“how do you prepare the surgical - the college of animal ... 4 circles are for donut… · “how...

“How do you prepare the surgical patient?”

Student Veterinary Nurse:“Just do a standard scrub.... Hibi and a

bit of water then a spray of spirit in theatre. Mind you, the spirit bottle

broke this week so we rinsed out the Mr Muscle bottle... seems to work

really well.”

“How do you prepare the surgical patient?”

Veterinary Surgeon:“What!?! I don’t know... They (the

nurses) just wash ‘em a bit” (randomly circles hands in air)

“Then spray them with something in theatre.”

Looking to the Human field

Skin is the source

In most SSIs, the source of pathogens is the endogenous flora of the patient’s own skinOwens CD et al. J Hosp Infect 2008; 70: 3-10.Florman S, Nichols RL. Am J Infect Dis 2007; 3: 51-61.McGrath DR, McCrory D. Ann R Coll Surg Eng 2005; 87: 366-368.

Skin is the source

80% of resident and transient skin flora reside in the first 5 celllayers of the epidermisHendley JO, Ashe KM. Antimicrob Agents

Chemother 1991;35:627-31


WHO Guidelines for safe surgery 2009:• Before a patient’s skin is prepared for a surgical procedure, it should be

cleansed of gross contamination (e.g. dirt, soil or any other debris) • Although preoperative showering has not been shown to reduce the

incidence of surgical site infection, it might decrease bacterial counts and ensure that the skin is clean

• The antiseptics used to prepare the skin should be applied with sterile supplies and gloves or by a no-touch technique, moving from the incision area to the periphery

• The person preparing the skin should use pressure, because friction increases the antibacterial effect of an antiseptic. For example, alcohol applied without friction reduces bacterial counts by 1.0–1.2 log10CFU compared with 1.9–3.0 log10CFU when friction is used. Alcoholic sprays have little antimicrobial effect and produce potentially explosive vapours

Veterinary Patient Preparation

Purpose of preoperative patient preparation

Preoperative preparation of the patient's skin can reduce the risk of postoperative surgical site infection by removing soil and microorganisms from the skin, reducing the resident microbial count to sub-pathogenic levels in a short period of time and with the least amount of tissue irritation

and inhibit rebound growth of microorganisms.Small Animal Surgery Textbook 4th edition By Theresa Welch Fossum

Preparation of the patient

• Patient skin preparation takes place in three very distinct stages:•• 1. Clipping: carried out in a preparation area outside the operating theatre area.

This may be a room that also has another function but it must be totally separate from the operating theatre itself.

•• 2. Initial skin preparation: also carried out in a preparation area outside the

operating theatre area. Again this may be a room that also has another function but it must be totally separate from the operating theatre itself.

•• 3. Final skin antisepsis preparation: carried out once in the theatre area under

completely sterile conditions.

PSS Scheme 2015 V1.0

Clipping

Immediately before surgery in a separate area. Vacuum loose hair. Clean and disinfect clippers between each patient.(FECAVA Key recommendations for Hygiene and Infection Control October 2013)

Initial Skin PreparationFor the removal of gross contamination majority of

practices use Hibiscrub (4%CHG)This should be diluted in equal parts with water (50:50)

This should be performed in a separate area away from the theatre.

Infection Control, An Issue of Veterinary Clinics of North America: Small Animal Practice 2015 By Jason Stull, VMD, MPVM, PhD , Ohio StateThe efficacy of chlorhexidine gluconate in canine skin preparation Evans LK, Knowles TG, Werrett G, Holt PE. J Small Anim Pract. 2009

Sep;50(9):458-65Hibiscrub Summary Of Product Characteristics. Regent Medical (Retrieved March 2012).

Initial Skin Preparation

Whilst removing gross contamination, gloves should be worn. 1. This provides a

barrier between the patient and healthcare worker

2. Provides PPE to the healthcare worker to prevent hypersensitivity to CHG

Initial Skin Preparation

Removal of gross contamination should be made using lint free swabs in a methodical back and forth motion initially focussing on incision site until swabs are clean

Bella Moss Foundation Guidelines for Preparing Patients for Surgery (retrieved Jan 2016)

Final Skin Antisepsis

Patient is moved into theatreIf used, disposable drape removedOnce patient is positionedGloves are removed

Type of antiseptic

Skin antisepsis should be performed using a chlorhexidine / alcohol combination antiseptic agent

PRINCIPALS OF SOFT TISSUE SURGERY APPLIED TO FARM ANIMALS André Desrochers DMV, MS DACVS, DECBHMFaculty of veterinary medicine, Université de Montréal, St-Hyacinthe, QC, Canada

Small Animal Surgery by Theresa Welch Fossum 4th edition

Analyses comparing the antimicrobial activity and safety of current antiseptic agents: a review. Hibbard JS J Infus Nurse 2005 May-Jun;28(3):194-207

Type of antiseptic

Type of antiseptic

Casey AL et al. Poster presented at ECCMID, Barcelona, Spain, April 2008

Application method

Woodhead K et al. J Hosp Infect 2002; 51: 241-55.

Application method• The practice of applying an antiseptic in concentric circles,

beginning in the area of the proposed incision, is only supported by theoretical epidemiological rationale1

• An important prerequisite of effective disinfection is to ensure that the area has adequate amounts of disinfectant applied…the practice of applying a disinfectant from a central point and working outwards in a spiral may be flawed because the actual site may be subject to inadequate disinfection.2

• Applying antiseptic as a spray does no more than soak an area – no significant cleaning action occurs3

– 1 Nicole Fortin Clinical Consultant Quebec AORN Nov 2006 Vol 84, No 5 Letters– 2 McDonald et al, Vox Sanguis (2001), 80, 135-141– 3 Inwood S. Br J Nurs 2007;16: 1390-4

Application method• This disinfection method offers the National Blood Service a validated, optimal 'best

practice' disinfection technique and should contribute significantly to the reduction in risk of transmission of bacteria by transfusion

• McDonald et al, Vox Sanguis (2001), 80, 135-141• Rigorous skin cleansing with a chlorhexidine gluconate 2% in alcohol or aqueous solution

is recommended prior to catheter insertion• Source: 2006 The British Committee for Standards in Haematology (BCSH) . • An antiseptic solution such as chlorhexidine solution or 70% alcohol should be applied in

an area of 4-5cm diameter with friction for 30-60 seconds. A quick wipe fails to reduce bacterial count (Weinstein Eighth Edition)

• The Royal Marsden Hospital Manual - Clinical Nursing Procedures Seventh Edition• Following this circular pattern may not allow penetration of the antiseptic solutions into the

cracks and fissures of the epidermal layer of the skin. It would seem more appropriate to apply each swab stick with mechanical friction, cleansing the skin from side to side and up and down.

• Crosby et al JVAD Spring 2001

Application method


• Concentric prep


• Spraying alcohol prep


• Friction prep


• The antiseptics used to prepare the skin should be applied with sterile supplies and gloves or by a no-touch technique, moving from the incision area to the periphery

• WHO Guidelines for safe surgery 2009

Conclusion

Conclusion

Veterinary Surgeon:“What!?! I don’t know... They (the nurses)

just wash ‘em a bit” (randomly circles hands in air)

“Then spray them with something in theatre.”

Thank you

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