Minor Surgical Procedures: Endotracheal Intubation, GIT Intubation, Esophagogastroscopy, and Proctosigmoidoscopy PDF

2.0 Endotracheal intubation, GIT intubation, esophagogastroscopy, proctosigmoidoscopy Introduction I. ENDOTRACHEAL INTUBATION It simply means placing a tube into the trachea Commonly done in an alt...

2.0 Endotracheal intubation, GIT intubation, esophagogastroscopy, proctosigmoidoscopy Introduction I. ENDOTRACHEAL INTUBATION It simply means placing a tube into the trachea Commonly done in an altered mental status, poor ventilation, and poor oxygenation The goal of endotracheal intubation in the emergency setting is to secure the patient’s airway and obtain first-pass success Team effort Cricothyroid membrane - landmark for emergent cricothyrotomy. In between the thyroid and cricoid is the cricothyroid ligament - an area for emergency access to airway in event wherein there is upper airway obstruction (e.g., choking because of clog due to a chunk of meat). What is the maneuver that will relieve you from the obstruction? – Heimlich Maneuver 1. Go at the back of patient 2. Put arm over the epigastrium of the patient 3. Forcefully pull the patient 4. Patient must increase the pressure in the thoracic/ abdominal cavity 5. Release the obstruction Clevelandclinic: This procedure is a life-saving maneuver. You see people at arrest or not breathing needing To perform the Heimlich maneuver, follow these steps: airway access. As a physician, it is mandatory to know how to place an ET. During cardiac arrest, ET must be immediate. The objective is to GAIN ACCESS TO AIRWAY TO FACILITATE 1. Stand behind the person, and put your arms around their abdomen. BREATHING. The tube is connected to a ventilator, etc. 2. Make a fist with one hand, and clasp your other hand tightly around it. 3. Place the thumb side of your fist just below their ribcage and about two inches above Brief History their belly button (navel). 4. Sharply and quickly thrust your hands inward and upward five times. “but that life may in a manner of speaking be restored to the animal, an opening must be attempted 5. Repeat this process until the object is freed (dislodged) or the person becomes in the trunk of the arteria aspera, into which a tube of reed or cane should be put; you will then blow unconscious. If the person becomes unconscious, start CPR. into this, so that the lung may rise again and the animal take in the air” - Vesalius (1543) In 1896, Trendelenburg performed the first successful tracheal intubation on anesthetized humans If the Heimlich Maneuver is not successful after several attempts and the patient is already in ○ He imagined a tube with an inflatable cuff at the distal end severe distress making it hard for him/her to breathe, then emergency cricothyroidotomy is the feasible thing to do. Anatomy and Physiology What is cricothyroidotomy? Upper airway consists of the oral cavity and pharynx, including the nasopharynx, Emergency airway puncture in the cricothyroid ligament. oropharynx, hypopharynx, and larynx Humidify and warm the air How to locate the entry? Pharynx is a tube-like passage that connects the posterior nasal and oral cavities to the 1. Touch the thyroid cartilage - the hard structure that is protruding. larynx and esophagus 2. Slide your hand down to feel the cricoid cartilage. In between cricoid cartilage and the thyroid cartilage is the cricothyroid ligament - the site to do a small slit with a knife and put in a hollow tube (any tube you can see for example a strong straw, ballpen tube with no ink) to provide airway access and relieve the patient from dyspnea. You must know how to perform this because anyone around you may need emergency cricothyroidotomy at any time and anywhere.  In the hospital, you may perform endotracheal intubation. Main Bronchi The right main bronchus is shorter, wider, and more perpendicular than the left bronchus The bronchi are supplied by the bronchial arteries from the aorta and drained by the azygos vein on the right and the hemiazygos vein on the left Indications and Contraindications Indications Contraindications Severe airway trauma, obstruction or Altered sensorium/loss of head & neck fractures that does not consciousness permit safe passage of an ○ GCS 6 lb (2.7 kg) posterior, right, left, is very important. ○ GI bleeding or iron deficiency anemia Picture: Orientation of the esophagus when the patient ○ Progressive dysphagia is in the left lateral decubitus position ○ Odynophagia ○ Water naturally stays in the left side of the ○ Persistent vomiting esophagus ○ Palpable mass or lymphadenopathy ○ Jaundice STOMACH Therapeutic Indications usually located beneath the diaphragm ○ Foreign body removal ~40 cm distal to the incisors in an adult ○ Dilation or stenting of strictures Gastric cardia ○ Esophageal variceal ligation ○ area of the stomach where the esophagus ○ Upper GI bleeding control enters ○ Placement of feeding or draining tubes Fundus ○ Management of achalasia ○ portion of the stomach above the junction of the esophagus and stomach Diagnostic Indications Incisura ○ Persistent upper abdominal pain or pain associated with alarming symptoms ○ along the lesser curvature of the stomach such as weight loss or anorexia ○ divides the gastric body from the antrum ○ Dyspepsia associated with alarm symptoms at any age endoscopically, the transition from the body to the ○ New onset dyspepsia in a patient ≥50 antrum is from rugae to flat mucosa ○ Dysphagia or odynophagia Pylorus ○ Symptoms of GERD that persist or recur despite appropriate therapy ○ muscular opening between the lower end of ○ Persistent vomiting of unknown cause the stomach and duodenum bulb ○ Diseases in which the presence of upper GI pathology may affect planned management decision to anticoagulate ○ Confirmation of radiological abnormalities When the patient is in the lateral left decubitus position, ○ Suspected neoplasia the ○ Assessment and treatment of GI bleeding (acute or chronic) ○ Greater curvature : bottom ○ Sampling of tissue or fluid ○ Lesser curvature : top ○ To document or treat esophageal varices ○ Posterior stomach wall : right ○ Surveillance for malignancy in high risk groups ○ Anterior