Medicine

1. ASEPSIS IN OT AND ICU
MODERATOR:DR.BASANTH SIR
GUIDE:DR.SHWETHA JAIN MAAM
PRESENTOR:DR.SHREEJAYANTH

2. INFECTION CONTROL IN OPERATION THEATRE
sources of infections acquired in OT :
• Patient's endogenous flora.
• Operating staff hand and skin flora.
• Contamination from the inanimate environmental surface of the OTS .
• Air contamination.
• Sharp injury leading to occupational exposure of theater staff to blood borne viruses.
• Improper disposals of items.

3. INFECTION CONTROL MEASURES
Size:
OT design is usually a quadrangular room with minimum dimensions of
• 7 x 7 m for general OTs and
• 10 x 10 m, for specialized OTS (cardiovascular, neurosurgical, etc.).
OT should have exclusive fixed or wall mounted cabinets and built-in shelves.
Main OT room should have access to the
• anesthetic room
• scrub room and
• supply room.
Separate exit doors should be provided.

4. Staff Immunization:
• Mandatory immunization of HCWs with hepatitis B vaccine.
• HCWs must have a documentation of a protective anti-HBs titer of > 10 mIU/mL
• The HCWs who are carriers of hepatitis B should be counseled and refrained from exposure
prone procedures
Physical Parameters in OT:
The semi-restricted area :
includes storage areas, sterile processing rooms, scrub stations, and corridors
(limited to access by authorized personnel and to the patient).
The restricted area :
• It is the core ot and maintained under high level of asepsis
• Surgical attire, head covering, and masks are required .

5. • NABH Recommendations:
• Air velocity should be at 25-35 feet per minute.
• Airflow needs to be unidirectional and downwards on the OT table.
• There should be a difference in positive pressure of 2.5 Pascal between OT and adjoining
areas
• Temperature should be 21 ± 3°C.
• Relative humidity can range from 20% to 60% (ideal is 55%).
• Window and split AC should never be used in OT as they are pure recirculating units and have
pockets for microbial growth.
• Air is supplied through HEPA filters (of efficiency 99.97% down to ≥0.3 µm) in the ceiling.
• Validation of HEPA filters is done biannually by DOP (Dispersed Oil Particulate) test.

6. Microbiological methods of air sampling:
includes
Passive monitoring:
• Done by Settle plate method
Active monitoring:
• Impaction on solid surface by using air samplers
• such as sieve sampler and
slit-to-agar impactor.
Air particle counter:
• It quantifies airborne particles containing microorganisms in real time

7. • Environmental Cleaning:
• First cleaning of the day (before cases begin) should be performed first, every morning
irrespective of whether the OT will be used or not.
• All horizontal surfaces are cleaned by wet wiping with a high-level disinfectant.
• OT is kept closed for 10-15 min with ventilation equipment on,after cleaning.
• Cleaning operating rooms in between cases should also be performed.
• Air handling unit should be kept on and OT door closed during the cleaning process.
• Detailed wash-down of the OT complex should be done at least once a week for OTS that are
used daily.
• Cleaning and disinfection of new OT and after any civil work includes general cleaning
procedures as discussed above, along with fogging using high level disinfectant
(glutaraldehyde based).

8. Pre-operative Preparation :
• Surgical hand preparation should be performed with an antimicrobial soap (4% CHG) and
water or handrubbing with an alcohol-based hand rub (ABHR) for an effective contact period
(2-5 minutes) .
• All jewelery should be removed, and artificial nails must not be worn as these promote
colonization with organisms.
• After performing the surgical scrub, members of the surgical team should keep hands up and
away from the body so that the water runs from the tips of the fingers toward the elbows.
• Double gloving is contro- versial and WHO does not have a clear recommendation on this
regard.
• Use of double gloves may help prevent transmission of BBVS.
• Gloves should be changed immediately after any accidental puncture.

9. • Surgical site preparation is done by alcohol-based chlorhexidine antiseptic solutions based on
WHO recommendation.
• Sterile surgical drapes are placed surrounding the surgical site covering a larger area to
prevent contact with unprepared surfaces.
• Surgeons should obliterate dead spaces, where possible.
• Scheduling dirty cases at the end of the day, as a measure to prevent SSIS is not a well-
accepted practice as it lacks supporting evidence.
• Antimicrobial coated surgical suture such as triclosan is shown to reduce microbial
colonization of the suture site.
• WHO and NICE recommends the use of triclosan-coated sutures as a strategy to prevent SSI.

