RATIONALE

• Skin prep aids in preventing surgical site

infections (SSI) by:
• removing debris from and cleansing the skin
• bringing the resident and transient microbes
to an irreducible minimum
• hindering the growth of microbes during the
surgical procedure
PURPOSE
• To reduce the resident and transient
microbial counts at the surgical site
immediately prior to making the surgical
incision
•To minimize rebound microbial
growth during the intraoperative
and postoperative period
•To reduce the risk of post-
surgical site infection
•To prevent injury to the patient
during surgical preparation
SKIN
PREPARATION
• Many surgeons prefer to have their
bathe with antimicrobial soap the
morning of the surgical procedure.
•The perioperative nurse should assess
the patient’s skin before, during and
after the prepping process.
•Abnormal skin irritation, infection, or
abrasion on or near the surgical site
might be a contraindication to the
surgical procedure and is reported to
the surgeon

This Photo by Unknown Author is licensed under CC BY

Preliminary Preparation
of the Patient’s Skin
HAIR REMOVAL – carried out per surgeon’s order, whether on the
preoperative unit or in the OR as close to the scheduled time for
surgical procedure as possible.
CLIPPERS – electric clippers with fine teeth cut hair close to the skin.
Clipping can be done immediately before the surgical procedure or up
to 24 hours preoperatively.
DEPILATORY CREAM – hair can be removed by chemical depilation
before the patient comes to the OR suite. This should not be used
around the eyes or genitalia. After the cream has remained on the skin
for the required time, usually about 20 min, it is washed off. The hair
comes off in the cream.
RAZOR –shaving should be performed as near the time of incision as
possible if this method is used.
SKIN DEGREASING – it is used to enhance adhesion of ECG or other
electrodes.
PREPPING AREAS CONSIDERED
CONTAMINATED
• UMBILICUS: some surgeons prefer the umbilicus to be
cleaned with cotton-tipped swabs before the main incision.
• STOMA: should be isolated with a sterile clear plastic adhesive
dressing to prevent fecal material from entering the wound.
• OTHER CONTAMINATED AREAS: the general rules of
scrubbing the most contaminated area last with separate
sponges applies.
•
FOREIGN SUBSTANCES – a none-irritating solvent should be
used to cleanse the skin.
• TRAUMATIC WOUNDS – the wound may be packed or covered
with the sterile gauze while the area around it is thoroughly
scrubbed and shaved if necessary.
•AREAS PREPARED FOR GRAFTS – the donor site for a skin
graft should be scrubbed with a colorless antiseptic agent so
that surgeon can properly evaluate the vascularity of the graft
postoperatively.
COMMON ANTISEPTIC
SOLUTIONS
• CHLORHEXIDINE CLUCONATE – used as
antiseptic skin cleansing soap preoperatively.
• IODINE AND IODOPHORS – it is used for
wound care
• ALCOHOL – a 70% concentration with
continuous contact for several minutes is
satisfactory for skin antisepsis if the surgeon
prefers a colorless solution that permits
observation of true skin color.
• TRICLOSAN– is a broad-spectrum
antimicrobial agent.
• PARACHLOROMETAXYLENOL – has a
bactericidal properties useful for skin
antisepsis.
STANDARDS OF PRACTICE FOR
SKIN PREP OF THE SURGICAL
PATIENT

STANDARD PRACTICE 1: The Patient

and surgical team members
should follow the surgeon’s
preoperative orders. Additionally,
preoperative preparations by the
surgical team should be completed.
STANDARDS OF
PRACTICE FOR SKIN
PREP OF THE
SURGICAL PATIENT
STANDARD PRACTICE 2: The
health care facility should
use FDA-approved agents that
have immediate, cumulative,
and persistent antimicrobial
action.
STANDARDS OF PRACTICE FOR
SKIN PREP OF THE SURGICAL
PATIENT

STANDARD PRACTICE 3: Standard of

Practice III Alcohol is an accepted
antiseptic agent; however, it should not be
used as the single agent but as part of the skin
prep regimen.
STANDARDS OF PRACTICE FOR
SKIN PREP OF THE SURGICAL
PATIENT

STANDARD PRACTICE 4:
Surgical team members should
perform a standardized patient skin
prep procedure based upon
manufacturer’s written instructions
that are specific to the
antimicrobial agent to be used and
according to health care facility
policy and procedures.
STANDARDS OF PRACTICE
FOR SKIN PREP OF THE
SURGICAL PATIENT

Standard of Practice 5
Contaminated areas require
special attention and
generally should be prepped
last.
STANDARDS OF PRACTICE FOR SKIN
PREP OF THE SURGICAL PATIENT

Standard of Practice 6: Surgical procedures,

such as grafts, abdominal-perineal and
abdominal-vaginal require two separate skin
preps to be performed.

