Arellano University

2010

College of Nursing

Dynamic Learning Program

Principles of Sterile Technique Post-Operative Complication

Rhegell B. Cafirma BSN-9 Grp 35-A

Principles of Sterile Technique

1. Only sterile items ate used within the sterile field. Some items such as linen, sponges, or basins may be obtained from stock supply of sterile packages. Every person who dispenses a sterile article must be sure of its sterility and of its remaining sterile until used. Known or potentially contaminated items must not be transferred to the sterile field, for example a. If sterilized package is found in a nonsterile workroom b. If uncertain about actual timing or operation of sterilizer. Items processed in a suspect load are considered unsterile c. If unsterile person comes into close contact with a sterile table and vice versa. d. If sterile table or unwrapped sterile items are not under constant observation. e. If sterile package falls on the floor, it must be discarded. 2. Gowns are considered sterile only from the waist to shoulder level in front and the sleeves. When wearing a gown , consider only the area you can see down to the waist as the sterile area. The following practices must be observed: a. Sterile person keeps hands in sight and at or above waist level b. Hands are kept away from the face. Elbows are kept close to sides. Hands are never folder under arms because of perspiration in the axillary region. 3. Tables are sterile only at table level. The result is that: a. Only the top of table with sterile drape is considered sterile. Edges and sies of drapes extending below table level are considered unsterile. b. Anything falling or extending over table edge, such as a piece of suture, is unsterile 4. Person who are sterile touch only sterile items or areas: person who are not sterile touch only unsterile items or areas. a. Sterile team members maintain contact with sterile field by means of gloves and gowns. b. Supplies for sterile team member reach them by means of their circulating nurse who opens wrapper on sterile packages. 5. Unsterile person avoid reaching over a sterile field; persons avoid leaning over an unsterile area. a. Unsterile circulating nurse never reach over a sterile field to transfer sterile items b. In pouring solution into sterile basin, circulating nurse holds only lip of bottles over basin to avoid reaching over a sterile area. 6. Edge of anything that encloses sterile contents is considered unsterile boundaries between sterile areas are not always rigidly defined. a. In opening sterile packages, a margin of safety is always maintained. Ends of flaps are secured in hand so they do not dangle loosely. The last flap is pulled

toward the person opening package thereby exposing package contents away from nonsterile hand. b. Sterile persons lift contents from packages by reaching down and lifting them straight up, holding elbows high. c. Steam reaches only the area within the gasket of a sterilizer. Instrument trays should not touch the edge of the sterilizer outside the gasket. d. If a sterile wrapper is used as a table cover, it should amply cover the entire table surface. Only the interior and surface level of the cover are considered sterile 7. Sterile field is created as close as possible to time of use. Degree of contamination is proportionate to length of time sterile items are uncovered and exposed to the environment. a. Sterile tables are set up just prior to the operation b. It is difficult to uncover a table of sterile contents without contamination. Covering sterile tables for later use is not recommended. 8. Sterile areas are continuously kept in view. Inadvertent contamination of sterile areas must be readily visible. To ensure this principles: a. Sterile persons face sterile areas b. When sterile packs are opened in the room, or a sterile field is set up, someone must remain in the room to maintain vigilance. 9. Sterile person keep well within the sterile area. Allow a wide margin of safety when passing unsterile areas. a. Sterile persons pass each other back to back b. Sterile person faces sterile area to pass it c. Sterile person asks nonsterile person to step aside Rather than risk contamination. 10. Sterile persons keep contact with sterile areas to a minimum. a. Sterile persons do not lean on sterile tables and on the draped patient. b. Sitting or leaning against the nonsterile surface is a break in technique. If the sterile teams sits to operate, they do so without the proximity to nonsterile areas. 11. Unsterile persons avoid sterile areas. A wide margin of safety must be maintained when passing sterile areas. a. Unsterile persons maintain at least on foot (30cm) distance from any area of the sterile field. b. Unsterile persons face and observe a sterile area when passing it to be sure they do not touch it. c. Unsterile parsons never walk between two sterile areas d. Circulating nurse restricts to a minimum all activity near sterile field.

Post-operative Complications
General post-operative complications

Immediate: o Primary haemorrhage: either starting during surgery or following post-operative increase in blood pressure - replace blood loss and may require return to theatre to re-explore wound. o Basal atelectasis: minor lung collapse. o Shock: blood loss, acute myocardial infarction, pulmonary embolism or septicaemia. o Low urine output: inadequate fluid replacement intra- and post-operatively. Early: o Acute confusion: exclude dehydration and sepsis o Nausea and vomiting: analgesia or anaesthetic-related; paralytic ileus o Fever (see below) o Secondary haemorrhage: often as a result of infection o Pneumonia o Wound or anastomosis dehiscence o Deep vein thrombosis (DVT) o Acute urinary retention o Urinary tract infection (UTI) o Post-operative wound infection o Bowel obstruction due to fibrinous adhesions o Paralytic Ileus Late: o Bowel obstruction due to fibrous adhesions o Incisional hernia o Persistent sinus o Recurrence of reason for surgery, e.g. malignancy

