Limiting Contamination of the Surgical Site

November 27, 2008

Limiting Contamination of the Surgical Site
~James Dunn

During surgery, the patient is at a high risk of infection from contamination of the surgical site. To control infection, control over the sources of contamination is required. Bacteria and fungus are present all around us, in the air, on everything we touch, within our bodies, and in areas we can not touch. All of these sources threaten contamination of the surgical site.

A few of these sources are (there are many more):

1. Members of the operating room team (their dress, breath, skin, etc.)

a. Brushing teeth to reduce airborne bacteria

i. Surgery staff, in addition to scrubbing before surgery

ii. Ensure the patients breath can not break sterile field

b. Washing face and other exposed areas with a mild disinfectant

i. Skin scales naturally and contain bacteria and fungus

2. The patient

a. “Findings suggest that when alcoholics require any sort of surgery, doctors should first run a blood test to determine the health of the patients’ immune systems, and prescribe immunotherapy agents to boost the body’s defense system before, during and after surgery.”

b. Ensure adjacent scale of exposed skin of patient can not be blown into surgery site

i. Seal off the gowned/blanketed area around the surgery site and re-disinfect the gowned/blanketed surfaces around the sealed off area

1. skin scale may have blown onto top side of gown/blanket during the sealing process that will work its way into the surgery site

2. even after bathing, the patient has been exposed to contaminants before entering the sterile field

c. Ensure surgery staff do not touch patients exposed skin or any material that has previously touched patients exposed skin or breath

i. Areas adjacent to patient masking remain contaminated

3. All items used in the wound and on the sterile setup

a. Ensure all personnel are decontaminated, masked and gloved before handling any and all surgical materials and OR apparatus

b. Pay special attention to package-to-contents contamination

i. Disinfect the package before opening a sterile package/container

c. Systematic swipes should be taken throughout the OR and tested for contamination on a daily basis, all areas and equipment of OR should systematically be tested over time.

i. Hot spots should be investigated for cause, cleaned, and OR retested.

4. Dust in the air

a. Take regular samples of air through approved procedures and test for particulate, bacterial, and fungal content

i. Where practical, initiate worst case shock to ventilation system while in normal operation, during sampling

b. The OR should be under constant positive pressure using a HEPA filter as a minimum, and ducting cleaned and disinfected periodically between the HEPA filter and the vent outlets into the OR

i. Contaminated dust laying in the ducting can become airborne in large amounts when the system is shocked by vibration or equipment starting

ii. Venting should not blow directly near surgical site

5. Other personnel in the operating room

a. All related information previously cited applies to all persons in the OR

b. “Movement. In 1948 Duguid and Wallace7 showed that increased activity enhanced the dispersion of bacteria. Movement can shed up to 10 000 skin scales per minute, of which 10% carry clusters of micro-organisms. These will contain Staphylococcus aureus and coagulase-negative staphylococci which are frequent causes of infection after joint replacement. In a well-run and organised theatre, movement is kept to a minimum and dispersal of skin organisms reduced.”

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