Sterilization of Sterilization of Operation TheatresOperation Theatres

an updatean update

Dr.T.V.Rao MDDr.T.V.Rao MD

Modern Surgery – A Tribute to Modern Surgery – A Tribute to Joseph ListerJoseph Lister

Beginning of Modern SurgeryBeginning of Modern Surgery Joseph Lister, 1st Baron ListerJoseph Lister, 1st Baron Lister, ,

(5 April 1827 – 10 February 1912) (5 April 1827 – 10 February 1912) was an English was an English surgeonsurgeon who who promoted the idea of promoted the idea of sterilesterile surgery surgery while working at the while working at the Glasgow Royal InfirmaryGlasgow Royal Infirmary. He . He successfully introduced successfully introduced carbolic acidcarbolic acid ((phenolphenol) to ) to sterilizesterilize surgical surgical instruments and to clean instruments and to clean woundswounds. .

Carbolic Acid the Beginning of Carbolic Acid the Beginning of Chemical methods in Modern Chemical methods in Modern

SurgerySurgery

Carbolic acid (Carbolic acid (phenolphenol) had been in use as ) had been in use as a means of deodorizing sewage, so Lister a means of deodorizing sewage, so Lister tested the results of spraying instruments, tested the results of spraying instruments, the surgical incisions, and dressings with a the surgical incisions, and dressings with a solution of it. Lister found that solution of it. Lister found that carbolic acidcarbolic acid solution swabbed on wounds solution swabbed on wounds markedly reduced the incidence of markedly reduced the incidence of gangrene and subsequently published a gangrene and subsequently published a series of articles on the series of articles on the Antiseptic Principle of the Practice of SurgeryAntiseptic Principle of the Practice of Surgery describing this procedure in Volume 90, describing this procedure in Volume 90, Issue 2299 of Issue 2299 of The LancetThe Lancet published on 21 published on 21 September 1867. September 1867.

Historical Aspects Changed Historical Aspects Changed the Historythe History

Lister era 1868Lister era 1868 Carbolic Acid in decontamination,Carbolic Acid in decontamination, Reduction of Hospital associated Reduction of Hospital associated

infectionsinfections Mortality reducedMortality reduced Morbidity reduced.Morbidity reduced.

Beginning of Safe Operation Beginning of Safe Operation Theatre PracticesTheatre Practices

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

1880 – 1880 – Johnson and JohnsonJohnson and Johnson introduces introduces antiseptic surgical dressings.antiseptic surgical dressings.

What is wrong with our PracticesWhat is wrong with our Practices

Disinfectants used indiscrimately,Disinfectants used indiscrimately, Used unnecessarilyUsed unnecessarily Not used when needed.Not used when needed. Concentration not adequateConcentration not adequate Economic consideration,Economic consideration, Business promotions.Business promotions. Laboratory testing X Hospital Laboratory testing X Hospital

conditions.conditions.

Unscientific methods – causes Unscientific methods – causes Economic loses and increases Economic loses and increases

infection ratesinfection rates

Money wasted on unnecessary use.Money wasted on unnecessary use. People concentrate onPeople concentrate on

Floors, Inanimate Floors, Inanimate objects,objects,

Basic PrinciplesBasic Principles Cleaning more ImportantCleaning more Important Disinfection and Sterilization ?Disinfection and Sterilization ? CleaningCleaning Removes contaminants,Removes contaminants, Dust, organic matter,Dust, organic matter,Disinfection Disinfection Reduces number of microbesReduces number of microbes

Disinfection Disinfection x x SterilizationSterilization Sterilization is absolute, removes Sterilization is absolute, removes

microbes and spores too.microbes and spores too. To achieve Sterilization is Expensive, To achieve Sterilization is Expensive,

not sustainable, many times not not sustainable, many times not needed.needed.

Basic care of Operation Basic care of Operation Theatres.Theatres.

Reduction of Microbial counts is important.Reduction of Microbial counts is important. Very rarely the Microbes reach the Very rarely the Microbes reach the

operation site,operation site, Paying attention to Floors Paying attention to Floors Using unnecessary, and too many Using unnecessary, and too many

chemicals not necessarychemicals not necessary Keep the environment Clean and DryKeep the environment Clean and Dry

- Bacteria are certain to reduce as most - Bacteria are certain to reduce as most Important component of Bacteria is water, Important component of Bacteria is water, a dry areas causes natural death except a dry areas causes natural death except spores.spores.

