The
operation
Preoperative
preparation of patient
Factors to be taken into account include the following.
• Preoperative showering with hexachlorophane is widely used in
Sweden but not elsewhere; subjects shower twice on the day before and once on
the day of surgery. This has been shown to reduce the incidence of wound
infection. The former practice of wrapping limbs, before vascular surgery, in
povidone—iodine dressings has not been shown to reduce infection rates.
• A short preoperative hospital stay is important; this reduces both
the presence of pathogenic bacteria on the skin and the incidence of nasal
carrier state (Staph ylococcus aureus) among patients on the ward.
• Preoperative screening with swabbing of the skin and nose
is expensive, and has not been shown to have been of value in altering outcome
in terms of infection.
• Shaving — the trauma of shaving undoubtedly results in
lacerations to the skin, which can increase infection rate; it is preferable to
use either clippers or, ideally, depilation cream but the latter is expensive.
• Transport — the value of trolleys as opposed to transportation
in the bed has not been shown to alter infection rates; similarly, the value of
transfer trolleys, i.e. keeping one trolley for outside theatre use and one for
inside theatre use, and the use of a sticky mat at the theatre entrance have
been shown to be ineffective measures.
Skin
preparation
Before arrival in theatres the skin of the operation site should be
washed with detergent-impregnated soap. This both cleans and degreases the skin.
In the operating theatre antiseptic solutions, usually of an alcohol-based
detergent such as chlorhexidine or povidone—iodine, give optimal disinfection.
The solution should be allowed to dry to maximise the reduction of bacteria, and
pools of residual alcoholic solution, such as occur at the umbilicus or in the
perineum, must be dried off completely, otherwise there is a danger of burning
with the use of diathermy. The vagina and perineum should be cleaned with
aqueous chlorhexidine and cetrimide solution. Adhesive plastic drapes are widely
used and have the advantage of keeping either cotton or fabric drapes in place,
but there is no evidence that they reduce the incidence of wound infection.
The
procedure
High standards of asepsis in the operating theatre demand clear
protocols or guidelines with regard to the conduct of surgery, and must be
monitored by the theatre manager. The proper performance of surgery ensures
safety for the patient, surgeon and staff.
Instruments
must be handled in such a way as to avoid injury to the patient and staff.
• Sharps should be kept in receivers and disposed of safely using
sealed containers.
• Instruments should not be left on drapes where they can
directly injure the patient or damage the drapes, breaching asepsis.
• Disposable instruments, particularly those with contaminated blood,
should be discarded securely in labelled containers.
• Instruments should be well maintained so that no body fluid
remains on the instruments after washing.
• When the preliminary count is done at the start of an
operation, instruments should be checked so that all joints, nuts, screws and
surfaces that slide over each other are clean with no detritus present, and move
freely.
• Swabs should be counted carefully and stored in the special
plastic racks containing individual ‘swab pockets’.
High-risk
infection procedures
Again, there should be careful protocols for the handling of blood and
body fluids in order to reduce the risk of auto-infection and cross-infection,
for hepatitis B and C viruses, HIV and cytomegalovirus; such precautions are of
particular importance in patients who have pre-existing infection or who are
immunosuppressed.
General
measures include:
• education of staff so that they are fully aware that there is a
full vaccination programme for hepatitis B;
• the availability of advice for staff in the event of injury.
practical
measures include:
identifying high-risk patients on the operating list;
• reduction of the number of staff in the theatres to cover essential
roles only;
• removal of all extraneous equipment from the theatre;
• Staff should avoid contact with contaminated body fluids, especially
blood, and in this respect abrasions should be covered. If the member suffers
from eczema, he or she should be excluded from the theatres and if contamination
does occur rapid washing should be undertaken.
• When handling potentially contaminated blood or body fluids,
scrub staff should use nonpermeable gowns and masks with eye protection and
should double glove.
Circulating
personnel should use plastic aprons and wear gloves.
• Spills should be dealt with by staff wearing gloves and using
absorbent disposable clothes; hypochlorite 1 per cent solution may be applied to
blood spilt on the floor.
• Particular care should be taken with the handling of sharps,
which should always be kept in receivers.
• Swabs should be counted but not left exposed, as for routine
operations on a spike rack, they should be placed in deep ‘swab pockets’ on
plastic racks.
• Disposable equipment should be
placed in yellow bags at the earliest possible time, then sealed and double
bagged with a hazard label attached.
• Soiled linen should be placed in special alginate bags and sent to
the laundry clearly marked. At the end of the case all surfaces should be
cleaned with detergents and the Domestic Officer informed.