When the patient is seen in OPD
| |
The patient and relative are counseled about the procedure, indication and the possible risks and complications associated with the procedure and that a note to that effect is made in the OPD paper.
| |
Once the plan for operative intervention is made, all routine investigations (Hemogram, liver function tests, renal function tests, blood sugars, urine routine for microscopy, HIV, Chest X-ray, PT-INR ECG as per patient’s age and underlying co morbidities ) are advised.
| |
Pap smear and Special investigations like the following are checked.
| |
partner's semen analysis in case of infertility,
| |
cervical swab in PID,
| |
endometrial aspirate in abnormal uterine bleeding.
| |
RGJAY eligibility of the patients is verified.
| |
OT diary entry and contact number of the patient is noted.
| |
The patient's fitness for anesthesia from OPD no 23 is confirmed.
| |
Fitness from other departments if required.
| |
All pending investigations required by anesthetist & other departments are checked.
| |
Last menstrual period date is checked in indicated cases.
| |
Ward admission is done as per senior’s opinion.
| |
The patient is given blood donation slip for blood bank
| |
In ward after admission
| |
Investigations are rechecked and pending ones are sent.
| |
Investigation chart is completely filled.
| |
Seniors are informed of the OT list.
| |
Anesthesia fitness is confirmed,
| |
Routine cross match is sent 24 hours prior to the procedure.
| |
OT list has been sent to
| |
Ward staff
| |
OT staff
| |
OT anesthetist
| |
OT staff & anesthetist are informed about patients registered under RGJAY.
| |
Check from OT staff about Availability of adequate CO2 in the cylinder for laparoscopic procedures.
| |
Consent is taken.
| |
Bowel preparation is done (after explanation of the need and effects of) for patients with previous abdominal surgeries or suspected adhesions on day prior to surgery.
| |
Baseline electrolyte levels are obtained.
| |
Adequate IV hydration is maintained once the patient is nil by mouth.
| |
Antibiotic and lignocaine sensitivity is tested.
| |
Prescription is given after confirming from OT staff about materials not available in OT.
| |
Prescription is confirmed to have the following.
| |
Date
| |
Name of patient
| |
Ipd no.
| |
Signature and name of the prescribing doctor
| |
Registration no
| |
No prescription is given to patients registered under RGJAY.
| |
It is checked with the anesthetist if patient requires standby ventilator and/or ICU bed and calls are sent for the same a day prior.
| |
Surgical pathology is informed if any sample for frozen section is being sent from OT.
| |
Specific materials are arranged as required.
| |
RCM media
| |
Blood culture bottle
| |
Schiller’s iodine and acetic acid
| |
CONSENT: The patient and relative are informed about the procedure, indication and the possible risks and complications associated with the procedure. In case of a minor (age <18), consent is taken from the guardian (preferably mother and father both). Assent is taken from patients aged between 12-14yrs.
| |
Rajiv Gandhi Yojana:
| |
Eligibility criteria are checked.
| |
District & procedure planned for the patient should fall under those enlisted under RGJAY
| |
Patient should have yellow/orange ration card along with a photo identity.
| |
Pre authorization form is filled by ward houseman along with required signatures and stamps, after the patient is admitted. It is sent to Gurukul with patient’s relative.
| |
Check approval letter and medicine form are issued.
| |
The following personnel are informed about patients eligible under RGJAY.
| |
Ward staff nurse
| |
OT staff
| |
OT anesthetist
| |
Instructions are given to the to patient:
| |
To stay nil by mouth overnight.
| |
To bathe in morning & wear fresh hospital gown.
| |
To have relatives waiting.
| |
Routine cross match and reservation of different units for patients with same blood group are confirmed.
| |
If blood is not in stock in KEM hospital blood bank, availability in other federation blood banks is checked, requisition slip is given for issue of blood from blood bank other than KEM and blood is sent to KEM blood bank for cross matching.
