3 – Aseptic Principles and Technique Flashcards

1
Q

Surgical site infection

A
  • Infection involving a surgical site within 30 days of surgery (1 year if implants are involved)
  • Account for 1/3 of infections acquired in hospitals
    1. Superficial: skin, SQ
    1. Deep: fascia, muscle, body cavity
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2
Q

Why are surgical site infections bad?

A
  • Patient morbidity or mortality
  • Increased costs
  • Angry clients with suspicions about the surgeons’ competence
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3
Q

History of surgeons

A
  • Used to be very dirty
  • Semmelweis: made doctors wash their hands
  • Then rubber cloves (publicly available in 1964)
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4
Q

Antisepsis

A
  • Killing of microorganisms
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5
Q

Asepsis

A
  • Avoiding introduction of microorganisms
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6
Q

Sterility

A
  • Complete absence of all microorganisms
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7
Q

Surgically clean

A
  • All accessible microorganisms on surface have been removed and clean
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8
Q

Clean surgery

A
  • Body part is entered using aseptic technique and has few microorganisms present
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9
Q

Contaminated surgery

A
  • Microorganisms are present (>million/square cm)
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10
Q

Dirty surgery

A
  • Microorganisms and other foreign materials are present
  • Ex. removing an anal sac
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11
Q

Infected

A
  • Microorganisms multiplying and generally producing a reaction in the patient
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12
Q

What are the sources of microorganisms?

A
  • Environment
  • Equipment
  • Patient
  • Surgical team
  • Surgical site
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13
Q

What are some environmental factors?

A
  • Hospital design or protocols
    o Room=positive air pressure
  • Cleanliness or protocols
  • Traffic
  • Number of people or talking
  • *use of antibiotics
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14
Q

What are some different ways to sterilize equipment?

A
  • Steam
  • Gas (ethylene oxide)
  • Plasma (H2O2)
  • Ionizing radiation
  • Cold chemical
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15
Q

Steam sterilization

A
  • Autoclave
  • Uses steam under pressure for specific time
    o 121 degrees C for 15-30mins
  • Requires
    o Clean instruments
    o Correct packing and wrapping
    o Proper positioning in unit
  • Special certificate program
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16
Q

How do we know if the steam sterilization worked?

A
  • Chemical indicators
    o Autoclave tape: outside the pack (black stripes)
    o Indicator strips: inside the pack
    o ALWAYS USE BOTH
  • Biological indicators
    o Non-pathogenic heat resistant spores (Bacillus spp.)
    o Bacterial growth=entire load NOT sterile
17
Q

Cold chemical sterilization: glutaraldehyde

A
  • Used for some equipment sensitive to heat
  • Can only be used on instruments that can be submerged in water
  • Regular bacteria killed within 10 mins, but 10-12 hrs to kill spores
  • *irritating=must RINSE well
  • Respiratory and dermal irritant
18
Q

Prophylactic antibiotics

A
  • Used to prevent infection rather than to treat it
  • *first generation cephalosporins
    o Staph and Enterobacter: dogs (+Pasteurella in cats)
    o Staph, Strep, E.coli: horses
  • Want high tissue levels at time of skin incision
    o IV is best (give 30-60mins before surgery begins)
    o Some studies: if continue for more than 24hrs after surgery=can increase likelihood of antibiotic resistance and infection
19
Q

Which operations are prophylactic antibiotics appropriate for?

A
  • Significant RISK of infection (contaminated or dirty operations)
  • Long surgeries (>90mins)
  • When large implants placed
  • When infection would be catastrophic
20
Q

Hair removal

A
  • Remove gross contaminants first
  • Tense skin while clipping
  • Clip, DON’T SHAVE (#40 blades recommended)
  • Do clipping after anesthesia is induced: 3-10x higher infection rate if done earlier
21
Q

Why do skin preparation?

A
  • Remove dirt
  • Eliminate transient bacterial flora
  • Reduce resident microbial count
  • Inhibit rapid rebound growth of microbes
22
Q

Skin preparation: antiseptics

A
  • Chlorhexidine followed by alcohol is more effective than povidone iodine (but use it still for eyes and prepuce area)
  • Chlorhexidine binds to keratin=prolonged residual activity
    o Still ~20% flora present in hair follicles
  • Contact time is important
    o Follow manufacturer’s recommendation
    o Minimum of 3min contact time
23
Q

Skin preparation: technique

A
  • Sterile prep: use sterile gloves
  • Use dominant hand to prep, other hand to pick up gauze
  • Circular pattern: from incision site to periphery
  • Do NOT go back to incision stie with same sponge
  • Don’t scrub too hard
24
Q

Protecting the surgical site

A
  • Drapes: barrier to prevent spread of microbes from patient’s skin/hair into incision
    o Cloth: needs special treatment to make it waterproof
     Thread count important
     If water can go through=so can bacteria
     Waterproof coating
    o Disposable
     Synthetic polymers
     Also need special treatment to be waterproof
25
Q

Surgical draping: technique

A
  • Initial layer: use 4 quarter drapes around the prepped area
  • Fold drape edges (makes 2 layers) for extra protection right around wound (and protects fingers when placing it)
  • Secure with towel clamps
  • Final drape: single large drape to cover entire patient and table
26
Q

What do you NO do with surgical draping?

A
  • Readjust drapes once placed (towards the incision)
  • Reuse towel clamps once they’ve penetrated skin
  • Use a penetrating towel clamp to secure the final drape
    o Can use NON-penetrating clamps, but not to the patient
27
Q

Surgeon preparation

A
  • Minimize contamination of incision by surgeon
  • Surgical scrubs
  • Surgical caps
  • Mask: use new one for each surgery
  • Shoe covers/booties OR dedicated shoes
28
Q

Surgical hand scrub

A
  • With antiseptic soap/sponge (under nails!)
  • Ethyl alcohol based rub solution (ex. Sterillium) for waterless scrub technique (used in between if doing multiple surgeries)
  • Short, clean nails
  • No rings/jewellery
29
Q

Surgical gowns

A
  • Waterproof impermeable barrier
    o Cuff are NOT impermeable=cover with gloves
  • Wet=contaminated
  • Use new gown for each surgery
  • No difference in infections if use paper vs. treated cloth as long as it is waterproof
30
Q

Surgical gloves

A
  • Not an absolute barrier (1.5% gloves have holes when open)
  • Up to 60% incidence of glove perforation by end of surgery
    o More common in non-dominant hand
    o Perforation more common during orthopedic surgery (use thicker gloves or double)
  • Change if you notice holes or suspect you punctured the glove
31
Q

Establishing vs. maintaining sterility

A
  • Constant vigilance is necessary
32
Q

What are some other factors that influence surgical site infection development?

A
  • Attention to aseptic technique
  • Tissue trauma
  • Amount of hemorrhage
  • Dead space
  • Surgical time: infection rate doubles each hour of surgery
33
Q

Surgical procedure and site factor

A
  • Overall infection: 5.1%
    o Increases as goes from clean (4.5%), clean-contaminated, contaminated to infected (18%)
  • **GI and feet are more prone to infection
34
Q

What are some patient factors influencing surgical site infection development?

A
  • General health
  • Distant infection
  • Duration of hospitalization
  • Total anesthesia time (increase each hour of anesthesia)
  • Hypotension and hypotension during surgery=increases chances of infection