GCC Perioperative Nursing Guide

Perioperative Nursing — GCC Edition

A comprehensive clinical reference for nurses working in pre-operative assessment, operating theatre (scrub and scout roles), anaesthesia nursing, and surgical safety across GCC healthcare settings.

WHO SSC Compliant JCI Standards GCC Context Interactive Tools

Pre-operative Checklist

Documentation & Consent

Signed informed consent — confirm patient understanding, correct procedure and site
Surgical site marked by operating surgeon with indelible marker (irreversible/bilateral procedures)
Allergy band applied — drug allergies AND latex allergy documented
ID band verified — name, DOB, MRN match consent form and notes
Blood group and crossmatch available if expected blood loss >500 mL

NBM (Nil By Mouth) Guidelines

Clear fluids: 2 hours pre-op | Solids & milk: 6 hours pre-op
Apply to adults and children >1 year. Breast milk: 4 hours. Formula: 6 hours.

Document last oral intake time — confirm verbally with patient
Chewing gum / sweets: treat as solids (6 h rule)
IV access established — confirm patency before theatre transfer

Medications

Take as usual Antihypertensives (except ARBs/ACEi — withhold morning of), beta-blockers, statins, thyroid meds, anticonvulsants, inhalers
Withhold Metformin — 24–48 h pre-op (lactic acidosis risk); OCP (4 weeks pre major surgery); NSAIDs 48 h pre-op
Specialist decision Anticoagulants (warfarin, DOACs), insulin (modified protocol), immunosuppressants

Physical Preparation

Remove nail varnish, jewellery, piercings, hearing aids, dentures (unless anaesthetist advises otherwise)
Compression stockings (TED) applied for VTE prophylaxis — check sizing
Pre-op shower/skin antisepsis (chlorhexidine) night before and morning of
Hair removal: clippers only at surgical site — never razors (infection risk)

ASA Physical Status Classification

Class	Description	Examples	Mortality Risk
ASA I	Normal healthy patient	No medical conditions, non-smoker, BMI <30	<0.1%
ASA II	Mild systemic disease	Well-controlled DM/HTN, mild asthma, smoker, BMI 30–40, pregnancy	0.2%
ASA III	Severe systemic disease	Poorly controlled DM/HTN, COPD, morbid obesity, active hepatitis, end-stage renal disease	1.8%
ASA IV	Life-threatening disease	Recent MI (<3 months), CVA, severe valve disease, sepsis	7.8%
ASA V	Moribund — not expected to survive without surgery	Ruptured AAA, massive trauma, intracranial bleed with herniation	9.4%
ASA VI	Brain-dead for organ donation	Brain death declaration, organ harvest	N/A

Suffix "E" added for emergency procedures (e.g., ASA III-E). Emergency surgery increases mortality risk by approximately 3-fold for each ASA class.

Pre-operative Investigations

Investigation	Indications	Notes
ECG (12-lead)	Age >45 years; known cardiac history; hypertension; diabetes	Baseline for comparison if perioperative cardiac event
Chest X-ray (CXR)	Known cardiac/pulmonary disease; recent respiratory symptoms; major thoracic/abdominal surgery	Not routine for all patients
FBC (Full Blood Count)	Major surgery; known anaemia; haematological disorders; elderly; chronic disease	Hb target >80 g/L for elective; transfusion trigger discussion with surgeon
U&E (Urea & Electrolytes)	Renal disease; diuretics/ACEi/ARB; diabetes; liver disease; age >60	Check K⁺ — hypokalaemia increases cardiac arrhythmia risk
Group & Save / Crossmatch	Expected blood loss >500 mL; vascular/cardiac surgery; Jehovah's Witness (cell salvage plan)	G&S for moderate risk; crossmatch for high-risk/cardiac
Clotting Screen (PT/INR/APTT)	Anticoagulant therapy; liver disease; haematological conditions; history of abnormal bleeding	INR target <1.5 for elective surgery
Blood Glucose / HbA1c	Diabetes; suspected undiagnosed diabetes	HbA1c >69 mmol/mol (8.5%) — consider postponing elective surgery
Pregnancy Test (urine/serum βHCG)	All females of childbearing potential undergoing anaesthesia	Confirm with patient; perform same day as surgery

WHO Surgical Safety Checklist — Overview

SIGN IN
Before induction of anaesthesia

Patient confirms identity, site, procedure, consent. Anaesthetic machine/medication check. Pulse oximeter. Known allergy check. Difficult airway/aspiration risk. Blood loss risk >500 mL.

