Sterilization Of O T

1. Sterilization of Operation Theatres update Dr.T.V.Rao MD

Book of Leviticus

Chapter11 15

Code of Hygiene

Aristotle Greek Philosopherrecommends

Boiling water toarmies. Advises the Alexander.

Recommends hygiene for healthy living

Practices, emphasizes the importance of washing hands with chlorinated water in Obstetricsto reduce maternal mortality

The Very First Requirement in

Hospitals that should do the sick no harm

Florence

Nightingale

( Notes on Nursing 1860 )

1867 Dr.Joseph Lister first identifies airborne bacteria and uses Carbolic acid spray in surgical areas

1880 Johnson and Johnson introduce antiseptic surgical dressings.

Lister era 1868 changed the concept of safe surgical procedures.

Carbolic Acid in decontamination caused Reduction of Hospital associated infections

Mortality reduced

Morbidity reduced .

Surgical site infections SSIare 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%. 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. By maintaining sterile environment in operation theatre we can control major part of exogenous infections.

Disinfectants used indiscrimately,

Used unnecessarily

Not used when needed.

Concentration not adequate

Economic consideration,

Business promotions.

Laboratory testing X Hospital conditions may not correlate.

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.

Cleaning more Important than Disinfection and Sterilization ?

However

Cleaning

Removescontaminants,

Dust, organic matter,

Disinfection

Reduces number of microbes

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.

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 naturaldeath exceptspores

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

Do not disturb unnecessarily,

Do not use ceiling fans they cause aerosol spread

Clean only when remodeling or accumulated ,good amount of dust.

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.

Use only vacuum cleaners

Don't broom

As it increases the bacterial flora in the environment

A simple detergent reduces flora by 80 %

Addition of disinfectant reduces to 95 %

In busy Hospitals counts raise in 2 hours

Do not waste chemicals.

Only remove the dust with cloth wetted with clean water,

Don't use chemicals/Disinfectantsas a habit,

Use only when contaminated with blood or body fluids.

Negative Air pressure vented to the operation theatre.

Environmental cleaning should be twice daily

DisinfectantPurpose

Sodium hypochloriteContaminated with

Blood and body

fluids

Bleaching powderToilets, bathrooms

9 grams/lit

Disinfectant

Alcohol70%

used in cleaning Metal surfaces and Trolleys

However expensive for hospitals in developing countreis

Formaldehydea Age old compound.

Low temp heating produce vapor

Vapor phase decontaminates the air/environment.

Kills vegetative bacteria / Spore ?

When Formaldehyde mixed with water and exposed to elevated temperature

Gaseous formaldehyde is generated

Time X Temp

To sterilize the operation theatre formaldehyde gas (bactericidal & sporicidal,viricidal) is widely employed as it is cheaperfor 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

Fumigation usually involves the following phases: First the area to be fumigated is usually covered to create a sealed environment; next the fumigant is released into the space to be fumigated; then, the space is held for a set period while the fumigant gas percolates through the space and acts on and kills any infestation in the product, next the space is ventilated so that the poisonous gases are allowed to escape from the space, and render it safe for humans to enter.

Thoroughly clean windows, doors, floor, walls and all washable equipments 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

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 potentialcarcinogen.

So the fumigating employee must be provided with the personal protective equipments .

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 .

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 at80 0 c 90 0 c

Can done also with addition of Formalin to potassium permanganate

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

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 vapor

Operation Theatre Volume = LBH = 20 15 10 =3000 cubic feet

Formaldehyde required for fumigation = 500 ml for 1000 cubic feet

= So1500 ml of formaldehyderequired

Ammonia required for neutralization = 150ml of 10% ammonia for 500 ml of formaldehyde

= So450 ml of 10% ammoniarequire

1. A need for Non Aldehyde based Chemicals is growing concern

2Need for quicker sterilization methods with ever increasing work loads.

3. Need for non toxic safe agents.

Formaldehyde-free disinfectant cleaner with low use concentration

very good cost/benefit ratio

good material compatibility

excellent cleaning properties

virtually no residue

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

A Chemical compoundVIRKONgaining importanceas non Aledyde compound.

Virkon proved to be safe

Virucidal

Bactericidal,

Fungicidal

Mycobactericidal

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.

Construction, carpentry, plumbing, electrical, cleaning and other works should be completed before the initiation of fumigation procedure.

If exhaust fan is used (instead of A/C) its exterior level fins should be closed.

Rooms allotted for operation (as shown in the plan) should not be used for other purposes.

The Construction must have

Separate dressing room for medical officer and staff nurses

Patient waiting room

Operation room

Veranda

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, donot keep any material which are necessary for operation theatreprocedures

Operation theatre should be cleaned and fumigated as the prevailing conditions of working and work load,

Depends on septic cases handled in the theatre

Legionnaires disease is associated with Air Conditioning system

Chlorination / Heating of water may prove better alternatives.

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 discardedsoiled gownsin the 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 Phenolserve as perfume and not as disinfectant.

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.

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.

There is a sea change in analysis of bacterial counts recent past with advances in medical technologiesas 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.

Very Effective /Highly sensitive

Fixed volume of air is sucked and bacterial counts are made

Estimations are done for detection of bacteria carrying particles in Air.

Factors influence

Number of persons present.

Body movements,

Disturbances of clothing.

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 37 c

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

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 relavance 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

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.

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.

andCommon

Yetthe best Antiseptic

William Osler

Simple soap routinely used.

Medicated Soap warranted in specific circumstances

Soap advertisementclaims are they real?

To frequent use of medicated soaps are injurious to skin and cause allergic dermatitis

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

Which suits the Circumstances.

Availability of Resources.

Economical.

Safe to you.

Some chemical containing compounds can cause sensitization and Allergic reactions.

They carry a prominent bacteria which can cause Hospital acquired infections.

Many Hospitalsadvise not to bring flowers to patients in Burns/Orthopedic wards and critical care areas.

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 .

Speicify the staff for duties and responsibilities.

Education is a matter of continuity

Train under the seniors observation.

Train the staff with scientificgoals

Thank You All

Health & Medicine

Sterilization Of O T