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ANES 1502 - M13 PPT: Cleaning and Sterilization of Instruments and Equipment
- 1. Asepsis and Sterile Technique ANES 1502 ANESTHESIA TECHNOLOGY FUNDAMENTALS COLLEGE OF DUPAGE
- 2. Human microbe relationships Indigenous microflora: microbes that live on the skin and inside human body - “opportunistic pathogens” - bacteria, fungi, viruses, and protozoa - microflora=harmless, however, microflora + surgical wound = pathogen Symbiosis -Mutualism -Commensalism -Parasitism
- 3. Pathogen and Infection Pathogens- microorganisms that cause infection - commensal microbes: opportunistic by entering through a surgical skin incision - nosocomial: UTI - airborne viruses: common cold
- 4. Human-Microbe Relationships Mutualism- both organisms benefit and depend on one another to a certain extent Escherchia coli: in the colon, produces vit K 1) Synergism- 2 organisms work together to achieve a result neither could obtain alone -Fusobacteria and spirochetes work together to cause trench mouth Commensalism- one organism benefits but the other neither benefits nor is harm -indigenous microflora on the skin can obtain nutrients but do not affect the skin -competitive exclusion Parasitism- one benefits and the host is harmed -endoparasites-: intestinal worms
- 5. Pathogens associated with SSI Bacteria -prokaryotes, binary fission Tuberculosis (TB) -Mycobacterium tuberculosis: airborne droplet nuclei -Precautions : wearing gloves, gowns, eyewear, and NIOSH approved respirators Viruses - nonliving particles that are completely reliant on the host cell for survival -largest: 300nm -smallest: poliovirus-30nm -Capsis: protein covering of DNA/RNA -Capsomeres: the capsis is composed of protein molecules -Nucleocapsid: nucliec acid-capsid combo
- 6. Pathogens- SSI Emerging Infectious Diseases -MDR: multidrug resistant strains -Strain “W” -viruses constantly mutate and evolve -ebola virus, dengue virus, Lassa virus Prions - Prusiner 1982 -Creutzfeldt-Jakob disease (CDJ), scrapie (sheep disease)
- 7. Pathogens- SSI Parasites -unicellular and multicellular protozoan -Helminths: round and flat -tapeworm, flukes, and roundworms -transmission: ingestions of contaminated food/water that contains the worm or eggs -skin, fecal-oral contamination, arthropod bite -protozoa-unicellular eukaryotes that are responsible for causing human diseases such as malaria and chronic sleeping sickness. - amebas, flagellates, ciliates, coccidia, and microsporidia -Entamoeba histolytica- cause of amebic dysentary
- 8. Pathogens-SSI Fungi -Mycology- study of fungi - examples: yeast, mushrooms, and molds -Mycoses- fungal diseases -Zygomycosis- bread mold -rhinocerebral zygomycosis - increased organ transplants and immunosuppressive drugs and antibiotics -plastic surgery and bone transplant
- 9. Methods of Transmission Primary agent: bacterium, virus, fungi, or parasite SSI: acquired at time of surgery, than after -environmental and endogenous Personnel-WEAR PROPER OR ATTIRE! Environment Fomites- inanimate object that harbors microorganisms. The Patient
- 10. Factors that increase SSI Age Obesity General Health Nasal Carriers of S. aureus Remote Infections Pre-op Hospitalization
- 11. Factors of SSI Preexisting illness and related treatment Pre-op hair removal Type of procedure Duration of procedure
- 12. Surgical conscience Is the practice of strict adherence to aseptic technique by ALL surgical team members, which includes, YOU, the SURGICAL TECHNOLOGIST! Honesty, moral integrity, responsibility Need the ability to recognize and correct breaks in aseptic technique If there is hesitation and/or unable to admit = there is no place for you in the OR THERE CAN BE NO COMPROMISE OF ASEPTIC TECHNIQUE STANDARD PRECAUTIONS
- 13. Basic terminology Antiseptic Asepsis Bacteriocidal Bacteriostatic Bioburduen Contamination Cross-contamination
- 14. Terminology cont’d Decontamination Disinfectant Event-related sterility Fomite Fungicide Infection Nosocomial
- 15. Terminology Pathogen Resident flora Sepsis Spore Sporicide Sterile Sterile field
- 16. Terminology Sterile technique Sterilization Strike-through contamination Surgically clean Terminal disinfection Terminal sterilization Transient flora Vector Virucide
- 17. Principle of Asepsis Principle 1: sterile field is created for each procedure Principle 2: sterile team member must be appropriately attired prior to entering sterile field Principle 3: movement in and around the sterile field must not compromise the sterile field
