourably postpone

Elective protocol
• Completely fit patient
• Multiple surgeries
• Informed written consent
• Photos and videos
Conclusion
• Departmental periodic review
• Accept the mistake
• Institutional CME
PREOPERATIVE CHECKLIST-PAEDIATRICS
Date of surgery: Name of the Surgical team:

Name of the Surgery: Name of the Anesthetist team:

Weight of the child on the day of the surgery:……………………………………….

1. Informed written consent obtained Yes No

2. Anaesthetist clearance obtained Yes No
3. CMCHIS clearance
Yes No (If No specify)
 4. Nil Oral form……………………………………
5. Allergic to:…………………………………………
6. Pre op Medication, specify

7. Skin Preparation Yes

No N/A
8. Site Marking YesNo N/A
9. Bath
Yes No
10. Nails cut /Nail Polish
removed Yes No N/A
11. ID Band present Yes
No
12. Gown and cap Yes
No
13. Last bowel movement at…………………………………..
Bowel preparation, Satisfactory Yes No
14. Bladder Pattern : Urine
voided Yes No
On Urinary catheter Yes No N/A
15. Contact lens removed
Yes No N/A
16. Loose Teeth /Crown
Yes No
17. Jewellery /Bands/ Metals
removed Yes No N/A
18. Reservation of blood component - blood group………………
Specify:…………………………………… Confirmed
with………………………..
19. Vital signs :
Temp: Pulse: RR: BP: Spo2: Pain score:
 20. Investigation:

21. HIV/Hbs Ag /
MRSA /HCV Positive (Universal Precautions Required) Yes No
Transported by: walk wheel chair Stretcher with Side rail
Completed by: (Ward) Handed over by:
Signatue of charge nurse: (OT) Take over by:

SURGICAL SAFETY CHECKLIST

SIGN IN - PRE OP WAITING TIME OUT – CIRCULATING SIGN OUT – CIRCULATING

ROOM STAFF NURSE STAFF NURSE STAFF NURSE

SURGEON, NURSE VERBALLY

PARENT /PATIENT HAS ANAESTHESIOLOGIST CONFIRMS WITH THE
CONFIRMED TEAM
AND NURSE VERBALLY
 IDENTITY CONFIRM THE NAME OF THE
 SITE PROCEDURE
 IDENTITY
 PROCEDURE
 SIDE RECORDED
 CONSENT
 PROCEDURE
ANTICIPATED CRITICAL
THAT INSTRUMENT,
EVENTS?
SPONGE AND
SURGEON REVIEWS
NEEDLE COUNT ARE
SITE MARKED /NOT :WHAT ARE THE
APPLICABLE CORRENT (OR
CRITICAL OR
NOT APPLICABLE)
UNEXPECTED STEPS,
ANAESTHESIA SAFETY CHECK
COMPLETED OPERATIVE DURATION,
ANTICIPATED HOW THE SPECIMEN IS
LABELLED
PULSE OXIMETER ON PATIENT BLOOD LOSS?
AND FUNCTIONING (INCLUDING PATIENT
ANESTHESIA TEAM
NAME)
REVIEWS :
ARE THERE ANY
PATIENT-SPECIFIC WHETHER THERE ARE
ANY
CONCERNS?
EQUIPMENT PROBLEMS
NURSING TEAM
TO BE
REVIEWS : HAS
ADDRESSED
STERILITY (INCLUDING
INDICATOR
 RESULTS) BEEN
CONFIRMED?
ARE THERE EQUIPMENT
ISSURED OR
ANY CONCERN?
DOSE PATINET HAVE A: HAS ANTIBIOTIC
PROPHYLAXIS BEEN
KNOW ALLERGY? SURGEON,
GIVEN WITHIN THE LAST
ANAESTHESIOLOGIST
NO 60 MINUTES
AND NURSE PREVIEW
YES
THE KEY
DIFFICULT AIRWAY YES
CONCERNS FOR
/ASPIRATION RISK?
RECOVERY AND
NOT APPLICABLE MANAGEMENT OF THIS
NO PATIENT?
YES, AND EQUIPMENT
/ASSISTANCE AVAILABLE?
IS ESSENTIAL IMAGING
DISPLAYED
RISK OF >500ML BLOOD LOSS
(7ML/KG IN CHILDREN)?
YES
NO
YES, AND ADEQUATE INTRA
VENOUS ACCESS AND FLUIDS NOT APPLICABLE
PLANNED

