Intraoperative wound contamination

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					Intra-operative wound

    Contamination VS Infection
 Contamination:
  “ presence of bacteria”

   Infection:
    “Invasion and multiplication of Bacteria”
    Wound Contamination
 Pre-Operative factors
 Post-operative factors
           History teaches
 Moynihan
“every operation in surgery is an experiment
  in bacteriology”

  John Charnley: Experiments
14 % then 7 % and now came down to 1-2%
Ideal is 0%
       Feared Consequences
 Wound infection from Contamination
 Deep infection
 Septic TKR or THR
 Revision over revisions and still need
 Deep peri-prosthetic infection is not only
  Disastrous for surgeons and patients but
  Expensive too
  “the estimated cost of treatment of infected
  site of THR or TKR exceeds £50,000”
 Prevention of wound infection
  Team work
 Optimising the wound environment
 Augmenting the host’s ability to fight
 Minimizing the number of bacteria in the
   Reduction of bacterial count
 Ultra-clean air flow Operating theatres
 Proper sterilization of the instrument
 Careful preparation of operating sites
 ONLY necessary equipment
 Traffic in and out of theatre
 Number of personnel & conversation
 Door opened to hallway
              Face Mask
Conflicting Reports
 JBJS March,1983- significant difference in
  bacterial count (p<0.05)
 Surgical hood over the mask-Colony count
  was significantly less
 Is it difficult to ask others to wear mask?
   Final positioning of patients
 Gloves during final preparation of patients
  has shown 28.7% contamination
 Preparation in anaesthetic room- Bacterial
  count is significantly low (20% low)
 Sealing the perineal area in anaesthetic
  room (30% low )
 Scrubbed leg-holder reduces contamination
               Light handles
 One out of seven were found contaminated
 Surgeons tend to move the lights-? UN-necess
 Attached to un-sterile lights
 Bigger size disturb the laminar flow and creates
  eddies of air Currents.
 Best compromise is to use sterile cloth and
 Adjust the light before you start- OTA
           Surgical Blades
 Skin blade 9.4% contamination
 Inside blade 3.2% contamination
 Although non has grown positive culture
 Recommendation is to change blade after
  incising skin
          The Sucker’s Tips
 Recognized source of wound contamination
 Instrument which sucks TONS of dirty air –Un-
  reasonable to use
 55% in one study 37% in other were
 Change it after every 30 minutes,change before
  using in femoral canal, turn off when not used
 Antiseptic solution in storage bag
             Splash Basin
 Source of bacterial contamination( clinical
  Ortho 1984)
 59% cultures grown coagulase-negative
  staph ( source of deep infection)
 Instrument which go to splash basin,
  should not come back to operating field
           Collection Bags
 High level of contamination ?used as
  holder by most of surgeon Un-knowingly
 Ideal growth media for bacteria
 Swabs and instruments- transfers bacteria
  to wounds
 Any object coming into contact with bag
  should be discarded
 Water proof gown 17% were contaminated
 Fabric gowns 50%
 Seepage of bacteria from sweating body
 Touching gowns should be minimized
 Gowns should not be touched by suction
 Suction of gloved hands and patient’s
 Gloves are contaminated when applied
 Change Gloves ?before ?after
 Takes 30 minutes for the bacterial counts
  to reach to pre-prep level
 When stripping off, what about Bacteria?
 Anti-septic use with care
             OT- uniform
 Contamination from wards, Cafeteria etc.
 Walk out ? Gown cover, Shoe cover
 Evidence is poor to prove it
 No evidence to disprove it
 NATN recommends change the clothes
       Rate of contamination in
   Sucker tips 11.4 %
   Light handle 14.5%
   Skin blades 9.4 %
   Inside blades 3.2%
   Gloves used in final prep. 28.7%
   Collection bags 20% samples grown bacteria
   Needles 10% for fascia closure
 Most common organism causing Septic TKR
  &THR is Coagulase - negative staphylococcus
 From 100 samples collected from theatres 76%
  were Coagulase-negative staph. Rest of 24% is
  made up by 9 other organisms
 63% operations showed contamination in the
  operating fields JBJS Sep.1999.
 Prolonged surgery leads to high contamination
 Contamination leads to infection
 Plan operating field before start
 Use equipment sensibly-minimal numbers
 Minimal number of personnel in
 Minimize the duration of surgery
 Minimal conversation
   Preparation in anaesthetic room
   Seal perineum in anaesthetic room
   Adjust lights before you start?light handles
   Scrubbed Leg-holder
   Do not use suckers if possible
   Sucker-turn off in between use
   ?? Collection bags, splash basins,
   For storage bags-antiseptic solutions
Questions ?

  Thank you for your

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