Slide 1 Asepsis antiseptics. Processing of hands of the surgeon and operational field. Sterilization of linen and dressing.
The ASEPSIS represents system of the preventive actions directed against hit of microorganisms to a wound, fabrics and bodies at surgeries, endoscopy and other medical and diagnostic actions.
The notion about antisepsis (anti suppurative) was brought by the English surgeon Pringl J. (1750) on the base of his observations. He studied the anti-putrefactive effect of mineral acids, which were used for disinfecting of sewage. In the beginning of the XIX century Pirogov N.I, used for the treatment of wounds the solution of carbolic acid, silver nitrate, zinc sulphate, spirits, iodium. He considered a wound processing an. infection and believed the possibility of fighting against it
The Hungarian obstetrician-gynecologist Zemmelvase noticed that the hands of a surgeon were the source of puerperal fever among women in childbirth. He was the first doctor who used chloral water for treatment of the surgeon's hands, birth tracts, instruments and materials. Increase the purulent secretion from wombs of women suffering from puerperal fever, the proved the presence of infections in this secretion. He managed to decrease the birth sepsis in 10 times.
In 1882 Trendelenburg constructed an apparatus for sterilization of surgical material and instruments with dry steam. In 1886 Bloodgood invented rubber gloves for protection of a surgeon's hands from infections. Since 1890 Holoted Y. and Isege (since 1897) became to use gloves for protection of a wound from a surgeon's hands.
Bergman E. and Shimelbus K. constructed a sterilizing machine for boiling the instruments; they created metallic drums for sterilization of clothes and dressing, perfected an autoclave.
The measures to prevent an infection from entering a wound are referred to as asepsis, while those to cause the exclusion or destruction of harmful microbes are generally called antisepsis.
The two principles represent the united whole in the prophylaxis of surgical infections. They have to be considered in terms of the interrelationship between the source of infection and its mode of transmission and the susceptibility of the body.
The source is taken to mean the place of dwelling, growth and proliferation of microorganisms. Relative to the patient the source of infection can be either exogenous (from outside) or endogenous (from within the body).
The main sources of exogenous infections include patients with purulent inflammation or healthy carriers of the microbes, and occasionally animals.
The modes of transmission from exogenous sources are usually as follows: airborne, direct contact and implantation.
The basic principle of an asepsis is underlain in the term: everything that adjoins to a wound has to be sterile, that is is deprived of microorganisms.
All surgical patients taking into account rendering this or that type of an operational grant to them have to be divided into 2 streams: pure and infected. Therefore, the asepsis includes the following complex of actions directed against hit of an infection to a wound.
It: a) implementation of special, sanitary and hygienic, organizational events in medical institution; b) observance of special rules of work of the surgeon and crew in general (during operation, bandaging); c) special processing of hands of the surgeon, d) sterilization of tools, materials, devices.
To prevent hit of an infection in a wound, it is necessary to know its sources and ways of distribution.
The major sources of endogenous infections incorporate chronic infections outside the area of the operation (e.g. skin diseases, dental or tonsillar conditions) or of the organs operated on as is (e.g. appendicitis, cholecystitis, osteomyelitis), as well as the oral, intestinal and respiratory saprophytes.
Among the modes oftransmissionof endogenous infections are direct contact, lympho- and haematogenous spread.
The main sources of exogenous infections include patients with purulent inflammation or healthy carriers of the microbes, and occasionally animals.
The modes of transmission from exogenous sources are usually as follows: airborne, direct contact and implantation
Microorganisms from environment can get into a wound in three ways:
In the air way from air, air with dust particles on which settle microorganisms, allocations from a nasopharynx and the top airways of patients, visitors and medical staff, wound separated from purulent wounds.
Contact (tools, linen, dressing)
In the implantation way of infection (sutural material, grids, artificial limbs of vessels, etc.)
The principle of observance of rules of an asepsis is the cornerstone of planning and the organization of a surgical hospital. The main structural divisions of a surgical hospital are: a) reception, b) medical and diagnostic offices and c) operational block.
The main objective of a reception division of a flow of patients on "pure" and "purulent", sanitary and hygienic processing of patients (partial, full) depending on planned or emergency hospitalization. For observance of this principle surgical offices of versatile hospitals are located on the top floors of buildings, and rooms are adapted for repeated damp cleaning with application of antiseptics.
