Preoperative preparation of patient
Factors to be taken into account include the following.
• Preoperative showering with hexachlorophane is widely used in Sweden but not elsewhere; subjects shower twice on the day before and once on the day of surgery. This has been shown to reduce the incidence of wound infection. The former practice of wrapping limbs, before vascular surgery, in povidone—iodine dressings has not been shown to reduce infection rates.
• A short preoperative hospital stay is important; this reduces both the presence of pathogenic bacteria on the skin and the incidence of nasal carrier state (Staph ylococcus aureus) among patients on the ward.
• Preoperative screening with swabbing of the skin and nose is expensive, and has not been shown to have been of value in altering outcome in terms of infection.
• Shaving — the trauma of shaving undoubtedly results in lacerations to the skin, which can increase infection rate; it is preferable to use either clippers or, ideally, depilation cream but the latter is expensive.
• Transport — the value of trolleys as opposed to transportation in the bed has not been shown to alter infection rates; similarly, the value of transfer trolleys, i.e. keeping one trolley for outside theatre use and one for inside theatre use, and the use of a sticky mat at the theatre entrance have been shown to be ineffective measures.
Before arrival in theatres the skin of the operation site should be washed with detergent-impregnated soap. This both cleans and degreases the skin. In the operating theatre antiseptic solutions, usually of an alcohol-based detergent such as chlorhexidine or povidone—iodine, give optimal disinfection. The solution should be allowed to dry to maximise the reduction of bacteria, and pools of residual alcoholic solution, such as occur at the umbilicus or in the perineum, must be dried off completely, otherwise there is a danger of burning with the use of diathermy. The vagina and perineum should be cleaned with aqueous chlorhexidine and cetrimide solution. Adhesive plastic drapes are widely used and have the advantage of keeping either cotton or fabric drapes in place, but there is no evidence that they reduce the incidence of wound infection.
High standards of asepsis in the operating theatre demand clear protocols or guidelines with regard to the conduct of surgery, and must be monitored by the theatre manager. The proper performance of surgery ensures safety for the patient, surgeon and staff.
Instruments must be handled in such a way as to avoid injury to the patient and staff.
• Sharps should be kept in receivers and disposed of safely using sealed containers.
• Instruments should not be left on drapes where they can directly injure the patient or damage the drapes, breaching asepsis.
• Disposable instruments, particularly those with contaminated blood, should be discarded securely in labelled containers.
• Instruments should be well maintained so that no body fluid remains on the instruments after washing.
• When the preliminary count is done at the start of an operation, instruments should be checked so that all joints, nuts, screws and surfaces that slide over each other are clean with no detritus present, and move freely.
• Swabs should be counted carefully and stored in the special plastic racks containing individual ‘swab pockets’.
High-risk infection procedures
Again, there should be careful protocols for the handling of blood and body fluids in order to reduce the risk of auto-infection and cross-infection, for hepatitis B and C viruses, HIV and cytomegalovirus; such precautions are of particular importance in patients who have pre-existing infection or who are immunosuppressed.
General measures include:
• education of staff so that they are fully aware that there is a full vaccination programme for hepatitis B;
• the availability of advice for staff in the event of injury.
practical measures include:
identifying high-risk patients on the operating list;
• reduction of the number of staff in the theatres to cover essential roles only;
• removal of all extraneous equipment from the theatre;
• Staff should avoid contact with contaminated body fluids, especially blood, and in this respect abrasions should be covered. If the member suffers from eczema, he or she should be excluded from the theatres and if contamination does occur rapid washing should be undertaken.
• When handling potentially contaminated blood or body fluids, scrub staff should use nonpermeable gowns and masks with eye protection and should double glove.
Circulating personnel should use plastic aprons and wear gloves.
• Spills should be dealt with by staff wearing gloves and using absorbent disposable clothes; hypochlorite 1 per cent solution may be applied to blood spilt on the floor.
• Particular care should be taken with the handling of sharps, which should always be kept in receivers.
• Swabs should be counted but not left exposed, as for routine operations on a spike rack, they should be placed in deep ‘swab pockets’ on plastic racks.
• Disposable equipment should be placed in yellow bags at the earliest possible time, then sealed and double bagged with a hazard label attached.
• Soiled linen should be placed in special alginate bags and sent to the laundry clearly marked. At the end of the case all surfaces should be cleaned with detergents and the Domestic Officer informed.
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