Thursday, December 30, 2010

KEY HOLE SURGERY



CARE OF FIBER OPTIC INSTRUMENT
As mentioned earlier post it is possible to undertake surgery
Through the fiber optic endoscope
The working end of the endoscope has outlets for instruments
The instruments are also adapted to reach and function at the operating site




WHAT ARE THE RULES OF SPECIAL CARE OF FIBRE-OPTIC ENDOSCOPES?

The special care required for fiber-optic instruments after
use:
The first principle is that `the useful life of endoscope
instruments is at risk if too many users with different use, and
Maintenance protocols, are using the same instrument.

- Debris and mucus must be removed from the instrument, and the
Channels immediately after use, with a mild detergent such as
Savlon 1 per cent
- Followed by rinsing in warm water
- After thorough cleaning, the insertion tube only of the
endoscope, can be disinfected by immersion in a chemical
fluid such as glutaraldehyde (Cidex)
- Endoscopes used for intra cavity operative procedures on
penetrating tissues, i.e., laparoscopes, arthroscopes,
thorascopes, choledocoscopes etc., must be used in a sterile
condition
- The length of fibroptic light cable, which connects the light
source to the endoscope, must be cleaned at end of each
procedure and handled with great care to prevent damage to
the light conducting glass fibres.
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Thursday, December 23, 2010

ENDOSCOPE THE PEEP TOOL






Endoscopes brought about a significant advance to surgery.
You can now see lesions that previously you could not.
You can now take a biopsy under vision and get tissue diagnosis
You can now see the effect of treatment on a lesion.
You can now keep along term record of the lesion for followup.
You can now use endoscopes to execute surgical procedures.



What is the light source



The fiber light bundle is connected at one end to the light
source and at the other to the endoscope.
- It contains a bundle of up to 20,000 flexible optical fibers
which can conduct light but not capable of carrying an
Image (E as shown in Fig 7.1)
- The bundles transmit a pre-focused light of high intensity
and uniform density to the endoscope
- The bundle’s outer covering is metal and PVC, and is flexible
- This light is called cold light since it carries no heat with it


- In addition, a separate set of up to 36,000 optical fibers
capable of carrying an image terminating proximally at an
Eyepiece, and distally at a lens at the end of the endoscope
(F as shown in Fig 7.1)
- Both these sets of optical fibers are contained in a
protective sheath of endoscope, generally this sheath
Incorporates additional channels for:
. Suction (G as shown in Fig 7.1)
. Gas inflation/irrigation (H as shown in Fig 7.1)
. A passage for flexible biopsy or operative forceps and
Electrodes Fig 5.3
. Some special instruments used thriugh this port are shown
in Fig 5.4
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Friday, December 17, 2010

ENDOSCOPY THE PEEP INSIDE



ENDOSCOPY
WHAT ARE RIGID ENDOSCOPES where are the used?

These viewing instruments are metallic telescopes, with light for Diagnosis, and biopsy.

They are introduced through natural body orifices eg. Bronchoscopy, esophascopy, colonoscopy etc.
-Today rigid endoscopes are also being used to view the interior of *joints (arthroscopies) and
*the kidney (nephroscope) and
*abdomen (laparoscope).

They are introduced through incised openings. They have four
Basic components:

* Eye piece (Viewing lens)
* Body tube contains light guide connector, valves to channels
* Shaft (lens channels)
* Distal end Objective lens

WHAT ARE FIBREOPTIC ENDOSCOPES?

These sophisticated instruments have made the diagnosis of
Lesions in the accessible segments of the GI tract possible,earlier, and accurate, since visual imaging, and biopsy of the lesions is possible.
High resolution images can be recorded on:
* Color films for case of record for follow up
* Cine film for arranging learning film material
* Television monitor for ease of viewing of procedure and learning
For realtime assistants

Fibre-optics lighting and imaging systems have replaced the
Conventional rigid optic and light systems in endoscopes.
- Fibre-optics is a term applied to a system for transmitting
light and images through thin optical fibers by total
Internal reflection Fig 5.1
- The fibre-optic endoscope system consists of three parts:
. The light source or generator unit (A as shown in Fig 7.1)
. The insertion tube with the optical image bundle (B as
shown in Fig 7.1)
. The instrument or endoscope control section near the eye
Piece(C as shown in Fig 7.1)
. The light source is a high-intensity lamp in a box with an
In-built curved reflector (D as shown in Fig 7.1)
- This ensures that cold light is passed to the instrument or
Endoscope since the heat is left in the light source box
- Special lamps such as quartz iodine, metal halide and xenon
have been developed to give a higher intensity of light of
up to 500 Watts.
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Friday, December 10, 2010

SET UP THE MICROSCOPE






STEPS OF PREPARATION OF THE MICROSCOPE FOR THE OPERATION

- Position the microscope over the table for the operation, and
as required by the surgeon, be sure to leave space required
by the assistant, scrub nurse, anesthesia team, equipment
and sterile trolleys
- Arrange the path of the mains lead from the wall socket to
Ensure that it is not in the path of flow of the OT staff

- check and tighten, if necessary, the safety locks between
Microscope and stand

- Ensure that correct objectives and binocular tubes are
Inserted for the particular operation
- Clean the objectives and eyepieces of main, and assistants’
Microscope
- Switch on the microscope
First at the wall socket
Second at the stand
Switch on the lights
- After the operation this procedure of switch off must be reversed
- First switch off lights, next stand, lastly wall switch
- Ensure all sterilzable caps or drapes are available

WHEN NOT IN USE CARE

Dust is very harmful for microscopes thus they should be kept
Covered with a dust cover when not in use and never left without
Objective, binocular tube or eyepieces fitted.
* Cameras are kept locked up for security; the dust cap should be put on the outlet
* All accessories, spare objectives, and eyepieces, should be
kept in dust proof containers
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Friday, December 3, 2010

OPERATING MICROSCOPE


HOW IS DOCUMENTATION AND TRAINING HELPED BY USE OF MICROSCOPES?

It has been possible to document (photograph) different
stages of the procedure, and record the finding, as observed
through the microscope.
This progress have been achieved through
Fig.
- Introduction of high speed artificial light color films
- Introduction of 35 mm film color camera with automatic
Exposure control
- Introduction of co-axial flash equipment, controlled through
Sensor in the modern 35 mm. camera

Cine camera also has been adapted for the microscope work.

Today high quality color television cameras have also been
Introduced:
A. These have facilitated Video recording of procedures.
B.These Video films are cheaper than Cine films
C.Light weight, Solid state inexpensive cameras can provide
excellent observation facilities for training of Microsurgery trainees

WHAT CARE AND MAINTENANCE IS REQUIRED?

. At least two members of OT staff should be trained for round
The clock responsibility of checking, setting up and storing
the instrument
. These staff members keep contact with the manufacturer/supplier of the microscope on the performance of microscope
. They should have read the supplied instruction books
. Supplies of spare parts, such as lamps, fuses and
sterilizableA caps or disposable drapes are always kept in stock
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Friday, November 26, 2010

MAGNIFICATION IN SUGERY


OPERATING MICROSCOPE 2




HOW TO CONTROL the functions of the microcope during surgery?

In the case of the manual microscope, all controls such as
Focusing, magnification, change the tilt of the microscope, are
Done by different hand knobs.
- These can be covered with sterilzable rubber caps provided
with the microscope OR
\
- The complete instrument (besides the eye pieces) can be draped with a loose sterile plastic drape, and the knobs adjusted through this drape
OR
With motorized microscopes, the functions are controlled by a foot switch.
- The controls can also be built into a specially designed
surgeons Operating chair. OR

- Alternatively a hand switch, inserted into a sterile plastic
bag for use during operation

What are the parts of the ASSISTANTS' MICROSCOPE ATTACHMENT?
An assistant’s microscope is a separate binocular viewing
system with eye pieces.
-It provides the same stereo image as seen in the main microscope.
-This is through a beam splitter, which splits the image and directs it to the assistants' microscope, which has its own independent magnification control.
-This makes it possible for the assistant to participate and
assist in Surgical procedures.

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Friday, November 19, 2010

MAGNIFICATION IN SURGERY



OPERATING MICROSCOPES

WHAT ARE THE USES OF MAGNIFICATION?
The use of controlled magnification has been a recent addition to the instrument list.

Loupes and magnifying glasses have been used in the past, but operating microscopes have improved the clarity ease of use, the depth of focus, and the lighting of the site of the operation.
Complicated two layer suture on small structures
- can be performed quickly,
- accurately and in comfort
- With no strain on the neck muscles.
Operating microscope can be:
1. Floor Mounted Fig 6.1
2. Ceiling Mounted Fig 6.2

What are the Features of an Operating Microscope?
They can be;
* Hand operation or foot operation microscopes for focus
* Automatic focuses and zooms
* Can have Assistant Microscope view arm so he can view and assist
* Camera attachment arm for recording procedures.

