OT TECHNIQUE AND SURGERY

1. Physical Environment of the Operation Theatre (OT)

A. Operation Theatre Room:

• Definition:
  A sterile, controlled environment where surgical procedures are performed.
• Design:
  • Modular OT: Modern, flexible, with integrated technology.
  • Zoning System:
    • Unrestricted Zone: Entry area (changing rooms).
    • Semi-restricted Zone: Corridors and storage areas (wear OT attire, caps).
    • Restricted Zone: Operating room (sterile attire required).
• Ventilation and Air Control:
  • Laminar Airflow System: Reduces airborne contamination.
  • HEPA Filters: Remove 99.97% of airborne particles ≥0.3 microns.
  • Positive Pressure Ventilation: Prevents entry of contaminated air.
• Lighting:
  • Shadowless Operating Lights: Provide uniform illumination.
  • Adjustable intensity and focus for different procedures.

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B. Cleaning and Disinfection Protocols:

1. Cleaning of Tables, Trolleys, Lights, and Equipment:
   • Before Surgery:
     • Wipe with 70% isopropyl alcohol or disinfectant.
     • Check functionality of equipment.
   • Between Cases:
     • Clean visible blood and body fluids using hypochlorite solution (0.5–1%).
     • Disinfect high-touch surfaces: OT tables, lights, anesthesia machines.
   • After the Last Surgery of the Day (Terminal Cleaning):
     • Wet mopping of floors with disinfectant.
     • Clean walls up to 5 feet.
     • Disinfect reusable equipment.
   • Weekly Deep Cleaning:
     • Includes ceilings, walls, air vents, storage cabinets.
2. Disinfection Solutions Used:DisinfectantConcentrationPurposeSodium Hypochlorite0.5–1%Surface disinfectionIsopropyl Alcohol70%Quick-drying for equipmentGlutaraldehyde2%High-level disinfection (endoscopes)Hydrogen Peroxide3%Environmental fogging
3. Sterilization of Instruments:
   • Autoclaving: Steam under pressure (121°C at 15 psi for 15–20 mins).
   • Ethylene Oxide Gas: For heat-sensitive equipment.
   • Plasma Sterilization: Low-temperature sterilization (for delicate instruments).

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2. Pre-operative Holding Area

Definition:

A designated area where patients are prepared and held before entering the OT.

Functions:

• Patient Verification: Confirm identity, surgical site, procedure (using a checklist).
• Pre-operative Assessment: Review of vitals, medical history, consent, allergies.
• IV Line Insertion: Start intravenous access if needed.
• Administration of Pre-medication: Sedatives, antibiotics, antiemetics.
• Marking the Surgical Site: To prevent wrong-site surgery.
• Psychological Support: Reduce anxiety and answer patient queries.

Infection Control in Pre-op Area:

• Maintain clean environment.
• Regular disinfection of stretchers and equipment.
• Hand hygiene compliance by all staff.

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3. Infection Control Measures in OT

• Aseptic Techniques:
  • Hand scrubbing (5–7 minutes).
  • Sterile gowning and gloving.
  • Maintaining sterile fields.
• Traffic Control:
  • Minimize personnel movement to reduce contamination.
  • Limit door opening during procedures.
• Personal Protective Equipment (PPE):
  • Masks, caps, gowns, gloves, shoe covers.

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4. OT Safety Protocols

• Universal Protocol:
  • Time-out Procedure: Pause before surgery to confirm patient, procedure, site.
  • Surgical Safety Checklist (WHO): Reduces complications and mortality.
• Electrical Safety:
  • Proper grounding of equipment.
  • Use of insulated surgical instruments.
• Fire Safety:
  • Manage oxygen sources carefully.
  • Availability of fire extinguishers.

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Key Points for Competitive Exams

1. Laminar Airflow + HEPA filters = Reduce surgical site infections.
2. Positive Pressure Ventilation = Prevents contaminated air from entering OT.
3. Sodium Hypochlorite (0.5–1%) = Standard for surface disinfection.
4. Autoclaving = Gold standard for sterilizing surgical instruments.
5. Pre-op Holding Area = Patient verification, IV access, pre-medication.
6. WHO Surgical Safety Checklist = Reduces surgical errors.
7. Time-out Procedure = Mandatory before incision to confirm surgical details.
8. Terminal Cleaning = Done at the end of the surgical day.
9. Ethylene Oxide Sterilization = For heat-sensitive instruments.
10. Traffic in OT = Kept to a minimum to reduce infection risk.

1. Scrubbing – Hand Washing

Definition:

Scrubbing is the process of aseptic hand washing to remove transient and resident microorganisms before surgery.

Types of Hand Washing:

1. Routine Hand Wash:
   • Used before entering OT.
   • Uses soap and water for 30–60 seconds.
2. Antiseptic Hand Rub (Alcohol-Based):
   • Used when hands are not visibly soiled.
   • Uses 70% alcohol-based rub.
3. Surgical Hand Scrub:
   • Required before every surgical procedure.
   • Uses antimicrobial agents (Chlorhexidine 4% or Povidone-Iodine 7.5%).

Surgical Hand Scrubbing Steps (WHO Technique):

1. Remove all jewelry.
2. First Wash (2–3 mins):
   • Clean nails with a nail pick under running water.
   • Scrub hands and forearms up to the elbows.
3. Repeat Scrub (3–5 mins):
   • Cover all hand surfaces in a circular motion.
   • Avoid touching non-sterile surfaces.
4. Rinse from fingertips to elbows (allowing water to flow downward).
5. Keep hands above waist level and proceed to gowning.

Key Points for Competitive Exams:

• Minimum scrubbing time = 5 minutes for first case, 3 minutes for subsequent cases.
• Scrub from clean to dirty = Fingers to elbows.
• Chlorhexidine 4% = Preferred antiseptic (better residual activity than iodine).

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2. Gowning (Sterile Surgical Attire)

Purpose:

• Prevents microbial contamination from surgical staff to the sterile field.