stomach wall : left Barrett’s esophagus hereditary gastric cancer families Gastroduodenal ulcers, achalasia, caustic injury, tylosis ○ Follow-up of gastric ulcer ○ Follow-up of patients who undergo endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) of an early cancer DUODENUM ○ Investigation of chronic anemia and/or iron deficiency C-shaped ○ Patients with a history of squamous cancer of the head, neck, pharynx, lung or located in the upper abdomen at the level of L1-L3 esophagus extends from the pylorus to the duodenojejunal angle ○ Gastric epithelial polyps Duodenum Bulb ○ Gastric intestinal metaplasia ○ an expanded region immediately distal to the ○ Pernicious anemia pylorus ○ Gastric/bariatric surgery patient ○ Hereditary non-polyposis colorectal cancer (HNPCC) ○ Familial adenomatous polyposis Biopsies should be taken from the largest duodenal polyps and from the Indications ampulla WARNING! Upper GI alarm symptoms In biopsying the ampulla, biopsies should be taken AWAY from ○ Age ≥50 with new onset symptoms the pancreatic orifice to avoid pancreatitis.  A safe area to biopsy is the upper left quadrant Contraindications Preparation There are no absolute contraindications to EGD. Routine Endoscopy: The examination, however, may be dangerous in the following cases: ○ Outpatient setting Known or suspected perforation. EGD should not be performed unless to insert a ○ Parenteral / General covered stent to treat the perforation ○ Bedside or OR Massive gastrointestinal hemorrhage suggesting an aortoduodenal fistula Acute cardiorespiratory failure not responding to medical therapy Diet: Hypovolemic shock not responding to aggressive resuscitation ○ Fasting (ASA guidelines) Minimum of 2hrs after ingestion of clear liquids EGD should be performed with caution in the following situations: Minimum of 6hrs after ingestion of light meals ○ Large Zenker’s diverticulum ○ Medication ○ Severe respiratory failure Stop taking: ○ Thoracic aortic aneurysm Aspirin ○ Strictures of the cervical esophagus. Blood thinners Anti coagulants You wouldn't know if you have aortoduodenal fistula. One indication for EGD is for massive GI ○ DM meds should be adjusted due to period of Fasting bleeding that is not stopping despite medications. Clip it right away or else you might lose a lot of blood unless you are dealing with aortoduodenal fistula where you cannot really see the bleeding site. But generally speaking, this is an indication for massive GI bleeding although it is difficult to locate the bleeding site. It is a life saving maneuver if you will operate on a patient. Localize and control the bleeding. Sedation and Monitoring ○ Minimize discomfort Equipment ○ Provide amnesia for the procedure ○ Provided by a Anesthesiologist Gastroscope ○ Anesthetics used: ○ Diameter: 10 mm Propofol ○ Instrument Channel : 2.8 Midazolam, Diazepam ○ Children: Fentanyl, Meperidine bone Most common type of soft tissue sarcoma 50% 5 year survival In adults, Female > Male 70 % in extremities painless mass TREATMENT Wide Surgical Excision Post OP radiation Amputation (unresectable) 65% 5 year survival 2. LIPOSARCOMA 2nd most common Sarcoma in adult (40 - 70 years old), malignant In deep compartments of extremities & retroperitoneum painful large mass (firm) Lipoblasts Several subtypes 4. FIBROSARCOMA ○ - Well differentiated/atypical lipoma Malignant tumor of fibroblast origin ○ - Myxoid / Round cell In the arms, legs, or trunk ○ - Pleomorphic In children and adults Spindle cells in a herringbone pattern TREATMENT Increased cellularity, high nuclear-cytoplasmic ratios Wide Surgical Excision Does not metastasize Must exclude other tumors which resemble fibrosarcoma 100 % 5 year survival ○ Peripheral nerve sheath tumor high recurrence rate (20%) ○ Synovial sarcoma TREATMENT Fibrosarcoma is caught early surgery is usually curative In more advanced stages a combination of surgery, radiation and chemotherapy may be needed. PRESENTATION, DIAGNOSIS, AND MANAGEMENT OF SOFT-TISSUE TUMORS.  1.0 ASEPSIS AND STERILIZATION What do you mean by asepsis? Sepsis - refers to infection HISTORY What is infection? Infection - appearance of microorganisms. Microorganisms at a certain number that will cause Asepsis and surgical antisepsis established the standard of utilizing scientific evidence to problems in the patient. It is not enough to say that just infection or just the number of microbes. determine the surgical practice. We do have a lot of microbes in our body but we are not infected. So when you say infection, there The microbiological discoveries of Louis Pasteur were the inspiration for Joseph Lister's is that great amount of microorganisms in the body that makes the body unstable, not normal (1860’s) use of carbolic acid(phenol) as a disinfectant which reduced postoperative situation appearance of manifestations., etc. In other words it makes you sick infections. What is that usual number or amount of microbes that cause infection? Robert Koch (1843–1910) who supported the work of Louis Pasteur and the idea of 10,000,000 asepsis. What do you mean by Asepsis? Semmelweis (1847) - washing hands prior to delivery reduced puerperal (childbed) fever. Absence of infection In the United States, surgeons followed their lead of their brethren across the Atlantic. What do you mean by sterility? Germ theory of louis pasteur were revolutionized medicine and public Devoid/Minimal number of microorganisms. Autoclaves were used to disinfect gloves and gowns in later decades. Sterilization is a procedure which you want to minimize or possibly eliminate organisms. These transitions in practice created the current model of the academic department of So as you mentioned there are several ways by which aseptic techniques are practiced. You surgery and the modern concept of surgical professionalism. mentioned handwashing but that doesn’t completely eradicate m.o. What is more effective than just handwashing? Aseptic and septic techniques have been established a long time ago. There have been so many Scrubbing – You have to follow proper technique in surgical scrubbing. Usually done when entering changes in the past. It is a very important procedure that is now creating a good techniques for OR., Wearing PPE., Use of antiseptics surgical procedures in our present setting What is Antiseptics? ASEPSIS Form of solution or chemical to be utilized for proper aseptic techniques. Who are the members of OR? Asepsis is a standard practice preventing the transfer of microorganisms to an open Surgeon, Nurses, Anesthesiologist, and other allied personnel – follows strict aseptic procedures wound/susceptible region on the patient’s body. before entering OR Asepsis is achieved by usage of sterile equipment and gloved ‘no touch’ technique during What are the things to follow and assist in a procedure or do the procedure (not in order) the medical & nursing procedures. 