Signature of the Staff Nurse Signature of Surgeon Signature of Anesthesiologist

SURGICAL CHECKLIST FOR UROLOGY

Open Urology procedures
Pre operative Check list -General
 Patient identity
 High risk written informed consent
 Planning session completed
 Side marked
 Test doses given: Antibiotics, Xylocaine
 Preparation of parts
 Dentures
 Blood and blood components
 Required investigations received : PT-INR , APTT, ABG
 Ventilator availability
 PACU bed availability
Per Operative Checklist
 Right patient
 Right procedure
 Right side
 Diathermy connection
 Defibrillator availability
 C-Arm availability
 Antibiotics administered
EndoUrological procedures Pre operative check list
 Contrast allergy
 Pre op optimisation for renal failure executed
 Medications to be continued (Anti platelets )
 Laparoscopy instruments, C-Arm, Endo instruments
 Lights, monitor, irrigation
 Should be checked prior to wheeling in of the patient

Safe surgery in Surgical Gastroenterology

Patient should have identity tags particularly when multiple specialities operate in the same OT
Complex-Responsibility of ward staff Nurse
WHO Safety list to be followed.-Responsibility of Treating Physician and Nursing Team
Audio/video consent to be obtained as patients may require Temporary/Permanent stomas and
may require Elective and Prolonged ventilatory support. The need for tracheostomy in case of
prolonged ventilatory care should be informed .The Need for Relaparotomies and Revision
surgeries should be informed.
 In case of Laparoscopic procedures the possibility of conversion to open surgery should be
explained -Responsibility of the Treating surgery team
LIVER SURGERY

1.Pringle in liver surgery

Anaesthetists should be informed about the time of Hepatic Inflow occlusion.
Application should not exceed 15 minutes at a time. It should be released after 15 minutes and
can be reapplied 5 minutes after release.
Implications-Pringles can alter Haemodynamics and can cause Liver ischemia in case of
continuous application beyond 15 minutes.
Both operating Surgeon and Anaesthetist are responsible
2. CVP Monitoring
Low CVP should be maintained during the Liver resection. The CVP pressure should be
displayed in the Monitor.
Anaesthesia team is responsible.
Advanced Laparoscopic surgery
Functioning of the Laparoscopic set including Camera unit, Insufflator and Light source
should be ensured before Anaesthetic Induction.
Operation table should be capable of tilting to various positions. Supports should be available
to prevent fall of the patient.
ET CO2 monitoring is mandatory
Adequate number of CO2 cylinders should be available.
At anytime only one gauge piece should be used during dissection.
A Standby Laparoscopic unit should be available
Digital Recording of all Laparoscopic procedures should be carried out
All above are the Responsibilities of Surgical team and OT Nursing staff
Prolonged GI surgery
Ensure the availability of the following facilities
Ventilator back up
Pneumatic compression device
Use of appropriate knee support in lithotomy position-Appropriate stirrups
 Fluid warmers
Warmer blankets to prevent Hypothermia
Appropriate diathermy earth pads to prevent electric burns
Removal of all metallic objects from the patient
Combined Resopnsibility of the Surgical team,Anaesthetist and Nursing staff

 Scrutinisation of blood products and Availability of blood warmers

-Responsibility of the Anaesthetists

 Availability of blue line gauge and pads

 Uniform instrument units arrangement
 Uniform pad and instrument count arrangements
-Responsibility of OT Nursing Staff