WHERE IS a microscope USED?

The operating microscope is used for two purposes:
- The first is to provide a magnified view of small structures
(Small vessel and nerve anastmosis).
- The second is to provide a magnified view of larger
Structure upon which more precise surgical procedure needs
To be performed (Disc surgery).

Explain what ARE THE features OF OPERATING MICROSCOPES?

There are two basic types of operating microscope, with
Several variations, depending upon the surgical specialty
Involved.
- The first is the manual type, featuring hand controlled
Fixed magnification stepwise(x6x9...) and control knobs for
Focus Fig. 6.3
- The second type is the zoom system, this has the advantage
Of offering continuous magnification through the whole range
Of the magnification of the system including focus through
Foot controls.
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Saturday, November 13, 2010

WOUND CLOSURE 7

SUTURES AND LIGATURES NON ABSORBABLE 2



Metallic wire

Suture wire is prepared mainly from three metals –
non-toxic Stainless steel,
the alloy Tantalum and
Silver.

All these may be obtained as a single-strand monofilament
suture
The first two as several strands, either twisted or
braided, known as multifilament wire.

Surgical stainless steel suture wire is used mainly in
orthopaedics and thoracic surgery.
A stouter wire of sizes 3 to 9(0 to 7) or 29 SWG would be needed for wiring fragments of bone together.

Metal clips (ligature)

Ligatures of flattened silver or tantalum wire are used in
Neurosurgery, and chest surgery, for arresting hemorrhage from
small vessels.
The insertion forceps and cartridges, allow their use for this purpose at depths with safety Fig 5.4.5.1

Metal clips (suture)

These are metal clips having two sharp points which when the
clip is closed, these points grip the edges of the skin incision
and hold them in apposition.

The original types in use are Michel and Kifa Fig 5.4.6.2

Staples

During the past few years there has been considerable
development in the field of suture staples.

These range from disposable magazines of staples which fit
an insertion instrument to completely disposable units.
Examples of two of the latter are
Proximate II(Ethicon) and
Appose (Davis & Geck) Fig 5.4.7.1a,b,c
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Sunday, November 7, 2010

WOUND CLOSURE 6

WHAT ARE THE SYNTHETIC NON-ABSORBABLES?

Polymide (Nylon) Mono-filament

This is a single strand of polyamide supplied in sizes
rangeing from 0.2 to 2 (10/0 to 2).

The material can be obtained in multiple pre-cut lengths,
from 35 cm to 1 m.

Polyamide as a single thread is inert and can be safely used
in the presence of infection. It may be left in the tissues with
very little reaction occurring.

Monofilament examples of this material include Ethilon, blue
(Ethicon);
Surgidek, blue or black (Surgicraft); and
Dermalon, white, blue or black (Davis & Geck).

BRAIDED

This is used in a similar manner to braided silk.
The sizes available range from 0.7 (6/0) to 2(5), with the same tensile strengths as braided silk.
The two colours available, black and blue.
It is generally supplied in multiple pre-cut lengths of
between 35 cm (14 in) and 1 m(40 in), sterile in peel-open packs.
The material is available also armed with non-traumatic needles.

Examples of this material include Nurolon (Ethicon) and
Surgilon (Davis and Geck).

Polypropylene

The material is available in sizes 0.2 to 5 (10/0 to 2),
with or without needles.
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Friday, October 22, 2010

WOUND CLOSURE 5

Suturs and ligatures 5




WHAT ARE THE NON-ABSORBABLE LIGATURES AND SUTURES?

Non-absorbable sutures are not generally used in an infected
wound as they may cause sinus formation.

SILK

This material, generally white or black, is braided from
numerous fine strands of silk. It is supplied on sterilizable
spools 20 to 100 m (25 to 125 yds), or in multiple pre-cut
lengths ranging from 35 to 45 cm (14 to 18 in), and a single pre-
cut length of 1.8 m(72 in).

The sizes available are 0.4(8/0) (Virgin silk), and from 0.7
to 6(6/0 to 4) or even stronger. It is important to use serum-
proofed silk to reduce capillary attraction which is a
peculiarity of plaited or braided materials. Examples of theses
materials include D & G silk (Davis and Geck), Mersilk(Ethicon),
and Surgisilk(Surgicraft).

Alternatively, threaded needles can be autoclaved as
required for an operation.

USES

Silk can be used for approximation of soft tissues including skin
It can also be used for secure ligation of blood vessals.

LINEN

Origin from fibres of flax plant, it has a braided
construction, spun and twisted. Relatively pliant and easy to
handle. `Drags' through tissues, knots very securely. Evokes
minor to moderate tissue reaction. Gains strength on wetting.

USES

It is used as a general ligature where a strong firm tie is
essential.

COTTON

Origin from fibres of cotton bush and is braided is not as
strong as silk. Gains strength on wetting.

USES

It is used similar to silk.
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Friday, October 15, 2010

WOUND CLOSURE 4

LIGATURE and Sutures 4


WHAT IS POLYGLYCONATE?

Maxon (Davis & Geck):
This is a monofilament synthetic
absorbable suture prepared from a coplymer of glycolic acid and
trimethylene carbonate.
The process of absorption is by non-
enymatic hydrolysis. Approximately 70% of the original suture
strength remains 2 weeks after implantation, and approximately
55% of the original suture strength remains 3 weeks after
implantation.
Absorption is completed 6 months after
implantation.

Maxon is available in sizes 0.7 (6/0)-3 (2/0)(Clear), and
sizes 1(5/0)04(1)(Green), mounted on atraumatic needles.

WHAT IS POLYGLACTIN 910?

Vicryl is a pliable, smooth fibre, which is made in nine sizes
from 0.3 to 5. Date from implantation studies show that more
than 55% of the original strength remains at 14 days, and over 20
per cent at 21 days.

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Friday, October 8, 2010

WOUND CLOSURE 3

SUTURES AND LIGATURES 3





WHAT IS CATGUT Chromic?
The origin of this suture material is the same as catgut (plain)
The material obtained from animal intestine is treated by immersion in a dichromate bath.
It is sterilized and packaged in a similar manner as plain catgut. Its treatment in a chromic bath delays its disintegration and this
suture loses 70% of its strength later by the end of second week.

USES

It is used as a ligature for blood vassals, and also for
suturing the mucosa, of the G.I. Tract, Urinary Tract, Respiratory
Tract, Peritoneum, and Muscle.

Surgical catgut is wet packaged in alcohol in sealed pack and pre-sterilised

WHAT IS POLYGLYCOLIC ACID?

Dexon (Davis and Geck) - This is a synthetic polymer of glycolic acid. The strands are made by extrusion as fine threads which are then braided to form a uniform gauge thread of seven sizes from 0.7 to 4. Polyglycolic acid sutures are extremely inert and cause minimal tissue reaction.

Compared with catgut, dexon suture is stronger, do not fray and are
not slippery, when knotting.
The sutures are sealed in two coverings and sterilized by a two-stage ethylene oxide process. With this method, the inner envelope is sterilized before sealing.
Gas sterilizes the outer envelope to complete the sterilization.
The increased strength compared with catgut, Dexon and other sythetic absorbable sutures, generally a size smaller than for catgut can be used with safety.
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Friday, October 1, 2010

WOUND CLOSURE 2

SUTURES AND LIGATURES 2




WHAT ARE ABSORBABLE SUTURE?
Catgut (Plain):- The origin of the fiber, is from the intestine of animals, and after processing 98% of the extracted material is collagen, and is absorbed when left in body tissues.

Each of the strands, is then graded and separated into six metric
sizes:
from the thinnest to the thickest, 2(4/0), 3(3/0),
3.5(2/0), 4(0), 5(1), and 6(2). (The sizes refer to metric
gauge, the sizes in brackets are the USP equivalents).
The metric size approximates the diameter of the strand in
millimeters X 10.

USES
The finished catgut is cut into lengths of about 70 cm.(30 in) or
1.52 m(5 ft) to form ligatures or `needled' sutures.

The attachment of non-traumatic suture needles is a machine
procedure.

There are two basic methods of needle attachment Fig.
A hole may be drilled into the blunt end of the needle shaft, or the needle can be flanged at this end to form a grove.
Machines are used to close the prepared needle tightly around the suture material, which is the "pull tested" to ensure that it is firmly attached to the needle.
This material is then sterilized and package in a fluid in small easy to handle packages.

Catgut passes through tissues smoothly and easily.
- It swells and loses its strength at the end of one week there
is loss of 70% of its strength
- It disintegrates by proteolysis and is rapidly absorbed.
- There is an inflammatory response to its presence in the body
tissues.

