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    Surgical Preparation: Lobna El Fiky

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    Mayursinh Solanki
    This document discusses the history and methods of surgical preparation and sterilization. It notes that antisepsis was first observed in ancient Greece and the use of chemicals like mercury chloride and iodine over time. Modern sterilization relies on physical methods like heat, radiation, and filtration or chemical methods. Proper cleaning is essential before sterilization. The main physical sterilization methods discussed are dry heat, moist heat/autoclaving, and radiation. Chemical disinfectants discussed include alcohols, aldehydes, phenols, iodine, chlorine, and glutaraldehyde. Gaseous methods like ethylene oxide are also outlined. Proper sterilization requires following

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    Surgical Preparation: Lobna El Fiky

    Uploaded by

    Mayursinh Solanki
    144 views51 pages
    This document discusses the history and methods of surgical preparation and sterilization. It notes that antisepsis was first observed in ancient Greece and the use of chemicals like mercury chloride and iodine over time. Modern sterilization relies on physical methods like heat, radiation, and filtration or chemical methods. Proper cleaning is essential before sterilization. The main physical sterilization methods discussed are dry heat, moist heat/autoclaving, and radiation. Chemical disinfectants discussed include alcohols, aldehydes, phenols, iodine, chlorine, and glutaraldehyde. Gaseous methods like ethylene oxide are also outlined. Proper sterilization requires following

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    STERILIZATION

    Original Title

    Sterilization

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    This document discusses the history and methods of surgical preparation and sterilization. It notes that antisepsis was first observed in ancient Greece and the use of chemicals like mercury chloride and iodine over time. Modern sterilization relies on physical methods like heat, radiation, and filtration or chemical methods. Proper cleaning is essential before sterilization. The main physical sterilization methods discussed are dry heat, moist heat/autoclaving, and radiation. Chemical disinfectants discussed include alcohols, aldehydes, phenols, iodine, chlorine, and glutaraldehyde. Gaseous methods like ethylene oxide are also outlined. Proper sterilization requires following

    Copyright:

    © All Rights Reserved
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    144 views51 pages

    Surgical Preparation: Lobna El Fiky

    Uploaded by

    Mayursinh Solanki
    This document discusses the history and methods of surgical preparation and sterilization. It notes that antisepsis was first observed in ancient Greece and the use of chemicals like mercury chloride and iodine over time. Modern sterilization relies on physical methods like heat, radiation, and filtration or chemical methods. Proper cleaning is essential before sterilization. The main physical sterilization methods discussed are dry heat, moist heat/autoclaving, and radiation. Chemical disinfectants discussed include alcohols, aldehydes, phenols, iodine, chlorine, and glutaraldehyde. Gaseous methods like ethylene oxide are also outlined. Proper sterilization requires following

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    Surgical Preparation

    Lobna El Fiky
    Assistant Professor of
    ORL, H&N surgery
    Ain Shams University

    Historical perspectives
    Antiseptic

    = Greek for against putrefaction


    Accidental observation of certain substances
    stopped putrefaction of meat
    Mercuric Chloride: Arabian physicians in
    Middle Ages
    Tincture of iodine: 1839
    Pasteurs publication: 1863: microbial origin
    of putrefaction

    Historical perspectives
    As

    often in history of medicine: Change of


    practice depended on the persistence of
    John Lister 1870,
    He introduced vigorous application of phenol
    in surgery, for dressing wounds, for
    sterilization of instruments

    Sterilization
    It

    is the process that destroys all microorganisms


    (including bacterial microspores).
    The skin could never be sterilized without its own
    destruction.

    Disinfection
    A process

    which destroys only the vegetative


    forms of organisms =basically clean.
    A disinfectant (germicide, antiseptic): any
    chemical substance with either a bactericidal or
    a bacteriostatic action.
    Antiseptic -- Agent applied to living tissue
    Disinfectant -- Agent applied to inanimate
    surface

    Surgical Disinfection
    This

    is an essential part of a programme for


    the control of infection.
    High Risk Items: as they come in close
    contact with broken skin or those that breach
    mucous membranes or are introduced into a
    sterile cavity.

    Requirements for decontamination


    practice
    The basic requirements for good decontamination
    practice are:
    A Management control system;
    Appropriate facilities;
    Appropriate equipment;
    Properly trained and supervised staff;
    Ensuring that single use medical devices are not
    reused;
    Records of decontamination are kept.

