Transcript Document 7110913

History of Surgery. Asepsis
and antisepsis
The notion about antisepsis (anti
suppurative) was brought by the English
surgeon Pringl J. (1750) on the base of his
observations. He studied the antiputrefactive effect of mineral acids, which
were used for disinfecting of sewage. In the
beginning of the XIX century Pirogov N.I,
used for the treatment of wounds the
solution of carbolic acid, silver nitrate, zinc
sulphate, spirits, iodium. He considered a
wound processing an. infection and believed
the possibility of fighting against it
The Hungarian obstetrician-gynecologist
Zemmelvase noticed that the hands of a
surgeon were the source of puerperal fever
among women in childbirth. He was the first
doctor who used chloral water for treatment
of the surgeon's hands, birth tracts,
instruments and materials. Increase the
purulent secretion from wombs of women
suffering from puerperal fever, the proved the
presence of infections in this secretion. He
managed to decrease the birth sepsis in 10
times.
In 1882 Trendelenburg constructed an
apparatus for sterilization of surgical material and
instruments with dry steam. In 1886 Bloodgood
invented rubber gloves for protection of a
surgeon's hands from infections. Since 1890
Holoted Y. and Isege (since 1897) became to use
gloves for protection of a wound from a surgeon's
hands.
Bergman E. and Shimelbus K. constructed a
sterilizing machine for boiling the instruments;
they created metallic drums for sterilization of
clothes and dressing, perfected an autoclave.
The measures to prevent an infection from entering a
wound are referred to as asepsis, while those to cause the
exclusion or destruction of harmful microbes are generally
called antisepsis.
The two principles represent the united whole in the
prophylaxis of surgical infections. They have to be considered
in terms of the interrelationship between the source of
infection and its mode of transmission and the susceptibility of
the body.
The source is taken to mean the place of dwelling, growth
and proliferation of microorganisms. Relative to the patient
the source of infection can be either exogenous (from outside)
or endogenous (from within the body).
The main sources of exogenous infections include patients
with purulent inflammation or healthy carriers of the microbes,
and occasionally animals.
The modes of transmission from exogenous sources are
usually as follows: airborne, direct contact and implantation.
The major sources of endogenous
infections incorporate chronic infections
outside the area of the operation (e.g. skin
diseases, dental or tonsillar conditions) or of
the organs operated on as is (e.g.
appendicitis, cholecystitis, osteomyelitis), as
well as the oral, intestinal and respiratory
saprophytes.
Among the modes of transmission of
endogenous infections are direct contact,
lympho- and haematogenous spread.
Types of antisepsis
Physical - the creation of unfavorable conditions
for development of microorganisms in a wound and
for suction of microbe toxins and products of tissue
decay. The drainage provides the outflow of wound
contents and promotes the removal of toxins,
microbes and products of tissue decay. Irrigation of
gauze with hypertonic solutions highly increases its
hydroscopic quality but tampons with wound
exudation prevent the outflow from the wound,
which is why they are not good for drainage.
The open method of treatment can be used (ATU).
The wounds are dried; as a result, unfavorable
conditions for development of microorganisms are
created.
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The mechanical antisepsis: the hygienic bath, shaving, and
extermination of tissues lacking vital capacity. In 1898 Fridrih
P. proposed the primary surgical treatment of a wound by
means of cutting off its borders, walls and a bottom within
healthy tissues.
Chemical - the use of different chemical substances with
bacterial and bacteriostatic effects. These substances must be
safe for the human organism and its cells. They are used for
treatment of the operational field, hands of a surgeon,
sterilization of gloves, surgical instruments, stitch materials,
desinfection of rooms.
Biological - is the procedure aiming to increase the
immunity and to strengthen the protective power of an
organism. A includes specific vaccines, immuno-serums,
globulin, blood transfusion, plasma, anatoxins.
Mixed - the simultaneous use of some types of antisepsis.
