Intraoperative Care: Sterile Field, Counts, and Equipment Safety
Maintaining the sterile field
Only sterile items belong on the field, and the field is sterile only at table level. The gown is sterile from chest to waist and along the sleeves to the cuffs; gloves are pulled over the cuffs. A contaminated item is removed or covered, and the person who is contaminated turns away from the field and regloves or regowns. Keep the 1-inch border of a wrapper from being treated as sterile.
Counts
The count begins before the incision and is repeated at the cavity closure and at skin closure. Count sponges, sharps, instruments, and small miscellaneous items such as vessel loops and needles. On a discrepancy: stop, notify the surgeon, search the field, floor, and linens, recount, obtain an intraoperative x-ray if unresolved, and document. Never assume a missing item will turn up.
Supplies and wound class
Know suture types (absorbable versus nonabsorbable), suture sizes (larger number = smaller caliber, e.g., 4-0 is smaller than 2-0), and needles (tapered for soft tissue, cutting for skin, blunt for friable tissue). Wound classification runs clean, clean-contaminated, contaminated, dirty/infected, and drives antibiotic and dressing decisions.
Energy devices and hazards
Place the dispersive pad on well-vascularized muscle, away from bony prominences, scars, hair, and implanted metal. Never let alcohol-based prep pool under drapes near an energy device. Use eye protection and smoke evacuation with lasers, and follow facility policy for tourniquet times.
Specimens and implants
Label specimens at the field with patient identifiers, source, and orientation. Fresh tissue goes for frozen section, formalin for routine pathology, and a sterile container for culture. Record implant lot and serial numbers.
Traps: placing the ESU pad over a pacemaker or metal implant; treating a count discrepancy as resolved because "it always shows up"; sending a frozen section in formalin.
Rule of thumb: count at four points - before, cavity, closing, skin.