Surgery

1. Surgery Sterilization, Aseptic Technique, Surgical Instruments, Wound Healing, Basic Suture Patterns

2. Objective is to control microorganisms (pathogens) to protect the patient • Can be found in the environment, fomites, each person, and the patient • Sterilization is the elimination of all life from an object (complete microbial control) • Important in surgical environment • Sanitizing and disinfecting often create acceptable levels of control Sterilize, Disinfect, Sanitize, Clean

3. Antiseptic-chemical agent that kills or prevents the growth of microorganisms on living tissue • Disinfectant- chemical agent that kills or prevents growth of microorganisms on inanimate objects • Sanitize -to make something free from dirt, infection, disease (pathogens) by cleaning, disinfecting, or sterilizing. • Clean- removal of dirt, and other unclean material Definitions

4. HIGH LOW Controlling microbes

5. Physical Methods • Chemical Methods Methods of microbial control

6. Physical • Dry Heat (oxidation) • Incineration-red hot/ fire • Hot Air Ovens- 1 hour exposure to high heat (340) • Moist Heat (denatures proteins) • Hot water – incomplete • Why do we add detergents –emulsifies oils and suspends soils…water is the universal solvent • Boiling – 3 hours for complete • Steam (90 min) • Steam under pressure (autoclave) Methods of microbial control

7. Autoclaves

8. Increase in pressure=increase in steam temperature=less time needed to sterilizeminimum 15 psi = steam at 121 degrees C (15 min)can get up to 35 psi = steam at 135 degrees C (1 min) • Steam and temperature indicators • Did the steam reach everything in the autoclave • Did the temperature reach target temperature (changes color) autoclaving

9. 3. Radiation (damages cell/ dna) • Ultraviolet-close range/ no penetration • Gamma radiation 4. Filtration (physically traps organisms) • Fluid filtration • Pore size of 0.45 microns removes most bacteria • 0.01 – 0.1 micron for viruses • Air filtration • Surgical masks, air duct filters, HEPA (high efficiency particle absorption) filters 5. Ultrasonic vibration-(disrupts cell walls/coagulates proteins) Useful for cleaning surgical instruments prior to sterilization in autoclave • Cleaning –physical removal of organic and inorganic soils and microbes Methods of microbial control

10. List 5 physical methods of microbial control: • What is autoclaving? • Which physical method is it? • Minimum effective pressure is _____psi? • How long to achieve sterilization at this pressure? Bell Work Monday April 21

11. Chemicals work by penetrating the organism cell walls and reacting with parts of the cell to destroy or inhibit growth. • Many chemicals are disinfectants with varying levels of activity; a few achieve sterilization • Remember Antiseptics are used on tissues and disinfectants are used on inanimate objects Chemical Methods of Microbial Control

12. Contact Time - The length of time an object is required to be exposed to a sanitizing or disinfecting agent before wiping or rinsing to ensure the effectiveness of the products’ kill claims. • The length of time a substance or article is held in direct contact with a treating agent • Contact time for sanitizing is generally 2 minutes. (Check the Product label for contact times) • Contact time is 10 minutes for disinfecting. Chemical Methods: Contact Time

13. 1. Soaps and Detergents Soaps in general have minimal disinfecting ability Soaps can be used for cleaning Detergents emulsify oils and suspend particles Detergents have some disinfecting ability Chemical Methods

14. Chlorines Chlorine gas, chlorine dioxide, Sodium hypochlorite (household bleach) Disinfectant: most bacteria, viruses, protozoa, fungi disinfect water, inanimate objects…irritating to skin Chemical Methods

15. Alcohols ethyl alcohol= 75% ethyl isopropyl alcohol = 70% isopropyl most effective because of dilution with ethyl, isopropyl Useful as a skin disinfectant (antiseptic) Irritating to tissues Rapid antiseptic Used as a solvent for other disinfectants and antiseptics (solvent: the liquid in which a solute is dissolved to form a solution) Ineffective after evaporation (which is pretty quick) porous surfaces such as furniture disinfectant Both disinfectant and antiseptic Chemical Methods