Walls and Roof ofWalls and Roof ofOperation TheatreOperation Theatre

Frequent cleaning has little effect.Frequent cleaning has little effect. Do not disturb these areas Do not disturb these areas

unnecessarily,unnecessarily, Floors get contaminated quickly, Floors get contaminated quickly,

depend on depend on Number of persons present in the Number of persons present in the Theatre / Movements they make,Theatre / Movements they make,On many occasions people make On many occasions people make

unnecessary movements than unnecessary movements than neededneeded..

Care of FloorsCare of Floors Do remember only 1 % of the flora on the Do remember only 1 % of the flora on the

floor are pathogenic.floor are pathogenic. On many occasion S.aureus.On many occasion S.aureus. Floor should be decontaminated withFloor should be decontaminated with Vacuum cleaner.Vacuum cleaner. Wet cleaning techniques Wet cleaning techniques Wet Mop / Keep the mops dry Wet Mop / Keep the mops dry

when not in use.when not in use.

Care of RoofCare of Roof Do not disturb unnecessarily,Do not disturb unnecessarily, Do not use ceiling fans they cause Do not use ceiling fans they cause

aerosol spread aerosol spread Clean only when remodeling or Clean only when remodeling or

accumulated ,good amount of dust.accumulated ,good amount of dust.

How you care for FloorsHow you care for Floors Use only vacuum Use only vacuum

cleanerscleaners Don't broomDon't broom Use a Mop keep it Use a Mop keep it

dry, dry,

Roof, Artificial ceilings, WallsRoof, Artificial ceilings, Walls

Do not Do not disturb every disturb every dayday

Routine Routine disinfection disinfection not not necessary necessary

Cleaning the FloorCleaning the Floor A simple detergent A simple detergent

reduces flora by 80 reduces flora by 80 %%

Addition of Addition of disinfectant disinfectant reduces to 95 %reduces to 95 %

In busy Hospitals In busy Hospitals counts raise in 2 counts raise in 2 hourshours

Environmental Cleaning of Environmental Cleaning of Operation TheatresOperation Theatres

Do not waste chemicals.Do not waste chemicals. Only remove the dust with cloth Only remove the dust with cloth

wetted with clean water,wetted with clean water, Don't use chemicals/Disinfectants as Don't use chemicals/Disinfectants as

a habit,a habit, Use only when contaminated with Use only when contaminated with

blood or body fluids.blood or body fluids.

Handling of Air in Operation Handling of Air in Operation theatre.theatre.

Negative Air Negative Air pressure vented to pressure vented to the operation the operation theatre.theatre.

Environmental Environmental cleaning should be cleaning should be twice dailytwice daily

FumigatationFumigatation Formaldehyde a Age old compound.Formaldehyde a Age old compound. Low temp heating produce vaporLow temp heating produce vapor Vapor phase decontaminates the Vapor phase decontaminates the

air/environment.air/environment. Kills vegetative bacteria / Spores ?Kills vegetative bacteria / Spores ? When Formaldehyde mixed with water and When Formaldehyde mixed with water and

exposed to elevated temperature exposed to elevated temperature Gaseous formaldehyde is generated Gaseous formaldehyde is generated Time X TempTime X Temp

Mode of Action - FormaldehydeMode of Action - Formaldehyde

Formaldehyde Formaldehyde inactivates inactivates microorganisms by microorganisms by alkylating the alkylating the Aminoacid and Aminoacid and sulfyhydral groups sulfyhydral groups and protiens and and protiens and ring nitrogen ring nitrogen atoms of purine atoms of purine bases.bases.

Procedure on FumigationProcedure on Fumigation

In principle we have to generate In principle we have to generate Formaldehyde gas.Formaldehyde gas.

Can be done byCan be done by Most easier way to mix the needed Most easier way to mix the needed

quantity of Formalin to water and heating at quantity of Formalin to water and heating at lower temperatures at 80 – 90lower temperatures at 80 – 9000c c

Addition of Formalin to potassium Addition of Formalin to potassium permanganatepermanganate

Procedure of FumigationProcedure of Fumigation Seal the room with adhesive tape.Seal the room with adhesive tape. Sealing the edges around the doors is Sealing the edges around the doors is

important,important, Measure the volume of your operation Measure the volume of your operation

theatretheatre For each 1000 cu ft use 500 ml of For each 1000 cu ft use 500 ml of

formaldehyde.formaldehyde. Mix with water @ 1000 ml for 500 ml Mix with water @ 1000 ml for 500 ml

of Formaldehyde needed.of Formaldehyde needed. Seal the Room for 24 hours,Seal the Room for 24 hours, Open the Door / Avoid the formalin Open the Door / Avoid the formalin

gas with maskgas with mask

Fumigation ( cont )Fumigation ( cont ) Neutralize Residual Neutralize Residual

formalin gas with formalin gas with Ammonia by Ammonia by exposing 250 ml of exposing 250 ml of Ammonia per liter Ammonia per liter of Formaldehyde of Formaldehyde used.used.

