OPERATION THEATRE ASEPSIS AND STERILIZATION

the presentation is about the Operation theatre asepsis. sterilization of nstruments to prevent the post surgical endopthalmitis.

1. OT ASPESIS AND STERILIZATION DR. ANANYA SINHA RESIDENT DEPT. OF OPHTHALMOLOGY RURAL MEDICAL COLLEGE PIMS, LONI 1 PRAVARA INSTITUTE OF MEDICAL SCIENCES 7/27/2020

2. DEFINITIONS Sterilization: This implies to a process by which all the organisms are killed including spores . Disinfection : process that involves the elimination of most pathogenic microorganisms(excluding bacterial spores) on inanimate objects. Chemicals used for disinfection are called Disinfectants Antiseptic : This implies to a substance that prevents growth or action of microorganisms either by inhibiting their activity or destroying them. Its role is generally seen on living tissue. 2 PRAVARA INSTITUTE OF MEDICAL SCIENCES 7/27/2020

3. ASEPSIS Asepsis includes prevention of wound contamination by using sterile material and minimizing air borne transmission . Even with all precautions the absolute sterility may not be possible . All infection prevention techniques contribute to the effort of achieving asepsis. Aseptic practices include: Proper preparation of the patient for the surgery Surgical hand scrub Using barriers such as gloves and surgical attire Maintaining sterile field Using good surgical technique Maintaining safe environment during the surgery. 3 PRAVARA INSTITUTE OF MEDICAL SCIENCES 7/27/2020

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5. DISINFECTION Disinfection : process that involves the elimination of most pathogenic microorganisms(excluding bacterial spores) on inanimate objects. 5 PRAVARA INSTITUTE OF MEDICAL SCIENCES 7/27/2020 DEVICE DEFINATION RISK OF INFECTION EXAMPLE REPROSSING PROCEDURE CRITICAL Devices that enter sterile tissue or vascular system High Surgical instruments, needle, ultrasound probes. Sterilization by steam or ETO SEMICRITICAL Come in contact with mucous membrane or non intact skin High / intermediate Flexible endoscopes, laryngoscope blade Sterilization desirable, high level disinfection NONCRITICAL Come in contact with intact skin Low BP Cuff, stethoscope Intermediate/ low level disinfection

6. DISINFECTANT CONC. MOA COMMERCIAL PREPARATION GLUTARALDEHYDE 2% Alkylation of amino acid and sulfhydryl groups CIDEX SODIUM HYPOCHLORITE .5% Disrupts cell membrane transport by causing inhibition of enzyme and damage to DNA CLOROX PUREX IODOPHORS 1-2% Protein and enzyme inactivation BETADINE ALCHOLS 60-90% Denatures proteins ISOPROPYL ALCHOL CHLORHEXIDINE 2-4% Coagulation of protein and cell membrane damage SAVLON PHENOL 1-3% Cell membrane damage DETTOL,LYSOL DISINFECTANTS 6 PRAVARA INSTITUTE OF MEDICAL SCIENCES 7/27/2020

7. STERILIZATION STEPS AND METHODS STEPS- 1.Cleaning 2.Packaging 3.Sterilization 4.Storage METHODS Steam under pressure (Autoclave) Dry heat (Hot air oven) Chemical agents such as ethylene oxide or low temperature methods Chemical sterilent as glutaraldehyde 2 % 7 PRAVARA INSTITUTE OF MEDICAL SCIENCES 7/27/2020

8. CLEANING OF INSTRUMENT Separate the sharp instruments from blunt instruments for the purpose of cleaning. Instruments should be thoroughly cleaned by washing in distilled water/mineral water. Surfactant cleaner can be used for effective cleaning. Use soft tooth brush to clean the instruments and change it every 15 days. After removing the instruments from ultrasonic cleaner, it will be thoroughly washed with clean or mineral water and dried with towel or hot air oven. 8 PRAVARA INSTITUTE OF MEDICAL SCIENCES 7/27/2020

