Chapter 7 Surgical Tech
Mutualism
Both organisms benefit from and depend on one another to a certain extent.
Examples of Mutualism
Synergism: Subcategory of mutualism
Commensalism
One organism benefits but second organism neither benefits nor is harmed.
Examples of Commensalism
Indigenous microflora on the skin of humans obtain nutrients, but do not affect the skin or human body. To a certain extent they benefit humans by occupying space and preventing other potentially harmful microbes from colonizing, a process referred to as competitive exclusion.
Neutralism: Subcategory of commensalism
Two organisms occupy the same area with no effect on each other.
Antagonism: Second subcategory of commensalism
Parasitism
One organism benefits and the host is harmed. Commensal microbes that become opportunistic by entering through a surgical skin incision. Nosocomial infections (infections acquired in a hospital) such as urinary tract infections. Airborne viruses, such as the virus that causes the common cold.
Examples of Parasitism
Endoparasites, such as intestinal worms, cause an infection and deplete the body of nutrition.
Symbiosis
. The relationship between human hosts and indigenous flora
refers to both organisms. The relationship may be harmless, harmful, or beneficial to one or both
CDC study on nosocomial infections
compiled recent data estimating that HAIs accounted for 1.7 million infections and 99,000 associated deaths per year. Of these:
Bacteria
prokaryotes
are less complex organisms whose organelles are not membrane bound like those of the eukaryotes. All bacteria are this. Bacteria divide by the process of binary fission, which is a simple division that results in two identical cells.
Bacteria
cellular structure is complex, and this classification includes protozoa; fungi; green, brown and red algae; and all plant and animal cells.
Morphology: size, shape, and arrangements of bacteria
Coccoid:
round-shaped bacteria (coccus, singular form; cocci, plural form)
Morphology: size, shape, and arrangements of bacteria
Diplococci:
paired bacteria
Morphology: size, shape, and arrangements of bacteria
Streptococci
chain of bacteria
Morphology: size, shape, and arrangements of bacteria
Staphylococci:
cluster of bacteria
Morphology: size, shape, and arrangements of bacteria
Bacillus
rod-shaped bacteria (bacillus, singular form; bacilli, plural)
Morphology: size, shape, and arrangements of bacteria
Spirilla
spiral-shaped bacteria
Motility: ability of a microbe to move by itself
long thin structure attached to the outside of the cell; uses whipping motion to provide motility to the cell
Motility: ability of a microbe to move by itself
Cilia
fine, short, hairlike extensions located on the surface of the cell; their coordinated, rhythmic movement allows the cell to move
Oxygen requirements: bacterial species classified according to oxygen and carbon dioxide needs
Gram Stain
cells are stained with crystal violet; washed with ethanol that removes purple stain from bacteria that don’t retain the stain; red dye safranin is applied; specimen is rinsed with water. Gram-positive bacteria retain the crystal violet and therefore are a purple color; gram-negative bacteria do not retain the crystal violet and are red from the safranin stain. Gram-variable bacteria, such as Mycobacterium tuberculosis, do not consistently stain red or purple.
Spore forming (sporulation): bacterial species capable of forming spores* Clostridium
Staphylococcus
most common in the o.r
Types of Staphylococcus
S. aureus
Toxic shock syndrome
Osteomyelitis
Endocarditis
Postoperative SSI
Types of Staphylococcus
S. epidermis
IV catheter infections
UTIs
Prosthetic device infections
Subacute bacterial infections
Endocarditis
S. pyogenes
Rheumatic fever: If you have had this you will be put on an antibiotic before surgery
Necrotizing fasciitis: Flesh eating disease
Aerobic Gram-Negative Cocci, Coccobacilli
Neisseria gonorrhoeae
Pelvic inflammatory disease leading to salpingitis
Aerobic Gram-Negative Cocci, Coccobacilli
Moraxella catarrhalis
Otitis media in children
Aerobic, Microaerophile Gram-Negative Bacilli, Spirochetes
Pseudomonas
Deep-tissue health care-associated
Aerobic, Microaerophile Gram-Negative Bacilli, Spirochetes
Helicobacter pylori
Chronic gastritis
Stomach ulcers
Peptic ulcers
Vanomycin
VRE
Family of penicillin
used so much people have become resistant to it
Facultative Anaerobic Gram-Negative Bacilli
influenzae
Respiratory tract infections
Bacterial pneumonia (elderly)
Otitis media
Eye infections
Septic arthritis
Cellulitis
Facultative Anaerobic Gram-Negative Bacilli
Klebsiella pneumoniae
Health care–associated UTIs
Wound and burn infections
Ankylosing spondylitis (sequelae of a Klebsiella infection)
Anaerobic Gram-Positive Bacteria
Clostridium
Gas gangrene infection
Mycobacteria
Mycobacterium tuberculosis
Tuberculosis
Mycobacteria
Chlamydia
Tuberculosis
caused by Mycobacterium tuberculosis and transmitted through airborne droplet nuclei, usually infects the lungs but may also infect the kidneys, bone, joints, or skin. Surgical procedures performed on known TB carriers require implementing isolation precautions, including the wearing of gloves, protective eyewear, gown, and National Institute of Occupational Safety and Health (NIOSH)–approved respirators.
