Operation Theatre - STERILIZATION

Presenter – Dr. Sukumar.T.K.

Freeing of an article from all living organisms including viable spores. Process that kills more than 106 organisms ,

including spores of a defined exceptionally high degree of resistance.

Sterilization

1867 – Dr. Lister Joseph, identifies airborne bacteria. Uses carbolic acid spray in surgical areas.

1880 – Johnson and Johnson introduce antiseptic surgical dressings.

Use of Carbolic acid reduced Hospital associated infections.

Safe Operation Theatre Practices – The Beginning

Surgical Site Infections

2nd most common cause of hospital acquired infections.

Mortality as high as – 77% . Sources –

Endogenous Exogenous

Maintaining sterile environment – control of major part of exogenous infections

Surgical Site Infection

Operating Room Environment Ventilation

Dust, lint, skin squames, respiratory droplets. Microbial level Number of people moving in

room. Operating room should be maintained at

Positive Pressure.

Sources of Infectious Agents in OT

Types of Ventilation Mixing Parallel Flow –(Laminar Airflow)

a)Vertical Parallel Flowb)Horizontal Parallel Flow

OP – Box Ventillation

Ventilation Systems

Mixing

Vertical Parallel Flow

Horizontal Parallel Flow

All ventilation systems in hospital should have two filter beds in series (first = ≥30% ; second = ≥90%) – Ultra clean air.

Laminar airflow and use of UV is suggested to reduce SSI (velocity – 0.3-0.5µm/sec). Minimum of 12 cycles/hr

Recirculated air passed through HEPA Filter.

Environmental Surfaces Routine cleaning has to be performed. Cleaned after contact with blood or potentially

infectious material. Wet vacuuming to be performed after last

operation of day or night.

Frequent cleaning of walls and roof - not needed.

These areas should not be disturbed unnecessarily.

Floors get contaminated quickly – Depends on number of people present.

Ceiling fans should not be used. Clean roof – when remodelling or

accumulated good amount of dust.

Roof, Floors and Walls

1% of microbes present on floor are pathogenic.

Simple detergent - reduces flora by 80%

Addition of disinfectant – 95%

70% alcohol – Disinfectant.

contd.

Fumigation

Formaldehyde vapour – Produced on low temp heating.

Vapour phase decontaminates the air / environment.

Mechanism – alkylates amino acids and sulfydral group of proteins and purine bases.

Used widely to sterilize huge areas like operation theatres INSPITE OF BEING HAZARDOUS as it is cheap.

Fumigation

Thoroughly clean windows, doors, floors and all washable equipment with soap and water.

Close windows and ventilators tightly. Switch off all lights, A/C and other electronic

items. Calculate room size and required amount of

formaldehyde.

Fumigation - Procedure

Electric Boiler Fumigation For 1000 cu.ft of ot – 500ml of formalin added

in 1000ml water In electric boiler. Boiler switched on and kept on for 45 min. Switched off without entering room.

Creating Formaldehyde

Potassium permanganate method For 1000 cu.ft add 450gm KMno4 to 500mlof

formalin. Seal room and leave it for 48hrs.

Residual formaldehyde gas neutralised by using ammonia. (3Hrs)

Ecofriendly, non toxic non irritating environmental disinfectant.

Has bactericidal, virucidal, tuberculocidal, fungicidal and sporicidal action.

Complex formulation of stabilised 11% w/v hydrogen peroxide with 0.01% silver nitrate solution

Eco shield™ (Bio shield)

Formaldehyde free. No residue. Glutaral 100mg/g, benzyl-C12-18-

alkyldimethylammonium chloride 60mg/g, didecyl-dimethylammonium chloride 60mg/g.

Wet wipe procedure.

Bacillocid rasant™

Virkon Disinfects medical devices. Disinfects laboratory equipment. Decontaminate spillages with blood and

body fluids. Replace autoclaving and saving time.

Newer non toxic compounds

Monitoring of hospital associated infections Training of health care workersInvestigations of outbreaksAny technical lapsesMonitoring of staff health

Infection Control Programmes

Education of universal precautionsAdvice on isolation of infectious patientsWaste disposalSafe use of antibiotics

Contd..

Role of Microbiology Department

Identifies pathogen Monitoring of antibiotic therapy Education on specimen collection Information on common antibiogram

patterns Data on hospital infection Surveillance of hospital environment Counselling of hospital staff.

Settle plate method Position, duration. Blood agar exposed for specified period and

incubated

Slit sampler method Very effective and highly sensitive. Fixed volume of air is sucked and counts made

Air surveillance

Factors influencing – i. Number of persons presentii. Body movementsiii. Disturbances of clothing

Counts vary on number of personnel present on given area.

Nature of procedures ONLY 1% ARE PATHOGENIC Presence of Staphylococcus aureus makes

difference

Significant count??

Detection of spores of Cl.tetani in ot – losing relevance

Routine testing for anaerobic spores not essential.

Anaerobic spores

AIMS To provide sterilized material from a central

department

To alleviate the burden of work of the nursing personnel

To facilitate the wards to function smoothly

Central Sterile Services Department

Receipt and delivery of equipment from all areas of the hospital

Supply of sterile materials for dressings and procedures carried out in wards and departments

Supply of operation theatres with the necessary sterile instruments and linen

FUNCTIONS

To disassemble, clean and check for proper function of equipment, such as suction machines, feeding pumps, i.v infusion pumps etc.

