An antisepsis. A care of patients with a purulent pathology.

A bandaging material  and operational linen sterilization. The organization of work in operational block. A surgical treatment of the surgeon's hands and a surgery field.

The organization of work in sterilization room. Preparation and sterilization cutting, optical and surgical instruments. Sterilization of a suture material.

 

ASEPSIS AND ANTISEPSIS

In surgery, infections are very common and may even lead to death in spite of a high quality of operative technique. The prevention of such a complication in surgical practice is therefore a major challenge, which should be based on the principles of asepsis and antisepsis.

Till the middle of the XIX century the main part of the surgical patients died because of different infections. The reason of such a situation was the absence of elements about asepsis and antisepsis. Hands and surgical instruments were cleaned not before an operation but after it. Bandage was used for dressing, it was dried after the usage and applied to another patient, as a result, and hospital infections were quite common. Every other operated patient died. Suppuration of wounds was considered to be an inevitable phenomenon.

English surgeon Pringl J. (1750) was brought the notion about antisepsis (anti suppurative) 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 and iodium. He considered a wound processing an infection and believed the possibility of fighting against it.

The Hungarian obstetrician-gynecologist Zemmelvaise 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.

By means of his numerous tests Lui Paster (1857-1863) proved that the development of microorganisms in some sterile material depends upon the penetration of microorganisms from without.

After 20 years Zemmelvase, Lister J. proposed to use the 2 % - 5 % solution of carbolic acid for a wound as well as for all instruments touching it. For air disinfecting in the operating room, the 2-3 % solution of carbolic acid was sprayed.

Lister J. published the materials of his investigation in 1867 and obtained the recognition - the brought the rules of antisepsis into the life.

In our country the pioneer of Lister's ideas was Sklifasovsky N.W., who worked in Odessa and then in Moscow.

After 15 years Lister noticed himself that carbolic acid is rather dangerous for a human organism and some other antisepsis were founded. At the end of the last century different methods of sterilization of surgical material and instruments were worked out. The scientists worked out methods of extermination of microbes by means of physical methods - high temperature, boiling and steam. A new branch of surgery appears, it is asepsis (without putrefaction), providing sterile conditions of the surgical activity.

Chemi V. was the first man who used the physical chemical sterilization he treated the instruments by means of boiling in the 5 % solution of carbolic acid.

Buhner E. (1878) proposed to sterilize the instruments by boiling, Tertsaron Z. (1883) - by dry steam.

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 Shimelbush K. constructed a sterilizing machine for boiling the instruments; they created metallic drums for sterilization of clothes and dressing, perfected an autoclave.

Bilrot I. said in his time: "With clean hands and clear conscience, an inexperienced surgeon may achieve better results now, than the most famous professor of surgery some years ago".

Asepsis and anesthesiology are the main principles of modern surgery.

Asepsis – the creation of sterile conditions with antisepsis - is the extermination of microorganisms from a wound, supplement each other and provide success in modern surgery.

In the seventies of our century many authors proposed simultaneously the devices for production of sterile air, the so-called aerotherapeutic devices. By means of these devices, the complete sterilization and comfort temperature can be achieved in the operating room. It can be supposed that the perfection of the apparatuses will bring surgery on a higher level. These apparatuses will be very helpful in the time of war.

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 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 of transmission of endogenous infections are direct contact, lympho- and haematogenous spread.

To successfully prevent an infection, it is necessary to affect each stage of the infectious process, i.e. the source of infection, the mode of transmission, and the host.

A surgical hospital contains the main functional blocks, which are as follows: a surgical block, surgery departments, plaster and treatment rooms and dressing rooms.

Antisepsis is a complex of procedures aiming to exterminate microbes from a wound or around it, in pathologic places or in the whole organism, to decrease virulence of microbes and to prevent their spreading.

Types of antisepsis: physical, mechanical, biological, chemical and mixed.

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 (ATD). The wounds are dried; as a result, unfavorable conditions for development of microorganisms are created. All types of physical procedures relate to this method.

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.

Chemical - the use of different chemical substances with bactericidal and bacteriostatic effects. These substances must be safe for the human organism and its cells. They are used for treatment of the operational field, hands of a surgeon, sterilization of gloves, surgical instruments, stitch materials, desinfection of rooms.

Biological - is the procedure aiming to increase the immunity and to strengthen the protective power of an organism. It includes specific vaccines, immuno-serums, globulin, blood transfusion, plasma and anatoxins.

Mixed - the simultaneous use of some types of antisepsis. For example for treatment of wounds: the primary surgical treatment is mechanical, washing a wound and surrounding skin - chemical, the use of antibiotics -biological, putting the dressing-physical.

Antisepsis possesses bactericidal and bacteriostatic effects. The best ones are those, which influence the tissue of an organism a little and, mixing with the contents of the wound, not lose their activity.

