Antisepsis

1
Antisepsis

• History
• Semmelweis 1847
• puerperal fever
• handwash with chlorine
• Pasteur 1866
• discovery of bacteria
• Lister 1867
• role of bacteria in wound infections
• principles of antisepsis
• Bergman 1886
• steam sterilisation

2
Principles of antisepsis I. Operating theatre

• Isolation of operating suite
• Air-conditioning, bacterium-filters
• Sterilisation (instruments, gloves, drapes etc.)
• Skin cleansing
• - transient and resident bacteria
• - ideal agent
• effective against all micro-
• organisms
• non-irritating
• non sensitizing
• Surgical hand desinfection
• - mechanic and chemical

3
Sterilization techniques

• Purpose elimination of microorganisms
• Steam (Autoclaving)
• instruments, dressings
• Dry heat
• instruments that could be corroded
• Gas
• ethylene oxide
• if heat sensitivity (rubber, plastic
  materials,
• endoscopic
  instruments)
• Radiation
• gamma rays
• solutions, catheters, sealed plastic
  materials

4
Preparations for operation

• Surgical personnel
• Clothing for operating room personnel
• Hand and arm disinfection (scrubbing)
• Gowning and gloving

5
Preparation of the patient

• Preoperatve tests
• Preoperative diet orders
• Preoperative medication
• Skin preparation
• Positioning on the operating table

6
Preparation of the operative area

• Bloodless field
• Skin disinfection
• Draping

7
Surgical instruments and sutures

• Cutting instruments
• Grasping instruments
• Retracting instruments
• Suturing instruments
• Suture material absorbable and nonabsorbable
• clips and staple
• Electrocautery

8
Principles of antisepsis II.

• Importance of the surgical technique
• - atraumatic, fine
• - proper exposure
• - thorough bleeding control
• - removel of devitalized tissues
• - adequate suture material
• - drainage if necessary

9
Surgical infections

• Cause significant morbidity
• - increase in hospital costs
• - extra workload on surgical
  personnel
• Definition
• - result of an operative procedure
• - or can be treated only by surgery
• Usually polymicrobial
• Significant tissue reaction
• - erythema, fluctuation, tenderness

10
Origin of surgical infections

• patient
• ward personnel
• operating theatre personnel
• instruments

11
Pathogenesis of infection

• Imbalance of the host defense system
• from
• a. overloading
• b. intrinsic abnormalities
• c. local factors

12
Intrinsic factors increasing incidence of
surgical infections

• Malnutrition
  3x
• Alcoholism
• Steroids
  2x
• Diabetes
  2x
• Poor tissue perfusion
• Anemia
• Obesity
  2x
• Chronic renal failure
• Malignancy
• Immune suppression
• Hypoproteinemia
• Infection at nonrelated site
  3x
• Age over 60 years
  3x

13
Local wound factors increasing incidence of
surgical infections

• Contaminated wound
  6x
• Foreign body
• Devitalized or necrotic tissue
• Preoperative hospitalisation
  4x
• Excessively tight sutures
• Emergency operation
  3x
• Long operation (over 3 hours) 2x
• Hematoma, seroma,
• Electrocautery
  2x
• Penrose drain use
  2x

14
Prevention of surgical infection

• Most effective and least expensive method
• Careful control of intrinsic and local factors
• Prophylactic antibiotics
• - only in high risk patients
• - improper use
• increased costs
• development of drug-resistence
• serious complications
• (e.g. pseudomembranous
  colitis)

15
Proper prophylactic antibiotics

• Short term
• Appropriate timing
• Only if significant risk
• (GI tract,
  cardiothoracic,
• vascular,
• urogenital, implanted prosthesis)
  

16
Diagnosis of surgical infections

• Physical examination
• X-ray
• US
• CT, MRI
• Labelled leukocyte (isotope)
• Culture

17
Principles of treating surgical infections

• Local treatment
• Incision and drainage of abscesses
• Removal of the diseased organ
• Debridement (removal of necrotic tissues)
• Colostomy (diversion of feacal stream)
• Antibiotics
• - if systemic manifestation
• - according to cultures