Viruses
are nonliving particles that are completely reliant on the host cell for survival.
contain either DNA or RNA and a protein coat that encases the nucleic acid.
Viral Pathogens Common to the OR
Hepatitis B (HBV)
Transmission:Percutaneous or permucous in blood, serum, and other body fluids
Description:Causes inflammation of the liver, jaundice, cirrhosis, and, in some cases, liver cancer
Viral Pathogens Common to the OR
Hepatitis C
Transmission: Blood-borne RNA; transmitted through blood and blood products
Description: Asymptomatic when acute; may be carried for 25 years; causes chronic hepatitis, cirrhosis, liver cancer
Viral Pathogens Common to the OR
Human immunodeficiency virus (HIV)
Transmission: Blood or other body fluids
Description: Compromises immune system
Viral Pathogens Common to the OR
Herpes simplex virus (HSV)
Transmission: Contact with fluid from lesions
Description: Causes localized blisterlike eruptions; can also cause keratoconjunctivitis, acute retinal necrosis, meningoencephalitis
Viral Pathogens Common to the OR
Papillomavirus
Transmission: Direct contact with another person
Description: Warts
Viral Pathogens Common to the OR
Cytomegalovirus (CMV)
Transmission: Direct contact with body fluids
Description: Infects salivary glands or viscera; opportunistic infection in patients with HIV or hepatitis
Viral Pathogens Common to the OR
Creutzfeldt-Jakob Disease (CJD)
Transmission: Exact mode of transmission unknown; thought to be by percutaneous inoculation with brain tissue or cerebral spinal fluid from infected persons; transmission has been associated with use of contaminated instruments; longer sterilization times required.
Description: Rapidly progressive fatal central nervous disease characterized by dementia, myoclonus
Prions
is short for “proteinaceous infectious particle.” , built of proteins and do not contain DNA or RNA. attack the brain, which is why the diseases they cause are called subacute spongiform encephalopathies
two common forms of prions
scrapie (a disease that infects sheep and goats) and bovine spongiform encephalopathy (commonly called mad cow disease).
Sample Guidelines for Suspected or Known CJD Patients
Preoperative Preparation
Sample Guidelines for Suspected or Known CJD Patients
Intraoperative Case Management
Sample Guidelines for Suspected or Known CJD Patients
Postoperative Case Management
Sample Guidelines for Suspected or Known CJD Patients
Environmental Cleaning
Parasites
two categories : unicellular protozoans and multicellular protozoans.
Parasites
Helminths
are popularly known as worms. Those that are most common in the human population are tapeworms, flukes, and roundworms.
The chances of a surgical technologist encountering a this type of infection have increased due to the mobility of the world population and immigration from Third World countries. Worms can damage body tissues and organs to the point that they require surgery.
Cysticeri
(Taenia solium)
are pork tapeworms that can migrate out of the intestinal tract and travel to muscle and brain tissue, and the eyes. can cause palpable lumps in soft tissues, blurred vision and retinal detachment, and when located in the brain tissue cause seizures, ataxia, headaches, and possibly death.