TIME OUT
Before skin incision

Team introduces themselves. Confirms patient, site, procedure. Antibiotic prophylaxis given within 60 min. Anticipated critical events discussed (surgeon, anaesthetist, nursing team). Imaging displayed.

SIGN OUT
Before patient leaves theatre

Procedure name confirmed. Instrument/sponge/needle counts correct. Specimens labelled. Equipment problems to address. Surgeon, anaesthetist, nurse review key recovery concerns.

WHO evidence: Implementation of WHO SSC reduces major surgical complications by 36% and mortality by 47% (Haynes et al., NEJM 2009). Mandatory at all JCI-accredited GCC facilities.

Anaesthetic Risk Estimator (ASA Guidelines)

ASA Physical Status Class Surgery Type Procedure Complexity

General Anaesthesia

Induction Agents

Agent	Key Points
Propofol	Most common; rapid onset/offset; watch for apnoea and hypotension; pain on injection
Ketamine	Dissociative; bronchodilator — useful in asthma/haemodynamic instability; emergence reactions; increases secretions
Thiopentone	Barbiturate; used in rapid sequence induction (RSI); causes histamine release; contraindicated in porphyria
Etomidate	Cardiovascular stability; adrenal suppression risk with infusion; myoclonus on induction

Maintenance

Volatile agents: Sevoflurane (preferred in GCC), isoflurane, desflurane — delivered via anaesthetic machine in O₂/air/N₂O
TIVA (Total IV Anaesthesia): Propofol infusion ± remifentanil; used when volatile agent contraindicated (MH risk, PONV prevention, neurosurgery)
BIS (Bispectral Index) monitoring: Target 40–60 for adequate depth of anaesthesia

Muscle Relaxants (Neuromuscular Blocking Agents)

Drug	Type	Notes
Suxamethonium	Depolarising	RSI — fastest onset (60 s); triggers MH; hyperkalaemia risk in burns/cord injury; short duration (5–10 min)
Rocuronium	Non-depolarising	RSI dose 1.2 mg/kg; reversed by sugammadex; preferred over suxamethonium if MH history
Vecuronium	Non-depolarising	Intermediate duration; renal/hepatic caution
Atracurium	Non-depolarising	Hofmann elimination — safe in organ failure

Reversal Agents

Neostigmine + glycopyrrolate: Reverses non-depolarising block; monitor TOF (Train of Four) — target TOF ratio >0.9
Sugammadex: Selective reversal of rocuronium/vecuronium; faster and more reliable

Regional Anaesthesia

Spinal Anaesthesia

Intrathecal injection of local anaesthetic (bupivacaine 0.5%) into CSF — L3/L4 or L4/L5 space
Onset: 3–5 min; duration: 2–3 h
Block level T4 (nipple line) = risk of hypotension AND bradycardia — cardiac accelerator fibres (T1–T4) blocked
Pre-load with 500–1000 mL crystalloid; have vasopressors (ephedrine, phenylephrine) ready
Complications: post-dural puncture headache, urinary retention, total spinal (emergency)
Contraindications: coagulopathy, infection at site, patient refusal, raised ICP

Epidural Anaesthesia

Catheter placed in epidural space — allows titration and prolonged analgesia
Bolus top-up: Surgeon or anaesthetist administers additional local anaesthetic via catheter during procedure
PCEA (Patient-Controlled Epidural Analgesia): Patient self-administers within programmed limits
Test dose mandatory (with adrenaline) before each top-up to exclude intravascular or intrathecal placement
Monitor: BP every 5 min for 20 min post top-up; block height; motor block

Peripheral Nerve Blocks

Block	Use	Key Watch
Femoral nerve block	Knee surgery, femur fracture	Quadriceps weakness — fall risk post-op
Brachial plexus block (interscalene/supraclavicular)	Shoulder / arm surgery	Phrenic nerve palsy (interscalene) — caution in poor respiratory reserve
TAP (Transversus Abdominis Plane)	Abdominal surgery analgesia	LA toxicity — monitor LAST (Local Anaesthetic Systemic Toxicity)
Adductor canal block	TKR — preserves quad function better than femoral	Incomplete coverage for posterior knee

LAST (Local Anaesthetic Systemic Toxicity): Perioral tingling → seizures → cardiovascular collapse. Treatment: 20% lipid emulsion 1.5 mL/kg IV bolus immediately.