Standard of Practice 7: Eye and facial preps

may require the use of alternative prep
solutions or diluted regular solutions in order
to avoid injury to the patient.
STANDARDS OF PRACTICE FOR
SKIN PREP OF THE SURGICAL
PATIENT

• Standard of Practice 8: Manufacturer’s

instructions should be followed for the storage
and warming of antiseptic agents.

• Standard of Practice 9: The Material Safety Data

Sheets (MSDS) for the antiseptic agents that are
stored and used in the surgery department must
be readily available and accessible to all surgical
personnel.

• Standard of Practice 10: The patient skin prep

should be well documented in the patient chart.
 SURGICAL
POSITIONING
1
 Introduction
Important to know the various implications of
patient positioning during surgery
Because of the various physiological effects it
exerts on the systems
In the last 2 decades newer surgical techniques
developed due to advances
In electronics
In technology as a whole
Better understanding of physiology

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 Goal of positioning
Goal of surgical positioning is to facilitate
surgeon’s technical approach while
balancing risk factors
All surgical positions have position-related
risks

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 Physiologic effects of change from
vertical to horizontal position
Body responses to alteration of positions is
due to gravity
Effects of Gravity:
On blood in venous / arterial / pulmonary
systems
On pulmonary mechanics
On pulmonary perfusion
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 Supine position
Commonest position for most of the
surgeries

Care should be exercised to prevent injuries

to the anesthetized patient

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 Supine position – Pressure points

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 Arm tucking in supine position

One arm if needed to keep by the side of the patient , the draw
sheet should cover the arm as shown & tucked under the patient
to prevent injury to brachial plexus
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 Arm tucking

Note the arms is tucked using draw sheet & arm is secured by the side of
the patient

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 Lithotomy
Used in gynecology & urology procedures
Elevation of legs promotes translocation of
vascular volume centrally
Areas supporting weight of legs prone for
nerve injury
Legs supported at knee & suspended by
stirrups

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 Lithotomy positioning - I

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 Lithotomy positioning - II

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 Final lithotomy position

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 Lithotomy position with stirrups

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 Lithotomy position

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 Urology - Lithotomy position

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 Lithotomy position

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 Various types of Lithotomy stirrups

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 Lithotomy position

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 Nerve injuries in lithotomy

Peroneal nerve injury

Saphenous nerve injury
Femoral nerve injury
Obturator nerve injury

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 Lithotomy position – Nerve injuries

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 Nerve injuries in lithotomy
Peroneal nerve injury:
Pressure of head of fibula by bar or support structures
compresses nerve
Saphenous nerve injury:
Pressure on medial condyle of tibia compress nerve
Femoral nerve injury:
Due to angulation of thigh such that inguinal ligament is
stretched & compresses nerve
Obturator nerve injury:
Due to greater degree of thigh flexion there is stretching of
nerve as it exits the obturator foramen

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 Lithotomy position - problems

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 Compartment syndrome in lower
limbs during lithotomy position
Long duration of lithotomy position
Tightening of leg straps
Dorsi-flexion of ankle
Surgeon leaning on suspended leg for long
duration

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 Upper limb injury during lithotomy
position
Compartment syndrome of hand occurs
when hand is tucked under the buttocks &
OR table
Extension of upper limb > 90* causes
traction of brachial plexus

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 Chemical burns in lithotomy position

Rare fortunately
Pooling of preparation solutions at buttock
& lower back causes chemical burns

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 Lateral position
A pad placed under the head
Arm perpendicular to torso, either on
pillow or an over arm rest
Pillow between the legs
Arm taped on this position
Care taken that tape does not press ulnar
nerve @ elbow or radial nerve @ radial
groove

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 Lateral position

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 Lateral position

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 Lateral position

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 Higher chest exposure in lateral
position
Arm kept in more anterior plane to body to
prevent stretching of brachial plexus
Lower chest supported by axillary role
Supports weight of thorax
Prevents compression of shoulder & axilla
Prevents brachial plexus injury in axilla
Palpate Radial artery of dependent arm to
ensure there is no compression
September 3, 2024 30
 Lateral position with kidney bridge