1. Change home clothing with scrub suit PRINCIPLES OF ASEPTIC TECHNIQUE: 2. Handwashing ○ Scrubbed persons function within a sterile field. 3. Wear gloves ○ All sterile items are used to create a sterile field. 4. Remove jewelries – rings, watch, bracelets, anklets, nose rings, tongue rings (not glasses) ○ Constant monitoring of sterile field 5. Wear mask Types of asepsis: SURGICAL AND MEDICAL 6. Wear caps – How do you wear them? Cover all hair (source of infection) MEDICAL SURGICAL 7. Wear gown – Usually sterilized 8. Proper scrubbing The core medical aseptic practices include the All health care providers and staff who have 9. Change shoes following: contact with the sterile field perform a surgical 10. Cut nails hand scrub with an antimicrobial agent before Handwashing donning a surgical gown and gloves. ANTISEPSIS Cleaning the environment, Wearing appropriate PPE (gloves, Always practiced in: Antisepsis is the removal or decrease of microorganisms in the skin or mucous gowns, masks, face shields, hair and Operating rooms membranes of living beings. shoe covers), Special procedure or diagnostic The method uses chemicals, called antiseptics well known as skin disinfectants. Disinfecting articles and surfaces, areas, Antisepsis has given a way to prevent surgical infections and made surgery safe. The use of antiseptics Burn units Dequalinium is used as a throat antiseptic. In labor and delivery areas. Isolation precautions are an example of medical asepsis It is also used during invasive procedures at Surgical Site Infections and Risk the bedside, such as inserting chest tubes, SSIs are one of the most common forms of healthcare‐associated infections for surgical central lines, and catheters patients.  SSIs result in delayed wound healing, increased hospital stays, increased use of antibiotics, unnecessary pain and, in extreme cases, the death of the patient.Hence the prevention of SSIs is a key aim for health services. TECHNIQUES OR PROCEDURES IN ANTISEPSIS Surgical Hand Antisepsis Surgical hand antisepsis includes antiseptic cleansing of the hands for those in the operating room. Hand washing removes transient microorganisms, surgical hand antisepsis further inhibit the growth of resident microorganisms, thereby minimising the risk of a patient developing an SSI (WHO 2009). Clinicians can perform antisepsis using either an antimicrobial solution with running water, referred to as a traditional scrub, or an alcoholic rub without water. Aqueous Scrub Aqueous scrubs are water based solutions containing active ingredients that are used during traditional hand scrubs. The most common solutions contain chlorhexidine gluconate or povidone iodine. Surgical scrubs are used to remove debris and transient microorganisms from nails, fingers and forearms. Patient Preparation How long do you do your scrubbing? Surgical site skin preparation is the preoperative treatment (cleaning and disinfection) of 3 to 5 minutes if correctly done.It depends, it can be as fast as 3 minutes or as slow as 10 mins. the patient’s intact skin done prior to surgery within the operating room (OR). So what is your objective when to stop scrubbing? What is your endpoint? Use an alcohol-based CHG solution (usually, a 2% chlorhexidine isopropanol solution) for If water flows freely and smoothly in your hands and elbows. No irregularities in the movement of surgical site skin preparation. water. After scrubbing, put your hands above your waist. Apply the solution using sterile gauze and instruments with movements from clean to dirty areas starting from the center of the incision site and moving outwards. Alcohol Rubs Then, allow to dry fully before incision Alcohol solutions containing additional active ingredients are used to perform an 'alcohol rub'. Patient Preparation - Shave prep Alcohol rubs inactivates microorganisms and suppress their growth temporarily. If the shave prep is ordered, it should be performed as close to the time of surgery as (WHO,2009). possible in order to reduce the risk for microbial growth in breaks in the skin. It is effective against a wide range of bacteria and other microorganisms. The shave prep should not be performed in the OR and should be performed in the preoperative holding area where the privacy of the patient can be maintained. Form which is scrubbing is omitted – Using strong antiseptics that will give equivalent weight just It is recommended that the skin and hair be wetted in order to perform a wet shave prep like scrubbing. therefore reducing the risk for skin irritation and cuts. So when do you do your shaving? A day before surgery is not advocated – already appearance of infection Best time - inside OR before anesthesia Open pores = possible site of m.o What is the other source of infection aside from the patient and the doctor? Surgical instruments, drapes, gowns Surgical Draping Drapes create a barrier between the surgical field and possible sources of microbes. Microbial migration and contamination from non-sterile to sterile areas is minimized by isolating the incision site and creating a sterile field with the use of sterile drapes.  