Types of Surgical Gowns:

1. Reusable Gowns: Made of cotton or polyester (require sterilization).
2. Disposable Gowns: Single-use, made of polypropylene or SMS fabric.

Gowning Procedure (Closed Technique):

1. Open the sterile gown pack without touching the outer surface.
2. Hold the inside of the gown and step into it.
3. Allow the circulating nurse to tie the neck and back straps.
4. Perform gloving without touching the gown’s outer surface.
5. Secure the gown’s waist ties without contaminating the front.

Key Points for Competitive Exams:

• Gowns are sterile only from the waist up and front-facing.
• Closed gloving must be done after donning the gown.
• Sterile field is maintained at waist level and above.

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3. Gloving (Sterile Gloves Application)

Types of Gloves:

1. Latex Gloves: Most commonly used.
2. Nitrile Gloves: For latex-allergic staff.
3. Sterile vs. Non-Sterile Gloves:
   • Sterile = For surgeries.
   • Non-sterile = For basic patient care.

Gloving Techniques:

1. Open Gloving: Used when gowning is not required (e.g., minor procedures).
2. Closed Gloving: Used after gowning, prevents contamination.
3. Assisted Gloving: Done with assistance from another sterile person.

Closed Gloving Procedure:

1. Open the sterile glove pack.
2. With the gown’s sleeves covering hands, pick up one glove and place it over the cuff.
3. Insert fingers inside without touching the outer glove surface.
4. Repeat for the second glove and adjust fit.

Key Points for Competitive Exams:

• Closed gloving = Used in major surgeries.
• Gloves must be changed if perforated or contaminated.
• Double gloving reduces risk of contamination.

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4. Positioning of Patients for Various Surgical Procedures

Surgical Position	Used For	Precautions
Supine (Dorsal Recumbent)	General surgeries, laparotomy, cardiac procedures	Pad pressure points to prevent ulcers
Prone	Spinal surgeries, posterior craniotomy	Protect eyes, maintain airway
Lithotomy	Gynecological, urological, perineal surgeries	Avoid nerve compression (sciatic, peroneal)
Trendelenburg	Lower abdominal & pelvic surgeries, shock management	Risk of aspiration, respiratory distress
Reverse Trendelenburg	Upper abdominal, head, and neck surgeries	Secure patient to prevent sliding
Lateral (Sims’)	Thoracic, renal, hip surgeries	Support head, pad bony prominences
Sitting/Fowler’s	Neurosurgery, shoulder surgery	Risk of venous air embolism
Jackknife (Kraske)	Anorectal surgeries (e.g., pilonidal sinus excision)	Protect knees and hips from hyperextension

Key Points for Competitive Exams:

• Trendelenburg = Used to improve venous return but may cause increased ICP.
• Lithotomy = Watch for nerve injury (common peroneal, femoral).
• Fowler’s = Used in brain surgery but increases embolism risk.

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5. Draping of the Patient

Definition:

Draping involves covering the patient with sterile sheets to isolate the surgical field.

Types of Drapes:

1. Reusable Drapes: Cotton-based, require sterilization.
2. Disposable Drapes: Made of synthetic materials, liquid-resistant.
3. Fenestrated Drapes: Have an opening for the surgical site (used in eye, abdominal, and orthopedic surgeries).
4. Adhesive Drapes: Stick to the skin, prevent bacterial migration.

Draping Procedure:

1. Ensure skin preparation is completed before draping.
2. Unfold drapes without touching non-sterile surfaces.
3. First, drape the side opposite to the surgeon.
4. Cover the surgical site last, ensuring sterile fields remain intact.
5. Secure drapes in place using towel clips.

Key Points for Competitive Exams:

• Sterile drapes must be placed with minimal movement to prevent contamination.
• Fenestrated drapes = Common for abdominal, eye, and joint surgeries.
• Drapes should not be readjusted after placement.

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Summary of Key Points for Competitive Exams

Technique	Key Exam Points
Scrubbing	5-minute scrub for first case, Chlorhexidine 4% preferred
Gowning	Sterile from waist up and front-facing only
Gloving	Closed gloving after gowning, double gloving for high-risk cases
Patient Positioning	Trendelenburg for pelvic surgeries, Fowler’s for brain surgery
Draping	Fenestrated drapes for specific sites, adhesive drapes for skin protection

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Final Exam-Oriented Takeaways

1. Scrubbing must be performed from clean to dirty (fingers to elbows).
2. Closed gloving must be used for sterile procedures after gowning.
3. Supine is the most common surgical position; Trendelenburg increases ICP.
4. Lithotomy position can cause sciatic and common peroneal nerve injury.
5. Drapes should never be readjusted after being placed.
6. HEPA filters and positive pressure ventilation reduce infection risk in OT.
7. Double gloving is recommended for high-risk exposure surgeries.
8. Sterile zones should be maintained at waist level and above.
9. Time-out procedure (WHO checklist) must be performed before incision.
10. Hand hygiene is the most effective infection control measure in OT.

1. Cleaning of Operation Theatre (OT)

Purpose:

To maintain a sterile and infection-free environment, minimizing the risk of surgical site infections (SSIs).

Types of Cleaning:

1. Routine (Daily) Cleaning:
   • Before the first surgery: Clean all horizontal surfaces (tables, lights, equipment) with 70% isopropyl alcohol.
   • Between surgeries: Spot cleaning with 1% sodium hypochlorite for visible contamination.
   • After the last surgery: Terminal cleaning (floors, walls up to 5 ft, equipment).
2. Terminal (Deep) Cleaning:
   • Done weekly or after infection outbreaks.
   • Includes ceilings, vents, walls, storage areas.

Cleaning Agents:

Agent	Concentration	Use
Sodium Hypochlorite	0.5–1%	Disinfection of surfaces
Isopropyl Alcohol	70%	Quick surface disinfection
Glutaraldehyde	2%	High-level equipment disinfection (endoscopes)
Bacillocid	As per manufacturer’s instruction	Used in OT for surface disinfection
Hydrogen Peroxide	3%	Fogging and fumigation

Key Points for Competitive Exams:

• Terminal cleaning = After last case daily.
• 1% sodium hypochlorite = Standard surface disinfectant.
• Bacillocid = High-level disinfectant for OT surfaces.

