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Do We Need Fumigation In Our

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Do We Need Fumigation In Our Indian Operation Theatres?? - Dr. Ajita Mehta President HIS-I Consultant Microbiologist P. D. Hinduja National Hospital & MRC – PowerPoint PPT presentation

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Title: Do We Need Fumigation In Our


1
Do We Need Fumigation In Our Indian
Operation Theatres?? - Dr.
Ajita Mehta President HIS-I
Consultant Microbiologist
P. D. Hinduja National Hospital MRC
Veer Savarkar Marg, Mahim (West)
Mumbai 400 016
2
  • Points to be discussed
  • Critical Parameters for ideal Operation Theatre
    (OT)
  • Indian Scenario about OT
  • What is Fumigation / Fogging
  • Do we need fumigation in India?
  • What will be the Take Home Message?

3
  • Critical parameters for OT
  • Filter air through 2 layer beds in series
  • (efficiency of the 1st filter bed being gt30
    that of the 2nd
  • filter bed being gt90)
  • HEPA filters (to remove gt 0.3 ?m with an
    efficiency of 99.97)
  • Positive pressure
  • Requirement of 15-20 air changes /hour with a
  • minimum of 3 air changes of fresh air (20).
  • Air should flow from the ceiling be
    exhausted
  • near the floor

4
  • Temperature of 20- 220C, is comfortable
    inhibits
  • bacterial growth
  • Relative humidity 30-60 to slow down bacterial
  • growth
  • Laminar airflow (ultra clean air) UV
    radiation
  • have been suggested as additional measures
    in
  • certain situations (orthopedic operations)

5
  • Heating Ventilation Air Conditioning (HVAC)
    Systems
  • HVAC system maintain indoor air temp.
    humidity,
  • control odours, remove contaminated air
    minimize
  • the risk of transmission of airborne
    microorganisms
  • Consists of air inlets, filter beds, humidity
    modification
  • mechanisms, heating cooling equipment, fan
    ducts
  • air exhausts

6
  • Fumigation is no longer used in the Western
    Literature
  • as they have all the modern critical
    parameters required
  • for OT

7
  • Indian Scenario
  • In India, there are extreme situations in
    operation
  • theater (OT) facilities, ranging from rooms
    with fans,
  • window air conditioning, to the more
    sophisticated
  • laminar airflow systems
  • More than 60-80 of OTs, donot have air handling
  • unit (AHU) other modern facilities with
    critical
  • parameters
  • In hospitals that lack heat ventilation air
    conditioning
  • (HVAC) systems the quality of air in the OT
    cannot
  • be guaranteed
  • What can we do in such circumstances??

8
  • Fogging
  • Nebulization of a disinfectant to decontaminate
    rooms
  • vacated by patients with communicable
    diseases.

The origin of fogging can be traced to the 19th
century when Lister aerosolized carbolic acid to
improve antisepsis in operative practice
9
  • What Is Fumigation?
  • Fumigation consisted of a mixture of formalin
    (280
  • ml) and potassium permanganate (150 gm) being
  • placed in a bowl. The room would then be
    sealed
  • opened 12-24 hours later. Later on this
    changed
  • formalin being sprayed with humidification by
    a
  • spraying device or automist.
  • Temperature 180C Humidity should be maintained
    to 600C

10
Different Methods 1. Carboxyl acid fumigation
with Formaldehyde Advantages Established age
old technique Cost
effective Disadvantages a. Carboxylic acid
has efficacy as
scouring and disinfecting agent
b. Time consuming, min 24 hrs
turn around
time c. Self
defeating OT fumigated with
Formaldehyde needs to be force
de-aired with
unclean air d.
Unsafe Formaldehyde is carcinogenic
11
2. Aldehyde based germicides Glutaraldehyde
formaldehyde (200 ml in 10 liters of water i.e
2) through fogging machine is the commonly used
procedure. Advantages- Effective Disadvantag
es a. Leaves sticky residue because of
surfactant base
b. Self defeating OT
fumigated with
Formaldehyde needs to be
force de-aired with unclean air
c. Unsafe- Formaldehyde has
been identified
as a carcinogen
12
  • Silver (Ag) and Hydrogen Peroxide (H2O2)
  • Advantages a. Has deep penetrating
    capability
  • b. Has no known
    resistant strains
  • c. Effective against
    Bacteria, Viruses,
  • Mycobacteria,
    Amoeba, Fungi and
  • spore forming
    organisms

