Pre-Operative Assessment & Preparation
AASA Physical Status Classification
| Class | Definition | Examples | Periop Mortality |
|---|
| ASA I | Normal healthy patient | No medical conditions; non-smoker | <0.1% |
| ASA II | Mild systemic disease | Well-controlled DM/HTN, BMI 30-40, mild asthma, current smoker | 0.2% |
| ASA III | Severe systemic disease | Poorly controlled DM/HTN, COPD, morbid obesity BMI≥40, active hepatitis, moderate ESRD | 1.8% |
| ASA IV | Severe disease — constant threat to life | Recent MI/stroke <3 months, severe valve disease, sepsis, ESRD not on dialysis | 7.8% |
| ASA V | Moribund — not expected to survive without surgery | Ruptured AAA, massive trauma, intracranial bleed with mass effect | 9.4%+ |
| ASA VI | Brain-dead — organ donation | Declared brain-dead; proceeding for organ harvest | N/A |
⚠Suffix "E" denotes emergency surgery (e.g., ASA III-E). Emergency surgery increases perioperative risk significantly at all ASA levels.
CPre-Op Assessment Clinic Role
- Assess surgical fitness and identify modifiable risk factors
- Order and review pre-operative investigations
- Obtain and document informed consent
- Perform risk stratification (ASA, RCRI, Caprini)
- Review current medications — hold/bridge anticoagulants
- Arrange anaesthetic pre-assessment for ASA III+
- Patient education: fasting, bowel prep, skin prep
- Arrange prehabilitation for high-risk patients
- Identify social support for post-discharge care
VVTE Risk & Prophylaxis
Caprini Risk Stratification
- Low (0-1) Early ambulation only
- Moderate (2) LMWH or mechanical compression
- High (3-4) LMWH + TED stockings
- Highest (≥5) LMWH + extended prophylaxis (28 days for cancer surgery)
Timing
- TED stockings: applied pre-operatively on ward
- Enoxaparin 40mg SC: 12h pre-op OR 6-12h post-op
- Pneumatic compression devices: intraoperatively
- Early mobilisation: post-op day 1 where possible
IPre-Operative Investigations by ASA, Age & Procedure
| Investigation | Minor Surgery | Intermediate | Major Surgery | Trigger Conditions |
|---|
| FBC (Full Blood Count) | ASA III+ / Age ≥65 | All patients | All patients | Anaemia, haematological disease |
| U&E / Electrolytes | Age ≥65 or diuretics | ASA II+ / Age ≥50 | All patients | Renal disease, DM, diuretics, ACEi |
| Coagulation (PT/APTT) | Anticoagulants only | Anticoagulants / ASA III+ | All major/vascular | Liver disease, bleeding disorder |
| Group & Screen | Not routine | Expected blood loss >500mL | Expected loss >500mL | Always for cardiac/vascular/ortho |
| ECG | Age ≥65 or cardiac Hx | Age ≥50 or cardiac Hx | Age ≥40 or ASA III+ | HTN, cardiac disease, DM, ≥40y major |
| CXR | Not routine | Cardiorespiratory disease | ASA III+ with resp/cardiac | COPD, cardiac failure, malignancy |
| HbA1c | Known DM | Known DM | Known DM or at-risk | Target HbA1c <69 mmol/mol for elective |
| LFTs | Liver disease only | Liver disease / hepatotoxic meds | Major abdominal / alcohol Hx | Cirrhosis, hepatitis, alcohol abuse |
| Pregnancy Test (β-hCG) | All females 12-55y | All females 12-55y | All females 12-55y | Mandatory pre-op in GCC hospitals |
| MRSA Screening | Implant procedures | Implant / high-risk | All admissions (some GCC hospitals) | Per institutional policy |
SSkin Preparation Protocol
- Chlorhexidine gluconate (CHG) 4% shower night before AND morning of surgery
- Remove nail varnish and acrylic nails from all 10 fingers — affects pulse oximetry
- Remove all jewellery: rings, piercings, body jewellery, necklaces
- If jewellery cannot be removed: document, tape wedding rings, avoid diathermy path
- Hair removal: electric clippers only if hair at surgical site — NOT razors (infection risk)
- Remove hair immediately pre-op, NOT night before
BBowel Preparation
ℹRoutine bowel preparation is NOT indicated for most colorectal surgery (ERAS evidence). Use only for specific indications.