10. Surgical Attire:
• PPES to be worn inside OT include a mask and headgear which fully covers hair, sideburns,
and neckline,because
• Microbes can be shed from hair, exposed skin, and mucous membranes of both OT personnel
and the patient's skin.
Shoes:
• HCWs and visitors of ICUs can wear either,
• shoes covers,
• ordinary shoes dedicated exclusively to the OT or
• their own clean shoes.
• There is no significant difference between use of any of these practices.
• If any surgical team member is suffering from a skin lesion such as a boil should refrain
himself/herself from working in the OT until the lesions are healed

11. Patient Related Factors in the OT:
• Surgical antimicrobial prophylaxis (SAP) should be administered within 120 minutes before
incision, along with due consideration to half-life and protein binding of the antibiotic.
• Perioperative oxygenation of Fio (80%) should be maintained for patients undergoing general
anesthesia with endotracheal intubation.
• Perioperative normothermia (36°C) should be maintained for surgical patients having
anesthesia duration of more than 60 minutes.
• Perioperative blood glucose control (140-200 mg/dL) is essential for both diabetic and
nondiabetics.

12. central line assosiated blood stream infection:
Site selection:
• Avoid using the femoral vein when possible
• Use the subclavian vein rather than the femoral vein or internal jugular vein when possible
• Use a catheter with the minimum number of necessary ports
Placement:
• Wear sterile gloves during catheter placement
• Perform hand hygiene with soap and water or alcohol-based sanitizer before catheter
placement
• Clean the patient’s skin with > 0.5% chlorhexidine with alcohol, iodine, or 70% alcohol in
patients with a chlorhexidine allergy before catheter placement
• Allow antiseptics to dry according to the manufacturer’s instructions

13. Dressing and securing:
• Use a sterile, semipermeable, transparent dressing to cover the catheter insertion site
• Replace the dressing if damp, loose, or soiled .
• Replace transparent dressings every 7 days.
• Use a sutureless securing device.
Replacement:
• Do not routinely replace catheters
• Do not perform guidewire exchanges to prevent infection
• Remove a catheter within 48 h if it was placed without aseptic technique
• Do not remove catheters based on fever alone
Removal:
• Promptly remove a catheter that is no longer needed

14. Catheter associated urinary tract infection:
• Insertion technique
• Perform appropriate hand hygiene before insertion or manipulation of a catheter.
• Insert catheters using aseptic technique and sterile equipment
• Use sterile gloves, drape, and aseptic solution to clean the periurethral space before
catheter insertion
• Secure indwelling catheters to prevent movement and urethral traction
• Perform intermittent catheterization at regular intervals in patients with urinary
retention
• Use ultrasound to assess bladder volume and help guide the timing of intermittent
catheterization
• Use the smallest catheter possible to prevent urethral and bladder trauma

15. Maintenance:
• Maintain a closed drainage and collection system
• Replace the catheter and collection system if there are any breaks that compromise sterility
• Maintain unobstructed urine flow by avoiding kinks and maintaining the drainage bag below
the bladder
• Do not give prophylactic antibiotics to prevent catheter-associated urinary tract infection
• Do not routinely clean the periurethral area with antiseptics
• If urine is needed for culture, sample it from a needleless port with a sterile syringe after
cleaning the area
Removal:
• Promptly remove a catheter that is no longer needed

16. INFECTION CONTROL IN ICU
FACTORS CONTRIBUTING TO INCREASED RISK OF INFECTION
• Acuity of illness:
More acute → ↓Energy stores →↓immunity →↑infection.
• Increased device use:
Central line, urinary catheter, ventilator, etc. ↑ the risk by biofilm formation.
• Response to physiological stressors :
pain, anxiety, and isolation
• Age and associated comorbidity:
Elderly > young. . Associated comorbidities like diabetes, chronic kidney disease also
serves as a risk factor.

17. • Indiscriminate use of antibiotics:
• promotes the development and spread of antibiotics-resistant organisms.
• Prophylaxis of stress ulcer:
• The increase in gastric pH induced by antacids may attenuate the bactericidal effect
of an acidic pH.
• Sleep deprivation.
• Malnutrition:
• Hypoalbuminemia impaires cellular immunity and ↑ susceptibility to bacterial
infections.
• Understaffing:
• Poor bed to nurse ratio ↑ risk of infection. In public sector hospitals nurse to bed ratio is
about 1:3 to 1:4, as compared to desirable standard of 2:1.

18. Source of infection
Primaryendogenous infections:
• the mostfrequentform of infection in the ICU (duringthe1stweek of ICU stay.)
• imported to the ICUs during admission of the patient (e.g. S. pneumoniae infection).
Secondary endogenous infections:
• after 1 week of ICU stay by aerobic MDR organisms.
• Gets colonized on the skin surface and cause infections
Exogenous infections:
• caused by the typical MDR nosocomial pathogens(difficult to treat).
• acquired by means of hands of HCWs and contaminated inanimate surface.