Sedation Monitoring — Ramsay Scale

Score	Level
1	Awake, anxious, agitated
2	Awake, co-operative, orientated (TARGET for conscious sedation)
3	Drowsy, responds to commands only
4	Asleep, brisk response to stimulation
5	Asleep, sluggish response
6	No response — over-sedation

Airway Management — LMA vs ETT

LMA (Laryngeal Mask Airway) Insertion

Deflate cuff fully; lubricate posterior surface with water-based gel
Patient supine — head extended, neck flexed ('sniffing position')
Open mouth — insert LMA along hard palate pressing posteriorly
Advance until resistance felt — inflate cuff (size 3: 20 mL / size 4: 30 mL / size 5: 40 mL)
Connect to circuit — confirm bilateral chest rise and ETCO₂ waveform
Secure with tape; suction catheter via dedicated channel if ProSeal

LMA contraindicated: full stomach / aspiration risk, restricted mouth opening, pharyngeal pathology, prolonged prone position.

ETT (Endotracheal Tube) Insertion

Pre-oxygenation: 3 min at 100% O₂ or 8 vital capacity breaths
Induction agent + muscle relaxant (RSI: cricoid pressure if aspiration risk)
Laryngoscope (Macintosh blade) — visualise vocal cords; BURP manoeuvre if difficult view
Advance ETT (women: 7.0–7.5 mm; men: 7.5–8.5 mm) to 21–23 cm at lips
Inflate cuff — pressure <30 cmH₂O (Lanz valve preferred)
Confirm: chest rise, auscultation, ETCO₂ waveform, CXR if uncertain
Secure tube; document cuff pressure and lip-level marking

Failed intubation: Call for help immediately. Follow Difficult Airway Society (DAS) algorithm — video laryngoscopy, supraglottic airway, surgical airway (FONA) as last resort.

Malignant Hyperthermia (MH)

LIFE-THREATENING emergency. Hypermetabolic crisis of skeletal muscle triggered by volatile anaesthetic agents and suxamethonium. Incidence ~1:10,000–1:50,000 anaesthetics.

Trigger Agents

Volatile halogenated agents: halothane, sevoflurane, isoflurane, desflurane
Suxamethonium (depolarising muscle relaxant)

Clinical Features (CHEAT)

CO₂ rise — rising ETCO₂ (earliest sign)
Hypermetabolism — tachycardia, arrhythmias, hyperventilation
Elevated temperature — rising core temp (>38.5°C; >1°C rise/5 min = diagnostic)
Acidosis — metabolic acidosis, raised lactate
Trismus/rigidity — masseter spasm, generalised rigidity

Management Protocol

Call for help — activate MH emergency protocol
Stop trigger agents immediately — switch to TIVA (propofol/remifentanil)
Hyperventilate with 100% O₂ (2–3× minute ventilation)
Dantrolene 2.5 mg/kg IV — repeat every 5–10 min (max 10 mg/kg) until controlled
Active cooling: ice packs to axillae/groin, cold IV saline, nasogastric cold lavage
Treat hyperkalaemia, acidosis, arrhythmias
Urine output >1 mL/kg/h — maintain to prevent myoglobinuric renal failure
Transfer to ICU — continue dantrolene 1 mg/kg 6-hourly × 24–48 h

MH kit must be available in all theatres using trigger agents. Dantrolene must be checked and in date. Contact EMHG (European MH Group) hotline for guidance.

Sterile Field Setup

Surgical Gowning Technique

Surgical scrub: 2–5 min nailbrush scrub with chlorhexidine or povidone-iodine
Dry hands with sterile towel — from fingertips toward elbows
Don sterile gown — circulator ties posterior ties only (front/sleeves remain sterile)
Closed gloving technique: glove fingers slip inside gown cuffs; pull gloves over cuffs without skin contact
Sterile zone: front of gown (chest to waist), gloved hands — keep in field of vision

Back Table Setup

Sterile drape applied to back table by circulator — scrub nurse opens packs onto table
Logical instrument layout: sharps segregated, sutures organised by size/type
Mayo stand positioned over patient — contains immediately-needed instruments only
All items opening to sterile field announced and counted before surgery begins

