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Manual of Operating Room: Discipline & Protocol
Inderdeep Singh Walia, Rajiv M Borle
CHAPTER 1:
Introduction
CHAPTER 2:
Historical Background
CHAPTER 3:
Definitions
DISINFECTANT
LEGAL DEFINITION (REDDISH, 1957)
ANTISEPTIC
LEGAL DEFINITION (FEDERAL FOOD, DRUG AND COSMETIC ACT, 1938) STATES
STERILIZATION
ALGICIDE
ANTIBIOTIC
ANTIMICROBIAL AGENT
Asepsis
BACTERICIDE
BACTERIOSTAT
BIOBURDEN
BIOCIDE
BIOLOGIC INDICATOR (BI)
CHEMISTERILANT
CONTAMINATION
DECONTAMINATION
Detergent
DROPLET NUCLEI
FOMITES
FUMIGATION
GERMICIDE
Commensals
Contamination
D Value, D10 Value, or Decimal Reduction Time (DTR)
High-level Disinfectant
Pyrogens
D Value (D10)
Decontamination
GNOTOBIOTICS
LAMINAR AIRFLOW
NOSOCOMIAL
CROSS-INFECTION
DISEASE
EXOGENOUS INFECTION
IMMUNOCOMPROMISED
IMMUNOSUPPRESSED
INFECTION
MICROORGANISMS OR MICROBE
OPPORTUNISTIC PATHOGENS
PATHOGEN
SEPTIC
SPORES
STERILE
STERILIZE
Chemiclave
Cleaning
VECTOR
VEGETATIVE FORM
VIRULENCE
VIRUS
Endoscope – Critical
Endoscope – Semicritical
High Level Disinfection (HLD)
Low Level Disinfection (LLD)
CHAPTER 4:
Microbial Control
MICROBIAL ETIOLOGY
Pathogens
BACTERIAL INFECTION
MOST COMMON BACTERIAL PATHOGENS
NONBACTERIAL INFECTION
VIABILITY OF ORGANISMS
TOXINS OF MICROBIAL ORIGIN
SOURCES OF CONTAMINATION
SKIN
HAIR
NASOPHARYNX
FOMITES
THE CDC IDENTIFICATION OF THOSE AT HIGH RISK2
HOW DISEASES ARE TRANSMITTED3?
AIR
HUMAN ERROR
CROSS INFECTION
PATTERN OF DEATH IN A MICROBIAL POPULATION6
WHEN IS A MICROBE REALLY DEAD?7
CONDITIONS THAT AFFECT ANTIMICROBIAL ACTIVITY
CHAPTER 5:
Biological Indicators for Verifying Sterilization
USE OF BIOLOGICAL INDICATORS (BI)
Analysis of Biologic Indicators
Management of Biologic Monitoring
In-office Monitoring
Mail-in Monitoring
What to do after a Sterilization Failure
CHEMICAL MONITORING
Mechanical Monitoring
Completer Monitoring Program
HANDLING OF PROCESSED INSTRUMENTS
Drying and Cooling
CHAPTER 6:
General Aseptic Precautions
APPLICATION OF PRINCIPLE OF ASEPTIC AND STERILE TECHNIQUES
General Observation
UNIVERSAL PRECAUTIONS
Precautions – Universal or Standard
Protective Barriers
Prevention of Puncture Injuries
Oral Procedures
CATEGORIES OF ISOLATION
SUGGESTED LABELS FOR CATEGORIES OF ISOLATION
Sterile Techniques and Their Applications
Red Lines
Adhesive Mats
TRANSFER ZONES
Recommendation: Category 2
Preparation of Environment (Figs 6.2 to 6.4)
Conditions Inside the OR
ACCOMMODATION
Principles of Sterile Technique
Only Sterile Items are Used within sterile field
Sterterile Persons are Gowned and Gloved
Tables are Sterile Only at Table Level
Sterile Persons Touch Only Sterile Items or Areas; Unsterile Persons Touch Only Unsterile Items or Areas
Unsterile Persons Avoid Reaching Over Sterile Field; Sterile Persons Avoid Leaning Over Unsterile Area
Edges of anything that encloses Sterile contents are Considered Unsterile
Sterile Field is Created as Close as Possible to the Time of Use
Sterile Areas are Continuously Kept in View
Sterile Persons Keep Well Within Sterile Area
Sterile Persons Keep Contact with Sterile Areas to Minimum
Unsterile Persons Avoid Sterile Areas
Destruction of Integrity of Microbial Barriers Results in Contamination
To Ensure Sterility
Microorganisms Must Be Kept to Irreducible Minimum
NO COMPROMISE OF STERILITY
CHAPTER 7:
Methods of Sterilization
PHYSICAL AGENTS
CHEMICALS
Sunlight
Drying
Heat
DRY HEAT1
Flaming
Incineration
HOT AIR OVEN
PRECAUTIONS TO BE TAKEN
ADVANTAGE OF THIS METHOD
DISADVANTAGE
HEAT TRANSFER DEVICES
MOIST HEAT
Temperature below 100°C
Vaccine Bath
Temperature at 100°C
Steam at Atmospheric Pressure (100°)
Steam Under Pressure [Autoclaving]
TYPES OF STERILIZERS
HOT OIL BATHS
FILTRATION
TYPES OF FILTRATION
RADIATION
NONIONIZING RADIATION
IONIZING RADIATION
RADIOISOTOPES