9. PACKING THE INSTRUMENTS FOR STERLIZATION For lumened instruments, flushing with distilled water thrice and then flushing with air thrice is mandatory Tubing should be cleaned and flushed with distilled water and later with air. Cannulas are cleaned daily with mineral water an enzyme solution may be added to it for 30 minutes. Instruments should be placed in a tray with perforated bottom for proper steam penetration around the instruments during autoclaving. Keep joints open. Working surface of the instruments should be exposed to steam Separate medium-sized drum for each set of surgery is preferable. 9 PRAVARA INSTITUTE OF MEDICAL SCIENCES 7/27/2020

10. VARIOUS METHODS WITH ADVANTAGES; DISADVANTAGES; SUITABILITY 10 PRAVARA INSTITUTE OF MEDICAL SCIENCES 7/27/2020 METHOD TIME ADVANTAGES DISADVANTAGES SUITABLE FOR AUTOCLAVE 121 degree C for 15min at 15 lbs Kills spores ,Can sterilize liquids Items must be hot and moisture resistant Gowns, Dressings, Drapes & Metal Instruments HOT AIR OVEN 160 degree C for 2hrs Not much pressure build up Prions not killed every time Metal Instruments (SHARP)swabs ETHYLENE OXIDE 5 psi -12 hrs 10 psi – 6 hrs 38 or 54degreeC Low Temperature Explosive , long duration Heat labile tubings and laser probes PLASMA SYSTEM Short Cycle 74 min Temp<50degreeC Low Temperature Specific Packing needs Same as ETO GLUTERALDEHYDE Vegetative forms 10-20 min Spores-3hrs For heat labile equipments irritant Metal Instruments Plastic Glass

11. STEAM UNDERPRESSURE- AUTOCLAVING It is mostly commonly done in our country Safe method: It kills bacteria, spores, viruses, and fungi. Parameters – Temp.121°C for 15 min at 15pound pressure is the most efficient method of sterilization for all heat stable critical items. Mode of action- Moist heat destroys microorganisms by irreversible coagulation and denaturation of enzymes and structural proteins. All items should be arranged so that steam circulates freely. Indicators are placed inside the drum one at top, in middle and at bottom. One indicator is outside the drum. Autoclaved instruments should be used with in 48 hrs. Biological indicator -bacillus stearothermophilus Utility - Metallic instruments, toughened plastics, glass and cloth. 11 PRAVARA INSTITUTE OF MEDICAL SCIENCES 7/27/2020

12. HORIZONTAL & VERTICAL AUTOCLAVE 12 PRAVARA INSTITUTE OF MEDICAL SCIENCES 7/27/2020

13. HIGH-SPEED PRE-VACCUM STERILIZER They are similar to gravity displacement sterilizers except they are fitted with a vaccum pump to ensure air removal from the sterilizing chamber and load before the steam is admitted. This allows the steam to penetrate porous areas of the load that was not able to be reached with simple gravity displacement. 7/27/2020 PRAVARA INSTITUTE OF MEDICAL SCIENCES 13 Cycles : sterilization Temperature/ Time 121 C/30 m, 132 C / 5 m., 132 C/15 m

14. MODE OF STERILIZATION IN BETWEEN CASES In case of large number of cases fast high speed sterilization is done. The instruments are cleaned in distilled water using the four bowl technique. Autoclaved for 5 min (holding time) in high-speed autoclave at 134°C temp and 30 lb pressure or in regular autoclave with holding time of 20 min after attaining required temperature and pressure The cleaning water should be changed after cleaning 4-5 sets or earlier if it appears soiled. 14 PRAVARA INSTITUTE OF MEDICAL SCIENCES 7/27/2020

