Asepsis Dr. Weiguo Hu 胡伟国 Dr. Weihua Qiu 邱伟华 Surgical Department Shanghai Rui-Jin Hospital Shanghai Second Medical University

History Significance and Definition Asepsis of Surgical instrument and Dressing Preparation for Dr. and Pt. Key Points Asepsis:

History and Significance

History: Hippocrates ( BC) Separated medicine from philosophy Irrigated wounds with wine or boiled water Foreshadowing of Asepsis Asepsis

Pasteur (1862) Discovered bacterium Developed Pasteurization process History:

Mikulicz-Radecki (1887) ---face masks Furbringer (1889) hands-scrubbing Halsted (1890) surgical-gloves History:

Sterilization for Surgical Instruments

Steam Sterilization History:

Steam Sterilization (1974)

Early type of hot air sterilizer Microwave Oven (1947)

Advanced Sterilizer Low temperature system for endoscopic devices (1989) Plasma sterilizing system (1993)

Basic principle of Surgery Basic principle of Medicine Significance :

Definition Sterile free of all living microorganisms Sterilization a process capable of destroying all forms of microbial life on inanimate surfaces Asepsis absence of microorganisms that cause disease; freedom of infection Disinfection （消毒） a process capable of destroying pathogenic microorganisms but, as ordinarily used, not bacterial spores

Sterilization and Disinfection Autoclaving Dry heat Microwave Infrared rays Boiling Burning Gas Sterilization Ethylene oxide Formaldehyde Soaking in Antiseptics 高压蒸气法 煮沸法 火烧法 蒸气熏蒸法 药液浸泡法

Autoclaving (Steam under Pressure) High pressure lbf/in 2 High temperature ℃ Time depend on T & P 30 min the most completely reliable sterilization

Storage time2 Weeks Attention 40cm  30cm  30cm Arrangement 3M Indicate Tape Flammable Stuff Liquid ---degas Autoclaving

Dry Heat Avoid being spoiled by moist heat Temperature = 160 ℃ Time = 1hours (4 hours for grease) ----exposure to continuous dry heat

Only if autoclaving, dry heat, gas sterilization is NOT available (for metal, glass or rubber stuff) Minimum period is 20 min Period can be decreased to 10 min safely in addition of alkali Not effective against spore unless period >1 hour Drip in completely Time Calculation Boiling

For metal instrument Only in special situation 95% Ethanol Causing damage to the metal instrument Burning

2% Glutaraldehyde30min 10% Formaldehyde20-30min 70% Ethanol30min 1 ： 1000 Bromo Geramine30min 1 ： 1000 Chlorhexidinium 30min For delicate instrument, endoscope or laparoscope Soak Cleaning in Antiseptics 洗必泰 新洁尔灭 戊二醛

Attention ： Clean Before Soaking Drip in Completely Open Axes Wash by Saline before using Soak Cleaning

Gas Sterilization Ethylene oxide & Formaldyhyde Excellent sterilization for most heat-sensitive materials Destroy bacteria, viruses, fungi, spores Flammable and toxic and causing severe burns

Microwave Temperature =100 ℃ Time = 5-20 min

Infrared rays Temperature =160 ℃ Time = min

Reservation Washing Infection of P.aeruginosa, Tetanus, Gas- gangrene and HBV positive Single-use Stuff Burnt out Asepsis: Asepsis: Others

Preparation for Dr. and Pt.

1.Gown, shoes cover 2.Head cover, face mask 3.Shorten nail General Preparation ： Asepsis: Asepsis: Preparation for Dr.

Washing hands & forearms with soap Delivering antiseptics onto wet hands, and scrubbing 3- 5 min Rinsing thoroughly, dry with a sterile towel Asepsis: Hands Scrubbing:

Iodophor & Iodine Most efficient and broad-spectrum activity Rarely skin reaction Prolonged activity Not use on delicate skin Chlorhexidine (Hibitane) Sensitive areas (perineum, face, genitalia, around eyes, infants) Antiseptics 洗必泰 碘伏

Direction for Sterilization Center  AroundAround  Center Distance for Sterilization 15cm Area for Sterilization Asepsis: Asepsis: Preparation for Pt.

- -- To separate contaminated area from sterile field Head cover Face mask Shoe cover Glove Gown Drape Aseptic Mechanical Barrier

Drape

Sterile Envelope

Large enough (>20*20 feet) With appropriate ventilation Remaining closed & positive pressure Operating Room

NOT touch any non-sterilized goods with scrubbed hands NOT pass equipment through the contaminated field Change position face to face or back to back NOT lift or move the sterile drapes Check before /after Operation Asepsis in operative procedure

Strict aseptic technique is essential to minimize surgical infection rate It is the most important to keep asepsis principle in mind during the any surgical procedure Conclusion

Blood Transfusion

History Type of Transfusion Indication Transfusion Reactions Autologous transfusion Component Transfusion Blood Transfusion

History and Significance

Lower Lower (1665) First blood transfusion

Philip (1825) First human blood transfusion

Landsteiner (1900) Discovery of ABO type

How to store blood longer? World war I

Is there any suitable Blood Substitutes World war II

Successful blood transfusion is relatively recent Crossmatching Anticoagulation Plastic storage container Blood Transfusion