- Indications: Left-sided colorectal resection, stoma reversal, intraoperative colonoscopy planned
- Oral prep: Polyethylene glycol (Klean-Prep) day before surgery
- Phosphate enema: Morning of surgery for rectal/left-sided procedures
- NOT indicated: Right-sided colectomy, upper GI, non-GI surgery
- Monitor hydration and electrolytes in elderly/renal patients
PPre-Op Antibiotic Prophylaxis
- Timing: 30-60 minutes BEFORE skin incision (optimal: at anaesthetic induction)
- First-line: Cefuroxime 1.5g IV for most procedures
- Penicillin allergy: Clindamycin 600mg IV or Metronidazole + Gentamicin
- Colorectal: Cefuroxime + Metronidazole 500mg IV
- Orthopaedic (MRSA risk): discuss Vancomycin with surgeon/microbiologist
- Repeat dose if surgery >4h or blood loss >1500mL (half-life dosing)
- Document: drug, dose, time given, route, given by whom
- NOT a substitute for aseptic technique
MPre-Operative Site Marking
- Surgeon marks operative site BEFORE patient reaches theatre
- Use indelible skin marker pen (must survive skin prep)
- Mark with arrow or initials — mark persists after draping
- Laterality: always mark side for limbs, breasts, kidneys, eyes, ears
- Exception: midline structures (hysterectomy, bowel) — no laterality needed
- Patient must confirm site marking is correct before sedation
- WHO SSC: site verification during Sign In, Time Out, and Sign Out
- Document in operative notes and SSC
CInformed Consent — Nursing Role
ℹIn GCC, legal frameworks (Saudi Health Law, UAE Patient Rights Law) require documented informed consent. Nurses do NOT obtain surgical consent — this is the operating surgeon's responsibility. Nursing role is to support, witness, and flag concerns.
- Verify consent form is present and correctly completed before patient enters theatre
- Confirm patient identity, procedure, and side match the consent form
- Witness patient signing consent (nurse witnesses signature, not content)
- Document in nursing notes that consent was checked
- Flag if patient expresses doubt, withdrawal, or misunderstanding
- Arrange interpreter if language barrier exists (professional — not family)
- Emergency override: document unable to consent and two-clinician certification
- Capacity assessment: if capacity doubted, escalate to senior clinician
Theatre Nursing Roles
SScrub Nurse Role
- Sterile gowned and gloved — within sterile field at all times
- Sets up and maintains sterile instrument trolley
- Hands instruments to surgeon anticipating surgical needs
- Performs and records instrument, swab, and sharps counts
- Manages specimens — labels, ensures correct container
- Maintains sterility of field throughout procedure
- Calls out and manages "sharps passing" protocol (neutral zone)
- Documents all implants (batch number, expiry, serial)
- Communicates with circulating nurse without breaking sterility
CCirculating Nurse (Scout) Role
- Non-sterile — moves freely around theatre environment
- Retrieves additional supplies and equipment as needed
- Opens sterile supplies onto scrub nurse's trolley aseptically
- Operates diathermy machine, suction, tourniquet controls
- Positions patient and applies diathermy pad
- Documents counts jointly with scrub nurse
- Completes WHO SSC (Time Out leadership role)
- Dispatches specimens to laboratory
- Records intraoperative events, timing, blood loss
- Manages theatre environment (temperature, lighting, waste)
NInstrument / Swab / Sharps Counting — 4-Count Rule
⚠NEVER close a wound if count is incorrect. Escalate immediately to surgeon and team. Perform X-ray before patient leaves theatre if count unresolved.
