The choice between surgical scrubbing and sterile covering before or after induction of anaesthesia: A prospective study

Introduction

Day surgery, where the patient leaves the hospital on the same day as surgery, is increasing. Shortening a hospital stay is associated to several benefits: Early ambulation reduces the risk for thromboembolic complications, as well as postoperative infections; and it will reduce health care costs. Thus, its implementation is of value for both patients and society. However, day surgery calls for good perioperative care, enabling rapid recovery to send patients safely home after a few hours following the end of surgery/anaesthesia. Shortening anaesthesia time, avoiding unnecessary anaesthetic exposure, has several potential benefits, including avoiding unnecessary cardiovascular depression, since there is a miss-match between anaesthetic depression and stimuli, thus requiring vasoactive support, improving early recovery, and reducing the amount of anaesthetic used.

The aim of the present study was to compare surgical scrub and sterile covering before vs. after induction of anaesthesia. Our hypothesis was that avoiding prolonged anaesthesia by inducing anaesthesia prior to surgical scrubbing and sterile covering would reduce the need for vasoactive medication. Additionally, the study aimed to determine if this different theatre logistic further affect drug doses of anaesthetic agents, post-anaesthesia care unit (PACU) time and quality of care.

Methods

Results

All 60 patients asked for participation accepted and signed informed consent. Assessment of quality of care during surgical scrub and sterile covering was assessed by all 60 patients; three patients were excluded from analysis of anaesthesia and recovery, as the surgery became more extensive than planned or for social reasons, and the patients were kept as inpatients. There were only minor demographic differences between the groups: the mean age of the awake group was 5 years older, but the ASA class was not different (Table 1).

Duration of anaesthesia and time with laryngeal mask airway was shorter in the awake group (Table 2). The amount of propofol and remifentanil required was also lower in the awake group: 10% reduction in propofol and 13% reduction of remifentanil, but this difference in drug amount was not significant. We found however no difference in vasoactive need between groups. There were no differences in early recovery or vital signs, and first pain was reported at similar times in both groups. Time in PACU was shorter for the awake patients (p<0.05), but time to discharge, pain and post-operative nausea and vomiting showed no difference between groups (Table 2).

In total, 27 of the awake patients would undergo surgery using the same logistics, two were indifferent and one was “negative”, while 21 of the anaesthetised patient would like to have the same logistics, and nine were indifferent. The theatre nurses rated patients being awake during surgical scrub and sterile covering as acceptable; 4out of the 7 nurses rated 10(scale 0 -10), while the remaining rated; 1 nurse made a rating of 6 and 2 nurses, both rated the process of washing and dressing as 8 (on the 0 -10 scale). All 7 nurses involved in the patient care considered it feasible to perform surgical scrub and sterile covering before induction of anaesthesia as routine procedure.

Discussion

We could not prove our hypothesis that sterile washing and dressing before induction of anaesthesia reduced anaesthetic drug usage. But, no difference in need for vasoactive medication was found. We found however that surgical scrub and sterile covering prior to induction of anaesthesia feasible and with a maintained quality of care. We have the experience that theatre nurses in Sweden prefer the patient being asleep while surgical scrubbing and sterile covering is performed is performed. The argument is that it may be distressful for patients if they are awake during preparation, surgical scrubbing and sterile covering. However, in this study, generally patients did not mind being awake, on the contrary some patients gave positive feedback about being awake during preparation. Some nurses also feel that the liquid used for scrubbing may cause a freezing sensation in patients; we did not hear any comments supporting this notion. There are also discussions regarding that awake patients may be at an increased risk for surgical site infections (SSI). In a majority of SSI cases, the pathogen source is the native flora of the patient’s skin and there is no firm evidence that the anaesthetic technique used, i.e. patient being awake or asleep during scrub and sterile covering, should impact the infection risk^1,2. Two recent studies in a huge number of patients undergoing orthopaedic procedures did not show any difference between general anaesthesia, spinal anaesthesia and peripheral blocks^3,4.

Washing and dressing after induction prolongs the time of anaesthesia and to titrate optimal depth keeping patient asleep with only merely minor stimulation following induction may cause additional need for vasoactive medications and may prolong recovery. Shortening the duration of anaesthesia and drug doses may be of value, especially for elderly patients. There are studies suggesting that tailoring anaesthesia reduces the risks for cognitive side effects⁵. We did not follow patients beyond discharge. All our patients had total intravenous anaesthesia; whether use of inhaled anaesthesia for maintenance could further improve emergence, the early recovery, and quality of recovery cannot be assessed from the present study. We found in a previous study that inhaled anaesthesia facilitates early recovery⁶. We could however not see any reduced need for vasoactive medication, thus our primary hypothesis was negative. We cannot give any firm explanation as to why this occurred, since in the awake group the need for both propofol and remifentanil was reduced.

Theatre turnaround time is of increasing importance. Efforts to improve efficacy has been addressed in several studies. Koenig et al. studied anaesthesia induction when the surgeon was in theatre or not, and its impact on waiting time and unnecessary anaesthesia duration⁷. They found a significant shortening of anaesthesia time when surgeons were readily available in the theatre. Saha et al. found that transfer of patient to and from theatre has a significant impact on theatre turnaround time⁸. We found clear logistical benefits associated with the use of local anaesthesia and sedation as compared to general anaesthesia in a previous study⁹. The benefit of local anaesthesia sedation technique has also been supported by others for vaginal prolapse surgery^10,11. Open hernia repair is commonly done under local anaesthesia only¹². Thus, avoiding anaesthesia during surgery preparation also seems to be a feasible alternative when patients are undergoing general anaesthesia. The anaesthetised patients were somewhat younger and whether that could have impacted the results, need for vasoactive medication cannot be stated, the ASA profile was however similar between the groups.

There are limitations to our study. We studied only one procedure, elderly male patients scheduled for inguinal hernia repair. We had need for vasoactive medication as the primary study objective; this may not be the optimal choice and the number of patients studied is also relatively few. The number of patients was based on our power analysis from pilot experience. Whether these results are transferable to other procedures needs further studies. Proper information around the importance of scrubbing and covering should be given to patients, and providing light sedation should be done in accordance to a patient’s wish. Whether fine tuning anaesthetic delivery could further impact the results cannot be stated. We could not find studies assessing the surgical scrub and sterile covering impact on quality of care or theatre time events, thus we are not able to truly put our findings into perspective of previous similar results. We still believe that our findings can be of interest and importance as lean operating theatre planning is of growing importance. Further studies are indeed warranted assessing impact of awake scrubbing and sterile covering on quality and efficacy of perioperative care. There are studies looking at different anaesthetic techniques and the use of a holding area for theatre preparation, which show benefits to introducing peripheral blocks before entry to the theatre¹³.

In conclusion, preparation, surgical scrub and sterile covering, before induction of anaesthesia is feasible, and does not jeopardise quality of care. In addition, it reduces anaesthetic agents need and may thus shorten recovery room stay.

Data availability

Dataset 1: Demographics, perioperative observations, and response to questionnaire of the patients undergoing surgical scrub and covering pre and post-anaesthesia. doi, 10.5256/f1000research.11965.d166034¹⁴