Ch 13 OR Flashcards
5 principles of conduct in an OR
Sharing goals
Having clear roles
Mutual trust
Effective communication
Agreeing with measurable processes and outcomes
surgical briefing and debriefing?
Sign-In - Confirm patient, consent, procedues and site
Briefing - Safety checks, steps of procedure, specific measures (ABx)
Sign-Out - Name of procedure, swab count, sharps count, confirm samples to be submitted
Debriefing - Review the procedure, any near-misses, if any different steps should have been taken, disclose the patient plan
What benefits are provided by a surgical checklist?
5
Decrease intra-op surgeon delay >80%
Improve patient surgical outcomes
Decrease intra-op adverse effects
Decrease post-op mortality
Overall reduction in hospital mortality
What is the recommended way for sterile team members to change position?
Back-to-back or face-to-face with adequate space between them
What is the recommended ventilation within an OR?
Horizontal, laminar air flow (constant, unidirectional flow)
Minimum of 15 air exchanges per hour with a minimun 20% outdoor air
30-60% humidity
Temperature 20-23C
Laminar airflow has been associated with a 61% decrease in room bacteria and 92% decrease at the wound site compared to conventional ventilation
Define surgical asepsis
Complete absense of contamination by pathogenic organisms
Define antiseptic and disinfectant
Antiseptic - prevents or reduces the growth or action of pathogenic organisms on living tissue Alcohols, Iodine
Disinfectant - Agents, usually chemical, that destroy most pathogenic organisms but not spores on inanimate objects. (Quaternarium ammonium compounts, phenols, chlorine and compounds)
What are the properties of an ideal drape?
Blood and fluid resistant
Lint free
Anti-static
Able to maintain an isothermic environment
What is the recommended gold-standard hand prep?
Well-formulated waterless hydroalcohol solutions
meta-analysis of human studies showed no difference in surgical site infection (SSI) rates between scrubbing with CHG or PI and using an ABR
k,crosse
ABRs offer comparable or even better efficacy in some aspects, along with advantages in terms of hand health, compliance, practicality, and resource efficiency
Commercial ABRs are considered as effective as a chlorhexidine gluconate (CHG) scrub regarding both immediate reduction of bacterial numbers and persistent effects. One study even demonstrated that a 61% ethanol solution with 1% CHG showed similar immediate efficacy to 4% CHG but improved reduction in bacterial counts at the end of surgery
List the benefits of disposable gowns
less permeable to bacteria
More economical
Decrease surgical infection rate
Bacteria have been found to easily penetrate reusuable woven gowns within 30min
What are the three options for gloving?
Closed
Open
Assisted
Assited gloving it the most sterile way. Closed and open gloving have been shown to cause contamination of the gown, particularly of the cuff, in 100% of cases compared to 0% with assisted
Influence of closed glove exchange on bacterial
contamination of the hands of the surgical team
Biehl 2022
Prospective experimental study.
Sample population: Surgical teams participating in 65 individual surgical
procedures were included, resulting in 200 individual enrollments.
Conclusion: Closed glove exchange did not increase bacterial hand contamination over baseline levels.
Comparative antimicrobial efficacy of 4 surgical hand-preparation procedures prior to application of an
alcohol-based hand rub in veterinary students
Viljoen 2021
To determine the influence of skin preparations before application
of an alcohol-based hand rub
Clinical prospective study.
Sample population: Veterinary students
the participants of groups that performed a hand preparation had lower total CFUs than those that did not perform a hand preparation (P = .001)
Surgeons should wash their hands prior to ABHR
Comparison of hydroalcoholic rubbing and conventional
chlorhexidine scrubbing for aseptic skin preparation in dogs
Asimus 2019
Study design: Experimental study.
Animals: Healthy dogs (n = 6) with no clinical signs of skin disease.
(1) 5 scrubbings with chlorhexidine gluconate and rinsing (CHXG),
(2) washing with mild soap prior to 3 rubbings with hydroalcoholic solution (soap-
HAR), or (3) 3 rubbings with hydroalcoholic solution (HAR
Rubbing with hydroalcoholic (HA) solution was as effective as CHXG
currently no known resistance to HA
Preoperative skin asepsis protocols using chlorhexidine
versus povidone-iodine in veterinary surgery:
A systematic review and meta-analysis
Marchionatti 2022
This study showed that asepsis protocols using chlorhexidine
were comparable to povidone-iodine in preventing postoperative SSI and
reducing skin bacterial colonization.
Insufficient information and detail were frequent among studies and precluded a clear assessment of bias.
Knowledge and attitudes towards surgical safety checklists: a survey of veterinary professionals
Davidow 2023
(66%) believed the checklist had prevented an error or complication.
