Acc to surgery explain universal precautions and hand hygiene
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Universal Precautions and Hand Hygiene in Surgery
Universal Precautions
Background and Context
Patients may present to surgeons for operative treatment when they are known to be infected or "at risk" (e.g., hepatitis B, hepatitis C, HIV/AIDS), or because they require surgical intervention related to their illness (vascular access, biopsy). The greatest surgical risk comes from blood-borne pathogens transmitted via needle-stick injury or cuts.
Key viral concerns for surgeons:
- Hepatitis B - blood-borne; risk of transmission both from patient to surgeon and vice versa. An effective vaccine exists; surgeons should know their immune status and be vaccinated.
- Hepatitis C - often becomes chronic with significant liver damage; potentially curable with interferon-alpha and ribavirin.
- HIV (Type I) - retrovirus transmitted by body fluids (especially blood) via needle-stick. Risk of seroconversion to AIDS in 25-35% of patients. The phase of seroconversion carries the greatest transmission risk. HAART (highly active antiretroviral therapy) suppresses but does not clear the virus.
Particular care is required when there is risk of splashing or aerosol formation, especially with power tools.
Universal Precautions (CDC, Adopted by NHS)
Universal precautions were drawn up by the CDC in the USA and largely adopted by the NHS in the UK. The following measures apply in any surgery involving a patient with known or suspected blood-borne infection:
| Precaution | Detail |
|---|---|
| Face protection | Full face mask (ideally) or protective spectacles |
| Gown and drapes | Fully waterproof, disposable - especially during seroconversion |
| Footwear | Boots (not clogs) to prevent injury from dropped sharps |
| Gloves | Double gloving required; a larger size on the inside is more comfortable |
| Theatre personnel | Only essential personnel in theatre |
| Movement | Avoid unnecessary movement in theatre |
| Sharps handling | Passage of sharps must be done with respect - use a kidney dish |
| Operative technique | Slow, meticulous technique with minimised bleeding |
- Bailey and Love's Short Practice of Surgery, 28th Edition
After Contamination (Needle-Stick Injury)
- Needle-stick injuries are commonest on the non-dominant index finger during operative surgery.
- Hollow needle injury carries the greatest risk of viral transmission.
- The injured part should be washed under running water and the incident reported immediately.
- Local policies dictate whether post-exposure antiretroviral treatment should be given.
- Occupational health advice is required after high-risk exposure, including hepatitis/HIV testing and the option for continuation in a non-operative specialty.
- Bailey and Love's Short Practice of Surgery, 28th Edition
Hand Hygiene
Historical Significance
The importance of hand hygiene in surgery was first recognized by Semmelweis, who noted the beneficial impact of hand hygiene on mortality rates among patients undergoing delivery by midwives. This understanding evolved further when William Stewart Halsted commissioned the Goodyear Rubber Company to develop rubber gloves, which he mandated all members of his surgical team wear throughout each operation to prevent infection.
- Sabiston Textbook of Surgery, The Biological Basis of Modern Surgical Practice
Surgical Hand Antisepsis (Hand Scrubbing)
Surgical hand antisepsis destroys bacteria and is routinely carried out before all invasive procedures. Key evidence-based points:
- Alcohol rubs are as effective as aqueous scrubbing in SSI (surgical site infection) prevention - confirmed in a review of 10 trials.
- Hand scrubbing for 2 minutes is as effective as traditional 5-minute scrubbing; optimal duration is not yet definitively determined.
- Waterless surgical hand rubs containing chlorhexidine are equally efficacious to conventional scrubs and superior to povidone-iodine scrubs.
- Chlorhexidine gluconate-based scrubs are more effective than povidone-iodine-based scrubs in terms of bacterial colony-forming units on the hands (evidence from 4 studies).
- Alcohol rub preceded by 1-minute non-antiseptic washing for the first case of the day is equally effective at SSI prevention as traditional scrubbing.
- Mulholland and Greenfield's Surgery, 7th Edition; Campbell's Operative Orthopaedics, 15th Edition
WHO 5 Moments for Hand Hygiene
Hand washing is the most important procedure for prevention of nosocomial (hospital-acquired) infections.
| WHO Moment | Indication |
|---|---|
| 1 | Immediately before touching a patient |
| 2 | Before performing an aseptic task (e.g., placing an indwelling device or handling invasive medical devices) |
| 3 | After contact with blood, body fluids, or contaminated surfaces |
| 4 | After touching a patient |
| 5 | After touching the patient's environment |
- Campbell's Operative Orthopaedics, 15th Edition (Table 22.1)
Operating Room Environment
- Airborne bacteria in the OR are usually gram-positive and originate almost exclusively from humans; each person sheds 5,000 to 55,000 particles per minute.
- Conventional OR air may contain 10-15 bacteria per cubic foot and 250,000 particles per cubic foot.
- Number of door openings and personnel increases airborne particles and should be kept to a minimum.
- Laminar flow and ultraviolet light are not currently recommended for reducing SSIs.
- Positive air pressure and high-efficiency particulate air (HEPA) filters are used to reduce airborne contaminants.
- Campbell's Operative Orthopaedics, 15th Edition; Sabiston Textbook of Surgery
Summary Points for Exam
- Universal precautions = CDC guidelines; apply to ALL patients (not just known infected cases).
- Double gloving + waterproof gown + face/eye protection are the triad of operative precautions.
- Seroconversion phase = highest risk of HIV transmission.
- Hollow needle injuries = greatest viral transmission risk; wash under running water immediately.
- Hand hygiene is the single most important infection control measure.
- 2-minute scrub = as effective as 5-minute scrub.
- Chlorhexidine > povidone-iodine for surgical hand antisepsis.
- Alcohol-based rubs = equivalent to aqueous scrubs.
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