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2. Needles and Sutures – Types and Uses

A. Types of Surgical Needles:

1. Based on Point Type:
   • Cutting Needle: Triangular tip; used for tough tissues (skin, tendons).
   • Reverse Cutting Needle: Stronger, reduces tissue trauma.
   • Taper Point Needle: Round body; for soft tissues (intestines, vessels).
   • Blunt Needle: For friable tissues (liver, spleen).
2. Based on Shape:
   • Curved Needle: Common for deep tissues.
   • Straight Needle (Keith’s Needle): For skin or superficial tissues.

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B. Types of Sutures:

1. Based on Absorbability:
   • Absorbable Sutures: Dissolve over time (no removal needed).
     • Natural: Catgut (fast-absorbing), Collagen
     • Synthetic: Vicryl (polyglactin 910), PDS (polydioxanone)
   • Non-absorbable Sutures: Permanent; require removal if superficial.
     • Natural: Silk, linen
     • Synthetic: Nylon, polypropylene, polyester
2. Based on Structure:
   • Monofilament: Single strand (less infection risk, e.g., nylon).
   • Multifilament: Braided (strong but higher infection risk, e.g., silk).
3. Common Uses:

Suture Type	Common Use
Vicryl (absorbable)	Internal soft tissue, fascia
PDS (absorbable)	Abdominal closure, pediatric surgeries
Silk (non-absorbable)	Vascular ligatures, drain fixation
Nylon (non-absorbable)	Skin closure
Prolene (non-absorbable)	Cardiovascular and plastic surgery

Key Points for Competitive Exams:

• Cutting needle = Skin suturing.
• Tapered needle = Soft tissues (intestines, vessels).
• Vicryl = Absorbable suture, commonly used for fascia.
• Silk = Non-absorbable, used for ligating vessels.

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3. Sterilization Techniques

Sterilization is the process of destroying all microorganisms, including spores.

A. Carbolization (Phenol Disinfection):

• Involves cleaning surfaces with carbolic acid (phenol solution).
• Not commonly used now due to toxicity and better alternatives (like Bacillocid).
• Used historically for surgical instruments and OT surfaces.

B. Ethylene Oxide (ETO) Sterilization:

• Low-temperature sterilization method for heat-sensitive equipment.
• Used for:
  • Plastic instruments
  • Endoscopes
  • Catheters
  • Electronic devices
• Procedure:
  • Equipment is cleaned, dried, and sealed in ETO chambers.
  • Sterilization time: 2–4 hours + aeration to remove residual gas (toxic if inhaled).

C. Fumigation (OT Fogging):

• Disinfecting OT air and surfaces using formaldehyde or hydrogen peroxide vapor.
• Formaldehyde Fumigation:
  • 500 ml of formaldehyde + 1 liter of water for a 1000 ft³ area.
  • Exposure time: 6–8 hours, followed by neutralization with ammonia.
• Modern Alternative: Hydrogen peroxide vapor (safer, less toxic).

D. Bacillocid Sterilization:

• A broad-spectrum disinfectant used for surface sterilization in OTs.
• Effective against bacteria, viruses, fungi, and spores.
• Applied via mopping, spraying, or fogging.

E. OT Swab Testing (Sterility Testing):

• Swab samples from OT surfaces are cultured to check for microbial contamination.
• Ensures that sterilization protocols are effective.

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Key Differences Between Sterilization Methods

Method	Used For	Key Point
Carbolization	Surface disinfection (obsolete)	Replaced by modern disinfectants
ETO Sterilization	Heat-sensitive instruments	Requires aeration after sterilization
Fumigation/Fogging	Air and surface disinfection in OT	Hydrogen peroxide safer than formaldehyde
Bacillocid	OT surfaces and equipment	Broad-spectrum disinfectant
Autoclaving	Surgical instruments (heat-resistant)	121°C, 15 psi, 15–20 mins

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4. Key Points for Competitive Exams

1. 1% sodium hypochlorite = Standard for OT surface disinfection.
2. ETO sterilization = For heat-sensitive equipment (endoscopes, plastics).
3. Bacillocid = Broad-spectrum disinfectant for OT surfaces.
4. Absorbable sutures = Vicryl, PDS (don’t require removal).
5. Non-absorbable sutures = Silk, nylon, prolene (require removal if superficial).
6. Cutting needles = Used for tough tissues like skin.
7. Tapered needles = Used for soft tissues like intestines.
8. Formaldehyde fumigation = Requires neutralization with ammonia after use.
9. OT Swab Testing = Ensures effectiveness of sterilization processes.
10. Double-gloving = Recommended for high-risk surgical procedures.

1. Absorbable Sutures

Absorbable sutures are gradually broken down in the body through enzymatic digestion or hydrolysis and do not require removal.

Suture Material	Type	Absorption Time	Advantages	Disadvantages
Plain Catgut	Natural	7–10 days	Cheap, easy to handle	Unpredictable absorption, tissue reaction
Chromic Catgut	Natural	10–21 days	Less reactive than plain catgut	Variable absorption, moderate tissue reaction
Vicryl (Polyglactin 910)	Synthetic	56–70 days (complete)	Predictable absorption, minimal tissue reaction	Expensive, reduced tensile strength after 2 weeks
PDS (Polydioxanone)	Synthetic	Up to 180 days	High tensile strength, long-lasting support	Stiff, harder to handle, expensive
Monocryl (Poliglecaprone 25)	Synthetic	90–120 days	Smooth, easy handling, minimal tissue reaction	Limited use for high-tension areas
Dexon (Polyglycolic acid)	Synthetic	60–90 days	Good knot security, minimal tissue reaction	Decreased tensile strength over time

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2. Non-Absorbable Sutures

Non-absorbable sutures are not degraded by the body and are either left in place permanently (internal use) or removed after healing (external use).