Implementation of an SSC in an academic teaching hospital decreased
the odds of perioperative and postoperative surgical complications
Conclusion: Trainee surgeons did not have greater intraoperative delays.
Delays were created when surgeons prepared their own instrumentation.
Workflow differed between experts and trainees.
Clinical significance: Advancing a trainee surgeon into the primary role is
unlikely to increase intraoperative delays, which can be reduced by the
inclusion of trained scrub technicians. A focus on efficient hemostasis and
fluidity when suturing may improve operative efficiency for surgical
trainees.
Surgical site infection-inflammation in dogs draped with a single-layer Kraton elastic seal extremity drape for stifle surgery
Morgera 2022
elective orthopedic surgery of the stifle after draping with a single-layer Kraton elastic seal patient drape or conventional double-layer drapes.
Study design: Prospective clinical trial.
Sample population: A total of 789 dogs.
No difference in postoperative infection-inflammation was
detected
Evaluation of Surgical Gown Cuff Contamination During Orthopaedic Surgery in a Veterinary Teaching Hospital
Brand 2023
determine the frequency of positive
cultures of the surgical gown cuffs among scrubbed personnel prior to
41.6%) cultures were positive Staphylococcus, Corynebacterium and
Streptococcus.
Using multivariable logistic regression models, humidity and the number of
individuals scrubbed had a significant effect on the likelihood of positive culture after surgery.
Pre-surgical hand preparation in veterinary
practice
KR Crosse
3 x vet studies: incidence
of glove perforation by end 23.3% (Character et al. 2003), 26.2%
(Hayes et al. 2014) and 17.9% (Biermann et al. 2018).
Staphylococcus pseudintermedius is now identified in recent studies as the most common isolate from canine SSI (Nazarali) can be isolated from veterinarians themselves
A deep sink that reduces splashing, hands-free tap systems and generous space outside a thoroughfare
o Initial scrub times of 10 minutes or longer were reduced to 5 minutes when equal efficacy was demonstrated.
o alcohol-based scrub solutions has shown that scrub times of 2 minutes, or even 1.5 minutes, can be as effective as traditional 3 or 5 minute scrubs, depending on the agent used.
goal of surgical hand srub
- eliminate transient flora
- reduce the resident flora at the start of each procedure
- prevent bacterial growth on the hands for the timespan of the procedure.
World Health Organisation > hands
should be washed in soap and the subungual area cleaned with a nail pick
ABR
ethanol-based rubs have a good
chance of equivalence to 60% propanol (European standard solution) if the concentration is >75% but <95%
CHG component may be
inactivated by emollients or thickeners
alcohol based rubs
Traditional scrub methods employing chlorhexidine gluconate or povidone-iodine have been compared to alcohol-based rub protocols with respect to immediate and prolonged efficacy, safety, cost etc.
Most from human medical facilities, extrapolation of the data to veterinary surgery is appropriate
Learnt from the published data > commercial ABR are well tolerated and as effective as a CHG scrub regarding
1. immediate reduction of bacterial numbers
2. persistent effects.
Across a wide range of products, there are conflicting results in the literature
An ABR (61% ethyl alcohol with
1% CHG) showed an immediate reduction in cfu that
was not different compared to that of a CHG scrub,
but after 2 hours significantly less cfu were present in
the ABR group (Edwards et al. 2017).
VET study: comparing CHG, PI and ABR, > PI significantly less effective at reducing cfu on hands than CHG (Verwilghen et al. 2011b). All these studies used bacterial culture to quantify cfu on participants’ hands as a
proxy for the actual outcome measure of effectiveness, namely SSI.
- Alcohols
o bactericidal activity but have variable efficacy against viruses and are generally ineffective against spores
o denaturing proteins
most effective concentration is reported to be 60% to 70%
o iodine-containing compounds
o Iodine, in its active forms, has rapid efficacy in killing bacteria, spores, viruses, and fungi
o activity is decreased in the presence of organic debris and blood
- Chlorhexidine
scrub formulations are recommended to be 2.0% to 4.0%,
o not considered to be sporicidal at normal temperatures, although sporicidal activity has been reported at higher temperatures (60° to 70° C)
o variable efficacy against viruses and fungi
at higher concentrations, it has a bactericidal effect caused by coagulation of cellular contents
PREPARATION OF THE PATIENT
studies have shown differing levels of microbe reduction with various protocols, very few have documented any associated effect on infection rate
o Approximately 20% of the skin flora remains protected in deeper layers and follicles, no matter which protocol is chosen
o Contact times can vary from as little as 30 seconds with some chlorhexidine-alcohol preparations to 2 minutes with povidone-iodine