15. STERILIZATION OF SPECIAL INSTRUMENTS Vitrectomy Cutter, Cautery Wire can be autoclaved or ETO Before doing ETO remove all lubricants from instruments and dry them properly Pack them in polythene bag with indicator tape inside the bag. Sutures if to be reused should be autoclaved or ETO done. 15 PRAVARA INSTITUTE OF MEDICAL SCIENCES 7/27/2020

16. IRRIGATING SOLUTIONS Check for clarity, Suspended particles, Colour change, or Turbidity by Physical inspection against the light Check for leakage and quantity of solution Note batch number For glass bottle do vaccum test (bubbles on inserting drip set). One bottle to be used for one patient. Keep Infusion bottle for 24 hrs (to confirm that it is not the source of infection in case, infection occurs). Autoclaving of the solution is debatable. 16 PRAVARA INSTITUTE OF MEDICAL SCIENCES 7/27/2020

17. DRY HEAT(HOT AIR OVEN) Kills bacteria by oxidative destruction of protoplasm. The most common time temperature relationships for sterilization with hot air sterilizer are - 170 C for 60 min, 160C for 120 min, 150 C for 150 min. Less preferred in recent era, but indicated for reusable glass, metal instruments, oil, ointments and powders. Biological indicator -B atrophaeus 17 PRAVARA INSTITUTE OF MEDICAL SCIENCES 7/27/2020

18. ETHYLENE OXIDE (ETO) – LOW TEMPERATURE STERLIZATION MOA- reacts with DNA and destroys the ability of microorganisms to metabolize or reproduce. This was a method of choice for many heat- and moisture-sensitive devices. For ETO sterilisation after loading the steriliser, air is removed with vacuum followed by heating up to 45-55°c with relative humidity of 60% exposure time is up to 12 hours if 5psi and 6 hrs if 10 psi. Gas is removed by vacuum and flushing with air 4 times. Gas sterilization using ethylene oxide is effective and safe for heat labile tubings , vitrectomy cutters, cryoprobes , laser probes, diathermy and most disposable items for cost reduction 18 PRAVARA INSTITUTE OF MEDICAL SCIENCES 7/27/2020

19. FACTORS TO DETERMINE TO EFFICIENCY Concentration : 400 - 1000 mg /lit. (Chamber) Temperature : 20 - 55 degree C. Humidity : 40 -100% in chamber Time of exposure : 4 - 18 hours. (Routinely 400 mg / lit at 32 degree C) Quarantine period - 4 days for instruments -7 days for rubber & plastics 7/27/2020 PRAVARA INSTITUTE OF MEDICAL SCIENCES 19

20. Advantages of ETO are reliability, wide capability, minimal damage to sterilized objects and the feasibility of prepacked and long-term storage. Disadvantage includes -- Expense Need for thorough training of personnel Toxicity - neurotoxic , mutagenic and carcinogenic. 20 PRAVARA INSTITUTE OF MEDICAL SCIENCES 7/27/2020

21. HYDROGEN PEROXIDE PLASMA STERILISATION MOA-inactivates microorganisms by the combined use of hydrogen peroxide gas and generation of free radicals. The cycle time is approximately 75 minutes. They have special packaging needs non woven polypropylene wraps . 21 PRAVARA INSTITUTE OF MEDICAL SCIENCES 7/27/2020

22. CHEMICAL STERLISATION – GLUTARLDEHYUDE 2% - CIDEX Cidex ( gluteraldehyde 2%) is used for chemical sterilization of sharp instruments Four trays are used, one for keeping Cidex soln and three trays for sterile water. Instruments are kept in activated solution of Cidex for 15 minutes and then washed 3 times with sterile water, kept in the three trays to eliminate the residual chemical from the instruments because residual glutaraldehyde is extremely irritating to tissues. Effective against vegetative pathogens in 15 minutes and for spores 3 hours. It is non-corrosive, does not impair the sharpness of cutting instruments and may be used with plastic, aluminium and rubber. 7/27/2020 PRAVARA INSTITUTE OF MEDICAL SCIENCES 22