Fungi
Mycology is the study of this
are eukaryotic organisms that are either unicellular yeasts or multicellular molds and mushrooms. reproduce either sexually or asexually by producing spores; a true spore is formed by either asexual cleavage or sexual meiosis. diseases are called mycoses (the plural of mycosis).
Common Fungal Infections
Candida albicans
Vaginal yeast infection Trench mouth (thrush) Immunocompromised patients prone to serious infections of the brain, meninges, and heart valves Patients intubated or who have indwelling venous catheter or other type long-term indwelling catheter should be monitored for infection
Common Fungal Infections
Pneumocystis jiroveci
Pneumocystis pneumonia
zygomycosis,
caused by a common bread mold
If the organism enters the bloodstream and destroys the cranial bones, the brain tissue will be invaded.
Precautions (Modes of Transmission)
are separate guidelines for infection control and prevention of cross-contamination of patients when the disease process has been diagnosed
disposable cover gowns and unsterile gloves should be worn by transporters of patients with known contact-transmissible diseases.
Personnel (Methods of Transmission)
The skin, hair, and nares of surgical personnel are reservoirs of bacteria, which may be discharged in particle form into the air and therefore pose a risk of SSI to the patient.
Gowns and drapes cover the skin on areas of the body other than the hands.
Basic Hand washing
Environmental (Methods of Transmission)
Fomites are inanimate objects that may contain infectious microorganisms including walls, floors, cabinets, furniture and equipment.
The Patient (Methods of Transmission)
The two primary sources of SSI risk to the patient are the endogenous flora encountered in contaminated procedures and the resident flora of the skin.
Factors That increase the risk of surgical site infections
Procedure-related risk factors that increase the danger of SSI include:
colonization
The growth and collection of microbes into a group that lives in a particular area
Asepsis
Absence of Microorganisms
Bacteriocidal
Substance that destroys/kills bacteria
Bacteriostatic
Substance that inhibits the growth and reproduction of bacteria
Bioburden
The number of microbes or amount of organic debris on an object at any given time
Contamination
The presence of pathogenic materials
Cross-contamination
The contamination of a person or object by another
Decontamination
To reduce to an irreducible minimum the presence of pathogenic material
Event-related sterility
Sterility determined by how a package is handled rather than time elapsed; a package is considered sterile until opened or the integrity of packaging material is damaged
Fomite
Inanimate object that harbors microorganisms
Fungicide
Agent that destroys fungus
Infection
Invasion of the human body or tissue by pathogenic microorganisms that reproduce and multiply, causing disease
Nosocomial
Infection acquired within a health care facility
Pathogen
Any microbe capable of causing disease
Resident flora
Microbes that normally reside below the skin surface or within the body
Sepsis
Infection, usually accompanied by fever, that results from the presence of pathogenic microorganisms
Spore
A resistant form of certain types of bacteria that are able to survive in adverse conditions
Sporicide
Substance that kills/destroys bacteria in the spore stage
Sterile
Having been rendered free of all living microorganisms, including spores
Sterile technique
Techniques of creating a sterile field and performing within the sterile field to keep microbes at an irreducible minimum
Sterile field
Specified area, usually the area immediately around the patient, that is considered free of microorganisms
Strike-through contamination
Contamination of a sterile field that occurs through the passage of fluid through, or a puncture in, a microbial barrier
Surgically clean
Mechanically cleaned and chemically disinfected but not sterile
Terminal disinfection
To render items safe to handle by high-level disinfection
Terminal sterilization
To render items safe to handle by sterilization
Transient flora
Microbes that reside on the skin surface and are easily removed
Vector
Living carrier that transmits disease
Virucide
Agent that destroys viruses
Antisepsis
is a process in which most but not all microorganisms located on animate surfaces, such as the skin, are destroyed.
Antiseptic:
name used to describe the solutions that are used by the sterile surgical team members to perform the surgical scrub and are used on the patient for skin preparation of the surgical site.
Classification of Patient Care Items
Critical
Items that will be used for invasive procedures or vascular access and carry a high potential for causing SSIs include: surgical instruments, devices that enter the vascular or urinary systems (needles, catheters), implantable items (wires, screws, joint replacements, mesh, sutures), and any monitors or probes that enter deep tissue layers or cavities. These items should be sterilized.
