Term
| what should any surgeon consider when treating any illness? |
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Definition
| relative risks and rewards |
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Term
|
Definition
consider...
-presence of any primary disorder or other illness
-potential for complications
-patient's use and quality of life
-long term prognosis |
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Term
| what incr. surgical risk? |
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Definition
-emergency procedures
-longer surgical times
-less experienced surgeons |
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Term
| how can surgical risk be decreased? |
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Definition
ASEPTIC TECHNIQUE
minimising tissue trauma by using good and min. invasive procedures where possible
-knowledge of the procedure
-avoiding unnecessary delays
-appropriate closure
-good post-op care
-monitoring |
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Term
| what are post operatative surgical site infections (SSI) a major cause of? |
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Definition
| morbidity and even mortality |
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Term
| what incr. the risk of surgical site infection (SSI) so that additional measures (e.g. prophylatic antimicrobials) are needed to decr. risks? |
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Definition
-microbe related factors (interplay amoung the no. of inf. organisms, their virulence, and hosts local and systemic dz)
-host related factors (e.g. systemic factors and decr. im resp., remote trauma or inf., cell damage by toxins, presence of FB)
-surgery related factors (emergency, longer duration, surgeon experience and technique,surgical implants e.g. sutures) |
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Term
| general intra-op recommendations to decr the risk of SII? |
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Definition
-use disposable water-R gowns and drapes
-change gloves that are punctured or torn
-minimise tissue trauma
-maintain good haemostasis
-irrigate wounds during surgery
-debride traumatic wounds thoroughly
-minimise sutures
-avoid dead spaces
-close in layers w/o tension
-keep surgery time to a minimum |
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Term
| what is the primary source of pathogens in surgery? |
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Definition
| the patient - any concurrent illnesses or dz. should ideally be tx. before surgery |
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Term
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Definition
| the process of removing pathogenic micro-organisms or protecting against these organisms |
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Term
| how can asepsis be achieved? |
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Definition
systematically eliminating sources of contamination
i.e. op theatre, surgeon, instruments |
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Term
| operating theatre asepsis |
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Definition
-traffic through the theatre should be minimal and one-way
-any person entering should wear appropriate surgical attire
-should be cleaned and disinfected regularly
-adequate drainage is important
-only essential furniture should be present
-air should be under mild positive P - air flows out rather than in |
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Term
| if there is only one theatre available. how should asepstic technique be maximised? |
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Definition
| -clean surgeries e.g. fractures should be performed before contaminated surgeries e.g. purulent abscess |
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Term
|
Definition
skin prep:
- hair removal
-cover feet
-clean skin to remove gross contamination
-disinfect skin
Draping patient |
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Term
|
Definition
-clipping not shaving (causes abrasions and so predisposes to bact. colonisation)
-preferably outside theatre and before anaes. induction
-should be at least 10-15cm away from intended surgical site |
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Term
| cleaning skin to remove gross contamination |
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Definition
-apply scrub solution w. gloved hands
-use sufficient water
-scrub until clean +/- 5 mins
-rinse inbetween
-whipe a white swab over area at end - should be clean |
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Term
|
Definition
-used gloved hands and swabs w. scrub solution and water
-start at surgical incision and work out
-5 mins |
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Term
|
Definition
-chlorhexidine
-Iodine compounds
-alcohol |
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Term
|
Definition
-disinfectant
-residual activity (binds to protein in skin) ~4-5hrs - so longer on skin, more protection i.e. time dependent activity
-low toxicity - bit can be toxic for fibroblasts |
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Term
|
Definition
-disinfectants
-no residual activity
-only free iodine is bactericidal i.e. iodine scrub must be diluted or combined w. detergent to release free iodine
-low toxcity
-synergistic w. alcohol
but...stains, radiopaque, smells
-inactivated by inorganic debris - hence need good gross decontamination! |
|
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Term
|
Definition
-disinfectent
-only active against bacteria
-no residual activity
-inactivated by inorganic debris
-commonly used as a rinse after surgical scrub i.e. remove soap / antiseptic etc |
