Operating Theatre Environment Research Articles

Human factors in pediatric anesthesia incidents

Anesthesia and the operating theater environment is a complex system involving man-machine and human-human interactions. Although we strive for an error free system, we are humans and errors and mistakes will occur. The aim of this study was to investigate the human factors behind events and incidents in pediatric anesthesia at our institution. This study consisted of a retrospective review and analysis of all contemporaneously reported anesthetic incidents between April 1, 2002 and March 31, 2004 at Birmingham Children's Hospital. Where there were anesthetic human factors involved in the event these were classified. There were 668 incidents reported, giving a rate of 2.4% of the 28 023 anesthetics recorded. Airway and respiratory incidents were the most common representing 52.2% of all incidents. A total of 284 anesthetic human factors could be identified and classified. Of these the most common were errors in judgment 43%, failure to check 17.8%, technical failures of skill 9.2%, inexperience 7.7%, inattention/distraction 5.6% and communication issues 5.6%. In our institution anesthetic human factors occur in 42.5% of in-theater incidents in pediatric anesthesia. Knowledge of these is necessary so that changes can be made in practice both by individuals and departments of anesthesia, to make anesthesia as safe as possible.

Sedation and anaesthesia for transvaginal oocyte collection: an evaluation of practice in the UK.

The objective of the survey was to evaluate sedation and anaesthetic practice employed for oocyte collection in the different assisted conception units in the UK and whether the guidelines of safe sedation were adhered to. A survey was carried out by means of a postal questionnaire sent out to the 100 reproductive medicine units of the UK, and 67 of the units responded. A response rate of 67% was achieved. Seventy-seven percent of responding units were part of hospitals with resuscitation facilities; 23% were free-standing without an in-house resuscitation team. Intravenous sedation was the preferred method of sedation for oocyte collection, being used in 62.4% of units. General anaesthesia was the primary method in 24.6% of units. A total of 47.4% of units used a medical member of the reproductive medicine team for administering sedation; 69% of cases were performed in a facility within the unit. One-hundred percent of respondents had oxygen, suction and tilting trolleys. It was reported that 23% of units were free standing, without cover from a resuscitation team. Sedation was performed by non-anaesthetic doctors in 46% and by nurses in 8.2%. In 69%, collections were performed outside of a general operating theatre environment. Also, 4.8% of units had no resuscitation trolley and 21.4% no defibrillator. Though most units complied with the guidelines of safe sedation and anaesthesia, gaps have been observed in the safe provision of sedation services for women undergoing oocyte retrieval in some units.

Changing trends in gynaecological surgery—a challenge for training

As gynaecology develops and grows, so does the range of surgical procedures we have to offer our patients. In the fields of both benign gynaecology and gynaecological oncology, there are many examples of the value of endoscopic procedures, both for diagnoses and therapy [1, 2]. How do we learn surgery, and how does it influence what we do? Traditionally, we have learnt from our teachers during our training, but increasingly this approach must be complemented by the foundation of evidence-based practice, structured formal training and careful supervised surgical technique. In the first issue of Gynecological Surgery it was suggested that the ESGE educational project is focussing specifically on delivery of quality educational programmes in the field of endoscopy and is well on the way to achieving this. As we move forward with this project, it is therefore timely to review where we have come from to reach the surgical standards we achieve today. In addition, it would be useful to reflect on the challenges ahead and how we can continue to improve our techniques to offer the highest level of care to our patients. The first consideration is the question, “What is the best place for surgery?” Traditionally, surgical procedures have always taken place in an operating theatre. Increasingly, we are seeing procedures that may be performed in the outpatient or office setting. As technology improves and the morbidity and pain of surgical procedures can be reduced, it may be that more operations need no longer be performed in the operating theatre setting. There has been a growth in “day surgery units”, “officebased procedure units” and the like, as the benefits of less medically invasive treatments are appreciated. Hysteroscopy is increasingly performed under local anaesthetic in the outpatient setting. It is even possible to perform relatively major surgery in some cases under local anaesthetic [3]. Diagnostic and therapeutic colposcopy is nearly always performed in the outpatient setting. Other procedures such as some bladder neck suspensions can be performed away from the traditional operating theatre environment. Global ablative technology in the treatment of menorrhagia is also another area where the treatment is increasingly leaving the operating theatre and moving into the office environment. Such fundamental changes in operating practice have many advantages. Firstly for the patient, not going into the operating theatre may be less stressful and anxiety provoking. For the surgeon, there is often a greater turnaround in the out-patient setting where the patients are waiting outside rather than the operating theatre where patients may have to travel from hospital wards, meaning a greater work-rate is possible. Secondly, there have been major changes in the need for general anaesthetic. The majority of gynaecological surgical procedures are still performed under general anaesthetic. As these procedures develop, and as our understanding of analgesia grows, so it is becoming increasingly possible to undertake many procedures under local or regional anaesthetic. Endometrial ablation, anterior colporraphy and bladder neck procedures can now all be performed under local anaesthetic [4]. Not only does this reduce the need for conventional anaesthetic support by avoiding general anaesthetic, but also the sickness and postoperative nausea can be abolished. Fifteen years ago patients undergoing hysterectomy would routinely spend up to 12 days in hospital, now it is only 3 or 4 days, and some colleagues perform the operation on a “day case” basis [5]. There has been an explosion in the development of new instrumentation for gynaecological surgery. One only has to wander through a medical exhibition at a conference to be aware of the massive developments in medical instrumentation over the last 10 years. Are we as surgeons being “hoodwinked” by the equipment companies that all of these new instruments, many of them disposable, are E. Downes Barnet and Chase Farm Hospital, Enfield, London, UK

