Surg Cmde Sudeep Naidu Prof & HOD Surgery

Transcription

1 Surg Cmde Sudeep Naidu Prof & HOD Surgery

2 Sir Joseph Lister

3 Before his times.

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5 Clean Care is Safer Care WHO Alcohol based Handrub Save Lives Clean hands Cleaning hands at the right times and in the right way 5 key components Safe water, soap, towels, alcohol based handrub Training / Education Evaluation / feedback Constant reminders Instituitional support Burden of endemic health-care-associated infection in developing countries: systematic review and meta-analysis Benedetta Allegranzi LANCET Volume 377, No. 9761, p , 15 January 2011

6 Hand Hygeine For operating team 5 min/ 3 min scrub Microbicidal soap Alcohol based hand rub Double gloves For ward staff Alcohol based hand rub Ignaz Semmelweis

7 Do your own survey!

8 William Halstead & Caroline Hampton Romance of Asepsis

9 Joseph Bloodgood gloves become standard

10 Br J Neurosurg Oct;22(5): doi: / Bacterial contamination of surgeons gloves during shunt insertion: a pilot study. Sorensen et al Alarming contamination rate Propionebacterium acnes in all coagulase-negative Staphylococci in 80 % 15 min is the contamination time Lesson learnt Change gloves before handling implants / grafts/ stents/ meshes Recommendation : Frequent Changing with alcohol handrub

11 Surgical Gowns Barrier function Protect the surgeon Protect the patient Comfort Reusable Disposable Strike through 90 % in reusable 11% in disposable 3% disposable reinforced Highest strike - at the cuffs, forearms, and thighs, Liquid Barrier Performance and Classification of Protective Apparel and Drapes Intended for Use in Healthcare Facilities US FDA Eur J Surg Aug;163(8): Factors that influence the effectiveness of surgical gowns in the operating theatre. Pissiotis CA et al

12 Present day surgery Extensive procedures Equipment oriented Extremes of age Exacting standards Early discharge We stand on the shoulders of giants

13 Surgical Site Infections (SSI) Post op infections at any level 0 30 days post op, 1 year if implant Superficial SSIs Skin Deep Incisional Fascia Muscle layers Organ / space Body organs Body space

14 Determinants of SSI 1. Agent micro organism Exogenous/ endogenous Virulence Inoculum Load Surface factors Toxins Synergism

15 Determinants of SSI 2. Local wound factors Surgical technique

16 Wound classification NNIS score (National Nosocomial Infection Surveillance) Wound class ASA class Duration of procedure

17 NNIS Score

18 Determinants of SSI 3. Patient factors Age Immunosuppression Steroids Malignancy Obesity Diabetes Malnutrition Multiple co-morbidities Transfusions Smoking Oxygen Temperature Glucose control

19 Environment Operation Theatres Keep OT floors clean & dry Vacuum, Wet Mop (Dry) Frequent cleaning has little effect Restrict traffic Ignore roof NO fans Use disinfectants only when blood/tissue present Zoning Air Changes HEPA filters Temp/ Humidity/ Ventilation

20 Prevention of infections Pre operative Micro organism Local wound Patient Short pre-op stay Hair clipping no shaving Antiseptic shower Nutrition Warming Hair clipping no shaving Stop smoking Rule out/ treat remote infections Blood sugar control Anibiotic prophylaxis

21 Intra operative Micro organism Local wound Patient Asepsis Prevent hematoma/ seroma Supplemental oxygen Antisepsis Good perfusion Intra operative warming Complete debridement Close dead spaces Fluid resuscitation Blood sugar control Monofilament sutures Justified closed drains Limit sutures/ FB Delayed closure if need be

22 Post operative Micro organism Local wound Patient Protect incision for h Remove drains ASAP Post op dressing h Early enteral nutrition Oxygen supplementation Avoid post op bacteremia Blood sugar control Surveillance programmes

23 Antibiotic Prophylaxis 1 hr prior to incision (Vanco 2hr) Aggressive dosing no half measures Use full dose before Tourniquet Intra op redosing > 4hr Set a time limit for the antibiotic STOP 24 hrs / Cardiac 48hrs Usually parenteral GI absorption unreliable in SIRS Primary GI pathology Cefazolin! Conundrum Always cover aerobics

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26 Sterilisation of Instruments Critical - eg scissors Autoclave Hot air oven ETO Flash sterilisation Semi critical - eg scopes Glutatarldehyde/ orthophthaldehyde Non critical Detergent Low level/ intermediate antiseptic Joseph Lister

27 Questions??? How do you sterilize your reusable laparoscopic instruments? Is there still, a role for 2% gluteraldehyde, OPA or peracetic acid. Many surgeons have shifted to autoclavable reusable instruments. But how do you sterilize your light cables and scopes. How do you sterilize the instruments in between cases. I would like to know the opinions of surgeons who perform laparoscopy routinely. Article: Port-site tuberculosis after laparoscopy - Report of eight cases, H Ramesh et al Jul 2003 Surgical Endoscopy

28 Antibiotic Impregnated devices Industry driven Catheters, Prostheses, shunts, drains, sutures Cost benefit? Morbidity decreases? LOHS? Morale Results further large, prospective, randomized and double-blind studies must be performed in order to confirm these results and the efficacy of other antibioticimpregnated devices

29 Combat Protocols Wounds bandaged with sterile dressing Fractures to be stabilised Fox shield for eyes Transfer to surgical facility Single dose point of injury antimicobial ( gm-ve, penn NO) Debride & irrigate Post Injury enhance Gm ve cover Continue irrigation Only facial & dural wound closure Topicals only for burns NPWT can be used

30 Checklists the B 17 story

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33 Primum non nocere

34 Conclusion. Infections after surgery have been found to be the costliest single group of medical error In India, a patient can often afford costly surgery but not its complications Infections mar the morale of the surgeon as well Predictable success against known enemies using conventional tactics

35 Thank You