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Asepsis & Antisepsis in Surgery

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1 Asepsis & Antisepsis in Surgery
Dept of Surgery National University of Singapore

2 Asepsis in Surgery Asepsis : freedom from infection or prevention of contact with microorganisms Aseptic technique : instruments, air, drapes, gloves and gowns are free from microorganisms Antisepsis : prevention of sepsis by inhibition or destruction of agents

3 Asepsis Defined as a process or procedure performed under conditions in which bacterial contamination has been minimised 1847 Semmelweis 1865 Lister

4 Asepsis Technique Lister - Lancet 1867
wash hands and instruments with carbolic acid wear gloves spray OT with carbolic acid Lister - Lancet 1867 amputation mortality 46%  15%

5 Asepsis Today OT Surgeon 20 air changes per hour filtered air
laminar flow if needed Surgeon hand scrub iodophors or hexachlorophene solution sterile gloves - technique sterile gown - technique aseptic technique in surgery

6 Asepsis today Patient Instruments - autoclave or gas sterilised
shave only day of op skin prep with iodophor or hexachlorophene drape with impermeable membrane protect wound beware long surgery, drains, other illness Instruments - autoclave or gas sterilised

7 Antisepsis Bacterial flora Resident: Coag –ve Staph, Corneybacterium,
Acinetobacter, enterobacterium Transient: Staph aureus, MRSA Antisepsis- Destruction or removal of the transient flora

8 Surgical Site Infection (SSI)
10-15% of nosocomial infections 60% at the incision site Significant morbidity and mortality Increased hospital stay and costs

9 Superficial Incisional SSI
Occurs within 30days and involves skin or subcutaneous tissue and one of the following Purulent discharge Positive culture Clinical signs of infection Clinical diagnosis

10 Deep incisional SSI Occurs within 30days if no implant left in situ
Occurs within 1yr if implant left in situ and one of the following Purulent discharge from deep incision Dehisence of deep incision Discharging abscess Clinical diagnosis

11 Organ/Space SSI Occurs within 30days if no implant left in situ
Occurs within 1yr if implant left in situ and one of the following Infection involves organ/ space or any related anatomy Purulent discharge from deep space Positive culture Deep abscess confirmed clinically or radiologically Clinical diagnosis

12 Surgical 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%)

13 Surgical 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%).

14 Patient factors Age Malignancy Nutrition Co-existing infection DM
Obesity Smoking Colonisation Immunosuppression Blood transfusion Anaemia Malignancy Co-existing infection Length of pre-operative stay

15 Operative factors Category of operation Duration of operation
Skin asepsis Surgical scrub Preoperative shaving Preoperative skin prep Antimicrobial prophylaxis OT sterilisation Sterilisation Foreign material Surgical drains Surgical technique Poor haemostasis Dead space obliteration Tissue trauma

16 Normal body flora Anatomical site Head and neck Thorax Upper GI
Staph (aureus & coag neg), Strep, cornybacteria, Neisseria, haemophilus, anaerobes Staph (aureus & coag neg), As oropharyngeal and Gram neg rods including enterobacter, Lactobacilli AerobicGram neg rods including enterobacter, enterococci. Anaerobes- bacteroides, clostridium yeasts Large bowel flora, Staph , Strep, corneybacteria and lactobacilli Anatomical site Head and neck Thorax Upper GI Lower GI Female genital tract

17 Hand hygiene Procedure Patient
Risk of SSI= Dose of bacterial contamination X virulence/ resistance of patient Hygienic hand wash: “ Post contamination procedure using a bactericidal wash that is active against transient organisms to prevent further transmission”

18 Asepsis in Surgery

19 Hygienic hand rub Bactericidal agent which is alcohol based without the addition of water Contains emollient Fast acting and easy to use Can be used repeatedly

20 Surgical scrub To remove debris and transient micro organisms from nails, fingers and forearms Reduce the resident flora to a minimum Inhibit rapid rebound growth on bacterial flora The anti microbial agent should reduce micro organisms on intact skin, be non irritant, broad spectrum, fast acting and have a residual effect.

