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Operation Theatre (OT) Nursing - Complete Study Guide

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Topic 3: Pre, Intra & Immediate Post-Operative Care

Pre-Operative Care

• Verify patient identity (name, ward, bed number, date of birth)
• Confirm the correct procedure and site (surgical site marking)
• Review consent form - ensure signed and witnessed
• Check NPO (Nothing by Mouth) status: solids 6-8 hrs, clear fluids 2 hrs before surgery
• Review history: allergies, current medications, previous anesthesia reactions
• Baseline vitals: BP, pulse, SpO2, temperature, weight
• Remove jewelry, nail polish, dentures, prosthetics, contact lenses
• IV access - ensure patent IV line with appropriate gauge cannula
• Pre-operative medications as ordered (anxiolytics, antacids, antibiotics prophylaxis)
• Enema/bowel preparation if indicated (bowel surgery)
• Skin preparation: shave/clip operative site if needed
• Pre-op investigations: CBC, blood group & crossmatch, BUN/Creatinine, coagulation profile, ECG, CXR
• Ensure blood/blood products are available if expected
• Patient education: explain procedure, post-op pain management, breathing exercises

• Confirm checklist before transfer (identity band, consent, investigation reports, X-rays)
• Transfer on stretcher/trolley with side rails up
• Maintain patient privacy and dignity

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Intra-Operative Care

• OT nurse receives patient, re-verifies identity, procedure, site
• WHO Surgical Safety Checklist - Sign In (before anesthesia), Time Out (before incision), Sign Out (before patient leaves OT)
• Position patient correctly on OT table (see Topic 11)
• Apply monitoring: ECG, SpO2, NIBP, temperature probe, catheter if needed
• Apply grounding pad for diathermy
• Skin preparation with antiseptic (povidone-iodine or chlorhexidine) in concentric outward circles
• Draping to create and maintain sterile field

• Maintain sterile field integrity
• Pass instruments, sutures, sponges as requested by scrub nurse/surgeon
• Count swabs, instruments, needles before incision and before closure
• Monitor and document fluid intake/output
• Specimen labeling and handling
• Communicate any concerns immediately

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Immediate Post-Operative Care (Recovery Room/PACU)

• Transfer patient with report to recovery nurse
• Monitor: vital signs every 5-15 min, level of consciousness (Aldrete score), pain score, SpO2
• Airway management: position in recovery position (left lateral), oxygen via mask
• Watch for: respiratory depression, laryngospasm, hypotension, tachycardia, excessive bleeding, nausea/vomiting
• Maintain IV fluids as ordered
• Pain management: administer analgesics as prescribed
• Wound check: dressing, drains (note output, color, amount)
• Urinary output monitoring (if catheterized, >0.5 mL/kg/hr is adequate)
• Warmth: blankets, warming devices (hypothermia common post-op)
• Discharge criteria: stable vitals, alert, pain controlled, no nausea, SpO2 >95%

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Topic 4: Common Surgical Procedures

Laparoscopic Cholecystectomy

• Indication: Gallstones, cholecystitis
• Position: Supine, Trendelenburg with right side elevated
• Steps: CO2 pneumoperitoneum → 4-port entry → identify Calot's triangle → clip & cut cystic duct and artery → dissect gallbladder from liver bed → extract through umbilical port
• Nursing role: Ensure laparoscopic tower ready, CO2 cylinder, laparoscope, monopolar diathermy, clip applicator, retrieval bag

Laparoscopic Appendectomy

• Position: Supine, slight Trendelenburg, tilt left
• Steps: 3-port technique → identify appendix → ligate mesoappendix → apply endoloop/stapler at base → remove in bag
• Key instruments: Endoscopic stapler or endoloop, laparoscopic graspers, irrigation/suction

Abdominal Hysterectomy (Total)

• Indication: Uterine fibroids, cancer, endometriosis
• Position: Supine with slight Trendelenburg; legs in low lithotomy for vaginal component
• Steps: Pfannenstiel or midline incision → round ligaments ligated → uterovesical peritoneum opened → uterine arteries clamped/ligated → vagina entered and uterus removed → vaginal vault closed
• Key instruments: Hysterectomy clamps (Heaney, Kocher), long curved scissors, self-retaining retractor (O'Sullivan-O'Connor)

Cesarean Section (LSCS)

• Position: Supine with left lateral tilt (wedge under right hip) to prevent aortocaval compression
• Anesthesia: Usually spinal; GA for emergencies
• Steps: Pfannenstiel incision → rectus sheath opened → uterus incised (low transverse) → baby delivered → placenta manually removed → uterus closed in 2 layers → fascial closure → skin closure
• Time to delivery: Target <3 min from incision in emergency
• Key instruments: Doyen retractor, Green-Armytage forceps, curved scissors, uterine closure needles (large round body)

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Topic 5a: Opening & Packing Used Sets & Single Packs

Opening Sterile Packs

• Check before opening: Label (contents), expiry date/sterilization date, indicator tape change, packaging integrity (no tears, moisture, holes)
• Technique for wrapped sets: Peel open away from sterile field; outer wrap opened first by circulating nurse using "open-peel" technique; contents dropped onto sterile trolley WITHOUT touching sterile field
• Single peel-packs: Hold at two corners of the peel edge, peel back slowly and evenly; present contents to scrub nurse or drop onto sterile field
• Rules: Never reach over sterile field; if in doubt, throw it out; wet packaging = contaminated

Packing Used Sets (After Surgery)

• Instruments sorted, counted, and placed in perforate trays/baskets
• Gross contamination removed (blood, tissue) under running water or with gauze
• Sharps (needles, blades) removed separately into sharps container
• Instruments placed in decontamination solution (enzymatic or 1% hypochlorite) for 30 min minimum
• Transported to CSSD in closed, labeled containers
• Never recap needles - place directly in sharps bin

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Topic 5b / Topic 6: CSSD - Sterilization Methods & Storage Duration

Central Sterile Supply Department (CSSD)

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Sterilization Methods

• At 121°C: kills spores in <5 min; standard cycle 15 min for safety margin
• Steam under pressure works by protein denaturation via hydrogen bond disruption
• Air must be fully removed - air pockets prevent steam penetration and lead to sterilization failure
• Pressure itself does NOT sterilize - it is only the mechanism to raise temperature

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Topic 6: Storage Duration (Shelf Life) of Sterile Sets

• Wrapped sets: Check every time before use
• Label should show: Date of sterilization, batch number, sterilizer ID, contents, date to be used by (if institutional policy)
• Storage conditions: Dry, dust-free, temperature controlled, away from direct sunlight, elevated off floor

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Topic 7: Disinfection, Decontamination

Definitions

• Sterilization: Destruction of ALL microorganisms including spores (absolute)
• Disinfection: Destruction of most pathogens (not necessarily spores)
• Decontamination: Process of removing/inactivating microorganisms to make items safe to handle
• Cleaning: Physical removal of dirt and organic material (must happen BEFORE disinfection/sterilization)

Instrument Decontamination

1. Rinse with cold water (hot water coagulates proteins)
2. Immerse in enzymatic detergent for 10-30 min
3. Manual scrub with brush (wear PPE: gloves, apron, eyewear)
4. OR: Washer-disinfector (automated, more reliable)
5. Rinse, dry, inspect, pack, sterilize