- 18. Principle 1 Time Instrument sets, peel packs and wrappers Chemical indicators Sterile edges Opening packages Items that fall below table edges Questionable sterility Causes of contamination
- 19. Principle 2 Sterile portion of gown Sterile portion of table Proper technique with arms and hands Surface for gowning and gloving Sitting during surgery Platform standing
- 20. Principle 3 Sterile to sterile Sterile individuals keep within sterile area Nonsterile to nonsterile
- 21. Characteristics of Bacteria Morphology: size, shape and arrangements of bacteria
- 23. Morphology Bacillus- rod shape Spirilla- spiral shape L-Form- bacteria that lose normal shape (environmental)
- 24. Growth and Motility Varies with agar medium Rate Flagella Cilia
- 25. Nutritional/02 Requirements Classifications: ex) oxygen, carbon, nitrogen - obligate aerobes -microaerophiles -obligate anaerobes -facultative anaerobes -aerotolerant anaerobes -capnophiles
- 26. Pathogenicity Ability to cause disease - release of exotoxins and endotoxins - release of enzymes - presence of a protective capsule - attachment to host cell
- 27. Metabolism, proteins, & genetics Metabolism is the secretion of waste products Proteins specific to bacterial species DNA is unique to each bacteria species
- 28. Staining Simple Gram Acid-fast
- 29. Spore forming Bacterial species capable of forming spores Unfavorable conditions = cell is enclosed in a protein capsuleto High survival NOT REPRODUCTION Difficult to destroy
- 30. Disinfection, decontamination, & sterilization Disinfection: process in which most but NOT ALL the microorganisms on INANIMATE are destroyed -Decontamination Antisepsis: process in which most but NOT ALL microorganisms on ANIMATE surfaces are destroyed -Antiseptic: solutions -Sterilization: destruction of ALL microorganisms, including SPORES, on inanimate surfaces
- 31. Disinfection principles and disinfecting agents Cleaning physical removal of blood and body fluids, as well as BIOBURDEN, from inanimate objects. Disinfection -high, intermediate, and low levels Sterilization -steam, chemical agents, high velocity electron bombardment, and ultraviolet radiation -critical, semi-critical, and noncritical
- 32. Disinfectant efficiency Concentration level of disinfectant solution Number and type of microbes present Physical factors of the solution - temperature - water hardness - pH level - exposure time ALWAYS FOLLOW MANUFACTURER’S INSTRUCTIONS!
- 33. High Level Disinfectant Compounds Glutaraldehyde/Cidex pH: 7.5-6.5 Best overall disinfectant/liquid sterilant Complete immersion in liquid Endoscopes Shelf life of 14 days/28 days
- 34. High Level Disinfectant Compounds Sodium hypochlorite Household bleach Disinfectant for surfaces, floors, and equipment CDC recommended on blood and body fluid spills
- 35. Intermediate Level Disinfectant Compound Phenol Carbolic acid Large areas and general basis Quaternary Ammonium Compounds “quats” Bactericidal, fungicidal, pseudomonacidal Not sporicidal or tuberculocidal Common: benzalkonium chloride, dimethyl benzyl ammonium chloride and the newer, diakyl quat Alcohol Isopropyl and ethyl alcohol: diluted 60-70% Bactericidal, virucidal, fungicidal, tuberculocidal, NOT sporicidal
- 36. Environmental decontamination Role: minimize microbial counts in the OR environment Surfaces and characteristics Pre-op, intra-op and post-op Standard precautions and PPE
- 37. Environmental services Decontamination practices in the OR -pre, intra, post, or between Terminal cleaning Weekly cleaning Dirty cases
- 38. Surgical Instrument Decontamination Process ALL ITEMS USED ON STERILE FIELD AND/OR ON OPEN TISSUE MUST BE STERILIZED! Decontamination is the first step Cleaning Disinfected Lubricated (if necessary) Sorted Reassembled Wrapped Sterilized Stored properly
- 39. Cleaning Presoaking in basin Sterile water Enzymatic solution Proteolytic enzymatic cleaner Lipolytic enzymatic cleaner Detergent solutions Table 7-8 Rinsed and dried Chelation, enzymatic, emulsification, and solubilization Table 7-9
- 40. Manual cleaning 1. Instruments immersed in a solution. Friction will loosen organic material. With stainless steel: back and forth motion; circular can scatch. 2. Rinse in distilled water. NO TAP WATER! 3. AVOID spotting the instruments, so DRY!