Drapes protect the patient from their own skin flora (endogenous source of contamination) PHYSICAL METHOD CHEMICAL METHOD and surgical team members and environment (exogenous sources of contamination). The surgical team should ensure that the drapes are not saturated with alcohol or that the Sunlight Drying Alcohol (Ethyl, isopropyl, tri-chlorobutanol), alcohol-based solution has not formed a pool underneath the patient before operating. Heat: Aldehydes, Formaldehyde, glutaraldehyde, Dry heat: flaming, incineration, hot air Dyes, Halogens, Phenols, Surface active Avoid touching unsterile objects. Don’t scratch head or nose when already gowned Moist heat: pasteurization, boiling, agents, Metallic salts, Disposable drapes are common nowadays steam under pressure. Filtration: candles, asbestos pads, Gases: Ethylene oxide, formaldehyde, beta membranes propiolactone Antiseptics - Mechanism of Action Radiation, Ultrasonic and sonic vibrations Denaturation of proteins and action against Gram-positive and Instruments – Gases are used.., buts some/mostly they use autoclaving ALCOHOLS gram-negative bacteria, some fungi and viruses HEAT STERILIZATION Breaking the cell wall of microorganisms. CHLORHEXIDINE Heat sterilization is one of the physical methods. Effective against gram-positive bacteria and some fungi The most reliable method of sterilization and should be the method of choice. POVIDONE-IODINE Breaking down cell wall and stimulating the oxidation of compounds. The factors influencing sterilization by heat: ○ Nature of heat-dry or moist Prevents the fatty acid synthesis required for lipid production in the ○ Temperature and time TRICLOSAN microbe. ○ Number of microorganisms present ○ Characteristics of organisms –species, strain, sporing capacity Differences ○ Type of material from which organisms have to be eliminated. ○ Killing effect is due to protein denaturation, oxidative damage and toxic effect of ASEPSIS ANTISEPSIS elevated level of electrolytes. ○ Killing effect of moist heat due to denaturation and coagulation Approaches passively defending an area Approaches actively acting against microbes. against microbes. Technique aim to remove the microbes. Thermal Death Time (TDT) Techniques usually aim at minimising infection. ○ “Minimum time required to kill a suspension of organisms at a predetermined Use of antiseptic solution or an agent to inhibit temperature in a specified environment. Thermal death time is inversely Use of sterile instruments and gloved no touch the growth of microorganisms, while in contact proportional to temperature. TDT is increased in the presence of organic technique with them. substances, proteins, nucleic acid, starch, gelatin , sugar , fats, oils. STERILIZATION Dry Heating Heating over fire, till they become red hot. History FLAMING 3000 B.C. - use of antiseptics such as pitch or tar, resins and aromatics- Egyptians Instruments like: Point of Forceps, Spatulas, Inoculating loops and Wires embalming bodies Moses (1450 BC) - First to describe purification by fire It is a process that involves the combustion of organic substances contained Hippocrates (460-377 BC) - Irrigation of wounds with wine or boiled water in waste materials. Galen (130-200 AD) - Boiled instruments used in caring for wounded Roman gladiators INCINERATION Items: contaminated cloth, animal carcasses 1679: French engineer Denis Papin - Steam pressure cooker 1860s: French biologist Louis Pasteur - Heating things to kill germs can prevent diseases Pathological material. PVC, polythene can be dealt. 1880s: Pasteur's collaborator, Charles Chamberland - Modern autoclave Hot air ovens are electrical devices used in sterilization. Introduction Sterilization is the process of killing, removing or deactivating all forms of microorganisms The oven uses dry heat to sterilize articles. HOT AIR OVEN Can be operated from 50 to 300 C (122 to 572 F). present in a specific surface, fluid or object. There are two types methods used in this process based on the agents used There is a thermostat controlling the temperature. This is the most widely used method of sterilization by dry heat.  Addition of 2% sodium bicarbonate may promote sterilization Items: glassware, forceps, scissors, scalpels, all-glass syringes, swabs, liquid paraffin, dusting powder, fats, grease. Used for the disinfection of medical and surgical equipment – when sterility is not essential in emergency or under field conditions An exposure of steam of 100C for 20 min on three consecutive days is Moist Heating (these are new ones) known as Tyndallization or intermittent sterilisation. ○ can be categorized into 3 groups: Temperature below 100 C The instrument used is Koch or Arnold steam sterilizer. TYNDALLIZATION Temperature of 100 C Temperature above 100 C Principle: First exposure kills all the vegetative forms, and in the intervals between the heatings the remaining spores germinate into vegetative forms which are killed on subsequent heating. TEMPERATURE BELOW 100° C Process in which packaged and non-packaged foods are treated with mild TEMPERATURE OF 100° C PASTEURIZATION heat, usually to less than 100 °C (212 °F), to eliminate pathogens and extend shelf life KOCH’S OR ARNOLD’S VACCINE BATH Bacterial vaccines are sterilized in special vaccine baths STEAM at 60°C for one hour. STERILIZER Usually used for media which are decomposed at high temperature of Serum or body fluids can be sterilized autoclave. by heating for one hour at 56°C in a water bath on several successive days. The articles are kept on a perforated tray through which steam can pass. They are exposed to steam at atmospheric pressure for 90 minutes. Most of the vegetative forms are killed by this method except thermophiles Some serum or egg media, such as Lowenstein-Jensen’s and Loeffler’s serum, are rendered sterile by heating at 80-85°C temperature for half an hour daily on three consecutive days. INSIPISSATION This process of sterilization is called inspissation. The instrument used is called inspissator. TEMPERATURE ABOVE 100° C LOW Items which cannot withstand the temperature of 100°C may be sterilized TEMPERATURE by a method known as low temperature steam formaldehyde (LTSF) Autoclave is a device that uses steam to sterilize equipment and other STEAM sterilization. objects. STEAM UNDER FORMALDEHYDE PRESSURE This means that all bacteria, viruses, fungi, and spores are inactivated (LTSF) In this method steam at sub atmospheric pressure at the temperature of AUTOCLAVE/ (prions may not be destroyed) STERILISATION 75°C with formaldehyde vapour is used STEAM STERILIZER Principle - Water boils when its vapour pressure equals the surrounding TEMPERATURE AT 100° C atmosphere. Thus, when pressure inside closed vessels increases, the temperature at Boiling at 100C for 10-30 min kills all vegetative bacteria and some which water boils increases too. bacterial spores. BOILING Holding Period - varies Sporing bacteria required prolonged periods of boiling. Very common Temperature - between 108° C and 147°C. Therefore, it is not recommended for sterilization of surgical instruments.  