| Count Point | What is Counted | Who Counts | Documentation |
|---|
| 1. At start of case (before patient enters) | All instruments, swabs, sharps, needles on trolley | Scrub + Circulating nurse together | Record starting numbers on whiteboard/form |
| 2. When additional items added to field | New instruments, extra swabs, additional sharps opened | Both nurses verbally confirm | Add to running count tally |
| 3. Before closure of cavity/wound | All swabs, instruments, sharps — full count | Both nurses; verbally announced | Surgeon informed count is correct before closing |
| 4. At skin closure / before patient leaves theatre | Final reconciliation — must equal starting count | Both nurses; document result | Sign count record; document in operative notes |
- Swabs: counted in sets of 5; radio-opaque marker in all surgical swabs — never use gauze dressings in body cavities
- Sharps: every needle counted by number; blades counted; scalpel handles accounted
- Incorrect count: stop closure, search field and off-field area, inform surgeon, consider X-ray, document all actions
ASterile Field — ANTT vs Full Sterile
ANTT (Aseptic Non-Touch Technique)
- Used for: IV cannulation, wound dressing, catheterisation
- Key parts (needle tip, wound) never touched
- Non-sterile gloves acceptable with ANTT
- Clean field maintained (not full sterile field)
Full Surgical Aseptic Technique
- Used for: all surgical procedures, invasive line insertion
- Full sterile gown + double gloves for implant surgery
- Sterile drapes establish surgical field
- All items entering field must be sterile — opened aseptically
- Field is contaminated if sterility is broken — replace immediately
DSurgical Draping Technique
- Drape from incision site outward — never drag drapes back toward clean area
- Fenestrated drapes: opening aligns with surgical site precisely
- Adhesive incise drapes (Ioban/Steri-drape): applied after skin prep has dried
- Surgeon and scrub nurse drape together — maintain sterility throughout
- Secure drapes with towel clips — do not penetrate sterile field below with clips
- If drape becomes wet or contaminated: replace before proceeding
- Extremity surgery: stockinette applied first, limb elevated for prep, then draped
IInstrument Identification
Retractors
- Langenbeck — handheld, general tissue retraction
- Deaver — deep abdominal retraction
- Balfour — self-retaining abdominal
- Weitlaner — self-retaining wound
- Hohmann — bone retractor (ortho)
Scissors & Clamps
- Mayo — heavy tissue/sutures
- Metzenbaum — delicate dissection
- Artery forceps (haemostat): Spencer Wells, Kelly, Mosquito
- Kocher — crushing clamp
- Allis — tissue grasping
Needle Holders & Suture
- Mayo-Hegar — standard needle holder
- Castroviejo — ophthalmic/fine
- Gillies — combined needle holder/scissor
- Suture sizes: 0 = heavy, 2/0, 3/0, 4/0 = finer
- Absorbable: Vicryl, PDS, Monocryl
SSpecimen Handling & Chain of Custody
- Scrub nurse receives specimen from surgeon — confirm type verbally
- Place in correct container immediately (no dry time)
- Histology: 10% neutral buffered formalin (2× volume of specimen)
- Microbiology: sterile swab or plain container — NO formalin
- Frozen section: fresh specimen in saline-moistened gauze — rush to path lab
- Label: patient name, MRN, date, specimen site, surgeon name
- Circulating nurse dispatches with completed request form
- Document in operative notes and swab/specimen record
- Never leave specimen unlabelled on trolley — immediate labelling rule
BBlood Loss Estimation & Surgical Smoke
Blood Loss Estimation
- Swab weighing: dry swab weight subtracted from wet weight; 1g ≈ 1mL blood
- Suction canister: volume minus irrigation used = blood loss estimate
- Surgical team informed at 250mL, 500mL, 750mL thresholds
- Communicate estimated blood loss at handover to PACU
Surgical Smoke Hazards
- Electrosurgery smoke: contains carcinogens, live viral particles, bacteria
- Use smoke evacuation system attached to diathermy — not standard suction
- All theatre staff wear high-filtration (N95) masks when smoke generated
- Keep evacuation device within 2cm of smoke source for 98% capture
Anaesthesia Nursing Support
RRapid Sequence Induction (RSI) — Nursing Role
⚠RSI is used when aspiration risk is high: full stomach, GORD, pregnancy, emergency surgery, bowel obstruction, trauma.
