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Operating Theater Management

Operating Theater Management

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Published by doctorrao
Operating Theater Management
Operating Theater Management

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Published by: doctorrao on Jan 10, 2014
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 January 2014
Prof T V Rao, Travancore Medical College
Despite the brief amount of time patients generally spend in an operating theatre (OT), this is an environment that plays a great role in the onset and spread of infections.
It is usually necessary to study the epidemiology of infection as a multidisciplinary approach. In resource poor circumstances, prevalent in most developing countries, people work in isolation and few facilities to make any epidemiological surveys. Many believe that routine microbiological monitoring is essential but in reality it is not practicable. Every hospital should, however, pay good attention to the proper maintenance of air conditioning and ventilator systems, and to having greater control of mechanisms and personnel involved in the disinfection and sterilisation of materials used in the theatres in operative procedures. Sterilisation means eradicating germs completely, which is not 100% possible in an operating theatre. The sources of bacterial contamination are from air and the environment, infected body fluids, patients, articles, or equipment.  The following methods are practised to keep the operating theatre bacteriologically safe and below accepted levels: 1. Special air flow pattern – this is such that filtered and purified air circulates and contaminated air is removed continuously. There is restriction of personnel traffic, closing of OT doors and a good ventilation system. 2. Standard cleaning, disinfection with appropriate chemical agents, good theatre practise and discipline can provide a microbiologically safe environment.
 Fumigation is an age old process of sterilising the environment - a sick room or operating theatre, for example. It is done with Formalin fumes, which are very pungent and harmful. When a room is fumigated, it is tightly closed and sealed before fumigation. The room is opened after fumigation, 12 to 24 hours later. The room can be used again once all the fumes are out. OSHA (Occupational Health and Safety Administration) indicated that Formaldehyde should be handled in the workplace as a potential carcinogen, and set an employee exposure standard for Formaldehyde that limits an eight hour time-weighted average exposure concentration of 0.75ppm.
Methods to replace fumigation
Commercially available disinfectant Formaldehydes are the most commonly used agents for high level disinfection of the theatre environment. Formaldehyde gas is generated from liquid formalin, utilising potassium permanganate crystals. 40% formalin liquid is added to potassium permanganate crystals to generate the gas.  Alternately, formalin liquid can be dispersed by a sprayer like device in the theatre environment. After a contact time of at least six to eight hours, the Formaldehyde needs to be neutralised by using ammonia, allowing at least two hours of contact time for ammonia to neutralise the Formaldehyde prior to the use of theatre.
 January 2014
How fumigation was done
1. Seal the room with adhesive tapes around the edges of the doors/windows, ventilators and apertures.2. For each 1,000 cu.ft of space place 500ml Formaldehyde (40% solution) and 1,000ml of water in an electric boiler. Switch on the boiler, leave the room and seal the door.3. Seal the room for 24 hrs. 4. Open the door and neutralise any residual Formaldehyde with ammonia by exposing 250ml of SG 880 ammonia/1L of Formaldehyde used. (Ref - Mackie and McCartney Practical Medical Microbiology 13th Edition). Fumigation is obsolete in many developed nations in view of the toxic nature of Formalin. Too frequent use and inhalation is hazardous. Several new safe chemicals are emerging but constrains of economy limit the practise of several hours of closing an operating theatre for the purposes of fumigation.
Looking at alternatives
 Aldehydes are potentially carcinogenic and it is therefore recommended that other agents such as hydrogen peroxide, hydrogen peroxide with silver nitrate, peracitic acid and other chemical compounds of Formaldehyde should be used in place of the currently prevalent practise of using Formaldehyde.  These agents are dispersed with the aid of a fogger-like device inside the theatre environment. The contact time is about an hour and the theatre can be used immediately after this. The following precautions have greatly reduced the rates of infection:1. Every hospital must establish an infection control committee to monitor the events in the hospital on all matters related to the control of infections.2. The entry of unnecessary personnel should be restricted into operation theatres as everyone potentially contributes to infection.3. A thorough washing with warm water and good detergent can bring more of an overall improvement than solely decontamination sterilisation with other chemicals, or fumigation. 4. Frequent monitoring and training of medical and paramedical staff must carry a high priority – don’t merely observe mechanical and chemical methods.5. Thorough washing and carbolisation, if done every day after the surgeries, will greatly enhance the safety standards and reduce the repeated expenditure on fumigation.Some of the emerging compounds developed for use in the sterilisation of operating theatres are more effective for environmental decontamination, have a very good cost/benefit ratio, good material compatibility, excellent cleaning properties and leave virtually no residues. One particular product available has the advantage of being a Formaldehyde-free disinfectant cleaner with low use concentration. Its active ingredients are: Glutaral 100 mg/g, benzyl-C12-18- alkyldimethylammonium chlorides 60 mg/g, didecyldimethylammonium chloride 60 mg/g.
 January 2014
Its advantages are:
 It provides complete asepsis within 30 to 60 minutes
 Cleaning with detergent or carbolic acid is not required
 Formalin fumigation is not required
 A shutdown of an OT for 24 hours is not required Another chemical compound which has gained importance as a non-Aldehyde compound is a multipurpose disinfectant which contains oxone (potassium peroxymonosulphate), sodium dodecylbenzenesulfonate, sulphamic acid and inorganic buffers. It is typically used for cleaning up hazardous spills, disinfecting surfaces and soaking equipment. The solution is used in many areas, including hospitals, laboratories, nursing homes, funeral homes, medical, dental and veterinary facilities, and anywhere else where control of pathogens is required.  This second product has a wide spectrum of activity against viruses, some fungi, and bacteria but it is less effective against spores and fungi than some alternative disinfectants. Several other compounds are emerging in the market for safer use, however.
A breadth of considerations
Operating theatres should be built with implementation of good civil engineering standards, which encompass numerous elements.
1. Operating theatre discipline
 Only people absolutely needed for an assigned task should be present in the operating theatres
 People present in theatre should make minimal movements and curtail unnecessary movements in and out of theatres.  This will greatly reduce bacterial count
 Airborne contamination is usually affected by the type of surgery and the quality of air, which in fact depends on the rate of air exchange
 All the persons, including the least cadre of employers, are partners in infection control and should be careful to comply with infection control regulations
 Prompt disposal of theatre waste is a top priority.  Any spillage of body fluids, including blood on the floors, is highly hazardous and prompts the rapid multiplication of nosocomial pathogens – in particular, Pseudomonas spp
 2. Surveillance of operating theatre
 The environment in the operating theatre is dynamic and subject to continuous change. Good infrastructures do not mean a safe environment, as people in fact make a greater impact by making the environment unsafe. The role of microbiological surveillance is crucial, and microbiologists should be aware of organisms, sites and populations as surveillance cultures should be chosen carefully to allow meaningful interpretation of results.Microbiologists should be familiar with the clinical techniques, as those normally used for culturing clinical specimens may not yield correct results when applied to environmental specimens.Sites and cultured reports should not be chosen as etiological sources in the present infections. Culturing unnecessary surface areas causes confusion and meaningful interpretation is lost.
3. Air as an infection source
Bacterial counts in operating theatres are influenced by the number of individuals present, ventilation and air flow.  The results should be interpreted taking this into consideration.
Surveillance of air borne pathogens
In resource poor hospitals settle plates with blood agar are used and can detect pathogens, commensals and saprophytic bacteria. Multiple plates are kept and results are based on overall assessment rather than on a single plate study in the room. Microbiologists will clarify the acceptable counts at the different physical locations in multispecialty hospitals.

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