13
A fogging system Droplets7microns thrust by a
motor running at 20,000 RPM to a distance of 15
m Solution Ecoshield 11 Hydrogen Peroxide and
0.01 dilute sliver nitrate
14
  • Efficacy of Fumigation / Fogging method
  • Viable bacteria may fail to grow when cultured
    in the
  • presence of disinfectants
  • Neutralization of disinfectant (ammonia vapours
    or water)
  • is must before collecting air samples or
    swabs
  • Lecithin Tween 80 in appropriate
    concentrations
  • are suitable neutralizing agents
  • Environmental contaminants are generally
    associated
  • with organic residues that bind deactivate
    most
  • disinfectants, (least likely to be benefit in
    those areas contaminated
  • with organic materials such as blood, feces
    or pus)

15
  • Fogging hastens the process of setting of
    airborne
  • microorganisms. Mist, generated by a
    disinfectant or
  • water would achieve the same process
  • Air sampling is useful to detect aerosols or
    particles of
  • microorganisms. (requires particle counter
    practical method for
  • evaluating efficiency of filters)

16
Air sampler
17
  • The Unresolved issues of microbiologic sampling
    are
  • Lack of standards
  • Lack of Standard protocols for testing
  • Sensitivity of sampler used
  • Such sampling should largely be reserved for
  • epidemiological investigations during outbreaks

18
  • No studies to demonstrate that fogging actually
    reduces
  • the incidence of nosocomial infection. The
    role of
  • contaminated environmental surfaces in
    causing
  • nosocomial infection remains to be elucidated
  • Controlled studies at CDC have demonstrated that
  • quaternary ammonium fog does not produce a
    significant
  • (one log )reduction in bacterial counts of S.
    aureus or
  • E. coli, even in areas in completely
    saturated with residual
  • disinfectant
  • CDC National Nosocomial Infections Study
    Quaterly Report, Third Quarter. 1971 isuued May
    1972)

19
  • In India, studies have not compared standard
    cleaning
  • practices with fumigation/fogging.
  • No substitute for vigorous scrubbing, washing of
    surfaces
  • removing the organic matter
  • Safety of repeated exposure of humans to
    disinfectant
  • fog has not been established
  • Inspite of these drawbacks it is the best
    alternative for
  • - litigation
  • - good safe hospital practices,
  • - check up of human default
  • - favourable psychological effect on staff
    patients
  • - to improve the standard of hospital hygiene
    asepsis

20
  • Points to support
  • Significant reduction in the number of bacteria
    in the
  • ambient air
  • Effective decontamination of exposed
    environmental
  • surfaces
  • Decreased risk of infection for housekeeping
    personnel
  • engaged in terminal cleaning
  • Decreased housekeeping costs
  • Secondary psychological benefits for hospital
    personnel

21
  • Take Home Message
  • Fumigation is the only alternative however
    following
  • precautions should be taken
  • Replace formalin with a safer agent like a H2O2
    stabilized
  • with a silver salt
  • It has no role in OTs with modern day HAVCs
  • For litigation after fogging do the air
    sampling keep the
  • record
  • This is not an alternative to mechanical
    cleaning of surfaces
  • If surgeries are being performed with window
    air-
  • conditioners fogging would be required on a
    daily basis
  • not on weekends alone as is practiced (WHO
    guidelines on
  • prevention control of Hospital Associated
    infections SEA-HLM-343. Jan 2002)

22
THANK YOU!
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