asepsis & antisepsis in surgery dept of surgery national university of singapore
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Asepsis & Antisepsis in Surgery
Dept of Surgery
National University of Singapore
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Asepsis in Surgery
Asepsis : freedom from infection or prevention of contact with microorganisms
Aseptic technique : instruments, air, drapes, gloves and gowns are free from microorganisms
Antisepsis : prevention of sepsis by inhibition or destruction of agents
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Asepsis
Defined as a process or procedure performed under conditions in which bacterial contamination has been minimised
1847 Semmelweis 1865 Lister
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Asepsis
Technique wash hands and instruments with
carbolic acid wear gloves spray OT with carbolic acid
Lister - Lancet 1867 amputation mortality 46% 15%
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Asepsis TodayOT
20 air changes per hour filtered air laminar flow if needed
Surgeon hand scrub iodophors or
hexachlorophene solution sterile gloves - technique sterile gown - technique aseptic technique in surgery
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Asepsis today
Patient shave only day of op skin prep with iodophor or hexachlorophene drape with impermeable membrane protect wound beware long surgery, drains, other illness
Instruments - autoclave or gas sterilised
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Antisepsis Bacterial flora
Resident: Coag –ve Staph, Corneybacterium,Acinetobacter, enterobacterium
Transient: Staph aureus, MRSA
Antisepsis- Destruction or removal of the transient flora
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Surgical Site Infection (SSI) 10-15% of nosocomial infections
60% at the incision site
Significant morbidity and mortality
Increased hospital stay and costs
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Superficial Incisional SSI Occurs within 30days and involves skin or
subcutaneous tissue and one of the following
Purulent discharge Positive culture Clinical signs of infection Clinical diagnosis
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Deep incisional SSI Occurs within 30days if no implant left in situ Occurs within 1yr if implant left in situ and
one of the following
Purulent discharge from deep incision Dehisence of deep incision Discharging abscess Clinical diagnosis
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Organ/Space SSI Occurs within 30days if no implant left in situ Occurs within 1yr if implant left in situ and one of the
following
Infection involves organ/ space or any related anatomy
Purulent discharge from deep space Positive culture Deep abscess confirmed clinically or radiologically Clinical diagnosis
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Surgical wound classification Clean / Class I- Uninfected operative wound in
which no inflammation is encountered. Primary closure with closed drainage. Respiratory, alimentary and genito-urinary tracks are not involved. (1.5%)
Clean-contaminated/ Class II- Any operative wound in which the respiratory, alimentary or genito-urinary tracks are opened in a controlled manner without contamination. (8%)
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Surgical wound classification Contaminated/ Class III- Open fresh accidental
wounds. Operations with major break in sterile techniques. Gross contamination or major spillage. Non purulent inflammation (10-15%).
Dirty-infected/ Class IV- Old traumatic wounds with devitalised tissue and those that involve existing clinical infection or perforated viscera. Organisms involved were present in the operative field before the operation (25%).
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Patient factors Age Nutrition DM Obesity Smoking Colonisation Immunosuppression Blood transfusion Anaemia
Malignancy Co-existing infection Length of pre-operative
stay
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Operative factors Category of operation Duration of operation Skin asepsis Surgical scrub Preoperative shaving Preoperative skin prep Antimicrobial
prophylaxis OT sterilisation Sterilisation
Foreign material Surgical drains Surgical technique Poor haemostasis Dead space obliteration Tissue trauma
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Normal body flora Anatomical site
Head and neck
Thorax
Upper GI
Lower GI
Female genital tract
Flora Staph (aureus & coag neg), Strep,
cornybacteria, Neisseria, haemophilus, anaerobes
Staph (aureus & coag neg), As oropharyngeal and Gram neg
rods including enterobacter, Lactobacilli
AerobicGram neg rods including enterobacter, enterococci. Anaerobes- bacteroides, clostridium yeasts
Large bowel flora, Staph , Strep, corneybacteria and lactobacilli
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Hand hygiene Procedure Patient
Risk of SSI= Dose of bacterial contamination X virulence/ resistance of patient
Hygienic hand wash: “ Post contamination procedure using a bactericidal wash that is active against transient organisms to prevent further transmission”
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Asepsis in Surgery
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Hygienic hand rub
Bactericidal agent which is alcohol based without the addition of water
Contains emollient
Fast acting and easy to use
Can be used repeatedly
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Surgical scrub To remove debris and transient micro organisms
from nails, fingers and forearms
Reduce the resident flora to a minimum
Inhibit rapid rebound growth on bacterial flora
The anti microbial agent should reduce micro organisms on intact skin, be non irritant, broad spectrum, fast acting and have a residual effect.
