Surgery represents a physiologic challenge to even healthy patients - and many patients enter surgery with risk-intensifying co-morbidities. As a result, medical emergencies can occur during any surgery. Recognition and early management of these crises is crucial. Thus, this chapter seeks to provide an overview of serious medical emergencies that may arise in the preoperative period, ranging from anaphylaxis to diabetic ketoacidosis. To provide context for investigations and treatment, a brief outline of the relevant pathophysiology and/or epidemiology accompanies each problem. Building upon that foundation, this chapter describes the rudiments of recognising the emergencies and managing them appropriately. It is not the goal of the chapter to address the included issues comprehensively but to impart basic, essential knowledge of medical emergencies that will help the reader to participate in the provision of safe care in the operative setting.

This chapter explore human factors, also known as ergonomics, which is an established scientific discipline that has become integral in healthcare in recent years. The catalyst for this in the UK was the Clinical Human Factors Group led by Martin Bromiley. Martin’s wife Elaine died following errors made during a routine operation when the theatre team failed to respond appropriately to an unanticipated anaesthetic emergency in part because of a variety of human factors. There is still confusion around the term ‘human factors’. This is partly because human factors cannot be explored in isolation but need to be understood in the context of human activity, error, and the culture around error.

Healthcare-associated infections and more specifically surgical site infections, represent one of the biggest challenges facing practitioners in the perioperative environment. This chapter addresses the key points related to the causes of infection, and how they can be prevented. Infections are caused by pathogenic organisms, consequently, it is important to understand how they enter the body. The chain of infection model describes a series of links that outlines how infections can spread and provides a foundation to understand how they can be prevented. It is essential that perioperative practitioners understand how to break the chain of infection as well as the consequences of not doing so.

Patients with various ailments present to hospital with pain. This chapter defines pain and explores the assessment and the fundamental pathophysiology behind this common symptom. Pain can be managed using various pharmacological and non-pharmacological methods including interventional techniques. This chapter also explains the principles of management of acute pain in chronic pain patients on long term opioids and the problem of chronic post-surgical pain.

Intravenous fluids are solutions containing various quantities of water, electrolytes, salts, and sugar. They are used to maintain haemostasis when the enteral route is insufficient to meet physiological demand. Fluid therapy maintains hydration, oxygen delivery, and thus organ function. Poor perioperative fluid control is associated with impaired physiological function, resulting in patient harm and increasing healthcare costs. Perioperative fluid management is based upon three distinct but related factors: patient (age and comorbidities), surgical (urgency, indication and duration) and anaesthetic. This chapter is an introduction to intravenous fluids, highlighting the physiological control mechanisms, the composition of intravenous fluids, and important clinical assessment principles.

This chapter explains the aims of patient positioning and the complications that can arise from incorrectly positioning patients as well as the physiological changes different positions can cause. The correct positioning and alignment of limbs for surgical procedures is vital, and all perioperative practitioners should understand their role and responsibility for safe patient positioning, and the rationale for it. Safe patient positioning is always a multidisciplinary team effort, whereby all members of the perioperative team should be present in the operating theatre at the crucial moment.

Within the operating theatre, perioperative practitioners will use a variety of different pieces of equipment to help them carry out their role and care for patients undergoing anaesthesia and surgery. Whether it is checking an anaesthetic machine, handling surgical instruments, or setting up an analgesic pump in the post-anaesthetic care unit, the management of medical equipment requires more understanding than just simply using it. This chapter explores the procurement, use, and maintenance of medical equipment.

Health and Safety within the perioperative area present unique challenges in terms of managing the unique hazards and risks that staff and patients can be exposed to. Hazards from lasers, electrical equipment, chemicals, moving and handling, exposure to noxious vapours and gases are just some of the common environmental risks staff are exposed to on a daily basis. This chapter focuses on putting some of the legislation and guidance into the perioperative context. One of the primary aims of the chapter is to foster a culture of appropriate risk assessment and safe practice which will reduce or minimise errors.

This chapter explains the fundamental elements of resuscitation. Patients in cardiorespiratory arrest require prompt and effective resuscitation to improve chances of a good outcome. Identification of the underlying cardiac rhythm and treatment of any reversible causes is critical to achieve patient survival. A structured ABCDE approach and the ALS algorithm are commonly adopted to optimise patient assessment and management. An awareness of both technical and non-technical skills are important when dealing with the acutely deteriorating patient.

Since initial experiments with nitrous oxide and ether in the nineteenth century, general anaesthesia has been near synonymous with inhaled agents. However, total intravenous anaesthesia may offer advantages in certain circumstances. Total intravenous anaesthesia can be defined as the induction and maintenance of general anaesthesia using agents given solely intravenously and in the absence of all inhalational agents including nitrous oxide. It may be necessary when volatile anaesthesia is contraindicated or infeasible or may be chosen for other benefits. This chapter provides an overview of the benefits and disadvantages of total intravenous anaesthesia, as well as describing the equipment and care required to use it safely.