Many types of radiation are used for sterilization like electromagnetic radiation (e.g. Items - dressings, instruments, laboratory ware, media and pharmaceutical products. gamma rays and UV light), particulate radiation (e.g. accelerated electrons). The major target for these radiation is microbial DNA. A lot of instruments are sterilized through autoclaving. Relatively cheap. Gamma rays and electrons cause ionization and free radical production while UV light Even gowns and drapes. NOT for sharp instruments causes excitation. Radiation sterilization with high energy gamma rays or accelerated elections has proven CHEMICAL METHODS to be useful method for industrial sterilization of Heat Sensitive products. Chemical Sterilization is the process of removal of microorganisms by the use of chemical Applied to articles in the dry state; including surgical instruments, sutures, prostheses, unit bactericidal agents. dose ointments, plastic syringes and dry pharmaceutical products. Even if the physical methods of sterilization are more appropriate for effective sterilization, UV light (lower energy, and poor penetrability) is used in the it is not always appropriate to use heat sensitive materials like plastic, fibre optics. ○ Sterilization of air Chemical methods are easy and economic-friendly. ○ Surface sterilization of aseptic work areas Chemicals can act as disinfectants to destroy pathogenic bacteria from the upper surface. ○ for treatment of manufacturing grade water, but is not suitable for sterilization of Used especially for sensitive instruments. Those with fibers like endoscope pharmaceutical dosage forms. Give specific things that will be utilized using radiation techniques? – Rooms itself STERILE FILTRATION Sterile filtration is the process of removing microorganisms from a fluid stream without adversely affecting product. Filtration is the preferred method of sterilizing heat sensitive liquid and gases without exposure to denaturation heat. Rather than destroying contaminating microorganisms, it simply removes them. It is the method of choice for sterilizing antibiotic solutions, toxic chemicals, radioisotopes, vaccines and carbohydrates which are all heat-sensitive. The liquid or gas is passed through a filter, a device with pores too small for the passage of microorganisms, but large enough to allow the passage of the liquid or gas. TYPES OF FILTERS These filters are made of cellulose. MEMBRANE FILTERS They can be used for sterilization during injection by placing the membrane between the syringe and the needle. Most common in gas = Ethylene oxide; Liquids = Hydrogen peroxide, Hypochlorite – used especially when sterilizing plastics or sensitive instruments like gastroscopes and bronchoscopes. These are usually made of asbestos. It really depends on the instrument (In the exam I will tell you the object and choose the appropriate SEITZ FILTERS technique.. Ex. for instruments, tables, scissors, drapes etc. familiarize with the diff sterilization They are pad-like and thicker than membrane filters techniques) These are an alternative type of filter that are Gaseous sterilization Liquid sterilization SINTERED GLASS FILTERS made of glass and hence do not absorb liquids during filtration. involves the process of exposing equipment or is the process of sterilization which involves devices to different gases in a closed heated the submerging of equipment in the liquid These are made of clay-like mud. or pressurized chamber sterilant to kill all viable microorganisms and their spores This special mud has tiny pores made by CANDLE FILTERS algae. RADIATION STERILIZATION The microbes get stuck during their travel through the pores These filtration techniques are usually done in areas where they utilize sensitive activities.. Not High-concentration can effectively inactivate viruses such as HIV, really in the OR hepatitis B, and hepatitis C. ADVANTAGES OF STERILE FILTRATION ALCOHOLS Chemicals present are usually ethanol or isopropanol. Less capital intensive. Suitable for heat-sensitive liquids (infusions, vaccines, hormones, etc). It is safe and inexpensive to use in a household environment, care Large volume of liquids can be filtered reasonably fast. has to be taken around inflammable items. Somewhat effective on spores and fungus also. LIMITATIONS OF STERILE FILTRATION ALDEHYDES Chemicals - formaldehyde and glutaraldehyde. Only liquids and gases can be sterilized by this process. Filters are expensive to replace, especially nano-filters. Cause the microorganism to collapse. Clogging may occur Chlorine and oxygen are strong oxidizers, so their compounds are DISINFECTION used for e.g. common household bleach. OXIDIZING AGENTS In fact it is the most cost-effective home disinfectant (sodium History hypochlorite solution) is used to clean toilets, drains, surfaces, and 1800’s Phenols were introduced as the first surface disinfectant. swimming pool. 1950's Alcohols such as Isopropyl and Ethanol continue to be used for surface disinfection 2000's Accelerated Hydrogen Peroxide powerful on pathogens but safer for users. It is the oldest known disinfectant for e.g. mouthwashes, Dettol. Phenols are restricted for use around children and banned in many countries due to a PHENOLICS Chemicals - Phenol, Chloroxylenol poor safety profile. 