 All major surgeries should be assisted by trained nursing personnel only

-Responsibility of Nursing Head

SAFETY CHECKLIST FOR CARDIAC CASES

Admission

↓
History Taking

↓
Pre-Op Work up ECG
Blood tests CBC
RFT
Serum Electrolytes
 LFT
PT-INR
TFT (if required)
ASO (for valve cases)
CRP (for valve cases)
Blood Grouping and Typing
Blood Glucose RBS
FBS
PPBS
Serology HIV
Anti-HBsAg
Anti-HCV
ECHO (Detailed 2D ECHO)
TEE (if required)
Height and Weight assessment for CPB

Imaging CXR – PA View

CXR Lateral view (previous cardiac/thoracic surgery)
CT Chest – Redo Cases
Carotid/ Vertebral Doppler (CAD Cases)
Bilateral lower limb arterial (CAD Cases)
Bilateral lower limb venous Doppler (CAD Cases)
MRI – Myocardial viability scan (CAD Cases EF <40%)
CT Pan Aortogram (Aortic Surgery)
↓
Opinions Thoracic Medicine
- With PFT
- Sputum C/S, Sputum AFB, CBNAAT (if required)

Rheumatology (for RHD – to r/o acute phase of Rheumatic fever)

- With ASO/CRP titre
 Cardiology
- With detailed ECHO
- CAG if age > 40 years (to r/o CAD in valvular heart
disease)

Vascular Surgery (for CAD patient only)

- Bilateral lower limb arterial and venous Doppler
- CV Doppler
Diabetology
- Glycemic Control

BIR
- Bronchial artery embolisation
- CT Guided biopsy
Dental
- To look for caries tooth extraction/ hygiene
- To avoid post op infective endocarditis
- To start IE prophylaxis
Blood Bank
- Blood donation
Specific Departments
- Based on complaints
- Neurology, Orthopedics, SGE, etc
Anesthesia
- For PAE and fitness
↓
Consent High risk informed/ written consent in patient’s own language
explaining surgery procedure and risks

↓
Pre-op (i) Blood Grouping/ typing
Preparations - Reserve adequate blood/ products
- Encourage blood donation
(ii) Physiotherapy
- Chest Physiotherapy
- Incentive Spirometry
 (iii)Patient and Attender Counseling

Pre-op (i) Anticoagulation

Modification of - Inj. Heparin 2500U TDS (stopped the night prior to
Drugs surgery)
- Acitrom (stopped 5 days prior to surgery)
(ii) Aspirin and Clopidogrel
- Stopped 7 – 10 Days prior to surgery
(iii)Digoxin
- Continued until day of surgery
(iv) Diuretics
- Continued until day of surgery
(v) Beta blockers
- Long acting Nitrates – Until day of surgery
(vi) Antihypertensives
- Until day of surgery
(vii) Antidiabetic medications
- As per anesthetist orders

↓
Arrangements for (i) Definitive OT List (Primary and Standby cases) submitted
Operation to theatre – day before surgery
(ii) Availability at working status of the following equipments
by Assistant Professor in Operation Theatre and CTPO
I
- ABG Machine
- ACT Machine
- Pulse generator
- Multipara Monitor
- Infusion pumps
- IABP
- Defibrillator Internal and External
- Inhaled Nitric Oxide therapy system
(iii)Confirming
- Blood availability from blood bank/ Ventilator and
monitor availability in CTPO I
- Mechanical prosthetic valves and Grafts from OT/
Stores
- Pump availability from perfusionist
(iv) Informing OT staff, Pump technicians, consultant
anesthetist
↓
Operating Theatre (i) Patient assessed in ward on the morning of surgery
 - Reports verified
- Vitals checked
- Consent verified and checked
- Patient and attenders counseled
- Blood availability confirmed
(ii) Patient shifted to OT complex
(iii)Patient assessed by consultant anesthetist and shifted into
OT
(iv) IV lines secured. ECG leads fixed. Central line secured.
Arterial line secured
(v) Current x-ray and films of CT scan/ MRI displayed on X-
ray lobby in OT
(vi) External defibrillator checked
(vii) Prophylactic antibiotics given half hour before skin
incision
(viii) Following are checked
(a) CVP
(b) ACT
(c) All Vitals
Antibiotic Protocol (i) Antibiotic Prophylaxis regimen
(a) Inj. Cefotaxim 1g IV at induction
↓
OPERATIVE PROCEDURE

