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Title: Sterilization of Operation Theaters


1
SterilizationofOperation Theatres
update
  • Dr.T.V.Rao MD

2
History of Hygiene
  • Bible
  • Book of Leviticus
  • Chapter 11 15
  • Code of Hygiene

3
Greek Era
  • Aristotle Greek Philosopher recommends
  • Boiling water to armies. Advises the
    Alexander.
  • Recommends hygiene for healthy living

4
HAND WASHING- Semmelweis
  • Practices, emphasizes the importance of washing
    hands with chlorinated water in Obstetrics to
    reduce maternal mortality

5
Beginning of Modern Nursing
  • The Very First Requirement in
  • Hospitals that should do the sick no harm
  • Florence
  • Nightingale
  • ( Notes on Nursing 1860 )

6
Florence Nightingale creates fundamentals in
Nursing care
7
Beginning of Safe Operation Theatre Practices
  • 1867 Dr.Joseph Lister first identifies airborne
    bacteria and uses Carbolic acid spray in surgical
    areas
  • 1880 Johnson and Johnson introduce antiseptic
    surgical dressings.

8
Historical Aspects Changed the History
  • Lister era 1868 changed the concept of safe
    surgical procedures.
  • Carbolic Acid in decontamination caused Reduction
    of Hospital associated infections
  • Mortality reduced
  • Morbidity reduced.

9
Sterile Environment reduces Surgical site
infections.
  • Surgical site infections SSI are the second most
    common cause of hospital acquired (Nosocomial)
    infections. These complications of surgical
    procedures cause considerable morbidity and, when
    these occur deep at the site of the procedure,
    can lead to mortality as high as 77. The source
    of SSIs may be endogenous (normal flora of the
    patients skin, mucous membranes, or hollow
    viscera) or exogenous, which includes surgical
    personnel (especially members of the surgical
    team), the operating room environment (including
    air), and tools, instruments, and materials
    brought to the sterile field during an operation.
    By maintaining sterile environment in operation
    theatre we can control major part of exogenous
    infections.

10
What is wrong with our Practices
  • Disinfectants used indiscrimately,
  • Used unnecessarily
  • Not used when needed.
  • Concentration not adequate
  • Economic consideration,
  • Business promotions.
  • Laboratory testing X Hospital conditions may not
    correlate.

11
Economical loss
  • Money wasted on unnecessary use.
  • People concentrate on
  • Floors, Inanimate objects,
  • If the resources are not spend with scientific
    understanding the limited resources are lost in
    particular developing countreis.

12
Basic Principles
  • Cleaning more Important than Disinfection and
    Sterilization ?
  • However
  • Cleaning
  • Removes contaminants,
  • Dust, organic matter,
  • Disinfection
  • Reduces number of microbes

13
Disinfection x Sterilization
  • Sterilization is absolute, removes microbes and
    spores too.
  • To achieve Sterilization is Expensive, not
    sustainable, many times not needed.
  • An effective Disinfection reduces the infections
    drastically.

14
Basic care of Operation Theatres.
  • Reduction of Microbial counts is important.
  • Very rarely the Microbes reach the operation
    site,
  • Paying great attention to Floors Using
    unnecessary, too many chemical not necessary
  • Keep the floor Clean and Dry - Bacteria are
    reduced,
  • Most Important component of Bacteria is water a
    dry areas causes natural death except spores

15
Frequent cleaning of Walls and Roof ofOperation
Theatre is not needed
  • Frequent cleaning has little effect.
  • Do not disturb these areas unnecessarily,
  • Floors get contaminated quickly, depend on
  • Number of persons present in the
  • Theatre / Movements they make, has direct
    relation to increase of bacterial counts

16
Do not disturb the Roof
  • Do not disturb unnecessarily,
  • Do not use ceiling fans they cause aerosol spread
  • Clean only when remodeling or accumulated ,good
    amount of dust.

17
Care of Floors
  • Do remember only 1 of the microbes present on
    the floors are pathogenic.
  • On many occasion S.aureus. Isolated as a
    prominent pathogen
  • Floor should be decontaminated with
  • Vacuum cleaner.
  • and Wet cleaning techniques
  • Keep the mops dry when not in use.

18
How you care for Floors
  • Use only vacuum cleaners
  • Don't broom
  • As it increases the bacterial flora in the
    environment

19
Cleaning the Floor
  • A simple detergent reduces flora by 80
  • Addition of disinfectant reduces to 95
  • In busy Hospitals counts raise in 2 hours

20
Environmental Cleaning of Operation Theatres
  • Do not waste chemicals.
  • Only remove the dust with cloth wetted with clean
    water,
  • Don't use chemicals/Disinfectants as a habit,
  • Use only when contaminated with blood or body
    fluids.