It is used as ligature for small vessels and also as a suture
for a subcutaneous stitch under the skin.
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Friday, September 24, 2010

WOUND CLOSURE 1

LIGATURE AND SUTURE MATERIALS 1
Surgical procedures require superficial tissue layers to be cut, to reach the required Organ.
-On closure at the end of the procedure, all these cut layers, must be stitched back in position, accurately to its opposing layer.
-Anatomical continuity, interrupted while opening up the body needs to be restored.

WHAT ARE THE SUTURES AND LIGATURES IN USE?

Surgeons have made use of sutures for achieving closure.
The following are some available techniques for skin closure.
1. Needle and suture
2. Skin clips
3. Staples
4. Adhesive closure
SUTURE
A suture or a stitch holds cut tissue layers, or structure
Together, this helps the process of healing.
LIGATURE
A ligature, or metal ligature, is the use of the material, to
Encircle a cut end of a blood vessel, so as to control bleeding.
Staples have been used to anastomose(join) hollow organs, and vassal

Suture can be:-
1 Absorbable or
2 Nonabsorbable
And both these varieties may be made of either natural or
synthetic fibre have to be used with a needle.

WHAT ARE THE NEEDLES AVAILABLE?

These are pointed metal instruments with an eye where thread has to be passed through so that two strands pass through the tissues causing little trauma.

* The same is true of sprng eye needles Fig.3.4
* Shapes of needles are shown in fig. and vary from quarter circle
to straight and the shape of the tip of the needle Fig.3.1A to D

* Atraumitic needle come with the suture materiel (single
strand) attached to the needle fig.3.2

These are pre-sterilized and come in double wraps. Fig 3.3
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Saturday, September 18, 2010

DISPOSABLES & INCINERATION

CAN YOU ACHIEVE STERILIZATION BY IONIZING RADIATION?

Most equipment, available prepackaged from the manufacturer, has been sterilized by ionizing radiation, Items such as
sutures,
sponges,
and disposable drapes, are just a few of the many types of presterilized products available. Included are anhydrous materials such as powders and petroleum goods.

NEW METHODS STERILIZATION BY LOW-TEMPERATURE STEAM AND FORMALDEHYDE (LTSF)

This is a physicochemical method which uses a combination of dry saturated steam and formaldehyde to kill vegetative bacteria, bacterial spores and most viruses and the method is thus suitable for heat-sensitive materials and items of equipment with intergal plastic components susceptible to damage by other processes.

Prior to removal of sterilized objects all formaldehyde must be removed to provide a dry, sterile, formalin-free load.

DISPOSE USED CONTAMINATED MATERIAL BY INCINERATION

This is the preferred method of disposal for all combustible and other material of an infectious nature .
contaminated needles,
plastic syringes and
clinical waste.
Disposable linen, and infected protective clothing, and drapes, should be by incinerated.
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Friday, September 10, 2010

VIRUS IN THE OT

OT accidents 2

WHAT IS HIV INFECTION?
THE VIRUS
The acquired immune deficiency syndrome (AIDS) was first described in 1981 and the human immunodeficiency virus (HIV) was first identified in 1983.
- Antibody tests were developed which revealed the HIV status of the individual.
- In 1986 a second strain, HIV 2, was isolated
.
- Like hepatitis B, the virus is present in blood and body fluids, but unlike hepatitis B is relatively easily destroyed outside the body, and is not as infectious as the hepatitis B virus.
- Infection of the surgeon can occur from contamination from infected blood or body fluids, either through an open wound, or from a puncture wound like a needle-stick injury.
- Following infection there is an asymptomatic period during which antibody to the virus is not yet present in the blood, and thus HIV tests will be negative.
- After approximately 6 months the infected individual may seroconvert, and the HIV antibody be detected.
- A high proportion will then progress to develop AIDS.
LOOK FOR
- A common presenting feature is AIDS sufferers is the Kaposi sarcoma, with an incidence of between 25%and 50%. Biopsy of such lesions may be the first indicator for the surgeon that the patient has this disease.
- Kaposi sarcomas present as pink to purple blotches like a bruise or blood blister.
They may be flat or raised.
They are skin cancer arising from the endothelial cells such as those lining blood vessels. Histological, malignant transformation causes the endothelial cells to become stippled with spindle-shaped tumor cells; lymphatic obstruction may occur, but they do not metastasize, and remain multimodal both on the skin and in the alimentary tract.
SURGEON’S RISK.
Despite the worry of surgeons about risks of infection, these risks are small.
- The prevalence rate of HIV 0.3-7% in our country.
Surgeons have been shown to contaminate themselves with blood in 8.7% cases, and sustain penetrating injuries in 1.7% cases
The transmission rate is 0.3-0.4%, yet statistically the risk of sero-conversion for a surgeon is one infection every 8 years in a high-risk area with a case-load of 15000 patients per year.
As small as one infection every 80 years, in a low risk area.
Thus the risk to surgeon at work, is exceptionally low
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Friday, September 3, 2010

THE NEW VIRUS IN OT

OT ACCIDENTS

WHAT IS HEPATITIS B (SERUM HEPATITIS)?
How does it occur in OT?
This is one of the most infective viruses.
- It may be transmitted from patient to patient by as little as 0.0001 ml. of infected blood.
- The virus remains active, for up to 6 months in dried blood, consequently instruments which have been poorly cleaned or disinfected, may be responsible for infecting other patients, whilst poor surgical technique, may result in the doctor becoming infected from the patient, or vice versa thru a needle prick.
- It has been estimated that there are possibly 200 million carriers of hepatitis in the world, representing up to 20% of the population in African, Pacific, and other tropical countries, and 0.5% of the population in Northern Europe. The current prevalence in the population is from 1-15.8%
- Thus, statistically the doctor or nurse has a 1 in 200 chance of treating a hepatitis B carrier.
- If the doctor becomes accidentally infected with the hepatitis B virus, not only may the disease develop, but the doctor may become a hepatitis B carrier, and is an unacceptable risk to patients and may have to give up surgery.
The transmission role in case of needle stick is 6 to 37%.
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Friday, August 20, 2010

STERILIZATION 4

STERILIZERS AND CONFIRM SUCCESS



WHAT ARE THE TYPES?


GRAVITY DISPLACEMENT STERILIZER The gravity (or "downward") displacement sterilizer uses the principle that air is heavier than steam.
-Within the sterilizer there is an inner chamber where goods are loaded and an outer jacket type chamber that injects steam forcefully into it.
-Any air in the inner chamber blocks the passage of pressureized steam to the surface of the goods and thus prevents sterilization.
-All the air must be removed because every surface of the supplies must be exposed to the pressurized steam to ensure sterilization.
-Therefore, the sterilizer is constructed in such a way that air is pushed downward by gravity (hence the name "gravity displacement sterilizer").

PRE-VACUUM STERILIZER The pre-vacuum sterilizer does not rely on gravity to remove air from the inner chamber. Instead, the air is pulled out of the chamber, which creates a vacuum in the chamber.
Steam is injected into the chamber to replace the air. This type of sterilizer offers greater steam penetration in a shorter time than the gravity displacement sterilizer.

FLASH STERILIZER The flash sterilizer has traditionally been used in the operating room and in other areas of the hospital to quickly sterilize items that are unwrapped.
It has been common practice to flash sterilize any instrument that had become contaminated during surgery.

HOW DO CONFIRM STERILIZATION?
- A chemical monitor is an object that is treated with material that changes its characteristics when sterilized.
This may be in the form of special ink that is impregnated into paper strips or tape and placed on the outside of the package, or it may be a substance that is incorporated into a pellet contained in a glass vial.
- The chemical responds to conditions such as extreme heat, pressure, or humidity but does not take into consideration the duration of exposure, which is critical to the sterilization process.
- Another monitoring method used to evaluate the steam sterilizer is the combined temperature time graphs that are installed within the control panel of the sterilizer. These graphs provide a permanent written record of all loads that have been processed.
- The surest way, to determine the sterility of given item, is with the use of biologic controls.
A highly resistant, nonpathogenic, spore-forming bacteria, is used as indicator. Contained in a glass vial or a strip of paper.
This is placed in the load of goods, to be sterilized.
For steam sterilization, the dry spores of the bacteria Bacillus Stearothermophilus are used.
The gas sterilization process uses the bacterium Bacillus Subtilis.
The vial or strip is recovered at the end of the sterilization process and cultured.
This process is time consuming and the results method of testing the efficacy of a sterilization process. Biologic controls should be administered at least once weekly. If feasible, they should also be used whenever an artificial implant or prosthesis is sterilized and the item withheld from use until the results are known to be negative.
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METHODS OF STERILIZATION 3

CHOICE of GOOD AUTOCLAVE & CYCLE




- A`quick' cycle would heat the water to 134 degree C (273 degree F) for 3.5 min. under a pressure of 30 1b/sq in.
- Slower cycle, more suitable for plastics, would heat the water to 121 degree C under a pressure of 15 1b/sq in 15 minutes.
- In practice, instruments are placed in the trays or in packs, the autoclave turned on, and left for the desired time.
- At the end of the cycle, the instruments are ready for use.
-They will be dry with vacuum and air outlet.

