Practical aspects of working in the operating room

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Practical aspects of working in the operating room
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Intraoperative neurophysiologic monitoring

• Electrophysiologic recordings in an electrical
  hostile environment
• Electrophysiologic recordings in an anesthetized
  patients
• The need to obtain interpretable records in a
  short time
• Interpretation of results must occur promptly
• What changes to report and what not to report?
• Communication with the surgeon
• Relation with the anesthesia team
• Relations with other members of the operating
  room team

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Electrophysiologic recordings in an electrical
hostile environment

• Survey an operating room that you not familiar
  with for sources of electrical interference
• Best done the evening before an operation
• Always be in the operating room early enough to
  solve unexpected problems
• Always monitor the recorded potentials directly
  during an operation
• EEG tells the signature of interference averaged
  potentials do not

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Find the source of interference
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Electrophysiologic recordings in an anesthetized
patient

• Advantages
• Can use needle electrodes freely
• Can stimulate peripheral nerves supramaximal
• Disadvantages
• Can cause injury by too strong electrical
  stimulation of nerves or CNS

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The need to obtain interpretable records in a
short time

• Use optimal stimulus and recording parameters
• Reduce noise as much as possible at its source
• Use optimal placement of electrode wirings
• Plan your recordings ahead to avoid waste of time

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Interpretation of results must occur promptly

• Prepare yourself ahead of time so you understand
  the recordings and their interpretation
• Understand the different kinds of changes that
  can occur and their meaning with regard to
  pathologies

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What to report to the surgeon?INFORMATION THAT
IS OF VALUE

• Changes in recorded potentials
• All unusual events
• In case of dramatic changes
• First assume a biologic cause and always notify
  surgeon immediately
• Then check equipment etc.

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What changes to report?

• Changes in the recorded potentials that are
  larger than the normal (small) variations

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What not to report?

• Data without interpretation
• A stream of numbers without interpretation is
  of little value

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Communication with the surgeon

• The surgeon is not a physiologist
• Therefore Provide interpreted results, not raw
  data
• Place the observed changes in relationship to the
  ongoing operation
• You must know the basic steps in the operation
  you are monitoring

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Interpretation of pathologic changes

• Which parameters are important?
• What to use as reference values?
• What is significant?

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Change in relation to what?

• How to get a representative baseline

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Which parameters are important?

• Latency
• Amplitude

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Non-pathologic changes

• Change in anesthesia
• Change in body temperature

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Artifacts

• Stimulus artifacts
• Movement artifacts
• Irrigation with cold saline may cause changes in
  recorded potentials

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False positivesFalse negatives

• Limited relevance for intraoperative monitoring

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Relation with the anesthesia team

• Always discuss a case with the anesthesia team
  before an operation
• What kind of anesthesia they want to use
• How that will influence your work
• For that you must know the basics of modern
  anesthesia techniques

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Relation with the anesthesia team

• Interchange of information
• You can provide information of value for the
  anesthesia team
• They can let you know of changes in vital signs
  and in anesthesia regimen

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Relation with the anesthesia team

• Discuss each operation with the anesthesiologists
  in advance
• Ask to be informed about any changes in the
  anesthesia regimen that may occur during an
  operation
• Watch their displays and understand what they
  mean
• Treat the anesthesiologists as your friends and
  try to understand their situation and problems

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Relations with other members of the operating
room team

• Keep a good relationship with all nurses in the
  operating room (they control the environment)
• Do not be afraid of offering a helping hand
• Remember that they (and you) are all there for
  one single purpose, namely to provide the best
  possible care for the patient

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Practical aspects of working in the operating room

• Should the person who is responsible for
  monitoring be present in the operating room? YES
• Can monitoring be done by watching a display of
  recorded potentials in an another room? NO

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