21
Handling of Air in Operation theatre.
  • Negative Air pressure vented to the operation
    theatre.
  • Environmental cleaning should be twice daily

22
Environmental cleaning of Hospital with
Chlorinated compounds.
  • Disinfectant Purpose
  • Sodium hypochlorite Contaminated with
  • Blood and body
  • fluids
  • Bleaching powder Toilets, bathrooms
  • 9 grams/lit

23
Environmental cleaning of instruments and
equipment in OT
  • Disinfectant
  • Alcohol 70
  • used in cleaning Metal surfaces and Trolleys
  • However expensive for hospitals in developing
    countreis

24
Fumigationa biohazard procedure ?
25
Fumigatation
  • Formaldehyde a Age old compound.
  • Low temp heating produce vapor
  • Vapor phase decontaminates the air/environment.
  • Kills vegetative bacteria / Spore ?
  • When Formaldehyde mixed with water and exposed to
    elevated temperature
  • Gaseous formaldehyde is generated
  • Time X Temp

26
Fumigation
  • To sterilize the operation theatre formaldehyde
    gas (bactericidal sporicidal,viricidal) is
    widely employed as it is cheaper for
    sterilization of huge areas like operation
    theatres. Formaldehyde kills the microbes by
    alkylating the amino acids and sulfydral group of
    proteins and purine bases.
  • In spite of the gas being hazardous continues to
    be used in several developing countreis

27
Fumigation
  • Fumigation usually involves the following phases
    First the area to be fumigated is usually covered
    to create a sealed environment next the fumigant
    is released into the space to be fumigated then,
    the space is held for a set period while the
    fumigant gas percolates through the space and
    acts on and kills any infestation in the product,
    next the space is ventilated so that the
    poisonous gases are allowed to escape from the
    space, and render it safe for humans to enter.

28
Procedure of Fumigation
  • Thoroughly clean windows, doors, floor, walls and
    all washable equipments with soap and water.
  • Close windows and ventilators tightly. If any
    openings found seal it with cellophane tape or
    other material.
  • Switch off all lights, A/C and other electrical
    electronic items
  • Calculate the room size in cubic feet (LBH) and
    calculate the required amount of formaldehyde as
    given in

29
Personal care during fumigation
  • Adequate care must be taken by wearing cap, mask,
    foot cover, spectacle .,
  • Formaldehyde is irritant to eye nose and it
    has been recognized as a potential carcinogen.
  • So the fumigating employee must be provided with
    the personal protective equipments.

30
Creating the Formaldehyde gas
  • Electric Boiler Fumigation Method For Each 1000
    cu.ft of the volume of the operation theatre
    500ml of formaldehyde (40 solution) added in
    1000ml of water in an electric boiler. Switch on
    the boiler, leave the room and seal the door.
    After 45 minutes (variable depending to volume
    present in the boils apparatus) switch off the
    boiler without entering in to the room .

31
Methods on Fumigation
  • In principle we have to generate Formaldehyde
    gas.
  • Can be done by
  • Most easier way to mix the needed quantity of
    Formalin to water and heating at lower
    temperatures at 800c 900c
  • Can done also with addition of Formalin to
    potassium permanganate

32
Adding Potassium Permanganate to formaldehyde..
  • Potassium Permanganate Method For every 1000
    cubic feet add 450gm of Potassium permanganate
    (KMnO4) to 500 ml of formaldehyde (40 solution).
    Take about 5 to 8 bowels (heat resistant place
    it in various locations) with equally divided
    parts of formaldehyde and add equally divided
    KMnO4 to each bowel. This will cause auto boiling
    and generate fume.
  • After the initiation of formaldehyde vapor,
    immediately leave the room and seal it for at
    least 48 hours.

33
Fumigation to be neutralized
  • Neutralize Residual formalin gas with Ammonia by
    exposing 250 ml of Ammonia per liter of
    Formaldehyde used.
  • Place the ammonia solution in the centre of the
    room and leave it for 3 hours to neutralize the
    formalin vapor

34
An example is set as..
  • Operation Theatre Volume LBH 20 15 10
    3000 cubic feet
  • Formaldehyde required for fumigation 500 ml for
    1000 cubic feet
  • So 1500 ml of formaldehyde required
  • Ammonia required for neutralization 150ml of
    10 ammonia for 500 ml of formaldehyde
  • So 450 ml of 10 ammonia require

35
Need for Newer Chemical Agents in Hospital Use
  • 1. A need for Non Aldehyde based Chemicals is
    growing concern
  • 2 Need for quicker sterilization methods with
    ever increasing work loads.
  • 3. Need for non toxic safe agents.