Rating Anaesthetists' Non-Technical Skills — The Ants System

Non-technical skills are the cognitive and social skills required in any operational task involving decision making and team work, such as aviation or surgical medicine. This study identified the key non-technical skills required in anaesthesia, and developed a behavioural marker system (Anaesthetists' Non-Technical Skills (ANTS)) for their assessment in theatre, in the simulator or from video recordings. It comprises four skill categories (task management, team working, situation awareness and decision making) divided into fifteen elements, each with example behaviours. A first stage evaluation was conducted by asking 50 consultant anaesthetists to rate the behaviour of a target anaesthetist using the prototype ANTS system in eight videos of simulated anaesthetic scenarios. The system appeared to be complete, and the skills were observable, and could be rated with acceptable levels of agreement and accuracy. The second stage evaluation is now testing the usability of the behavioural rating system in the operating theatre environment.

Propofol should be the induction agent of choice for caesarean section under general anaesthesia

Since its launch, propofol (2,6-diisopropylphenol) has become the most widely used induction agent for general anaesthesia in this country. Its main attractions include an improved quality and speed of recovery combined with a relatively low incidence of postoperative nausea and vomiting which have made it particularly popular for the ever-increasing proportion of patients undergoing day-stay surgical procedures. The fortuitous timing of the introduction of the laryngeal mask airway to anaesthetic practice at about the same time as propofol has no doubt contributed to its rapid acceptance as the induction agent of choice when this device is used. However, it has also become popular in patients intubated and ventilated for short operations as well as longer and more specialised surgical procedures including cardiac and neurosurgery. Furthermore, its rapid elimination and lack of cumulative effects make it suitable for administration by continuous infusion for the maintenance of anaesthesia or sedation in conjunction with a regional block. Continuous infusions of propofol have also been used outside the operating theatre environment for sedation of patients undergoing radiological or endoscopic investigations as well as those in the intensive care unit.

Student nurse theatre placements. The new curriculum.

Following the implementation of the Fitness for Practice (FFP) nurse education curriculum, opportunities are available for student nurses to return to the operating theatre environment during their surgical module. This follows a ten-year absence in most parts of Wales. This article investigates what realistic placement objectives are available for student nurses in Wales and how close mentor supervision can enhance the learning process and promote the clinical experience of theatre nursing.