- Pre-oxygenate: 100% O₂ via tight-fitting mask for 3-5 minutes (or 8 vital capacity breaths)
- Position: head-up 20° if possible (reduces aspiration risk)
- Prepare drugs: induction agent + suxamethonium or rocuronium
- Cricoid pressure (Sellick's manoeuvre): apply 10N (resting) → 30N at induction
- Cricoid pressure: controversial — current evidence shows may worsen laryngoscopy view; release if needed for intubation
- Confirm tube placement: EtCO₂ waveform (gold standard) + bilateral breath sounds
- Inflate cuff immediately; release cricoid only after cuff confirmed in trachea
- Do NOT ventilate between induction and intubation (classical RSI)
FFailed Airway Management
⚠Can't Intubate, Can't Oxygenate (CICO) — a life-threatening emergency requiring immediate front-of-neck access (FONA). All theatre nurses must know the location of the emergency front-of-neck kit.
- Difficult airway trolley: always in anaesthetic room, checked at start of each list
- Contents: video laryngoscope, fibreoptic bronchoscope, range of blade sizes, bougies, supraglottic airway devices (LMA, iGel), surgical airway kit
- Failed intubation → supraglottic airway (2nd generation LMA/iGel)
- CICO protocol: call for help, attempt oxygenation via supraglottic → if fails → FONA
- FONA (scalpel technique preferred): horizontal stab incision below thyroid cartilage, dilate, insert cuffed tracheal tube or commercial kit
- Nursing: open FONA kit, assist positioning, document timeline of events
IIV Induction Agents — Properties
| Agent | Onset | Duration | Key Properties | Cautions |
|---|
| Propofol | 30-40s | 5-10 min | Smooth induction, antiemetic, allows rapid titration; TIVA agent | Pain on injection, hypotension, apnoea; egg/soya allergy (caution) |
| Thiopentone | 10-20s | 5-15 min | Cerebral protection; used in RSI, status epilepticus | Severe hypotension, laryngospasm, no analgesia, not for porphyria |
| Ketamine | 30-60s | 10-20 min | Dissociative; maintains airway reflexes; analgesic; bronchodilator — useful in asthma/haemodynamic instability | Emergence hallucinations (give midazolam); raises ICP/IOP; hypertension |
| Etomidate | 15-45s | 3-5 min | Cardiovascularly stable — preferred in haemodynamically compromised patients | Adrenocortical suppression (single dose still debated); myoclonus |
NNeuromuscular Blocking Agents
| Agent | Class | Duration | Key Points |
|---|
| Suxamethonium | Depolarising | 3-5 min | RSI first-choice; fastest onset (60s); CI: burns/crush >48h, hyperkalaemia, malignant hyperthermia risk, myopathies |
| Rocuronium | Non-depolarising | 30-60 min | RSI alternative at high dose (1.2 mg/kg); reversible with Sugammadex |
| Vecuronium | Non-depolarising | 25-40 min | Cardiovascularly stable; hepatic metabolism |
| Atracurium | Non-depolarising | 20-35 min | Hofmann elimination — safe in renal/hepatic failure; causes histamine release |
Reversal
- Sugammadex: reverses rocuronium/vecuronium (dose 2-16 mg/kg); immediate reversal — preferred in GCC hospitals
- Neostigmine + glycopyrrolate: reverses all non-depolarising agents; slower; risk of bronchospasm/bradycardia
- TOF (Train-of-Four) monitoring: target ratio >0.9 before extubation
RRegional Anaesthesia Nursing Support
Spinal Anaesthesia
- Position: sitting (easier) or lateral decubitus (fetal) — maintain throughout needle insertion
- Level: L3-L4 or L4-L5 interspace (below conus medullaris)
- Assist with positioning; patient must remain still during needle placement
- Monitor BP every 3 minutes after injection for 15 minutes — hypotension is common
Epidural Anaesthesia
- Used for: labour, thoracic surgery, major abdominal, post-op analgesia
- Loss-of-resistance technique; catheter secured and labelled "EPIDURAL"
- Test dose: lignocaine + adrenaline before full dose (check for intravascular/intrathecal placement)
- Nerve blocks: nursing role — patient positioning, monitoring for LAST (local anaesthetic systemic toxicity): perioral tingling → seizures → cardiac arrest; Intralipid 20% must be available
BBIS Monitoring (Bispectral Index)
- Measures depth of anaesthesia from processed EEG
- Scale: 0 (isoelectric) to 100 (fully awake)
- Target intraoperatively: 40-60
- <40: excessively deep — risk of hypotension, prolonged recovery
- >60: risk of awareness under anaesthesia
- BIS sensor: applied to forehead; requires good skin contact
- Nursing: apply BIS sensor before induction, monitor throughout, document values
- Limitations: affected by electrocautery; not validated for all agents (ketamine)
MMalignant Hyperthermia Emergency
⚠Malignant hyperthermia (MH) is rare but can be rapidly fatal. All theatres must stock Dantrolene and staff must know the protocol.