Suture Material	Type	Absorption/Removal	Advantages	Disadvantages
Silk	Natural	Not absorbed; removed after 7–10 days (external use)	Easy to handle, good knot security	High tissue reactivity, loses strength over time
Nylon (Ethilon)	Synthetic	Requires removal	Minimal tissue reaction, strong	Poor knot security, requires multiple knots
Polypropylene (Prolene)	Synthetic	Permanent	High tensile strength, minimal tissue reaction	Slippery, difficult knot tying
Polyester (Ethibond)	Synthetic	Permanent	Strong, good for cardiovascular surgeries	May cause tissue drag, harder to handle
Stainless Steel Wire	Synthetic	Permanent	Strongest suture, no tissue reaction	Difficult to handle, risk of wire breakage, skin irritation

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Key Differences Between Absorbable and Non-Absorbable Sutures

Criteria	Absorbable Sutures	Non-Absorbable Sutures
Degradation	Broken down by body enzymes/hydrolysis	Remain in the body unless removed
Common Use	Internal tissues (e.g., fascia, bowel)	Skin closure, cardiovascular surgeries
Tissue Reaction	Minimal (synthetic), moderate (natural)	Minimal (synthetic), higher (natural)
Removal Needed	No	Yes (if external)
Examples	Vicryl, PDS, Catgut	Nylon, Prolene, Silk, Stainless Steel

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3. Advantages and Disadvantages of Suture Materials

Natural Sutures (Catgut, Silk):

• Advantages:
  • Easy handling
  • Good knot security (silk)
  • Readily available
• Disadvantages:
  • Higher tissue reaction
  • Unpredictable absorption (catgut)
  • Risk of infection

Synthetic Absorbable Sutures (Vicryl, PDS, Monocryl):

• Advantages:
  • Predictable absorption
  • Minimal tissue reaction
  • Strong tensile strength (PDS)
• Disadvantages:
  • Expensive
  • Some are difficult to handle (PDS)
  • Loss of strength over time

Synthetic Non-Absorbable Sutures (Nylon, Prolene):

• Advantages:
  • Strong, durable
  • Minimal tissue reactivity
  • Suitable for long-term support
• Disadvantages:
  • Slippery (prolene), requires multiple knots
  • May cause discomfort if left in place externally

Metal Sutures (Stainless Steel):

• Advantages:
  • Highest tensile strength
  • No tissue reaction
  • Corrosion-resistant
• Disadvantages:
  • Difficult to handle
  • Risk of cutting through tissues
  • May cause skin irritation

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4. Suture Selection Based on Surgical Site

Surgical Site	Preferred Suture
Skin	Nylon, Prolene (non-absorbable)
Fascia	PDS, Vicryl (absorbable, strong)
Intestines	Vicryl, Monocryl (absorbable)
Cardiovascular Surgery	Prolene (non-absorbable, strong)
Ophthalmic Surgery	Nylon, Prolene (fine sutures)
Orthopedic Surgery	Stainless Steel Wire
Urological Surgery	PDS (long-lasting absorbable)

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Key Points for Competitive Exams

1. Vicryl absorption = Complete in 56–70 days.
2. PDS = Longest absorption time (up to 180 days).
3. Silk = Non-absorbable but loses tensile strength over time.
4. Nylon = Strong, minimal tissue reaction, poor knot security.
5. Prolene = Preferred in vascular surgeries due to strength.
6. Catgut = Natural, absorbed unpredictably, higher tissue reaction.
7. Stainless steel = Strongest suture, no tissue reaction.
8. Monofilament = Less infection risk, but harder to tie knots.
9. Multifilament = Better knot security, higher infection risk.
10. Absorbable sutures = Preferred for internal tissues to avoid removal.

1. Packing of Surgical Materials

A. General Principles of Packing:

• Use sterile, lint-free materials (cotton cloth, crepe paper, non-woven materials).
• Ensure proper labeling: Date of sterilization, expiry date, and batch number.
• Avoid overpacking to ensure proper sterilant penetration.
• Use indicator tapes/strips (chemical or biological) to confirm sterilization.

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B. Packing of Specific Items:

1. Dressings and Gauze Packs:
   • Sterile gauze folded neatly into packs.
   • Packed in autoclavable wrappers or sterilization pouches.
   • Use indicator tape to ensure sterilization status.
2. Linen (Gowns, Drapes, Towels):
   • Folded to allow easy unfolding in a sterile manner.
   • Bundled loosely to allow steam penetration.
   • Packed in double-layered cloth wraps for autoclaving.
3. Rubber Ware (Gloves, Catheters, Tubes):
   • Cleaned thoroughly, dried, and powdered (for gloves).
   • Rolled or folded without creasing to prevent damage.
   • Packed in perforated trays or sterilization pouches.
4. Suture Materials:
   • Pre-sterilized suture packets (commercially packed) are common.
   • For in-house packing: Place sutures in sterile containers, properly labeled.
5. Surgical Instruments:
   • Cleaned and dried after use to prevent rust.
   • Hinged instruments opened to allow steam penetration.
   • Placed in sterilization trays or wrapped in double-layered cloth.
6. Needles and Sharp Instruments:
   • Stored in puncture-proof containers or metal boxes.
   • Use sterilization pouches with clear windows for easy identification.

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2. Sterilization Methods

Method	Principle	Used For	Temperature/Time
Autoclaving (Steam Sterilization)	Moist heat under pressure	Instruments, linen, dressings, glassware	121°C, 15 psi, 15–20 mins
Dry Heat Sterilization	Oxidation of microbial proteins	Glass syringes, metal instruments	160°C for 2 hours or 170°C for 1 hour
Ethylene Oxide (ETO) Sterilization	Alkylation of DNA/RNA	Heat-sensitive items (plastic, rubber)	2–4 hours at 37–55°C
Chemical Sterilization (Cold Sterilization)	Use of disinfectants (glutaraldehyde, formalin)	Endoscopes, delicate equipment	2% glutaraldehyde for 20 mins (disinfection), 10 hours (sterilization)
Radiation Sterilization	Ionizing radiation	Disposable medical devices	Gamma rays or electron beams
Plasma Sterilization (Hydrogen Peroxide Plasma)	Reactive species from hydrogen peroxide	Heat and moisture-sensitive items	Low temperature (≤50°C)

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3. Sterilization of Specific Materials

A. Dressings and Gauze Packs:

• Method: Autoclaving (preferred).
• Procedure:
  • Packed in double-layered wraps.
  • Steam sterilized at 121°C, 15 psi for 20 minutes.