↓
Post Procedure (i) Patient shifted along with monitoring lines, inotropic
Transit support, pacing, etc.
(ii) Shifted with ET tube, connected to monitors and mobile
ventilator/ ambu bag with consultant
anesthetist/Assistant Professor accompanying patient
(iii)Tubes in situ
- Foleys catheter – monitoring output
- ICD tube connected to bag – Drain output and
functioning monitored
(iv) IV Fluids on flow
(v) Inotropes on flow
(vi) IABP
Reception from (i) Patient received by Duty DACTS , Anaesthesia consultant
Operation Theatre and duty ICU staff nurses.
(ii) Patient connected to ventilator
(iii)Baseline observations – HR/ Rhythm/ shifting loss /ABG/
CVP/ Arterial BP made after zeroing calibration
(iv) IV Fluids and inotropes attached to pump after appropriate
 labeling
(v) Pacer wire connected to pulse generator
(vi) Order initial tests – CBC, CBG, RFT, LFT, ABG, ACT, CT
(vii) Position patient 15° – 25° propped up (unless BP is
low)
(viii) Detailed operation notes recorded. Anesthetist notes
and perfusionist notes attached
↓
Early Post-op Care (i) Crystalloids – 2 ml/kg/hr
(ii) Colloids
(iii)Blood and blood products
- Blood transfusion if Hb ≤ 8.0 g/dL
- FFP if ACT, CT deranged
- Platelets if platelet counts low
(iv) Serial ABG analysis and electolyte correction
(v) Ventilation
- Gradual weaning from mechanical ventilator
support
- Usually extubation – morning of POD 1
(vi) Sedation and Analgesia (watch for BP)
(vii) Urine output monitoring (Maintain output of 0.5 – 1
ml/kg/hr)
(viii) Chest x-ray (supine)
- Taken on the evening on the day of surgery
- Taken after removal of ICD
↓
Nutrition (i) NPO till extubation
(Ryles tube feeding may be initiated for cases requiring
prolonged ventilation)
(ii) TPN – if required
↓
Routine Post Op (i) Post Op Day 1 – 3
Care - Titration of inotropes
- Chest physiotherapy/ Incentive Spirometry
- Correction of electrolyte abnormalities based on
serial ABG/ Routine investigations
(ii) Removal of lines
(a) Arterial lines – POD 2 – 3
(b) Central lines – 1 day after stopping inotropes
(c) ICD/ Chest Drains – hourly <30ml for 3
consecutive hours (or) <100ml/day (or) 2 – 4 hours
after central line removal
POST REMOVAL – CXR MANDATORY
 (d) Foley’s catheter – Usually POD 3 – 4/ after
stopping inotropes, before shifting out of CTPO I to
CTPO II
(e) ECG monitoring for POD 3 – 4 till shifted out of
CTPO I and before discharge
(iii)Anticoagulants
(iv) Diuretics
(v) Digoxin, Beta-blockers, ACE Inhibitor
(vi) Physiotherapy
- Earliest ambulation possible
- Chest physiotherapy by physiotherapist/ staff
- Incentive Spirometry encouraged

↓
Shifting out of Based on general condition of patient, after weaning all inotropic
CTPO1 supports if stable
↓
CTPO II Regular dressing
Post-op ECHO, ECG, Chest X-Ray done
Titration of Cardiac Drugs
On Discharge - Outpatient drugs prescribed
- Oral anticoagulants titrated based on PT-INR/ APTT
- Target INR for MVR – 2.5 to 3.5
AVR – 2.5 to 3
- Discharge notes with brief history, operative notes,
discharge advice, date for OPD review – checked and
signed by the Unit Assistant Professor