Instrument Passing Technique

Scalpel: passed handle-first in kidney dish — NEVER hand-to-hand directly
Scissors/clamps: passed handle-first with rings facing surgeon's thumb
Retractors: passed handle-first; ensure surgeon acknowledges before release
Sutures: cut to length as requested; pass needle loaded in driver, needle pointing anteriorly
Diathermy: pass with insulating tip guard; confirm settings with circulator

Specimen Handling

Receive specimen in designated bowl — never touch with bare gloves from non-sterile sources
Label immediately: patient name, MRN, date/time, tissue type, orientation (marking sutures)
Separate containers for each specimen — do not combine different tissue types
Pass to scout nurse who completes request form and despatches to pathology
Unexpected findings (e.g., unsuspected tumour): preserve specimen intact, do not bisect; immediately inform surgical team; document clearly

Instrument, Sponge & Sharps Counting Protocol

Retained surgical items (RSI) are a never event. Counting is a shared responsibility between scrub nurse and circulator. All counts must be performed verbally and recorded.

Count 1 — Before Surgery Begins

Count all instruments, swabs, and sharps together (scrub + circulator)
Circulator records numbers on whiteboard/count sheet
Any discrepancy: do not proceed until resolved

Count 2 — Before Cavity Closure

Count all instruments, swabs, sharps again — before peritoneum/fascia closure
Surgeon informed of count status before proceeding to close
If count incorrect: inform surgeon immediately — do not close

Count 3 — End of Procedure

Final count of all items before patient leaves theatre
Confirm count matches initial count
Documented as correct in patient notes and theatre register

Incorrect Count Protocol: If final count is incorrect — (1) Inform surgeon and stop closure if still open; (2) Search wound, drapes, floor systematically; (3) Request intraoperative X-ray (plain abdominal film) BEFORE patient leaves theatre; (4) Complete incident report; (5) Retain all soiled items in sealed bags for recount. Do not attempt to close until item is accounted for or X-ray is reviewed by surgeon.

Needle & Sharp Tracking

All suture needles tracked on magnetic needle mat — count needles per pack, match to empty packets
Broken needles: count all fragments, bag all pieces, document in notes
Blade safety: announce "sharp passing" when exchanging blades; place used blades in sharps tray (never passed hand-to-hand)
Diathermy tip: separate count; kept in insulating quiver when not in use

Theatre Equipment Setup

Diathermy (Electrosurgical Unit)

Monopolar: Active electrode (patient) + neutral/return electrode (pad) — current travels through patient's body
Bipolar: Both electrodes on forceps — current travels only between tips; safer near nerves/vessels
Cutting mode: continuous sine wave — clean cut; coagulation mode: interrupted — haemostasis
Confirm settings with surgeon before use; announce power settings aloud

Suction Setup

Two suction systems available (primary + backup)
Yankauer (oropharynx), Poole (abdominal), Frazier (neurosurgery/microsurgery)
Measure suction loss in irrigation-heavy cases (cystoscopy, arthroscopy) for accurate blood loss calculation

Retractors

Self-retaining: Balfour (abdominal), Thompson, Norfolk & Norwich — position carefully to avoid nerve/vessel compression
Hand-held: Langenbeck, Deaver, Hohmann — scrub nurse must monitor for tissue pressure during long retraction periods
Padding under hard retractors on bowel/vascular structures

Irrigation Fluids

Confirm fluid type with surgeon — normal saline (most common), glycine (TURP — hyponatraemia risk), sterile water (not isotonic — caution with open vessels)
Warm to 37–40°C to prevent patient hypothermia
Document volumes in and out for fluid balance

Theatre Environment Safety

Diathermy Pad Placement

Place on large muscle mass (thigh preferred) — maximum contact, even distribution
Avoid: bony prominences (current concentration → burn), over metal implants, scar tissue, hairy skin (poor contact), tattoos
Place as close as possible to surgical site (minimise current path through body)
Check pad after placement — full contact, no lift-off at edges
Explosion risk: Never use monopolar diathermy near supplemental O₂ (FiO₂ >0.3) — ignition of flammable draping materials. Use bipolar or argon beam instead.