ULTRASONIC AND SONIC VIBRATION
Chemical Agents
Alcohols2
As Disinfectants
As an Antiseptic
Aqueous Quaternary Ammonium Compounds
Aldehydes
Phenols
Dyes
Halogens
Hexachlorophene
Gases
Ethylene Oxide4
Formaldehyde Gas
Betapropiolactone (BPL)
Surface Active Agents
Metallic Salts
Common antiseptics used in OT
STERILIZATION VS. DISINFECTION5
Bioburden
Microbiologic Safety
STERILIZATION PROCESS
Parameters of Sterilization
Product-Associated Parameters
Process - Associated Parameters
Sterilization Cycle
Monitoring of Sterilization Process
Administrative Monitoring
Mechanical Indicators
Chemical Indicators
Biologic Indicators
Guidelines for Use of Chemical and Biologic Indicators
Chemical
Placement
Biologic
Steam
Ethylene oxide
THERMAL STERILIZATION
Steam Under Pressure – Moist Heat
Advantages of Steam
Disadvantages of Steam
Types of Steam Sterilization
Gravity Displacement Sterilizer
Prevacuum Sterilizer
Flash / High – Speed Pressure Sterilizer6
Washer Sterilizer
Precautions
Preparing Items for Steam Sterilization
Surgical Instruments
Basin Sets
Drape Packs
Rubber Goods and Thermoplastics
WOOD PRODUCTS
All Items
Packaging7
Woven Textile Fabrics
Nonwoven Fabrics
Paper
Plastic
Combination of Paper and Plastic
Rigid Sterilizer Containers
Loading Sterilizer
Timing Load
Minimum Exposure Time Standard for Steam Sterilization After Effective Steam Penetration
Drying Load
Biologic Testing for Steam Sterilization
Gravity Displacement
Prevacuum
Flash / High Speed Pressure
HOT AIR-DRY HEAT
Advantages of Dry Heat
Disadvantages of Dry Heat
Types of Dry Heat Sterilizer
Mechanical Convection Oven
Gravity Convection Oven
Preparing Items for Dry Heat Sterilization Oils
Impregnated Gauze
Powders
Talc
Packaging Materials for Dry Heat
Loading Sterilizer
Timing Load
Biologic Testing
Microwaves
CHEMICAL STERILIZATION
Ethylene Oxide Gas8
Advantages of EO Gas
Disadvantages of EO Gas
Types of Gas Sterilizers
Preparing Items for Gas Sterilization
All Items
Lumens
Lensed Instruments
Lubricated Instruments
Camera
Packaging
Woven Textile Fabric
Nonwoven Fabric
Paper
Plastic
Combination of Paper and Plastic
Loading Sterilizer
Timing Cycle
Aerating Items Following EO Sterilization
CHAPTER 8:
Attire, Surgical Scrub, Gowning and Gloving
OPERATING ROOM ATTIRE
Purpose
Definition
Dress Code2
Components of Attire
Body Cover
Head Cover4
Shoe Covers
Theater footwear5
Recommendation: Category 3
Mask
Face Masks
Recommendation: Category 2
Protective Attire
Aprons
Eyewear
Gloves
Gown
Gloves
To summarize the Criteria for Operating Room Attire should be as follow
SURGICAL SCRUB
Definition
Preoperative Hand Hygiene
Recommendation: Category 3
Microorganisms
Purpose
Scrub Sink
Equipment
Agents for Antisepsis
Antiseptics
Preparation for Surgical Scrub (Fig. 8.11)
General Preparations
Length of Scrub
Surgical Scrub Procedure
Time Method
Five-minute Scrub
Brush-Stroke Method
GOWNING AND GLOVING
Drying Hands and Arms
Gowning and Gloving Techniques
Closed Glove Technique
Gowning for Closed Glove Technique (Fig. 8.14)
Open Glove Technique
Gowning for Open Glove Technique
Gloving by Closed Glove Technique (Figs 8.15 to 8.18)
Gloving by Open Glove Technique (Figs 8.19 to 8.21)
Gowning Another Person
Gloving Another Person (Fig. 8.22)
Changing Gown During Surgical Procedure
Changing Glove During Surgical Procedure
Removing Gown and Gloves
Removing Gown
Removing Gloves
CHAPTER 9:
Preparation of Patient Skin and Draping the Surgical Site
SKIN PREPARATION AT OPERATION
Recommendation: Category 2
SKIN PREPARATION AND DRAPING OF THE SURGICAL SITE
Physical preparation of patient
Urinary Tract Catheterization
SKIN PREPARATION OF PATIENT
Purpose of Patient's Skin Preparation
Preliminary Preparation of Patient's Skin6
Mechanical Cleaning
Hair Removal
Clipper
Depilatory Cream
Razor
