The source of infection refers to the habitat, development, and reproduction of microorganisms. In relation to the body of the patient (wounded), it is customary to distinguish between two main types of sources of infection - exogenous and endogenous. Exogenous are sources located outside the patient’s body. Endogenous are sources located in the patient’s body.

The main exogenous sources: 1) patients with purulent-septic diseases, 2) bacilli carriers, 3) animals. It should be remembered that not only pathogenic, but also opportunistic and saprophytic bacteria, which can be found on surrounding objects, can pose a danger to a surgical patient. From patients or carriers of bacilli, microorganisms enter the external environment with mucus, sputum, pus, and other secretions. Less commonly, sources of surgical infection are animals. From the external environment, infection can enter the body in several ways - airborne, droplet, contact, implantation.

1. Air route. Microorganisms come from the surrounding air, where they are freely suspended or adsorbed on dust particles. Air, as a means of transmission of infection, plays important role, especially in operating rooms, emergency rooms and intensive care units.

2. Drip path. Pathogens contained in tiny droplets of secretions from the upper respiratory tract that enter the air when talking, coughing, or sneezing penetrate the wound.

3. Contact path. Microorganisms enter through objects that come into contact with the wound during operations or other manipulations (surgeon's hands, instruments, dressings, etc.);

4.Implant path. Pathogens enter the body tissues if foreign material is deliberately left there (suture material, metal rods and plates, artificial heart valves, synthetic vascular prostheses, pacemakers, etc.).

The source of endogenous infection is chronic inflammatory processes in the body, both outside the operation area (diseases of the skin, teeth, tonsils, etc.), and in the organs on which the intervention is performed (appendicitis, cholecystitis, osteomyelitis, etc.), as well as the microflora of the oral cavity, intestines, respiratory, urinary tract etc. The main routes of endogenous infection are contact, hematogenous, lymphogenous. Through contact, microorganisms can enter the wound: from the surface of the skin near the surgical incision, from the lumen of organs opened during the intervention (for example, from the intestines, stomach, esophagus, etc.), from the source of inflammation located in the operation area. In the hematogenous or lymphogenous route, microorganisms from foci of inflammation located outside the operation area enter the wound through the blood or lymphatic vessels.

Aseptic methods are used to combat exogenous infection, and antiseptic methods are used to combat endogenous infection. For successful prevention it is necessary that the fight be carried out at all stages (source of infection - routes of infection - organism) through a combination of aseptic and antiseptic methods.

To prevent infection of the environment in the presence of a source of infection - a patient with a purulent-inflammatory disease - it is necessary first of all organizational events: treatment of such patients in special surgical infection departments, performance of operations and dressings in separate operating rooms and dressing rooms, availability of special personnel for treating and caring for patients. The same rule exists in outpatient setting: Reception of patients, treatment, dressings and operations are performed in special rooms.

inflammatory diseases. Doctors, nurses, materials and instruments, as well as rooms for such patients should be separated from other patients. In addition, it is known that the content of microorganisms in the air of the operating room increases significantly during the day, therefore, when working in the operating room, it is extremely important to dress in sterile clothes, use sterile gauze masks, caps, completely limiting any possibility of microorganisms entering the wound. It is especially important to follow these rules for students observing the operation directly next to surgical field.
2. Sterilization
This is a method aimed at eliminating living microorganisms and their spores from the surface of materials, instruments and other objects that come into contact with the wound surface before, after and during surgery.
Dressings, underwear, suture material, rubber gloves (some simple outpatient procedures, such as taking blood for analysis, can be carried out in disposable sterile gloves), and instruments should be sterilized. Distinguish following methods sterilization.
1. Boiling (the duration depends on the type of contamination).
2. Treatment with flowing steam or steam supplied under pressure in a special apparatus - an autoclave (for sterilization of contaminated dressings, linen, gowns, shoe covers). Its temperature is controlled various methods. One of these methods is to place test tubes containing substances whose melting point is equal to or slightly lower than the required temperature in the sterilization apparatus. The melting of these substances indicates that the temperature required for sterilization has been reached.
3. Bactericidal effect ultraviolet radiation(for air disinfection in operating rooms, dressing rooms and manipulation rooms).
Germicidal lamps are turned on at the end of the working day after cleaning the room for 3 hours, and if there is a large flow of patients during the day, it is advisable to carry out treatment with lamps during the day.
3. Treatment of the surgeon’s hands using the Spasokukotsky-Kochergin method
Hand washing is one of the the most important methods asepsis, which completely prevents the access of microorganisms to the surgical field.
Before treating your hands using this method, you must wash your hands with soap and a brush. The surgeon's hands are thoroughly soaped using a brush in a certain direction. They begin to process the hands from the proximal phalanges of the fingers, first their palmar surface, and then their dorsal surface.
Carefully treat each finger and interdigital spaces, following the specified sequence. Then they wash the wrist: first from the palm, then from back side. In the same sequence

