Guidelines for infection control in operations

(Surgical hand washing)                                                                                            

The Purpose of Hand Washing:

The warm and humid environment inside surgical gloves promotes rapid microbial growth on the hands. Therefore, performing surgical handwashing with an antiseptic before surgery helps prevent this rapid growth for a certain period, reducing the risk of infection if the glove gets punctured or torn during the procedure.

Surgical Hand Washing:

1.    Do not wear rings, bracelets, or watches in the operating unit.

2.    Keep nails short and avoid nail polish.

3.    Artificial nails are not allowed.

4.    Handwashing is recommended between each surgery, but if multiple surgeries are performed in succession, apply 3–5 mL of alcohol hand rub and rub hands until dry to prevent skin irritation from excessive betadine use.

5.    Betadine is commonly used for surgical handwashing, but the latest method involves washing hands with warm water and liquid soap, followed by alcohol hand rub.

6.    Always keep hands above the elbows to allow water to flow from the least contaminated (hands) to the most contaminated (arms).

Recent studies have shown that using a soft brush does not significantly reduce microbial count. Instead, it may cause skin cracks, micro-injuries, and irritation, leading to an increased infection risk.

When to Perform Surgical Handwashing:

• Before surgical procedures.
• Before inserting a urinary catheter.
• Before placing a central venous catheter.
• Before dressing deep wounds and burns.

Steps for Alcohol Hand Rub Before Surgery:

1.    Before applying alcohol rub, wash hands thoroughly with regular soap following the standard technique.

2.    Dry hands completely before applying approximately 5 mL of alcohol into one palm.

3.    Rub hands and forearms, ensuring the alcohol reaches under the nails and up to the forearm.

4.    Repeat the process on the other hand and forearm.

Steps for Surgical Hand Washing:

1.    Remove all jewelry from hands and wrists.

2.    Wet hands and forearms up to the elbow.

3.    Clean under each fingernail and around the nail beds. Do not use a stiff brush, as it may cause skin irritation and increase infection risk.

4.    Apply antiseptic to hands and forearms, keeping hands raised above the elbows.

o   Start at the fingertips, scrub between fingers, and work down to the elbows in a circular motion.

o   Repeat for the other hand and forearm.

o   The process should last at least 5 minutes before the first surgery of the day and 2–5 minutes before subsequent procedures.

5.    Rinse each arm separately, starting from fingertips to elbows, keeping hands elevated.

6.    Use a sterile towel to dry.

o   Use one side of the towel for one hand and the other side for the opposite hand.

7.    Keep hands above the waist and avoid touching anything before putting on a sterile gown and gloves.

Cleaning, Disinfection, and Sterilization:

Cleaning, disinfection, and sterilization are performed based on the type of instrument and its intended use.

1. Cleaning (Pre-Sterilization Process)

• The first essential step in reprocessing instruments.
• Involves using a detergent or enzymatic solution to remove dirt, organic matter, and microorganisms.

2. Disinfection:

• A chemical or physical process that reduces the microbial load to a safe level.
• It does not necessarily kill all spores but reduces the risk of infection.

3. Types of Disinfectants:

• Disinfectant (Surface & Equipment Use): A chemical or physical agent (e.g., heat, UV light, or X-rays) that eliminates most microbes, but may not kill bacterial spores.
• Antiseptic (Skin & Tissue Use): Used on living tissues to kill or inhibit microbial growth.

Types of Disinfectants Based on Their Effectiveness:

1. Low-Level Disinfectant (LLD):

• Eliminates vegetative bacteria (excluding tuberculosis bacteria), lipid viruses, and some non-lipid viruses and fungi.

2. Intermediate-Level Disinfectant (ILD):

• Kills most vegetative bacteria, including tuberculosis bacteria, lipid and some non-lipid viruses, and fungal spores.
• Does not kill bacterial spores.

3. High-Level Disinfectant (HLD):

• Capable of killing some bacterial spores when used at the right concentration, temperature, and exposure time.
• Eliminates vegetative bacteria, fungi, and most viruses, including Mycobacterium tuberculosis.
• Does not completely eliminate all bacterial spores.

Types of Viruses Based on Resistance to Disinfectants:

1. Lipid Viruses (Enveloped Viruses):

• These viruses have a lipid-protein outer layer, making them susceptible to disinfectants.
• Examples: HIV, Hepatitis B & C viruses.
• Can be inactivated using low-level disinfectants.

2. Non-Lipid Viruses (Non-Enveloped Viruses):

• Do not have a lipid envelope, making them more resistant to disinfectants.
• Examples: Coxsackie virus, Enteroviruses.

Other Infection Control Terms:

1. Pyrogens:

• Fever-inducing substances such as bacterial endotoxins from Gram-negative bacteria.

2. Spaulding Classification:

• A system developed by Dr. Earle Spaulding for instrument reprocessing.
• Medical devices are classified based on risk of infection:
• Critical: Instruments that penetrate sterile tissues (e.g., surgical instruments) → must be sterilized.
• Semi-Critical: Instruments that contact mucous membranes (e.g., endoscopes) → require high-level disinfection if heat sterilization is not possible.
• Non-Critical: Instruments that contact intact skin (e.g., blood pressure cuffs) → require low-level disinfection.

Sterilization and Sterilization Agents:

1. Sterilization:

• A physical or chemical process that eliminates all microorganisms, including spores.
• Required for all critical instruments (e.g., scalpels, surgical tools).

2. Sterilant:

• A chemical or physical agent that destroys all forms of microbial life, including prions.

3. Sterilization Methods:

• Steam Sterilization (Autoclaving): Uses pressurized steam to kill microorganisms.
• Dry Heat Sterilization: Uses high temperatures to sterilize heat-resistant instruments.
• Low-Temperature Sterilization: Used for heat-sensitive equipment, such as ethylene oxide gas sterilization.

Table (11): Hierarchical Order of Microbial Resistance to Disinfection and Sterilization

Prions are characterized by their resistance to conventional disinfection and sterilization methods.