- 41. Decontamination Washer-sterilizer Washer decontaminator Ultrasonic washer Considerations: Use of tray- perforated/wire mesh Heavier instruments place on the bottom Hinges left open Disassemble any instrument Concave surfaces should be placed upside down
- 42. Washer decontaminator “WD” DOES NOT INCLUDE STERILIZING PHASE Purpose: allow hands off processing Considered “clean”
- 43. Washer sterilizer “WS” Stainless steel and heat tolerated items MUST BE CLEAN BEFORE USE! Stainless steel must not be placed near other metals = fusion Use free rinsing, low sudsing, neutral pH detergent NOT USED DIRECTLY ON PATIENTS NOT A BIOLOGICALLY MONITORED PROCESS Types of WS machines Tunnel like chmaber Horizontal/cabinet type Gravity cycle of 270 degrees
- 44. Ultrasonic cleaner After instruments are placed in WD or WS, they’re place in the ultrasonic cleaner Removes small organic particles, or places that cannot be reached Box locks, serrations, and ratchets Cavitation High frequency sound waves Molecules are forced in a rapid motion which form bubbles Implosion occurs to create a vacuum, dislodging particles Metal mesh trays Each cycle last 4-5 minutes
- 45. Special Care Items with lumens Rigid and flexible endoscopes Lubrication “milking”
Editor's Notes
- Symbiosis-human host and indigenous microflora: harmless, harmful or beneficial to one or both
- Competitive exclusion- indigenous microflora benefit human by occupying space and preventing other potentially harmful microbes from colonizing
- Infection: multiplication of organisms in the tissue of a host Nosocomial: infection developed in a hospital -patient, family, and health care personnel 25% nosocomial infections acquired are not apparent until the pt is discharged from the hospital PRIMARY GOAL: use sterile technique to prevent the transmission of microbes and preventing SSI: surgical site infections Characteristics of bacteria on pg 143 Infects lungs, kidneys, bone, joint, or skin Elective operations are post-poned until drug therapy is effective Patients must wear a mask and given info on how to prevent cross- contamination 3)Have students read bullets on pg 142 for characteristics of viruses Viruses enter the body though: inhalation of respiratory droplets, exchange of body fluids, ingestion of food and water, bites by arthropod vectors Steps of the process of infection- rhinovirus: common cold pg 142
- 1)Follow hospital policy on how to take special care to these patients to protect yourself and others -neutral zone and signage 2)Prion is short for proteinaceous infectious particle -built of proteins but do not contain DNA/RNA -human body produces the same protein called PrP but the human PrP is slightly different than the infectious prion. PrP changes from a alpha helical form to a beta sheet: when a prion contact normal PrP, it starts a chain reaction to create all beta sheets. Prions attack the brain- Diseases they cause are subacute spongiform encephalitis. Beta sheet prions accumulate in the lysosomes and eventually kill the neurons causing holes in the brain tissues, which allows prions to continue to attack healthy neurons. PRIONS TRANSMISSION- is not through human to human, but contaminated surgical instruments with the prion from an infected individual. CDJ: mimics alzheimers and depression; later dementia and loss of physical function Diagnosis: Electroencephalogram, histologic exam….NO VACCINE OR CURE HIGH RISK: eye tissue, dura mater, brain tissue and spinal cord When working with a patient with CJD, due to the resistance of chemical and physical sterilization such as pressure, Ethylene oxide and dry heat, it is recommended to use single use, disposable instruments. Pg. 147 table 7-5
- 3) Worms can damage body tissues and organs to the point that require surgery; intestinal blockage and may rupture intestinal wall E. histolytica- pt’s who undergo sigmoidoscopy / colonoscopy- nondisposable instrumentation should be thoroughly decontaminated and should be carefully handled during the surgery as to not cross contaminate other parts of the body
- Reproduce sexually or asexually by production of spores; a true spore is formed by asexual cleavage or sexual meiosis. Fungi are opportunistic pathogens that cause disease when the host is immunocompromised; common in ADIS patients and related to spread of HIV R. zygo causes extensive damage to the bone and tissues of the face, including loss of one/both eyes ex. Cranial bone damage, then brain tissue is invaded