The main disadvantage of the smaller autoclave is that instrument packs cannot be sterilized as there is not a vacuum cycle to extract air and dry the packs.

However, most materials including rubber, plastics and metal can be readily sterilized, the only exception being sealed containers.
Steam is the gaseous form of water. If it is to sterilize effectively, by killing all spores:
- It must be at an appropriate temperature (which implies an appropriate pressure).
- It the chamber must be saturated with STEAM.
- Thus not be mixed with air, so it must displace all the air in the chamber of the autoclave.
- And, it must reach all parts of the load. If it contains droplets of water, it will soak into porous materials.

If no air is discharged, the bottom of the chamber may be much cooler, than the top.
As soon as the chamber of an autoclave is full of steam, at the desired temperature, and pressure, it must be held there, for a critical time-the holding time.
The standard holding time is 15 minutes, at 121 degree C, but you may need to vary it.

Single walled autoclaves are strong metal chambers with water in the bottom, like large pressure cookers. They have several disadvantages and may not be acceptable foe hospital use..

A good autoclave (with double wall & vacuum) is by far the most efficient method of sterilization for materials that will stand up to heat and moisture.
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Friday, August 6, 2010

METHODS OF STERILIZATION 2

STERILIZATION BY HOT-AIR OVENS:
These are thermostatic controlled ovens, with an electric heating element, similar to a domestic electric oven.
- Instruments to be sterilized are heated to 160 degree C (320 degree F) for 1 hour.
- Sterilization is achieved, but it is not suitable for rubber or plastic instruments.
- In hospital has been used for sterilizing powders and petroleum products and sharp delicate instruments

The efficiency of dry heat sterilization depends on the initial moisture of the microbial cells, but all microorganisms are killed at 160 degree C for a hold time of not less than 2 hours.

The main advantages of dry heat sterilization are its ability to treat solids, non-aqueous liquids, grease/ointments and to process closed (airtight) containers.
Lack of corrosion is important in the sterilization of non-stainless metals and surgical instruments with fine cutting edges.

WHAT ARE AUTOCLAVES?
This is the most efficient method of sterilizing instruments, packs and dressings, and is suitable for most materials.
An autoclave is basically a pressure cooker and in fact, there is no reason why a domestic pressure cooker should not be used to sterilize instruments in a small clinic.
The small autoclaves produced for the doctor's surgery offer a choice of temperatures, pressures and sterilizing times:

The highest temperature that can be reached by boiling water at sea level in an open vessel is 100 degree C.
With increased pressure, the water can be raised to much higher temperatures before it boils, e.g., at a pressure of 0.35 kg per cm2 (5 p.s.i.) the temperature reaches 105.5 degree C: at 0.7 kg per cm2 (10 p.s.i.). 115 degree C; and at 1.05 kg per cm2 (15 p.s.i.) the temperature will reach 121 degree C, etc. In a sterilizer chamber (autoclave) which has been well exhausted of air the steam entering promptly fills the free spaces surrounding the load.
As steam contacts the cool outer layers of the fabrics a film of steam condenses, leaving a minute quantity of moisture in the fibres of the fabrics.
Air contained in the fabric interstices, being heavier than steam, is displaced by gravity in a downward direction, and the latent heat given off during the process of condensation is absorbed by that layer of the fabrics. fig 2.15

The next film of steam immediately fills the space created when the first film condensed into water, and it does not condense on the outer layer of the fabrics but penetrates into the second layer, condenses and heats it.
This process continues until the whole load is heated through and no further condensation occurs, the temperature within the pack remaining at that of the surrounding steam.
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Friday, July 30, 2010

METHODS OF STERILIZATION

The reusable instruments have already been decontaminated.
We need to select an available method for sterilizing them for reuse in the next procedure.

STERILIZING AND DISINFECTING INSTRUMENTS:
Sterilization is the destruction of all living organisms.
- An item may only be STERILE or NON-STERILE.
- It CANNOT be NEARLY sterile.
- Disinfection, on the other hand is the REDUCTION of a population of pathogenic micro-organisms without achieving sterility.
- In these cases not all bacterial spores are destroyed.

Antiseptics are used in the skin to prevent infection. They are milder than disinfectants e.g. Iodine, Hydrogen peroxide and Chlorhexadine.

There are four methods of disinfecting and sterilizing instruments in Hospital practice:
1. Antiseptic solutions.
2. Boiling.
3. Hot air ovens.
4. Autoclave.

DISINFECTING SOLUTION
- Alcohol (Ethyl + Isopropyl) 70% was the solution most widely used.
- Recently of 0.5% chlorhexidine is widely used for emergency disinfection of surgical instruments
It requires only 2 minutes immersion.
- Where instruments are left for longer periods or stored continuously, addition of one tablet of sodium nitrite 1g will prevent rusting.
As the tablet dissolves over several days, another is added.
- The aldehydes (Formaldehyde & Gluteraldhyde) are powerful disinfectants and sterilizers.
A solution containing 2% glutaraldehyde will disinfect instruments if they are soaked for 10 minutes, and sterilize if left soaking for 10 hours.
The disadvantages are that the solution needs to be fresh, and it can cause staining if left on the skin.
- A detailed list is given at the end of this chapter (Table I.V)

BOILING:
This is still the most widely used method of disinfecting instruments in the World;
- it is simple, quick and reasonably effective, but
- will not destroy certain bacterial spores (tetanus, gas-gangrene)
- and certain viruses.
- Normally, instruments are cleaned, and then boiled for 5 minutes (100 degree C or 212 degree F).
- A boiling water `sterilizer' is badly named, because at a height of 3000 metres water boils at 90 degree C and is thus much less effective.
- This method is obviously not suitable for dressings or drapes.
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Friday, July 23, 2010

DECONTAMINATE BEFORE REUSE

HOW TO DECONTAMINATE USED SURGICAL INSTRUMENTS?

Washer Steriliser

The washer-sterilizer operates much the same as the steam
sterilizer.
The washer-sterilizer sends large amounts of soapy
water over the instruments.
Steam under pressure and air are then injected into the water, which activates the water significantly.
As the water is drained from the chamber, tissue
debris and scum are filtered off and steam fills the entire
chamber.
The temperature is then maintained at 270oF for 3
minutes.
Near the completion of the cycle, the steam is released
through the exhaust system.

Ultrasonic Cleaner

Following processing in the washer-sterilizer, all instruments
should be placed in the ultrasonic cleaner.
This process further removes particles and debris through a process called cavitation.
During cavitation, high frequency sound waves are generated
through a water bath in which the instruments are placed along
with a neutral to slightly alkaline detergent.
Cavitation explode inwardly (implosion), and this causes their release from the surface of the instrument.
Following cavitation, instruments are rinsed thoroughly and dried.

If the equipment mentioned is not available hand washing in running
Water is the alternative. Followed by detergent and hand brushing the
Instruments.

WHAT ARE THE DISPOSABLE MEDICAL WASTE?

The operation of a single surgical OT generates a large amount
of medical waste.

Among these are :

* gloves
* gowns
* backtable covers
* patient drapes
* needles and other sharps
* body fluids and secretions
* and other items that must be disposed of.

The types of regulated waste from health care facilities.

* These are radioactive waste, which is regulated by the
Nuclear Regulation Agency
* Hazardous chemical waste, which is regulated by environmental
protection agency
* The third type is potential infective waste, which, for
the purpose of this text will be referred to as regulated
medical waste these are all the items used in an operative procedure and
have been listed above.
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Thursday, July 15, 2010

CLOSING ACT

WHAT IS THE END OF DAY CLEANING THEATER ROUTINE?
Clean OT thoroughly after each day's list, and completely every week.


Decontamination of Furniture and Fixed Equipment

* The room itself and its furniture and fixed equipment can be cleaned and disinfected.
* All equipment and furniture used during a surgical procedure are thoroughly cleaned
* Floors should be cleaned using a wet-vacuum system. This can be a centralized built in system or a portable wet-vacuum. If neither is available, the following procedure may be used:

1) Two buckets are filled with disinfectant/detergent
2) Mop heads must be sterilized or a disposable mop head (used once only) used in the operating room suite.
3) Solutions and mop heads are changed for each suite and the buckets cleaned before new solution is mixed.