2010's Accelerated Hydrogen Peroxide formulated Quaternary ammonium These are effective low level disinfectants. Chemicals - compounds ("quats") benzalkonium chloride Differences DISINFECTION STERILIZATION Biguanide polymer polyaminopropyl bactericidal at very low concentrations (10 mg/l) biguanide To disinfect means to eliminate most To sterilize means to kill ALL DEFINITION harmful microorganisms from surfaces or microbes - whether harmful or objects not High-intensity shortwave used to disinfect smooth, opaque materials ultraviolet light Phenolic disinfectants, heavy metals, Heat, chemicals, irradiation, METHODS halogens, bleach, alcohols, hydrogen high pressure, and filtration Common sodium has disinfectant properties peroxide, detergents, heating bicarbonate (NaHCO3) Air disinfectants, alcohols, aldehydes, Steam, heating, chemical 1.1 GOWNING AND GLOVING TYPES oxidizing agents, phenolics sterilization, radiation sterilization, sterile filtration INTRODUCTION The gowning and gloving is an important procedure required to reduce the risk of Disinfection is used mostly to Sterilization is used for food, contamination by microorganisms during operative procedures. APPLICATION decontaminate surfaces and air medicine and surgical The process of gowning, and gloving is one that all members of the surgical team must instruments complete before each operation. A sterile surgical gown and pair of gloves are subsequently donned, creating an aseptic Types of Disinfection environment. ○ Consider the person in surgical gown as sterile Disinfectant is dispersed as either as an aerosol or vapour at a The gowning and gloving are important component of aseptic technique sufficient concentration in the air to cause the number of viable These procedures avoid the introduction of pathogens or disease causing AIR DISINFECTANTS infectious microorganisms to be significantly reduced. microorganisms. Chemicals used propylene glycol and triethylene glycol. Maintaining asepsis in product preparation is critical for the specialized patient.  The “AAMI Standard” (ANSI/AAMI PB70:2012) provides standards for liquid barrier performance in GOWNING the critical zones of gowns and drapes, the areas where OR personnel are most likely to come in direct contact with potentially infectious material, such as blood and bodily fluids. Gowning is the process of wearing special garment’s in order to control particulate contamination. This diagram shows the critical zones on a surgical gown Correct gowning procedures are also of paramount importance. One of the problems with particulate contamination is that it is largely invisible to the naked eye. Any contamination introduced into the cleanroom on the outer surface of clothing will go unnoticed and so any breakdown in correct gowning procedures will not be immediately apparent. Thus it is vital that operators are well versed and well practiced in correct gowning procedures. It can be very helpful if a system of mutual help is in place. That is, the operators observe each other and, in a non-threatening way, point out faults that may occur. Types of Surgical gown: Critical Zones are defined as the areas where direct contact with blood, bodily fluids, and other 1. Reusable Materials potentially infectious material is most likely to happen (Areas A and B). For surgical gowns, this In the past cotton fabrics were the fabrics of choice but now they have almost includes the fabric and the construction (sleeve seams, front tie attachment) in areas A and B. completely disappeared from the operating room due to their low resistance to liquid penetration, their high porosity and their high tendency to generate lint. The entire gown (Areas A, B, and C), including seams but excluding cuff, hems, and bindings, is Tightly woven textiles of a blend of polyester and cotton have since appeared on required to have a barrier performance of at least Level 1. the market. The back of the surgical gown (Area D) may be non-protective. With a good water repellent chemical finish they exhibit relatively good AAMI liquid barrier standards also apply to surgical drapes performance. ○ You have to know the different areas of your gown, it is made up of different parts, for example: Letter C is called the neckline (sterile area) Letter B where you put your arms inside is sterile. Letter A is called body or the trunk (also sterile) 2. Single-Use Materials ○ Remember the front of your gown is considered to be sterile, inside part is unsterile Nonwoven materials are the essential component of single-use surgical gowns ○ All the exposed parts of the gown, exteriorly, are supposed to be sterile, and the inside part and drapes. of the gown which is in contact with your body is unsterile. They are based on various forms of natural and synthetic fibres; that is ○ Distal part of the gown (white color) is the cuffs it is provided with a tighten area where it components such as wood pulp and cotton, or polyester, polyolefin respectively. will be covered by your gloves Based on the way the links between the fibres take place in the ○ The lowermost portion is called the hemline, the hemline should not be touching the nonwoven - chemically, physically, mechanically, thermally – nonwovens are ground. segmented in different categories. Levels of AAMI BARRIER For surgical gowns a nonwoven should be soft and breathable while a high level of barrier protection is also required. Several types of nonwovens can AAMI Level Description Applicability meet these requirements ○ Very common since this time of pandemic (easily discarded) Used for MINIMAL risk situations Provides a slight barrier to small amounts Basic care of fluid penetration AAMI LIQUID BARRIER PERFORMANCE Level 1 Single test of water impacting the surface standard hospital medical unit of the gown material is conducted to assess The Association for the Advancement of Medical Instrumentation (AAMI) standards are barrier protection performance designed to help medical-device companies meet global standards for the safe use of medical devices. Used in LOW risk situations Blood draw from a vein Provides a barrier to larger amounts of fluid Suturing Level 2 penetration through splatter and some fluid Intensive care unit exposure through soaking Pathology Laboratory  Two tests are conducted to assess barrier protection performance. 