16. Peroxygen compounds paracetic acid, hydrogen peroxide , benzyl peroxide oxidizing agents active against bacteria, fungi considered a sterilant, although there are some things it does not kill bubbling action releases oxygen…helps to remove pus and cellular debris benzyl peroxide-can be used on skin, as a shampoo, for pyoderma, keratyltic, antiseborrheic (flaky, itchy skin conditions) Chemical Methods

17. Halogens iodine iodine is used in solution with water or alcohol alcohol enhances antibacterial activity of iodine kills bacteria, viruses, fungi, not spores The darker the color, the greater the activity iodophors iodine plus detergent used as surgical scrub-non staining/ non irritating Betadine, Povidone-Iodine Antiseptic Chemical Methods

18. Biguanides -Chlorhexadine gluconate -Has bacteriostatic and bacteriocidal properties, some viruses, fungi -Useful as a disinfectant and antiseptic surgical scrub of animal, wounds, skin, mouth, and surfaces Nosocomial infections by Pseudomonas spp have developed from the use of contaminated chlorhexidine solutions in which the bacteria persisted Chemical Methods

19. Quaternary ammonium compounds (Quats) benzalkonium chlorides, centrimide, roccal -disinfectant -check formulations –bacteria/ some bacteria, some viruses, some fungi -roccal-parvovirus -inactivated by organic material, soap, hard water Chemical Methods

20. Phenols carbolic acid (C6 H5 O H), coal tar, lysol synthetic phenols are nonirritating/ non toxic Disinfectant…but in some formulations antiseptic check labels: may be toxic particularly to cats, also rabbits and rodents Not generally used as antiseptic, but sometimes combined Pine tar is a viscid blackish brown liquid, used primarily for antiseptic bandaging of wounds of the hoof and horn. Pine tar contains phenol derivatives that provide antimicrobial properties activity decreased by quats not inactivated by organic matter, soap, or hard water bacteria, some viruses, some fungi Chemical Methods

21. Aldehydes formaldehyde, gluteraldehyde active against bacteria, most viruses, fugi, bacterial spores considered to be a sterilant, but may require 12 hours contact time formaldehyde-can be diluted with alcohol toxix/ irritant to tissue, repiratory tract “Cold Sterilization” gluteraldehyde with 70 % alcohol is a potent germicide-useful for instruments, particularly endotracheal tubes, laryngoscopes, endoscopy equipment, rubber, plastics Chemical Methods

22. Ethylene Oxide (EO) colorless, oderless gas, rapid penetration flammable, explosive, toxic, carcinogenic, and irritant useful against bacteria, viruses, fungi, bacterial spores specialized procedure-similar to autoclaving, but more specialized due to precautions Chemical Methods

23. High –cidal activity Low –cidal activity Which kill better?

24. Why do we need to know how chemicals are grouped and their properties? • Antiseptics with antifungal activity • Phenols, Chlorhexidine, Iodine, Povidone Iodine, Sodium Hypochlorite (bleach), Cetrimide (quat) • Antiseptics with antiviral activity • Isopropanol alcohol, ethyl alcohol, formaldehyde, sodium hypochlorite (bleach), phenols, H2O2 (hydrogen peroxide), iodophors (betadine) Preferred Antiseptics

25. GENERAL GUIDELINES FOR CLEANING/ DISINFECTING For cleaning and disinfecting the following hard non-porous surfaces: including equipment, utensils, instruments, cages, kennels, stables, stalls and catteries. (Non- porous surfaces means they are solid and do not absorb any fluid…surface is non- penetrable.) • Remove all animals and feeds from premises, animal transportation vehicles, crates etc. • Remove all litter, droppings and manure from floors, walls and surfaces of facilities occupied or transversed by animals. • Thoroughly clean all surfaces with soap or detergent and rinse with water. • Saturate surfaces with an appropriate disinfectant for a period of 10 minutes. • Ventilate buildings and other closed spaces. • Do not house animals or employ equipment until treatment has been absorbed, set or dried. • Thoroughly scrub all treated feed racks, automatic feeders, waterers and other equipment which dispenses food or water with soap or detergent, and rinse with potable water before reuse. Cleaning and Disinfecting of animal facilities

