Sterilization of Operation Theatres

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SterilizationofOperation Theatres

• Dr.T.V.Rao MD
• Professor Microbiology
• Travancore Medical college Kollam, India

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HAND WASHING- Semmelweis

• Practices, emphasizes the importance of washing
  hands with chlorinated water in Obstetrics to
  reduce maternal mortality

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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.

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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.

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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.

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Source of Surgical site Infections

• 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.

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Our efforts Make Difference

• By maintaining sterile environment in operation
  theatre we can control major part of exogenous
  infections.

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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.

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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.

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Basic Principles

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

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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.

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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

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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

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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.

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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.

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How you care for Floors

• Use only vacuum cleaners
• Don't broom
• As it increases the bacterial flora in the
  environment

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Cleaning the Floor

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

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Handling of Air in Operation theatre.

• Negative Air pressure vented to the operation
  theatre.
• Environmental cleaning should be twice daily

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Environmental cleaning of Hospital with
Chlorinated compounds.

• Disinfectant Purpose
• Sodium hypochlorite Contaminated with
• Blood
  and body
• 
  fluids
• Bleaching powder Toilets, bathrooms
• 9 grams/lit

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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

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Fumigationa biohazard procedure ?
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What Is Formaldehyde?

• Formaldehyde has the chemical elements carbon,
  hydrogen and oxygen in its structure.
  Hydrocarbons are among the most common of
  chemical compositions. Formaldehyde is usually
  sold as an aqueous or watery solution called
  formalin, which contains 37 to 50 percent
  formaldehyde by weight. It is soluble in water,
  but not in most organic solvents, except alcohol
  and ether.

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Fumigation

• 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

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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

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Procedure of Fumigation

• Thoroughly clean windows, doors, floor, walls and
  all washable equipment's 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

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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 equipment's.

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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 .

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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

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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 vapour,
  immediately leave the room and seal it for at
  least 48 hours.

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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 vapour

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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

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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.

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Several Chemicals are available but the Economic
Limitation are great hurdle in exploring the
Utility in Developing countries
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Bacillocid rasant

• Formaldehyde-free disinfectant cleaner with low
  use concentration
• very good cost/benefit ratio
• good material compatibility
• excellent cleaning properties
• virtually no residue

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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

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Newer and Non Toxic compounds.

• A Chemical compound VIRKON gaining importance
  as non Aldehyde compound.
• Virkon proved to be safe
• Virucidal
• Bactericidal,
• Fungicidal
• Mycobactericidal

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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.

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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,
  Do not keep any material which are not 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

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Safety of Air conditioning andWater cooling
systems

• Legionnaires disease is associated with Air
  Conditioning system
• Chlorination / Heating of water may prove better
  alternatives.

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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.

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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.

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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.

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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.

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Settle plates for bacterial counts are used by
Microbiologists
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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.

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Slit Sampler

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

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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.

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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

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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

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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 relevance 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

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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.

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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.

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Factors which influence SafetyinHospital
Environment
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OPERATION THEATRE - DISCIPLINE

• 1. Only people absolutely needed for an assigned
  work should be present.2. People present in
  theatre should make minimal movements and curtail
  unnecessary movements in and out of theatres,
  which will greatly reduce bacterial count. 3.
  Air borne contamination is usually affected by
  type of surgery, quality of air which in fact
  depends on rate of air exchange.

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Every body Partners in Infection Control

• All the persons including the least cadre of
  employers are partners in infection control and
  should be aware to comply with infection control
  regulations4 Prompt disposal of Theatre waste
  out of the theatre is of 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

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Hand washing is your personal contribution
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Good Hand Washing Practices Save many Lives
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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

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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

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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.

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Confused with promotions of commercial interests
?.
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Use your Wisdom

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Who/What is Important in prevention of Infections
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Remember we are More important than many Chemicals
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THE FOLLOWING PRECAUTIONS HAVE GREATLY REDUCED
THE RATES OF INFECTION

• 1. Every Hospital must constitute Infection
  control committee to monitor the events in the
  Hospital, on all matters related to control of
  Infections.2. The entry of unnecessary personnel
  to be restricted into operation theatres as every
  one contributes to Infection.3. A thorough
  washing with warm water and good detergent and
  carbonization can bring overall improvement than
  mere fumigation

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• Frequent monitoring and training of medical and
  paramedical staff must carry high priority than
  mere mechanical and chemical methods.5. Thorough
  washing and carbonization if done every day after
  the surgeries will greatly enhance the safety
  standards and economize the repeated expenditure
  on fumigation.

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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.

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Importance of Staff Education

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

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Operation Theatre Safety isResponsibility Of
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Everyone
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Frequent Washing of Hands saves several Lives
Universally
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