Sterile Precautions

Wound infection results from bacterial contamination

What is the source of bacterial contamination of surgical wounds?

1- Endogenous (from the patient himself):
Patients skin flora (skin preparation) Patients viscera (colon preparation before resection)

2- Contamination from air in the O.R. :

Personnel circulation in the O.R.

O.R. ventilation.

3- Direct contamination: Instruments, punctured gloves.

The Theatre
The aim is to reduce the number of the organisms in the air of the O.R. to a minimum.

Clean and dirty areas should be separated & well demarcated.

Trafficking of personnel should be kept to a minimum through the sterile area. Doors of the theatre and the O.R. should be closed.

O.R. air quality control

Exogenous wound contamination is mainly air born.

1- Reduce the number of individuals in the theatre.

Pickup other mistakes.

O.R. air quality control

2- Avoid excess movement of individuals in the theatre.

O.R. air quality control

3- Doors should be closed.

O.R. air quality control

4- Air vents should not be obstructed.

O.R. air quality control

Ideal situation:

controlled ventilation with air filters

(changing the air of the theatre 20 times / hour)

This is important in orthopedic surgery were air is the main source of wound contamination.

Instruments

Instruments
Cleaning instruments (removal of contamination) is an essential step before sterilization (destroying microorganisms)

Definitions
Sterilisation Disinfection

Complete destruction of all viable microorganisms including spores & viruses.

Reduces the number of viable microorganisms

Solid instruments

Skin & delicate instruments

Sterilisation

by steam

Autoclaves
It kills vegetative bacteria (including TB), viruses (e.g. Hepatitis) & heat resistant spores.

Autoclaves
Organisms are killed by the combined effect of pressure, moist heat & time.
Temp. Press. Time 134 C 30 lb/in2 3 min. 121 C 15 lb/in2 15 min.

Unwrapped instruments can be sterilised in small autoclaves within the theatre.

This is suitable to sterilise instruments when accidentally dropped.

Monitoring of adequate sterilisation

Chemical indicators

Before

After

Chemical indicators

Sterilisation by Ethylene Oxide Gas

For heat sensitive materials including

electrical equipments.

Sterilisation by Ethelene Oxide Gas

Ethylene Oxide reacts

with organic debris

(serum) forming toxic

compounds, so dont use

it with contaminated

equipments (ventilator

equipments)

Sterilisation by Hot Air

oven

Compared to moist steam sterilisation it is less efficient.

It does not cause corrosion, so it is used for instruments with fine cutting edges

(opthalmic instruments).

Sterilisation with

gama rays
Industrial process used to sterilise large batches of similar products, such as syringes, catheters and

intravenous cannulas.

Disinfection
(reduce the number of the viable organisms)

Levels
High Medium Low

Spores, bacteria & viruses.

Bacteria & viruses

Bacteria & weak viruses.

Disinfection
The efficacy of disinfection depends on:

The nature of the microorganism. The load of the microorganism. Duration of exposure to the agent. The temperature.

Disinfection
Boiling water (100 c for 5 minutes)

Low temperature steam (73 c for 20 minutes)

Formaldehide gas (in air tight cabinet at 50 c)

Glutaraldehyde solution (2%)

Kills most bacteria & viruses. Used for Endoscopes

Disinfection with

Toxic; should

be washed.

Theater Staff
Personnel with infected skin lesions or upper respiratory tract infection must be excluded from the O.R. team.

To decrease the bacterial count in the air of the O.R. You should change your normal clothes to clean O.R. linen before entering the theater.

Cotton gowns cannot serve as a barrier (cotton pores are 100 um in

size while skin scales are 5-60 um)

Wrong

Wrong

Caps & Masks

Protects the wound from organisms (in the oropharynx).
Offers protection to the wearer.

Caps & Masks

Wrong

Wrong

Caps & Masks

Wrong

Right

Scrubbing
Povidone Iodine or chlorhexidine soap, for 3-5

minutes.

Scrubbing
Use the brush for the nails.

Scrubbing

Wrong

Scrubbing
Dry your hands
What is wrong?

Street clothes

Gloves
Offers a two-way protection

Preoperative Patient Preparation

Short preoperative hospital stay

(reduces inoculation by hospital resistant organisms).

Preoperative showering.
Shaving (as it causes skin lacerations) should be done in the morning of surgery to avoid skin inoculation by hospital organisms.

Patients skin preparation

In the ward:
Wash the skin of the operation site with soap impregnated detergent (Povidone Iodine or Chlorhexidine) Iodine may cause skin allergy.

history, Patch test)

(Take

Patients skin preparation

In the O.R.

Povidone Iodine or Clohexidine paint.

Patients skin preparation

Allow the solution to dry for maximum bacterial reduction.

Wrong