For example for treatment of wounds: the primary surgical
treatment is mechanical, washing a wound and surrounding
skin - chemical, the use of antibiotics -biological, putting the
dressing-physical.
Chemical substances.
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The group of haloids - the derivatives of chlorine and
iodine. Their interaction with hydrogen of a microbe cell
causes coagulation of protoplasm proteins. They use
chloramin B (0,5 – 2% solution), iodonate (1% water
solution), uodopiron, and iodophorm.
Oxidants, getting in contact with tissue, release oxygen
with possesses a strong oxidizing effect, thus unfavorable
conditions for anaerobic and putrefactive microbes are
created. They use: the solution of hydrogen peroxide (3%
water solution), potassium permanganate (0,1-2% water
solution).
Acids and alkalis - more often salicylic acid and boric acid,
sodium hydrocarbonat are used.
Aldehydes are strong bactericidal preparations:
formaldehyde, glutaldehyde, and hexamethylentretramine.
Severe toxic.
Spirits are strong disinfective means. As usual ethyl spirits
(70-96% solution) are used.
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Hypertonic solutions - are weak antiseptics possessing
irritating and counter-attracting effects. They use the
hypertonic solutions of sodium chloride (10%), glucose
(10% and 40% solutions).
Salts of heavy metals - are strong and drastic antiseptics
clocking sulphohydrical groups and causing the protein
coagulation of microorganisms. Many substances of this
type are not used now because of their toxic effects. They
use the preparations of silver.
Phenols are processing products of coat-tar, oil and resins.
They denaturate and coagulate proteins of protoplasma in
bacteria. There are phenocarbolic acid, birch tar, ihtiol, and
naphtalene oil.
Dyestuffs – are organic combinations dying tissue and
processing bactericidal effect: methylene blue, brilliant
green, and acridine lactate (rivanol).
Detergents – are drastic surface-active combinations,
retailing to the group of ammonium bases. They are widely
used ammonium bases. They are widely used in surgerv
and an operating field. They are widely used in surgery for
treatment. There are cerigel, degmicide, hexidine chloride,
roccal etc.
Alexander Fleming made discovery
of the penicillin mold in 1928.
► The
group of penicillin
► The group of cephalosporines
► Macrolids
► The group of levomycetine
► Tetracyclines
► Riphampicins
► Antibiotics of different groups
► Antibiotics of last generation
► Antifungous antibiotics
Sulphanilamid preparations.
It is large group with antimicrobial action.
They break methabolic processes in bacterial
cells and cause bacteriostatic effect. They
differ the sulphanilamids of short activity:
streptocid, etazol, sulphadimezin and the
sulphanilamides of prolonged activity:
sulphapiridasin, sulphadimetoxin, sulphalen
and others. Because of their bad dissolubility,
sediments may fall out thus blocking liver
balls.
Zones in the surgical block:
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The sterile zone, i.e. the operating theatre (to
operate on patients), scrub-up room (for
preoperative cleansing surgeons' hands and arms)
and the room for sterilisation (to sterilise the
instruments to be used during the operation).
The clean zone, i.e. the rooms for personal
hygiene and changing clothes of the staff.
The technical zone, i.e. the rooms where
apparatus for air-conditioning or oxygen supplying
and vacuum devices are stored.
The dirty zone, i.e. the sister's room, the room of
the head of surgery and the one for dirty clothes
etc
Cleaning of the operating room
Cleaning of the room is doing by a damp cloth (1 % chloramin, 3
% hydrogene oxide, 0,5 % detergents).
• The current cleaning - they pick balls of cotton from the floor;
wipe the blood from the floor.
• The cleaning of the operating room after the operation
provides its cleanness before the next operation.
• The every day cleaning at the end of the operational day and
after some extra operations.
• The general cleaning if fulfilled once a week according to the
plan, in a day free from operations - they use hot water with
soap, 3-6 % solution of hydrogene peroxisde, 0,5 % solution
of detergent.