23. CONFIRMING STERILIZATION & RECORD KEEPING Chemical Indicator Strips – The change of colour of the strips indicates attainment of the desired temperature. The colour of the strip should be jet black; otherwise, the cycle should be repeated. The indicator strips should be pasted in autoclave register and signed by operating surgeon before session starts. Biological indicator should be used to confirm proper functioning of the machine. 7/27/2020 PRAVARA INSTITUTE OF MEDICAL SCIENCES 23

24. BOWIE-DICK TEST It is a sensitive and rapid means of detecting air leaks, inadequate air removal, inadequate steam penetration, and non-condensable gases. Should be conducted every day before the first processed load. A Bowie-Dick test pack uses a Class II chemical indicator for the test. Usually the cycle time is 3.5 to 4.0 minutes with no dry time. 7/27/2020 PRAVARA INSTITUTE OF MEDICAL SCIENCES 24

25. BIOLOGICAL MONITORING     Bacillus stearothermophilus    mophilus spores for steam sterilization and  Bacillus subtilis  for dry heat and ETO cycles are used. The ampule  is put in the load along with other items once a month. Failure of biological indicator test should be taken seriously to check the functioning of the autoclave machine 7/27/2020 PRAVARA INSTITUTE OF MEDICAL SCIENCES 25

26. Sterilization methods of choice for articles during eye surgery 26 PRAVARA INSTITUTE OF MEDICAL SCIENCES 7/27/2020

27. THE OPERATION THEATRE:BASIC ARCHITECTURE Modern operation theatre design incorporates zoning of areas within the OT complex. Zones are areas of varying degree of cleanliness in which the bacteriological count progressively diminishes from the outer to inner zones. It is also maintained by a differential decreasing positive pressure ventilation gradient from inner zone to the outer zone. The major zones of an OT complex are : a ) Outer zone, b ) Clean zone , c ) Aseptic zone, and d) Disposal zone 27 PRAVARA INSTITUTE OF MEDICAL SCIENCES 7/27/2020

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29. ZONES OF THE OT The outer zone is a reception area and is accessible to all personnel and supplies . The clean zone comprises of Changing room Store room Anesthetist room Patient transfer area Nursing staff room Recovery room 29 PRAVARA INSTITUTE OF MEDICAL SCIENCES 7/27/2020

30. ASEPTIC ZONE This is the sterile area within the OT complex. It is the area where we do not want any contamination and minimum bacterial presence. It consists of – Preparation Room Scrub Area where we wash the hands and it should be outside the operation room Gowning Area Operation Room. 30 PRAVARA INSTITUTE OF MEDICAL SCIENCES 7/27/2020

31. DESIGN OF OT The OT should have one entrance and a separate opening towards a sterile area marked for instrument packing and sterilization. Walls should preferably be of non-porous material with minimum joints to enable proper cleaning and carbolization. It should be water and stain proof. Artificial ceilings are not desirable. Flooring should be smooth, non slippery, PVC in roll form having minimum joints. The head-end of the operating table should be directed away from the entrance. Doors should be wide enough to allow passage of largest equipment (ideally 1.2meters) and they should open into the room. The space should be so designed so that ventilatory flow in this zone is directed outwards from the operating field. 31 PRAVARA INSTITUTE OF MEDICAL SCIENCES 7/27/2020

32. OT CONTROL PANEL Electronic control panel mounted in the theatre wall. The control panel may consist of 6 tiles or 9 tiles. Time of Day Clock Elapsed Time Clock Temperature Display/Control Humidity Display/Control Lighting Control/ Dimming Medical Gas Alarm Systems Hands Free Telephone HEPA Filter Status Indicator OT Pressure Indicator Music Control

33. VENTILATION The OT should be well-ventilated Sterile air can be obtained with help of HEPA filters ,laminar air flow systems and uv radiation. High Efficiency Particulate Air (HEPA) systems remove most microorganisms ranging in size from 0.3-5.0 μ. LAF provides unidirectional air flow towards ot table with 300 air exchange per hour. Large setups can have proper Heating,Ventilation and air conditioning systems (HVAC SYSTEM) 33 PRAVARA INSTITUTE OF MEDICAL SCIENCES 7/27/2020

34. LAMINAR AIR FLOW Flow of air is continuous, steady and unidirectional turbulence free flow of clean air. A  laminar air flow unit  is sub micron air filtration apparatus that provide clean atmosphere on a small area for instance filling area or a table top.

