Basic surgical principles -- Revisited.

Aseptic techniques

Care and use of instruments

Aseptic techniquesToo little attention

Broad spectrum antibiotics unjustified security

Lack of proper training to Surgeons Nurses others

Medico legal aspectsCrime

Act Intention

Voluntarily Dishonestly Corruptly Malignantly Wantonly Rashly and negligently

VoluntarilyKnowledge

A person is said to cause an effect voluntarily when he causes it by means whereby he intends to cause it, or by means, which, at the time of causing those means, he knew or had reason to believe to be likely to cause it.

Rashly and negligentlyNot described in IPC

Touching the sterile areas with unsterile hands

Diathermy injuries Keeping the instruments and wet packs

over the perineum Not using Mayo’s trolley

Theatre dress Pyjamas and shirts – both males and females Shirts to be tucked in. Shoes Cap and masks

Controversial reports. Better to have both. Protect the theatre air from droplets and

desquamated epithelia. Masks should cover the nose and mouth

Common mistakes Gowning

Improper packing Touching the areas which may come in contact

with sterile areas Cleaning the hands and forearm with gown

Gloving Improper packing Improper wearing Improper conduct

Wearing gown.Separate towel to dry the hand; if gown

is used for the purpose the lower most edge to be used.

Adjusting the length of the sleeve shall be done with ungloved hand holding in the axilla of the gown.

Other areas shall not be touched with ungloved hand.

Wearing glovesPresent system of packing makes it

impossible to wear the glove in a proper way.

The parts of the glove which come in contact with the sterile areas shall not be touched with bare hand.

Double gloving is advisable with questionable value.

After Gowning and gloving One shall not touch unsterile areas, shall

move 30 cm away facing the same One shall not touch sterile areas (other than

the operating field), shall move 30 cm away facing the same

One shall keep the hands up in the level of chest not in the axilla

During painting the surgeon’s gown shall not touch the table.

Others

Movement shall be kept minimumOne shall not touch sterile areas

shall move 30 cm away facing the sameThe shirt to be tucked in

Sterile areasSterility is to be ascertained rather than

assumed.One person shall be kept to watch the

sterile area alwaysAny breech in asepsis to be reported

forthwith.

Sterilization Methods

Heat Moist heat Hot air Boiling ?

Chemical Activated gluteraldehyde Formalin vapour Ethylene oxide gas

Radiation

Moist heat Steam under pressure

Autoclave Advantages

Easiest,safest, surest Fastest Least expensive Automatic Many items withstand repeated processing

AutoclaveDisadvantages

Preparation and package to be careful Item must be clean and free from grease

and oil Steam must have direct contact with all

areas of an item Timing depends on material and load

chance of human error Impurities in water (steam)

Boiling NOT a method of sterilization. But can be

used as a disinfectant. Vegetative forms are killed in few minutes at

54 to 65oC. Certain bacterial spores will withstand 115oC

for 3 hours! No living things can survive saturated steam

at 121oC longer than 15 minutes.And hence autoclaving.

Dry heatAnhydrous oils petroleum products, bulk

powders DisadvantageLong exposure period.

Autoclaving Instruments not destroyed by heat.

Blunt stainless steel instruments, gloves, tubes, aprons and drapes.

Sharp instruments not to be autoclaved.Tubes to be filled with water Trays to be separated by gauze

Activated gluteraldehydeADVANTAGESNon-corrosive Low surface tension.Not absorbed by rubber or plastics.Low volatility.Active at room – temperature

Activated gluteraldehydeDISADVANTAGESBuffer to be added for activation.Gradually loses effectiveness.May cause skin irritation.Mild odour.

Activated gluteraldehydeFor instruments which are destroyed by

heat Bactericidal, pseudomonacidal,

Fungicidal and Virucidal in 10 minutes. Disinfection only !

Tuberculocidal in 45 minutes.Sporicidal in 10 hours.

Formalin chamberTo sterilize items which are destroyed

by heat Scopes, diathermy cables, etc.

Ethylene oxideEffective agent to sterilize items which

are destroyed by heat.Cannot be used in a hospital set up.Pre-sterilised in factory set up and

supplied Syringes, needles, plastics etc.

RadiationEffective agent to sterilize items which

are destroyed by heat.Cannot be used in a hospital set up.Pre-sterilised in factory set up and

supplied.No residual radio activity.

Instruments Identify the instrument. Know the method of sterilization.Know the use.Know the method of use.Don’t use it for other purposes.

Use of instrumentsCurvature of instrument should follow

the curvature of the hand.Only one ratchet lock should be applied.Cleaning ideally by ultrasonic waves.Light detergent may be used.

Mosquito Artery forcepsUses

To catch a bleeding point DON’T use it for

Ligature Dissection Holding gauze, mops, towels.

Artery forceps - UsesTo Hold a bleeding point / blood vessel.For blunt dissection.Ligature.DON’T use it for

Extracting needle from tissues. Holding towels. To open bottles. To hold sponge.

Needle holder – UsesTo hold a curved needle.To extract a needle from the tissue.To ligate.DON’T use it as a bone nibbler.

Mayo’s Scissors - Uses To cut tissues other than skin, bone and

tendons. Push cutting is useful not only to tailors but to

surgeons also. To do blunt dissections. Don’t use it for cutting suture material, gauze,

pad. Metzenbaum Scissors to be used for delicate

tissues.

Alli’s forceps andother tissue holding forceps

They are tissue forceps.To hold delicate tissues.DON’T use it for

Holding the towel. Holding the apron of surgical team.

Intestinal occlusion clampTo occlude the lumen of intestine and

the blood vessels.Two or three ratchet locks may be

applied.DON’T use it for

Holding skin grafting blade/razor blade

Anaesthesia screenMust to prevent contamination.

RecordingAccurate recording of the procedure

Will help to conduct studies – both prospective and retrospective.

Is important in medico-legal aspects. Help in surgical audit.

DoorsSliding doors are to be used.Opening and closure shall be kept

minimum.Traffic in and out of theatre to be

minimum

MirrorMirror should be kept in the scrub area.This will facilitate the surgical team to

adjust the cap and mask correctly before scrubbing.

Circulating nurseThere shall be a circulating nurse.Presently the job is done by nursing

assistants and attendants Nursing assistants and attendants are

un-qualified to handle sterile things.

Mayo’s trolleyThe most versatile equipment.Unfortunately not used in our hospital.Advantages

Prevent contamination of instruments. Prevent injuries to the patient. Provide an easy access to instruments.

Theatre head nurseMost powerful person of the theatre.Responsible for theatre discipline Maintains stock of medicines and

equipments Ascertains asepsis Supervises the nursing staff

T h a n k Y o u

Medical Powerpoints

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