JC-Asepsis and antisepsis in operating room

Skin preparing and role of antibiotics

Under the guidance of Dr. P.V. Buddha,(M.S)

Dr. Venkat Reddy(M.S) Dr.Satyavani(M.S)

Dr.Sailaja Rani(M.S) Dr.Satyanarayana(M.S)

Ignaz Semmelweis

Puerperal fever transmission

Joseph Lister• Started using carbolic acid dressings and

spraying carbolic acid in OT.

In 1882 Trendelenburg constructed an apparatus for sterilization of surgical material and instruments with dry steam. In 1886 Bloodgood invented rubber gloves for protection of a surgeon's hands from infections. Since 1890 Holoted Y. and Isege (since 1897) became to use gloves for protection of a wound from a surgeon's hands.

Bergman E. and Shimelbus K. constructed a sterilizing machine for boiling the instruments; they created metallic drums for sterilization of clothes and dressing, perfected an autoclave.

Introduction to Sterile Technique

• Proper aseptic techniques is one of the most fundamental and

essential principles of infection control in the clinical and

surgical setting

• Aseptic Techniques are those which:

– Remove/reduce or kill microorganisms from hands and objects

– Employ sterile instruments

– Reduce patient risk of exposure to microorganisms that cannot be

removed

The measures to prevent an infection from entering a wound are referred to as asepsis, while those to cause the exclusion or destruction of harmful microbes are generally called antisepsis.

The two principles represent the united whole in the prophylaxis of surgical infections. They have to be considered in terms of the interrelationship between the source of infection and its mode of transmission and the susceptibility of the body.

The major sources of endogenous infections incorporate chronic infections outside the area of the operation (e.g. skin diseases, dental or tonsillar conditions) or of the organs operated on as is (e.g. appendicitis, cholecystitis, osteomyelitis), as well as the oral, intestinal and respiratory saprophytes.

Among the modes of transmission of endogenous infections are direct contact, lympho- and haematogenous spread.

Aseptic Technique

• Immediately before and during surgical procedures

to reduce post-operative infection:

– Surgical Attire

– Surgical scrub, sterile gowning & gloving

– Patients surgical skin prep

– Using surgical barriers (surgical drapes and PPE)

– Using safe operative technique

Asepsis

• Absence of microorganism that cause disease

• Freedom from infection

• Aspetic Technique = methods by which

contamination with microorganisms is prevented

Principles of Aseptic Technique

• Only sterile items are used within the sterile field

• Sterile persons are gowned and gloved

– Gowns are only sterile from waist to shoulder

– Gloved hand must be kept in sight at all times

• Only the top of a draped table is considered sterile

• Sterile persons touch only sterile items or areas

• Unsterile persons avoid reaching over the sterile field

• The edges of anything that encloses sterile contents

are considered unsterile

• Sterile field is created as close as possible to the time

of use

• Sterile areas are continuously kept in view

• Sterile persons keep well within the sterile area

• Sterile persons keep contact with sterile areas to a

minimum

• Unsterile persons avoid sterile areas

• Destruction of the integrity of microbial barriers

results in contamination

The Surgical Hand Antisepsis• Process of removing as many microorganisms as

possible from the hands and arms by mechanical

washing and chemical antisepsis before participating

in a surgical procedure

– Despite the mechanical action and the chemical

antimicrobial component of the scrub process, skin is

never sterile

Surgical Hand Antisepsis

• 4 factors affecting the effectiveness of surgical hand

antisepsis:

– The preparation before cleansing

– The choice of antiseptic solution

– The cleansing method

– The duration for hand cleansing

Choice of Antiseptic Solution

• Antimicrobial soaps, aqueous scrubs (ex. biguanides),

alcohol rubs used as antiseptic solutions+

• Alcoholic chlorhexidine was found to have greater

residual antimicrobial activity

– Review by Tanner et al, reported that biguanides (ex

Chlorohexidine gluconate are more effective in removing

microorganism on hands than Iodophors (ex. Providone

iodine)

