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Modern Surgery – A Tribute to Joseph Lister
Beginning of Modern Surgery
Joseph Lister, 1st Baron Lister, (5 April 1827 – 10 February 1912) was an English surgeon who promoted the idea of sterile surgery while working at the Glasgow Royal Infirmary. He successfully introduced carbolic acid (phenol) to sterilize surgical instruments and to clean wounds.
Carbolic Acid the Beginning of Chemical methods in Modern Surgery
Carbolic acid (phenol) had been in use as a means of deodorizing sewage, so Lister tested the results of spraying instruments, the surgical incisions, and dressings with a solution of it. Lister found that carbolic acid solution swabbed on wounds markedly reduced the incidence of gangrene and subsequently published a series of articles on the Antiseptic Principle of the Practice of Surgery describing this procedure in Volume 90, Issue 2299 of The Lancet published on 21 September 1867.
Historical Aspects Changed the History
Lister era 1868 Carbolic Acid in decontamination, Reduction of Hospital associated infections Mortality reduced Morbidity reduced.
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 introduces antiseptic surgical dressings.
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.
Unscientific methods – causes Economic loses and increases infection rates
Money wasted on unnecessary use. People concentrate on
Floors, Inanimate objects,
Cleaning more Important Disinfection and Sterilization ? Cleaning Removes contaminants, Dust, organic matter, Disinfection Reduces number of microbes
Disinfection x Sterilization
Sterilization is absolute, removes microbes and spores too. To achieve Sterilization is Expensive, not sustainable, many times not needed.
Basic care of Operation Theatres.
Reduction of Microbial counts is important. Very rarely the Microbes reach the operation site, Paying attention to Floors Using unnecessary, and too many chemicals not necessary Keep the environment Clean and Dry - Bacteria are certain to reduce as most Important component of Bacteria is water, a dry areas causes natural death except spores.
Walls and Roof of Operation Theatre
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, On many occasions people make unnecessary movements than
Care of Floors
Do remember only 1 % of the flora on the floor are pathogenic. On many occasion S.aureus. Floor should be decontaminated with Vacuum cleaner. Wet cleaning techniques Wet Mop / Keep the mops dry when not in use.
Care of Roof
Do not disturb unnecessarily, Do not use ceiling fans they cause aerosol spread Clean only when remodeling or accumulated ,good amount of dust.
How you care for Floors
Use only vacuum cleaners Don't broom Use a Mop keep it dry,
Roof, Artificial ceilings, Walls Do not disturb every day Routine disinfection not necessary
Cleaning the Floor
A simple detergent reduces flora by 80 % Addition of disinfectant reduces to 95 % In busy Hospitals counts raise in 2 hours
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.
Handling of Air in Operation theatre.
Negative Air pressure vented to the operation theatre. Environmental cleaning should be twice daily
Formaldehyde a Age old compound. Low temp heating produce vapor Vapor phase decontaminates the air/environment. Kills vegetative bacteria / Spores ? When Formaldehyde mixed with water and exposed to elevated temperature Gaseous formaldehyde is generated Time X Temp
Mode of Action - Formaldehyde
Formaldehyde inactivates microorganisms by alkylating the Aminoacid and sulfyhydral groups and protiens and ring nitrogen atoms of purine bases.
Procedure 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 80 – 900c Addition of Formalin to potassium permanganate
Procedure of Fumigation
Seal the room with adhesive tape. Sealing the edges around the doors is important, Measure the volume of your operation theatre For each 1000 cu ft use 500 ml of formaldehyde. Mix with water @ 1000 ml for 500 ml of Formaldehyde needed. Seal the Room for 24 hours, Open the Door / Avoid the formalin gas with mask
Fumigation ( cont )
Neutralize Residual formalin gas with Ammonia by exposing 250 ml of Ammonia per liter of Formaldehyde used.
Comparing the Sporicidal activity of Formaldehyde - Glutaraldehyde
The sporicidal action of formaldehyde was slower than that of Glutaraldehyde in comparative tests with 4% aqueous formaldehyde and 2% Glutaraldehyde against the spores of B.anthracis.
Formaldehyde - Disadvantages
OSHA indicated that Formaldehyde should be handled in the workplace as potential carcinogen and set an employee exposure standard for formaldehyde that limits an 8-hour time-weighted average exposure concentration of 0.75ppm. Long term exposure to low levels in the air or on the skin can cause Asthma like respiratory problem, dermatitis and itching.
Shall we discontinue Fumigation ?
Most of the Devloping world countries depend on Fumigation as a regular practice in disinfection of operation theatres and critical areas, in spite of Scientific evidence of dangers of Formaldehyde. The feared conditions of Tetanus and Gas gangrene have reduced in developing world with practice of Hygiene and good hand washing practices and trained paramedical staff.. The great problem in implementing the policy of discontinuation of fumigation is associated with lack of awarness on the modern developments.
Safety of Air conditioning and Water cooling system
Legionnaires disease is associated with Air Conditioning system with infected water storage and ducts. Chlorination / Heating of water may prove better alternatives. The safety of the operation theatres is broad based scientific approach. No single factor is the basis, A united scientific approach is the real foundation.
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 ( 1 % available chlorine ). Always discard wastes in prescribed plastic bags – Don’t accumulate biohazard waste in the operation theatres. Don’t discard discarded soiled gowns in the operation theatre.
At the End of the Day in 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.
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.
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.
Surveillance of Operation theatre Examination of Air
Estimations are done for detection of bacteria carrying particles in Air. Factors influence Number of persons present. Body movements, Disturbances of clothing.
Methods of Air surveillance
1 2 3
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
Very Effective / Highly sensitive Fixed volume of air is sucked and bacterial counts are made
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 of different bacteria and fungi confuse the people But remember only 1 % are pathogenic Presence of S. aureus makes difference
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.
Factors which influence Saftey in Hospital Environment stands good in Operation Theatres
Implement basic principle of Hygiene and propagate self discipline
Importance of Hand Washing
Soap Water and Common Sense Yet the best Antiseptic
Hand washing is your personal contribution
Good Hand Washing Practices Save many Lives
Choice of Soap
Simple routinely used, can serve the routine purpose Medicated Soap have role in specific occasion when dealing with highly contaminated sites Soap advertisement claims are they real? Several important scientific studies prove Alchool based hand scrubs are highly effective in dealing with infected wounds and critical care areas.
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
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.
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.
Baccilocid® rasant A newer and effective compound in environmental decontamination
very good cost/benefit ratio good material compatibility excellent cleaning properties virtually no residues Formaldehydefree disinfectant cleaner with low use concentration
Active ingredients Glutaral 100 mg/g, benzyl-C12-18alkyldimethylammoniumchlorides 60 mg/g, didecyldimethylammonium chloride 60 mg/g.
Areas of application Bacillocid® rasant is suitable for the disinfectant cleaning of washable surfaces using the wet-wipeprocedure. Especially suitable for economic short-term disinfection in risk areas that are likely sources of infection.
Newer and Non Toxic compounds.
A Chemical compound VIRKON gaining importance as non Aledyde compound. Virkon proved to be safe Virucidal Bactericidal, Fungicidal Mycobactericidal
Many More Chemicals are available but the Economic Limitation are great hurdle in exploring the Utility in Developing countries
Who/What is Important in prevention of Infections
We are responsible for Success
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, least successful
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
Operation Theatre Saftey is Responsibility Of
Theatre Saftey is Responsibility of
Our Future Vision for Developing world should be
Thank You All
Created for benefit of Medical and Paramedical staff in the Developing world
Dr.T.V.Rao MD Email firstname.lastname@example.org
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