OT Table Decontamination

• After each case: remove gross contamination with paper towel
• Wipe with hospital-approved disinfectant (1000 ppm hypochlorite or 70% alcohol/quaternary ammonium compound)
• Allow contact time (usually 1-5 min)
• After contaminated/infectious cases: use 10,000 ppm hypochlorite (full decontamination)
• Check articulating parts, mattress covers for tears (replace damaged covers)

OT Room & Floor Decontamination

• Between cases: Damp mop with phenolic disinfectant; wipe all surfaces (tables, lights, equipment)
• End of day: Full terminal cleaning - mop floor, clean walls to 2m height, wipe all equipment
• Weekly: Ceiling, light tracks, vents
• Fumigation: Formaldehyde vapor (40 mL formalin + 20 g KMnO4 per 1000 cu ft) - 24-48 hrs, then ventilate; OR UV-C light (less effective, supplementary)
• OT surfaces should be non-porous, seamless, easy to clean
• Air: positive pressure ventilation in OT (min. 20 air changes/hr with HEPA filtration)

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Topic 8: Roles of Scrub Nurse, Circulating Nurse & Anesthesia Nurse

Scrub Nurse (Instrument/Theatre Sister)

• Performs surgical hand scrub and wears sterile gown and gloves
• Sets up sterile trolley with instruments, sutures, swabs, drains
• Checks and records all instruments, swabs, needles BEFORE incision and BEFORE closure (count should match)
• Prepares and hands instruments, sutures, drains to surgeon
• Keeps instruments clean and organized during procedure
• Maintains sterility of the sterile field throughout
• Labels and handles specimens correctly
• Must report any breach in sterile technique immediately
• In HIV/Hepatitis B cases: works in close harmony with surgeon to prevent needlestick
• Reports correct or discrepant swab/instrument count to surgeon before closure

Circulating Nurse (Runner/Scout Nurse)

• Does NOT scrub; moves freely in non-sterile zone
• Receives patient, checks identity and documentation
• Assists scrub nurse before gowning (adjusts height of trolley, opens packs)
• Opens and presenting sterile packs/supplies to scrub nurse without contaminating
• Documents: operative procedure, time incision, count results, specimens, blood loss
• Counts swabs and instruments with scrub nurse (verifies the count)
• Operates equipment: suction, diathermy, tourniquet, image intensifier, lights
• Communicates with blood bank, pathology, X-ray as needed
• Manages specimens: labels, fills forms, sends to lab
• Connects suction, diathermy cables from sterile field to machine (with sterile technique)
• Assists anesthetist with non-sterile supplies

Anesthesia Nurse (OT Nurse for Anesthesia/Anesthesia Technician)

• Prepares anesthesia machine: check circuit, gases (O2, N2O), vapourizer level, suction
• Prepares anesthesia tray (see Topic 13)
• Assists anesthetist during induction: positions patient, applies monitoring, assists with IV placement, holds mask
• Draws up and labels all drugs (in presence of anesthetist - double check)
• Assists with intubation: holds cricoid if RSI, hands tube, inflates cuff, confirms position
• Monitors patient continuously intra-operatively
• Administers drugs as directed by anesthetist
• Documents all drugs, fluids, vital signs on anesthesia chart
• Manages patient during regional anesthesia procedures (positioning for spinal)
• Assists with emergence and extubation
• Transfers patient to recovery with complete verbal and written handover

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Topic 9: Types of Sutures, Staplers, Threads, Needles & Drains

Suture Classification

• Monofilament: Single strand (Prolene, PDS, Monocryl) - less tissue drag, less infection
• Multifilament/Braided: Multiple strands (Vicryl, Silk, Ethibond) - stronger, easier to handle, more tissue reaction

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Needles

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Staplers

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Drains

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Topic 10: Surgical Instrument Sets

Appendectomy Set

• Towel clips (4-6)
• Scalpel handle No. 3 + No. 4
• Dissecting forceps: toothed (Adson) and non-toothed (McIndoe)
• Artery forceps: curved and straight (Mosquito, Halsted, Kocher) x 6-8
• Babcock forceps x 2 (to hold appendix)
• Allis forceps x 2
• Scissors: Mayo (straight & curved), Metzenbaum
• Needle holders x 2
• Retractors: Langenbeck x 2, Morris retractor
• Abdominal swabs and gauze
• Suction tip (Yankauer/Poole)
• Diathermy lead
• Bowl for antiseptic

Laparotomy Set (Basic)

• Large self-retaining retractor (Balfour or O'Sullivan-O'Connor)
• Large Langenbeck retractors x 2
• Deep retractors (Deaver, Morris)
• Intestinal clamps (Allen, Lane)
• Large curved artery forceps
• Peritoneal forceps (toothed, long)
• Large needle holders (Mayo-Hegar) x 2
• Poole suction
• Abdominal packs (large) x 10-12
• Diathermy with long extension

Cesarean Section Set

• Towel clips x 6
• Scalpel handles (No. 3, No. 4)
• Dissecting forceps (long toothed x 2, non-toothed x 2)
• Artery forceps (Kocher x 6, curved x 6)
• Doyen retractor (specific for LSCS - retracts bladder)
• Green-Armytage forceps x 4 (uterine hemostatic forceps)
• De Lee's universal retractor x 2
• Scissors: Mayo + Metzenbaum
• Large needle holders x 2 (for uterine closure)
• Allis x 4
• Wound retractors
• Suction (Yankauer + Poole)
• Bulb syringe (for suctioning baby)
• Large absorbable sutures (Vicryl 1 or PDS 1 for uterus)

Incision & Drainage (I&D) Set

• Scalpel handle + blade (No.11 or 15)
• Sinus forceps/probe
• Artery forceps x 2
• Scissors
• Irrigating syringe
• Packing gauze/ribbon gauze
• Bowl for pus culture swab
• Towel clips x 2
• Wound swab for culture

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Topic 11: OT Table Types & Patient Positioning

Types of OT Tables

1. Standard/General OT Table - for most procedures; multiple sections, hydraulic/electric
2. Orthopedic Table (Fracture table) - traction attachments, leg holders, image intensifier compatible
3. Gynecological/Urological Table - lithotomy poles and stirrups built in
4. Neurosurgical Table - head clamps (Mayfield), prone positioning attachments
5. Cardiac/Vascular Table - radiolucent top, arm boards
6. Ophthalmology Table - head section adjustment, reclining

Common Positions

• Check with anesthetist before repositioning after induction
• Protect IV lines and ET tube during position changes
• Pad ALL bony prominences
• Arms: padded arm boards, not hyperextended >90°
• Eyes protected (taped closed) in prone/lateral
• Log-roll technique for prone positioning (team of 4+)

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Topic 12: Types of Anesthesia

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Topic 13: Preparation of Anesthesia Tray

Anesthesia Machine Check (Before Any Case)

• O2, N2O, Air cylinders: check pressure and flow
• Breathing circuit: leak test (>30 cmH2O, <200 mL/min leak)
• Vaporizer: check level, calibration
• Suction: functioning
• Emergency O2 flush: working
• Scavenging system connected