|
|
Pre
operative Chart
|
|
|
Name
|
|
|
Age
|
|
|
Indoor Reg No
|
|
|
Date of
admission
|
|
|
LMP
|
|
|
Clinical
diagnosis
|
|
|
Medical
history
|
|
|
Surgical
history
|
|
|
Seen by
Professor/ Assistant professor/ Date
|
|
|
Operation
advised
|
|
|
Per abdomen
|
|
|
Per speculum
|
|
|
Per vaginum
|
|
|
Investigations
|
|
|
Hemoglobin
|
|
|
Urinalysis
|
|
|
White cell
count
|
|
|
Blood urea
nitrogen
|
|
|
Serum
creatinine
|
|
|
Plama sugars
|
|
|
Serum
electrolytes
|
|
|
Prothrombin
time, INR
|
|
|
Chest
radiograph
|
|
|
Electrocardiogram
(if indicated)
|
|
|
Pap smear
|
|
|
Endometrial
aspiration cytology if applicable)
|
|
|
Blood group
|
|
|
Antibiotic
sensitivity
|
|
|
Lignocaine
sensitivity
|
|
|
Fitness for
anesthesia
|
|
|
References
|
|
OT day morning
| |
The patient's fasting status is confirmed.
| |
The following things have been done:, whether
| |
shaving
| |
patient has been given fresh clothes with identification label.
| |
Venous cannulation.
| |
Preoperative medications is given within 1 hour of expected time of start of procedure.
| |
Patient's relative (preferably the one who has given consent) is confirmed to be present.
| |
Morning dose of routine medications is given as indicated.
| |
In Operation Theater
| |
Patient is identified.
| |
It is confirmed that the patient removed inner clothes and has voided urine.
| |
Consent to be checked by the operating surgeon and senior.
| |
Communication is maintained between the operating surgeon and anesthetist about procedure, duration of surgery and expected blood loss, suitable anesthesia.
| |
Neonatologist is available before starting cesarean section.
| |
Patient is given appropriate position.
| |
Suction machine, cautery and other required equipment are attached.
| |
In case of laparoscopic and hysteroscopic procedures: camera, normal saline bottle, light source & gas cylinder are confirmed to be ready.
| |
Scrubbing, painting and draping is done by the operating team under aseptic precautions.
| |
Catheterization of urinary bladder is done under aseptic precautions with appropriate sized Foley’s catheter.
| |
Patient consent
| |
Size of catheter.
| |
Urobag.
| |
Savlon swabs
| |
10 cc NS in syringe
| |
During surgery
| |
Mops, instruments count is taken.
| |
Checking is done with the anesthetist before starting procedure if patient is adequately anesthetized.
| |
Suction, cautery, laparoscopy / hysteroscopy instruments, special instruments are confirmed to be available as per procedure and in working condition.
| |
Hemostasis is confirmed before starting closure
| |
Adequate, clear urine output is confirmed if patient is catheterized.
| |
Instrument, mops, needle count is confirmed to be the same as before starting the procedure.
| |
The patient is cleaned before shifting out.
| |
Post procedure
| |
Relatives are shown the surgical specimen, if any
| |
Histopathology form is filled with all details
| |
Microbiology samples are dispatched, if any.
| |
Entries are checked.
| |
OT record book
| |
Front page entry on patient’s file
| |
Post operative orders.
| |
Tubal ligation/MTP/Copper T book.
| |
Postponed cases and the reason mentioned in the OT book
| |
The entries checked and signed by the registrar and the assistant professor.
| |
The patient is shifted to ward with servant and relative after anesthetist’s permission.
| |
Post operatively in ward
| |
The patient is given appropriate position, as indicated- head low, propped up or supine.
| |
Vital parameters are monitored.
| |
HGT, urine sugar/ketones of diabetic patients are checked and random blood sugar is sent.
| |
Investigations asked for by anesthetist (ECG, ABGA, references etc) are done.
| |
Foley’s catheter is strapped to medial aspect of thigh.
| |
Special precautions
| |
HGT, urine sugar/ketone are checked and charted in diabetic patients. If patient is on insulin infusion, drip rate is given as per HGT (as per prior endocrinologist’s advice).
| |
Foley’s catheter is kept in situ of patients who have undergone anterior colporrhaphy (3 days) or had bladder injury (21 days) during procedure.
| |
Patients who have undergone perineorrhaphy are given perineal care and povidone iodine vaginal pessary from day 3 onwards.
