Asepsis antiseptic surgery. Asepsis methods

The nature of putrefaction and fermentation discovered in 1863 by Louis Pasteur, having become a stimulus for the development of microbiology and practical surgery, made it possible to assert that microorganisms are the cause of many wound complications.

The introduction of asepsis and antiseptics into surgical practice (along with anesthesia and the discovery of blood groups) is one of the fundamental achievements of medicine in the 19th century.

Before the advent of antiseptics, surgeons almost never took the risk of operations associated with opening the cavities of the human body, since interventions in them were accompanied by almost one hundred percent mortality from surgical infections. Professor Erikoen, Lister's teacher, stated in 1874 that the abdominal and thoracic cavities, as well as the cranial cavity, would forever remain inaccessible to surgeons.

Asepsis- a set of measures aimed at preventing the entry of microbes into the wound.

Asepsis in Greek means: a - without, septikos - purulent. Hence the basic principle of asepsis says: everything that comes into contact with the wound must be free from bacteria, i.e. must be sterile. Any surgical intervention must be performed under sterile conditions, this applies not only to surgery itself, but also to ophthalmic surgery, traumatology, maxillofacial surgery, otorhinolaryngology, endoscopy and other specialties. Therefore, knowledge of asepsis is mandatory for almost any medical specialty.

Microbes can enter the wound in two ways: exogenous and endogenous. Exogenous sources of infection: a) air (air infection); b) drops of liquid that enter the wound (splashes of saliva, mucus) when talking, coughing, sneezing, etc. - (droplet infection); c) objects in contact with the wound (contact infection); d) objects left in the wound intentionally (sutures, drains) or unintentionally (metal particles flying off the instrument, gauze threads, forgotten tampons, etc.). This also includes technical errors (incorrect supply of sterile items). Endogenous sources of infection are microbes that are in the patient's body. Under the influence of the weakening of the body, they can acquire pathogenic properties and cause, for example, postoperative pneumonia, penetrating through the lymphatic and blood tracts.

The principles of asepsis are carried out using various methods: chemical, physical, biological.

Asepsis includes:

Sterilization of instruments, materials, surgical linen, devices;

Treatment of the surgeon's hands;

Compliance with special rules and methods of work in the production of operations, research, etc.;

Implementation of special sanitary-hygienic and organizational measures in a medical institution.

Sterilization- complete release of any object from all types of microorganisms, including bacteria and their spores, fungi, virions, as well as from prion protein found on surfaces, equipment, food and medicines.

Sterilization methods:

Thermal: steam and air (dry heat).

Chemical: gas or chemical solutions (sterilants).

Radiation sterilization - used in the industrial version.

The membrane filter method is used to obtain a small amount of sterile solutions, the quality of which can deteriorate sharply under the action of other sterilization methods (bacteriophage, selective nutrient media, antibiotics).

Steam sterilization is carried out by supplying saturated water vapor under pressure in steam sterilizers (autoclaves).

Steam sterilization is considered the most effective method due to the fact that the bactericidal action of hot air increases as it is humidified, and the higher the pressure, the higher the temperature of the steam.

Steam sterilization is carried out on textile products (linen, cotton wool, bandages, suture material), rubber, glass, some polymeric materials, nutrient media, and drugs.

dry air, or dry heat sterilization- a method, the active beginning of which is air heated to 160-200 ° C.

Dry heat has a fairly effective effect not only on vegetative forms of organisms, but also on spores. Factors limiting this method are the duration of sterilization and the limited materials that can transfer it (used mainly for sterilizing instruments).

radiation method or radiation sterilization with γ-rays, they are used in special installations for industrial sterilization of a single use - polymer syringes, blood transfusion systems, Petri dishes, pipettes and other fragile and thermolabile products.

Sterilization with gases quite promising. It does not damage the sterilized objects, does not change their properties.

Sterilization with formalin vapor is of the greatest practical importance. Cystoscopes, catheters and other objects in glass cylinders are sterilized.

Surgeon training Before the operation, it is performed in the preoperative room (dressing in a surgical shirt suit, trousers, cap, mask, shoe covers and hand treatment in the accepted way) and in the operating room (final hand treatment and putting on sterile gloves).

The preparation of hands for the operation involves mechanical cleaning of the skin, the destruction of microbes remaining on the skin and its compaction in order to close the ducts of the sebaceous and sweat glands.

Antiseptics- a system of measures aimed at the destruction of microorganisms in the wound, pathological focus, organs and tissues, as well as in the patient's body as a whole, using mechanical and physical methods of exposure, active chemicals and biological factors.

