Presentation on theme: "Asepsis & Antisepsis in Surgery"— Presentation transcript:
1Asepsis & Antisepsis in Surgery Dept of SurgeryNational University of Singapore
2Asepsis in SurgeryAsepsis : freedom from infection or prevention of contact with microorganismsAseptic technique : instruments, air, drapes, gloves and gowns are free from microorganismsAntisepsis : prevention of sepsis by inhibition or destruction of agents
3AsepsisDefined as a process or procedure performed under conditions in which bacterial contamination has been minimised1847 Semmelweis1865 Lister
4Asepsis Technique Lister - Lancet 1867 wash hands and instruments with carbolic acidwear glovesspray OT with carbolic acidLister - Lancet 1867amputation mortality 46% 15%
5Asepsis Today OT Surgeon 20 air changes per hour filtered air laminar flow if neededSurgeonhand scrub iodophors or hexachlorophene solutionsterile gloves - techniquesterile gown - techniqueaseptic technique in surgery
6Asepsis today Patient Instruments - autoclave or gas sterilised shave only day of opskin prep with iodophor or hexachlorophenedrape with impermeable membraneprotect woundbeware long surgery, drains, other illnessInstruments - autoclave or gas sterilised
7Antisepsis Bacterial flora Resident: Coag –ve Staph, Corneybacterium, Acinetobacter, enterobacteriumTransient: Staph aureus, MRSAAntisepsis- Destruction or removal of the transient flora
8Surgical Site Infection (SSI) 10-15% of nosocomial infections60% at the incision siteSignificant morbidity and mortalityIncreased hospital stay and costs
9Superficial Incisional SSI Occurs within 30days and involves skin or subcutaneous tissue and one of the followingPurulent dischargePositive cultureClinical signs of infectionClinical diagnosis
10Deep incisional SSI Occurs within 30days if no implant left in situ Occurs within 1yr if implant left in situ and one of the followingPurulent discharge from deep incisionDehisence of deep incisionDischarging abscessClinical diagnosis
11Organ/Space SSI Occurs within 30days if no implant left in situ Occurs within 1yr if implant left in situ and one of the followingInfection involves organ/ space or any related anatomyPurulent discharge from deep spacePositive cultureDeep abscess confirmed clinically or radiologicallyClinical diagnosis
12Surgical wound classification Clean / Class I- Uninfected operative wound in which no inflammation is encountered. Primary closure with closed drainage. Respiratory, alimentary and genito-urinary tracks are not involved. (1.5%)Clean-contaminated/ Class II- Any operative wound in which the respiratory, alimentary or genito-urinary tracks are opened in a controlled manner without contamination. (8%)
13Surgical wound classification Contaminated/ Class III- Open fresh accidental wounds. Operations with major break in sterile techniques. Gross contamination or major spillage. Non purulent inflammation (10-15%).Dirty-infected/ Class IV- Old traumatic wounds with devitalised tissue and those that involve existing clinical infection or perforated viscera. Organisms involved were present in the operative field before the operation (25%).
14Patient factors Age Malignancy Nutrition Co-existing infection DM ObesitySmokingColonisationImmunosuppressionBlood transfusionAnaemiaMalignancyCo-existing infectionLength of pre-operative stay
15Operative factors Category of operation Duration of operation Skin asepsisSurgical scrubPreoperative shavingPreoperative skin prepAntimicrobial prophylaxisOT sterilisationSterilisationForeign materialSurgical drainsSurgical techniquePoor haemostasisDead space obliterationTissue trauma
16Normal body flora Anatomical site Head and neck Thorax Upper GI Staph (aureus & coag neg), Strep, cornybacteria, Neisseria, haemophilus, anaerobesStaph (aureus & coag neg),As oropharyngeal and Gram neg rods including enterobacter, LactobacilliAerobicGram neg rods including enterobacter, enterococci. Anaerobes- bacteroides, clostridium yeastsLarge bowel flora, Staph , Strep, corneybacteria and lactobacilliAnatomical siteHead and neckThoraxUpper GILower GIFemale genital tract
17Hand hygiene Procedure Patient Risk of SSI= Dose of bacterial contamination X virulence/ resistance of patientHygienic hand wash: “ Post contamination procedure using a bactericidal wash that is active against transient organisms to prevent further transmission”
19Hygienic hand rubBactericidal agent which is alcohol based without the addition of waterContains emollientFast acting and easy to useCan be used repeatedly
20Surgical scrubTo remove debris and transient micro organisms from nails, fingers and forearmsReduce the resident flora to a minimumInhibit rapid rebound growth on bacterial floraThe anti microbial agent should reduce micro organisms on intact skin, be non irritant, broad spectrum, fast acting and have a residual effect.