- Trigger: volatile anaesthetic agents (halothane, isoflurane, sevoflurane, desflurane) + suxamethonium
- Signs: rapidly rising EtCO₂, tachycardia, muscle rigidity, hyperthermia, metabolic acidosis
- Action: STOP trigger agent immediately; call for help; switch to TIVA
- Dantrolene 2.5mg/kg IV bolus — repeat every 5-10 min to max 10mg/kg
- Active cooling: ice packs, cold IV fluids, cold NG lavage
- Correct acidosis, hyperkalemia; monitor urine output (myoglobinuria risk)
- Dantrolene reconstitution: each 20mg vial in 60mL sterile water — takes time; assign nurse to this task
- Post-MH: ICU admission; patient counselling; genetic testing + family screening
Intraoperative Nursing Management
PPatient Positioning — Positions & Complications
| Position | Procedures | Setup Requirements | Complications to Prevent |
|---|
| Supine | Abdominal, cardiac, ENT, lower limb | Heels padded; arms padded at sides or on arm boards (<90°); occipital padding | Heel pressure injury, brachial plexus stretch (arm >90°), occipital alopecia (long cases) |
| Trendelenburg (head down) | Laparoscopic pelvic, lower GI | Anti-slip shoulder supports; padded, not pressure points; table in 15-30° | Brachial plexus injury (shoulder braces), facial oedema, raised ICP, ventilatory compromise |
| Reverse Trendelenburg (head up) | Laparoscopic upper GI, bariatric, thyroid | Footboard; anti-DVT devices; secure patient well | DVT/hypotension (venous pooling), patient sliding, foot pressure injury |
| Lloyd-Davies | Colorectal, urology, gynaecology | Stirrups padded (Allen or Lloyd-Davies); lithotomy with Trendelenburg; legs raised simultaneously | Compartment syndrome (leg), common peroneal nerve injury (lateral knee pressure), DVT |
| Lateral decubitus | Thoracic, hip arthroplasty, nephrectomy | Axillary roll; dependent arm padded; beanbag/positioner; kidney rest if needed | Brachial plexus (axillary compression), ear/eye pressure, dependent lung atelectasis |
| Prone | Spine, posterior fossa, rectal | Montreal mattress/Wilson frame; arms at <90° forward; eyes checked every 30 min; ETT secured | Corneal abrasion (check eyes), blindness (orbital pressure), venous air embolism, pressure injury to genitalia/breasts |
| Beach chair | Shoulder arthroscopy | Head in padded holder; protect cervical spine; monitor BP at head level (MAP correction) | Cerebral hypoperfusion (MAP must be corrected for head height), bradycardia (vagal response) |
⚠For cases >2 hours: apply silicone foam dressings prophylactically to bony prominences (sacrum, heels, malleoli) before positioning. Document dressings applied and skin condition on transfer.
WPatient Warming — Normothermia
✓Target core temperature: 36.0–37.5°C throughout perioperative period. Hypothermia increases surgical site infection, coagulopathy, cardiac events, and prolonged recovery.