Allocate types of antiseptics depending on the nature of the methods used: mechanical, physical, chemical and biological antiseptics. In practice, different types of antiseptics are usually combined.

Depending on the method of application of antiseptics, chemical and biological antiseptics are divided into local and general; local, in turn, is divided into superficial and deep. With superficial antiseptics, the drug is used in the form of powders, ointments, applications, for washing wounds and cavities, and with deep antiseptics, the drug is injected into the tissues of the wound inflammatory focus (chopping, etc.).

General antiseptics mean saturation of the body with antiseptic agents (antibiotics, sulfonamides, etc.). They are brought into the focus of infection by blood or lymph flow and thus affect the microflora.

Mechanical antiseptic- the destruction of microorganisms by mechanical methods, that is, the removal of areas of non-viable tissues, blood clots, purulent exudate. Mechanical methods are fundamental - if they are not carried out, all other methods are ineffective.

Mechanical antiseptic includes:

Wound toilet (removal of purulent exudate, removal of clots, cleansing of the wound surface and skin) - performed during dressing;

Primary surgical treatment of the wound (dissection, revision, excision of the edges, walls, bottom of the wound, removal of blood, foreign bodies and foci of necrosis, restoration of damaged tissues - suturing, hemostasis) - helps prevent the development of a 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 streaks, wound drainage) - is performed in the presence of an active infectious process. Indications - the presence of a purulent focus, the lack of adequate outflow from the wound, the formation of extensive zones of necrosis and purulent streaks;

Other operations and manipulations (for example, opening abscesses).

Physical antiseptic- these are methods that create unfavorable conditions in the wound for the development of bacteria and the absorption of toxins and tissue decay products. It is based on the laws of osmosis and diffusion, communicating vessels, universal gravitation, etc.

Physical antiseptics include:

The use of hygroscopic dressings (cotton wool, gauze, tampons, napkins - they suck out the wound secret with a mass of microbes and their toxins);

Hypertonic solutions (used to wet the dressing, pull its contents out of the wound into a bandage. However, you should be aware that hypertonic solutions have a chemical and biological effect on the wound and microorganisms);

Environmental factors (washing and drying). When dried, a scab forms, 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, one liquid is injected, another is removed in an equal volume, active drainage - drainage with a pump);

Technical means:

laser - radiation with high directivity and energy density, the result is a sterile coagulation film;

ultrasound;

ultraviolet - for the treatment of rooms and wounds;

hyperbaric oxygenation;

x-ray therapy - treatment of deeply located purulent foci with osteomyelitis, bone panaritium.

Chemical antiseptic- the destruction of microorganisms in a wound, pathological focus or the patient's body with the help of various chemicals.

Currently, many simple and chemically complex antiseptic preparations have been proposed. Among them are substances of both inorganic nature - halides (chlorine and its preparations, iodine and its preparations), oxidizing agents (boric acid, potassium permanganate, hydrogen peroxide), heavy metals (preparations of mercury, silver, aluminum), and organic - phenols, salicylic acid, formaldehyde.

Chemical antiseptics also include sulfanilamide and nitrofuran preparations, as well as a large group of artificially obtained antibiotics.

Biological antiseptic- the use of drugs that act both directly on microorganisms and their toxins, and on the macroorganism.

These drugs include: antibiotics that have a bactericidal or bacteriostatic effect; enzyme preparations, bacteriophages, antitoxins - specific antibodies (agents for passive immunization) formed in the human body under the action of sera, toxoids (agents for active immunization), immunostimulating agents.

Asepsis- a system of measures aimed at preventing the introduction of infectious agents into the wound, tissues, organs, body cavities of the patient during surgical operations, dressings and diagnostic procedures.

It is achieved by the destruction of microbes and their spores through disinfection and sterilization using physical agents and chemicals.

There are 2 types of surgical infection: endogenous and exogenous. The endogenous source is in the patient's body, the exogenous source is in the environment. In the prevention of endogenous infection, the main role belongs to antisepsis, exogenous - asepsis.

The fight against air infection is primarily the fight against dust. The main measures aimed at reducing air infection are as follows: proper ventilation of operating rooms and dressing rooms; wet cleaning of premises, regular airing and irradiation of premises with UFL; reducing the time of contact with air of an open wound. Fight against droplet infection: prohibition of conversations in the operating room, dressing room, mandatory wearing of gauze bandages, timely current operating room cleaning. Of particular importance is the observance of the special regime of the medical institution, with the allocation of special zones of strict regime.