B. Linen (Gowns, Drapes):

• Method: Autoclaving.
• Procedure:
  • Folded loosely to allow steam penetration.
  • Sterilized at 121°C for 20 minutes.

C. Rubber Ware (Gloves, Catheters):

• Method: ETO Sterilization or Autoclaving (if heat-stable).
• Procedure:
  • Thoroughly cleaned and dried before sterilization.
  • ETO sterilization preferred to prevent damage.

D. Suture Materials:

• Synthetic Sutures: Commercially pre-sterilized.
• Natural Sutures (Catgut): Sterilized using gamma radiation or chemical sterilization (e.g., iodine solution for catgut).

E. Surgical Instruments:

• Method: Autoclaving (preferred) or dry heat sterilization (for sharp instruments).
• Procedure:
  • Hinged instruments opened.
  • Autoclaved at 121°C for 15–20 minutes.

F. Needles and Sharp Instruments:

• Method: Dry heat sterilization (preferred) or autoclaving.
• Procedure:
  • Placed in puncture-proof containers.
  • Sterilized at 160°C for 2 hours (dry heat) or autoclaved.

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4. Bacillocid Sterilization

• Bacillocid: A high-level disinfectant used for environmental sterilization in OTs.
• Application:
  • Surface disinfection (floors, walls, equipment).
  • Dilution as per manufacturer’s instructions.
  • Mopping or fogging technique used.

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5. Fumigation of Operation Theatre

Purpose:

To sterilize the OT environment, including air, walls, and equipment surfaces.

Common Agents:

• Formaldehyde Fumigation: Traditional method.
• Hydrogen Peroxide Fogging: Modern, safer alternative.

Procedure (Formaldehyde Method):

1. Seal the OT to prevent gas leakage.
2. Use 500 ml of formalin + 1 liter of water per 1000 ft³ area.
3. Add 150 gm of potassium permanganate to initiate fumigation.
4. Leave the OT closed for 6–8 hours.
5. Neutralize formaldehyde with ammonia before re-entry.

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6. Sterility Indicators

Type	Purpose	Example
Chemical Indicators	Color change indicates exposure to sterilization conditions	Autoclave tape (stripes turn black)
Biological Indicators	Confirm sterilization efficacy using spores	Bacillus stearothermophilus for autoclaves
Mechanical Indicators	Monitor sterilizer performance (time, temperature, pressure)	Autoclave gauges

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Key Points for Competitive Exams

1. Autoclaving = Most common sterilization method (121°C, 15 psi, 15–20 mins).
2. ETO sterilization = Preferred for heat-sensitive equipment (plastic, rubber).
3. Dry heat sterilization = Ideal for glassware, sharp instruments (160°C for 2 hours).
4. Bacillocid = High-level disinfectant for OT surfaces.
5. Fumigation = Uses formaldehyde or hydrogen peroxide for OT air sterilization.
6. Biological indicators = Confirm sterilization (Bacillus stearothermophilus).
7. Surgical instruments must be packed with hinges open for effective sterilization.
8. Gloves = Sterilized using ETO or autoclaved after powdering.
9. Sterile packs are considered sterile for 30 days if properly sealed.
10. Chemical indicators (autoclave tape) change color to confirm sterilization exposure.

1. Physical Preparation

A. General Physical Preparation:

• Personal Hygiene:
  • Bathing with antiseptic soap to reduce skin flora.
  • Oral hygiene to prevent postoperative infections.
  • Shaving or clipping hair around the surgical site (preferably with clippers, not razors, to reduce infection risk).
• Skin Preparation:
  • Cleaning with antiseptic solution (e.g., povidone-iodine or chlorhexidine).
  • Avoid abrasions or cuts.
• Fasting (NPO):
  • To prevent aspiration during anesthesia.
  • Solid food: Restricted 6–8 hours before surgery.
  • Clear fluids: Allowed up to 2 hours before surgery.
• Bowel Preparation:
  • Laxatives or enemas for abdominal or pelvic surgeries.
  • Empty bladder before surgery.
• Vital Signs Monitoring:
  • Baseline BP, pulse, temperature, respiration, SpO₂.
• Removal of Personal Items:
  • Dentures, jewelry, contact lenses, nail polish (to assess capillary refill).
• IV Access:
  • Insert intravenous cannula for fluids and medications.

Key Points for Competitive Exams:

• Hair clipping preferred over shaving to reduce infection risk.
• NPO for 6–8 hours (solids), 2 hours (clear fluids) before surgery.
• Remove dentures, jewelry, and nail polish before surgery.

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2. Psychological Preparation

A. Addressing Anxiety and Fear:

• Patient Education:
  • Explain the procedure, expected outcomes, risks, and postoperative care.
  • Use simple, understandable language.
• Emotional Support:
  • Encourage the patient to express fears and concerns.
  • Involve family members for reassurance.
• Relaxation Techniques:
  • Deep breathing exercises, guided imagery, meditation.
  • Helps reduce anxiety and improve cooperation.
• Preoperative Counseling:
  • Discuss possible ICU stay, ventilator support, or postoperative pain management if relevant.

Key Points for Competitive Exams:

• Effective communication reduces preoperative anxiety.
• Involve family members to provide emotional support.
• Preoperative teaching improves patient outcomes and cooperation.

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3. Pre-medications (Pre-anesthetic Medications)

A. Purpose of Pre-medication:

• Reduce anxiety and fears.
• Provide sedation and amnesia.
• Reduce secretions (antisialagogues).
• Prevent nausea and vomiting.
• Minimize autonomic responses (bradycardia, hypotension).