This chapter explores the different kinds of sutures available, as well as some additional methods of skin closure. Surgical sutures are a medical device used to hold body tissue together following injury or surgery. There is evidence of suture use going back thousands of years. The application of a suture generally involves using a needle with an attached length of suture thread. Suture thread can be made from numerous materials. The original sutures were made from biological materials, such as catgut, cotton, and silk. Today, most sutures are made of synthetic polymer fibers, with silk being the only biological material still in use.

This chapter explains the key aspects of operating department design that facilitate a highly skilled multidisciplinary team to provide essential care to a vulnerable group of patients. It is important that the surgical facilities are designed to support the smooth flow of patients from admission to discharge. Surgical activities are broad ranging from scheduled or unscheduled, complex, to routine day surgery. Theatre services are central within the hospital system and rely on interdependant relationships with other hospital departments. This presents organisational, planning, and design challenges, as healthcare providers seek to improve services and utilise existing infrastructure to offer facilities that meet demand in a fast-paced and progressive field. Patients are entitled to receive high-quality healthcare, which is provided safely and effectively, and theatre teams should expect to deliver those high standards of care in an appropriate workspace. Theatre design is an essential component of the perioperative pathway, allowing surgical interventions to be carried out safely and efficiently to enable the best possible patient outcomes.

The ECG is a non-invasive representation of the activity of the cardiac electrical conducting system. ECGs are widely available in all hospitals and therefore interpretation is of great importance. ECGs allow assessment of cardiac rate, recognition of conduction blocks, myocardial ischaemia, life-threatening arrhythmias, and the effects of drugs. Therefore ECGs provide a wealth of information allowing safe and appropriate treatment strategies for patients. This chapter summarises the most salient features of common arrhythmias seen in clinical practice.

In the immediate post-anaesthesia phase the patient’s airway, breathing, and circulation are subject to dynamic change as the effects of anaesthesia begin to wear off. If not carefully managed, life threatening complications can occur rapidly. The experienced practitioner uses risk appraisal to inform physical assessment in order to pre-empt complications or correct them if they occur. This chapter focuses on the key priorities of assessment together with other essential factors such as pain control.

Care is a fundamental principle that is at the centre of operating department practice. It involves consideration of the patients‘ physical, psychological, and emotional needs whilst respecting their social and cultural beliefs. Perioperative care is not a single event but rather a process that starts with the assessment of patient needs and identification of risks, which are then planned for, implemented, and evaluated as the patient moves through each stage of their journey. The whole process is documented using the framework of a nursing model and perioperative practitioners become experienced in prompt care planning to ensure that the care delivered is safe, effective, and responsive. All perioperative practitioners are responsible for the care they deliver through a duty of care to their employer and the patient. Registered practitioners are also accountable to their regulatory body who set the standards for education and practice. Reflection, as part of continuing professional development, allows practitioners to gain a deeper understanding of the care they provide.

An understanding of the physiological role of blood and its role in the supply of oxygen to tissues is important for the perioperative care of the patient. A thorough approach to administration of blood components is vital in this setting. This chapter adresses the special properties of the red blood cells in promoting oxygen carriage, the methods of safe blood component transfusion, and consideration of the hazards of transfusion.

Critical ill patients are often haemodynamically unstable and accurate continuous monitoring is vital. Haemodynamic monitoring describes the measurement of the cardiovascular stability of the patient. Invasive blood pressure monitoring and central venous pressure monitoring provide a ‘real time’ measurement of the patients haemodynamic status and better allows clinicians to pre-emptively treat a patient before a more serious problem arises. Although invasive blood pressure monitoring has several advantages compared to non-invasive blood pressure monitoring, it is not without risk. Central venous pressure monitoring is similarly beneficial in that it supports the clinical decision making regarding a patient’s fluid status but also comes with additional risks. This chapter explores invasive blood pressure and central venous pressure monitoring in detail.

This chapter is written for practitioners working within the perioperative environment that require an understanding of how to assess and manage a patient’s airway. An introduction to airway anatomy highlights relevant anatomical landmarks, and a number of techniques that can be employed for both basic and advanced airway management are described. Airway equipment used by the anaesthetic practitioner will vary depending on requirements of the patient and procedure. Therefore, an overview of both standard and specialist airway equipment available, and how this is used to establish and maintain a patent airway, is provided.

This chapter provides an overview of artificial ventilation, an intervention that has developed from a basic resuscitation technique to highly sophisticated intensive care ventilators used today. Artificial ventilation is provided to unconscious patients, whether unconsciousness was caused by a medical problem (e.g., head injury) or by anaesthesia. Ventilation is usually provided through an endotracheal tube, via a breathing system which is attached to a ventilator. A heat and moisture exchange filter is used to warm and humidify the gases that reach the patient. The healthcare professional caring for the patient will adjust various parameters to ensure the ventilation strategy is appropriate for each patient and their specific needs. Positive-pressure ventilation is used to push gases into the airways of the patient and allow gas exchange to occur. Ventilators may have several different modes for delivering breaths to patients but usually are based around limiting tidal volume or peak inspiratory pressure. Artificial ventilation can affect many different physiological systems particularly the heart and blood vessels, the brain, and the kidneys.