Classification of Patient Care Items
SEMI-CRITICAL
Items that come into contact with mucous membranes or non-intact skin carry a lesser risk of infection due to the properties of resistance of intact mucosal linings to many commonly encountered bacterial spores. Examples include: laryngoscopes, anesthesia and respiratory equipment, and some endoscopes. High-level disinfection should be used for items in this category.
Classification of Patient Care Items
NON-CRITICAL:
Items that come into contact with a patient’s intact skin and clean environmental equipment items pose the least risk of infection. Examples include blood pressure cuffs, pulse oximeters, OR transport stretchers, and other furniture. These items require either intermediate-level or low-level disinfection.
Disinfection Principles and Disinfecting Agents
Cleaning
The physical removal of blood, body fluids, and/or gross debris (bioburdenbioburdenAmount of gross organic debris or the number of microorganisms on an object at any given time bioburden Amount of gross organic debris or the number of microorganisms on an object at any given time ) from an inanimate object.
Disinfection Principles and Disinfecting Agents
Disinfection
Destruction of pathogenic microorganisms or their toxins or vectors by direct exposure to chemical or physical agents. Disinfection is discussed on three levels.
Disinfection Principles and Disinfecting Agents
High-level disinfection
Kills all microorganisms except spores and prions (CJD).
Disinfection Principles and Disinfecting Agents
Intermediate-level disinfection Intermediate-level disinfection Level of disinfection in which most microorganisms are killed except spores
Kills most microorganisms, including bacteria, most viruses and fungi. M. tuberculosis and HBV; ineffective against spores.
Disinfection Principles and Disinfecting Agents
Low-level disinfection
Kills some fungi and viruses, and most bacteria, but is not effective against spores and M tuberculosis.
Disinfection Principles and Disinfecting Agents
Sterilization
Destruction of all microorganisms in or about an object with steam (flowing or pressurized), chemical agents (alcohol, phenol, heavy metals, or ethyl-ene oxide gas), high-velocity electron bombardment, or ultraviolet radiation.
Glutaraldehyde
is a high-level disinfectant. Its common commercial name is Cidex.
is used for devices that can withstand complete immersionimmersion Placing an item in a container so it is completely covered by a liquid, such as immersing a surgical instrument in glutaraldehyde in liquid. The liquid must contact all surface areas of the item, including lumens.
Sodium Hypochlorite
household bleach) is an effective disinfectant for surfaces, floors, and equipment. is such an effective and fast-acting solution, and the CDC recommends its use in cleaning blood and body fluid spills.
Phenol (Carbolic Acid)
is usually used as a concentrate with detergent additives and is diluted with tap water. is used to disinfect large areas such as floors and countertops and is used on a general basis as a health care facility cleaning agent.
Quaternary Ammonium Compounds
commonly called quats, are bactericidal, fungicidal, and pseudomonacidal. They are not sporicidal, vi-rucidal, or tuberculocidal. Common compounds include ben-zalkonium chloride and dimethyl benzyl ammonium chloride; however, newer and more effective compounds are available, such as dialkyl quats. Some facilities consider quats low-level disinfectants because of their inability to kill TB, spores, or viruses and their vulnerability to inactivation.
Alcohol
Isopropyl and ethyl alcohol
dilution of 60-70% alcohol concentration are tuberculocidal, bactericidal, virucidal, and fungi-cidal; they are not sporicidal. most useful in cleaning and disinfecting small noncritical surfaces. Recent studies show that these solutions may be as effective or more effective than other compounds for use in skin disinfection for surgical scrub and patient skin prep. Further studies are warranted.
Guidelines for house keeping laundry and regulated waste procedures
Cleaning Actions
Decontamination Practices in the or
The surgical technologist, along with environmental services personnel, may be involved in the “turnover” of the room, which marks the preparation for the next procedure.
More Decontamination practices
Terminal Cleaning
Each health care facility designs its own end-of-day or “terminal cleaning” routine
Weekly Cleaning
Dirty Cases
the floor should be cleaned with a phenolic detergent and all equipment and furniture should be wiped down with 70% alcohol solution. Rubber and plastic tubing in the room should be replaced and if gross contamination of walls and ceilings has occurred, these should be wiped down with a disinfectant solution as well
Usually last in the room
Surgical Instrument Decontamination Process
any critical patient item or instrument that will be used on open tissue or be placed in the sterile field must be sterilized to remove all microbes, including spores.