forearm is treated. First to wash left hand, then the right one according to the same principle. This allows you to cleanse the skin of your hands from contaminants received during the day during professional and household activities. Subsequently, the skin of the hands is treated using a special technique.
The first stage includes treating hands in a 0.5% solution of ammonia. The sequence of treatment of the surgeon's hands must be carefully followed. Solution ammonia placed in two basins, in each of which the hands are treated sequentially according to the described method for 3 minutes: first in one basin, and then for the same time in the other. After this, hands are blotted with a sterile napkin and then wiped dry.
The second stage is hand treatment in the same sequence with 96% alcohol solution within 4-5 minutes. After this, the surgeon puts on sterile gloves, after which he can only touch the surgical field.
Special attention is given to the treatment of the hands of a surgeon working in the department of purulent surgery. Sterility control must be especially thorough, for which it is necessary to disinfect hands not only before surgery, but also after examination purulent wound, manipulations in it, dressings. To do this, hands are treated according to the specified method. gauze swabs, moistened with 70% ethyl alcohol for 3 minutes.
46 Dressing - definition, indications.
The concept of dressing
Bandages are usually applied in a dressing room. This is where the dressing process takes place. Bandaging means therapeutic and diagnostic a procedure consisting of removing the old bandage, performing preventive, diagnostic and therapeutic measures in the wound and applying a new bandage. To perform a dressing, appropriate indications are needed.?
The main indications for dressing are:?
1. 1st day after surgery. The need for bandaging one day after the operation is due to the fact that in the presence of any wound, even one seemingly hermetically sutured, the lower layers of gauze always get wet with ichor within the first day, since fibrin has not yet bonded the edges of the wound.?
The ichor is good nutrient medium for microorganisms.
The purpose of dressing on the 1st day after surgery is prophylactic - removing the wet dressing material and treating the edges of the wound with antiseptics to prevent infectious complications.?
2. Necessity of implementation diagnostic measures in the wound: monitoring the healing process.?

3. The need for therapeutic manipulations: removal of sutures, removal of drainage, excision of necrotic tissue, rinsing with antiseptics, stopping bleeding, administration medicines and much more.?
4. The bandage has ceased to perform its function, the immobilizing bandage does not provide immobility, the hemostatic bandage does not stop bleeding, the occlusive bandage does not create a tightness, etc..?
5. Wetting the bandage. A bandage that is wet with wound discharge or blood does not fulfill its function and is a conductor for secondary infection.?
6. The bandage has moved from the place where it was applied.?
When removing an old dressing, two basic principles should be followed: minimum discomfort for the patient and compliance with aseptic standards.?
To remove the bandage painlessly, you should carefully peel off the gauze, while holding the skin around it with adhesive bandages, do not put pressure on the wound area, and do not make sudden movements. When the dressing dries to extensive wounds in some cases, it is soaked with antiseptic solutions: 3% hydrogen peroxide, 2-3% boric acid etc..?
Removal of the upper non-sterile layers of the bandage, gauze is carried out with gloved hands; all procedures in the dressing room are performed in rubber gloves! After this, removing the sterile dressing material that is in direct contact with the wound, as well as performing all further manipulations with the wound, can only be done with a sterile instrument.
The material used during dressing is dumped into a kidney-shaped basin, and after its completion from the basin into special tanks for disposal, while the basin itself and the used instruments are placed in a storage tank for disinfection.?
47Measurement of pulse, blood pressure and respiratory rate.
When measuring the pulse, the patient's hand should lie freely, without tension. The subject's hand in the area wrist joint clasp right hand so that the I finger is located on the ulnar side, and the II, III and IV - on radial artery. Having felt the pulsating artery, it is pressed with moderate force to inside radius. If it is impossible to determine the pulse on the radial artery, the pulse is examined on the temporal or carotid arteries, and this must be done especially carefully, since pressure on the artery can cause dizziness in the patient and a slowdown in cardiac activity.
If there is a sudden increase in heart rate, up to 150 beats per minute, nurse must provide the necessary first aid. To do this, she counts the pulse, determines its filling, tension and rhythm, and then takes the necessary measures to relieve the patient’s psycho-emotional stress by putting her to bed.?