Chemical substances

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.

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 surgery and an operating field. They are widely used in surgery for treatment. There are cerigel, degmicide, hexidine chloride, roccal etc.

Chemical therapeutics

This group comprises antibiotics, sulphanilamide preparations, derivatives of nitrofuran, 4 and 8 oxinoline, proteolitical ferments and their inhibitors.

Antibiotics (anti - against, bio - life) relate to the biological antisepsis. Antibiotics are used in surgery as adjunctive measures to prevent potential infection or to treat established infection.

First of all, optimal initiation of therapy requires identification of the microorganism. Because therapy may be required before bacteriologic confirmation of the infecting microbe, the doctor must begin therapy based on the most likely infecting organisms.

Alexander Fleming made discovery of the penicillin mold in 1928.

 There are following groups of antibiotics:

1.       The group of penicillin is produced by different microbes of would - penicillinium. Benzilpenicilline is effective in the treatmen of infection caused by grampositive bacteries (staphylococcus, pneumococcus etc) semisynthetic preparations (oxacillin and methicillin) have provided therapeutic agents to combat this resistant microbe.

2.       The group of cephalosporines - 7-aminocephalosporine acid is their basis; possess a wide range of activities. Like the penicillins, this group has as their mechanism of action the inhibition of bacterial cell wall formation and includes cephalothin, cefazolin, and cephradine. The third generation of cephalosporins has increased antimicrobial activity against Pseudomonas organisms. This generation includes cefoperazone, cefotoxime, and cefuroxime.

3.       Macrolids - the compounds containing a macrocyclical lactonic ling in a molecule. Erythromycin and oleandomycine phosphate are active with grampositive and gramnegative spheres. Erytromycine is taken by 0,5-2,0 gr.

4.       The group of levomycetine - dissoluble succinate and chloticide - 2-4 gr per 24 hours.

5.       Tetracyclines - antibiotics of wide spectrum. Terramycine, neomycine, morphocycline, and rondomycine are brought by means of injections 1-2 gr per 24 hours.

6.       Riphampicins - natural antibiotics, produced by radiant fungus and their derivatives. Ryphampycine - 0,5-1,5 gr. per day.

7.       Antibiotics of different groups:

-            Lincomycin - wide spectrum of activity - 1,5-2,0 gr. in three stages per 24 hours.

-            Ristomycin- 1,0-1,5 ml per 24 hours.

-            Phusidin - 0,5-1,5 gr per 24 hours.

-            Polymixin - intramuscular injection, 0,5-0,7 mg/kg 3-4 times per day.

8.       Antibiotics of last generation.

Mephoxin is the first representative of the new class of antibiotics. It is a half synthetic antibiotic with wide spectrum of activity, parenteral injections (intravenous, intramuscularly) 1g every 8 hours.

Cifran is a new fluorinequinile antimicrobe preparation with wide spectrum of effects with gram-positive and gram-negative bacteria. Cifran as well blocks DNA and violates the function of DNA causing the extermination of bacteria. The antibiotic damages the membrane of a bacterial cell letting the cell contents out.

Norbactin – is effective antibiotic with wide range of activity. The mechanism of activity: it is a specific blockader causing lyses of bacteria, 400 mg once per 24 hours, per orally.

Zanocin - its bacterial effect depends upon its ability to resist to a bacterial ferment DNA and to damage the membrane of a bacteria cell. The preparation with wide spectrum of activity, prescribed - 200 mg twice per day, per orally.

1.       Antifungous antibiotics - nistalin, levorin are active with pathogenic yeast fungi. There are consumes in tablets 250.000 - 500.000, 3-4 times per day.

Sulphanilamid preparations

It is large group with antimicrobial action. They break methabolic processes in bacterial cells and cause bacteriostatic effect. Sulphanilamids differs 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 cells.

Dioxidin is for local use only, in the form of 1 % solution, intravenous injections in 10,0 ml. The dose for 24 hours is 60,0 in 2-3 stages.

Derivatives of 8-oxihynolin possess antibacterial, antiparasitical and antifungous activities.

Hynosol - the solution 1:1000 is used with infections of urogenital tract. Prescribed in 1,0 gr 4 times a day.

Derivatives of 4 nitromidazole are used for treatment of trichomonadosis, amoebias.

Metronidazole is prescribed with purulent process. It is taken orally. Synonyms are trichopole, vaginicid, and clion.

Different antibacterial preparations natural origin.

Chlorophilipt is a derivative of eucalyptus leaves for the local use and parenteral use.

Ectericid contains waterdissoluble products of cod-liver oil oxidation, for the local use only.