Another case of electromagnetic interference in the operating theatre

Electromagnetic interference in the operating theatre can be a hazard for patients. Understanding of the phenomena that can lead to it is of paramount importance. I highlight a form of interference that to my knowledge has not been reported before and which posed a risk of injury to the patient. A 61-year-old male patient with non-insulin-dependent diabetes mellitus was anaesthetised for evacuation of a right chronic subdural haematoma. There was no focal deterioration and the Glasgow Coma Scale (GCS) was 14–15. The anaesthetic technique consisted of induction with propofol, fentanyl and atracurium and maintenance of anaesthesia with a mixture of nitrous oxide and isoflurane in oxygen. Neuromuscular blockade was maintained with incremental doses of atracurium, as indicated by monitoring of the neuromuscular junction. The peripheral nerve stimulator used was a Dakmed 750 Digital, attached just below the lateral aspect of the right knee, over the common peroneal nerve. Train-of-four (TOF) stimulation was applied on demand for the assessment of neuromuscular blockade. During the intervals between testing, the stimulator was switched on but idle. The diathermy device used was a Valleylab Force 2 CEM Electrosurgical Generator. The indifferent electrode paddle was sited at the left thigh. During the course of the anaesthetic, it was noticed that the right foot was jerking vigorously and the peripheral nerve stimulator was discharging in an erratic way. Just prior to that, TOF stimulation had shown clinical recovery of only the first twitch and no additional muscle relaxant was used, because the operation was nearing an end. Triggering of chaotic peripheral nerve stimulator activation coincided with activation of the monopolar diathermy. On closer observation, it was noticed that the cable of the monopolar probe of the diathermy was lying behind the stimulator, almost in contact with it. Activation of the diathermy after the diathermy cable was moved away from the stimulator did not affect the stimulator or cause jerking of the foot; the malfunction of the stimulator and movements of the foot recurred if the cable was returned to its original position. Interference between diathermy equipment and almost any electronic device in use in the theatre environment has been described before. There is extensive literature on the effects and safety of pacemakers and implantable cardioverter-defibrillators when diathermy is used [1]. Interference between a peripheral nerve stimulator and pacemaker that led to cardiac arrest has been described [2]. In this case, the unintentional proximity of the cable of the monopolar diathermy with the peripheral nerve stimulator caused uncontrolled discharge from the stimulator. The vigorous jerking of the foot may have several explanations, one of which is post-tetanic potentiation. I am not able to say if the voltage output of the stimulator was also increased during the incident (transformer-like inductive coupling effect could explain such a phenomenon). The fact that neuromuscular function was recovering facilitated the diagnosis; however, we do not know if harmful current was applied over the peroneal nerve during earlier phases of the operation. Prolonged application of an excessive voltage over a nerve could result in transient or permanent nerve damage. The diathermy device uses frequencies of 0.5–10 MHz, well above the 100 Hz tetanic stimulus used by a peripheral nerve stimulator. This frequency could be applied indirectly by inductive coupling to the nerve stimulator and then directly to the nerve through the stimulator leads. We do not know what are the effects of prolonged application of such frequencies to human nerves. Clinical examination revealed no damage to the patient's peroneal nerve. Nerve conduction studies were not performed. This incident is an example of a potentially harmful event in the operating theatre environment. Electromagnetic interference is ‘invisible’ even to an otherwise experienced eye and can have catastrophic results [3]. Diathermy cables should always be kept well separated from any other electronic equipment. Separation criteria should be followed for all electronic devices [4]. Special care should be taken in the presence of implantable electronic devices. At present, health workers are not trained to be aware of problems arising due to electromagnetic interference. Standards on electromagnetic compatibility and interference prevention of electronic devices exist, i.e. the European standard EN55011 [5], but more attention needs to be given in healthcare practice and planning to minimise risks.

Rituals versus risks in the contemporary operating theatre environment.

Rituals versus risks in the contemporary operating theatre environment.

Occupational stress in the operating theatre suite: should employers be concerned?

Research conducted amongst perioperative nurses during 1996 investigated both the causes of occupational stress and nurses' perceptions of the effects of modern medical technologies on several aspects of their work life during the preceding three years. It found that there was a strong perception amongst the 433 nurses in the study that medical technologies had contributed to their increased workloads and higher levels of stress. This article presents the key findings on occupational stress and discusses some of their implications for health service managers who have responsibility for the occupational health and safety of nurses working in the operating theatre environment.

The palpation of pulses

In 554 anaesthetised patients, the times taken to separately palpate and identify each of the carotid, radial, brachial and femoral pulses were recorded. The patients were divided into three groups based on the form of airway management chosen (tracheal tube, facemask or laryngeal mask airway). Our results demonstrate that in the operating theatre environment the identification of the radial pulse is the most rapid and reliable; by 5 s, 98% and by 10 s, more than 99% of radial pulses were identified. The carotid pulse was not so easily identified, requiring 10 s to enable an identification rate of greater than 95%. The presence of a laryngeal mask airway or a tracheal tube did not hinder the identification of carotid pulse.

Laryngeal mask and anaesthetic waste gas exposure.

In recent years there has been a growing awareness of the possible hazards caused by anaesthetic gases in operating theatres. The laryngeal mask airway provides an alternative both to tracheal intubation and the face mask although the implications for operating theatre contamination have not been quantified. This paper describes the incidence and magnitude of exposure of theatre personnel to waste anaesthetic gases during laryngeal mask airway anaesthesia. The leakage of anaesthetic gases to the anaesthetist's breathing zone was monitored using a Bruel & Kjaer Multi Gas Monitor, Type 1302 during 50 general anaesthetics employing either spontaneous (n = 24) or controlled (n = 26) ventilation. All patients were anaesthetised with propofol, alfentanil and nitrous oxide. There was no statistically significant association between the amount of anaesthetic gas leakage and ventilation method. The laryngeal mask airway meets occupational safety requirements on nitrous oxide concentrations in the operating theatre environment.

