Surgical Preparation

Lobna El Fiky Assistant Professor of

ORL, H&N surgery

Ain Shams University

Historical perspectives

Antiseptic = Greek for “against putrefaction” Accidental observation of certain substances

stopped putrefaction of meat… Mercuric Chloride: Arabian physicians in

Middle Ages Tincture of iodine: 1839 Pasteur’s publication: 1863: microbial origin

of putrefaction

Historical perspectives

As often in history of medicine: Change of practice depended on the persistence of John Lister 1870,

He introduced vigorous application of phenol in surgery, for dressing wounds, for sterilization of instruments

Sterilization

It is the process that destroys all microorganisms (including bacterial microspores).

The skin could never be sterilized without its own destruction.

Disinfection

A process which destroys only the vegetative forms of organisms =basically clean.

A disinfectant (germicide, antiseptic): any chemical substance with either a bactericidal or a bacteriostatic action.

Antiseptic -- Agent applied to living tissue Disinfectant -- Agent applied to inanimate

surface

Surgical Disinfection

This is an essential part of a programme for the control of infection.

High Risk Items: as they come in close contact with broken skin or those that breach mucous membranes or are introduced into a sterile cavity.

Requirements for decontamination practice

The basic requirements for good decontamination practice are:

A Management control system; Appropriate facilities; Appropriate equipment; Properly trained and supervised staff; Ensuring that single use medical devices are not

reused; Records of decontamination are kept.

Methods of Disinfection

Physical: The most important as they can be relied on to ensure the sterilization of articles used in the treatment of patients:

– Thermal: Heat or Steam – Radiation: infra-red radiation, - rays, particles– Filtration:utilizing filters capable of screening out microorganisms

Chemical: Less effective, used for personnel– Organic– Inorganic

Gaseous disinfectants: very efficient, not routine– Formaldehyde gas– Ethylene oxide

MANUAL CLEANING

Cleaning is vital prior to any decontamination procedure.

‘Detergent’ removes the nutritive material on which bacterial survival and multiplication may take place.

This reduces the number to a level which is not harmful for health.

MANUAL CLEANING

Effective cleaning to remove protein from medical devices is paramount (agents such as CJD are not inactivated by heat).

Dismantle or Open the instrument to be cleaned Friction for 2-3 minutes Brush, Wipe, Agitate, Irrigate, jet wash or

hand spray the item to dislodge and remove all visible soil

Rinse the item thoroughly with clean water Drying

Physical Methods of Disinfection HEAT

DRY HEAT Kills by Destructive oxidation of cell constituents Surest incineration Hot-air oven:

– inefficient, poor conductor of heat, penetrates feebly.– 160°C for 1 hour: damages fabrics, melts rubber– Used for: Glassware, oily fluids, powders

Physical Methods of Disinfection HEAT

MOIST HEAT

Effective at low temperature, in a shorter period of time

Boiling: 100°C for 30 minutes Pasteurisation: 63°C for 30 minutes Tyndallisation: steaming for 20 minutes for 3

successive days Steaming under pressure= Autoclaving

Advantages of steam

Kills by denaturing & coagulating enzymes & proteins

More rapid (maximum needed time 45mn) & at lower temperature

Condensation of steam leads to liberation of latent heat which raises the temperature, and gives more penetration

Half dense as air, so has better penetration

Steam Sterilization: Autoclave

Principle: An autoclave is a self locking machine that sterilizes with the high temperature that steam under pressure can reach.

High-vacuum pumps remove as much as possible air before the steam is admitted, so the required temperature is reached very rapidly.

Steam criteria

Dry: no suspended droplets of water Close to its point of condensation: not

superheated Free from air: as it decreases the temperature

and the penetration Temperature

– 121°C: 15mn-30mn– 134°C: 4-7mn Flashing

Steps of autoclaving

Water in the surrounding container full and heated Articles in cabinet, doors bolted Vacuum to evacuate as much air as possible Steam is admitted at a high pressure of and when the

thermometre reaches the required temperature, sterilisation begins

Sterilisation is continued for the required time and then the steam is turned off.

Drying is carried-out by reapplying a vacuum to evacuate the steam, introducing dry filtered air into the cabinet (for 15 minutes).

Efficient Autoclaving

All instruments must be double wrapped in linen or special paper or placed in a special metal box equipped with a filter before sterilization.

The white stripes on the tape change to black when the appropriate conditions (temperature) have been met.

Expiration dates should be printed on all equipment packs.

There should be a uniform development of bars throughout the length of the strips.

Ready made plastic bags with strips printed with a sensitive ink.