Skin Degreasing
PATIENT'S SKIN ON OPERATING TABLE
Set up
Antiseptic Solutions
Chlorhexidine Gluconate
Iodine and Iodophores
Alcohol
Triclosan
Basic Preparation Procedure for Clean Areas
Contaminated Areas Within Surgical Field
Umbilicus
Stoma
Other Contaminated Areas
Foreign Substances
Traumatic Wounds
Areas Prepared for Grafts
Special Considerations in Specific Anatomic Areas
Ears, Face, or Nose
Neck
Lateral Thoracoabdominal (Fig. 9.2)
Chest and Breast
Shoulder
Upper Arm
Elbow and Forearm
Hand
Rectoperineal
Vagina
Hip (Fig. 9.4)
Knee and Lower Leg (Fig. 9.5)
Ankle and Foot
Skin Marking
Documentation
Airborne Dispersion
DRAPING
Draping Materials
Self – Adhering Plastic Sheeting
Advantages of a self-adhering plastic drape are:
Nonwoven Fabric Drapes
Laser Resistant Drapes
Thermal Drape
Woven Textile Fabrics
European Standard for Theater Gowns and Drapes
Recommendation: Category 2
Style/ Type of Drapes
Towels
Fenestrated Sheets
Laparotomy Sheet
Thyroid Sheet
Breast Sheet
Kidney Sheet
Hip Sheet
Perineal Sheet
Combined Sheet
Separate Sheet
Split Sheet
Medium Sheet
Single Sheet
Leg-Pocket Drapes
Stockinette
Techniques to Remember while Draping
Procedures for Draping Patient
Laparotomy
Head
Face
Eye
Ear
Chest and Breast
Shoulder
Elbow
Perineum
Hip
Knee
Lower Leg and Ankle
Foot
CHAPTER 10:
Physical Facilities
PHYSICAL LAYOUT OF THE SURGICAL SUITE
Construction or Renovation Planning and Design Team1
Principles in Construction or Renovation Planning
Strategic Planning
Plans for Emergencies
Exclusion of contamination from outside the suite with sensible traffic patterns to and from the suite
Separation of clean areas from contaminated areas within the suite during the building phase
Noise control
Location
Space Allocation and Traffic Patterns
The outer zone or non-restricted zone
The clean or semirestricted zone
Aseptic or restricted area
Remember
Unrestricted Area
Semirestricted Area
Restricted Area
TRANSITION ZONES
Preoperative Check-In Unit
Preoperative Holding Area
Postanesthesia Care Unit
Changing Rooms and Lounges
OPERATING ROOM2,3
Size
Substerile Room
Doors
Ventilation
Floors
Walls and Ceiling
Pipelines for Gases, Computer Lines, and Electrical Systems
Lighting
X-ray View Boxes
Clocks
Cabinets or Carts
Furniture and Other Equipment
Communication Systems
Voice Intercommunication System
Call Light System
Closed Circuit Television
Computers
Monitoring Equipment
SPECIAL PROCEDURE ROOMS
Cardiac Catheterization Room
Endoscopy Room
Cystoscopy Room
CHAPTER 11:
Biomedical Waste Management
DEFINITION1
COMPONENTS OF BIOMEDICAL WASTE
INFECTIOUS WASTE
WHO Classification of Biomedical Waste2
Types of Infectious Waste3
Health Hazards Associated with Poor Management of Biomedical Waste 4
Environmental Concern
Infectious Waste Management Plan5
PACKAGING OF INFECTIOUS WASTE6
Storage
Treatment
Disposal
Staff training
Treatment and Disposal Methods
Steam/Autoclaving Treatment
Gas/Vapor Treatment
Standards for Incinerators
Standards for Liquid Waste
STANDARDS FOR MICROWAVING
Standards for Deep Burial
Contingency Measures
Legal Aspects and Environmental Concern
Scope and Application of the Rules
CHAPTER 12:
Hospital Acquired Infection
HOSPITAL ACQUIRED INFECTION (HAI)
HISTORICAL MILESTONES
Frequency of Infection
Pathophysiology
CLASSIFICATION OF SURGICAL WOUNDS
RISK FACTORS AFFECTING THE RATE OF POSTOPERATIVE WOUND INFECTIONS
Predisposition to infection
Factors Influencing the Development of Nosocomial Infections
The Microbial Agent
Patient Susceptibility
Environmental Factors
Bacterial Resistance
Month of Operation
Use of Electric Cautery
Duration of Operation
Transmission
Diagnosing an Infection
CONTROL OF NOSOCOMIAL INFECTIONS
Prevention from Nosocomial Infections
INDEX
TOC
Index
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