Determination of respiratory rate (RR)
The combination of inhalation and subsequent exhalation is considered one breathing movement. The number of breaths in 1 minute is called the respiratory rate (RR) or simply the respiratory rate.
Normally, breathing movements are rhythmic. The frequency of respiratory movements in an adult healthy person at rest is 16-20 per minute; in women it is 2-4 breaths more than in men. In the lying position, the number of breaths usually decreases to 14-16 per minute, in an upright position it increases to 18-20 per minute. In a newborn, the respiratory rate is 40-50 times per minute, by the age of 5 it decreases to 24, and by the age of 15-20 it is 16-20 times per minute. For athletes, the respiratory rate can be 6-8 per minute.
Determination of the frequency of respiratory movements is carried out unnoticed by the patient; at this moment, the position of the hand can simulate the determination of the pulse rate. The patient’s position is lying or sitting, while taking his hand as for examining the pulse, but observing the excursion chest and count the breathing movements for 1 minute. The result of the NPV is recorded in the appropriate documentation.
48Asepsis.Methods.
Asepsis methods
Asepsis includes the consistent implementation of measures for sterilization of linen, clothing, dressings, instruments, air in the operating room and dressing rooms, and preparation of personnel hands.
Asepsis methods. Infertility is achieved by such physical factors as high temperature hot dry air, boiling, flowing steam, steam under pressure, ultraviolet irradiation, ionizing radiation, ultrasound, etc.
Ultraviolet rays
The sun's rays have a bactericidal property, especially short-wave ultraviolet rays. Under the influence sun rays bacteria die quickly, spores are less susceptible to action ultraviolet rays. High dust content in the air sharply reduces bactericidal effect sun rays.
Ionizing radiation
Radioactive isotopes cobalt-60 and cesium-137 emit y-rays that have a bactericidal effect. Sterilization by ionizing radiation is carried out in special installations at medical industry enterprises. Reliable disinfection is achieved suture material, items made of plastic, rubber.
Ultrasonic sterilization
The method is in the research stage, but practical activities devices are used to sterilize the surgeon's hands. The method is fast, reliable and convenient.
Air filtration

In operating rooms where organ transplants are performed, special air purification is used. The air is filtered through special filters that retain chamberlain candle microbes. Conventional operating rooms are equipped with air conditioners or air purifiers.
Yu. Hesterenko
49 Antiseptics. Methods .
Antiseptics lat. anti - against, septicus - rotting - a system of measures aimed at destroying microorganisms in a wound, pathological focus, organs and tissues, using mechanical and physical methods of influence, active chemicals and biological factors.
Types of antiseptics
There are types of antiseptics depending on the nature of the methods used: mechanical, physical, chemical and biological antiseptics. In practice they usually combine different types antiseptics.
Depending on the method of using antiseptics, chemical and biological antiseptics are divided into local and general; local, in turn, is divided into superficial and deep. For superficial antiseptics, the drug is used in the form of powders, ointments, applications, for washing wounds and cavities, and for deep antiseptics, the drug is injected into the tissue of the wound inflammatory focus, etc.
General antiseptics mean saturating the body with antiseptic agents, antibiotics, sulfonamides, etc. They are carried into the source of infection by the blood or lymph flow and thus affect the microflora.
Mechanical antiseptics
See also: Primary surgical treatment of a wound
Mechanical antiseptics - destruction of microorganisms by mechanical methods, that is, removal of areas of non-viable tissue, blood clots, purulent exudate. Mechanical methods are fundamental - if they are not carried out, all other methods are ineffective.
Mechanical antiseptics includes: toileting the wound, removing purulent exudate, removing clots, cleansing wound surface and skin - during dressing, primary surgical treatment of the wound is performed: dissection, revision, excision of the edges, walls, bottom of the wound, removal of blood, foreign bodies and foci of necrosis, restoration of damaged tissue - suturing, hemostasis - helps prevent the development purulent process, that is, it turns an infected wound into a sterile wound. Secondary surgical treatment, excision of non-viable tissues, removal of foreign bodies, opening of pockets and leaks, drainage of the wound - is carried out in the presence of an active infectious process.