Design of the decontamination area
Cleaning
The first step in the decontamination process begins at the point of use.
The solutions that may be used to soak insturments
2.Enzymatic solution
3.Detergent solutions
Advantages and Limitations of Presoaking Solutions
Sterile water
Advantages: Keeps organic debris moist
Limitations: Ineffective in softening or removing dried debris
Advantages and Limitations of Presoaking Solutions
ENZYME
Advantages: Removes moistened and dried debris without the need for mechanical action
Limitations:Efficiency depends on concentration of solution, temperature, and contact time
Advantages and Limitations of Presoaking Solutions
Detergent
Advantages:Keeps organic debris moist while loosening dried-on debris
Limitations: Mechanical action is necessary to completely remove soil
Common Chemical Cleaners
Enzymatic
Organic substance that aids in the chemical reaction of breaking down organic debris. As previously stated, enzymes are specific to the type of debris to be removed. Enzymes are usually used as a soaking solution. They require dilution and are more effective in warm water than cold because the temperature of the warm water increases the speed of the chemical reaction.
Common Chemical Cleaners
Ultrasonic
Cleaning solutions are manufactured specifically for use in ultrasonic cleaners. The solution may contain a surfactant (to enhance wetting ability) and chelating agents.
Common Chemical Cleaners
Manual Detergent
Products usually used for hand cleaning of items and/or for presoaking. Some of the manual cleaners are high foaming and therefore should not be used in mechanical cleaning equipment. They must be diluted for use but are safe to use on most materials, including stainless steel. Mechanical action is required to assist in removing the soil. Surgical instruments must be thoroughly rinsed after being placed in the detergent.
Common Chemical Cleaners
Washer Decontaminator
Liquid solution that is available in three different pH levels. Neutral-pH product: Least corrosive to surgical instruments but less effective at removing substantial amount of organic soil.
Washer Decontaminator
Moderate-pH product
Low-level alkaline; may be combined with surfactants and chelating agents. Safe for use on stainless steel instruments but could be harmful to the chromium oxide layer that protects the instruments from corrosion.
Washer Decontaminator
HIGH-PH Product
Most effective for removing heavy amounts of soil. Can be corrosive to stainless steel. If used, it must be neutralized by a neutralizing rinse to prevent damage to the instruments.
Different Cleaning Solutions
Step one of the cleaning process (manual)
Instruments are immersed in a solution of lukewarm water, detergent, and/or enzymatic cleaner with a neutral pH. Hot water should not be used to initially rinse instruments to avoid blood and tissue from being set with heat on the metal surface. The manufacturer’s instructions must be followed for correct dilution, temperature, and use of detergent solutions. The enzymatic cleaner aids in the removal of bioburden. Each instrument must be individually cleaned with a soft-bristled brush using friction to loosen the organic debris. The foundation of manual cleaning is friction. Friction will loosen the organic material to allow its removal during the rinsing process. When cleaning stainless steel instruments, a back-and-forth motion should be used to follow the grain of the instrument. Do not use a circular motion, which can scratch the surface of the item. The instrument and brush must be kept submerged in the solution during cleaning to prevent contaminated water droplets from aerosolizing. Particular attention must be directed toward serrations on jaws, ratchets, box locks, and teeth of instruments. Instruments with lumens may be cleaned with a tube brush, pipe cleaner, or handheld water pressure gun. The cleaning solution should be changed frequently to avoid buildup of microbes and soil.
Step 2 of the cleaing process (manual)
The last step is to rinse the instruments in distilled water. Do not use tap water because it may contain minerals that can stain and form a film on the instruments when the tap water evaporates.
Step 3 of the cleaning process (manual)
To avoid spotting the instruments, the items should be immediately dried after rinsing.
recommendation should be followed when decontamination
Washer Decontamination Cycles
1.Prerinse cycle: Some models allow the use of an enzymatic solution in this phase.