21 Fingernails Sub ungal regions harbour bacteria Trimmed nails
No varnish or artificial nails Use a scrub

22 Patient preparation Length of stay proportional to SSI rate
MRSA colonisation Shower with antiseptic agent Shaving before procedure 1% Iodine or 0.5% Chlorhexidine in 70% alcohol Care with diathermy

23 Drapes Aseptic barrier Careful placement around surgical field
Cotton vs. disposable Wet drapes provide ideal culture medium

24 Antiseptic agents Rapid action Broad spectrum Persistent effect Safety
Acceptability Alcohol, chlorhexidine, Triclosan, Iodine, Iodophores Binds to stratum corneum

25 Antiseptic agents Alcohol Chlorhexidine Triclosan Iodine / Iodophores
Denaturation of protein Disruption of cell wall Oxidation/substitution of free iodine

26 Skin care Avoid damaged / cracked skin Latex allergy Gloving

27 A good scrub.. Thoroughly moisten hands and forearms
Sub ungal areas cleaned with nail cleaner Apply antimicrobial agent with friction Fingers and arms scrubbed on 4 sides Thoroughly moisten hands and forearms Sub ungal areas cleaned with nail cleaner Apply antimicrobial agent with friction Fingers and arms scrubbed on 4 sides Hands higher than elbows Avoid splashing Discard brush Repeat as necessary! Hands higher than elbows Avoid splashing Discard brush Repeat as necessary!

28 Decontamination Decontamination- 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.

29 Decontamination Disinfection- 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.

30 Methods of decontamination
Disinfection Physical- Low temp steam Boiling water Washer disinfections Chemical Chemical disinfectants (Glutareldehdye 2%, Cidex, Miltons, Clearsol, alcohol)

31 Methods of Sterilisation
Steam (autoclaving) Hot air (ovens) Ethylene Oxide Low temp steam and formaldehyde Gas plasma Irradiation Sporicidal chemicals

32 Drains

33 Drains Apparatus used to remove debris after surgery
Early drains were gauze or rubber Modern drains - plastic, siliconised, soft rubber

34 Drains Types of drains Open drains Closed drains suction or free
sump drains

35 Drains Open drains External end left free Collection into bag or gauze
Closed drains External end into collection device Suction may be applied

36 Drains Open drains soft and atraumatic open system - bacteria
skin in contact difficult to measure demanding nursing care can’t handle large amounts no suction

37 Drains Closed drains closed system - bacteria can be minimised
skin - effluent diverted away easy to measure easier to nurse can handle large amounts suction available stiffer - more traumatic

38 Using Drains Decide on indication Decide on drain type Positioning
Care - complications Removal

39 Drains - Indications Prophylactic Therapeutic anticipated collection
leak after anastomosis abscess wall continues to secrete Therapeutic collection present pneumothorax, haemothorax liver abscess peritoneal haematoma

40 Drains - Type Body area Type of fluid Amount of fluid
head/ neck /joints small caliber abdomen/thorax any caliber Type of fluid viscous large caliber irritating closed system Amount of fluid large amounts suction ± sump Drains - Type

41 Drains - Position Dependent Not in contact with bowel if possible
Away from anastomosis Never through main wound

42 Drains - Complications
Blockage Dislodge in or out Viscera damage Skin infection Cavity infection

43 Drains - Care Check for blockage Ensure secure anchor Protect skin
ensure suction working empty containers Ensure secure anchor Protect skin keep dry dressing change Cavity infection remove early antiseptic in collection container Monitor amounts and type of fluid

44 Drains - Removal Therapeutic indication Prophylactic Amounts
abdomen/chest < 100mls head/neck <20 mls Imaging ensures cavity recovered May remove in stages to allow collapse of cavity Prophylactic Time of event has passed

45 Case discussion This is 20 year old male patient who had surgery a week ago What has happened? Signs & symptoms Investigations? Treatment?

46 Case 2

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