Effect of operation theatre environment on laparotomy wound infection in bovines.

Right flank laparotomies were performed on five clinically healthy cross-bred calves. A significant (P less than 0.05) increase of 22.1 and 2.7 times in bacterial count in subcutaneous tissue and incised skin edges, respectively, and a non-significant increase (1.1 times) in muscles and peritoneum had occurred during 15 minutes exposure to the operation theatre environment. Poly-morphonuclear cells and Gram-positive and Gram-negative bacterial infiltration was also demonstrated histopathologically in muscles and peritoneum. Organisms isolated from operation theatre air were Staphylococcus aureus, other Staphylococcus spp., Bacillus spp., Micrococcus spp., and yeast. Usually similar organisms were also found on the laparotomy wound, just before closure of abdomen. Operation theatre environment is concluded to be a significant source of operative wound contamination. Provision of separate operation theatres for different types of surgery in different species is recommended and the necessity for their regular disinfection is stressed.

Clinical recording of laser-induced fluorescence spectra for evaluation of tumour demarcation feasibility in selected clinical specialities

Laser-induced autofluorescence spectra from humans were recorded in vivo at three different clinics in a study aimed at investigating the capability of this method to discriminate between malignant tumours and normal surrounding tissues. For the recordings a mobile trolley with the necessary equipment was constructed for use in an examination room or in an operating theatre environment. Laser light was guided through a 600μm optical fibre to the target tissue. The fluorescence from the excited tissue was collected with the same fibre and was fed to an optical multichannel analyser. Two excitation wavelengths were used (337 and 405 nm) in order to optimize the fluorescence signals in two interesting wavelength regions (380–500 and 550–700 nm). Oral and oropharyngeal tumours excited with 405 nm light contained detectable endogenous porphyrins and were in this way discriminated from the normal mucosa. Astrocytoma grade III–IV fluorescence different from that of normal brain tissue, while tumours in the bronchial tree were not detectable using the spectral shape of the pure tissue autofluorescence.

The laryngeal box: an aid to laser microlaryngeal surgery

AbstractWe report the use of the ‘laryngeal box’, which permits instruction of a trainee in laser microlaryngeal surgery outside the operating theatre environment.

The Stability of Atracurium in Clinical Practice

Atracurium has an unusual intrinsic Hofmann elimination which is increased by an alkaline environment and increased temperature. Normally the relaxant is stored at pH 3.3 and kept at a temperature of 4 degrees C. However, it is convenient to have a reasonable quantity available within the operating theatre. This study examined the rate of degradation of atracurium in the operating theatre environment of 20 degrees C. Atracurium within one month of its expiry date was placed in the drawer for anaesthetic drugs in each of three operating theatres. At the end of each month, further drug was added to the stock. At the end of the study, atracurium which had been stored continuously at 4 degrees C, was at 102.9% of nominal strength, having started with 113.5% at manufacture. Atracurium which had been at room temperature for one, two and three months respectively retained 99%, 95% and 92% strength respectively. These results show that even three months' exposure to room temperature does not cause enough deterioration to be clinically significant.

A Versatile Antipollution Device

Removal of anaesthetic pollutants from the operating theatre environment requires the use of relatively sophisticated equipment which must be added to an existing life support system (the anaesthetic machine). The interface is only one part of this system and to be safe and satisfactory it must be as simple and versatile as possible and be designed in such a way as to render incorrect connection and use virtually impossible.

TRACE CONCENTRATIONS OF HALOTHANE IN HUMAN BREAST MILK

Halothane concentrations of 2 p.p.m. have been found in the breast milk of a lactating, practising anaesthetist. This concentration was consistent with the operating theatre environment. The authors fell that, in spite of the limited scope of the study, this is an additional reason for the elimination of waste anaesthetic agents from the operating theatre.

Correspondence: Health hazards in operating theatre environments.

Correspondence: Health hazards in operating theatre environments.

Atmospheric pollution with halothane in operating theatres. A clinical study using activated charcoal.

Considerable reductions of halothane pollution in the operating theatre environment can be achieved with canisters containing activated charcoal attached to the expiratory limb of the anaesthetic circuit. This study indicates that the efficiency is greatest with cases requiring endotracheal intubation. If the facemask is employed, it is essential to achieve a tight seal with the contours of the face to eliminate unnecessary pollution.

Ward design in relation to postoperative wound infection. II.

A detailed investigation has been carried out into the behaviour of wounds after 1,000 general surgical operations, about equal numbers of patients having been studied in two different ward and operating theatre environments. The wound sepsis rate was reduced after transfer to the new type of ward. It is concluded that features of the new ward environment were responsible for the observed fall in the incidence of cross-infection.