The Methodology of the Scrub

• The time method:

– All surgical scrubs are 3-5 minutes in length

– All are performed using a surgical scrub brush and

an antimicrobial soap solution

Preparation Before Surgical Scrub

• Removal of finger rings/jewelry, nail polish and artificial

nails

– Finger rings and jewelry can harbor microorganism and

dead skin

– Dark nail polish obscures the subungual space and

likelihood of careful cleansing is reduced

– Artifical nail ↑ the microbial load on hands

Preparation Before Surgical Scrub

• Performa a preliminary hand washing with

antimicrobial soap

• Wash both of your hands and arms, lathering up well

– Rinse and dry

• Clean underneath your fingernails with a nail file

Surgical Scrub Procedure

• 1. Remove sterile disposable brush-sponge from its

wrapper and moisten the sponge

• 2. Lather fingertips with sponge side of brush, then

using brush side of brush scrub the spaces under the

fingernails of the right or left hand with 30 circular

strokes

Surgical Scrub Procedure

• 3. Lather digits; scrub 20 circular strokes on all four

sides of each finger

• 4. Lather palm, back of hand, heel of hand and space

between thumb and index finger (scrub 20 circular

strokes) on each surface

Surgical Scrub Procedure

• 5. Forearm scrub – divide the forearm into 3 inch increments (the brush is 3 inches lengthwise)– Use the sponge side of the brush lengthwise to

apply soap around the wrist– Scrub 20 circular strokes on all four sides of wrist– Then move up the forearm – lather, then scrub

ending 2 inches above the elbow

Surgical Scrub Procedure

• 6. Repeat the previous steps for the other arm

• 7. Discard the brush• 8. Rinse hands and arms without retracing or

contaminating; allow the water to drip from the elbows

Surgical Scrub Procedure

• 8. After final rinse, turn water off and keep scrubbed

hands and arms in view to avoid contamination and

back into operating room

• 9. In the operating room, dry hands and arms with a

sterile towel before donning a sterile surgical gown

and gloves

Drying the Hands

• Step 1: Reach down to the opened sterile package

containing the gown, and pick up the towel

– Be careful not to drip water onto the pack

• Step 2: Open the towel full-length, holding one

end away from the non-sterile scrub attire

– Bend slightly forward

Drying the Hands

• Step 3: Dry both hands thoroughly but independently

– To dry one arm, hold the towel in the opposite hand and,

using the oscillating motion of the arm, draw the towel up to

the elbow

• Step 4: Carefully reverse the towel, still holding it away

from the body

– Dry the opposite arm on the unused end of the towel

Gowning Technique

– The gown is pulled on, leaving the cuffs of the

sleeves extended over the hands

– The back of the gown is securely tied or fastened

at the neck and waist, touch the outside of the

gown at the line of ties or fasteners in the back

only

Gowning Technique

• Summary Principles:

– Touch only the inside of the gown while donning it

– If touch the outside, the gown is considered contaminated

– Scrubbed hands and arms are considered contaminated if

they fall below the waist level or touch the body

– After donning the gown, the only parts of the gown that are

considered sterile are the sleeves and front from waist level

to a few inches below neck opening

Gloving by the Closed Glove Technique

• Preferred method over open-gloving technique

• Provides a bacterial barrier between patient and

surgeon

• Step1: Using the right hand and keeping it within the

cuff of the sleeve, pick up the left glove from the

inner wrap of the glove package by grasping the

folded cuff

Gloving by the Closed Glove Technique

• Step 2: Extend the left forearm with the palm

upward

– Place the palm of the glove against the palm of the

left hand, grasping in the left hand the top edge of

the cuff, above the palm

– In correct position, glove fingers are pointing toward

you and the thumb of the glove is down

Gloving by the Closed Glove Technique

• Step 3: Grasp the back of the cuff in the left hand

and turn it over the end of the left sleeve and hand

– The cuff of the glove is now over the stockinette cuff of the

gown, with the hand still inside the sleeve

Gloving by the Closed Glove Technique

• Step 4: Grasp the top of the left glove and underlying

gown sleeve with the covered right hand

– Pull the glove on over the extended right fingers until it

completely covers the stockinette cuff

• Step 5: Glove the right hand in the same manner

– Use the gloved left hand to pull on the right glove

• Proper aseptic technique is one of the most

fundamental and essential principles of

infection control

• This stepwise process of proper aspetic

technique should be performed every single

time in the OR

Modifiable Risk Factors

• Skin or site preparation ineffective– Removal of hair with clipper than razors

• Colorectal procedures – Inadequate bowel prep/antibiotics– Improper intraoperative temperature regulation

• Antimicrobial prophylaxis– Inappropriate choice (procedure specific)– Improper timing (pre-incision dose)– Inadequate dose based on body mass index, procedures

>3h, or increased blood loss

• Excessive OR traffic• Inadequate wound dressing protocol• Improper glucose control• Colonization with preexisting microorganisms• Inadequate intraoperative oxygen levels

Prevention Strategies

Administer antimicrobial prophylaxis in accordance with evidence based standards and guidelines– Administer within 1 hour prior to incision*• 2hr for vancomycin and fluoroquinolones

– Select appropriate agents on basis of• Surgical procedure• Most common SSI pathogens for the procedure• Published recommendations

• Remote infections-whenever possible:– Identify and treat before elective operation– Postpone operation until infection has resolved

• Do not remove hair at the operative site unless it will interfere with the operation; do not use razors – If necessary, remove by clipping or by use of a

depilatory agent

• Operating Room (OR) Traffic– Keep OR doors closed during surgery except as

needed for passage of equipment, personnel, and the patient

• Redose antibiotic at the 3 hr interval in procedures with duration >3hrs (* See exceptions to this recommendation in*Engelman R, et al. The Society of Thoracic Surgeons Practice Guideline Series:Antibiotic Prophylaxis in Cardica Surgery, Part II:Antibiotic Choice. Ann Thor Surg 2007;83:1569-76)

• Adjust antimicrobial prophylaxis dose for obese patients (body mass index >30)*Anderson DJ, Kaye KS, Classen D, et al. Strategies to prevent surgical site infections in acute care hospitals. Infect Control Hosp Epidemiol 2008;29 (Suppl 1):S51-S61

• Use atleast 50% of inspired oxygen intraoperatively and immediately postoperatively in select procedure()*Maragakis LL, Cosgrove SE, Martinez EA, et al. Intraoperative fraction of inspired oxygen is a modifiable risk factor for surgical site infection after spinal surgery. Anesthesiology 2009;110:556-562.

• Aqueous-based iodophors, such as povidone-iodine, contain iodine complexed with a solubilizing agent, allowing for the release of free iodine when in a solution. Iodine acts in an antiseptic manner by destroying microbial proteins and DNA. Iodophor-containing products enjoy widespread use because of their broad-spectrum antimicrobial properties, efficacy, and safety on nearly all skin surfaces regardless of the patient’s age.

• Alcohol-based solutions are quick, sustained, and durable, with broader spectrum antimicrobial activity. These agents seem ideal for longer open surgeries with the potential for irrigation or surgical spillage.

• Ethyl and isopropyl alcohol are 2 of the most effective antiseptic agents available. When used alone, alcohol is fast and short acting, has broad-spectrum antimicrobial activity, and is relatively inexpensive. Flammability can be avoided by allowing skin to completely dry and by avoiding preparation of areas with excessive body hair that can delay alcohol vaporization.

• Recent studies suggest that alcohol-based solutions may have greater efficacy, easier application, improved durability, and a superior cost profile when compared with traditional aqueous-based solutions.