SAFETY CHECKLIST FOR THORACIC CASES

Admission

↓
History Taking

↓
Pre-Op Work up Chest X-ray PA View
ECG
 PFT
Blood tests CBC
RFT
Serum Electrolytes
LFT
PT-INR
Blood Grouping and Typing
Blood Glucose RBS
FBS
PPBS
Serology HIV
Anti-HBsAg
Anti-HCV
Special FBS
Investigations (when
PPBS
required)
TFT
Sputum/Pleural Fluid Culture & Sensitivity
AFB Staining
KOH Mount
CBNAAT
Fibre Optic Diagnostic and therapeutic
Bronchoscopy

Imaging (i) CT Chest

(ii) CECT Chest
(iii)CT Pulmonary Angiogram
- In Malignant tumors
- In Pulmonary thromboembolism
(iv) CT Guided Biopsy (if required)
(v) CT Guided intervention (if required)
Consent Written and informed high-risk consent in patient’s own language
explaining the procedure and risks in detail
↓
Opinions (i) Thoracic Medicine
- With PFT, CXR
(ii) Cardiology
 - With 2D ECHO and ECG
(iii)Diabetology
- Glycemic Control

(iv) BIR
- Bronchial artery embolisation
- CT Guided biopsy
(v) Anesthesia
- For PAE and fitness
↓
Pre-op Preparations (i) Blood Grouping/ typing
- Reserve adequate blood/ products
- Encourage blood donation
(ii) Physiotherapy
- Chest Physiotherapy
- Incentive Spirometry
(iii)Patient and Attender Counseling
(iv) Side of surgery marked on patient’s chest with marker
↓
Arrangements for (i) Definitive OT List submitted to theatre – day before
Operation surgery
(ii) Confirming
- Blood availability from blood bank
(iii) Informing OT staff, consultant anesthetist
↓
Operating Theatre (i) Patient assessed in ward on the morning of surgery
- Reports verified
- Vitals checked
- Consent verified and checked
- Patient and attenders counseled
- Blood availability confirmed
(ii) Patient shifted to OT complex
(iii)Patient assessed by consultant anesthetist and shifted into
OT
(iv) IV lines secured. ECG lines secured. Peripheral lines
secured.
(v) Urinary Catheterization if needed
(vi) Current x-ray and films of CT scan/ MRI displayed on X-
ray lobby in OT
(vii) Prophylactic antibiotics given half hour before skin
incision
(viii) Vitals are Checked
 (ix) Double lumen Endo tracheal intubation

↓
Antibiotic protocol Inj. Cefotaxime 1g IV @ induction

↓
Fibre Optic Confirming position of DLET tube
Bronchoscopy
↓
OPERATIVE PROCEDURE