Indications - presence of a purulent focus, lack of adequate outflow from the wound, formation of extensive areas of necrosis and purulent leaks, other operations and manipulations, opening of ulcers, puncture of ulcers
“Ubi pus - ubi es” - “you see pus - release it.”
Thus, mechanical antisepsis is a true treatment for infection surgical methods, by using surgical instruments.
Physical antisepsis
Physical antiseptics are methods that create unfavorable conditions in the wound for the development of bacteria and the absorption of toxins and tissue breakdown products. It is based on the laws of osmosis and diffusion, communicating vessels, universal gravitation, etc. Methods: the use of hygroscopic dressings, cotton wool, gauze, tampons, napkins - they suck out the wound secretion with a mass of microbes and their toxins; hypertonic solutions are used to wet the dressing, pulling it out of the wound contents in a bandage. However, you should be aware that hypertonic solutions have chemical and biological effect on the wound and on microorganisms, environmental factors, washing and drying. When dried, a scab is formed, which promotes healing sorbents carbon-containing substances in the form of powder or fibers drainage passive drainage - the law of communicating vessels, flow-flushing - at least 2 drainages, liquid is introduced one at a time, the other is removed in an equal volume, active drainage - drainage with a pump technical means laser - radiation with high directionality and energy density, the result is a sterile coagulation film; ultrasound - cavitation bubbles and H+ and OH?,
UV - for treating rooms and wounds, hyperbaric oxygen therapy, X-ray therapy - treatment of deeply located purulent foci with osteomyelitis, bone panaritium.
Chemical antiseptic
Chemical antiseptics is the destruction of microorganisms in a wound, pathological focus or the patient’s body using various chemicals.
Highlight: disinfectants used in asepsis for processing instruments, washing walls, floors, etc., actually antiseptic agents externally, for treating the skin, surgeon's hands, washing wounds and mucous membranes, chemotherapeutic agents, antibiotics and sulfonamides - inhibit the growth of bacteria, an important property - the only means having specific action to

certain groups of microorganisms are classified as biological antiseptics.
Chemical antiseptics are substances used for topical use, allowing the creation of a high concentration of an antibacterial drug directly at the site of inflammation. These drugs are more resistant than antibiotics to the effects of inflammation and tissue necrosis. Positive qualities drugs are wide range antibacterial action bactericidal effect, low drug resistance microorganisms. The drugs are characterized by poor absorption, the possibility of long-term storage, and rare side effects.
Chemical antiseptics include derivatives of nitrofuran, acids and alkalis, dyes, detergents, oxidizing agents, derivatives of quinoxyxaline, metal salts sublimate, lapis.
Methods of using chemical antiseptics. Local application: and the use of bandages with antiseptic drugs in the treatment of wounds and burns; drugs can be used in the form of solutions; they wash the wound during dressing, ointments and powders; b introduction of solutions antibacterial drugs into the wound, closed cavities followed by aspiration through drains.
General Application: and reception antibacterial agents orally in the form of tablets in order to influence the patient’s microflora during his preparation for intestinal surgery, as well as subsequent general action on the body after absorption of the drug into the blood; b intravenous administration some drugs furazidin, sodium hypochlorite.
Biological antiseptics
Biological antiseptics is the use of biological products that act both directly on microorganisms and their toxins, and act through the macroorganism.
These drugs include: antibiotics and sulfonamides, which have a bactericidal or bacteriostatic effect; enzyme preparations, bacteriophages - eaters of bacteria; antitoxins - specific antibodies, means for passive immunization, formed in the human body under the influence of serums, toxoids, means for active immunization, immunostimulating agents. Antitoxins are one of the immunity factors for tetanus, diphtheria, botulism, gas gangrene and other diseases.
Antibiotics are chemical compounds biological origin, causing selective damage or destructive effect to microorganisms. Antibiotics used in medical practice, are produced by actinomycetes, molds, as well as some bacteria. This group of drugs also includes synthetic analogues and derivatives of natural antibiotics.