• DuraPrep solution, an antiseptic skin solution that contains iodine povacrylex in isopropyl alcohol, shows durability in the surgical/procedural environment and enhances adhesion between surgical drapes and the prepared skin surface, theoretically limiting the spread of organisms onto the surgical field.

JOURNAL CLUB

• Effects of Preoperative Skin Preparation on Postoperative Wound Infection Rates: A Prospective Study of 3 Skin Preparation Protocols.

• Authors swenson etal • In 2009• OBJECTIVE To compare the effects of different skin

preparation solutions on surgical-site infection rates.

DESIGN

Three skin preparations were compared by means of a sequential implementation design.

Period 1 used a povidone-iodine scrub-paint combination (Betadine) with an isopropyl alcohol application between these steps.

Period 2 used 2% chlorhexidine and 70% isopropyl alcohol (ChloraPrep).

Period 3 used iodine povacrylex in isopropyl alcohol (DuraPrep).

Surgical-site infections were tracked for 30 days .

CONCLUSIONS• Skin preparation solution is an important

factor in the prevention of surgical-site infections. Iodophor-based compounds may be superior to chlorhexidine for this purpose in general surgery patients.

• Perioperative antibiotic prophylaxis: improved compliance and impact on infection rates

• By E. PROSPERO, P. BARBADORO, A. MARIGLIANO, E. MARTINI and M. M. D'ERRICO

• In Cambridge journals in 2010

• Aim- of this study were to determine adherence to the perioperative antibiotic prophylaxis (PAP) protocol used at a large Italian teaching hospital during a 6-year period, to assess the variables associated with inappropriate administration, and to measure the impact on surgical site infection (SSI) rates

• Results - 28 621 patients surveyed of which 74·6% received PAP. An improvement in adherence to the PAP protocol was registered for 58·8% of patients.

• During the study period, a significant reduction in SSIs rates was detected

• Conclusion - global reduction of inadequate PAP administration signifies the efficacy of a multidisciplinary quality improvement initiative on antimicrobial utilization, and this is supported by the observed reduction of the SSI rate.

• Timing of Surgical Antibiotic Prophylaxis and the Risk of Surgical Site Infection

• By Mary T. Hawn, MD, MPH etal• In JAMA Surg. 2013• Objective - To determine whether

prophylactic antibiotic timing is associated with SSI occurrence

• Design - Retrospective cohort study

• Results • Of the 32 459 operations, prophylactic

antibiotics were administered at a median of 28 minutes (interquartile range, 17-39 minutes) prior to surgical incision, and 1497 cases (4.6%) developed an SSI

• Compared with procedures with antibiotic administration within 60 minutes prior to incision, higher SSI rates were observed for timing more than 60 minutes prior to incision

• Conclusions and Relevance - The SSI risk varies by patient and procedure factors as well as antibiotic properties but is not significantly associated with prophylactic antibiotic timing. While adherence to the timely prophylactic antibiotic measure is not bad care, there is little evidence to suggest that it is better care.

• A systematic review of the ASEPSIS scoring system used in non-cardiac-related surgery

• By C J Shia et al• In Journal of wound care in Aug 2013

• Objective: To assess the validity, reliability and sensitivity of the ASEPSIS scoring system, used to assess non-cardiac related surgery for surgical wound infection.

• Method: Five studies were included in this review. One study discussed the development of the ASEPSIS scoring system; two studies were on its reliability, one study on the sensitivity and the final compared the ASEPSIS scoring system against other surgical wound infection criteria and definitions. Due to variation in study designs, the findings were summarised and presented in a narrative format.

• Results: Validity and reliability were not established in assessing non-cardiac surgical sites. Sensitivity level was reported for non-cardiac surgical sites, but its reliability level declined as the severity of infection worsened.

• Conclusion: This review revealed that there are limited choices of scoring systems to assess different surgical sites for surgical wound infection. Currently, only the ASEPSIS scoring system is available, but it is not validated for use with sternal wounds. Therefore, it should be used cautiously when assessing non-cardiac surgical wound infection.

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