Comparing the Sporicidal activity of Comparing the Sporicidal activity of Formaldehyde - GlutaraldehydeFormaldehyde - Glutaraldehyde

The sporicidal The sporicidal action of action of formaldehyde was formaldehyde was slower than that of slower than that of Glutaraldehyde in Glutaraldehyde in comparative tests comparative tests with 4% aqueous with 4% aqueous formaldehyde and formaldehyde and 2% Glutaraldehyde 2% Glutaraldehyde against the spores against the spores of B.anthracis.of B.anthracis.

Formaldehyde - DisadvantagesFormaldehyde - Disadvantages

OSHA indicated that Formaldehyde should OSHA indicated that Formaldehyde should be handled in the workplace as potential be handled in the workplace as potential carcinogen and set an employee exposure carcinogen and set an employee exposure standard for formaldehyde that limits an standard for formaldehyde that limits an 8-hour time-weighted average exposure 8-hour time-weighted average exposure concentration of 0.75ppm.concentration of 0.75ppm.

Long term exposure to low levels in the air Long term exposure to low levels in the air or on the skin can cause Asthma like or on the skin can cause Asthma like respiratory problem, dermatitis and respiratory problem, dermatitis and itching.itching.

Shall we discontinue Shall we discontinue FumigationFumigation ? ?

Most of the Devloping world countries depend on Most of the Devloping world countries depend on Fumigation as a regular practice in disinfection of Fumigation as a regular practice in disinfection of operation theatres and critical areas, in spite of operation theatres and critical areas, in spite of Scientific evidence of dangers of Formaldehyde.Scientific evidence of dangers of Formaldehyde.

The feared conditions of Tetanus and Gas The feared conditions of Tetanus and Gas gangrene have reduced in developing world with gangrene have reduced in developing world with practice of Hygiene and good hand washing practice of Hygiene and good hand washing practices and trained paramedical staff..practices and trained paramedical staff..

The great problem in implementing the The great problem in implementing the policy of discontinuation of fumigation is policy of discontinuation of fumigation is associated with lack of awarness on the associated with lack of awarness on the modern developments.modern developments.

Safety of Air conditioning andSafety of Air conditioning andWater cooling systemWater cooling system

Legionnaires disease is associated with Air Legionnaires disease is associated with Air Conditioning system with infected water Conditioning system with infected water storage and ducts.storage and ducts.

Chlorination / Heating of water may prove Chlorination / Heating of water may prove better alternatives.better alternatives.

The safety of the operation theatres is The safety of the operation theatres is broad based scientific approach.broad based scientific approach.

No single factor is the basis, No single factor is the basis, A united scientific approach is the real A united scientific approach is the real

foundation.foundation.

Between procedures in the Between procedures in the Operation Theatres.Operation Theatres.

Clean operation tables, theatre equipment Clean operation tables, theatre equipment with disinfectant solution with detergent,with disinfectant solution with detergent,

In case of spillage of blood / body fluids In case of spillage of blood / body fluids decontaminate with bleaching decontaminate with bleaching powder/chlorine solution ( 1 % available powder/chlorine solution ( 1 % available chlorine ).chlorine ).

Always discard wastes in prescribed plastic Always discard wastes in prescribed plastic bags – Don’t accumulate biohazard waste bags – Don’t accumulate biohazard waste in the operation theatres.in the operation theatres.

Don’t discard discarded soiled gowns in Don’t discard discarded soiled gowns in the operation theatre.the operation theatre.

At the End of the DayAt the End of the Dayin Operation theatre.in Operation theatre.

Clean all the table tops sinks, door handles Clean all the table tops sinks, door handles with detergent / low level of disinfectant.with detergent / low level of disinfectant.

Clean the floors with detergents mixed Clean the floors with detergents mixed with warm water,with warm water,

Finally mop with disinfectant like Phenol in Finally mop with disinfectant like Phenol in the concentration of 1 : 10the concentration of 1 : 10

Low concentration of Phenol serve as Low concentration of Phenol serve as perfume and not as disinfectant.perfume and not as disinfectant.