This position is used for surgeries on the

kidney & ureters
Kidney bridge is elevated & this opens up
the retro pelvic space for optimal exposure

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 Lateral position with kidney bridge

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 Lateral oblique
Three quarters prone position
Used for exposure of posterior cranial fossa
Head rotated from supine to lateral
Head holder pins are inserted
Upper leg is bought forward & flexed slightly
Lower leg is left straight
Axillary role placed under chest to support weight of body
Lower shoulder bought to forward edge of bed or just slightly
over it
Upper arm placed downward near the side comfortably
Patient looks like he is trying to look at the floor

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 Lateral oblique position
Assistant

Surgeon

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 Lateral oblique position
Assistant
Surgeon

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 Lateral oblique position
Assistant
Surgeon

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 Lateral oblique position

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 Lateral oblique position

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 Lateral oblique position

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 Problems in lateral oblique position
In obese patients difficulty in placing lower arm
below torso
Cause considerable weight on humeral head &
acromion
Lower breast can get compressed – pressure on
nipple & areola
Extreme neck flexion cause cervical spinal cord
hypo-perfusion
ECG electrodes can cause pressure necrosis

September 3, 2024 40
 Prone position

Lumbar Laminectomy
Spinal instrumentation
Steffi’s plating
Harrington’s rod
Pilonidal sinus excision

September 3, 2024 41
 Prone position - problems
Careful positioning from supine position
Prevent pressure on abdomen
Prevent pressure on eyes
Pillows to rest the lower limbs
Prevent pressure on male external genitalia

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 Prone position – induction on trolley

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 Prone position

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 Prone position

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 Prone position

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 Prone position with laminectomy
frame - pressure points

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 Trendelenburg’ s position
Modification of supine position
Places head down along with the whole body
Advantages of this position:
Moves viscera cephalad
Helpful in lower abdominal surgeries
To ↑ venous return after spinal anesthesia
To ↑ central blood volume to facilitate central
vein cannulation
To minimize aspiration during regurgitation
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Effects of Trendelenburg’ s position
↑ CVP
↑ ICP
↑ IOP
↑ myocardial work
↑ pulmonary venous pressure
↓ pulmonary compliance
↓ FRC
Swelling of face, eyelids, conjunctiva & tongue
observed in long surgeries

September 3, 2024 49
 Trendelenburg position

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 Reverse Trendelenburg’s position
This is the opposite of Trenlenberg’s position
This position places head end up & feet down
This position helps in caudal movement of abdominal
contents
Used in upper abdominal laparoscopic surgeries – Lap
gastric banding
Causes venous pooling in lower limbs
To prevent DVT stockings is a must

September 3, 2024 51
 Reverse Trendelenburg position

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 Jack knife position ( Kraske )
Used for anal surgeries, pilonidal sinus
excision
Places patient prone with head & feet at a
lower level

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 Jack knife position

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 Knee chest position
Further exaggeration of knee-chest position
Used for sigmoidoscopies or lumbar
laminectomies
Severe hypotension is seen due to pooling of
blood in the legs

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 Knee chest position – pressure points

September 3, 2024 62
 Orthopedic surgeries positions
Orthopedic fracture table – Wattson-Jone’s
Body section to support head & thorax
Sacral plate for pelvis
Perineal post
Adjustable foot plates
Table maintains traction of the extremity
Allows surgical & fluroscopic access
Anesthesia induced & then the patients are
positioned on this table (pain)
Arm on # side placed so that it will not interfere
with surgical access

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 Orthopedic surgeries needing
Wattson-Jone’s table

# shaft femur for Interlocking

DHS with plate
Inter-trocanteric # femur

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 Wattson Jone’s table used for Ortho
surgery

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 Wattson Jone’s table used for Ortho
surgery

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 Lateral position on Wattson Jone’s
table

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 Problems with this position
Brachial plexus injury
Due to > than 90* extension of the upper limb
Lower extremity compartment syndrome
Due to long surgeries & compression
Pudendal nerve injury
Due to pressure of the perineal post

September 3, 2024 62
 Positions for shoulder surgery
Beach chair / barber chair / semi-recumbent
position
Provides both anterior & posterior access to
shoulder
Provides freely mobile upper limb
Endotraheal tube secured well to prevent
accidental extubation

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 Beach chair position for shoulder
surgery (Semi Fowler position)

