Asepsis and antisepsis, disinfectans and sterilization.
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Transcript of Asepsis and antisepsis, disinfectans and sterilization.
Asepsis and antisepsis, disinfectans and sterilization
The major theatre
Although aseptic surgery has been done in a tent, under a tree, or on a kitchen table, it is safer if it is done in a room which has been designed to preserve the sterility of the surgical field, to make surgical routines easier, and to prevent mistakes.
Asepsis
The most serious sources of infection in a theatre are bacteria from:
The pus and extcreta left behind by previous patient
The clothes, hands, skin, mounths of the staff
The patient himself
Keeping the theatre as clean as possible, so that the pus and excreta of previous patients are removed
Making sure that the autoclaving is done conscientiously
Minimize the risk of infection by:
Following the rules about the indications for operating, the timing of operations, wound closure, and careful tissue handling
Creating and maintaining the sterile zone
Minimize the risk of infection by:
Sterile zone
The sterile zone
Has to be created anew for each patient in a theatre in which the risk of infection has been reducted as much as possible
Its creation starts when a nurse swabs the top of troley with antiseptic, puts two sterile towels on it and lays out sterile gowns and gloves
The sterile zone
The operations site joins the sterile zone as it is prepared with an antiseptic solution and draped
Nothing which is contaminated must touch anything in this zone until the end of the operation
The sterile zone
If the technique of the team is poor, the sterile zone becomes smaller and smaller as he operation proceeds.
Should be as small as possible . It consist:
Yourself the surgeon
Your assistant, when you need one
The scrub nurse responsible for the instruments
The circulating nurse to fletch and carrry
The anaesthetist
His assistant, if he has one
Operative team
The theatre charge nurse responsible for organizing the theatre
Theatre dresser , who is less educated, but unlike the nurses who come and go, has spent his whole career in the theatre, and so knows its routines and where things are
Two other people are important
Aseptic technique
Entering the theatre:
Anyone entering the theatre must change, in the changing room, into clogs or sandals and into a suit.
Decide which operations nedd gowns, gloves or masks.
Scrubbing up:
Adjust the elbow taps to deliver water at a comfortable temperature
Wet your hands, apply a little soap or forearms to 5cm above your elbows for one complete minute
Wash your forearms
Aseptic technique
Scrubbing up:
Then take a sterile brush and put soap on it
Scrub the lateral side of your left thumb, then its medial side, then the lateral and medial aspects of each succeive finger
Scrub your nails, and then the back and front of your left hand
Do the same with your right hand
Scrub for 5 minutes in all
Aseptic technique
Scrubbing up:
Rinse the suds from your hands while holding them higher than your elbows
Turn off the taps with your elbow
Dry your hands with a sterile towel before you put on a sterile gown
Dry your hand first, then your forearms
Aseptic technique
Scrubbing up:
Grasp the folded towel with the fingers of both hands, then step clear, so that you don´t touch anything with the open towel
Blot your hands on one corner, then dry your forearms
Try not to bring a wet (unsterile) part of the towel back to a dry area
Aseptic technique
Gowning:
Hold the gown away from your body, high enough to be wel above floor
Allow it to drop open, put your arms into the arm holes while keeping your arms extended
Then flex your elbows and abduct your arms
Aseptic technique
Gowning:
Wait for circulating nurse to help you
She will grasp the inner sides of the gown at each shoulder and pull them over your shoulders
Aseptic technique
Gloving:
Dust your hands with powder and rub them together to spread it
Be careful to touch only the inner surface on the gloves
Grasp the palmar aspect of the turned down cuff of a glove and pull it on to your opposite hand
Leave its cuff for the moment
Aseptic technique
Gloving:
Put the fingers of your already gloved hand under the inverted cuff of the other glove, and pull it on to your bare hand
It is a good routine to wash your gloved hands sterile water to remove powder
Now help the next person who has gowned on with their gloves
Aseptic technique
Trauma
The operation site
Shaving:
The operation site should be socially clean before the operation, and you may have to check this
There is usually no need to shave a patient
If you shave him, do so on the morning of the operation, or as part of the operation
The operation site
Shaving:
If you shave him a day or two before , minute abrasions in his skin will become infected and the risk of wound infection will increase
If hair is going to get in the way, all you need to do is to clip it short immediately before the operation
The operation site
Preparation:
Do this as soon as the patient is anaesthetized
Start with a soapy solution, and follow this with spirit, or better if there is a low sensitivity to iodine in the community , usealcoholic iodine
Take a sterile swab on a hoder, start in the middle of the opertion site, and work outwards
The operation site