35. OPERATION ROOM GUIDELINES BY NABH PARAMETERS DESIRED RANGE Temperature (C) 21± 3 Relative Humidity % 40 – 60 Air Movement From clean to less clean area Pressure Positive Pressure (15 Pascals ) pressure by manometric control Air Changes Minimum 20 air changes per hour Filtration by Air handling units, High efficiency particulate air Air Velocity 90 – 120 feet per minute at grille / diffuse level. 35 PRAVARA INSTITUTE OF MEDICAL SCIENCES 7/27/2020

36. DISPOSAL ZONE The disposal zone is the area where used equipment and supplies are processed. The main functions of the Bio-Medical Waste Systems (BMWS) is to ensure proper handling, segregation, mutilation, disinfection, storage, transportation and final disposal of waste. 36 PRAVARA INSTITUTE OF MEDICAL SCIENCES 7/27/2020

37. COLOR CODING FOR SEGREGATION OF BMW 1998 COLOR WASTE TREATMENT YELLOW Human and animal anatomical waste / Microbiology waste and soiled cotton dressings, linen, beddings etc. Incineration RED Tubing, Catheters, IV Sets Autoclave, Chemical treatment. BLUE / WHITE Waste Sharps (Needles, Syringes, Scalpels, Blades etc. ) Autoclave, Chemicaltreatment . Destruction / shredding BLACK Discarded Medicines and cytotoxic drugs Incineration ash and Chemical waste Disposal in land field 37 PRAVARA INSTITUTE OF MEDICAL SCIENCES 7/27/2020

38. O.T.CLEANING Daily cleaning with detergent and water. The surfaces should be wiped with phenol. All walls to be wiped to hand height. Floor to be scrubbed with water, detergent or lysol / bacillocid 30 ml per 100 ml of water & dried . Weekly - empty all shelves, wipe, dry, re-stack. 7/27/2020 PRAVARA INSTITUTE OF MEDICAL SCIENCES 38

39. EQUIPMENTS & FURNITURE : Wiping metal & Plastic surfaces with detergent. Removal of blood stains & Rust stains. Bacillocid spray between operating sessions. Formalin fogging is still relevant. Wet swabs from table, walls, equipments every month. 7/27/2020 PRAVARA INSTITUTE OF MEDICAL SCIENCES 39

40. FUMIGATION Once a week. 150 gm of KMnO4 and 280 ml of formalin / 1000 cft . Humidity 60% or more Seal room for 24 hours. (12 hours for routine clean cases) 3 swabs - 1st swab after 48 hrs. 2nd swab 24 hrs. after 1st swab 3rd swab - 12 hrs. after 2nd swab 7/27/2020 PRAVARA INSTITUTE OF MEDICAL SCIENCES 40

41. ASEPTIC PRACTICES FOR OPERATION THEATER PERSONNEL (ETIQUETTE) Operation theatre (OT) personnel include all entering the operation theatre, i.e. staff, doctors, and patients. One should enter the OT environment only after wearing theatre slippers and autoclaved OT dress, cap and mask which should ideally cover the hair and mouth properly. OT personnel with skin lesions or infections or septic foci should not be allowed in the theatre. It is desirable to restrict the number of people in the theatre. 41 PRAVARA INSTITUTE OF MEDICAL SCIENCES 7/27/2020