2.Cleaning cycle: Detergent solution is used in this cycle.
3. Final rinse: Hot water is used during this rinse. The water temperature is maintained at 180°–195°F
4.Drying phase: High temperature is used to dry the instruments.
Washer Sterilizer cycles
1.Prerinse: A continuous cool or tepid water spray rinse aids in removing organic and soil matter such as blood and tissue.
2.Automatic detergent injection: The machine injects a measured amount of detergent into the chamber.
3.Fill phase: The chamber is filled with water for total instrument immersion and cleaning.
4.Wash phase: Water is agitated inside the chamber for soil removal; the machine controls water temperature.
5.Postrinse: Loose soil and detergent film are rinsed off items.
6.Sterilization phase: Steam sterilization cycle-this is usually a gravity cycle.
7.Lubrication (milking)
8.Drying phase
Ultrasonic Cleaners
A machine used to remove minute organic particles and soil from the areas of instrumentation hardest to reach by manual or other mechanical methods of cleaning; the washer utilizes the process of cavitation for cleaning instruments
How the Ultrasonic Cleaners Work
Powered Insturments
must never be submerged in cleaning solution or placed in any type of mechanical decontaminating equipment.
What happens in the clean room
Instruments must be checked for function and integrity and prepared for sterilization
What does Impervious to moisture mean
Waterproof
Two Types of Peel Pack
Rigid Instrument Containers
How Heavy should instrument sets be
no more than 25lbs
What should be followed for proper inspection of powered instruments
The manufacturer’s instructions An instrument may need to be lubricated and operated for a designated amount of time to ensure lubricant distribution. The power hose should be checked for cracks and cuts. The power hose should be coiled loosely to prevent kinking and damage.
What will proper preparation ensure?
What should instruments be placed in?
in a mesh-bottom or wire mesh basket with an absorbent towel lining the bottom.
Instruments with lumens should be prepared like?
require special preparation. Air trapped in the lumen may prevent steam from contacting the inner surface. To prevent this entrapment of air, a residual amount of distilled water should be left inside the lumen. The water will boil during sterilization, turning to steam and displacing the air within the lumen.
Basin Sets
are conducive to the formation and retention of condensate due to their density. Basins that will be nested within each other or that may contain other metal items must have adequate air space between each item. An absorbent towel should be used to separate the basins and items
Julian Date
that indicates the date of sterilization. The Julian date is the number of the calendar day (1-365/366); for example, the Julian date for February 27, 2013 is 58 and March 5, 2013 is 64.
Steam Sterilizer
The destruction of all microorganisms in or about an object can be accomplished with the use of stream under pressure, chemical agents (alcohol, phenol, heavy metals, and ethylene oxide gas), high-velocity electron bombardment, or ultraviolet radiation
Advantages of Steam Sterilizers
Saturated steam is many times more effective in trans-ferring thermal energy than hot air.
It is the most economical and inexpensive sterilizing agent.
It is the safest method of sterilization in comparison to other methods.
Factors that are critical to steam sterilizers
Contact: The sterilant must have contact with all surfaces of the items being sterilized.
Pressure: Pressure increases the temperature of steam to the level where it can destroy all microbes. Pressure that is greater than that of the atmosphere is necessary to increase the temperature of the steam in order to cause the destruction of microbes.
Cycle Time
Contents 270°F Drying Times
Instrument set, 4 minutes 20–30 minutes Wrapped
Instrument set, 3 minutes NA unwrapped, no lumen instrument
Reason For failure in Sterilizers
2.Containers are positioned incorrectly on the sterilization cart. Instrument trays, basins, and peel packs must be positioned to allow air to escape.
3.Items to be sterilized are inadequately cleaned. Soil and debris prevent the saturated steam from making direct contact with surface areas to kill microbes.
Autoclaves
generate their own steam When steam is suppliedfrom an outside source, the walls of the chamber are preheated before the steam is allowed into the chamber. This is accomplished with a metal jacket that is built around the chamber. The space between the jacket and chamber is filled with steam to preheat the chamber walls when the machine is turned on.
Gravity dIsplacement Sterilizer
are slower than prevacuum/dynamic-air-removal sterilizers because gravity is relied on to remove the air.