* The pads of the operating table are removed to expose the undersurface of the table. All surfaces of the table and pads are cleaned with particular attention to hinges, pivotal points, and castors.
* Doors and walls are spot cleaned with disinfectant

End of Day Cleanup

* Surgical lights and slide tracks
* All ceiling-mounted equipment
* All furniture including castors or wheels
* All shelves, counters, work tables and autoclave cabinet tops
* All floor surfaces in the department the surfaces are carbonized.
* Scrub sinks
* Soap dispensers

Weekly Cleanup

* Ventilation and air conditioning/heating duct grills must be vacuumed to prevent the release of bacteria-laden dust into the surgical environment
* Utility rooms, including those used to store house keeping supplies, sewer hoppers, and linens, must be cleaned
* OT Fumigation is utilized after occurrence of infection.
Cleaning Instruments:
Use an old scrub brush. Open hinged instruments fully,
scrub them, and take special care to clean their jaws and serrations
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Thursday, July 8, 2010

ACT ONE SCENE ONE

THE MAIN EVENT



HOW DO YOU PREPARE THE OPERATION SITE?
Shaving:
The operation area should be clean and free of infection before the operation, and the ward nurse to check this in the ward before sending the patient to the O.T. (Figs 2.12A – E)
- Shave the area on the morning of the operation, or as part of operation.

Preparation:
Prepare the skin as soon as the patient is anaesthetized.
- Start with a soap solution, and follow this with spirit.
- If there is a low sensitivity to iodine in the community, use alcoholic iodine.
- Take a sterile swab on a holder start in the middle of the operation site, and work outwards.
- Discard both swab and holder, and repeat the process with a second swab (some surgeons use a third).
- The last is spirit which will evaporate to leave the skin dry.
- Be sure to prepare a wide enough area of skin.
- In an abdominal operation this should extend from the patient's nipple line to below his groin.

Draping
The skin has been prepared:
-Place the first towel across the lower part of the operation site. fig 2.13a
-Place another towel at right angle on the nearer edge of the operation site. fig 2.13b
-Apply a towel clip at the point of crossing of the two towels. fig 2.14
-Place another towel at the far edge of the operation site.
-The final towel goes across the top end of the site.
All the corners should have towel clips to prevent them from slipping they can go through the skin if the operation is under G.A.
-In an abdominal operation an abdominal sheet covers the abdomen on top of the towels. This sheet has an opening in its middle to provide access to the operation site [double toweling]
-If any area close to the operation site becomes contaminated at any time during the operation, place another sterile towel over the contaminated site.

SWABS
Ten cm. gauze squares folded and held in sponge forceps are used for swabbing
PACKS Large squares of gauze or linen are used as packs. These packs are placed in cavities so as to keep organs and vital structures out of reach of sharp instruments being used at the operation site.
All these swabs and packs are counted and placed on the sterile trolley
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Thursday, July 1, 2010

A DAY AT THE THEATRE

PREPAREEVERY OT DAY


HOW TO PREPARE THE OT?
- All equipment, particularly the operating theatre table and
all storage ledges within the OT rooms should be cleaned with damp
duster.
Floors are cleaned before sterile trolleys are prepared.
- Sterile nail brushes, scrub solution gown packs and all items
required in the OT should be checked and replaced if required
- The required number of bottles or flasks of sterile saline or
water for hand-lotion bowls are placed in position.
- Fresh replacements of bandages, strapping, splints and lotions,
etc., should be available before the operation list commences.
- Finally equipment required for the first operation is checked by
the senior operating theatre nurse or the scrub nurse also selects
sterile packs, may prepare instruments and special apparatus for
sterilization.
- Special attention is given to the operation table and
accessories to ensure that these are present and in working
order, lights are inspected for illumination and focus.
- All electro medical apparatus such as the diathermy and suction
machines or pipeline suction set are switched on and tested.

HOW TO PREPARE AN INSTRUMENT TROLLEY?
- Instrument trolley should be prepared immediately before an
operation.
- It is a bad practice to prepare all trolleys’ required for a
list in the morning, for even if they are covered carefully, it
is impossible to guarantee sterility when required later.
- All metal surfaces of trolleys and tables which are to be used
for setting out sterile instruments and apparatus should first
be covered with a sterile water-proof material before the
application of sterile drapes.
- If the instrument trays have been placed on the trolleys
aseptically, the instruments are laid out by a nurse wearing
sterile gown and gloves.
- It is a bad practice for an" unscrubbed"person to complete
this arrangement using Cheatle forceps, because of the great
risk of contamination occurring when ungloved hands are moved
to and fro over the sterile trolley.
THERE IS NO PLACE IN A MODERN OPERATING ROOM FOR USE OF UN-STERILE
FORCEPS STORED HALF SUBMERGED IN A CONTAINER OF DISINFECTANT.
- Prepared sterile packs containing all the necessary equipment
relevant to a listed operation, and incorporating trolley
drapes which fall into position as the pack is opened, will
shorten the time taken for preparation and cut down bacterial
contamination in the O.T.
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Wednesday, June 23, 2010

JOIN THE TEAM

GOWNING
Hold the gown away from your body, high so as that it does not touch the floor.
- Allow it to open up and put your arms into the arm holes while keeping your arms extended.The inside of the gown is facing you
- Then flex your elbows and abduct your arms. fig 2.6
- Wait for the nurse to help you.
-She will hold the inner sides of the gown at each shoulder and pull them over your shoulders fig 2.7 and will tie the tapes of the gown at the back. fig 2.8

GLOVING
Dust your hands with powder and rub them together to spread it.
- Be careful to touch only the inner surface of the gloves.
- Grasp the inner aspect of the turned down cuff of a glove, and pull it on to your opposite hand. fig 2.9
- Leave its cuff for the moment.
- Put the fingers of your already gloved hand under the inverted cuff of the other glove, and pull it on to your bare hand. (fig 2.10, fig 2.11a, & b)
- It is a good practice to wash your gloved hands in sterile water to remove the powder.

EYE PROTECTION

Masks and protective eyewear or face shields should be worn during procedures that are likely to generate droplets of blood or other body fluids, the face should prevent exposure of mucous membranes of the mouth, nose and eyes of the surgeon.

They are lightweight, adjustable and do not obstruct vision. An educational programme is necessary to introduce surgeons to these new barriers.
You are now ready to prepare the op-site for cleaning.

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Monday, June 14, 2010

START THE DAYS WORK

SCRUBBING UP
ALL taking part in the surgical procedure and the OT .team must scrub.
The scrub rooms are situated before the entrance to the O.T.
Adjust the elbow tap levers to deliver water without splashing fig 1.1.In most tropical countries only a cold water tap is necessary.
- Wet your hands, apply a little soap or detergent, and work up a good FOAM.
- Scrub your hands and forearms to 5 cm above your elbows for one complete MINUTE.
- Wash your forearms.
- Then take a sterile brush and put soap on it. fig 2.1
- Scrub the lateral side of your left thumb, then its medial side, then the lateral and medial aspects of each successive finger. fig 2.3
- Scrub your nails, and then the back and front of your left hand.
- Follow same routine with your right hand. Scrub for 5 minutes in all.

Some surgeons only scrub their nails, and then thoroughly wash and rinse their hands and arms upto their elbows a number of times for 5 minutes.
Rinse the suds from your hands while holding them higher than your elbows. fig 2.4
- Turn off the taps with your elbows. fig 2.5
Dry your hands with a sterile towel before you put on a sterile gown.
- Dry your hands first, then your forearms.
- Grasp the folded towel with the fingers of both hands, then let it drop open, so that you don't touch anything with the open towel.
- Dry your hands on one corner, then dry your forearms.
- Try not to bring a wet (unsterile) part of the towel back to a dry area of your arms and hands
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Saturday, June 5, 2010

OTMANAGE CRITICAL CONTROL

INFECTION CONTROL, STERILIZATION & OT CLEANING

How does Air Entry Air Conditioning Effect Infection in OT?

There must be a positive pressure in the OT compared to wash rooms, utility rooms and corridors to prevent entry of contaminated air.

The temperature be kept at 68 to 700F (20-23 C) with a humidity of 30-60 percent.
-This reduces bacterial growth and static electricity.
-Each O.T. should have independent temperature controls.

Air in flow should be filtered through high efficiency particulate system (HEPA) with 15 air exchange per hour at least three of these must be fresh air.
-Air must enter the OT through vents in the ceiling and leaves through vents near the floor.

-The air ventilation system must have a regular routine for inspection and maintenance including change of filters.

-All these steps will control bacterial growth and thus wound infections.

What are Infection Control Mechanisms?

