Intraoperative Radiography

DMI 63

2 28 2014 online ed.

Working in OR requires :

• Super awareness of sterile environment!

• Skill in use of portable machine and c-arm

• Skill in working OR table

• Using radiation protection appropriately

• Knowledge of anatomic landmarks- whether you can see them or not!

• Ability to work with surgery staff under high pressure circumstances

Mobile Image Intensifier

Commonly referred to as? C-arm

Is it sterile?

No!

Unless----

Portable X-ray UnitSterile?

No!

Unless covered with sterile plastic covers after portable brought into OR

(X-ray machine should be cleaned prior to entering each OR!)

OR table

Learn how to work control boxSterile?

No!

Unless-

Covered with sterile drapes!

Radiation Protection

Shield patient if possible!If it doesn’t interfere with exam

The mobile unit should not be used as shield by you

YOU must provide Lead aprons for all personnel!

Monitoring badges should be worn by all personnel

You are responsible for making sure all personnel who can or want to leave room prior to making an exposure are given a loud clear warning and have a chance to get out

Fluroscopy

When using the c-arm, the radiation source is generally under pt, so where should shielding should be placed?

Under the pt!between source and ptMust be done before pt is put on table

If you are not sure, consider it sterile!

During surgery

Technologist works under direction of surgeon not a radiologist

Who will appear to hate you!

You must be able to perform accurately and quickly! “Repeat” is no longer in your vocabulary!

Remember: it’s a high stress situation for all –but success or failure rests on surgeon’s shoulders

Check your ego at the door!You no longer have a name - you are “X-ray”

Only person lower than you is guy who cleans OR- at least they know his name! (Jose)

Expect some abuse!

Good part -if you screw up, they won’t recognize you outside OR!

You must be able to read minds!

• When running c-arm, when Dr. wants fluoro, he expects you to understand that:

– “X-ray”– “now” – “ OK”– “uh huh”– “ready”– grunt– mumble – Or maybe just a glance at monitor

• Mean: hit the fluoro pedal- even when used interchangeably

God help you if you fluoro when he didn’t want it!!!

3 Areas of OR

• Unrestricted• Semi-restricted• Restricted

Unrestricted areas of OR

• Provides outside to inside access

• No traffic restrictions

• Street clothes permitted

Semi-restricted areas of OR

Provides access from unrestricted area of OR to restricted area

Authorized personnel onlyPts and staff

Proper OR attire requiredScrubs, head and shoe covers

Examples of Semi-restricted area

• Hallways within OR rooms

• Instrument and supply processing area

• Non-sterile supply areas and utility rooms

Restricted Areas

Where surgical procedures are carried outProper OR attire and mask must be worn

Examples:Scrub sink areasSterile supply roomsOperating suites

The Surgical Suite

Restricted area!

•Scrub clothes must be worn, and covered with robe if leaving department

•Know Who is sterile and who isn’t! •Know What equipment is sterile and what isn’t!

•No items should be touched without permission of circulating nurse or person in charge!

Operating Room Attire

Clean, fresh attire, surgical “scrubs,” donned at beginning of each shift

Are they sterile?no

Change as necessary

Should soiled scrubs be worn outside OR suite?no!

What the surgery team wears!

Masks worn at all times in OR!

Are they sterile?

No!

Operating Room Attire

CapsWorn in all areas of OR to contain hair

Hoods available to cover any facial hair not contained by mask

Are they sterile?

No!

Surgical Shoe Covers

Purpose:

Top prevent you from tracking in contaminants

To prevent contaminants from soiling your shoes

Are they sterile?

NO!

Operating Room Attire for Techs

GlovesWorn to protect tech from body fluids –sterile?

No!

Radiation badge

Proper ID

Lead attire

Person with known transmittable infection should not be permitted in OR suite!

oColdoAcute infectionoOpen cold soreoSore throatoCarrier of transmittable conditions

Pathogens fall into two broad categories:Pathogens fall into two broad categories:Blood and body fluid borne Blood and body fluid borne AirborneAirborne

Universal Precautions

The practice in medicine of avoiding contact with patients' bodily fluids, by means of wearing of nonporous articles such as medical gloves, goggles, and face shields

to prevent exposure to pathogens of potential portals of entry for infection (nose, mouth, mucous surfaces, conjunctival membranes, abrasions and lacerations on skin, etc.)