Post-operative fever

Days 0 to 2: o Mild fever (T <38 C) (Common) o Tissue damage and necrosis at operation site o Haematoma o Persistent fever (T >38 C) o Atelectasis: the collapsed lung may become secondarily infected o Specific infections related to the surgery, e.g. biliary infection post biliary surgery, UTI post-urological surgery o Blood transfusion or drug reaction Days 3-5: o Bronchopneumonia o Sepsis o Wound infection o Drip site infection or phlebitis o Abscess formation, e.g. subphrenic or pelvic, depending on the surgery involved o DVT
o

After 5 days: o Specific complications related to surgery, e.g. bowel anastomosis breakdown, fistula formation o After the first week o Wound infection o Distant sites of infection, e.g. UTI o DVT, pulmonary embolus (PE)

Haemorrhage

If large volumes of blood have been transfused, then haemorrhage may be exacerbated by consumption coagulopathy. May also be due to pre-operative anticoagulants or unrecognised bleeding diathesis. Perform clotting screen and platelet count, ensure good intravenous access and insert central venous pressure (CVP) catheter. Give protamine if heparin has been used. Order cross-matched blood. If clotting screen abnormal, give fresh frozen plasma (FFP) or platelet concentrates. Consider surgical re-exploration at all times.

Infection

Infectious complications are the main causes of post-operative morbidity in abdominal surgery. Wound infection: most common form is superficial wound infection occurring within the first week presenting as localised pain, redness and slight discharge usually caused by skin staphylococci. Cellulitis and abscesses: o Usually occur after bowel-related surgery o Most present within first week but can be seen as late as third post-operative week, even after leaving hospital Gas gangrene is uncommon and life-threatening. Wound sinus is a late infectious complication from a deep chronic abscess that can occur after apparently normal healing. Usually needs re-exploration to remove nonabsorbable suture or mesh, which is often the underlying cause.

Wound dehiscence

Serious complication with a mortality of up to 30%. Usually occurs between 7 and 10 days post-operatively. Often heralded by serosanguinous discharge from wound. Initial management includes opiate analgesia, sterile dressing to wound, fluid resuscitation and early return to theatre for resuture under general anaesthesia.

Incisional hernia

Occurs in 10-15% of abdominal wounds usually appearing within first year but can be delayed by up to 15 years after surgery. Risk factors include obesity, distension and poor muscle tone, wound infection and multiple use of same incision site.

Presents as bulge in abdominal wall close to previous wound. Usually asymptomatic but there may be pain, especially if strangulation occurs. Tends to enlarge over time and become a nuisance.

Respiratory complications

Atelectasis (alveolar collapse): o Caused when airways become obstructed, usually by bronchial secretions. Most cases are mild and may go unnoticed o Symptoms are slow recovery from operations, poor colour, mild tachypnoea, tachycardia and low-grade fever Pneumonia: requires antibiotics, physiotherapy. Aspiration pneumonitis: o Sterile inflammation of the lungs from inhaling gastric contents o Presents with history of vomiting or regurgitation with rapid onset of breathlessness and wheezing. Non-starved patient undergoing emergency surgery is particularly at risk o May help avoid this by crash induction technique and use of oral antacids or metoclopramide Acute respiratory distress syndrome: o Rapid, shallow breathing, severe hypoxaemia with scattered crepitations but no cough, chest pains or haemoptysis, appearing 24-48 hours after surgery o Requires intensive care with mechanical ventilation with positive-end pressure

Thrombo-embolism

Many cases are silent but present as swelling of leg, tenderness of calf muscle and increased warmth with calf pain on passive dorsiflexion of foot. Diagnosis is by venography or Doppler ultrasound. Pulmonary embolism: o Classically presents with sudden dyspnoea and cardiovascular collapse with pleuritic chest pain, pleural rub and haemoptysis. However, smaller PEs are more common and present with confusion, breathlessness and chest pain o Diagnosis is by ventilation/perfusion scanning and/or pulmonary angiography or dynamic CT Management: intravenous heparin or subcutaneous low molecular weight heparin for 5 days plus oral warfarin.

Common urinary problems

UTI: very common, especially in women, and may not present with typical symptoms. Treat with antibiotics and adequate fluid intake. Acute renal failure: o May be caused by antibiotics, obstructive jaundice and surgery to the aorta o Often due to episode of severe or prolonged hypotension o Presents as low urine output with adequate hydration

Complications of bowel surgery

Delayed return of function: o Temporary disruption of peristalsis: may complain of nausea, anorexia and vomiting and usually appears with the re-introduction of fluids. Often described as ileus o More prolonged extensive form with vomiting and intolerance to oral intake called adynamic obstruction and needs to be distinguished from mechanical obstruction. If involves large bowel usually described as pseudo-obstruction. Diagnosed by instant barium enema Early mechanical obstruction: may be caused by twisted or trapped loop of bowel or adhesions occurring approximately 1 week after surgery. May settle with nasogastric aspiration plus IV fluids or progress and require surgery.