The access control of offices limited for visitors, the most strict working hours of surgical divisions, including special methods of their cleaning also belongs to organizational measures.
Prevention of an airborne infection. The main methods of prevention of hit of microorganisms include in air and their destructions: correct planning and corresponding equipment of rooms; carrying out regular damp cleaning of rooms; air sterilization by the bactericidal ultra-violet lamps placed over an entrance to the room at distance of 2-3 m from each other (operational, dressing, procedural offices, postoperative and resuscitation chambers, chambers for purulent patients). In operational, dressing obligatory wearing masks, the personnel of surgical divisions it is obliged to observe and control personal hygiene, carrying overalls, hats and boot covers in the operational.
The operational block is the purest place of a surgical hospital where observance of rules of an asepsis is strictly obligatory. The device of the operational block is based on the principle of zonality which consists in increase of requirements of an asepsis as approaching the operational hall.
There are 4 zones of sterility in the operational:
1 zone (absolute sterility) includes rooms to which concerning an asepsis strict requirements are assumed (these are operational halls and sterilizing).
2 zone (relative sterility) are rooms which are directly connected with operational (preoperative, narcotic).
3 zone (the limited mode) make rooms for storage of blood, the figurative equipment, devices for service operational, the room of surgeons, nurses, anesthesiologists, laboratory.
4 zone (the all-hospital mode) includes rooms the entrance in which isn't connected with passing through the sanitary inspection room or a lock.
The corresponding mode of sterility is reached by observance of certain measures of the prevention, distribution of microorganisms in operational. For this purpose there are following types of cleaning operational:
The preliminary consists in damp wiping of horizontal surfaces and all subjects, preparation of tool tables at the beginning of the working day.
The current cleaning is carried out to operating time, incidentally fallen subjects, removal of the used dressing gather from a floor.
Final cleaning is carried out at the end of the working day. It consists in washing and damp wiping of window sills, heaters, furniture and a floor with application antiseptics. After cleaning the room is irradiated with ultra-violet light, including wall or ceiling irradiators for 60 minutes.
Clear-out is carried out once a week (the fixed day). The equipment with use of disinfecting solutions is processed by wall antiseptics.
There are superpure organs transplantation, operational for performance of operations, the burn patients having the huge area of entrance gate for an infection. It is necessary to carry the operational to them:
- with a laminar stream of air (air arrives via the bacterial filter);
- baroperatsionnye-pressures chamber with an elevated pressure (on surgeons - special hermetic suits, on the head device for breath).
- with the abakterilny environment
Control of the mode of sterility of the operational block is exercised by bacteriological researches of air operational once a month.
It is necessary for the prevention of contact infection, what everything that adjoins to a wound, was sterile. It is reached by sterilization of surgical tools, operational linen, dressing and surgical linen, hands of the surgeon, an operational field.
Preventive measures of contact and implantation infections
Sterilization is achieved by means of physical and chemical methods.
Physical - thermal and ray sterilization - boiling, the sterilization by steam under pressure, dry heat sterilization, gamma-radiation.
Chemical - the sterilization by ethylene oxide, the treatment by acetic acid, the chemical therapeutic treatment. Sterilization in the autoclave (water steam) is fulfilled with 120-132ฐ C, pressure - 1,1 atm/sm2 during 45 min. The ray sterilization - is by ionic radiation of high energetic power. They use beta- and gamma-radiations. The ultra-ionic sterilization is also possible - the sterilizer is filled with some antiseptic, which under the influence of ultrasonic waves sterilizers surgical instruments.
The chemical sterilization: ethylen oxide possesses a bacterial effect. By means of gas sterilization they treat the instruments of which cannot be treated in autoclaves or air sterilizators. They use ethylen oxide for sterilization of catheters, gloves, endoscopes, apparatuses for the artificial blood-circulated room.
Slaid 15Sterilization of dressing, operational linen.
Gauze balls, tampons, napkins, bandage, turunda, wadded and gauze tampons belong to dressing. Dressing is prepared usually just before sterilization, using special receptions for prevention of fall of separate threads of a gauze. For convenience of calculation balls stack on 50-100 pieces. Dressing isn't reused and after application is burned.
Requirements to dressing: to be biologically and chemically intact, to possess good hygroscopicity, to be minimum loose, soft, elastic, not to injure fabric, it is easy to be sterilized and not to lose the properties, to be cheap in production.
