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#Post#: 74--------------------------------------------------
Operation Theatre
By: osmaniaortho Date: April 22, 2012, 2:27 am
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Includes
• Properly preparing a client for clinical procedures
• Handwashing
• Surgical hand scrub
• Using barriers such as gloves and surgical attire
• Maintaining a sterile field
• Using good surgical technique
• Maintaining a safe environment in the surgical/procedure area
External link for download
HTML http://www.ems.org.eg/esic_home/data/giued_part2/Operating%20Theatre.pdf<br
/>
#Post#: 75--------------------------------------------------
Re: Operation Theatre
By: osmaniaortho Date: April 22, 2012, 5:30 am
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Operating-Room Environment
Introduction | Preoperative Period | Operating-Room Environment
| Postoperative Period | Overview | References
Clean-Air Technology
The use of ultraviolet light to sterilize air particles carrying
bacteria was initiated in 1936, but the absolute effectiveness
of this technology in the clinical setting has not been
definitively determined, as studies to date have been
retrospective, with comparison of clinical experiences and
historical controls41,50,64. The lack of conclusive clinical
studies combined with concern regarding exposure of
operating-room personnel to ultraviolet light has led to only
tentative acceptance of this methodology. However, recent
cost-effectiveness comparisons have created a resurgent interest
in ultraviolet-light technology since it is considerably less
expensive than laminar airflow systems8,64.
In 1969, Charnley and Eftekhar reported a dramatic reduction in
the prevalence of postoperative infection after total hip
arthroplasty, from 9 per cent (seventeen of 190) to 1 per cent
(nine of 708), with the implementation of a clean-air operating
theater16. Careful analysis of their data suggested that
multiple factors over the course of the study, such as the
method of subcutaneous wound closure and the use of antibiotics,
may also have contributed to the reduced rate of infection. In a
subsequent report that attempted to clarify these other
variables, Charnley concluded that clean air was the most
important factor but was not the sole reason for this reduction
in the prevalence of infection15. It should be noted that he
suggested that clean air is optimally provided by a combination
of laminar airflow, with a room-air-exchange turnover rate of
more than 300 times an hour; the use of a vertical airflow
system; and the use of personnel isolator suits. He also
stressed that horizontal laminar airflow systems should be used
with body-exhaust systems and impermeable gowns15. Finally, he
stated: "I most certainly do not wish to be reported as
advocating clean air as a panacea for all surgeon's problems of
sepsis in total hip replacement."15
Subsequently, substantial interest developed in the use of
clean-air technology as a method of preventing infection in
association with total joint arthroplasty. Many initial studies
retrospectively evaluated the efficacy of laminar airflow
systems by comparing historical rates of infection, and a
thorough review by Nelson et al. detailed many of these
studies85. A large multicenter prospective randomized clinical
trial62 evaluating the effect of laminar airflow during 6781 hip
arthroplasties and 1274 knee arthroplasties performed between
1974 and 1979 was published in 1982. Infection occurred in
sixty-three (1.5 per cent) of 4129 patients in the control group
and in only twenty-three (0.6 per cent) of 3923 patients in the
ultraclean-air group (p < 0.001)62. Although these results
seemed to provide irrefutable evidence as to the efficacy of
laminar airflow systems, the study design had flaws that
included randomization irregularities and lack of patient
stratification, and, furthermore, the use of prophylactic
antibiotics was not controlled59. This study did demonstrate
clearly that body-exhaust suits reduced the bacterial counts in
the room air and, in general, that vertical airflow systems
performed better than horizontal airflow systems. The
inconsistency in the use of prophylactic antibiotics in this
study62 was a major problem because, in the presence of
prophylactic antibiotics, the independent effect of laminar
airflow was reduction of the prevalence of infection further
from twenty-four (0.8 per cent) of 2968 in the control group to
ten (0.3 per cent) of 2863 in the ultraclean-air group, which
was not significant (p < 0.1) (Table II). However, in the
absence of prophylactic antibiotics, the rate of infection was
reduced from thirty-nine (3.4 per cent) of 1161 to thirteen (1.2
per cent) of 1060, which was significant (p < 0.01) (Table II).
