Patient Connection OPERATING ROOM
Pregnant in the OR: Potential hazards Regardless of your position, occupational hazards exist when working in the operating room. Unfortunately, studies on pregnant healthcare workers (and other occupations) are diffi cult to interpret due to the fact that they predominantly consist of retrospective cohort data rife with selection and recall bias or animal studies of direct exposure to substances. Nevertheless, here is a list of some things to consider when working pregnant in the operating room or hospital setting: Anesthetic gases. While every effort is made to
avoid elective surgery during pregnancy, even preg- nant women need to have general anesthesia under urgent circumstances; there is no evidence that gases administered at concentrations appropriate for general anesthesia cause fetal harm. Thus, sub-anesthetic lev- els that would be passively inhaled in an occupational capacity should theoretically be safe as well. That be- ing said, it is generally recommended that pregnant women in the OR avoid inhalation of the gases when possible. We facilitate this by using ventilator circuits with scrubbing systems and taking care to turn off anesthetic gases if the circuit is open to air for a pe- riod of time (such as between mask ventilation and intubation). This is mostly routine practice regardless of pregnancy status. Methylmethacrylate. MMA is a common ingredi- ent in cement mixtures for joint prosthetics. When mixed, it forms a strong scent which dissipates over a number of minutes as the mixture cures. As a preg- nant provider, your choices are to not work on cases using MMA, ask the scrub mixing the cement to use a vacuum device to remove the fumes, or temporarily leave the room during the mixing process. Radiation. For radiation, potential harmful effects
are directly related to the dose of exposure. The Cen- ters for Disease Control and Prevention (CDC) website has a table of radiation doses with corresponding maternal/fetal risks at different gestational ages. At doses higher than 50 rads, risks range from failure of implantation and miscarriage at early stages to growth retardation, mental delay, and increased risk of cancer at later stages. Protective shielding goes a long way to reduce exposure. However, the garments must encircle the body and not just cover the front of the body in apron form. Infection. If a pregnant woman contracts an in-
fectious disease while working in the OR, potentially teratogenic effects of certain microbes and their treat- ments and/or long-term transmission of viral infections to the fetus such as HIV or HCV are considerations that should provide pause and vigilance when employing personal protection. Stress. This is the most diffi cult "hazard" to avoid.
Theoretically, emotional and physical stress can cause neuroendocrine and cardiovascular alterations that could affect fetal physiology and hence possible outcomes. Limited studies implicate longer working hours, night shift work, prolonged standing, and physical work as risk factors for preterm birth, SGA infants and miscarriage.
A delicate balance
Keeping patient temperatures at optimum a must for successful outcomes, infection prevention by Valerie J. Dimond
P
erioperative clinicians already know how vital it is to maintain normo- thermia in their surgical patients
(keeping the core body temperature between 36°C/96.8°F and 38°C/100.4°F). But that doesn’t mean it’s easy. A good number of surgical cases — up to 20 percent — still slip into unintended hypothermia, a potentially serious condition in which even a slight drop below 36°C can mean trouble. Hypothermia increases risk of surgical site infections (SSIs) and other complications that can threaten patient safety and comfort, prolong recovery time, increase length of stay and drain valu- able staff time and resources. “When you look at PACU (post-anesthesia care unit) time, patients are usually dis- charged in increments of 15 minutes. If a patient takes a little bit longer to wake up and is shivering and in pain then you have to give them more pain medicine and you have to monitor their oxygen a little longer,” said Stephanie
Stephanie Stroever
Stroever, MPH, CIC, Infection Prevention & Control Consultant, Infection Prevention & Management Associates Inc. “Unfortunately, in the operating room (OR) and PACU, time is money.”
Hypothermia, dangerous and costly
Stroever, who recently gave a lecture on preventing perioperative hypothermia at the Association for Professionals in Infection Control and Epidemiology (APIC) conference in June, says hypother- mia is dangerous because it narrows blood vessels, restricting blood fl ow to the tissues and disrupting the delivery of oxygen and immune elements throughout the body. “In surgical site infection prevention, we want tissues to stay well oxygenated, which assist in the healing of the wound, and for the immune system to reach the surgical site to fi ght against microbes that do not belong and can cause infection,” she said. “Maintenance of normothermia is vital to
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keep these key functions of the body up and running to the places they are needed.” She says all surgical patients face the risk of developing hypothermia during surgery but for those with certain co-morbidities, such as neonates/infants and geriatric patients, underweight patients and those with metabolic disorders, the risk climbs. Surgery type, duration and ambient tem- perature are also contributing factors. “Characteristics of the surgery and surgi-
cal environment can place patients at high- er risk,” Stroever said. “Patients who have longer duration surgeries are at increased risk of perioperative hypothermia due to length of anesthesia. Environmental tem- peratures in the operating suite can cause the loss of metabolic heat due to convec- tion, especially in patients who must have a lot of skin exposed for the procedure.” According to one study published in the
journal Surgery last June, mortality rates increased four times among unintentional hypothermic patients undergoing elective operations. They also had twice as many complications, in which sepsis and stroke increased the most. Other independent risk factors for hypothermia that supported a need for preoperative intervention, in- cluded anemia, chronic renal impairment, and unintended weight loss, severity of illness on admission, age, male sex, and neurologic disorders.
Pre-warming, a new standard? Cindy Wasmund, R.N., Patient Temperature Management Clinical Advisor, Cincinnati Sub-Zero, says recent research indicates that even shorter surgeries can pose a substantial risk for hypothermia, perhaps even more so. “We’ve always looked at actively warming patients for cases that are an hour or longer because we think they’re going to get cooler,” Wasmund said. “With heat redistribution from the anesthesia, from the room, with everything going on, the shorter cases are actually coming out poorer because they don’t have the time for autoregulation to kick back in.”
OPERATING ROOM
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