The Intraoperative Period

The intraoperative period is the time involved with the surgical procedure. The
focus during this time is on asepsis and protection of the patient. Within the oper-
ative suite, the staff wears scrub suits. They change into the scrub shirt and pants
when they get to the locker room within the surgical area. A surgical cap covers
hair. Shoe covers are worn to prevent tracking bacteria or dirt from other areas into
the operating rooms.
THE SURGICAL TEAM
Members of the surgical team include the surgeon, a surgical assistant, an anesthesi-
ologist or anesthetist, a circulating nurse, a scrub nurse or surgical tech, and a hold-
ing area nurse. The surgeon is the doctor who will perform the surgery. The surgical
assistant may be another surgeon, a surgical resident, an RN first assist, or a physi-
cian’s assistant. The person providing anesthesia and monitoring the vital signs of
the patient is either an anesthesiologist (a physician) or a certified registered nurse
anesthetist (CRNA). The circulating nurse is a registered nurse who acts as the
patient advocate, obtains the necessary supplies for the procedure, makes sure diag-
nostic studies and blood products are available if necessary, prepares the operative
table, positions the patient (padding bony prominences if necessary), and cleanses
the skin in the operative area before positioning surgical drapes. The scrub nurse or
surgical tech sets up the sterile field, assists with draping the patient, and hands ster-
ile supplies into the operative field and takes used instruments from the surgeon. The
circulating nurse and scrub nurse (or surgical tech) together count all instruments,
sponges, and sharps used in the surgical field. The count is performed before, dur-
ing, and after the procedure. The holding area nurse cares for the patients who have
been brought into the operating room suite but who are not yet ready to go into the
operating room. The holding area nurse may be managing several patients at one
time and can also help to transport and transfer the patient.
Before entering the operating room, the members of the surgical team scrub at
the sink just outside the room in which the surgery will be performed. Prior to start-
ing the scrub, the team member applies a mask with face shield or goggles. The
surgical scrub is usually timed and covers the area from the fingertips to 2 inches
above the elbows. The surgical scrub renders the skin clean, not sterile. After the
scrub, the skin is dried with a sterile towel. A sterile gown, then sterile gloves are
applied. The front of the gown is considered sterile in the front from two inches
below the neck to the waist and from the elbow to the wrist. The circulating nurse
applies the gown and gloves unassisted, and then assists the other members of the
team into their gown and gloves as they enter the room.

RISK FOR INJURY
During the surgery, the patient is anesthetized and cannot tell you if there is pres-
sure anywhere. The patient is positioned to allow for maximal access to the opera-
tive site. This sometimes causes unnatural positioning of the patient or the patient’s
extremities. The operative table is padded to decrease pressure on the patient. There
may be additional padding added to areas of flexion or bony prominences to reduce
the risk of pressure ulcer formation or nerve damage due to positioning.
Heat loss can occur during surgery. The patient is sent to the operating room in
a hospital gown, which may be pulled up or removed depending on the body loca-
tion of the surgery. The body is draped for privacy so that only the surgical area is
exposed. The temperature within the operating room is kept rather cool because
the air exchange rate is higher within the operating room than in other rooms

(to decrease bacterial counts), and the staff are wearing double layers of clothes.
Warmers can be set up for the patients during certain procedures when heat loss is
expected—a large, open operative site or a long duration of surgery.
At the end of the surgical procedure, the wound is closed. The closure is to hold
the wound edges together and to prevent contamination. Closure may be achieved
with sutures (either absorbable or nonabsorbable), staples, glue, or skin closure
tape. Nonabsorbable sutures and staples will have to be removed in the post-
operative period.
Drains may be inserted near the operative site if significant wound drainage is
anticipated. Some drains are attached to suction, some have self-suction, and some
will drain due to gravity. The wound site is covered with a sterile dressing before
the patient is transferred out of the operating room.

ANESTHESIA
Anesthesia can be administered via general or regional routes (for major proce-
dures) or conscious sedation (for minor procedures). General anesthesia renders
the patient unconscious and incapable of breathing on his or her own; pain recep-
tion is also blocked. These patients must be intubated and mechanically ventilated
for the duration of the anesthesia. Regional anesthesia can be achieved through
nerve blocks, or epidural or spinal anesthesia. Nerve blocks occur when an anes-
thetic agent is injected into an area immediately surrounding a particular nerve
or nerve bundle. The nerve tissue becomes anesthetized, effectively causing the
tissue that it supplies to become pain-free. With epidural anesthesia, an anesthetic
agent is injected into the epidural space surrounding the spinal column, usually in
the lower lumbar area. The nerves become anesthetized as they leave the spinal
column, causing the area of the body supplied by these nerves to become pain-free.
This anesthesia is most commonly associated with childbirth but is used for many
surgical procedures. Spinal anesthesia is not commonly used; the anesthetic agent
is injected into the cerebrospinal fluid. Patient positioning is very important, as
gravity will cause the anesthetic agent to travel. The patient must remain flat after
the procedure to prevent leakage of cerebrospinal fluid from the puncture site.