Disorders Of The Scrotum

surgery Surgical Asepsis, Antisepsis

surgical asepsis, antisepsis

definitions žr. 214 (1-3) p. infection

• 
  antiseptikos eros pradžia – 1867 Joseph Lister veikalas “On the Antiseptic Principle in the Practice of Surgery”.
  
• 
  swiss surgeon and Nobel laureate Theodor Kocher 1899 reported 2.3% infection rate in clean wounds; this remains standard for modern surgeons.
  
• 
  antiseptika ir aseptika chirurgijoje neatskiriamos – abi skirtos infekcijai išvengti:
  

Antiseptika - mikrobų naikinimas žaizdoje ir aplinkiniuose audiniuose.

Aseptika – priemonės, neleidžiančios mikrobams patekti į žaizdą (aseptikos pagrindas – sterilizacija).

Dezinfekcija - mikrobų naikinimas aplinkoje.
Sources of perioperative infection (pagal svarbą):

1. 
   patient
   
2. 
   Operating room ENVIRONMENT
   
3. 
   Operating room team
   

1. Patient

N.B. the most important source of contamination in OR is patient!!!

Svarbiausias momentas - preparation of patient's skin:

1. 
   Shower with antibacterial preparation (e.g. chlorhexidine) night before elective procedures.
   
2. 
   Į operacinę atvežamas su bachilais ir kepure.
   
3. 
   Hair removal only when hair may interfere with procedure - use electric clippers (not razor!) in operating room. N.B. shaving with razor night before operation rises wound infection rate by 100%.
   
4. 
   Pasaulyje pripažinti trys antiseptikai:
   

1. 
   Iodophors (e.g. povidon-iodine “Betadine”) - most commonly used antiseptics for intact (!) skin;
   

• 
  iodine has broad-spectrum (fungi, viruses, bacteria).
  
• 
  highly complexed iodine compounds are very stable, do not stain, have no odor, considerably less irritating to tissues than tincture of iodine, prolonged activity (after contact with skin, complexes release iodine slowly).
  

2. 
   Chlorhexidine
   
3. 
   Hexamidine
   

5. 
   Most commonly accepted technique in cleansing patient's skin is to begin with area where incision is to be made and to consider this as cleanest portion.
   

• 
  contaminated sponge stick should never be returned to cleansing solution.
  
• 
  skin is cleansed in ever-widening circles, and surgeon never returns cleansing sponge to incision site from periphery.
  
• 
  pirmiausiai 5-7 minutes ruošiama germicidiniu detergentu, po to antimikrobiniu tirpalu (arba iodine tincture, arba povidone-iodine, arba chlorhexidine)
  

6. 
   Drapes should be nearly impermeable to bacteria, even when wet.
   

• 
  in draping process, material should be held above waist level, in compact position, draping from operative site to periphery.
  
• 
  when placing drapes, gloved hand should be protected by cuffing draping material over hands.
  
• 
  once placed in position, sterile drapes should not be moved or lifted.
  
• 
  kai kurioms operacijoms op. laukas užklijuojams sterilia plėvele – tuomet nenaudoti detergentų odos paruošimui; oda turi būti sausa.
  

2. Operating Room environment

• 
  minimum recommended OR size is 2020 feet (66 m), which allows space for:
  

1. 
   operative team gowning
   
2. 
   patient draping
   
3. 
   other personnel movement without contamination of sterile areas.
   

• 
  dabartinėse operacinėse nei grindys, nei oras nėra infekcijos šaltinis:
  

• 
  nuo grindų pakilusius m/o tuoj pat pašalina ventiliacija (degree of floor contamination should not increase infection rates!);
  
• 
  operacinės oras kondicionuojamas taip:
  
  1. 
     changing air 20-25 times per hour
     
  2. 
     high-efficiency particulate air (HEPA) filter - efficiently removes bacteria and fungi but not viruses!
     
  3. 
     air inflow pattern is designed to decrease turbulence at operating table and prevent entrapment of air from periphery.
     
  4. 
     all OR doors should remain closed.
     
  5. 
     OR air pressure should be positive relative to outside.
     
  6. 
     pabaigus operacijas – kvarcuojama.
     

3. operating room Team

1. 
   scrub hands & arms to elbows with antiseptic solution before each operation.
   

• 
  equally effective agents:
  

1. 
   iodophors
   
2. 
   chlorhexidine + detergent
   

• 
  3-5 minutes scrub time is enough.
  

2. 
   mask should cover mouth & nose comfortably, yet snugly enough to alter projectile effect introduced by talking and breathing.
   

1. 
   No good evidence that shoe covers are beneficial.
   

2. 
   Gloves are commonly made of latex and are disposable.
   

• 
  gloves perform dual function:
  

1. 
   protect patient from surgeon hands.
   
2. 
   protect surgeon from potentially contaminated blood.
   

• 
  pirštinės po nešvaraus operacijos etapo pereinant prie švaraus (pvz. baigus žarnų anastomozę, kai užsidaro žarnos spindis) keičiamos arba nuplaunamos; idealu būtų pakeisti ir chalatą.
  
• 
  incidence of puncture holes is 50-70%
  

• 
  90% perforations in gloves are found after operations that last > 2 hours.
  
• 
  left (nondominant) index finger is most common site for perforation (44%).
  
• 
  pradurtą pirštinę reikia nedelsiant pakeisti (nors mikrobų ant chirurgo rankų ir nedaug, bet jie greitai dauginasi, kai patenka kraujo).
  

• 
  idealiausia dėvėti dvi pirštinių poras (išorinės puse numerio didesnės).
  

3. 
   Most important aspect of gown material is impermeability to moisture (wicklike effect of wet gown transmits bacteria from one side of material to other).
   

1. 
   procedures of small blood loss (< 100 ml.) & short duration (< 2 hr.) - single-layer gown.
   
2. 
   procedures of 2-4 hours or 100-500 ml. blood loss, or any abdominal or chest cavity procedure - reinforced gown.
   
3. 
   procedures lasting > 4 hours or with > 500 ml. blood loss - plastic-reinforced (impervious) gown.
   

4. 
   Instruments should be passed deliberately (arrive securely in surgeon's hand in functional position).
   

• 
  when maneuver is finished, assistant should return instrument to its proper place on stand for future use.
  
• 
  all cables, lines should be secured onto sterile field with nonperforating clamp.
  
• 
  po nešvaraus operacijos etapo instrumentai keičiami.
  

Sterile field should be constantly monitored & maintained:

• 
  every team member should observe for events that may compromise sterile field and initiate corrective action.
  
• 
  scrubbed surgical team members may move from sterile area to sterile area; if they must change positions, they should turn back to back or face to face, while maintaining safe distance between one another.
  

Panaudota literatūra:

Merck Manual 1999

Sabiston Textbook of Surgery 2001

NMS Surgery, Emergency Medicine, Pathological Anatomy, Medicine, Pediatrics

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