Surgical dressing gowns, sheets, towels belong to operational linen and podkladny. Material for their production are cotton fabrics. The operational linen of repeated application after use passes washing, and separately from other types of linen.
Ways of laying in the steam sterilizer: the linen and dressing keeps within the steam sterilizer so that it was possible to take any them them, without having affected another for what the sector of the steam sterilizer (universal laying) is allocated for each subject, or the steam sterilizer is filled with a certain type of material (specific laying); purposeful laying - keeps within the steam sterilizer the dressing and operational linen, tools intended for one typical operation (a kateterization of a subclavial vein, for peridural anesthesia, a trakheostomiya).
Dressing and linen will be sterilized in the autoclave at 132 ฐC; 2 atm 20 minutes. Before sterilization dressing and linen keeps within packings for sterility preservation.
Sterility preservation term the windows of steam sterilizers 3 days; steam sterilizers with the anti-bactericidal filter 21 days. If the steam sterilizer opens for a capture of part of material, the left material is considered rather sterile during a shift (6 hours).
The term of preservation of sterility of packing with a double layer of nonwoven fabric 3 months, a layer of krepirovanny paper with a layer of nonwoven fabric 2 months, a kraft-package 3 days.
The sterilization of instruments.
► In air sterilization procedure is carried out during 60 min with tฐ - 180ฐC.
► Instruments made of corrosion-resistant metals or of plastics are sterilized in the 6% solution of hydrogen peroxide with temperature 180ฐC during 360 min. Instrument are sterilized also in the solution of 3 components (2 % formaline, 0,3 % phenol, 1,5 % sodium bicarbonate) during 45 min.
► Syringes are sterilized in dry-hot case with temperature - 180ฐC during 60 min.
► Endoscopes, catheters, cistoscopes are sterilized by means of glutar dialdehyde and sodium hypochloride, the duration of treatment is 45-180 min.
Sterility quality control
Distinguish visual, physical, chemical, bacteriological types of control.
- Visual control. Check correctness of use of packing materials, level of loading of packings and sterilizing cameras, validity of the chosen sterilization method.
- Physical control. Estimate indicators of instrumentations of the sterilizing equipment: the maximum thermometers, manometers and the level of a deviation of indicators from standards.
- Chemical control. Carry out by means of chemical test indicators. Today it is necessary to use test indicators of 4 generations which allow to control all parameters of sterilization (pressure, temperature, time). Distinguish test indicators for control out of packing and in packing.
Internal indicators are placed in packing on 3 levels at uniform laying (at the mixed bookmark in each type of the sterilized material place the additional test). Internal test indicators allow to control sterilization parameters in packing. External test indicators control sterilization parameters in the sterilizing camera and are placed in certain points of the camera.
Test indicators are estimated directly after the end of sterilization (external test indicators) and after packing opening (internal).
Rules of a laying of the test indicator in sterilizing packings:
- in uniform laying test indicators are put on three levels (a bottom, the middle, top).
- in the combined laying test indicators are put on 3 levels and in addition in the middle of each type of material.
In soft laying of small volume is admissible to put one test indicator in the middle.
Bacteriological control (direct control method) is exercised by crops of dabs taken from various sites of the sterilized material, tools, skin of hands of the surgeon. For the operational block, intensive care units of research on quality of sterilization 1 time in 10 days, for other regime offices once a month is carried out; 2 times a year similar researches are conducted by SEA sanitary-epidemiological station.
Among contact ways of transfer of an exogenous infection the main place is taken by the direct method of a kontamination which is carried out directly through hands of members of surgical crew.
Disinfections of surgeons hands
Disinfections of hands are a good removal of microorganisms from the hands. And such a case they use the tannage of skin, which prevents the penetration of microorganisms onto the surface of the skin. The principal of surgical treatment: care of hands, care of nails, the mechanical cleaning is with soap and a brush during 2- 5 min, then disinfections. A disinfectant must be:
1. exterminate the micro flora quickly;
2. exterminate microbes in the juice of gloves;
3. possess a cumulative effect - hands must be free from microorganisms even in the intervals of disinfections;
4. not irritate the skin.
The most often now in use of mechanical cleaning and disinfection.