- Pre-warming: forced-air warming blanket 30-60 min pre-induction (reduces heat redistribution)
- Intraoperative: forced-air warming upper/lower body blanket over non-surgical area
- Warm IV fluids: all IV fluids warmed to 37-41°C via fluid warmer for volumes >500mL
- Heated humidified anaesthetic circuits for long cases
- Heated mattress: circulating warm water or resistive heating mattress under patient
- Theatre temperature: maintain 20-22°C for most adults; 24-26°C for neonates/infants
- Exposed viscera: warm irrigation fluids (NOT cold saline); cover bowel with warm moist packs
- Monitor: oesophageal temperature probe or bladder temperature is most accurate intraoperatively
DDiathermy Safety
- Types: monopolar (current flows from electrode through body to diathermy pad) vs bipolar (current between two tips — safer for delicate structures)
- Diathermy pad (dispersive electrode): place on large muscle mass, close to operative site, away from bony prominences
- Avoid placement over: implanted cardiac devices, metal prosthetics, areas with poor perfusion, scar tissue
- Skin prep must be DRY before activating diathermy (pooled chlorhexidine + spark = fire)
- Not recommended near implanted cardiac devices (pacemakers/ICDs): use bipolar only or discuss with cardiologist
- Document: diathermy pad site, settings used, patient skin condition at removal
- Check pad adhesion every 30 min for repositioned patients
TTourniquet Use
- Indication: limb surgery (orthopaedics, hand) for bloodless field
- Application: pneumatic cuff over padding, proximal to surgical site
- Inflation pressure: limb occlusion pressure (LOP) + 50-75 mmHg safety margin
- Typical pressures: upper limb 200-250 mmHg; lower limb 250-350 mmHg
- Time documentation: record inflation time; communicate at 30-min intervals
- Maximum recommended time: 90-120 minutes continuous (upper); 2 hours (lower)
- Deflation: inform surgeon at 60-min mark; allow reperfusion if extended
- Post-release: monitor for reperfusion oedema, tourniquet pain, compartment syndrome signs
- Contraindications: peripheral vascular disease, sickle cell disease, DVT in limb
PPressure Injury Prevention
- Pre-positioning skin inspection: document existing pressure injuries before positioning
- Silicone foam dressings: sacrum, heels, malleoli for cases >2h
- Eye protection: tape eyes closed in all unconscious patients; eye pads in prone/lateral
- Corneal protection: methylcellulose drops before taping eyes in GA
- Ear: foam pad under dependent ear in lateral positioning
- Gel pads: under all bony prominences in contact with table surface
- Post-op: full skin inspection at PACU — document any new pressure changes
- Report: any new pressure injury as a patient safety incident (CBAHI/JCI requirement)
PACU & Post-Operative Recovery
HPACU Handover — SBAR from Anaesthetist
S — Situation
- Patient name, age, MRN
- Procedure performed
- Anaesthetic type (GA/spinal/regional/sedation)
B — Background
- Relevant PMH, allergies
- Medications given intraoperatively
- Blood loss, fluids given, urine output
A/R — Assessment & Recommendation
- Current vital signs, airway status
- Pain score, nausea, temperature
- Anticipated post-op issues; analgesic plan; specific observations needed
MImmediate PACU Monitoring Protocol
First 30 Minutes (every 5 minutes)
- SpO₂, RR, HR, NIBP
- Level of consciousness (AVPU or Aldrete)
- Pain score (NRS 0-10)
- Temperature
- Airway patency assessment
Stable Phase (every 15 minutes)
- Continue above monitoring
- Wound site: bleeding, drain output
- Urine output (catheterised patients)
- Fluid balance
AAldrete Score — PACU Discharge
| Parameter | Score 2 | Score 1 | Score 0 |
|---|
| Activity | Moves 4 limbs | Moves 2 limbs | No movement |
| Respiration | Deep breath & cough | Dyspnoea/limited | Apnoeic |
| Circulation | BP ±20% pre-op | BP ±20-50% | BP ±50% |
| Consciousness | Fully awake | Arousable | Not responding |
| SpO₂ | ≥92% on air | ≥90% on O₂ | <90% on O₂ |
✓Discharge from PACU requires Aldrete score ≥9/10. Modified Aldrete or PADSS used for day surgery discharge.