Type of Transfusion ： Whole Blood ； Blood Component ； RBC PLT FFP Leukocyte concentrate Plasma Substitutes ； Blood Transfusion Use of whole blood is considered to be a waste of resources

Symptomatic anemia (providing oxygen-carrying capacity) Transfusion trigger (HCT<30% ; HB<10g/dl) 1 Unit increases 3% HCT or 1g/dl Shelf life =42 d (1-6 ℃ ) Red Blood Cells

Thrombocytopenia (< 50,000) Platelet dysfunction Each unit increase 5,000 PLTs after 1 H Platelets

Profoundly granulocytopenia (<500) Serious infection not responsive to antibiotic therapy Granulocytes

Coagulation factor deficiencies 1 ml increases 1% clotting factors Being used as soon as possible Albumin, hetastarch, crystalliods are equally effective volume expander but safer than FFP After use of 5 U of RBCs, matching 2 U of FFP Fresh Frozen Plasma (FFP)

-- Volume Expander Dextran Most widely used Low/Middle M.W. (40,000-70,000) Massive transfusion could impair coagulation Occasional ALLERGIC reaction Hydroxyethyl Starch Formulation (HES) More stable Containing essential electrolytes No allergic reaction Plasma Substitutes

Indication ： Acute massive blood loss; Anaemia and hypoalbuminemia; Overwhelming Infection; Dysfunction of Coagulation; Blood Transfusion

Technique of Transfusion: Approach Route: Peripheral Vein, Center Vein Filtration before Transfusion ： Velocity of Transfusion ： 5-10ml/min Blood Transfusion

Double Check: Name, Type and Crossmatch Storage Time: Citrate Phoshate Detrose Acidic Citrate Detrose 21D, 35D Pre-heat ： No any other Medication ： Observation during / after Transfusion ： Blood Transfusion Attention ：

Incidence ： 2% Chills, Fever C Headache, Sweatiness Nausea, Vomiting, Flushing 15min-1hr Febrile Reactions ： Transfusion Reactions

Immuno-reaction ： Endo-toxins ： Contamination or Hemolysis ： Analyze possible reasons ： Stop Transfusion ： General Support ： Treatment ： Febrile Reactions ： Transfusion Reactions

Urticaria Abdominal cramps Dyspnea Vomiting Diarrhea Anaphylactic reactions ： Transfusion Reactions

Immuno-reaction ： IgE Hereditary Immunoglobulin ： IgA Reason ： Administer antihistamines Administer epinephrine, diphenhydramine, and corticosteroids ： Support airway and circulation as necessary ： Treatment ： Anaphylactic reactions ：

Burning at the intravenous (IV) line site Fever, Chills, Dyspnea Shock Cardiovascular Collapse Hemoglobinuria, Hemoglobinemia Renal Failure DIC Hemolytic transfusion reactions Transfusion Reactions

ABO incompatibility Rh Incompatibility Non-immune Hemolysis Immune Hemolysis Hemolytic Transfusion Reactions Reasons ：

Stop Transfusion as soon as reaction is suspected Check the name, type and crossmatch Urine Exam Renal Protection (Aggressive Fluid Resuscitation, Furosemide) DIC Monitor Treatment ： Hemolytic Transfusion Reactions

Double Check name,type and crossmatch Operate carefully and routinely Temperature Monitor Prevention ： Hemolytic Transfusion Reactions

Transfusion Reactions Massive transfusion complications: Volume Overload Congestive Heart Failure Tachycardia Tachypnea Cyanopathy

Massive Transfusion Complications: Volume Overload Heart Functional Failure Lung Functional Failure Reasons ： Stop Transfusion Heart Functional Support Diuresis (Furosemide) Treatment ：

Transfusion Reactions Contamination: Fever Shock DIC Bacterial Contamination Reasons ：

Contamination: Stop Transfusion Bacterial Exam and Culture Antibiotics Treatment ： Double Check Operate carefully Prevention ：

Transfusion Reactions Hepatitis B, Hepatitis C HIV Cytomegalovirus (CMV) Syphilis Malaria Acquired diseases ：

Autotransfusion ： No risk of infectious disease transmission No transfusion reactions No compatibility testing Reduced demand on blood bank stores An immediate source of autologous blood

Component Transfusion ： Red Blood Cells Packed RBC White Blood Cells Pooled Platelets Blood Cell ：

Saving blood source Less likely carrier of transmitted diseases Shortage of quality blood Greater shelf life than whole blood Helping to make blood safer by filtration Infusing regardless of ABO type in some blood products giving only essential/desired blood component Component Transfusion ：

Fresh Frozen Plasma Coagulation Factors Fibrinogen Frozen Plasma FVFVIII Cryoprecipitate VWF FVIII Plasma ： Component Therapy ：

Albumin Albumin or Volume expander Immunoglobin Coagulation Factors Haemophilia VW Plasma Derivatives ： Component Therapy ：

谢 谢！