Control of autoclave efficiency

Bowie-Dick test: Used for high-vacuum autoclaves, Done every day:

– In the middle of a test pack of towel, a paper on to which a strip of a specific tape is put, for testing.

– Uniform development of dark color indicates that the steam has passed freely and rapidly to the center of the load.

Biological sterilization indicators: Spores of a non-pathogenic organism: Done weekly

– They are killed at 121°C after 15 minutes.– Attempts to culture them is subsequently made

RADIATION DISINFECTION

High energy ionizing radiation destroys microorganisms and is used to sterilize prepacked, Single-use, surgical equipment by manufacturers

Common sources of radiation include electron beam and Cobalt-60

CHEMICAL DISINFECTION

A SATISFACTORY AGENT SHOULD: Be active against a wide range of organisms and

spores. Only few are truly sterilizer Have a rapid action Should not be toxic or irritant to the skin Should be Persistent

There is no one disinfectant which can be used to kill all micro-organisms in all

situations.

Types of Chemical disinfectants

Inorganic:– Iodine– Chlorine

Organic:– Alcohols– Aldehydes– Phenols– Cationic surface-active agents

Inorganic disinfectants

The halogens: Chlorine and Iodine Have a rapid action against vegetative

organisms and spores= true sterilizers Their action is annulled by foreign organic

material

Iodine disinfectants

The broadest spectrum of all topical anti-infectives, with action against bacteria, fungi, viruses, spores, protozoa, and yeasts.

Tincture iodine: – 2.5% iodine & 2.5% potassium iodide in 90% ethanol.– Best skin disinfectant– Irritating to raw surfaces: due to its alcoholic component– Allergic dermatitis

Iodophors: Solutions of iodine in non-ionic detergents= Povidone iodine= Betadine

– Less irritating and less staining– Less disinfectant than tincture

Chlorine disinfectants

Powerful, Disinfect water Particularly active against viruses Concentrated solutions too corrosive Usually diluted with a compatible detergent

Organic Disinfectants

Alcohols: bactericidal: 50-70% ethanol Aldehydes:

– Formalin: irritant, powerful=sterilizer– Glutaraldehyde: less irritant, not volatile, more rapid action.

Phenols: continued activity in organic matter as human excreta.

– Phenol: Toxic, expensive– Cresols: Lysol– Chloroxylenol: Dettol– Chlorhexidine: Hibitane- Alkanol– Hexachlorophane

Cationic surface-active agents:– Cetrimide: Cetavlon

Alcohol

Isopropyl Alcohol 70% (or Ethyl Alcohol 90%)

ADVANTAGES: Causes protein denaturation, cell lysis, and metabolic

interruption. Degreases the skin.

DISADVANTAGES: Ineffective against bacterial spores and poorly effective

against viruses and fungi.

Glutaraldehyde (Cidex)

Cold Sterilization: Instruments must be dry before immersion. Glutaraldehyde is bactericidal, fungicidal,

viricidal, and sporicidal Sterilization: a 10 hour immersion. This

prolonged chemical action can be more detrimental to surgical instruments.

3 hours exposure time is needed to destroy spores.

If the instruments need to be "disinfected" only, cold sterilization is okay as disinfection will take place in only 10 minutes.

Lysoformin

Formaldehyde & glutaral Lysoformin: liquid concentrate with which any dilution

required can be made by simply adding water (20ml + 4-8L)

The timing depends on the concentration used:– flexible endoscopes– deactivation of HBV & HIV

Used for heat labile instruments and cleaning Does not harm metal instruments

1.5 % - 30 min2.0 % - 15 min

Chlorhexidine Gluconate Hibitane vs Alkanol

Broadest spectrum Better residual activity than iodophors Occasional skin sensitivityADVANTAGES: Rapid action Residual activity is enhanced by repeated use Less susceptible to organic inactivation than povidone iodineDISADVANTAGES: Occasional skin sensitivity. Inactive against bacterial spores Activity against viruses and fungi is variable and inconsistent May harm metal instruments

Gaseous Disinfection Ethylene Oxide Sterilization: EO Gas

Colorless gas, available as cartridges Toxic and flammable, Odor similar to

ether Has an extremely well penetration, even

through plastics Microorganism destruction is caused by a

chemical reaction Effective sterilization is dependent on

concentration of gas, exposure time, temperature, and relative humidity

Powerful sterilizer: Kills all known viruses, bacteria (including spores), and fungi

EO Gas Sterilizer

Is used in large hospitals, as it is expensive, dangerous, needs more expertise.

Used for heat sensitive instruments: fabrics, plastics, suture material, lenses, endoscopes, electrical equipment and finely sharpened instruments.