AAirway Management in PACU
- Positioning: lateral recovery (semi-prone) for drowsy patients — reduces aspiration risk
- Jaw thrust: for tongue obstruction in unconscious patient
- Nasopharyngeal airway (NPA): better tolerated in semi-conscious; contraindicated in base of skull fracture
- Oropharyngeal airway (Guedel): fully unconscious patient only — causes vomiting if gag present
- Suction: yankauer sucker at bedside; suction airway if secretions/vomit — but avoid stimulating gag in light anaesthesia
- Laryngospasm: CPAP with jaw thrust; if persists → suxamethonium 0.1-0.5mg/kg IV; call anaesthetist
- O₂ therapy: all PACU patients receive O₂ 4-6L/min for minimum 30 min post-GA
SPost-Spinal Nursing Care
Bromage Scale — Motor Block Assessment
| Grade | Criteria | Meaning |
|---|
| 0 | Free movement of legs and feet | No block |
| 1 | Can flex knees, feet free | Partial (33%) |
| 2 | Cannot flex knees, feet free | Almost complete (67%) |
| 3 | Cannot move legs or feet | Complete block |
- Monitor for hypotension (SBP <90 or drop >20%): IV fluid bolus 250-500mL; vasopressor (ephedrine/phenylephrine) if refractory
- Urinary retention: may not void until block resolves (Bromage 0); in-out catheter if unable to void >6h post-spinal
- Post-dural puncture headache: positional (worse upright, better supine); treatment: caffeine, hydration; blood patch if persistent >24-48h
- Do not ambulate until Bromage score = 0 and proprioception returned
NPost-Operative Nausea & Vomiting (PONV)
Apfel Score (risk factors)
- Female gender (+1)
- Non-smoker (+1)
- History of PONV or motion sickness (+1)
- Post-op opioid use (+1)
- Score 0 = 10%, 1 = 20%, 2 = 40%, 3 = 60%, 4 = 80% risk
Prophylaxis (Apfel ≥2)
- Ondansetron 4mg IV at end of surgery (5-HT3 antagonist)
- Dexamethasone 4-8mg IV at induction (most effective prophylactic)
- Avoid nitrous oxide and volatile agents (TIVA preferred)
- Rescue: cyclizine 50mg IV or droperidol 0.625mg IV
- Ensure adequate hydration; treat pain adequately (opioid-sparing reduces PONV)
PPain Management in PACU
- Pain score NRS 0-10: assess at arrival and every 15 min
- Target: NRS ≤3/10 at rest before ward transfer
- Multimodal analgesia: paracetamol + NSAIDs + opioid (opioid-sparing)
- Titrate IV morphine 1-2mg boluses every 5-10 min (NRS ≥5); monitor SpO₂ and RR
- Naloxone 0.1-0.4mg IV for respiratory depression (RR <8, SpO₂ <92%)
- Regional analgesia top-up: epidural bolus by trained nurse per protocol
- Document all opioids: dose, time, route, who gave, patient response, SpO₂ pre/post
Post-Op Shivering
- Forced-air warming blanket first-line
- Pethidine (meperidine) 25mg IV — specifically effective for shivering via kappa-receptor
GCC Perioperative Context
JJCIA & CBAHI Operating Theatre Standards
JCI (Joint Commission International)
- IPSG 1: Correct patient identification (2 identifiers before every procedure)
- IPSG 4: Correct-site surgery — site marking, WHO SSC mandatory
- ACC standards: post-anaesthesia care documented criteria for discharge
- FMS: theatre equipment checked and documented; crash trolley sealed
- QPS: near-miss and adverse event reporting for all SSC non-compliances
CBAHI (Saudi — Central Board for Accreditation of Healthcare Institutions)
- Surgical services chapter: covers theatre design, staffing ratios, equipment
- WHO SSC compliance required for accreditation — audited quarterly
- Mandatory swab count policy with double-nurse signature
- Implant traceability: batch number documented in patient record
- Infection control standards: Sterile Services (CSSD) turnaround, sterilisation logs
WWHO Surgical Safety Checklist — GCC Compliance
ℹGCC hospitals have shown variable SSC compliance rates. Quality improvement programmes across Saudi Arabia, UAE, and Qatar have demonstrated significant improvement with structured SSC champions and mandatory training.