Anesthesia Tray / Trolley Contents

• Face masks (sizes 0-5)
• Oral airways (Guedel) sizes 1-4
• Laryngoscope with blades (Mac 3, Mac 4; Miller 2)
• Check bulb/LED before use
• Endotracheal tubes (ETTs): sizes 6.0, 6.5, 7.0, 7.5, 8.0 (have range ready)
• ETT stylet/bougie
• Laryngeal Mask Airway (LMA) sizes 3, 4, 5
• Magill forceps
• 10 mL syringe for ETT cuff inflation
• Stethoscope for bilateral auscultation (confirm ETT position)
• Capnograph connected (ETCO2 monitoring - mandatory to confirm ETT placement)
• Tape/tie for securing ETT

• IV cannulas: 18G, 16G, 14G
• IV fluids: Normal saline, Lactated Ringer's/Hartmann's
• IV giving sets
• 3-way stopcocks
• Syringes: 2 mL, 5 mL, 10 mL, 20 mL

• ECG electrodes + leads
• SpO2 probe
• NIBP cuff (correct size)
• Temperature probe
• Capnograph line
• BIS monitor (if available)

• Induction: Propofol (10 mg/mL) or Thiopentone (500 mg powder)
• Opioid: Fentanyl (50 mcg/mL) or Morphine
• Muscle relaxant: Succinylcholine (1 mg/mL for RSI), Rocuronium or Vecuronium (for intubation)
• Reversal: Neostigmine + Glycopyrrolate (for neuromuscular blockade reversal)
• Maintenance: Volatile agent in vaporizer (Sevoflurane/Isoflurane)
• Antiemetics: Ondansetron, Metoclopramide
• Anticholinergic: Atropine (0.6 mg/mL ready)
• Vasopressor: Ephedrine, Phenylephrine (diluted, ready for hypotension)
• Emergency: Adrenaline (epinephrine) 1:10,000 in syringe

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Topic 14: Complications of Anesthesia

General Anesthesia Complications

• Anaphylaxis/anaphylactoid reaction (to induction agents, antibiotics, muscle relaxants)
• Failed intubation / difficult airway
• Aspiration of gastric contents (Mendelson's syndrome)
• Laryngospasm / bronchospasm
• Hypotension (especially with propofol)
• Dental damage (during laryngoscopy)

• Awareness under anesthesia (rare, <0.1-0.2%)
• Malignant hyperthermia (rare, triggered by succinylcholine + volatile agents - life-threatening)
• Hypoxia / hypercarbia
• Arrhythmias
• Hypothermia

• Respiratory depression / apnea
• Post-operative nausea and vomiting (PONV) - very common
• Emergence delirium (especially children with sevoflurane)
• Sore throat (from ETT/LMA)
• Myalgia (from succinylcholine)
• Prolonged neuromuscular blockade

Regional Anesthesia Complications

• High/total spinal (hypotension, respiratory arrest)
• Post-dural puncture headache (PDPH) - from spinal needle CSF leak
• Urinary retention
• Nerve damage
• Hematoma at injection site
• Infection/epidural abscess
• Shivering (very common with spinal)
• Nausea/vomiting (from hypotension)

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Topic 15: Steps of Induction of General Anesthesia

1. Pre-oxygenation: 100% O2 via tight-fitting face mask for 3-5 minutes (fills functional residual capacity, gives ~8-10 min apnea tolerance)
2. Pre-medication (if ordered): Fentanyl 1-2 mcg/kg IV, Midazolam 0.02-0.05 mg/kg IV (given 1-2 min before induction)
3. Induction agent: Propofol 1.5-2.5 mg/kg IV slowly (or Thiopentone 3-5 mg/kg) - patient becomes unconscious
4. Confirm unconsciousness: Eyelash reflex lost, jaw relaxed, no response to name
5. Mask ventilation: Maintain airway with jaw thrust; ventilate gently with O2
6. Muscle relaxant:
   • For routine intubation: Rocuronium 0.6 mg/kg or Vecuronium 0.1 mg/kg (wait 60-90 sec)
   • For RSI: Succinylcholine 1.5 mg/kg (+ cricoid pressure applied by nurse/assistant)
7. Laryngoscopy & Intubation:
   • Sniffing position: neck flexed, head extended
   • Insert laryngoscope, visualize vocal cords (Cormack-Lehane grade)
   • Advance ETT through cords, inflate cuff
8. Confirm ETT placement:
   • Visual: see tube pass through cords
   • Auscultation: bilateral equal breath sounds
   • ETCO2: waveform on capnograph (most reliable)
   • Chest rise
9. Secure ETT: Tape/tie, note cm mark at teeth (usually 21-23 cm in adult)
10. Connect ventilator: Set parameters (TV 6-8 mL/kg IBW, RR 10-14, FiO2 0.4-0.5)
11. Commence maintenance: Volatile agent + opioid infusion as planned

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Topic 16: Spinal Anesthesia (SAB - Subarachnoid Block)

Procedure

• Consent obtained; IV access secured; resuscitation equipment ready
• Baseline BP, HR, SpO2 recorded
• IV fluid preloading: 500-1000 mL crystalloid (Ringer's Lactate) before spinal

• Spinal needles: 25G or 27G Quincke (cutting) or Whitacre/Sprotte (pencil-point - less PDPH)
• Introducer needle (for small gauge needles)
• Syringe 2 mL + 5 mL
• Local anesthetic: Bupivacaine 0.5% heavy (hyperbaric) - most common; Lidocaine 2%
• Antiseptic solution (iodine or chlorhexidine)
• Sterile drape, gloves, gown

• Sitting: Legs hanging, back curved (C-shape), lean forward on pillow - best for obese, easier midline
• Left lateral decubitus: Knees to chest, spine curved

1. Position patient (sitting or lateral), identify L3-L4 or L4-L5 interspace (line between iliac crests = L4)
2. Skin prep with antiseptic x 3 in circular motion; drape
3. Infiltrate skin with 1% lignocaine (local anesthetic)
4. Insert introducer if using fine needle
5. Advance spinal needle perpendicular to skin, midline, slightly cephalad
6. Feel "two pops" (ligamentum flavum, then dura) - or one pop for combined structures
7. Remove stylet - confirm CSF flow (clear, drips freely)
8. Attach syringe, aspirate CSF gently to confirm position, inject drug slowly
9. Aspirate at end to confirm still in intrathecal space
10. Remove needle; apply small dressing

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Patient Care - Pre, Intra, Post Spinal

• Explain procedure; consent for regional
• IV access x 2; IV fluid preload
• Check coagulation (avoid if anticoagulated)
• NPO for same duration as GA
• Check for contraindications: coagulopathy, infection at site, raised ICP, hypovolemia, patient refusal, some cardiac diseases

• Monitor BP every 2-3 min for first 15-20 min (hypotension most common side effect)
• SpO2, HR continuous monitoring
• Test block level with ice/alcohol swab, pinprick, or ethyl chloride spray before surgery
• If hypotension: IV fluids + Ephedrine 5-10 mg IV or Phenylephrine 50-100 mcg IV
• If bradycardia: Atropine 0.6 mg IV
• High block warning signs: difficulty breathing, hands becoming weak, patient anxious - treat urgently

• Keep supine (1-2 hrs) - do NOT sit upright until block wearing off (fall risk)
• Monitor: BP, HR, SpO2, motor block regression, urinary output
• Post-dural puncture headache (PDPH): worse when sitting/standing, better lying flat
  • Treatment: bed rest, IV fluids, analgesics, caffeine; if persistent >48 hrs → Blood patch
• Urinary retention: may need catheterization (block of S2-S4)
• Reassure patient as sensation and motor power return
• Documentation: level of block achieved, drugs used, complications, timing