Initially developed in 1987 by the Centers for Disease Control and Prevention in US

Surgical gloves now worn when performing simple procedures such as drawing blood from veins

and conducting intra-oral exam

OSHA (Occupational Safety and Health Administration) standards include procedures for cleaning and disposing of used surgical equipment, needles, and laundry, and for disposal of contaminated waste

• Supplement, not replace routine infection-control procedures, such as handwashing and use of surgical gloves

• Does not eliminate need for other categories of disease-specific isolation measures, such as isolation procedures used for open pulmonary tuberculosis and "enteric" procedures used for cases of infectious diarrhea

• At first regarded use of universal precautions as actually or potentially stigmatizing—tending to label patients as "contaminated" but this attitude has been overcome by careful explanation and educational material

Universal precautions are intended to:

Aseptic Vs Sterile

Aseptic :Free from pathogenic (disease

causing) microorganisms

Sterile:Free from all living

microorganisms

Nosocomial infections

Infections resulting from of treatment in a hospital or a healthcare service unit

Infections are considered nosocomial if they first appear:

48 hours or more after hospital admission

or within 30 days after discharge

Nosocomial infections (cont’d)

In US, Centers for Disease Control and Prevention estimates 1.7 million hospital-associated infections, cause or contribute to 99,000 deaths each year

Commonly transmitted when hospital officials become complacent and do not practice correct hygiene regularly

Increased use of outpatient treatment means people hospitalized are more ill and have more weakened immune systems than may have been true in past

Radiographers or other non-sterile personnel must maintain a safe margin from any sterile field-

What is worse than contaminating a sterile field?- not reporting it!

What is the sterile corridor?

• Area between instrument table and draped pt

• Must notnot be entered by any non-sterilenon-sterile personnel!

• NotifyNotify proper personnel immediatelyimmediately if a sterile field is contaminated!!

What parts of sterile gown are considered sterile?

On sleeves- elbow to cuffs

On body- shoulder to level of sterile field

Logistical Problems

• Getting c-arm or portable through jungle of equipment and people

• Getting cassette under pt without breaking sterile field

• Centering CR to pt and to cassette when you can’t see or touch either one!

• Grid cut off!

• When x-ray is performed table top, covered with sterile cloth- you can’t see body part!

• Watch out for your lead apron hitting field

Loading A Cassette in Sterile Cover

2 person job!

Tech

Tech

OR staff

Retrieving IR in Sterile Field

Why must Radiographer be wearing gloves?

in case IR cover is contaminated with blood or body fluids

Surgical tech or nurse gives covered IR to radiographer

OK to contaminate cover now, but not person handing you cassette!

Cover and gloves are disposed of properly before handling uncovered IR

After the exposure:

Hot foot it up department and develop image STAT and return with image to OR ASAP

Remember:Longer time pt. spends under anesthesia the

greater risk to patient

Prolonged exposure unnecessarily adds to the risk of infection

Longer time spent in the OR for pt, the greater the cost to pt!

Longer time you take, the angrier the Dr.s will be with you!

Cardiac Surgery

Anything pertaining to heart and related major blood vessels

Most common procedures: – pacemaker and automatic internal

cardiac defibrillator insertions (C-arm)

– Coronary artery bypass grafts

Post-op CXR generally required after above mentioned procedures

Cholangiogram

Neurosurgery

• Laminectomies– Requires x-table lateral

projections

• Shunt placements

• Transphenoidal cases– Requires C-arm or skull films

Cross-Table Lateral Cervical Spine

Oncology

Catheter placementsUsually by C-armRequires a post-op CXR

Brachytherapy localizationRequires two views at right angle to each other

Cesium Implant

Orthopedic Surgery

ORIF stands for?

Open reduction internal fixationMay require C-arm or plain film radiography

Closed reduction is what?No surgical incision- just manipulationC-arm or plain films

Joint Replacement

Orthopedic Surgery

Pain Management

• Requires C-arm to locate injection site for facet block

• Usually in:– Lumbar spine or– SI joint or– Cervical spine

Vascular Surgery

Utilizes both plain film and mobile fluoroscopy

AV fistulas, AV grafts are most common procedures

What is an AV fistula? abnormal connection or passageway

between artery and vein)

Urology Suite

Retrograde Pyelograms (contrast flows from bladder up to kidney)

IVU’s

Kidney & gallstone extractions

Percutaneous Nephrolithotomy (removal stones from kidney by small puncture wound (up to about 1 cm) through skin)

Summation of Important Things To Remember in OR!

• Upon entering OR, alert all staff of your presence and purpose

• Be aware of sterile fields and personnel• Enlist aid of circulating nurse to move equipment

out of way• Any cassettes placed in sterile field must be

covered first by a sterile member of the team• Allow team to clear room prior to making the

exposure• Do it right the first time!!!