↓
Post Procedure Early extubation/ On table extubation attempted based on ABG/
General assessment of the patient
↓
Post Procedure (i) Patient shifted with monitors
Transit (ii) If not extubated on table, shifted with ET tube and mobile
ventilator/ ambu bag with consultant anesthetist/
Assistant professor
(iii)Tubes in situ
- ICD tube connected to bag – Drain output and
functioning monitored
- If Foleys catheterized – output monitoring
(iv) IV Fluids on flow
Reception from (i) DACTS and nurses receives the patient
Operation Theatre (ii) Baseline observations – HR/ Rhythm/ BP
(iii)IV Fluids connected
(iv) Order initial tests – CBC, CBG, RFT, LFT, ABG
(v) Epidural infusion, if present, connected and restarted
(vi) Position patient 15° – 25° propped up (unless BP is low)
(vii) Detailed operation notes recorded. Anesthetist notes
and perfusionist notes attached
↓
Early Post-Op Care (i) Antibiotic Prophylaxis
(ii) Thromboprophylaxis
- Early ambulation
(iii)Analgesia and Antiemetics
- To continue epidural analgesia till POD 1
 (iv) Urine output
- Minimum of 0.5 – 1ml/kg/hr
(v) Physiotherapy
↓
Management of (i) ICD Charting (Output)
Chest Drains (ii) ICD care
- Look for clots
- Frequent suctioning
- ICD bag kept open
- Look for air leak
↓
Imaging CXR
- Immediate post-op
- Then when clinically indicated
- Post ICD removal
↓
Nutrition NPO for 4 hours after extubation
Followed by liquid diet
Soft solid then normal diet by POD 1
↓
Shifting out to Based on general condition of the patient usually by POD 2 – 3
CTPO 2
↓
On Discharge Outpatient drugs prescribed
Collect biopsy report
Actie physiotherapy advised
Discharge notes with brief history/ operative notes/ discharge
advice/ date to review – Unit Assistant Professor to review the
discharge summary and check and sign the summary.
 PREOPERATIVE BLOOD TRANSFUSION- SAFE PRACTICES

Consent for use of Blood & Blood products: (consent for transfusion of blood &
blood components)

 The consent for blood transfusion is taken by the Medical Officer from the patient/
patient representative.

 Consent from the patient should be obtained only in informed consent form meant for
blood transfusion and not a general consent form.

 In case of emergencies, transfusion of blood and blood products may be done without a
signed consent form if it is life saving and the consent can be obtained later from the
relatives However, the treating consultant should sign on the emergency blood release
form

Blood Requisition
  Blood and blood components to be reserved for all elective surgeries one day
before in the reservation record available at the blood bank
 Staff nurse should check the patient details and the printed form is checked &
signed by the doctor before sending the form along with blood sample to the
blood centre.
 All the details in the transfusion request form should be filled mandatorily
including mentioning it as emergency surgery/ Elective surgery.
 The recipient’s and donor’s samples should be retained in the blood bank for 7
days at 4◦C after each transfusion. In case of a need for transfusion after 48 hours
a fresh sample shall be requested.

Issue of Blood

 The reason for transfusion and patient consent has been documented in the patient’s
clinical record
 The blood centre receives the request form and issues the requested blood
components after a thorough cross check with the blood request form and if any
discrepancies noted by the blood centre staff, repeat sample required.
 Each unit shall be visually inspected before issue. It shall not be issued if there is
any leakage, hemolysis or suspicion of microbial contamination such as turbidity,
or change in color and the same should be checked by the staff nurse during the
surgery.
 Issue of blood to the surgery or EOT will be done on a need based requirement.
 Blood required for two separate patients in the OT will not be issued to the same
staff member at the same time. The blood Centre will issue only one unit of blood
and blood product at a time except in emergencies.

RECEIVING BLOOD IN THE OT

 The person that received the unit of blood should check the correct unit of
blood has been collected and delivered.
 Time of receiving and the condition of the blood unit should be documented
in the patient medical records & (Transfusion Feedback form) with the
 blood bag details.

Blood Grouping

 All patients that require a blood transfusion should be tested for the blood group and Rh
typing should be present in the patient’s medical record

Patient Identification:

 All patients are identified by two unique identifiers Patient’s name and IP NO

PRE-TRANSFUSION PRECAUTIONS

 Transfusion should begin as soon as possible after receiving of blood products and the
timeline for transfusion as follows:

Blood/Blood Products Start Transfusion Complete Transfusion

Red Blood cells Within 30 minutes Within 4 hours

Platelet Concentrate Within 30 minutes Within 4 hours

Fresh Frozen Plasma and As soon as possible Within 4 hours

Cryoprecipitate Within 30 minutes

 Blood should not be stored in the domestic refrigerator.