At 20°C-25°C: sterilization takes 18hours At 50°C-60°C: sterilization takes 4 hours In Demerdash: The average of the cycle is 8-14

hours

Sterility Check List

Before assuming a pack is sterile, always evaluate the following before opening the pack:

Expiration date Indicator color change General condition of wrapper and how it

had been stored Always check for holes or moisture damage

Standards forSurgical Scrubbing, Gowning and

Gloving

The pre-surgical practice of scrubbing, gowning and gloving is integral to the minimization of risk of infection from micro-organisms present in the wound at the time of surgery.

Accessing to the operating theatre

Wear prescribed operating suite attire

Remove jewellery Keep fingernails short,

clean, healthy Wear appropriate

protective attire: masks, head, overshoes..

REMEMBER

What went inside the machines is the STERILISED material

Personnel are only DISINFECTED

Surgical Hand scrub

No touch: infrared robinets, with your elbow, leg… Use brush?? The ideal duration of the scrub is not agreed. Accepted time is 5 minutes: appears safe Some surgeons do not rinse off the chlorhexidine or

Betadine in order to enhance residual activity. Alternative: Two-stage surgical scrub:

– an initial 1- or 2-minutes scrub with 4% chlorhexidine gluconate or povidone-iodine followed by application of an alcohol-based product

Surgical Hand scrub

Trim fingernails and Wash for 30-60 seconds with surgical scrub.

Scrub fingers with a sterile scrub brush Make sure to scrub all sides of each finger,

including the area between fingers.

Surgical Hand scrub

Scrub hands and arms with a sterile scrub brush. Make sure to scrub each surface of each hand and arm

An accepted contact time is 10 brush strokes per surface During scrubbing, rinsing and drying, hands are held

above elbows. This is done so that water will not be dripping from upper arms onto lower arms and hands

Drying Hands

A sterile towel is included within the sterile gown pack. One hand and forearm are dried by one side of the towel. Always dry in the direction of hand to elbow so that

contamination of the upper arm is not spread by the towel to the surgeon's hand.

Gowning

All gowns are folded and packaged for sterilization, with the inside exposed so that the surgeon may handle the gown without contaminating the outside of the gown.

Grasp the exposed inside of the gown and lift the gown away from the table.

Your hands are disinfected and the gown is sterilized

Gowning

Unfold the gown by placing hands into the white arm holes. Continue placing hands and arms through the sleeves..

Gowning

An assistant fastens the neck tie and the inside waist tie.PLEASE: DO NOT DRY YOUR HANDS IN

THE FRONT OF THE GOWN

Types of Gowns

Disposable Paper Gown: resistant to wetting so they are less permeable to bacteria, expensive. It is usually a wrap around gown. The ties "wrap around" the surgeon.

Linen (cloth): comfortable and reusable. When it becomes wet, bacteria can permeate. The cloth gown is also known as a front sterile gown. The gown is just tied in the back.

Gloving

Sterile surgical gloves can be worn by:

Open method: – The gloves are presented to enable the introduction of the

hands on the inside surface directly – The nurse with her sterile glove opens the glove for the

surgeon who introduces directly his hands on the inside surface of the glove

DO NOT ADJUST THE FIRST GLOVE BEFORE PUTTING

THE SECOND ONE !!!

Gloving

Closed gloving: This is the introduction of hands covered with the

cuff of a sterile gown. So, If you are planning on closed gloving, do not

thrust hands through the cuffs. This is usually performed by the first person to

be sterilized= the nurse

Gloving: Closed method

An assistant opens the sterile pack of gloves and drops them into the sterile field.

The inside of the cuff of the glove is grasped by the opposite hand (still within the gown) until introduction

Patient Preparation

Sterilization is best done with a detergent followed by a disinfectant on a larger area of the surgical field. H&N??

Use Ample Detergent Scrub roughly the skin in any direction for 2-3mn

??Remove the excess of the detergent Apply the disinfectant first on the most clean

area Scrub in one direction only

Draping

Standard head drape: two towels, one under the shoulders and the other wrapped around the head

Better to suture the drapes to the skin to prevent shifting

Towels are used for lateral draping Drapes should lie flat

Practical SterilizationInstruments sterilization

Metal Instruments: Avoid chemical sterilization– Autoclave– EO chamber– Formaldehyde beads or powder

Sharp-edged: avoid heating & wetting:– EO chamber– Formaldehyde beads or powder

Practical SterilizationInstruments sterilization

Catheters, gloves,…: depend on pre-sterilized, disposable equipment

– Radiation– EO chamber

Endoscopes: avoid heat– Cidex– Lysoformin– Autoclaving

Handles of drills:– Autoclave after washing and oiling– EO chamber

THANK YOU