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发表于 2016-8-2 08:22:24
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本帖最后由 胡杨 于 2016-8-2 18:11 编辑
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节选：Guidelines on the facilities required for minor surgical procedures and minimal access interventions H. Humphreys et al. / Journal of Hospital Infection 80 (2012) 103-109
Professional practice
If the hands of the operator are not visibly dirty, alcohol hand rubs or equivalent may be used between cases. However, a conventional surgical scrub is indicated at the start of a list, i.e. before the first case or procedure. Sterile gloves and a plastic apron are the minimum personal protective equipment requirement for carrying out minor surgical procedures.
However, full precautions, including fresh sterile gowns for each case, are required for MAI, for minor surgical procedures if a sterile device is being implanted and when there is a risk of significant post-procedure infection, or if there are other factors predisposing to infection.
Masks are not usually required except when a sterile device is being implanted, or when there are other issues predisposing to infection. However, face protection (e.g. mask with eye protection) for operators and other staff who may be affected is required, if splashing is likely. Further details on pre-, peri- and post-operative interventions to minimize SSI can be accessed elsewhere.
All surgical procedures should involve a checklist. Those involving general anaesthesia should be modelled on the World Health Organization checklist for safe surgery (http://www.who.int/patientsafety ... list_finalJun08.pdf) to include aspects of mechanical theatre ventilation, e.g. checking that the ventilation is working, in facilities for MAI. Modifications to these may be made for MAI and minor surgical procedures as appropriate.
History of hospital operating theatres
Over the centuries, surgeons have moved from operating under primitive conditions to an environment which is venti- lated to specific high standards and considerably advanced from that of their redecessors. The practice of surgery demands the training of surgical trainees in the use of masks, sterile clothing and the need to minimize movement into and within the operating theatre. 3 There is also emphasis on minimizing the duration of each procedure as it is accepted, based on evidence, that prolonged procedures carry increased risk for SSI. 4
Specialized ventilation systems in operating theatres Originally, powerful extract ventilation was provided
for operating theatres to remove steam from boiling ater ‘sterilizers’, pulling in air from surrounding areas (i.e. the theatre was at negative pressure), but this led to infections caused by airborne bacteria being drawn in from adjacent wards. With the general provision of clean air under positive pressure, clean wound infection rates fell by a factor of 10. 5e7
The principle of modern conventional theatre ventilation is to remove airborne contamination generated in the theatre and to prevent the ingress of possibly contaminated air from the surrounding areas. This is achieved by actively supplying relatively clean air into the theatre faster than excess air can be passively removed.
The air escapes through pressure release dampers and any gap in the fabric of the theatre (e.g. around doors) and, in flowing outwards, it prevents any air from surrounding areas flowing inwards.
The main source of airborne contamination is the skin of those moving inside the theatre, i.e. the staff. 8 This is diluted by the air supplied to the theatre, with air then flowing out to less sensitive areas such as corridors, carrying the contamination away with it. 8 A classic study of operating theatre ventilation found that counts of airborne microbes increased with the degree of movement and numbers of personnel within the theatre. 9 It was shown later that airborne skin squames carrying micro-organisms in a ‘raft-like’ fashion are shed from the skin surface; during modest activity, humans can shed microbe-carrying skin scales yielding up to 10,000 colonyforming units (cfu) every minute. 10e12
The importance of ventilation in controlling airborne contamination was shown in an early study in England where thecomparative rates of infection inhospital ranged from2% to 7% and the cut-off between a low and high rate was an aircount of 5 cfu/ft 3 referred to in the so-called Lidwell Report,
the forerunner of Health Technical Memorandum 2025, ‘Ventilation in healthcare premises’. 13,14
In ‘clean’ surgery, surgical sites can be exposed to airborne bacteria, either directly into the wound or indirectly by microbes settling ontosurgical/operativeinstrumentswhich will then, on use, transfer this contamination to the surgical site. This latter route probably accounts for the majority of airborne
bacteria in a surgical site or wound. 15 The smaller the incision, such as during laparoscopy, the greater will be the proportion of bacteria that enter the wound via indirect airborne sources. Thus instrument contamination contributes proportionally more to surgical site contamination in this scenario.
The critical areas within the operating theatre suite are the operating theatre itself and the preparation room, where sterile instrument packs may be opened and exposed to the air before use. The soiled utility room is under negative pressure (i.e. inward airflow) so that it does not contribute to airborne contamination in theatre.
There is a need to define procedures in terms of the susceptibility of the surgical or operative site to contamination and to define the basic physical requirements of facilities in which many minor surgical procedures and MAI may be carried out. Aetiology of post-operative infections in minor procedures and MAI In the National Institute for Health and Clinical Excellence (NICE) guidelines on SSI, no distinction is made between minor surgical procedures, MAI and conventional surgical operations. 2
However, it is not always clear what is meant by minor surgical procedures or MAI and the individual perception of this may vary according to background and professional practice.
Laparoscopic procedures are associated with lower infection rates than those after open procedures but patients who undergo laparoscopic procedures may be pre-selected and have a lower risk of infection as more complicated cases are carried out as conventional surgical operations. 16,17
Surveillance data of orthopaedic procedures from the Health Protection Agency revealed that Staphylococcus aureus accountedfor39e44%ofthebacteriaresponsibleforSSIinthese procedures followed by Enterobacteriaceae in 14e19% of cases. 18 The bacteria recovered from specimens taken from
infected wounds following laparoscopic abdominal surgery, or hand surgery or day surgery,largely reflect the endogenous flora of both patients and staff, and appear to be no different from those following conventional surgical operations. 19,21 For example, S. aureus was responsible for 44% of infections of the hand and Pseudomonas aeruginosa and other Gram-negative bacilli are more likely to be responsible for infections arising from laparoscopic gastrointestinal procedures. 19,20 Therefore there does not appear to be any difference in the causative microbes of post-operative infection whether carried out as a conventional surgical operation or as an MAI/minor surgical procedure.
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