Methods of antiseptics usage

Asepsis (without pus) is a system of preventive measures which averts microbes getting into an operating wound, because of some organizational procedures fulfilled by means of physical, chemical and biological methods everything getting in contact with a wound must be sterile. The microflora is extermination: physically - by boiling, hot water steam under pressure, hot air, gamma-radiation, ultra-sound; chemically - ethylene oxide, acetic acid, different antisepsis (disinfections).

The development of asepsis and antisepsis let to form the new branches or surgery-cardio-surgery, microsurgery, transplantology.

The ways of spreading of infections in the organism

The exogenic way: from the air - aerial, dropping, contact, implantation.

The endogenic way of inflammatory processes of integuments of the body, an infections seat of the alimentary canal, infections of breathing tracts, inflammatory processes of urogenital tract, sets of unknown infection.

An operating unit houses special rooms for operating on patients. It has to be isolated from surgery departments on a separate floor or detachment of the building and be connected with them by a corridor.

To provide the regimen of sterility, there are the four special functional zones in the surgical block:

1.       The sterile zone, i.e. the operating theatre (to operate on patients), scrub-up room (for preoperative cleansing surgeons' hands and arms) and the room for sterilisation (to sterilise the instruments to be used during the operation).

2.       The clean zone, i.e. the rooms for personal hygiene and changing clothes of the staff.

3.       The technical zone, i.e. the rooms where apparatus for air-conditioning or oxygen supplying and vacuum devices are stored.

4.       The dirty zone, i.e. the sister's room, the room of the head of surgery and the one for dirty clothes etc.

The operating theatres equipped for using laminated sterile conditioned air are needed for the following types of operation: tissue grafting with subsequent application of immune suppressors, implantation of prosthetics, operations for burns.

Setting of a special isolator box with laminated airflow is possible in the operation rooms built long ago.

The compounds that have antibacterial effects fall into two main groups - chemotherapeutic agents and chemical agents for disinfection and sterilisation.

The compounds for disinfection and sterilisation are used to prevent microbes from entering the wound, i.e. to affect their transmission. Several chemical antibacterial agents can be applied as both chemotherapeutic agents and those for disinfection and sterilisation (e.g. chlorhexidine, hydrogen peroxide).

In the operating room such conditions are created so that there are will be no any possibilities for bringing an exogenic infection into the operational wound. There is a lamp, an operational-table, a table for instruments, stands for an anesthetic apparatus, electric coagulator. People can be let into the operating room only because of extreme necessity and after the sanitary-hygienic treatment.

Cleaning of the room is doing by a damp cloth (1 % chloramin, 3 % hydrogene oxide, 0,5 % detergents).

1.       The current cleaning - they pick balls of cotton from the floor; wipe the blood from the floor.

2.       The cleaning of the operating room after the operation provides its cleanness before the next operation.

3.       The every day cleaning at the end of the operational day and after some extra operations.

4.       The general cleaning is fulfilled once a week according to the plan, in a day free from operations - they use hot water with soap, 3-6 % solution of hydrogene peroxide, 0,5 % solution of detergent.

5.       In the morning before the beginning of work all horizontal surfaces are wiped by means of a damp cloth. Bactericidal ultraviolet lamps are used for disinfections of air. Ventilation is fulfilled by means of conditioners, the filter of which exterminates microorganisms. Temperature is no more than 24° C, humidity is no more than 50 %. For special clean operations they use operating rooms with laminar airflow.

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 120-132° C, pressure - 1,1 atm/cm2 during 45 min. The ray sterilization - is by ionic radiation of high energetic power. They use beta- and gamma-radiations. The ultra-sound 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.

The sterilization is controlled by means of a color thermoindicator or a hydroquinion. The thermoindicator paint is putting on the paper of pale green color; under the temperature of 175-180°C it becomes dark brown.

Except every day control they have a bacteriological control once a week or every 10 days.

The sterilization of instruments

The easiest method of sterilization of instruments is considered to be boiling in the 2 % solution of sodium hydrocarbonate or in water during 45 min. Before the sterilization, instruments are washed with hot water during 30 sec and then they are put into the detergent solution with the temperature of 50°C during 15 min. For 30 sec the instruments are washed in the detergent solution, then in running water, boiled in distilled water and dried by hot air with the cleaning before sterilization is measured with amidopirine, benzidin, fenolphtaleine-tests. These tests show if there are some components of the detergents or blood on the instruments.

In case there is some pus on the instruments the disinfection must be carried out - boiling in the 2 % solution of sodium hydro carbonate. With anaerobic infections the duration of boiling is 90 min.

In air sterilization procedure is carried out during 60 min with t° - 180°C.

Instruments made of corrosion-resistant metals or of plastics are sterilized in the 6% solution of hydrogen peroxide during 90 min. Instruments 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 - 180°C during 60 min.