B. Common Pre-medications:

Drug Class	Examples	Purpose
Sedatives/Anxiolytics	Diazepam, Lorazepam, Midazolam	Reduce anxiety, provide sedation
Opioid Analgesics	Morphine, Fentanyl	Pain relief, reduce anesthetic dose
Anticholinergics	Atropine, Glycopyrrolate	Reduce secretions, prevent bradycardia
Antiemetics	Ondansetron, Metoclopramide	Prevent nausea and vomiting
H2 Blockers/PPIs	Ranitidine, Omeprazole	Reduce gastric acidity
Antibiotics	Cefazolin, Ampicillin	Prevent surgical site infections (given prophylactically)

Administration Guidelines:

• Given 30–60 minutes before surgery (as prescribed).
• Monitor for side effects: respiratory depression, hypotension, allergic reactions.

Key Points for Competitive Exams:

• Atropine = Reduces secretions and prevents bradycardia.
• Midazolam = Provides sedation and amnesia.
• Ondansetron = Prevents postoperative nausea and vomiting.
• Antibiotic prophylaxis = Given 30–60 minutes before incision.

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4. Legal and Ethical Considerations

A. Informed Consent (Legal Requirement):

• Definition:
  A process where the patient voluntarily agrees to undergo surgery after understanding the risks, benefits, and alternatives.
• Components of Valid Consent:
  1. Disclosure: Explanation of the procedure, risks, benefits, and alternatives.
  2. Capacity: Patient must be mentally competent to make decisions.
  3. Voluntariness: No coercion or undue influence.
  4. Documentation: Signed consent form (witnessed if needed).
• Special Situations:
  • Minors: Consent by parents or legal guardians.
  • Emergencies: Implied consent if the patient is unconscious and no family is available.
  • Mentally Incapacitated: Legal guardian or power of attorney provides consent.

B. Ethical Principles in Pre-operative Care:

• Autonomy: Respecting the patient’s right to make decisions.
• Beneficence: Acting in the best interest of the patient.
• Non-maleficence: “Do no harm” – minimizing risks during care.
• Justice: Ensuring fairness and equality in treatment.
• Confidentiality: Protecting patient information.

Key Points for Competitive Exams:

• Informed consent = Legal requirement before any surgical procedure.
• Emergency = Implied consent if life-threatening and no guardian available.
• Minors = Consent from parents or legal guardians.
• Ethical principles = Autonomy, beneficence, non-maleficence, justice.

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5. Summary of Pre-operative Preparation

Aspect	Key Points
Physical Preparation	NPO for 6–8 hours, antiseptic bath, IV access
Psychological Preparation	Counseling, emotional support, patient education
Pre-medications	Sedatives, anticholinergics, antiemetics, analgesics
Legal Considerations	Informed consent, patient autonomy, documentation
Ethical Considerations	Beneficence, non-maleficence, justice, confidentiality

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Key Takeaways for Competitive Exams

1. Hair clipping (not shaving) reduces infection risk.
2. Informed consent = Must include risks, benefits, alternatives.
3. Atropine = Reduces secretions and prevents bradycardia pre-op.
4. Fasting guideline = 6–8 hours for solids, 2 hours for clear fluids.
5. Anxiolytics like midazolam = Provide sedation and amnesia.
6. Consent for minors = Provided by parents/guardians.
7. Preoperative antibiotics = Given within 60 mins before incision.
8. Psychological preparation reduces anxiety and improves recovery.
9. Patient confidentiality = Ethical obligation for all healthcare providers.
10. Ethical principle of autonomy = Respect the patient’s right to refuse treatment.

1. Surgical Team

A. Members of the Surgical Team:

1. Surgeon:
   • Leads the surgical procedure.
   • Responsible for patient’s surgical care and decision-making.
2. Assistant Surgeon:
   • Assists the primary surgeon.
   • Performs specific tasks under supervision.
3. Anesthesiologist/Anesthetist:
   • Administers anesthesia.
   • Monitors patient’s vital signs, airway, and level of consciousness.
4. Scrub Nurse (Sterile Nurse):
   • Prepares and handles sterile instruments.
   • Assists the surgeon directly in the sterile field.
5. Circulating Nurse (Non-Sterile Nurse):
   • Manages the operating room environment.
   • Provides necessary supplies, maintains documentation, ensures asepsis.
6. OT Technician:
   • Assists in preparing surgical equipment and maintaining OT machinery.

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2. Nursing Activities and Responsibilities During Surgery

A. Pre-operative Responsibilities:

• Verify patient identity and surgical site.
• Ensure informed consent is signed.
• Check availability of all instruments and equipment.
• Assist with patient positioning and skin preparation.
• Confirm NPO status and remove prosthetics (dentures, jewelry).

B. Intra-operative Responsibilities:

1. Scrub Nurse Responsibilities:
   • Maintain aseptic technique.
   • Hand instruments and supplies to the surgeon.
   • Count sponges, instruments, and needles before and after the procedure.
   • Monitor sterile field for contamination.
2. Circulating Nurse Responsibilities:
   • Ensure proper functioning of OT equipment.
   • Obtain additional supplies as needed.
   • Document intra-operative care (time of anesthesia, incision, medication given).
   • Maintain environmental control (lighting, temperature).

C. Post-operative Responsibilities:

• Assist in transferring the patient to the Post-Anesthesia Care Unit (PACU).
• Document surgical counts to prevent retained surgical items.
• Provide a handover report to the recovery nurse.

