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Needle- stick injuries
Many doctors have received needle- stick injuries without serious consequences (Table2.5). However, if you have just been exposed, get advice
as soon as possible.
ImmediatelyStop what you are doing. If it is urgent, phone your se-
nior/ colleague to do it. Your future health is your top priority.
Percutaneous exposure(Needle or sharp.) Squeeze around the wound so
that blood comes out and wash with soap and water; avoid scrubbing or
pressing the wound directly.
Mucocutaneous exposure(Eyes, nose, mouth.) Rinse with water (or L of
0.9% saline through a giving set for eyes/ nose).
Within anhour
A colleague should:
• Talk to the patient alone, explain what has happened, and ask about
risk factors:
•
injecting drugs, blood transfusions, tattoos or piercings in
foreign countries, unprotected sex (particularly in last 3mth, in
a developing country or, if male, with a man), prior testing for
hepatitis B+C or HIV and the results
• Ask to take a blood sample for testing for hepatitis B+C andHIV.
You should:
• Phone occupational health if during oce hours or go to the ED and
follow their advice exactly
• Document the event in the patient’s notes and complete an
incidentform.
Post- exposure prophylaxis You may be prescribed antiretrovirals
(PEP, within 72h), hepatitis B immunoglobulin (within 24h), or hepatitis
B booster (within 24h) according to the signicance of the exposure.
There is currently no post- exposure prophylaxis for hepatitisC.
Over the next few weeks The patient’s blood tests should take
<2d for HIV and hepatitis B+C results. Following high- risk exposure you
may be advised to have a blood test in the future (2– 6mth); during this
time you should practise safe sex (condoms) and not donate blood. You
cannot be forced to have an HIV test. Discuss with occupational health
about involvement in surgery.
Table2.5 Viruses associated withneedle- stick injuries
Hepatitis B Hepatitis C HIV
UK prevalence <0.5% <0.5% <0.%
Transmission risk in 3 (without vaccine) in 50 in 300
Vaccination Vaccines at 0, , + 6mth None None
Post- exposure Immunoglobulin or booster None Triple therapy
103NEEDLE-STICK INJURIES
104 CHAPTER2 Life onthewards
Pre- op assessment
Elective patients attend pre- op clinics well before their operationto:
• Assess the patient’s problem (ie do they still need the operation?)
• Gauge their medical tness for an anaesthetic and surgery
• Request any pre- op investigations (see NICE guidelines, Table2.6)
• Check consent (this should only be obtained by the surgeon performing
the procedure or a person competent to undertake it, Ep. 31)
• Answer any questions the patient mayhave.
Pre- op investigationsSee Table2.6.
Table2.6 Preoperative investigations
Ix Indication
FBC All major surgery, or intermediate surgery if CVS or renal disease
Sickle cell All patients with a positive family history of sickle cell disease
U+E If at risk of AKI plus (i)ASA and major surgery, (ii) ASA 2 and
Clotting (i) intermediate/ major surgery if ASA 3/ 4 with liver failure, or
HbA
β
ECG If (i)minor surgery, ASA 3/ 4, and none in last 2mth;
Echo Any patient with either (i)signs/ symptoms of heart failure or (ii)a
PFT/ ABG Discuss with anaesthetist if intermediate or major surgery and ASA
†
varicose vein excision, tonsillectomy, knee arthroscopy), or major (eg hysterectomy, discectomy,
prostate resection, joint replacement, lung operations, colonic resection). American Society of
Anaesthesiologists Physical Status Classication. ASA (healthy), ASA 2 (mild systemic disease),
ASA 3 (severe disease), or ASA 4 (life- threatening severe disease).
Source: data from NICE guidelines: Mnice.org.uk/guidance/ng45
intermediate surgery, or (iii) ASA 3/ 4 and minor surger y
(ii)in a patient taking an oral anticoagulant
All patients with diabetes and no HbAc in last 3mth
c
- hCG Urine β- hCG if any doubt whether a patient may be pregnant
(ii)intermediate surgery, cardiovascular, renal, or diabetic disease,
and ASA 2; or (iii) major surgery, >65yr, and none in last 2mth
murmur with SOB, presyncope, syncope, or chest pain
3/ 4 due to known or suspected respiratory disease
Surgeries are either minor (eg skin excision, breast abscess), intermediate (eg inguinal hernia,
Requesting bloodpre- op Each hospital will have guidelines on the
transfusion requirements for mostelective operations; become familiar
with these. Blood for transfusion is in limited supply and should only be
crossmatched when necessary. Table2.7 shows common blood requirements for elective surgery.