To dry, wrap, bag and seal items in preparation for sterilization

CSSD can broadly be classified into two parts:

Central Unit: Responsible for receiving dirty utilities, cleaning, processing, sterilization, storage and supply.

Peripheral Unit: Mainly responsible for DISTRIBUTION to various areas

TSSU (Theater Sterile Supply Unit)

PLANNING OF A CSSD

TSSU: In large hospitals, where number of OTs function, these have peripheral sterilization units known as Theater Sterile & Supply Units. (TSSU) These work under high pressure and takes less

time for sterilization. Specially in hospitals, where the Central Unit

does not function round the clock.

PERIPHERAL UNIT

Dressing set/ tray Suture removal set Suturing set Cut down tray Tracheostomy set Gloves(nowadays disposable)

ITEMS COMMONLY HANDLED BY CSSD STORES

HSG and CT set Lumbar puncture set Bone marrow/ liver/ kidney biopsy set Burn pack Intra costal drainage (ICD) procedure set

Catheter set Tapping/Aspiration set

1. Receiving used items2. Cleaning3. Packing4. Sterilizing5. Storing (temporary)6. Distributing to user departments

Major Activities in CSSD

RECEIVE

DIRTY ITEMS

CLEANING &DRYING

PACKAGING &LABELLING

GLOVERS, DRIP SET

RUBBER GOODS

SYRINGES ,LINENSGAUZE,COTTON

INSTRUMENTS

ETOGAMMA

RADIATION HEAT

DRY/ MOIST CHEMICAL

STERILIZATION

STERILE STORAGE DISTRIBUTION

Should have access to outside through a window with a counter.

The items (especially for instruments in trays) are counted and received.

Instruments are inspected and blunt/unsuitable instruments are segregated/ discarded.

Necessary entries are made for records. Items shifted to cleaning area.

RECEIVING AREA

Washing-Cleaning is the removal of visible soil (e.g., organic and inorganic material) from objects and surfaces

If used items are not decontaminated in user department then blood/ body fluid soiled items should be decontaminated with sodium hypochlorite before handling further.

Rinsing-Sorting-Soaking-Washing-Drying

CLEANING AREA

Rinsing-Detergents (preferably enzymatic) &brushes of various sizes and shapes are required in this area.

Instruments washed either manually or in machines.

For manual washing sinks with water supply and working counters are organized

Tunnel washer - highly sophisticated machine that allow totally hand-off processing.

Instruments coming from operating room or other departments are placed into the tunnel washer without any further handling. The instruments are subjected to cycles washing, rinsing, ultrasonic cleaning and drying.

Ultrasonic washer is a machine used for cleaning surgical instruments

It converts high frequency sound waves into mechanical vibration that produces small bubbles that burst on the internal surfaces of instruments and dislodge the waste particles.

After the instruments are washed, they are dried in oven dryer and shifted to packing area.

CATEGORY ITEMS PROCEDURE

Critical Enter tissue, through which

blood flows

Sterilization

Semi – Critical Touch mucous membrane, touch

non intact skin

High level disinfection

Non – Critical Bandage, BP Cuffs Low level disinfection

Procedures Used

High Temp – Steam Sterilization Low Temp – Ethylene Oxide gas, Hydrogen

peroxide gas plasma

Sterilization

Liquid Immersion ≥2.4% Glutaraldehyde for 10hrs 1.12% Glutaraldehyde and 1.93% phenol for 12 hrs 7.35%hydrogen peroxide and 0.23%peracetic acid

for 3hrs 7.5% Hydrogen peroxide for 6hrs 1.0% Hydrogen peroxide and 0.08% peracetic acid

for 8hrs. ≥ 0.2% peracetic acid for 50 min at 50-56 degree

Celsius

Heat automated – Pasteurization for 50 min Liquid immersion

2% glutaraldehyde for 20 – 45min 0,55% ortho – pthalaldehyde for 12 min 1.12% glutaraldehyde and 1.93% phenol for 20

min 7.35% hydrogen peroxide and 0.23% paracetic

acid for 15 min 650 – 675 ppm chloride for 10 min

High level Disinfection

The shelf life of the sterile materials depend on the quality of packing materials used and the status of cleanliness of storing area.

Generally the items sterilized by steam autoclave can be used for one week and ETO packs can be used for 6 months.

SHELF LIFE OF STERILIZED ITEMS

Receipt register- to keep account of all the trays with instruments received in CSSD

Issue register to keep account of all the materials issued to users

Stock ledger of non consumable items- e.g. trays, instruments

RECORDS

Stock ledger of consumables- to keep account of the cotton and gauze received, and issued by the CSSD

Number of loads per machine per day Duty rosters of staff Log book of machine

Soap, Water and Common Sense – Yet the best

antiseptic

Importance of Hand Washing

WILLIAM OSLER

VENTILATION SYSTEMS IN OPERATING THEATRES, ASPECTS TO CONSIDER. A JOHNSON MEDICAL BULLET IN (REPUBLISHED 2002)

Operating theatre commissioning -Microbiological From HICSIG

Guidelines for prevention of hospital acquired infections. Yatin Mehta, Abhinav Gupta, etal.

Guideline for Prevention of Surgical Site Infection, 1999. Alicia J, Teresa C, etal

Reference

Recommendations for Infection Control for the Practice of Anaesthesiology. Developed by the ASA Committee Occupational Health Task Force on Infection Control.

Procedure-associated Module SSI – CDC OT Sterilization. T V Rao Text book of microbiology Mackie and

McCartney-14th edition.

THANK YOU