21Fingernails Sub ungal regions harbour bacteria Trimmed nails No varnish or artificial nailsUse a scrub
22Patient preparation Length of stay proportional to SSI rate MRSA colonisationShower with antiseptic agentShaving before procedure1% Iodine or 0.5% Chlorhexidine in 70% alcoholCare with diathermy
23Drapes Aseptic barrier Careful placement around surgical field Cotton vs. disposableWet drapes provide ideal culture medium
27A good scrub.. Thoroughly moisten hands and forearms Sub ungal areas cleaned with nail cleanerApply antimicrobial agent with frictionFingers and arms scrubbed on 4 sidesThoroughly moisten hands and forearmsSub ungal areas cleaned with nail cleanerApply antimicrobial agent with frictionFingers and arms scrubbed on 4 sidesHands higher than elbowsAvoid splashingDiscard brushRepeat as necessary!Hands higher than elbowsAvoid splashingDiscard brushRepeat as necessary!
28DecontaminationDecontamination- process of removing or destroying micro-organisms and organic matter. Making a re-usable item safe for patients and staff.Cleaning- process that physically removes organic matter ( blood, tissue, body fluids) but does not remove micro-organisms.
29DecontaminationDisinfection- process that reduces the number of micro-organisms to a level that is not harmful at the site of use. Kills or removes micro-organisms with the exception of bacterial spores.Sterilisation- process which frees an object of all living organisms.
33Drains Apparatus used to remove debris after surgery Early drains were gauze or rubberModern drains - plastic, siliconised, soft rubber
34Drains Types of drains Open drains Closed drains suction or free sump drains
35Drains Open drains External end left free Collection into bag or gauze Closed drainsExternal end into collection deviceSuction may be applied
36Drains Open drains soft and atraumatic open system - bacteria skin in contactdifficult to measuredemanding nursing carecan’t handle large amountsno suction
37Drains Closed drains closed system - bacteria can be minimised skin - effluent diverted awayeasy to measureeasier to nursecan handle large amountssuction availablestiffer - more traumatic
38Using Drains Decide on indication Decide on drain type Positioning Care - complicationsRemoval
39Drains - Indications Prophylactic Therapeutic anticipated collection leak after anastomosisabscess wall continues to secreteTherapeuticcollection presentpneumothorax, haemothoraxliver abscessperitoneal haematoma
40Drains - Type Body area Type of fluid Amount of fluid head/ neck /jointssmall caliberabdomen/thoraxany caliberType of fluidviscouslarge caliberirritatingclosed systemAmount of fluidlarge amountssuction ± sumpDrains - Type
41Drains - Position Dependent Not in contact with bowel if possible Away from anastomosisNever through main wound
42Drains - Complications BlockageDislodge in or outViscera damageSkin infectionCavity infection
43Drains - Care Check for blockage Ensure secure anchor Protect skin ensure suction workingempty containersEnsure secure anchorProtect skinkeep drydressing changeCavity infectionremove earlyantiseptic in collection containerMonitor amounts and type of fluid
44Drains - Removal Therapeutic indication Prophylactic Amounts abdomen/chest < 100mlshead/neck <20 mlsImaging ensures cavity recoveredMay remove in stages to allow collapse of cavityProphylacticTime of event has passed
45Case discussionThis is 20 year old male patient who had surgery a week agoWhat has happened?Signs & symptomsInvestigations?Treatment?