By spectrum antimicrobial action antibiotics differ quite significantly; in addition, by acting on a microorganism, antibiotics cause either a bacteriostatic or bactericidal effect.
There are four main mechanisms of antimicrobial action of antibiotics: disruption of bacterial cell wall synthesis, disruption of permeability cytoplasmic membrane disruption of intracellular protein synthesis; disruption of RNA synthesis.
In the process of using antibiotics, microorganisms may develop resistance to them. The emergence of resistant strains is a serious problem in modern medicine. To avoid or slow down this process, there are principles of antibiotic treatment: careful justification of prescriptions, justification for the choice of antibiotic based on laboratory data, characteristic clinical picture It is impossible to prescribe antibiotics with the same side effect that coincides with the existing pathology, individual sensitivity, characteristics of penetration into various tissues, as well as the age of the patient; prescribing an adequate dose is always therapeutic; withdrawal should be abrupt optimal course treatment is on average a week, lengthening is possible, but less is not possible, since clinical recovery occurs earlier than laboratory - the danger of relapse, the choice of route and frequency of administration depends on the localization of the process and the duration of action of the antibiotic, a mandatory assessment of the effectiveness of the action, if not effective, it is recommended to combine antibiotics with each other friend, or with sulfonamides, but it is dangerous to prescribe more than two drugs at the same time due to pronounced side effects.
IN clinical practice Using only one method to combat infection is impractical and often ineffective. Therefore, the concept of mixed antiseptics is introduced.
Mixed antiseptics is the effect on the microbial cell, as well as on the human body, of several types of antiseptics. More often their action is complex. For example: primary surgical treatment of a wound, mechanical and chemical antiseptics are supplemented by biological antiseptics by introducing antitetanus serum, antibiotics and the prescription of physiotherapeutic procedures, physical antiseptics.
Also an example of mixed antiseptics is peritoneal dialysis for purulent peritonitis

Ways of infection entering the wound

The skin and mucous membranes isolate the internal environment from the external and reliably protect the body from the penetration of microbes. Any violation of their integrity is entrance gate for infection. Therefore, all accidental wounds are obviously infected and require mandatory surgical treatment. Infection can occur from the outside (exogenous) by airborne droplets(when coughing, talking), by contact (when touching the wound with clothing, hands) or from the inside (endogenous). Sources of endogenous infection are chronic inflammatory diseases skin, teeth, tonsils, ways of spreading infection - blood or lymph flow.

As a rule, wounds become infected with pyogenic microbes (streptococci, staphylococci), but infection can also occur with other microbes. It is very dangerous for a wound to become infected with tetanus bacilli, tuberculosis, gas gangrene. Prevention of infectious complications in surgery is based on strict adherence to the rules of asepsis and antisepsis. Both methods represent a single whole in the prevention of surgical infection.

Antiseptics - a set of measures aimed at destroying microbes in the wound. There are mechanical, physical, biological and chemical methods of destruction.

Mechanical antiseptics includes carrying out primary surgical treatment of the wound and its toilet, i.e., removal of blood clots, foreign objects, excision of non-viable tissue, washing of the wound cavity.

Physical method is based on the use of ultraviolet radiation, which has a bactericidal effect, the application gauze bandages, which absorb wound discharge well, dry the wound and thereby contribute to the death of microbes. The same method involves the use of concentrated saline solution(law of osmosis).

Biological method based on the use of serums, vaccines, antibiotics and sulfonamides (in the form of solutions, ointments, powders). Chemical method The fight against microbes is aimed at the use of various chemicals called antiseptics.