| |
Catheter of patients of anterior colporrhaphy is removed on day 3 and residual urine to be measured.
| |
Special situations: OT list on other day
| |
Confirm the OT list of the concerned unit.
| |
Permission to be taken from:
| |
Head of the unit
| |
Unit heads of the concerned and the parent unit
| |
OT sister in charge
| |
Anaesthetist
| |
Intraoperative consent
| |
The intraoperative findings, proposed further management, the risks and consequences associated with the above are informed to the patient’s relative in the language understood by them.
| |
A written informed valid consent signed by the patient’s relative and the doctor is taken.
| |
Intraoperative assistance from other Department
| |
The available unit of the other department is informed about the procedure, intraoperative findings and the assistance required.
| |
A written call is sent.
| |
It is checked if the OT notes have been attached after the completion of procedure.
| |
Instruments from other OT
| |
Permission is taken from the concerned unit and sister in charge of the other OT.
| |
A request letter signed by the registrar is given to the OT staff.
| |
Instrument is cleaned after use.
| |
Returned to the sister of the other OT and the request letter is taken back.
| |
Emergency OT
| |
Inform OT and ward staff on duty.
| |
Send anaesthesia call indicating the name , concerned unit, the nature of the procedure and the indication.
| |
Shift patient to OT on a trolley accompanied by a resident doctor.
| |
Inform neonatologist in case of LSCS.
| |
Anesthesia fitness
| |
Elective surgery
| |
The procedure of anesthesia fitness of a patient who is to undergo an elective surgery begins with the first visit of the patient to the OPD.
| |
Routine and special investigations and references are done based on the history, findings and clinical examination of the patient.
| |
Further line of management is decided at the next visit based on the review the previous step.
| |
Patient is seen in OPD 23, with all investigations for preanesthesia check.
| |
If OPD anesthetist has advised any fresh investigations and references, those are done.
| |
If OPD anesthetist has advised any fresh references, those are done.
| |
Before re-referring the patient to anesthetist, all pending investigations/references are confirmed to have been done.
| |
Confirmation of fitness is done after OPD anesthetist has certified so.
| |
A list of patients to be posted for elective surgery is given to respective OT’s anesthesia team a day prior. Special mention of patients under RGJAY to be done in OT list.
| |
If ventilator or ICU standby is needed, call is sent for the same a day prior and confirmation is done on morning of surgery.
| |
Note: Always remember
| |
All the blood investigations should be recent, preferably within last 3 months.
| |
If investigations are old, send fresh ones.
| |
Antibiotic and Lignocaine sensitivity of all patients posted for elective surgery to be done.
|
Disease
|
Pre op
|
Post op
|
Oral hypogycemics
|
Confirm conversion to Insulin as per Endo advice
|
Started once patient is on full oral intake.
|
Insulin
|
Omit morning dose
|
To be restarted as per sugar values.
|
Antihypertensives
|
To be continued
|
To be continued
|
Heparin
|
Stop 12 hours prior
|
Start 12 hours later
|
Warfarin
|
Omitted pre op
|
|
Aspirin
|
Stop 7 days prior
|
Restart 7 days later
|
Immunomodulator
|
Continue
|
Continue
|
Thyroxine
|
Dose with sips of water
|
Continue
|
Bronchodilators
|
Continue
|
Continue
|
Steroids
|
Switch to intravenous formulation
|
Taper IV steroid and convert to oral
|
Emergency surgery
| |
A call is sent to on call anesthesia team from OT.
| |
It is checked whether patient has been seen by anesthetist before being taken on OT table.
| |
All essential investigations have been done.
| |
CBC
| |
Blood grouping & cross matching
| |
PT-INR in selected cases such as eclampsia/pre-eclampsia, intra-uterine fetal demise, liver disorders, patients on anticoagulation etc.
| |
If anticoagulation is not stopped prior as in emergency surgery, blood and blood products' (fresh frozen plasma, cryoprecipitates and platelet concentrate) availability is confirmed.
|
Epidural anaesthesia
In case of epidural anesthesia, check that post op top up is given.
| |
On 2nd postoperative day, check that catheter is removed by OT anaesthetist.
|