1. Water impacting the surface of the gown material 2. Pressurizing the material Used in MODERATE risk situations Provides a barrier to larger amounts of fluid penetration splatter and more fluid Arterial blood draw exposure through soaking than Level 2 Inserting an IV Level 3 Two tests are conducted to assess barrier Emergency Room protection Trauma 1. Water impacting the surface of the gown material 2. Pressurizing the material Used in HIGH risk situations Prevents all fluid penetration for up to 1 hour Pathogen resistance May prevent VIRUS penetration for up to 1 Infectious diseases hour Level 4 (non-airborne) PICKING UP THE GOWN In addition to the other tests conducted Large amounts of fluid under levels 1-3, barrier level performance is 1. With one hand, pick up the entire folded gown from the wrapper by grasping the gown over long periods tested with simulated blood containing a through all layers, being careful to touch only the inside top layer which is exposed. virus. If no virus is found at the end of the 2. Once your hands are securely pinching the gown in these slots, step back from the shelf test, the gown passes and allow the gown to drop. 3. Make sure the gown does not touch any surrounding unsterile objects. GOWNING PROCEDURE INSERTING YOUR ARMS INTO THE SLEEVES OF THE GOWN 1. Grasp the inside shoulder seams and open the gown with the armholes facing you. 1. The individual moves into an area where the gown may be opened without contamination 2. Carefully insert your arms part way into the gown one at a time, keeping hands at 2. Gown is unfolded so that the inside is toward the surgeon shoulder level away from the body. 3. Touch only the inside of the gown while donning it. 3. Slide the arms further into the gown sleeves and when the fingertips are level with the 4. If you touch the outside, the gown is considered contaminated. proximal edge of the cuff, grasp the inside seam at the cuff hem using thumb and index 5. Scrubbed hands and arms are considered contaminated if they fall below the waist level finger. Be careful that no part of the hand protrudes from the sleeve cuff. or touch the body. 6. After donning the gown, the only parts of the gown that are considered sterile are the sleeves and front from waist level to a few inches below the neck opening.  GLOVING The term defines placing of gloves on hands. It is actually done to avoid or to protect the patient from transmission of infection or to protect the patient from any kind of external contamination during a surgery. It’s the physician’s duty to be careful with any infection regarding the patient. 1. CLOSED METHOD Usually done without any assistance 2. OPEN METHOD Gloving done by non-sterile team members. FASTENING THE GOWN 1. The circulating nurse will fasten the gown behind you, positioning it over the GLOVING CLOSED METHOD shoulders by grasping the inside surface of the gown at the shoulder seam. The theatre Here in surgery, it’s the method of placing gloves in hands. assistant’s hands should only ever be in contact with the inside surface of the gown. The scrub person’s /surgeon’s hand remains inside the sleeves thus avoiding touching the 2. The circulating nurse then prepares to secure the gown at the neck and upper back. cuffs. Gowns differ in how they are secured, but most have either ties, buttons or Velcro tabs. It involves several steps: 1. First open the inner glove packet placed inside the sterile field Before you wear your gloves, you have to know what are the different parts of the gloves Opening - cuff Inside part of the gloves (unsterile) If you touch the right glove, it should be with your left hand. (vice-versa) GOWNING ANOTHER PERSON 1. Grasp the gown near the neckband using the thumb and index finger of each hand and 2. Pick up one glove using your roll the gown so that the outside surface is over (protecting) your gloved hands. folded cuff edge with your sleeve covered hand 2. The arm holes of the gown are facing the team member being gowned. What happens if you displace some 3. Offer the inside of the gown to the scrubbed team member and allow him to slip his fingers in different holes of the gloves? - arms into the gown sleeves. Continue gloving the 2nd glove 4. The scrub (fellow member) pulls the gown over the team member's shoulders. The circulator then secures the neck of the gown and ties the inside waist tie. 5. Now gently, pull the cuffs back over the person’s hands. Be careful that your gloved 3. Place the glove on the opposite hands do not touch his/her bare hands. gown sleeve. Please note that the glove is facing towards us. Place the glove’s rolled cuff edge at the palm which connects the sleeve to the gown cuff. Grab on to the bottom rolled cuff edge of the glove with the thumb and index finger.make sure to keep the glove on the top.  GLOVING OPEN METHOD Donning of gloves in OPEN METHOD ○ In the open-glove technique, the scrub person's hands slide all the way through 4. Hold on to one end of the cuff the sleeves out beyond the cuffs. with one hand and the other cuff with the opposite hand. 5. Grasp on to the glove firmly and stretch the cuff of the glove over the hand Grasp both the cuffs using the opposite sleeve covered hand. Make sure to pull any excessive glove sleeve underneath the cuff of the glove. 6. Continue the same steps for the other hand. Always make sure that gown cuff is secured and covered completely by the cuff of the glove. 7. By gentle wiggling adjust the fingers of each glove as needed, so that it fits properly. Pick up the cuff of the right glove with your left hand. Slide your right hand into the glove Points to ponder over: until you have a snug fit over Please take note that you do not touch any external things after gloving, to avoid the thumb joints and knuckles. contamination Your bare left hand should only Always keep your hands above your waist and in front of you. touch the folded cuff – the rest of the glove remains sterile. DOFFING/ REMOVAL OF GLOVES IN CLOSED METHOD 1. Place the left thumb under the cuff exposed on the right glove and stretch it over the right hand. Pull down the glove with your left hand by keeping your right fingers straight. 2. Make sure to keep the white cuff remains inside the glove. 3. Repeat the same for the opposite hand.  