Contact infection - sterilization of all devices, instruments and materials in contact with the wound. The hands of the health worker and the skin of the patient are thoroughly disinfected. Any surgical operations and other invasive manipulations associated with a violation of the integrity of the skin should be performed in an operating room or dressing room with adequate preparation of the skin in the area of ​​intervention (antiseptic treatment) and isolation of the surgical field with sterile surgical covers. It is always preferable to use disposable sterile covering materials such as 3M Steri-Drape. To prevent the entry of resident skin flora into the surgical wound, it is desirable to apply the cut adhesive coating "3M Steri-Drape-2" to the prepared surgical field, which maintains a sterile barrier between the patient's skin and the surgeon's hands, instruments, etc. until the end of the operation. The best solution is to use the antimicrobial cuttable film "ZM Ayoban", containing in its composition a complex iodine compound that actively suppresses the resident skin flora throughout the operation of any duration. Important is the prevention of implant infection (sterilization of suture material, drains, etc. and, if possible, the less frequent use of foreign bodies left in the wound). Implant infection can often be dormant and manifest itself after a long period of time when the body's defenses are weakened.

An important measure to ensure asepsis is the rehabilitation of medical personnel. In cases where sanitation does not give results, it is necessary to resort to the employment of carriers outside the surgical departments.

Antiseptics- a complex of therapeutic and preventive measures aimed at the destruction of microbes in a wound, other pathological formation or the body as a whole.

Distinguish:

• Preventive antiseptic - is carried out in order to prevent microorganisms from entering the wound or the patient's body (treatment of the hands of medical staff, treatment of the injection site with an antiseptic, etc.).
• Therapeutic antiseptics, which include: mechanical (removal of infected and non-viable tissues, removal of foreign bodies, primary surgical treatment of wounds, opening of streaks and pockets, etc.), physical (hygroscopic dressings, solutions with high osmotic pressure, the effect of dry heat, ultrasound and etc.); chemical (use of various bactericidal and bacteriostatic substances); biological (antibiotics, antitoxins, bacteriophages, proteolytic enzymes, etc.) methods and their combination.

The hands of health workers involved in the provision of medical care can be a factor in the transmission of pathogenic and opportunistic microbes. The microflora of the skin of the hands is represented by two populations: resident and transient. Resident (permanent) microflora lives in the stratum corneum of the skin, sebaceous and sweat glands, hair follicles and is represented by epidermal staphylococci, diphtheroids, propionibacteria, etc. The species and quantitative composition of the resident microflora population is relatively stable and to a certain extent forms the barrier function of the skin. In the area of ​​the periungual folds and interdigital spaces, in addition to the above microorganisms, Staphylococcus aureus, akinetobacteria, Pseudomonas, Escherichia coli, Klebsiella vegetate.

These biotopes for the listed groups of bacteria are the natural habitat.

Transient microflora enters the skin during work as a result of contact with infected patients or contaminated environmental objects and remains on the skin of the hands for up to 24 hours. It is represented by obligate and conditionally pathogenic microorganisms (E. coli, Klebsiella, Pseudomonas, Salmonella, Candida, adeno- and rotaviruses, etc.), characteristic of a certain profile of a medical institution.

Mechanical action on the stratum corneum, leading to a violation of the stability of the population of resident microflora (the use of hard brushes, alkaline soap for washing hands, aggressive antiseptics, the absence of softening additives in alcohol-containing antiseptics) contributes to the development of skin dysbacteriosis. The manifestation of the latter is the predominance of gram-negative opportunistic microflora in the resident population, including hospital strains resistant to antibiotics, antiseptics and disinfectants. As a result, the hands of medical workers can be not only a factor in the transmission of these microorganisms, but also their reservoir.

While transient microorganisms can be mechanically removed from the skin of the hands by routine handwashing or destroyed by the use of antiseptic agents, it is almost impossible for a resident population of microorganisms to be completely removed or destroyed by conventional handwashing or antiseptic treatment. Sterilization of the skin of the hands is not only impossible, but also undesirable, since the preservation of the stratum corneum and the relative stability of the resident population of microflora prevents the colonization of the skin by other, much more dangerous microorganisms, primarily gram-negative bacteria.

In this regard, in Western European countries, traumatic, long-term, ancestral methods of processing hands (according to Alfeld-Furbringer, Spasokukotsky-Kochergin) have been radically changed and improved.

Of the many existing methods for disinfecting the skin of the hands, only one has the qualifications of the European standard and is duly registered as the "European Norm 1500" (EN 1500). According to the regulation of the European Committee for Standardization, this standard is followed in Belgium, Denmark, Germany, Finland, France, Greece, Ireland, Iceland, Italy, Luxembourg, the Netherlands, Norway, Austria, Portugal, Sweden, Switzerland, Spain, the Czech Republic, Great Britain.