36
Several Chemicals are available but the Economic
Limitation are great hurdle in exploring the
Utility in Developing countries
37
Bacillocid rasant
  • Formaldehyde-free disinfectant cleaner with low
    use concentration
  • very good cost/benefit ratio
  • good material compatibility
  • excellent cleaning properties
  • virtually no residue

38
Bacillocid rasant
  • Active ingredients Glutaral 100 mg/g,
    benzyl-C12-18-alkyldimethylammonium chlorides 60
    mg/g, didecyl-dimethylammonium chloride 60 mg/g.
  • Bacillocid rasant is suitable for the
    disinfectant cleaning of washable surfaces using
    the wet-wipe-procedure.
  • Especially suitable for economic short-term
    disinfection in risk areas that are likely
    sources of infection

39
Newer and Non Toxic compounds.
  • A Chemical compound VIRKON gaining importance
    as non Aledyde compound.
  • Virkon proved to be safe
  • Virucidal
  • Bactericidal,
  • Fungicidal
  • Mycobactericidal

40
VIKRON is Finding Place in
  • As a Chemical disinfectant.
  • Disinfects Medical devices.
  • Disinfects Laboratory equipment.
  • Decontaminate spillages with Blood and body
    fluids.
  • Finding usefulness in replacing autoclaving and
    saving time.

41
Guidelines to be considered constructing safe
operation theatres
  • Construction, carpentry, plumbing, electrical,
    cleaning and other works should be completed
    before the initiation of fumigation procedure.
  • If exhaust fan is used (instead of A/C) its
    exterior level fins should be closed.
  • Rooms allotted for operation (as shown in the
    plan) should not be used for other purposes.
  • The Construction must have
  • Separate dressing room for medical officer and
    staff nurses
  • Patient waiting room
  • Operation room
  • Veranda

42
Care of the self and surroundings
  • Theatre dress (includes head cap, mask, apron,
    chapel, should be made available for all persons
    who are entering into the operation theatre
    (surgeons, anaesthetist, microbiologist team,
    nurses, theatre assistants helper).
  • Surroundings should be clean and free from
    garbage, open drainage, bushes, shrubs, wastes,
    donot keep any material which are necessary for
    operation theatre procedures
  • Operation theatre should be cleaned and fumigated
    as the prevailing conditions of working and work
    load,
  • Depends on septic cases handled in the theatre

43
Safety of Air conditioning andWater cooling
systems
  • Legionnaires disease is associated with Air
    Conditioning system
  • Chlorination / Heating of water may prove better
    alternatives.

44
Between procedures in the Operation Theatres.
  • Clean operation tables, theatre equipment with
    disinfectant solution with detergent,
  • In case of spillage of blood / body fluids
    decontaminate with bleaching powder/chlorine
    solution ( 10 available chlorine ).
  • Always discard wastes in prescribed plastic bags
    Dont accumulate biohazard waste in the
    operation theatres.
  • Dont discard discarded soiled gowns in the
    operation theatre.

45
At the End of the Dayin Operation theatre.
  • Clean all the table tops sinks, door handles with
    detergent / low level of disinfectant.
  • Clean the floors with detergents mixed with warm
    water,
  • Finally mop with disinfectant like Phenol in the
    concentration of 1 10
  • Low concentration of Phenol serve as perfume and
    not as disinfectant.

46
Infection control programmes
  • 1 Monitoring of Hospital associated infections.
  • 2 Training of Health care workers.
  • 3 Investigations of outbreaks.
  • 4 Any technical lapses.
  • 5 Monitoring of staff health
  • 6 Education on Universal Precautions
  • 7 Advise on isolation of Infectious patients.
  • 8 Waste disposal
  • 9 Safe use of Antibiotics / Antibiotic policy.

47
Role of Microbiology Departments.
  • Identifies the pathogens
  • Monitoring of Antibiotic therapy,
  • Education on specimen collection and
    transportation,
  • Information on common Antibiogram patterns
  • Data on Hospital Infection
  • Surveillance of the Hospital environment
  • Counseling of the Infected Hospital Staff.

48
Settle plates for bacterial counts are used by
Microbiologists
49
Recent advances in Air Sampling
  • There is a sea change in analysis of bacterial
    counts recent past with advances in medical
    technologies as in Joint replacement surgeries
    dealing with critical patients, Slit sampler and
    Air centrifuge equipment for bacterial counts are
    replacing settle plates.
  • The safe levels of colony counts can calculated
    as per the standards created with peer reviewed
    studies by microbiologists and manufacturers.