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3. Anesthetic Agents and Types of Anesthesia

A. Types of Anesthesia:

1. General Anesthesia (GA):
   • Definition: Causes complete unconsciousness and loss of sensation.
   • Methods: Inhalation (gas), IV administration.
   • Common Agents:
     • Induction Agents: Propofol, thiopental sodium, etomidate.
     • Inhalational Agents: Isoflurane, sevoflurane, desflurane, nitrous oxide.
     • Muscle Relaxants: Succinylcholine (short-acting), vecuronium, rocuronium.
     • Analgesics: Fentanyl, morphine.
   • Complications:
     • Respiratory depression
     • Hypotension
     • Malignant hyperthermia (rare but life-threatening)

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2. Regional Anesthesia:
   • Definition: Blocks sensation in a specific region of the body while the patient remains conscious.
   • Types:
     • Spinal Anesthesia: Injection into the subarachnoid space (L3–L4 level).
       • Used for: Lower abdominal, pelvic, orthopedic surgeries.
       • Complications: Hypotension, headache (post-dural puncture), urinary retention.
     • Epidural Anesthesia: Injection into the epidural space (outside dura mater).
       • Used for: Labor pain management, cesarean sections, lower limb surgeries.
       • Complications: Similar to spinal, but slower onset.
     • Nerve Block: Injection near specific nerves (brachial plexus block, femoral nerve block).
       • Used for: Orthopedic and dental surgeries.

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3. Local Anesthesia:
   • Definition: Numbs a small, specific area without affecting consciousness.
   • Agents: Lidocaine, bupivacaine, procaine.
   • Methods: Infiltration, topical, or field block.
   • Used for: Minor procedures (suturing, dental work, mole removal).

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4. Monitored Anesthesia Care (MAC)/Conscious Sedation:
   • Definition: Sedation with or without local anesthesia; patient remains responsive.
   • Agents: Midazolam, fentanyl, propofol (low dose).
   • Used for: Endoscopies, minor surgeries, cardiac catheterization.

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4. Role of the Nurse in Anesthesia Care

A. Pre-Anesthesia Responsibilities:

• Verify pre-operative checklist (NPO status, consent, allergies).
• Prepare emergency resuscitation equipment.
• Assist anesthesiologist with IV cannulation, airway equipment setup.

B. Intra-Anesthesia Responsibilities:

• Monitor Vital Signs: HR, BP, SpO₂, ECG, capnography.
• Assist with Airway Management: Intubation, ventilation support.
• Observe for anesthesia-related complications (hypotension, allergic reactions).
• Maintain aseptic technique during airway management.

C. Post-Anesthesia Responsibilities:

• Transfer patient to PACU.
• Monitor for recovery from anesthesia: consciousness level, breathing, circulation.
• Manage postoperative nausea, vomiting, pain, and potential airway obstruction.
• Provide a detailed handover report to the recovery nurse.

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5. Complications Related to Anesthesia

Type	Common Complications	Management
General Anesthesia	Respiratory depression, hypotension, malignant hyperthermia	Oxygen support, dantrolene (for MH), fluid resuscitation
Spinal Anesthesia	Hypotension, headache, urinary retention	IV fluids, analgesics, catheterization
Epidural Anesthesia	Infection, nerve damage, bleeding	Sterile technique, close monitoring
Local Anesthesia	Allergic reactions, toxicity (if overdose)	Antihistamines, airway management, lipid therapy (for toxicity)
Conscious Sedation	Airway obstruction, oversedation	Airway management, reversal agents (naloxone, flumazenil)

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6. Monitoring During Anesthesia (Intra-operative Monitoring)

• Basic Monitoring:
  • Heart rate (ECG monitoring)
  • Blood pressure (non-invasive or invasive)
  • Oxygen saturation (pulse oximetry)
  • End-tidal CO₂ (capnography)
  • Temperature monitoring (especially for malignant hyperthermia risk)
• Advanced Monitoring (for critical surgeries):
  • Arterial line (continuous BP monitoring)
  • Central venous pressure (CVP) monitoring
  • Neuromuscular blockade monitoring (train-of-four stimulation)

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7. Key Points for Competitive Exams

1. General anesthesia = Complete unconsciousness; airway management required.
2. Spinal anesthesia = Injected into subarachnoid space (L3–L4), causes lower body numbness.
3. Epidural anesthesia = Injected into epidural space; used in labor analgesia.
4. Local anesthesia = Lidocaine is the most common agent for minor procedures.
5. Malignant hyperthermia = Life-threatening complication; treated with dantrolene.
6. Preoperative fasting = Prevents aspiration during general anesthesia.
7. Role of circulating nurse = Managing environment, supplies, documentation.
8. Role of scrub nurse = Handling sterile instruments during surgery.
9. Conscious sedation = Patient remains awake but relaxed (e.g., endoscopies).
10. Capnography = Monitors ventilation status during anesthesia.

1. Immediate Post-operative Care

A. Objectives:

• Ensure patient safety during recovery from anesthesia.
• Monitor for early detection of complications.
• Provide pain relief and comfort.

B. Key Activities:

• Airway Management: Ensure the airway is patent.
• Breathing: Monitor oxygen saturation (SpO₂), respiratory rate.
• Circulation: Check blood pressure (BP), heart rate (HR), skin color, capillary refill.
• Consciousness: Assess level of consciousness using the Glasgow Coma Scale (GCS).
• IV Lines & Drains: Ensure patency of IV lines, monitor surgical drains.
• Pain Assessment: Use pain scales (e.g., Numeric Rating Scale).
• Temperature Monitoring: Prevent hypothermia or hyperthermia.

Key Points for Competitive Exams:

• ABC (Airway, Breathing, Circulation) = First priority in immediate post-op care.
• Monitor vitals every 15 minutes for the first hour.
• Glasgow Coma Scale = Used to assess consciousness.

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2. Transferring the Patient from the Operation Theatre

A. Preparation:

• Ensure the stretcher is ready, with safety straps in place.
• Maintain oxygen supply, IV fluids, and monitoring devices during transfer.
• Secure all tubes, catheters, and drains.

B. Transfer Technique:

• Use a transfer board or sheet to move the patient.
• Maintain head and neck alignment if spinal precautions are necessary.
• Monitor vital signs continuously during transfer.

C. Handover to Recovery Room Nurse:

• Provide a detailed report:
  • Type of surgery performed
  • Anesthesia used
  • Intra-operative events (bleeding, medication given)
  • IV fluids, drains, and catheters
  • Pain management plan

Key Points for Competitive Exams:

• Airway and oxygen supply must be maintained during transfer.
• Detailed handover is essential for continuity of care.
• Secure all tubes and lines before transferring.