This method is the most optimal for hygienic and surgical antisepsis of hands of personnel of health care facilities and does not require constant bacteriological control of the effectiveness of disinfection. In the Republic of Belarus, there is an instruction “Hygienic and surgical antisepsis of the skin of the hands” No. 113-0801 of 09/05/2001.

Hygienic antiseptic hand skin.

Indications for hygienic hand antisepsis:

• before and after contact with infectious patients of known or suspected etiology (patients with AIDS, viral hepatitis, staphylococcal dysentery, etc.);
• contact with secretions of patients (pus, blood, sputum, feces, urine, etc.);
• before and after manual and instrumental examinations and interventions not related to penetration into sterile cavities;
• after visiting boxing in infectious diseases hospitals and departments;
• after visiting the toilet;
• before leaving home.

Stages of hygienic antisepsis of the skin of the hands:

1. antiseptic apply to the hands in an amount of 3 ml and carefully rub into the palmar, back and interdigital surfaces of the skin of the hands for 30-60 seconds in accordance with the attached scheme until completely dry:

1. Rub palm on palm.
2. Left palm on the back of the right hand and vice versa.
3. Rub your palms with fingers crossed.
4. The back of the bent fingers on the palm of the other hand.
5. Rub your thumbs alternately in a circular motion.
6. Rub the palms with the fingertips of the opposite hand alternately in multidirectional circular motions.

2. When heavily contaminated with biomaterials(blood, mucus, pus, etc.) are first removed with a sterile cotton-gauze swab or gauze napkin moistened with a skin antiseptic. Then 3 ml of an antiseptic is applied to the hands and rubbed into the skin of the interdigital areas, palmar and dorsal surfaces until completely dry, but not less than 30 seconds, after which they are washed with running water and soap.

Surgical antisepsis of the skin of the hands.

Indications for surgical antisepsis of the skin of the hands: manipulations, associated with contact (direct or indirect) with the internal sterile environments of the body (catheterization of central venous vessels, punctures of joints, cavities, surgical interventions, etc.).

Stages of surgical antisepsis of the skin of the hands:

1. Within 2 minutes, the hands and forearms are washed without brushes under warm running water with neutral liquid soap (hygienic washing), which helps to remove contaminants and reduces the amount of transient microflora on the hands of medical personnel).
2. The hands and forearms are dried with a sterile napkin.
3. For 5 minutes, carefully rub the antiseptic in portions of 2.5 - 3 ml into the skin of the hands and forearms according to the standard method, preventing the skin from drying out. The total consumption of antiseptic | in accordance with the instructions for the drug.
4. Air dry hands.
5. Sterile gloves are put on dry hands.
6. After carrying out surgical procedures and removing gloves, hands are washed with warm water and liquid soap for 2 minutes. To prevent the drying effect of alcohols, a cream is applied for 1-3 minutes.

Hand sanitizer requirements:

1. rub the antiseptic only into dry skin;
2. use adequate amounts of antiseptic for the level of processing (avoid excess), for which it is necessary to use elbow dispensers;
3. do not use napkins, sponges, tampons, other foreign objects for applying the drug;
4. alternate the use of antiseptics containing active substances with different mechanisms of antimicrobial action;
5. thoroughness of the processing technique;
6. observe the sequence of actions, the dosage of the drug and the exposure of the treatment at each stage.

Depending on the method of application of antiseptics, local and general antiseptics are distinguished. Local antiseptics, in turn, are divided into superficial (use of powders, ointments, applications, washing wounds and cavities) and deep (injection of the drug in the wound or inflammatory focus - chipping, blockade).

Under the general antiseptic is understood the saturation of the body with an antiseptic.(antibiotics, sulfonamides) entering the site of infection with the blood stream or affecting the microflora contained in the blood.

When using this or that type of antiseptic, one should take into account its possible side effects, which in some cases can be dangerous, causing intoxication (chemical antiseptic), damage to vital anatomical structures (mechanical antiseptic), photodermatitis (physical antiseptic), allergic reactions, dysbacteriosis, candidiasis (biological antiseptic), etc.

The means used for antiseptics must meet the following requirements:

1. have a wide spectrum of action (bacteria-, viruli-, fungi-,tuberculocidal);
2. quickly achieve the effect;
3. achieve complete destruction of transient microflora;
4. to achieve a reduction in contamination with permanent microflora tosafe level;
5. have a sufficiently long effect after treatment (within three hours);
6. there should be no skin-irritating, allergenic, carcinogenic, mutagenic and other side effects;
7. to ensure the slow development of resistance of microorganisms; be economically available.

Answer structure: Definition, types, characteristics.