Preparation:
Discard both swab and holder, and repeat the proces with the second swab
The spirit will evaporate to leave the skin dry
Some surgeon consider thie over-elaborate, and merely use a single application of iodine
The operation site
Preparation:
Be sure to prepare a wide enough area of skin
In an abdominal, operation this should extend from the patient´s nipple line to below his groin
The operation site
Draping:
Wait until he is anaesthetized
Place the first towel across the lowe end of the operation site
Palce another across its nearer edge
Apply a towel clip at their intersection
Place another towel across the opposite edge of the site, and finally one across its upper edge
The operation site
Draping:
Clip them at their intersections
If necessary, grip his skin with the clips, or secure the towels with a stitch
Alternatively , drape him with two longutidunal towels clipped at each end, with a towel above and below
The operation site
Draping:
Then, in an abdominal operation cover his whole abdomen with an abdominal sheet with a narrow quadrangular hole in it
If important areas near the surgeon become contaminated, cover them with fresch sterile towels
The operation site
Swabs and packs:
Use 10 cm gauze squares on spongeholding forceps (swabs on sticks)
You wil also need abdominal packs
The operation site
Cleaning the theatre:
Clean it thoroughly after each day´s list, and completely every week
Cleaning instruments:
Use an old nail brush
Open hinged instruments fully, scrub them, and take special care to clean their jaws and serrations
Boiling and autoclaving
Sterilization is the total desctruction of all forms of life, including bacterial spores
It is best done with heat, either dry heat in an oven, or steam under pressure in an autoclave
Processes (usually chemical) which do not destroy spores are termed „disinfection“
Boiling and autoclaving
The basis of aseptic surgery is to kill all micro-organisms on all instruments and dressings, preferably by exposure to steam under pressure
If this is impractical, imerssion in boiling water for 10 minutes at sea level will kill all viruses and all vegetative bacteria, but not spores, particularly those of tetanus and gas gangrene
Autoclaves
The sterilize is effectively, if there is killing all spores
Autoclaves : simple walled autoclaves
double walled autoclaves
Autoclaves
Autoclaves
Disinfectants and antiseptics
Although heat is the best way of killing micro-organisms, you will have to use chemicals to kill them on a patient´s skin, or on anything which heat might harm, such as drains or some suture materials.
Antiseptics and disinfectants
Skin:
Any alcoholis solution will do
Alcoholic iodine is best:
Use it routinally, except in children, on the scrotum, and in allergic patients
0,5% chlorhexidine in spirit is a less satisfactory alternative
Apply it to skin after removing all traces of soap
Antiseptics and disinfectants
Wounds:
There is no substitude for scrubbing brush, plenty of water from a jug, and a thorough surgical toiler
Chlorhexidine is useful for cleaning the skin round a wound
Antiseptics and disinfectants
Instruments , suture materials and drains:
The following agent are effective against HIV and HBV in addition to the classical pathogens
2% alkaline buffered glutaraldehyde is the best
5% fromlain in 70% spirit
0,5% solution of chlorhexidine in 70% spirit with 0,5% sodium nitrite
Plain 70% spirit
Antiseptic and disinfectants
10 minutes is the absolute minimum time in these soutions, 24 hours is safer
Ideally nothing should be considered sterilized until it has been immersed for 24 hours
Wash all equipment well before using it
Antiseptic surgery
This used to be standard practice before aseptic methods made it obsolete
Aim to sterilize everything coming into contact with the wound by soaking it for a sufficien time in an antiseptic solution
Antiseptic surgery
Antiseptic solutions:
Use chlorhexidine 5% concentrate to make two solutions:
1. A weak solution of 1/2000 of the active agent in water, use this for soakng towels
2. Make up small quantities of solutions frequently, make them up hot, and clean out the containers well between batches
Antiseptic surgery
Sterilizing equipment and drapes:
Soak everithing which will come into contact with the wound in one of these solutions for at least 30minutes.
Soak sutures and gloves in the solutions
Use monofilament for ligatures and sutures, and the minimum number of simple instruments.
Antiseptic surgery
Sterilizing equipment and drapes:
The most appropriate drape, for a tubal ligation, for example , may be a single solution soaked plastic sheet long enough, and widw enough, to cover the whole patient, with a hole in the middle through which to operate.
Antiseptic surgery
Perioperative antibiotics:
For rutine use in antiseptic surgery
Some operators have given their patients antibiotics prophylactically
Antiseptic surgery
While operating:
Treat the patient´s skin with the solution for at least five minutes before the operation
Wash your hands as usual and put on the wet gloves
If you are not using gloves, soak your hands in solutions for five minutes
Antiseptic surgery
After operating:
Rinse everything free of blood
Rinse the instruments, and put them away
If possible carry nothing over to the next operation
Thank you for your attention!