Infection will occur if high standards of preoperative,
intra-operative,
and postoperative rules are not observed in relation to the care of instruments and patients.
If there is any break of these rules by the surgical team;
-The occurrence of infection and cross-infection will rise.
-Resulting in anything from minor wound infections to a major disaster(tetanus)
-Standing rules and procedures need to be DEFINED by hospital Infection Control Committees (ICC) and OBSERVED by the surgical teams.

The infection control committee, usually headed by a physician, infection control nurse, or nurse epidemiologist.
Following the standards set by the ICC, provides the hospital with an effective program with the following goals:

-Investigate and identify source of the infection in each case.
-The source may be a person, a patient or an employee or may be the practice of one or more employees of poor aseptic technique. or
-A team member may be harboring a specific disease organism that is transmitted to the patients in his or her care.
-Provide effective isolation of infected patients.

-The ICC also identifies need for change in rule book to prevent a future outbreak

What are Common Bacteria on Skin and Surface?
Bacteria include staphylococci and streptococci these are responsible for the majority of cases of cellulites and abscesses seen on the skin.
-Most respond to an appropriate broad spectrum antibiotics.

-Abscesses in the perineal area are frequently infected with anaerobic bacteria or are mixed infections.
-In these situations metronidazole or some similar antibiotic needs to be given

• WHERE INFECTION is suspected in patent or staff, a bacterial SWAB should be taken, this will guide the treating physician to select the correct antibiotic.
• Fungal infection on toe-nails and finger-nails may be easily recognized by sending nail clippings or even the complete nail for mycology. Such action may avoid the need for surgery and establish a definitive diagnosis.
• Candida (fungus infection in mouth) infections are easily recognised and treated with any of the antimycotic agents.

Most cases of infection in surgery can be avoided by:
• Careful aseptic technique in the OT (given below).
• Attention to rules and procedures for sterilization of instruments and dressings (to be defined by the hospital administrators).
• However, in addition to problems of common bacterial pathogens, surgeons are now having to address themselves to the problems of viral agents such as HEPATITIS B, C, and HIV infection, which may have very many more serious long term consequences (guidelines at the end of this chapter).
• Infection is not always a one-way problem of patients infecting doctors and other patients: in a few instances an infected surgeon or his team can infect the patient, or other colleagues.
• It is therefore important for all members of the surgical team to be aware of the potential DANGER of their personal infections, and to know how to avoid them by strict personal hygiene and to treat these infections if they occur.
They must be freed from OT duties for the duration of their infection
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Wednesday, May 26, 2010

DOWN MEMORY LANE

REVIEW AND RECALL



SELECT DEFINITIONS YOU NEED TO KNOW

ANTISEPSIS

A process that destroys most harmful microorganisms on
The surface of Instruments

BACTERICIDAL

Drugs, chemicals, and other agents able to kill bacteria

BACTERIOSTATIC

Agents capable of inhibiting the growth of bacteria but not killing them


CAVITATION

A process in which air pockets are imploded (burst inward),
Releasing energy to dislodge particles of soil or tissue debris
Sticking to instruments. Antiseptics chemicals used for reducing
Contamination of body surfaces

CLEANING

A process that removes organic or inorganic residue or debris by hand cleaning and brushing

CONTAMINATED

Any instrument or body surface that is known to be unsterile.
A sterile instrument comes in contact with non-sterile objects and thus may harbor Microorganisms

DECONTAMINATION

A process of disinfection

DISINFECTION

A process by which most but not all harmful microorganisms are
Destroyed on instrument surfaces

CRITICAL ITEMS

Those items that must be sterile before use in or on a patient; items
That goes into body tissues or the vascular system

STERILIZATION

A process by which all microorganisms are destroyed

ULTRASONIC CLEANER

Equipment that cleans instruments through cavitations

WASHER STERILIZER

Equipment that washes and sterilizes instruments following an
Operative procedure

FOMITE
An item(towel, bedsheet) that is capable of harboring bacteria and transmitting
Disease.

HOST
Organism that provides nutrition for parasites

PATHOGENIC
Disease causing bacteria

STRICT AEROBES
Bacteria that cannot survive without oxygen

STRICT ANAEROBES
Bacteria that cannot survive in the presence of oxygen
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Saturday, May 22, 2010

RECYCLED INSRUMENTS AND MEDICAL WASTE

HOW TO DECONTAMINATE SURGICAL INSTRUMENTS?

Washer Steriliser

The washer-sterilizer operates much the same as the steam
sterilizer.
The washer-sterilizer sends large amounts of soapy
water over the instruments.
Steam under pressure and air are then injected into the water, which activates the water significantly.
As the water is drained from the chamber, tissue debris and scum are filtered off and steam fills the entire chamber.
The temperature is then maintained at 270oF for 3 minutes.
Near the completion of the cycle, the steam is released
through the exhaust system.

Ultrasonic Cleaner

Following processing in the washer-sterilizer, all instruments
should be placed in the ultrasonic cleaner.
This process further removes particles and debris through a process called cavitation.
During cavitation, high frequency sound waves are generated
through a water bath in which the instruments are placed along
with a neutral to slightly alkaline detergent.
Cavitation explode inwardly (implosion), and this causes their release from the surface of the instrument.
Following cavitation, instruments are rinsed thoroughly and dried.

WHAT ARE DISPOSAL MEDICAL WASTE?

The operation of a single surgical OT generates a large amount
of medical waste.

Among these are:

* gloves
* gowns
* backtable covers
* patient drapes
* needles and other sharps
* body fluids and secretions
* and other items that must be disposed of.

The types of regulated waste from health care facilities.

* These are radioactive waste, which is regulated by the
Nuclear Regulation Agency
* Hazardous chemical waste, which is regulated by environmental
protection agency
* The third type is potential infective waste, are for
the purpose of this text will be referred to as regulated
medical waste.

CATEGORIES OF MEDICAL WASTE

Sharps (used and unused)

Discarded medical devices that have been used in human
patient care, medical research, or industrial laboratories and
that are capable of pucturing or cutting the skin and thus
transmitting bacterial or virus infections.

This includes:
* needles
* syringes with needles attached
* trocars
* pipettes
* scalpel blades
* blood vials
* broken or unbroken glassware

Cultures and stocks of infectious wastes

Discarded cultures and stocks of infectious agents and associated
microbiologicals should be considered regulated medical waste.

Animal Waste

Discarded material originating from animals inoculated with
infectious agents during research or production of biological or
pharmaceutical testing.

Pathological waste

Discarded pathological wastes (eg. human tissues, organs, body
parts) removed during surgery, autopsy or other medical
procedures


Human blood, blood products, body fluids

This category includes discarded free-flowing human blood and
blood products (eg. plasma, serum), any free-flowing body
Secretion containing blood components (egg. pleural, peritoneal,
Amniotic fluid), human excretions (egg. urine, stool)
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Monday, May 17, 2010

THE INSTRUMENT CARE

Preparing the Tools for a Procedure







HOW TO TAKE CARE OF SURGICAL INSTRUMENTS?
Like all other equipment,medical and surgical instruments also
require a regular care and maintenance protocol so that they
retain their useful character and prolong their life.
Instruments that are dirty or rusty are not only a source of
infection, but ultimately break before their expected life span.

CARE OF STAINLESS STEEL:
Stainless steel is the material of choice for most surgical
instruments;it combines a high resistance to corrosion and rust
and has a smooth surface. However the surface of the finest
stainless steel instruments can become pitted and stained, if
great care is not used in washing, cleaning, polishing and
lubrication of these instruments. Rough handling or the use of
abrasives can permanently mark stainless steel.
- So to start with all instruments after use should be cleaned
with a hard brush under running cool water.Very hot water will
cause coagulation of blood and exudate and make subsequent
cleaning more difficult.
- If use of an Ultrasonic cleaning bath using instrument
detergents is available, this will be ideal and insure good
cleaning and continued high polish of the instruments. This
equipment is available only in some hospitals in India.
- After washing,instruments should be dried to avoid water
remaining in any joint and causing corrosion.
- Lubrication using a water-soluble lubricant applied on joints is
recommended and will greatly prolong the useful life of any
instrument if they are to be stored.
- Salt solutions are a major cause of pitting,and instruments
should never be soaked in them, nor should a saline solution be
allowed to dry on an instrument.
- Whenever cleaning or washing instruments, keep all ratchets
unlocked and box joints open and avoid using wire wool or rough
brushes on the surface of instruments.
- Surgical blades and needles, both of which may rust and corrode
more easily than stainless steel instruments and therefore the
rules above apply to them also.
- Serrated surfaces on artery forceps and needle holders can be
effectively cleaned with a small brass wire brush
- Instruments or plastic parts of instruments are washed
with warm soapy water with a soft cloth sterilization may be
by either soaking in antiseptic solutions or autoclaving at a
lower temperature (121 degree C under 151b/in2 for 15 min.)
than is used for steel instruments.Cleaning and polishing
should only be undertaken using recommended cleansers and
polishers. Most plastics are best stored in a dry state rather
than prolonged soaking in antiseptic solutions.