Infection control programmesInfection control programmes

1 Monitoring of Hospital associated 1 Monitoring of Hospital associated infections.infections.

2 Training of Health care workers.2 Training of Health care workers.3 Investigations of outbreaks.3 Investigations of outbreaks.4 Any technical lapses.4 Any technical lapses.5 Monitoring of staff health5 Monitoring of staff health6 Education on Universal Precautions 6 Education on Universal Precautions 7 Advise on isolation of Infectious patients.7 Advise on isolation of Infectious patients.8 Waste disposal8 Waste disposal9 Safe use of Antibiotics / Antibiotic policy.9 Safe use of Antibiotics / Antibiotic policy.

Role of Microbiology Role of Microbiology Departments.Departments.

Identifies the pathogensIdentifies the pathogens Monitoring of Antibiotic therapy,Monitoring of Antibiotic therapy, Education on specimen collection and Education on specimen collection and

transportation,transportation, Information on common Antibiogram Information on common Antibiogram

patternspatterns Data on Hospital InfectionData on Hospital Infection Surveillance of the Hospital environmentSurveillance of the Hospital environment Counseling of the Infected Hospital Staff.Counseling of the Infected Hospital Staff.

Surveillance of Operation theatreSurveillance of Operation theatreExamination of AirExamination of Air

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

Factors influence Factors influence Number of persons present.Number of persons present. Body movements,Body movements, Disturbances of clothing.Disturbances of clothing.

Methods of Air surveillanceMethods of Air surveillance 11 Settle plate method.Settle plate method.22 Slit sampler method (from given volume)Slit sampler method (from given volume)33 Counts vary from one to manyCounts vary from one to many Settle plates methodSettle plates method Record position – Time - DurationRecord position – Time - Duration Plates with media as Blood agar exposed Plates with media as Blood agar exposed

for specified period and incubated in the for specified period and incubated in the incubator for 24 hours at 37º c incubator for 24 hours at 37º c

Slit SamplerSlit Sampler Very Effective / Very Effective /

Highly sensitiveHighly sensitive Fixed volume of air Fixed volume of air

is sucked and is sucked and bacterial counts bacterial counts are madeare made

How many bacteria are How many bacteria are pathogenicpathogenic

Counts vary On number of Counts vary On number of personal present in the personal present in the given area.given area.

Behavior of the persons.Behavior of the persons. Depend on nature of Depend on nature of

procedures, type of procedures, type of operations.operations.

Varying ranges of different Varying ranges of different bacteria and fungi confuse bacteria and fungi confuse the peoplethe people

But remember only 1 % But remember only 1 % are pathogenic are pathogenic

Presence of S. aureus Presence of S. aureus makes differencemakes difference

Do we need surveillance Do we need surveillance regularlyregularly

Bacteriological surveillance testing at Bacteriological surveillance testing at regular internals is not warranted,regular internals is not warranted,

But warranted when modification of But warranted when modification of operation theaters are done,operation theaters are done,

In any unforeseen increase of In any unforeseen increase of incidence of infection form any incidence of infection form any particular operation theatre.particular operation theatre.

Factors which influence SafteyFactors which influence Safteyinin

Hospital Environment stands Hospital Environment stands good in Operation Theatresgood in Operation Theatres

Implement basic principle of Implement basic principle of Hygiene and propagate self Hygiene and propagate self

disciplinediscipline

Importance of Hand WashingImportance of Hand Washing SoapSoap WaterWater andand Common Common SenseSense Yet the best Yet the best

AntisepticAntiseptic

William OslerWilliam Osler

Hand washing is your personal Hand washing is your personal contribution contribution

Good Hand Washing Practices Good Hand Washing Practices Save many LivesSave many Lives

Choice of SoapChoice of Soap Simple routinely used, can serve the Simple routinely used, can serve the

routine purposeroutine purpose Medicated Soap have role in specific Medicated Soap have role in specific

occasion when dealing with highly occasion when dealing with highly contaminated sitescontaminated sites

Soap advertisement claims are they real?Soap advertisement claims are they real? Several important scientific studies prove Several important scientific studies prove

Alchool based hand scrubs are highly Alchool based hand scrubs are highly effective in dealing with infected wounds effective in dealing with infected wounds and critical care areas.and critical care areas.

Which hand wash solution is Which hand wash solution is best ?best ?