50
Slit Sampler
  • Very Effective / Highly sensitive
  • Fixed volume of air is sucked and bacterial
    counts are made

51
Surveillance of Operation theatreExamination of
Air
  • Estimations are done for detection of bacteria
    carrying particles in Air.
  • Factors influence
  • Number of persons present.
  • Body movements,
  • Disturbances of clothing.

52
Methods of Air surveillance
  • Settle plate method.
  • Slit sampler method (from given volume)
  • Counts vary from one to many
  • Settle plates method
  • Record position Time - Duration
  • Plates with media as Blood agar exposed for
    specified period and incubated in the
  • incubator for 24 hours at 37º c

53
How many bacteria are pathogenic
  • Counts vary On number of personal present in the
    given area.
  • Behavior of the persons.
  • Depend on nature of procedures, type of
    operations.
  • Varying ranges
  • But remember only 1 are pathogenic
  • Presence of S. aureus makes difference

54
Surveillance for Anaerobic spores
  • The age old tradition of detection of anaerobic
    spores of Cl.tetani and other gas gangrence
    producing spores in the operation theatre and
    closing the theatres is losing relavance with
    changing understaning and newer concepts
  • Routine and regular testing for Anerobic spores
    is not essential except when there was suspected
    case of Tetanus or Gas Gangrene attributed to
    operting in a particular operation theatre

55
Anaerobic spores are isolated from Robertson
Cooked medium
56
Ideal to Survey for Anaerobes
  • It is ideal to survey the operation theatres for
    anaerobes when operating in newly constructed or
    after remodelling and structural alterations are
    done
  • In these circustances survelaance will increase
    safety of the theatres.

57
Do we need surveillance regularly
  • Bacteriological surveillance testing at regular
    internals is not warranted,
  • But warranted when modification of operation
    theaters are done,
  • In any unforeseen increase of incidence of
    infection form any particular operation theatre.

58
Factors which influence SafteyinHospital
Environment
59
Importance of Hand Washing
  • Soap
  • Water
  • and Common
  • Sense
  • Yet the best Antiseptic
  • William Osler

60
Hand washing is your personal contribution
61
Good Hand Washing Practices Save many Lives
62
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63
Choice of Soap
  • Simple soap routinely used.
  • Medicated Soap warranted in specific
    circumstances
  • Soap advertisement claims are they real?
  • To frequent use of medicated soaps are injurious
    to skin and cause allergic dermatitis

64
Which hand wash solution is best ?
  • 1 Alcohol with Chlorhexidine.
  • 2.Alchool without Chlorhexidine.
  • 3 Chlorhexidine 2
  • 4 Chlorhexidine 4
  • 5 Povidone with Iodine 7.5
  • 6 Triclosan 1
  • Or Anything NEW

65
BEST HAND WASH IS
  • Which suits the Circumstances.
  • Availability of Resources.
  • Economical.
  • Safe to you.
  • Some chemical containing compounds can cause
    sensitization and Allergic reactions.

66
Confused with promotions of commercial interests
?.
67
Use your Wisdom

68
Are Flowers Safe in the Hospital ?
69
Why flowers are Harmful
  • They carry a prominent bacteria which can cause
    Hospital acquired infections.
  • Many Hospitals advise not to bring flowers to
    patients in Burns/Orthopedic wards and critical
    care areas.

70
Who/What is Important in prevention of Infections
71
Remember we are More important than many
72
Sterilization and Disinfection policies.
  • Create you own Infection control team which suits
    your Hospital,
  • Infection control team decides the policies.
  • Educate the staff on Methods and policies in
    Hospital safety and Hygiene
  • Educate the staff on few useful option, many
    theoretical ideas confuse.
  • To many Chemicals Costly, need not be effective.

73
Importance of Staff Education
  • Speicify the staff for duties and
    responsibilities.
  • Education is a matter of continuity
  • Train under the seniors observation.
  • Train the staff with scientific goals

74
Operation Theatre Saftey isResponsibility Of
75
Everyone
76
Frequent Washing of Hands saves several Lives
Universally
77
Our Future Vision for Developing world should be
  • Thank You All

78
Follow me for Articles of Interest on infectious
diseases and Microbiology ..
79
Created by Dr.T.V.Rao MD for e learning
resources for Medical Professionals in Developing
World
  • Email.
  • doctortvrao_at_gmail.com
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