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Topic 17: OT Hazards, Prevention & Management

Physical Hazards

Chemical Hazards

Biological Hazards

Psychological Hazards

• Burnout, stress, compassion fatigue
• Prevention: adequate staffing, rotation, debriefing after traumatic cases, peer support

Fire Triad in OT (must remember):

• Oxidizer (O2, N2O) + Fuel (drapes, alcohol prep, bowel gases) + Ignition (diathermy, laser)
• ALL THREE must be present for fire - remove ANY one element

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Summary Table: Key Drugs in Anesthesia Tray

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• Pye's Surgical Handicraft, 22nd Edition - scrub/circulating nurse roles, intraoperative care
• Schwartz's Principles of Surgery, 11th Edition - GA induction, airway management
• Barash, Cullen & Stoelting's Clinical Anesthesia, 9th Edition - spinal anesthesia
• Morgan & Mikhail's Clinical Anesthesiology, 7th Edition - GA induction, regional anesthesia
• Sherris & Ryan's Medical Microbiology, 8th Edition - sterilization methods

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OPERATION THEATRE POSTING REPORT

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INTRODUCTION

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Topic 3: Pre, Intra & Immediate Post-Operative Care

Pre-Operative Care Observed

• The ward nurse sent the patient to OT with a completed pre-operative checklist that included: patient identity band, signed informed consent, NPO status (6-8 hours for solids, 2 hours for clear fluids), and all investigation reports (CBC, blood group, coagulation profile, ECG, X-ray).
• On arrival in the OT reception area, the OT nurse re-verified the patient's identity by checking name, age, diagnosis, and the procedure to be performed.
• The patient's IV line patency was checked, pre-operative medications (such as IV antibiotic prophylaxis) were administered as per the surgeon's order, and a urinary catheter was inserted where required.
• The patient was counseled briefly to reduce anxiety. Dentures, jewelry, and nail polish had been removed before transfer.
• The WHO Surgical Safety Checklist was followed: Sign In (before anesthesia induction), Time Out (before surgical incision), and Sign Out (before patient left the OT).

• Patient Name: _________ Age: ________ Sex: ________
• Diagnosis: ____________________
• Planned Surgery: ____________________
• Surgeon: Dr. _____________ Anesthetist: Dr. _____________

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Intra-Operative Care Observed

• The patient was transferred to the OT table and positioned correctly (as described in Topic 11).
• Monitoring was attached: ECG, SpO2 probe, NIBP cuff, and temperature probe.
• The diathermy grounding pad was applied to the patient's thigh.
• Skin preparation was done with povidone-iodine solution in concentric outward circles, and sterile draping was applied to expose only the operative site.
• I observed the scrub nurse and circulating nurse performing the instrument, swab, and needle count before the incision was made.
• Throughout the surgery I observed the surgeon, assistant, and scrub nurse working together. The circulating nurse was seen connecting suction, operating the diathermy machine, and recording all details.
• A specimen (__________) was collected, labeled, and sent to the laboratory by the circulating nurse.
• Final swab and instrument count was performed and confirmed correct before wound closure.

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Immediate Post-Operative Care Observed

• After the procedure, the patient was transferred to the Post-Anesthesia Care Unit (PACU)/Recovery Room.
• The anesthesia nurse gave a verbal handover to the recovery nurse: name, procedure, type of anesthesia used, blood loss, IV fluids given, and any intra-operative complications.
• I observed vital signs being monitored every 5-15 minutes: BP, HR, SpO2, RR, and temperature.
• The patient was placed in the recovery position (left lateral) until fully conscious, with oxygen given via face mask.
• The wound dressing and drain output were checked.
• Pain was assessed using the pain scale; analgesics were given as prescribed.
• The patient was discharged to the ward once the Aldrete Score was satisfactory (≥9/10): consciousness, airway, BP, SpO2, and activity all within normal limits.

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Topic 4: Surgical Procedures Observed

Case 1: ___________________________ (e.g., Laparoscopic Cholecystectomy)

• The patient was positioned supine with slight Trendelenburg and right side elevated.
• Pneumoperitoneum was created with CO2 gas via a Veress needle inserted at the umbilicus.
• Four ports were inserted. The laparoscopic camera was introduced and the gallbladder was visualized.
• The surgeon identified Calot's triangle. The cystic duct and cystic artery were clipped with metal clips using a clip applicator and divided with scissors.
• The gallbladder was dissected from the liver bed using monopolar diathermy and extracted through the umbilical port in a retrieval bag.
• The ports were removed, pneumoperitoneum released, and port sites closed with absorbable sutures.
• I observed the circulating nurse documenting the operative details and the scrub nurse performing the final count.

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Case 2: ___________________________ (e.g., LSCS - Cesarean Section)

• Spinal anesthesia was administered at the L3-L4 interspace with the patient in the sitting position.
• A wedge was placed under the patient's right hip to provide left lateral tilt, preventing aortocaval compression.
• A Pfannenstiel (transverse) incision was made. Rectus sheath was opened and the uterus was exposed.
• A Doyen retractor was placed to retract the bladder downward.
• A low transverse uterine incision was made, and the baby was delivered. The airway was suctioned with a bulb syringe. Time of delivery was noted.
• The placenta was delivered manually. Green-Armytage forceps were used to control uterine bleeding.
• The uterus was closed in two layers with Vicryl 1 suture. Abdomen was closed in layers. Skin closed with Prolene or staples.
• I noted the scrub nurse passing instruments and sutures in a systematic manner throughout the procedure.

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Case 3: ___________________________ (Write your 3rd case here)

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Topic 5a: Opening & Packing Used Sets and Single Packs

What I Observed:

• Before opening any pack, I observed the scrub nurse checking: the name/contents of the pack, the chemical indicator tape (color change confirms sterilization was completed), the expiry/sterilization date, and the integrity of the packaging (no tears, no moisture, no holes).
• The circulating nurse opened outer wraps using a peel-open technique, touching only the outer surface, and presented the inner sterile contents to the scrub nurse without crossing over the sterile field.
• Small single peel-packs (e.g., sutures, drain tubes) were peeled open at the corners and the contents were either dropped onto the sterile trolley or handed to the scrub nurse.
• The rule I observed being followed was: "When in doubt, throw it out."

• After the procedure, instruments were counted and sorted onto a tray.
• Gross contamination (blood, tissue) was wiped off with gauze.
• All sharps (needles, blades) were removed directly into the sharps container - no recapping.
• Instruments were placed in a closed, labeled container and transported to CSSD for decontamination and re-sterilization.

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Topic 5b & 6: CSSD - Sterilization & Shelf Life of Sterile Sets

What I Observed in CSSD:

• Paper/plastic peel-sealed pack: 6 months to 1 year
• Double-wrapped linen/muslin: 1-2 weeks (if stored dry and undisturbed)
• Flash/unwrapped autoclaved items: Must be used immediately - no storage
• Hard-case rigid container: Up to 6 months (or event-related)

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Topic 7: Disinfection, Decontamination of Instruments, OT Table & OT Room

What I Observed:

1. Instruments were rinsed with cold water first (hot water coagulates proteins and makes cleaning harder).
2. They were then immersed in enzymatic detergent solution for 10-30 minutes.
3. Staff wore PPE (gloves, apron, eye protection) while scrubbing with a brush.
4. After scrubbing, instruments were rinsed, dried, inspected for damage, packed, and sent for sterilization.