Doffing of gloves in OPEN METHOD Use the glove on the right hand, pick up the folded cuff of the left glove and pull the glove up to the gowned wrist. Place the fingers of the gloved right hand under the cuff of the partially gloved left hand. Unfold the cuff down over your gown sleeves. Make sure your gloved finger tips do not touch your bare forearms or wrists FINAL TIE INSTRUMENTATION Instruments are classified by their function: Cutting & Dissecting 1. Detach cardboard slip Grasping & Holding from short tie and pass to assistant Clamping & Occluding Exposing & Retracting Suturing & Stapling Viewing Suctioning Dilating & Probing Measuring 2. Turn whilst the assistant Micro-instruments holds the cardboard Powered instruments SURGICAL INSTRUMENT A surgical instrument is a tool or device for performing specific actions or carrying out desired effects during a surgery or operation, such as modifying biological tissue to provide access for viewing it. 3. Detach the tie from the TOOLS FOR CUTTING & DISSECTING cardboard and tie a knot Are sharp and are used to cut body tissue or surgical supplies. The purpose of a knife handle is to increase the knife's strength, so it holds up well during heavy usage. Cutting and Dissecting Instruments Removing Gown 1. Unfasten ties 2. Peel gown away from neck and shoulder 3. Turn contaminated outside toward the inside 4. Fold or roll into a bundle 5. Discard Other term for knife handle - scalpel Knife handle (left) Scissor (Right) Scalpel Holder Types of Blade Handle for Surgical Blade Hold scalpel blade Act as a handle Scalpel Holder with Blades Scalpel Holder (to hold blades) Fig. 1 Pencil Grip (Left) and FingerTip Grip (Right). Pencil Grip Fingertip Grip This position helps in allowing maximum Length of blade lies in contact with the skin control over penetration into the surface. It is hence used in making long incisions, usually used while making ports for laparoscopic on the skin. 7 handle with 15 blade (deep knife) Used to cut deep, delicate tissue. surgeries. 3 handle with 10 blade (inside knife) Used to cut superficial tissue. Types of Scalpel These are the different types of scalpel and the fifth one is lancet. 4 handle with 20 blade (skin knife) Used to cut skin A lancet is a pointed piece of surgical steel encased in plastic, used to puncture the skin on one's finger (or other body part) to get a blood sample. Scalpels may be single-use disposable or reusable. Disposable scalpels usually have a plastic Reusable scalpels can have permanently handle with an extensible blade (like a utility attached blades that can be sharpened or, knife) and are used once, then the entire more commonly, removable single-use blades. instrument is discarded. Types of Blades with their functions. Important things to remember: No. 10 is very common, it is used for incisions of the abdomen No. 11 is important to use in incision and drainage No. 12 is not very common No.15 is common, it is used in incisions of very delicate areas like in the face, you do not utilize a blade 10 or 20 No. 20 is also common, it's a bit bigger compared to no. 10 No. 21 is no much available, also 22, 23 there are some hospitals that are provided with such type of blades, used also in opening the abdomen (abdomen = 10,20) Scissors Differentiation General Purpose : Used for general cutting of sutures, gauze, and other materials. Used to cut delicate tissue. Metzenbaum Available in regular and long sizes. Comparison of mayo and metzenbaum, Scissors your mayo is bigger and stouter, the metzenbaum is thinner Used to remove scissors. Iris Suture Blades have hook or beak to slide Scissors under the suture. Straight Mayo Used to cut sutures and supplies. Scissors Also Known as suture Scissors. Used to cut and dissect tissue. Sharp/Sharp Both blade tips are sharp. Scissors Almost the same with your mayo scissors only it is very much pointed Used to cut heavy tissue (fascia, Curved Mayo muscle, uterus, breast). Scissors Available in regular and long sizes.  Grasping and holding Grasping and holding it means to seize and hold by or as if by clasping with the fingers or arms. Mechanism of grasping and holding A surgical grasping and holding forceps has a shaft, at least two mouthparts and a grip. Used to cut and dissect fascia and Sharp/Blunt A mechanism for opening and closing the mouth parts is in working engagement with the muscles. Scissors grip. One blunt tip and one sharp tip. The mechanism is acted upon by spring force in such a way that the mouth parts are pushed in a closing direction. Rigid linkage and engaging mouth parts are positively movable into a defined final closed position in which they exert a predefined holding force on an object received between them is provided. Instruments used to grasp & hold Tissue Forceps A tissue forcep is a two-bladed instrument with a handle, used for compressing or grasping tissues in surgical operations, handling sterile dressings, and other purposes. Tissue forceps are specifically used to pick up or hold soft tissue Curved Blunt/ and vessels. Both blade tips are blunt. Blunt Tissue forceps can be without teeth or with one or more small teeth Can be curved or straight. Scissors at the end of each blade, designed for handling tissues with minimal trauma during surgery. Also known as "pick-up' forceps. They are used to grasp tough tissue such as the fascia and breast tissue. These forceps resemble tweezers but tapered with serrations at the tips for delicate tissues. These are forceps with serrated blades and with or without teeth. ○ Tissue forceps are toothed or untoothed ○ Toothed forceps is tissue forceps ○ Pick-up forceps is a non-toothed forcep Used to remove bandages and Lister dressings. Bandage Probe tip is blunt; inserted under Scissors bandages with relative safety. Most common are: Mayo, Metzenbaum, Iris and suture scissors  CLAMPING & OCCLUDING Also called locking forceps, these are ratcheted instruments used to hold tissue or objects, or provide hemostasis. Satinsky Debakey Vascular Clamps are used for blocking Satinsky blood from blood vessels. clamps This clamp holds the desired section, and blood continues to flow through the unclamped side Hemostatic forceps - sometimes are called clamps, they can be of different sizes, you have the Traumatic toothed clamp used to Kocher clamp mosquito, the median size and t