26. Disinfecting • Detergents for clothing, blankets, gowns (soak in water prior) • Sodium Hypochlorite for clothing, gowns, blankets, floors, blood spills, other objects and surfaces • Quats and Phenols for floors, some surfaces (such as Roccal for kennels) • ChlorhexadineGluconate formulated for surfaces, instruments, kennels • Glutaraldehyde for instruments, laryngoscopes, endotracheal tubes, endoscope (germicidal/sterilant) • Surgical instruments: immersed, rinsed, ultrasonic vibration, autoclaved---achieves sterility Antiseptics and Disinfectants for hospital use (including veterinary)

27. Antiseptics • Hydrogen peroxide- removal of blood clots from tubes, dressing/ cleaning wounds • After a wound is cleaned, debrided, sutured up, use of hydrogen peroxide can be detrimental because can cause destruction of healthy cells, also carries contaminants from outside sterile field • Ethyl alcohol (isopropanol alcohol)- can use at injection sites, has many advantages including rapid onset of action, synergistic with chlorehexidine, remember-irritant of tissues • Furniture disinfection (furniture is a porous surface) Antiseptics and Disinfectants for hospital use (including veterinary)

28. Antiseptics • Povidone Iodine for surgical scrub of patient, handwash/ presurgical hand scrub, dressings (wounds) • Chlorhexadinegluconate formulated as surgical scrub (synegistic with alcohol), can use in mouth (dilute), wounds • Has residual activity, low toxicity Antiseptics and Disinfectants for hospital use (including veterinary)

29. Some things to note: • Contamination of chemical agents can occur: For example Nosocomial infections by Pseudomonas spp have developed from the use of contaminated chlorhexidine solutions in which the bacteria persisted • Always pay attention to proper concentrations- more is not better! • Physically remove organic matter as part of first step before moving on to disinfecting/ antiseptic use • Use the proper chemical for the situation

30. Here is a label from a quaternary ammonium compound. Interpret the label as best as you can: Broad spectrum, hospital grade disinfectant cleaner and deodorizer. Bactericide, virucide and fungicide. Effective at 1 oz. per gallon of water against antibiotic resistant bacteria, HBV, HBC, Avian Influenza, HIV and many others. Effective in the presence of high organic soil and 400 ppm hard water. Bell Work Wednesday April 23

31. Definition: Aseptic technique is a procedure used by medical staff to prevent the spread of infection. The goal is to reach asepsis, which means an environment that is free of harmful microorganisms. Each healthcare setting has its own set of practices for achieving asepsis. In veterinary medicine is most used for surgery of patients ASEPTIC TECHNIQUE

32. Major procedures require a dedicated surgery room similar to what is used for human patients. • MAJOR SURGERY: Major surgery (e.g., laparotomy, thoracotomy, joint replacement, and limb amputation) penetrates and exposes a body cavity, produces substantial impairment of physical or physiologic functions, or involves extensive tissue dissection or transaction. Aseptic Technique: Where

33. Many minor procedures use aseptic technique in a clean environment, such as the treatment room MINOR SURGERY: Minor surgery does not expose a body cavity and causes little or no physical impairment; this category includes wound suturing, and most procedures routinely done on an “outpatient” basis in veterinary clinical practice. Aseptic Technique: Where

34. Initial procedures: • preparation of surgical team, operating room, instruments, patient • During surgical procedures: • Contact of a sterile surface with other surfaces avoided. • Contamination prevention procedures: 1. Cleansing and disinfection of operating room 2. Preparation of incision site and draping the animal 3. Aseptic preparation of the surgical team 4. Sterilization of surgical instruments and materials • Prevention also includes responsibility of surgeon. • gentle handling of tissue and proper suturing technique • Like a chain, aseptic technique is only as strong as its weakest link… Aseptic Technique:

35. What is the definition of aseptic technique? Aseptic technique is a procedure used by medical staff to prevent the spread of infection. The goal is to reach asepsis, which means an environment that is free of harmful microorganisms. • What are some things that contribute to aseptic technique preparation of surgical team, operating room, instruments, patient, surgeon’s handling of tissues/ suturing surgical site closed Bell Work Thursday April 24

36. Preparing the patient • Where the incision will be • Clipping the area • How to scrub • Keeping the area around the animal sterile by draping The patient

37. Some common incisions • Ventral midline incision • Most abdominal surgeries • Paramedian –near midline (sagittal plane) • Paracostal incision • Near the ribs for kidney or liver surgeries • 4. Flank Incision Incisions

38. Sternum • Manubrium cranially • Xiphoid caudally • Umbilicus • Midpoint of pubic bone (pubic symphysis) • Rib arch (costal arch) Identify useful landmarksprior to clipping fur for surgery

39. Clip away hair With #10 blade Get rid of loose hairs Preparation of the patient

40. Ask the surgeon • Varies, 1 inch to 4 inches around expected incision (on all sides) • Keep it neat (for the owner) How do you know how much fur to clip?

41. Surgical scrub of patient

42. Wet fur along borders so fur lays flat before beginning • Most common antiseptics are chlorhexadine scrub, povidone iodine, betadine, alcohol • Sterile water or alcohol commonly used as rinse • To begin scrub, start with where the incision will be and continue in a spiral or circular pattern outward until you reach the end of the clipped area. The scrub is generally followed by either a rinse or use of a soaked sponge (gauze squares) of sterile water or alcohol to get rid of detergent. Surgical Scrub of patient

43. Recommended scrub solutions are chlorhexidine or povidone-iodine • Scrubs have detergent in them (must be rinsed off) and solutions have alcohol or sterile water • Your first preps would be with scrub and final would be with solution • Detergents help clean skin (dirt and soils) • Solutions have no detergent, correct concentration of chemical • Chlorhexadine has residual effect • Chlorhexidine-alcohol mixtures are particularly effective in that they combine the antiseptic rapidity of alcohol with the persistence of chlorhexidine.   • Povidone Iodine needs prolonged contact, so you usually don’t rinse off Surgical Scrub of patient

44. Start with incision site and work away from site in circles. • Discard the gauze when you reach the end (the periphery) • There is no one correct method • May use alcohol between detergent scrub and non-detergent solution • Each clinic will have its own protocol/ it’s own procedure

45. The scrub process is repeated. Patients are usually scrubbed three to five times. Why the repetition…contact time! Some surgeons like the area to be dried after the final scrub and rinse. Accomplished with sterile dry gauze. A final “paint” of betadine is often applied with spray or same process of scrub. Surgical scrub of patient

46. Clip • Generally clip both sides of ear flap (pinna) • If ear canal surgery clip side of face also • Antiseptics - ask surgeon • Usual skin prep on ear flaps but may need to plug the ear canals • Use of antiseptics in ear canal may depend on whether ear drum (tympanic membrane) is open or not Ear prep

47. Difficult to achieve asepsis in pads and under nails • Clip nails • Consider soaking whole foot in antiseptic for several minutes • Hold foot by placing a towel clamp into a long toenail Paw Pads/ foot prep

48. Apply Sterile Lubricant (e.g. K-Y) into wound and onto surrounding hair • it will wipe & rinse out well • Clip an outside ring first • Then clip towards the wound • Finally clip wound margins last • Rinse wound with sterile saline Wound prep

49. Clip hair around eye-check with surgeon how much area to clip • Rinse eye with betadine solution due to sensitive membranes • Final surgical skin prep around eye with betadine solution Eye prep

50. Preparation of the incision site and draping the animal. Preparation of the incision site and draping the animal