Aios guidelines endoph new
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All India Ophthalmological Society issued guidelines for prevention and prophylaxis of the most devastating complication of intra ocular surgery , namely post operative infectious endophthalmitis .
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Aios guidelines endoph new
- 1. AIOS Guidelines For Prevention of post Operative Intraocular infections Dr.NSD Raju Team AIOS
- 2. I have no financial interests or relationships to disclose
- 4. Preoperative Measures • Blood glucose level: less than 200 mg/dL Systemic Blood Pressure: less than 150/90 mmHg
- 5. External Eye Examination • Meticulous external eye examination • Infection of adnexia • No routine syringing • No surgery - if regurgitation of pus
- 6. Preop Measures • Physicians clearance (Cardiac hepatic neurological Renal HIV Endocrine )
- 7. Pre operative Measures Topical antibiotics 4th generation fluoroqinolones 4 times 2 days prior to surgery
- 8. Camp/Large Volume surgery Usual precautions for Surgery Physicians clearance Avoid Patients with high risk systemic problems Combined surgery to be avoided
- 9. Operative Measures Pulse oximeter Anesthetist stand by Emergency Drugs Operating microscope
- 10. Dedicated Ophthalmic O T Lay out Outer zone- reception Clear zone- Changing Room transfer zone Aseptic zone
- 11. The Surgeon and Assistant Sterile gloves for every case Change gown at least after 5 cases No street clothes in O R
- 12. General Operative Measures Staff with obvious infection not allowed Standard protocol for hand washing gowning Betadine/ Chlorhexidine Running water aqua guard No contact procedures tonometry biometry Fresh Phaco tip for each case Not more than 25 cases/session
- 13. Pre operative Patient Preparation Postpone surgery if congestion or discharge in the eye O T dress for the patient with cap Betadine 5% skin periorbital area and conjunctial sac 3 mts Disposable drape isolate the lashes
- 14. Post Operative Patching optional Topical anesthesia no patching Follow up visit 1 3 7 and 30 days Slit lamp evaluation Protective glasses 1 wk Topical antibiotics and steroid eye drops for minimum 4 weeks
- 15. Documentations Document all procedures and clinical findings Surgeon available at the hospital for at least 1 w
- 16. Important Considerations • Max 5 personnel in O R per 180 sq ft • Fumigation -Sterility of OR thorough AldeKol -For 400 sq ft 325 ml sprayed for 30 mts - Close the OR for 2 hrs - switch on the AC for 2 hrs -Theatre ready in 3 hrs
- 17. Fumigation Three fumigations for the first time Running OT single fumigation Protocol: 30 ml of 40% formalin in 90 ml of clean water 6 hrs to be followed by carbolization 2% carbolic acid Alternatively 35 ml of 40% formalin in 10 gm Pot. Permanganate for1000cft for 24 hrs
- 18. Sterilization of Instruments • Autoclave • ETO • Flash Autoclave • Between Cases Autoclave • No chemical sterilization
- 19. Monitoring of Sterilization • Use Chemical Indicators • On Outermost wrap • On inside wrap • Inside the tray • Microbiological indicators • Log book • Disposable instruments
- 20. Post operative infection Discuss with patient and relatives Explain: - mechanics of infection - still treatable prognosis - patient cooperation - need for referral Batch number of all solutions Samples for culture
- 21. Post op Infection Document all findings Review sterilization Get peer review Inform AIOS Legal cell/professional protection
- 22. Cluster Infection/Outbreak Two or more infections at a time Repeated infections Inform DMO/DHS Infection control committee Inform AIOS /Legal Cell Seek local legal help Press briefing CMO/Medical committee
- 23. Conclusion AIOS guidelines Legal validity Court of Law www.aios.in AIOS Guidelines soft copy: http://aios.org/endophguidelines2011.pdf
- 24. Thank you
Editor's Notes
- Post operative intraocular infection is the most dreadful and devastating complication of intraocular surgery especially following cataract surgery. The all India ophthalmological society has formulated general guidelines to prevent post operative endophthalmitis . Please remember that these are only guidelines and may not be legally binding or valid in a court of law. These measures however if implemented properly will help prevent the occurrence of post op endophthalmitis
- Although extremely rare Endophthalmitis is a frightening condition with very disastrous consequences. Let us therefore briefly review the general measures to be adopted for prevention post op infection as formulated and recommended by All India Ophthalmological Society.