1 Alcohol with Chlorhexidine.1 Alcohol with Chlorhexidine.2.Alchool without Chlorhexidine.2.Alchool without Chlorhexidine.3 Chlorhexidine 2 %3 Chlorhexidine 2 %4 Chlorhexidine 4 %4 Chlorhexidine 4 %5 Povidone with Iodine 7.5 %5 Povidone with Iodine 7.5 %6 Triclosan 1 %6 Triclosan 1 % Or Anything NEWOr Anything NEW

BEST HAND WASH ISBEST HAND WASH IS Which suits the Circumstances.Which suits the Circumstances. Availability of Resources.Availability of Resources. Economical.Economical. Safe to you.Safe to you. Some chemical containing Some chemical containing

compounds can cause sensitization compounds can cause sensitization and Allergic reactions.and Allergic reactions.

Need for Newer Chemical Need for Newer Chemical Agents in Hospital UseAgents in Hospital Use

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

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

3. Need for non toxic safe agents.3. Need for non toxic safe agents.

Baccilocid® rasantBaccilocid® rasantA newer and effective compound in A newer and effective compound in

environmental decontaminationenvironmental decontamination

very good cost/benefit ratio very good cost/benefit ratio good material compatibility good material compatibility excellent cleaning properties excellent cleaning properties virtually no residues Formaldehyde-virtually no residues Formaldehyde-

free disinfectant cleaner with low use free disinfectant cleaner with low use concentrationconcentration

Baccilocid® rasantBaccilocid® rasant Active ingredientsActive ingredients

Glutaral 100 mg/g, benzyl-C12-18-Glutaral 100 mg/g, benzyl-C12-18-alkyldimethylammonium­chlorides 60 alkyldimethylammonium­chlorides 60 mg/g,mg/g,didecyldimethylammonium­­ chloride didecyldimethylammonium­­ chloride 60 mg/g. 60 mg/g.

Bacillocid® rasantBacillocid® rasant

Areas of application Areas of application Bacillocid® rasant is suitable for the Bacillocid® rasant is suitable for the disinfectant cleaning of washable disinfectant cleaning of washable surfaces using the wet-wipe-surfaces using the wet-wipe-procedure. Especially suitable for procedure. Especially suitable for economic short-term disin­fection in economic short-term disin­fection in risk areas that are likely sources of risk areas that are likely sources of infection. infection.

Newer and Non Toxic Newer and Non Toxic compounds.compounds.

A Chemical compound VIRKON A Chemical compound VIRKON gaining importance as non Aledyde gaining importance as non Aledyde compound.compound.

Virkon proved to be safeVirkon proved to be safe VirucidalVirucidal Bactericidal,Bactericidal, Fungicidal Fungicidal MycobactericidalMycobactericidal

Many More Chemicals are Many More Chemicals are available but the Economic available but the Economic

Limitation are great hurdle in Limitation are great hurdle in exploring the Utility in exploring the Utility in Developing countriesDeveloping countries

Who/What is Important in Who/What is Important in prevention of Infectionsprevention of Infections

We are responsible for We are responsible for SuccessSuccess

Sterilization and Sterilization and Disinfection policies.Disinfection policies.

Create you own Infection control team Create you own Infection control team which suits your Hospital,which suits your Hospital,

Infection control team decides the policies.Infection control team decides the policies. Educate the staff on Methods and policies Educate the staff on Methods and policies

in Hospital safety and Hygiene in Hospital safety and Hygiene Educate the staff on few useful option, Educate the staff on few useful option,

many theoretical ideas confuse.many theoretical ideas confuse. To many Chemicals – Costly, least To many Chemicals – Costly, least

successfulsuccessful

Importance of Staff EducationImportance of Staff Education Speicify the staff for duties and Speicify the staff for duties and

responsibilities.responsibilities. Education is a matter of continuityEducation is a matter of continuity Train under the seniors observation.Train under the seniors observation. Train the staff with scientific goalsTrain the staff with scientific goals

Operation Theatre Saftey Operation Theatre Saftey isis

Responsibility Responsibility OfOf

??

Theatre Saftey is Responsibility Theatre Saftey is Responsibility ofof

Our Future Vision for Our Future Vision for Developing world should beDeveloping world should be

Thank You AllThank You All

Created for benefit of Created for benefit of Medical and Paramedical Medical and Paramedical

staff in the Developing staff in the Developing worldworld

Dr.T.V.Rao MDDr.T.V.Rao MDEmailEmail

doctortvrao@gmail.comdoctortvrao@gmail.com