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3. Patient Care in the Recovery Room (Post-Anesthesia Care Unit – PACU)

A. Monitoring in the PACU:

• Airway: Ensure airway patency.
• Breathing: Oxygen saturation, respiratory rate, effort.
• Circulation: BP, pulse, capillary refill.
• Neurological Status: Level of consciousness, pupil reaction.
• Pain: Assess and manage appropriately.
• Urine Output: Monitor via catheter (if present).

B. Aldrete Scoring System:

Used to assess readiness for discharge from PACU.

Parameter	Score (0–2)
Activity	0–2
Respiration	0–2
Circulation (BP)	0–2
Consciousness	0–2
Oxygen Saturation	0–2

• Score ≥9 = Ready for transfer to the ward.

Key Points for Competitive Exams:

• Aldrete Score ≥9 indicates readiness to leave PACU.
• Continuous monitoring for at least 1–2 hours post-op.
• Pain and airway management are top priorities.

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4. Recovery from Anesthesia

A. Phases of Recovery:

1. Emergence: Patient regains consciousness, airway reflexes return.
2. Intermediate Recovery: Stabilization of vital signs.
3. Complete Recovery: Full return of motor and cognitive functions.

B. Signs of Recovery:

• Ability to follow simple commands.
• Stable vital signs.
• Adequate spontaneous breathing.
• Return of protective reflexes (cough, gag).

Key Points for Competitive Exams:

• Return of gag reflex = Sign of recovery from anesthesia.
• Monitor for airway obstruction and respiratory depression.
• Delayed awakening may indicate anesthesia-related complications.

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5. Post-operative Observation and Nursing Management

A. Vital Signs Monitoring:

• Every 15 mins for the first hour.
• Every 30 mins for the next 2 hours.
• Hourly until stable, then every 4 hours.

B. Focus Areas:

• Airway and Breathing: SpO₂, respiratory effort.
• Circulation: BP, HR, skin color, temperature.
• Neurological Status: Level of consciousness, pupil reaction.
• Pain Assessment: Use appropriate scales.
• Wound Site: Check for bleeding, infection, swelling.
• Urine Output: At least 0.5 mL/kg/hr.

C. Nursing Interventions:

• Maintain a patent airway.
• Administer oxygen as prescribed.
• Position the patient to prevent aspiration (semi-Fowler’s if awake).
• Provide pain management (analgesics, non-pharmacological methods).
• Monitor IV fluids, drains, catheters.

Key Points for Competitive Exams:

• Urine output <30 mL/hour may indicate renal compromise.
• First post-op vital signs are critical for identifying complications.
• Semi-Fowler’s position reduces aspiration risk.

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6. Carrying Out Post-operative Orders

A. Medical Orders to Implement:

• Medications: Analgesics, antibiotics, antiemetics.
• IV Fluids: Monitor rate and type.
• Diet: NPO until bowel sounds return, then advance as tolerated.
• Wound Care: Dressing changes as per protocol.
• Early Mobilization: To prevent DVT and pneumonia.

B. Documentation:

• Vital signs, intake/output, wound condition, medication administration.

Key Points for Competitive Exams:

• Verify orders carefully before administration.
• Monitor for side effects of post-op medications.
• Early ambulation prevents thromboembolic complications.

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7. Post-operative Complication Observation, Prevention, and Management

Complication	Signs/Symptoms	Prevention/Management
Hemorrhage	Low BP, tachycardia, pallor, bleeding	Apply pressure, IV fluids, surgery if severe
Shock	Hypotension, cold clammy skin, weak pulse	Oxygen, fluid resuscitation, vasopressors
Infection	Fever, redness, swelling at wound site	Aseptic technique, antibiotics if needed
Pulmonary Embolism	Chest pain, dyspnea, cyanosis	Early ambulation, anticoagulants, oxygen
DVT (Deep Vein Thrombosis)	Leg swelling, pain, redness	Leg exercises, compression devices, anticoagulants
Pneumonia	Fever, cough, crackles on auscultation	Deep breathing exercises, incentive spirometry
Urinary Retention	Inability to urinate, bladder distention	Bladder scan, catheterization if necessary
Paralytic Ileus	Absent bowel sounds, abdominal distention	NPO, NG tube decompression, IV fluids
Wound Dehiscence/Evisceration	Separation of wound edges, organ protrusion	Cover with sterile saline-soaked gauze, emergency surgery
Post-op Nausea/Vomiting	Nausea, vomiting, dehydration	Antiemetics (ondansetron), slow reintroduction of diet

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8. Summary for Competitive Exams

Aspect	Key Points
Immediate Care	ABCs (Airway, Breathing, Circulation)
Transfer from OT	Secure tubes, continuous monitoring, handover
Recovery Room Care	Aldrete score ≥9 = Ready for transfer
Anesthesia Recovery	Return of protective reflexes (gag, cough)
Observation	Vitals every 15 mins initially, pain management
Post-op Orders	Medications, IV fluids, early mobilization
Complications	Hemorrhage, shock, infection, PE, DVT
Urine Output	At least 0.5 mL/kg/hour (≥30 mL/hr)
Early Ambulation	Prevents DVT, pneumonia, constipation
Pain Management	Multimodal approach (pharmacological + non-pharma)

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Key Takeaways for Competitive Exams

1. Airway management = First priority in post-op care.
2. Aldrete score ≥9 = Safe for PACU discharge.
3. Urine output <30 mL/hr indicates possible renal impairment.
4. DVT prevention = Early ambulation, compression stockings.
5. Wound dehiscence = Cover with sterile saline gauze, notify surgeon.
6. Post-op fever >48 hours = Consider infection.
7. Hypotension post-op = Suspect bleeding or shock.
8. Pain management = Regular assessment using pain scales.
9. Semi-Fowler’s position reduces aspiration risk post-op.
10. First sign of hypoxia = Restlessness and agitation.