- WHO SSC introduced in 2009; adopted by all GCC health ministries
- Compliance barriers in GCC: time pressure, hierarchy in theatre, language diversity in team
- Strategies: mandatory for accreditation; video-based training; SSC champions programme; leadership walkrounds
- Theatre nurse role: lead or co-lead Time Out; document completion; escalate if surgeon refuses
- Evidence: 47% reduction in deaths and major complications where fully implemented
- GCC adaptation: Arabic/English bilingual checklist versions available; culturally adapted for team dynamics
CCultural & Religious Considerations in GCC Operating Theatres
Consent Framework
- Legal framework varies: Saudi Arabia and UAE give legal weight to family in certain situations but patient autonomy is increasing
- Competent adult patients have right to consent; family cannot override
- For incapacitated patients: next of kin consent required; document clearly
- Nursing role: ensure patient (not just family) has understood and consented
- Escalate if patient appears coerced by family — safeguarding consideration
Gender Considerations
- Female patients may request female scrub/anaesthetic staff — document preference in pre-op
- Where possible, allocate female staff — escalate to charge nurse if unavailable
- Explain necessity: in emergency/CICO situation, life takes precedence over gender preference
- Chaperone policy: female nurse present if male practitioner examines female patient
- Dignity: minimise exposure at all times; extra drapes provided
Ramadan & Fasting Surgery
- Standard fasting rules apply during Ramadan: 6h solids, 4h breast milk, 2h clear fluids
- Islamic jurisprudence (fatwa): medical necessity takes priority over religious fasting — surgery is permitted during Ramadan
- Patients may be reluctant to take pre-op medications — explain necessity and halal status
- Schedule elective surgery early in the day (patient can break fast at Iftar)
- IV fluid maintenance avoids dehydration in fasting diabetic patients
HHalal Status of Anaesthetic Agents
⚠Islamic scholars have issued rulings that life-saving medications are permissible even if they contain impermissible substances (necessity ruling — darura). Nurses should be aware of agents containing porcine gelatin.
- Propofol (Diprivan): contains soya bean oil and egg lecithin — generally considered halal
- Some gelatin-containing preparations (certain IV colloids, some drug capsules): porcine-derived gelatin present — discuss with patient pre-op; alternatives sought where available
- Blood transfusion: permissible under necessity ruling; document patient has been counselled
- Alcohol-based skin preps (chlorhexidine in isopropyl alcohol): external use permissible — not consumed
- Maintain clear documentation of any concerns raised and how they were addressed
LLanguage Barriers in Theatre
ℹGCC theatre teams are among the most linguistically diverse in the world: Arabic, English, Hindi, Malayalam, Tagalog, Urdu commonly spoken. Structured communication mitigates risk.
- Pre-operative consent: professional medical interpreter mandatory — family members must not interpret for consent
- WHO SSC Time Out: conducted in common team language (usually English); ensure all understand before proceeding
- Handover (SBAR): structured format reduces language-related miscommunication
- Read-back technique: for verbal drug orders — receiver reads back dose and drug name
- Labelling: all labels, syringes, bags in English AND Arabic in bilingual GCC hospitals
- Emergency calls: standardised codes (Code Blue, Code Red) understood by all staff regardless of language
- Patient communication: use interpreter app for patients who speak neither English nor Arabic
MMedical Tourism & Private Sector Surgery in GCC
- GCC private hospitals attract medical tourists from across the Middle East, North Africa, and South/Southeast Asia
- Common elective procedures: bariatric surgery, orthopaedics, cosmetic surgery, ophthalmology, cardiac
- Nursing implication: patients may have incomplete medical records from home country — thorough pre-op assessment is critical
- Language barriers amplified with international patients — dedicated medical tourism coordinators as liaison
- Pre-op assessment may be done remotely (telemedicine) — theatre nurse should verify all investigations are received
- Post-op: discharge planning for travel may be complex — liaison with physiotherapy, patient coordinator
- Insurance and consent documentation: may require multiple languages; ensure original language consent with certified translation
- Follow-up care: arrange with patient's home physician; discharge summary to be provided in English + patient's language