    Methods of Disinfection

    Physical: The most important as they can be relied on to


    ensure the sterilization of articles used in the treatment
    of patients:

    Chemical: Less effective, used for personnel

    Thermal: Heat or Steam


    Radiation: infra-red radiation, - rays, particles
    Filtration:utilizing filters capable of screening out microorganisms
    Organic
    Inorganic

    Gaseous disinfectants: very efficient, not routine

    Formaldehyde gas
    Ethylene oxide

    MANUAL CLEANING
    Cleaning

    is vital prior to any decontamination


    procedure.
    Detergent removes the nutritive material on
    which bacterial survival and multiplication
    may take place.
    This reduces the number to a level which is
    not harmful for health.

    MANUAL CLEANING
    Effective

    cleaning to remove protein from


    medical devices is paramount (agents such as
    CJD are not inactivated by heat).
    Dismantle or Open the instrument to be cleaned
    Friction for 2-3 minutes
    Brush, Wipe, Agitate, Irrigate, jet wash or hand
    spray the item to dislodge and remove all visible
    soil
    Rinse the item thoroughly with clean water
    Drying

    Physical Methods of Disinfection


    HEAT
    DRY HEAT
    Kills by Destructive oxidation of cell constituents
    Surest incineration
    Hot-air oven:

    inefficient, poor conductor of heat, penetrates feebly.


    160C for 1 hour: damages fabrics, melts rubber
    Used for: Glassware, oily fluids, powders

    Physical Methods of Disinfection


    HEAT
    MOIST HEAT
    Effective at low temperature, in a shorter period of
    time
    Boiling: 100C for 30 minutes
    Pasteurisation: 63C for 30 minutes
    Tyndallisation: steaming for 20 minutes for 3
    successive days
    Steaming under pressure= Autoclaving

    Advantages of steam
    Kills

    by denaturing & coagulating enzymes &


    proteins
    More rapid (maximum needed time 45mn) & at
    lower temperature
    Condensation of steam leads to liberation of
    latent heat which raises the temperature, and
    gives more penetration
    Half dense as air, so has better penetration

    Steam Sterilization: Autoclave

    Principle: An autoclave is a self locking


    machine that sterilizes with the high
    temperature that steam under pressure
    can reach.
    High-vacuum pumps remove as much as
    possible air before the steam is admitted,
    so the required temperature is reached
    very rapidly.

    Steam criteria
    Dry:

    no suspended droplets of water


    Close to its point of condensation: not
    superheated
    Free from air: as it decreases the temperature
    and the penetration
    Temperature

    121C: 15mn-30mn
    134C: 4-7mn Flashing

    Steps of autoclaving

    Water in the surrounding container full and heated


    Articles in cabinet, doors bolted
    Vacuum to evacuate as much air as possible
    Steam is admitted at a high pressure of and when the
    thermometre reaches the required temperature,
    sterilisation begins
    Sterilisation is continued for the required time and then
    the steam is turned off.
    Drying is carried-out by reapplying a vacuum to evacuate
    the steam, introducing dry filtered air into the cabinet (for
    15 minutes).

    Efficient Autoclaving

    All instruments must be double


    wrapped in linen or special paper or
    placed in a special metal box
    equipped with a filter before
    sterilization.
    The white stripes on the tape change
    to black when the appropriate
    conditions (temperature) have been
    met.
    Expiration dates should be printed on
    all equipment packs.
    There should be a uniform
    development of bars throughout the
    length of the strips.
    Ready made plastic bags with strips
    printed with a sensitive ink.

    Control of autoclave efficiency

    Bowie-Dick test: Used for high-vacuum autoclaves, Done


    every day:

    In the middle of a test pack of towel, a paper on to which a strip of


    a specific tape is put, for testing.
    Uniform development of dark color indicates that the steam has
    passed freely and rapidly to the center of the load.

    Biological sterilization indicators: Spores of a nonpathogenic organism: Done weekly

    They are killed at 121C after 15 minutes.


    Attempts to culture them is subsequently made

    RADIATION DISINFECTION
    High

    energy ionizing radiation destroys


    microorganisms and is used to sterilize
    prepacked, Single-use, surgical equipment
    by manufacturers
    Common sources of radiation include
    electron beam and Cobalt-60

    CHEMICAL DISINFECTION
    A SATISFACTORY AGENT SHOULD:
    Be active against a wide range of organisms and
    spores. Only few are truly sterilizer
    Have a rapid action
    Should not be toxic or irritant to the skin
    Should be Persistent

    There is no one disinfectant which can be


    used to kill all micro-organisms in all
    situations.