 Platelet concentrates should be kept at room temperature not inside the BBR

Guidelines for starting the transfusion: TRANSFUSION PROCESS

 No drugs or intravenous fluids should be added to the blood or blood component

before or during the transfusion process.
 No drugs should be administered through the line used for blood transfusion
during the process of transfusion
 Platelets, FFP and cryoprecipitate may be transfused through a normal blood
administration set. Platelet concentrate should not be administered through a set that has
been previously used for the transfusion of red cells as this may cause aggregation and
retention of platelets in the line.
Documentation of Blood Transfusion: The following information shall be recorded in the
progress notes of patient’s medical record:

 Type and volume of each product, Unit ID, Blood group transfused

 Time at which the transfusion of each unit commenced and completed.

 The staff nurse and the doctor monitoring the transfusion are responsible for the
transfusion process and should document and sign the notes in the patient’s
record.

 Monitoring of the patient vital signs before, during and after the transfusion

 If any transfusion reactions occur the same should be intimated with pre and post
transfusion sample along with blood bag and filled transfusion reaction form.

Monitoring the patient during the transfusion

 The infusion should start slowly, approx. 2 ml per minute for the first 15
minutes. Severe reactions may occur after as little as 10 ml has been
transfused and most reactions occur within 10-15 minutes of the start of
transfusion
ISSUE OF BLOOD IN EMERGENCIES
 Patients whose ABO and Rh (D) type is not known shall receive red cells of Group O Rh
(D) Negative if available; otherwise O Rh (D) positive blood should be used after
obtaining an emergency blood release consent form from the treating physician

TAT(Turnaround time) for obtaining blood components

TYPE OF TAT PRODUCT

REQUEST

Routine 45-60 min Serologically compatible Unit

Urgent 15-30 min Crossmatched ABO & Rh

Emergency 5-10 min PRBs of patient’s ABO and
Rh type blood group

<5 min Group O Rh(D) negative

blood
 PERI-OPERATIVE DIABETES MANAGEMENT

INTRODUCTION
In both diabetic and non-diabetic individuals, hyperglycemia in the peri-operative
period is an independent marker of poor surgical outcomes. It is well known that patients with
diabetes experience higher number of hospitalizations and surgeries with longer hospital stays,
higher treatment costs and greater risks of morbidity and mortality than patients without diabetes.
The stress of surgery, anesthesia, infection and dehydration induces a stress response resulting in
an outpouring of counter-regulatory hormones like cortisol, growth hormone, catecholamines
and glucagon, all of which contribute to the initiation and perpetuation of a hyperglycemic state.
EFFECTS OF DIABETES ON SURGERY
Uncontrolled or poorly controlled glycemic status can lead to delayed wound
healing and increased morbidity resulting in poorer outcomes. General Anesthesia increases
cortisol levels much more than Spinal Anesthesia or epidural anesthesia and hence is likely to
cause more hyperglycemia. Diabetic complications like autonomic neuropathy can cause delayed
gastric emptying and so the stomach may still contain food or liquid even after 4 or 6 hours fast
prior to anesthesia. Post –operative nausea & vomiting are more likely in patients with diabetic
gastro paresis. Diabetic autonomic neuropathy can also be associated with increased risk of
postural hypotension and cardiac arrhythmias which can also lead to a sudden cardiac death,
especially in patients with diabetes of longer duration. Abnormal vascular and cardiac reflexes
may occur during induction of anesthesia or tracheal intubation / extubation. Incomplete bladder
emptying and post-operative retention of urine is more common in patients with diabetic
neuropathy. In diabetic patients with extensive vascular involvement, dehydration due to post-
operative hyperglycemia can result in acute MI, CVA or peripheral arterial obstruction in
patients who were asymptomatic prior to surgery. There is an increased risk of electrolyte
disturbances, fluid overload and acute pulmonary edema in the post-operative period in patients
with diabetic nephropathy. NSAIDS should be avoided in post-operative patients with diabetes.
PERI OPERATIVE MANAGEMENT
The peri-operative period is divided into three phases
 Pre operative
 Intra operative
 Post operative