Drugs used against pathogens of surgical infections can be divided into 3 groups: disinfectants, antiseptics and chemotherapy. Disinfectants substances are intended primarily to destroy infectious agents in the external environment (chloramine, sublimate, triple solution, formaldehyde, carbolic acid). Antiseptic products are used to destroy microbes on the surface of the body or in serous cavities. These drugs should not be absorbed in significant quantities into the blood, as they can have a toxic effect on the patient’s body (iodine, furatsilin, rivanol, hydrogen peroxide, potassium permanganate, brilliant green, methylene blue).

Chemotherapy the drugs are well absorbed into the blood when in various ways administration and destroy microbes in the patient’s body. This group includes antibiotics and sulfonamides.

The skin and mucous membranes isolate the internal environment from the external and reliably protect the body from the penetration of microbes. Any violation of their integrity is an entry point for infection. Therefore, all accidental wounds are obviously infected and require mandatory surgical treatment. Infection can occur from the outside (exogenous) by airborne droplets (when coughing, talking), by contact (when touching the wound with clothing, hands) or from the inside (endogenous). Sources of endogenous infection are chronic inflammatory diseases of the skin, teeth, tonsils, and the route of infection spread is the blood or lymph flow.

As a rule, wounds become infected with pyogenic microbes (streptococci, staphylococci), but infection can also occur with other microbes. Infection of a wound with tetanus bacilli, tuberculosis, and gas gangrene is very dangerous. Prevention of infectious complications in surgery is based on strict adherence to the rules of asepsis and antisepsis. Both methods represent a single whole in the prevention of surgical infection.

Antiseptics are a set of measures aimed at destroying microbes in a wound. There are mechanical, physical, biological and chemical methods of destruction.

Mechanical antiseptics includes primary surgical treatment of the wound and its toilet, i.e., removal of blood clots, foreign objects, excision of non-viable tissue, washing of the wound cavity.

The physical method is based on the use of ultraviolet irradiation, which has a bactericidal effect, and the application of gauze dressings, which absorb wound discharge well, dry the wound and thereby contribute to the death of microbes. The same method involves the use of a concentrated saline solution (the law of osmosis).

The biological method is based on the use of serums, vaccines, antibiotics and sulfonamides (in the form of solutions, ointments, powders). The chemical method of combating microbes is aimed at using various chemicals called antiseptics.

Drugs used against pathogens of surgical infections can be divided into 3 groups: disinfectants, antiseptics and chemotherapy. Disinfectants are intended primarily to destroy infectious agents in the external environment (chloramine, sublimate, triple solution, formaldehyde, carbolic acid). Antiseptics used to destroy microbes on the surface of the body or in serous cavities. These drugs should not be absorbed into the blood in significant quantities, as they may have toxic effect on the patient's body (iodine, furatsilin, rivanol, hydrogen peroxide, potassium permanganate, brilliant green, methylene blue).

Chemotherapeutic agents are well absorbed into the blood through various methods of administration and destroy microbes in the patient’s body. This group includes antibiotics and sulfonamides.

Asepsis (from the Greek a - negative particle and septikos - causing rotting, suppuration), a set of mechanical, physical and chemical methods and techniques that prevent the introduction of pathogenic microbes into wounds and into the body as a whole. Asepsis is a set of measures aimed at creating germ-free, sterile conditions for surgical work. Mechanical asepsis includes primary processing accidental wounds in the first 6 hours after its occurrence, as well as mechanical treatment - washing in hot water with soap on instruments and other objects that, when in contact with the surface of the wound, can infect it. Physical asepsis forms the basis of asepsis. It consists of destroying microbes by sterilizing instruments and other objects by boiling in solutions of soda (carbon dioxide or bicarbonate), borax, and caustic alkali. Chemical asepsis- the use of disinfectants when preparing the hands of the surgeon and his assistants, the surgical field, as well as when sterilizing suture material by impregnating it with bactericidal and bacteriostatic substances. Aseptic methods and techniques are used in close connection with antiseptic methods, that is, they use the aseptic-antiseptic method characteristic of modern surgery.