    Types of Chemical disinfectants


    Inorganic:

    Iodine
    Chlorine

    Organic:

    Alcohols
    Aldehydes
    Phenols
    Cationic surface-active agents

    Inorganic disinfectants
    The halogens: Chlorine and Iodine
    Have a rapid action against vegetative
    organisms and spores= true sterilizers
    Their action is annulled by foreign organic
    material

    Iodine disinfectants

    The broadest spectrum of all topical anti-infectives, with action


    against bacteria, fungi, viruses, spores, protozoa, and yeasts.
    Tincture iodine:
    2.5% iodine & 2.5% potassium iodide in 90% ethanol.
    Best skin disinfectant
    Irritating to raw surfaces: due to its alcoholic component
    Allergic dermatitis
    Iodophors: Solutions of iodine in non-ionic detergents=
    Povidone iodine= Betadine
    Less irritating and less staining
    Less disinfectant than tincture

    Chlorine disinfectants
    Powerful,

    Disinfect water
    Particularly active against viruses
    Concentrated solutions too corrosive
    Usually diluted with a compatible detergent

    Organic Disinfectants

    Alcohols: bactericidal: 50-70% ethanol


    Aldehydes:

    Phenols: continued activity in organic matter as human


    excreta.

    Formalin: irritant, powerful=sterilizer


    Glutaraldehyde: less irritant, not volatile, more rapid action.

    Phenol: Toxic, expensive


    Cresols: Lysol
    Chloroxylenol: Dettol
    Chlorhexidine: Hibitane- Alkanol
    Hexachlorophane

    Cationic surface-active agents:

    Cetrimide: Cetavlon

    Alcohol
    Isopropyl Alcohol 70% (or Ethyl Alcohol 90%)
    ADVANTAGES:

    Causes protein denaturation, cell lysis, and metabolic


    interruption.

    Degreases the skin.


    DISADVANTAGES:

    Ineffective against bacterial spores and poorly effective


    against viruses and fungi.

    Glutaraldehyde (Cidex)
    Cold Sterilization:
    Instruments must be dry before immersion.
    Glutaraldehyde is bactericidal, fungicidal,
    viricidal, and sporicidal
    Sterilization: a 10 hour immersion. This
    prolonged chemical action can be more
    detrimental to surgical instruments.
    3 hours exposure time is needed to destroy
    spores.
    If the instruments need to be "disinfected"
    only, cold sterilization is okay as
    disinfection will take place in only 10
    minutes.

    Lysoformin

    Formaldehyde & glutaral


    Lysoformin: liquid concentrate with which any dilution
    required can be made by simply adding water (20ml + 48L)
    The timing depends on the concentration used:

    flexible endoscopes
    deactivation of HBV & HIV

    1.5 % - 30 min
    2.0 % - 15 min

    Used for heat labile instruments and cleaning


    Does not harm metal instruments

    Chlorhexidine Gluconate
    Hibitane vs Alkanol
    Broadest spectrum
    Better residual activity than iodophors
    Occasional skin sensitivity
    ADVANTAGES:
    Rapid action
    Residual activity is enhanced by repeated use
    Less susceptible to organic inactivation than povidone iodine
    DISADVANTAGES:
    Occasional skin sensitivity.
    Inactive against bacterial spores
    Activity against viruses and fungi is variable and inconsistent
    May harm metal instruments

    Gaseous Disinfection
    Ethylene Oxide Sterilization: EO Gas

    Colorless gas, available as cartridges


    Toxic and flammable, Odor similar to
    ether
    Has an extremely well penetration, even
    through plastics
    Microorganism destruction is caused by a
    chemical reaction
    Effective sterilization is dependent on
    concentration of gas, exposure time,
    temperature, and relative humidity
    Powerful sterilizer: Kills all known
    viruses, bacteria (including spores), and

    EO Gas Sterilizer
    Is

    used in large hospitals, as it is expensive,


    dangerous, needs more expertise.
    Used for heat sensitive instruments: fabrics,
    plastics, suture material, lenses, endoscopes,
    electrical equipment and finely sharpened
    instruments.
    At 20C-25C: sterilization takes 18hours
    At 50C-60C: sterilization takes 4 hours
    In Demerdash: The average of the cycle is 8-14
    hours

    Sterility Check List

    Before assuming a pack is sterile, always


    evaluate the following before opening the
    pack:
    Expiration date
    Indicator color change
    General condition of wrapper and how it
    had been stored
    Always check for holes or moisture damage

    Standards for
    Surgical Scrubbing, Gowning and
    Gloving
    The

    pre-surgical practice of scrubbing,


    gowning and gloving is integral to the
    minimization of risk of infection from microorganisms present in the wound at the time
    of surgery.