- Frequent hand washing to avoid transient microbes SSI are the 2nd most frequent nosocomail infections….pg 148 read bullets to describe SSI facts to remember Environmental: personnel, environment, and contaminated instruments Endogenous: patient’s flora 4) Personnel:skin, hair and nares of surgical personnel are reservoirs of bacteria, which can ve discharged in the air; S. aureus increased rate of infection, so wear hair covers and mask. Primary purpose is to create a barrier from patient to personnel. Human error! Errors should be noted, communicated and corrected immediately. A practice called SURGICAL CONSCIENCE! 4)FOMITES AND AIR! Safe, clean, and spacious OR helps to provide alower level of microbes. Minimize airborne pathogens with laminar air and proper attire. Contamination is #1 environmenal SSI. Fomites include walls, floors, cabinets, furniture, and non sterile supplies. 5)2 risks are ENDOGENOUS FLORA FROM CONTAMINATED PROCEDURES AND RESIDEN FLORA OF THE SKIN. Preoperative prophylaxis with antibiotics reduces SSI. Carriers of S.aureaus are at particular risk for SSI in clean procedures- they’re deep into the skin making skin prep ineffective; this is as well for pt with UTI.
- Have students read bullets; other factors include malnutrition, smoking, diabetes, immunosuppresion, and malignancy
- Aseptic technique: prevent microbial contamination of the surgical environment Standard precautions: prevent personnel from exposure to infections from pathogens in blood/body fluids on surfaces, instruments, or equipment!
- Have students fill out their outline at this time, then go over any questions….THEY MUST KNOW ALL TERMS!!!
- 2) Rate is a key characteristic for which bacteria multiply
- 1)Classified to nutritional needs Obligate aerobes: require oxygen Microaerophiles: require little oxygen 5% Obligate anaerobes: will not grow if there is any oxygen Facultative anaerobes: both Aerotolerant: grow best without oxygen but can survive up to 15% Capnophiles: high conc. of carbon dioxide
- Acid fast: Purpose: To differentiate between acid-fast and non acid-fast bacteria. Principle: Some bacteria contain a waxy lipid, mycolic acid, in there cell wall. This lipid makes the cells more durable and is commonly associated with pathogens. Acid fast cell walls are so durable that the stain (carbol fuschin) must be driven into the cells with heat. The cells are then decolorized with acid-alcohol, all other cells will decolorize with this strong solvent, but acid fast bacteria will not. Other cells are then counterstained with methylene blue.
- Bioburden: gross debris High: all microorganisms including spores and prions Intermediate: most, including HBV and M. tuberculosis Low: fungi and viruses Critical: used on tissue or within body cavity; must be sterile prior to use; ex: surg instruments, implants, hypodermic needles Semi: used on mucous membrane or non intact skin, but not within body cavity; ex: cystoscopes, colon and laryngo scopes Non: used with intact skin and environmental services; ex: blood pressure cuff, OR furniture
- High conc. Of disinfectant increase disinfection it may cause corrosion such as on rubber -MUST CLEAN ITEMS PRIOR TO STERILIZING/DISINFECTING DUE TO BIOBURDEN -INSTRUMENTS THAT HAVE MULTIPLE PARTS MUST BE DISESSEMBLED - 20-30 mins for high level disinfection, intermediate/low=10-15 mins
- Read safety list on pg 157 Surfactants are wetting agents that lower the surface tension of a liquid, allowing easier spreading, and lower the interfacial tension between two liquids -make sure items are dry before immersion to avoid dilution -rinsed with sterile water so patient doesn’t get burned -minimum exposure of 20 mins to render sterile; immersed for 10 hours render sterile
- Read bullets on 160-162- discuss in further in between
- Read bullets on 163
- Read bullets on 163 left column -first step: purpose is to remove debris, use neutral pH detergent other may damage instrument -pH 0 high pH 14 alkaline; distilled water is 7; high or low pH damaging to metals, rubber, plastics
- Read cycles on pg 165