• Gross contamination was removed with disposable paper towels.
• The table was wiped down with hospital-approved disinfectant (1000 ppm sodium hypochlorite or 70% isopropyl alcohol), and contact time was maintained before wiping off.
• After any contaminated/infectious case, a stronger solution (10,000 ppm hypochlorite) was used.
• Mattress covers were inspected for tears (replaced if torn, as torn covers cannot be properly disinfected).

• Between cases: Damp mop with phenolic disinfectant; all surfaces wiped (OT lights, trolleys, equipment).
• End of each day (terminal cleaning): Floor mopped, all surfaces (walls to 2 m height, OT table, equipment, overhead light) thoroughly cleaned with disinfectant.
• Weekly: Ceiling, vents, and light tracks cleaned.
• I observed that the OT maintained positive pressure ventilation (so air flows out, not in) with HEPA-filtered air and a minimum of 20 air changes per hour.

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Topic 8: Roles of Scrub Nurse, Circulating Nurse & Anesthesia Nurse

What I Observed:

• She performed a surgical hand scrub (2-3 minutes) and wore a sterile gown and gloves using the closed-glove technique.
• She set up the sterile instrument trolley and counted all instruments, swabs, needles, and sutures with the circulating nurse before the operation began.
• Throughout surgery she passed instruments to the surgeon in a firm, deliberate manner, kept the trolley organized, maintained the sterile field, and alerted the team if any breach occurred.
• At the end, she performed the final count and reported to the surgeon: "Count is correct" before wound closure.
• She handled and labeled all surgical specimens.

• She moved freely in the non-sterile area and supported the scrub nurse by opening sterile packs and presenting them to the sterile field.
• She operated the suction machine, diathermy unit, and OT lights.
• She documented: patient details, procedure, time of incision, anesthesia given, swab and instrument counts, specimens dispatched, blood loss, and IV fluids administered.
• She communicated with the blood bank, pathology lab, and X-ray department as needed during surgery.

• She prepared the anesthesia machine and tray before the case (described in Topic 13).
• She assisted the anesthetist with positioning the patient, attaching monitoring, and IV insertion.
• During spinal anesthesia, she held and supported the patient in the sitting position, keeping their back curved.
• She drew up and labeled all drugs in the presence of the anesthetist.
• She monitored and recorded vital signs continuously on the anesthesia chart.
• After surgery, she gave a complete verbal and written handover to the recovery nurse.

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Topic 9: Types of Sutures, Threads, Needles & Drains I Observed

Sutures Observed in OT:

Staplers Observed:

• Skin stapler - used for rapid skin closure
• Linear cutter (Endo-GIA) - for bowel in laparoscopic procedures
• Ligating clips (Hem-o-lok/metal clips) - for cystic duct and artery in lap cholecystectomy

Drains Observed:

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Topic 10: Instrument Sets I Observed in OT

LSCS (Cesarean Section) Set - Instruments I Noted:

• Towel clips x 6
• Scalpel handles (No.3 and No.4) with blades (No.22, No.10)
• Toothed and non-toothed dissecting forceps (long)
• Kocher's artery forceps x 6, curved artery forceps x 6
• Doyen's retractor (to retract bladder downward)
• Green-Armytage uterine hemostatic forceps x 4
• De Lee's retractor x 2
• Mayo scissors (straight), Metzenbaum scissors (curved)
• Large needle holders x 2
• Allis tissue forceps x 4
• Poole suction tip + Yankauer suction
• Bulb syringe (for suctioning baby's airway)

Appendectomy Set - Instruments I Noted:

• Scalpel handles + blades
• Artery forceps (Mosquito, Halsted, Kocher) x 6-8
• Babcock forceps x 2 (to hold appendix without crushing)
• Allis forceps x 2
• Dissecting forceps (toothed + non-toothed)
• Metzenbaum scissors, Mayo scissors
• Langenbeck retractors x 2
• Needle holders x 2
• Suction tip
• Swabs and abdominal packs

Laparotomy Set (additional items beyond appendectomy set):

• Balfour or O'Sullivan-O'Connor self-retaining retractor
• Deaver retractors (deep)
• Intestinal clamps (Allen/Lane)
• Long artery forceps
• Poole suction tip (wide bore, for abdomen)
• Large abdominal packs x 10-12

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Topic 11: OT Table Types & Patient Positioning I Observed

OT Table Used:

• General/Standard hydraulic OT table (electric and manual adjustment of head, back, leg, and height sections)

Positions I Observed:

• Patient lying flat on back
• Arms on padded arm boards at <90°
• Heels, sacrum, and occiput padded
• For LSCS: wedge placed under right hip (15° left tilt to prevent aortocaval compression)

• Legs placed in stirrups, hips and knees flexed
• I observed padding placed under the popliteal fossa to protect the common peroneal nerve
• Sacrum padded

• Table tilted head-down
• Shoulder braces placed to prevent patient sliding

• Team of at least 3-4 for transfer to OT table
• Anesthetist protected the ETT during any repositioning
• All bony prominences were padded before draping
• Eyes were taped closed in lateral or prone positions

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Topic 12: Types of Anesthesia I Observed

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Topic 13: Preparation of Anesthesia Tray - What I Observed

• O2 cylinder pressure checked (should be >1000 psi full)
• Breathing circuit leak test performed
• Suction tested and functional
• Vaporizer level (sevoflurane) checked and filled
• Emergency oxygen flush button tested

• Face masks (multiple sizes)
• Oral airways (Guedel sizes 2, 3, 4)
• Laryngoscope with Mac-3 blade (bulb checked)
• ETTs: sizes 7.0, 7.5, 8.0 (for adult female/male) - cuff checked
• Stylet/bougie
• LMA (size 3, 4) as backup
• Magill forceps
• 10 mL syringe for cuff inflation
• Tape for securing ETT
• IV cannulas (16G, 18G), syringes, IV fluids

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Topic 14: Complications of Anesthesia - What I Observed/Learned

• I observed Post-Operative Nausea and Vomiting (PONV) in a patient after GA - treated with IV ondansetron 4 mg.
• One post-spinal patient complained of headache when sitting up - suspected post-dural puncture headache (PDPH). Patient was advised bed rest and oral hydration.

• Sudden drop in SpO2 or ETCO2
• Severe hypotension or bradycardia after spinal
• Patient becoming restless or agitated (may indicate awareness)
• Rapidly rising temperature + muscle rigidity (Malignant Hyperthermia - emergency)

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Topic 15: Steps of Induction of General Anesthesia - What I Observed

1. Pre-oxygenation: Patient breathed 100% O2 via face mask for 3-5 minutes. I understood this fills the lungs with oxygen to provide a safety margin during apnea.
2. Pre-medication: Fentanyl 100 mcg IV + Midazolam 2 mg IV given slowly. Patient became calm and drowsy.
3. Induction: Propofol 150 mg IV was given slowly. The patient lost consciousness within 30-40 seconds (eyelash reflex checked by anesthesia nurse - no response).
4. Mask ventilation: The anesthetist maintained the airway with jaw thrust and mask; the patient was gently ventilated with O2.
5. Muscle relaxant: Rocuronium 50 mg IV was given. I was told to wait 60-90 seconds for full relaxation.
6. Laryngoscopy: The anesthetist inserted a Mac-3 laryngoscope, visualized the vocal cords, and passed a 7.5 mm ETT through the cords.
7. Confirmation: Anesthesia nurse auscultated both sides of the chest - bilateral equal breath sounds. ETCO2 waveform appeared on the capnograph. The tube was secured at 21 cm at the teeth.
8. Maintenance: Sevoflurane (2%) via breathing circuit commenced. Vitals stabilized and surgery proceeded.
9. At end of surgery: Sevoflurane stopped, patient breathed down, neostigmine + glycopyrrolate given for reversal, extubation done when patient was awake and following commands.