WHAT ARE CRITICAL ITEMS?

Critical items are those that must be sterile. These objects
enter sterile tissue or the vascular system. Examples of
critical items include:

* Surgical instruments
* Cardiac and urinary catheters
* Implants
* Needles

NONCRITICAL ITEMS
This group of items comes in contact with skin. Skin is
effective in protecting the inner tissues of the body against
bacteria and viral invasions. This category includes items :

* Blood pressure cuffs
* Bed linens
* Bedside tables
* Crutches
* Some food utensils
* Bed frames
* Floors
* Walls
Any questions be sent to drmmkapur@gmail.com

Friday, May 14, 2010

TO PREPARE FOR THE EVENT

An OT Day
HOW TO PREPARE OT?
- All equipment, particularly the operating theatre table and
all storage ledges,within the rooms,should be cleaned with damp
duster.Floors are cleaned before sterile trolleys are prepared.
- Sterile nail brushes,scrub solution gown packs and all items
required in the OT should be checked and replaced if required
- The required number of bottles or flasks of sterile saline or
water for hand-lotion bowls are placed in position.
- Fresh replacements of bandages, strapping, splints and lotions,
etc., should be available before the operation list commences.
- Finally equipment required for the first operation is checked by
the senior operating theatre nurse or the scrub nurse also selects
sterile packs, may prepare instruments and special apparatus for
sterilization.
- Special attention is given to the operation table and
accessories to ensure that these are present and in working
order, are inspected for illumination and focus of lights.
- All electromedical apparatus such as the diathermy and suction
machines or pipeline suction set are switched on and tested.

HOW TO PREPARE AN INSTRUMENT TROLLEY?
- Instrument trolley should be prepared immediately before an
operation.
- It is a bad practice to prepare all trolleys required for a
list in the morning,for even if they are covered carefully,it
is impossible to guarantee sterility when required later.
- All metal surfaces of trolleys and tables which are to be used
for setting out sterile instruments and apparatus should first
be covered with a sterile water-proof material before the
application of sterile drapes.
- If the instrument trays have been placed on the trolleys
aseptically,the instruments are laid out by a nurse wearing
sterile gown and gloves.
- It is a bad practice for an" unscrubbed"person to complete
this arrangement using Cheatle forceps, because of the great
risk of contamination occurring when ungloved hands are moved
to and fro over the sterile trolley.
THERE IS NO PLACE IN A MODERN OPERATING ROOM FOR USE OF UNSTERILE
FORCEPS STORED HALF SUBMERGED IN A CONTAINER OF DISINFECTANT.
- Prepared sterile packs containing all the necessary equipment
relevant to a listed operation, and incorporating trolley
drapes which fall into position as the pack is opened, will
shorten the time taken for preparation and cut down bacterial
contamination in the O.T.
WHAT ARE THE DUTIES OF THE SCRUB NURSE?
- The nurse or operating department assistant (ODA) acting as
scrub nurse, scrubs up puts on sterile gown, and sterile gloves
on the hands like the rest of the surgical team
- When scrubbing up to carry out surgical hand disinfection, care
must be taken to ensure that all parts of the hands and
forearms are cleaned thoroughly, special attention being given
to the nails and between the fingers.
- It is important that no person should scrub unless free from
upper respiratory infection and skin lesions.
- Cuts and abrasions or infected pimples can endanger the patient
by increasing the possibility of post-operative infection.
- She/he anticipates and provides all instruments required by the
surgeon.
- Keeps count of them and all swabs used.

WHAT ARE YOUR DUTIES AS CIRCULATING NURSES?
- In addition to the scrub nurse,one or two nurses or ODAS are
on duty to act as circulators.One stays in the operating
theatre, watching the scrub nurse and ready to bring anything
she requires.
- The main duties of the second circulating nurse are to see
that the instruments and trolleys are READY for the NEXT CASE,
and she should help in PLACING the PATIENT on the operation
table if a porter or technician is not available.
- She anticipates and gives to the scrub nurse articles from
sterile bags or packs, she REPLACES sterile gowns and gloves
used up on the sterile trolley reserved for the purpose.
- The first circulating nurse also TIES up the gowns, being
careful to avoid touching any part of the gown other than
the tapes.
- She should identify the patient by the identity tag and case
notes before he/she enters the OT.
Any questions be sent to drmmkapur@gmail.com

Friday, May 7, 2010

DRESS CODES AND TABLE POSITIONS

ENTRY RULES & POSITIONS



Some more positions


HOW DO YOU GET THE LATERAL POSITION OF EXTENSION?
This is used for operations on the kidney and chest, but may be
modified slightly for operations on the hip.
For the former operations the patient is positioned over the kidney bridge which is raised to extend this region.
Alternatively if an operation which incorporates a `break back' is used, extension is achieved by positioning the patient over the division in the centre section before adjusting the angle of the table top. Fig 8

HOW TO GET THE PRONE CRANIAL POSITION?
This position is used for cerebella operations and high cervical
laminectomy.
Some reverse Trendelenburg tilt is used and a padded strap placed round the thighs and the table top for additional security.
The shoulders and thorax are supported by shoulder supports in conjunction with small pillows. Fig. 9

HOW TO GET PATENT IN SITTING CRANIAL POSITION?
This is a position for cerebella cranial operations and high
cervical laminectomy and is an alternative to that described.
The patient is sitting and stabilised by the cranial support.
The hands are placed in the lap and the body immobilised by
securing the arms with body supports which are attached to the
operation table at each side.
These have been omitted in the illustration in order to show the position of the arms. fig 10

RULES YOU OBSERVE IN OT?
No one should enter the operating rooms without first washing his
hands and changing into clean OT clothing and footwear such as
theatre rubber shoes, sandals or slipper.
The main objective is to prevent entry of street bacterial contamination into the operating rooms.
This rule must apply even when there are no operations in progress.
- Personnel preparing to assist at operations cover their hair
and wear masks in addition to wearing suitable clothing and
footwear.
Visitors and other staff are similarly attired.
- Cotton, poplin or polyester cotton are the most commonly used
materials for theatre clothing; Blue, grey colour or white for
scrub suits, and green colour or white for operating gowns.
- The hair should be completely covered with a closely fitting
caps.
- The most efficient mask is one made from synthetic fibres or
fibre glass, linen masks can be used in case these are not
available.
- These masks, which should be moulded to fit the facial outline
snugly when worn, actually filter the air rather than deflect
as with the paper or cloth masks.
Any questions be sent to drmmapur@gmail.com D

Thursday, May 6, 2010

NEED TO KNOW

TABLE MANNERS





Who Should Know?
It is essential that all members of the theatre staff familiarize
Themselves with the operation table and its accessories which
must be easily available and ready for immediate use.
To insure this, passing on of this information is a part of the introductory briefing of all new staff.
- The whole apparatus must be maintained in good working order
and checked before each operation list.
Careful and correct positioning of the patient is very important.
- It is essential to provide good access for surgery.
- And also to take into account patient safety.
- Anesthesia technique requirements.
- Monitoring and position of i.v. lines.
- The table top rubber mattress must provide insulation and
Prevent harm to the patient due to pressure, especially on
Nerves and bony prominences.
Most of the following positions are demonstrated on an general
purpose operation table which incorporates the majority of the
features described already.

What are the Positions?
In Supine or Dorsal Recumbent Position (Fig.2)
In this position the patient lies on his back and is used for MOST operations, including those on the
- Eye
- Ear
- Face
- Chest
- Abdomen
- Legs or Feet
- And with modifications is suitable for operations on the breast
and arms or hands, which may be placed across the chest or
extended on an arm table.

WHAT IS BREAST AND AXILLA POSITION?
This is the position for operations on the breast and axilla. It
is a modified supine position, either with both arms extended and
secured on arm tables, or one arm secured by the side of the
patient and the other on the affected side abducted and
supported by a nurse (Fig 3).

WHAT IS NECK POSITION?
This position is used for operations on the neck, especially
Thyroidectomy, and tracheotomy.
The patient is placed in the supine position with a pillow or sandbag under the shoulder blades, and the head is held by a nurse or assistant with the neck well extended, a padded horse-shoe provides a good support for the head in such operations.

WHAT IS SUPINE HIP POSITION?
This is used mainly for nailing a femoral neck fracture, but is
suitable for osteotomy, slipped femoral epiphysis,etc.
The patient is in a supine position, with his pelvis supported by a
supplementary table top which is translucent to X-rays and
incorporates a slot for introducing anterior position film
cassettes under the pelvis fig 4.