PRE-OPERATIVE ASSESSMENT
 The pre-operative assessment of a patient with diabetes includes detailed account regarding
the primary problem for which surgery is being done, the nature of surgery, the type of
anesthesia used, the age of the patient, the type, duration & symptoms of diabetes, drugs used for
the treatment, presence or absence of co-morbidities and diabetes related micro and macro
vascular complications etc. Physical examination includes PR, BP measurement both in lying
and standing positions and system examination. Baseline assessment of blood sugar, HbA1c
(wherever available), renal function, electrolytes, ECG should be done for all patients with
diabetes.
PRE-OPERATIVE GLYCEMIC CONTROL
The pre-operative glycemic control should be maintained between 80 – 180 mgs %. Elective
procedures should not be done if the blood glucose levels are above 400 mgs %. If glycemic
control is unsatisfactory, it is better to admit the patient 2 or 3 days prior to the planned elective
surgery so as to stabilize the glucose levels.
In patients undergoing minor surgery, the procedure can be carried out if glycemic control is
maintained even with oral hypoglycemic agents. But for major surgeries, OHAs should be
withdrawn and patient should be switched over to insulin for glycemic control. For emergency
surgeries, try to correct the metabolic decompensation/hyperglycemia before surgery wherever
possible. In such patients, an insulin infusion can be started using a drug infusion pump at the
rate of 0.1 unit /kg body weight to bring down the blood glucose level to around 200 mgs % and
the patient can be taken up for emergency surgical procedures. Ketones or Acetone could be
present in the urine in patients waiting for surgical procedures and this is a reflection of the stress
response of the patient. If there is no evidence of acidosis (as evidenced clinically by a RR >
36/min), the patient can be taken up for emergency surgical procedures.
INTRA-OPERATIVE GLYCEMIC CONTROL
Hyperglycaemia in surgeries of shorter duration (< less than 4 hours) with expected
hemodynamic stability and minimal fluid shift can be managed with repeated blood glucose
checks. In surgeries that may involve hemodynamic fluctuations, massive fluid shifts or last
longer than 4 hours duration, if blood glucose is greater than 180mg/dl, it should be managed
with intravenous insulin infusion and the blood glucose should be monitored every 1 to 2 hours.
During surgery, blood sugar levels should be maintained between 140 – 180 mgs % and this
monitoring could be done using a glucometer in the operation theatre by the anesthetist and
blood glucose levels can be maintained using an insulin infusion, if needed.

POST-OPERATIVE GLYCEMIC CONTROL & CARE OF DIABETES

PATIENTS
 Insulin infusions should be continued in the post operative period until oral feeding
commences. Higher doses of insulin may be needed in patients who are on steroid therapy. On
transfer from ICU care, the pre-operative insulin regimen can be restarted. OHAs should be
restarted only when the patient is medically stable and eating regularly.
A) After recovery in the PACU, ambulatory surgery patients who are stable and tolerating
oral intake can be discharged home with the previous antihyperglycemic regimen.
B) Non-critically ill patients and patients who have been started on oral feeds should have
both basal and prandial insulin as basal bolus regimen with monitoring of fasting, pre-
lunch and pre-dinner blood sugars.
C) Critically ill patients should be managed in a medical or surgical intensive care unit with
continuous insulin infusion (CII) with regular insulin and blood glucose monitoring every
1 to 2 hours. Subcutaneous insulin can be started once the patient stabilizes.
CHECK-LIST FOR PATIENTS WITH DIABETES
 Check BP in both lying & standing positions to detect postural hypotension secondary to
diabetic autonomic neuropathy.
 OHAs should be withdrawn and insulin initiated in all patients undergoing major elective
surgeries and emergency surgeries.
 High risk, informed consent should be obtained in all diabetic patients of long-standing
duration, those with co-morbidities or complications.
 Spinal or Epidural anesthesias are preferable to GA, wherever possible.
 Patients with diabetes should be posted as first case in the morning in the operating
theatre, whenever possible.