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Topic 16: Spinal Anesthesia - What I Observed

• IV access secured (16G, right hand)
• IV fluid (Ringer's Lactate 500 mL) started as preload before spinal
• Baseline BP, HR, SpO2 recorded
• Resuscitation drugs (ephedrine, atropine, adrenaline) drawn up and kept ready by anesthesia nurse

• Patient was positioned sitting on the edge of the table, legs hanging down, spine curved in a C-shape, leaning forward onto a pillow held in her arms. The anesthesia nurse stood in front, supporting and calming the patient.
• Anesthetist identified the L3-L4 interspace (using the iliac crest line as landmark for L4).
• Skin was cleaned with betadine in circles. Sterile drape applied.
• Skin infiltrated with 1% lignocaine.
• A 25G Quincke spinal needle was inserted in the midline.
• Clear CSF was seen dripping from the hub - confirming subarachnoid placement.
• Bupivacaine 0.5% heavy (2.5 mL = 12.5 mg) was injected slowly after aspiration confirmed CSF.
• Patient was immediately laid supine with left lateral tilt.
• Block level was tested with ice at 5-minute intervals - level confirmed at T4-T6 before incision.

• BP checked every 2-3 minutes for the first 20 minutes
• Patient experienced mild hypotension (BP 90/60) - treated with IV fluids and Ephedrine 10 mg IV
• Patient also experienced shivering - warm blankets applied; I was told shivering is common with spinal

• Patient kept flat (no pillow) for 2 hours
• Bladder monitored via urinary catheter
• Anesthesia nurse advised patient she would feel heaviness/tingling in legs as the block wore off - this is normal
• Patient was reassured when leg sensation and movement slowly returned over 2-3 hours

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Topic 17: OT Hazards I Observed and Learned About

What I Observed in OT Regarding Safety:

• The diathermy grounding pad was always applied to the patient's thigh (large muscle, away from ECG electrodes, metal implants, bony prominence) before activating the unit.
• No fluids were allowed to pool under the patient near the diathermy pad.

• I observed that alcohol-based skin prep was allowed to dry completely before draping and before diathermy activation - to prevent fire.
• I was taught the fire triad in OT: Oxidizer (O2, N2O) + Fuel (drapes, alcohol prep) + Ignition source (diathermy, laser). Removing any one element prevents fire.

• I observed the "neutral zone" technique (also called hands-free technique): the scrub nurse placed sharps in a kidney tray/marked zone, and the surgeon picked them up, rather than hand-to-hand passing - to prevent needlestick injuries.
• All needles went directly into the sharps bin. No recapping was done.

• When the C-arm (image intensifier) was used, all non-essential staff stepped back behind a lead screen. Staff remaining wore lead aprons and thyroid shields.

• Standard precautions were followed for all patients.
• Surgical hand scrub was performed correctly (2-3 minutes minimum).
• Double gloving was used for suspected high-risk cases.

• The scavenging system was connected to remove waste anesthetic gas from the OT. I was told chronic exposure to trace anesthetic gases can cause liver damage, kidney toxicity, and reproductive harm - hence the scavenging system is mandatory.

• Glutaraldehyde (used for endoscopes) was handled with gloves and in a ventilated area.

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CONCLUSION

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How to use this report:

• Fill in the blank spaces (_______) with your actual patient names, ages, diagnoses, surgeon names, and dates.
• In Topic 4, describe the actual 2-3 surgeries you watched (the format is already there - just fill in the details).
• Change "I observed" to "I assisted" wherever you actually participated (e.g., held a retractor, helped position the patient, drew up a drug).
• Add your college/hospital name at the top.
• If you need this as a Word document (.docx) to print and submit, just say so!

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Topic 7: Disinfection & Decontamination

Brief Description (add this before your observations)

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What I Observed: (then continue with exactly what I gave you before)

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• ✅ Keep the description short (3-5 lines max) - just define the terms and why it matters
• ✅ Then write your observations as "what I did/saw"
• ❌ Don't write a 2-page theory essay - this is a clinical posting report, not a theory assignment

1. Identify the gadget
2. State purpose, types, and use clearly
3. State precautions while using it
4. Explain special care methods after use
5. Prepare a list of gadgets + develop a report on one of your interest

• A list of OT gadgets (Criteria 5 - first part)
• A full detailed report on Surgical Stapler as your chosen gadget (all 5 criteria covered)

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OPERATION THEATRE GADGET REPORT

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LIST OF GADGETS USED IN OPERATION THEATRE

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GADGET REPORT

Chosen Gadget: SURGICAL STAPLER

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Criteria 1: Identification of the Gadget

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Criteria 2: Purpose, Types and Use of Surgical Stapler

Purpose:

• To close the cut ends of hollow organs (bowel, stomach, bronchus)
• To divide tissue while simultaneously sealing both cut ends
• To create anastomosis (joining two hollow structures end-to-end or side-to-side)
• To close skin wounds rapidly
• To ligate and divide blood vessels and ducts in laparoscopic surgery

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Types and Uses:

• Fires 2-4 rows of staples in a straight line but does NOT cut
• Used to close the end of bowel, bronchus, or stomach
• Available in lengths: 30 mm, 55 mm, 90 mm
• Use: Bowel resection (closes the stump), lung resection, gastric sleeve surgery

• Fires two double rows of staples AND cuts between them simultaneously
• Divides AND closes both sides in one action
• Use: Bowel anastomosis (side-to-side), dividing mesentery, laparoscopic appendectomy, sleeve gastrectomy
• This is the most commonly used stapler in abdominal surgery

• Circular/doughnut-shaped head fires a circular row of staples and cuts a circular core of tissue
• Creates an end-to-end or end-to-side circular anastomosis inside a hollow organ
• Use: Colorectal surgery (bowel joining after resection), esophageal anastomosis, low anterior resection
• Available in sizes: 21 mm, 25 mm, 28 mm, 31 mm (diameter)

• Handheld device that fires single staples one at a time to close skin wounds
• Faster than suturing for long wounds
• Use: Skin closure after abdominal surgeries, orthopedic procedures, scalp lacerations
• Stainless steel staples; removed after 7-10 days using a staple remover

• Same as linear cutter but with a long, narrow shaft that fits through a laparoscopic port (12 mm port)
• Use: Laparoscopic bowel resection, sleeve gastrectomy, laparoscopic appendectomy, lobectomy

• Applies two ligating clips and divides between them
• Use: Vessels and tubular structures

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Summary Table:

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Criteria 3: Precautions to be Taken While Using Surgical Stapler