WHAT IS THE TRENDELENBURG POSITION (HEAD DOWN)?
This position, a modification of supine, is used for intrapelvic
operations. Fig 5.
- The object being to allow the intestines to displace away from
the pelvic cavity by gravity towards the upper abdomen.
- They may also be packed off readily to leave easier access to
the pelvic organs.

HOW IS THE GALL-BLADDER AND LIVER POSITION ARANGED?
This is another modified supine position which is used for
operations on the gall-bladder or liver.The patient is
positioned over the back elevator which is raised to produce
extension; and thereby push the gall-bladder towards the anterior
abdominal wall. Fig.6

HOW TO ARRANGE FOR LITHOTOMY POSITION?
This is used for operations on the external genital organs,
perineum and anal region. The buttocks project well over the
edge of the table at the junction of the centre and foot section
which is lowered or removed.The legs are flexed at the hips and
knees, and raised with the feet supported in webbing slings
suspended from the lithotomy poles. A douching funnel may be
fitted below the perineal area to collect blood.
Any questions be sent drmmkapur@gmail.com

Tuesday, May 4, 2010

THE WORK TABLE

2 What are the requirements of the O.T. TABLE?

The modern operation table is a mechanical apparatus capable of
Adjustment to give a variety of positions for a patient
undergoing surgery.
- Most tables are designed to provide suitable positions for a
wide range of general surgical operations.
- It can be adapted for specialised procedures by the addition
Of accessories (neurosurgery, orthopedics).
- The introduction of complex operative procedures has required
The manufacture of more sophisticated operation with the table
Base unit positioned in the centre of the theatre on to which
Is fitted a removable top.
- This facilitates the transport of the operated patient.
An operation table which offers power operation,
Interchangeability of table top for ease of patient transport is
Illustrated. Fig. 1A, and 1B
The table must have the following functions:
* Can be tilted downwards at the head and foot ends.
* Can be tilted from side to side.
* Can be elevated or lowered as a whole.
* Can be broken at hip level for gynaecological operation (e.g.
vaginal hysterectomy), renal surgery, and certain orthopaedic
operations.
* Can have the head and foot ends of the table removed to allow
for other attachments, eg. the application of a neurosurgical
frame.

What are the Accessory Equipments?
Most operating tables should have the following accessory
equipment or attachments:
* A rubber mattress placed on top of the table to prevent the
patient's body touching any metal part of the table in all
positions.
- The mattress is divided into head, body and leg sections,
which may be attached together to prevent slipping.
* A non-slip mattress designed to prevent movement of the patient
in tilted positions.
* An anaesthetic screen - a metal frame, the base of which slides
under the mattress.The top of the frame allows for the
operative drape to be placed over it, thus separating the
sterile operative area from the anaesthetic area.
* A head rest frame - a horseshoe shaped metal frame which is rubber
padded. It attaches to the operating table to stabilize the
patient's head during neurosurgical operations.
* Acrylic plates - transparent plastic bridges which may be placed
on the operating table under the mattress. X-rays can be taken
during an operation by slipping a X-ray plate under the plastic bridge.
* A kidney bridge - a bridge under the mattress at waist level which,
when elevated, arches the middle of the body for easy exposure
of the right or left kidney.
* An arm rest - used to support the patient's arm for intravenous
therapy,blood pressure monitoring or hand operations.It may
also be used to extend the arm for a radical mastectomy,thus
exposing the axilla for access to the axillary lymph nodes.
* An armslide supports the unused arm and preventing it from
falling over the edge of the table.
* Leg stirrups are usually marked left and right.They are used to
stabilise the patient's legs in the lithotomy position,eg.for
a dilation and curettage operation.
* The laminectomy bridge is an arched frame over which the patient
is placed face down.It allows for extension of the
vertabrae and exposure of the lamina.
* A hand table may be attached to the operating table to allow for
a wide working field during operations on the hand or arm.
* Sandbags assist in stabilizing a limb, eg. they may be placed
under a patient's knee for support during a menisectomy
operation.
In a thyroidectomy, the neck may be extended slightly backwards and the head stabilized in a round rubber ring.
A sandbag may be placed on either side of the head for
stability.
* Pillows to provide cushioning and protection for a patient's body
and limbs.
Any questions may be sent to drmmkapur@gmail.com

Saturday, May 1, 2010

CRITICAL LOCUS REQUIRMENTS

THE OT COMPLEX MANAGEMENT
THE OT PLAN AND DESIGN

Where should it be located?
All operating theatres should be centralized in one operating
Area rather than spread in the hospital.
this has been shown to be the most economic approach;
-For good engineering and
-Focused nurse’s services,
-Use of equipment and
-Training of staff.

How is it designed?

Present trends in hospital design favor the low-rise building,
Two/three floors high.
With an internal courtyard. This enables maximum use of natural light and ventilation.
The operating department should be constructed separate from general traffic and air movement in the rest of the hospital.

How to plan?
Movement of patients is made easier if at the time of planning
The requirement of the operating department surgical wards and
Intensive care unit (ICU)
Accidents and emergency departments (AED)
Radio diagnostic (X-ray) departments are all considered.
The laboratory facilities should also be close by.

How to Design and Control Environmental?
The term operating suite is sometimes used to designate the room used for surgery.
This room is usually 400sq ft with minimum of 20 feet distance from cabinets and wall shelfs.
Special surgery suits cardiac, orthopedic neurosurgery and minimal invasive surgery and requires 600 sq ft. of space.
The support areas (changing rooms, scrub and utility
Rooms) are separate.
All operating suites are similar in design.

They are roomy enough to allow scrubbed staff to move around
Sterile equipment without the risk of contamination.
The design is such that dust is not trapped in areas that would be difficult to clean.
The surface vinyl material is free of joints and crevices.

The operating suite, is designed to insure maximum patient safety

* The floors, ceilings, and other surfaces are smooth, non-
Porous, and made of fireproof materials.
* The smooth surfaces allow thorough cleaning and prevent the
trapping of biologic material that could cause cross
Contamination
* All surface materials are made to withstand frequent washings
And cleaning with strong disinfectants
The ventilation system in the surgical suite has filters to
Prevent the contamination of the clean environment by
Air-borne bacteria.
The entry of air is thru high up vents
* The current requirements is, 15 exchanges of air per
Hour, 3 of which must be fresh air.
• Clean air exchange is possible if there is a positive pressure within the suite.
• This air is derived directly from the outside to avoid circulating air that might be contaminated By passage through other areas of the hospital
* The humidity is also controlled to minimize static
Electricity and consequent ignition of any flammable
Solutions or objects used in the operating room.
* The ideal humidity level to achieve minimal static and also
Reduce bacterial growth is 30% to 55%.
The air temperature
Is maintained at 200C to 240C (680F to 750F).
* Emergency signal. The O.T.Management committee should
Consider installing an alarm system in case of a life
Threatening emergency. The activation of this alarm will
Save valuable time to mobiles. The emergency designate staff
And direct them to the site of the emergency.

A CRITICAL HOSPITAL LOCUS

THE RESOURCE FOR OTMANAGE

Tryseffcare is a Metaphor, with emphasis on self, as a motivator, and care providing the path to good performance and achieving your personal development goals


The hospital scene is fast changing in India, it is
estimated that over 15 thousand hospitals and nursing homes already exist, and this number is fast increasing.
This makes a demand on the training requirement of manpower in position.
This could in part be met by making available self learning hand books, or electronic media, to improve absorption capacity for high technology in use in modern Operating Theatres.

The health care outlet (public private hospital/nursing homes) have needs, for upgrading knowledge and skill of staff in place (Nurses & nurse assistant),.and new entrants to these cadres.

This involves areas of high levels of new technology in use in the OT complex. Advanced technique used by surgeons in the operating room complex need to be accessible.
Nurses and thru them other staff (OR assistants and theatre orderlies) need to acquire a commensurate learning abilities to remain efficient, provide quality service and meet the needs of their personal development goals.
The most cost effective means to improve absorption abilities of nurses and staff in position and new ,staff employed is to provide access to inexpensive self learning handbooks in surgical specialties and to introduce them to new required instruments used in modern procedures in these specialties.@

The instruments are illustrated for ease of recognition for organizing sets for procedures
The procedures are outlined in a standard format including;
• objectives of the procedure
• position of the patient during the procedure
• Anesthesia required for the procedure
• Steps of the procedures
• Instruments required (sets and special instruments)

The hand book also covers the important subject of infection control in the OT. Management of the OT complex,
Information on ligature, and
Suture material.
Defibrillators,
Ultrasonic equipment,
Lasers,
Diathermy,
Cryoprobes
.All this information imparts management and nursing skills to the OT staffThis information can be of use trainers as a training guide.

@A Complete Hospital Manual of Instruments and Procedures 2005 Jaypee ISBN81-8061-546-4