Presentation on theme: "Surgical Preparation Lobna El Fiky Assistant Professor of ORL, H&N surgery Ain Shams University."— Presentation transcript:
Surgical Preparation Lobna El Fiky Assistant Professor of ORL, H&N surgery Ain Shams University
Historical perspectives Antiseptic = Greek for “against putrefaction” Accidental observation of certain substances stopped putrefaction of meat… Mercuric Chloride: Arabian physicians in Middle Ages Tincture of iodine: 1839 Pasteur’s publication: 1863: microbial origin of putrefaction
Historical perspectives As often in history of medicine: Change of practice depended on the persistence of John Lister 1870, He introduced vigorous application of phenol in surgery, for dressing wounds, for sterilization of instruments
Sterilization It is the process that destroys all microorganisms (including bacterial microspores). The skin could never be sterilized without its own destruction.
Disinfection A process which destroys only the vegetative forms of organisms =basically clean. A disinfectant (germicide, antiseptic): any chemical substance with either a bactericidal or a bacteriostatic action. Antiseptic -- Agent applied to living tissue Disinfectant -- Agent applied to inanimate surface
Surgical Disinfection This is an essential part of a programme for the control of infection. High Risk Items: as they come in close contact with broken skin or those that breach mucous membranes or are introduced into a sterile cavity.
Requirements for decontamination practice The basic requirements for good decontamination practice are: A Management control system; Appropriate facilities; Appropriate equipment; Properly trained and supervised staff; Ensuring that single use medical devices are not reused; Records of decontamination are kept.
Methods of Disinfection Physical: The most important as they can be relied on to ensure the sterilization of articles used in the treatment of patients: – Thermal: Heat or Steam – Radiation: infra-red radiation, - rays, particles – Filtration:utilizing filters capable of screening out microorganisms Chemical: Less effective, used for personnel – Organic – Inorganic Gaseous disinfectants: very efficient, not routine – Formaldehyde gas – Ethylene oxide
MANUAL CLEANING Cleaning is vital prior to any decontamination procedure. ‘Detergent’ removes the nutritive material on which bacterial survival and multiplication may take place. This reduces the number to a level which is not harmful for health.
MANUAL CLEANING Effective cleaning to remove protein from medical devices is paramount (agents such as CJD are not inactivated by heat). Dismantle or Open the instrument to be cleaned Friction for 2-3 minutes Brush, Wipe, Agitate, Irrigate, jet wash or hand spray the item to dislodge and remove all visible soil Rinse the item thoroughly with clean water Drying
Physical Methods of Disinfection HEAT DRY HEAT Kills by Destructive oxidation of cell constituents Surest incineration Hot-air oven: – inefficient, poor conductor of heat, penetrates feebly. – 160°C for 1 hour: damages fabrics, melts rubber – Used for: Glassware, oily fluids, powders
Physical Methods of Disinfection HEAT MOIST HEAT Effective at low temperature, in a shorter period of time Boiling: 100°C for 30 minutes Pasteurisation: 63°C for 30 minutes Tyndallisation: steaming for 20 minutes for 3 successive days Steaming under pressure= Autoclaving
Advantages of steam Kills by denaturing & coagulating enzymes & proteins More rapid (maximum needed time 45mn) & at lower temperature Condensation of steam leads to liberation of latent heat which raises the temperature, and gives more penetration Half dense as air, so has better penetration
Steam Sterilization: Autoclave Principle: An autoclave is a self locking machine that sterilizes with the high temperature that steam under pressure can reach. High-vacuum pumps remove as much as possible air before the steam is admitted, so the required temperature is reached very rapidly.
Steam criteria Dry: no suspended droplets of water Close to its point of condensation: not superheated Free from air: as it decreases the temperature and the penetration Temperature – 121°C: 15mn-30mn – 134°C: 4-7mn Flashing
Steps of autoclaving Water in the surrounding container full and heated Articles in cabinet, doors bolted Vacuum to evacuate as much air as possible Steam is admitted at a high pressure of and when the thermometre reaches the required temperature, sterilisation begins Sterilisation is continued for the required time and then the steam is turned off. Drying is carried-out by reapplying a vacuum to evacuate the steam, introducing dry filtered air into the cabinet (for 15 minutes).
Efficient Autoclaving All instruments must be double wrapped in linen or special paper or placed in a special metal box equipped with a filter before sterilization. The white stripes on the tape change to black when the appropriate conditions (temperature) have been met. Expiration dates should be printed on all equipment packs. There should be a uniform development of bars throughout the length of the strips. Ready made plastic bags with strips printed with a sensitive ink.