Fire Triangle in Theatre

Fuel: Drapes, skin prep solutions (alcohol-based — allow 3 min drying time), hair, bowel gas | Heat/Ignition: Diathermy, laser, light sources | Oxidiser: O₂, N₂O

Fire response: RACE — Remove patient from fire, Alarm activation, Contain fire, Extinguish (CO₂ extinguisher near patient, not water). If patient airway fire: stop gases, remove ETT, flood airway with saline.

Patient Warming

Target core temperature >36°C throughout perioperative period
Perioperative hypothermia (<36°C) increases: surgical site infections, cardiac events, coagulopathy, prolonged drug metabolism
Bair Hugger (forced-air warming blanket): most effective — apply pre-induction and throughout surgery; upper-body or lower-body blanket depending on surgical field
IV fluid warmer (e.g., Ranger, Hotline): for infusions >500 mL; warms fluids to 37–40°C
Warm theatre environment (23–26°C) for paediatric and neonatal cases
Temperature monitoring: nasopharyngeal, oesophageal, bladder probe

Surgical Positioning

Position	Procedures	Key Risks & Precautions
Supine	Abdominal, cardiac, most general surgery	Pressure points: heels, sacrum, occiput — pad all. Arm boards <90°. Brachial plexus stretch if arm abducted >90°.
Lithotomy	Gynaecological, perineal, rectal, urological	Compartment syndrome risk >2 hours — lower leg swelling, pain post-op. Bilateral leg lowering simultaneously to prevent haemodynamic shifts. Common peroneal nerve injury at fibula head (padding essential). DVT risk.
Prone	Spinal surgery, posterior fossa, burns	Eye protection essential (corneal abrasion/blindness risk). Dedicated prone pillows/frame (Montreal mattress, Jackson table). Pressure: breasts, genitalia, iliac crests, knees, toes. Airway — secure ETT before turning. Venous pooling → haemodynamic instability on turning.
Lateral (decubitus)	Thoracic, renal, hip surgery	Axillary roll under dependent arm (not axilla) — prevents brachial plexus/axillary vessel compression. Padding: fibular head, lateral eye, ear, shoulder. Sandbags/beanbag for stabilisation. Head neutral.
Trendelenburg	Laparoscopic pelvic, robot-assisted surgery	Head-down 15–30°. ICP elevation — eye pressure, cerebral oedema. Shoulder supports must not compress brachial plexus. Facial/airway oedema in prolonged cases. Avoid in raised ICP.
Reverse Trendelenburg	Head/neck, upper abdominal laparoscopic	Venous pooling → hypotension. Foot support (anti-slip board) — prevent patient sliding. Monitor BP closely after position change.

Position documentation: Record time in position, padding locations, pressure point checks (every 2 hours for prolonged cases), and any intraoperative repositioning in the intraoperative nursing notes.

Scout Nurse Responsibilities Overview

Before Procedure

Confirm theatre booking: correct patient, procedure, laterality, surgeon, anaesthetist
Prepare and check all equipment: instruments, diathermy, suction, imaging
Position theatre table, obtain positioning aids
Open sterile packs to scrub nurse without contaminating field
Participate in Sign In and Time Out with surgical team
Complete pre-op count with scrub nurse, document on count sheet

During & After Procedure

Remain in theatre — available to obtain additional supplies without contaminating sterile field
Manage diathermy settings as directed, document changes
Receive and label specimens, complete pathology request forms
Monitor patient (positioning, temperature, urine output, blood loss estimation)
Participate in Sign Out — confirm counts, specimens, documentation
Assist with patient transfer to recovery; handover to recovery nurse

Laparoscopic Surgery Nursing

CO₂ Insufflation

CO₂ insufflated to 12–15 mmHg IAP (intra-abdominal pressure) to create pneumoperitoneum
Absorbed systemically → hypercapnia; anaesthetist increases minute ventilation
Shoulder tip pain post-op: referred diaphragmatic irritation from residual CO₂ — reassure, encourage mobilisation, analgesia
Veress needle insertion: LIF (Palmer's point) safer in obese/previous surgery
Port sites: typically 5 mm and 10–12 mm; fascial closure required for >10 mm ports (hernia risk)

Trendelenburg Position Complications

ICP elevation — headache, visual changes, corneal oedema in prolonged cases
Regurgitation risk — maintain ETT cuff pressure; use cuffed tube
Facial and airway oedema — plan for potentially difficult extubation

Robotic Surgery (Da Vinci System)