- In the preoperative evaluation patients with Diabetes Mellitus and systemic hyperension adequate control has to be ensured preferably certified by a qualified physician
- A meticulous external eye examination is mandatory. Infections of the adnexia are a contraindication to surgery. Routine syringing is not recommended but surgery to be avoided in the presence of frank regurgitation of pus
- Patients with systemic disease needs to produce a medical clearance and medial fitness certificate
- Broad spectrum topical antibiotics in the eye two days prior to surgery. Fourth generation fluoroquinolones are a good choice
- Physicians fitness certification is mandatory in this situation .Also avoid high risk patients .
- During surgery Pulsoximeter and anesthetist stand by are desirable. Tray with emergency medicine must be handy . An operating microscope is a must and an essential requirement for surgery
- The Operation Room must be exclusively dedicated to ophthalmic surgery and the layout should be such that the aseptic O R is buffered initially by an outer and clear zone where we have the pre op/post op care room and a middle semi sterile transfer zone
- Gloves to be changed every Surgical gown at least 5 cases And of course no street clothes to be allowed in the operation room
- Other measures include Personnel with any obvious infection not allowed in the OR. Standardized approved protocol for scrubbing , sterile gowning and gloving . Do not perform any contact procedures . Separate Phaco tip for each case. The maximum cases per session /surgeon limited to 25
- Do not do surgery if discharge or congestion. Proper O T Dress for patient with surgical cap. Betadine painting Periorbital area and conjunctival cul de sac Picture to be added
- Although no patch surgery is widely practiced and proved safe , surgery done under infiltrating anesthesia patching need to be given for at least for couple of hours. Protective goggles for one week Slit lamp Past op evaluation on 1st, 7th and 30 day. Steroid antibiotic drops for 4 weeks
- It is important to document all procedures including the clinical findings in every case . Ensure availability of surgeon for at least 1 week after the surgery
- Max 5 personnel Operation Room Sterility to be ensured with fumigation using Aldekol. Also shows the quantity of the fumigant and the duration for effective fumgation
- Let us also briefly look at the fumigation process . For a new operation theater 3 fumigations will have to be done , but for a running OT one is enough
- Ideally all instruments must be fully autoclaved as per the standard recommended procedure . Other items must be sterilized by ETO. In emergency situation Flash Autoclave sterilization can be used . But ideal is to autoclave the instruments between cases . Chemical sterilization must never be resorted to .Maintain a log book of sterilization procedures
- Usually 3 strips chemical indicators as shown. Interpretation of sterile status on color change of the strips as recommended by the manufacturer. More definitive method of assessing actual sterilization status is to use the biological indicators . A color change would indicate a non sterile status . Maintenance ce of a log book is mandatory . When possible use disposable instruments
- When a post operative infection occurs the matter should be discussed with the patients and relatives. The prognosis must be well explained to them and that it is still a treatable condition . The possible need for referral must be informed to them The batch number of all solutions must be carefully noted and samples sent for culture and sensitivity
- All procedures and findings to be documented and the whole sterilization processes thoroughly reviewed. Seek a peer review and promptly administer intravitreal antibiotics If need be, refer to VR specialist. All solutions kept in safe custody Culture from operation theater Always inform the AIOS legal cell and professional protection scheme
- In case of cluster infection or outbreak of infection additional measures required are informing the DMO/DHS, initiating the infection control committee , and of course contact the AIOS and its legal cell besides taking local legal help. Press briefing must never be done by the Surgeon himself It must be by the CMO or the Medical committee
- So these are the measures formulated and issued by the AIOS as guided lines for the prevention of Post operative endophthalmitis. And although not a legally valid document ,because we do not have the statutory power to formulate one, it certainly has an important and significant role in a court of law as our strict adherence to these guidelines will establish that we have taken all necessary steps to prevent intraocular infection and that there is no act of commission or omission on our part. These guidelines are available on our web site and this is the link to the document. We also have a hard copy which we will supply against your request. Thank you for your kind attention