Control of autoclave efficiency Bowie-Dick test: Used for high-vacuum autoclaves, Done every day: – In the middle of a test pack of towel, a paper on to which a strip of a specific tape is put, for testing. – Uniform development of dark color indicates that the steam has passed freely and rapidly to the center of the load. Biological sterilization indicators: Spores of a non- pathogenic organism: Done weekly – They are killed at 121°C after 15 minutes. – Attempts to culture them is subsequently made
RADIATION DISINFECTION High energy ionizing radiation destroys microorganisms and is used to sterilize prepacked, Single-use, surgical equipment by manufacturers Common sources of radiation include electron beam and Cobalt-60
CHEMICAL DISINFECTION A SATISFACTORY AGENT SHOULD: Be active against a wide range of organisms and spores. Only few are truly sterilizer Have a rapid action Should not be toxic or irritant to the skin Should be Persistent There is no one disinfectant which can be used to kill all micro-organisms in all situations.
Inorganic disinfectants The halogens: Chlorine and Iodine Have a rapid action against vegetative organisms and spores= true sterilizers Their action is annulled by foreign organic material
Iodine disinfectants The broadest spectrum of all topical anti-infectives, with action against bacteria, fungi, viruses, spores, protozoa, and yeasts. Tincture iodine: – 2.5% iodine & 2.5% potassium iodide in 90% ethanol. – Best skin disinfectant – Irritating to raw surfaces: due to its alcoholic component – Allergic dermatitis Iodophors: Solutions of iodine in non-ionic detergents= Povidone iodine= Betadine – Less irritating and less staining – Less disinfectant than tincture
Chlorine disinfectants Powerful, Disinfect water Particularly active against viruses Concentrated solutions too corrosive Usually diluted with a compatible detergent
Organic Disinfectants Alcohols: bactericidal: 50-70% ethanol Aldehydes: – Formalin: irritant, powerful=sterilizer – Glutaraldehyde: less irritant, not volatile, more rapid action. Phenols: continued activity in organic matter as human excreta. – Phenol: Toxic, expensive – Cresols: Lysol – Chloroxylenol: Dettol – Chlorhexidine: Hibitane- Alkanol – Hexachlorophane Cationic surface-active agents: – Cetrimide: Cetavlon
Alcohol Isopropyl Alcohol 70% (or Ethyl Alcohol 90%) ADVANTAGES: Causes protein denaturation, cell lysis, and metabolic interruption. Degreases the skin. DISADVANTAGES: Ineffective against bacterial spores and poorly effective against viruses and fungi.
Glutaraldehyde (Cidex) Cold Sterilization: Instruments must be dry before immersion. Glutaraldehyde is bactericidal, fungicidal, viricidal, and sporicidal Sterilization: a 10 hour immersion. This prolonged chemical action can be more detrimental to surgical instruments. 3 hours exposure time is needed to destroy spores. If the instruments need to be "disinfected" only, cold sterilization is okay as disinfection will take place in only 10 minutes.
Lysoformin Formaldehyde & glutaral Lysoformin: liquid concentrate with which any dilution required can be made by simply adding water (20ml + 4- 8L) The timing depends on the concentration used: – flexible endoscopes – deactivation of HBV & HIV Used for heat labile instruments and cleaning Does not harm metal instruments 1.5 % - 30 min 2.0 % - 15 min
Chlorhexidine Gluconate Hibitane vs Alkanol Broadest spectrum Better residual activity than iodophors Occasional skin sensitivity ADVANTAGES: Rapid action Residual activity is enhanced by repeated use Less susceptible to organic inactivation than povidone iodine DISADVANTAGES: Occasional skin sensitivity. Inactive against bacterial spores Activity against viruses and fungi is variable and inconsistent May harm metal instruments
Gaseous Disinfection Ethylene Oxide Sterilization: EO Gas Colorless gas, available as cartridges Toxic and flammable, Odor similar to ether Has an extremely well penetration, even through plastics Microorganism destruction is caused by a chemical reaction Effective sterilization is dependent on concentration of gas, exposure time, temperature, and relative humidity Powerful sterilizer: Kills all known viruses, bacteria (including spores), and fungi
EO Gas Sterilizer Is used in large hospitals, as it is expensive, dangerous, needs more expertise. Used for heat sensitive instruments: fabrics, plastics, suture material, lenses, endoscopes, electrical equipment and finely sharpened instruments. At 20°C-25°C: sterilization takes 18hours At 50°C-60°C: sterilization takes 4 hours In Demerdash: The average of the cycle is 8-14 hours
Sterility Check List Before assuming a pack is sterile, always evaluate the following before opening the pack: Expiration date Indicator color change General condition of wrapper and how it had been stored Always check for holes or moisture damage
Standards for Surgical Scrubbing, Gowning and Gloving The pre-surgical practice of scrubbing, gowning and gloving is integral to the minimization of risk of infection from micro- organisms present in the wound at the time of surgery.