Endoscopes, catheters, cystoscopes are sterilized by means of glutar dialdehyde and sodium hypochloride, the duration of treatment is 45-180 min.

Sterilization of dressing and operational linen

The dressing materials and linens are placed in special tightly closed drums and are taken to the dressing or operating rooms after the end of sterilization. Before placing the drum in the autoclave, the holes in its sides, lid and bottom be opened to allow the steam to get in. After sterilization, as the drum is removed from the autoclave, these holes must be closed. The drum not be packed too tightly, otherwise enough steam will not pass through the articles and the latter will not be adequately sterilized. Canvas bags or even pillowcases may be used for sterilization if no metal drums are available. The rules of sterilization must be followed strictly.

Before packing, the drums must be wiped dry. The lid must be closed and fastened and the grid opened. All non-sterile drums, as a rule, are kept apart from the drums containing sterile material.

Dressing and linen are sterilized in autoclaves, the pressure —1,1 atm, t - 120°C, during 60 min, or 2,0 atm, t -132°C during 30 min. Linen can be kept in 3 days.

Disinfections of surgeon’s 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.

Classic methods of disinfections of hands according to Furbringer (1897), Spasokukotsky-Kochergin (1829) are not used nowadays, because they demand a lot of time. Now we use quick methods:

1.       The treatment of hands with the solution of hydrogen peroxide and formic acid (1970). At the day of operation they prepare 30-33 % of hydrogen peroxide and 85-100 % of formic acid, the proportion is 1:2.4.

2.       The treatment of hands with chlorhexidine bigluconate (1977). The preparation is mixed with the 70 % spirits; the proportion is 1:40. Hands are washed with soap, dried and wiped twice (by two tampons) with 0,5 % spirits solution.

3.       The treatment of hands with detergents - hands are washed with soap then put into a basin with detergents (“Novost”, “Astra”) for 3-5 min. The solution of detergents is prepared at the day of the operation 1 spoonful for 3 litres of warm water. After drying with a towel, the hands are wiped with the 95 % ethanol during 3 min.

4.       The treatment of hands with degmin and dergycine (1968) - hands are washed with soap during 2-3 min, then wiped by two tampons with 1 % solution of the preparation, 3 min for each tampon, dried and gloves are put on.

5.       The treatment with cerigel. After washing hands with soap, cerigel (4 gr) is put on the hands. Hands are dried by air during 2-3 min. Then the 95 % ethyl spirits washes out cerigel.

6.       The treatment with iodophorm (1972) (1% iodopiron - polyvinilpirolidon) - iodophorm and hexachlorofen in soap solution during 3-5 min. Hands are dried with towel, gloves are put on.

7.       The treatment of hands with ultrasounds. There is a special apparatus with ultrasonic baths, washing and disinfections during 1 min. Hands are put into the solution of an antiseptic (0,05 % water solution of hybitan), through which the ultrasonic waves pass, they provides the disinfections of hands.

The preparation of the operating field starts from the hygienic bath, shaving of hair. For the treatment of the operating field it is used iodonate, iodopiron, chlorhexidin before its usage, dissolving the initial solution in 4,5-5 times boiled or sterilized water. The other antiseptics are used for the treatment of the operating field: 1% solution of degmycide, 1% solution of roccal or catamine A-B, 2,4 % solution of pervomur. For the disinfections of the mucous membrane it is used 1 % solution of diamond green, 3 % solution of hydrogen peroxide, 1 % solution of iodonate or iodopiron, 0,5 % spirits solution of hibitan

Care of patient with an intercostal drain

·        Rapid full expansion of a completely collapsed lung may lead to pulmonary oedema. For very large effusions, clamp the tube for 1 hour after 1.5 litres have drained, before allowing free drainage. Make sure all staff are aware the tube is clamped and what time the clamp is to be removed.

·        Instruct the patient to keep water bottle below waist level, to remember it is attached and not to pull it accidentally.

·        For mobile patients, a weighted metal stand should be used to carry the bottle and to prevent it falling over.

·        Prescribe adequate analgesia (pethidine or morphine may be required) – remember the surgical “injury” you have caused is equivalent to a stab wound.

·        Adjustment of position: If drain is too far in, it is acceptable using sterile technique and after careful antiseptic swabbing, to loosen the retaining stitch and retract the drain a few cm before resecuring it, taking care not to withdraw so far that the side holes leave the pleural space.

·        The drain should NEVER be advanced further into the chest after the initial insertion – this carries infection forward into the pleural space.

·        Only clamp a chest drain if draining a very large effusion (see above), if the bottle breaks or the tube becomes disconnected.

·        If a patient with a chest drain in situ requires transfer by ambulance a trained nurse with experience in the management of chest drains must be part of the escortAlastair Innes, April, 2007