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Term
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Definition
| prevent mvmt of debris and bacteria from non-sterile areas to surgical site |
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Term
|
Definition
-impermeable, disposable drapes are best
-cloth drapes become permeable to bact. once wet |
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Term
|
Definition
-drape from clean to dirty
i.e. do not slide surgical drape over patient towards surgical site, but from site outwards
-surgeon keep hands on sterile parts of drapes - double gloves recommended (then remove second gloves before incision) |
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Term
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Definition
| -can be used during surgery if concerned about contamination |
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Term
|
Definition
-held in place by using towel clamps
-remember, if these are removed during the procedure, they are not sterile! |
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Term
|
Definition
-designated clothing
-hand disinfection / scrubbing
-gowning ang gloving |
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Term
| designated theatre personnel clothing |
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Definition
-scrubs - shirt tuked into trousers
-cap (avoid hair contamination)
-mask
-designated footwear - only to be worn in theatre (or foot covers) |
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Term
| hand disinfection (scrubbing) - aim |
|
Definition
-remove gross contamination
-decr. bact. count on skin
-ideally prolonged effect on transient and resident microflora should be achieved (contaminents from environ. and permanent) |
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Term
| why is scubbing so important? |
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Definition
-accepted industry standard is that 1.5% of gloves are punctured before use
-at end of surgery 30% of gloves are punctured |
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Term
| hand disinfection - nails |
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Definition
| nails should be kept short, clean and free of polish and artificial nails |
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Term
| Hand disinfection - scurb protocol |
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Definition
-wash hands and forearms w. water and soap
-clean fingernails
-use surgical scrub brush to wash w. antiseptic soap - repeat routine twice, w. rinsing between
-total scrub time 3-5 mins
-dry w. sterile towels |
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Term
| what is important to remember when applying surgical scrub? |
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Definition
-contact time is important
-make sure include front and back of hands, four sides of each finger and thumb, fingertips, fingernails, between each finger, wrists and forearms
-keep hands above elbows at all times |
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Term
| what it is important to remember when drying hands post scrubbing? |
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Definition
-use sterile towels!
-hands first, then wrist to elbow and discard towel
-second towel for other hand and forearm |
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Term
|
Definition
-povidone iodine
-chlorhexidine gluconate - superior due to prolonged residual activity |
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Term
| main principle when applying gloves |
|
Definition
| fingers do not leave gown until covered w. glove to decr. contamination |
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Term
| gowning and gloving - what must be remembered when putting on |
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Definition
| -put on w/o ever touching the outside surface! |
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Term
|
Definition
water resistent
comfortable
breathable |
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|
Term
| what is preferable technique for applying gloves? |
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Definition
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Term
| aseptic technique involving surgical instruments |
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Definition
-cleaning
-packing
-sterilsation |
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Term
| cleaning of surgical instruments |
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Definition
-should be rinsed immediately after use to remove blood and debris
-complex instruments should be disassembled
-after cleaning, instruments should be placed in instrument milk / oil to lubricate and protect surface |
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Term
| cleaning methods of instruments |
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Definition
-manual e.g. warm soapy water or enzymatic detergent
-ultrasonic cleaner - uses high-freq vibratory waves that clean through caviation |
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Term
| packing of clean surgical instruments |
|
Definition
-marked w. content, date of sterilisation, person responsible
-crepe papers > cotton/ muslin wraps (more durable, good handling qualities and longer storage times) |
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Term
|
Definition
-heat
-chemical - ethylene oxide
-gas plasma
-peracetic acid
-electrolysed acid water |
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Term
| most common and practical sterilisation method? |
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Definition
|
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Term
|
Definition