†
Table2.7 Summary ofoperations and blood requirements
Blood request Operation
No request Minor day- case surgery (carpal tunnel, peripheral lipoma)
Group and save Laparoscopy, appendicectomy, cholecystectomy, hernia,
X- match 2units Colectomy, arthroplasty, laparotomy, TURP, hip replacement
X- match 4units Abdominoperineal resection, hepatic/ pancreatic surgery
X- match 6units Aneurysm repair (book ICU bed post- op)
hysterectomy, liver biopsy, mastectomy, varicosity, thyroid
Patients withmedical problems
DM If HbA
optimization prior to surgery. Put the patient rst on the operatinglist.
>69mmol/mol, patients should be referred for treatment
c
Insulin dependent diabetics who will be NBM for a considerable period
of time should commence variable rate IV insulin infusion prior to surgery
(E pp. 342–4).
CVSInform the anaesthetist if patients have had recent chest pain, an un-
diagnosed murmur, or symptoms of heart failure. The anaesthetist may
want you to request an echo or may see the patient personally.
Rheumatoid arthritis/ ankylosing spondylitisInform the anaesthetist as these
patients may be dicult to intubate or have an unstable C- spine— the
anaesthetist may want to see the patient or request radiological imaging.
Contacting the anaesthetist/ ICU Find out the anaesthetist for your
patient’s list and tell them about any patients who may need further investigations or a review preoperatively. If your patient will need an ICU bed post- op
inform ICU well in advance (contact details available from the anaesthetic department oce) and conrm with ICU on the day that the bed is still available.
Writing thedrug chart Try and do this at pre- admission clinic to
save yourself time later. Document any allergies. Things to check include:
Prophylactic anticoagulationSee Table 2.8 and Epp. 428–30.
AntibioticsConsider pre- op antibiotics (check local guidelines).
Bowel preparation and IV uid(Ep. 06.)
Regular drugs Review these and write up those which should be con-
tinued in hospital (Ep. 09).
TED stockingsPrescribe these for all patients.
Analgesia and antiemetics(E pp. 92–5 and E pp. 38–9.) The anaes-
thetist will usually write these up during the operation.
Instructions forthe patient
• Where and when to go for admission (write this down forthem)
• If they are to have bowel prep, they should usually be on clear uids at
least 24h before the operation (Ep. 08)
• Tell the patient about any drains, NG tubes, or catheters which may
be inserted during the operation
• Tell them if they are being admitted to ICU post- op.
105PRE-OP ASSESSMENT
Table2.8 Bridging anticoagulation
Group Pre-op Post-op
Low risk No bridging Restart regular anticoagulation if
†
High risk
Very high risk
patients
†
VTE <3mth ago; recurrent VTEs on anticoagulation; AF with CVA/TIA <3mth ago; AF and pre-
vious CVA/TIA and >3 of CCF, HTN, >75yr old, DM; mechanical heart valves.
Treatment dose
LMWH (last dose
24h before surgery)
or unfractionated
heparin infusion
Surgery should be delayed if possible. If unavoidable, discuss
with haematologist
haemostasis secure
Restart regular anticoagulation if
haemostasis secure. For warfarin,
continue bridging anticoagulation until
INR in therapeutic range
106 CHAPTER2 Life onthewards
Bowel preparation
Before endoscopy and some GI surgery procedures, patients are given
laxatives to clear the bowel (Table2.9). For surgery, the aim is to reduce the risk of post- op anastomotic leak and infections. Accumulating
evidence suggests that it does not improve complication rates and may
even be harmful, hence use of bowel preparation prior to surgery is
declining. Check your local policy for guidance. Where bowel preparation is required, it is vital that patients are instructed properly and the
importance of good compliance is stressed. For example, during colonoscopy inadequate bowel preparation can lead to pathology being
missed or the procedure being aborted (Box2.4)
Table2.9 Procedures and thepotential need forbowel preparation
Bowel preparation Procedure
None OGD, ERCP, closure (reversal) ileostomy
Phosphateenema
(on day of surgery)
Full bowel prep
(Box 2.4)
Box 2.4 Full bowel preparation
A variety of oral bowel cleansing products are available in the UK. In
2009, the National Patient Safety Agency (NPSA) issued an alert in response to safety incidents including a reported death following bowel
preparation. In particular, patients at risk of renal impairment and electrolyte imbalance need careful identication and prescribing.