These data suggest that both factors have an independent effect
on the reduction of infection but leave open the question of
whether laminar airflow is necessary when prophylactic
antibiotics are used.
A large retrospective study of 2384 total hip arthroplasties
resulted in additional doubt about the absolute efficacy of
laminar airflow technology when prophylactic antibiotics are
used69. Between 1975 and 1978, when none of the patients
received prophylactic antibiotics, infection developed after
nine (3.1 per cent) of 289 arthroplasties performed in a
conventional operating room, compared with nine (2.5 per cent)
of 363 arthroplasties performed in a laminar airflow room (p =
0.5). After the use of prophylactic antibiotics was initiated in
1979, infection developed following six (0.9 per cent) of 669
arthroplasties performed in the conventional operating room,
compared with three (0.3 per cent) of 1063 arthroplasties
performed in a laminar airflow room. Again, these differences
were not significant (p = 0.1). The difference in the rates of
infection between the two study periods (2.8 per cent without
antibiotic prophylaxis, compared with 0.5 per cent with
antibiotic prophylaxis) was highly significant (p < 0.00001)69.
Although retrospective, the study was limited to patients who
had had the arthroplasty performed by the same surgeons in one
hospital and who had received the same prosthesis, and it was
based on excellent documentation of the use of prophylactic
antibiotics and consistent use of vertical laminar airflow and
body-exhaust suits69.
A large retrospective study by Salvati et al. of 3175 total hip
and knee replacements, performed with or without a horizontal
unidirectional filtered airflow system, demonstrated a
detrimental effect of laminar airflow104. It is extremely
important to note that personnel isolator suits were not used in
this study. The paradoxical increase in the rate of infection
after total knee arthroplasty performed in the laminar airflow
rooms was attributed to positioning of the operating team
between the patient and the airflow unit, with subsequent
entrainment of air containing particulate matter and bacteria
from the operating-room personnel into the operative wound104.
The preliminary results were recently reported for a randomized
blinded prospective study of 7305 patients who had a total hip
or knee arthroplasty with use of horizontal unidirectional
airflow and no personnel isolator suits33. All of the patients
received antibiotic prophylaxis. Although there was no
significant difference in the rate of deep periprosthetic
infection between the patients who had the procedure in a room
with activated laminar airflow and those who had it in the
presence of conventional airflow, it should be noted that these
preliminary results essentially parallel the results of Salvati
et al.104, in that there was a trend toward a higher rate of
infection in some groups with laminar airflow but not in others.
These recent studies emphasize the need for appropriate
application of clean-air technology and the paradoxical effects
that can occur with the misunderstanding of clean-air concepts.
Although there is still considerable controversy regarding the
necessity of laminar airflow for the performance of total joint
arthroplasty if prophylactic antibiotics are used, the following
points can be reasonably drawn from the available literature.
1. Vertical laminar airflow units generally reduce airborne
contamination better than horizontal airflow units. This is
especially true when personnel isolator suits are not used.
2. Strict attention to laminar airflow protocol is essential,
and there can be paradoxical increases in the rates of infection
if these concepts are disregarded.
3. During the past few decades, the appropriate use of clean-air
technology to reduce airborne contamination has reduced the
prevalence of infection after total hip and knee arthroplasty.
4. The current literature has not established that clean-air
technology can greatly reduce the prevalence of infection when
prophylactic antibiotics are also used. However, if the rate of
early postoperative infection following the procedures performed
by an individual surgeon or at a specific institution exceeds
four or five per 1000 total hip arthroplasties and six, seven,
or eight per 1000 total knee arthroplasties, the use of some
method of clean-air technology should be considered to reduce
further the prevalence of infection15,16,33,49,61,62,108. It is
important to remember that, with this low prevalence of
infection of less than 1 per cent, analysis of more than 6000
patients is required to achieve the statistical power necessary
to determine the effect of any one independent variable, such as
airflow, on the rate of infection after total joint
replacements.
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