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					Theatre Skills

 Dr Sarah Jones
•   A little history
•   Safety and the flight deck comparison
•   Standard aseptic precautions and procedures
•   Theatre etiquette
•   ‘Scrubbing up’ for surgery
•   Gowns, gloves, etc

The Operating Theatre
         Landmarks in Surgery and
•   First arterial clamp C16th
•   Ether (Morton, 1846, USA)
•   Chloroform (Simpson, 1847, Edinburgh)
•   Carbolic acid (Lister, 1865)

                  Safety first
• Hippocrates – “first do no harm”
• 39% “wrong site surgery” is wrong sided
• 61% completely the wrong procedure
• 728 in 2007 (around 1 in 3000 procedures)
• Lifetime risk for individual orthopod = 1 in 4
• 500 lost swabs/ instruments per year

         Sterility 1: Instruments
• Increasingly single use
  (eg. laparoscopic ports)
• Metal work is sterilised
  in the CSSU within the
• Autoclave (Cumberland,
  1879) uses vacuum and
  high pressure steam at

             Sterility 2: Staff
• Surgical scrub, hat, mask, gloves and gown
• Masks and hats do not significantly reduce
  cross infection in non-scrubbed staff
• Gloves are replaced after any ‘unclean’
  procedure eg. Catheterisation or if punctured
• Care should be taken to avoid contamination

            Sterility 3: Patients
• Skin is cleaned, with 2% iodine solution
  (Betadine®) or chlorhexidine (Hibiscrub®)
• Area cleaned from centre out beyond the
  operative field
• Patient is covered in sterile drapes (disposable
  drapes reduce transfer of bacteria)
• No evidence for adhesive coverings of skin

     Sterility 4: Why all the fuss?
• 10% HAIs are due to surgery
• Around 2.5% of all surgical patients acquire a
  wound infection
• It is costly: both to the patient (emotionally,
  physically) and to the trust (extra hospital stay,
  interventions, litigation)

 Sterility 5: How clean is your theatre?
• The inanimate environment has a negligible
  effect on post-op infection rates
• Spillages must be cleaned immediately
• Floors are disinfected at the end of each day
  and walls twice a year

      Sterility 6: Theatre Design
• Positive pressure ensures that airborne
  bacteria from a “dirty” case can be reduced by
  a factor of 50 in less than 20 minutes
• Laminar flow is a developing technology which
  provides clean/ ultra clean air to theatres
• There is a gradient of sterility within the
  theatre suite

          Sterility 7: orthopaedics
• Joint replacement is a highly
  clean procedure and
  prosthesis infection is a
  surgical emergency,
  requiring re-replacement
  and with long term
  implications in terms of
  unrecoverable function
• Highly specialised laminar
  flow systems and total body
  exhaust suits further reduce
  peri-operative wound

• (Jane Austen quote) (or
  amateur transplants song!)
• Who’s in charge? And of
  what? (Theatre sister/scrub
  nurse; the ‘Surgeon’;
• Talking, interrupting, music,
• Awake patients

• First of the day scrub should be 2 minutes
• Bare to above elbows
• Open wounds must be covered
• Can use sponge and must clean under
• Ayeliffe technique plus extend to elbows on
  first cycle
• Dry hands with corners of sterile paper towels

• Disposable gowns reduce bacterial shedding
• Try to find appropriate size
• Put on with no touch technique with plenty of
• Tie all ties
• Remember they can be hot and restrictive, it
  is common to feel faint during the early days
  of experience in theatres

• Check accurately your size as fit can affect
• Must be put on in an aseptic manner and
  extended over gown cuffs
• Double gloving (“Universal Precautions”) is for
  high risk cases only

                Other things

•   Eye protection
•   Glasses/ contact lenses
•   Heat and sweat(!)
•   ?De-scrubbing
•   ?When to tidy and When Not To

•   Get out there and enjoy
•   Eat breakfast
•   Scrub so you can see
•   Ask questions if you don’t understand

Any questions?

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