    Accessing to the operating theatre

    Wear prescribed
    operating suite attire
    Remove jewellery
    Keep fingernails short,
    clean, healthy
    Wear appropriate
    protective attire: masks,
    head, overshoes..

    REMEMBER
    What

    went inside the machines is


    the STERILISED material
    Personnel are only DISINFECTED

    Surgical Hand scrub

    No touch: infrared robinets, with your elbow, leg


    Use brush??
    The ideal duration of the scrub is not agreed.
    Accepted time is 5 minutes: appears safe
    Some surgeons do not rinse off the chlorhexidine or
    Betadine in order to enhance residual activity.
    Alternative: Two-stage surgical scrub:
    an initial 1- or 2-minutes scrub with 4% chlorhexidine
    gluconate or povidone-iodine followed by application
    of an alcohol-based product

    Surgical Hand scrub

    Trim

    fingernails and Wash for 30-60 seconds


    with surgical scrub.
    Scrub fingers with a sterile scrub brush
    Make sure to scrub all sides of each finger,
    including the area between fingers.

    Surgical Hand scrub

    Scrub hands and arms with a sterile scrub brush. Make


    sure to scrub each surface of each hand and arm
    An accepted contact time is 10 brush strokes per surface
    During scrubbing, rinsing and drying, hands are held
    above elbows. This is done so that water will not be
    dripping from upper arms onto lower arms and hands

    Drying Hands

    A sterile towel is included within the sterile gown pack.


    One hand and forearm are dried by one side of the towel.
    Always dry in the direction of hand to elbow so that
    contamination of the upper arm is not spread by the towel
    to the surgeon's hand.

    Gowning

    All gowns are folded and packaged for sterilization, with


    the inside exposed so that the surgeon may handle the
    gown without contaminating the outside of the gown.
    Grasp the exposed inside of the gown and lift the gown
    away from the table.
    Your hands are disinfected and the gown is sterilized

    Gowning

    Unfold the gown by placing hands into the white arm


    holes. Continue placing hands and arms through the
    sleeves..

    Gowning

    An

    assistant fastens the neck tie and the


    inside waist tie.
    PLEASE: DO NOT DRY YOUR HANDS IN
    THE FRONT OF THE GOWN

    Types of Gowns

    Disposable Paper Gown: resistant to wetting so they


    are less permeable to bacteria, expensive. It is usually a
    wrap around gown. The ties "wrap around" the surgeon.
    Linen (cloth): comfortable and reusable. When it
    becomes wet, bacteria can permeate. The cloth gown is
    also known as a front sterile gown. The gown is just tied
    in the back.

    Gloving
    Sterile surgical gloves can be worn by:
    Open method:

    The gloves are presented to enable the introduction of the


    hands on the inside surface directly
    The nurse with her sterile glove opens the glove for the
    surgeon who introduces directly his hands on the inside
    surface of the glove

    DO NOT ADJUST THE FIRST


    GLOVE BEFORE PUTTING
    THE SECOND ONE !!!

    Gloving
    Closed gloving:
    This

    is the introduction of hands covered with the


    cuff of a sterile gown.
    So, If you are planning on closed gloving, do not
    thrust hands through the cuffs.
    This is usually performed by the first person to be
    sterilized= the nurse

    Gloving: Closed method

    An assistant opens the sterile pack of gloves and drops


    them into the sterile field.
    The inside of the cuff of the glove is grasped by the
    opposite hand (still within the gown) until introduction

    Patient Preparation
    Sterilization

    is best done with a detergent


    followed by a disinfectant on a larger area of the
    surgical field. H&N??
    Use Ample Detergent
    Scrub roughly the skin in any direction for 2-3mn
    ??Remove the excess of the detergent
    Apply the disinfectant first on the most clean
    area
    Scrub in one direction only

    Draping
    Standard

    head drape: two towels, one under


    the shoulders and the other wrapped around
    the head
    Better to suture the drapes to the skin to
    prevent shifting
    Towels are used for lateral draping
    Drapes should lie flat

    Practical Sterilization
    Instruments sterilization
    Metal

    Instruments: Avoid chemical sterilization

    Autoclave
    EO chamber
    Formaldehyde beads or powder

    Sharp-edged:

    avoid heating & wetting:

    EO chamber
    Formaldehyde beads or powder

    Practical Sterilization
    Instruments sterilization

    Catheters, gloves,: depend on pre-sterilized,


    disposable equipment

    Endoscopes: avoid heat

    Radiation
    EO chamber
    Cidex
    Lysoformin
    Autoclaving

    Handles of drills:

    Autoclave after washing and oiling


    EO chamber

    THANK YOU

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