1. Correct size selection: Always select the correct stapler size (length and diameter) as per the tissue thickness. Using wrong size leads to incomplete staple formation and anastomotic leak.
2. Check before use: Inspect stapler for damage, expiry date, and integrity of packaging before opening. Ensure safety pin is in place until ready to fire.
3. Tissue must be free of tension: Do not apply stapler to tissue under tension - staples may cut through and cause dehiscence (breakdown).
4. Adequate tissue bite: Ensure sufficient tissue is within the jaws of the stapler before firing. Too little tissue = incomplete closure.
5. Keep staple line dry: Control bleeding and clear the field before firing. Blood and secretions can interfere with proper staple formation.
6. Do not refire on same tissue: After firing, do not attempt to refire a single-use stapler. Each cartridge is single-use only.
7. Bowel preparation: For bowel staplers, ensure the bowel is empty and adequately prepared to reduce infection risk.
8. Check anastomosis after firing: After circular stapler use, always check the two "doughnuts" (tissue rings cut out) are complete circles - confirms complete anastomosis. Also perform air/saline leak test.
9. Loaded cartridge only: Never fire a stapler without a loaded cartridge - it will damage the instrument and not achieve hemostasis.
10. Sterile technique: Staplers must be handled with full sterile precautions. The scrub nurse must confirm sterility before presenting to the surgeon.
11. Caution near major vessels: Do not fire close to major blood vessels or nerves without the surgeon confirming safe margins.

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Criteria 4: Special Care Methods After Use

For Disposable (Single-Use) Staplers:

• After the procedure, the used stapler is handled as clinical waste
• It is placed in a puncture-resistant clinical waste bag (not sharps bin, as it is not a sharp itself, but it does contain metal components)
• Never reprocess or reuse disposable staplers - this is strictly prohibited as it poses infection risk and the device loses its mechanical reliability
• The spent cartridge is removed by the scrub nurse and discarded appropriately

For Reusable Staplers (if used in your hospital):

1. Decontamination: After surgery, remove any tissue and blood immediately under cold running water (not hot - hot water coagulates proteins)
2. Disassembly: Disassemble all removable parts as per manufacturer's instructions
3. Enzymatic soak: Immerse all parts in enzymatic detergent solution for 10-20 minutes to loosen organic material
4. Manual cleaning: Scrub all surfaces with a soft brush, paying special attention to joints, hinges, and the cartridge channel
5. Rinse thoroughly: Rinse under running water to remove all detergent
6. Inspection: Check all moving parts, jaws, and locking mechanism for damage or wear. Damaged parts must be replaced before re-sterilization.
7. Lubrication: Apply instrument lubricant/milk to all joints and moving parts
8. Packaging: Wrap in double muslin cloth or place in a perforated instrument tray with appropriate indicator inside
9. Sterilization: Autoclave at 134°C (pre-vacuum) for 3-4 minutes OR as per manufacturer's recommendation. Some staplers with plastic/electronic components may require EO gas sterilization
10. Storage: Store in a clean, dry, sterile storage area. Check indicator tape before re-use.
11. Documentation: Record sterilization date, batch number, and sterilization method in the CSSD register

Skin Staple Remover:

• The staple remover is a separate sterile instrument kept ready in the ward/dressing trolley
• It is sterilized separately (autoclave) and used only for staple removal
• After use, decontaminate and re-sterilize as per standard instrument protocol

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CONCLUSION

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Quick checklist before submitting:

• ✅ Criteria 1 - Gadget identified (stapler) with description
• ✅ Criteria 2 - All 6 types with purpose and use clearly stated
• ✅ Criteria 3 - 11 precautions listed
• ✅ Criteria 4 - Care after use (disposable + reusable + staple remover)
• ✅ Criteria 5 - List of 15 OT gadgets + detailed report on one (stapler)

This covers all 5 marking criteria at a "Very Good (2)" level. Fill in your name, date, and submit! 😊

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Nursing Care of Patient Undergoing Spinal Anesthesia

(Pre, Intra & Post Spinal Anesthesia Care - As Observed in OT)

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PRE-SPINAL ANESTHESIA CARE

1. Patient Assessment (Observed Before Entering OT)

• History: Previous spinal anesthesia experience, allergies (especially to local anesthetics), back problems or spinal deformities, any bleeding disorders
• Medications: Anticoagulants (e.g., aspirin, heparin) - these are a contraindication to spinal anesthesia
• Investigations reviewed: CBC (platelet count - must be >80,000/mm³), coagulation profile (PT, INR), serum electrolytes
• NPO status confirmed: Patient was kept nil by mouth for 6-8 hours for solids and 2 hours for clear fluids (same as for GA)
• Informed consent: Signed consent for regional anesthesia was verified - patient was explained the procedure, its benefits, and possible complications like headache, hypotension, and urinary retention

2. Pre-Procedure Preparation

• IV access secured with a 16G IV cannula in the right hand dorsum
• IV fluid preload: 500 mL of Ringer's Lactate was started and run fast before the spinal injection to prevent hypotension (this is called co-loading or preloading)
• Baseline vitals were recorded and documented:
  • Blood Pressure: _____ mmHg
  • Heart Rate: _____ bpm
  • SpO2: _____ %
  • Respiratory Rate: _____ breaths/min
• Monitoring attached: ECG leads, SpO2 probe, and NIBP cuff applied before positioning
• Oxygen kept ready via face mask for any emergency
• Resuscitation drugs were drawn up and labeled by the anesthesia nurse and kept immediately accessible:
  • Ephedrine 30 mg in 10 mL (3 mg/mL) - for hypotension
  • Atropine 0.6 mg - for bradycardia
  • Adrenaline 0.5 mg - for anaphylaxis/cardiac arrest
• Emergency equipment checked: suction, bag-valve-mask, laryngoscope, ETT (in case spinal fails and GA is needed)

3. Spinal Anesthesia Tray Prepared

4. Patient Positioning for Spinal

• Patient sat on the edge of the OT table
• Legs were allowed to hang down or rest on a footstep
• Patient was asked to curve the back like a "C" shape - chin to chest, shoulders rounded forward
• A pillow was placed in the patient's lap to hug, which helps round the back
• The anesthesia nurse stood directly in front of the patient, held both her shoulders, talked calmly to reassure her, and made sure she did not move during needle insertion
• I observed that keeping the patient still and calm during needle insertion is one of the most important nursing responsibilities

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INTRA-SPINAL ANESTHESIA CARE (During Procedure & Immediately After Injection)

1. During the Spinal Injection

• Back was cleaned with betadine in circular motions x 3 times; sterile drape applied
• L3-L4 interspace identified using the iliac crest line as a landmark (a line drawn across the top of both iliac crests crosses the spine at approximately L4)
• Skin and subcutaneous tissue infiltrated with 1% lignocaine - a small bleb raised
• Introducer needle inserted first to guide the spinal needle
• 25G spinal needle inserted through the introducer, advanced slowly in the midline with a slight upward angle
• I was told the anesthetist feels two distinct "pops" - first through the ligamentum flavum, then through the dura mater (some describe it as one pop)
• Stylet was removed - clear CSF dripped freely from the hub, confirming correct subarachnoid placement
• Syringe with Bupivacaine 0.5% Heavy 2.5 mL (12.5 mg) attached - CSF aspirated gently to reconfirm position, then drug injected slowly over 20-30 seconds
• CSF aspirated again at the end to reconfirm intrathecal placement
• Needle removed; small sterile dressing applied at puncture site