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Fingernails Sub ungal regions harbour bacteria
Trimmed nails
No varnish or artificial nails
Use a scrub
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Patient preparation Length of stay proportional to SSI rate
MRSA colonisation
Shower with antiseptic agent
Shaving before procedure
1% Iodine or 0.5% Chlorhexidine in 70% alcohol
Care with diathermy
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Drapes Aseptic barrier
Careful placement around surgical field
Cotton vs. disposable
Wet drapes provide ideal culture medium
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Antiseptic agents Rapid action Broad spectrum Persistent effect Safety Acceptability
Alcohol, chlorhexidine, Triclosan, Iodine, Iodophores
Binds to stratum corneum
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Antiseptic agents
Alcohol
Chlorhexidine
Triclosan
Iodine / Iodophores
Denaturation of protein
Disruption of cell wall
Disruption of cell wall
Oxidation/substitution of free iodine
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Skin care
Avoid damaged / cracked skin
Latex allergy
Gloving
Emollients
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A good scrub..
a) Thoroughly moisten hands and forearms
b) Sub ungal areas cleaned with nail cleaner
c) Apply antimicrobial agent with friction
d) Fingers and arms scrubbed on 4 sides
a) Hands higher than elbows
b) Avoid splashing
c) Discard brush
d) Repeat as necessary!
• Thoroughly moisten hands and forearms
• Sub ungal areas cleaned with nail cleaner
• Apply antimicrobial agent with friction
• Fingers and arms scrubbed on 4 sides
• Hands higher than elbows
• Avoid splashing
• Discard brush
• Repeat as necessary!
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Decontamination
Decontamination- process of removing or destroying micro-organisms and organic matter. Making a re-usable item safe for patients and staff.
Cleaning- process that physically removes organic matter ( blood, tissue, body fluids) but does not remove micro-organisms.
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Decontamination
Disinfection- process that reduces the number of micro-organisms to a level that is not harmful at the site of use. Kills or removes micro-organisms with the exception of bacterial spores.
Sterilisation- process which frees an object of all living organisms.
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Methods of decontamination Disinfection
Physical- Low temp steam Boiling water Washer disinfections
Chemical Chemical disinfectants (Glutareldehdye 2%, Cidex, Miltons, Clearsol,
alcohol)
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Methods of Sterilisation
Steam (autoclaving) Hot air (ovens) Ethylene Oxide Low temp steam and formaldehyde Gas plasma Irradiation Sporicidal chemicals
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Drains
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Drains
Apparatus used to remove debris after surgery
Early drains were gauze or rubber
Modern drains - plastic, siliconised, soft rubber
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Drains
Types of drains
Open drains
Closed drains suction or free sump drains
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Drains
Open drains External end left free Collection into bag or gauze Closed drains External end into collection
device Suction may be applied
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Drains
Open drains soft and atraumatic open system - bacteria skin in contact difficult to measure demanding nursing care can’t handle large amounts no suction
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Closed drains closed system - bacteria can be minimised skin - effluent diverted away easy to measure easier to nurse can handle large amounts suction available stiffer - more traumatic
Drains
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Using Drains
Decide on indication Decide on drain type Positioning Care - complications Removal
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Drains - Indications Prophylactic
anticipated collection leak after anastomosis abscess wall continues to secrete
Therapeutic collection present pneumothorax, haemothorax liver abscess peritoneal haematoma
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Body areaBody areahead/ neck /joints head/ neck /joints
small calibersmall caliberabdomen/thoraxabdomen/thorax
any caliberany caliber
Type of fluidType of fluidviscousviscous
large caliberlarge caliberirritatingirritating
closed systemclosed system
Amount of fluidAmount of fluidlarge amountslarge amounts
suction ± sumpsuction ± sump
Drains - Type
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Drains - Position
Dependent
Not in contact with bowel if possible
Away from anastomosis
Never through main wound
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Drains - Complications
Blockage Dislodge in or
out Viscera damage Skin infection Cavity infection
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Drains - Care Check for blockage
ensure suction working empty containers
Ensure secure anchor Protect skin
keep dry dressing change
Cavity infection remove early antiseptic in collection container
Monitor amounts and type of fluid
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Drains - Removal
Therapeutic indicationTherapeutic indication AmountsAmounts
abdomen/chest < 100mlsabdomen/chest < 100mls head/neck <20 mlshead/neck <20 mls
Imaging ensures cavity recoveredImaging ensures cavity recovered May remove in stages to allow collapse of cavityMay remove in stages to allow collapse of cavity
ProphylacticProphylactic Time of event has passedTime of event has passed
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Case discussion
This is 20 year old male patient who had surgery a week ago
What has happened?
Signs & symptoms
Investigations?
Treatment?
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Case 2