19. Prevention:
Hand hygiene :
• Alcohol based handrubs (alcohol with or without chlorhexidine) by WHO.
• Chlorhexidine handwash is preferred in visibly dirty hand or while handling patients
with diarrhea or C. difficile infection.
Washbasins :
• should be elbow/foot operated type .
• placed near the ICU entrance and at key points within the ICU .
Personal protective equipment:
• gloves,surgical masks or eye and face protection and gowns which must be worn during
central line and procedures involving blood,body fluids, secretions or excretions.

20. Transmission-based Precautions:
• followed specific transmissions such as airborne,droplet and contact precautions.
Airborne precaution:
• geographically separation from other patients, in an isolation room.
• HCWs must wear respirator (N95 mask) while handling these cases.
Droplet precaution:
• diseases such as influenza, diphtheria, meningococcal meningitis, etc.
• Includes, patient placement in an isolation room,
• wearing surgical mask, gloves and gown, and adherence to strict hand hygiene
Contact precaution:
• Done in known or suspected MDRO patients.

21. Engineering Controls:
• Adequate space between the beds should be maintained at minimum of 3 feet to allow free
movement of staff .
Curtains should be of materials that is cleaned easily and changed weekly, and on discharge.
• Toilets should be located outside the ICU.
• Medication preparation areas should be separate from patient care areas and should be
maintained as a clean area.
• An area should be identified for storing collected bedside waste and should be maintained
separate from direct care .
• Sharps discarding container should be within easy access of each bed.
• Windows should remain closed in order to control all airborne risks plants and flowers
should be avoided in ICU vicinity.

22. Environmental Disinfection and Cleaning:
• All surfaces including floor cleaning, toilet and corridor should be thoroughly cleaned, at least
three times a day.
• High dusting of ceiling and shelves should be done routinely.
• High touch surfaces in the patient zone area such as (bed railings, bedside table top/ counter,
and door handles) should be cleaned thoroughly
• Cleaning is done by detergent (soap) and water
• Disinfection is done by Low disinfectant quater- nary ammonium chloride with glutaraldehyde .

23. Visitors and non-ICU Staff:
Visitors:
• Initial screening of the visitors pertaining to infectious disease has to be done as per local
policy.
• They should be instructed in hand washing prior to assisting the patient.
Non-ICU staff :
• Street coats and white coats must be removed
• Hands should be washed on entering the ICU
• Standard precautions should be followed when attending the patient
• Hands should be washed before leaving the unit.

24. NICU and PICU Structural Facility:
• NICU:
should have the following structural facility:
• The NICU shall be in close proximity to the birth unit (e.g. labor room); but on separate
floors so as to limit the spread of infection.
• Each infant care space shall contain a minimum of 120 sq ft, excluding sinks and aisles.
• There shall be an aisle adjacent to each infant care space with a minimum width of 4ft (1.2
m) in multiple-bed rooms.
• Isolation room should be available.

25. PICU:
should have the following structural facility
• PICU cubicles should have sliding glass doors to allow full visibility.
• Patient area in open PICU should be 150-200 sq ft.
• In a cubicle, the minimum area should be 200-250 sq ft with at least one wash basin for two
beds.
• At least one, preferably two room should have an isolation capability with an area of 250 sq ft
with an ante room.
• It is the separate area at wearing least 20 sq ft for hand washing and should have separate
ventilation.
• The area around the bed should allow enough space for performing routine ICU procedures.

26. Bedsores and its prevention:
Bedsores:
• Develop when there is constant pressure on the skin.
• More common in bedridden patients of ICUS and wards.
• These sores not only cause pain and discomfort, but may lead to secondary infections,
like meningitis, cellulitis and endocarditis.
Common sites:
• The shoulder blades, tailbone, elbows, heels and hips.
Pathogenesis:
• When movements are ceased, it hinders adequate blood flow to the skin, depriving it of
nutrients and oxygen, causing skin necrosis.

27. • Prevention of bedsores:
• Change positions frequently (e.g. turning lateral) ↓ constant pressure on particular area of
skin .
• Skin should be kept clean, and hydrated.
• Use of pillows between body parts that press against each other.
• Exercise: Performing a few range of motion exercises (e.g. arm lifting) can reduce the risk.
• Nutrition: Good nutrition is essential for pressure ulcer prevention and healing.
• Pressure-redistributing mattresses to redistribute pressure and to provide comfort.

28. • Perioperative normovolemia must be maintained by goal-directed fluid therapy (colloid or
crystalloid) to prevent tissue hypoxia.
• Wound protector devices can be used for non-clean abdominal surgeries.
• Hair should be removed only with a clipper. Shaving by razor is strongly discouraged.
• Incisional wound irrigation can be performed with an aqueous povidone iodine (PVP-1)
solution for clean and clean- contaminated wounds.
• Irrigation with saline or antibiotic solution is not recommended.