2. Immediately After Injection

• Patient was immediately laid supine on the OT table - done quickly but carefully
• For LSCS: a wedge was placed under the right hip to give a 15° left lateral tilt - this prevents the pregnant uterus from compressing the inferior vena cava (aortocaval compression syndrome)
• The patient was told she would feel warmth and heaviness in her legs within 2-3 minutes - this is the first sign that the block is working

3. Monitoring During Block Establishment (first 20-30 minutes - most critical period)

• BP: Every 2-3 minutes for the first 20 minutes, then every 5 minutes
• HR and SpO2: Continuously on the monitor
• Block level testing: The anesthesia nurse tested the level of the block using an ice cube/cold swab - asked patient "can you feel cold here?" starting from the lower limbs upward
  • For LSCS: block level of T4-T6 (nipple level) was confirmed before the surgeon was allowed to start
  • Motor block was also assessed - patient could no longer move her legs
• Oxygen given via nasal cannula or face mask during surgery

4. Complications Observed/Managed During This Period

• Hypotension: The patient's BP dropped to 90/60 mmHg approximately 5 minutes after the spinal
  • Immediate treatment: IV fluid bolus 200 mL Ringer's Lactate given fast
  • Ephedrine 10 mg IV administered by anesthesia nurse as directed by anesthetist
  • BP came back to 110/70 mmHg within 2-3 minutes
  • I learned that hypotension occurs due to sympathetic block causing vasodilation - it is the most common complication of spinal anesthesia
• Shivering: Patient started shivering about 10 minutes after the spinal
  • Warm blankets were applied
  • I was told shivering is very common with spinal anesthesia due to the temperature difference between the anesthetized and non-anesthetized body parts
  • In some cases, small dose of IV pethidine or tramadol is given to stop severe shivering
• Nausea: Patient complained of mild nausea when BP was low
  • Resolved after BP was corrected with ephedrine
  • Metoclopramide 10 mg IV given as additional antiemetic

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POST-SPINAL ANESTHESIA CARE

1. Immediate Post-Operative Care in Recovery Room

• Patient name, age, surgery performed
• Type of anesthesia: spinal
• Drug used: Bupivacaine 0.5% heavy 12.5 mg at L3-L4
• Complications during procedure: mild hypotension - corrected
• Total IV fluids given intraoperatively: _____ mL
• Urine output via catheter: _____ mL
• Current vitals and block level status

2. Monitoring in Recovery

• Vital signs: BP, HR, SpO2, RR every 15 minutes
• Regression of block: The nurse checked sensory and motor block return every 30 minutes
  • Sensory: patient can feel touch/pinprick returning from the feet upward
  • Motor: patient can move toes → ankles → knees progressively
• Level of consciousness: Patient was fully conscious throughout (spinal does not affect brain)
• Pain: Initially patient feels no pain (block still active). As block wears off, pain score was assessed and analgesics given as prescribed before the block wore off completely (pre-emptive analgesia)

3. Patient Positioning Post-Spinal

• Patient was kept flat (supine, without pillow) for the first 2 hours
• Reason explained to patient: To help prevent post-dural puncture headache and to allow safe recovery from the block
• Patient was told NOT to try to sit up or stand until the nurse confirms both leg sensation and motor power have fully returned (otherwise risk of fall)

4. Urinary Care

• Urinary catheter (Foley's) was in situ and draining well
• Urine output was documented every hour - adequate output confirmed (>0.5 mL/kg/hr)
• If catheter not in place: patient to be monitored for urinary retention (spinal blocks S2-S4 - the micturition reflex). Patient not allowed to void until able to walk safely.

5. Complications Watched for in Post-Operative Period

6. Discharge from Recovery

• ✅ Vital signs stable for at least 30 minutes
• ✅ Sensory block fully regressed (patient feels touch in both legs)
• ✅ Motor block regressed (patient can move both legs, bend knees)
• ✅ No active bleeding
• ✅ Pain controlled
• ✅ Nausea absent
• ✅ Urine output adequate

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MY LEARNING FROM THIS EXPERIENCE

• The anesthesia nurse plays a vital role - not just in preparing equipment but in calming and supporting the patient, monitoring for complications, and reacting quickly to changes
• Hypotension is the most common complication and must be anticipated by preloading with IV fluids and having ephedrine drawn up and ready before the spinal is given
• PDPH is more common with larger gauge cutting needles - which is why 25G or 27G pencil-point (Whitacre/Sprotte) needles are preferred when available
• The first 20 minutes after spinal injection are the most critical and require close, continuous monitoring
• Patient communication and reassurance throughout is as important as technical care

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Pre, Intra & Post Spinal Anesthesia Care

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PRE-SPINAL CARE

• Informed consent verified for regional anesthesia
• Patient history checked: allergies, back problems, bleeding disorders, anticoagulant medications
• Investigations reviewed: platelet count, coagulation profile (PT/INR)
• NPO status confirmed (6-8 hrs solids, 2 hrs clear fluids)
• IV cannula (16G) secured and IV fluid preload (500 mL Ringer's Lactate) started before spinal injection to prevent hypotension
• Baseline vitals recorded: BP, HR, SpO2, RR
• ECG, SpO2 probe, and NIBP cuff attached
• Resuscitation drugs drawn up and kept ready:
  • Ephedrine (for hypotension)
  • Atropine (for bradycardia)
  • Adrenaline (for emergency)
• Emergency equipment checked: suction, BVM, laryngoscope, ETT
• Spinal tray prepared with: spinal needle (25G), introducer, syringes, Bupivacaine 0.5% heavy, betadine, sterile drapes, gloves
• Patient positioned in sitting position - spine curved in C-shape, chin to chest, hugging a pillow
• Anesthesia nurse stood in front supporting and reassuring the patient throughout

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INTRA-SPINAL CARE

• Back cleaned with betadine x 3 times; sterile drape applied
• L3-L4 interspace identified using iliac crest line as landmark
• Skin infiltrated with 1% lignocaine for local anesthesia
• 25G spinal needle inserted; stylet removed - clear CSF confirmed correct placement
• Bupivacaine 0.5% heavy 2.5 mL (12.5 mg) injected slowly over 20-30 seconds
• Patient immediately laid supine; wedge placed under right hip (left lateral tilt for LSCS - prevents aortocaval compression)
• Patient informed she would feel warmth and heaviness in legs - normal sign of block working
• BP monitored every 2-3 minutes for first 20 minutes (most critical period)
• Block level tested with ice swab - level confirmed at T4-T6 before surgery started
• Motor block confirmed - patient unable to move legs
• Oxygen administered via face mask throughout

• Hypotension (BP 90/60): IV fluid bolus + Ephedrine 10 mg IV given → BP corrected
• Shivering: warm blankets applied
• Nausea: Metoclopramide 10 mg IV given

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POST-SPINAL CARE

• Complete verbal handover given to recovery nurse (patient details, drug used, complications, fluids, urine output)
• Patient kept flat without pillow for first 2 hours (reduces risk of post-dural puncture headache)
• Vitals monitored every 15 minutes
• Sensory and motor block regression checked every 30 minutes:
  • Sensory: touch/pain sensation returning from feet upward
  • Motor: patient able to move toes → ankle → knees progressively
• Pain score assessed; analgesics given before block wore off completely
• Urine output via catheter monitored every hour (target >0.5 mL/kg/hr)
• Patient advised NOT to sit or stand until full motor and sensory return confirmed

• Vitals stable, block fully regressed, pain controlled, urine output adequate, no nausea

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