| moist heat kills by coagulation of critical proteins |
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Term
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Definition
| kills by oxidation and removal of water |
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Term
| moist or dry heat sterilisation? |
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Definition
moist > dry
because can decr. temp and exposure times necessary for sterilisation |
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Term
| Min. guidelines in steam autoclave for sterilisation |
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Definition
|
|
Term
|
Definition
-air displacemtn by steam, either by gravity or creating a vacuum
-air displacment by steam is critical to achieve condensation which is necessary to transfer heat to the instruments |
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Term
| placement of instruments in autoclave |
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Definition
so air does not get trapped and no air pockets persist - ensure enough room between packs
e.g. place bowls w. opening facing down (NOT as if using) |
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Term
|
Definition
-commercially available test to ensure autoclave functioning well - should be tested regularly
-ensures that air removal and stram penetration are complete |
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Term
| why use indicator systems in autoclaves? |
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Definition
| -used to ensure that instruments are exposed to adequate times and temperatures |
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Term
| types of indicator systems in autoclaves |
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Definition
-chemical indicators change colour on exposure to sterilising temp
-biological indicators have heat-R bact spores that require a period of incubation after sterilisation to ensure absence of bact. growth - not as pratical
-indicator tape on outside of pack - inferior! colour change on outside does not mean contents are sterile! |
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Term
| most commonly used agent in chemical sterilisation |
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Definition
|
|
Term
| ethylene oxide chemical sterilisation |
|
Definition
-alkylating agent - kills by inactivation of proteins, DNA and RNA
-gas so rapidly penetrates packaging and items at low temperature
-tolerated by almost all materials |
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Term
| when should ethylene oxide chemical sterilisation be used? |
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Definition
| -should only be used for items that are not suitable for heat sterilisation |
|
|
Term
| limitations of ethylene oxide |
|
Definition
-size of equipment
-time requirement (often requires 24hours!)
-concerns about toxicity (for handler and animal) |
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Term
| gas plasma chemical sterilisation |
|
Definition
| -H2O2 is injected into chamber
-radiowaves create an electrical field and so H2O2 converted to gas plasma and free radicals that ollide w. and inactivate microorganisms |
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Term
| peracetic acid chemical sterilisation |
|
Definition
aka cold sterilisation - can be used at room temp
-it inactivates proteins
-contact time 10-15min
-0.09% conc recommended |
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|
Term
| Electrolysed acid water sterilisation |
|
Definition
| generates hydroxy free radicals w. rapid and potent bactericidal effect |
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|
Term
| when should prophylatic antimicrobials be used? |
|
Definition
only in procedures w. high liklihood of infection
e.g. using implants / when development of inf. is life threatening
-any procedure in which the wound is anything but "clean" |
|
|
Term
|
Definition
-elective procedure
-aseptic technique has been used
-closed primarily
-no drain placed |
|
|
Term
|
Definition
-as for clean wound but during the procedure...
-the GI, resp or urogenital tract has been entered under controlled conditions and w. usual contamination
+/- there was a minor break in aseptic technique |
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Term
|
Definition
-traumatic wounds
-gross spillage of GIT
-presence of an acute non-purulent inflammation
-major break in aseptic technique |
|
|
Term
| Dirty and infected wounds |
|
Definition
-if exudates or perforated viscous is encountered during the procedure
-traumatic wound w. delayed tx, devitalised tissue, faecal contamination +/or FBs |
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Term
| which prophylatic antimicrobials? |
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Definition
-should always be bactericidal
-not the same as antimicrobials used to tx. established inf.
-need knowledge of most common bact. isolated from SSI in specific procedures e.g. only skin contamination then gram +ve spectrum is probably adequate
-also consider cost, admin, potential s. effects |
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Term
| how long use prophylatic antibodies? |
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Definition
- no apparent benefit to continuing antimicrobial prophylaxis for more than 24hours
-bact. R can be promoted gr. than this |
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Term
| if bact. inf. occurs despite prophylatic antimicrobials... |
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Definition
| ...bact should be considered R and therapeutic antibodies should be given (preferably based on culture and susceptibility) |
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