• Sodium picosulfate/ magnesium citrate combinations (eg Picolax
give excellent bowel preparation and are relatively acceptable to
patients; they are relatively contraindicated in those with stage 4 or 5
CKD or those at risk of electrolyte imbalance, cardiac, or liver failure
• Polyethylene glycols/ macrogols (eg Klean- Prep
large volumes of liquid to be drunk, but are safer in at- risk groups.
Consider admitting elderly patients and those with comorbidities
for IV uids and monitoring during bowel preparation. Oral medications should not be taken h before or after administration of bowel
cleansing preparations; where reduced absorption could prove catastrophic (eg immunosuppressives post- transplant) consider admission for IV administration. Advise patients taking the OCP to take
alternative precautions during the week following taking the bowel
preparation.
Oer patients written dietary advice on low- residue foods for the 2d
prior to their procedure (local documents should be available); those
taking insulin will require specic advice and guidance for management.
Anal ssure, haemorrhoidectomy, examination
under anaesthetic (sigmoid colon/ rectum/
perianal area), exible sigmoidoscopy
Colonoscopy, rectopexy, right hemi- / left hemi- /
sigmoid/ pancolectomy, anterior resection,
abdominoperineal resection, Hartmann’s reversal
®
, MoviPrep®) require
®
)
Surgical terminology
Prex/ sux Meaning and example
Angioplasty— reconstruction of a blood vessel
Cholecystitis— inammation of the gallbladder
Hemicolectomy— excising half the colon
Hysterectomy— removal of the uterus
Laparotomy— opening the abdomen
Nephrotoxic— damaging to the kidney
Pancolectomy— complete removal of the colon
Percutaneous— going through the skin
Perianal— near the anus/ around the anus
Proctoscopy— examination of the rectum
Pyelonephritis— inammation of the renal pelvis
Thoracotomy— opening the thorax
Transoesophageal— across the oesophagus
107SURGICAL TERMINOLOGY
Nephrectomy— removal of a kidney
Angiogram— contrast study of arteries
Pyelonephritis— inammation of the renal pelvis
Faecolith— solid, stone- like stool
Sigmoidoscope— device for looking into the distal colon
Colostomy— opening of the colon to the skin
Craniotomy— opening the cranium (skull)
Myringoplasty— repair of the tympanic membrane
108 CHAPTER2 Life onthewards
Preparing in-patients forsurgery
Checklist Before your patient goes to theatre, check the following
have beendone:
• The consent form has been signed by the patient and surgeon
• The patient has been seen by the anaesthetist
• The operation site has been marked by the surgeon (imperative if the
operation could be bilateral, eg inguinal hernia repair)
• The preoperative blood results are in thenotes
• The preoperative ECG and/ or CXR are available
• Prophylactic LMWH, TED stockings, and antibiotics have been
prescribed where relevant
• The patient has received bowel preparation if necessary
• The patient has been adequately fasted (see next section)
• Blood has been crossmatched and is available if required (Epp. 420–5)
• Check if the patient has any last- minute questions or concerns and is
still happy to proceed with the operation.
Oral intake pre- and post- op In general, patients should not eat
for at least 6h before going to theatre but can have clear uids until 2h.
In emergencies this rule may be overruled, but the risk of aspiration of
gastric contents will be increased.
If patients are having an operation which requires bowel preparation,
check local guidelines as to what oral intake the patient is allowed while
taking the laxatives—usually it is either clear uids only or a low- residue
diet (Ep. 06).