42. COMPLETE WORK UP OF THE PATIENT PRIOR TO SURGERY Local ocular examination to rule out any septic focus which includes- Examination of conjunctival sac and surrounding of the eye for discharge and congestion Patency of lacrimal passages to be ensured. All the contact procedures like tonometry , IOL power calculation should be done before admission Dental check up- poor oral hygiene is potential threat Systemic examination to rule out any septic focus e.g. skin infections, abscess, urinary tract infection, etc. 42 PRAVARA INSTITUTE OF MEDICAL SCIENCES 7/27/2020

43. Pre-operative Preparation of the Patient – Day Prior to Surgery Complete head bath and thorough face wash . Antibiotic eye drops - at least 6 times/day on the previous day in the eye to be operated - this takes care of the conjunctival flora. Couple of studies showed that topical moxifloxacin administered 2 h before surgery achieved significantly higher aqueous concentrations as well as was effective in reducing conjunctival and eyelid flora. In patients with risk systemic antibiotics may be given IM a day prior. 43 PRAVARA INSTITUTE OF MEDICAL SCIENCES 7/27/2020

44. Pre-operative Preparation on the Day of Surgery Preferably, we should use separate bottle of eye drops for each patient Preferably, we should ask the patient to do potassium permanganate gargles to take care of oral hygiene The patient should change completely into OT attire - give head and foot covers Ensure foot wash for the patient as our patients carry lot of dust and with it organisms into the OT Povidone iodine (10%) painting of the periorbital area should be done carefully using copious quantity of povidone iodine One drop of 5% povidone -iodine eye drops should be instilled into the conjunctival sac before giving block. 44 PRAVARA INSTITUTE OF MEDICAL SCIENCES 7/27/2020

45. SCRUB FACILITIES Stainless steel AISI 304 (316) of highest quality with touch less sensors of custom size. Hands free operation should include infra red sensors with built-in range of adjustment. All units should have reduced anti- splash fronts. Knee operated switch should be there

46. HAND SCRUBBING 46 PRAVARA INSTITUTE OF MEDICAL SCIENCES 7/27/2020

47. COMMON ANTISEPTICS USED IN OT FOR HAND SCRUBBING Alcohol (60–70% Ethyl or Isopropyl) - It is effective against a broad range of microorganisms, e.g. bacteria and mycobacteria . Chlorhexidine Gluconate (4%) - It is effective against a broad range of microorganisms, but less so against gram negative bacteria and fungi with minimal efficacy against M. Tuberculosis. It is recommended antiseptic for surgical hand antisepsis and skin preparation. 47 PRAVARA INSTITUTE OF MEDICAL SCIENCES 7/27/2020

48. PERIORBITAL AREA PREPARATION Clean the periorbital area with Savlon which removes the greese and dirt from the skin pores The periorbital area is then painted with Povidine Iodine ( Betadine ) which is Iodophor . It contains iodine in complex form. Povidone – It is non irritating and non toxic. Antibacterial Spectrum of Povidone – It is effective against broad range of microorganisms (mainly Gram + ve and Gram – ve bacteria) It is less effective against mycobacteria It becomes effective within two minutes of application. In eye the Povidone 1% drops are instilled and kept in conjunctival sac for 1 minute. The longer duration of contact has corneal epithelial toxicity. 48 PRAVARA INSTITUTE OF MEDICAL SCIENCES 7/27/2020

49. GOLDEN RULES OF ASEPSIS Sterile persons should keep well within the sterile area. When sterility is questionable - consider the item contaminated. Sterile tables are sterile only at table height Gowns are sterile in front except axillary region . Contact with sterile goods to be kept to minimum Moisture carries bacteria from non sterile to sterile surface. Non sterile persons should not reach over sterile surfaces. Sterile team members should face each other & to sterile field. 7/27/2020 49 PRAVARA INSTITUTE OF MEDICAL SCIENCES

50. THANKS 7/27/2020 PRAVARA INSTITUTE OF MEDICAL SCIENCES 50