Asepsis & Antisepsis in

Surgery
Dept of Surgery
National University of Singapore
sepsis in Surgery
sepsis : freedom from infection or
prevention of contact with
microorganisms
septic technique : instruments, air,
drapes, gloves and gowns are free from
microorganisms
ntisepsis : prevention of sepsis by
inhibition or destruction of agents
Asepsis
Defined as a process or procedure performed
under conditions in which bacterial
contamination has been minimised
1847 Semmelweis
1865 Lister
sepsis
%echnique
wash hands and instruments with
carbolic acid
wear gloves
spray OT with carbolic acid
ister - ,ncet 1867
amputation mortality 46% F15%
sepsis Today
%
air changes per hour
filtered air
laminar flow if needed
Surgeon
hand scrub iodophors or
hexachlorophene solution
sterile gloves - technique
sterile gown - technique
aseptic technique in surgery
sepsis today
Patient
shave only day of op
skin prep with iodophor or hexachlorophene
drape with impermeable membrane
protect wound
beware long surgery, drains, other illness
nstruments - autoclave or gas sterilised
Antisepsis
acterial flora
Resident: Coag ve Staph, Corneybacterium,
cinetobacter, enterobacterium
Transient: Staph aureus, MRS
Antisepsis- Destruction or remov, of the
tr,nsient for,
Surgic, Site Infection (SSI)
1-15% of nosocomial infections
6% at the incision site
Significant morbidity and mortality
ncreased hospital stay and costs
Superfici, Incision, SSI
Occurs within 3days and involves skin or
subcutaneous tissue and one of the following
Purulent discharge
Positive culture
Clinical signs of infection
Clinical diagnosis
Deep incision, SSI
Occurs within 3days if no implant left in situ
Occurs within 1yr if implant left in situ and
one of the following
Purulent discharge from deep incision
Dehisence of deep incision
Discharging abscess
Clinical diagnosis
rg,n/Sp,ce SSI
Occurs within 3days if no implant left in situ
Occurs within 1yr if implant left in situ and one of the
following
nfection involves organ/ space or any related
anatomy
Purulent discharge from deep space
Positive culture
Deep abscess confirmed clinically or radiologically
Clinical diagnosis
Surgic, wound c,ssific,tion
Clean / Class - Uninfected operative wound in
which no inflammation is encountered. Primary
closure with closed drainage. Respiratory,
alimentary and genito-urinary tracks are not
involved. (1.5%)
Clean-contaminated/ Class - ny operative wound
in which the respiratory, alimentary or genito-urinary
tracks are opened in a controlled manner without
contamination. (8%)
Surgic, wound c,ssific,tion
Contaminated/ Class - Open fresh accidental
wounds. Operations with major break in sterile
techniques. Gross contamination or major spillage.
Non purulent inflammation (1-15%).
Dirty-infected/ Class V- Old traumatic wounds with
devitalised tissue and those that involve existing
clinical infection or perforated viscera. Organisms
involved were present in the operative field before
the operation (5%).
!,tient f,ctors
ge
Nutrition
DM
Obesity
Smoking
Colonisation
mmunosuppression
lood transfusion
naemia
Malignancy
Co-existing infection
Length of pre-operative
stay
per,tive f,ctors
Category of operation
Duration of operation
Skin asepsis
Surgical scrub
Preoperative shaving
Preoperative skin prep
ntimicrobial
prophylaxis
OT sterilisation
Sterilisation
Foreign material
Surgical drains
Surgical technique
Poor haemostasis
Dead space obliteration
Tissue trauma
orm, body for,
natomical site
Head and neck
Thorax
Upper G
Lower G
Female genital tract
Flora
Staph (aureus & coag neg), Strep,
cornybacteria, Neisseria,
haemophilus, anaerobes
Staph (aureus & coag neg),
s oropharyngeal and Gram neg
rods including enterobacter,
Lactobacilli
erobicGram neg rods including
enterobacter, enterococci.
naerobes- bacteroides, clostridium
yeasts
Large bowel flora, Staph , Strep,
corneybacteria and lactobacilli
,nd hygiene
Procedure
Patient
Risk of SS= Dose of bacterial contamination X
virulence/ resistance of patient
Hygienic hand wash: " Post contamination
procedure using a bactericidal wash that is active
against transient organisms to prevent further
transmission
sepsis in Surgery
ygienic h,nd rub
actericidal agent which is alcohol based
without the addition of water
Contains emollient
Fast acting and easy to use
Can be used repeatedly
Surgic, scrub
To remove debris and transient micro organisms
from nails, fingers and forearms
Reduce the resident flora to a minimum
nhibit rapid rebound growth on bacterial flora
The anti microbial agent should reduce micro
organisms on intact skin, be non irritant, broad
spectrum, fast acting and have a residual effect.
