What is the comprehensive operating room protocol for surgery, covering pre‑operative verification, antibiotic prophylaxis, patient positioning, intra‑operative monitoring, blood loss management, and postoperative hand‑off?

Comprehensive Operating Room Protocol for Surgery

Administer intravenous antibiotic prophylaxis 30-60 minutes before surgical incision as a single dose, using cefazolin 2g for most procedures, with re-dosing only if surgery exceeds 4 hours or blood loss exceeds 1.5L. 1

Pre-operative Verification ("Time Out")

Implement a mandatory pre-operative checklist immediately before incision that verifies:

• Patient identity confirmation
• Correct surgical procedure and site (including laterality when applicable)
• Allergies and contagious disease status
• Patient positioning requirements
• Review of anticipated critical moments

This verification process significantly increases patient safety and provides opportunity to identify and solve problems before they occur 2. The checklist should involve all team members present (surgeon, anesthesiologist, nurses) and be completed with all OR doors sealed except one 3.

Antibiotic Prophylaxis Protocol

Timing and Administration

Critical window: 30-60 minutes before incision 1, 4. This timing ensures adequate serum and tissue concentrations during the period of potential contamination. Administration within 120 minutes is acceptable for most antibiotics, but the 30-60 minute window is optimal 1.

Dosing by Procedure Type

Orthopedic Surgery (joint prosthesis, implants):

• Cefazolin 2g IV slow, re-inject 1g if duration >4 hours 5
• Alternative: Cefamandole or cefuroxime 1.5g IV, re-inject 0.75g if duration >2 hours
• Allergy: Clindamycin 900mg IV or vancomycin 30mg/kg over 120 minutes 5

Cardiac Surgery:

• Cefazolin 2g IV + 1g in priming, re-inject 1g at 4th hour intraoperatively 5
• Alternative: Cefamandole/cefuroxime 1.5g IV + 0.75g priming, re-inject 0.75g every 2 hours
• Allergy: Vancomycin 30mg/kg over 120 minutes 5

Bariatric Surgery:

• Gastric band: Cefazolin 4g over 30 minutes, re-inject 2g if duration >4 hours 5
• Bypass/sleeve: Cefoxitin 4g over 30 minutes, re-inject 2g if duration >2 hours 5
• Doses calculated on actual body weight for obese patients 1

Colorectal Surgery:

• Cefazolin or cefuroxime with metronidazole coverage 6, 4
• Consider oral antibiotic decontamination 18-24 hours preoperatively in addition to IV prophylaxis (reduces SSI from 39% to 13%) 6

Cesarean Section:

• Cefazolin 2g IV single dose 5
• Allergy: Clindamycin 900mg IV 5

Re-dosing Criteria

Intraoperative re-dosing required when:

• Surgery duration exceeds 2-4 hours (typically >2 half-lives of the antibiotic) 1
• Blood loss exceeds 1.5L 1
• For cefazolin specifically: re-dose at 4 hours
• For cefamandole/cefuroxime: re-dose at 2 hours

Critical Pitfalls to Avoid

• No postoperative prophylactic antibiotics - there is no evidence supporting continuation beyond 24 hours, and it increases resistance 1
• Obese patients (≥120kg) require higher doses based on actual body weight 1, 5
• Vancomycin must be infused over 120 minutes and should end at latest at incision start, ideally 30 minutes before 5

Skin Preparation

Use chlorhexidine 2% in alcohol for skin preparation - this is superior to povidone-iodine solution 7, 4. However, exercise caution with alcohol-based solutions when using electrocautery due to fire risk 4.

If hair removal is necessary, use clipping rather than shaving with razors to reduce SSI risk 4.

Patient Positioning

Position-specific injury prevention is mandatory for all cases 8:

Key positioning principles:

• Maintain perioperative normothermia throughout (prevents hypothermia-related complications) 7
• Use prophylactic dressings at pressure points
• Consider neurophysiological monitoring for high-risk positions
• Document positioning and protective measures used

Common positions and risks:

• Supine: pressure on occiput, scapulae, sacrum, heels
• Prone: facial/ocular pressure, chest compression, nerve compression
• Lithotomy: compartment syndrome, nerve injury
• Lateral: brachial plexus injury, pressure on dependent side

Position-related injuries depend on procedure length and patient factors (weight, age, frailty) 8.

Intra-operative Monitoring

Standard Monitoring

• Continuous vital signs (HR, BP, SpO2, EtCO2)
• Temperature monitoring to maintain normothermia 7
• Neuromuscular monitoring when muscle relaxants used 4

Anesthetic Protocol

Use short-acting agents 4:

• Induction: Propofol with short-acting opioid (fentanyl, alfentanil, or remifentanil infusion)
• Maintenance: Sevoflurane or desflurane in oxygen-enriched air, or total intravenous anesthesia (TIVA)
• Muscle relaxants: Titrate using neuromuscular monitoring; maintain deep block during surgery for optimal surgical access

Glycemic Control

Maintain blood glucose <180mg/dL (10mmol/L) with insulin infusion 7, 9. Perioperative hyperglycemia increases oxidative stress, prothrombotic effects, and inflammation. Target normoglycemia throughout the perioperative period.

Blood Loss Management

Antifibrinolytic Use

Administer tranexamic acid or epsilon aminocaproic acid for on-pump cardiac procedures 9:

• Maximum tranexamic acid dose: 100mg/kg total (higher doses associated with seizures)
• Reduces blood product transfusions and major hemorrhage requiring reoperation

Transfusion Thresholds

Follow institutional patient blood management protocols including:

• Preoperative anemia identification and treatment
• Intraoperative blood scavenging
• Data-driven transfusion algorithms
• Safe transfusion thresholds based on patient factors 9

Thromboembolism Prophylaxis

Implement mechanical and pharmacological VTE prophylaxis 7, 4:

• Low molecular weight heparin (LMWH) or unfractionated heparin started 2-12 hours before surgery
• Intermittent pneumatic compression devices
• Well-fitting compression stockings

Timing considerations:

• Do not place or remove epidural catheters within 12 hours of heparin administration 4
• Extended prophylaxis for 28 days post-discharge for major cancer surgery 4

Postoperative Hand-off

Immediate Post-procedure Documentation (in OR)

Complete before patient transfer 3:

• Surgical planning and case documentation
• Early recovery monitoring
• Specimen handling (double-sealed bags if infectious concern)

Transfer Communication

Structured hand-off should include:

• Procedure performed and any complications
• Antibiotic prophylaxis given (agent, dose, timing, re-dosing)
• Estimated blood loss and fluid balance
• Glycemic control status
• VTE prophylaxis administered
• Pain management plan
• Specific postoperative monitoring requirements

Early Postoperative Care

• Early mobilization from morning after surgery 7
• Early oral intake - most patients can eat normal food on postoperative day 1 7
• No routine nasogastric intubation (increases pulmonary complications) 7
• Continue insulin therapy for normoglycemia 7

Wound Management

• Prophylactic abdominal drainage: evidence non-conclusive, use at surgeon discretion 7
• For liver resection: consider omentum flap coverage to reduce delayed gastric emptying after left-sided hepatectomy 7

Operating Room Environment Control

Minimize OR traffic and access 3:

• Limit team members to essential personnel
• Restrict entry/exit to medically necessary purposes
• Maintain sealed doors except one designated entry
• Use disposable supplies when possible
• Set electrocautery to lowest effective settings to minimize surgical smoke 3