Modern ways of processing of hands
Processing by "Pervomur" is a peroxide of hydrogen + formic acid. Processing assumes washing of hands flowing water with soap, then in a basin with "Pervomur" - 1 minute; the hlorgeksidiny 0,5% spirtovy solution of 2-3 minutes; degminy, degmitsiny (cleaners) 5-7 minutes;
the tserigely film-forming antiseptics from group of cleaners; the evrosepty the operating beginning ethanol ๕๋๎๐ใๅ๊๑่ไ่ํ 2-3 minutes.
Any of the existing methods of processing of hands doesn't provide an absolute aseptichnost therefore all operations, manipulations
are carried out by surgeons in sterile gloves.
Processing of the operational field Way of Grossikha-Filonchikov (1904-1908) it is based on a skin tanning which provides an obturation of output channels of glands: grease and stalemate also creates an obstacle for an exit of microbes to a surface (4-fold greasing of skin of 10% iodine solution) 1) in 5-10 minutes prior to operation, 2) before a section, 3) before suture, 4) after their imposing. This method excluded washing of an operational field soap and a brush therefore for mechanical cleaning used gasoline. ]
The antiseptics - system of measures, is directed on reduction of quantity and destruction of microbes in a wound or the patient's organism.
Depending on the nature of the used methods 4 types of antiseptics differ:
The principle of modern antiseptics - complexity, simultaneous or consecutive use of all 4 of its types.
Slaid 31 The mechanical antisepsis: the hygienic bath, shaving, and extermination of tissues lacking vital capacity. In 1898 Fridrih P. proposed the primary surgical treatment of a wound by means of cutting off its borders, walls and a bottom within healthy tissues.
A number of receptons is for this purpose used:
a) the wound toilet - is carried out by removal by tools of the foreign matters which are torn away and freely lying in a wound or by washing away their sterile antiseptic r-mi physiological concentration.
Use of the modern equipment and methods of quantitative bacteriology allowed to use large amounts of the sterilizing liquids for washing. In recent years its processing by means of the pulsing stream is made for a toilet of a wound. By means of cavitation BONDS.
B) Primary surgical processing of a wound the most optimum processing of a wound no later than 12 hours after wound.
C) Secondary surgical processing of a wound is carried out in cases when wound process was complicated by an infectious inflammation. Necrotic fabrics are removed, it becomes clear, whether isn't present in a wound of purulent pockets or zatek. Seams on a wound aren't imposed, operation finish drainage of purulent cavities.
Physical - the creation of unfavorable conditions for development of microorganisms in a wound and for suction of microbe toxins and products of tissue decay. The drainage provides the outflow of wound contents and promotes the removal of toxins, microbes and products of tissue decay. Irrigation of gauze with hypertonic solutions highly increases its hydroscopic quality but tampons with wound exudation prevent the outflow from the wound, which is why they are not good for drainage.
The open method of treatment can be used (ATU). The wounds are dried; as a result, unfavorable conditions for development of microorganisms are created.
Chemical antiseptics. It is the method of fight against an infection in a wound based on use of chemicals which have bactericidal and bacteriological effect.
Classification of anti-septic tanks. To destination and to a method of application. allocate: 1) disinfectants for processing of tools and washing of walls, floors; 2) antiseptic substances of external application for processing of skin of hands of the surgeon, washing of wounds, cavities; 3) chemotherapeutic means - in an organism - chemical antibacterial means for fight against an infection in a wound.
1. The group of haloids - the derivatives of chlorine and iodine. Their interaction with hydrogen of a microbe cell causes coagulation of protoplasm proteins. They use chloramin B (0,5 2% solution), iodonate (1% water solution), uodopiron, and iodophorm.
2. Oxidants, getting in contact with tissue, release oxygen with possesses a strong oxidizing effect, thus unfavorable conditions for anaerobic and putrefactive microbes are created. They use: the solution of hydrogen peroxide (3% water solution), potassium permanganate (0,1-2% water solution).
3. Acids and alkalis - more often salicylic acid and boric acid, sodium hydrocarbonat are used.
4. Aldehydes are strong bactericidal preparations: formaldehyde, glutaldehyde, and hexamethylentretramine. Severe toxic.
5. Spirits are strong disinfective means. As usual ethyl spirits (70-96% solution) are used. Slaid 37
6. Hypertonic solutions - are weak antiseptics possessing irritating and counter-attracting effects. They use the hypertonic solutions of sodium chloride (10%), glucose (10% and 40% solutions).