ingern,is
Sub ungal regions harbour bacteria
Trimmed nails
No varnish or artificial nails
Use a scrub
!,tient prep,r,tion
Length of stay proportional to SS rate
MRS colonisation
Shower with antiseptic agent
Shaving before procedure
1% odine or .5% Chlorhexidine in 7% alcohol
Care with diathermy
Dr,pes
septic barrier
Careful placement around surgical field
Cotton vs. disposable
Wet drapes provide ideal culture medium
Antiseptic ,gents
Rapid action
road spectrum
Persistent effect
Safety
cceptability
lcohol, chlorhexidine, Triclosan, odine,
odophores
inds to stratum corneum
Antiseptic ,gents
lcohol
Chlorhexidine
Triclosan
odine / odophores
Denaturation of protein
Disruption of cell wall
Disruption of cell wall
Oxidation/substitution
of free iodine
Skin c,re
void damaged / cracked skin
Latex allergy
Gloving
Emollients
A good scrub..
a) Thoroughly moisten hands
and forearms
b) Sub ungal areas cleaned
with nail cleaner
c) pply antimicrobial agent
with friction
d) Fingers and arms scrubbed
on 4 sides
a) Hands higher than elbows
b) void splashing
c) Discard brush
d) Repeat as necessary!
Thoroughly moisten hands
and forearms
Sub ungal areas cleaned
with nail cleaner
pply antimicrobial agent
with friction
Fingers and arms scrubbed
on 4 sides
Hands higher than elbows
void splashing
Discard brush
Repeat as necessary!
Decont,min,tion
Decontamination- process of removing or
destroying micro-organisms and organic
matter. Making a re-usable item safe for
patients and staff.
Cleaning- process that physically removes
organic matter ( blood, tissue, body fluids) but
does not remove micro-organisms.
Decont,min,tion
Disinfection- process that reduces the
number of micro-organisms to a level that is
not harmful at the site of use. Kills or
removes micro-organisms with the exception
of bacterial spores.
Sterilisation- process which frees an object of
all living organisms.
ethods of decont,min,tion
Disinfection
Physical-
Low temp steam
oiling water
Washer disinfections
Chemical
Chemical disinfectants
(Glutareldehdye %, Cidex, Miltons, Clearsol,
alcohol)
ethods of Steriis,tion
Steam (autoclaving)
Hot air (ovens)
Ethylene Oxide
Low temp steam and formaldehyde
Gas plasma
rradiation
Sporicidal chemicals
Drains
Drains
pparatus used to remove debris
after surgery
Early drains were gauze or rubber
Modern drains - plastic, siliconised,
soft rubber
Drains
%ypes of dr,ins
Open drains
Closed drains
suction or free
sump drains
Drains
Open drains
External end left free
Collection into bag or gauze
Closed drains
External end into collection device
Suction may be applied
Drains
pen dr,ins
soft and atraumatic
open system - bacteria
skin in contact
difficult to measure
demanding nursing care
can't handle large amounts
no suction
osed dr,ins
closed system - bacteria can be minimised
skin - effluent diverted away
easy to measure
easier to nurse
can handle large amounts
suction available
stiffer - more traumatic
Drains
Using Drains
Decide on indication
Decide on drain type
Positioning
Care - complications
Removal
Drains - ndications
Prophylactic
anticipated collection
leak after anastomosis
abscess wall continues to secrete
Therapeutic
collection present
pneumothorax, haemothorax
liver abscess
peritoneal haematoma
ody ,re, ody ,re,
head/ neck /joints head/ neck /joints
small caliber small caliber
abdomen/thorax abdomen/thorax
any caliber any caliber
%ype of fuid %ype of fuid
viscous viscous
large caliber large caliber
irritating irritating
closed system closed system
Amount of fuid Amount of fuid
large amounts large amounts
suction suction sump sump
Dr,ins - %ype
Drains - Position
Dependent
Not in contact with bowel if possible
way from anastomosis
Never through main wound
Drains - Complications
lockage
Dislodge in or out
Viscera damage
Skin infection
Cavity infection
Drains - Care
Check for blockage
ensure suction working
empty containers
Ensure secure anchor
Protect skin
keep dry
dressing change
Cavity infection
remove early
antiseptic in collection container
Monitor amounts and type of fluid
Drains - Removal
%her,peutic indic,tion %her,peutic indic,tion
mounts mounts
abdomen/chest < 1mls abdomen/chest < 1mls
head/neck < mls head/neck < mls
maging ensures cavity recovered maging ensures cavity recovered
May remove in stages to allow collapse of cavity May remove in stages to allow collapse of cavity
!rophy,ctic !rophy,ctic
Time of event has passed Time of event has passed
Case discussion
This is year old male
patient who had surgery a
week ago
What has happened?
Signs & symptoms
nvestigations?
Treatment?
Case