Nil bymouth (NBM)Patients cannot have any oral food or signicant uid
intake; hydration must be maintained with IV uids. However, oral medication (eg antiarrhythmics) may be taken with a sip of water, if not taking
them would put the patient at more risk. Non- essential medication such
as vitamin supplements may be omitted; check with your seniors.
Clear uidsInclude non- carbonated drinks such as black tea, black coee,
water, squash drinks (not milk or fruit juice).
Sips30mL water/ h orally, usually given for the rst day after major ab-
dominal surgery involving bowel anastomoses.
Soft diet This includes food such as soup and jelly. Once patients have
been tolerating clear uids postoperatively for at least 24h, they may be
allowed to start a softdiet.
Most patients can safely drink clear uids up to 2h before surgery. The
following increase the risk of aspiration:
• Pregnancy
• Being elderly
• Obesity
• Stomach disorders, eg hiatus hernia,reux
• Pain (+ opioids).
Adjusting medications for surgery
Anticoagulants and antiplatelets Patients admitted for elective
surgery should have been advised to stop their anticoagulants in the
pre-op assessment clinic. For those admitted with acute surgical problems who may require surgery that admission, it is generally a good
idea for their anticoagulants to be withheld to avoid delays to surgery.
Patients who are high risk for thromboembolism may require ‘bridging’
anticoagulation with LMWH (Table 2.8, p. 105).
Warfarin Warfarin half-life is 36h and should be stopped at least 5d pre-op.
Check INR the day before surgery, the target is <.5 for most procedures.
DOACs Usually stopped d before low bleeding risk surgery (2d if high
bleeding risk). This rises to 2d and 3d respectively if CrCl <30mL/min. The
exception is dabigatran. Check guidelines
DOACs can be started 6–2h post surgery if haemostasis is secure.
Antiplatelets Clopidogrel must be stopped 7d before surgery
is usually continued unless otherwise instructed by senior surgeon (if in
doubt check with the operating surgeon/ consultant).
Diabetes In general, patients admitted for elective surgery who are
missing a single meal can stay on their usual regimen with certain doses
omitted. Seek advice from diabetic specialist nurses. Emergency surgical
admissions, patients missing more than one meal, and those with persistent hyperglycaemia (>2mmol/L) should commence a variable rate
IV insulin infusion (E p. 341).
3
Oral medications SGLT-2 inhibitors are associated with euglycaemic DKA
and should be withheld both the day before and the day of surgery.
Sulfonylureas are omitted on the day of surgery.
Oestrogens and progestogens HRT can be continued as long as
DVT/ PE prophylaxis is given. Progestogen- only contraceptives can be
continued, but combined oral contraceptives should be stopped 4wk
prior to surgery and alternative means of contraceptionused.
SteroidsPatients taking regular steroids must have extra steroid cover
during surgery and be converted to IV preparations if NBM. Discuss
each patient’s needs with your team and the anaesthetist (E p. 75).
AntihypertensivesAngiotensin-converting enzyme (ACE) inhibitors
can be associated with hypotension during anaesthesia and should be
discontinued for 24h before surgery. Consider withholding diuretics if
renal function is likely to be impaired.
or consult with haem if unsure.
2
; aspirin
109ADJUSTING MEDICATIONS FOR SURGERY
British Society for Haematology guidelines for perioperative management of
anticoagulation and antiplatelet therapy: Mhttps://b-s-h.org.uk/guidelines/guidelines/
peri-operative-management-of-anticoagulation-and-antiplatelet-therapy/
2
Hip fracture surgery is an exception to this and can take place early in patients on clopidogrel.
3
Centre for Perioperative Care guidelines for people with diabetes undergoing elective and emer-
gency surgery: Mcpoc.org.uk/guidelines-resources-guidelines-resources/guideline-diabetes
110 CHAPTER2 Life onthewards
Booking theatrelists
Box 2.5 Electivelists
In some centres this is done by the surgeon or their secretary, however in many places this task may fall to the surgical FP trainee. If you
are required to book elective lists this will likely be electronically using
a local system which you should receive training for (very occasionally
paper systems are still in place). You should nd out about your local
procedures for booking electivelists.
Discuss the order of the list with your consultant/ registrar (you may
need to obtain the operating list from your consultant’s secretary or
direct from theatre).