Robotic arms docked to patient after port placement — cannot be rapidly undocked in emergency
Scout nurse must know emergency undocking procedure (robotic arm release in <30 s for cardiac arrest)
Longer theatre time (setup 30–60 min) — plan patient warming accordingly
Limited instrument haptics for surgeon — scrub nurse vigilant for tissue damage
Specialised instruments (monopolar scissors, bipolar forceps, needle driver) — expensive, fragile
Vision system: 3D endoscope, surgeon console — nurse monitors on bedside display

Emergency conversion: If robotic emergency, undock immediately, convert to open or standard laparoscopic approach. All robotic theatre teams must drill emergency scenarios annually.

Day Surgery Nursing

PONV Management (Post-op Nausea & Vomiting)

High-impact issue in day surgery — leading cause of unplanned admission.

Apfel Score risk factors: Female sex; non-smoker; PONV/motion sickness history; opioid use post-op (1 pt each — score 3–4 = high risk)

Risk	Prophylaxis Strategy
Low (0–1)	No prophylaxis or ondansetron 4 mg alone
Medium (2)	Ondansetron 4 mg + dexamethasone 4–8 mg
High (3–4)	Triple therapy + TIVA + avoid N₂O + minimise opioids

Discharge Criteria (Modified Aldrete / PADSS)

Vital signs stable >1 hour
Alert and orientated × 3 (person, place, time)
Pain controlled — oral analgesia sufficient (VAS <4/10)
Nausea/vomiting controlled — tolerating oral fluids
Mobile or return to pre-op baseline mobility
Voided urine (mandatory for spinal/epidural cases and urological procedures)
Responsible adult escort confirmed — written discharge instructions given
Post-op instructions understood — wound care, activity restrictions, warning signs

Written instructions: Mandatory in GCC for day surgery discharge — include emergency contact number, no driving/alcohol for 24 h, wound signs of infection, follow-up appointment.

Emergency Laparotomy & Damage Control Surgery

Damage Control Surgery (DCS)

Abbreviated surgery to control haemorrhage and contamination — not definitive repair
Indications: coagulopathy (INR >1.5), acidosis (pH <7.2), hypothermia (<35°C) — "lethal triad"
Stage 1: control bleeding (packing), control contamination (staple bowel ends), temporary closure
Stage 2: ICU resuscitation — correct triad, warm patient, FFP:PRBC 1:1 ratio
Stage 3: return to theatre 24–48 h — definitive repair, formal closure

Open Abdomen Management

Bogota bag (sterile IV bag), Wittmann patch, or VAC (vacuum-assisted closure) dressing
Large fluid and heat losses — aggressive warming, fluid replacement
Nursing care: dressing changes in ICU under sedation, fluid output measurement, bowel viability assessment
Nutritional support: early enteral nutrition via NG/NJ tube if bowel viable

Paediatric Theatre

Equipment sizing: ETT size = (age/4) + 4 (cuffed); LMA size by weight
Temperature control: warm theatre (26°C), heated blankets, warm humidified gases
Post-op pain assessment: FLACC scale (Face, Legs, Activity, Cry, Consolability) for pre-verbal children
Parental presence at induction: growing evidence supports reduced anxiety — consult surgeon and anaesthetist

GCC Healthcare & Surgical Landscape

Surgical Volume & Tourism

GCC private hospitals perform among the highest elective surgical volumes globally per capita — driven by extensive insurance coverage and health spending
Surgical tourism: Patients from across MENA (Egypt, Jordan, Lebanon, Yemen) elect to receive surgery at GCC facilities — higher clinical acuity and complex cases
Common elective procedures: bariatric surgery, orthopaedic (joint replacement, spine), ophthalmology (LASIK, cataract), cardiac surgery
Short-stay and day surgery models expanding in UAE and KSA to manage demand

WHO SSC Implementation

Mandatory in all JCI-accredited GCC hospitals
Saudi Central Board for Accreditation of Healthcare Institutions (CBAHI) requires SSC compliance
Regular internal audits — checklist completion rates reported quarterly
Non-compliance is a patient safety reportable event under JCI standards