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 Sitting position - Fowler position
For posterior cranial fossa position
Better surgical exposure
Less tissue retraction & damage
Less bleeding
Less cranial nerve damage
More complete resection of lesion
Ready access to airway, chest & extremities
Modern monitoring gives early warning of venous
air-embolism
65
September 3, 2024
 Sitting position - Neuro surgery

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 Sitting position – pressure points

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 Sitting position

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 Relative contra-indication to sitting
position
V-P shunt in position
Cerebral-ischemia upright awake
Patent foramen ovale & R –L shunt
Cardiac instability
Extremes of ages
Left AP < RAP -------Platypnea –Orthodeoxia
Patient becomes deoxygenated on assuming erect
position
Arterial gradients reverses on assuming erect
position
These patients open up foramen ovale & VAE can
enter systemic circulation
September 3, 2024 69
 Problems in sitting position
Venous air embolism
Hypotension (prevented by stockings)
Arms – if not well supported cause
brachial-plexus stretching

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 Venous air-embolism
Most feared complication in sitting position
With subsequent PAE to the brain

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 Air embolism
Right atrium
with air embolus
CVP catheter in
situ

September 3, 2024
72
 Air – embolism monitor warnings

September 3, 2024 73
 Mandatory monitoring
EKG
BP
SpO2
EtCO2
Doppler
CVP
Pulmonary artery catheter

September 3, 2024 75
 Pre-cordial Doppler device
Most advocated monitoring
Reasonably priced
Relatively easy to use
Non-invasive
Sensitive
Sounds heard both by surgeons &
anesthesiologist

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Mechanism of peripheral nerve injury

2 basic forces impairing nerve function

Nerves that course superficially for long distances
are prone for stretch injury
Nerve that pass over bony structures over small
area prone for compression
Final result – nerve ischemia – nerve injury
Ischemia > 30 minutes result in nerve palsy

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 Types of nerve injury

Neuropraxia
Axonotomasis
Neurotomasis

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 Neuropraxia

Occurs with loss of function

Without demonstrable anatomic injury
Related to positioning under anesthesia
Recovery complete in 6 weeks

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 Axonotomesis
Occurs with anatomic disruption of axons but
preservation of nerve sheath & connective tissue
Axon degenerates distal to lesion
Regenerates @1mm / day
Function gradually returns but in longer nerves
of upper limb will take upto 1 year
Physical therapy helpful to prevent degeneration
of joints & muscles
79
September 3, 2024
 Neurometesis

Results in axon, sheath & connective tissue

disruption
Leads to degeneration of axon distal to
injury

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 Course of
Upper limb
nerves

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 Brachial plexus in the axilla

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 Coarse of
nerves in thigh

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 Coarse of nerves in leg

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 Cubital-tunnel external compression
syndrome
Ulnar nerve passes through cubital tunnel
of elbow
Forearm pronated will cause compression
of ulnar nerve
Flexion @ elbow > 90* tenses arcuate
ligament & reduces the tunnel size &
compress nerve

September 3, 2024 85
 Ulnar nerve injury

Ulnar nerve
pressure

Pronated arm Supinated arm

Unpadded Elbow padded

elbow

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 Ulnar nerve @ cubital fossa

September 3, 2024 87
 Eye injury
Excessive pressure on eyes Excessive pressure on eyes
↓ > than
↓ more than Arterial pressure
↓
Venous pressure Arterial inflow ↓
↓ ↓
Venous collapse Ischemia to Retina
↓
Arterial inflow goes on
↓
Arterial haemorrhage occurs

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 Eye injury
Corneal abrasion due to physical injury
occurs
Taping of eyelids after instillation of
artificial tears will prevent this

September 3, 2024 89
 Eye injury
Horse shoe rest
for the head
Note no
pressure on the
eyes

September 3, 2024 90
 Summary

All the team members should

be familiar with possible risks
to maintain patient safety

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 Summary
1. Make sure the OR table will permit the
position
2. Gather all positioning accessories before the
patient arrives to OR
3. Check with the anesthesia provider prior to
moving the patient
4. Provide the number of personnel needed
5. Use slow movements & do not drag the
patient. Move with a team approach

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 Summary
1. Pad all bony points adequately
2. Protect all superficial nerves
3. Ensure that the legs are not crossed to
prevent pressure on nerves or blood vessels
4. Secure the patient to OR bed properly to
prevent slipping
5. Maintain patient dignity & privacy by
avoiding unnecessary exposure
September 3, 2024 93
 THANK YOU
FOR
LISTENING

September 3, 2024 94