The list must usually be submitted by the afternoon before the
operating day. You should include:
• Theatrenumber
• Name of the consultant surgeon
• Name, sex, age, hospital number, and location of each patient
• Special patient requirements (eg DM, blood requested, ICU bed
booked)
• Operation and side in full (eg open repair left inguinal hernia)
• Sign and leave your bleepnumber
• If the order of the list needs to be changed, contact theatres and
inform them as soon as possible.
Box 2.6 Booking theorder ofoperations
In general, surgeons tend to prefer a specic order of patients:
• Older patients before younger (except children)
• Patients with comorbidities (eg DM) before healthy
• Clean operations before dirty (eg bowel resection)
• Longer, more complex operations before shorter.
3Box 2.7 Booking emergency operations
• Ensure you discuss the case with the STI/ 2 and registrar on- call
and that they have agreed to put the patient on thelist
• Enter the patient’s details as previously outlined, noting the time at
which the patient lastate
• Inform the anaesthetist covering the emergency theatre about the
patient (usually the on- call anaesthetic registrar)
• Check the patient has been consented and make sure the results
of any relevant investigations are available (including a G+S sample
and a pregnancy test in women of child- bearingage)
• You also need to inform the theatre coordinator.
Surgical instruments
(a) (b)
r
Retractors
(c) (d)
(e) (f)
(g) (h)
111SURGICAL INSTRUMENTS
Needle-holders
Scissors
Dissecting forceps
Tissue forceps
(i)
(l) (m)
(n) (o)
Haemostatic forceps
Fig.2.9 Surgical instruments.
(a) Mayo (b) Halsey
(c) Curved (d) McIndoe
(e) Non-toothed (f) Toothed
(g) Allis (h) Littlewoods
(j)
(k)
(i) Mosquito Halstead (j) Spencer Wells
(k) Kocher’s artery forceps
(l) Langenbeck (m) Morris (n) Doyen (o) Deave
112 CHAPTER2 Life onthewards
The operating theatre
Theatre design Operating theatres include an operating area, a
scrubbing- up area, a preparation room, a sluice (area for dirty equipment and dirty laundry), and an anaesthetic room. There will also be
a whiteboard (to document date, operation, and number of swabs/
blades/ sutures used), a display system for viewing radiology, and an area
to write up the operation notes and histopathology forms. Above the
operating table, there are usually main sets of lights, as well as smaller,
more mobile units (satellites).
Theatre sta Each operating theatre has a team of assistants who
clean and maintain the theatre. The ‘scrub nurse’ scrubs for each operation to select instruments as requested by the surgical team. One other
trained nurse and an auxiliary nurse act as ‘runners’ to fetch equipment
for the scrub nurse and to monitor the number of swabs and sutures
used (displayed on the whiteboard). An operating departmental assistant
(ODA) maintains the anaesthetic equipment and assists the anaesthetist. Each operation is logged, with details of the patient, name of the
operating surgeon, patient’s consultant, and anaesthetist.
Theatre clothing Fresh scrubs should be worn for each operating
list and should be changed between lists, or between cases if they become dirty or potentially infected with MRSA. Theatre shoes are essential for safety purposes and you will not be allowed to enter without
them. Theatre scrubs and shoes should not be worn uncovered outside
of theatres except in an emergency.
Scrubbing up Scrubbing up is an art and a key part of minimizing
infection risk to the patient. If in doubt, a theatre nurse can show you
how todoit.
• Prior to scrubbing, remove jewellery and put your mask and a
theatrehaton
• Open a gown pack and drop a pair of sterile glovesontop
• When scrubbing up for the rst patient, scrub under your nails using a
brush with iodine or chlorhexidine. Wash hands for a further5min
• Unravel your gown; ensure that it does not touch theoor
• Touching its inner aspects only, put it on with the end of the sleeves
covering yourhands
• Put on your gloves. Do not touch the outside of your gloves with your
barehands
• For high- risk operations (eg Caesarean, HIV +ve) double- glove and
protect your eyes with a visor or safety spectacles
• Wait for an assistant to tie your scrub gown frombehind
• If your hand becomes non- sterile, change your glove. If your gown
becomes non- sterile you need to rescrub; change your gown and
gloves.