Leading Surgical Centres in GCC

Centre	Location	Speciality Focus
Cleveland Clinic Abu Dhabi	Abu Dhabi, UAE	Cardiac, neurosurgery, oncology
American Hospital Dubai	Dubai, UAE	Oncology, orthopaedic, robotic surgery
NMC Healthcare	UAE (multi-site)	General surgery, obstetrics, orthopaedics
Johns Hopkins Aramco Healthcare	Dhahran, KSA	Tertiary care, occupational medicine, trauma
King Faisal Specialist Hospital	Riyadh, KSA	Transplant, oncology, paediatric surgery
Hamad Medical Corporation	Doha, Qatar	Trauma, emergency surgery, burns

Perioperative Ramadan Considerations

Clinical significance: During Ramadan, fasting from dawn (Fajr) to sunset (Maghrib) — typically 13–16 hours. Muslim patients may refuse elective surgery during Ramadan fasting hours or decline IV fluids out of religious duty.

Scheduling Strategy

Early morning (pre-dawn) cases: patient can eat/drink before Fajr — NBM maintained for appropriate period; surgery completed before the fast becomes an issue
After Iftar (sunset meal) scheduling: patient eats at Iftar, then NBM — early evening surgery slot (may extend theatre sessions)
Avoid mid-day elective cases where possible — dehydration and fasting overlap
Emergency surgery: Islamic scholars widely agree that saving life takes precedence over fasting — document clearly in notes

Anaesthetic & Clinical Risks

Dehydration: 16+ hours of fluid restriction → reduced circulating volume → hypotension on induction; haemoconcentration increases DVT risk
Pre-op IV rehydration where possible (with patient/family education about medical necessity vs religious duty)
Diabetic patients: unstable glycaemic control during Ramadan fasting — tighter glucose monitoring perioperatively
Oral medication timing: work with patient to plan alternative dosing schedules; consult pharmacist
Cultural sensitivity: involve patient in scheduling decisions; provide Islamic scholars' rulings on medical exemptions if requested

Infection Control in Theatre

Pre-operative MRSA Screening

Swabs: anterior nares, axillae, groin — sent 48–72 h pre-op (elective) or at admission (emergency)
MRSA-positive patients: decolonisation protocol — mupirocin nasal ointment × 5 days + chlorhexidine body wash
Surgical antibiotic prophylaxis: MRSA-positive patients receive glycopeptide (vancomycin 15 mg/kg IV over 60 min pre-op) in addition to standard prophylaxis
Theatre scheduling: MRSA-positive patients last on list; enhanced terminal clean post-procedure

Theatre Ventilation — Laminar Flow Systems

Ultra-clean ventilation (UCV) or laminar flow: unidirectional airflow 0.3 m/s in vertical column over operating table
HEPA filtration — reduces particulate count to <10 CFU/m³ in field (vs 180 in conventional theatre)
Required for: joint replacement, cardiac surgery, vascular implants, transplant
Maintain door discipline: reduce theatre traffic during surgery; each door opening introduces non-filtered air
Number of people in theatre inversely correlates with air quality — limit non-essential personnel

Theatre cleaning: Between-case clean (5 min), enhanced clean (30 min after contaminated case), terminal clean (end of list, 1 hour). Surfaces, equipment, floor with 1000 ppm chlorine solution.

Perioperative Specialist Nurse Career in GCC

Scrub Nurse vs Operating Department Practitioner (ODP)

	Scrub Nurse	ODP
Background	Registered nurse with theatre specialisation	ODP diploma/degree (UK) or equivalent
Scope in GCC	Most common model in UAE/KSA/Qatar	Increasingly recruited — UK-trained ODPs valued
Anaesthesia role	Limited unless additional qualification	Core competency — anaesthetic ODP role
Recognition	DOH/DHA/MOH licensed as RN speciality	Recognised by NHS-affiliated hospitals; DoH review ongoing

Career Pathway

Staff Nurse (Theatre): 2–3 years general nursing + 1 year theatre rotation
Senior Scrub Nurse / Team Leader: 3–5 years theatre; competency in 2+ specialities
Charge Nurse / Theatre Coordinator: Management of theatre lists, staffing, instrument procurement
Clinical Nurse Specialist — Perioperative: MSc level; audit, quality improvement, education lead
Advanced Practice Nurse (APN): Nurse surgical assistant (NSA) role — expanding in GCC private sector

Recommended certification: CNOR (Certified Nurse Operating Room) — offered by AORN. Widely recognised by GCC JCI-accredited hospitals as a perioperative nursing credential.