• In the morning before the beginning of work all horizontal
surfaces are wiped by means of a damp cloth. Bactericidal
ultraviolet lamps are used for disinfections of air. Ventilation is
fulfilled by means of conditioners, the filter of which
exterminates microorganisms. Temperature is no more than
24° C, humidity is no more than 50 %. For special clean
operations they use operating rooms with laminar airflow.
Preventive measures of contact and implantation infections.
Sterilization is achieved by means of physical and chemical methods.
Physical - thermal and ray sterilization - boiling, the sterilization by
steam under pressure, dry heat sterilization, gamma-radiation.
Chemical - the sterilization by ethylene oxide, the treatment by acetic
acid, the chemical therapeutic treatment. Sterilization in the
autoclave (water steam) is fulfilled with 120-132° C, pressure - 1,1
atm/sm2 during 45 min. The ray sterilization - is by ionic radiation
of high energetic power. They use beta- and gamma-radiations.
The ultra-ionic sterilization is also possible - the sterilizer is filled
with some antiseptic, which under the influence of ultrasonic waves
sterilizers surgical instruments.
The chemical sterilization: ethylen oxide possesses a bacterial effect.
By means of gas sterilization they treat the instruments of which
cannot be treated in autoclaves or air sterilizators. They use
ethylen oxide for sterilization of catheters, gloves, endoscopes,
apparatuses for the artificial blood-circulated room.
The sterilization is controlled by means of a color thermodicator or a
hydroquinion. They put on the paper the thermoindicator paint of
pale green color; under the temperature of 175-180°C it becomes
dark brown.
Except every day control they have a bacteriological control once a
week or every 10 days
The sterilization of instruments.
► In
air sterilization procedure is carried out during 60
min with t° - 180°C.
► Instruments made of corrosion-resistant metals or of
plastics are sterilized in the 6% solution of hydrogen
peroxide with temperature 180°C during 360 min.
Instrument are sterilized also in the solution of 3
components (2 % formaline, 0,3 % phenol, 1,5 %
sodium bicarbonate) during 45 min.
► Syringes are sterilized in dry-hot case with
temperature - 180°C during 60 min.
► Endoscopes, catheters, cistoscopes are sterilized by
means of glutar dialdehyde and sodium hypochloride,
the duration of treatment is 45-180 min.
Sterilization of dressing and
operational linen
► Before
packing, the drums must be wiped dry.
The lid must be closed and fastened and the
grid opened. All non-sterile drums, as a rule,
are kept apart from the drums containing
sterile material.
► Dressing and linen are sterilized in autoclaves,
the pressure —1,1 atm, t - 120°C, during 45
min, or 2,0 atm, t -132°C during 20 min.
Linen can be kept in 3 days.
Disinfections of surgeon’s hands
Disinfections of hands are a good removal of
microorganisms from the hands. And such a case
they use the tannage of skin, which prevents the
penetration of microorganisms onto the surface of
the skin. The principal of surgical treatment: care of
hands, care of nails, the mechanical cleaning is with
soap and a brush during 2- 5 min, then
disinfections. A disinfectant must be:
1. exterminate the micro flora quickly;
2. exterminate microbes in the juice of gloves;
3. possess a cumulative effect - hands must be free
from microorganisms even in the intervals of
disinfections;
4. not irritate the skin.
The preparation of the operating field
Starts from the hygienic bath, shaving of hair.
For the treatment of the operating field they use
iodonate, iodopiron, chlorhexidin before its usage,
dissolving the initial solution in 4,5-5 times boiled or
sterilized water. They use the other antiseptics for
the treatment of the operating field 1% solution of
degmycide, 1% solution of roccal or catamine A-B,
2,4 % solution of pervomur. For the disinfections of
the mucous membrane they use 1 % solution of
diamond green, 3 % solution of hydrogen peroxide,
1 % solution of iodonate or iodopiron, 0,5 % spirits
solution of hibitan