7. Salts of heavy metals - are strong and drastic antiseptics clocking sulphohydrical groups and causing the protein coagulation of microorganisms. Many substances of this type are not used now because of their toxic effects. They use the preparations of silver.
8. Phenols are processing products of coat-tar, oil and resins. They denaturate and coagulate proteins of protoplasma in bacteria. There are phenocarbolic acid, birch tar, ihtiol, and naphtalene oil.
9. Dyestuffs are organic combinations dying tissue and processing bactericidal effect: methylene blue, brilliant green, and acridine lactate (rivanol).
10. Detergents are drastic surface-active combinations, retailing to the group of ammonium bases. They are widely used ammonium bases. They are widely used in surgerv and an operating field. They are widely used in surgery for treatment. There are cerigel, degmicide, hexidine chloride, roccal etc.
Biological antiseptics. In difference from other types of antiseptics it is not simply biological methods of destruction of microorganisms. The biological antiseptics is divided into two look: a) the substances of a biological origin which are directly influencing microorganisms biological antiseptics of direct action (antibiotics, proteolytic enzymes, preparations for passive immunization: medical serums, anatoksina, gamma globulins, bacteriophages, hyperimmune plasma); b) the substances and methods of various origin rendering stimulating with impact on an organism the mediated action (Ural federal district, the laser, transfusion of components of blood, T-aktivin, the interferon, interleykina, preparations stimulating the specific immune answer, vaccines anatoksina).
Slaid 39 Alexander Fleming made discovery of the penicillin mold in 1928. Main groups of antibiotics
► The group of penicillin
► The group of cephalosporines
► The group of levomycetine
► Antibiotics of different groups
► Antibiotics of last generation
► Antifungous antibiotics
Principles of a rational antibiotikoterapiya:
1) application of antibiotics according to indications,
2) at heavy infections the antibiotikoterapiya is begun with the shock dose exceeding sredneterapevtichesky twice, in the subsequent continue treatment in usual doses according to recommendations in the instruction,
3) to observe within a day frequency rate of introduction, for maintenance of bactericidal concentration of a preparation in blood plasma.
4) At appointment it is necessary to choose an antibiotic on the basis of allocation of microflora and its definition on sensitivity to antibiotics. But what to do if the strain of microorganisms isn't sowed yet and sensitivity isn't defined it? The doctor has to carry out so-called empirical therapy. At empirical therapy there are 2 principles: 1) principle of the maximum range of action, 2) principle of reasonable sufficiency. Therefore at a heavy infection at empirical therapy appoint or a combination of antibiotics of the first stage (penicillin + macroleads + aminoglikozida), or to carry out monotherapy by an antibiotic of the second turn (tsefalosporina, semi-synthetic aminoglikozida), or in hard clinical cases use reserve antibiotics.
Slaid 415) In all cases it is necessary to use compatibility of several groups of antibiotics and other anti-septic tanks since antibiotics are capable to strengthen action of each other (sinergizm) or to neutralize action
(antagonism). Compatibility is determined by special tables or it is specified in the instruction on use of a preparation.
6) Treatment duration antibiotics is controlled by clinical efficiency, but even at normalization of temperature it is continued by 3-5 more days.
7) Change of antibiotics with other group is carried out: at sharp pyoinflammatory diseases in 5-7 days; at an aggravation of chronic processes in 10-12 days.
8) In all cases from the fifth day of an antibiotikoterapiya it is necessary to appoint antikandiozny treatment "Nystatin" or "Levorin".
9) At emergence the dispepsicheskikh of changes of the patient it is necessary to survey on dysbacteriosis (koprogramm) and in the presence of pathology of intestinal microflora to carry out corrective therapy (at the dysbacteriosis caused by an antibiotikoterapiya "Baktisubtil", "Bifidumbakterin", "Befungin", "Laktobakterin" are most effective.
10. Optimum ways of introduction.
It is large group with antimicrobial action. They break methabolic processes in bacterial cells and cause bacteriostatic effect. They differ the sulphanilamids of short activity: streptocid, etazol, sulphadimezin and the sulphanilamides of prolonged activity: sulphapiridasin, sulphadimetoxin, sulphalen and others. Because of their bad dissolubility, sediments may fall out thus blocking liver balls.