Accessing to the operating theatre Wear prescribed operating suite attire Remove jewellery Keep fingernails short, clean, healthy Wear appropriate protective attire: masks, head, overshoes..
REMEMBER What went inside the machines is the STERILISED material Personnel are only DISINFECTED
Surgical Hand scrub No touch: infrared robinets, with your elbow, leg… Use brush?? The ideal duration of the scrub is not agreed. Accepted time is 5 minutes: appears safe Some surgeons do not rinse off the chlorhexidine or Betadine in order to enhance residual activity. Alternative: Two-stage surgical scrub: – an initial 1- or 2-minutes scrub with 4% chlorhexidine gluconate or povidone-iodine followed by application of an alcohol-based product
Surgical Hand scrub Trim fingernails and Wash for 30-60 seconds with surgical scrub. Scrub fingers with a sterile scrub brush Make sure to scrub all sides of each finger, including the area between fingers.
Surgical Hand scrub Scrub hands and arms with a sterile scrub brush. Make sure to scrub each surface of each hand and arm An accepted contact time is 10 brush strokes per surface During scrubbing, rinsing and drying, hands are held above elbows. This is done so that water will not be dripping from upper arms onto lower arms and hands
Drying Hands A sterile towel is included within the sterile gown pack. One hand and forearm are dried by one side of the towel. Always dry in the direction of hand to elbow so that contamination of the upper arm is not spread by the towel to the surgeon's hand.
Gowning All gowns are folded and packaged for sterilization, with the inside exposed so that the surgeon may handle the gown without contaminating the outside of the gown. Grasp the exposed inside of the gown and lift the gown away from the table. Your hands are disinfected and the gown is sterilized
Gowning Unfold the gown by placing hands into the white arm holes. Continue placing hands and arms through the sleeves..
Gowning An assistant fastens the neck tie and the inside waist tie. PLEASE: DO NOT DRY YOUR HANDS IN THE FRONT OF THE GOWN
Types of Gowns Disposable Paper Gown: resistant to wetting so they are less permeable to bacteria, expensive. It is usually a wrap around gown. The ties "wrap around" the surgeon. Linen (cloth): comfortable and reusable. When it becomes wet, bacteria can permeate. The cloth gown is also known as a front sterile gown. The gown is just tied in the back.
Gloving Sterile surgical gloves can be worn by: Open method: – The gloves are presented to enable the introduction of the hands on the inside surface directly – The nurse with her sterile glove opens the glove for the surgeon who introduces directly his hands on the inside surface of the glove DO NOT ADJUST THE FIRST GLOVE BEFORE PUTTING THE SECOND ONE !!!
Gloving Closed gloving : This is the introduction of hands covered with the cuff of a sterile gown. So, If you are planning on closed gloving, do not thrust hands through the cuffs. This is usually performed by the first person to be sterilized= the nurse
Gloving: Closed method An assistant opens the sterile pack of gloves and drops them into the sterile field. The inside of the cuff of the glove is grasped by the opposite hand (still within the gown) until introduction
Patient Preparation Sterilization is best done with a detergent followed by a disinfectant on a larger area of the surgical field. H&N?? Use Ample Detergent Scrub roughly the skin in any direction for 2-3mn ??Remove the excess of the detergent Apply the disinfectant first on the most clean area Scrub in one direction only
Draping Standard head drape: two towels, one under the shoulders and the other wrapped around the head Better to suture the drapes to the skin to prevent shifting Towels are used for lateral draping Drapes should lie flat
Practical Sterilization Instruments sterilization Metal Instruments: Avoid chemical sterilization – Autoclave – EO chamber – Formaldehyde beads or powder Sharp-edged: avoid heating & wetting: – EO chamber – Formaldehyde beads or powder
Practical Sterilization Instruments sterilization Catheters, gloves,…: depend on pre-sterilized, disposable equipment – Radiation – EO chamber Endoscopes: avoid heat – Cidex – Lysoformin – Autoclaving Handles of drills: – Autoclave after washing and oiling – EO chamber